Edward Steinfeld,Arch D., Professor of Architecture
Scott M. Shea, M. Arch, Research Associate
Rehabilitation Research Center on Aging, State University of New York
Environmental barriers can significantly reduce the independence of
older people with disabilities living in a residential setting. Removing
these barriers through home modification is one way to increase independence.
This study focuses on the effectiveness of technical assistance in helping
people to make modifications, and the reasons why modifications are
not made. Recommendations for improvements to service delivery are proposed
based on the study findings.
Research Goals and Background Issues
Potential barriers to the accessibility, safety, security and usability
of home environments for older people with disabilities are well known
(see Pynoos, 1987 and Watzke and Kemp, 1992). As older people "age
in place", these barriers present serious threats to independence
and increase caregiver burden. Many methods for eliminating barriers
and creating enabling environments have been proposed. However, the
needs of individual households vary significantly and they differ from
those of younger people with disabilities. There is a need for information
on the types of barriers that "handicap" older disabled people,
the specific interventions that should be high priorities and the level
of acceptance of interventions among the older population. Such information
can be used to identify priorities for policy, innovative design concepts,
service programs and design of assistive technology. It can help to
prevent disability among the older population and increase autonomy.
This paper presents findings from the second phase of a multi-year research
study concerned with the identification of barriers to aging in place
and consumer acceptance of actions to remove those barriers. A previous
publication reported on the first phase of the research (Steinfeld and
Shea, 1993). The research reported here focuses primarily on the reasons
why participants do not implement recommendations of professionals,
particularly those that they themselves agree are a high priority.
In an earlier phase of this study we could not explain the priorities
consumers gave to recommendations on the basis of cost alone. By analyzing
consumer priorities and from informal interaction, we obtained insight
into the decision making process (Steinfeld and Shea, 1993). From a
cost-benefit perspective, interventions are valued if their benefit
outweighs the cost compared to other alternative methods of coping,
such as changing behavior. In a risk assessment model, the perceived
risk associated with some barriers may be greater than with others,
and may be misplaced. Barriers perceived as having low risk are not
viewed as real problems. In a cognitive dissonance model, some problems
are perceived to be unsolvable and, thus, expectations for resolution
are lowered in order to accept the situation more easily. In a social
construction model, accepting the need for an intervention is a "reconstruction"
of self image, an acknowledgment to others that one can no longer function
effectively without adjusting relationships with the everyday world.
Denying the need for intervention, on the other hand, presents a courageous
image - "It's tough, but I can handle it." As we began the
next phase of our research, we realized that there are differences between
establishing priorities and actually committing resources to action,
thus we considered two other decision making models.The economic constraint
model acknowledges that some individuals simply do not have the ability
to pay for an intervention, even if they place a high priority on it.
Furthermore, in certain cases, an item might be perceived as too expensive
when in fact it is affordable. The stress management model is based
on the premise that making a change requires some expenditure of psychic
resources and energy; some things are perceived as "too much trouble,"
despite their obvious value. Because of the effort involved, however
slight, a change is unacceptable regardless of the impact it might have
on their life in the future.
The first phase of our work obtained descriptive data about the extent
and type of barriers to aging in place found in the homes of a sample
of older people with disabilities. A barrier was defined as an environmental
feature that reduced functional capacity or put a person at risk. We
identified 4 categories of barriers: activities of daily living, safety,
security and the structural deficiencies. Barriers were identified using
a self report method administered as part of a comprehensive Consumer
Survey conducted by the RERC on Aging (Mann et al.,1994) and a free
home assessment service completed in homes occupied by people selected
from the Consumer Survey sample. Recommendations for interventions through
home modifications and other related services were prepared and discussed
with each individual in order to identify priorities. The participants
were alternately assigned to one of two groups as they were recruited.
Group One received only the free home assessment and Group Two received
additional technical assistance and referral services to help implement
any of the recommended interventions. In the second phase, a follow
up interview was conducted by telephone approximately 18 months later
to identify which additional recommendations had been implemented. For
each recommendation that was not implemented, the individuals were read
a list of possible reasons and asked to tell us which statement most
closely matched their own reason for not carrying out the recommendation.
The reasons were based on the decision making models described above
but worded in everyday language. Open ended responses were also solicited
if the respondent felt our choices didnot apply. Most of the open ended
responses fit easily into one of the existing categories. All the participants
in the study were over 62, had a disability and lived in non-institutional
community housing in the Buffalo metropolitan area. A wide range of
disabilities was represented.
Table 1 shows the total number of recommendations that were implemented.
Barriers counted in Phase One were completed prior to the priorities
interview and were considered high priority barriers by default. Phase
Two data includes the additional actions that were completed after the
priorities interview and prior to the follow up.
The individuals in Group Two implemented almost twice as many recommendations
as those in Group One by the end of Phase Two. This would seem to indicate
that technical assistance and referral services were helpful for resolving
problems. However, roughly the same ratio held for the number of barriers
resolved by the end of Phase One, before any additional services were
actually provided. This indicates that the people in Group Two were
generally more inclined ormore able to change their environments than
those in Group One.
|Table 1. Frequency
In addition,the number of recommendations implemented
decreased over time. This is contrary to what one would expect if providing
technical assistance and referral services are effective as a sole intervention.
However, this finding does suggest that assessments on their own have
an impact in increasing the rate of modifications. The initial assessment
apparently focused participants' attention to problems and encouraged
them to act.
Overall, only 18.2% of the barriers identified were resolved.However,
of the 747 barriers encountered, 289 were considered a high priority
and 47.1% of these were resolved. Thus, older people are willing to
devote resources toward improving their home environment if they perceive
barriers to be serious but they will not devote resources to low priority
problems. What are the reasons for the lack of resolution for over half
of the high priority barriers? Answering this question can help us discover
ways to increase the rate of problem resolution.
An unanticipated reason for inaction was discovered during the interviews,
perceived lack of control over the circumstances. This reflects a model
of decision making based on autonomy. The individual wishes to resolve
the problem but is unable to do so because others have control. This
can be attributed in part to respondents living in rental properties.
They were reluctant to approach a landlord or had already had a request
refused and were hesitant to press their case. Roughly the same number
of homeowners gave autonomy as a reason for not taking action. These
people all cited family members who were unresponsive to their requests
for assistance. Despite owning the home, they were dependent on others
to make improvements. However, these homes had fewer barriers.
2. Frequency of Reasons for Inaction
Table 2 shows the frequency distribution of reasons
given for inaction on high priority recommendations. Overall, the barriers
that were identified and the proposed solutions were perceived as relevant
and important, as indicated by the extremely low number identified as
cost-benefit, or "not making enough of a difference." While
economic constraint was the most frequent reason given for inaction
on a recommendation, 68.4% of the barriers were left unresolved for
other reasons. Cost is clearly not the only reason why individuals do
not make modifications. Stress management was the next most cited reason
reflecting another dimension of resource constraints. The frequency
of the other reasons were considerably lower than these two. It is possible
that our original categories masked the relative importance of different
reasons. Upon reflection, we noticed a close affinity between the risk
assessment and cost benefit models of decision making. In both cases,
the level of perceived benefit can trigger action. Until that benefit
is perceived to be significant, either in terms of value or reduced
threat, action will be deferred. Likewise, the cognitive dissonance
and social construction models are both concerned with self concept.
In the former, individuals do not act because they deny a change in
status and in the latter, because they blame their limitations as the
cause of the problem. Inaction, in both cases, can be attributed to
an unrealistic assessment of self. Thus, we revised the categories to
collapse these four models to two, "deferredpriority" and
"self concept." Conceived this way economic constraints and
stress management are still the top two, but self concept is not far
Over half of the barriers that were identified as high priorities by
the participants themselves were not resolved at the end of the study
period. While, in one sense, it is encouraging to find out that households
that have older people with disabilities will take action to remedy
problems, a higher level of resolution would be desirable. What can
be done to increase the rate of action? Our findings indicate that technical
assistance and referral services alone are not sufficient to help improve
the rate of action. A different type of intervention is needed.
The results show that there are three major reasons why the older people
in our sample did not take action on a recommendation for a home modification.
The first is that the economic cost of implementation was perceived
as being outside their means. The second was that the physical and psychic
energy required to implement the recommendation was perceived to be
beyond their capacity. Third, implementation required a realistic assessment
of self, specifically the belief that a change in the environment can
make a difference in one's quality of life. Such a reassessment was
not acceptable in many cases. Two additional but, still important reasons
are that the ability to make the change was out of the control of the
respondent and that the barrier was not perceived to be important enough
yet to demand action.
Previous demonstration studies on this topic have not only provided
assessments but also either offered to make modifications free of charge
or provided cash grants (see for example Trickey et. al.). These studies
reported higher implementation rates. Our findings confirm that the
availability of financial assistance is the most important incentive
for insuring action. It is important to note, however, that the previous
studies did not compare the rate of implementation prior to and after
the service intervention. Our findings indicate that this should be
an important methodological component of intervention studies.
The research has several implications for improving the delivery of
home modification services to support aging in place. First, more attractive
financing mechanisms need to be developed. A funding program that could
address all the implications of aging in place together and provide
a menu of health care, social service and shelter options would increase
flexibility in the use of existing funds and thereby address the diverse
needs of households. Second, service providers should reduce the stress
of implementing home modifications by providing "one stop shopping"
for all related services and maintaining high quality and reliability
standards that will promote trust and security. Third, ways to reduce
the cost of service delivery are needed. Fourth, case managers and outreach
personnel need to address the issue of lack of control with strategies
to encourage landlords and families to fulfill their obligations. Fifth,
educational programs are needed to improve the awareness of aging in
place and the advantages of home modifications for the older consumer.
Sixth, there is a need to develop low cost, "hassle free"
and age appropriate solutions to the common barriers to aging in place.
Mann, W. C. et. al. The Rehabilitation Engineering Center on Aging.
Technology and Disability.Butterworth-Heinemann: Stoneham, MA. 1994.
Pynoos J, CohenE, David LJ, Bernhardt S. Home Modifications: Improvements
that extend independence. In Regnier V, Pynoos J, eds. Housing the Aged.
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Steinfeld, E and Shea,S. Enabling Home Environments: Identifying Barriers
to Independence.Technology and Disability. Butterworth-Heinemann: Stoneham,
MA. Fall1993. p. 69
Trickey, Francine et.al. Home Modifications for the Elderly: which ones
do they want? Which ones will they use? WINDOW on Technology. vol. 7,
no. 4. pg. 8
Watzke, J.R. and Kemp, B. Safety for Older Adults: The role of technology
and the home environment. Topics in Geriatric Rehabilitation. Aspen,
This research was fundedby NIDDR as part of the RERC on Aging at the
State University of New York at Buffalo.
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