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Enabling Home Environments: Identifying Barriers to Independence

Conclusions

Our findings suggest that methods of measuring environmental barriers deserve more research attention. Self report data on the presence of barriers to independent living do not provide an accurate picture of the actual situation in the home. For greatest reliability, it is best if skilled specialists conduct assessments through interview and inspection. However, reliable self report screening techniques could facilitate the assessment process. They would be useful in doing local needs assessments for program planning and large scale survey research for policy development. Our data indicates that the conventional focus in home assessments on ADL issues should be expanded to include other types of barriers like behavior problems, security, fire safety and construction issues.

Both use of stairs and use of bathtubs and showers lead the list of frequent ADL barriers. But our grouped data suggest that the use of tubs and moving around the home is a more common problem than using stairs. Problems using the toilet were less prevalent but still frequently observed. Problems using appliances and furniture were two other categories that were very common. The former was also rated as a high priority. Frequency of problems was not always associated with high priority ratings. Participants gave a high priority to use of tub/shower, but they also rated using the telephone, appliances and the toilet highly and did not rate using stairs as high. Many shelter related concerns were also rated as high priorities but those that were observed most frequently were not.

The data on priorities raise some interesting questions. Why are only a few ADL barriers rated high? What accounts for the comparatively higher ratings for Fire Safety and Construction issues? Why aren't Security concerns rated more highly?

From a cost-benefit perspective, interventions are valued if th eir benefit outweighs the cost compared to other alternative methods of coping. Many ADL and Behavior problems could be perceived as conditions one has to live with in old age. Physical interventions usually cost money and effort to implement. If one can adapt to a barrier by changing behavior, there is no cost involved at all. Climbing stairs and moving around one's home,for example, can be avoided by reducing one's activity level to a point where the limitation is tolerable. But this is not as easy to do for activities like bathing, toileting, cooking and telephone communications. Perhaps our sample gave higher priority ratings to those barriers for which avoidance strategies cannot be used as easily for adaptation.

A risk assessment model provides another perspective. The perceived risk associated with some barriers may be greater than with others. This perspective is particularly applicable to the Security and Fire Safety barriers. The sample seemed little concerned with security other than having good locks, doors and windows. This finding may be due to the generally suburban makeup of the sample. However, how important would a younger and healthier sample rate barriers such as lack of escape planning and unmarked valuables? As important as these issues may be for fire safety, the general population probably would agree with this sample on priorities. We might expect age and disability to significantly change assessment of risk. The frequency of ADL and Behavior problems can be attributed to age related changes in health. But, from a psychological perspective, many of these problems may not be perceived as a serious risk. Perhaps by searching for and identifying all these "barriers" we are simply reinforcing a "misery perspective" of aging (Tornstam, 1992) that is not shared by older people themselves.

A third perspective is based on a cognitive dissonance model. The participants could view some problems as unsolvable and lower their expectations in order to accept the unresolved situation more easily. For example, eliminating a barrier like "difficulty using stairs" is very expensive and beyond the means of many people in the sample. As another example, the problem of forgetfulness may seem impossible to solve. Priorities assigned to the interventions for these problems are low because expectations for implementation are low. The effectiveness of our recommendations related to such barriers may be perceived simply as "wishful thinking."

A fourth explanation is based on a social construction perspective. Accepting the need for an intervention is a"reconstruction" of self image. It is an acknowledgment to others (the interviewer) that the individual can no longer function effectively without adjusting their relationship 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."

Very few of our recommendations for the ADL and Behavior barriers were rated as high priorities. Yet, if participants ranked an item high and saw that effective action could be taken, they did. Thus, five of the eight people who ranked using the bathtub/shower as a high priority did something about it. This suggests that increasing awareness about the effectiveness of interventions should be a major priority for home modification programs. This could be accomplished in a variety of ways, for example, loaning assistive technology and a demonstration center on home modification where people could try out "barrier free" environments.

Our experience indicates that a micro-analysis is necessary to understand the relative importance of specific barriers. What may be unimportant to a couple living in a safe suburban neighborhood in their post World War II home may be extremely important to a single person living in a rented flat in a high crime neighborhood. Furthermore, the experiences of a lifetime and expectations for the future will play major roles in how each household establishes priorities for coping. Quantitative data is useful to find broad patterns but qualitative data is important to understand the realities of environmental barriers and the meaning they have to each individual. The qualitative approach will also be useful for obtaining an in-depth understanding of the decision making process used to establish priorities and implement changes. Perhaps it will shed some light on the validity of the various alternative explanations above.

 
 
 
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New York-Presbyterian. The University Hospitals of Columbia and Cornell