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Chapter 3: Assessment of Existing NeedsMost Important Problems This chapter presents the assessment of the existing needs of Idahoans with disabilities. First discussed are the statewide survey results involving general needs, including the most important problems, social and support opportunities, transportation, health insurance, public access, personal financial resources, public services, and government responsiveness. The chapter then discusses the effects of demographic factors in order to determine the specific types of needs for different types of Idahoans. Next an assessment of the supplemental interviews completed by the Idaho Centers for Independent Living is presented. The chapter concludes with a summary of Idahoans with the greatest needs. MOST IMPORTANT PROBLEMS The survey asked each respondent "What is the most important problem that you face?" Their answers were then coded into categories. Respondents most frequently listed personal coping or independence problems and the lack of personal financial resources as their most important personal problem. Many responses actually used the word independence, while others were equally clear, such as "not feeling in control." Personal coping and independence problems also included low self-esteem, consequences of a disability (such as not being able to drive or walk), and emotional difficulties (such as loneliness, isolation, stress, or depression). Responses that mention not being able to pay for things other than health care insurance were coded as personal finance problems, for example, "not being able to afford a new roof." Responses that indicated adequate health care was hard to find or that there were problems with health insurance (including its cost) were coded as health care problems. Responses that specifically mentioned difficulty paying medical bills were coded as personal financial problems. Respondents also were asked: "What is the most important problem facing people with disabilities?" This question elicited a different pattern of responses. Personal coping and independence problems remained the most frequently cited, but that understanding and respect moved from the third least frequent to the second most frequent response. Many of the responses coded in this category specifically mentioned discrimination. SOCIAL AND SUPPORT OPPORTUNITIES Most respondents appear to have adequate social and support opportunities. Nearly 90 percent agreed or strongly agreed that they had social opportunities available. Over 80 percent of respondents believed that recreational opportunities were available. Only one-third of respondents say it is likely or very likely that they would participate in a support group with other people with disabilities Over three-quarters of those interviewed agree that adequate housing is available. Over 60 percent of those surveyed agreed that affordable housing is available. However, nearly twice as many people disagreed that affordable housing was available as those who disagreed that adequate housing was available. Respondents tended to take opposing stands on how well their transportation needs were being met. Whereas almost sixty percent of those interviewed agree that transportation services in their communities meet their needs, over thirty percent disagreed. Most survey respondents appear satisfied with their health insurance. Over 60 percent agreed that their health insurance is flexible enough to cover services and equipment. 66 percent agreed that their health care coverage adequately meets their needs. In general, the survey respondents feel positively about public access issues. Over two-thirds of respondents agreed that parking spaces and curb cuts are adequate. 60 percent of respondents agreed that city streets and sidewalks provide safe and easy access. Over 80 percent feel that public buildings are easily accessible. There is less agreement with the extent to which laws establishing designated parking spaces for people with disabilities are enforced. As many respondents disagreed as agreed with the proposition that the parking laws are adequately enforced. PERSONAL FINANCIAL RESOURCES As discussed earlier, the lack of financial resources was the most important personal problem for 22 percent of the respondents, more frequently cited than all other problems with the exception of personal coping and independence. Unfortunately, the survey did not contain many questions that addressed personal financial resources. Over 60 percent of the respondents agreed that resources are available to help purchase special equipment. The survey results show that most respondents believe that useful educational services are available to them. Nearly 80 percent agreed with the survey statement. Nearly 60 percent of respondents agreed they receive good job training. Only slightly more than one out of ten have received any vocational rehabilitation. However, more than 60 percent of those who have received vocational rehabilitation believed that the counselors adequately addressed their needs. Only 2.8 percent reported that they had used the services of a Center for Independent Living. Of those who have used the services, three-fourths agreed that their needs were adequately addressed.. Nine out of ten of those who used Center for Independent Living services agreed that the services were helpful. About 45 percent of those interviewed say they have visited a health care provider, social service agency, or other public agency to obtain services related to their health condition. Over eighty percent felt that the health care providers understood their disability and needs. In contrast, only two-thirds believed that social service providers understood their disability and needs. Even fewer respondents (62 percent) agreed that public agency providers understood their disability and their needs. GOVERNMENT RESPONSIVENESS Other responses reveal how well different levels of government in Idaho meet their needs as persons with disabilities. For each level--city, county, and state--only a bare majority agreed that these needs have been met. 54.5 percent agreed that local city government meets their needs. 53.5 percent believed that county government meets their needs. 53.7 percent believed that state government meets their needs. DEMOGRAPHIC AND REGIONAL DIFFERENCES Effects of Region The effects of the region of the state were examined for all questions concerning needs. No consistent pattern of regional effects was found. In a few instances region had a weak effect although even in those instances the effect did not reach traditional levels of statistical significance. Most importantly, even in those instances where there were weak effects, they did not form a consistent pattern either along a rural to urban dimension or for specific areas of the state. In those few instances where region appeared to have a weak effect, Regions One through Three appeared to be slightly different than Regions Four through Six. For example, Regions One through Three were slightly less satisfied with city and county governments. However, there was no difference on state government. Respondents in Regions Five and Six were slightly less likely to agree that health care providers understood their needs than those in Regions One through Four, but there was no difference on attitudes toward social service and public agency providers. Respondents in Regions One through Three tended to report less satisfaction with transportation services than those in Regions Four through Six, and those in Regions Four through Six were slightly more likely to be interested in support groups than those in Regions One through Three. Many observers believe that transportation services are less satisfactory in rural areas than in urban areas. As measured by region of the state, this survey does not support that contention. There are at least two possible reasons for this. First, it may be that even though there are more transportation services in urban areas than in rural areas, they are not deployed in a manner that meets the needs of Idahoans with disabilities. Thus, more is not necessarily better in the eyes of people with disabilities. A second possibility is that region may not be a sufficiently precise measure of the rural to urban dimension. Even within Ada County there are both highly rural and highly urban areas. Kuna is not the same as Boise. Within regions the blending of rural and urban areas is perhaps even more extreme. Gem County is not the same as Ada County. Self-Efficacy and Independence Effects The effects of each of the measures of the extent to which a person believed themselves to be independent were examined for all questions concerning needs. One problem with measuring the extent to which people identify with the independent living philosophy is that they may actually act independently but may have never heard of the independent living philosophy. Two approaches were taken to measuring independence. The first approach was based on the idea that what is meant by living independently is similar to what sociologists have termed self-efficacy. The concept of self-efficacy means the extent to which people believe they have the ability or the efficacy to handle the problems that emerge in life and that their actions are the deciding factor in what happens to them. That is, they do not believe in luck or fate. A set of questions has been developed by sociologists to measure the extent to which people believe themselves to be self-efficacious. As discussed in Chapter 1, the Center adopted a subset of those questions as a way to develop a measure of one dimension of independence. The scale was composed of five items that asked respondents which of a pair of statements they most agreed with. Each of the five pairs of statements included one that indicated a belief in fate or luck and one that indicated a believe in self-reliance or self-efficacy. The Center analyzed these items separately and as a single index. The self-efficacy questions and the overall self-efficacy index was consistently associated with a positive outlook across all variables. However, it was not the best predictor of a positive outlook. The second method of measuring the extent to which respondents believed themselves to live independently was to provide respondents with a definition of independence and then ask them the extent to which they believed they lived independently. The extent to which respondents reported living independently was strongly associated with the extent to which the respondents were self-efficacious. Indeed, the independent living question was an even stronger predictor of positive attitudes than the self-efficacy questions. The extent to which respondents reported living independently was consistently related to virtually all of the survey questions. The more independently a respondent reported living, the more likely they were to agree that parking is adequate, parking laws are enforced, streets are safe and accessible, buildings are accessible, good job training is available, all levels of government meet their needs, their insurance is flexible and the coverage adequate, service providers understand their disability, social, recreational, and educational opportunities are available, personal resources are adequate for purchasing equipment related to their disability, and that adequate and affordable housing is available. Conversely, the less independently a respondent reported living, the more likely they were to have visited a health care provider, the more likely they were to have received vocational rehabilitation, and the more they were interested in support groups. Effects of the Significance and Type of Disability The foregoing shows that, while Idahoans who qualified for the survey under one or more of the screening questions tend to feel positive about life, the degree to which respondents believe themselves to be independent and self-efficacious are important factors that differentiate between those who feel relatively more or less positive about most things. In order to further differentiate between those who feel relatively more or less positive, the Center sought to find a way to examine the effects of the significance of the disabilities the respondents reported. As in any survey, the most frequently occurring characteristics of the target population are the ones that are most frequently represented in the survey results. It can be expected that many of the survey respondents have disabilities that are not highly significant. The views of these respondents may overshadow those of the respondents with relatively more significant disabilities. In order to examine this possibility, Center staff created an index of significance from the 12 separate questions on the survey that were constructed from the four Census questions. The Census asked people whether they had a health condition that (1) limited the amount of work they could do, (2) prevented them from working at a job, (3) made it difficult for them to leave their home, and (4) made it difficult for them to take care of their personal needs. For each of these questions respondents were asked whether the condition had lasted more than 6 months and whether it had lasted more than 12 months. This resulted in a total of 12 questions to which the respondent could answer "yes" or "no." The index was created by assigning a significance score equal to the number of "yes" responses. Thus each respondent received a score that could vary from zero to 12. According to this index, significance was highly associated with both self-efficacy and the degree to which respondents reported living independently. That is, the higher the significance score, the less self-efficacious and the less independent the respondent. Not surprisingly, the higher the significance score the less positive the respondent's outlook for all types of need. Across all attitudes related to need, significance was strongly associated with a positive outlook slightly less often than the degree of independence. In some instances, however, significance was more strongly associated. One area where significance was more strongly associated than perceived independence was whether a respondent reported receiving vocational rehabilitation. This is understandable: The more significant the condition, the more likely it is that a person would seek vocational rehabilitation. However, when the reported extent to which vocational rehabilitation addressed the respondents needs is examined, the strength of the association is reversed. Perceived independence is more strongly related to satisfaction with vocational rehabilitation than is significance of condition. That is, controlling for significance, people with low perceived independence are still less convinced that vocational rehabilitation addresses their needs than those with higher perceived independence. Controlling for perceived independence, there is no tendency for more those with more significant conditions to be less satisfied with vocational rehabilitation than those with less significant conditions. One final analysis performed by the Center was related to the type of the disability reported. Since the degree of independence, disability significance, and self-efficacy were strongly associated with overall outlook, it was important to determine whether some of the screening questions were more strongly associated with independence, significance, and self-efficacy. Most of the types of reported conditions that may qualify respondents as having a disability were not strongly related to all of the three critical variables. Only mobility and brain trauma disabilities were consistently more likely to be highly significant, low on self-efficacy, and low on independence. Several other reported types of disabilities were highly associated with one or two of the three key variables but not to all. For example, respondents who reported being blind were much more likely to be less independent, but they were not less likely to be self-efficacious, and they were not more likely to have high significance scores. Some disability conditions, such as deafness, that might be expected to be strongly related to significance, self-efficacy, or independence were not strongly related to either of the three. This analysis of the type of condition reported suggests that independence and self-efficacy are not determined by the physical condition. There is a substantial mix of people with any given condition, some who are highly independent and self-efficacious and some who are not. All three variables (independence, self-efficacy, and significance) taken together are only slightly better at predicting the attitudes of respondents than the perceived degree of independence alone. The reported degree of independence was the strongest predictor of positive outlook regarding the extent to which needs are met of all variables in the survey. Effects of Other Demographic Factors Other demographic variables measured included age, employment status, gender, race and ethnicity, and type of insurance. Some important effects were found for each of these variables, and together they help form a more complete picture of the needs of Idahoans with disabilities. Age was not consistently related to attitudes about needs, although as expected it was related to other important demographic variables. Employment Status. The employment status of the respondent was strongly associated with self efficacy. Underemployed respondents had the lowest reported self-efficacy, even lower than those who reported being completely unemployed. The difference between part-time employment and underemployment is that part-time employment means that respondents have the level of employment they want, whereas underemployment implies that the respondent would like to work more. Respondents who reported being employed full-time reported the highest self-efficacy, followed by those who were employed part-time and those who were self-employed. Employment status was also strongly associated with the significance of the reported condition in the same manner as it was with self-efficacy. Although employment status was strongly associated with independence, the pattern of association was different. Student respondents reported the lowest degree of independence, followed by unemployed and then underemployed respondents. As expected, employment status was also associated with age. Retired respondents had the highest mean age (71 years) and students had the lowest mean age (18 years). Respondents who reported being employed full-time and those that reported being unemployed had the same mean age of 39 years. Similarly, those respondents reporting unemployment or underemployment were the least likely to agree that good job training was available, whereas those respondents who reported full- or part-time employment were the most likely to agree that good job training was available. The likelihood of receiving vocational rehabilitation was also associated with employment status but with a slightly different pattern. Those who reported unemployment or part-time employment were the most likely to have received vocational rehabilitation. Those reporting full-time employment were the least likely to have received vocational rehabilitation. Unemployed respondents were the least likely to report satisfaction with all levels of government, while underemployed espondents reported the lowest level of satisfaction with the flexibility and the coverage provided by their health insurance. Those respondents reporting that they were self-employed or students were the least likely to agree that public agencies understood their disability. Employment status was not related to whether health or social service providers understood their disabilities. Underemployed respondents were least likely to agree that recreational or educational opportunities are available or that housing is affordable, while unemployed respondents were the least likely to agree that they had sufficient resources to purchase needed equipment related to their disability. Employment status was strongly associated with the first type of insurance the respondent reported, although the pattern of association was the more complicated. Respondents who reported self-, full-, or part-time employment were the most likely to have private insurance, while those who were unemployed or retired were the least likely. Unemployed and retired respondents were the most likely to have Medicaid or Medicare. Interestingly, in addition to those who were unemployed, respondents who reported self-employment were the most likely to have no insurance. Employment status was not related to any of the other attitudinal questions in the survey. It is not a strong predictor of an overall positive outlook, unlike degree of independence, self-efficacy, and significance of disability. Gender. The gender of the respondent also had strong effects, although it was not a strong predictor of overall outlook. Surprisingly, women reported being somewhat more independent than men, but somewhat less self-efficacious; this despite the fact that independence and self-efficacy are themselves strongly associated. The tendency for women to feel less self-efficacious than men is a little stronger than the tendency for women to report more independence than men. Women were more likely than men to visit health care providers and to believe that public agencies understood their needs. They were also less likely than men to believe they had adequate recreational opportunities or that they had adequate personal resources to buy equipment related to their disability. In addition, women were most likely to have Medicaid or Medicare and were equally likely to have private insurance or no insurance. They were also least likely to list veterans benefits or workers compensation insurance as their first type of insurance. It is perhaps not surprising that respondents who reported being homemakers were exclusively women. However, it is important to note that the average age of those women reporting being homemakers was substantially above the mean age of all women. This suggests that the homemaker status is in decline and that younger women no longer adopt the homemaker role. Similarly, those who reported being retired were predominantly men. It is likely that this too will change dramatically in the next decade. Race and Ethnicity. The race and ethnicity of the respondent was related to some important variables. In general, Native Americans, African Americans, and the "other" group tended to be less positive in outlook than others. However, the effects were not strong and they do not form a consistent pattern. For example, Native Americans and the "other" group were least likely to agree that parking is adequate, that buildings are accessible, and that health care providers understand their needs. However, African Americans joined Native Americans and the "other" group in being more likely not to agree that job training was adequate. Only African Americans were more likely to report that adequate and affordable housing was unavailable. Only Native Americans were more likely to report that recreational opportunities were unavailable. African Americans and the "other" group were more likely to believe that transportation services were inadequate. Native Americans were the least likely to report living independently and had the highest reported significance scores. On balance, the "other" group was most likely to have a more negative outlook than the rest. In addition to those needs just discussed, the "other" group was more likely to believe that social services and public agencies do not understand their needs and that social and educational opportunities were unavailable. Breaking the pattern observed previously, Native American and Hispanic respondents were more likely to have received vocational rehabilitation than others, while the "other" group reported the lowest significance scores. Race and ethnicity was also related to age: The "other" group had the highest mean age, while Hispanic respondents had the lowest. Race and ethnicity were not related to self-efficacy or employment primarily due to the small sample sizes. However, Native Americans were much more likely to be unemployed than others. Type of Insurance. The type of insurance the respondents reported first was not strongly related to outlook, although there was a slight tendency for respondents who reported having private insurance to have a more positive outlook and for those with other or no insurance to have a less positive outlook. For example, people with private insurance were most likely to agree that parking is adequate and that good job training is available. Respondents with other or no insurance were least likely to believe that city governments meet their needs, that health care providers understand their needs, that social opportunities are available, and that adequate and affordable housing is available. Respondents with Medicaid were least likely to believe that Centers for Independent Living were helpful, yet respondents with Medicaid or Medicare were most likely to report that county and state governments met their needs and those with veterans benefits were least likely to report that they had adequate recreational opportunities. The type of insurance does differentiate between respondents on some important dimensions. Respondents reporting Medicaid or veterans benefits as their first type of insurance were most likely to have received vocational rehabilitation. Those with private insurance, Medicaid, or Medicare were more likely than those with workmen's compensation, Veterans Benefits, or other insurance to visit a health care provider, and to agree that their insurance provided adequate flexibility and coverage. The analysis of health insurance provides important clues to understanding the possible factors that may account for a person believing that they live independently. First, people who reported having private health insurance as their first type of insurance were much more likely to report living independently, while people who reported having Medicaid or Medicare were less independent. Further, the type of insurance reported first was strongly related to significance and self-efficacy. Respondents with private insurance had the lowest significance scores, while those with Medicaid or Medicare had the highest. Respondents with Medicaid had the lowest self-efficacy, while people with private insurance or no insurance had the highest. SUPPLEMENTAL INTERVIEWS CONDUCTED BY As discussed in Chapter 1, one issue that was discussed in designing the survey methodology was the ability of a general population survey to reach minorities and people with relatively more rare types of disabilities. In any general population survey, respondents with the most prevalent characteristics will be most often represented in the survey. Although this is appropriate for a statewide needs assessment survey, it still means that very few of some types of Idahoans will be reached. In order to collect additional data on relatively rare types of Idahoans, the four Centers for Independent Living together completed 103 supplemental interviews. These interviews do not represent a statistically valid sample. Their purpose was to provide additional qualitative information about Idahoans with relatively rare characteristics. A comparison of the results of these interviews with those of the general population survey showed that the general population survey was highly successful. Every type of Idahoan represented in the 103 supplemental interviews was found in the general population survey, with the exception that the general population survey did not identify anyone who reported tribal or Indian health services as their first reported type of insurance. In the 103 supplemental interviews, two respondents reported tribal or Indian health services as their first type of insurance. As expected, the respondents in the supplemental interviews reported more significant disabilities, less independence, and less self-efficacy than the respondents in the general statewide survey. As would be predicted on the basis of the results of the statewide survey, the 103 supplemental respondents were less positive in outlook than the average in the general population survey. Their responses were consistent with the level of significance, dependence, and self-efficacy reported. That is, people in the general survey who reported similar levels of significance, self-efficacy, and independence had similar outlooks regarding needs. The respondents in the supplemental interviews were more likely to receive services, more likely to be interested in support groups, less likely to report private health insurance as their first reported type of insurance, more likely to report Medicaid or Medicare as their first insurance, less likely to believe their health insurance is sufficiently flexible or provides adequate coverage, and less likely to report full-time employment. Once again, the views of the respondents in the supplemental interviews were similar to those in the general population survey with the same characteristics. CONCLUSIONS: IDAHOANS WITH THE GREATEST NEEDS The survey results suggest that, while there are no areas of strikingly unmet need for people with disabilities in the state, some Idahoans with disabilities have substantially greater degrees of unmet need than others. Persons with greater unmet needs are those with more significant disabilities, those with lower perceived independence and self-efficacy, those lacking private health insurance, minority group members and women, and unemployed and underemployed Idahoans. Results of the survey indicate that in many ways the needs and concerns of Idahoans with disabilities parallel those of Idahoans in general. Idahoans with disabilities who have low perceived independence tend to have more unmet needs and use more services in all areas examined than those with higher perceived independence. This raises a chicken-and-egg question about causality: Do higher levels of perceived independence and self efficacy enable people to better meet their needs and so require fewer services, or do people with less significant conditions whose needs are met require fewer services and so perceive themselves to be more independent? The finding that the level of perceived independence is strongly associated with a positive outlook about unmet needs more often than any other factor measured suggests that, in spite of other important factors such as significance of the condition, some people have learned ways to more effectively reduce the environmental barriers that produce dependence than others. This conclusion, upheld in other studies, would support the view of the independent living movement that a combination of system changes to reduce objective barriers to independence and self-help strategies to raise the level of coping skills are called for. |
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