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RESEARCH ARTICLE |
a Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
b Department of Economics, Brown University, Providence, Rhode Island
c School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
Susan M. Allen, Center for Gerontology and Health Care Research, Brown University, Box G-B213, Providence, RI 02912 E-mail: Susan_Allen{at}Brown.edu.
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Abstract |
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Methods. The authors analyzed data collected from 9,230 respondents to the Adult Followback Survey of the Disability Supplement to the 1994 and 1995 National Health Interview Survey (NHIS-D) who reported both mobility and limitations in daily living activities to test study hypotheses, using regression analyses to control for selection effects in mobility equipment use.
Results. Use of canes and crutches (but not walkers and wheelchairs) reduced both formal and informal hours of care received per week by sample members; there was also evidence of substitution on the individual activities of daily living task level. Use of canes and crutches was also associated with lower out-of-pocket costs for formal helping services.
Discussion. Findings suggest that canes and crutches are effective and efficient home care resources that have the potential to increase the autonomy of adults with disabilities and to facilitate chronic condition self-management.
Asubstantial body of research has shown that the family is the mainstay of people who require supportive assistance to remain at home (Messeri, Silverstein, and Litwak 1993
; Peters, Hoyt, Babchuk, Kaiser, and Iijima 1987; Stone, Cafferata, and Sangl 1987). Formal home care services are used in the absence of family or as a supplement to family care when needs exceed the helping capacity of the informal system (Chappell 1985; Hanley and Wiener 1991; Noelker and Bass 1989). However, researchers are only beginning to examine how assistive technology may modify the role of formal and informal care systems. In this research, we investigated the use of mobility equipment as a third helping resource to adults with chronic mobility and personal care impairment. Specifically, we examined whether use of mobility equipment can reduce the amount of human assistance received in the performance of daily activities, and we also examined whether use of mobility equipment results in out-of-pocket cost savings associated with use of formal home care services.
The conceptual framework that informed this research was that of the disablement process (Verbrugge and Jette 1994), a sociomedical model of disability that describes the potential of human and technological intervention to mitigate difficulty in task performance. This model conceptualizes disability as a gap between the task performance capability of the individual (intrinsic disability) and the demands of the environment. The model further describes the opportunity for various interventions that may be effective in reducing environmental demands to improve person/environment fit, thus reducing or avoiding "actual disability," the task performance capability of the individual supported by interventions. We focused on two such interventions: personal assistance (both formal and informal) and equipment designed for the mobility impaired (i.e., wheelchairs, walkers, crutches, and canes).
Because mobility equipment is generally an infrequent expense, substituting such aids for home care services may substantially increase the efficiency of home care delivery. Furthermore, a need for assistive technology may be viewed as a lesser form of dependence than a need for human assistance, in that the former increases the autonomy of adults with disabilities and facilitates chronic condition self-management.
In the following sections we briefly review research conducted to date on the interaction of formal and informal human supports to people with chronic care needs as well as research examining the cost effectiveness of community-based long-term care. We then review the limited but promising research that addresses the use of assistive technology.
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Formal and Informal Care |
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; Moscovice, Davidson, and McCaffrey 1988). When formal services are utilized, informal caregivers do not withdraw their assistance. Even when individuals become severely disabled, the literature suggests that family members will continue to assume primary responsibility for care (Hanley, Wiener, and Harris 1991). When substitution of formal for informal care does occur among functionally disabled elderly persons, it is primarily due to the limited availability of informal care (Tennstedt, Crawford, and McKinlay 1993). Further, such substitution represented a temporary situation, rather than a permanent replacement for informal assistance.
Correlates of formal service use reported in the literature are older age; female gender; White, non-Hispanic ethnicity; not being married; having less access to informal care; more severe impairment; and coverage by Medicaid insurance (Hanley and Wiener 1991; Houde 1998; Munson 1999; Stoller and Cutler 1993). Tennstedt and colleagues found that living alone is the strongest predictor of reliance on formal care and that level of impairment or frailty is a predictor of formal service use only for those who live alone (Tennstedt, Sullivan, McKinlay, and D'Agostino 1990). Elderly persons who reside with their caregiver, particularly their spouse, are unlikely to use any formal assistance regardless of their level of frailty. However, more recent findings suggest that family members other than spouses may be supplementing their caregiving efforts with formal care as they juggle work and family responsibilities (Langa, Chernew, Kabeto, and Katz 2001). Thus, it is expected that both demographic and social trends will result in increased demand for alternative models of home support that decrease reliance on family care.
Informal care is assumed to be preferable to formal assistance as a home care resource (Litwak 1985; Penning 1990). However, investigations of problematic social support have indicated that some caregivers overprotect family members, with negative consequences to the care recipient. For example, Monteiro 1990 found that help and social support available to women during recovery from myocardial infarction actually deterred their return to pre-myocardial-infarction activity levels. Similarly, a study of stroke patients revealed that overprotection by caregivers was predictive of higher levels of depression and negatively related to motivation to recover (Thompson, Sobolew-Shubin, Graham, and Janigian 1989). A different scenario that may have similar consequences is one involving a strained relationship between caregiver and receiver (Allen, Goldscheider, and Ciambrone 1999). Further, younger people with impairment oppose both medical (agency-based) and informal support models of home care because they undermine the autonomy of the individual (DeJong, Batavia, and McKnew 1992). Finally, as projections of need for long-term care escalate, the costs of care are a major concern to public payers and to families alike.
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Cost Effectiveness and Community-Based Care |
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; Kemper, Applebaum, and Harrigan 1987). Programs that target people at high risk for nursing home placement have been more successful, although findings generally indicate small savings or cost neutrality (Greene, Ondrich, and Ladika 1998; Kemper et al. 1987; Skellie, Mobley, and Coan 1982). More promising are the cost savings associated with the capitation of long-term care services in combination with acute care (Riley and Mollica 1996).
However, it is clear from research conducted to date that a substantial amount of services is required to keep elderly people with disabilities in the community and that family members are the greatest protection against the public costs of community care. The combined paid and unpaid caregiving costs to families are considerable, with annual estimates ranging from $10,000 to $20,000, depending on the nature of the population requiring care (Given, Given, and Stommel 1994; Harrow, Tennstedt, and McKinlay 1995; Stommel, Collins, and Given 1994). Out-of-pocket costs associated with formal home care may be prohibitive for many patients and families (Liu, Manton, and Liu 1985).
In this study we investigated whether assistive aids, an understudied source of help vis-à-vis informal and formal care, may be preferable as a substitute for human help, by allowing those in need to reduce environmental demand with maximum autonomy and efficiency, thus reducing public and family burden alike.
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Technical Aids |
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). On the other hand, reliance on personal assistance only decreased during a comparable time period (1982–89) as more severely impaired individuals (e.g. those with five to six activities of daily living [ADL] needs) began to supplement their personal care with technical aids (Manton, Corder, and Stallard 1993). There appears to be substantial unmet need for technical aids; poor people both use more technical aids and report more unmet need. Financial barriers are most often cited by those who report unmet need (LaPlante, Hendershot, and Moss 1992).
Findings from research on the National Survey of Self-Care and Aging support the notion that people use technology to supplement, rather than substitute for, human help at the more severe levels of disability and indicate that disabled persons use aids more often to assist with mobility and ADL care than with instrumental activities of daily living (IADL) care. Results also suggest that elderly people who live alone are more likely to use technical aids and home modifications to minimize the effect of functional limitations than people who reside with family and/or friends (Norburn et al. 1995). Thus, people with impairment who live alone appear to be unique in their patterns of care and offer some validity to the hypothetical substitutability of technical assistance for human help.
Verbrugge, Rennert, and Madans 1997 examined the efficacy of human and technical assistance in reducing difficulty with daily living tasks. They found that although difficulty with activities diminished with both types of assistance, respondents using equipment only had the best chances of improvement, whereas those relying on personal assistance only had the lowest chances of improvement. Among this sample there appears to be a hierarchy of preference wherein people use equipment first, then if equipment is inadequate they seek personal assistance. Similarly, on the basis of analyses of data collected from a national sample of community-dwelling persons aged 70 and older, Agree 1999 reported that people with disability who use equipment only to perform ADLs report less residual difficulty than people who use personal assistance, whether alone or in combination with special equipment. The efficacy of equipment used alone was observed to decrease with increasing levels of impairment severity, however.
Similarly, analyses of Phase II of the 1994–95 NHIS-D revealed that people with disability who use simple assistive devices (e.g., canes) are less likely to use informal care, whereas people who use complex devices such as wheelchairs are more likely to use them as a supplement to formal care (Agree and Freedman 2000). Because equipment complexity is typically a function of disability severity, these findings mirror Agree 1999 earlier findings suggesting that opportunities for substitution are most likely at lower levels of disability severity.
In summary, research conducted to date has suggested that formal care is often used in the absence of or as a supplement to family care, whereas technological assistance has promise as a substitute for human assistance, particularly at lower levels of disability. However, research on technological assistance is in the early stages and has been limited by a lack of specificity in the types of equipment studied, in lack of control for selection effects in the use of technological equipment, and in a narrow definition of what constitutes substitution. Specifically, the research focus has been confined to whether or not use of aids is negatively related to receipt of any human help; the potential for reductions in levels of human help has been ignored. Finally, although cost saving associated with technological assistance has been assumed (Agree and Freedman 2000), empirical data that substantiate this assumption in regard to mobility equipment have not been presented.
In this study we focused on the substitutability of mobility equipment for human help, including complete substitution (i.e., are people who use mobility equipment less likely to have a caregiver?) and partial substitution (i.e., do people who use mobility equipment have fewer hours of human help? And do people who use mobility equipment require human help with fewer tasks?). We hypothesized that use of mobility equipment partially substitutes for human help, given prior research indicating that substitution tends to be task specific (Agree and Freedman 2000). We controlled for severity of functional limitation, the availability of human help, and other indicators of selectivity in the use of mobility equipment. We also hypothesized that substitution of equipment for human help would result in lower out-of-pocket costs for formal helping services.
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Methods |
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Analytic Sample
As discussed previously, selection into the DFS was based on a wide variety of indicators of disability; hence the sample was heterogeneous in its health-related characteristics. Given that research in the area of assistive technology and its relationship to human assistance is in its infancy, we thought it best to work with a relatively homogenous sample, preferably one in which use of technological equipment is fairly well understood. For example, people who are blind may use their canes differently from people who have mobility limitations; thus, we decided it was best not to mix these populations.
We therefore selected our analytic sample on the basis of mobility limitations. Specifically, we used three indicators of mobility limitations as eligibility criteria for sample selection: difficulty walking a quarter mile, difficulty walking up 10 steps, and difficulty standing for 2 hr. A total of 12,814 respondents, virtually half the DFS sample (49.7%), met at least one of these criteria, and nearly half of those eligible (47%) met all three. The analytic sample was further limited to respondents who reported difficulty with at least one ADL or one IADL, because data on formal and informal assistance were collected only from respondents who reported any such difficulty. Application of these additional criteria resulted in a final analytic sample of 9,230 respondents.
The three indicators of mobility limitations on which this sample was selected captured fully 95% of all respondents to the DFS who used any mobility equipment and 92% of DFS respondents who reported any ADL or IADL difficulty. Thus we believe that we have included the vast majority of DFS respondents for whom this research is relevant.
Measures
We used four dependent variables in regression analyses to test study hypotheses. Following the assessment of ADL and IADL limitation (difficulty in performance) and dependency (receipt of help), respondents who indicated any source of human help were asked who helped, and information was obtained for each helper named, to a maximum of four helpers. Respondents were asked which ADL/IADL activities each helper helped with, the number of days in the 2 weeks preceding the interview that help was provided, and the number of hours of help provided per day that help was received, on average. From these data, dependent variables were created. First, two dichotomous indicators of receipt of any help were created, one indicating any formal (paid) help, and the second any informal help.
Next, interval variables representing total hours of formal care received per week and, separately, total hours of informal care received per week were created. The average number of hours of care provided per week in the 2 weeks before the interview was calculated for each helper. We then derived the total hours of formal care received per week by adding together the hours of care associated with each formal helper and dividing by two. We performed a similar calculation to derive total hours of informal care received per week.
Approximately 17% of the sample members were missing data on hours of care. We reclaimed 319 cases by imputing hours of care for respondents who had complete hours data for at least their primary helper but missing hours data for secondary helpers. In these cases the median number of hours for the helper in question (second, third, or fourth) was imputed. Analyses we performed to determine bias associated with the remaining cases (14% of sample) excluded because of missing data on hours of care revealed few differences in the characteristics of respondents included and excluded from these analyses. Excluded cases were more likely (p < .05) to be men, to live with someone, to be married, and to have greater severity of mobility impairment. There were no differences by age, race, educational status, insurance status, mobility equipment use, or other indicators of illness severity (i.e., number of conditions, hospitalizations, or ADL and IADL difficulties).
A third dependent variable was created from these data indicating the number of ADL activities (bathing, dressing, eating, toileting, transferring, walking, getting outside) and, separately, number of IADL activities (preparing meals, shopping, managing money, using the telephone, doing heavy housework, doing light housework, getting to places outside of walking distance, and managing medication) for which help was received in the previous 2 weeks.
Finally, an indicator of yearly out-of-pocket costs associated with use of formal services was calculated. Cost data were collected in the context of ascertaining the previous year's use of a range of services that may be required by a person with disabilities. Information about each service used was gathered, including out-of-pocket costs that were not or would not be reimbursed by insurance mechanisms. Out-of-pocket costs were totaled across four services most relevant to the provision of daily living assistance, including services from a personal care attendant (other than a family member or friend), services from a center for independent living, and services from an adult day care center or day activity center, and transportation services. Visiting nurse services were not included in these analyses, because the tasks performed tend to be medical rather than supportive. Although homemaker and home health aide services are also relevant to assistance with daily living tasks, these services were not included in the section of the interview that ascertained out-of-pocket costs and thus are not included here.
The key independent variables for these analyses were four types of mobility equipment: canes, crutches, walkers, and wheelchairs. Dichotomous (1,0) indicators of use in the past 2 weeks were created. Respondents who did not use any mobility equipment, 65% of the sample, were the reference group. Our main hypothesis was that mobility equipment would substitute for both formal and informal human help and thus have a negative relationship with all outcome variables. However, on the basis of past research in this area (Agree 1999; Agree and Freedman 2000; Verbrugge et al. 1997), we expected this effect to be confined to equipment used at lower levels of disability severity, that is, canes and crutches.
In addition, we identified factors associated with increased likelihood of mobility equipment use in this sample using regression analyses, including age (older), gender (male), race (Black), education (greater than high school), living arrangement (alone), marital status (not married), level of impairment (more severe), and type of health care insurance (Medicare, Medicaid; Allen, Foster, and Berg 2000). These factors were included as independent variables in all analyses testing substitution effects reported in this article, because it is recognized that the use of mobility equipment may be selective with respect to patient characteristics that also affect outcomes of interest, that is, presence and degree of human help as well as costs associated with use of formal services.
On the basis of the results of previous research in this area (e.g., Hanley and Wiener 1991; Munson 1999; Tennstedt et al. 1990, Tennstedt et al. 1993), both the form of the independent variables and key expected associations with human assistance are summarized briefly in the following section.
Age (range 18–99) was included as an interval variable and was expected to be positively associated with the receipt of both formal and informal care. Women, although less likely to use mobility equipment, have been consistently reported in the literature to be more likely than men to use formal services. Dichotomous indicators of Black and Hispanic ethnicity were included in models, with Caucasian race as reference group, because these growing minority groups have been shown to be less likely to receive formal care relative to elderly Caucasians, although findings regarding ethnicity and use of informal care have been mixed. Similarly, dichotomous indicators of educational attainment less than a high school diploma and education beyond a high school diploma were included, with high school diploma as a reference category. Here educational level was used as an indicator of the likelihood of knowledge of formal service availability as well as a proxy for income (17% of sample members were missing values on income; hence this variable was not included in regression models). Therefore, respondents who had not graduated from high school were expected to be more reliant on informal care and less likely to receive formal home care services. The reverse was expected to be associated with education beyond high school, which served as proxy for both greater knowledge of formal service availability as well as the ability to pay for formal care.
We included dichotomous variables indicating access to human help (i.e., living alone, being married, living in elderly housing) to control for possible confounding of access with use in all models. Living alone and being married have been identified as virtually opposite situations in the caregiving literature (e.g., Lima and Allen 2001; Litwak 1985; Tennstedt et al. 1990). People who lived alone were expected to be less likely to have an informal caregiver, and fewer hours of informal care, and more likely to receive formal care, at higher levels, whereas the effects of being married were expected to be the reverse. Because housing for elderly people often contains case management services or other types of services intended to provide or facilitate access to needed community-based services, residing in elderly housing was also expected to be positively associated with receipt of formal, but not informal, care.
We included dichotomous indicators of type of insurance (private, Medicare, Medicaid, other government) in multivariate models to control for their facilitative effect in the receipt of formal services. Medicaid, the primary insurer of community-based long-term care services, was expected to be most strongly and positively related to both the receipt of and level of formal care services. Coverage by Medicare was also expected to positively influence formal service receipt, although this effect was not expected to be as strong as coverage by Medicaid, because the focus of Medicare home care is intended to be on postacute services. We wanted to determine the efficacy of various types of coverage; hence, uninsured was selected as the reference category.
Finally, we included a number of indicators of disability/illness severity in all models to control to the extent possible (given available data) the potentially confounding influence of severity, or need for assistance, on all outcome measures. These were interval measures of respondents' number of mobility limitations (range = 1–3), ADL limitations (range = 0–7), and IADL limitations (range = 0–8). Limitations was defined as reported difficulty in task performance, as opposed to receipt of help. Given the highly skewed distributions of both number of chronic conditions and number of hospitalizations, dichotomous indicators of these variables were created with cutoff points selected on the basis of findings from research on similar populations (Allen and Mor 1998), that is, three or more conditions versus two or fewer, and any hospitalizations versus none.
Analytic Approach
We conducted logistic regression to determine whether mobility equipment use completely substitutes for human help, controlling for factors indicative of selectivity in the use of mobility equipment, as described previously. These factors were also controlled in multiple regression analyses we conducted to test hypotheses regarding other outcomes, all of which were interval variables, that is, formal and informal hours of care, number of ADL and IADL activities for which help was received, and out-of-pocket costs associated with use of formal helping services. We used sampling weights to account for the core NHIS sampling design, for nonresponse to the NHIS core and the NHIS-D Phase I survey, and for nonresponse to the DFS. Thus, findings from this study can be generalized to community-dwelling adults aged 18 and older with limitations in mobility as well as in daily living activities.
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Results |
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), nearly half the sample reported less than a high school education (43.4%); 24% reported education beyond high school. Regarding access to human help, approximately one quarter (27.2%) of sample members lived alone, half (51.5%) were married, and a small minority (4.8%) lived in housing for elderly persons. The vast majority of the sample (94.2%) had some insurance coverage, with only approximately 6% of the sample reporting no source of insurance. Finally, measures of illness severity indicated that sample members had substantial health problems, with more than half (54.3%) reporting three or more medical conditions. Approximately one quarter (25.2%) reported being hospitalized in the past year. Average levels of impairment severity reported by sample members were more than two mobility impairments (M = 2.35, SD = 0.79), two ADL limitations (M = 2.23, SD = 1.98), and two IADL limitations (M = 2.23, SD = 2.09).
Table 1 presents findings on respondents' current use of mobility equipment, that is, use in the 2 weeks preceding the survey. Only slightly more than one third of the sample reported using mobility equipment. Not surprisingly, sample members who did not use such equipment appeared to be the least limited in daily living activities. Canes were the most prevalent type of equipment in use, and crutches the least. Nearly equivalent proportions of the sample (approximately 10%) reported using wheelchairs and walkers, and users of these equipment types reported the most severe level of activities limitations in the sample.
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Multiple regression analyses testing for reductions in levels of human help as a function of mobility equipment use are presented in Table 3 . We found that canes predicted approximately 1 less hr of formal help and nearly 4 fewer hr of informal help per week. Crutches were also negatively related to receipt of human help, with reductions of approximately 2 hr of formal help and 9 hr of informal help. Walkers and wheelchairs, on the other hand, were highly pre-dictive of receiving more hours of formal and informal help (approximately 3 hr and 6.5 hr, respectively), and wheelchairs (but not walkers) were also positively associated with greater levels of informal help (about 14 hr). For this analysis as well as the analyses described in the following sections, the effect of using multiple types of mobility equipment can be ascertained by summing the coefficients of each.
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In addition to reported associations between mobility equipment and informal care hours, factors positively associated with level of informal care were older age, being Black or Latino, education less than high school, coverage by Medicaid or other government insurance, number of hospitalizations, and number of ADL and IADL limitations. In addition, living alone and living in housing for elderly persons were negatively associated with level of informal care.
Substitution on the level of individual tasks was tested in models predicting the number of ADL and, separately, IADL activities for which help was received, regardless of whether help was from formal or informal sources (see Table 4 ). Results revealed evidence of the efficacy of canes (p < .05) and crutches (p < .001) in reducing the number of ADL activities for which human help was required. Supporting analyses indicated that canes and crutches were most likely to substitute for human help with toileting and transferring, activities for which the ability to balance is essential (data not shown). In contrast, canes were positively related to the number of IADL activities for which help was received (p < .001). Strong positive associations were also noted between use of walkers or wheelchairs and the number of both ADL and IADL activities for which help was received (p < .001).
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Finally, descriptive analyses of out-of-pocket cost data associated with use of transportation and home care services (i.e., personal care attendant services, adult day care, and independent living services) revealed that 1,075 respondents (11% of sample) used at least one of these services in the year before the interview, and average out-of-pocket costs among all users was $561 (SD = $3,461). Average out-of-pocket costs among the subsample of persons with any such costs (n = 233) were $2,588 (SD = $7,084), and median expenditure was $180.
Expenses associated with transportation services were substantially lower than those associated with home care services. Of the 1,075 service users, 451 (42%) used only transportation services, and the average out-of-pocket costs for this group were only $36 (SD = $195).
We regressed out-of-pocket costs for the full sample for all four services on indicators of mobility equipment use, controlling for selection factors. Findings indicated an average $69 reduction in out-of-pocket costs for formal services associated with use of a cane, whereas use of a wheelchair resulted in an additional $191 (see Table 5 ).
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Discussion |
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Our findings are encouraging, and they support previous research on the more general area of "special equipment" in performance of ADLs. Results suggest that complete substitution of mobility equipment for human help is unlikely overall, although it is possible that, despite our efforts to include a variety of indicators of illness severity in multivariate modeling, there may still be unobserved severity masking such an effect. However, study findings indicate that substitution is quite possible at the level of individual ADL tasks through use of canes or crutches. Similarly, use of canes and crutches is associated with overall reduced levels (hours) of both formal and informal care.
In contrast, there is no evidence of a substitution effect involving use of walkers and wheelchairs. Use of these types of equipment appears to be indicative of a level of need for human assistance (impairment severity) that is unlikely to be offset by mobility equipment alone. Thus, walkers, and particularly wheelchairs, may be necessary but not sufficient interventions to enable mobility and task performance without human assistance. However, it is beyond the scope of this study to determine from available data which walker and wheelchair users have the option of using this equipment. As we discussed previously, unobserved severity may compromise our ability to detect a substitution effect among people at higher levels of impairment. This possibility is supported by study data indicating that people who use walkers average two more limitations in daily living tasks and people who use wheelchairs three more limitations, than people who use canes.
In any case, canes and crutches are clearly more optional resources in that it is relatively common for people to choose to do without them until absolutely necessary, for reasons of stigma (Rush and Ouellet 1997); access; or lack of knowledge of their relatively easy availability, low cost, and great utility. Such people are likely to depend on friends and relatives instead or on formal helpers in the absence of informal support and may not realize the unnecessary loss of autonomy associated with this "choice." Nor, judging from past research (Agree 1999; Verbrugge et al. 1997), may they realize the greater effectiveness of equipment over human help as an intervention to close the gap between capability and environmental demand.
Our findings support other research indicating that equipment use is more effective in assisting with ADLs than with IADLs (Agree and Freedman 2000). This is intuitive, because canes and crutches may be all that are needed to achieve the balance necessary to perform simple daily living tasks, for example, getting to the bathroom, sitting, and standing as one toilets. On the other hand, it is hard to imagine how a cane or crutch could be a sufficient intervention to reduce environmental demand to the point that performance of more complex activities such as housework or cooking could be accomplished without human help or substantial modification to the home environment.
It is clear that illness or disability severity, social support availability, and mobility aids are not the only factors affecting receipt of human assistance. Older age consistently predicts both having any care and the amount of care received. This finding may reflect greater fraility among older than younger people with disability, as well as greater availability of helping resources. However, it may also reflect the desire for greater autonomy among younger people, as well as perceptions by family members and people with disability themselves that dependency is appropriate for people at older but not younger stages of the life course. Such perceptions and attitudes may also at least partly account for lower rates of use of mobility equipment among younger populations with disability, relative to their older counterparts (Allen et al. 2000). Interventions to destigmatize use of assistive technology may promote greater autonomy and quality of life for people with disability while reducing monetary and opportunity costs of care.
Given the cross-sectional nature of these data, we acknowledge the possibility of reciprocal relationships, that is, that equipment use may be a result of as well as a cause of formal care use. Further, our attempt to determine out-of-pocket costs savings is imperfect given that this information was not collected for homemaker or home health services, key service types in the provision of supportive care in the home. However, given the dearth of research in this area, it is our intention to use this unique data set that includes adults of all ages with disabilities, and a full range of disability-related topics, to identify promising areas of investigation for future research on the substitution of assistive technology for human help.
Future efforts should focus on other specific types of technology, such as hearing aids and home modifications, which may be underutilized because of relatively easily modifiable barriers to access and actual use. Longitudinal research is needed to determine the direction of causality of the technology/human help relationship. An interesting question that can also be addressed by longitudinal research is whether the physical effort required for disabled persons to use some types of assistive technology, for example, canes, crutches, and walkers, may help to slow functional decline. As the population ages and medical advances continue to lengthen the human life span, we believe that the promising findings reported here may be but a preview of an exciting and fruitful area of research on assistive technology as a patient-centered, effective, and efficient home care resource.
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Acknowledgments |
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Received for publication January 26, 2001. Accepted for publication May 15, 2001.
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 H. Hoenig, D. H. Taylor Jr, and F. A. Sloan Does Assistive Technology Substitute for Personal Assistance Among the Disabled Elderly? Am J Public Health, February 1, 2003; 93(2): 330 - 337. [Abstract] [Full Text] [PDF]
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