Effects of cultural identification and disability status on perceived community rehabilitation needs of American Indians.

Native American groups include American Indians, Eskimos, and Aleuts. Most empirically based counseling literature on Native Americans has focused on American Indians (Ponterotto & Casas, 1991). American Indians are culturally diverse and geographically dispersed throughout the United States. LaFromboise (1988) discussed the heterogeneity existing among American Indians, citing the work of Manson and Trimble (1982) who identified 511 federally recognized Native entities and an additional 365 state-recognized American Indian tribes. In addition, American Indians are becoming increasingly urbanized, moving to cities for subsistence and gainful employment. Nearly 200 distinct tribal languages are spoken among this diverse population. Given the enormous diversity among American Indian people, it is not possible to describe a "typical" or "generic" American Indian.

American Indians have been the object of continuing oppression, discrimination, prejudice, violence, misunderstanding, and stereotyping (Markides & Mindel, 1987). They typically have little educational, economic, and political power and, more often than not, have little influence over events occurring in the broader society or even those that occur in their own individual lives (Ponterotto & Casas, 1991). Further, the prevalence of disabilities differs between American Indians and non-Indians (Hodge & Weinmann, 1987). For example, American Indians experience visual impairments three times more frequently and hearing losses four times more frequently than the general population (Northern Arizona University & University of Arizona, 1987). American Indians are also more likely to experience disabilities that are caused by accidents, violence, and trauma. Motor vehicle accidents, which frequently result in orthopedic and/or brain injuries, are nearly 4.4 times more prevalent among American Indians than among the general population (May, 1982). The leading cause of death among American Indians is accidents, and 75% of all accidents are related to alcohol (Indian Health Service, 1985). As a result of these various factors, the rehabilitation and mental health needs of American Indians are likely to be substantial, compared to other segments of the U. S. population.

Nearly one-fourth of American Indian people reside in "identified areas" or reservations, and they remain within state and federal jurisdiction and service delivery, continuing to be served by agencies such as the state vocational rehabilitation agencies within the state-federal rehabilitation system. However, O'Connell (1987) reported that the rate at which the state-federal vocational rehabilitation system provides rehabilitation services to American Indians with disabilities was substantially lower than for other people with disabilities, even though American Indians were 1.5 times more likely than the general population to have a disability affecting their employability. Further, the rate of successful closure of American Indians with disabilities who were served within the state-federal rehabilitation system was found to be substantially lower than for other clientele served.

Services are provided to American Indians through a complex, multiple-government system, including the Bureau of Indian Affairs (BIA), Indian Health Service (IHS), and a variety of local tribal agencies, as well as many nontribal agencies, including the state-federal rehabilitation system. Many American Indian people with disabilities may simply be unaware of service agencies that exist on and off the reservations. In terms of accessing services, many American Indians have experienced economic dependency, psychological depression, and poverty, which may result in passive resistance or hopelessness (Johnson, Joe, Locust, Miller, & Frank, 1987). White (1987) found that cultural differences become barriers to service unless rehabilitation agencies make a concerted effort to understand cultural differences and to provide services within the context of those differences. White also noted that many American Indians are reluctant to seek services from the state-federal rehabilitation system, pointing out that relationships to the BIA and IHS are often characterized by dependency, while the state-federal vocational rehabilitation program requires self initiative and a commitment to long-term planning.

Cultural identification of American Indians with disabilities may be one factor influencing service delivery. In a study conducted within the state-federal rehabilitation system, White (1987) found that administrators did not perceive language differences to be a barrier to service delivery, leading White to conclude that administrators may lack sensitivity to the importance of cultural factors. Clark and Kelley (1992), citing work by Trimble (1981) and Matheson (1986), indicated that an understanding of tribal and individual cultural variations is important for effective counseling. Clark and Kelley went on to emphasize the importance of appropriate commUnication styles in counseling with American Indians in order to establish rapport and effective working relationships. Further, the lack of family or culturally appropriate support systems has been cited as a factor that often affects rehabilitation service delivery. These and other cultural elements can play a significant role in the entire rehabilitation process.

Culture has been described in many ways by different authors and influences the thoughts and behavior of individuals (Wallace, 1970). Cultural identification is a long-term, persistent underlying characteristic that influences the organization of emotions, cognitions, and behaviors (Oetting, 1993). Thus, cultural identification would seem likely to influence perceptions of community rehabilitation needs, challenges related to disabilities, potential solutions to problems, and the community response to addressing community-based rehabilitation needs.

Despite the prevalence of disability among American Indians and evidence indicating that American Indians with disabilities are often inadequately served, few studies have attempted to identify community rehabilitation needs of American Indian people. Given the unique structure and customs of individual tribes, defined groups of American Indians must be studied separately in attempting to identify needs (O'Connell, 1987). The purpose of the present study was to contribute to the identification of community rehabilitation needs through studying one defined group of American Indians, along with factors that might influence their perceptions of needs. More specifically, the purpose of the study was to identify the perceptions of rehabilitation needs among American Indians residing on one particular rural reservation and to examine the roles that disability experience and cultural identification might play in their perceptions.

Method

Participants

The population of interest in this study was a tribe of American Indians residing on a rural reservation in the Midwest. With the approval of several tribal committees and the elders of the tribe, volunteers were recruited in the waiting room at the community health center on the reservation over a continuous one-week period. Selection criteria included self-identification as an enrolled tribal member and age of 16 years or older, with no upper age limit.

A total of 156 individuals agreed to participate and provided complete responses to the survey instrument used in the study. A total of 111 (71.2%) of the participants were female, and the mean age of the sample was 50.2 years. The majority had lived on the reservation for more than 30 years; 49 (31.4%) had never lived off the reservation; while the remainder had lived off the reservation for some period of time and subsequently returned. Only 15 (9.6%) indicated that they spoke the tribal language, with 8 (5.1%) indicating that the tribal language was the primary language spoken at home. A total of 73 (46.8%) indicated that they had a disability, with the most prevalent being diabetes (24.4%), mental retardation or cognitive disabilities (11.5%), and heart problems (8.3%).With respect to education, 62 (39.7%) had completed some post-secondary education, while an additional 54 (34.6%) had graduated from high school or completed the high school equivalency. The most prevalent occupational categories were professional-managerial (19.2%), semi-skilled (18.6%), skilled (17.4%), and unskilled (16.0%), while 34 (21.7%) indicated that they had retired.

Community Survey Instrument

General Information. The instrument used in this study was a questionnaire, the Community Survey, developed specifically for the study and comprised of three parts. The first part, General Information, requested demographic information that was used to describe participants. One item was included to quantify disability status, one of the independent variables in the study. Participants were asked to check a "yes" or "no" response to the question, "Do you have a disability? (DISABILITY is a functional limitation that results from a physical, cognitive, or psychosocial impairment an/or which results in eligibility for SSDI, SSI, VA disability benefits, workers' compensation, or special education)."

Cultural Identification Scale. The second part of the Community Survey, the Cultural Identification Scale, was based on the Orthogonal Cultural Identification Model (Oetting & Beauvais, 1990-1991). According to the model, identification with one culture is viewed as orthogonal or independent of identification with another culture; in other words, high identification with one culture does not preclude high identification with another. For purposes of the present study, identification with American-Indian and White-American or Anglo cultures were quantified. Six items comprised the Cultural Identification Scale, each representing a different type of cultural activity (i.e., special activities or traditions, such as holiday parties and religious or spiritual activities; special things done together or special traditions; way of life of family; way of life of the individual; success in way of life of the family; and success in the way of life of the individual). In each case the participant was asked to respond twice, indicating "how close you are to different cultures," with each rating on a four-point scale (4 = "a lot," 3 = "some," 2 = "a few," 1 = "none at all") (a) in relation to American-Indian culture or way of life, and (b) in relation to White-American or Anglo culture or way of life. Oetting and Beauvais have found through large-scale surveys conducted with adults that scales as short as two items tend to result in internal consistency reliabilities in the .70s and that the use of four or more items has been found to increase reliabilities to the high .80s.

According Oetting and Beauvais (1990-1991), mean scores across items of 3.0 or higher are indicative of high identification with a culture. Using this criterion, each participant was classified into one of four categories of cultural identification by computing the mean ratings across the six items on each of the American Indian and White-American or Anglo scales: (a) American Indian identification (mean score of 3.0 or higher on American Indian identification, but less than 3.0 on Anglo identification); (b) Anglo identification (mean score of 3.0 or higher on Anglo identification, but less than 3.0 on American Indian identification; (c) bicultural identification (mean scores of 3.0 or higher on both American Indian and Anglo identification); and (d) anomie identification (mean scores lower than 3.0 on both American Indian and Anglo identification).

Concerns Report Survey. The Concerns Report Survey comprised the third part of the questionnaire. This part was developed according to the Concerns Report Method (Fawcett, Suarez de Balcazar, Johnson, Whang-Ramos, Seekins, & Bradford, 1987; Fawcett, Suarez de Balcazar, Whang-Ramos, Seekins, Bradford, & Mathews, 1988). This method is a unique process to systematically identify the strengths and problems of local communities through the use of surveys and public discussions, gathering information and acquiring ideas for improvements from the citizens themselves. The method seeks to maximize community involvement in all steps of identifying community needs in order to improve the validity of the results and a sense of community ownership and commitment to addressing the needs identified. Only limited evidence has been provided to document the reliability and validity of the method in identifying community strengths and problems, but the evidence has been encouraging (Schriner & Fawcett, 1988; Marshall, Johnson, Martin & Saravanabhaven, 1990).

Following the method specified by Fawcett et al. (1987), a pool of 300 concern items was initially generated by the authors on the basis of a through literature review of community concerns and needs. Three "working groups," each comprised of eight tribal members who lived on the reservation and had either disabilities themselves or family members with disabilities, were then selected on the basis of input from elected tribal officials, human service providers and administrators, and elders of the tribe. The three groups were: (a) a "traditional" working group, with members who were identified as maintaining the tribal language, culture, and traditions; (b) a "bicultural" working group, with members who were identified as knowing and accepting the cultural traditions of both the tribe and Anglo society and being able to move between the two cultures with ease; and (c) an "acculturated" working group, with members who were identified as embracing the values and culture and being accepted by Anglo society. Each working group was given the task of selecting 40 items from the 300-item pool for inclusion in the Concerns Report Survey, and meetings were facilitated by the first author. The bicultural working group completed the task in a single meeting that lasted between two and three hours, while the other two groups each required three two-hour meetings.

Among the 40 items selected by each of the three groups, 9 were selected by all three, while 15 others were selected by two of the three. All items identified by at least two of the groups were then selected for inclusion in the Concerns Report Survey. Two of the items were judged by the authors to be similar in content and were merged, reducing the total number of items to 23. In the final version of the survey, respondents were asked to rate each of the concerns on five-point scales in terms of both importance (from "0 = Of no importance to me" to "4 = Very important") and satisfaction (from "0 = Very dissatisfied" to "4 = "Very satisfied").

Procedure

Efforts were made to maximize involvement of the tribal community in all aspects of the study. The research prospectus was initially reviewed by three separate tribal committees, the Health, Business, and Legislative Operating Committees. A meeting was then held to discuss the research with a diverse group, consisting of representatives from the three tribal committees, human service providers, individuals with disabilities, family members of individuals with disabilities, and tribal elders in order to solicit input. Potential membership of the working groups was discussed at the meeting, and a decision was made to recruit participants for the survey at the tribal community health center. Several hundred flyers were then distributed throughout the community, announcing the study and inviting participation during the one-week period at the community health center. Also, an informational advertisement was published in the official tribal newspaper.

During the one-week period of data collection, the first author spent the entire day, each day of the week, at the health center. Potential participants were informed about the research as they registered with the receptionist and were given an overview of the project and its importance to the tribal community, along with an informed consent form. Those agreeing to participate were then given a copy of the Community Survey, clipboard, and pencil, and they completed the Survey in the waiting room. The participant was then asked to give the completed Survey to the first author, who was available in the waiting room. He then quickly scanned the survey for completeness and provided the participant with an envelope containing a thank you note and a token $5.00 cash gift.

Results

Community Rehabilitation Needs

In general, the importance ratings on the community concerns were high, with mean ratings for all 23 concerns falling between "3" ("Important") and "4" ("Very important"), with the lowest mean importance rating being 3.35. In addition, the majority of ratings for each of the 23 concerns were in the "very important" category. The highest rated concerns, all with mean importance ratings above 3.50, were: (a) "Public and tribal transit systems (e.g., buses, cabs) are safe, accessible, and available" (M = 3.63); (b) "People with disabilities know their rights as citizens" (M = 3.62); (c) "Your local and tribal government responds to the needs of people with disabilities in the community" (M = 3.61); (d) "Good medical and dental care is available for people with disabilities" (M = 3.58); (e) "Health care providers (e.g., dentists, doctors, psychologists, and general practitioners) are educated to work with people with severe disabilities and are able to provide competent and safe health care" (M = 3.55); (f) "Routed and regularly scheduled transportation systems to and from school are available to students with disabilities" (M = 3.53); and (g) "Public and tribal schools meet the needs of students with disabilities" (M = 3.52).

While importance ratings indicated high importance for all concerns, satisfaction ratings indicated only limited satisfaction with the response of the community to the various concerns. Mean satisfaction ratings for all 23 concerns were below 2.50 ("2 = somewhat satisfied" and "3 = satisfied"). In addition, for 22 of the 23 concerns both the median and modal responses were "2"; the exception was for "Public and tribal transit systems (e.g., buses, cabs) are safe, accessible, and available," which had a median and modal response of "3." Two concerns had mean satisfaction ratings below 2.0: (a) "People with disabilities can earn enough money at jobs to make up for the loss of disability benefits" (M = 1.86); and (b) "Adequate job training programs are available for people with disabilities" (M = 1.99).

Importance and satisfaction ratings were also combined to identify "priority" and "high priority" community rehabilitation needs, those concerns that were rated as both high in importance and low in satisfaction with the community response to addressing the concern. A participant's ratings for a particular concern were classified as indicating a "priority" need if importance was rated as either "important" or "very important" (a rating of "3" or "4") and satisfaction was rated as either"somewhat satisfied," "dissatisfied," or "very dissatisfied" (a rating of "2," "1," or "0"). In addition, a participant's ratings were defined as indicating a "high priority" need if importance was rated as "very important" (a rating of "4) and satisfaction was rated as either "dissatisfied" or "very dissatisfied" (a rating of "1" or "0").

According to the criteria specified, each of the 23 concerns or needs was rated as a "priority" need by 41.0% or more of the participants, including 10 rated as "priority" needs by 50.0% or more and 5 by 55.0% or more. The five concerns or needs with the highest percentages of participants indicating that the concern was a "priority" need were as follows: (a) "People with disabilities can earn enough money at jobs to make up for loss of disability benefits" (60.3%); (b) "Adequate job training programs are available for people with disabilities" (59.6%); (c) "People with disabilities know their rights as citizens" (59.0%); (d) "Your local and tribal government responds to the needs of people with disabilities" (55.8%); and (e) "Public and tribal schools meet the needs of students with disabilities" (55.8%). In addition, three concerns were rated as "high priority" needs by at least 20.0% of all participants: (a) "People with disabilities can earn enough money at jobs to make up for the loss of disability benefits" (27.6%); (b) "Group home placement for people with disabilities of all ages is available in the community" (22.4%); and (c) "People with disabilities know their rights as citizens" (24.4%).

Influence of Disability Status and Cultural Identification on Perceptions of Community Rehabilitation Needs

Disability status and cultural identification were investigated as two factors that might influence an individual's perceptions of community rehabilitation needs. With respect to disability status, 73 (46.8%) participants indicated that they had disabilities, while the remaining 83 (53.2%) indicated that they did not. With respect to cultural identification, using criteria previously specified, 51 (32.7%) indicated "high" identification with American Indian culture, and 69 (44.2%) indicated "high" identification with Anglo culture. Also using previously specified criteria, participants were categorized as follows: (a) 58 (37.2%) with anomic identification, not indicating high identification with either American-Indian or Anglo culture; (b) 47 (30.1%) with Anglo identification; (c) 29 (18.6%) with American Indian identification; and (d) 22 (14.1%) with bicultural identification, indicating high identification with both American Indian and Anglo culture.

Four 2-way ANOVAs were conducted to examine the influence of disability status and cultural identification on each of the four dependent variables: (a) mean importance ratings across all concerns, (b) mean satisfaction ratings across all concerns, (c) the number of concerns indicated as "priority" community rehabilitation needs, and (d) the number of concerns indicated as "high priority" community rehabilitation needs. No evidence was provided that perceptions of importance of concerns or needs differed according to disability status, F(1,148) = 0.70, ns, cultural identification, F(3,148) = 0.15, ns, or for the interaction between disability status and cultural identification, F(3,148) = 1.54, ns.

Evidence was provided that perceptions of satisfaction with the extent to which concerns or needs were addressed differed according to disability status, F(1,148) = 8.15, p [is less than] .05, as well as cultural identification, F(3,148) = 2.95, p [is less than] .05, but not for the interaction between disability status and cultural identification, F(3,148) = 1.35, ns. Examination of the mean satisfaction ratings according to disability status suggested that participants with disabilities indicated greater satisfaction with the community response to concerns (M = 2.41) than nondisabled participants (M = 2.02). Mean satisfaction ratings were compared for every possible pair of the four cultural identification categories, using Tukey's honestly significant differences test, and the results suggested that participants with an American Indian identification were less satisfied with the community response (M = 1.78) than either those with bicultural identification (M = 2.21) or anomic identification (M = 2.29).

No evidence was provided that the number of priority community rehabilitation needs identified differed according to disability status, F(1,148) = 1.18, ns, cultural identification, F(3,148) = 0.38, ns, or for the interaction between disability status and cultural identification, F(3,148) = 2.21, ns. Similarly, no evidence was provided that the number of high priority needs identified differed according to disability status, F(1,148) = 3.71, ns, cultural identification, F(3,148) = 2.34, ns, or the interaction between disability status and cultural identification, F(3,148) = 1.36, ns.

Discussion

Given the diversity existing among the various Native entities and tribes (LaFromboise, 1988; Manson & Trimble, 1982), each American Indian community should be considered unique. Consequently, the community rehabilitation needs identified in this study are best viewed as reflecting the unique concerns and needs of members of the tribe who resided on the reservation under study, and caution should be observed in generalizing results to other groups of American Indians. In general, all concerns identified in items on the Community Survey were viewed as "important" to "very important" concerns, supporting the decisions of the working groups in selecting items for the survey that actually represented relevant concerns. However, participants tended to express only limited satisfaction with the community response to concerns, with the mean ratings for all concern items below the midpoint between "somewhat satisfied" and "satisfied" and with median and modal responses for all but one concern as only "somewhat satisfied."

Those concerns ranking highest in terms of mean importance ratings were more general concerns about the knowledge of people with disabilities regarding their rights and the response of local and tribal government to the needs of people with disabilities, along with more specific concerns regarding transportation, health care, and public and tribal schools in accommodating the needs of people with disabilities. In contrast, mean satisfaction with community response to concerns was most limited in the areas of job training and employment opportunities for people with disabilities. "Priority" and "high priority" community rehabilitation needs were also identified as those concern items rated both high in importance and low in satisfaction with community response, and those concerns with the highest proportions of priority or high priority need ratings included the more general concerns about the knowledge of people with disabilities regarding their rights and the response of local and tribal government to the needs of people with disabilities, along with more specific concerns in the areas of job training and employment opportunities, public and tribal schools, and special living arrangements for people with disabilities.

The information on community rehabilitation needs that was generated through the present survey was intended to be useful to the community and its tribal members in developing culturally appropriate programming and follow-up. As suggested by the Concerns Report Method, local community members use the information for an action agenda, at least part of which is initiated by the tribal members themselves (Fawcett et al., 1987; Fawcett et al., 1988). More specifically, the data gathered is intended to place control of the agenda in the hands of local community members. This unique process is consistent with the emphasis on American Indian self-determination. Consistent with the Concerns Report Method, the results of the study have been provided directly to the community through "town hall" meetings in order to facilitate the interpretation and use of the information gained in planning to better meet the needs of members of the tribe with disabilities.

Studies of community rehabilitation needs using the Concerns Report Method have also been conducted with American Indians with disabilities in the urban areas of Denver, Minneapolis-St. Paul, and Dallas-Ft. Worth by the American Indian Rehabilitation Research and Training Center at Northern Arizona University (Marshall, Day-Davila, & Maskin, 1991; Marshall et al., 1990; Schacht, Hickman, Klibaner, & Jordan, 1993). Among the concerns identified in those studies were a number that were similar to those identified in the present study, including transportation, job training and employment opportunities, and health care for people with disabilities, while some different areas also emerged in the urban areas (e.g., safety and affordable housing needs).

In examining differences in perceptions of rehabilitation needs in the present study according to experience with disability and cultural identification, no significant differences were found on mean importance ratings across all concerns, the number of "priority" needs identified, or the number of "high priority" needs. However, significant differences were found on mean satisfaction ratings across all concerns, with participants having disabilities showing greater satisfaction than nondisabled participants. The fact that individuals with disabilities expressed greater satisfaction with community response to disability-related concerns is encouraging, as individuals with disabilities would be more likely to have first-hand knowledge of the adequacy of community response. On the other hand, the greater dissatisfaction expressed by nondisabled participants, who have less direct knowledge, may indicate a public awareness problem on the part of agencies and programs serving people with disabilities.

In addition, participants with American Indian cultural identification showed less satisfaction with community response to the concerns than those with bicultural or anomie identification. Less satisfaction on the part of individuals with an American Indian identification could be due to a number of factors. Service programs may not be sufficiently sensitive to traditional American Indian values, and services may be provided in a less than culturally appropriate manner; if so, individuals with traditional American-Indian cultural identification would tend to be less satisfied with services and programs. In addition, individuals with a more traditional American Indian identification may be more likely to reject programs offered by government and other Anglo-controlled organizations in general, which play major roles in meeting the needs of community members with disabilities.

In interpreting the results of this study it is important to recognize the possibility that the sample surveyed was not representative of all members of the tribe residing on the reservation studied. Literature suggests that the Concerns Report Method should include full community representation in the survey process. Full community representation would have provided all community members an opportunity to share their attitudes, expectations, aspirations, values, traditions, and ideas. However, the sample was comprised entirely of volunteers, who were recruited at the tribal community health center as suggested by several community members and, although efforts were made to publicize the study throughout the community and to encourage broad participation, those participating may not have been truly representative of the tribe as a whole. Thus, caution should be observed in generalizing results to the entire community. As previously emphasized, there would appear to be no clear basis for generalizing results to other groups of American Indians in other locations.

The Concerns Report Method would appear to be a promising method for identifying community rehabilitation needs. The method allows for consumer control of the information generated, as opposed to control on the part of outside experts, facilitating not only the accuracy of information obtained but also the sense of ownership and commitment on the part of consumers to use the information in future planning. This method is consistent with the concept of empowerment (Rappaport, 1985), and the "bottom up" nature of the research design process allows for solutions to local problems that are driven by the tribal members themselves.

Given the potential contributions of the Concerns Report Method, continuing research is recommended to further develop a sound empirical base. Little is known about the measurement characteristics of the survey instruments developed, particularly in terms of item selection through the working group process and the agreement that can be expected in items selected by different working groups chosen to represent the same community. In addition, the reliability and validity of the survey instruments developed should also be further investigated. Similarly, further research should be conducted on the Orthogonal Cultural Identification Model, and the measurement of cultural identification. Such research could contribute to the continuing identification and understanding of community rehabilitation needs, not only of American Indians, but also of other cultural groups of people with disabilities, leading to more effective and culturally sensitive rehabilitation services and improved quality of life for people with disabilities.

Author Notes

Complete ratings for all community rehabilitation concerns, the initial pool of 300 concern items, and the Community Survey instrument may be obtained from the first author. The research was funded in part by the National Institute on Disability and Rehabilitation Research (NIDRR), U. S. Department of Education, Washington, DC; the contents of this paper do not necessarily represent the interpretations or opinions of NIDRR or the U. S. Department of Education.

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Mark A. Stebuicki, Rh.D., CRC, LPC, CCM, Assistant Professor, Department of Psychology and Counseling, MRC Program, PO Box 1560, Arkansas State University, State University AR 72467