The rehabilitation needs of American Indians with disabilities in an urban setting.

The results of this study were based on data collected in Denver, Colorado through 100 face-to-face interviews with American Indians who have disabilities. On average, the Indian people surveyed had lived in the Denver area for 18 years, reported 2.8 disabling conditions each, and were 46.5 years of age. Sixty-seven percent of the sample were Sioux; 55% were female. A wide range of disabling conditions were reported, including arthritis (37%), diabetes (33%), substance abuse (24%), visual impairment (21%), heart problems (16%), orthopedic disorders (14%), and emotional disorders (12%). In terms of functional limitations, 64% reported having problems with walking, 62% with lifting, and 50% with working on a job. A primary concern identified by the survey population was the lack of outreach services provided by social agencies.

During the 1950s and early 1960s, efforts were made to assimilate Indian people into the majority society through the relocation of American Indians to cities for jobs or job training (see, e.g., Fixico, 1986; Higgins, 1982). Upon arrival in the city, "the newcomer received a check to be spent under the supervision of the relocation officer. Next, the officer usually accompanied the new urbanite to a nearby store to purchase toiletries, cookware, groceries, bedding, clothes, and an alarm clock to insure punctual arrival at work" (Fixico, 1986, p. 136). However, many failed to adjust to urban life, perhaps, in part, because they "were often resettled by the BIA in areas where they had little contact with other Indians" (Johnson, Joe, Locust, Miller, & Frank, 1987, p.9). In addition, the work which American Indians were able to obtain was not always permanent. The reality for many was placement "in seasonal railroad and agricultural work, the lowest paying and least secure type of employment" (Fixico, 1986, p. 138); not surprisingly, "the end result of relocation is that over one-half of today's Indian population now resides in urban areas" (p. 183). Unfortunately, "in many cases, urban Indians have traded rural poverty on reservations for urban slums" (Fixico, 1986, p. 156). According to Metcalf (1982), "25 years of relocation ... has succeeded in increasing substantially the probability that young Indian families will live at least part of their lives in urban poverty and that Indian women will be raising their children in city slums" (pp. 74-75).

In summarizing research conducted by faculty and staff of the American Indian Rehabilitation Research and Training Center (AIRRTC), O'Connell (1987) reported that the rate at which the State-Federal rehabilitation system provided rehabilitation services to American Indians with disabilities was substantially lower than that for the U.S. population as a whole. Specifically, Rehabilitation Services Administration (RSA) data "showed that American Indians who are disabled appeared to be underrepresented in the State-Federal system . . . in the area of sensory disorders (conditions of the eye and ear), orthopedic impairments due to accidents, asthma and allergies, diabetes, speech conditions, and skin conditions" (O'Connell, 1987, p. 8). Further, when investigating the use of state agency rehabilitative services by adult Native Americans, Morgan and O'Connell (1987) found that "client output after successful rehabilitation closures for Native Americans did not differ from that of the general population. However, the rate of successful closure among Native American clients was substantially below that of the general population" (p. 143).

In terms of difficulties in accessing services, it may be that many Indian people with disabilities, even in urban areas, are simply unaware of the service agencies which exist. Regarding urban American Indians with disabilities, White (1987) found that state vocational rehabilitation agency administrators did not perceive language differences to be a barrier to service delivery as "English is spoken by most urban Indians" (p. 156). However, respondents did note the "frequent occurrence of program dropouts among urban Indian clients," and suggested as potential problem areas the fact that "urban Indians often do not have family or cultural support systems and have no identified central agency with whom to communicate." Further, living independently in an urban area often requires readily available financial resources; work devoted to meeting fiscal crises may inhibit the individual's ability to participate in a long-term vocational rehabilitation program.

Method

The purpose of this research was to determine the needs of urban American Indians with disabilities at the community level, with an emphasis on utilizing consumer involvement. Use of the Concerns Report Method (Fawcett, et al., 1987; Fawcett, Seekins, Whang, Muiu, & Suarez de Balcazar, 1982; Suarez de Balcazar, Bradford, & Fawcett, 1989) reflected the AIRRTC's commitment to including Indian people with disabilities in the planning, design, and implementation of research.

Subjects

Based upon a survey conducted through telephone interviews with 12 urban Indian Center directors, Denver, Colorado, was selected as the target community for this project. The 1980 U.S. Census identified Denver as having an American Indian population of 9,535 (Bureau of the Census, 1983). Of these individuals, 6,438 reported being age 16 or over, with 1,153 (18%) reporting a disability. John Compton (1989), Assistant Executive Director of the Denver Indian Center, has referred to Denver's Indian community as a "multi-nation population," with "probably" more Sioux representation than any other among the approximately 50 tribes. Agency support for this research was obtained from the Denver Indian Center, Inc., the Denver Indian Health and Family Services, and the Colorado Rehabilitation Services. Sponsoring agencies assisted researchers in identifying subjects (hereafter referred to as interviewees) for the survey. Four primary criteria were established. Interviewees were to: (a) be an American Indian with a physical, intellectual, or emotional disability, (b) be between the ages of 14 and 70, (c) not have alcoholism as his or her sole disability, and (d) live in the Denver-metro area.

Persons were identified as American Indian, and as having a disability, based solely on self-report. A total of 109 individuals were interviewed. Of these, five persons were below the age of 14 and three were older than 70; the interviews with these eight individuals are not included in the results presented below. In one case, permission was not obtained from an interviewee to use her interview for research purposes. Therefore, the survey population used for analysis in this study included 100 individuals.

Instrumentation

A critical piece of the Concerns Report Method involves the "working group," and its role in developing the instrumentation of the survey. According to Fawcett, et al. (1988), "the working group consists of six to eight consumers with representative disabilities [who identify] approximately 30 items of local concern to appear on the survey ...." (p. 17). For this project, Indian service providers and consumers recommended that members of the "working group" be identified both by service providers and by American Indian elders. It was also recommended that the elders be invited to attend a meeting where the project would be explained to them, and where dinner would be served to signify the importance of the event, an American Indian custom. The elders were asked to bring a potential candidate for the working group to the dinner. Issues identified as "concerns" included: (a) the need for respite care, (b) the need for accessible housing, (c) the need for accessible transportation, and (d) the need for American Indians with disabilities to have access to information regarding services. Consumers attending this first working group meeting agreed that a second meeting would be necessary to complete the process of identifying issues to be included on the survey instrument. The consumers in attendance at the second "working group" meeting focused on reviewing the content and the format of the items developed for the interview instrument. Suggestions were made to include items in the interview related to spirituality and educational opportunities. Demographic items on the instrument were derived in large part from a study previously conducted by the AIRRTC involving the Pueblo Indians in New Mexico (Martin & O'Connell, 1986). The instrument also contained demographic questions, as well as items addressing satisfaction with service delivery, which were derived from a questionnaire developed by Demmler, Shern, Coen, and Wilson (1988).

Procedure

Following a pilot-test of the interview instrument, 11 persons were trained as interviewers. All interviewer trainees were American Indians; several had disabilities. The style of the training was interactive, with trainees contributing suggestions as to how interviews should be conducted, what additional questions should be asked, and giving feedback as to how they were affected by the interview process. For example, the trainees recommended that while they believed it was important to ask about "American Indian illness" and treatment (see Figure 1), it was extremely important not to probe these areas. The importance of using native language when requested was also confirmed by the trainees. For example, one trainee, in practicing the role of the interviewer, remarked how flat the affect of the interviewee was when questions were asked in English; she further commented, "When I use Sioux, I can see the answer on her face."

In order to be hired as an interviewer, each interviewer trainee was required by the end of the training to demonstrate competency and reliability in using the instrument by achieving a percentage of agreement score of at least 80% (Borg & Gall, 1983). Percentage of agreement scores for each interviewer trainee were obtained by dividing the number of responses recorded correctly by the total number of possible correct recordings (n = 289). Percentage of agreement for those trainees hired as interviewers ranged from 94.5% to 99.7%, with the mean percentage being 97.9%. Reliability and accuracy of recorded responses were further ensured in that each person hired as an interviewer was observed by the on-site coordinator when conducting one of his or her initial interviews; feedback was given immediately following the interview, or when necessary during the interview to correct the way in which a question was asked or recorded.

Eight of the 11 interviewer trainees were hired as interviewers. The average age of the interviewers was 39.8 years [Range = 29-60]; the majority [n = 5(62%)] were female. Tribal affiliations were Navajo, Northern Arapahoe, Pawnee, Pima, Oglala Sioux, Standing Rock Sioux, Cheyenne River Sioux, and Three Affiliated Tribes. Three of the persons hired were also employed full-time in a human services/health related field; two were employed part-time. Four persons spoke their native language. All had at least a high school diploma or a GED; two persons held a bachelor's degree, while two were students in an undergraduate human services program. One person had a master's degree in a human services field.

Service agencies in the Denver-metro area were sent flyers advertising the study in an attempt to recruit interviewees. The on-site coordinator also contacted several service agencies and churches known to be utilized by American Indians with disabilities. Interviewers were asked to use their own informal networks to identify potential interviewees; however, it was agreed that interviewers would not interview immediate family members. All interviews were assigned to interviewers by the on-site coordinator. Interviewers were paid $20.00 for each interview completed, plus a minimum of $5.00 compensation for travel costs. Interviewees were mailed a check for $20.00 in appreciation for their time.

Public meeting

Approximately four weeks after the interviews were completed, a meeting was held to provide preliminary results of the study to the community of American Indians with disabilities, as well as to elicit from them recommendations for community change. A major portion of the meeting was devoted to a discussion between community members and service providers regarding the desire of community members to receive services from American Indian service personnel. One woman commented: "My whole point was that . . . if once those applications came into your agency . . . and you knew they were Indian clients making the application, it would be nice if they were routed to the Indian personnel that you already have." Similarly, a young man stated:

I think that what the point was, was that there's generally a lack of trust for an Indian person going into a non-Indian agency. For myself, I'd rather go and talk to somebody with a brown face . . . . And if there were Indian people to talk with Indian people, then maybe more could be accomplished, and then your agency would be fulfilling it's task . . . . You've got to hire Indian people to help Indian people . . . ."

Finally, in describing the services of vocational rehabilitation, James Weiland, State Coordinator for Native American Programs, Colorado Rehabilitation Services, stated: "I believe that the Indian people, especially in the metro area, have been grossly underserved. I'm not going to point fingers at anyone; I think we all share responsibility to do something about it . . . ."

Results

The majority of interviews were completed in the interviewees' homes. A large majority of interviews were conducted in English, with 7% being conducted in a native language. Interviews took an average of 87 minutes to complete. In all but three cases, the person interviewed was also the person who had a disability; exceptions included a parent, a sibling, and a wife who spoke for the person with a disability. The following discussion of demographic information refers to the person who has a disability; however, the term "interviewee" is used for convenience. The majority of interviewees were Sioux (see Table 1); 92% of all interviewees reported having a tribal census number, with 100% having a social security number.

Interviewees were almost evenly divided between males (45%) and females (55%), with an average mean age of 46.5 years [Range = 23-69]. The marital status of the interviewees was evenly divided between those married (27%) and those divorced (27%). An additional 22% were either never married or single, 12% were either widowed or widowers, and 3% were separated; 9% did not identify their marital status. The majority of the interviewees were registered voters in both their tribes (55%) and in counties of residence (51%). The mean annual income of interviewees was calculated to be approximately $6,086; however, the majority (58%) reported having an income of less than $5,000 annually.

On the average, interviewees reported having lived in the Denver-metro area for 18 years. For those persons who have lived in areas other than Denver, the average length of time most recently spent in Denver was 11 years. The majority of persons interviewed (62%) reported that they plan to always live in Denver. Frequently reported reasons for staying in Denver included: "This is my home" (18%), employment (16%), family (13%), "I like Denver" (8%), and services/treatment (8%). In response to the question, "Do you have a reservation that you consider home?," a large majority (86%) indicated that they did. The plurality of these individuals (42%) stated that they visited their reservation "once or twice" a year. In terms of transportation, 44% of the survey population reported owning a car, with a slight majority (54%) having a driver's license. When asked, "What means of transportation do you use most?," interviewees primarily reported equal use of public transportation, that is, the city bus (37%), and their personal car (37%).

The survey population (100%) reported that they could speak English fluently, with 97% reporting that they could read English and 96% reporting that they could write English. Additionally, 59% reported being able to speak their native language fluently. Of these individuals, 78% identified their native language as Sioux. A plurality of the survey population (39%) had obtained at least a high school diploma, with an additional 13% having obtained a GED. Of those individuals not completing high school (n=29), the average amount of education received was 8.7 years. In terms of higher education, 16% reported having attended a college or university. However, 3% reported obtaining an AA Degree, and 6% reported obtaining a Bachelor's Degree. No one reported having a graduate degree.

Disability Information

Disabling conditions represented in the survey population are listed in Figure 1. Examples of disabling conditions, or chronic medical conditions, categorized as "Other" include atypical vertigo, chronic pain, heart murmur, complications of diabetes (e.g., skin not healing) and AIDS.

In terms of assistive devices and treatment, interviewees reported primarily using glasses (70%) and medication (68%). Similarly, the majority of interviewees also reported needing, or needing improved glasses (55%), as well as needing, or needing improved medications (17%). Those interviewees who utilize medications as part of their treatment (68%), reported primarily taking medication such as insulin for diabetes and over-the-counter medication such as ibuprofen for pain; over a third of these individuals use three or more medications. Almost half of the medication users (44%) reported noticing side effects; for example, 20% reported that the medications made them feel drowsy and 10% reported they felt dizzy. Other side effects reported included dry mouth, stomach pain, water retention, and headache.

In general, a plurality of interviewees (41%) reported their health as "fair," followed by a third (33%) reporting their health as "good." Only two individuals (2%) reported their health as "excellent"; almost a quarter of the population (24%) reported their health as "poor." In response to the question, "Does your disability limit you in doing the following activities?," a majority of interviewees reported functional limitations in key living activiteis such as walking (64%) and lifting (62%), with 50% reporting that their disability(ies) limited them in terms of working on a job (se Figure 2). Functional limitations categorized as "Other" include, for example, difficulties in driving a car, sleeping, home repair, cleaning, and exercising.

Services Information (Formal Support Systems)

Interviewees were asked to report on the type of helping services they had received in the past year, and to rate the helpfulness of each service. In addition, if interviewees had not received the service in question, they were asked whether they in fact had needed or wanted the service. Interviewees who indicated that they had needed or wanted the service, but failed to receive it, were asked to identify the barriers that had prevented them from obtaining the service. The majority of interviewees reported receiving medical care, as well as assistance in receiving benefits such as food stamps. In each case, for those who received services, a large majority found the service to be helpful. However, in many cases, interviewees reported needing a service, for example, dental care, but not receiving the service. Specifically, 61% of those interviewees who needed dental care (n = 67), or 41 individuals, were not able to see a dentist. Typical explanations cited as to why a service was not received included the fact that the service was not offered to the individual and the fact that he or she did not transportation to the service (see Table 2).

At the time of the survey, close to a third of the interviewees were receiving services from private medical doctors, the State Division of Social Services, the Social Security Administration, and through Medicare or Medicaid. Only two persons were receiving services from the State Division of Vocational Rehabilitation (see Table 3). [TABULAR DATA OMITTED]

In response to the question, "What services would you like to have available to you that you don't get now?," 14% responded that they needed transportation, for example, to keep medical appointments. Additionally, 14% stated that they would like to see changes in the medical services which they received, for example, financial assistance in buying medications, and being able to attend a clinic where they would see the same physician each time they went. Dental services were the next most frequently cited service needed (11%).

Consumer Concerns

A major portion of the survey instrument consisted of 40 issue statements also referred to as "Consumer Concerns." Relative strengths of the Denver-metro area are listed below in Table 4. Relative problems are listed in Table 5. Any issue that was more than one standard deviation from the mean in either category was considered a top strength or a top problem.

Social Information

In terms of living accommodations, 41% of the interviewees lived in a house and 37% in an apartment, with 22% reported "Other" living arrangements such as a duplex, a trailer, public housing, or a shelter. Of those living in a house (n = 41), the majority (51%) rent. Fifteen of the 100 individuals interviewed reported owning or buying his or her home. In order to obtain a measure of their satisfaction in the community, and with their personal living arrangements, interviewees were asked to respond to nine "quality of life" statements. While the majority of interviewees appear to be comfortable with their personal living arrangements, they also reported finding it difficult to access services (55%). [TABULAR DATA OMITTED]

The majority of respondents (70%) stated that their income was not enough on which to live; a typical comment was, "We pay bills, eat, but cannot save." While 63% of the survey population reported being covered by some form of medical insurance or assistance, the majority of these individuals received coverage through Medicaid benefits (53%). Additionally, 13% of those covered received health care through the Veteran's Administration, 10% through Medicare, 8% through public health services, 6% through private medical insurance, and 3% through the Indian Health Service. Eleven percent (11%) reported having more than one kind of coverage or assistance. Of those not having any type of coverage (37%), the majority (62%) stated simply that they "cannot afford" medical insurance. [TABULAR DATA OMITTED]

Employment Information

One quarter (25%) of the survey population reported working for pay; they earn a mean average annual income of $10,139. These individuals have a mean average age of 47.3 years, with the range being from 27 to 67 years of age. The mean average annual income for employed women was $9,667; the mean average annual income for employed men was $10,800.

Positions held by employed interviewees (n = 25) included: residential specialist for persons who have a developmental disability, health aid, nursing assistant, night manager, secretary (2 persons), janitor (3 persons), cleark (4 persons), maid (2 persons), postal clerk (2 persons), florist, seamstress, cook, minister, sexton, cashier, and office assistance. The majority (78%) of these individuals reported being satisfied with their job.

The majority of interviewees (84%) reported that they were not looking for a job, but have had problems finding a job in the past (60%). Of those who reported difficulties in finding a job, the plurality identified having a disability as a problem [n = 28(48%)], followed by lack of transportation [n = 23(40%)], and a lack of money [n = 19(33%)].

Discussion

Of concern in generalizing the results of this study to other populations, including the population of all American Indians with disabilities in the Denver-metro area, is the fact that the survey population was not randomly selected, but a volunteer population obtained primarily through the networks of interviewers, and through Indian health and social service agency referrals. It is important to keep in mind that the total population of American Indians who have disabilities, and who live in the Denver-metro area, is an unknown population.

Specific concerns which can be identified from the results of this study include the age of the population. According to Weibel-Orlando (1982), "Indians who migrated to urban centers in the mid-fifties and remained to work ... are currently approaching retirement age" (p.2). Special services focused on the needs of an aging population, with multiple disabilities, may be warranted. Not surprising, given the age of the population, over a third reported having arthritis. A third reported having diabetes, and almost a quarter, problems with substance abuse. Of those reporting problems with substance abuse, over a third also had orthopedic-related disabilities; the same number also had arthritis. The majority reported functional limitations in basic life activity areas such as walking and lifting. It is of concern that the vast majority of the survey population viewed their health as being only fair or poor, with 50% reporting that their disability(ies) limited their ability to work.

This aging, multiply-disabled population consistently reported having problems with transportation. Less than half of the interviewees own a car. A lack of transportation was frequently cited as a barrier to those needing, but not receiving services. Additionally, 40% of those reporting problems in securing employment cited lack of transportation as a factor. Transportation is clearly related to access. Given problems with transportation, it is not surprising that 55% of the survey population reported difficulty in accessing services in general.

Other access concerns include the lack of affordable housing; only 15% of the population surveyed own, or are buying, their own homes. Access to medical care is of concern given this population. While the majority do receive medical assistance or have medical insurance, almost a third of the interviewees reported being without either; quality of health care was not addressed in this survey. Areas in which interviewees were satisfied with access include the availability of accessible parking spaces [handicapped parking] adult education opportunities, special education services in the public schools, and religious services.

The fact that only 25% of the survey population was employed is of concern. Employment appears to increase the individual's income level. Only 2% of the survey population reported receiving vocational rehabilitation services at the time of the survey. Data provided by the Colorado Rehabilitation Services indicated that in the year prior to this study (July 1988 - June 1989), 44 American Indians were listed on counselor caseloads in the Denver-metro area. Of those, 15 persons (32%) were found to be ineligible for rehabilitation services; the cases of an additional 9% were closed before they were considered rehabilitated. Eight of the individuals (18%) had submitted an application, but eligibility had not been determined at the time of the report. Four persons (9%) were considered rehabilitated, that is, having worked for at least 60 days.

The lack of outreach from social service agencies appears to be of primary concern to the interviewees. This concern is substantiated by the frequency with which "services not offered" was cited as a barrier by those needing, but not receiving, servics. In particular, regarding case-management (coordination of services by a professional), of those who did not receive this service, 53% indicated that they needed the service. In terms of accessing information regarding services, the survey population reported depending primarily upon friends and relatives. Lewis (cited in Red Horse, Lewis, Feit, & Decker, 1978) has confirmed the importance of family and friends to urban American Indians, and suggested that the "sequential path" typically used in seeking help begins with the family network, followed by the social network, contacting a religious leader, the tribal community, and finally the mainstream health care system. Thus it would appear essential that outreach efforts by social service and rehabilitation agencies begin in the home, with families, versus, for example, only in health car facilities as informational pamphlets. In terms of culturally appropriate service delivery, those surveyed felt less than 50% satisfied that social agencies treated them with respect and dignity.

Only a third of the population surveyed reported being satisfied with advocacy efforts in the community. Similarly, the population was relatively unsatisfied with the amount of knowledge they had regarding their legal rights as citizens with disabilities, and with the amount of education and information regarding benefits and services available to them that is provided by social agencies and by the media. In many ways, the concern of the survey population with these issues leads to the question of self-advocacy, and their sense of each other as a community of American Indians who have disabilities. According to Higgins (1982), "One of the more obvious practical issues involved with the relatively small size of these urban [Indian] communities is the difficulty they have achieving political representation or developing planning consideration within a local system of government" (p. 14). Thus it would appear reasonable that if American Indians with disabilities are to experience improvement in their access to services and in the quality of the services they receive, it would be important for them to identify as a community.

Finally, the survey population appears to be predominantly a bicultural group of individuals, with commitment to both being Indian and living in the majority culture. For example, the majority are registered to vote in both their tribes and in their counties of residence. The vast majority of interviewees (92%) reported having a tribal census number and a reservation which they consider "home" (86%); however, the survey population has lived an average of 18 years in the Denver-metro area. The majority (62%) plan to always live in the Denver area. Everyone interviewed reported that they could speak English fluently, with a majority (59%) also being able to speak their native language fluently. Thus, service delivery systems must be responsive to a population that can function in the majority society, but is grounded in Indian culture.

Conclusions and Recommendations

Strengths of this research included the involvement of the Indian community throughout the research process, especially the participation of consumers in the developing the survey instrument. Problems included the fact that the face-to-face interviews constituted "labor intensive research." Interviewers traveled across meto-Denver--approximately 90minutes from north to south and from east to west. Communication was hampered due to the fact that interviewees frequently had no telephone; at least one interviewer did not have a telephone.

Reid, O'Neil, Manson, Lundberg, and Joe (1990), in commenting during a panel discussion upon the relationship of researchers to the Indian community, stated that community-based research requires both accountability and respect for the community. However, they also agreed that "it is up to the community and to the tribe to take the information from research and develop culturally appropriate programming or follow-up." It is in that spirit that the following recommendations are made--the community may well find other directions in which to pursue change. In order to address the concerns identified through this research, it is recommended that: 1. In-home outreach to identify individual needs should bne conducted by those agencies sincerely wishing to serve American Indians with disabilities. This outreach should be accomplished through the use of Indian case finders, and should be conducted under the auspices of a single agency, for example, an Indian health or social services agency, in order to avoid duplication of effort.

2. Case-management services should be available through Indian service agencies to ensure that basic needs are met. Interviewees consistently referred to problems with transportation, and accessing basic health care such as dental services. They need very basic assistive devices such as glasses.

3. Vocational rehabilitation services, which focus on the special needs of an aging workforce with multiple disabilities, should be made available within the Indian community.

4. Increased employment opportunities must be made available. While 78% (n = 18) of those working reported being satisfied with their current positions, increased levels of employment must be available to those who would want them.

5. American Indians with disabilities in Denver need to both recognize themselves, and identify themselves, as a community. As a community, they can engage in self-advocacy activities, perhaps beginning with a drive to increase the number of American Indians with disabilities who are registered to vote.

6. Service agencies interested in the needs of this population can assist their community-building efforts through education and information programs focusing on their legal rights, in particular as regards employer accommodation to disability and accessibility issues.

7. Indian health agencies should develop education and information programs for the general Indian community which stress the "health and wellness" aspects of disability, and provide specific information for persons with disabilities on how to cope with their conditions in order to avoid, as much as possible, functional limitations.

8. Finally, the request of American Indians with disabilities to be served by American Indians cannot be ignored. Service agencies in Denver and other urban settings must renew their efforts to train, hire, and retain American Indians to serve this population.

This research is only a beginning. Many more issues related to the needs of American Indians with disabilities must be addressed, not only in the Denver-metro area, but in other urban settings as well. For example, while efforts were made to include transition age youth in this research, interviewees ages 14-22 were not identified. Where is this population? Are the schools adequately meeting their needs? Are they working? Shannon and Bashshur (1982) have defined "access" in terms of "convenience factors," such as travel time, appointment delay time, and waiting room time. Using this definition of access, how accessible are health, social service, and rehabilitation agencies to American Indians with disabilities? The results of this study indicated a disparity between men and women's income, and men and women's functional limitations (Marshall, Johnson, Martin, & Saravanabhavan, 1990). What special services, if any, should service agencies employ to address these differences?

References

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Compton, J. (1989). American Indian values: How cultural differences can lead to the mislabeling of Indian elders. Presentation at a workshop entitled, "Culture alert: How to make services accessible to American Indian elders." Denver Indian Center, Denver, Colorado, November 9, 1989.

Demmler, J., Shern, D.L., Coen, A., & Wilson, N.Z. (1988). Client and collateral perspectives on the CMI initiative programs. (Available from the Colorado Division of Mental Health, 3520 West Oxford Avenue, Denver, CO 80236.)

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Johnson, M.J., Joe, J., Locust, C., Miller, D., & Frank, L. (1987). Overview of the American Indian population and the influence of culture on individuals with disabilities. In J.C. O'Connell (Ed.), A study of the special problems and needs of American Indians with handicaps both on and off the reservation, Vol. 2, (pp. 1-13). Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center and Tucson, AZ: University of Arizona, Native American Research and Training Center. (Available from the American Indian Rehabilitation Research and Training Center, P.O. Box 5630, Flagstaff, AZ 86011.)

Marshall, C.A., Johnson, M.J., Martin, W.E., & Saravanabhavan, R.C. (1990). The assessment of a model for determining community-based needs of American Indians with disabilities through consumer involvement in community planning and change: Final report. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, American Indian Rehabilitation Research and Training Center. (Available from the American Indian Rehabilitation Research and Training Center, Institute for Human Development, Northern Arizona University, P.O. Box 5630, Flagstaff, AZ 86011.)

Martin, W.E., Jr., & O'Connell, J.C. (1986). Pueblo Indian vocational rehabilitation services study. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center. (Available from the American Indian Rehabilitation Research and Training Center, P.O. Box 5630, Flagstaff, AZ 86011.)

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Funded by the National Institute on Disability and Rehabilitation Research (NIDRR), Office of Special Education and Rehabilitative Services, U.S. Department of Education, Washington, DC, Grant No. H133B80066.

The content of this report is the responsibility of the American Indian Rehabilitation Research and Training Center and no official endorsement by the U.S. Department of Education should be inferred.