Training programs for working with older American Indians who are visually impaired.

The importance of the cultural/environmental context upon the behavior of people with disabilities is evident when working with people living on reservations. Lewin (1942) advanced the theoretical framework that in order to understand or to predict behavior, the person and the environment have to be considered as one constellation of interdependent factors. He called this constellation life space.

Marshall, Martin, Thomason, and Johnson (1991) reflect a psychology of ecology point of view when they state, "People with disabilities may have more difficulty in ameliorating their physical limitations in such environments" (p. 231). These difficulties include unemployment rates 5.47 times higher than that of the total civilian labor force (Martin & Frank, 1987), a 1.5 times higher rate of work disability than for the general population (O'Connell, 1987), and more health-related problems at younger ages than the general population (Maddux, 1987). In keeping with social affordance theory (Loveland, 1991), environments offer opportunities for perception and action to people in the context of their capacities, both physical and psychological. These perceptions and actions are in neither the environment nor person but are derived from an ecological relationship between both.

It is evident that American Indians with disabilities living on reservations have substantial unmet needs and limited resources and services. Action research methods become highly relevant under these conditions. Lewin developed a theme of social change in his notion of action research, which was an outgrowth of field theory. In explaining this concept, Lewin stated, "It is a type of action research, a comparative research on the conditions and effects of various forms of social action and research leading to social action" (Lewin, 1948, p. 203). Lewin also stressed that residents from the area being studied should actively take part in the research process. Current community-based research approaches including participatory action research (Whyte, 1991), social impact assessment (Tester & Mykes, 1981), and qualitative research (Strauss & Corbin, 1990), incorporate Lewin's thematic underpinnings. Several community-based action research projects have been conducted with tribal members to understand and improve services to Indian people with disabilities. Martin and O'Connell (1986) found that the life space factors of many individuals living on the 19 Pueblos of New Mexico consistently interfered with the interchange of effective services. An alternative service delivery approach was undertaken by the investigators to test the feasibility of a state vocational rehabilitation (VR) agency working interdependently with American Indians living on reservations to benefit from rehabilitation services. Local, indigenous persons living within the Pueblos were trained as rehabilitation technicians to identify individuals with disabilities in need of services and then refer them to state VR counselors. The state division of vocational rehabilitation implemented a new system of services resulting from the recommendations of the study.

Lonetree (1990) identified the service resource needs associated with delivering services within American Indian Vocational Rehabilitation Projects administered by 14 tribes throughout the nation. As a result of the study, specific training and technical assistance activities were initiated to improve service delivery. Saravanabhavan (1991) investigated the needs of the elderly American Indians who were visually impaired or blind and living on the Hualapai reservation in Arizona. He employed a triangulation method of data sources and data collection. The data sources included samples of elderly American Indians, service providers, and client records. The data collection methods included administration of the OARS Multidimensional Functional Assessment Questionnaire, an assistive device survey, and a service provider survey. A protocol also was developed to extract data from client records. From this multimethod approach, the researcher was able to make systemic recommendations to improve services. Community-based research methods used in these studies were applied to a training program to improve services to older American Indians with visual impairments.

While there have been minimal research data generated about older Americans Indians with visual impairments, there is some information available about the health needs of American Indian elders. Saravanabhavan and Marshall (1991) reported that American Indians "age faster" as evidenced by research that showed that American Indians experienced a lower life expectancy and quality of life when compared to non-Indian populations. Because of this phenomenon, American Indians acquire limitations in activities of daily living at earlier ages than the non-Indian population. The researchers pointed out that "unless providers of health care and human services are reservation-based, they may not see this population" (p. 17). Edwards, Edwards, and Daines (1980) surveyed personnel from Bureau of Indian Affairs offices, tribal headquarters, and state departments of aging serving American Indian/Alaska Native elderly. They found that paraprofessional staff were most often employed to provide services to older American Indian people. They concluded that "more American Indian people could benefit from receiving services provided by staff who are professionally trained in identifying and meeting the needs of older American Indian people" (p. 221). The purpose of this project was to provide education and specialized training to reservation-based community representatives who work with people who are elderly and visually impaired and who reside on Arizona reservations.

Method

The method used in developing the training program will be described in this section. The processes described are development of the training manual and protfolio of resource information, development of the training curriculum, and selection of trainees.

Development of the Training Manual

A manual (White & Carlise, 1991) was developed to help the reservation-based community representatives understand and review material presented during the workshop and copies were distributed to trainees at workshops in Tucson and Flagstaff. Rehabilitation counselors, rehabilitation specialists, mobility specialists, tribal members, and people with visual impairments were consulted throughout the manual's development. In addition, other training manuals on mobility and daily living skills were reviewed for ideas. Portions of the manual dealing with assistive and technical devices were written to be relevant to rural areas, where running water or electricity is often scarce. Drawings were used to help clarify and simplify the text. The manual underwent eight revisions before a first draft was completed. Professionals from Arizona tribes, Arizona State Services for the Blind and Visually Impaired (SBVI), and the Institute for Human Development reviewed and made recommendations for improving the manual. The resulting manual contains drawings and text appropriate for consumers, family members, paraprofessionals, and others to use effectively. It includes information and instructions on definitions of parts of the eye, basic sighted guide instruction, signaling for narrow passageways, going

through doorways, traversing stairs with a guide, walking over uneven and dirt roads, trailing, squaring off, seating techniques, forearm and lower body protection techniques, advice and suggestions on staying oriented in rural areas, finding dropped objects, paper money organization, coin identification, making a telephone directory, dialing a telephone, using a pushbutton phone, exploring tabletops, food identification, identifying food on a plate, pouring liquids, using flatware, labeling containers, labeling dials, telling time, using writing and signature guides, matching clothing, washing dishes, sweeping a floor, and enhancing useable vision.

The appendix contains information to assist reservation-based community representatives when working with elderly visually impaired people. Included is an orientation/mobility evaluation procedure, an independent living skills assessment process, information on how to make a large print telephone directory, an application for exemption from directory assistance, a braille alphabet form, and a resources form. The resources form was compiled to assist the representatives on where additional information, catalogs, or questions may be obtained when serving elders with visual impairments on reservations.

Of 200 manuals produced, 105 were given to workshop participants. Reservation-based community representatives each received two copies of the manual, one to keep and one to distribute at their discretion. Forty-eight copies of the manual were handed out during the followup phase of the project to consumers, family members of people who were visually impaired, professionals in other reservation organizations, and other interested persons.

Development of a Portfolio of Resource Information

Portfolios were developed containing information about visual impairments and listing organizations that serve the elderly and/or visually impaired. Each packet contained a senior services directory, The Vision Shared for the Visually Impaired (A Transition Resources Directory), a talking books brochure and application, a catalog of aids and appliances for people with visual impairment, a pamphlet of modifications on insulin techniques produced for visually impaired people by the Greater Detroit Society for the Blind, a 2X magnifier, a black felt pen, a description of magnifier characteristics, catalogs, and a listing of nationwide vision services for people who are visually impaired produced by Science Products for the Visually Impaired.

The senior services directory was distributed to inform trainees of organizations and services available for elders in their region and was used as a guide to discuss the organizations serving people who are elderly and/or visually impaired specific to each representative's reservation. The Vision Shared Directory identifies specific state and federal organizations and the services they provide to people who are visually impaired.

Because diabetes is so prevalent on reservations and is a leading cause of blindness, a manual developed by the Detroit Society for the Blind was included in the portfolio. This manual describes how to use staples to make a template for drawing insulin, how to insert a needle into the insulin vial, and how to draw and inject insulin. A black felt pen was provided to emphasize the importance of contrast when working with people who have low vision. Black ink on white or yellow paper helps people with low vision to distinguish letters, numbers, pictures, etc.

Development of the Training Workshop Curriculum

In August 1990, a meeting was conducted at the Arizona SBVI office in Phoenix to discuss the curriculum to be used for the training program and to identify trainers for the workshops scheduled in Tucson and Flagstaff. Because the project was a statewide, cooperative endeavor, those involved included administrators and rehabilition counselors from SBVI, an administrator, rehabilitation teacher, and orientation and mobility instructor from the Institute for Human Development at Northern Arizona University, a professor from the Special Education and Rehabilitation Department at the University of Arizona, and a trainer from the American Indian Rehabilitation Research and Training Center (AIRRTC) at Northern Arizona University.

The following eight content areas were identified to be included in the curriculum:

* Physiology of the Eye

* Techniques of Mobility (sighted guide)

* Techniques of Daily Living

* Implications of Blindness

* Technical Aids and Devices

* Social Service Agencies and Information

* Cultural and Rural Issues

* Concerns of the Elderly.

An agenda was established with these main topic areas as guides. Trainers who had expertise related to the identified topics were identified during the meeting and were later contacted and asked to participate in the workshop. Because two workshops were to be conducted, two sets of trainers were identified. Each trainer who agreed to participate was sent a list of the objectives and expected training outcomes to ensure consistency across the two workshops. Emphasis was placed on providing a format and climate for the representatives to be active participants and not passive receptors of information.

Selection of Key Personnel to Participate in the Training

Because trained professionals indigenous to each reservation and trained in the field of visual impairments are virtually nonexistent, tribal community health directors and directors of programs for elders and social services were contacted to identify interested reservation-based community representatives who already work in the systems that provide services to American Indian elders.

Fifty trainee recruitment packets were sent to representatives of the 21 recognized tribes in Arizona. The list of names and addresses was created from various sources, including tribal leaders, the AIRRTC at Northern Arizona University, and the SBVI.

Two hundred people were identified as potential trainees. These individuals were sent an application letter as well as a brochure explaining the project. Fifty-one people returned the self-addressed stamped envelope indicating an interest in the program. Those individuals represented 14 of the 21 tribes in Arizona. The majority (31) of the returned applications came from tribal health programs and Indian Health Services. Sixteen application forms were returned by people who worked for senior citizens centers or other special services. Four persons employed by SBVI and who work for the Rural Elderly Blind program returned applications. Applications were not received from six tribes.

Results

First, results are presented concerning the training program for community representatives to provide independent living skills to those who are elderly and visually impaired. Next, the followup inservice training for the reservation-based community representatives, consumers, family members, and tribal officials is discussed, including a description of the numbers of people with visual impairments served by the trained representatives. Finally, plans for continuation of project activities are discussed.

Training Program for Reservation-Based Community Representatives

A total of 38 people attended the first phase training workshops in Tucson and Flagstaff. The trainees represented 12 Arizona tribes. Twenty-five individuals worked in tribal health departments, eight were from tribal senior citizen programs, four represented the Rural Elderly Blind Program of the SBVI, and one person worked in a tribal group home for people with developmental disabilities.

An ophthalmologist provided information concerning physiology of the eye and issues related to eye disease and eye care. A psychologist discussed problems relating to family systems involving an individual who is visually impaired. A gerontologist provided information on elderly needs and concerns. The latest array of technical and low vision equipment were demonstrated by a representative from a local company, and trainees were encouraged to try out this equipment. Cultural issues were presented by an American Indian researcher from the AIRRTC. Various social agencies, such as Native Americans for Community Action, gave brief overviews of their services. Mobility specialists taught and practiced sighted guide skills with the trainees and discussed issues related to independent travel. Rehabilitation specialists taught home, personal, and communication management skills.

The rehabilitation specialists also displayed various aids available for people with visual impairments. Many of the devices were provided for trainees to use with people on their reservations. Each representative also received bold line writing paper, an envelope writing guide, a signature guide, a check writing guide, a letter writing guide, Hi-Marks, a magni-guide, a medicine bottle opener, a safety food turner, a hot pan grip, an inner lip plate, oven mitts, a magnifier, low vision playing cards, a pill organizer, a large print telephone dial, and one 33-inch and one 36-inch orthopedic folding cane. The trainees were given adequate time to practice using these devices with people who are visually impaired. They were also able to practice their newly acquired skills on each other before using these skills to benefit their clients.

There were two workshops, each lasting 5 days. Reservation-based community representatives from the southern and central tribes were invited to the Tucson Workshop at the Arizona State School for the Deaf and Blind from February 25 to March 1, 1991, and representatives from the northern tribes were invited to the Flagstaff Workshop at Northern Arizona University on March 18-22, 1991.

Fifteen trainees representing six tribes participated in the Tucson workshop where they practiced their skills with nine visually impaired elders who had volunteered from the Tucson Association for the Blind. Their Practicum was held at the Tucson Center for the Blind.

Twenty-three representatives from six northern Arizona tribes participated in the Flagstaff Workshop and practiced their skills with six residents of Flagstaff with visual impairments.

The practicum at both workshops provided a valuable learning experience for the representatives. Many of the trainees identified the practicum as one of the most valuable experiences of the workshop.

The knowledge and skills acquired during the 1-week training sessions were competency based. The learning outcomes specified in the pretest/post-test questions were matched to the learning outcomes described in the objectives. The pretest/post-test consisted of 40 multiple choice questions. The pretest group mean for the trainees was 17 and the post-test group mean was 31. The difference between the pretest and post-test means was significantly different, t(37) = - 15.44, p< .0001.

Followup Inservice Training

Followup inservice training was provided for those completing the Tucson and Flagstaff workshops and consisted of two telephone consultations and one meeting on the reservation that included inservice training for tribal members. The followup training focused on needs specific to the reservation and helped to enhance training areas that needed more attention and improvement, correct misunderstandings, and reinforce the use of techniques learned at the workshop. The inservice training focused on the same curricumlum as the workshop. Overall, community inservice training was provided to 17 tribes through 23 onsite visits. Sixty-two percent of those who attended were people with visual impairments or relatives of people with visual impairments, 25 percent were Indian Health Services representatives, 10 percent were senior citizen center representatives, and the remaining 3 percent were from various agencies.

Overall, 282 people attended at least one of the 23 inservice training sessions on the reservations. Seventy-one of the participants were Indian Health employees, of which 3 were nurses and 51 were Certified Health Representatives. One hundred seventy-six were elderly visually impaired or relatives of people who were visually impaired. Twenty-eight people who attended one of the inservice sessions worked for senior citizen programs or centers. One person attending the Tobacco O'Odham session was a children's home supervisor; another was a supervisor of developmental disability services. A deligate from the tribal chairman's office of the Hopi Tribe attended one of the training sessions at Moencopi. Four other persons worked for the SBVI Rural Elderly Blind Program.

Some of the representatives who attended the workshop and inservice followup conducted their own inservice training for tribal members. Two representatives from the Navajo Trive presented three sessions, while one representative from the Hopi Tribe conducted two additional sessions.

People with Visual Impairments Served by the Trained Community Representatives

A total of 211 people with visual impairments--or an average of 5.76 persons per trainee--were served by the trained reservation-based community representatives. The numbers served by tribe were: Fort Apache, 6; Fort McDowell, 2; Fort Mohave, 8; Gila River, 9; Hopi, 20; Kaibab, 6; Navajo, 121; Pasqua Yaqui, 3; Hualapai, 10; Salt River, 16; San Carlos, 8; and Tohono O'Odham, 2.

Continuation of Project Activities

Because this training project was funded for only 1 year, efforts were made to identify ways to maintain the momentum of services to American Indian elders with visual impairments. Administrators from the SBVI planned followup activities to ensure that the reservation-based community representatives would continue to develop skills to work more effectively with their clients. These followup activities are part of a grant titled, Independent Living Services for Older Blind Individuals Program, which was funded under Title VII, Part C, of the Rehabilitation Act, as amended. Activities under this grant included additional training for the representatives in 1992, 1993, and possibly 1994. In addition to these activities, the participating tribes were allocated approximately $300 per year to purchase assistive materials and equipment.

Discussion

A training model was developed and implemented to train indigenous personnel in skills needed to aid American Indian elders with visual impairments. The model emphasized training tribal members who were already working for health and social systems within the tribe and followed methodology used in action research (Lewin, 1948; Whyte, 1991). From a psychological ecology perspective, training members of the tribes ensured ready access to tribal elders who were visually impaired and circumvented distance difficulties and language and cultural differences that might have inhibited rehabilitation interventions. Additionally, training people already within the services system was valuable in promoting culturally relevant programs that encourage networking within tribal agencies. When formal services are provided through state agencies or other non-tribal entities, the services tend to be sporadic, poorly utilized by the tribe, and use little or no networking. McNeely and Colen (1979) noted that because formal professional services are hindered by the lack of indigenous staff, informal networks are important in identifying persons at risk, determining needed services, and providing services. Litwak (1985) noted that members of the informal process are typically indigenouus workers and these workers are invaluable because they are regularly members of both formal and informal groups and are in touch with community members. Training tribal members ensured that persons within the community had the knowledge and skills to assist individuals who are elderly and visually impaired. These persons also are used as contacts for state agency personnel who also serve people who are visually impaired. Collaborative efforts with the Arizona State Services for the Blind and Visually Impaired will help ensure the continuation of benefits gained from this project.

References

[1.] Edwards, E.D., Edwards, M.E., & Danines, G.M. (1980). American Indian/Alaska Native elderly: A current vital concern. Journal of Gerontological Social Work, 2 (3), 213-225.

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[4.] Litwak, E. (1985). Helping the elderly: The complementary roles of the informal networks and formal systems. New York: Gulford.

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[6.] Loveland, K.A. (1991). Social affordances and interaction II: Austism and the affordances of the human environment. Ecological Psychology, 3 (20, 99-119.

[7.] Maddux, C. (1987). Analysis of the prevalence of disability among American Indians: School-based data. 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. 98-144). Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center.

[8.] Marshall, C.A., Martin, W.E., Jr., Thomason, T.C. & Johnson, M.J. (1991). Multiculturalism and rehabilitation counselor training: Recommendations for providing culturally appropriate counseling services to American Indians with disabilities. Journal of Counseling and Development, 70 (1), 225-234.

[9.] Martin, W.E., Jr., & Frank, L.W. (1987). An analysis of the labor market participation of American Indians with implications for rehabilitation. 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, 2, pp. 98-144. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center.

[10.] 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.

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[12.] O'Connell, J.C. (Ed.). (1987). A study of the special problems and needs of American Indians with handicaps both on and off the reservation, Vol. 1. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center.

[13.] Saravanabhavan, R.C., & Marshall, C.A. (19910. The aging American Indian: Implications for providers of health care and human services. Paper presented at the eight national forum on research in aging, Lincoln, NE.

[14.] Saravanabhavan, R.C. (1991). Rehabilitation needs of the elderly American Indians who are visually impaired or blind and living on the Hualapai reservation in Arizona. Unpublished doctoral dissertation, Northern Arizona University.

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[17.] White, K., & Carlise, K. (1991). Training programs for individuals working with older American Indians who are blind and visually impaired. Flagstaff, AZ: Northern Arizona University, Institute for Human Development, Native American Research and Training Center.

[18.] Whyte, W.F. (1991). Particpatory action research. Newbury Park, CA: Sage.