R-7: An Evaluation of a Goal-Oriented Training Package to Increase Community Participation of People with Mobility-Related Disabilities

IntroductionPassage of Laws such as the Americans with Disabilities Act of

1990 opened doors for people with disabilities to join the mainstream of society. Despite continued and collaborative efforts by consumers, community organizations and researchers, people with disabilities still face community barriers to increase and maintain enhanced participation (White, Simpson, Gonda, Ravesloot, & Coble, 2010). As a result, people with disabilities experience more social isolation, poorer health, and lower socioeconomic status (Howard, Russoniello, & Rogers, 2004; Nosek, 2005) and less satisfaction when they do participate compared to people without disabilities (National Organization on Disability & Harris Interactive, Inc. [NOD/Harris], 1994; NOD/Harris, 2000).

There has been increasing attention to and literature on community participation of people with disabilities. This literature addresses conceptual issues (Dijkers, 1998), measurement construction (Stark, Hollingsworth, Morgan, & Gray, 2007), and instrument development (Gray, Hollingsworth, Stark, & Morgan, 2006). There have only been a few empirical studies involving interventions to assess and analyze community participation of people with disabilities. The purpose of this project was to increase frequency and diversity of community participation of people with mobility-related disabilities through an information and skills training package, and peer support to help consumers attain goals for increased community participation.

Research Questions1. What are the effects of a community participation training package

(Get Out & About!) on participants’ acquisition of knowledge and skills?

2. What are the effects of a community participation training package (Get Out & About!) and weekly social support on increasing the frequency and variety of community participation of people with mobility-related disabilities?

MethodFocus Group

Six consumers with various physical disabilities attended a focus group and discussed their views on community participation. Focus group members stated that community participation is a means to “get voices heard”, “connect with folks”, “give back to the community” and “educate the public about people with disabilities”. No one reported receiving training related to topics that might enhance community participation (e.g., IL skills, advocacy, employment).

Training Material DevelopmentThe Living Well with a Disability manual (Ravesloot et al., 1998) was

used as a foundation and guide for the Get Out and About! training manual. Based on feedback from our focus group of people with disabilities, four chapters from the LWWD manual were selected and revised. The Get Out and About! training manual was evaluated by three external reviewers with disabilities for content validity. Chapters selected included:

1. Goal Setting

2. Problem Solving

3. Information Seeking

4. Advocacy

Operational Definition of Community ParticipationFor the purpose of this study, we defined community participation as:

One discrete event or outing executed 1) outside of the participant’s home and/or property and, 2) within 50 miles distance from the participant’s home.

Example - If a person saw a movie at a theater, and stopped by the grocery store to shop on the way home, this would count as two discrete outings in the community.

Non-Example –If a person traveled out-of-state for a vacation.

Participants and Settings•Two persons with mobility-related disabilities

•Midwestern community (Population 92,000)

•Data collection – In participants’ natural environment

•Trainings – A meeting room in a university building

•Social support meetings – Cafeteria at the local grocery store (near participants’ homes)

Design•Single-Subject Design, ABCDC Design (pre-baseline, baseline, post-

workshop training + social support, NO SS, and SS)

Materials/Equipment/Incentives•The Treo Handspring Visor Pro PDA

•Sanyo VPC-E1090 digital camera

•PDA instruction handbook

•Get Out & About! Training Manual

•Up to $250 cash at the end of the study

•$5 cash for attending each meeting

Independent Variables•2 day Get Out and About! Training Workshop

•Weekly social support meeting

Dependent Variables•Scores from pre/post test on manual and training content

•Number of discrete places visited in the community (diversity, duration, social context, satisfaction)

•Number of goals/objectives and action steps completed

•Social validity of procedures and outcomes

Procedure Pre-Baseline

•Participants were asked to retrospectively self-report their community participation activities in the past 7 days.

Baseline•During the baseline, each participant carried a Personal Digital

Assistance (PDA) which had been pre-programmed to signal four times per day at 12 pm, 3 pm, 6 pm and 9 pm. At these prompts, each participant accessed their PDA and answered a short survey (see Table 1). The researcher visited participants’ homes twice weekly for data collection. Participants were also asked to save any permanent products associated with their outings (i.e., receipt, ticket stubs, brochures, medical appointment cards, photos, etc.) and submit them to the researcher.

Table 1

Frequency Location Activity Social Context Duration Satisfaction Verification

Reminder

Did you go out in the past 3

hours?

Where did you go in the

past three hours?

What kind of

activity (or activities)

did you engage in?

Who are you primarily doing this

activity with?

How long were you out in the

community?

How satisfied were you with this activity?

Please save any

permanent products

associated with your outings.

•Yes •Entertainment facility •Education •Alone •Less than 30

minutes •1= dissatisfied •Yes

•No •Grocery/Drug Store •Employment •Business Person •30 min. to 1

hour•2 = slightly

dissatisfied •No

•Gym or exercise facility

•Household chores •Family •1 hour to 2

hours •3= neutral

•Health care facility •Leisure •Friends •2 hours to 3

hours•4 = slightly

satisfied

•Home •Social •Significant other •N/A (didn’t go out) •5= satisfied

•Office building •Self-care •Mixed group

•Park/forest/lake •Resting •Peers or coworkers

•Public sidewalk •Transportation •Pet(s)

•Religious facility •Other •Professionals

•Restaurant/café/bar •Significant other

•Retail store •Strangers

•School •Other

•Someone else’s home

•Other

Treatment Conditions•Participants attended two, five-hour training sessions over a two day

period. The workshop included PowerPoint presentations, individual exercise questions and group discussion, and a working lunch. Participants also took pre and posttest surveys to determine the acquisition of knowledge and skills gained from the Get out & About! training.

•Following the training, participants were invited to attend weekly social support meetings. During each social support meeting, participants reported progress toward their goals and barriers or problems they encountered in reaching their goals since the last meeting.

ResultsGraph 1

55

63

28

59

66

77

53

7875

100

0

10

20

30

40

50

60

70

80

90

100

Overall Goal Setting Problem Solving Information Seeking Advocacy

Pre Post

Mick's Pre/Post Test Score

Test

Sco

re (

%)

Graph 2

55

4036

55

86

78

90

70

80

73

0

10

20

30

40

50

60

70

80

90

100

Overall Goal Setting Problem Solving Information Seeking Advocacy

Test

Sco

re (

%)

Pre Post

Don's Pre/Post Test Scores

Graph 1 and 2 present pre and posttest scores of Mick and Don. Mick’s overall test score increased by 22%, with significant improvement except for his post test score on the Goal Setting chapter. Don’s overall test score was increased by 23%. Don’s test score also improved noticeably with the exception of the Advocacy chapter.

Graph 3

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Num

ber

of D

iscr

ete

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Days

Out of state trip

Pre-Baseline Baseline w/PDA monitoring Post Training + SS

Training

SS Mtg SS Mtg

Out of

SS

Post Training + No SS

SS Mtg

Post Training + SS

Mick's Daily Community Participation Data

Graph 4

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Don's Daily Community Participation DataPre-

Baseline

Baseline w/ PDA Monitoring Post Training + SS

TrainiSS

SS

SS

Post Training + NO SS

SS

Post Training + SS

Graph 3 and 4 present daily community participation rates for Mick and Don. Mick had an average of 1.25 outings during the pre-baseline condition. His daily community participation rate almost doubled (2.47

outings per day) during the baseline condition compared to the pre-baseline condition. During the post training and social support condition, Mick’s daily community participation rate averaged 1.55 outings. When social support was withdrawn, his average community participation rate decreased to 1.37 outings per day. Mick’s daily community participation rate decreased to 1.31 when social support was re-introduced in the last condition.

Don had an average of 1 outing per day during the pre-baseline condition. His community participation rate increased to 1.7 outings per day during the baseline condition. After the training and social support were implemented, Don’s community participation rate decreased to 1.45 outings per day. Don’s highest community participation rate occurred during the post training and no social support condition with an average rate of 2.1 outings per day. His community participation rate decreased to 1.75 outings per day when social support was re-introduced in the last condition.

Overall, there is a high degree of variability within each condition and no clear trend was observed.

Graph 5

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1 2 3 4 5

Cum

ulat

ive

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of G

oal/O

bjec

tives

/Act

ion

Step

s Co

mpl

eted

Social Support Meeting SessionsCumulative Number of Goal Met

Cumulative Number of Objectives Met

Cumulative Number of Action Steps Met

Mick's Progress Toward Reaching His Goal

Graph 6

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Social Support Meeting SessionsCumulative Number of Goal Met

Cumulative Number of Objectives Met

Cumulative Number of Action Step Met

Don's Progress Toward Reaching His Goal

Achieved his goal of enrolling

in a weeklyTai-chi Class

Graph 5 and 6 present cumulative data of Mick and Don’s progress toward reaching their goal.

Since the training, Mick reported completing 10 action steps that are related to his goal. Mick reported accomplishing one objective during the fourth social support meeting, but was not able to achieve another objective or a goal before the study concluded.

Don completed seven actions steps by the end of the study. In the fourth social support meeting, he reported reaching his goal of enrolling in a weekly Tai-chi class and then attended a Tai-Chi class every Friday.

DiscussionIn response to research question one, both participants increased their test

scores by an average of 22.5%, which indicates that participants were able to acquire knowledge and skills from the Get Out & About! training.

Using a PDA to collect participants’ data and measure community participation was successful. In contrast to a similar study by Seekins, Ipsen, and Arnold (2007), participants in this study had steady and high PDA survey completion rates (i.e., 100 % for Don, 99.7 % for Mick). These results suggest that the high PDA completion rate may have been achieved and maintained by having a contingency contract based on the percentage of on-time PDA survey entries. The lower the completion rate, the lower the incentive that was paid out at the end of the study. Additionally, PDA performance feedback provided at twice a week visits by the researcher might also have accounted for the high PDA survey completion rate. Both participants produced high verification levels of their self-reported community participation activities by submitting permanent products associated with their outings (e. g., Don = 100%, Mick = 93%). The researchers checked each permanent product to verify that the time and place of outings matched participants’ PDA survey form self-reports. Regarding their frequency of community participation, participants did not have increased community participation rates over baseline levels.

Even though increased community participation was not observed in both participants, one participant (Don) made significant progress toward reaching his goal of enrolling in weekly Tai-Chi class as a result of the Get Out & About! training package. The other participant (Mick) chose a more complex and distal goal (i.e., obtaining part-time employment), which might not have been an attainable goal during the course of a 12-week study. Both participants expressed that the weekly social support sessions helped them to pursue their goals. It was encouraging to see the participants exchanging information and resources to help one another during the social support sessions.

Lessons Learned Initially, the PDA was used as a dependent measure to monitor

community participation of study participants. However, the data suggest that in addition to measuring participant’s outings, the PDA also functioned as a strong prompting effect and participants were reactive to PDA prompting as noted in the second baseline.

It is possible that the Get Out & About! training workshop may be necessary to help participants meet their goals, but perhaps not sufficient to get them out into the community more frequently. This may partly be due to participants spending more time in their homes making phone calls, searching on the web and/or reading the newspaper to complete action steps in order to accomplish their stated goals.

Even though the main study goal was not achieved, we discovered that using a PDA to measure community participation was successful and reliable. Having participants submit the permanent products associated with participants outings also verified their self-reported community participation activities.

Future Research Future research should examine the quality of participants’ community

participation and evaluate how the environment, social contexts, health conditions, roles and degree of involvement affects community participation of people with disabilities.

The experiences of people with disabilities are unique and different from the rest of the population. It is important to assess normative data to have a better understanding about community participation for all citizens. Thus, it would be useful for researchers to further explore how people without disabilities participate in their communities and review the barriers and facilitators to enhance community participation. These data will be helpful for comparative evaluation with people with disabilities.

FunderThis research is funded by the National Institute on Disability and

Rehabilitation Research at the US Department of Education, award number H133B060018.

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Howard, D., Russoniello, C., & Rogers, D. (2004). Healthy people 2010 and therapeutic recreation: Professional opportunities to promote public health. Therapeutic Recreation Journal, 38, 116-32.

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Nosek, M. (2005). Wellness in the context of disability. In: J.E. Meyers & J. Thomas (Eds.), Counseling for Wellness: Theory, Research and Practice. Alexandria, VA: American Counseling Association.

Ravesloot, C., Young, Q. R., Norris, K., Szalda-Petree, A., Duffy, S., White, G., . . . Humphries, K. (1998). Living Well With A Disability. Missoula, MT: University of Montana. Rural Institute on Disabilities.

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Stark, S., Hollingsworth, H., Morgan, K., & Gray, D. (2007). Development of a measure of receptivity of the physical environment. Disability and Rehabilitation, 29(2), 123-137.

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Chiaki Gonda, B.A. & Glen W. White, Ph.D. Research and Training Center on Independent Living & Department of Applied Behavioral Science at the University of Kansas