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a Ghent University, Faculty of Psychology, Research Group Ageing Studies, Belgium
b Free University of Brussels, Public Health Care, Belgium
Correspondence: Marc Roelands, MA, Ghent University, Faculty of Psychology, Dunantlaan 2, 9000 Ghent, Belgium. E-mail: marc.roelands{at}rug.ac.be.
Decision Editor: Laurence G. Branch, PhD
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Abstract |
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Key Words: Socioeconomic status • Self-efficacy • Attitude • Care • Planned behavior
During the last few decades assistive devices (ADs) for self-care and mobility have been developed to improve the fit between the competency of elderly persons and the demands of the environment. Examples of ADs are wheelchairs, shower seats, and sock aids. They are intended to improve the autonomy and quality of life of elderly persons in a cost-effective way. Furthermore, they are prescribed with the aim of influencing the quality and cost of social care and health care in a positive way by lowering the need for intramural care (de Klerk and Huijsman 1995
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The prevalence of AD use has been estimated in the general population in the United States (LaPlante, Hendershot, and Moss 1992; Mann, Hurren, and Tomita 1993). In the age group of 65 to 74 years old, 22% of the U.S. population use mobility ADs, which increases in the age group of 75 years old and older to 43%. The type of AD used by elderly persons has been investigated in 76-year-old Swedish people: Grab rails (16% of total population) and canes (15%) were used by the largest proportion of the population (Sonn and Grimby 1994).
To explain and predict the use of ADs, models that incorporate many factors involved in the use of ADs, including social and psychological factors, have been proposed on the basis of clinical evidence or literature review (Rogers and Holm 1992; Scherer and McKee 1989). We believe, however, that these important models could benefit from both empirical/methodological improvements, such as appropriate data-analytic techniques, and theoretical improvements. A more established theoretical background would allow an effective protocol to be developed to introduce ADs in a more structured way by taking crucial variables into consideration. Several social–cognitive models of human behavior have been described that predict human behavior quite adequately. They emphasize the role of attitudes, subjective norms, behavior intention, self-efficacy (Ajzen 1991; Bandura 1997), and awareness (McGuire 1985).
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A Social-Cognitive Model of the Use of ADs |
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). The theory of planned behavior takes into consideration the influence of personal evaluations (attitudes), perceived social pressure (subjective norm), and perceived behavioral control in predicting the intention to perform a specific behavior. The predictors are understood as expectations weighted by personal values. It is therefore also referred to as an expectancy value model (Ajzen and Fishbein 1980). It has been used successfully in understanding and predicting health-related behaviors such as alcohol consumption (Conner, Warren, Close, and Sparks 1999), uptake of a cervical smear test (Bish, Sutton, and Golombok 2000), condom use (Gagnon and Godin 2000), dietary behavior (Povey, Conner, Sparks, James, and Sheperd 2000), the adoption of hormone replacement therapy (Legare, Godin, Guilbert, Laperriere, and Dodin 2000), and exercise adherence (Rhodes et al. 1999). An overview can be found in Armitage and Conner 2000. When adapted to the use of ADs, the following concepts can be organized at four levels. In the context of the presence of disabilities (disabilities are understood as activity limitations; see World Health Organization 1980), the intention to use ADs (Level 2) is the most direct determinant of the actual use of ADs (Level 1). The intention to use ADs is determined by the following proximal variables (Level 3): the person's attitude toward the use of ADs, the AD self-efficacy, and the subjective norm regarding ADs. Bandura 1997(p. 3) described self-efficacy as "beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments." Ajzen and Madden 1986 stated that the self-efficacy concept is similar to the perceived-behavior-control concept in their theory of planned behavior. Perceived behavior control is defined as the person's belief as to how easy or difficult the performance of a behavior is likely to be. Because self-efficacy beliefs are specific regarding activity domain, we prefer the term assistive devices self-efficacy, which is used in our model.
The subjective norm refers to a person's perception of the strength of significant others' expectations to use ADs and the will to conform to these expectations, and has been proposed as a factor influencing the decision to use ADs or ask for personal help (Scherer and McKee 1989). The theory of planned behavior does not include background variables, as it is assumed that individual characteristics affect the central concepts in the model indirectly by shaping beliefs and evaluations (Ajzen and Fishbein 1980). Following McGuire 1985, we included awareness as distal variable (Level 4).
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Methods |
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The required sample size was estimated to be about 500 persons. For statistical reasons the sample ought to be large enough to include at least 20 individuals of each gender with severe disabilities on the basis of the assumption that AD use is related to disability. The prevalence of most disabilities is lowest in men and is about 10% or higher (Demarest et al. 1998). Taking into consideration the distribution of gender in the population and assuming that AD use is related to disabilities, it could be calculated that the smallest groups in the study include 20 persons if the sample size is 500 (500 persons x 0.4 men x 0.1 disabilities).
We opted for a representative sample to allow extrapolation of the descriptive data toward the population. An indirect or two-stage sample selection was used to limit the geographic dispersion. In the first stage, a limited number of municipalities were randomly sampled. Because a connection between health behavior and socioeconomic status (SES) has been established (Lynch, Kaplan, and Salonen 1997; Stronegger, Freidl, and Rasky 1997) and to avoid a loss of representativeness regarding this important variable—which could occur because of the relatively small number of municipalities selected—the sample of municipalities was stratified by SES. A typology of all municipalities in Flanders, on the basis of the equipment of the houses and supplemented with some financial indicators, was available (Thomas and Vanneste 1997), and was chosen for two reasons. First, the equipment of the houses is considered to be a good indicator of the SES of a population (Thomas and Vanneste 1997). Second, the quality of the house is a measure of the environment in which AD is used. Six types are distinguished, of which five can be found in Flanders. The municipalities were selected as follows (Deliens 1998). A random sample of municipalities was selected within each stratum. To make the sample self-weighting, which avoids conversion of the results to the population, the population size had to be taken into consideration. A municipality could receive 0, 1, or more sample points. A sample point consists of 14 effective persons and 2 x 14 persons who were on the reserve list. The 40 sample points were distributed over the strata of municipalities in proportion to the size of their population. Within these strata, sample points were distributed using a systematic drawing to warrant random selection. If a municipality received no sample points, this implied that it was not included in the sample of municipalities.
In the second stage, in each of these municipalities a random sample of people born between January 1, 1910, and December 31, 1929, was selected, using the population register provided by the municipalities. Of the 35 municipalities that were originally contacted, 2 refused to cooperate for reasons of protection of privacy and were replaced at random within the same stratum. Persons who could not be contacted after three attempts or refused to cooperate were replaced by the next person on the randomly ordered list from the random sample in the municipality until this sample was exhausted.
Data Collection Procedure
Once selected, the person was informed of his or her selection by letter. Thereafter, the researcher contacted the person by telephone to ask for his or her consent and to make an appointment. Trained interviewers, using a standardized questionnaire to interview elderly persons at home, did the data collection. The response categories were presented to the interviewee.
Instruments
Awareness, Possession, and Use of ADs.
The Assistive Devices Awareness Scale (ADAS) has been developed by the authors to measure awareness of ADs and possession and use of ADs (Roelands, Van Oost, Buysse and Depoorter in press). Thirty-two ADs were chosen on the basis of their prevalence in patients of home nurses, as reported by a sample of nurses. The 32 ADs were presented visually by using photographs and mentioning their names. For every AD, the person was asked some interrelated questions. First, the person was asked whether he or she possessed it or not. If the person did possess the AD, he or she was asked whether he or she used it (code 2) or not (code 1). If the person did not possess the AD, he or she was asked whether he or she knew of its existence (code 3) or not (code 4). Because of the interdependency of the concepts of awareness, use, and possession and because of the attention that has been given to the smoothness of the interaction during the interview some calculations are necessary to arrive at the dichotomies of "aware or not," "use or not," and so forth. To calculate the scale for awareness of supply, we recoded the answer for every AD in two categories: aware (codes 1, 2, and 3) versus not aware (code 4). To calculate the scale for the possession of AD, we recoded the answer for every AD in two categories: possessed (codes 1 and 2) versus not possessed (codes 3 and 4). To calculate the scale for the use of the AD, we recoded the answer for every AD in two categories: use of AD (code 2) versus not used (codes 1, 3, and 4). The minimum score on the three interval scales is 0, the maximum score is 32. Cronbach's alpha was .86, .68, and .50, respectively.
Five subscales were developed to measure the awareness of groups of ADs (those that help with dressing, washing, mobility, going to the toilet, bed transfer) and five subscales were developed to measure the use by groups of ADs. The items can be found in the table on awareness. In the scale on mobility the personal alarm system was not included. The Cronbach's alphas of the awareness scales were acceptable, taking into account the dichotomous nature of the items: .57, .53, .74, .54, and .54, respectively. The Cronbach's alphas of the scales relating to AD use were .05, .25, .38, .12, and .43, respectively.
Attitudes Toward AD Use.
The Attitudes Toward Assistive Devices Scale (AADS) consists of 12 items that measure the opinions of community-dwelling elderly persons on different aspects regarding ADs: the substitution of care, the financial aspect of care, and the perceived effect on privacy. The items are listed in the table on attitudes. To increase the internal consistency of the scale to measure the multidimensional concept, while keeping it short, we first slightly modified the 21 items that were developed by de Klerk and Huijsman 1993 regarding wording and presented them to community-dwelling elderly persons. Twelve items could be retained using factor analysis on the 21 items (Roelands, Van Oost, and Depoorter 1999). An example of an item is "When using ADs you are less dependent on others." We chose a Likert scale with 5 points from 5 (totally agree) to 1 (totally disagree). A total score was calculated. The theoretical minimum score on this interval scale is 12, the maximum score is 60. A high score indicates a positive attitude. The scale has high face validity. Comparison with established measures of attitudes toward ADs to estimate the validity is hampered by a lack of these measures. The internal consistency was .61, which is sufficient.
To further elaborate on the attitude toward the use of ADs, we developed a scale within the expectancy-value model of attitude, measuring attitude according to the guidelines of Ajzen and Fishbein 1980. Six modal salient beliefs about the consequences of AD use were obtained from the literature (de Klerk and Huijsman 1995; Sonn and Grimby 1994), regarding autonomy, stigmatization, efficiency, speed of performance, care substitution, and safety. An example of an item is "If I use ADs other people will think I am old and sick." The strength of the belief could be indicated on a bipolar Likert scale with 5 points from 5 (totally agree) to 1 (totally disagree). All respondents also valued the personal importance of these beliefs. An example of an item is "To what extent is it important to you that other people do not think you are old and sick?" For each belief the person evaluated on a bipolar, 5-point Likert scale whether this consequence was 5 (very important) to 1 (very unimportant) to her or him. The product of the level of agreement regarding a consequence and its evaluation was calculated for each perceived consequence. A total score of the six products was calculated. A high score indicates that positive consequences are expected. The scale ranges from 6 to 150. The reliability of this interval scale was sufficient: Cronbach's alpha was .58.
Subjective Norm on AD Use.
The Subjective Norm on Assistive Devices Scale (SNADS) was developed for the study to predict the subjective norm regarding the use of ADs. The scale measures with one item the significant others regarding the use of ADs (partner, children, friends, general practitioner, nurse, and other professional caregiver), with six items on the normative beliefs, and with six items on the motivation to comply with the beliefs. There is one item per significant other measuring the normative belief and one item measuring motivation to agree with that significant other. An example of a normative belief item is "Do you think that your partner thinks you should use assistive devices in case you cannot perform an activity on your own?" A bipolar, 5-point Likert scale ranging from 5 (totally agree) to 1 (totally disagree) was used. An example of the motivation to comply items is "To what extent would you allow yourself to be guided by the opinion of your partner?" The unipolar, 5-point Likert scale ranged from 5 (very strongly) to 1 (very little). The product of the strength of the normative belief and the corresponding motivation to comply was calculated for each normative belief, ranging from 1 to 25. A total score of the six products was calculated. A high score indicates a high subjective norm. The interval scale ranges from 6 to 150. Cronbach's alpha was not computed as the assumption of internal consistency does not hold for this linear composite score.
Self-Efficacy Regarding AD Use.
The self-efficacy regarding the use of ADs was measured with three items we developed, each presenting increasing barriers. The introduction was "What do you think about yourself in these situations? Assume that you possess an assistive device." The items were "You want to use the AD when you cannot perform the activity alone," "You want to use the assistive devices every time if required by the situation," and "You want to use the AD, even if it is tiring and difficult sometimes." A 5-point Likert scale ranging from 1 (I know I cannot do it) to 5 (I know I can do it) was used. A total score was calculated, with a high score indicating high self-efficacy. The interval scale ranges from 3 to 15. The reliability of this scale was good: Cronbach's alpha was .78.
Intention to Use ADs.
The intention to use ADs was measured with three items we developed, presenting increasing levels of intention. The introduction was "What would you do in the following situations? Assume you possess an assistive device." The three items were: "Would you use the assistive device when you cannot perform the activity alone?" "Would you use the assistive device every time if required by the situation?" and "Would you use the assistive device, even if it is tiring and difficult sometimes?" A 5-point Likert scale ranging from 1 (I do not have the intention to do this at all) to 5 (I certainly have the intention to do this) was used. A total score was calculated, with a high score indicating a high intention to use ADs. The interval scale ranges from 3 to 15. To optimize the distribution of the scores, we performed a square root transformation. This score was used in the analysis. The reliability of this scale was good: Cronbach's alpha was .71.
SES.
As a measure of the SES of the person, we used the objective income ("What is the net income of the household?"; Demarest et al. 1998).
Functional Status.
Functional status was measured with two instruments. A subscale of the Dutch version of the Short Form-36 (SF-36) measured physical functioning (Aaronson et al. 1998). The scale on physical functioning consists of 10 items on a 3-point Likert scale, with 10 being totally unlimited, 5 being a bit limited, and 0 being seriously limited. With our scoring, a high score indicates a high level of physical functioning. Cronbach's alpha was .93 in this study, a value that was also found by Gandek and colleagues 1998.
An activities of daily living scale (ADL scale) was included, too. It consists of two scales. One is the Katz Scale (Katz and Akpom 1976), which is a measure of functional status, more specifically a measure of the need for care. Our version of the Katz Scale is the official version that is used for financing Belgian home nursing care. It consists of six items: dressing, washing, indoor mobility, eating, continence, and going to the toilet. Each item has four particular response categories, the content of which depends on the specific item. Moreover, in this study, six items were added, giving valuable information regarding disabilities in instrumental ADL (IADL; shopping, cleaning, washing clothes, ironing, cooking, and managing the housekeeping). Four response categories are provided to measure IADL that differ from the Katz Scale: (a) "is completely independent regarding ..." (b) "is independent regarding ..., except for some aspects" (c) "is dependent regarding ..., but can perform some aspects" and (d) "is totally dependent regarding ..." The minimum score on the total 12 items of the interval scale is 12; the maximum is 48. A high level of functional status results in a high score. The internal consistency as a measure of reliability was good: Cronbach's alpha was .87 in this sample.
Statistical Analysis
To test for differences (regarding age, gender, and SES) between nonparticipants—those refusing participation—and participants, we used 
2 analyses. In this analysis age was dichotomized in 10-year age groups. The differences between the different normative beliefs and between the perceived consequences were tested with paired-sample t tests to ascertain if the differences between normative beliefs or between perceived consequences could be accepted as real differences, indicating a hierarchy. The differences regarding awareness and use by specific groups of ADs between persons with and without a specific disability were tested with independent-sample t tests. Levene's test was used to test for equality of variances. With path analysis, using correlations, partial correlations, and linear regression analysis, the relation was tested between the distal variable awareness of AD, the proximal variables of attitudes, self-efficacy, and subjective norm, and the intention to use ADs. Furthermore, regression analysis tested the relation between the intention to use ADs and functional status (measured with the ADL scale) as independent variables and the use of ADs as the dependent variable. The scale scores of the Intention to Use AD Scale were square root transformed because the data were skewed to the right. The distribution was ameliorated toward a more normal one. These results were the only ones that could benefit from a transformation. All analyses were performed with SPSS for Windows 7.5 (SPSS Inc., Chicago, IL).
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2(4, N = 1019) = 6.16, p > .05 and age 2(1, N = 1004) = 0.10, p > .05. More women refused to cooperate than men 2(1, N = 1019) = 4.50, p < .05. Of the women who satisfied the inclusion criteria, 54.1% refused; the refusal rate was 47.4% in men. The demographic characteristics of the sample are presented in Table 1 .
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The Possession and Use of ADs
The majority of the community-dwelling people aged between 70 and 89 possessed (89.9%) and used (80.6%) at least one of the 32 ADs. More specifically, the respondents possessed between 0 and 21 devices of the 32 ADs that were investigated; the mean number was 3.11 (SD = 2.52). Table 2 presents the possession and use for each AD. The respondents used between 0 and 11 ADs of the 32 that were investigated; the mean number was 1.95 (SD = 1.69).
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Regarding going to the toilet and bed transfer, there was a tendency toward the use of more ADs by people with the specific disability (any level of assistance needed in, respectively, going to the toilet and bed transfer, as measured with the respective items of the Katz Scale), compared with persons without this disability (no personal assistance or AD needed; Table 3 ). After a Bonferroni adjustment for multiple comparisons, the differences between persons with and without a disability were significant only for mobility (independent-sample t test: p < .005). The difference regarding a disability in washing was in the opposite direction; persons without this disability tended to use more ADs compared with persons with this disability. The difference between persons with and without a disability regarding dressing was not significant.
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People with a disability regarding dressing or washing (any level of assistance needed in, respectively, dressing and washing, as measured with the respective items of the Katz Scale) tended to have a slightly lower level of awareness of the specific groups of ADs compared with persons without this specific disability (no personal assistance or AD needed; independent-sample t test; Table 3 ). After a Bonferroni adjustment for multiple comparisons, these differences were not significant. An equal level of awareness was found in persons with and without a specific disability regarding mobility, bed transfer, and going to the toilet.
Attitudes Toward the Use of ADs
On the basis of the 12-item scale, we found that the attitude toward the use of ADs of community-dwelling elderly adults was positive. The mean total score on the scale was 45.07 (minimum = 28, maximum = 58; SD = 5.45). The item scores are presented in Table 5 . The agreement with the opinion that ADs are a good solution to certain problems was high. These community-dwelling elderly people expected increased autonomy when using ADs and believed in the potential of ADs to substitute care. They thought that the use of ADs would make someone less dependent on personal assistance, and they expected that by using ADs they would be able to remain longer at home when they become more in need for care. In general, the elderly persons subscribed to the opinion that care substitution has its limits and the use of ADs could not exclude personal help. Elderly persons valued the control they maintain over their lives when using ADs. The agreement with the belief that if they had an AD they could do things their own way was high.
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The attitudes were also measured with the scale of perceived consequences of the use of ADs (Table 6 ). The community-dwelling elderly adults particularly expected increased safety and efficiency. Secondly they expected autonomy, followed by speed of performance. Care substitution and stigmatization were least expected. The differences between all pairs of means were significant (paired-sample t test: p < .001), except for the difference between stigmatization and care substitution, and between efficiency and safety.
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The product of the degree to which one agrees with a perceived consequence on the one hand and the personal valuation of the importance of this consequence on the other is a measure of the importance of each attitude for this person (Table 6 ). The most important attitude was the perceived increase in safety, and the second most important attitudes were autonomy and efficiency. Less important attitudes are, in decreasing order, increased speed of performance, care substitution, and stigmatization. The differences between all pairs of means were significant (paired-samples t tests: p < .01), except for the difference between autonomy and efficiency.
The mean total score was 95.14 (minimum 29, maximum 150; SD = 20.18).
Subjective Norm Regarding the Use of ADs
The general practitioner was mentioned most often (by 63.4% of the respondents) as the person whose opinion is valued regarding the use of ADs, closely followed by the children (52.8%) and the partner (47.2%). Nurses (21.3%) and friends (12.3%) were mentioned less. Only 4.1% of the elderly persons mentioned that they did not value anybody's opinion regarding the use of ADs.
The product of the perceived strength of a significant other's expectation to use ADs on the one hand and the motivation to comply with this expectation on the other is a measure of the strength of a normative belief for this person. The most important normative belief concerned the general practitioner, and the second most important normative belief concerned the children and the partner (Table 4 ). In order of importance, the other important normative beliefs concerned the nurse and friends. The differences between all pairs of means were significant (paired-samples t test: p < .0005), except for the difference between the normative beliefs regarding the partner and the children. The mean subjective norm was 36.13 (SD = 23.41).
Self-Efficacy Regarding the Use of ADs
The mean self-efficacy score, obtained with the three-item scale, was 12.02 (SD = 2.06, minimum = 3, maximum = 15). Elderly persons believe they can use an AD when they cannot perform the activity on their own, they believe they can use the AD if this is required by the circumstances, and they believe they can continue to use the AD, even if it is tiring and difficult (Table 4 ).
A Model of the Use of ADs
The model was tested with path analysis, testing significant and nonsignificant relations. Specific, significant relations were expected between the proximal variables of attitude, subjective norm, and self-efficacy on the one hand and intention to use ADs on the other. The attitude was measured with the most reliable scale, the AADS. Moreover, significant relations were expected between the proximal variables and the more distal variable awareness of ADs. Finally, a relation between the intention to use ADs and functional status on the one hand and the use of ADs on the other was expected. After standardization of the raw scores in z scores of all variables that were included in the model to be tested, the relations were tested with two regression analyses and three correlations. The beta and p values are presented in Table 7 . Awareness was found to be significantly correlated to attitudes (Pearson r = .17, p 
.001) and subjective norms (Pearson r = .16, p .001), but not to self-efficacy. Direct effect of awareness on the intention to use ADs was investigated with the partial correlation between awareness and intention, controlled for attitude, subjective norm, and self-efficacy. It was expected to be nonsignificant and proved to be so. All expected relations within the core of the model were confirmed, although the relationship was often small. It is important to note that the scores on the functional-status instrument and the measure of the use of ADs are positively related, which means that the concepts are negatively related. The significant relations are presented in Fig. 1.
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Because the study focused on ADs for self-care and mobility in the general elderly population, almost all ADs were low tech, and many had already existed for quite a long time. The use of ADs was not exceptional. Almost all community-dwelling persons between 70 and 89 years possessed and used at least one of the 32 ADs for self-care and mobility. Elderly persons possess and use ADs especially regarding taking a bath and mobility. Notwithstanding these positive findings, the study revealed that many ADs were not possessed and used by a substantial proportion of elderly persons. ADs that have been developed more recently in particular (e.g., the personal alarm system, a device to pull on socks) were not possessed by the majority of elderly persons between 70 and 90 years of age, although these ADs can be helpful, not only to compensate for disabilities, but also to increase efficiency and safety in nondisabled persons. Even more problematic is the finding that the presence of specific disabilities, which is an obvious reason to use ADs, did not result in the use of more of the relevant ADs, except regarding mobility. Another topic of concern is the extent of the nonuse of ADs that elderly persons already possess. The proportion of the number of people that possess a specific AD but do not use it varies considerably from one AD to another. It can be hypothesized that the nonuse of canes, toilet seats, and long shoehorns can be attributed to the fact that these cheap ADs are passed on from one generation to the next and are stored until a person becomes disabled and needs them. But more expensive ADs are not used either, which is a waste of resources. Examples are the hydraulic hospital bed, the walking frame, the rollator, the manual wheelchair, the electric wheelchair, and the staircase lift. This finding suggests the need for improvement of follow-up. Although this finding is based on a small numbers of persons, we found nonuse for each of the 32 ADs, which supports the reliability of this result. The presence of disabilities is an obvious reason to use ADs: The data show that persons with disabilities regarding mobility, bed transfer, and going to the toilet used more ADs specific to these activities than did persons without these disabilities.
Before people can develop an attitude toward ADs, they need to be aware of them. This study showed a good awareness in the community-dwelling elderly regarding the existence of ADs that have been available for decades. These relate to mobility and transfer: the wheelchair, the parrot, the cane, and crutches; for washing: the anti-slip mat; regarding dressing: the long shoehorn; regarding going to the toilet: the toilet chair and incontinence material. Many people also possess these ADs. But some ADs regarding mobility that have been developed more recently were also known to most elderly persons, for example, the hydraulic hospital bed, a grip in the toilet, and the walking frame. This may be due to their presence in hospitals and rehabilitation centers. They are also well known to home nurses. But a lower level of awareness of 21 other ADs was found. These ADs may nevertheless increase the comfort and safety of elderly persons, and consequently their quality of life. Moreover, it was expected that persons with a disability would be more aware of the specific AD that would be relevant to increase their functional level than would persons without this disability, as the acquisition of a disability would trigger a search for information. This was not confirmed by the data. The findings suggest an equal level of information regarding all groups of ADs in people with specific disabilities.
In accordance with other studies, we found that the attitude of community-dwelling elderly people was rather positive toward the use of ADs. A clear order emerged. The finding that elderly persons do not use ADs solely with the aim of increasing autonomy (Sonn and Grimby 1994) was confirmed. The elderly persons in particular expected safety and efficiency as consequences of AD use, even more than, in descending order, autonomy and speed of performance. They also valued safety in the context of ADL highest, together with autonomy. They valued efficiency as secondary.
The elderly persons expected that AD use would substitute personal care at home and substitute intramural care by home care. But they thought that the substitution of care is limited and that AD use would not preclude personal help.
For health care workers introducing ADs, the consequences that should be emphasized are not only the increase in autonomy but the increased efficiency and safety, too. Because people expect these consequences and value them highly, these aspects of ADs can facilitate their introduction. The effect on care substitution and on stigmatization should be discussed in greater depth with disabled persons, but with some caution as negative attitudes can be expected, and in general these consequences are valued less. Increased feelings of loneliness when using ADs because of the decreased help from other people were expected by some. This negative aspect of ADs deserves further consideration.
The subjective norm regarding the use of ADs was found to be a small yet significant determinant of the intention to use ADs. General practitioners and relatives are the most important significant others. Their willingness and cooperation was found to be important for successful introduction of ADs.
Data analysis was improved compared with preceding studies by using techniques that controlled for other variables. Social cognitive variables were organized in a social cognitive model of AD use. The previously developed model to describe the use of ADs (Roelands et al. in press) was modified in accordance with the theory of planned behavior and proved to be of some significance. Functional status was confirmed as an important determinant of the use of ADs, which is evident because it is a prerequisite for using ADs. The model on the psychological variables increases the variance in the use of ADs that is explained. Intention to use ADs was determined especially by self-efficacy regarding the use of ADs, but the relative importance of the variables should be considered fully, as we discuss below. Intention to use ADs was also determined by the attitude toward the use of ADs and to a lesser extent by the subjective norm regarding the use of ADs. The role of awareness regarding ADs and attitudes toward the use of ADs were confirmed. But the partial correlations showed that because of the inclusion of more proximal factors in the model, awareness of ADs became a more distal factor and was positively correlated with the attitude toward the use of ADs and the subjective norm.
The psychological variables in the model predicted a moderate amount of variance in intention to use ADs, but intention to use ADs and functional status predicted a rather small amount of variance in use of ADs. We can hypothesize that in use of ADs factors at other levels are involved, too. Some will act as barriers, others as facilitators. Some of these factors can be summarized as network factors, for example, aspects of AD supply by health care services (e.g., costs, sensitivity of needs screening, quality of AD introduction process, extent and quality of supply), and availability of personal help regarding ADLs and IADLs. The model presented in this article focuses only on psychological factors involved in use of ADs. The predictive power of other factors should be evaluated in intervention studies and studies comparing health care systems to allow further optimalization of AD use by older persons.
A complex sample-selection procedure was used to obtain a representative distribution of age, sex, and SES (at municipal level). It is very likely that the sampling strategy resulted in a representative sample of elderly persons living in Flanders to be contacted. Nevertheless, some results suggest some selection bias in the final sample in favor of men. The gender ratio in Flanders in this age group is 57.7% women and 42.3% men, as it is 51.9% women and 48.1% men in the sample of respondents. Three mechanisms may be involved. First, as lack of a telephone is probably related to SES and a correlation has been established between being an older woman and low SES, perhaps more women were excluded. Second, it is well known that disabilities are more common in women. Third, more women refused to cooperate, which may be because of the procedure, because most of the telephone calls to obtain consent were done by a male researcher, although it was mentioned that the actual interviewer would be a woman. Nevertheless, the deviation from the distribution of the person's sex in the population was rather small, and effects on the descriptive data are therefore minimal. The representativeness of the sample regarding physical functioning can be estimated by comparing the SF-36 subscale score of the people aged between 75 and 89 in this study (N = 290) with a representative sample of community-dwelling and institutionalized people aged 75 and older in the Belgian National Health Interview Survey (BNHIS; N = 195). When people are not disabled in any of the 10 types of activities, they have a score of 100, the minimum score is 0. The mean level of functioning is similar between the two samples (BNHIS: M = 57.8; this study: M = 59.6). A one-sample t test did not reveal any significant differences between this sample and the BNHIS, t(289) = 1.027. The comparison of functional status with another representative sample, and the comparison of age and SES of the municipality between respondents and persons who refused, indicate that the respondents are a representative sample of the community-dwelling persons between 70 and 89 years old in Flanders, taking into account the exclusion criteria, most of which are common in surveys.
Many instruments were developed for this study to measure the concepts that were introduced. The PCAD, the SEAD, and the IAD were sufficiently reliable, although there was some room for improvement. The reliability of the instruments and the relations in the model could increase if some adaptations were done. First, the beliefs were specified as related to devices for self-care and mobility. This was sufficient for this study as the model was confirmed. It is, however, likely that a person's self-efficacy, perceived consequences and intention to use depend on the specific AD. A second reliability issue relates to the evaluation component of the attitude beliefs. As discussed by Young, Lierman, Powel-Cope, Kasprzyk, and Benoliel 1991(p. 142) regarding the theory of planned behavior, "in asking a respondent to evaluate an item ... one assumes that the respondent holds an absolute opinion about that belief and that it is possible to make this evaluation acontextually." It is, however, likely that this opinion depends on related factors such as the activity and the AD concerned. For example, "to perform activities independently with an AD" can be considered very unimportant if it regards self-care, but very important regarding mobility. A third reliability issue is especially important in lower educated elderly people. It has already been mentioned (Mullen, Hersey, and Iverson 1987; Young et al. 1991) that the format of the attitude questionnaire can pose a conceptual challenge to participants. The evaluation items are similar to the belief items and the respondents may perceive them as the same, resulting in feelings of frustration. With some respondents, we had the impression that they fell back on response sets.
In general, the intention of elderly persons to use ADs was high, but some caution is required. The high level of intention may also be due to a socially desirable response. Although showing a positive attitude regarding the use of ADs was always avoided, and this was strongly stressed during the training of the interviewers, it is not entirely impossible that the presentation of the study or the items was not totally neutral. The socially desirable response, if and to the degree it occurred, would also decrease the relationships in the model.
Some caution is necessary regarding the interpretation of the correlations between variables and their determinants and consequently regarding the interpretation of the relative weights of the determinants to predict a variable (the ßs). In the theory of planned behavior the correspondence between the variables regarding action, target, context, and time elements is essential to be able to predict behavioral intentions and behavior (Ajzen and Fishbein 1980, p. 56). It seems to us that the rather low betas in the model on the use of ADs can be increased by improving the correspondence between the measures. Where correspondence was high, so too was the self-efficacy (intention correlation) beta. Although it has been mentioned that this high correlation between two successive similar scales that follow one another in the questionnaire may be due to a response set, the different response categories slightly reduce the effect. An improvement in the correspondence would also challenge the relative importance of the variables in predicting the intention to use ADs. Moreover, an improved correspondence would probably increase the predictive validity of the intention to use ADs. The correspondence could be increased by being more specific regarding the context of using ADs (e.g., when one is alone, when it is free of charge), the target (e.g., to increase autonomy or safety or efficiency), the time elements (every time when it is required or sometimes), and also regarding the object of the behavior under consideration. We assume that the relative weights of the concepts differ depending on the specific AD.
The low number of ADs in the subscales related to AD use and the dichotomous nature of the individual items limited the internal consistency of the scales. The finding that AD use is related to presence of specific disabilities requires confirmation with larger subscales.
A social–cognitive model of the use of ADs was empirically tested in community-dwelling elderly persons. Finally, the validity and usefulness of this model should be evaluated in intervention studies, which could develop and evaluate protocols to introduce ADs in a more structured way. We expect that interventions meant to increase the intention to use ADs and the use of ADs, when required by the functional status and wanted by the person with disabilities, to increase their effectiveness, should take these variables into consideration. These concepts and the model could also be evaluated in specific populations (e.g., persons with arthritis or dementia, persons living in institutions) and for specific ADs.
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We gratefully acknowledge the assistance of Hilde Merckx and Marianne DeGrave in the data collection.
Received for publication October 19, 2000. Accepted for publication September 10, 2001.
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