A study investigating the relative success of different methods of outreach was conducted with a sample of 210 low-income elderly. Individuals were randomly assigned to receive either a personal letter, telephone call, or home visit from an outreach worker in an effort to encourage participation with local senior centers. The results significantly demonstrate that a home visit is the most effective method of initial contact for each of the three response measures examined. In addition, cost/benefit considerations of personal letter and telephone call contact, are discussed.
Alternative Modes of Outreach: An Experimental Comparison1
The Problem of Access In recent years there has been increasing concern expressed over the needs and rights of the elderly in our society. This has been a result of the elderly comprising an increasing proportion of the population at large and the concomitant political and media attention which has focused on this group. In addition, there has been an increase in the fiscal support provided for services and research aimed at elderly groups. From a variety of perspectives, theoretical and administrative explanations of, and solutions to, the problems in living experienced by the elderly have been suggested. The entire range of ideological and theoretical alternatives has been tapped in this regard. Certain authors have emphasized the importance of the biological aging process as a determining factor (Btumenthal, 1962; Busse & Pfeiffer, 1969; Shock, 1962; Verwoerdt, 1973). The primary intervention approaches suggested by these positions include: nutritional enhancement, friendly visitors, and medical care. A second set of major propositions can best be described as psychological theories. The psychological conceptions have included specific notions of sensory deterioration (e.g., Carp, 1973; Harris, 1975; Melroseetal., 1963; 'Preparation of this article was supported in part by Grant MH29160 from the National Institutes of Mental Health. This project was conducted in conjunction with the Stale of Michigan's Office of Services to the Aging. The authors wish to thank Region IV Area Agency on Aging and its seven associated senior citizen centers for their extensive cooperation. Requests for reprints should be sent to the second author at the Dept. of Psychology, Michigan State Univ., East Lansing 48824. 'Field Research Supervisor, Dept. of Psychology, Michigan State Univ., East Lansing. 'Director, Adolescent Diversion Project and Asst. Professor, Dept. of Psychology, Michigan State Univ.
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Riley & Foner, 1968), decreasing self-concept (Verwoerdt, 1973), and decreasing social reinforcement (Ferster, 1973). The major programmatic implications of the psychological position have included the increased provision of mental health services, companionship programs, and nutritional enhancement. Finally, the importance of situational and environmental aspects has been highlighted. Specific factors which were generally cited as problematic include: a substantial drop in income (Butler, 1975), forced iretirement (Blau, 1973), substantial role change (Buhler & Kleemier, 1961; Lowenthal, 1968), and social separation and isolation (Bennett, 1973; Blau, 1973). The suggestions for intervention within this perspective included: income supplements, alternative living situations, and increased social services. The impact of each of the aforementioned briefly reviewed positions on current social programming for the elderly has been substantial. Many of the needs expressed by the specific theoretical positions have been well documented (e.g., Ball, 1972; Brady, 1973; Butler, 1973; Kaplan, 1973). In fact, they provide the underlying rationale for the multifaceted service approach our society currently has designed for the elderly. However, it is also unfortunately true that, for one reason or another, many of the most needy elderly are simply not getting the services they require, even when those services are currently available. This fact was strikingly demonstrated by the results of the nationwide "Project FIND" study (National Council on Aging, 1972) covering
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Martin G. Kushler, MA,2 and William S. Davidson II, PhD3
12 major communities across the country. Of the 50,000 elderly individuals surveyed, 28,079 cases of need were discovered where referrals could be made to services already existing in the community but with which the individual had not had contact (as well as 24,124 cases of need for unavailable services). Thus, the problem exists not only to further develop services for needy elderly within a community but also to link needy elderly with services already available.
Information and Referral To help solve the problem of linkage, the concept of an "information and referral" service has been utilized. However, as Brumfield et al. (1968) point out, the problem with information and referral is that the client must initiate the request for services. Hence, most of the factors that prevent the client from contacting the service providers directly also prevent him/her from contacting the information and referral service. These factors are hypothesized to include: client unaware of service; general fear of, or avoidance of, unnecessary outside contact; denial of any problem (Gaitz, 1974); client apathy toward service; general misinformation of many kinds (such as "I'm not eligible", etc.); and the desire to avoid "welfare" (Alexander & Podair, 1969). To help overcome these obstacles, the concept of "outreach" has been added to information and referral. When the information service reaches out and contacts the client directly, it is hoped that most or all of the above mentioned obstacles can be remedied. This is the approach that many area agencies on aging have developed in their information and referral/outreach service. In the past several years, the information and referral/outreach program has become a significant facet of our society's approaches to the elderly. Certainly, ample testimony exists citing the beneficial outcomes that have occurred for elderly as a result of outreach pro- Method Setting. — This project was carried out in gram efforts (Cohen, 1974; Heisel & Faulkner, cooperation with a regional area agency on 1975; National Council on Aging, 1972). Indeed, such correlates of life satisfaction aging responsible for information and referral as social participation (Graney, 1975), income, programs for a three-county area in Michigan. living situation, and health (Toseland & Sykes, This three-county area included a mix of rural, 1977), can all be positively impacted through small town and urban populations. The area service access facilitated by outreach programs. agency on aging had a total of seven local In spite of the importance of information Information and Referral (I and R) Centers referral/outreach, however, little is known scattered throughout this region, each of which
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about its actual functioning and impact. Obviously, within such a program there are many specific operating procedures which can be followed. Yet, to date there has been little systematic research on the effects of varying information referral/outreach procedures. One notable exception was a study conducted by Newcomer et al. (1976) which contrasted a centralized telephone system approach with a direct contact neighborhood outreach approach. The results of this study were mixed. Both programs were found to be reaching problematic populations and there was little difference between the two in client coverage characteristics. As might be expected, the cost and staff measures favored the telephone system. However, overall service utilization and problem solution rates favored the neighborhood outreach approach. Hence, the policy implications as to the optimal approach were necessarily inconclusive (although several related suggestions for service improvement are offered). Aside from the above report, very little literature exists specifically addressing the problem of how best to provide information and referral/outreach services to the elderly. In an effort to improve this situation and provide further information to persons involved in information and referral/outreach services, this article will report the results of a study in which varying outreach strategies were directly compared in an experimental format. The modes of contact to be examined in this study (mail, telephone, and home visit) all have some support for such use in the literature (Brumfield et al., 1968; Goodrow, 1975; Havelock, 1971). In addition, they can all be easily utilized by the typical information and referral center or area agency. As suggested by the best available evidence (National Council on Aging, 1972; Newcomer et al., 1976), it was hypothesized that more personal modes of outreach would produce better results.
provided full cooperation and assistance in the project. The study was conducted during the spring and summer seasons and lasted approximately 7-mo from initial planning to completion of the follow-up survey.
Design. — The design used in this project was a post-only design involving multiple dependent variables. There were five levels of treatment condition (control, informational mail, personal mail, telephone and in-person contact). Equal n's were randomly assigned to each of the five treatment conditions.
In-person contact group. — Individuals in this group received a personal visit by an individual I and R/outreach worker. The personal visits followed a standardized format which included a brief personal introduction, a detailed explanation of I and R center services, and a final request to call or write the I and R center if they would like to sign up for a monthly newsletter. This condition allowed for immediate feedback to any client initiated questions, requests, etc. When such occurred, the outreach worker handled them as in any normal outreach contact. Telephone contact group. — The individuals in this group received a telephone call from an individual I and R/outreach v/orker, actually establishing verbal contact and presenting essentially the same information as was provided in the in-person condition. As much as possible, the format for the telephone contact group was identical to that of the in-person contact group.
''Personal" mail contact group. — Individuals in this group received a direct mail contact from the I and R/outreach worker. This letter identified the basic services available through Procedure. — As soon as the final target the I and R center and invited the individual subjects were identified and random assignment to contact the center by phone, or in person to condition had taken place, a 2-day training if he/she would like any further information session was held to explain to outreach per- or would like to request services. The style sonnel in the seven I and R centers the protocols of the letter was made personalized through to be followed in conducting the various aspects the consistent use of "you", "your neighbors", of the program. Also, the procedures for data "we", etc. when presenting the material and collection were reviewed and an appropriate particularly by listing four or five names of checklist distributed. At the completion of the other community members who used the I and training, assignments of clients in each of the R center. The names were listed in a personfive conditions were distributed to the I and R alized request to contact the helpful people center personnel. Each center received an at the I and R center. equivalent number of assigned contacts in Informational mail contact group. — Indieach experimental condition. Also, to avoid the possible biasing effects of order, weather, viduals in this group received a direct mail time, etc., contacts of each type were propor- letter from the I and R/outreach worker which tionally staggered throughout the outreach included the same informational content as phase. Actual implementation of the programs the letter described for the personal mail. occurred over a 6-week period. Administrative However, the overall tone of the letter, although
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Subjects. — Subjects for this study represent random selection from the target population and random assignment to condition. A population of approximately 2,000 low-income elderly (age 65 and over) in a three-county area was identified by means of a specially prepared list from the Michigan Department of Social Services. The list was first broken down into geographic areas corresponding to the seven information and referral centers in that threecounty region. All persons who were institutionalized or with whom the information and referral centers had had previous contact were then removed from the list. From the remaining population (n = approximately 1,000), a random sample of 335 persons was selected for use in the study. The results of a follow-up survey revealed that the sample selected had a mean age of 75 years, was 75% female, 78% white and 22% black, and had an average of eight years of formal education.
personnel from the regional office supervised daily project operations. In addition, the first author was available for telephone consultation whenever needed as well as personally monitoring the operations on a weekly basis. The experimental and control conditions for this study consisted of the following:
the number of people who received a service was used as the third dependent variable. This variable provided an indication of the effect of type of initial contact on the elderly availing themselves of community services.
Control group. — Individuals in this group served as a control by which to measure the relative effectiveness of each of the other treatment categories. Hence, the individuals in this category received no contact directly resulting from I and R/outreach services. They, of course, were not prevented from any exposure to incidental information concerning available services (i.e., by word of mouth, from other groups, by self inquiry, from the media, etc.) that would have otherwise been available.
Follow-up interview. — Approximately 1 -mo after initial contact, all subjects in each of the four experimental conditions and the control condition were visited by an outreach worker from the local I and R center for a follow-up interview. The major function of this follow-up survey was to provide necessary background data on the subjects involved in this project. A variety of demographic and attitude information was gathered. Results
Measures. — Two distinct sets of measures were used in this study. The first set was drawn from agency records and the second from follow-up interviews. The dependent variables were taken from agency records and included the following: (1) Client card — whenever an I and R/outreach worker contacted an individual for the first time and a "successful" outreach contact was made, appropriate demographic and needs information was recorded on a standardized form labeled the client card. This variable was coded dichotomously with a positive response being the completion of a client card. The client card was used as an indicator of successful outreach contact in that its completion signified a degree of commitment on the part of the elderly person toward participating with the I and R center. Also, it was felt that if the worker had established sufficient rapport in interaction with the individual to acquire the necessary information for the client card, presumably the worker had been able to observe and assess the major needs and could thus provide access to potentially appropriate community resources. (2) Newsletter sign up — each mode of the outreach described above concluded with a request for the elderly person to call or write the I and R center to be placed on a mailing list for the monthly newsletter. Although this variable is less reflective of the actual purpose of outreach, it was nevertheless a relevant indicator of the degree of involvement produced by the various conditions. (3) Receiving services — since the linkage of the elderly with available community resources was one of the main functions of the I and R/outreach,
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As with any large field experiment such as that described in this study, problems were encountered in maintaining the original number of subjects assigned to each experimental condition. The final number of subjects available for data analysis was 210. Originally, 67 subjects were assigned to each of the five conditions. The final viable sample, constructed only of persons for whom the initial contact actually took place, included the following distributions: in-person contact, n = 43; telephone contact, n = 43; personal mail contact, n = 38; informational mail contact, n = 45; control condition, n = 41. It can be seen from these numbers that the subject mortality rate across conditions was approximately equal. Chi-square analyses were completed to verify this observation and there was no significant relationship between subject mortality and mode of contact. In addition, the final sample was checked for the adequacy of the original randomization. Namely, all demographic and descriptive data were analyzed using appropriate analysis of variance and chi-square procedures for differences between experimental conditions. Of the total of 21 demographic and descriptive variables examined, only one of the 21 variables (age) was found to vary between the groups at a significant level (p < .05). Further analyses revealed that age demonstrated no significant relationship to any of the primary outcome variables (e.g., client card, newsletter sign up, receiving services). Hence, it appears that the original randomization procedure did indeed produce functionally equivalent groups for purposes of this study.
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courteous, was primarily informational in nature, and emphasized a "services to meet needs" approach. No personalized request and no list of names of other persons using the center were included.
Table 1. Major Outcome Analyses for Client Card Registration. Control
Informational Mail
Personal Mail
Telephone
InPerson
Client card No client card
0 41
1 44
4 34
12 31
34 '9
Total
41
45
38
43
43
a
51 159 N =210
X J = 99.47 df = 4(p < .001)
Table 2. Major Outcome Analyses for Receipt of Service. Informational Mail
Personal Mail
Telephone
InPerson
Received service Did not receive service
0 41
2 43
4 34
8 35
10 33
Total
41
45
38
43
43
24 186 = 210
= 15.94 df = 4(p < .003)
Table 3. Major Outcome Analyses for Newsletter Sign-up. Control
Informational Mail
Personal Mail
Telephone
InPerson
Signed up Did not sign up
0 41
0 45
3 35
1 42
5 38
Total
41
45
38
43
43
a
9 201 = 210
J
X = 11.19 df = 4(p < .024)
A chi-square analysis was performed to test for significant effects between the mode of contact and each of the three major outcome variables. These results are shown in Tables 1, 2, and 3 for the client card, receipt of service, and newsletter variables respectively. As can be seen from the tables, all three dependent variables showed a significant and strong relationship to the mode of outreach contact. In all cases, the in-person mode of contact achieved the highest rate of effectiveness with the less personal modes showing gradually decreasing rates of success. It appears obvious then, from these findings, that the mode of contact is a critical determinant in whether the elderly individuals actually gain access to community resources. An additional set of analyses were completed to attempt to distinguish other possible predictors of outreach success besides the mode of contact relationships described above. A stepwise-multiple-regression procedure was used. The demographic variables and the follow-up interview variables were entered as predictors in each of three separate analyses
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using the client card, the newsletter, and the service receipt outcome variables as criteria. No significant predictors emerged from these multivariate analyses. This is not particularly surprising due to the magnitude of the experimental effects observed. Essentially, it can be seen that a large proportion of the variance in the major outcome variables was accounted for by experimental condition.4
Discussion and Policy Implications
The primary purpose of this study was to examine experimentally the relative efficacy of four alternative modes of conducting outreach in providing access to community resources to low-income elderly persons. The results of this study demonstrate considerable differential effectiveness for the in-person, telephone, personal mail, and informational mail modes. 4 The same analyses as described above were recomputed adding the experimental condition (mode of contact) as an additional independent variable. In each of these analyses the type of contact was the only significant variable in the multiple regression equation.
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Control
For the client card variable, there was an extremely strong relationship between type of contact and positive responding. The home visit mode demonstrated a very high (79%) rate of positive responding. This was followed by telephone contacts (28%), personal letter (11%), and informational mail (2%). The control group condition, which included no form of direct outreach contact, produced no positive responses at all.
Nearly identical results are observed in terms of whether or not the individual actually received service and whether or not the individual signed up to participate in the newsletter, although the magnitude of the proportion of individuals responding across condition was considerably less. It may be that both of these variables are reflective of a higher degree of personal need and investment, and that in the population in question, the self-perceived need is not of sufficient strength or the outreach modality used is not of sufficient intensity to overcome individual resistances and produce higher levels of responding. Nevertheless, it is important to note that the effects of type of outreach contact persisted across all three dependent variables, with the more personal modes of contact consistently producing the highest levels of response. A further note on the subject of response levels is called for at this point. Although the total frequencies of response on these outcome measures appear low, they must be interpreted in the proper context. A relatively low level of participation with the senior centers might well have been anticipated in this situation. Previous research has revealed a lower incidence of elderly participation in voluntary associations in general as compared to middleaged persons, and particularly so when low income, lack of suitable public transportation,
However, cerning the also worthy effectiveness
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a second policy implication conchoice of a mode of contact is of note. Although their overall was much lower than the in-
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One very prominent interpretation for these results was that the level of interaction between the source and the target allowed by the contact mode is related to the type and amount of response obtained; that is, that those modes which allow direct contact, immediate feedback, two-way personal communication, etc. are the ones that demonstrate the greatest success. In this sense, the results of this study tend to confirm the work of other authors in related fields (Havelock, 1971; Klippel & Sweeney, 1974) and highlight the importance of an active outreach strategy.
and distances too long to walk are problems (Cutler, 1974). Most or all of these negative factors were present for all of the elderly involved in this study. Also, it must be kept in mind that, by design, this was a particularly resistant target population. These were persons who, for whatever reasons (lack of awareness, lack of means of contact, personal bias against accepting "welfare", etc.), in spite of previous media announcements and local organizational campaigns, had made no prior contact with the senior centers. The purpose of the study in this respect was to test these outreach methods on the most difficult target group available (i.e., one that would be best expected to represent those often most in need of outreach services). In view of these facts, the response frequencies obtained are not particularly surprising. However, they do reaffirm the existence of a central problem in the field of service delivery to the elderly. Unfortunately, as others have observed (Gaitz, 1974; Lopata, 1975; National Council on Aging, 1972), there are often serious levels of underutilization of available services by needy elderly, even when such nonusers are aware that services exist. The policy implications of this study are multiple. In spite of the necessary preliminary nature of inferences to be drawn from this data, it is felt that the results obtained from such a large-scale, well-controlled experiment can indeed be of use to policy-makers, administrators and others involved in fields related to service provision for the elderly. In particular, the most obvious implication of the results is in terms of the relative efficacy of the various modes of outreach tested. Quite clearly, the results indicate that the method of home visiting is significantly more successful than any of the other modes of contact. In this respect, the results of this study seem to support the findings of the National Council on Aging (1972), which also concluded that the mode of home visiting was the most effective method of conducting outreach to a target group of low-income elderly. The order and magnitude of the effects observed in the present study imply that in order to gain the participation of the elderly in accessing themselves to community resources, it is necessary to use a relatively high level of personal contact.
•Careful estimation of incurred costs for each mode of contact revealed that the average in-person visit was at least three times more expensive (in terms of worker time, materials and related expenses) than the telephone call mode, and approximately six to seven times more expensive than the letter mode (see M . Kushler, 1976).
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felt that these results further demonstrate, rather vividly, that a vigorous, personal approach to outreach is required in order to insure access to available resources. A final implication of this study is, of course, the need for further systematic research on the effectiveness of programs aimed at providing the elderly increased access to community services. The results of this study address themselves to the first step in the process (i.e., identifying which types of initial contact best facilitate access to a community service center). It is critical that the field also pursue policy relevant research aimed at providing answers to the long-term impact of service programs for the elderly. We can no longer just assume that, by definition, what we are doing in programming for the elderly is necessarily the most effective course of action. This is not intended as an indictment of the current social service system for the elderly. Clearly, many persons are currently receiving much needed services through the existing networks. To the extent that outreach provides access to these services, many beneficial outcomes will result. However, it is equally clear by the often low levels of participation by needy elderly, that the service system is not functioning at an optimum level. It is unlikely that improved information and referral/outreach efforts alone can solve this problem. Perhaps these services need to be improved, made more attractive, expanded, or made more accessible. Toward this larger problem, this article does not attempt to offer a solution but, rather, suggests an approach to investigating possible solutions. It is hoped that experiments such as the one described here will provide a vehicle for exploring the effectiveness of service programs for the elderly, particularly by developing and including systematic methods for gaining direct feedback, in terms of participation and opinion, from the elderly themselves.
References
Alexander, R. S., & Podair, S. Educating New York City residents to the benefits of Medicaid. Public Health Reports, September, 1969,84, 767-772. Ball, R. M. Income maintenance for the aged and handicapped. Public Welfare, 1972, 30, 33-38. Bennett, R. Living conditions and everyday needs of the elderly with particular reference to social isolation. International journal of Aging & Human Development, 1973,4, 179-184.
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person mode, the lower cost5 modes of telephone and personal letter contact appear to have potential usefulness in certain circumstances (i.e., where outreach budgets are very limited and/or whenever the goals of outreach are nonthreatening and noncomplex, e.g., the transmission of fairly simple information, the generation of name awareness, etc.). Indeed, in spite of the low rate of actual response, the follow-up survey revealed that 59% of those sent a personal letter remembered the letter and associated it with the senior center at the time of follow-up (approximately 1 to 2-mo subsequent to the mailing). As for the telephone contact recipients, 78% remembered the phone call and associated it with the senior center at time of follow-up. Thus, it appears that personal letters or telephone contacts would also be suitable for use with this target population at least for certain noncrucial service purposes such as simple information provision. A third policy implication that is apparent is the fact that even at the minimal levels of individual response required to secure accessibility to community resources in the I and R centers targeted in this study, a very active approach to outreach was essential. It should be highlighted that none of the control group made any positive response in terms of any of the three dependent variables examined. In fact, no member of the control group achieved access to any of the I and R center services during the course of the study. This was in spite of the fact that various opportunities for securing access to the I and R centers existed throughout this time period, including response to mass media ads, church announcements, bake sales, raffles and, of course, through informal word-of-mouth contacts. Interestingly, at the time of follow-up those persons in the control group were provided with a home visit outreach contact encouraging their participation with the local I and R center. In what was, in effect, a mini-replication of the results for the in-person mode of the original experiment, approximately three-fourths of those persons previously in the control group responded positively to this contact and registered a "client-card" with the center. It is
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Blau, Z. S. Old age in a changing society. New Viewpoints, Havelock, R. G. Planning for innovation: Through dissemination and utilization of knowledge. Inst. for New York, 1973. Social Research, Ann Arbor, 1971. Blumenthal, H. (Ed). Medical and clinical aspects of Heisel, M. A., & Faulkner, A. O. Evaluation of an outreach aging. Columbia Univ. Press, New York, 1962. project with elderly blacks. Paper presented at the Brody, S. J. Comprehensive health care for the elderly: 28th Annual Scientific Meeting of the Gerontological An analysis. Cerontologist, 1973, 13, 412-417. Society, Louisville, October, 1975. Brumfield, W. A., Jr., Fox, R. I., & Goldman, J. S. Reaching Kaplan, J. Services without the facts. Cerontologist, 1973, the target population. Public Health Reports, July, 13, 132. 1968,83, 597-602. Klippel, E. R., & Sweeney, T. W. The use of information Buhler, C. & Kleemier, R. W. (Eds). Aging and leisure. sources by the aged consumer. Cerontologist, 1974, Oxford Univ. Press, New York, 1961. 14, 163-166. Busse, E. W., & Pfeiffer, E. (Eds). Behavior and adaptation Kushier, M. Three modes of conducting outreach to lowin late life. Little, Brown and Company, Boston, 1969. income elderly: An experimental examination. Michigan Butler, R. N. Taking stock of the status of the elderly. Office of Services to the Aging, Lansing, Ml, 1976. International Journal of Aging & Human Development, Lopata, H. Z. Support systems of elderly urbanites: Chicago 1975,6, 179-182. of the 1970's. Gerontologist, 1975, 15, 35-41. Butler, R. N. How to grow old and poor in an affluent Lowenthal, M. F. The relationship between social facts and mental health in the aged. Aging in Modern Psychiatry. society. International Journal of Aging & Human American Psychiatric Assoc., New York, 1968. Development, 1973,4, 277-279. Carp, M. The psychology of aging. In R. R. Boyd & C. G. Melrose, J., Welsh, O. L., & Luterman, D. Auditory responses in selected elderly men. Journal of Gerontology, Oakes (Eds.), Foundations of Practical Gerontology. 1963, 18, 267-270. Columbia Univ. of South Carolina Press, 1973. National Council on Aging and U.S. Office of Economic Cohen, R. G. Outreach and advocacy in the treatment of Opportunity. The golden years: A tarnished myth the aged. Social Casework, 1974, 55, 271-277. (Project FIND), National Council on Aging: WashCutler, S. J. The effects of transportation and distance on ington, 1972. voluntary association participation among the aged. Newcomer, R. J., Anguera, J., Newcomer, S. R., & International Journal of Aging & Human Development, Yesselman, M. Evaluating information and referral 1974,5, 81-94. services for the homebound elderly. County of San Ferster, C. B. A functional analysis of depression. American Diego Dept. of Human Services, 1976. Psychologist, 1973,28, 857-864. Riley, M. W., & Foner, A. Aging and society, Vol. 1. Gaitz, C. M. Barriers to the delivery of psychiatric services Russell Sage Foundation, New York, 1968. to the elderly. Cerontologist, 1974, 14, 210-214. Shock, N. W. (Ed). Biological aspects of aging. Columbia Goodrow, B. A. Limiting factors in reducing participation Univ. Press, New York, 1962. in older adult learning opportunities. Cerontologist, Toseland, R., & Sykes, J. Senior citizens center participation 1975, 15, 418-422. and other correlates of life satisfaction. Gerontologist, Graney, M. J. Happiness and social participation in aging. 1977, 17, 235-241. Verwoerdt,A. Biological characteristics of the elderly. In R. R. Journal of Gerontology, 1975,30, 701-706. Boyd & C. G. Oakes (Eds.), Foundations of Practical GerHarris, R. Breaking the barriers to better health care ontology. Columbia Univ. of South Carolina Press, 1973. delivery for the aged. Cerontologist, 1975, 15, 52-56.
Alternative Modes of Outreach: An Experimental Comparison1
The Problem of Access In recent years there has been increasing concern expressed over the needs and rights of the elderly in our society. This has been a result of the elderly comprising an increasing proportion of the population at large and the concomitant political and media attention which has focused on this group. In addition, there has been an increase in the fiscal support provided for services and research aimed at elderly groups. From a variety of perspectives, theoretical and administrative explanations of, and solutions to, the problems in living experienced by the elderly have been suggested. The entire range of ideological and theoretical alternatives has been tapped in this regard. Certain authors have emphasized the importance of the biological aging process as a determining factor (Btumenthal, 1962; Busse & Pfeiffer, 1969; Shock, 1962; Verwoerdt, 1973). The primary intervention approaches suggested by these positions include: nutritional enhancement, friendly visitors, and medical care. A second set of major propositions can best be described as psychological theories. The psychological conceptions have included specific notions of sensory deterioration (e.g., Carp, 1973; Harris, 1975; Melroseetal., 1963; 'Preparation of this article was supported in part by Grant MH29160 from the National Institutes of Mental Health. This project was conducted in conjunction with the Stale of Michigan's Office of Services to the Aging. The authors wish to thank Region IV Area Agency on Aging and its seven associated senior citizen centers for their extensive cooperation. Requests for reprints should be sent to the second author at the Dept. of Psychology, Michigan State Univ., East Lansing 48824. 'Field Research Supervisor, Dept. of Psychology, Michigan State Univ., East Lansing. 'Director, Adolescent Diversion Project and Asst. Professor, Dept. of Psychology, Michigan State Univ.
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Riley & Foner, 1968), decreasing self-concept (Verwoerdt, 1973), and decreasing social reinforcement (Ferster, 1973). The major programmatic implications of the psychological position have included the increased provision of mental health services, companionship programs, and nutritional enhancement. Finally, the importance of situational and environmental aspects has been highlighted. Specific factors which were generally cited as problematic include: a substantial drop in income (Butler, 1975), forced iretirement (Blau, 1973), substantial role change (Buhler & Kleemier, 1961; Lowenthal, 1968), and social separation and isolation (Bennett, 1973; Blau, 1973). The suggestions for intervention within this perspective included: income supplements, alternative living situations, and increased social services. The impact of each of the aforementioned briefly reviewed positions on current social programming for the elderly has been substantial. Many of the needs expressed by the specific theoretical positions have been well documented (e.g., Ball, 1972; Brady, 1973; Butler, 1973; Kaplan, 1973). In fact, they provide the underlying rationale for the multifaceted service approach our society currently has designed for the elderly. However, it is also unfortunately true that, for one reason or another, many of the most needy elderly are simply not getting the services they require, even when those services are currently available. This fact was strikingly demonstrated by the results of the nationwide "Project FIND" study (National Council on Aging, 1972) covering
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Martin G. Kushler, MA,2 and William S. Davidson II, PhD3
12 major communities across the country. Of the 50,000 elderly individuals surveyed, 28,079 cases of need were discovered where referrals could be made to services already existing in the community but with which the individual had not had contact (as well as 24,124 cases of need for unavailable services). Thus, the problem exists not only to further develop services for needy elderly within a community but also to link needy elderly with services already available.
Information and Referral To help solve the problem of linkage, the concept of an "information and referral" service has been utilized. However, as Brumfield et al. (1968) point out, the problem with information and referral is that the client must initiate the request for services. Hence, most of the factors that prevent the client from contacting the service providers directly also prevent him/her from contacting the information and referral service. These factors are hypothesized to include: client unaware of service; general fear of, or avoidance of, unnecessary outside contact; denial of any problem (Gaitz, 1974); client apathy toward service; general misinformation of many kinds (such as "I'm not eligible", etc.); and the desire to avoid "welfare" (Alexander & Podair, 1969). To help overcome these obstacles, the concept of "outreach" has been added to information and referral. When the information service reaches out and contacts the client directly, it is hoped that most or all of the above mentioned obstacles can be remedied. This is the approach that many area agencies on aging have developed in their information and referral/outreach service. In the past several years, the information and referral/outreach program has become a significant facet of our society's approaches to the elderly. Certainly, ample testimony exists citing the beneficial outcomes that have occurred for elderly as a result of outreach pro- Method Setting. — This project was carried out in gram efforts (Cohen, 1974; Heisel & Faulkner, cooperation with a regional area agency on 1975; National Council on Aging, 1972). Indeed, such correlates of life satisfaction aging responsible for information and referral as social participation (Graney, 1975), income, programs for a three-county area in Michigan. living situation, and health (Toseland & Sykes, This three-county area included a mix of rural, 1977), can all be positively impacted through small town and urban populations. The area service access facilitated by outreach programs. agency on aging had a total of seven local In spite of the importance of information Information and Referral (I and R) Centers referral/outreach, however, little is known scattered throughout this region, each of which
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about its actual functioning and impact. Obviously, within such a program there are many specific operating procedures which can be followed. Yet, to date there has been little systematic research on the effects of varying information referral/outreach procedures. One notable exception was a study conducted by Newcomer et al. (1976) which contrasted a centralized telephone system approach with a direct contact neighborhood outreach approach. The results of this study were mixed. Both programs were found to be reaching problematic populations and there was little difference between the two in client coverage characteristics. As might be expected, the cost and staff measures favored the telephone system. However, overall service utilization and problem solution rates favored the neighborhood outreach approach. Hence, the policy implications as to the optimal approach were necessarily inconclusive (although several related suggestions for service improvement are offered). Aside from the above report, very little literature exists specifically addressing the problem of how best to provide information and referral/outreach services to the elderly. In an effort to improve this situation and provide further information to persons involved in information and referral/outreach services, this article will report the results of a study in which varying outreach strategies were directly compared in an experimental format. The modes of contact to be examined in this study (mail, telephone, and home visit) all have some support for such use in the literature (Brumfield et al., 1968; Goodrow, 1975; Havelock, 1971). In addition, they can all be easily utilized by the typical information and referral center or area agency. As suggested by the best available evidence (National Council on Aging, 1972; Newcomer et al., 1976), it was hypothesized that more personal modes of outreach would produce better results.
provided full cooperation and assistance in the project. The study was conducted during the spring and summer seasons and lasted approximately 7-mo from initial planning to completion of the follow-up survey.
Design. — The design used in this project was a post-only design involving multiple dependent variables. There were five levels of treatment condition (control, informational mail, personal mail, telephone and in-person contact). Equal n's were randomly assigned to each of the five treatment conditions.
In-person contact group. — Individuals in this group received a personal visit by an individual I and R/outreach worker. The personal visits followed a standardized format which included a brief personal introduction, a detailed explanation of I and R center services, and a final request to call or write the I and R center if they would like to sign up for a monthly newsletter. This condition allowed for immediate feedback to any client initiated questions, requests, etc. When such occurred, the outreach worker handled them as in any normal outreach contact. Telephone contact group. — The individuals in this group received a telephone call from an individual I and R/outreach v/orker, actually establishing verbal contact and presenting essentially the same information as was provided in the in-person condition. As much as possible, the format for the telephone contact group was identical to that of the in-person contact group.
''Personal" mail contact group. — Individuals in this group received a direct mail contact from the I and R/outreach worker. This letter identified the basic services available through Procedure. — As soon as the final target the I and R center and invited the individual subjects were identified and random assignment to contact the center by phone, or in person to condition had taken place, a 2-day training if he/she would like any further information session was held to explain to outreach per- or would like to request services. The style sonnel in the seven I and R centers the protocols of the letter was made personalized through to be followed in conducting the various aspects the consistent use of "you", "your neighbors", of the program. Also, the procedures for data "we", etc. when presenting the material and collection were reviewed and an appropriate particularly by listing four or five names of checklist distributed. At the completion of the other community members who used the I and training, assignments of clients in each of the R center. The names were listed in a personfive conditions were distributed to the I and R alized request to contact the helpful people center personnel. Each center received an at the I and R center. equivalent number of assigned contacts in Informational mail contact group. — Indieach experimental condition. Also, to avoid the possible biasing effects of order, weather, viduals in this group received a direct mail time, etc., contacts of each type were propor- letter from the I and R/outreach worker which tionally staggered throughout the outreach included the same informational content as phase. Actual implementation of the programs the letter described for the personal mail. occurred over a 6-week period. Administrative However, the overall tone of the letter, although
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Subjects. — Subjects for this study represent random selection from the target population and random assignment to condition. A population of approximately 2,000 low-income elderly (age 65 and over) in a three-county area was identified by means of a specially prepared list from the Michigan Department of Social Services. The list was first broken down into geographic areas corresponding to the seven information and referral centers in that threecounty region. All persons who were institutionalized or with whom the information and referral centers had had previous contact were then removed from the list. From the remaining population (n = approximately 1,000), a random sample of 335 persons was selected for use in the study. The results of a follow-up survey revealed that the sample selected had a mean age of 75 years, was 75% female, 78% white and 22% black, and had an average of eight years of formal education.
personnel from the regional office supervised daily project operations. In addition, the first author was available for telephone consultation whenever needed as well as personally monitoring the operations on a weekly basis. The experimental and control conditions for this study consisted of the following:
the number of people who received a service was used as the third dependent variable. This variable provided an indication of the effect of type of initial contact on the elderly availing themselves of community services.
Control group. — Individuals in this group served as a control by which to measure the relative effectiveness of each of the other treatment categories. Hence, the individuals in this category received no contact directly resulting from I and R/outreach services. They, of course, were not prevented from any exposure to incidental information concerning available services (i.e., by word of mouth, from other groups, by self inquiry, from the media, etc.) that would have otherwise been available.
Follow-up interview. — Approximately 1 -mo after initial contact, all subjects in each of the four experimental conditions and the control condition were visited by an outreach worker from the local I and R center for a follow-up interview. The major function of this follow-up survey was to provide necessary background data on the subjects involved in this project. A variety of demographic and attitude information was gathered. Results
Measures. — Two distinct sets of measures were used in this study. The first set was drawn from agency records and the second from follow-up interviews. The dependent variables were taken from agency records and included the following: (1) Client card — whenever an I and R/outreach worker contacted an individual for the first time and a "successful" outreach contact was made, appropriate demographic and needs information was recorded on a standardized form labeled the client card. This variable was coded dichotomously with a positive response being the completion of a client card. The client card was used as an indicator of successful outreach contact in that its completion signified a degree of commitment on the part of the elderly person toward participating with the I and R center. Also, it was felt that if the worker had established sufficient rapport in interaction with the individual to acquire the necessary information for the client card, presumably the worker had been able to observe and assess the major needs and could thus provide access to potentially appropriate community resources. (2) Newsletter sign up — each mode of the outreach described above concluded with a request for the elderly person to call or write the I and R center to be placed on a mailing list for the monthly newsletter. Although this variable is less reflective of the actual purpose of outreach, it was nevertheless a relevant indicator of the degree of involvement produced by the various conditions. (3) Receiving services — since the linkage of the elderly with available community resources was one of the main functions of the I and R/outreach,
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As with any large field experiment such as that described in this study, problems were encountered in maintaining the original number of subjects assigned to each experimental condition. The final number of subjects available for data analysis was 210. Originally, 67 subjects were assigned to each of the five conditions. The final viable sample, constructed only of persons for whom the initial contact actually took place, included the following distributions: in-person contact, n = 43; telephone contact, n = 43; personal mail contact, n = 38; informational mail contact, n = 45; control condition, n = 41. It can be seen from these numbers that the subject mortality rate across conditions was approximately equal. Chi-square analyses were completed to verify this observation and there was no significant relationship between subject mortality and mode of contact. In addition, the final sample was checked for the adequacy of the original randomization. Namely, all demographic and descriptive data were analyzed using appropriate analysis of variance and chi-square procedures for differences between experimental conditions. Of the total of 21 demographic and descriptive variables examined, only one of the 21 variables (age) was found to vary between the groups at a significant level (p < .05). Further analyses revealed that age demonstrated no significant relationship to any of the primary outcome variables (e.g., client card, newsletter sign up, receiving services). Hence, it appears that the original randomization procedure did indeed produce functionally equivalent groups for purposes of this study.
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courteous, was primarily informational in nature, and emphasized a "services to meet needs" approach. No personalized request and no list of names of other persons using the center were included.
Table 1. Major Outcome Analyses for Client Card Registration. Control
Informational Mail
Personal Mail
Telephone
InPerson
Client card No client card
0 41
1 44
4 34
12 31
34 '9
Total
41
45
38
43
43
a
51 159 N =210
X J = 99.47 df = 4(p < .001)
Table 2. Major Outcome Analyses for Receipt of Service. Informational Mail
Personal Mail
Telephone
InPerson
Received service Did not receive service
0 41
2 43
4 34
8 35
10 33
Total
41
45
38
43
43
24 186 = 210
= 15.94 df = 4(p < .003)
Table 3. Major Outcome Analyses for Newsletter Sign-up. Control
Informational Mail
Personal Mail
Telephone
InPerson
Signed up Did not sign up
0 41
0 45
3 35
1 42
5 38
Total
41
45
38
43
43
a
9 201 = 210
J
X = 11.19 df = 4(p < .024)
A chi-square analysis was performed to test for significant effects between the mode of contact and each of the three major outcome variables. These results are shown in Tables 1, 2, and 3 for the client card, receipt of service, and newsletter variables respectively. As can be seen from the tables, all three dependent variables showed a significant and strong relationship to the mode of outreach contact. In all cases, the in-person mode of contact achieved the highest rate of effectiveness with the less personal modes showing gradually decreasing rates of success. It appears obvious then, from these findings, that the mode of contact is a critical determinant in whether the elderly individuals actually gain access to community resources. An additional set of analyses were completed to attempt to distinguish other possible predictors of outreach success besides the mode of contact relationships described above. A stepwise-multiple-regression procedure was used. The demographic variables and the follow-up interview variables were entered as predictors in each of three separate analyses
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using the client card, the newsletter, and the service receipt outcome variables as criteria. No significant predictors emerged from these multivariate analyses. This is not particularly surprising due to the magnitude of the experimental effects observed. Essentially, it can be seen that a large proportion of the variance in the major outcome variables was accounted for by experimental condition.4
Discussion and Policy Implications
The primary purpose of this study was to examine experimentally the relative efficacy of four alternative modes of conducting outreach in providing access to community resources to low-income elderly persons. The results of this study demonstrate considerable differential effectiveness for the in-person, telephone, personal mail, and informational mail modes. 4 The same analyses as described above were recomputed adding the experimental condition (mode of contact) as an additional independent variable. In each of these analyses the type of contact was the only significant variable in the multiple regression equation.
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Control
For the client card variable, there was an extremely strong relationship between type of contact and positive responding. The home visit mode demonstrated a very high (79%) rate of positive responding. This was followed by telephone contacts (28%), personal letter (11%), and informational mail (2%). The control group condition, which included no form of direct outreach contact, produced no positive responses at all.
Nearly identical results are observed in terms of whether or not the individual actually received service and whether or not the individual signed up to participate in the newsletter, although the magnitude of the proportion of individuals responding across condition was considerably less. It may be that both of these variables are reflective of a higher degree of personal need and investment, and that in the population in question, the self-perceived need is not of sufficient strength or the outreach modality used is not of sufficient intensity to overcome individual resistances and produce higher levels of responding. Nevertheless, it is important to note that the effects of type of outreach contact persisted across all three dependent variables, with the more personal modes of contact consistently producing the highest levels of response. A further note on the subject of response levels is called for at this point. Although the total frequencies of response on these outcome measures appear low, they must be interpreted in the proper context. A relatively low level of participation with the senior centers might well have been anticipated in this situation. Previous research has revealed a lower incidence of elderly participation in voluntary associations in general as compared to middleaged persons, and particularly so when low income, lack of suitable public transportation,
However, cerning the also worthy effectiveness
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a second policy implication conchoice of a mode of contact is of note. Although their overall was much lower than the in-
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One very prominent interpretation for these results was that the level of interaction between the source and the target allowed by the contact mode is related to the type and amount of response obtained; that is, that those modes which allow direct contact, immediate feedback, two-way personal communication, etc. are the ones that demonstrate the greatest success. In this sense, the results of this study tend to confirm the work of other authors in related fields (Havelock, 1971; Klippel & Sweeney, 1974) and highlight the importance of an active outreach strategy.
and distances too long to walk are problems (Cutler, 1974). Most or all of these negative factors were present for all of the elderly involved in this study. Also, it must be kept in mind that, by design, this was a particularly resistant target population. These were persons who, for whatever reasons (lack of awareness, lack of means of contact, personal bias against accepting "welfare", etc.), in spite of previous media announcements and local organizational campaigns, had made no prior contact with the senior centers. The purpose of the study in this respect was to test these outreach methods on the most difficult target group available (i.e., one that would be best expected to represent those often most in need of outreach services). In view of these facts, the response frequencies obtained are not particularly surprising. However, they do reaffirm the existence of a central problem in the field of service delivery to the elderly. Unfortunately, as others have observed (Gaitz, 1974; Lopata, 1975; National Council on Aging, 1972), there are often serious levels of underutilization of available services by needy elderly, even when such nonusers are aware that services exist. The policy implications of this study are multiple. In spite of the necessary preliminary nature of inferences to be drawn from this data, it is felt that the results obtained from such a large-scale, well-controlled experiment can indeed be of use to policy-makers, administrators and others involved in fields related to service provision for the elderly. In particular, the most obvious implication of the results is in terms of the relative efficacy of the various modes of outreach tested. Quite clearly, the results indicate that the method of home visiting is significantly more successful than any of the other modes of contact. In this respect, the results of this study seem to support the findings of the National Council on Aging (1972), which also concluded that the mode of home visiting was the most effective method of conducting outreach to a target group of low-income elderly. The order and magnitude of the effects observed in the present study imply that in order to gain the participation of the elderly in accessing themselves to community resources, it is necessary to use a relatively high level of personal contact.
•Careful estimation of incurred costs for each mode of contact revealed that the average in-person visit was at least three times more expensive (in terms of worker time, materials and related expenses) than the telephone call mode, and approximately six to seven times more expensive than the letter mode (see M . Kushler, 1976).
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felt that these results further demonstrate, rather vividly, that a vigorous, personal approach to outreach is required in order to insure access to available resources. A final implication of this study is, of course, the need for further systematic research on the effectiveness of programs aimed at providing the elderly increased access to community services. The results of this study address themselves to the first step in the process (i.e., identifying which types of initial contact best facilitate access to a community service center). It is critical that the field also pursue policy relevant research aimed at providing answers to the long-term impact of service programs for the elderly. We can no longer just assume that, by definition, what we are doing in programming for the elderly is necessarily the most effective course of action. This is not intended as an indictment of the current social service system for the elderly. Clearly, many persons are currently receiving much needed services through the existing networks. To the extent that outreach provides access to these services, many beneficial outcomes will result. However, it is equally clear by the often low levels of participation by needy elderly, that the service system is not functioning at an optimum level. It is unlikely that improved information and referral/outreach efforts alone can solve this problem. Perhaps these services need to be improved, made more attractive, expanded, or made more accessible. Toward this larger problem, this article does not attempt to offer a solution but, rather, suggests an approach to investigating possible solutions. It is hoped that experiments such as the one described here will provide a vehicle for exploring the effectiveness of service programs for the elderly, particularly by developing and including systematic methods for gaining direct feedback, in terms of participation and opinion, from the elderly themselves.
References
Alexander, R. S., & Podair, S. Educating New York City residents to the benefits of Medicaid. Public Health Reports, September, 1969,84, 767-772. Ball, R. M. Income maintenance for the aged and handicapped. Public Welfare, 1972, 30, 33-38. Bennett, R. Living conditions and everyday needs of the elderly with particular reference to social isolation. International journal of Aging & Human Development, 1973,4, 179-184.
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person mode, the lower cost5 modes of telephone and personal letter contact appear to have potential usefulness in certain circumstances (i.e., where outreach budgets are very limited and/or whenever the goals of outreach are nonthreatening and noncomplex, e.g., the transmission of fairly simple information, the generation of name awareness, etc.). Indeed, in spite of the low rate of actual response, the follow-up survey revealed that 59% of those sent a personal letter remembered the letter and associated it with the senior center at the time of follow-up (approximately 1 to 2-mo subsequent to the mailing). As for the telephone contact recipients, 78% remembered the phone call and associated it with the senior center at time of follow-up. Thus, it appears that personal letters or telephone contacts would also be suitable for use with this target population at least for certain noncrucial service purposes such as simple information provision. A third policy implication that is apparent is the fact that even at the minimal levels of individual response required to secure accessibility to community resources in the I and R centers targeted in this study, a very active approach to outreach was essential. It should be highlighted that none of the control group made any positive response in terms of any of the three dependent variables examined. In fact, no member of the control group achieved access to any of the I and R center services during the course of the study. This was in spite of the fact that various opportunities for securing access to the I and R centers existed throughout this time period, including response to mass media ads, church announcements, bake sales, raffles and, of course, through informal word-of-mouth contacts. Interestingly, at the time of follow-up those persons in the control group were provided with a home visit outreach contact encouraging their participation with the local I and R center. In what was, in effect, a mini-replication of the results for the in-person mode of the original experiment, approximately three-fourths of those persons previously in the control group responded positively to this contact and registered a "client-card" with the center. It is
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Blau, Z. S. Old age in a changing society. New Viewpoints, Havelock, R. G. Planning for innovation: Through dissemination and utilization of knowledge. Inst. for New York, 1973. Social Research, Ann Arbor, 1971. Blumenthal, H. (Ed). Medical and clinical aspects of Heisel, M. A., & Faulkner, A. O. Evaluation of an outreach aging. Columbia Univ. Press, New York, 1962. project with elderly blacks. Paper presented at the Brody, S. J. Comprehensive health care for the elderly: 28th Annual Scientific Meeting of the Gerontological An analysis. Cerontologist, 1973, 13, 412-417. Society, Louisville, October, 1975. Brumfield, W. A., Jr., Fox, R. I., & Goldman, J. S. Reaching Kaplan, J. Services without the facts. Cerontologist, 1973, the target population. Public Health Reports, July, 13, 132. 1968,83, 597-602. Klippel, E. R., & Sweeney, T. W. The use of information Buhler, C. & Kleemier, R. W. (Eds). Aging and leisure. sources by the aged consumer. Cerontologist, 1974, Oxford Univ. Press, New York, 1961. 14, 163-166. Busse, E. W., & Pfeiffer, E. (Eds). Behavior and adaptation Kushier, M. Three modes of conducting outreach to lowin late life. Little, Brown and Company, Boston, 1969. income elderly: An experimental examination. Michigan Butler, R. N. Taking stock of the status of the elderly. Office of Services to the Aging, Lansing, Ml, 1976. International Journal of Aging & Human Development, Lopata, H. Z. Support systems of elderly urbanites: Chicago 1975,6, 179-182. of the 1970's. Gerontologist, 1975, 15, 35-41. Butler, R. N. How to grow old and poor in an affluent Lowenthal, M. F. The relationship between social facts and mental health in the aged. Aging in Modern Psychiatry. society. International Journal of Aging & Human American Psychiatric Assoc., New York, 1968. Development, 1973,4, 277-279. Carp, M. The psychology of aging. In R. R. Boyd & C. G. Melrose, J., Welsh, O. L., & Luterman, D. Auditory responses in selected elderly men. Journal of Gerontology, Oakes (Eds.), Foundations of Practical Gerontology. 1963, 18, 267-270. Columbia Univ. of South Carolina Press, 1973. National Council on Aging and U.S. Office of Economic Cohen, R. G. Outreach and advocacy in the treatment of Opportunity. The golden years: A tarnished myth the aged. Social Casework, 1974, 55, 271-277. (Project FIND), National Council on Aging: WashCutler, S. J. The effects of transportation and distance on ington, 1972. voluntary association participation among the aged. Newcomer, R. J., Anguera, J., Newcomer, S. R., & International Journal of Aging & Human Development, Yesselman, M. Evaluating information and referral 1974,5, 81-94. services for the homebound elderly. County of San Ferster, C. B. A functional analysis of depression. American Diego Dept. of Human Services, 1976. Psychologist, 1973,28, 857-864. Riley, M. W., & Foner, A. Aging and society, Vol. 1. Gaitz, C. M. Barriers to the delivery of psychiatric services Russell Sage Foundation, New York, 1968. to the elderly. Cerontologist, 1974, 14, 210-214. Shock, N. W. (Ed). Biological aspects of aging. Columbia Goodrow, B. A. Limiting factors in reducing participation Univ. Press, New York, 1962. in older adult learning opportunities. Cerontologist, Toseland, R., & Sykes, J. Senior citizens center participation 1975, 15, 418-422. and other correlates of life satisfaction. Gerontologist, Graney, M. J. Happiness and social participation in aging. 1977, 17, 235-241. Verwoerdt,A. Biological characteristics of the elderly. In R. R. Journal of Gerontology, 1975,30, 701-706. Boyd & C. G. Oakes (Eds.), Foundations of Practical GerHarris, R. Breaking the barriers to better health care ontology. Columbia Univ. of South Carolina Press, 1973. delivery for the aged. Cerontologist, 1975, 15, 52-56.
