Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service

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Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service
UNDERSTANDING
THE
      Quality of life   OF

      ADULTS WITH
       DISABILITIES
Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service
This publication is also available online at https://www.ncss.gov.sg/Press-Room/Publications
Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service
CONTENTS
                                                                                                          06                         18                          64
                                                                                                          PRESIDENT'S                Studies                     What Can You Do?
                                                                                                          FOREWORD                   18 Q
                                                                                                                                         uality of Life Study
                                                                                                          by Mr Hsieh Fu Hua,           on Persons with          65
                                                                                                          NCSS President                Disabilities             Acknowledgements
                                                                                                                                     32 Needs Assessment
                                                                                                          07                             on Respite Care for     66
                                                                                                          FOREWORD                       Caregivers of Persons   References
                                                                                                          by Dr Gerard Ee,               with Disabilities       Annexes
                                                                                                          Chairman of the NCSS
                                                                                                                                     42 Study on Public         67 A: Glossary of Quality
                                                                                                          Advocacy and Research
                                                                                                                                         Attitudes Towards           of Life Domains and
                                                                                                          Panel
                                                                                                                                         Persons with                Facets
                                                                                                          08                             Disabilities            68 B
                                                                                                                                                                     : Glossary of
                                                                                                          MESSAGE                                                   Disability Services
                                                                                                          from Mr Leo Chen Ian,      50
                                                                                                          Founder and Partner,       Insights And Ideas
Copyright © 2017 by National Council of Social Service                                                    Insight N Access Pte Ltd
ISBN: [978-981-11-3870-6]                                                                                                            62
All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any
                                                                                                          09                         The Disability
                                                                                                          An Overview Of             Service Landscape
means, electronic or mechanical, including photocopying, recording, or by any information storage         Disability                 62 Persons with
system and retrieval system, without the written permission of the copyright owners.                                                     Disabilities

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Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service
Before I became President of NCSS, I used                                                  Regardless of ability, condition or age, our lives
                                   to volunteer for a charity, handing out food                                               are made up of many diverse facets, aspects and
                                   provisions to vulnerable families. Many recipients                                         experiences intricately woven together. Even as
                                   were kind and invited me into their homes. What                                            individuals, we are shaped by the ecosystem we
                                   struck me during these visits was the sight of                                             live in, be it the people close to us, community or
                                   stacks of unconsumed and even expired food.                                                wider society. Hence, focusing on a few aspects
                                   They explained to me that when social service                                              rather than the whole – the individual rather than
                                   organisations offered help, it was usually food.                                           his or her interactions with the entire ecosystem –
                                                                                                                              prevents us from seeing meaningful linkages that
                                   While well-intentioned, gifts of food address                                              contribute to who a person is.
                                   hunger as opposed to what keeps people hungry.
                                   That food goes uneaten and families remain                                                 With this in mind, NCSS carried out a series of
                                   vulnerable tells us that hunger is but one need                                            studies to examine the quality of life of various
                                   among many. It also reminds us that people’s real                                          vulnerable populations and seniors through
                                   needs can be very different from what we believe                                           a person-centred and holistic approach. To
                                   them to be.                                                                                understand their aspirations, needs and well-being
                                                                                                                              from their perspective, we adopted the World
                                   In addressing these issues, NCSS advocates                                                 Health Organisation’s framework on Quality of Life,
                                   a quality of life approach to understanding                                                conducting surveys, interviews and discussions.
                                   needs. Areas such as psychological well-being,
                                   independence and having social support are vital                                           This is one in a series of publications that presents
                                   to living well. This entails encouraging people                                            the results of those findings to practitioners, social
                                   to express what they need, and to be active                                                service professionals, volunteers and service users
                                   participants in addressing their own needs.                                                for their application. Each contains rich information
                                                                                                                              that can be used to guide social service providers,

PRESIDENT'S                                                                               FOREWORD
                                   The Quality of Life Study has shed valuable                                                funders and other stakeholders in the social
                                   insights on how all individuals can hold onto                                              service ecosystem, to dive into understanding
                                   their aspirations, use their abilities and be active
FOREWORD
                                                                                                                              and developing solutions so as to empower service
                                   in society. While we have taken steps towards          Dr Gerard Ee                        users towards achieving their fullest potential.
                                   inclusion for persons with disabilities by improving   Chairman of the NCSS Advocacy and
MR Hsieh Fu Hua                    the infrastructure and opportunities for training      Research Panel                      Among numerous applications, the insights
NCSS President                     and employment, we now need to draw upon their                                             gleaned from these findings have contributed
                                   participation and contribution in the journey to                                           towards national initiatives such as the Enabling
                                   further better their lives.                                                                Masterplan 3, the nation’s disability blueprint,
                                                                                          "Regardless of ability,             as well as the Social Service Sector Strategic
"That food goes uneaten and        Ultimately, it is my hope that every contributor to    condition or age, our lives         Thrusts, a five-year strategic roadmap for the
families remain vulnerable tells   this sector can join NCSS in taking a person-first
                                                                                          are made up of many diverse         sector developed in partnership with the public,
                                   perspective, seeing individuals beyond recipients                                          private and people sectors.
us that hunger is but one need     of help alone and empowering all to live with          facets, aspects and experiences
among many."                       dignity in a caring and inclusive society.
                                                                                          intricately woven together."        I am extremely grateful to our advisors. They are
                                                                                                                              experts in the field of statistics, psychology, social
                                                                                                                              work, disability, mental health and seniors and
                                                                                                                              research. I am also thankful to each and every
                                                                                                                              respondent who participated in the study, along
                                                                                                                              with the many who helped ensure that their
                                                                                                                              opinions were heard.

6                                                                                                                                                                                 7
Quality of life ADULTS WITH DISABILITIES - UNDERSTANDING - National Council of Social Service
AN OVERVIEW OF DISABILITY

                                                 It must be unimaginable that someone with
                                                 cerebral palsy could be married with two beautiful
                                                 children, run his own consultancy firm and
                                                 complete a kayaking expedition around Singapore
                                                 to raise funds. Indeed, I would have never achieved                                             AN OVERVIEW OF DISABILITY
                                                 these milestones if my mother had sent me to an
                                                 institution when I was born, on the advice of the
                                                 paediatrician, as there was “nothing much she
                                                 could do” – that my life wasn’t worth the effort.

                                                 Growing up under preconceived notions remains
                                                 very much a part of my life. When I was in school, my
                                                 teachers would constantly advise me not to take P.E.
                                                 lessons and look after my schoolmates’ belongings
                                                 instead. I was also told to quit kayaking as a CCA,
                                                                                                                                                                                                                                   Restrictions to
                                                 because I would “injure myself and die out there”.
                                                                                                                                                                                                                                    participation
                                                 Even though human beings are made up of                                                   Defining Disability1                                                                    Problem being involved
                                                 countless possibilities, society often fails to look                                        Disability reflects the interaction                                                       in life situations
                                                 beyond what they see as a disabling condition. As                                           between features of a person’s
                                                 a result, the self-worth of a person with disability                                        body, and the society in which
                                                 takes a beating from young, snowballing over time                                                   he or she lives in.
                                                 into a lens of pity, helplessness and resignation, both
                                                 for the person and the people around him or her.                                                 It is an umbrella term that
                                                                                                                                                  covers three main aspects:
                                    an Library   I hope that the studies presented here will inform
                      it: The Hum
         Photo cred
                                                 service providers and the community towards a
                                                 vision of empowerment and solidarity, rather than

MESSAGE                                          liability. As long as we put in the effort, we will
                                                 discover beyond a single difference that there are
                                                 far more similarities which we share. With time, it is
Mr Leo Chen Ian                                  my wish that prejudiced lenses will be shed away.
Founder and Partner, Insight N Access Pte Ltd
                                                 An ideal world is certainly not unreachable. It is
                                                 simply about being able to perform the everyday
                                                 tasks that most of us can do, be it shopping for
"As long as we are willing                       groceries, doing one’s laundry, having friends and
                                                                                                                           Impairments                                                   Limitations
to put in the effort, we will                    romantic relationships and being treated just like
                                                                                                                             Problem in body                                             in activity
                                                                                                                                function or                                           Difficulty performing
                                                 anyone else.
soon discover beyond a                                                                                                           structure                                               a task or action
single difference that there                     The next time you meet a person with a disability,
                                                 resist the urge to judge what they can do, who they
are far more similarities                        are and how different they might be. Instead, start
which we share."                                 a conversation about what they want to do, who
                                                 they aspire to be and most of all, how you can
                                                 journey with them to achieve it.

                                                 As for me, I continue to take life’s challenges in my
                                                 stride, and strive constantly to lead a meaningful        1 World Health Organization. (n.d.). Disabilities. This definition reflects a bio-psycho-social model of disability.
                                                 life and to contribute back to Singapore.
8                                                                                                                                                                                                                                                             9
AN OVERVIEW OF DISABILITY                                                                                                                                                                                                          AN OVERVIEW OF DISABILITY

Some Types of Disabilities

                                                                                                                                                                   Learning
                                                                                                                                                                   Cognitive deficits that impact academic achievement.

                                                                                                                     Dyscalculia                                                                   Dyslexia
                                                                                                                     Difficulties in the reception, comprehension                                  Difficulty in reading skills such as word
                                                                                                                     or production of quantitative and spatial                                     reading, comprehension and overall
                                                                                                                     information.                                                                  fluency.

                                                                                                                     Dyspraxia                                                                     Dysgraphia
                                                                                                                     Difficulties in movement, balance and                                         Difficulty in writing, resulting in work that
                                                                                                                     coordination that often result in an                                          may be illegible or inaccurately spelt.
                                                                                                                     appearance of clumsiness.

                                                  Physical
 Total/partial loss of bodily function (e.g. walking, motor skills) or a part of the body (e.g. amputation).

                                                                                                                                                                   Developmental
     Muscular Dystrophy                                     Spina Bifida                                                                                           Diverse group of conditions that occur in the developmental period
     An umbrella term for a group of muscular               A birth defect of the spine that manifests                                                             of a child, resulting in difficulties in personal, social, academic or
     disorders characterised by muscle                      in various forms of severity. Spina bifida                                                             occupational functioning2.
     weakness, wasting and contractures,                    occulta is the mildest form, having no
     which are usually progressive in nature                signs and symptoms or neurological
     and sometimes even life-threatening.                   problems. More severe manifestations                     Autism Spectrum Disorder                                                      Down Syndrome
     These disorders result from inherited gene             include meningocele or the potentially                   A range of developmental disorders                                            A genetic condition caused by the
     abnormalities.                                         life-threatening myelomeningocele                        characterised by difficulties in social                                       presence of an extra chromosome, it
                                                            (open spina bifida).                                     interac tion, language and social                                             is associated with a range of physical
     Spinal Cord Injury                                                                                              communication as well as flexibility of                                       impairments and developmental
     Injuries to the spinal cord that result often in       Paralysis                                                thought and behaviour. Some examples                                          delays, including delayed motor and
     weakness in both lower limbs (paraplegia)              The loss of the ability to move (and                     on the spectrum are Autism, Asperger                                          cognitive skills.
     or in all four limbs (tetraplegia) with                sometimes to feel anything) in part or                   syndrome and Childhood Disintegrative
     potentially life- threatening complications.           most of the body, typically as a result of               Disorder.                                                                     Intellectual Disabilities
                                                            illness, poison or injury.                                                                                                             Having significant limitations in adaptive
     Polio                                                                                                           Cerebral Palsy                                                                functioning along with an IQ below 70.
     A viral infection typically recognised by              Amputation                                               A group of non-progressive disorders                                          It is characterised by impairments in
     weakness, paralysis or reduced muscle tone.            Surgical removal of all or part of a limb,               occurring in young children in which                                          academic and social functioning as well
                                                            an organ, or projecting part or process                  injury to the brain causes impairment of                                      as skills needed for daily living.
                                                            of the body.                                             motor function.

                                                                                                               Sources: Cerebral Palsy Alliance Singapore, Down Syndrome Association (Singapore), Dyslexia Association of Singapore, Institute of Mental Health,
                                                                                                               Ministry of Health, Muscular Dystrophy Association (Singapore), National University Hospital, NCSS, NUH Women's Centre, Singapore National Stroke
                                                                                                               Association, Society of Rehabilitation Medicine (Singapore).

                                                                                                               2 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM- 5.

10                                                                                                                                                                                                                                                           11
AN OVERVIEW OF DISABILITY                                                                                                                                                                                            AN OVERVIEW OF DISABILITY

                                    Sensory                                                                    People, including those with disabilities, are living longer. As the nation faces an ageing population, the
                                    When one of the senses – sight, hearing, smell, touch, taste and spatial   number of persons with disabilities acquired from accidents and illnesses is likely to rise. In addition,
                                    awareness – is impaired.                                                   there will be less familial support for persons with disabilities.

      Deafness/Hearing Impairment                          Visual Impairment
      The partial or complete loss of hearing in           Moderate to severe visual loss that
      one or both ears. Ranges from moderate               cannot be corrected to a normal level
      hearing loss, in which conversations may             by medication, operation or the use of
      be hard to hear, to profound hearing loss            optical lenses (e.g. spectacles).
      where no sound is audible.                                                                                                                                      Resident Old-Age Support Ratio
                                                                                                                                                   16
                                                                                                                                                        13.5
                                                                                                                                                   14
KEY TRENDS                                                                                                                                                     11.3
                                                                                                                                                                          10.5
                                                                           s t - 18
                                                                      po
                                                                                                                                                   12
                                                                                                                                                                                   9.0
          Under-18                                                     Rising demand for                                                           10

                                                                                                                           Old-Age Support Ratio
                                                                                                                                                                                            7.4
                                                                       longer-term                                                                 8                                                   6.0
      More children are                                                                                                                                                                                       5.7           5.4
      being diagnosed with
                                                                       care services, as
                                                                       persons with disabilities                                                   6
      developmental                                                    age and seniors acquire
      issues                                                           disabilities                                                                4

                        Increasing numbers                                                                                                         2
                        of children diagnosed                    Greater demand for
                                                                 quality and diverse                                                               0
                        with Autism
                                                                 service arrangements                                                                   1970   1980       1990     2000     2010       2014   2015         2016
                         Spectrum                                for persons with
                         Disorder                                 moderate to
                                                                  severe disabilities

Source: Enabling Masterplan 3.                                                                                 Source: Department of Statistics.

12                                                                                                                                                                                                                                         13
INTRODUCTION
When thinking about disability, attention is often drawn to the
condition rather than the person who bears it. From then on, it
becomes the primary lens with which needs, and the solutions to
address them, are conceived. Subsequently, efforts are focused on
rehabilitating the condition alone, which may skim across broader
contexts that persons with disabilities are part of.

To meet needs in a more effective, collective and sustained manner,
NCSS supports a person-centred and ecosystem approach towards
helping individuals achieve quality of life. This is also the value which
underlies the Social Service Sector Strategic Thrusts (2017-2021), a
5-year roadmap for the social service sector.3

         Person-Centred
         A person-centred approach operates on the belief that
         an individual has the capacity to understand, articulate
         and work through problems, making decisions on how to
         overcome them.4

         Ecosystem
         Addressing individuals holistically also means seeing them
         as enmeshed in different, interrelated contexts that influence
         every aspect of an individual's life - an ecosystem5 comprising
         caregivers and family, community and wider society. In practice,
         this means that understanding the needs of persons with
         disabilities necessitates taking into account their interactions
         with the ecosystem, towards more holistic understanding and
         solution creation.

         Quality of Life
         Taking a multi-faceted approach to individual well-being,
         an essential outcome is that individuals' quality of life is
         optimised in the form of a core set of diverse, essential needs.
         These needs are evaluated from individuals' own point of
         view, which gives credence to peoples' own awareness of
         what they need. This is important because researchers agree
         that the assessment of quality of life is subjective 6, and
         because individuals perceive needs and give importance to
         them in different ways.

3 T he Social Service Sector Strategic Thrusts document may be found on NCSS' website at http://
   www.ncss.gov.sg/4ST.
4 The term 'person-centred' was first introduced by the psychologist Carl Rogers in the 1940s. Further
   information about the person-centred approach can be found at http://adpca.org/content/history-0.
5 Bronfenbrenner, U. (1986). Ecology of the Family as a Context for Human Development: Research
   Perspectives.
6 Blatt, B. (1987). The Conquest of Mental Retardation; Taylor, S. & Racino, A. (1991). Community
   Living: Lessons For Today.

14                                                                                                        15
Domains
                                                                              facets
The World Health Organisation             Physical
defines Quality of Life as such7:                                             1 Pain and Discomfort      2 Energy and Fatigue                3 Sleep and Rest

                                          Level of
        An individual’s                   Independence                        1 Mobility                 2 ACTIVITIES OF             3 DEPENDENCE ON MEDICAL                        4 WORK CAPACITY
                                                                                                           DAILY LIVING                    TREATMENT / MEDICATION
    perception of their
  position in life in the                 Social
 context of the culture                   Relationships                       1 PERSONAL RELATIONSHIPS   2 SOCIAL SUPPORT                    3 SEXUAL ACTIVITY

  and value systems in
   which they live and                    Environment
                                                                              1 SAFETY AND SECURITY      2 HOME ENVIRONMENT                3 FINANCIAL ADEQUACY          4 HEALTH AND SOCIAL CARE
    in relation to their
   goals, expectations,                                                       5 OPPORTUNITIES            6 RECREATION AND                  7 PHYSICAL                    8 TRANSPORT
                                                                                TO ACQUIRE NEW             LEISURE                           ENVIRONMENT
        standards and                                                           INFORMATION AND SKILLS
           concerns.
                                          Psychological
                                                                              1 POSITIVE FEELINGS        2 THINKING, LEARNING,             3 SELF-ESTEEM    4 BODY                          5 NEGATIVE
It conceptualises Quality of Life
                                                                                                           MEMORY AND                                            IMAGE AND                      FEELINGS
in six constituent domains, sub-
                                                                                                           CONCENTRATION                                         APPEARANCE
divided into 24 facets. More details
on the domains and facets may be
found in Annex A.                         Personal Beliefs
                                                                              1 PERSONAL BELIEFS,
                                                                                SPIRITUALITY/ RELIGION

                                                                                        Society             Study on Public Attitudes
                                       With this in mind, NCSS conducted                                    towards Persons with Disabilities
                                       three major studies to better                                        To ascertain public attitudes
                                       understand the needs of persons
                                                                                       Caregiver            Needs Assessment on Respite Care for
                                       with disabilities in Singapore. Each
                                                                                                            Caregivers of Persons with Disabilities
                                       corresponds to an agent within
                                                                                                            To understand the needs of caregivers
                                       the disability ecosystem:
                                                                                       Individual           Quality of Life Study on
                                                                                                            Persons with Disabilities
                                                                                                            To examine their needs, from
                                                                                                            their perspective                               7W
                                                                                                                                                              orld Health Organization. (1993). Study Protocol for the World
                                                                                                                                                             Health Organization Project to Develop a Quality of Life Assessment
                                                                                                                                                             Instrument (WHOQOL).

16                                                                                                                                                                                                                           17
STUDIES                                                                                                                                                                                                                                                                                           STUDIES

QUALITY OF                                              tracked over time. This helps social service stakeholders to assess
                                                        the impact of their initiatives and identify trends for future planning.
                                                                                                                                                                             RESPONDENT BREAKDOWN BY DISABILITY TYPE                               RESPONDENT BREAKDOWN BY HOUSING TYPE

LIFE STUDY ON                                                                                                                                                                Physical
                                                                                                                                                                             Impairment
                                                                                                                                                                                             Sensory
                                                                                                                                                                                             Impairment
                                                                                                                                                                                                              Intellectual
                                                                                                                                                                                                              Disability/
                                                                                                                                                                                                                               Multiple
                                                                                                                                                                                                                               Disabilities
                                                                                                                                                                                                                                                        1-2 Room 3 Room
                                                                                                                                                                                                                                                        15.4%    29.3%
                                                                                                                                                                                                                                                                             4 Room
                                                                                                                                                                                                                                                                             34.7%
                                                                                                                                                                                                                                                                                        5 Room/
                                                                                                                                                                                                                                                                                        Executive/
PERSONS WITH                                            Research Objectives                                                                                                  23.1%           13%              Autism           23.2%                                                    Others

DISABILITIES                                               • T o identify the needs of persons with disabilities from their
                                                                                                                                                                                                              Spectrum
                                                                                                                                                                                                              Disorder
                                                                                                                                                                                                                                                                                        15.4%
                                                                                                                                                                                                                                                                             Private Apartment/
                                                              perspective, across six domains of quality of life9:                                                                                                                                      Adult Residential/
                                                                                                                                                                                                              36.7%
                                                                                                                                                                                                                                                        Nursing Home         Condominium
Introduction                                                                                                                                                                                                                                                                 1.6%
                                                                1 Physical                                    4 Environment                                                                                                                             2%
In 2016, NCSS completed the                                                                                                                                                                                   Others
Quality of Life Study on persons                                2 Level of independence                       5 Psychological                                                                                 (e.g. learning                            Hostel/
with disabilities in Singapore, a                                                                                                                                                                             disabilities)                             Community
                                                                3 Social Relationships                        6 Personal Beliefs                                                                              4%
nationwide survey which sought                                                                                                                                                                                                                          Group Home
to ascertain what areas they felt                          • To obtain a quantitative baseline for the quality of life for                                                                                                                              1.6%
contributed most to their well-                              persons with disabilities
being and could be improved                                • To surface priority areas for intervention
upon. It is the first large-scale
quantitative study that highlights                      Method
what persons with disabilities                          Participants were obtained through random sampling from SG Enable's
themselves consider important                           database10, and administered a survey face-to-face which they had to
to their well-being.                                    complete by themselves as far as possible. The final sample comprised
                                                        981 responses. Respondents were asked to complete the survey on                                                                            RESPONDENTS WHO HAVE USED/ARE ACCESSING SERVICES^
Collectively, these findings                            their own (with clarifications where necessary), failing which a proxy                                                     Disability Schemes (e.g. Car Park                                                                   571
support existing knowledge                              (main caregiver) answered on their behalf.11                                                                                                Label Scheme)
and feedback, and will help the
sector in deeper research, service                      KEY DESCRIPTIVES                                                                                                            Financial Assistance (e.g. public                                               366
planning efforts, public education                                                                                                                                                     assistance, grants, ComCare)
and policy recommendations. In                            3.4% of                     2.1% of                      13.3% of                    30.4%                             Early Intervention Programme for                                             271
particular, the latest Enabling                           Singaporeans                students aged                Singaporeans                have >1                          Infants and Children (EIPIC)/Special
Masterplan, a 5-year roadmap                              aged 18 to                  7 to 18 have a               aged 50 and                 disability type*                                   Education School
that guides initiatives for the                           49 have a                   disability+                  above have a                                                                     Assistive Devices                                     249
disability sector, adopted both                           disability*^                                             disability*^
the Quality of Life framework and                                                                                                                                               Employment-Related Services (e.g.                                       213
                                                          49%                         55.6%                        12.6%                                                            skills upgrading, job support)
findings in its strategic directions
and recommendations8.                                     have a                      have a chronic               have a                                                                       Sheltered Workshop                                174
                                                          moderate                    disease (e.g.                mental health                                                                 Day Activity Centre                        141
The results from this inaugural                           to severe                   heart disease,               condition*
study serve also as a baseline                            disability*                 diabetes,                                                                                 Counselling and Case Management                           106
for future comparison, allowing                                                       stroke and                                                                                                     Support Groups                  77
changes in quality of life to be                                                      asthma)*^
                                                                                                                                                                                           Other Disability Services            41
*
   Findings are self-reported.                                                                                                                                                 Residential Homes/Residential Care              30
^
  Includes those who acquired disabilities from accidents and illness.
+
  Source: Ministry of Education. Based on number of reported cases of students with sensory impairment, physical impairment, Autism                                                           Befriending Services            27
   Spectrum Disorder and intellectual disability. The total student population is put at approximately 460,000.
                                                                                                                                                                                                           Helplines           27
8  The Enabling Masterplan 3 document can be found on NCSS' website at https://www.ncss.gov.sg/NCSS/media/NCSS-Documents-and-Forms/EM3-Final_
       Report_20161219.pdf.
                                                                                                                                                                                   Hostel/Community Group Home                 25
9  More details on the domains, and facets under each domain, in Annex A.
10 SG Enable captures persons with disabilities (aged 18 and above) who have accessed services in government-funded social service organisations, special
                                                                                                                                                                                                                        0		200		400		600
      education schools or other schemes and support services administered by SG Enable at least once in their life. No other more representative national registry                                                       Number of Respondents
      for persons with disabilities currently exists. Response Rate = 75.4%. Of 1,300 surveys distributed, 1,000 were completed and 981 responses used after cleaning.   ^
                                                                                                                                                                             Respondents were allowed to indicate their attendance of more than one service.
11 5 0.9% were proxy responses.

18                                                                                                                                                                                                                                                                                                    19
STUDIES                                                                                                                                                                                                                                                                         STUDIES

                                       RESPONDENT BREAKDOWN BY EDUCATION                                                         In this survey, three World Health Organisation Quality of Life (WHOQOL) instruments were used. Further
                                                                                                                                 questions were asked on their satisfaction of services accessed, the types of services they would like as
     None              Primary           Secondary         Graduated          Institute of
                                                                                                                                 well as the Quality of Life domains in which they desired the most improvement. All items were translated
     12.2%             School            School            from SPED          Technical
                                                                                                                                 into Chinese, Malay or Tamil where necessary.
                       17.2%             13.3%             42.1%              Education
                                                                              4.8%
     Polytechnic       Junior            University        Others                                                                                         Quality of Life            WHOQOL-BREF13
     4%                College/Pre-      Degree            0.6%                                                                                                                      This is a 26-item scale that asks respondents to rate their state of well-
                       University        Holders                                                                                                                                     being in the last two weeks. Questions are answered on a five-point
                       1.6%              4.2%                                                                                                                                        scale, and comprise:
                                                                                                                                                              WHOQOL-DIS               • 24 facet-level questions that correspond with six domains of
                                                                                                                                                                                         Quality of Life
                                                                                                                                                                                       • Two questions that ask about perception of life and health overall

                                                                                                                               Specific to Persons with
          RESPONDENT BREAKDOWN BY EMPLOYMENT AND DISABILITY TYPE
     0%                                                                      31                                                                                                      In addition to the sample of persons with disabilities, the WHOQOL-

                                                                                                                                     Disabilities
                                                                                                       23
                                                                                                                                                                                     BREF was administered to that of the general population as well.
                          70                                                                                                                                  WHOQOL-BREF
                                                    43
    20%                                                                                                44                                                                            WHOQOL-DIS
                                                                             133                                                                                                     An add-on module of WHOQOL-BREF that surveys respondents on
                          17                                                                                                                                                         three areas of life regarded as important to persons with disabilities –
    40%                                             10                                                 44    Open Employment
                          26                        10                                                                                                                               Autonomy, Discrimination and Social Inclusion14. Similarly, questions
                                                                                                             Sheltered                                                               were answered on a 5-point scale and based on respondents'
                                                                                                                                                              WHODAS 2.0
                                                                             89                              Workshops^                                                              experiences in the last two weeks. There were 13 questions in total,
    60%                                                                                                                                                                              including:
                                                                                                             Accessing
                                                    65                                                       Education/
                          114                                                                          117   Day Activity                                                              • One question asking about the effect of the disability on one's
    80%                                                                      107                             Centres^/Others                                                             life overall
                                                                                                             None                         Other Areas Surveyed                         • 12 questions on aspects of Autonomy, Discrimination and Social
                                                                                                                                                 by NCSS                                 Inclusion, including:
100%

                                                                                                                                                                                      Facet                    Areas Covered
                                                                                                                                                                                      Autonomy         Feeling in control of one's life
                                                                                                                                                    1. Demographics                                    Being able to make day-to-day choices and big
                                                                                                                                                    2. D esired Areas of                              decisions in life
                                                                                                                                                        Improvement                   Discrimination Unfair treatment
               Physical                 Sensory                 Intellectual             Multiple
             Impairment               Impairment             Disability/Autism          Disabilities                                                3. P
                                                                                                                                                        erception of Health                           Needing to stand up for oneself
               (n=227)                  (n=128)             Spectrum Disorder            (n=228)                                                       Status and Health                               Worries about the future
                                                                  (n=360)                                                                                                             Social Inclusion Feeling accepted and respected in society
                                                                                                                                                       Conditions
                                                                                                                                                                                                       Ability to communicate effectively with people
^
    For more information on what these terms refer to, please refer to Annex B.                                                                     4. Service-Related
                                                                                                                                                                                                       Opportunities to be involved in social and local
                                                                                                                                                        Questions
                                                                                                                                                                                                       activities
                                                                                                                                                                                                       Feeling that dreams, hopes and wishes will be
COMPARISON TO THE GENERAL POPULATION                                                                                                                                                                   realised
As a basis for comparison, NCSS also obtained a representative sample (n = 942) of the general population
through the Department of Statistics12.                                                                                          12 R
                                                                                                                                     esponses from the general population sample which indicated that they had mental health conditions or disabilities were removed so that the general
                                                                                                                                    population sample could be used as a control group for comparison with the other target groups. 1,400 surveys sent out. Response rate: 67.3%.
                                                                                                                                 13 According to WHOQOL Group (1998), the WHOQOL-BREF has been validated cross-culturally for various populations worldwide. An example may be
                                                                                                                                     found on the WHO's website at http://www.who.int/mental_health/media/en/76.pdf.
                                                                                                                                 14 Items were generated from focus group discussions, tested and validated across 15 countries (Power, Green & The WHOQOL-DIS Group, 2010).

20                                                                                                                                                                                                                                                                                   21
STUDIES                                                                                                                                                                                                                                                                                                                            STUDIES

WHODAS 2.0 (WHO                                      Domain                                    Areas Covered                                                             Finding #2
Disability Assessment                                Cognition                                 Understanding and communicating
Schedule)15                                                                                                                                         Persons with disabilities scored lower than the general population across all quality of life domains^,
This 36-item instrument                              Getting Along                             Interacting with other people                        especially on level of independence, personal beliefs and social relationships, particularly in the area of
measures functioning levels                          Life Activities                           Domestic responsibilities, leisure, work and         social support from friends.
in six domains of health and                                                                   school
disability. Responses are                                                                                                                                                                                                                                                                                 General Population
indicated on a five-point scale                      Mobility                                  Moving and getting around
                                                                                                                                                                                                                              Quality of Life Score by Domain                                             Persons with Disabilities
to measure intensity and extent                      Participation                             Joining in community activities,
of respondents' difficulty in                                                                  participating in society                                                  100                  75.9
                                                                                                                                                                               69.0 62.7**                                     70.2                  69.0                   69.8                  67.6             69.8
performing these activities:
                                                     Self-Care                                 Attending to one's hygiene, dressing, eating                              80

                                                                                                                                                 Quality of Life Score
                                                                                                                                                                                                     53.7**                                                  57.0**                53.3**                                 53.4**
                                                                                               and staying alone                                                                                                                      48.7**                                                             45.3**
                                                                                                                                                                         60
                                                                                                                                                                         40
Key Findings
                                                                                                                                                                         20
     Finding #1
                                                                                                                                                                          0
                                                                                                                                                                               Physical         Level of      Social    Environment Psychological                                                 Personal        Overall QOL
Persons with disabilities experienced a lower quality of life than the general population.                                                                                                   Independence Relationships                                                                            Beliefs

It was even lower for persons with disabilities who had complex needs (i.e. having a disability or being                                            ** p < 0.01. A Multivariate Analysis of Variance was performed on the six domains related to quality of life (DV) and group membership (IV).
over the age of 65).

                                                                                 Quality of Life Score by Presence of Complex Needs                 At the facet level^, persons with                                                                       Quality of Life Score by Facet
                                                                                                                                                    disabilities reported the:                                                                          Physical Environment                                             69.0
                                                                                                                                                                                                                                                         Pain and Discomfort                                            67.7
                                                                                 100                                                                                                                                                                                                                                               Top 5
                                                                                                                                                                   • Worst scores in financial                                                            Home Environment                                             65.6        facets
                                                                                                                                                                                                                                                            Negative Feelings                                          65.1
                                                                                                                                                                     adequacy and thinking,                                                               Safety and Security                                         64.5
                                                                                  80                                            General                              learning, memory and                                                             Health and Social Care                                          64.1
                                                                                                                                                                     concentration                                                                             Sleep and Rest                                        62.3
                                                                                                                        Population: 69.8
                                                                                                                                                                                                                                                                     Transport                                      61.9
                                                                                                           55.0                                                                                                                    Dependence on Medication or Treatments                                          59.4
                                                         Quality of Life Score

                                                                                                                                                                   • Best scores in physical

                                                                                                                                                                                                         WHOQOL-BREF Facets
                                                                                  60           45.9                        Persons with      *                                                                                                            Energy and Fatigue                                       58.0
                                                                                                                        Disabilities: 53.4                           environment and pain and                                                         Personal Relationships                                      56.0
                                                                                                                                                                     discomfort                                                                                       Mobility                                    55.8
                                                                                                                                                                                                                                                     Activities of Daily Living                                  54.7
                                                                                  40                                                                                                                                                            Body Image and Appearance                                        54.2
                                                                                                                                                                                                                                                                  Self-Esteem                                   52.5
                                                                                                                                                                                                                                                             Positive Feelings                                 50.4
       Complex Needs                                                                                                                                                                                                          Opportunities to Acquire Information and Skills                                 47.8
                                                                                  20                                                                                                                                                                          Personal Beliefs                               45.3
       No Complex Needs                                                                                                                                                                                                                                        Social Support                                45.2
                                                                                                                                                                                                                                                                Work Capacity                                45.0
                                                                                   0                                                                                                                                                                           Sexual Activity                              44.8
                                                                                                                                                                                                                                                      Recreation and Leisure                                44.4 Bottom 5
*p < 0.05                                                                                   Persons with Disabilities                                                                                                         Thinking, Learning, Memory and Concentration                                  44.3
                                                                                                                                                                                                                                                                                                                     facets
                                                                                                                                                                                                                                                          Financial Adequacy                              38.6
                                                                                                                                                                                                                                                                                  0          20          40       60        80          100

                                                                                                                                                                                                                                                                                      Quality of Life Score
15 The WHODAS 2.0 has been tested in different cultural settings and health populations and has robust psychometric properties (Gold, 2014).        ^
                                                                                                                                                          For more information on the Quality of Life domains and facets, please refer to Annex A.

22                                                                                                                                                                                                                                                                                                                                      23
STUDIES                                                                                                                                                                                                                                                                                                                           STUDIES

                        Finding #3                                                                                                                                         Finding #5

   When asked about which areas they wished to see improved, persons with disabilities prioritised level of                                                           Regardless of disability type, persons with moderate-severe disabilities experienced lower quality of life
   independence, followed by psychological well-being and in their environmental resources.                                                                           than those with mild disabilities.
                                                                                                                                                                                                                                                         Quality of Life Score by Disability Type
                                                                                                                                                                                                                                                                                                     *
                                                Despite social
                                                                                                                                                                                                                                                    *                      *
                                                relationships
                                                                                                                                                                                                                                        100                                                                                    *
                                                scoring low,                                                                                         Seven of 10                                                                                                                             64.8
                                                respondents                                                                                         would like to                                                                        80    59.7                 62.3
                                                                                                                                                                                                                                                                                                                        58.2

                                                                                                                                                                                                               Quality of Life Score
                                                did not                                                                                             have greater
                        100                                                                                                                        independence                                                                                                                                          48.8
                                                desire to see
                                                                                         62.7                                                                                                                                            60             42.1                   42.6                                                40.5
                        80      45.3            improvements
                                                                                                                                   53.3
                                                                                                                                                    in their lives.
                                                in this area.                           Physical
Quality of Life Score

                               Personal                                                                                       Psychological
                        60      Beliefs                                                                                                                                                                                                  40

                        40                                                                                     57.0                                   53.7                                                                               20
                                                   48.7                                                                                                                     Mild
                                                                                                            Environment                              Level of
                        20                          Social                                                                                        Independence              Mod-Severe                                                    0
                         0                      Relationships
                                                                                                                                                                                                                                                 Physical             Sensory                Intellectual                 Multiple
                                                                                                                                                                      *p < 0.05                                                                Impairment           Impairment              Disability/ASD               Disabilities
                              Smallest desired improvement                                                                 Greatest desired improvement
                                                                                                                                                                           Finding #6

                                                                                                                                                                      Persons with disabilities felt that they lacked autonomy and control over their lives and in life decisions.
                        Finding #4
                                                                                                                                                                      They also felt excluded from contributing meaningfully to society, and did not feel that they could fulfil
                                                                                                                                                                      their personal potential.
   Depending on disability type, respondents reported slightly different needs:                                                                                                                            WHOQOL-DIS Scores by Area

             • Those with physical or sensory impairments experienced lower quality of life in terms of their                                                                       Best                                                  Discrimination                                                          69.3
               personal beliefs, social relationships and psychological well-being
                                                                                                                                                                                                                                       Social Acceptance                                                               69.0
             • Those with intellectual disability and Autism Spectrum Disorder experienced lower quality of life in
               the domains of personal beliefs, level of independence and social relationships                                                                                                                                          Future Prospects                                                        60.2
                                                                                                                                                                                                                                                  Choice                                                 48.6
                                                                                                 Quality of Life Score by Disability Type
                                                                                                                                                                                                                                                Advocacy                                          47.2

                                                                                                                                                                                  WHOQOL-DIS Areas
                         Physical                                                100                                                                                                                                                             Respect                                                 47.1
                                                                                 80
                                                                                                                           67.3                                                                                Communication Ability                                                              46.6
                         Independence                                                  57.2                         56.8                                  57.1
                                                         Quality of Life Score

                                                                                              51.4 55.7 49.0 52.8                 55.6 51.3
                         Psychological                                           60                                                           42.2 45.2                                               Social Network and Interaction                                                       38.0
                         Personal Beliefs                                        40                                                                                                                                                           Autonomy                                        34.4

                         Social Relationships                                                                                                                                                                                                    Control                              33.0
                                                                                                                                                                                                                                                                                                            Bottom
                                                                                 20                                                                                                                                                                                                                         5 areas
                         Environment                                                                                                                                                                                                   Personal Potential                                    30.9
                                                                                   0
                                                                                        Physical/Sensory Impairment           Intellectual Disability/ASD                           Worst            Social Inclusion and Contribution                                            29.1

                                                                                                                                                                                                                                                               0      20              40            60            80               100
                                                                                                                                                                                                                                                            WHOQOL-DIS Score
   24                                                                                                                                                                                                                                                                                                                                     25
STUDIES                                                                                                                                                                                                                                                                             STUDIES

                                                                                                                                        Respondents who participated in sports or physical recreation reported higher quality of life than
     24-year-old full-time national serviceman Samuel                                                                                   those who did not.
     aspires to find work in the financial sector and boost                                                                                                                         Quality of Life Score by Frequency of
     his employability by earning a degree. Having had                                                                                                                           Participation in Sports/Physical Recreation
     positive working experiences with Mount Alvernia                                                                                                                                        100         *
     Hospital and in the Air Force, he sums up his thoughts                                                                                                                                                *
     about how persons with disabilities can be better                                                                                           At least 3 times a week                                                              80

                                                                                                                                                                                                              Quality of Life Score
                                                                                                                                                                                                                                             56.4 55.2 52.4
     included in society:                                                                                                                        At least 1 time a week                                                               60

     “Having an inclusive society means that everyone                                                                             123            Non-participants                                                                     40
     is given an equal opportunity to have a try on                                                                                                                                                                                   20
                                                                                                                                        *
                                                                                                                                            p
STUDIES                                                                                                                                                                                                                                                                                    STUDIES

     Finding #9

Persons with disabilities who were not engaged in a main daily activity, particularly employment, experienced                                                                   Social Relationships                                                           Personal Beliefs
lower quality of life.                                                                                                                                                                    *                                                                           *
                                                                                                                                        100                                                                                            100
                                                  Quality of Life Score by Daily Activity Type
                                                                          *                                                             80                                                                                                  80
                                                                                                                                                 52.4                             51.5        49.3                                                  52.5

                                                                                                                                                                                                                    Quality of Life Score
                                                                                                                Quality of Life Score
                                                                                       *                                                                                                                46.0                                                     45.1         44.8         42.9
                                        100                                                                                             60                                                                                                  60

                                        80      63.3           60.6                                                                     40                                                                                                  40
                                                                                 52.1         46.7
                Quality of Life Score

                                        60                                                                                              20                                                                                                  20

                                        40                                                                                               0                                                                                                   0
                                                                                                                                                 Open      Sheltered Education/                         None                                        Open       Sheltered Education/        None
                                        20                                                                                                    Employment Employment Day Activity                                                                 Employment Employment Day Activity
                                                                                                                                                                       Centre/Others                                                                                       Centre/Others
                                         0
                                                                                                                                                       Occupation/Main Activity                                                                          Occupation/Main Activity
                                                 Open       Sheltered          Education/     None
                                                                                                                       *p < 0.05                                                                                        *p < 0.05
                                              Employment   Employment          Day Activity
                                                                              Centre/Others
                                                                                                                                         Finding #10
*p < 0.05                                                  Occupation/Main Activity

                                                                                                                       Those in employment reported a higher level of independence.
They reported diminished psychological well-being, social relationships and sense of meaning in life.
                                                                                                                                                                                                       Level of Independence
                                                           Psychological Well-being
                                                                                                                                                                                                                       *
                                                                          *
                                                                                                                                                                                100                                                                *
                                        100
                                                                                                                                                                                 80                       63.5
                                        80                                                                                                                                                 58.9                                                  53.1
                                                56.1

                                                                                                                                                        Quality of Life Score
                                                                                                                                                                                                                                                                 47.4
                Quality of Life Score

                                                               45.1              44.8         42.9                                                                               60
                                        60
                                                                                                                                                                                 40
                                        40
                                                                                                                                                                                 20
                                        20
                                                                                                                                                                                  0
                                         0
                                                                                                                                                                                            Open        Sheltered                       Education/               None
                                                 Open       Sheltered          Education/     None                                                                                       Employment    Employment                       Day Activity
                                              Employment   Employment          Day Activity                                                                                                                                            Centre/Others
                                                                              Centre/Others
                                                                                                                       *p < 0.05
                                                                                                                                                                                                         Occupation/Main Activity
*p < 0.05                                                   Occupation/Main Activity

28                                                                                                                                                                                                                                                                                             29
STUDIES                                                                                                                                                                                                                                 STUDIES

                                                                                                                                   Finding #11
However, those in open employment tended to feel discriminated against.

                                                                   Discrimination                                               Many were not engaged in any activities even if they were higher functioning (e.g. can move, get around
                                                                       *                                                        by themselves, can care for themselves, can communicate well), could care for themselves and were able
                                                               *                                                                to communicate well.
                               100

                               80                                     61.7              65.0
                                                   57.6                                                                                                                              WHODAS 2.0 Score by Occupation/Main Activity
                                                                                                                                 Each dot represents
            WHOQOL-DIS Score

                                                                                                           55.6                  one respondent.
                               60                                                                                                                                              100
                                                                                                                                 The WHODAS 2.0
                               40                                                                                                domains are (p.22):
                                                                                                                                 • Cognition                                    75

                                                                                                                                                            WHODAS 2.0 Score
                               20                                                                                                • Getting Along
                                                                                                                                 • Life Activities                             50
                                0                                                                                                • Mobility
                                        Open                        Sheltered        Education/            None                  • Participation
                                                                                                                                                                               25
                                     Employment                    Employment        Day Activity                                • Self-Care
                                                                                    Centre/Others
                                                                                                                                                                                0
*p < 0.05                                                             Occupation/Main Activity

                                                                                                                                                                                        Open       Sheltered              Education/    None
Several faced interpersonal issues as well, though this was not limited to employment alone.                                                                                         Employment   Employment             Day Activity
                                                                                                                                                                                                                        Centre/Others
                                                                                                                                                                                                    Occupation/Main Activity

                                                          Getting Along (WHODAS 2.0) Score by Occupation/Main Activity
  Each dot represents
  one respondent.
  The WHODAS 2.0                                        100
  domains are (p.22):
  • Cognition
  • Getting Along                                        75
                                     WHODAS 2.0 Score

  • Life Activities
  • Mobility
  • Participation                                       50
  • Self-Care

                                                        25

                                                         0
                                                                  Open              Sheltered             Education/     None
                                                               Employment          Employment             Day Activity
                                                                                                         Centre/Others
                                                                                     Occupation/Main Activity

30                                                                                                                                                                                                                                          31
STUDIES                                                                                                                                                                                                                                                                                                                         STUDIES

NEEDS                                                   Comprising both a survey and focus group discussions, it sought to                                                                                                           KEY DESCRIPTIVES
                                                        unearth caregivers' understanding of respite care, their views and
ASSESSMENT ON                                           preferences of respite care services as well as their need for such services                                                                                                         123

RESPITE CARE                                            in relation to various predictors (e.g. stress levels, characteristics of
                                                        care recipients).
                                                                                                                                                                                               Age of Caregiver                                             RELATION OF CAREGIVER TO CARE RECIPIENT

FOR CAREGIVERS                                                                                                                                                            65
                                                                                                                                                                                                                                         8.3%
                                                                                                                                                                                                                                                                 Parent
                                                                                                                                                                                                                                                                 90%
                                                                                                                                                                                                                                                                                  Sibling
                                                                                                                                                                                                                                                                                  6.0%
                                                                                                                                                                                                                                                                                                  Grandparent
                                                                                                                                                                                                                                                                                                  1.0%
                                                                                                                                                                                                                                                                                                                          Others
                                                                                                                                                                                                                                                                                                                          3.0%
OF PERSONS                                              Findings of the study revealed suggestions to alleviate caregiver
                                                        stress. In particular, these recommendations informed the Enabling
WITH DISABILITIES                                       Masterplan 3, and it was announced in the Singapore Budget 2017 that
                                                        the government would set up a disability caregiver support network to
Introduction                                            provide information, planned respite, training and peer support, and
Caregivers16 are often the main                         work together with social service organisations to strengthen caregiver
pillars of support for persons                          support for caregivers of people newly diagnosed with disabilities20.
with disabilities. As instrumental
agents in the latter's quality of                       Research Objectives
life, they have a direct impact on
the well-being of care recipients.                        • To unearth caregivers' understanding and views of respite care
                                                          • To ascertain their need for such services in relation to various
While they play a crucial role in                           predictors (e.g. stress levels, characteristics of care recipients)
the disability support ecosystem,
little research has been done on
these individuals, nor on their                         Method
respite care needs. It is important                     This assessment comprised a quantitative survey as well as pre-survey
that we understand caregivers                           focus group discussions.21                                                                                                Education Level of Caregiver                                                                  Household Income
better as they bear tremendous
responsibilities that affect their                      Focus Group Discussions                                                                                            Primary         Secondary            Junior              Tertiary                     $6000
own lives – and those of their                          Six focus group discussions were held with caregivers22 of pre-schoolers                                           13.2%           44.3%                College             34.8%                        15.5%              $3000               $6000              22.7%
                                                                                                                                                                                                                7.8%                                                                36.3%               25.5%
care recipients – in equally                            with special needs (0-6 years), students (7-21 years) and adults (21
consequential ways, be it higher                        years and above). Each session had five to six participants, totalling 33.
levels of guilt or worry17, stress18
or decreased work participation                         The discussions captured ideas of what respite care meant to caregivers,
in general19.                                           existing service gaps, services received and the adequacy of services
                                                        in meeting caregiver needs. These inputs went into the subsequent
Following up on feedback                                quantitative survey, which concentrated on gathering data on the
received during the Enabling                            profile of caregivers and their care recipients, current knowledge of
Masterplan 2 (2012-2016) as                             respite care and preference for respite care services.
well as that obtained from
caregivers and members of the                           Quantitative Survey
public, NCSS conducted a study                          Social service programmes were stratified first according to the various
to understand the respite care                          age groups served23, and then by service type24. Random sampling
needs of caregivers of persons                          was then carried out on each stratum. Based on calibrated numbers,
with disabilities.                                      a total of 1,600 surveys were distributed. The achieved sample size
                                                        was 78925.
                                                                                                                                                                        19 C
                                                                                                                                                                            han, Ostbye, & Malhotra (2013) noted that in Singapore, 47% of caregivers are not working and of those who did, 29% indicated that they had to leave
                                                                                                                                                                           work at least once in six months for care recipients' doctor's appointments.
                                                                                                                                                                        20 L am, L. (2017, February 20). Singapore Budget 2017: Integrating Disabled into Workforce and Supporting Caregivers Focus of New Govt Masterplan.
16 A caregiver is an individual who assists others with medical tasks and activities of daily living. Formal caregivers perform this role in institutional settings   21 Where real stories, accounts or quotes are used, names have been changed for reasons of privacy.
    while informal caregivers, usually unpaid, care for others at home, in public and other more informal settings.                                                     22 C aregiver contacts were provided by relevant social service organisations.
17 S torch et al. (2009) found that caregivers who are often very personally attached to the care recipient suffer from strong feelings of guilt and worry.            23 0-6 years old, 7-21 years, 19 years and above.
18 Goh, Chong & Chan (2010) noted that 54% of parents with children in Early Intervention Programmes for Infants and Children (EIPIC) experience clinically            24 Early Intervention Programme for Infants and Children, Special Education as well as training places such as Day Activity Centres and Sheltered Workshops.
    significant levels of stress.                                                                                                                                       25 Response Rate: 49.3%. Of 1,600 surveys distributed, 967 surveys were returned, of which 178 were considered invalid (12 nil returns, 166 incompletely filled).

32                                                                                                                                                                                                                                                                                                                                    33
STUDIES                                                                                                                                                                                                                                                   STUDIES

                                    Caregiver Support Services Accessed^                                     CARE RECIPIENT'S DISABILITY TYPE                                            SEVERITY OF CARE RECIPIENT'S DISABILITY
                                                                                                     Physical                       Sensory                      Intellectual                        Mild               Moderate              Severe
Family Support                                                                                       Impairment                     Impairment                   Disability                          39.4%              49.1%                 11.5%
                                             14                                                      13%                            3%                           32%

                                                                                                     Autism                                                      Multiple
                                                                                                     Spectrum                                                    Disabilities
Caregiver Training                                                                                   Disorder                                                    22%
from Hospitals                                    21
                                                                                                     29%

Others
                                                                                                                          CARE
                                                           43

Home Help Services
                                                           44

                                                                                                    The sur vey probed into                               Social and Time. Positive responses to 7 or more items indicate a
Religious Support Groups                                                                            respondents' caregiving and care                      high level of strain that may warrant clinical attention.
                                                                    62                              recipient profiles as well as his or
                                                                                                    her knowledge, perception and                         General Health Questionnaire-12 (GHQ-12)27
                                                                                                    utilisation of respite care. Three                    In this tool, 12 questions are asked that identify common psychiatric
Caregiver Programmes                                                                                instruments were also included                        conditions in both clinical and general populations. It assesses the
from Social Service                                                 64                              in the questionnaire.                                 severity of mental disturbances over the past few weeks on a 4-point
Organisations                                                                                                                                             scale (from 0 to 3), with a higher score representing greater levels of
                                                                                                    Caregiver Strain                                      mental distress.28
Mutual Help/Support                                                                                 Index (CSI)26
Groups                                                                          102                 A 12-question tool measuring                          Kessler-6 (K6)29
                                                                                                    strain related to care provision,                     Developed for use in the US National Health Interview Survey (NHIS),
                                                                                                    t h e C S I i s u s e d to a s s e s s                K6 comprises six questions on a scale of 1-5, to distinguish cases of
                                                                                                    individuals on the following                          serious mental illness from non-cases. A case would be defined if the
Counselling
                                                                                              149   domains affecting well-being:                         sum of all six items is greater than or equal to 13.
                                                                                                    Financial, Employment, Physical,
                                0       20         40          60    80   100     120   140   160

                                                                                                    26 F rom Robinson (1983). More information on the scale can be found at https://consultgeri.org/try- this/general-assessment/issue-14.pdf. The CSI has
                                                                                                        been found to be internally consistent when used with different family caregivers (Blake et al., 2003, Khan et al., 2007). In this study, Cronbach α = 0.87.
                                                                                                    27 From Goldberg & Williams (1988). The GHQ-12 is known for its brevity and use in clinical settings and has been translated and validated in at least
                                                                                                        two languages in addition to English. It has been found to be psychometrically viable in countries as diverse as Germany (Romppel, Braehler, Roth &
                                                                                                        Glaesmer, 2013), Spain (Sanchez-Lopez & Dresch, 2008) and Iran (Montazeri, Harirchi, Shariati, Garmaroudi, Ebadi & Fateh, 2003). More information
                                                                                                        on the scale can be found at http://www.psicothema.com/pdf/3564.pdf. In this study, Cronbach α = 0.93.
                                                                                                    28 0 -1 re-scoring also provides a total score, for which a 3-4 cut off point is commonly used to indicate caseness.
                                                                                                    29 A truncation of K10 (Kessler et al. 2003). More information on the scale can be found at https://www.gem-measures.org/public/DownloadMeasure.
^
    Caregivers were allowed to select more than one service.                                            aspx?mid=35In this study, Cronbach α = 0.91.

34                                                                                                                                                                                                                                                              35
STUDIES                                                                                                                                                                                                                                STUDIES

                                                                                                            Finding #2
Key Findings
      Finding #1                                                                                                                   Factors Contributing to High Caregiver Stress

Close to half of caregivers of persons with disabilities experienced caregiver strain, with 4 in 10 being
                                                                                                                                                                              1   Disability of care recipient is severe
psychologically distressed.
                                                                                                                                                                                                                                 8.2

                                                                                                                                                   Strain Index Score (CSI)
More than 6 in 10 felt burdened by the weight of their caregiving duties.

                                                                                                                                                      Average Caregiver
                                                                                                                                                                                                         6.5

                                                                                                                                                                                      4.8
     Petrina is mother to 17-year-old Jayden, who
     has Autism Spectrum Disorder. As a freelance
                                                               4    in 10 are
                                                                    psychologically
                                                                    distressed                                                                                                       Mild             Moderate         Severe/Profound
     editor, she home-schools Jayden, and faces                                                                                                                                        Severity of Care Recipient's Disability
     many challenges caring for him on a daily basis.
     She has had to borrow money from her father
     to get by. Jayden is also often aggressive, be
     it with her or other people. As a result, she              6   in 10 feel burdened
                                                                    by caregiving                               Maybe I was still in a
                                                                                                                                                                              2   Care recipient is young
                                                                                                                                                                                      7.2

                                                                                                                                                   Strain Index Score (CSI)
     experiences what she terms as “stress and                                                                 denial stage, I cannot

                                                                                                                                                      Average Caregiver
     tension” on a daily basis.                                                                                                                                                                                                  5.9
                                                                                                                 understand that he                                                                      5.7
     “I’ve had a stressful episode where my son                                                                    has this problem
     attacked me for about less than one minute.
     Do you know what it feels like to be attacked
                                                                                                                  ‘cause he looks so
     by somebody bigger than you, someone you                                                                        normal…that’s                                                    0-6                7-21              Above 21
     have been taking care of? He’s grabbing at you,
     kicking you…it only happened for less than a
                                                                                                                  the thing I cannot                                                           Age of Care Recipient
     minute, but it will take a few days for the scars                                                                  accept…
     to recover. Every time I pick up my shirt or my                                                                                                                          3   Presence of chronic illness in either
     handbag, it’s going to hurt my back because                                                                 Caregiver of child with Autism                                   caregiver or care recipient

                                                                                                                                                   Strain Index Score (CSI)
     of the way he attacked me.”                                                                                            Spectrum Disorder                                                                     7.6

                                                                                                                                                      Average Caregiver
                                                                                                                                                                                            5.6

                                                                                                                                                                                       No Chronic        Either or Both have
                                                                                                                                                                                         Illness            Chronic Illness
                                                                                                                                                                                             Presence of Chronic Illness

                                                                                                                                                                              4   Care recipient has Autism Spectrum
                                                                                                                                                                                  Disorder or intellectual disability

                                                                                                                                                                              5   Low average household income

                                                                                                                                                                              6   High education

36                                                                                                                                                                                                                                         37
STUDIES                                                                                                                                                                                                                                       STUDIES

                                                                Having a degree did not shield Anne from the struggle
                                                                of caring for her son, 7-year-old Cody. She treasures
                                                                spending time together with Cody, whether at picnics,
                                                                 running and biking, or bringing him to parties where                                                                     While hiring a foreign domestic worker might seem
                                                                 she frequently tells family and friends about him.                                                                       helpful, Helen constantly worries about her helper.
                                                                  However, there was a time when she had high hopes                                                                       There is perpetual uncertainty on whether she would
                                                                  for her first son – hopes that were crushed after he                                                                     stay on the job and be able to care effectively for
                                                                  was diagnosed with Autism Spectrum Disorder.                                                                             16-year-old Cedric, who has special needs. Holding
                                                                                                                                                                                            a full-time job, she is especially concerned that her
                                                                   “The first year was difficult for me. ‘Cause he                                                                          helper would leave on short notice, leaving her short-
                                                                   was my oldest son so when he came I was very                                                                              handed and with no immediate options to turn to.
                                                                    idealistic…I want to be a perfect, cool mum…and
                                                                    then when we found out that he had Autism the                                                                            “[My previous helper said] mum, I get another new
                                                                     world crumbled. Within a year, we were so busy                                                                          employer, staying in a private house, condo, I’m
                                                                     with therapies and trying to learn everything that                                                                       sorry to tell you ah, that I would want to transfer
                                                                     I closed off. I think [that] my coping [period] was                                                                      there. And [even after] I paid for everything for
                                                                      one year, after that I came out publicly, talk[ed]                                                                       her to come…After she (new helper) came in, I
                                                                      about it on Facebook, Twitter, what have you. I                                                                          [started to] monitor her even when I’m in office.
                                                                       advocate for people with disabilities. I fight for                                                                       But she’s not keen at all to look after special
                                                                       people who don’t understand…I tell everybody                                                                             needs children!”
                                                                        about him, and for me it helped a lot.”

       Finding #3                                                                                                                            Finding #4

Profile of Caregiver Needing Respite Care                                                                                                Most caregivers were not aware of the term “respite care”, with nearly 6 in 10 not having heard about it.

                                                                                                                                         Participants understood respite care mostly in terms of temporary relief from caring for those in their
                                             02
                                                                                                                                         charge (e.g. babysitting, child care, day care centre).
                                                   Higher
                                                 income or
                                                 education

                                                                                                                                                                          Those who have encountered the term "respite care" found out
                                 01
                                                                                                                                                                          about it through social service providers
                                        Has a                                           03
                                      chronic                                                Employs
                                       illness                                               a foreign
                                                                                             domestic
                                                                                              worker^

                                                                                                                                                                          Others came to know of it through the media or personal contacts

^
     ontrasts with the Singapore Survey on Informal Caregiving (Chan, Ostbye, Malhotra & Hu, 2013), which observed that caregivers of
    C
    elderly care recipients experienced less stress when receiving help from a foreign domestic helper.

38                                                                                                                                                                                                                                                   39
STUDIES                                                                                                                                                                                                               STUDIES

     Finding #5                                                                                                          Finding #6

Caregivers regarded child safety, affordability and having trained personnel as important in respite                  Caregivers expressed greatest need for respite care during situations of emergency.
care services.
                                                                                                                      In general, respite care was perceived as temporary and reactive, rather than constant and preventive.
                                          Components of Respite                                % of Caregivers Who
                                          Care Services                                        Rated as Important
                                          Child Safety                                         68%
          64%                                                                                                                                  Situations Requiring Respite Care
                                          Affordability                                        64%
                                          Trained Personnel                                    55%
64% feel that respite carers should
                                          Convenience/Proximity                                33%                                                      Change of
be trained/social workers.                                                                                                                                                     Have to care
                                          Home Security                                        32%                                                      domestic
                                                                                                                                                         worker               for another ill
                                          Easy Access to Public Transport                      26%                                                        48%                  dependent
                                          Feature Support Services for Caregivers              24%                                  Crisis situation                               72%
                                                                                                                                                                                                 Feeling
                                                                                                                                     (e.g. death of
                                                                                                                                                                  Go on                         physically
                                                                                                                                   family member)                 holiday                        unwell
Caregivers were more in favour of centre-based respite (e.g. day care centres, residential homes) of caregiving                           71%                      49%
as opposed to informal or home-based care.                                                                                                                                                        81%
                                                                                                                     Overseas
                                                                                                                       trip
                                  Acceptance of Types of Respite Care                                                 54%                                                                                      Need a
                                                                                                                                                                                                             short break/
                              Informal                       31                                          69                                                                                                 breathing time
                                                                                                                           Exhaustion or                                                                         65%
                      Trained worker at                                 49                               51                  burnout
                        your own house
                                                                                                                               75%                                                          Psychologically
                      Residential Home
                                                                                                                                                                                             overwhelmed
                                                                               59                        41
                                                                                                                                                                                                 72%

                        Day care centre                                                      86          14

                                          0        20         40          60         80            100

                                               % of Caregivers who indicated "Yes"
                                               % of Caregivers who indicated "No" or "Uncertain"

40                                                                                                                                                                                                                        41
STUDIES                                                                                                                                                                                                                                                                                          STUDIES

STUDY ON                                           Permanent Residents aged 18 to 69 years old to uncover the societal                                    Method                                                                      Education Level
                                                   attitudes towards persons with disabilities.                                                           The study was conducted in three                   No formal           Secondary/           Junior               Degree/
PUBLIC                                                                                                                                                    stages, comprising a quantitative                  education/          Institute of         College/             Postgraduate
ATTITUDES                                          A multidimensional survey sought to understand what members of
                                                   the public understood and knew about persons with disabilities. It
                                                                                                                                                          survey as well as pre- and post-
                                                                                                                                                          survey qualitative components30.
                                                                                                                                                                                                             Primary
                                                                                                                                                                                                             16.4%
                                                                                                                                                                                                                                 Technical
                                                                                                                                                                                                                                 Education
                                                                                                                                                                                                                                                      Polytechnic
                                                                                                                                                                                                                                                      21.6%
                                                                                                                                                                                                                                                                           Degree/
                                                                                                                                                                                                                                                                           Others
TOWARDS                                            also looked at the level of acceptance and exposure to persons with                                                                                                           36.8%                                     25.3%

PERSONS WITH                                       disabilities in general and revealed domain-specific perceptions in
                                                   key areas such as social interaction, education and employment.
                                                                                                                                                          Pre-Survey Qualitative
                                                                                                                                                          Five focus group discussions
DISABILITIES                                                                                                                                              and an in-depth discussion were
                                                   To better understand the survey findings, focus group discussions were                                 conducted with persons across
Introduction                                       carried out subsequently with persons across all types of disability, to                               a range of disabilities31. To seek
Individuals live and relate to                     shed further light on needs and perspectives identified in the survey.                                 the perspectives of caregivers, a
others, and are in turn influenced                 It also touched on topics such as how they felt the public perceived                                   focus group discussion was held
by them. Invariably, the society                   them, how they wished to be treated as well as barriers to inclusion.                                  with caregivers of persons with
that a person exists in exercises                                                                                                                         Autism Spectrum Disorder and                                                            Age
a profound impact on the way                                                                                                                              Down syndrome as well.                                               18-34            35-49              50-69
that person behaves, thinks and                                                                                                                                                                                                31.1%            30.9%              38%
feels – whether towards him or                                                                                                                            The objectives of these
herself, and others.                                                                                                                                      discussions were to understand
                                                                                                                                                          the pain points of persons with
A society that looks upon a person                                                                                                                        disabilities, how the public views
differently for his or her disability                                                                                                                     them and to guide the formation
has significant bearing on the                                                                                                                            of the quantitative survey.
affected individual's quality of                   The See The True Me campaign educates the public on communication tips and support strategies for
life. In the face of a dominant                    persons with disabilities, and encourages them to see persons with disabilities for who they are and   Quantitative Survey
                                                   include them in society.
narrative that associates disability                                                                                                                      To find out what members of the
with challenge, persons with                       Insights from this study informed strategies for NCSS to work towards                                  public thought about persons
disabilities face everything from                  building a more inclusive society, such as NCSS' 5-year disability                                     with disabilities, a representative,
casual insensitivities, reduced                    awareness and public education campaign supported by Tote Board                                        randomised sample of 1,500
career opportunities and even                      entitled “See The True Me”.                                                                            Singaporeans was obtained from                                                    Ethnicity
cultural aversion. On the contrary,                                                                                                                       the Department of Statistics32. The                        Chinese           Malay             Indian             Others
a community that is caring and                     Research Objectives                                                                                    final sample achieved was 1,400,                           74.7%             12.4%             10.4%              2.5%
inclusive towards persons with                                                                                                                            of which half were surveyed on
disabilities significantly improves                  • To establish a baseline for the public's perception of, and                                        Autism Spectrum Disorder and
their quality of life, as it provides                  understanding towards, persons with disabilities                                                   sensory impairment, while the
resources necessary for their                        • To understand the perception of opportunities and                                                  other half, on physical impairment
acceptance in society.                                 discrimination towards persons with disabilities in the areas                                      and intellectual disability.33
                                                       of education, employment, social interaction and access to
Recognising the importance of                          services and facilities                                                                            The survey was done face-to-face
community and society in the                         • To examine relationships between respondents' demographic                                          and self-administered34. Beyond
disability support ecosystem,                          characteristics and their attitudes towards persons with                                           demographics such as age and
                                                                                                                                                                                                 33 Out of 1,500 contacts. Response Rate = 93.3%.
NCSS conducted a study on                              disabilities                                                                                       ethnicity, a composite instrument      34 In cases where participants were illiterate, responses were assisted. The “next birthday” method
Singaporean Citizens and                                                                                                                                  was constructed based on                   of random respondent selection was used to select a member of each household whose birthday
                                                                                                                                                                                                     will come up next.
                                                                                                                                                          questions from a variety of scales35   35 Scales consulted:
30 Where real stories, accounts or quotes are used, names have been changed for reasons of privacy.                                                      and pilot-tested for reliability and      Instruments 			                                          Study
31 Participants had a range of physical and sensory impairments as well as Autism Spectrum Disorder, and acquired them at birth. They were adults who    validity (n = 200).                       Disability Social Distance Scale (DSDS)                  Tringo (1970)
    are home-based and not institutionalised, as they would have ample chance to interact with the general population.                                                                              Scale of Attitudes Toward Disabled Persons (SADP)        Antonak (1982)
32 Randomised sampling was performed on the 50 geographical areas that are equally distributed across Singapore, following which quotas were set by                                                Issues in Disability Scale (IDS) 		                      Makas, Finnerty-Fried, Sigafoos & Reiss (1988)
    the respective house types within each area. Only Singapore Citizens and Permanent Residents aged 18 to 69 years old were sampled.                                                              Multidimensional Attitudinal Scale (MAS)                 Findler, Vilchinsky & Werner (2007)

42                                                                                                                                                                                                                                                                                                     43
STUDIES                                                                                                                                                                                                                                                                      STUDIES
                                                                                                                                        Key Findings
                                                                                                                                             Finding #1
Respondents were queried on their attitudes, perceptions of, exposure to and knowledge regarding
persons with disabilities. In particular, attitude scores were measured along on three dimensions: Affect,
Behaviour and Cognition36.                                                                                                              Public attitudes towards persons with intellectual disability or Autism Spectrum Disorder were less favourable
                                                                                                                                        than those with physical or sensory impairment.
 Dimension           Description                                              Example
 Affective           How the individual feels towards persons                 “I am comfortable with a person who is                                                                              Attitude Score by Disability Type
                     with disabilities.                                       with Autism Spectrum Disorder to be my                                                                                                  *
                                                                              supervisor.”
                                                                                                                                                                                                                                 *
 Behavioural         How the individual acts towards persons                  “If I were an employer, I would hire
                     with disabilities.                                       persons who are with physical                                                                                                  *
                                                                              impairment.”                                                                                                                            *
                                                                                                                                                                                     7
 Cognitive           How the individual thinks about the role                 “I think that companies can benefit from
                     of persons with disabilities.                            hiring persons with disabilities.”                                                                            5.4             5.42
                                                                                                                                                                                     6                                       5.11              5.25
 As a basis for comparison, participants were also asked to respond on the above categories with regard to a control group of persons
^

 without disabilities.
                                                                                                                                                                                     5

                                                                                                                                                               Attitude Mean Score
In addition, they were asked on
                                                           Physical               Intellectual               Visual
the extent that they would be                                                                                                                                                        4
                                                           Impairment             Disability                 Impairment
comfortable relating to a person                           40                     29                         10
with disability, as a measure of                                                                                                                                                     3
social distance (e.g. as speaking                                    Hearing                  Multiple
acquaintances, close friends or                                      Impairment               Disabilities                                                                           2
to keep them out of Singapore).                                      6                        3
                                                                                                                                                                                     1
Post-Survey Qualitative
                                                        Post-Survey Qualitative Respondent Breakdown                                                                                       Physical        Sensory        Intellectual   Autism Spectrum
To better understand the needs                                                                                                          *p < 0.05                                        Impairment      Impairment        Disability        Disorder
and perspectives of persons with
disabilities, NCSS commissioned a
series of focus group discussions                                                                                                       Discussions with persons with disabilities revealed that they felt treated differently because of their disability,
and interviews among persons                                                                                                            be it in terms of:
across all types of disability. These
were conducted with the help of
                                                                                                                                              Stereotypes,                                             ver-protectiveness
                                                                                                                                                                                                      O                                        Pity, and having
various social service organisations
including Bizlink, MINDS, DPA and
Cheshire Home.
                                                                                                                                        1     judgements and                                      2   and differential                   3     “support” imposed
                                                                                                                                              misconceptions                                          treatment                                upon them
A total of 88 respondents                                                                                                                     “…they think (I) cannot                                 “…my mother wouldn’t let                 “They don’t see us as able
participated in the dialogues,                                                                                                                contribute to society…when                              me do anything by myself,                bodied…sometimes the
which helped provide a better                                                                                                                 they talk to me, they won’t                             not even wash the dishes, just           lecturer will pity…and will
understanding of barriers to                                                                                                                  talk directly to me but to my                           because I don’t have an arm.”            give good grades.”
the inclusion of persons with                                                                                                                 sister or parents…but I’m
disabilities as well as potential                                                                                                             only physically challenged,                             – Focus group participant               – Focus group participant
solutions in specific domains such                                                                                                            not mentally challenged.”                                  with physical impairment                 with hearing impairment
as employment.
                                                                                                                                              – Focus group participant
In addition, the perspectives of                                                                                                                 with physical impairment
33 sponsors, partners and other
stakeholders were sought in a                                                                                                           36 A
                                                                                                                                            multi-faceted approach to attitude. The underlying theory sees the construct of attitude in terms of what we feel (Affect), how we behave
half-day workshop.                                                                                                                         (Behaviour) or how we think (Cognition). (Olson & Zanna, 1993).

44                                                                                                                                                                                                                                                                                 45
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