A subjective measure of environmental facilitators and barriers to participation for people with mobility limitations

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A subjective measure of environmental facilitators and barriers toparticipation for people with mobility limitations

DAVID B. GRAY, HOLLY H. HOLLINGSWORTH, SUSAN STARK & KERRI A. MORGAN

Washington University School of Medicine, Program in Occupational Therapy, St Louis, Missouri, USA

AbstractPurpose. The aim of this paper is to describe the development and psychometric properties of a self-report survey ofenvironmental facilitators and barriers to participation by people with mobility impairments.Method. A measure called the Facilitators And Barriers Survey of environmental influences on participation among peoplewith lower limb Mobility impairments and limitations (FABS/M) was developed using items based on focus groups to ensurecontent validity. Discriminant validity was assessed on 604 individuals who completed the FABS/M once. Internalconsistency and test-retest reliabilities were based on 371 individuals who completed two surveys.Results. The FABS/M includes 61 questions, 133 items and six domains including the type of primary mobility device; builtfeatures of homes; built and natural features in the community; community destination access; community facilities access;community support network. Environmental items are scored for the frequency of encounter and the magnitude of influenceon their participation. The internal consistencies and the test-retest reliabilities of the domains of the FABS/M ranged fromlow to moderate. The discriminant validity of domains differed for device and diagnostic groups.Conclusion. The FABS/M joins the MQE and the CHIEF as another subjective measure for use in assessing environmentalfeatures important for understanding participation. The FABS can be used to assess the influence of environmentalinterventions at the individual and community levels of analysis. The type of primary mobility device that is used can berelated to reported environmental barriers. Community-based improvements in built features, access to destinations, accessto facilities and augmented support networks can be tracked through the reports of people with mobility impairments.

Keywords: Disability evaluation, psychometrics, rehabilitation, environment assessment and consumer participation

Introduction

Several scientific disciplines have incorporated the

concept that environmental features differentially

influence the expression of behaviors of people with

biological differences [1]. Variability within a species

provides the diversity required for natural selection

by environmental factors, both physical and social.

For example, in behavior genetics, the differential

expression of schizophrenia rests upon both the

genetic makeup of the person and the stressors that

person experiences in their environments [2]. Know-

ing the stressors for the general population may

explain very little if anything about the expression of

schizophrenia. In a similar fashion, knowing the

barriers to participating in major life activities for

people without disabilities and with disabilities are

unlikely to differentiate those factors in the environ-

ment that influence the participation of specific

subsets of humans who live with different capabilities

be they physical or cognitive. Human ecological

models hold that the interactions between levels of

personal competencies and different levels of envir-

onmental press can be used to predict adaptive and

maladaptive behaviors [3 – 7]. Recent shifts in the

conceptualization of disability posit that the expres-

sion of disability changes with nature of the environ-

ment as well as the type and severity of the

impairment [8 – 13]. This change has created a need

for reliable, valid measures of the environment. But

salient aspects of the environment are difficult to

select for study and measure because most environ-

mental features will have little, if any, influence on

the expression of disability. The same environmental

Correspondence: David B. Gray, PhD, Washington University School of Medicine, Department of Neurology, Program in Occupational Therapy, Campus Box

8505, 4444 Forest Park, St. Louis, MO 63108, USA. Tel: þ1 314 286 1659. Fax: þ1 314 286 1601. E-mail: [email protected]

Disability and Rehabilitation, 2008; 30(6): 434 – 457

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.

DOI: 10.1080/09638280701625377

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features may have different effects for people with

differing types and severity of impairments [14]. In

2001, the World Health Organization (WHO)

published a classification scheme, International

Classification of Functioning, Disability and Health

(ICF) that includes a component for classifying

environmental factors [13]. The development of this

classification system began in 1992 and has provided

the impetus for the development of measures of

environmental factors pertinent to what people do in

the context of the lived environment [13,15].

One example of a subjective measure of the inter-

action of person and environment is the Measure of

the Quality of the Environment (MQE) – Version 2.0

[16]. A list of 85 environment features are scored on

a 7 point scale ranging from major facilitator (þ3) to

major barrier (73) to social participation. The

environmental factors are classified into six cate-

gories: support and attitudes of family; income, job

and income security; governmental and public

services; physical environment and accessibility;

technology; and equal opportunity and political

orientations. The question used for each environ-

mental factor is ‘Indicate to what extent the following

factors or situations influence your daily activities

and social roles by taking into account your abilities

and personal limits’. The content validity is based on

the guidance of rehabilitation professionals.

The usability of the MQE was developed by testing

the MQE on people with disabilities. Test retest

results found agreement for 60% to 85% of the

items. The environmental features are characterized

by accessibility, accommodation resource availabil-

ity, social support, and equality. The MQE assess-

ments provide a guide to those environmental factors

that need to be removed to reduce restriction in

participation (obstacles) or added to increase social

participation (facilitators). The MQE was developed

for use with a heterogeneous group of people with

different disabling conditions for participation in

activities that take place in generic settings.

Although the MQE provides guidance for features

of the environment that apply to participation

restrictions for many individuals with disabilities,

the specificity often important to homogeneous

groups (e.g., people with mobility limitations) inter-

acting in different environments is not addressed by

this measure. Further, the frequency of encountering

environmental features is not assessed.

Whiteneck and colleagues [17] developed the

Craig Hospital Inventory of Environmental Factors

(CHIEF) which includes items that were based on

comments made at mixed focus groups of health care

professionals, administrators of service programs,

academics and people with disabilities. The CHIEF

items are scored for the frequency of encountering

environmental barriers and the impact of the barrier

on participation. The CHIEF includes five barrier

factors: (i) attitude and support; (ii) services and

assistance; (iii) physical and structural; (iv) policy;

and (v) work and school. The internal consistency

and stability tests of the CHIEF were moderate to

high. The CHIEF provides a measure of general

environmental barriers that can be used for popula-

tion surveys comparing people with and without

disabilities. The questions used in the CHIEF are

inclusive of many aspects of an environmental

domain. For example, one question on the barriers

or restrictions to participation includes temperature,

terrain and climate while a second question includes

lighting, noise and crowds. The influence of each

environmental feature is not distinct from the other

features within the same question. Thus, the

specificity of environmental features that may influ-

ence participation in major life activities for people

with one disabling condition is limited since the item

development was based on a heterogeneous group of

disabling conditions. In addition, specific environ-

mental facilitators to participation for people with

different impairments are not included in the

CHIEF. Thus, use of the CHIEF for studying within

group variability and planning relevant interventions

may face some limitations [18].

Purpose

This paper reports the methods used to develop, and

the psychometric properties of, a measure of environ-

mental features important for facilitating or restricting

participation in major life activities for people with

mobility impairments. The measure was developed

using qualitative and quantitative methods within the

general guidelines of participatory action research

[19]. All phases of this project were approved by the

Washington University Human Studies Committee.

Methods

Phase One: Qualitative study of item development and

content validity

The development of the Facilitators And Barriers

Survey of environmental influences on participation

among people with lower limb Mobility impairments

and limitations (FABS/M) coincided with the devel-

opment of a measure of participation [20]. As

reported previously, a qualitative approach was

used to develop items with content validity for the

FABS/M [21]. See the Appendix for the full FABS

Survey form used in this study.

People with mobility impairments and limitations

were drawn from five diagnostic conditions: spinal

cord injury (SCI), cerebral palsy (CP), multiple

sclerosis (MS), stroke, and post poliomyelitis (polio).

Environmental facilitators and barriers to participation 435

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The purposive sample included individuals who used

a variety of mobility devices (a power wheelchair,

manual wheelchair, scooter, cane(s), crutch(es), or

walker) or had difficulty walking three blocks).

Individuals from each mobility impairment group

provided comments on environmental facilitators

and barriers to participation that were used to frame

questions for focus group discussions. Five focus

groups, one for each of the diagnostic conditions;

five focus groups with significant others from each

diagnostic groups; and five groups of health care

professionals who served people in each diagnostic

group were convened (n¼ 141). The discussions

were recorded and transcripts were made from the

audio tapes.

Common events and themes were revealed by using

a process of analytic coding [22,23] of the focus

groups transcripts. These qualitative studies provided

the basis for the content validity of items used in the

instrument. The reports of an environmental feature

having the possibility of being both a facilitator and

barrier to participation necessitated a measurement

scale with positive and negative values. A pilot test was

conducted using 40 people with mobility impairments

and limitations from all five diagnostic conditions and

four mobility device user groups. The results of the

pilot test were used to adjust items to improve their

level of comprehension, to revise the scale values used

and to alter the format of the survey.

Phase Two: Quantitative study of reliability

Participants. The internal consistency and test retest

reliability of the FABS/M was evaluated using a

purposive sample of 604 people with mobility

impairments and limitations (Table I). Five diag-

nostic groups were included: SCI (23%), MS (21%),

CP (15%), polio survivors (28%), and stroke

survivors (13%). The sample of 604 included: people

who had difficulty walking three city blocks but did

not use a mobility device (12.7%), multiple device

users (10.4%), manual wheelchair users (22.4%),

power wheelchair users (16.2%), scooter uses

(4.6%), cane, crutch or walkers (29.3%). The

responses of 26 participants (4.3%) were not possible

to classify by device group.

Excluded from the study sample were people who

were less than 17 or more than 92 years of age,

unable to give informed consent to participate in the

survey, lived in a nursing home, had a history of

mental illness or were able to walk three blocks

without difficulty. The mean age was 51.5 with a

standard deviation of 15.4. The study sample was

57.5% female, 88.2% white, 47.9% married, 26.9%

with incomes over $50,000, 34.7% college gradu-

ates, and 26.7% employed. The sample of indivi-

duals was recruited from charitable organizations

and service provider agencies which included the

Paralyzed Veterans of America, Paraquad, GINI

International Polio Network, Multiple Sclerosis

Society, United Cerebral Palsy and a stroke survivor

support group. Newsletters of these organizations

described the project and requested those interested

to contact the research team. Commercial newspaper

advertisement was included in the recruitment of

study participants.

Procedure. Consent forms and surveys were sent to

701 individuals who responded to the recruitment

efforts. The surveys were the CORE, PARTS/M [20]

and FABS/M. The CORE (Characteristic of Re-

spondents) included information on basic demo-

graphics, social benefits received, health status,

personal assistance use, primary mobility personal

devices, and forms of transportation used to partici-

pate in their communities.

A total of 471 (67%) of the 701 surveys distributed

by mail were completed and returned by mail. In

addition, 133 people with mobility impairments and

limitations with upper extremity paralysis or weak-

ness chose to have a staff member visit their homes to

provide assistance in completing their surveys. For

each of the 604 completed surveys, the participants

were paid $25.

After six to eight weeks, a second set of surveys were

again mailed to the 471 individuals who had completed

the initial survey by mail to assess test-retest reliability.

Completed second surveys were returned by 79%

(371) of the 471 individuals sent mailings.

Data entry and analysis. Survey responses were

entered into the computer-assisted data entry pro-

gram [25]. This program restricts data entry to only

those responses that matched the scale values,

reducing data entry errors. SPSS, release 11.5.1,

for Windows was used to analyze the data [26].

Survey instrument description. The FABS/M includes

65 main questions. Depending on the respondent’s

answer to the lead questions, other questions may

ensue. The maximum number of items generated by

the FABS/M is 133 which are organized into six

domains of environment that influence participation

(Table II). The first domain includes two questions

on the primary mobility device they use in their

community: how often they are used and the

magnitude of the influence the device had on

participation by respondents. The home environ-

ment domain includes 12 features commonly found

in homes (e.g., stairs, carpet, ramps). Domain three,

community features domain, includes 8 items on the

built environment and 6 items on the natural

environment. The community destination access

domain includes questions on how the access of

436 D. B. Gray et al.

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buildings, the physical structure of the building and

parking at the building influence participation. The

community facilities domain has a focus on restroom

and transportation accessibility. The community

support network domain queries the frequency of

encounters and the help provided by nine groups of

people who interact with people with mobility

impairments in their homes and communities.

Results

Reliability

The internal consistency and test-retest (stability)

reliabilities of the facilitators and barriers survey for

mobility (FABS/M) are based on the 371 individuals

who completed the survey twice (Table III). Relia-

bility statistics for the mobility device question

cannot be computed, since it is a single item. The

magnitude of influence on participation and fre-

quency of encounters of home features show

moderate internal consistency and stability. Moder-

ate internal consistency and stability were found for

community built features. Due to seasonal changes

between the first and second administrations of the

survey, the items covering natural features have

lower internal consistency and stability. Community

destination access magnitude, physical structure and

parking items showed high to moderate internal

consistency and moderate stability.

The access to restrooms and transportation items

in the community facilities access domain have

Table II. FABS/M: Domains, items and response options.

Domain One: Primary Mobility Device

Please check one of the following mobility devices that you most often use when you participate in community activities.

¤ Manual wheelchair ¤ Cane ¤ Other device ______________________

¤ Power wheelchair ¤ Crutches ¤ Other device ______________________

¤ Scooter ¤ Walker ¤ Do not use any type of mobility device*

Mobility Device ________ Make ________________ Year Purchased _______

How often do you use this device participating in your community?

¤ Always ¤ Often ¤ Some ¤ Never

How does it influence your participation in community activities?

¤ Helps a lot ¤ Helps some ¤ Limits some ¤ Limits a lot

Domain Two: Home Built Features (12 features)

In your home, do the following influence your participation in activities?

Environmental Feature _________ (Stairs, carpet, doors, hardwood floors, ramps, room temperature and handrails)

¤ Yes ¤ How much? ¤ Helps a lot ¤ Helps some ¤ Limits some ¤ Limits a lot

How often? ¤ Daily ¤ Weekly ¤ Monthly ¤ Less than monthly

¤ No ¤ ____ do not influence participation or ¤ N/A¤ do not have them in my home (Go to next question)

Domain Three: Community Built and Natural Features (14 features – 8 built and 6 natural features)

Built features: gravel, paved surfaces, curb cuts, ramps, automatic doors, elevators, escalators and specialized equipment

Natural features: summer weather, winter weather, rain, flat terrain, crowds and noise

In your community, do the following influence your participation in activities?

¤ Yes ¤ How much? ¤ Helps a lot ¤ Helps some ¤ Limits some ¤ Limits a lot

How often? ¤ Daily ¤ Weekly ¤ Monthly ¤ Less than monthly

¤ No ¤ ____ do not influence participation or ¤ N/A¤ do not have them in my community (Go to next question)

Domain Four: Community Destination Access (13 sites)

How does the accessibility of ___ (the site) influence your participation in daily activities?

¤ Helps a lot ¤ Helps some ¤ Has no effect ¤ Limits some ¤ Limits a lot

Is access limited at _____ (one of the 13 community sites) by _______? ¤ None ¤ Not limited

¤ Physical structure ¤ Parking

Domain Five: Community Facilities Access Domain

Restrooms Accessibility (8 community sites)

How accessible are restrooms in _________ (restaurant, hotel, library, airport, mall, theater, fast food, sports arena)

¤ Very accessible ¤ Somewhat accessible ¤ Not accessible ¤ Don’t know ¤ Not applicable

Transportation Accessibility (6 types of transportation)

How accessible are the following types of transportation (car, taxi, Paratransit, public-bus/rail, and airline)

¤ Not accessible ¤ Somewhat accessible ¤ Very accessible ¤ Don’t know ¤ Not applicable

Domain Six: Community Support Network (9 sites: doctor, therapists, paid personal attendants, special equipment repairs personnel, store clerks,

strangers, peers, friends, family)

How often do you go to____________?

¤ More than twice a week ¤ Once or twice a month ¤ Rarely ¤ Once or twice a week ¤ Once or twice a year

¤ Never (Go to next question)

How does the care you receive influence your participation in daily activities?

¤ Help a lot ¤ Help some ¤ Have no effect ¤ Limit some ¤ Limit a lot

How do the attitudes of doctors influence your use of health care services?

¤ Help a lot ¤ Help some ¤ Have no effect ¤ Limit some ¤ Limit a lot


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moderate to high internal consistency and moderate

stability. The items included in the community

support network domains have moderate internal

consistency and test-retest (stability) reliability.

Discriminant validity

Differences in the scores given to environmental

features by the different diagnostic and device groups

support the discriminant validity of the FABS/M

(Tables IV and V). The diagnostic groups differed in

the frequency of use of their primary mobility device,

community features, and community contacts. The

magnitude of help in participation provided by built,

natural and site access features was high but differed

by diagnostic groups. Parking limitations and build-

ing structure limitations differed by diagnostic

groups. Care provided by people in the community

was reported to be of at least some help by all groups

but differed between groups. The diagnostic groups

differed in their reports of the accessibility of

restrooms but did not for helpful attitudes or in the

accessibility of transportation in their communities.

Device groups differed on all FABS/M domains

except home feature encounters and magnitudes of

the home features on participation. The device

groups differed in their reports of transportation

accessibility but the differences were not statistically

significant.

Discussion

The FABS/M is a measurement tool that provides

a means of examining what people with mobility

impairments perceive to be facilitators and barriers to

their participation in their lived environments. The

qualitative methods used to develop the measure

(interviews and focus groups) support the face and

content validity of the FABS/M. For most of the

FABS/M domains, the internal consistency and

stability values are moderate to high. Environmental

facilitator and barrier descriptors were created for

each item to allow comparisons for difference in

diagnostic and device user groups. The FABS/M

showed good discriminant validity for device and

diagnosis groups for most of the different domains of

the environment. At the individual level of analysis,

the client responses can be compared to mean and

standard error of relevant comparison groups, which

can illustrate where individuals are in relation to

others with the same diagnosis and who use the same

personal mobility device.

The FABS/M joins the Measure of the Quality of

the Environment (MQE) [16] and Craig Hospital

Inventory of Environmental Factors (CHIEF)

[17] as a measure of environmental factors that

influence the lives of people with disabilities. All

three were constructed during the period of time

when the International Classification of Functioning,

Table III. FABS/M: Internal consistency and test-retest reliabilities.

Domain Number of items a* Sample n r{ Sample n

1 Personal Mobility Device Domain^ 1

2 Home Built Features Domain

Frequency of influencing participation 12 0.60 236 0.65 236

Magnitude of influencing participation 12 0.68 189 0.67 189

3 Community Built & Natural Features Domain

Built



Natural



4 Community Destinations Access Domain


Parking limits participation 13 0.89 358 0.82 358

Physical Structure limits participation 13 0.87 358 0.80 358

5 Community Facilities Access Domain

Restrooms accessibility 8 0.90 37 0.70 37

Transportation accessibility 6 0.72 52 0.66 52

6 Community Support Network Domain

Services

Frequency of contact 9 0.67 296 0.81 296

Magnitude of help 9 0.70 193 0.77 193

Attitudes

Magnitude of help 9 0.76 175 0.77 175

*Internal consistency calculated using the Cronbach a. {Stability measured by test-retest correlation the Pearson r. ^No values for internal or

test retest reliability could be calculated for the primary mobility device since only one question was included in the survey.


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Disability and Health (ICF) was developed as were

three measures of participation: PARTS/M [20],

LIFE-H [28], and CHART [29]. Figure 1 provides a

comparison of the ICF and these three measures of

environmental factors. The ICF environmental

factors are contained in five chapters with several

Table IV. Discriminant validity of FABS/M domains for diagnostic groups.

Diagnosis

Community

PMD Use

Frequencya

Community

PMD Use

Magnitudeb

Home

Features

Frequencyc

Home

Features

Magnitudeb

Community

Features

Frequencyc

Community

Features

Magnitudeb

Community

Natural

Frequencyc

Community

Natural

Magnitudeb

SCI 3.53 3.58 3.78 3.37 3.05 3.37 3.04 2.24

MS 3.14 3.63 3.75 3.24 2.87 3.45 3.11 1.98

CP 3.28 3.53 3.78 3.51 3.44 3.65 3.41 2.45

Polio 2.93 3.57 3.82 3.29 2.84 3.49 3.00 2.31

Stroke 3.07 3.53 3.65 3.08 2.87 3.27 3.07 2.11

Total 3.21 3.58 3.77 3.32 2.99 3.45 3.10 2.21

p ¼ 0.00 0.852 0.315 0.004 0.00 0.00 0.06 0.00

Diagnosis

Community

Site Access

Magnitudeb

Community

Parking

Limitedd

Community

Structures

Limitedd

Community

Contacts

Frequencye

Community

Care

Helpf

Community

Attitude

Helpf

Community

Restroom

Accessibleg

Community

Transport

Accessibleg

SCI 3.55 0.13 0.28 3.06 4.42 4.25 2.29 2.42

MS 3.47 0.14 0.19 3.52 4.33 4.26 2.35 2.42

CP 3.87 0.06 0.23 2.83 4.39 4.33 2.37 2.45

Polio 3.71 0.18 0.23 3.72 4.21 4.24 2.49 2.54

Stroke 3.24 0.08 0.14 3.57 4.27 4.13 2.46 2.52

Total 3.59 0.00 0.00 3.37 4.32 4.24 2.40 2.45

p ¼ 0.000 0.000 0.002 0.00 0.017 0.530 0.001 0.492

aFrequency scale: 1¼never, 2¼ sometimes, 3¼often, 4¼ always. bMagnitude scale: 1¼ limits a lot, 2¼ limits some, 3¼ helps some,

4¼helps a lot. cFrequency scale: 1¼ less than monthly, 2¼monthly, 3¼weekly, 4¼daily. dLimited scale: 0¼not limited, 1¼ limited.eFrequency scale: 1¼ rarely, 2¼once or twice a year, 3¼once or twice a month, 4¼once or twice a week, 5¼more than twice a week. fHelp

scale: 1¼ limits a lot, 2¼ limit some, 3¼no effect, 4¼helps some, 5¼helps a lot. gAccessible scale: 1¼not accessible, 2¼ somewhat

accessible, 3¼ very accessible.

Table V. Discriminant validity of FABS/M domains for device groups.

Device

Community

PMD Use

Frequencya

Community

PMD Use

Magnitudeb

Home

Features

Frequencyc

Home

Feature

Magnitudeb

Community

Built

Frequencyc

Community

Built

Magnitudeb

Community

Natural

Frequencyc

Community

Natural

Magnitudeb

None 3.61 3.23 2.98 3.42 3.12 2.22

Multiple 3.09 3.63 3.61 3.23 2.98 3.51 3.05 2.31

CCW 3.11 3.54 3.76 3.26 2.87 3.35 3.18 2.14

Scooter 3.09 3.69 3.80 3.35 3.19 3.70 2.96 2.18

MWC 3.38 3.45 3.76 3.30 2.94 3.42 2.91 2.22

PWC 3.39 3.76 3.81 3.47 3.27 3.59 3.27 2.29

Total 3.22 3.58 3.77 3.33 3.00 3.46 3.10 2.21

p ¼ 0.000 0.014 0.567 0.233 0.00 0.00 0.01 0.20

Device

Community

Site Access

Magnitudeb

Community

Parking

Limitede

Community

Structures

Limitede

Community

Contacts

Frequencyd

Community

Care

Helpf

Community

Attitude

Helpf

Community

Restroom

Accessibleg

Community

Transport

Accessibleg

None 3.51 0.08 0.09 3.94 4.18 4.14 2.71 2.62

Multiple 3.51 0.17 0.31 3.27 4.19 4.13 2.25 2.38

CCW 3.47 0.18 0.21 3.64 4.30 4.25 2.46 2.50

Scooter 3.47 0.14 0.32 3.18 4.29 4.19 2.12 2.49

MWC 3.65 0.11 0.24 3.24 4.35 4.25 2.36 2.36

PWC 3.87 0.07 0.26 2.73 4.54 4.42 2.21 2.45

Total 3.59 0.13 0.23 3.73 4.32 4.25 2.39 2.45

p ¼ 0.042 0.000 0.000 0.000 0.000 0.00 0.000 0.065

aFrequency scale: 1¼never, 2¼ sometimes, 3¼ often, 4¼ always. bMagnitude scale: 1¼ limits a lot, 2¼ limits some, 3¼helps some, 4¼ helps a

lot. cFrequency scale: 1¼ less than monthly, 2¼monthly, 3¼weekly, 4¼daily. dFrequency scale: 1¼ rarely, 2¼ once or twice a year, 3¼once or

twice a month, 4¼ once or twice a week, 5¼more than twice a week. eLimited scale: 0¼not limited, 1¼ limited. fHelpful scale: 1¼ limits a lot,

2¼ limit some, 3¼no effect, 4¼helps some, 5¼helps a lot. gAccessibility scale: 1¼not accessible, 2¼ somewhat accessible, 3¼ very accessible.


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levels that detail the main categories in the chapters.

The items in this scheme can be coded for the

magnitude of the effect the environmental factor has

on the lives of people with disabilities.

The environmental factors can be classified as

facilitator or barriers in the impairments, activities

and participation component of the ICF. Of the

three environmental measures, the MQE covers the

broadest scope of possible environmental factors

using 84 items that are scored from þ3 to 73 as

facilitators to barriers. The CHIEF has 25 items that

are scored using the product of frequency of

encounters and the magnitude of the barrier.

The FABS/M uses 61 questions to examine the

influence of environmental factors on participation.

The MQE and the CHIEF are applicable to both

people with disabilities and people who do not have

disabilities. The FABS/M is designed for use with

people who have lower limb impairments and

mobility limitations.

Figure 1. Environment: Classification and measures.


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Limitations and future research

The samples used to develop the FABS/M were

purposive samples directed towards gaining a better

measure of the facilitators and barriers as perceived

by people with mobility impairments and limitations

who use some type of mobility device. Thus, the

FABS/M is not applicable to all impairment groups.

However, the approach of focusing on the relevant

environmental factors of one cluster of impairment

conditions could be replicated for people who have

visual, auditory or cognitive impairments. The size of

the sample used to develop the FABS/M needed to

be larger for several of the diagnostic and device user

groups to establish group sample characteristic for

use in comparing the influence of environment on

participation.

Many of the home and community built and man-

made facilitators and barriers were perceived by all

respondents in the same way which reduced between

group differences. Future research should include

other environmental features which better differenti-

ate diagnostic or device group users.

All the participants in the sample reported in this

study had completed their initial rehabilitation at

least one year prior to completing the survey and

many participants had lived with their impairments

for nearly their entire life. Thus, the responses to the

FABS/M survey items are based on a history of

person environment interactions over many years.

The initial encounters with environmental barriers

occurred in the distant past. At the time they

completed the survey, they may have learned to

avoid or limit their encounters with environmental

barriers.

Thus, they responded that the FABS/M items do

not apply to them or have no effect on their

participation. In future studies, the individual pro-

files could be used to track changes over time. For

example, the FABS/M survey findings from a

respondent taken during the first two years after

discharge from a rehabilitation facility could provide

an outcome measure for the effectiveness of rehabi-

litation treatments for participation in the commu-

nity. Changes in the ecological niche as people with

mobility limitations return to their communities can

provide valuable information to others prior to their

discharge so that they can prepare for when they

return to their communities. This approach to

environmental measurement will help bring into

balance their social and physical environments with

their personal preferences for high quality participa-

tion in major life activities.

The FABS/M items that focus on community sites

require the respondent to provide a generic response

to all sites in a category (e.g., grocery store, mall, and

restaurant). The picture drawn by the responses is of

some value in determining the relative levels of

facilitators and barriers within communities. How-

ever, detailed analyses of specific community sites

are not possible to make. More work is needed to

develop a person environment measure that will be

more sensitive to specific facilitators and barriers in

community sites. Such a measure would provide a

tool for examining environmental changes in re-

sponse to social policy changes and community

advocacy projects.

Conclusion

The FABS/M, MQE and CHIEF are subjective

measures of the environmental factors that are

important for person environment interactions.

While the CHIEF and MQE are designed for use

by people with various disabilities, the FABS/M has a

narrow focus on people with mobility limitations.

The FABS/M can be used at the individual level to

develop community participation interventions and

as an outcome measure of the effectiveness of those

interventions.

The environmental facilitators and barriers can be

aggregated by diagnostic conditions, mobility device

and demographic variables to give a broader view of

environmental changes that may influence the

participation of people with mobility impairments.

Objective measures of the facilitators and barriers to

participation by people with mobility limitations are

needed to evaluate the subjective findings. Taken

together, the subjective and objective assessments of

communities could be used to guide services,

systems and policies. To achieve this level of

influence, computer-assisted programs for sorting

and matching relational databases are needed for

selecting subjective and objective measures of the

environment for use with impairment clusters and

environmental factors as classified in the ICF

framework.

Author note

This study was supported by the Centers for Disease

Control and Prevention (grant no. R04/

CCR714134), the Missouri Department of Public

Health Contract (grant no. C003019001), and the

National Institutes of Health (grant no. R21

HD45885-01).

No commercial party having a direct financial

interest in the results of the research supporting this

article has or will confer a benefit upon the authors or

upon any organization with which the authors are

associated.

We would like to acknowledge the contributions

of Donald Lollar, Louis Quatrano, Denise Curl,

Kathleen Murphy, Mary Gould, Jerome Bickenbach,


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Dorothy Edwards, Tony Margherita, Joan Headley,

Elena Andresen, Karen Hirsch, Kathy Kniepmann,

William Shannon, Curtis Weight, Evan Shaw,

Michael Scheller, Polly Gray and Washington Uni-

versity Occupational Therapy students from 1997 to

2006.

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Documents

A subjective measure of environmental facilitators and barriers to participation for people with mobility limitations