ORIGINAL ARTICLE Association of Environmental Factors With Levels of Home and Community Participation in an Adult Rehabilitation Cohort Julie J. Keysor, PhD, PT, Alan M. Jette, PhD, PT, Wendy Coster, PhD, OTR, Janet Prvu Bettger, ScD, TRS, Stephen M. Haley, PhD, PT ABSTRACT. Keysor JJ, Jette AM, Coster W, Bettger JP, Haley SM. Association of environmental factors with levels of home and community participation in an adult rehabilitation cohort. Arch Phys Med Rehabil 2006;87:1566-75. Objective: To examine whether home and community en- vironmental barriers and facilitators are predictors of social and home participation and community participation at 1 and 6 months after discharge from an acute care or inpatient rehabil- itation hospital. Design: Cohort study. Setting: Postacute care. Participants: Adults (N=342) age 18 years or older with a diagnosis of complex medical, orthopedic, or neurologic con- dition recruited from acute care and inpatient rehabilitation facilities. The mean age  standard deviation of participants was 6814 years; 49% were women and 92% were white. Interventions: Not applicable. Main Outcome Measures: Participation in social, home and community affairs as assessed with the Participation Mea- sure for Post-Acute Care. Results: Adjusting for covariates, 1 month after discharge a greater presence of home mobility barriers (P.01) was asso- ciated with less social and home participation; whereas greater community mobility barriers (P.01) and more social support (P.001) were associated with greater participation. At 6 months, social support was the only environmental factor as- sociated with participation after adjusting for covariates. Conclusions: This study provides new empirical evidence that environmental barriers and facilitators do influence participation in a general rehabilitation cohort, at least in the short term. Key Words: Disabled persons; Environment; Outcome as- sessment (health care); Rehabilitation. © 2006 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation E NVIRONMENTAL FACTORS ARE hypothesized to be crucial determinants of people’s participation in daily life activities, 1-7 yet there is little empirical evidence to support this notion. Mobility barriers in a home (eg, stairs or doors) may limit one’s ability to function in that home, whereas mobility barriers in the community (eg, uneven sidewalks or curbs without curb-cuts) may limit one’s involvement in community activities. Conversely, mobility adaptive technologies (eg, walkers or wheelchairs) may enhance a person’s participation in daily life by providing some physical assistance with per- formance of specific tasks, while transportation facilitators (eg, availability of a car or public transportation) could result in greater involvement in community activities. Gaining a clearer perspective on how the environment is related to participation has important clinical and policy implications. First, the impact of environmental barriers and facilitators on participation could explain the apparent paradox often seen in clinical care: people who have the same severity of disease and level of impairment often function differently in daily life. For example, a person with knee osteoarthritis who has limited func- tional mobility may live in a community that has many architec- tural and physical barriers and few transportation facilitators may be quite limited in community activities, while another person with a similar clinical profile may be heavily engaged in commu- nity activities. Also, if environmental factors are indeed central to a person’s ability to participate in life role activities, health care providers could focus patient education on overcoming barriers that pose threats to involvement in life activities. Third, policy changes could be enacted to minimize barriers and enhance facil- itators through changes in regulations, insurance, and modifica- tions to the environment. The International Classification of Functioning, Disabilities and Health (ICF) 7 framework explicitly states that participa- tion is influenced by the environmental context in which people live. In the ICF model, the environmental context is described as the social and physical circumstances in which a person lives, 7 with the 5 environmental domains specified: (1) prod- ucts and technology; (2) natural environment and human-made changes; (3) support and relationships; (4) attitudes; and (5) services, systems, and policies. 7 The ICF environmental frame- work is similar to frameworks that have been advocated by other investigators. 2,8 Reports in the literature have shown that people with mo- bility limitations report that certain social, technologic, and environmental barriers affect their participation, but the impact may not be as large as once thought. 9-13 Whiteneck et al 9 reported that environmental barriers explained a modest amount of variance in participation restriction (5% variance) among a population of 2726 people with spinal cord injury. When demographic, impairment, and activity variables were included in the models, environmental barriers generally did not contribute significantly to the variance explained in partic- ipation restriction. Similar findings were reported in other From the Departments of Physical Therapy and Athletic Training (Keysor) and Occupational Therapy and Rehabilitation Counseling (Coster) and ScD Program in Rehabilitation Science (Prvu Bettger), Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA; and Health and Disability Research Insti- tute, Boston University School of Public Health, Boston, MA (Jette, Haley). Presented in part to the American Congress of Rehabilitation Medicine, September 28-October 2, 2005, Chicago, IL. Supported by the National Institute of Disability and Rehabilitation Research, U.S. Department of Education (grant no. H133B990005), the National Institute of Child Health and Human Development (grant no. 5 K12 HD043444-02), and the Arthritis Foundation (arthritis investigator award). 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 author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Julie J. Keysor, PhD, PT, Sargent College of Health and Rehabilitation Services, Boston University, 635 Commonwealth Ave, Rm 521, Bos- ton, MA 02215, e-mail: jkeysor@bu.edu. 0003-9993/06/8712-10803$32.00/0 doi:10.1016/j.apmr.2006.08.347 1566 Arch Phys Med Rehabil Vol 87, December 2006