Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study
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To develop and evaluate a model of environmental factors-participation relationships for persons with traumatic brain injury (TBI), stroke, and spinal cord injury (SCI), and test whether this model differed across three diagnostic groups, as well as other demographic and clinical characteristics.
A cross-sectional observational study included 545 community-dwelling adults with neurological disorders (TBI = 166; stroke = 189; SCI = 190) recruited at three academic medical centers. Participants completed patient-reported measures of environmental factors and participation.
The final structural equation model had acceptable fit to the data (CFI = 0.923; TLI = 0.898; RMSEA = 0.085; SRMR = 0.053), explaining 63% of the variance in participation in social roles and activities. Systems, services, and policies had an indirect influence on participation and this relation was mediated by social attitudes and the built and natural environment. Access to information and technology was associated with the built and natural environment which in turn influence on participation (ps < 0.001). The model was consistent across sex, diagnosis, severity/type of injury, education, race, age, marital status, years since injury, wheelchairs use, insurance coverage, personal or household income, and crystallized cognition.
Social and physical environments appear to mediate the influence of systems, services, and policies on participation after acquired neurological disorders. These relations are stable across three diagnostic groups and many personal and clinical factors. Our findings inform health and disability policy, and provide guidance for implementing the initiatives in Healthy People 2020 in particular for people with acquired neurological disorders.
KeywordsEnvironment Participation Stroke Spinal cord injury Traumatic brain injury
Americans with Disabilities Act
Access to information and technology
Built and natural environment
Confirmatory factor analysis
Comparative Fit Index
Community Participation Indicators
Environmental Factors Item Banks
Glasgow Coma Scale
International Classification of Functioning, Disability and Health
Patient-Reported Outcomes Measures
Patient-Reported Outcomes Measurement Information System
Quality of life
Root mean square error of approximation
Spinal cord injury
Structural equation modeling
Social roles and activities
Standardized Root Mean Square Residual
Systems, Services and Policies
Traumatic brain injury
World Health Organization
The contents do not necessarily represent the policy of the Department of Health and Human Services or the Craig H. Neilsen Foundation. We certify that all financial and material support for this research and work are clearly identified in the title page of the manuscript. The first and last authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. We acknowledge Patrick Semik, BS at the Rehabilitation Institute of Chicago for data management and analysis. Additionally, we would like to acknowledge Megen Devine, MA, and Ojoyi Agbo, BS at Washington University School of Medicine for their editorial assistance.
This study was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research, the Administration on Community Living, the U.S. Department of Health and Human Services to the Rehabilitation Institute of Chicago (Grant No. H133B090024) and to Washington University in St. Louis (Grant No. H133F140037), and by the Craig H. Neilsen Foundation to Washington University in St. Louis (Grant No. 290474).
Compliance with ethical standards
Conflict of Interest
All authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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