Is the presence of home entrance steps associated with community participation of people with mobility impairments?

Abstract

Background:

Little is known about how home entrances are related to community participation for people with mobility impairments.

Objective:

This investigation explored how the need to navigate steps at the entrance of a home affects the community participation levels of people with mobility impairments.

Methods:

This survey study used pre-measure data collected from three different samples. Participants were adults living independently in the community aged 18–94 years old who self-reported having a mobility impairment. Measures included the Brief Community Engagement Questionnaire to examine potential differential effects on the number of non-discretionary trips people make into the community (e.g., getting groceries, medications) versus the number of discretionary activities (e.g., socializing outside the home) people reported over seven days.

Results:

People with mobility impairments were less likely to report a stepped entrance than people without MI, but when the entrance they use the most had steps they reported significantly higher exertion to use the entrance. The presence of steps had no effect on non-discretionary trips (p = .74), but was associated with 49% (p < .01) fewer discretionary activities reported by people with mobility impairment relative to those without MI.

Conclusion:

Steps at the home entrance of people with mobility impairment may be an important mediating factor in their level of participation. When researchers and practitioners evaluate interventions that aim to increase community participation of people with mobility impairment, they should control for the presence of steps at their home entrance.

Community participation starts at home where people prepare for the day. Yet, many people who report having a mobility impairment (difficulty walking or climbing steps), live in homes with steps at the entrance.¹ Consequently, these people have to do something difficult (navigate steps) if they want to participate in activities outside the home. In this paper, we describe home entrances for people with and without mobility impairments and we examine the relationship between having steps at their home entrance and participating in the community.

Participation, defined as “involvement in a life situation,”² continues to be a central outcome of physical medicine and rehabilitation.^3–5 Participation itself is the outcome of the complex interaction of many factors, including environmental features (e.g., steps).^2,6 As a core component of community life, limited community participation is associated with social isolation and poorer health status.⁷

Many people with disabling conditions report participation restrictions (PR). For example, a study of respondents to the National Health Interview Study found that 11% of people with arthritis report PR.⁸ Evidence from 34 studies representing 8053 participants found a strong correlation between participation restrictions in social/recreational activities and depression for people with medical conditions (r = 0.45).⁹ Not all participation is equal with regard to how it affects people with disabilities (PWD). There are differences between participation in discretionary and non-discretionary activities.¹⁰ People with arthritis who participate in valued discretionary social and recreational activities report lower levels of depression even after controlling for pain, activity of daily living limitations, disability, and overall levels of participation.^10,11

The majority of studies on participation restriction examine personal factors such as disease severity¹² and self-efficacy.¹³ Far fewer studies examine the effects of the environment on participation, although the need for this area of research is evident.^5,14 For example, a systematic review of housing accessibility studies conducted between 2004 and 2014 identified 14 eligible studies.¹⁵ None of these examined participation as an outcome, although two reported significant effects for quality of life improvements. A systematic review of community participation among people with spinal cord injury identified accessible and affordable housing as a factor in their community integration.¹⁴ More recently, Norin et al.¹⁶ reported that people who lived in homes they rated as more accessible using the Housing Enabler scale¹⁷ reported higher rates of community participation.

Alternatively, a systematic review of interventions to increase participation among stroke survivors reported on 18 studies that included a variety of targets which were mostly focused on increasing social and recreational activities.⁴ Eight studies addressed increasing/improving interpersonal relationships and another six focused on increasing community life by increasing knowledge about community events. Only one study on using public transportation addressed environmental access; however, accessibility of the home was absent from this review.

Most people with disabilities live in inaccessible homes,^1,15,18 despite social policy enacted to increase accessible housing options (e.g., US Fair Housing Act, 1988). These policies are important, yet over 30 years later, 54.2% of people with mobility impairments in the US live in homes that have at least one step at the entrance. Further, 23.8% live up at least one flight of steps in a building with no elevator.¹

The fact is, most home environments are not designed for PWD,^18–21 which limits their daily activities.^15,22 This may be in part because PWD exert themselves more throughout the home than people without disabilities to accomplish daily activities like bathing and cleaning.⁶ When PWD reported at least one home accessibility barrier, they were 3.7 times more likely to report an activity of daily living difficulty.²³ While there has been considerable research exploring the relationship between home environment and participation within the home,^22,23 much less has explored how the home environment impacts people’s participation outside the home. A logical place to start is at the home entrance, the portal to community participation.

With this study, we begin to fill the research gap regarding the link between the home environment and participation. First, we compare people with and without mobility impairment for the presence of steps at the entrance to their homes. Then, we explore whether steps at the entrance affect the amount of exertion participants report for getting in and out of their home. Lastly, we explore the relationship between the presence of steps to enter and exit people’s homes and their participation in non-discretionary and discretionary community activities. We hypothesized that when people with mobility impairment have steps at their home entrance, they participate less than people with mobility impairment whose homes do not have steps.

Methods

Sample

This survey study used pre-measures collected from three samples enrolled in two different intervention studies; a sample of people with mobility impairment drawn from the general population and two samples drawn from Centers for Independent Living (CIL) consumers. First, we recruited a sample of PWD from the general population by mailing 44,141 recruitment letters with postage-paid return postcards to randomly selected individuals (aged 18–75 years) living in five adjacent zip codes in a small western US city. We asked recipients who have “serious difficulty walking or climbing stairs” to return a postcard if they were willing to complete a survey. We used Dillman’s²⁴ procedures for materials development (e.g., cover letter content) and follow-up. We received 992 postcards from eligible participants who subsequently returned 800 surveys (80.645%). The American Community Survey identified 2752 people aged 18–75 within these zipcodes (US Census, 2019). Hence, our sampling frame represented approximately 29.070% of the eligible population. Participants received $5 with the survey as an incentive for completing it. Next, we contacted respondents who returned the survey to participate in a follow up study. Of 671 people that consented to be re-contacted from the survey, we collected data from 197 individuals (29.359%).

The other two samples were recruited by staff from one of two Centers for Independent Living (CILs), one in a mid-western US city and the other in a small western US city. These participants (n = 234) were recruited to participate in a study about the effects of consumer-directed home modification goals. These participants received $10 for completing the initial survey. Demographics for the analytic sample are included in Table 1.

Table 1.

Demographics.

Variable	PWD from General Population (n = 197)	CIL Consumers (n = 234)	Mobility Impairment (n = 320)	No Mobility Impairment (n = 103)
Female	66%	62%	67%	56%
Mean age, range	63, 22–82	54, 18–94	58, 21–94	58, 18–77
White	95%	71%	80%	87%
Bachelor’s Degree	38%	26%	30%	36%
Married/Cohabiting	52%	24%	34%	43%
Mobility Impairment	65%	85%	–	–
Mobility Severity	5.1	7	7.4	2.1
Mean Household Income	30k–40k	10k–20k	10k–20k	20k–30k
Median household size	2	2	2	2
Homeowner	67%	23%	39%	55%
Single-family home	69%	41%	50%	64%
Townhome/Condo	4%	5%	4%	4%
Duplex/Triplex	6%	5%	4%	7%
Apartment (4+)	14%	42%	33%	21%

Note: Some respondents who answered “no” to the binary mobility impairment question provided a low rating of mobility impairment severity. The number of participants who responded to the mobility impairment question does not match the sample size total n due to missing responses for that item.

Measures

We collected the same measures used in this study across all three samples. We used the paper and pencil survey to collect basic demographics including age, gender, income, use of adaptive equipment and number of people in the household. The survey also included the six yes/no disability questions used in the American Community Survey.²⁵ Additionally, we collected severity ratings (0–10) for modified versions of these six questions to assess severity over 30-days. We collected exertion ratings within the home, including at the entrance, using a modified Borg Scale.^26,27 We used the Brief Community Engagement Questionnaire (BCEQ)²⁸ that queries the number of trips into the community (e.g., grocery store, pharmacy) and number of social and recreation activities (e.g., exercise, fishing, socializing outside the home, religious activities) individuals reported over the prior seven days. We used the number of trips as a proxy for non-discretionary activities and social and recreational activities for a proxy of discretionary activities. The trips and activities for the BCEQ were chosen to reflect categories of participation in the International Classification of Functioning, Disability, and Health (ICF).² This measure demonstrated good convergent validity with Ecological Momentary Assessment.²⁸ Lastly, the survey queried the type of housing (e.g., single family home) and tenure in the home.

We collected housing characteristics using adaptive computer technology implemented on a smart phone to assess basic accessibility features of the home. Among other accessibility features, this assessment included the number of steps that must be negotiated to enter or exit the home at any entrance and the number of steps at the entrance used most often.

Procedures

Participants attended a meeting where they completed the Home Characteristics survey using a Smartphone touch screen device. This orientation was conducted by either research or service staff (depending on how they were recruited) and was conducted in various locations such as in the participants’ homes, at the service agency, or in a public location. The Home Characteristics survey took participants approximately 10 min to complete.

The institutional review board at the University of Montana approved the procedures for both studies. All data were collected prior to the COVID-19 pandemic.

Analytic approach

Survey data were entered into Excel with delimiters that prevented entering out of range values and then checked for data entry accuracy. Electronic data were collected from the smart phones and formatted for analysis. Data analysis was performed with Stata 15.0. Preliminary analyses included descriptive statistics to examine the data for multivariate normality. Inferential analytic routines included linear regression for normally distributed continuous data and negative binomial regression for predicting participation outcomes given the number of zero values in the participation data. We analyzed the effects of stepped entrances on trips and social/recreational activities separately to examine the data for independent effects. Lastly, we examined data for people with and without mobility impairment (MI) to assess differential effects. We used statistical controls for both person level (e.g., gender, age) and environmental (e.g., zip code, building type) variables. Given that the exertion measure was very skewed and contained zeros, we transformed it using the inverse sine transformation.²⁹

Results

We first examined the frequency with which people reported having steps at their home entrance. Of people who reported a mobility impairment, 41% reported they could enter their home without using steps at the entrance they used most often compared to 19% of people without MI. Next, we used linear regression with individual and home characteristics controls to examine whether or not having steps at the entrance affected the amount of exertion people reported for entering their home. People with mobility impairment reported 63% less exertion for entering their home when they could do so without steps, an effect that was not observed for people without mobility impairment Table 2.

Table 2.

The effect of steps on exertion at the entrance for people with and without mobility impairment.

	Exertion at entrance
	Mobility impairment		No mobility impairment
Any entrance no stairs	−0.44** (0.11)		0.11 (0.18)
Most used entrance no stairs		−0.63** (0.11)		−0.22 (0.18)
Mobility impairment severity	0.06** (0.02)	0.07** (0.02)	0.11** (0.03)	0.11** (0.03)
Observations	227	227	84	84
R-squared	0.21	0.27	0.42	0.43

Notes: Regressions include controls for age, gender, income, number of people in household, study, 3-digit zip code, and building type. Some respondents who answered “no” to the binary mobility impairment question provided a low rating of mobility impairment severity. Robust standard errors in parentheses.

^*p < .05;

^**p < .01.

Next we examined the non-discretionary community activities people with and without mobility impairment reported making based on having an entrance with steps. There were no significant effects of having a stepped entrance on non-discretionary activities for either the mobility impairment or no mobility impairment group.

Finally, we examined the discretionary community activities reported based on having an entrance with steps. People with mobility impairment reported 3.96 activities when they had steps compared with 5.23 activities when they did not have steps (p < .05). People without mobility impairment reported 6.00 and 6.36 activities respectively (p = .74). To examine this effect further, we computed a negative binomial regression by regressing the number of activities onto the presence or absence of a stepped entry along with individual and home characteristic controls. This analysis indicated that people with mobility impairment report 49% fewer activities (p < .01) when they had steps at the entrance they used most often (Table 3).

Table 3.

Negative binomial regressing the number of social and recreational activities on the absence of steps at the entrance for people with mobility impairment.

	Number of social/recreational activities
	Mobility impairment		No mobility impairment
Any entrance no stairs	0.44** (0.14)		−0.25 (0.19)
Most used entrance no stairs		0.49** (0.14)		0.04 (0.26)
Mobility impairment scale	−0.08** (0.02)	−0.09** (0.02)	−0.06* (0.03)	−0.06+ (0.03)
Observations	231	231	84	84

Notes: Negative binomial regressions include controls for age, gender, income, number of people in household, study, 3-digt zip code, and building type. Robust standard errors in parentheses.

⁺ p < .10;

^*p < .05;

^**p < .01.

Discussion

Overall, these results support our hypothesis that for people who report a mobility impairment, having to navigates steps to enter and exit their home is associated with a reduction in community participation. They also support the broad tenet of the International Classification of Function (WHO, 2001) that participation is a function of personal and environmental factors. That is, when controlling for severity of impairment, there remains reliable variance attributable to the environment (i.e., stepped home entry). This effect has been observed among people with spinal cord injury, the majority of whom (69%) reported that an accessible entrance is a facilitator for community participation.³⁰

These results are similar to results from the American Housing Survey (AHS) for the percentage of people with mobility impairments that report having steps to enter their home. For these samples, 41% of respondents with mobility impairment reported steps compared with 44–54% from the AHS.¹ This finding suggests that about half of the US population with mobility impairment might experience fewer social and recreational activities, in part because they have to negotiate steps at their home entrance. To the extent that social isolation affects health status of PWD,⁷ the cost of social programs that help people live in accessible homes might be at least partially offset by medical cost savings. Future research could explore the fiscal and quality of life impact of moving people with mobility impairment into homes without steps.

This cross-sectional study contributes to the literature by highlighting that home entrancing may mediate the effects of community participation interventions (e.g., increasing knowledge about community events). Additionally, this study suggests that exertion associated with entrancing may be one mechanism by which people choose to engage or not engage in discretionary activities. In this study, people with mobility impairment reported nearly a standard deviation and half less effort necessary to enter their home when they reported not having to use steps at the entrance they used the most. This finding might reflect research that indicated people were 10% more likely to go home or stay home for each unit increase they reported on a measure of fatigue over the course of the day.³¹ In fact, fatigue is a common condition reported by people with disabilities^32,33 that impacts their community participation.⁵ We did not find effects of stepped entrances on non-discretionary activities like shopping for necessities (e.g., groceries, medications). Perhaps these necessary trips increase fatigue to the point that discretionary activities are decreased, in part due to having a stepped entrance. Future prospective research could examine this effect directly and ascribe causality to the effect of no step entrancing on discretionary community participation.

Limitations

This study had limitations that should be considered when interpreting results. First, all data collected were self-reported and are subject to the limitations commonly acknowledged for this data collection method. Second, we used the six question disability set currently being used in US surveys (e.g., the American Community Survey) to identify 45.7% of the people with mobility impairment in this study. These questions identify people with both enduring and transitory disability.^34,35 The effects of home entrancing on participation may be temporary for people with transitory disability who may not adapt to having a mobility impairment and instead choose to curtail discretionary activities temporarily. Third, these data were collected from people in two geographic locations in the mid-west and western United States and may not generalize to places with very different housing and community participation opportunities. For example, these samples had higher rates of White respondents and may not reflect the experiences of people of color. Lastly, we did not control for variables that may interact with our community participation outcome and home access, such as proximity of housing to community participation venues and availability of transportation.

Conclusion

Participation in valued, discretionary activities like social and recreational activities is important to the health, mental health and quality of life of people with disabilities. Research to develop interventions for maintaining and improving participation have rarely addressed environmental factors. The results of this exploratory study suggest that providing people with mobility impairments with a step-free home entrance may be an important intervention target for helping them to both continue and improve their participation in social and recreational activities.