INVESTIGATION OF THE FACTORS THAT EFFECT THE COMMUNITY
PARTICIPATION OF DISABLED PEOPLE
Gökçen Akyürek, PT, MS, Gonca Bumin, PT, Prof
Hacettepe University Faculty of Health Sciences
Department of Occupational Therapy, Ankara , Turkey
1. INTRODUCTION
Participation is defined as “becoming a part of life”. Social participation means
all activities [that regulate a person’s life] (1). Social participation activities are
organized behaviors within a specific social system (2). According to the
[International Classification of Functioning] ICF, fields of participation are defined as
communication, mobility, self-care, inter-personal interaction, living spaces at home
and at work, community life, social life and civic duties (3).
In the previous studies, it was observed that the factors affecting social
participation are addressed individually and there are no studies examining the
impact of all factors on social participation.
No study analyzing the social participation of the disabled with various mobility
levels has been encountered either.
Therefore, this study has been projected with a view to determine and compare
the functional levels, anxiety status, quality of life, activity performance and
satisfaction, leisure activities, perceptions of the physical and social environment,
and social participation levels of disabled individuals with various mobility levels in
our country. It will also analyze the relationship of such factors to social participation.
2. METHODS
2.1. Subjects
Our study has been conducted on 270 physically disabled volunteers from 21
provinces of Turkey and Cyprus.
The study was conducted on 270 handicapped people divided into 3 groups,
each consisting of 90 people according to their mobility levels. These are wheelchair
user, assistive devices user and independent disableds.
2.2. Apparatus
A comprehensive history was requested from each participant, and their
demographic characteristics and life conditions were recorded. Age, gender,
education level, marital status, vocational status, doing sport, living spaces (Table 1).
Table 1 Demographic characteristics of the individuals
Grup I
Grup II
Grup III
Total
n
%
n
%
n
%
n
%
Male
55
20,4
72
26,7 56
20,7
183
67,8
Famale
35
13,0
18
6,7
34
12,6
87
32,2
Married
20
7,4
43
15,9 49
18,1
112
41,5
Single
62
23,0
42
15,6 36
13,3
140
51,9
Divorsed
8
3,0
5
1,9
5
1,9
18
6,7
Educational
Literate
12
4,4
3
1,1
8
3
23
8,5
status
Primary
46
17,0
38
14,1 29
10,7
113
41,9
High school
19
7,0
38
14,1 31
11,5
88
32,6
University
13
4,8
11
4,1
8,1
46
17
Vocational
Not working
78
28,9
49
18,1 39
14,4
166
61,5
status
Working
12
4,4
41
15,2 51
18,9
104
38,5
90
33.3
90
33.3 90
33.3
270
100
Gender
Marital status
school
Total
22
Grup I
Grup II
Grup III
Total
N
%
n
%
n
%
n
%
84
31,1 90
33,3
89
33
263
97,4
Work-school
17
6,3
36
13,3
51
18,9
104
38,5
Club
39
14,4 28
10,4
26
9,6
93
34,4
Cafe
2
0,7
6
2,2
5
1,9
13
4,8
Open air
14
5,2
20
7,4
18
6,7
52
19,3
Dormitory
7
2,6
1
0,4
1
0,4
9
3,3
Living space House
Sports center
29
10,7 36
13,3
25
9,3
90
33,3
2.3. Procedure
The evaluation was made based on the ICF disability model. Accordingly,
body functions, activity performance, participation, leisure activities, anxiety status,
the effect of the environment, and the quality of life of the participants were
evaluated.
The Canadian Occupational Performance Measure (COPM) was used as a
client-centered measure to evaluate the activity performance of the individuals. The
Functional Independence Measurement (FIM) was used in order to evaluate
functional independence. The Measurement of the Quality of the Environment (MQESF), which is used to assess the effect of environmental factors on participation, is
modified ICF format. The Leisure Satisfaction Questionnaire short form was used in
order to evaluate leisure activities. The Turkish version of the State-Trait Anxiety
Inventory (STAI) was used to determine the anxiety level related to the psychological
conditions of the individuals. The Short Form 12 (SF-12) was used to evaluate the
quality of life. The World Health Organization’s Disability Assessment Schedule
(WHO DAS II) was used in our study to evaluate social participation. The Community
Integration Questionnaire (CIQ) was also applied to assess community participation.
2.4.
Analysis
A multiple regression analysis was conducted to analyze the main dependent
variables (WHO DAS II, CIQ). The analysis of variance was carried out to analyze
the variation according to the mobility levels of other variables. Alpha type I error rate
was accepted as 0.05 in all statistics.
3. RESULTS
3.1.
Factors affected participation
Three factors significantly affecting both CIQ and WHO DAS II scores were
found as a result of the regression analysises. These are functional independence
level, vocational status, mobility level (Table 2, 4).
When the factors affecting participation (WHO DAS II and CIQ) in regression were
brought under control, the social participation level of the group using wheelchairs
was found to be significantly low (p<0.05). No difference was found between those
using walking aids and those who can independently walk, in terms of social
participation (p>0.05) (Table 3, 5).
Table 2 Coefficients of the WHO DAS II score according to the regression analysis
Model
Unstandardized
Standardize
Coefficients
dCoefficient
s
B
Std.erro
Beta
t
Sig.
9,93
,001*
r
(Constant)
92,13
9,27
FIM
-,42
,06
-,37
-6.79
,001*
Trait anxiety inventory
,31
,069
,20
4,49
,001*
SF12 physical
-,53
,071
-,28
-7,49
,001*
SF12 mental
-,24
,072
-,14
-3,40
,001*
Mobility
5,44
1,86
,15
2,91
,004*
Vocational status
-2,85
1,27
-,85
-2,24
,025*
Table 3 Bilateral comparisons between the WHO DAS II scores and the groups
(I)
(J)
95% Confidence Interval
Of the Difference
Mean difference
Std. error
Sig.
(I-J)
Lower
Upper
bound
bound
Grup I
Grup II
4,95
1,91
,010*
1,17
8,72
Grup I
Grup III
6,50
2,09
,002*
2,38
10,62
Grup II
Grup III
1,55
1,39
,266
-1,19
4,29
Table 4 Coefficients obtained as a result of the regression analysis of the CIQ score
Unstandardized
Standardize
Coefficients
dCoefficient
s
B
Std. Error
(constant)
-13,707
2,824
FIM
,135
,022
LSS
,038
COPM Performance
Beta
t
Sig.
-4,854
,001*
,406
6,107
,001*
,012
,137
3,129
,002*
,026
,012
,094
2,188
,030*
Mobility
1,898
,662
,187
2,867
,004*
Educational status
,849
,261
,154
3,249
,001*
Vocational status
2,537
,602
,258
4,211
,001*
Living space: School-
1,674
,619
,170
2,706
,007*
1,418
,442
,140
3,210
,001*
work
Living space: Sports
Center
Table 5 Intergroup bilateral comparisons of the CIQ scores
(I)
(J)
95% Confidence
Interval
of the Difference
Mean
Std.
difference (I-
Error
Sig.
Lower
Upper
bound
bound
J)
Grup I
Grup II
2,017(*)
,682
,003*
,673
3,360
Grup I
Grup III
1,656(*)
,741
,026*
,196
3,115
Grup II
Grup III
-,361
,496
,467
-1,339
,616
3.2.
Findings on the effect of the mobility level on participation and other factors
A one-way analysis of variance was conducted for the purpose of detecting
how mobility affects the other factors.
When the FIM and the SF-12 are considered, a significant difference was found
between the Group I and the other two groups (p<0.05). In addition, it was observed
that the significant difference between the group II and group III which functional
independence level and quality of life of the group using an assistive device was
lower than that of the independent group (p<0.05) (Table 6).
Table 6 Display of the intergroup differences of the FIM and SF 12 scores
Dependent
variable
FIM
SF-12
Mean
(I) Mobility
(J) Mobility
difference
(I-J)
Std.
error
Sig.
Grup I
Grup II
-21,32
1,376
,001*
Grup I
Grup III
-25,07
1,376
,001*
Grup II
Grup III
-3,74
1,376
,019*
Grup I
Grup II
-3,071
1,2423
,037*
Grup I
Grup III
-6,511
1,2423
,001*
Grup II
Grup III
-3,440
1,2423
,017*
When the MQE and the COPM scores are considered, a significant difference
was found between the Group I and the other two groups (p<0.05). There was no
significant difference between Group II and Group III (p>0.05) (Table 7).
Table 7 Display of the intergroup differences of the MQE and COPM scores
Dependent
variable
MQE
COPM
(I) Mobility
(J) Mobility
Grup I
Grup II
Grup I
Mean difference
Std. error
Sig.
-6,611
2,5433
,027*
Grup III
-12,078
2,5433
,001*
Grup II
Grup III
-5,467
2,5433
,082
Grup I
Grup II
-7,79
2,527
,006*
Grup I
Grup III
-7,39
2,527
,010*
Grup II
Grup III
0,39
2,527
,987
(I-J)
Other scores were not affected by the mobility level (p>0,05).
4. DISCUSSION
In our study, 38% of the participants were in actively working, and nearly half
of the unemployed were wheelchair users. In the study the employment status of the
individual was found to affect social participation significantly. Other studies similar to
ours revealed (4, 5). Commuting between work and home is in itself participation and
their employment will contribute to making them feel that they are a part of society,
becoming productive and having ideals.
In our study, it was revealed that the mobility level of the individuals affected
social participation significantly. The results of our research support other study
results (6-10). Through years of studies and the statements of our participants, it was
understood that wheelchair users were therefore limited in society and had a low
level of benefit from job-related and educational opportunities.
In our study, the functional independence level is the parameter that has the
greatest impact on social participation. A low functional independence level affects
the performance of basic and collateral daily activities, as well as productive
activities (7, 8). In addition, this situation may cause the individual to drift away from
social life, interpersonal interactions, and/or leisure activities, and may diminish their
social participation (11).
College graduates proved to participate in voluntary activities, like sports, and
artistic events such as theatre, cinema and dance. Such people were observed to be
one step ahead of others, with respect to coping with obstacles, holding on to
life/enjoying life and struggling for their freedom. For this reason, educational level is
considered to correspond to social participation.
The results of our study indicate that leisure activities positively affect social
participation. Participation in leisure activities enhances interpersonal interaction and
communication, positively affecting the individuals’ psychological conditions and
quality of life. It further has favorable effects on enjoying life and, thus, on health and
wellness.
Previously conducted studies suggest that the environment affects social
participation to a considerable extent (6, 9, 10, 12, 13). In our study, transportation
has been identified as the most outstanding activity causing difficulty, according to
the COPM evaluation. However, a significant relationship could not be found
between the MQE and both participation scales when a multiple regression analysis
was performed together with other factors. This situation leads us to believe that the
MQE has been insufficient for evaluating the quality of the environment, that the
questions of the MQE have not brought additional innovation to the questionnaire we
have been using, and/or that the participants have run into contradictions in scoring.
In our study, a rise in general anxiety levels of the disabled has been
adversely affected social participation. Whether the individuals adopt health
perspective, at peace with themselves or as desperate individuals unable to cope
with their problems, they still expressed their concerns for daily life and the future. In
addition, other people in society presented different attitudes of curiosity or pity, and
abused or embarrassed them, verbally or, sometimes, through behavior. Such
behaviors are factors that trigger anxiety and diminish the social participation of the
disabled.
The quality of life has a directly proportional relationship with social
participation, as can be seen in our study. Most of the participants of our study
underlined that they spent a certain part of their lives at hospital, medical stores,
using medicines and at physiotherapy and psychology centers, and thus the amount
of quality time they shared with their families was shortened. Furthermore, they
suffer from extraordinary challenges such as getting married, finding a job,
benefitting from social services and exposure to stress, due to their low functional
independence levels, and that this situation directly affects the quality of life.
There are some limitations in our study. Most of the participants were active in
their lives and were engaged in sports. They were also living in city centers. The
limited number of the disabled individuals living in rural areas can be considered as a
limitation to our study.
On the other hand, the strength of our study is the acquisition of a significant
amount of data about the disabled, by reaching 270 disabled individuals in total, from
every region of Turkey. According to the results of the power analysis, what matters
is obtaining 90% reliable results. We believe that such results might create resource
for future studies in our country.
5. CONCLUSION
Functional
activity
training
and
long-term
follow-ups
through
detailed
assessments to be performed by occupational therapists and physiotherapists, and
client-centered interventions are important.
The vocational trainings of the disabled can be guaranteed and made sustainable
such as ensuring flexibility of working hours and times.Increasing the number of
artistic, cultural and sportive athletic activities performed by the disabled or for the
disabled within our society.
Consequently, activity-related factors affecting the social participation of the
disabled should be addressed by client-centered evaluations performed by
occupational therapists in future studies. They should be analyzed in a more detailed
manner, and occupational therapy interventions should be planned in line with the
results to be obtained from the aforementioned studies and analyses.
REFERENCES
1. American Occupational Therapy Association. 2002. “Occupational therapy
practice framework: Domain and Process”, American Journal Occupational
Therapy, 56, 6, pp. 609-639.
2. Mosey AC. 1996. “Applied scientific inquiry in the health professions: A
epistemological orientation”, 2nd ed. Bethesda, MD: AOTA.
3. Law M, Dunn W, Baum C. 2005. “Measuring Participation”, Law M, Baum C,
Dunn W. (eds) Measuring occupational performance: supporting best practice
in occupational therapy, 2.ed. Thorofare NJ, Slack Incorporated, pp. 107-126.
4. Ostir GV, Granger CV, Black T, Roberts P, Burgos L, Martinkewiz P,
Ottenbacher KJ. 2006. “Preliminary result for the PAR-PRO: A measure of
home and community participation”, Archives Physical Medicine and
Rehabilitation, 87, pp. 1043-51.
5. Yorkston KM, Bamer A, Johnson K, & Amtmann D. 2011. “Satisfaction with
participation in multiple sclerosis and spinal cord injury”, Disability and
Rehabilitation, pp. 1-7.
6. Hollingsworth H, & Gray DB. 2010. “Stractural equation modelling of the
relationships between participation in leisure activities and community
environments by people with mobility impairments”, Archives Physical Medicine
and Rehabilitation, 91, pp. 1174-81.
7. Jang Y, Wang Y, & Wang J. 2005. “Return to work after spinal cord injury in
Taiwan: The contribution of fonctional independence”, Archives Physical
Medicine and Rehabilitation, 86, pp. 681-6.
8. Barf HA, Post M, Verhoef M, Jennekens-schinkel A, Gooskens M, & Prevo H.
2009. “Restrictions in social participation of young adults with spina bifida”,
Disability and Rehabilitation, 31, 11, pp. 921-7.
9. Wee J, & Lysaght R. 2009. “Factors affecting measures of activities and
participation in persons with mobility impairment”, Disability and Rehabilitation,
31, 20, pp. 1633-42.
10. Hjelle KM, & Vik K. 2011. “The ups and downs of social participation:
experiences of wheelchair users in Norway”, Disability and Rehabilitation, 33,
25-26, pp. 2479-89.
11. Trigg R, Wood VA, & Hewer RL. 1999. “Social reintegration after stroke: the
first stages in the development of the subjective index of physical and social
outcome (SIPSO)”, Clinical Rehabilitation, 13, pp. 341-53.
12. Noreau L, & Boschen K. 2010. “Intersection of participation and environment
factors: a complex interactive process”, Archives Physical Medicine and
Rehabilitation, 91, 1, pp. 44-53
13. Whiteneck G, Meade MA, Dijkers M, Tate DG, Bushnik T, & Forchheimer MB.
2004. “Environmental factors and their role in participation and life satisfaciton
after spinal cord injury”, Archives Physical Medicine and Rehabilitation, 85, pp.
1793-803.