The Effects of Social and Physical Barriers on Community Participation of Individuals with Spinal Cord Injury

Eliana Ferretti, M.S., Rory A. Cooper, Ph.D, Michael L. Boninger, M.D. Rosemarie Cooper M.P.T., A.T.P, Shirley G. Fitzgerald, Ph.D., David Gray, Ph.D.
Departments of Rehabilitation Science & Technology, University of Pittsburgh,
Human Engineering Research Laboratories, VA Pittsburgh Healthcare System
Washington University School of Medicine

ABSTRACT

The purpose of this study was to determine the frequency of the social and physical barriers on community participation of individuals with spinal cord injury (SCI). The first specific aim was to determine the most common social and physical barriers that individuals with SCI rank as the most limiting for community participation. The second specific aim was to determine if differences exist between individuals who use manual and power wheelchairs regarding the frequency of social and physical barriers on community participation. The third specific aim was to determine if differences exist between individuals with tetraplegia and paraplegia regarding the frequency of social and physical barriers on community participation. Accessibility of shelves and freezers was the most common physical barrier limiting participation in the grocery store. Tables too close together and width of aisles was the most common physical barrier limiting participation in restaurant and clothing stores respectively. A greater number of individuals that use a power wheelchair reported that lack of personal assistance as a social barrier that limits their participation in their place of employment and in the grocery store. A greater number of individuals that use a power wheelchair reported lack of special equipment as a physical barrier that limits their participation in the shopping malls. No significant difference was found between individuals with tetraplegia and paraplegia regarding the frequency of social and physical barriers on community participation.

Keywords:

Assistive technology; wheelchair; spinal cord injury; outcomes; participation; activities of daily living.

BACKGROUND

The perception of disability has been evolving greatly in international circles within the last decade. The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF; WHO, 2001) emphasizes what people do on a daily basis as opposed to what they have the ability to do. Thus, disability has not only been related to physical or mental limitations, but more so, has been considered a dysfunction of the interaction between an individual and his environment [2]. In this framework, the environment is composed of physical and social factors. The physical factors are defined as having the availability of resources, as such, accessibility of streets, buildings and transportation. The social factors are composed by attitudes of others, public priorities, policies and availability of services [1]. The latter, encompasses the individual’s ability to assess assistive technology (AT) devices. Therefore, the function of people with disabilities is affect by technology and the physical environment as much as by their physiological impairments. With this in mind, AT and the social and physical environment are assumed to affect the extent to which an individual performs daily activities and ultimately, participates in the community. The overall aim of this study was to investigate the frequency of the social and physical barriers on community participation of individuals with spinal cord injury (SCI). The first specific aim was to determine the most common social and physical barriers that individuals with SCI rank as the most limiting for community participation. The second specific aim was to determine if differences exist between individuals who use manual and power wheelchairs regarding the frequency of social and physical barriers on community participation. It was hypothesized that the frequency of social and physical barriers faced by individuals who use power wheelchairs would be higher than individuals who use manualwheelchairs. The third specific aim was to determine if differences exist between individuals with tetraplegia and paraplegia regarding the frequency of social and physical barriers on community participation. It was hypothesized that the frequency of social and physical barriers faced by individuals with tetraplegia would be higher than individuals with paraplegia.

METHODS

Subjects:

Fourthly-nine individuals (12 females) with SCI who use wheelchairs for mobility provided written informed consent. The average age of the participants was 41 (± 12) years. 27 individuals had paraplegia and 18 had tetraplegia. Two individuals reported that they did not know their injury level and two individuals did not answer the question. Thirty four individuals had a manual wheelchair and 15 had a power wheelchair. All participants had been discharged from rehabilitation for at least one year and lived in a community setting. Protocol: A written survey that recorded AT usage in daily activities was distributed among clients from Pittsburgh (Pitt) and Saint Louis (SL). Pitt subjects were recruited through research centers and through an AT clinic. SL subjects were recruited from research centers and rehabilitation centers. In both locations, subjects were recruited via a flyer or approached by clinical study coordinators, who asked if they were interested in participating. Questionnaire: The questionnaire used in this study was a combination of two surveys: 1) Participation Survey/Mobility (PARTS/M) and, 2) Facilitators and Barriers Survey/Mobility (FABS/M). The PARTS/M is composed of 25 major life activities. The FABS/M consists of 191 items that probe the situational specificity of activity limitations, requests information on the type of assistive technology used in activities, and asks respondents to categorize aspects of their environments as barriers or facilitators to participation. For this study, only questions related to accessibility of buildings within the home and community were analyzed. Subjects were asked 10 questions related to their accessibility limitations frequency within the home and community. The 10 questions are listed in Tables 1-10.

Statistical analysis:

SPSS software (SPSS, Inc.) was used to calculate frequencies of perceived social and physical barriers limitations for community participation. Differences between individuals who use manual and power wheelchairs regarding the frequency of social and physical barriers on community participation were analyzed using a Kruskal-Wallis test. Differences between individuals with tetraplegia and paraplegia regarding the frequency of social and physical barriers on community participation was also analyzed using a Kruskal-Wallis test. The significance level was set a priori at p < 0.05.

RESULTS

The data show that accessibility of shelves and freezers (49%) was the most common physical barrier limiting participation in the grocery store. Waiting rooms and exam rooms (22%)was also the most limiting physical barrier in the doctor’s office. In addition, tables too close together (65%) was the most common physical barrier limiting participation in restaurants followed by entrances (60%) and height of counters, tables and booths (50%). In the movie theaters, stadium seating (45%) was pointed out as the most common physical barrier limiting participation. Width of aisles (59%) was the most common physical barrier limiting participation in clothing stores followed by height of clothing racks (49%). Lack of paved paths (73%) was the most limiting factor to participation in the parks (see table 3-10). The data also revealed significant differences between manual and power wheelchair regarding the accessibility of place of employment, grocery store and shopping malls (Table 2, 3 & 8; p<0.05). A greater number of individuals that use a power wheelchair reported that lack of personal assistance (PAS) as a social barrier that limits their participation in their place of employment (13%) and in the grocery store (40%) when compared to individuals that use manual wheelchairs (employment= 0% & grocery store=3%). In addition, a greater number of individuals that use a power wheelchair (20%) reported lack of special equipment as a physical barrier that limits their participation in the shopping malls when compared to those who use manual wheelchairs (0%). No elevators, narrow aisles and power doors do not work were some of the answers justifying the lack of special equipment in the shopping malls. No significant difference was found between individuals with tetraplegia and paraplegia regarding the frequency of social and physical barriers on community participation. Tables 1 to 10 illustrate the relative percentages of social and physical barriers within the home and community for all participants, by wheelchair type and by injury level.

Table 1. Illustrate the relative percentages of social and physical barriers in the residence.
What about your residence limits you?
% of participants
(n=49)		 Type of wheelchair Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
14
15
13
11
18
Bathroom
18
18
20
22
11
Kitchen
31
24
46
39
26
Lack of personal finances
20
18
27
6
7
Lack of Personal assistance
6
6
7
22
19
Parking
8
12
0
17
4
Lack of special equipment
20
21
20
11
26
Not limit
45
44
47
50
40

 

Table 2. Illustrate the relative percentages of social and physical barriers in the place of employment.
What about your place of employment?
% of participants
(n=49)		 Type of wheelchair Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
0
0
0
0
0
Workstation
2
0
6
6
0
Bathroom
6
6
7
6
7
Parking
6
6
7
11
4
Lack of child care
0
0
0
0
0
Lack of transportation
0
0
0
0
0
Lack of personal assistance
4
0
13*
11
0
Lack of special equipment
6
3
13
11
4
Not limit
26
32
13
22
33
No response
14
6
33
17
7
N.A.
36
44
20
33
37
*P < 0.05

 

Table 3. Illustrate the relative percentages of social and physical barriers in the grocery store.
 What about your grocery store limits you? % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
6
6
7
0
11
Accessibility of shelves and freezers
49
44
60
56
45
Lack of scooter/wheelchair at the store
0
0
0
0
0
Lack of personal finances
8
9
7
11
7
Parking
27
30
27
39
26
Lack of transportation
8
6
13
17
4
Lack of personal assistance
14
3
40*
22
11
Lack of child care
0
0
0
0
0
Lack of special equipment
4
3
7
6
4
Not limit
29
32
20
33
30
*P < 0.01

 

Table 4. Illustrate the relative percentages of social and physical barriers in the doctor’s office.
 What about your doctor’s office limits you? % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
16
12
28
28
11
Lack of personal assistance
4
6
0
0
7
Lack of insurance
6
9
0
6
8
Lack of child care
0
0
0
0
0
Lack of personal finances
4
6
0
0
7
Waiting rooms and exam rooms
22
21
27
17
26
Lack of transportation
2
3
0
0
4
Parking
14
12
20
17
15
Lack of special equipment
18
18
20
28
15
Not limit
47
50
40
50
44
No response
6
6
7
6
4

 

Table 5.  Illustrate the relative percentages of social and physical barriers in the religious institution.
 What about your religious institution limits you?  % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
12
9
20
16
11
Seating
14
18
7
11
18
Lack of personal finances
0
0
0
0
0
Parking
12
12
13
11
15
Lack of child care
0
0
0
0
0
Lack of transportation
2
0
6
5
0
Lack of personal assistance
2
3
0
5
0
Lack of special equipment
4
6
0
0
7
Not limit
33
35
27
28
37
No response
12
15
7
11
11
N.A.
27
30
20
33
22

 

Table 6. Illustrate the relative percentages of social and physical barriers in restaurants.
 What about restaurants limits you? % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
60
62
53
56
63
Lack of personal finances
12
15
7
17
11
Table too close together
65
62
73
72
63
Parking
39
38
40
44
37
Lack of child care
0
0
0
0
0
Lack of transportation
6
11
4
Height of counters, tables and booths
50
38
60
55
37
Lack of personal assistance
10
6
20
11
7
Lack of special equipment
8
6
13
5
7
Not limit
8
6
13
11
7
No response
4
3
6
0
4

 

Table 7. Illustrate the relative percentages of social and physical barriers in movie theaters.
 What about movie theaters limits you?   % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
16
17
13
27
11
Stadium seating
45
38
60
61
37
Lack of personal finances
10
12
7
11
7
Parking
18
11
33
27
11
Lack of child care
0
0
0
0
0
Lack of transportation
10
6
20
11
7
Lack of personal assistance
6
6
7
6
7
Lack of special equipment
2
0
6
0
0
Not limit
22
21
27
17
26
No response
14
17
7
6
15

 

Table 8. Illustrate the relative percentages of social and physical barriers in shopping malls.
 What about shopping malls limits you?   % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
18
21
13
17
22
Lack of personal finances
12
15
7
17
11
Parking
27
27
27
28
30
Lack of child care
0
0
0
0
0
Lack of transportation
6
6
7
11
4
Lack of personal assistance
8
6
13
17
4
Lack of special equipment
6
0
20*
11
0
Not limit
49
50
47
56
44
No response
6
6
7
0
7
*P < 0.01

 

Table 9. Illustrate the relative percentages of social and physical barriers in clothing stores.
 What about clothing stores limits you?   % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Entrance
25
21
33
27
22
Lack of personal finances
18
21
13
17
19
Width of aisles
59
53
73
67
52
Parking
18
15
26
28
11
Height of clothing racks
49
50
47
50
48
Lack of child care
0
0
0
0
0
Lack of transportation
10
9
13
11
4
Lack of personal assistance
6
3
13
11
0
Lack of special equipment
4
3
7
11
0
Not limit
10
9
13
11
11
No response
6
6
7
0
7

 

Table 10. Illustrate the relative percentages of social and physical barriers in the parks.
 What public parks limit you?   % of participants
(n=49)		  Type of wheelchair  Level of injury
M
%		 P
%		 Tetraplegia
%		 Paraplegia
%
Lack of paved paths
73
71
80
77
70
Picnic areas
31
30
33
33
30
Lack of personal finances
10
9
13
11
11
Parking
22
23
20
27
22
Lack of child care
0
0
0
0
0
Lack of transportation
12
9
20
11
7
Lack of personal assistance
4
3
7
6
4
Lack of special equipment
2
0
7
0
0
Not limit
16
20
7
11
22
No response
4
6
0
5
0

 

DISCUSSION

The data shows a significant difference between manual and power wheelchair regarding the accessibility of places of employment, grocery stores and shopping malls. A greater number of individuals that use a power wheelchair reported that lack of PAS as a social barrier that limits their participation in their place of employment and in the grocery store when compared to individuals that use manual wheelchairs. The performance of people who use wheelchairs is often influenced by the presence of social barriers in the environment [3] [4]. In addition, a greater number of individuals that use a power wheelchair reported lack of special equipment as a physical barrier that limits their participation in the shopping malls when compared to those that use manual wheelchairs. This might be due to the fact that the progress made over the years to advance technology and improve access to buildings is not sufficient. Although, the majority of businesses, grocery stores and shopping malls are considered accessible overall, in fact, they are not truly accessible if small tasks or subtasks are examined. Interestingly, our study showed that accessibility of shelves and freezers was the most common physical barrier limiting participation in the grocery store. Waiting rooms and exam rooms was also the most limiting physical barrier in the doctor’s office. Tables too close together and width of aisles was the most common physical barrier limiting participation in restaurants and clothing stores respectively. Richards et al. (1999) reported that environmental access increases the likelihood that a person with SCI will engage in a variety of meaningful activities. Thus, all the possible tasks that an individual with disability could perform should be taken into consideration when planning for accessible environments. The lived experience of disability is an excellent resource. Hence, individuals with disability should be involved as part of a team for assessing accessibility and recommending additional accommodations. Fifteen years ago, Congress passed one the most significant laws the Americans with Disabilities Act. Because of that, all buildings and facilities have to be constructed following the ADA regulations and therefore, have to be wheelchair accessible. Although progress has been made over the years to improve access to employment, public accommodations, commercial facilities, housing, schools, significant challenges related to accessibility still remained.

REFERENCES

  1. World Health Organization. ICIDH-2: International Classification of functioning, Disability and Health. Final draft, full version. Geneva: world Health Organization, 2001.
  2. Scherer MJ, Glueckauf R. Assessing the Benefits of Assistive Technologies for Activities and Participation. Rehabilitation Psychology (2005) 50(2):132-141.
  3. Chaves, E.S., Boninger, M.L., Cooper, R., Fitzgerald, S.G., Gray, D.B., Cooper, R.A. Assessing the influence of wheelchair technology on perception of participation in spinal cord injury. Archives of Physical Medicine and Rehabilitation (2004) 85(11):1854-8.
  4. Richards JS, Bombardier CH, Tate D, Dijkers M, Gordon W, Shewchuk R, DeVivo M. Access to the environment and life satisfaction after spinal cord injury. Arch Phys Med Rehabilitation (1999) 80:1501-1506.

ACKNOWLEDGEMENTS

This study was supported by NIDRR Model Systems for SCI (#H133N000019).

Author Contact Information:

Eliana Ferretti,
7180 Highland Drive building 4,
2nd floor, East Wing, 151R-1
Pittsburgh, PA, 15206.
Ph: (412) 365-4850
e-mail: esc14@pitt.edu

Highlights

  • Source Ordered
  • No Tables
  • Very Compatible

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