Research focusing on how the built environment impacts people recovering from strokes in outpatient care settings, such as home environments, is sparse. It is important to consider the physical environment of one’s home prior to hospital discharge. This study found that persons recovering at home largely struggled with environmental barriers related to hand and arm use and suggests that collaboration between architects and healthcare providers could help create improved in-home designs.
To investigate if elements of the physical environment are associated with rehabilitation outcomes among patients recovering from strokes while in outpatient living situations.
This study involved 34 patients with stroke who were recruited from three different hospitals. Inclusion criteria were as follows: 1) the patient must have experienced a mild to moderate stroke according to the Barthel Index; 2) the patient must have been discharged directly to their home; and 3) the patient must be capable of formulating answers during interviews.
Data were collected over eight months using an instrument called the Housing Enabler (HE), which is based on Swedish national standards for housing design. The HE consists of three steps:
- Gauging functional limitations in a given patient (12 items concerning factors such as visual impairment, reduced fine motor skills, poor balance, etc.) as well as dependency on mobility devices (two items). These are all assessed dichotomously (marked not present or present) through an interview and observation process, and a score is generated as part of a “functional profile” portraying a person’s overall physical health.
- Environmental barriers are observed and assessed dichotomously (present or not present). This included 161 environmental barriers in three different areas: 87 in the home (e.g., no grab bar near the toilet or in the shower/bath), 46 at the entrance of the building (e.g., level differences or high steps), and 28 in the immediate environment (e.g., trash cans that can only be reached via steps or by changing floors). A sum score of all factors is generated.
- The scores from steps 1 and 2 are juxtaposed to calculate a new person-environment fit score; higher scores indicate more accessibility issues.
Other variables measured included participants’ perceived health, self-efficacy, perceived impact of stroke, falls, decision-making, and possibilities of discussing the physical environment with staff.
The average age of participants was 72, ranging from ages 34 to 90. Approximately half were living alone, and the majority lived in multifamily structures. The length of stay within the present homes ranged from 19.3 to 27.5 years. Six participants had already implemented housing adaptations, and 50% were reliant on a walking aid. Participants reported anywhere between two to six functional limitations.
Environmental barriers were identified in all assessed dwellings. Most accessibility problems were found indoors in all dwelling types. High accessibility problem scores were more frequent in the entrances of senior housing and multifamily structures. High accessibility problem scores for exterior surroundings were most common in multifamily dwellings.
Most indoor accessibility problems were generated by “wall-mounted cupboards and shelves placed high in the kitchen” as well as the lack of grab bars in the toilet and/or shower/bath. For exteriors, difficulty with reaching the refuse bin and the mailbox were ranked the highest. The highest-ranking problems at entrances were the lack of elevators and high steps and/or thresholds.
59% of study participants had fallen at home at least once since being discharged from the hospital. The vast majority of participants stated that their home supported their everyday activities on the whole. Despite this, high accessibility problem scores demonstrated significant negative relationships with perceived health, recovery after stroke, and perceived environmental support, suggesting that living in highly inaccessible buildings was associated with worse rehabilitation outcomes.
The authors note several limitations in this study. A relatively small sample size was involved, and the cross-sectional nature of the study design impeded the determination of causality. A more longitudinal study design could help improve upon this. While practical aspects of in-home designs are important to consider, they may not always account for people’s perceived well-being and personal daily routines, which can be especially difficult to assess quantitatively.