This does leave existing stroke survivors hanging but that can be solved by figuring out exactly how to encourage neuroplasticity and neurogenesis. These are going to be difficult problems to solve but LEADERS tackle the hard problems, they don't ignore them!
http://www.tandfonline.com/doi/full/10.1080/09687599.2016.1223606
Pages 1-17 | Received 09 Dec 2015, Accepted 09 Aug 2016, Published online: 19 Sep 2016
Abstract
This
study investigated the environment’s role in community reintegration
amongst persons with experience of stroke. Focus group discussions with
29 individuals recruited from community stroke clubs in Scotland
revealed that stroke influenced a person’s perceptions, experience, use
and enjoyment of the environment. Multiple specific (e.g. theatres,
cafes) and more general (out-of-the-home) environments appeared capable
of supporting community reintegration, providing settings in which
individuals were able and willing to interact with others and
participate in various functional, social and recreational activities.
The article reflects on the study’s implications for policy and
practice.
Points of interest
| • | Community reintegration post stroke may be supported by multiple specific (e.g. theatres, parks, the home) and more general (out-of-the-home) environments. | ||||
| • | These can provide settings in which individuals are motivated to interact with others and participate in various functional, social and recreational activities. | ||||
| • | Stroke can have a profound impact on an individual’s perceptions, experience, use and enjoyment of the environment. | ||||
| • | Peer support is valued by, and may bring important benefits to, stroke survivors. | ||||
Introduction
There are over 1.2 million stoke survivors in the United Kingdom whilst every year some 152,000 strokes occur, equivalent to one every 3 minutes 27 seconds (Stroke Association 2016 Stroke Association. 2016. State of the Nation – Stroke Statistics. London: Stroke Association.). The prevalence of stroke increased by 12.5% between 1999 and 2008, whilst the incidence of stroke fell by approximately 30% (Lee, Shafe, and Cowie 2011 Lee, Sally, Anna C. E. Shafe, and Martin R. Cowie. 2011. “UK Stroke Incidence, Mortality and Cardiovascular Risk Management 1999–2008: Time-Trend Analysis from the General Practice Research Database.” BMJ Open 1 (2): e000269.[CrossRef]). Improved drug treatment in primary care is likely to be a major contributor to the latter (Lee, Shafe, and Cowie 2011 Lee, Sally, Anna C. E. Shafe, and Martin R. Cowie. 2011. “UK Stroke Incidence, Mortality and Cardiovascular Risk Management 1999–2008: Time-Trend Analysis from the General Practice Research Database.” BMJ Open 1 (2): e000269.[CrossRef], 1). Our ageing population (Mayo et al. 2002 Mayo, Nancy E., Sharon Wood-Dauphinee, Robert Côté, Liam Durcan, and Joseph Carlton. 2002. “Activity, Participation, and Quality of Life 6 Months Poststroke.” Archives of Physical Medicine and Rehabilitation 83 (8): 1035–1042. doi:10.1053/apmr.2002.33984.[CrossRef], [PubMed], [Web of Science ®], [CSA]), with age being the single most important risk factor for stroke (Stroke Association 2016 Stroke Association. 2016. State of the Nation – Stroke Statistics. London: Stroke Association.), combined with developments in acute stroke management and rehabilitation, leading to reduced stroke mortality (Lee, Shafe, and Cowie 2011 Lee, Sally, Anna C. E. Shafe, and Martin R. Cowie. 2011. “UK Stroke Incidence, Mortality and Cardiovascular Risk Management 1999–2008: Time-Trend Analysis from the General Practice Research Database.” BMJ Open 1 (2): e000269.[CrossRef]), mean that an increasing number of people with stroke are now returning to the community (Wood, Connelly, and Maly 2010 Wood, Jennifer P., Denise M. Connelly, and Monica R. Maly. 2010. “‘Getting back to Real Living’: A Qualitative Study of the Process of Community Reintegration after Stroke.” Clinical Rehabilitation 24 (11): 1045–1056. doi:10.1177/0269215510375901.[CrossRef], [PubMed], [Web of Science ®]).In the context of stroke, community reintegration can be defined as a person’s return to everyday functional activities, instrumental activities of daily living, recreational and social activities, and interactions with family members and others (Pang, Eng, and Miller 2007 Pang, Marco Y. C., Janice J. Eng, and William C. Miller. 2007. “Determinants of Satisfaction with Community Reintegration in Older Adults with Chronic Stroke: Role of Balance Self-Efficacy.” Physical Therapy 87 (3): 282–291. doi:10.2522/ptj.20060142.[CrossRef], [PubMed], [Web of Science ®]). It is, therefore, a relatively broad concept concerned with participation in various life domains. We focus here on community reintegration because evidence suggests it captures processes which are important to stroke survivors (although no judgement is passed on whether or why these processes should be considered important) (Bergström et al. 2015 Bergström, A. L., L. von Koch, M. Andersson, K. Tham, and G. Eriksson. 2015. “Participation in Everyday Life and Life Satisfaction in Persons with Stroke and Their Caregivers 3–6 Months after Onset.” Journal of Rehabilitation Medicine 47 (6): 508–515. doi: 10.2340/16501977-1964.[CrossRef], [PubMed], [Web of Science ®]; Wood, Connelly, and Maly 2010 Wood, Jennifer P., Denise M. Connelly, and Monica R. Maly. 2010. “‘Getting back to Real Living’: A Qualitative Study of the Process of Community Reintegration after Stroke.” Clinical Rehabilitation 24 (11): 1045–1056. doi:10.1177/0269215510375901.[CrossRef], [PubMed], [Web of Science ®]). That poor community reintegration has been associated with depression, social isolation, a poor quality of life (Wood, Connelly, and Maly 2010 Wood, Jennifer P., Denise M. Connelly, and Monica R. Maly. 2010. “‘Getting back to Real Living’: A Qualitative Study of the Process of Community Reintegration after Stroke.” Clinical Rehabilitation 24 (11): 1045–1056. doi:10.1177/0269215510375901.[CrossRef], [PubMed], [Web of Science ®]) and reduced life satisfaction (Astrom, Asplund, and Astrom 1992 Astrom, M., Kjell Asplund, and T. Astrom. 1992. “Psychosocial Function and Life Satisfaction after Stroke.” Stroke 23 (4): 527–531.10.1161/01.STR.23.4.527[CrossRef], [PubMed], [Web of Science ®]) underlines its importance.
Community reintegration is, of course, neither an unproblematic nor an uncontested concept (Myers et al. 1998 Myers, Fiona, Alastair Ager, Patricia Kerr, and Susan Myles. 1998. “Outside Looking in? Studies of the Community Integration of People with Learning Disabilities.” Disability & Society 13 (3): 389–413. doi:10.1080/09687599826704.[Taylor & Francis Online], [Web of Science ®], [CSA]; Mirza et al. 2008 Mirza, Mansha, Andrea Gossett, Nathan Kai-Cheong Chan, Larry Burford, and Joy Hammel. 2008. “Community Reintegration for People with Psychiatric Disabilities: Challenging Systemic Barriers to Service Provision and Public Policy through Participatory Action Research.” Disability & Society 23 (4): 323–336. doi:10.1080/09687590802038829.[Taylor & Francis Online], [Web of Science ®]; van de Ven et al. 2005 van de Ven, Leontine, Marcel Post, Luc de Witte, and Wim van den Heuvel. 2005. “It Takes Two to Tango: The Integration of People with Disabilities into Society.” Disability & Society 20 (3): 311–329. doi:10.1080/09687590500060778.[Taylor & Francis Online], [Web of Science ®]). Some, for instance, might take exception to its implicit support for ‘normalisation’, a concept concerned with how disabled people can ‘slot’ into ‘everyday living’ and lead an ‘ordinary life’ (King’s Fund Centre 1980, 1988 King’s Fund Centre. 1980. An Ordinary Life: Comprehensive Locally-Based Residential Services for Mentally Handicapped People. London: King’s Fund Centre.
King’s Fund Centre. 1988. Ties and Connections: An Ordinary Community Life for People with Learning Difficulties. London: King’s Fund Centre.). Popular in the 1980s, this concept has since been criticised for overlooking the social construction, and socially constructed meanings, of ‘disability’ and ‘normality’ (Chappell 1992 Chappell, Anne Louise. 1992. “Towards a Sociological Critique of the Normalisation Principle.” Disability, Handicap & Society 7 (1): 35–51. doi:10.1080/02674649266780041.[Taylor & Francis Online]); indeed, by not focusing on deconstructing the meanings attached to disability, writers from critical disability studies may argue that it misses that which should ground our approach to disability (Corker 1999 Corker, Mairian. 1999. “Differences, Conflations and Foundations: The Limits to ‘Accurate’ Theoretical Representation of Disabled People’s Experience?” Disability & Society 14 (5): 627–642. doi:10.1080/09687599925984.[Taylor & Francis Online], [Web of Science ®], [CSA]; Vehmas and Watson 2014 Vehmas, Simo, and Nick Watson. 2014. “Moral Wrongs, Disadvantages, and Disability: A Critique of Critical Disability Studies.” Disability & Society 29 (4): 638–650. doi:10.1080/09687599.2013.831751.[Taylor & Francis Online], [Web of Science ®]). It has also been accused of ignoring the material constraints that impact the lives of disabled people, problematizing rather than valuing difference, and requiring individuals to ‘fit in’ to an unchanged society rather than requiring a changed society to be ‘fit for’ the individual (Chappell 1992 Chappell, Anne Louise. 1992. “Towards a Sociological Critique of the Normalisation Principle.” Disability, Handicap & Society 7 (1): 35–51. doi:10.1080/02674649266780041.[Taylor & Francis Online]; Myers et al. 1998 Myers, Fiona, Alastair Ager, Patricia Kerr, and Susan Myles. 1998. “Outside Looking in? Studies of the Community Integration of People with Learning Disabilities.” Disability & Society 13 (3): 389–413. doi:10.1080/09687599826704.[Taylor & Francis Online], [Web of Science ®], [CSA]; Pothier and Devlin 2006 Pothier, D., and R. Devlin, eds. 2006. Critical Disability Theory: Essays in Philosophy, Politics, Policy, and Law. Vancouver: UBC Press.; Vehmas and Watson 2014 Vehmas, Simo, and Nick Watson. 2014. “Moral Wrongs, Disadvantages, and Disability: A Critique of Critical Disability Studies.” Disability & Society 29 (4): 638–650. doi:10.1080/09687599.2013.831751.[Taylor & Francis Online], [Web of Science ®]; Ward 1992 Ward, L. 1992. “Foreword.” In Normalisation: A Reader, edited by Hilary Brown and Helen Smith, x–xi. Abingdon: Routledge.).
Such concerns aside, given the apparent importance of community reintegration to stroke survivors it is troubling that so many find it difficult and challenging (Pang, Eng, and Miller 2007 Pang, Marco Y. C., Janice J. Eng, and William C. Miller. 2007. “Determinants of Satisfaction with Community Reintegration in Older Adults with Chronic Stroke: Role of Balance Self-Efficacy.” Physical Therapy 87 (3): 282–291. doi:10.2522/ptj.20060142.[CrossRef], [PubMed], [Web of Science ®]; Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]; Wood, Connelly, and Maly 2010 Wood, Jennifer P., Denise M. Connelly, and Monica R. Maly. 2010. “‘Getting back to Real Living’: A Qualitative Study of the Process of Community Reintegration after Stroke.” Clinical Rehabilitation 24 (11): 1045–1056. doi:10.1177/0269215510375901.[CrossRef], [PubMed], [Web of Science ®]). A study with 434 stroke survivors interviewed 6 months post stroke found that 39% reported a limitation in self-care (bathing, dressing, grooming and feeding), 20% reported difficulties in walking and negotiating stairs, 54% reported limitations with instrumental activities of daily living (e.g. housework, shopping and preparing a meal) and 65% reported restrictions in reintegration into community activities (e.g. social and recreational activities, moving around the community and having an important activity to fill the day) (Mayo et al. 2002 Mayo, Nancy E., Sharon Wood-Dauphinee, Robert Côté, Liam Durcan, and Joseph Carlton. 2002. “Activity, Participation, and Quality of Life 6 Months Poststroke.” Archives of Physical Medicine and Rehabilitation 83 (8): 1035–1042. doi:10.1053/apmr.2002.33984.[CrossRef], [PubMed], [Web of Science ®], [CSA]). A study with 105 stroke survivors found that, between three and six months post stroke, 83% perceived restrictions in their participation in everyday occupations, defined as activities people need and want to do, such as household chores, work or work-related activities, travel, leisure and social activities (Bergström et al. 2015 Bergström, A. L., L. von Koch, M. Andersson, K. Tham, and G. Eriksson. 2015. “Participation in Everyday Life and Life Satisfaction in Persons with Stroke and Their Caregivers 3–6 Months after Onset.” Journal of Rehabilitation Medicine 47 (6): 508–515. doi: 10.2340/16501977-1964.[CrossRef], [PubMed], [Web of Science ®]).
Suggestive of the status and influence of the medical model of disability (Brandon and Pritchard 2011 Brandon, Toby, and Gary Pritchard. 2011. “‘Being Fat’: A Conceptual Analysis Using Three Models of Disability.” Disability & Society 26 (1): 79–92. doi:10.1080/09687599.2011.529669.[Taylor & Francis Online], [Web of Science ®]; Schuelka 2015 Schuelka, Matthew J. 2015. “The Evolving Construction and Conceptualisation of ‘Disability’ in Bhutan.” Disability & Society 30 (6): 820–833. doi:10.1080/09687599.2015.1052043.[Taylor & Francis Online], [Web of Science ®]), studies have considered the role of various person-related factors in aiding and/or impeding community reintegration including physical function (Carter et al. 2000 Carter, Bob S., Diedre Buckley, Regina Ferraro, Guy Rordorf, and Christopher S. Ogilvy. 2000. “Factors Associated with Reintegration to Normal Living after Subarachnoid Hemorrhage.” Neurosurgery 46 (6): 1326–1334.10.1097/00006123-200006000-00008[CrossRef], [PubMed], [Web of Science ®]; Ostir et al. 2005 Ostir, Glenn V, Pamela M Smith, David Smith, and Kenneth J Ottenbacher. 2005. “Functional Status and Satisfaction with Community Participation in Persons with Stroke following Medical Rehabilitation.” Aging Clinical and Experimental Research 17 (1): 35–41. doi:10.1007/BF03337718.[CrossRef], [PubMed], [Web of Science ®]), mental health (Carter et al. 2000 Carter, Bob S., Diedre Buckley, Regina Ferraro, Guy Rordorf, and Christopher S. Ogilvy. 2000. “Factors Associated with Reintegration to Normal Living after Subarachnoid Hemorrhage.” Neurosurgery 46 (6): 1326–1334.10.1097/00006123-200006000-00008[CrossRef], [PubMed], [Web of Science ®]), cognitive ability (Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]), self-efficacy (Pang, Eng, and Miller 2007 Pang, Marco Y. C., Janice J. Eng, and William C. Miller. 2007. “Determinants of Satisfaction with Community Reintegration in Older Adults with Chronic Stroke: Role of Balance Self-Efficacy.” Physical Therapy 87 (3): 282–291. doi:10.2522/ptj.20060142.[CrossRef], [PubMed], [Web of Science ®]) and self-awareness (Leung and Liu 2011 Leung, Daniel P. K., and Karen P. Y. Liu. 2011. “Review of Self-Awareness and Its Clinical Application in Stroke Rehabilitation.” International Journal of Rehabilitation Research 34 (3): 187–195.10.1097/MRR.0b013e3283487f31[CrossRef], [PubMed], [Web of Science ®]). Certain factors external to the individual, including social and professional support, have also attracted a degree of attention (Chau et al. 2009 Chau, Janita, David Thompson, Sheila Twinn, Anne Chang, and Jean Woo. 2009. “Determinants of Participation Restriction among Community Dwelling Stroke Survivors: A Path Analysis.” BMC Neurology 9 (49). doi: 10.1186/1471-2377-9-49.10.1186/1471-2377-9-49[CrossRef], [PubMed], [Web of Science ®]; Ellis-Hill et al. 2009 Ellis-Hill, C., J. Robison, R. Wiles, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Going Home to Get on with Life: Patients and Carers Experiences of Being Discharged from Hospital following a Stroke.” Disability & Rehabilitation 31 (2): 61–72.10.1080/09638280701775289[Taylor & Francis Online], [Web of Science ®]; Nicholson et al. 2013 Nicholson, Sarah, Falko F. Sniehotta, Frederike van Wijck, Carolyn A. Greig, Marie Johnston, Marion E. T. McMurdo, Martin Dennis, and Gillian E. Mead. 2013. “A Systematic Review of Perceived Barriers and Motivators to Physical Activity after Stroke.” International Journal of Stroke 8 (5): 357–364.10.1111/ijs.2013.8.issue-5[CrossRef], [PubMed], [Web of Science ®]; Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]; Walsh et al. 2014 Walsh, Mary E., Rose Galvin, Cliona Loughnane, Chris Macey, and N. Frances Horgan. 2014. “Factors Associated with Community Reintegration in the First Year after Stroke: A Qualitative Meta-Synthesis.” Disability and Rehabilitation 37 (18): 1–10. doi:10.3109/09638288.2014.974834.[Taylor & Francis Online], [Web of Science ®]). Compared with these factors, the physical environment – defined here as the objective and perceived qualities and characteristics of the physical settings in which individuals spend time (Van Van Cauwenberg et al. 2011 Van Cauwenberg, Jelle, Ilse De De Bourdeaudhuij, Femke De De Meester, Delfien Van Van Dyck, Jo Salmon Salmon, Peter Clarys, and Benedicte Deforche. 2011. “Relationship between the Physical Environment and Physical Activity in Older Adults: A Systematic Review.” Health & Place 17 (2): 458–469. doi:10.1016/j.healthplace.2010.11.010.[CrossRef], [PubMed], [Web of Science ®]) – although pertinent (Lord and Rochester 2005 Lord, Susan E., and Lynn Rochester. 2005. “Measurement of Community Ambulation after Stroke Current Status and Future Developments.” Stroke 36 (7): 1457–1461.10.1161/01.STR.0000170698.20376.2e[CrossRef], [PubMed], [Web of Science ®]), appears critically understudied.
On the relevance of the physical environment, home modifications and equipment have been identified as valuable to stroke survivors (Gustafsson and Bootle 2013 Gustafsson, L., and K. Bootle. 2013. “Client and Carer Experience of Transition Home from Inpatient Stroke Rehabilitation.” Disability and Rehabilitation 35 (16): 1380–1386.10.3109/09638288.2012.740134[Taylor & Francis Online], [Web of Science ®]; Schulz et al. 2012 Schulz, Celia H., Gayle I. Hersch, Jessica L. Foust, Alicia L. Wyatt, Kyler M. Godwin, Salimah Virani, and Sharon K. Ostwald. 2012. “Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment.” Physical & Occupational Therapy in Geriatrics 30 (2): 109–123.10.3109/02703181.2012.687441[Taylor & Francis Online]) whilst returning to the familiar home environment is recognised as a key milestone in recovery and a major source of motivation (Wood, Connelly, and Maly 2010 Wood, Jennifer P., Denise M. Connelly, and Monica R. Maly. 2010. “‘Getting back to Real Living’: A Qualitative Study of the Process of Community Reintegration after Stroke.” Clinical Rehabilitation 24 (11): 1045–1056. doi:10.1177/0269215510375901.[CrossRef], [PubMed], [Web of Science ®]). Studies suggest that stroke survivors view the home as a safe place, an environment in which they feel comfortable and confident (Reed et al. 2012 Reed, Mary Catherine, Victorine Wood, Rachel Harrington, and Jane Paterson. 2012. “Developing Stroke Rehabilitation and Community Services: A Meta-Synthesis of Qualitative Literature.” Disability & Rehabilitation 34 (7): 553–563.10.3109/09638288.2011.613511[Taylor & Francis Online], [Web of Science ®]). However, within the home, narrow doorways, stairs, absent handrails, heavy doors and limited space have been found to complicate movement, with poorly designed baths, showers and toilets impeding washing and personal care (Brookfield et al. 2015 Brookfield, Katherine, Claire Fitzsimons, Iain Scott, Gillian Mead, John Starr, Neil Thin, Anthea Tinker, and Catharine Ward Ward Thompson. 2015. “The Home as Enabler of More Active Lifestyles among Older People.” Building Research & Information 43 (5): 616–630. doi:10.1080/09613218.2015.1045702.[Taylor & Francis Online], [Web of Science ®]; Reid 2004 Reid, Denise. 2004. “Accessibility and Usability of the Physical Housing Environment of Seniors with Stroke.” International Journal of Rehabilitation Research 27 (3): 203–208.10.1097/00004356-200409000-00005[CrossRef], [PubMed], [Web of Science ®]; Schulz et al. 2012 Schulz, Celia H., Gayle I. Hersch, Jessica L. Foust, Alicia L. Wyatt, Kyler M. Godwin, Salimah Virani, and Sharon K. Ostwald. 2012. “Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment.” Physical & Occupational Therapy in Geriatrics 30 (2): 109–123.10.3109/02703181.2012.687441[Taylor & Francis Online]). Outside the home, uneven surfaces and absent handrails have been found to contribute to trips and falls (Reid 2004 Reid, Denise. 2004. “Accessibility and Usability of the Physical Housing Environment of Seniors with Stroke.” International Journal of Rehabilitation Research 27 (3): 203–208.10.1097/00004356-200409000-00005[CrossRef], [PubMed], [Web of Science ®]) and/or a fear of falling (Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]). Either may slow a person’s walking pace (Lennon et al. 2013 Lennon, Olive C., Catherine Doody, Cliodhna Ni Ni Choisdealbh, and Catherine Blake. 2013. “Barriers to Healthy-Lifestyle Participation in Stroke: Consumer Participation in Secondary Prevention Design.” International Journal of Rehabilitation Research 36 (4): 354–361.10.1097/MRR.0b013e3283643d48[CrossRef], [PubMed], [Web of Science ®]) and/or influence an individual’s willingness to go outside (Barnsley, McCluskey, and Middleton 2012 Barnsley, Lara, Annie McCluskey, and Sandy Middleton. 2012. “What People Say about Travelling Outdoors after Their Stroke: A Qualitative Study.” Australian Occupational Therapy Journal 59 (1): 71–78. doi:10.1111/j.1440-1630.2011.00935.x.[CrossRef], [PubMed], [Web of Science ®]; Lennon et al. 2013 Lennon, Olive C., Catherine Doody, Cliodhna Ni Ni Choisdealbh, and Catherine Blake. 2013. “Barriers to Healthy-Lifestyle Participation in Stroke: Consumer Participation in Secondary Prevention Design.” International Journal of Rehabilitation Research 36 (4): 354–361.10.1097/MRR.0b013e3283643d48[CrossRef], [PubMed], [Web of Science ®]; Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]). Indeed, research suggests that stroke survivors can consciously adapt their participation in valued activities in response to perceived/experienced environmental limitations (Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]). Highlighted by several of these examples, where research has considered the physical environment, attention has often focused on how it might frustrate community reintegration.
Taking a different tack, in this study the physical environment was conceived as a potentially positive resource capable of supporting community reintegration by providing settings in which individuals can, perhaps are encouraged to, interact with others and undertake various functional, social and recreational activities. Several factors structured this conceptualisation. First, findings from non-stroke populations which suggest that certain environmental details are associated with participation in the community and everyday activities were noted. For example, proximity to recreational facilities has been linked to participation in recreational physical activity in older adults (Berke et al. 2006 Berke, Ethan M., Ronald T. Ackermann, Elizabeth H. Lin, Paula H. Diehr, Matthew L. Maciejewski, Barbara Williams, Marcia B. Patrick, and James P. LoGerfo. 2006. “Distance as a Barrier to Using a Fitness-Program Benefit for Managed Medicare Enrollees.” Journal of Aging and Physical Activity 14 (3): 313–324.10.1123/japa.14.3.313[CrossRef], [PubMed], [Web of Science ®]) whilst proximity to retail facilities has been linked to recreational walking (Michael et al. 2006 Michael, Y., T. Beard, D. Choi, S. Farquhar, and N. Carlson. 2006. “Measuring the Influence of Built Neighborhood Environments on Walking in Older Adults.” Journal of Aging and Physical Activity 14 (3): 302.10.1123/japa.14.3.302[CrossRef], [PubMed], [Web of Science ®]).
Second, models of disability which, whilst diverse, share the view that the physical environment influences participation and the performance of everyday activities were considered. This included the biopsychosocial model of disability, which views disability as the outcome of an interactive relationship between intrinsic features of the human body and features of the external environment (Bickenbach 2012 Bickenbach, Jerome. 2012. “Ethics, Disability and the International Classification of Functioning, Disability and Health.” American Journal of Physical Medicine & Rehabilitation 91 (13): S163–S167. doi:10.1097/PHM.0b013e31823d5487.[CrossRef], [PubMed], [Web of Science ®], S164–S165), and the social model, which understands disability as a form of social oppression produced by physical, social and economic factors/structures external to the individual (Tregaskis 2002 Tregaskis, Claire. 2002. “Social Model Theory: The Story So Far ….” Disability & Society 17 (4): 457–470. doi:10.1080/09687590220140377.[Taylor & Francis Online], [Web of Science ®], [CSA]).
Third, theories from environmental psychology which suggest that individuals are inclined to ‘approach’ – enter, explore, be satisfied with and interact with others within – ‘pleasing’ environments were considered (De Nisco and Warnaby 2014 De Nisco, Alessandro, and Gary Warnaby. 2014. “Urban Design and Tenant Variety Influences on Consumers’ Emotions and Approach Behavior.” Journal of Business Research 67 (2): 211–217. doi:10.1016/j.jbusres.2012.10.002.[CrossRef], [Web of Science ®]; Donovan et al. 1994 Donovan, Robert J., John R. Rossiter, Gilian Marcoolyn, and Andrew Nesdale. 1994. “Store Atmosphere and Purchasing Behavior.” Journal of Retailing 70 (3): 283–294. doi:10.1016/0022-4359(94)90037-X.[CrossRef], [Web of Science ®]; Mehrabian and Russell 1974 Mehrabian, Albert, and James A. Russell. 1974. An Approach to Environmental Psychology. Cambridge, MA: The MIT Press.[CrossRef]; Vieira 2013 Vieira, Valter Afonso. 2013. “Stimuli–Organism-Response Framework: A Meta-Analytic Review in the Store Environment.” Journal of Business Research 66 (9): 1420–1426. doi:10.1016/j.jbusres.2012.05.009.[CrossRef], [Web of Science ®]). Additionally, research which suggests that stroke survivors limit their contact with environments/environmental factors experienced or perceived as ‘problematic’ was noted (Brookfield et al. 2015 Brookfield, Katherine, Claire Fitzsimons, Iain Scott, Gillian Mead, John Starr, Neil Thin, Anthea Tinker, and Catharine Ward Ward Thompson. 2015. “The Home as Enabler of More Active Lifestyles among Older People.” Building Research & Information 43 (5): 616–630. doi:10.1080/09613218.2015.1045702.[Taylor & Francis Online], [Web of Science ®]; Gustafsson and Bootle 2013 Gustafsson, L., and K. Bootle. 2013. “Client and Carer Experience of Transition Home from Inpatient Stroke Rehabilitation.” Disability and Rehabilitation 35 (16): 1380–1386.10.3109/09638288.2012.740134[Taylor & Francis Online], [Web of Science ®]; Robison et al. 2009 Robison, J., R. Wiles, C. Ellis-Hill, K. McPherson, D. Hyndman, and A. Ashburn. 2009. “Resuming Previously Valued Activities Post-Stroke: Who or What Helps?” Disability and Rehabilitation 31 (19): 1555–1566. doi:10.1080/09638280802639327.[Taylor & Francis Online], [Web of Science ®]).
Lastly, the conceptualisation was influenced by research from Barnsley, McCluskey, and Middleton (2012 Barnsley, Lara, Annie McCluskey, and Sandy Middleton. 2012. “What People Say about Travelling Outdoors after Their Stroke: A Qualitative Study.” Australian Occupational Therapy Journal 59 (1): 71–78. doi:10.1111/j.1440-1630.2011.00935.x.[CrossRef], [PubMed], [Web of Science ®]) which found that stroke survivors with ‘meaningful destinations’, places such as pubs, clubs and shopping centres that individuals wished to visit, were more likely to travel outdoors.
Set against this background, the research aimed to identify the environments/environmental factors enjoyed by persons with experience of stroke, whilst not presupposing that these would differ from those enjoyed by anyone else, in order to tease out qualitative insights into the environment’s role in community reintegration. A deeper understanding of the physical environment’s place in community reintegration may lead to the identification of new and effective ways to support stroke survivors to lead self-directed lives of their choosing in the community.
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