Home and Community Environment

Last Updated

August 10, 2024

Purpose

The HACE is a self-report measure focusing on aspects of the home and community environment which influence community participation. The instrument assesses barriers and facilitators in the patient's environment.

Link to Instrument

Instrument Details

Acronym HACE

Area of Assessment

Activities of Daily Living
Functional Mobility
Social Relationships

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

CDE Status

Not a CDE -- last searched 8/10/2024.

Diagnosis/Conditions

Brain Injury Recovery
Cerebral Palsy
Multiple Sclerosis
Parkinson's Disease & Movement Disorders
Spinal Cord Injury

Osteoarthritis

Older Adults and Geriatric Care

Mixed Populations

Wheelchair Usage

The HACE is composed of 6 Domains.
Home mobility: 9 items assess architectural barriers within the patient's home.
Community mobility: 5 items assess the presence of architectural barriers within the patient's community.
Basic mobility devices: 9 items assess the number of assistive technologies available to the patient.
Communication devices: 4 items assess the number of communication devices available to the patient.
Transportation factors: 5 items assess driving and transportation.
Attitudes: 6 items assess the patient's perceptions of other people's attitudes toward disability.

Number of Items

6-30 minutes

Required Training

No Training

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team; Updated with references for the TBI population by Sue Saliga, PT, DHSc, CEEAA, Anna de Joya, PT, DSc, NCS, and the TBI EDGE task force of the Neurology Section of the APTA in 2012.

Updated on 8/10/2024 by Megan Taketa, Makena Douglas, Natalie Kwortnik, Nika Slade (Master of Occupational Therapy students) and Danbi Lee (Faculty Mentor), PhD, OTD, OTR/L, Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington, Seattle

ICF Domain

Participation
Environment

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	N/A	N/A	N/A	N/A

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	No	No	No	Not reported

Considerations

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Normative Data

Complex medical, orthopedic, & neurologic conditions: (Keysor et al., 2006; n = 342, mean age = 68 (14) years; assessed one month after discharge)

HACE Norms

HACE Domain	Range	Mean (SD)
Home mobility barriers	0 to 9	3.0 (2.1)
Community mobility barriers	0 to 4	0.7 (0.9)
Mobility technology facilitators	0 to 9	3.9 (2.0)
Communication technology facilitators	0 to 4	1.0 (1.0)
Transportation facilitators	0 to 5	3.2 (1.2)
Social support	0 to 100	83 (19)

Neurological conditions: (Heinemann et al., 2016; n = 568; Stroke n = 202; mean age = 56.0 (12.8) years; mean time post stroke = 2.8 (2.5) years; Spinal Cord Injury (SCI) n = 192; mean age = 45.2 (13.9) years; mean time post SCI = 12.2 (10.1) years; Traumatic Brain Injury (TBI) n = 174; mean age = 38.7 (16.8) years; mean time post TBI = 6.1 (5.6) years)

Mean (SD) scores by Home and Community Environment (HACE) Instrument domain

HACE Domain (n)	Mean (SD)
Transportation (568)	3.64 (1.6)
Community (560)	1.13 (0.9)
Negative Attitudes (567)	0.26 (0.6)
Technology Communication (568)	1.83 (0.7)
Technology Mobility (568)	2.35 (2.1)
Home (568)	1.66 (1.8)

Test/Retest Reliability

Complex medical, orthopedic, & neurologic conditions: (Keysor et al, 2006; n = 342; mean age = 68 (14) years; assessed 1 month and 6 months after discharge) –Assessed with Participation Measure for Post Acute Care (PM-PAC)

1 month after discharge: a greater home mobility barriers (P<.01) was associated with less social and home participation; greater community mobility barriers (P<.01) and more social support (P<.001) were associated with greater participation
6 months after discharge, social support was the only environmental factor associated with participation

Internal Consistency

Neurological conditions: (Heinemann, 2016; n = 568)

Adequate internal consistency for the Technology Mobility domain (α = 0.73)
Poor internal consistency for HACE domains:
- Transportation (α = 0.32)
- Community (α = 0.37)
- Negative Attitudes (α = 0.55)
- Technology Communication (α = 0.45)
- Home (α = 0.41)

Construct Validity

Neurological conditions: (Heinemann, 2016; n = 568)

Poor to adequate construct validity between HACE domains and Craig Hospital Inventory of Environmental Factors (CHIEF), Measure of the Quality of the Environment (MQE), and Environmental Factors Item Banks (EFIB)

Correlation coefficients between HACE domains and other environmental measures

HACE Domain	CHIEF	MQE Barrier	MQE Facilitator
HACE Transportation	-.19	.13	-.07
HACE Community	.30^a	-.09	.03
HACE Negative Attitudes	.22^a	-.15	-.04
HACE Technology Communication	.05	.03	.11
HACE Technology Mobility	.28^a	-.27^a	.18^a
HACE Home	-.15	.13	-.15

HACE Domain	EFIB Built and Natural Environment	EFIB Systems, Services, and Policies	EFIB Social Barriers	EFIB Social Facilitators	EFIB Access to Information and Technology
HACE Transportation	-.24	.27^b	.16	.18	.27^b
HACE Community	.28^b	-.32^b	-.15	-.23	-.26^b
HACE Negative Attitudes	.23^b	-.12	-.29^b	-.18	-.18
HACE Technology Communication	-.08	.20	.05	.09	.34^b
HACE Technology Mobility	.48^b	-.08	-.33^b	-.11	-.08
HACE Home	-.21	-.05	.21	.02	-.06

^aCorrelation is significant at p < 0.00065, a group-wise p value of 0.05 using Sidak’s correction.

^bCorrelation is significant at p < 0.00064, a group-wise p value of 0.05 using Sidak’s correction

Content Validity

Two experts examined a prototype version of the HACE to assess its ability to adequately measure important aspects of the patients home and community environments. Revisions were made on the final version of the HACE based on this feedback.

Instrument pilot tested with 62 individuals and items removed based on inadequate response, and Kappa statistics indicating moderate agreement . (Keysor et al, 2005)

Face Validity

During the measure's construction, items with 20% or fewer respondents answering, “don’t know” and having not reached a moderate level of agreement were eliminated from the final version of the HACE.

Test/Retest Reliability

Elderly Adults: (Keysor et al, 2005; n = 62; mean age = 70 (17) years, 85% of the sample recruited from the community, 15% recruited from a rehabilitation facility)

HACE Test retest reliability:
Domain	Items	Median percent agreement (Range)	Median Kappa (range)
Home mobility	9	89% (71–100)	0.66 (0.28–1.0)
Community mobility	5	75% (58–92)	0.47 (0.20–0.64)
Basic mobility devices	9	92% (75–100)	0.65 (0.45–1.0)
Communication devices	4	94% (88–96)	0.79 (0.75–0.83)
Transportation	5	100% (67–100)	1.0 (0.29–1.0)
Attitudes	4	88% (84–95)	0.62 (0.51–0.77)

Construct Validity

Elderly Adults: (Keysor et al, 2005):

Patients living in single or multi-family dwellings reported significantly more obstacles than patients residing in other living situations (See table below)

Home mobility Items	Total Sample Percent (n)	Single or multi-family home Percent (n)	Multi-unit complex dwelling Percent (n)	p
	(n = 62)	(n = 19)	(n = 43)
1 or more obstacle at the main door	48 (30)	100 (19)	100 (19)	<0.001
1 or more obstacle from the main door to main living area	10 (6)	26 (5)	2 (1)	0.009
1 or more obstacle inside main living area barriers	16 (10)	56 (10)	0 (0)	<0.001
1 or more home mobility obstacle (summary score)	48 (30)	100 (19)	26 (11)	<0.001

Normative Data

Older adults with osteoarthritis (OA): (van der Pas et al., 2016; n = 2757 (n = 2130 with lower limb OA (LLOA) present and n = 627 controls without LLOA); mean age = 73.8 (5.6) years (lower limb OA mean age = 74.3 (5.7) years and control mean age = 73.6 (5.6) years); female = 71.1% for LLOA present and 52.4% for LLOA not present)

Percentage of HACE neighborhood resource use by lower limb osteoarthritis status and country*

Use of parks and walking areas

Country	LLOA	No LLOA
Sweden	89.1	95.2
UK	62.3	63.8
The Netherlands	58.8	74.3
Germany	90.3	91.2
Italy	56.1	56.4
Spain	69.0	73.1

Use of places to sit and rest

Country	LLOA	No LLOA
Sweden	46.5	78.3
UK	38.9	60.2
The Netherlands	37.3	46.0
Germany	35.8	69.5
Italy	19.7	11.2
Spain	63.4	82.0

Use of public transportation

Country	LLOA	No LLOA
Sweden	78.3	85.6
UK	60.2	50.6
The Netherlands	46.0	50.2
Germany	69.5	66.5
Italy	11.2	10.4
Spain	82.0	86.3

Use of Car

Country	LLOA	No LLOA
Sweden	58.2	69.8
UK	56.5	71.8
The Netherlands	45.1	66.6
Germany	69.8	80.9
Italy	68.0	74.4
Spain	18.5	42.1

*Bold figures indicate significant difference between groups with and without LLOA within country (p ≤ 0.05).

Older adults with osteoarthritis: (White et al., 2010; n = 436; age ≥ 65; mean age = 70.4 (3.9) years; mean Western Ontario and McMaster’s University Osteoarthritis (WOMAC) Physical Function subscale = 20.3 (10.6))

Percentage of study subjects reporting HACE neighborhood features

Feature	Present (% of 436)	Don’t know (% of 436)
Uneven sidewalks or other walking areas	79	4
No parks and walking areas that are easy to get to and easy to use	12	2
No safe parks or walking areas	12	4
No places to sit and rest at bus stops, in parks, or in other places where people walk	21	8
No curbs with curb cuts	20	5
Public transportation that is close to your home	58	18
Public transportation with adaptations for people who are limited in their daily activities	92	1
Adequate handicap parking	45	5
Have a car available to you at your home	98	0
Able to drive	96	0

Internal Consistency

Osteoarthritis: (Abdelnasser et al.,, 2019; n = 150; age ≥ 60; mean age = 64.89 (6.56) years; female=71.3%; inclusion criteria: disease duration ≥ 1 year and report of “any difficulty” with of at least two of the following: going up stairs, rising from sitting, or bending or squatting to the floor; Arabic translation of HACE)

Adequate internal consistency (Cronbach's alpha = 0.70)

Construct Validity

Osteoarthritis: (Abdelnasser et al., 2019)

Poor to adequate construct validity between HACE and Late-Life Function & Disability Instrument (LLFDI).

Multiple linear regression analysis of environmental factors that affect functional disability levels

Factor	Stand. coeff. Beta	Significance
Home Mobility	0.004	0.947
Community Mobility	0.004	0.946
Social environment	0.154	0.015*
Assistive & mobility devices	-0.003	0.956
Communication devices	-0.383	0.000*
Transportation	0.350	0.000*
Attitude	-0.016	0.801

Normative Data

Wheelchair users: (Sakakibara et al., 2014a, Sakakibara et al., 2014b, & Sakakibara et al., 2015; n = 124; mean age = 59.7 (7.49) years; age range = 50-84 years; male = 74 (59.7%); mean years of experience with wheelchair = 22.31 (16.05) years; inclusion criteria: age ≥ 50 and ≥ 6 months experience with manual wheelchair use)

Mean number of home barriers = 1.10 (1.22)
Mean number of community barriers = 1.06 (0.85)

Construct Validity

Convergent validity:

Wheelchair users: (Sakakibara et al., 2014a)

Poor convergent validity of Home and Community barriers with Participation Frequency as measured by Late-Life Disability Instrument (LLDI) (r = -.05 and -0.13, respectively)

Wheelchair users: (Sakakibara et al., 2014b)

Poor convergent validity of Home and Community barriers with Life-space Mobility as measured by the Life-Space Assessment (r = -.07 and -0.10, respectively)

Wheelchair users: (Sakakibara et al., 2015)

Poor convergent validity of Home and Community barriers with Wheelchair-Use Confidence as measured by the Wheelchair Use Confidence Scale (WheelCon) (r = 0.06 and -0.14, respectively)

Bibliography

Abdelnasser, N. O. E., Moneim, S. A., & Fouad, R. A. (2019). The relationship between environmental factors and health-related functional disability of older adults with osteoarthritis. International Scientific Meeting on Public Health and Sports, 26(30), 2468-5739. httLavalley, M. P., ps://doi.org/10.2991/ahsr.k.201203.005

Heinemann, A.W., Miskovic, A., Semik, P., Wong, A., Dashner, J., Baum, C., Magasi, S., Hammel, J., Tulsky, D.S., Garcia, S.F., Jerousek, S., Lai, J.S., Carlozzi, N.E. & Gray, D.B. (2016). Measuring environmental factors: Unique and overlapping International Classification of Functioning, disability and health coverage of 5 instruments. Archives of Physical Medicine and Rehabilitation, 97(12), 2113-2122. https://doi.org/10.1016/j.apmr.2016.05.021

Keysor, J., Jette, A., et al. (2005). "Development of the home and community environment (HACE) instrument." J Rehabil Med 37(1): 37-44. Find it on PubMed

Keysor, J. J., Jette, A. M., et al. (2006). "Association of environmental factors with levels of home and community participation in an adult rehabilitation cohort." Arch Phys Med Rehabil 87(12): 1566-1575. Find it on PubMed

Sakakibara, B. M., Miller, W. C., Routhier, F., Backman, C. L., & Eng, J. J. (2014a). Association between self-efficacy and participation in community-dwelling manual wheelchair users aged 50 years or older. Physical Therapy, 94(5), 664-674. https://doi.org/10.2522/ptj.20130308

Sakakibara, B. M., Miller, W. C., Eng, J. J., Backman, C. L., & Routhier, F. (2014b). Influences of wheelchair-related efficacy on life-space mobility in adults who use a wheelchair and live in the community. Physical Therapy, 94(11), 1604-1613. https://doi.org/10.2522/ptj.20140113

Sakakibara, B. M., Miller, W. C., Eng, J. J., Routhier, F., & Backman, C. L. (2015). Health, personal, and environmental predictors of wheelchair-use confidence in adult wheelchair users. Physical Therapy, 95(10), 1365-1373. https://doi.org/10.2522/ptj.201405137

Van der Pas, S., Schaap, L. A., Castell, M.V., Cooper, C., Denkinger, M., Edwards, M. H., Herbolsheimer, F., Maggi, S., Sanchez-Martinez, M., Pedersen, N. L., Peter, R., Zambon, S., Wiegersma, S. B., Dekker, J., Dennison, E. M., & Deeg, D. J. (2016). Availability and use of neighborhood resources by older people with osteoarthritis: Results from the European Project on Osteoarthritis. Health & Place, 37, 1-7. http://doi.org/10.1016/j.healthplace.2015.10.006

White, D. K., Jette, A. M., Felson, D. T., Lavalley, M. P., Lewis, C. E., Torner, J. C., Nevitt, M. C., & Keysor, J. J. (2010). Are features of the neighborhood environment associated with disability in older adults? Disability and Rehabilitation, 32(8), 639-645. https://doi.org/10.3109/09638280903254547

Last Updated

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

CDE Status

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Normative Data

Test/Retest Reliability

Internal Consistency

Construct Validity

Content Validity

Face Validity

Test/Retest Reliability

Construct Validity

Normative Data

Internal Consistency

Construct Validity

Normative Data

Construct Validity

Bibliography

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