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Rehab Measures: Craig Hospital Inventory of Environmental Factors

Link to instrument

Information Available in the Craig Hospital Website 

Title of Assessment

Craig Hospital Inventory of Environmental Factors  

Acronym

CHIEF/ CHIEF-SF

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team; Updated with references from the SCI population by Candy Tefertiller PT, DPT, NCS, Jennifer Kahn PT, DPT, NCS and the SCI EDGE task force of the Neurology section of the APTA in 2012; Updated with references from 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.

Summary Date

1/18/2013 

Purpose

To assess the degree to which elements of the physical, social, and political environments act as barriers or facilitators to full participation for people with disabilities. 

Description

  • Assesses the overall impact of environmental barriers across 5 domains
  • Calculated by both the frequency and the degree of problem encountered
  • Domains assessed include:
    • Accessibility
    • Accommodation
    • Resource availability
    • Social support
    • Equality
  • CHIEF: Scores are calculated by multiplying each of the 25 items with the frequency score (range:0 to 4 ) by magnitude (range: 1 to 2) to yield a an overall “impact” score (range: 0-8)
    • Frequency: frequency with which barriers are encountered
    • Magnitude: indicates the size of the problem the barrier presents
    • Frequency magnitude product: Product of frequency X magnitude to determine overall impact of the barrier
  • CHIEF-SF: 12 item version developed from original CHIEF maintains all 5 subscales. It is composed of those items with the highest scores, indicating greater barriers, highest correlations with subscale and total scores, greatest conceptual clarity and discriminant validity(differentiating between those with and without disability); Scores are calculated as stated for the CHIEF using only 12 items within the original 5 subscles instead of 25 items. The following criteria were utilized to determine which items of the CHIEF long form should be retained for inclusion in the CHIEF-SF:
    • Items that had the highest frequency of barrier mean scores
    • Items that had the highest magnitude of barrier mean scores
    • Items that had the highest item score-subscale score correlations
    • Items that were the most frequently reported barriers
    • Items that best differentiated between people with and without disability
    • Items were also kept if the authors conceptually felt they should be included in the scale

Area of Assessment

Activities of Daily Living; Patient Satisfaction; Quality of Life 

Body Part

Not Applicable 

ICF Domain

Environment 

Domain

ADL 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

CHIEF - 10 minutes; CHIEF-SF - 5 minutes; Add 5 minutes to each test if administered by interview

Number of Items

CHIEF: 25 items across 5 domains; CHIEF-SF: 12 items across 5 domains 

Equipment Required

None

Training Required

None.  The CHIEF Manual can be found here

Type of training required

No Training; Reading an Article/Manual 

Cost

Free 

Actual Cost

Free

Age Range

Adolescent: 13-17 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Acquired Brain Injury; Arthritis; Cardiac Conditions; Cerebral Palsy; Geriatrics; Hip fracture; Knee Dysfunction; Lower Limb Amputation; Movement Disorders; Multiple Sclerosis; Parkinson’s Disease; Peripheral Neuropathy; Spinal Cord Injury; Stroke; Traumatic Brain Injury 

Populations Tested

  • Stroke
  • Cerebral Palsy
  • Spinal Cord Injury
  • Traumatic Brain Injury
  • Multiple Sclerosis
  • Amputee Population

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Community Dwelling Elderly Adults With and Without Stoke: (Han et al, 2005; n = 400; mean age = 71.5 (5.03); mean Barthel Index score for participants with stroke = 19.9 (0.099) points; Barthel Index score for participants without stroke = 16.5 (3.93) South Korean Sample)
  • Mean total scores (Korean language sample) = 13.0 (14.77)

Chronic and Acute SCI: (Kennedy et al, 2009; n = 80, 10% complete tetraplegia, 29% incomplete tetraplegia; 21% complete paraplegia, 29% incomplete paraplegia; mean age = 50.37 (range = 18 to 81) years) 

Results suggested that environmental barriers did not seem to have a large impact on activities (for this sample)

Mean scores (SD) by domain:

  • Attitudes and Support = 0.51 (1.14)
  • Services and Assistance = 1.44 (1.85)
  • Physical and Structural = 2.24 (2.27)
  • Policies = 0.86 (1.76)
  • Work and School = 0.18 (0.56)

Children and Youth with Physical Disabilities: (Law et al, 2007; n = 427; aged 6 to 14 years; 50.8% with CP or related disorder)

  • 3 age cohorts: 6-8; 9-11; 12-14 yo
    • Children aged 12 to 14 experienced significantly more barriers than children in other cohorts

CHIEF Norms for Children with Disabilities:
Domain
Total
6 to 8 years
9 to 11 years
12 to 14 years
Services and assistance*
1.02 (1.20)
0.86 (1.14)
0.97 (1.14)
1.25 (1.32)
Attitudes*
0.88 (1.18)
0.65 (1.04)
0.83 (1.14)
1.16 (1.30)
School and work*
1.55 (1.88)
1.31 (1.67)
1.47 (1.66)
1.90 (2.30)
Natural and built environment
1.31 (1.35)
1.11 (1.30)
1.25 (1.28)
1.59 (1.46)
Policies*
1.24 (1.71)
1.08 (1.64)
1.18 (1.60)
1.48 (1.90)
Values = Mean (SD)
*Significant means for the 12 to 14 group in comparison with all groups (p<.05).
†Significant means for the 12 to 14 group in comparison with 6 to 8 year olds (p<.001).


Chronic SCI: (Whitemeck, Meade et al, 2004; n = 2762 participants enrolled in the Model Spinal Cord Injury Systems (MSCIS) program; CHIEF 12 item Short Form used)

Mean CHIEF-SF Score by AIS Grade:
Group
n % (n = 2686) 
CHIEF Total
Physical & Structural
Services & Assistance
Work & School*
Attitudinal & Support
Policy
C1-4 ABC
13%
.90
1.22
0.95
.43
.64
.86
C5-8 ABC
25%
.78
1.16
0.80
.25
.58
.71
Para ABC
41%
.76
1.07
0.80
.26
.56
.67
AIS D
20%

.63

1.09
0.65
.21
.39
.50

Test-retest Reliability

Spinal Cord Injury : (Whiteneck, Harrison-Felix, et al, 2004 n=409 with 103 of the total 409 receiving 2nd CHIEF 2 weeks after initial assessment; n=125 participants family/friends completed CHIEF as proxy )

  • Excellent test-retest reliability total CHIEF (ICC = 0.93)
  • Excellent sub-scale test reliability ( ICC range = 0.77-.89)

SCI and TBI : (Quoted from Whiteneck, Meade, et al, 2004; n = 103; 2 weeks between assessments)

  • Excellent CHIEF total score test-retest reliability (ICC > 0.90)
  • Excellent sub-scale test-retest reliability (ICC's ranged from 0.77 to 0.89)

Multiple Diagnosis (Spinal Cord Injury, Traumatic Brain Injury, Multiple Sclerosis, Amputee, Cerebral Palsy, Auditory/Visual impairments, Developmental Disabilities): (Whiteneck, Harrison-Felix, et al, 2004; n=125 (SCI=46; TBI=54; Others=25); 2 weeks between assessments; CHIEF long form was used in this study)

  • Subject-Proxy Agreement (family members/friends of the 125 participants: Adequate total score test retest reliability (ICC=.62)

Interrater/Intrarater Reliability

Participant/Proxy Agreement:

Spinal Cord Injury : (Whiteneck, Harrison-Felix, et al, 2004 n=409 with 103 of the total 409 receiving 2nd CHIEF 2 weeks after initial assessment; n=125 participants family/friends completed CHIEF as proxy )

  • Adequate participant proxy agreement (ICC= 0.62)

Internal Consistency

SCI, TBI, MS, Amputation, or "other" impairment: (Whiteneck, Harrison-Felix et al, 2004; 2 samples n = 97 (50 with disabilities and 40 without disabilities), n= 409 with disabilities; mean age = 44)
 
Internal Consistency (Cronbach's alpha)
Scale:
Strength
alpha
Total scale
Excellent
0.93
Physical and structural barriers subscale
Adequate
0.77
Policy barriers subscale
Adequate
0.77
Work and school barriers subscale
Excellent
0.81
Attitude and support barriers subscale
Adequate
0.79
Services and assistance barriers subscale
Adequate
0.76

Criterion Validity (Predictive/Concurrent)

Chronic TBI: (Whiteneck et al, 2004; n = 73; Discharge FIM Physical sub-scale = 83.5 (11.0), Cognitive Sub-scale = 27.9 (4.32) points)
 
CHIEF Total and sub-scale scores with other 1-year outcomes
1-year outcomes
Total CHIEF
Physical barriers
Attitudes and barriers
Services and assistance
Policies
Work / School
Life satisfaction (SWLS)
−0.39*
−0.40*
−0.30*
−0.23
−0.27*
−0.16
total CHART
−0.38*
−0.18
−0.33*
−0.29*
−0.20
−0.29
Cognitive independence
−0.26*

−0.10

−0.29*
−0.30*
−0.17
−0.12
Physical independence
−0.11
−0.04
−0.25*
−0.13
−0.07
--
Mobility
−0.33*
−0.33*
−0.28*
−0.28*
−0.28*
−0.18
Social integration
−0.16
−0.16
−0.26*
−0.13
−0.20
−0.16
Occupation/productive
−0.37*
−0.29*
−0.30*
−0.35*
−0.23*
−0.33*
Economic self-sufficiency

−0.16

−0.02

−0.18

−0.09

−0.12

−0.10

*p < .05 using the Spearman’s rho correlation.
r < = Poor
r .31 to .59 = Adequate
r > .6 = Excellent
SWLS = Satisfaction with Life Scale
CHART = Craig Handicap Assessment and Reporting Technique

Construct Validity (Convergent/Discriminant)

Chronic TBI: (Whiteneck, Gerhart, et al, 2004; n = 73; mean age at injury: 16-30 years old= 44, 31-45 years old=19, 46-60 years old=10; gender=55, male; CHIEF long form was used in this study)

Discharge FIM Physical sub-scale = 83.5 (11.0), Cognitive Sub-scale = 27.9 (4.32) points)

CHIEF Total and sub-scale scores with other 1-year outcomes

1-year outcomes

Total CHIEF

Physical barriers

Attitudes and barriers

Services and assistance

Policies

Work / School

Life satisfaction (SWLS)

−0.39*

−0.40*

−0.30*

−0.23

−0.27*

−0.16

total CHART

−0.38*

−0.18

−0.33*

−0.29*

−0.20

−0.29

Cognitive independence

−0.26*

−0.10

−0.29*

−0.30*

−0.17

−0.12

Physical independence

−0.11

−0.04

−0.25*

−0.13

−0.07

--

Mobility

−0.33*

−0.33*

−0.28*

−0.28*

−0.28*

−0.18

Social integration

−0.16

−0.16

−0.26*

−0.13

−0.20

−0.16

Occupation/productive

−0.37*

−0.29*

−0.30*

−0.35*

−0.23*

−0.33*

Economic self-sufficiency

−0.16

−0.02

−0.18

−0.09

−0.12

−0.10

*p < .05 using the Spearman’s rho correlation.

r < = Poor
r .31 to .59 = Adequate
r > .6 = Excellent

SWLS = Satisfaction with Life Scale
CHART = Craig Handicap Assessment and Reporting Technique

Chronic TBI : (Whiteneck, Gerhart, et al, 2004; n=73; mean age at injury: 16-30 years old= 44, 31-45 years old=19, 46-60 years old=10; gender=55, male; CHIEF long form was used in this study)

Mean product scores for CHIEF and FIM

FIM Sub-scale

Total Score Strength

Total CHIEF

Physical Barriers

Attitudes and Support

Services and Assistance

Politics

Work / School

Physical independence items ≥ 6*

Adequate

0.44

0.51

0.40

0.43

0.44

0.26**

Physical independence items not ≥ 6

Excellent

0.76

0.93

0.72

0.69

0.82

0.55**

Cognitive independence items ≥ 6*

Poor

0.28**

0.41

0.23

0.31

0.27**

0.13

Cognitive independence items not ≥ 6

Excellent

0.69**

0.80

0.54

0.58

0.61**

0.37

**p < .05 Mann-Whitney Test for 2 groups; Kruskal-Wallis Test for more than 2 groups

*indicating independence without assistance from others

Pearson Correlations of CHIEF and other 1 year outcomes

1-year outcomes

Total CHIEF

Physical barriers

Attitudes and barriers

Services and assistance

Policies

Work-School

Life Satisfaction (SWLS total score)

-0.39†

-0.40†

-0.30†

-0.23

-0.27†

-0.16

Handicap/lack of social participation (total CHART)

-0.38†

-0.18

-0.33†

-0.29†

-0.20

-0.29

Cognitive Independence (CHART subscale)

-0.26†

-0.10

-0.29†

-0.30†

-0.17

-0.12

Physical Independence (CHART subscale)

-0.11

-0.04

-0.25†

-0.13

-0.07

Mobility (CHART subscale)

-0.33†

-0.33†

-0.28†

-0.28†

-0.28†

-0.18

Social Integration (CHART subscale)

-0.16

-0.16

-0.26†

-0.13

-0.20

-0.16

Occupation/productive capacity (CHART subscale)

-0.37

-0.29†

-0.30†

-0.35†

-0.23†

-0.33†

Economic self-sufficiency (CHART subscale)

-0.16†

-0.02

-0.18

-0.09

-0.12

-0.10

P < .05 using the Spearma n’s rho correlation; ‡Correlation not calculated

Population based sample (in Colorado): ( Whiteneck, Harrison-Felix et al., 2004 (n=2269; (mean age=44; gender=57% male; with and without disabilities)

  • Initial principle components factor analysis of the CHIEF’s 25 item product scores: 6 factors with eigenvalues over 1.0.
  • After varimax rotation, the 5-factor solution (accounting for 48% of the cumulative variance) was far more interpretable.
  • The 5 factors formed logical constructs, which were labeled “attitude and support barriers,” “services and assistance barriers,” “physical and structural barriers,” “policy barriers,” and “work and school barriers.”

Discriminant Validity

Multiple Diagnosis: (Whiteneck, Harrison-Felix, et al, 2004; n=409 (SCI=124; TBI=120; Multiple Sclerosis=55; Amputees=35; Auditory/Visual Impairments, developmental disabilities, cerebral palsy, multiple impairments=75 )

  • All CHIEF items, all subscales, and the total score produced statistically significant differences across the impairment groups
  • People with disabilities consistently reported an overall higher level of environmental barriers on all subscales and the total CHIEF score
  • People with severe disabilities in the disability sample (eg, those with SCI, TBI) generally scored higher on subscales and the total score than the full range of people reporting any disability in the BRFSS sample
  • People with TBI scored lower on physical barriers than those in the other 2 major disability groups (SCI, other diagnoses)
  • People with SCI reported more barriers related to personal equipment, but attitudes in the home were more problematic for people with TBI

Multiple Diagnosis and population-based sample: (Whiteneck, Harrison-Felix, et al, 2004; n=409 (SCI=124; TBI=120; Multiple Sclerosis=55; Amputees=35; Auditory/Visual Impairments, developmental disabilities, cerebral palsy, multiple impairments=75; BRFSS sample=2269; development of the CHIEF-SF )

  • Correlations between CHIEF subscales and total score from the long form and short form ranged from .794 to .960
  • Mean score findings are consistent with the CHIEF long form findings

Content Validity

Spinal Cord Injury, Traumatic Brain Injury, MS, amputation or “other” impairment : (Whiteneck, Harrison-Felix, et al, 2004; n = 97 (50 with disabilities and 40 without disabilities), 409 = with disabilities; mean age = 44)

  • All CHIEF items, all subscales, and the total score produced statistically significant differences across the impairment groups
  • People with disabilities consistently reported an overall higher level of environmental barriers on all subscales and total CHIEF score than those without disabilities
  • People with severe disabilities generally scored higher on subsclaes and the total score than the full range of people reporting any disability.

Content validity was demonstrated through the consensus of 4 Subject Matter Experts (SME's) charged. The SME panel created 4 instruments that largely overlapped with each other. These instruments were then synthesized into a single measure (see Whiteneck et al, 2004 for more information).

Face Validity

Not Statistically Assessed

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

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 (VEDGE) 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

NR

NR

NR

LS

LS

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

R

R

 

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)

SCI EDGE

No

No

No

Not reported

TBI EDGE

No

Yes

Yes

Not reported

Considerations

The CHIEF-SF (Short Form) is composed of 12 items

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

Bibliography

Han, C. W., Yajima, Y., et al. (2005). "Validity and utility of the Craig Hospital Inventory of Environmental Factors for Korean community-dwelling elderly with or without stroke." Tohoku J Exp Med 206(1): 41-49. Find it on PubMed

Kennedy, P., Sherlock, O., et al. (2009). "A multi-centre study of the community needs of people with spinal cord injuries: the first 18 months." Spinal cord 48(1): 15-20.

Law, M., Petrenchik, T., et al. (2007). "Perceived environmental barriers to recreational, community, and school participation for children and youth with physical disabilities." Arch Phys Med Rehabil 88(12): 1636-1642. Find it on PubMed

Whiteneck, G., Meade, M. A., et al. (2004). "Environmental factors and their role in participation and life satisfaction after spinal cord injury." Arch Phys Med Rehabil 85(11): 1793-1803. Find it on PubMed

Whiteneck, G. G., Gerhart, K. A., et al. (2004). "Identifying environmental factors that influence the outcomes of people with traumatic brain injury." J Head Trauma Rehabil 19(3): 191-204. Find it on PubMed

Whiteneck, G. G., Harrison-Felix, C. L., et al. (2004). "Quantifying environmental factors: a measure of physical, attitudinal, service, productivity, and policy barriers." Archives of physical medicine and rehabilitation 85(8): 1324-1335. Find it on PubMed

Year published

1999 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
CHIEF Manual.pdf    
CHIEF.pdf    
Created at 4/5/2011 12:48 PM  by Jason Raad 
Last modified at 9/3/2014 10:07 AM  by Jason Raad