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RehabMeasures Instrument

Craig Hospital Inventory of Environmental Factors

Last Updated

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. 

Acronym CHIEF/ CHIEF-SF

Area of Assessment

Activities of Daily Living
Patient Satisfaction
Quality of Life

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Brain Injury
  • Cardiac Dysfunction
  • Cerebral Palsy
  • Multiple Sclerosis
  • Parkinson's Disease + Neurologic Rehabilitation
  • Spinal Cord Injury

Key Descriptions

  • Assesses the overall impact of environmental barriers across 5 domains.
  • Calculated by both the frequency and the degree of problem encountered.
  • Domains assessed include:
    1) Accessibility
    2) Accommodation
    3) Resource availability
    4) Social support
    5) 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).
    1) Frequency: frequency with which barriers are encountered
    2) Magnitude: indicates the size of the problem the barrier presents
    3) 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:
    1) Items that had the highest frequency of barrier mean scores
    2) Items that had the highest magnitude of barrier mean scores
    3) Items that had the highest item score-subscale score correlations
    4) Items that were the most frequently reported barriers
    5) Items that best differentiated between people with and without disability
    6) Items were also kept if the authors conceptually felt they should be included in the scale

Number of Items

25
Short form: 12

Time to Administer

5-10 minutes

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

Required Training

Reading an Article/Manual

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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.

ICF Domain

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

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!

Mixed Populations

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Normative Data

Community Dwelling Elderly Adults With and Without Stoke: (Han et al, 2005; = 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).

 

 

 

 

 

Test/Retest Reliability

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)

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

Construct Validity

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).

Brain Injury

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Test/Retest Reliability

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)

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

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

Spinal Injuries

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Normative Data

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)

 

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 2ndCHIEF 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)

Interrater/Intrarater Reliability

Participant/Proxy Agreement:

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

  • Adequate participant proxy agreement (ICC= 0.62)

Non-Specific Patient Population

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Construct Validity

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.”

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

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