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Strategy training is a rehabilitation intervention that aims to enhance problem-solving skills with respect to daily activity–related challenges and has achieved favorable results in Western countries. This study explored the perspectives of individuals with acquired brain injury (ABI) in Taiwan who received strategy training. Semi-structured interviews with community-dwelling adults with ABI were conducted, and reflective memos made by research team members were recorded. Interviews and memos were analyzed through thematic analysis This study included 55 participants. The analysis of the participants’ interview responses and memos yielded nine themes under three categories: 1) expectations regarding strategy training, 2) perceived benefits of strategy training, and 3) barriers affecting the process and outcomes of strategy training. All the participants endorsed strategy training through different gains. Most participants’ expectations before the intervention were uncertain. Including family members into the strategy training is of key importance for a successfulness of their goals. The participants’ experiences about strategy training were affected by various barriers (i.e., health and medical problems, the physical environment, and natural events). Clinicians and researchers should consider these expectations, benefits, and barriers when studying and implementing strategy training in non-Western contexts.IMPLICATIONS FOR REHABILITATIONStrategy training provides clients the opportunity to actively engage in their own goal setting and decision making.Strategy training increases the client’s confidence in their ability to participate in the community, communicate, and perform daily living and physical activities.Therapists should consider the health conditions and physical environment of clients when helping them set goals and before facilitating their engagement in the community.Taiwanese family members play a crucial role in supporting acquired brain injury survivors in strategy training. Strategy training provides clients the opportunity to actively engage in their own goal setting and decision making. Strategy training increases the client’s confidence in their ability to participate in the community, communicate, and perform daily living and physical activities. Therapists should consider the health conditions and physical environment of clients when helping them set goals and before facilitating their engagement in the community. Taiwanese family members play a crucial role in supporting acquired brain injury survivors in strategy training.

Background and Objectives With a growing aging stroke population and the changing structure of the society, the demand for foreign caregivers has rapidly increased in Taiwan and many other developed countries. However, little is known regarding the perception, values, and abilities of foreign caregivers and how those may influence their quality of care. This study aimed to explore and describe the experiences of Indonesian foreign caregivers, the largest migrant working population in Taiwan, who reside with and provide support to older adults with stroke and their families. Research Design and Methods By adopting a descriptive qualitative approach, we conducted semistructured interviews with 22 Indonesian caregivers (mean age: 36 years) who were providing care to community-dwelling older stroke survivors (age ≥ 65 years) in Taiwan. Data were analyzed through thematic analysis. Results Six themes were constructed from the interviews: (a) foreign caregiver’s background, (b) foreign caregiver’s perception of the health and functional status of stroke survivors, (c) foreign caregiver’s values and preferences, (d) consequences of caring for stroke survivors, (e) skills/abilities/knowledge of foreign caregivers to provide stroke survivors with required care, and (f) potential resources that foreign caregivers can use. Discussion and Implications Foreign caregivers described the positive and negative aspects of caring for stroke survivors. Differences in language, religion, culture, values, and expectations between foreign caregivers and stroke survivors influence the caregiving experience. These findings can help Taiwan and other developed countries to better support foreign caregivers providing critical care to older adults with stroke and their families.

Strategy training is a promising stroke rehabilitation intervention commonly delivered in Western countries. We examined the perspectives of rehabilitation therapists who have delivered strategy training in Taiwan and the United States to understand the influence of culture on strategy training implementation.In this rapid ethnographic study, the maximum variation sampling approach was used to recruit seven therapists in Taiwan and seven therapists in the United States with experience delivering strategy training. Data was collected from multiple sources, including interviews, study documents, therapist notes, and reflective memos. Interviews with the recruited therapists in Taiwan and the United States were conducted in Mandarin and English, respectively. Data were analyzed using a constant comparative approach.The following two themes were generated: (1) differences between conventional rehabilitation and strategy training, namely that conventional rehabilitation is therapist-directed and emphasizes impairment reduction, whereas strategy training empowers clients and focuses on real-life generalization, and (2) challenges in implementing strategy training in practice, including difficulty in achieving client buy-in and disengagement.Therapists from both countries shared similar perspectives on the perceived advantages of strategy training, such as enhancing client empowerment and engagement, and the generalization of strategies. Family involvement was more prominently discussed by therapists in Taiwan than by those in the United States.IMPLICATIONS FOR REHABILITATIONStrategy training differs from conventional rehabilitation in its emphasis on clients' life participation and empowerment, generalization of strategies, and enhancement of their engagement, confidence, and problem-solving skills.Therapists may face challenges related to client buy-in and disengagement as well as difficulties in establishing a therapeutic rapport at the beginning of strategy training because clients have different expectations from those of conventional rehabilitation.Cultural differences in norms and expectations and the clinical experiences of therapists may influence the delivery of strategy training to clients.Family support may influence the success of strategy training.Thoughtful conversations to reach a mutual understanding regarding the expectations of strategy training among clients, family, and rehabilitation practitioners are necessary prior to implementing strategy training.

Objective: To investigate the effect of force applied during massage on relieving nonspecific low back pain (LBP). Methods: This single-blinded, randomized controlled trial enrolled 56 female patients with nonspecific LBP at a single medical center. For each participant, the therapist performed a 30 min massage session (20 min general massage and 10 min focal massage) using a special instrument with a force sensor inserted, for a total of six sessions in 3 weeks. During the 10 min focal massage, HF and LF groups received high force (HF, ≥2 kg) and low force (LF, ≤1 kg) massage, respectively. The primary outcome was pain intensity (i.e., visual analog scale (VAS), 0–10), and secondary outcomes comprised pain pressure threshold, trunk mobility, LBP-associated disability, and quality of life. Results: No significant between-group differences were observed in baseline characteristics. The HF group exhibited significantly lower VAS than did the LF group, with a mean difference of −1.33 points (95% CI: −2.17 to −0.5) at the end of the intervention, but no significant difference was noted at the end of the follow-up. A significant time effect (p < 0.05) was detected in all secondary outcomes except the pain pressure threshold and trunk mobility. A significant time × group interaction (p < 0.05) was found only for the VAS and pain pressure threshold. Conclusions: Compared with LF massage, HF massage exerted superior effects on pain relief in female patients with nonspecific LBP at the end of intervention. Applying different levels of force showed no effects on LBP-associated disabilities and quality of life.

Objective To determine whether dextrose prolotherapy offers clinical benefits in patients with shoulder pain and bursitis. Design Double-blinded, randomized controlled trial. Setting Outpatient rehabilitation department of a single medical center. Participants Patients (N=50) who had received a diagnosis of shoulder pain and bursitis through clinical tests and ultrasound examination. Interventions Participants were randomly assigned to the 15% dextrose injection (D15W) group or the placebo group to receive either D15W or normal saline injection, respectively. All participants received ultrasound-guidance bursal injection every 2 weeks for a total of 3 injections. Main Outcome Measures The primary outcome was maximal pain level while performing activities. The secondary outcomes included resting pain level, function and disability assessment results, and ultrasonographic parameters. Participants were followed up for 3 months after completion of the injection course. Results No significant differences in baseline characteristics were observed between the D15W and placebo groups. Significant time effects were observed for all outcome parameters (all P Conclusions Supporting evidence is insufficient regarding the clinical benefits of 15% dextrose bursal injection administered through 3 sessions in patients with chronic shoulder pain and bursitis. The findings indicate that these injections may increase the tissue stiffness of the supraspinatus tendon, as indicated by elastography assessment results, but further research is required to determine the nature of such changes in elastography findings.

Community participation is an indicator of recovery for younger adults after stroke who generally have a greater need to return to society than do older adults. However, little is known about the trends of participation and their determinants in this population.To explore the trends of community participation by younger (65 years) adults with stroke in Taiwan after their hospital discharge and to identify predictors of these trends.This longitudinal, multicenter, prospective cohort study enrolled 570 relatively young adults (aged 20-65 years) with stroke. Participants were assessed at hospital discharge and at 3-, 6-, and 12-month follow-up. The primary outcome measure was the Participation Measure-3 Domains, 4 Dimensions (PM-3D4D). Sociodemographic and stroke-related variables were derived by using standardized instruments and questionnaires. Mixed models were used to derive the trends of each participation domain and to identify predictors.PM-3D4D score changes showed a positive trend from discharge to 1-year follow-up (particularly in social and community subscales); however, the improvement was mild and mainly occurred in the first 3 months. Sociodemographic factors, such as income and education levels, and stroke-related variables, such as stroke severity, comorbidity, and physical function, significantly predicted changes in PM-3D4D scores over time. Physical function demonstrated the strongest prediction ability for all participation domains and dimensions.Multiple sociodemographic and stroke-related variables, particularly physical function, predicted improvement in community participation by younger adults after stroke. These findings may help clinicians identify younger adults at risk of unfavorable long-term participation outcomes after stroke.

Background Family caregivers of patients on prolonged mechanical ventilation (PMV) may encounter challenges concerning medical decision-making besides witnessing patient suffering. Palliative care (PC) should be a good support for both patients and caregivers; however, for PMV families, PC is not always a choice through long companion time. This qualitative study clarifies family caregivers' burden of assisting patients on PMV and evaluates the need for PC information and support. Methods Interviews were caregivers of patients on ventilator support for more than 60 days in five hospitals of the Taipei City Hospital System. Based on phenomenology, this study was conducted by using a semistructured questionnaire comprising three questions: (I) what was the most crucial moment of deciding to intubate? (II) how would you describe the quality of life of your ventilator-dependent family member? (III) what type of assistance do you expect from the PC team for your ventilator-dependent family member? Results Twenty-one caregivers of patients on PMV in five hospitals of the Taipei City Hospital System agreed to participate in face-to-face interviews. The identified themes, including stressful decision-making, companion pain/discomfort, and unwillingness to accept PC, elucidated the difficulties experienced by caregivers when providing care. Conclusions Understanding family caregivers' experiences can enable physicians to improve communication with them, encourage the PC team to support them during surrogate decision-making for patients on PMV during critical moments, and enhance the overall PC service.

Purpose: To develop a tablet-based participation measure and to evaluate its reliability and acceptability to an older Chinese population in rehabilitation settings.Method: A multidimensional, self...

IntroductionStroke can lead to life-long disability and constitutes a huge financial burden on the family and society. Stroke survivors with cognitive impairment often experience considerable challenges in the process of recovery and returning to society. Interventions that effectively help individuals resume essential daily activities and return to active participation in their communities are lacking. This study examines the efficacy of a newly-developed intervention programme, the Optimising Participation after Stroke through Strategy-training (OPASS) programme, for improving community participation among stroke survivors with cognitive impairment.Methods and analysisA single-blind, parallel-group randomised controlled trial with allocation concealment and assessor blinding will be implemented to assess the efficacy of the OPASS programme. An expected 210 adults with cognitive impairment following stroke will be randomly assigned to either the experimental intervention (OPASS) group or the attention control group. In addition to their usual rehabilitation, both groups will receive 45 min sessions, twice weekly for a total of 12–15 sessions. The primary outcome is change in participation performance, which will be measured using the participation measure—three domains, four dimensions scale. Additional measures include the Activity Measure for Post-Acute Care generic outpatient short forms, Montreal Cognitive Assessment, Stroop Test, Trail Making Test and General Self-Efficacy Scale. These scales will be administered at baseline, post-intervention, 3-month follow-up, 6-month follow-up and 12-month follow-up. Their results will be analysed using multiple linear regression models and mixed-effects regression models. Further assessment of feasibility and acceptability of the intervention will be conducted through structured interviews with participants, caregivers and therapists. These interviews will be transcribed and thematically analysed.Ethics and disseminationEthics approval was obtained from the Ethics Committee of Taipei Medical University (approval number: N201804055). The findings will be disseminated through presentations at scientific conferences and through publication in peer-reviewed journals.Trial registration numberNCT03792061; pre-results.

Objective To identify predictors of admission to post-acute inpatient rehabilitation settings follow-ing acute care for stroke survivors in Taiwan. Design Prospective observation study. Participants Stroke survivors (n = 558) admitted to acute care wards for inpatient rehabilitation (62% male; mean age 60.0 ± 12.2 years). Methods The primary outcome was whether survivors were admitted to post-acute inpatient rehabilitation settings after discharge from acute care wards. Logistic regression model was adopted to examine the predictors of admission to post-acute inpatient rehabilitation. A receiver operating characteristic curve was drawn to compute the ability of the predictors to discriminate the outcome. Results Multivariate analysis results indicated Activity Measure Post-Acute Care "6-Clicks" Basic Mobility score to be the only significant predictor of admission to post-acute inpatient rehabilitation (odds ratio = 0.44, 95% confidence interval: 0.34-0.56). Receiver operating characteristic curve analysis results indicated that the cut-off point for Basic Mobility was 13 (standardized score: 33.99). This yielded a sensitivity value of 0.98 and a specificity value of 0.96 for determining the admission to post-acute inpatient rehabilitation. Conclusion Activity Measure Post-Acute Care "6-Clicks" Basic Mobility subscale scores at admission for acute care can predict admission to post-acute inpatient rehabilitation for stroke survivors in Taiwan. This tool can aid clinicians in formulating adequate discharge plans at an early stage, and thus improve the quality of care.

Importance: Before introducing strategy training into a cross-cultural (Chinese) context, it is necessary to evaluate its feasibility. Objective: To examine the feasibility of applying strategy training to improve participation outcomes of rehabilitation patients in Taiwan and evaluate the potential intervention effects. Design: A single-group, repeated-measures study. Setting: Rehabilitation outpatient settings. Participants: A convenience sample of adults (N = 20) with a primary diagnosis of acquired brain injury (ABI) and with cognitive impairment received the intervention and were assessed before and after it. Intervention: The participation-focused strategy training intervention, a modified version of the strategy training intervention, was provided to participants in 1–2 sessions weekly for a total of 10–20 intervention sessions. Outcomes and Measures: Feasibility indicators, Participation Measure–3 Domains, 4 Dimensions (PM–3D4D), and Canadian Occupational Performance Measure (COPM). Results: Eighteen participants completed 100% of the scheduled intervention sessions. Participants had very good engagement in the intervention sessions with sufficient comprehension. Participants reported moderate to high satisfaction. Positive score changes were observed for the PM–3D4D (d = 0.46–1.25) and COPM scales (d = 1.82 and 2.12). Conclusions and Relevance: This study demonstrated the feasibility of delivering participation-focused strategy training in Taiwan to people with cognitive impairment after ABI. The preliminary evidence also showed that participants who received the strategy training intervention had positive changes in participation outcomes and in performance of their self-identified goals. On the basis of this study’s findings, a larger clinical trial is warranted to evaluate the efficacy of the strategy training intervention. What This Article Adds: Participation-focused strategy training is feasible and acceptable for Taiwanese community-dwelling adults with cognitive impairment after ABI. However, because strategy training is quite different from traditional rehabilitation delivered in Taiwan, additional instructions and discussion among the therapist, client, and caregiver may be needed before the intervention is provided.

Importance: A standardized functional measure that can be used across rehabilitation care settings in Taiwan is urgently needed. Objective: To generate a Mandarin version of the Activity Measure for Post-Acute Care (AM–PAC) “6-Clicks” for patients in acute care. Design: Mixed-methods study with a cross-sectional design. Setting: Acute care wards of three teaching hospitals in Taiwan. Participants: A sample of 231 neurological patients in acute care (62.3% female; mean age = 63.2 yr, standard deviation = 14.6). Outcomes and Measures: The 6-Clicks consist of three subscales: Basic Mobility, Daily Activity, and Applied Cognition. They were translated into Mandarin, and their internal consistency, test–retest reliability, interrater reliability, and convergent validity were tested. Results: All subscales of the Mandarin version of the 6-Clicks showed good internal consistency (α = .97–.98). Test–retest and interrater reliabilities were excellent for all subscales (intraclass correlation coefficients >.8). Convergent validity was supported by strong correlations of the Basic Mobility and Daily Activity subscales with the Barthel Index (r = .73 and .72, respectively) and between the Applied Cognition subscale and the Montreal Cognitive Assessment (r = .82). Conclusion: Our results provide psychometric evidence supporting the use of the Mandarin version of the 6-Clicks in acute care settings in Taiwan. What This Article Adds: This study confirms the appropriateness of the use of the Mandarin version of the AM–PAC “6-Clicks” with patients in acute rehabilitation, making it a valuable addition to validated measures available for use by occupational therapists in Taiwan.

To learn about the experiences of stroke recovery among young stroke survivors in Taiwan and to elucidate the beliefs, goals, and facilitators of and barriers to their recovery. A qualitative approach was used for data collection, and data were obtained from five focus groups consisting of stroke survivors aged 20–64 years (n = 25). Data were transcribed verbatim and analyzed thematically by two independent coders using NVivo version 10. “Returning to prestroke status” was a common belief of recovery for stroke survivors; their goals of recovery changed overtime from regaining physical functions, independent living, and participating in work and leisure activities to maintaining functions or returning to normality. Their perceived personal and environmental facilitators of recovery included positive attitude, family and friends, and rehabilitation, whereas barriers to recovery included psychological factors, social stigma, and physical environment. These findings provide useful insights for rehabilitation clinicians to develop culturally tailored interventions to improve poststroke recovery outcomes in young stroke survivors.Implications for rehabilitationRehabilitation clinicians should understand stroke survivors’ beliefs and goals of recovery to provide tailored services.Optimizing the goal-setting process and patient–provider communication may help clinicians and survivors examine and adjust their expectations toward recovery during rehabilitation.Interventions will be needed to address personal and environmental supports and barriers, such as motivation, psychological factors, social support, and the physical environment to help survivors achieve their recovery goals. Rehabilitation clinicians should understand stroke survivors’ beliefs and goals of recovery to provide tailored services. Optimizing the goal-setting process and patient–provider communication may help clinicians and survivors examine and adjust their expectations toward recovery during rehabilitation. Interventions will be needed to address personal and environmental supports and barriers, such as motivation, psychological factors, social support, and the physical environment to help survivors achieve their recovery goals.

Purpose Since the vocational outcomes of people with schizophrenia should be viewed in a holistic way, the second edition of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) might provide an evaluation regarding employment potential. To determine whether the WHODAS 2.0 scores can be used to predict employment status, we examined the probabilistic cut-off values of the scores and analyzed the relationship between work status and demographic characteristics. Methods We selected 31,793 people aged between 18 and 65 with schizophrenia or schizoaffective disorder from the disability evaluation database in Taiwan and separated them into two groups based on employment status (employed and unemployed). We used logistic regression to explore the association between employment and demographic characteristics. Moreover, we conducted a receiver operating characteristic (ROC) analysis to determine the cut-off point to assist in determining employment potential based on the WHODAS 2.0 score. Results Among the 31,793 participants, 3367 were employed and 18,801 were unemployed. The unemployed participants accounted for a higher percentage of disability in each domain of the WHODAS. The ROC analysis revealed that the optimal cut-off point of the WHODAS score to distinguish the people who were employed and unemployed was 25.78 (area under curve = 0.80). Conclusions The present study indicated that work status can be determined by the total score across the six domains of the WHODAS score. Furthermore, the probability of employment may be determined initially by the cut-off point of the WHODAS score in order to economize evaluation time and prepare prevocational training for those with scores above 25.78.

To explore the perceptions and attitudes among people with disabilities towards the newly implemented International Classification of Functioning, Disability and Health-based disability evaluation system (the new system) in Taiwan.Using a self-administered questionnaire, we conducted a nationwide survey. The questionnaire focused on the domains of quality, satisfaction, and revision of the new system. In total, 1073 persons (age, ≥18 years) with disabilities or their primary caregivers, who experienced both the old and the new system, responded to the questionnaire.Most participants were satisfied with the new system overall (58.7%) and the subscale of quality of structure (91.3%) and quality of outcome (63.6%). However, only 20.5% of the participants were favourable to the quality of process. The probability of being satisfied with the system overall was low for the quality of process subscale (adjusted odds ratio range, 0.3 ∼ 0.4) and its item of long interval (0.2 ∼ 0.6). Contrariwise, the probability was high for the other subscales (3.9 ∼ 13.7) and the item of identifying needs (21.9 ∼ 23.4).Persons with disabilities and their primary caregivers have positive attitudes towards the new system. It is important to simplify the assessment tools and procedures to improve the system's quality of process and facilitate its usability. IMPLICATIONS FOR REHABILITATION Persons with disabilities have positive attitudes towards the newly implemented International Classification of Functioning, Disability, and Health-based disability evaluation system in Taiwan. The system that provides comprehensive information about functioning and disability of persons with disabilities is able to capture the difficulties and needs of those individuals in their daily lives. The system hence helps people to mitigate the effects of disability and guide rehabilitation. The assessment items and processes of the system, however, were perceived to be complicated, time-consuming, and inconvenient. Simplifying the assessment items and processes, such as developing a short form version of the assessment tool and increasing the service time, may facilitate the usability of the system.

Objective To examine the construct validity of the Participation Measure–3 Domains, 4 Dimensions (PM-3D4D), a multidimensional participation measure developed for use in rehabilitation practice. Design Cross-sectional study. Setting Outpatient rehabilitation programs. Participants Rehabilitation patients (N=556; mean age, 61.4±23.6y; 47.1% women). Interventions Not applicable. Main Outcome Measures The PM-3D4D is a 19-item measure designed to evaluate participation in 3 domains—Productivity, Social, and Community—across 4 dimensions—Diversity, Frequency, Desire for change, and Difficulty. Intercorrelations among the 4 dimensions of the PM-3D4D and correlations between the PM-3D4D and 3 legacy instruments—Participation Assessment with Recombined Tools-Objective, Participation Measure for Post-Acute Care, and Satisfaction With Life Scale—were examined to establish the convergent and divergent validity of the PM-3D4D. Known-group validity was evaluated by comparing PM-3D4D scores across age groups and groups of people classified by functional level. Results The Diversity scale of the PM-3D4D was strongly correlated with the Frequency scale (Spearman correlation coefficient, r s =.83–.96 across the 3 domains), and these 2 scales showed moderate to strong correlations with the Difficulty scale ( r s =.42–.70) but weak ( r s =−.4 to 0) and insignificant correlations with the Desire for change scale. The Frequency and Difficulty scales of the PM-3D4D showed moderate to strong correlations with the Participation Assessment with Recombined Tools-Objective and Participation Measure for Post-Acute Care ( r s =.41–.82), respectively, and the Desire for change scale had weak correlations with the Satisfaction With Life Scale ( r s =−.32 to −.18). Significant differences in PM-3D4D scores were found by age and functional level. Conclusions Findings of this study support the construct validity of the PM-3D4D, providing evidence for using the PM-3D4D to assess rehabilitation patients' participation performance and helping practitioners identify intervention priorities to improve patients' participation outcomes.

Research Objectives To compare the perspectives of clients and therapists regarding the expectations for, benefits of, and factors influencing the implementation of strategy training for adults with cognitive impairment in Asian countries. Design Qualitative analysis of data collected via semi-structured interviews. Setting Rehabilitation outpatient settings. Participants Forty-six participants (mean age 55.78 years; 30 males) and their strategy training therapists (N=12) participated in semi-structured interviews. Interventions Participation-focused strategy training were provided 2 sessions per week for a total of 12 to 15 sessions, from trained therapists to the clients. Main Outcome Measures Interviews were audio recorded, transcribed verbatim, coded, and synthesized. Results Expectations, benefits and challenges toward strategy training varied between clients and therapists’ perspectives. While most of the clients did not have specific expectations before the training, the therapists expected strategy training to enhance clients’ functional abilities and participation. While the clients described that strategy training successfully enhanced their strategy planning and functional abilities, the therapists particularly acknowledged the effectiveness of strategy training for increasing clients’ self-confidence. Clients found physical impairments and therapists’ support are the strong factors influencing the training effect; therapists found clients’ personality played a substantial role in the training. Both clients and therapists agreed that family support was a key factor in the successful implementation of strategy training. Conclusions While clients and therapists had different expectations toward strategy training, both groups identified benefits of this training approach, particularly when incorporating family support. Further discussion of strategies to address factors that may influence the effectiveness of strategy training is warranted, including ways to better understand clients’ physical and psychological status, leverage encouragement, and involve family members in the training process. Author(s) Disclosures All the authors declare that no conflicts of interest exist.

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. We examined similarities and differences in cultural values, beliefs, and experiences between OTs in Taiwan and the United States with respect to the delivery of a strategy-training intervention approach to stroke survivors. Findings of this study increase understanding of the distinctions between strategy training and traditional rehabilitation practice and highlight the potential factors that may affect the delivery of strategy training to stroke survivors in different cultural contexts. Primary Author and Speaker: Feng-Hang Chang Contributing Authors: Jessica Kersey, Chao-Yi Wu, Minmei Shih, Beth Fields, and Elizabeth Skidmore

To identify environmental factors associated with participation and gain an in-depth understanding of relationships between environmental factors and participation among people with spinal cord injury.Six focus groups (n= 30) with individuals with spinal cord injury were conducted. Two independent coders thematically analyzed the transcribed data.Twenty environmental factors were identified, all of which were classified into eight categories: built environment; natural environment; assistive technology; transportation; information and technology access; economics; social support and social attitudes; and systems, services and policies. While all factors had direct impacts on individuals' participation outcomes, factors within the categories of societal attitudes, policies and economics also affected participation through affecting other environmental factors. Some factors together also showed cumulative or countering effects on participation. Accordingly, a conceptual model of the relationships between environmental factors and participation was constructed.This study highlighted key environmental factors and their impacts on participation of people with spinal cord injury. The findings support previous research findings but also suggest that different factors may have different levels of impact on participation. Based on our findings, rehabilitation practitioners and policymakers can prioritize intervention plans to optimize the environment for people with spinal cord injury and improve their societal participation. Implications for rehabilitation Environmental factors are critical contributors to participation among people with spinal cord injury (SCI) and need to be addressed in rehabilitation programs. Factors with broader impacts on participation, such as societal attitudes and policies, should be treated as priorities in intervention plans aimed at improving participation among people with SCI. Rehabilitation practitioners should not only consider how the community supports people with SCI but also consider how rehabilitation programs change the community.

Objectives To describe the development of a participation measure that assesses 3 domains (productivity, social, and community) and 4 dimensions (frequency, diversity, desire for change, and perceived difficulty) of participation and to evaluate the initial psychometric properties in rehabilitation outpatients. Design A mixed-method approach included a literature review, item selection, expert reviews, cognitive interviews, and field testing with rehabilitation outpatients. Confirmatory factor analysis (CFA) and Rasch analysis were used to validate the construct validity of the difficulty dimension of the instrument. Setting Outpatient rehabilitation programs. Participants An expert panel consisting of 12 rehabilitation and measurement experts contributed to measurement development; 20 rehabilitation outpatients participated in cognitive interviews; and a sample of rehabilitation outpatients (N=556) (average age, 61.36±23.62y; 53% men) participated in field testing. Interventions Not applicable. Main Outcome Measure The Participation Measure–3 Domains, 4 Dimensions (PM-3D4D). Results A scoring method for each dimension of the PM-3D4D was established. The instrument displayed good overall model fit in the CFA and unidimensionality across 3 domains after removing and collapsing locally dependent items identified from a principal component analysis. However, considering the poor personal reliability of the social subscale and its high correlation with the community subscale, we decided to merge the 2 subscales into 1. The combined subscale showed improved reliability and good construct validity by demonstrating a good model fit (comparative fit index, .985; Tucker-Lewis Index, .982, root mean square error of approximation, .061) and item fit. Conclusions The PM-3D4D is a newly developed participation measure designed to assess multiple domains and dimensions of participation by rehabilitation patients. The psychometric analysis results supported the construct of the instrument and helped item revision. Further examination of the validity and reliability of the PM-3D4D will be conducted.

Objectives To examine the responsiveness and predictive validity of the Participation Measure–3 Domains, 4 Dimensions (PM-3D4D) in people receiving outpatient rehabilitation following stroke. Design Prospective cohort observational study. Setting Outpatient rehabilitation settings. Participants Volunteer patients (N=269) with stroke (mean age ± SD [y], 55.36±12.46; 70.26% male). Interventions Not applicable. Main Outcome Measures The PM-3D4D was designed to measure 3 domains (Productivity, Social, and Community) and 4 dimensions (Diversity, Frequency, Desire for change, and Difficulty) of participation in individuals with rehabilitation needs. All participants completed the PM-3D4D, the Participation Assessment with Recombined Tools-Objective (PART-O), the Participation Measure for Post-Acute Care (PM-PAC), and the EuroQol-5-Dimension (EQ-5D) at the baseline assessment and again following 3 months of outpatient rehabilitation. Results Significant mean changes in scores were observed for most of the PM-3D4D subscales, with the largest score change observed in the Difficulty subscale (standardized response mean=0.57∼0.88). The minimal detectable change and meaningful clinically important differences were calculated for each subscale. The Frequency and Difficulty dimensions of the PM-3D4D demonstrated significantly greater responsiveness than the PART-O and PM-PAC, respectively. The baseline PM-3D4D scores, except for Desire for change subscales, were significantly correlated with the PART-O, PM-PAC, and EQ-5D scores after 3 months of rehabilitation. Conclusions This study provides evidence supporting the responsiveness and predictive validity of the PM-3D4D in survivors of stroke. Among all subscales of the PM-3D4D, the Difficulty dimensional scale demonstrated the greatest responsiveness. The Desire for change dimension of the PM-3D4D showed less responsiveness, and we recommend that it be used as a goal-setting tool rather than an outcome measure. The PM-3D4D can potentially be used to predict participation outcomes and the health-related quality of life following rehabilitation interventions.

To analyse the disability status of elderly Taiwanese dementia patients by using the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0).We enrolled 12 126 disabled elderly (65 years) patients with dementia during July 2012-January 2014 from the Taiwan Data Bank of Persons with Disability. Trained interviewers evaluated the standardised scores in the six WHODAS 2.0 domains. Student's t test was used for comparing WHODAS 2.0 scores of male and female dementia patients with different age groups.The study population comprised 12 126 patients; 7612 were women and 4514 were men. The WHODAS 2.0 scores showed that the dementia patients had global activity limitation and participation restriction in all domains. Dementia-induced disability was prominent in male patients in all of the domains of the WHODAS 2.0. The domains of life activities, getting along with people and cognition were more strongly affected than the other domains. However, women experienced more rapid functional decline than men did as they aged.The data analysed in this large-scale, population-based study revealed crucial information on dementia-induced disability in elderly patients on the basis of the WHODAS 2.0 framework. Implications for rehabilitation Dementia patients have global functional disability in all domains of WHODAS 2.0 and multidisciplinary team is needed for rehabilitation programme intervention for these patients. When considering the rehabilitation resource and strategy, the domains of cognition, activities of daily living and life activities should be focussed. When dementia patients aged 65-75 years old, male patients got more restriction of function than female and more medical resource allocation for disabled male patients is recommended. With ageing, female dementia patients exhibited more rapid functional decline than male patients did and more budget about rehabilitation for maintain functional and dementia progression is crucial for female patients.

Date Presented 03/28/20 We developed a tablet-based participation measure and compared its reliability, concordance, and acceptability to older adults in outpatient rehabilitation settings with the paper-form version. Findings of this study provide supportive evidence for administering a tablet-based participation measure to older populations in rehabilitation settings and suggest a promising measurement methodology for future OT practice. Primary Author and Speaker: Feng-Hang Chang Contributing Authors: Yu Su, Zong-Liang Tseng

Date Presented 03/27/20 We explored the experiences of clients and their therapists using strategy training in outpatient settings in Taiwan with qualitative data to understand the benefits and challenges that they perceived during the intervention. Findings of this study support the use of strategy training in individuals with chronic stroke and brain injury and indicate potential challenges that OTs may encounter as delivering strategy training to clients in outpatient settings in Taiwan. Primary Author and Speaker: Feng-Hang Chang Additional Authors and Speakers: Chao-Yi Wu, Elizabeth Skidmore Contributing Authors: Wan-Chi Lin, Yi-Hsuan Wu, Pei-Chun Yeh, Yen-Nung Lin

Purpose: The purpose of this study was to investigate the cultural and semantic equivalence of the Activity Measure Post-Acute Care (AM-PAC) outpatient short forms after they were translated from American English to Mandarin Chinese. Method: This study was conducted with a composite sample of a group of 483 American adults (mean age 63.1 years, 42.4% males) and 553 Taiwanese adults (mean age 60.6 years, 47.2% males) who were undergoing home care or outpatient rehabilitation services. A confirmatory factor analysis tested the cultural equivalence of the AM-PAC dimensions between the US and Taiwanese samples. Semantic equivalence was tested through an item response theory-based differential item functioning (DFI) analysis. Results: Results of the confirmatory factor analysis demonstrated good model-data fit of the AM-PAC in both the US and Taiwanese samples. Significant DFI was found for six Basic Mobility items, two Daily Activity items, and four Applied Cognition items. A DFI adjusted conversion table was generated to transform the raw scores of the measure for comparisons between the two countries. Conclusions: This study provides evidence to support the conceptual equivalence of the AM-PAC when used in rehabilitation patients between American and Taiwanese cultural contexts. Some DFI items between the two groups were found, suggesting that some differences in semantic understanding of these items between cultures require cross-cultural adjustments.Implications for RehabilitationCultural equivalence needs to be tested before applying a clinical measure to another context.The findings of this study supported the three activity domains that the Activity Measure Post-Acute Care measures: Basic Mobility, Daily Activity, and Applied Cognition, which are all important rehabilitation outcomes that need to be assessed and monitored across rehabilitation settings.Differential item functioning was observed between the English and Chinese versions of the Activity Measure Post-Acute Care, indicating that linguistic and cultural differences across countries need to be adjusted for before using the translated measure in clinical practice. Cultural equivalence needs to be tested before applying a clinical measure to another context. The findings of this study supported the three activity domains that the Activity Measure Post-Acute Care measures: Basic Mobility, Daily Activity, and Applied Cognition, which are all important rehabilitation outcomes that need to be assessed and monitored across rehabilitation settings. Differential item functioning was observed between the English and Chinese versions of the Activity Measure Post-Acute Care, indicating that linguistic and cultural differences across countries need to be adjusted for before using the translated measure in clinical practice.

The aims of this study were to (1) construct a multidimensional measure of participation (the Community Participation Domains Measure (CPDM)) based on a conceptual model of participation and (2) test the construct validity of the CPDM in adults with serious mental illnesses (SMI).The sample consisted of 235 adults with SMI who completed the Temple University Community Participation Measure (TUCP), Community Participation Indicators (CPIs), Colorado Symptom Index (CSI), along with other scales. A conceptual model, descriptive analysis and expert reviews were employed to select a subset of items to include in the measure. Confirmatory factor analysis (CFA) and Rasch analysis were used to test the item and model fit for each scale.Based on the conceptual model, the items of the CPDM were divided into three domains: Productive Activities, Social Participation and Recreation/Leisure. This 3-factor model showed good model-fit (CFI = 0.940, TLI = 0.933, RMSEA = 0.048) in CFA and good item-fit in Rasch analysis.The CPDM is a validated measure that can be used to assess levels of participation in adults with SMI.Participation is an important goal and rehabilitation outcome indicator for individuals with serious mental illnesses (SMI). Participation is a multidimensional concept, which includes three distinct domains: Productive Activities, Social Participation and Community Activities. The Community Participation Domains Measure (CPDM) is a valid measure that can be used to assess the multidimensional construct of participation in adults with SMI.

Objectives To develop an interactive voice response (IVR) version of the Late-Life Function and Disability Instrument Computer Adaptive Test (LLFDI-CAT) and to evaluate its reliability and acceptability in older adults. Design The IVR system was embedded within the LLFDI-CAT program. To test the test–retest reliability and concordance of the IVR version of LLFDI-CAT with the telephone interviewer form (TIF), participants received the two versions of the LLFDI at baseline and at 1-week follow-up. Setting Community. Participants Community-dwelling adults aged 65 and older (N = 50). Measurements The LLFDI is a self-reported outcome measure developed to assess function and disability in older adults. Results The IVR version of the LLFDI-CAT showed acceptable overall test–retest reliability (intraclass correlation coefficient (ICC) = 0.79–0.80) and concordance (ICC = 0.74–0.97) with the TIF. Although most participants preferred the TIF, the majority did not find the IVR version more difficult to use. Conclusion The IVR version of the LLFDI-CAT achieved reliability levels that were comparable with those of the TIF version. Future work is needed to improve the IVR design to better fit older adults’ needs and preferences.

The definition of disability had been unclear until the International Classification of Functioning, Disability, and Health was promulgated in 2001 by the World Health Organization (WHO). Disability is a critical but relatively neglected public-health concern. We conducted this study to measure disabilities by using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) and identify the factors that contribute to disabilities. We obtained and analyzed the data on people who applied to Taiwan’s disability registration system between September 2012 and August 2013. A total of 158,174 cases were selected for this study. Among the people included in this study, 53% were male, and the females were on average 3 years older than the males. More males than females were of a low socioeconomic status, but the rate of employment was higher among the males than among the females. Age, sex, place of residence, and types and severity of impairment were all determined to be factors that independently contributed to disability. This study has demonstrated that disability can be measured and compared using WHODAS 2.0. Increasing the public-health attention devoted to disability and identifying the factors associated with disability can promote independence and social participation in people with disabilities.

The aims of this study were to translate and adapt the Activity Measure Post-Acute Care (AM-PAC) from US English to Mandarin using the dual-panel method, and to assess its psychometric properties in an outpatient rehabilitation setting.The AM-PAC outpatient short forms were translated using the dual-panel method. The translated AM-PAC was tested in 550 Chinese-speaking rehabilitation outpatients. Floor and ceiling effects were evaluated and internal consistency was assessed using Cronbach's alpha. Spearman correlation was used to assess the concurrent validity of the AM-PAC with the Barthel Index and the Mini-Mental State Examination. Test-retest reliability was determined by administering the AM-PAC twice to 57 participants within a 2-7 day interval.Some ceiling effects (20%) were observed in the Applied Cognition subscale. All subscales exhibited good internal consistency (α 0.70). Supportive evidence for concurrent validity was found in strong correlations between Basic Mobility subscale and Barthel Index (r = 0.68), and Daily Activity subscale and Barthel Index (r = 0.70); and moderate correlations between Applied Cognition subscale and Mini-Mental State Examination (r = 0.50). Test-retest reliability for all subscales was high (intraclass correlation coefficient =0.89-0.98).The dual-panel approach was successfully used to translate the AM-PAC from English to Mandarin. Adequate reliability and validity in rehabilitation outpatients in Taiwan were established. Implications for Rehabilitation The dual-panel method is a modern translation technique, which was successfully used to adapt the Activity Measure Post-Acute Care from English to Mandarin. The Mandarin version of Activity Measure Post-Acute Care demonstrates adequate internal consistency, concurrent validity, and test-retest reliability in rehabilitation outpatients. The Activity Measure Post-Acute Care is superior to existing functional measures used to monitor activity performance for rehabilitation patients in Taiwan.

Objective The Quality of Life after Brain Injury (QOLIBRI), a cross-cultural instrument, has been validated in several languages; however, traditional psychometric approaches have critical limitations. Therefore, we applied the Rasch model for validating the 37-item QOLIBRI scale among a Chinese population with traumatic brain injury. Participants and setting In total, 587 participants (mean age: 44.2 ± 15.4 years; women, 46.3%) were surveyed in neurosurgery departments at 6 hospitals in Taipei, Taiwan. Main outcome measure The QOLIBRI. Results Of the 6 subscales of the QOLIBRI, 4 (cognition, self, daily life and autonomy, and social relationships) were unidimensional, valid, and reliable, whereas the remaining 2 (emotions and physical problems) exhibited poor unidimensionality, item and person reliability, and person-item targeting. Five items (energy, concentrating, getting out and about, sex life, and achievements) showed considerable differential item functioning among age groups, disability levels, and time since traumatic brain injury. Conclusion According to item response theory, we identified psychometric issues in the emotions and physical problems subscales of the QOLIBRI as well as several differential item functioning items. Future research is required to determine whether similar results are observed in other language versions of the QOLIBRI or in other countries.

The intent of this study was to examine and compare the ability to detect change of two patient reported outcome (PRO) instruments that use a computerized adaptive test (CAT) approach to measurement. The Patient Reported Outcomes Measurement Information System (PROMIS®) Physical Function scale is a generic PRO, while the Osteoarthritis Computerized Adaptive Test (OA-CAT) is an osteoarthritis-specific PRO. This descriptive, longitudinal study was conducted in a community setting, involving individuals from the greater Boston area. Inclusion criteria: age > 50, self-reported doctor-diagnosed knee osteoarthritis (OA) and knee pain. The PROMIS® Physical Function CAT and OA-CAT Functional Difficulty scale were administered at baseline and at the conclusion of a 6-week exercise program. Effect sizes (ES) were calculated for both measures, and bootstrap methods were used to construct confidence intervals and to test for significant ES differences between the measures. The OA-CAT Functional Difficulty scale achieved an ES of 0.62 (0.43, 0.87) compared to the PROMIS® Physical Function CAT ES of 0.42 (0.24, 0.63). ES estimates for the two CAT measures were not statistically different. The condition-specific OA-CAT and generic PROMIS® Physical Function CAT both demonstrated the ability to detect change in function. While the OA-CAT scale showed larger effect size, no statistically significant difference was found in the effect size estimates for the generic and condition-specific CATs. Both CATs have potential for use in arthritis research. This trial is registered with ClinicalTrials.gov on 6/21/11 (Identifier NCT01394874 )

This study aimed to examine the ability of different domains of activity limitation to predict discharge destination (home vs. nonhome settings) 1 mo after hospital discharge for postacute rehabilitation patients.A secondary analysis was conducted using a data set of 518 adults with neurologic, lower extremity orthopedic, and complex medical conditions followed after discharge from a hospital into postacute care. Variables collected at baseline include activity limitations (basic mobility, daily activity, and applied cognitive function, measured by the Activity Measure for Post-Acute Care), demographics, diagnosis, and cognitive status. The discharge destination was recorded at 1 mo after being discharged from the hospital.Correlational analyses revealed that the 1-mo discharge destination was correlated with two domains of activity (basic mobility and daily activity) and cognitive status. However, multiple logistic regression and receiver operating characteristic curve analyses showed that basic mobility functioning performed the best in discriminating home vs. nonhome living.This study supported the evidence that basic mobility functioning is a critical determinant of discharge home for postacute rehabilitation patients. The Activity Measure for Post-Acute Care-basic mobility showed good usability in discriminating home vs. nonhome living. The findings shed light on the importance of basic mobility functioning in the discharge planning process.

Objective To evaluate the test-retest reliability and the concordance between the interviewer-administered version and the self-administered version of a newly developed participation measure, Participation Measure–3 Domains, 4 Dimensions (PM-3D4D). Design Multicenter observational study. Setting Outpatient rehabilitation programs. Participants Rehabilitation outpatients (N=262) participated in the study, including those (n=202) who participated in the test-retest study and those (n=60) who participated in the 2 modes of the administration study. Interventions Not applicable. Main Outcome Measures The PM-3D4D includes 19 items measuring participation in productivity, social, and community domains across 4 dimensions: diversity of participation, frequency of participation, desire for change, and difficulty in participation. Results The test-retest reliability was good across domains and dimensions (intraclass correlation coefficients, .76–.96) as well as in neurological and nonneurological groups. The test-retest reliability was also mostly good at the item level. A high concordance was found between the 2 administration modes (intraclass correlation coefficients, 0.96–1.00). Conclusions The study results lend support to the use of the PM-3D4D to reliably assess participation of rehabilitation patients. The high concordance between the 2 administration modes suggests the potential use of the instrument in population-based research.

Patients with traumatic brain injury (TBI) often present with disabilities associated with a high burden of care for caregivers or family members at home. When family members cannot afford to care for patients with TBI, they are often required to find them residence in long-term care institutions. To date, there are no quantitative assessment tools developed to predict institutionalization. Therefore, this study analyzed the accuracy of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for predicting the institutionalization of patients with TBI. We designed a cross-sectional study using a nationwide disability database. We analyzed the data of 8630 patients with TBI with injury for more than six months from the Taiwan Data Bank of Persons with Disability during July 2012&ndash, October 2018. The demographic data and WHODAS 2.0 standardized scores of patients with TBI who resided in community and long-term care institutions were analyzed. Receiver operating characteristic curve (ROC) analysis was performed to investigate the predictive accuracy of WHODAS 2.0 for being institutionalized, and the optimal cut-off point was determined using the Youden index. Binary logistic regression was employed to determine the predictors of the participants being institutionalized. The WHODAS 2.0 scores in each domain were lower in the community group than in the institutionalized group. ROC analysis revealed the highest accuracy for the summary scores of WHODAS 2.0 (area under the curve = 0.769). Binary logistic regression revealed that age, gender, work status, urbanization level, socioeconomic status, severity of impairment, and WHODAS 2.0 domain scores were factors associated with the institutionalization status of patients with TBI. Our results suggest that WHODAS 2.0 may be a feasible assessment tool for predicting the institutionalization of patients with TBI.

The Practical Skills Test (PST) is a new assessment of individuals’ knowledge of life skills. We evaluated the PST’s reliability, validity, and sensitivity to change among a homeless population. Participants were 123 homeless persons in a longitudinal experimental study who were assessed before and after intervention with the PST, Allen Cognitive Level Screen–2000 (ACLS–2000), and Impact of Event Scale–Revised (IES–R). The PST showed generally good internal consistency, no floor effects, and limited ceiling effects (

Chang F-H, Wang Y-H, Jang Y, Wang C-W. Factors associated with quality of life among people with spinal cord injury: application of the International Classification of Functioning, Disability and Health Model. Objective To identify the factors that influence an individual's quality of life (QOL) after spinal cord injury (SCI) based on the International Classification of Functioning, Disability and Health (ICF) framework. Design Cross-sectional exploratory study. Setting Taiwan community. Participants Community-dwelling adults (N=341) who had suffered an SCI at least 1 year previously and were between the ages of 18 and 60 years. Interventions Not applicable. Main Outcome Measure(s) A combination of self-report questionnaire and interview. The dependent variable, QOL, was measured by the abbreviated version of the World Health Organization Quality of Life, while the independent variables—participation, activity, impairment, and contextual factors—were measured using the Frenchay Activity Index, Barthel Index, and a demographic form. Results Multivariate analysis results indicated that participation, activity, and marital status are significant factors in the QOL outcome. Results also indicated that among the various factors that affect each domain of QOL (physical health, psychological health, social relationships, and environment), participation was the strongest determinant. Conclusions The ICF provided an excellent framework with which to explore the factors influencing QOL after SCI. The results demonstrated that marital status, participation, and activity exert the strongest influence on QOL, while impairment and other variables do not directly influence QOL.

To identify the contextual factors that influence community participation in rehabilitation outpatients from the perspectives of patients and their service providers.Five focus groups with rehabilitation outpatients (n = 22) and three focus groups with occupational and physical therapists (n = 17) were conducted. Two independent coders thematically analyzed the transcribed data.Patients and their providers identified three common personal factors (personal interests, personal values, and finances) and four major categories of environmental factors (products and technology; support and relationships; attitudes; and services, systems, and policies) that have great influence on patients' participation in the community. Additionally, some patients perceived the impacts of fear of falling and climate on their participation, whereas some service providers reported that age, adaptability, and successful experiences could determine the patients' participation in the community.This study synthesized and contrasted perspectives from both rehabilitation outpatients and their service providers to identify the contextual factors that enable or restrict patients from participating in the community. Both patients and service providers identified numerous personal and environmental factors associated with participation, thus highlighting areas that can be addressed in rehabilitation outpatient programs and considered in policy development. Implications for Rehabilitation Community participation is an outcome of dynamic interactions among multiple factors and is highly environmentally and culturally sensitive. Both personal and environmental factors have substantial impacts on rehabilitation patients' participation outcomes. Rehabilitation practitioners and policy-makers need to incorporate perspectives from both patients and providers when developing interventions targeting to improve patients' community participation.

Background WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) is a feasible tool for assessing functional disability and analysing the risk of institutionalisation among elderly patients with dementia. However, the data for the effect of education on disability status in patients with dementia is lacking. The aim of this large-scale, population-based study was to analyse the effect of education on the disability status of elderly Taiwanese patients with dementia by using WHODAS 2.0. Methods From the Taiwan Data Bank of Persons with Disability, we enrolled 7698 disabled elderly (older than 65 years) patients diagnosed with dementia between July 2012 and January 2014. According to their education status, we categorised these patients with and without formal education (3849 patients each). We controlled for the demographic variables through propensity score matching. The standardised scores of these patients in the six domains of WHODAS 2.0 were evaluated by certified interviewers. Student’s t - test was used for comparing the WHODAS 2.0 scores of patients with dementia in the two aforementioned groups. Poisson regression was applied for analysing the association among all the investigated variables. Results Patients with formal education had low disability status in the domains of getting along and social participation than did patients without formal education. Poisson regression revealed that standardised scores in all domains of WHODAS 2.0—except self-care—were associated with education status. Conclusions This study revealed lower disability status in the WHODAS 2.0 domains of getting along and social participation for patients with dementia with formal education compared with those without formal education. For patients with disability and dementia without formal education, community intervention of social participation should be implemented to maintain better social interaction ability.

Understanding individual experiences is crucial for consumer-centered practice and policy. However, limited literature has thoroughly explored individual employment experiences outside of rehabilitation programs. The purpose of this study is to demonstrate the challenges that two individuals with severe mental illness (SMI) had experienced in competitive employment settings. Through in-depth interviews followed by an inductive qualitative analysis, the barriers that restrained them from obtaining and keeping a job were identified. Even though the two cases had dissimilar backgrounds and diagnoses, they had both been struggling with multiple problems including psychiatric symptoms, medications, and social stigma. The findings indicate that a flexible work schedule and a supportive work environment are important to their work participation. However, many competitive employment settings did not allow them to have a flexible schedule for frequent medical leaves. The stigma toward mental illness was also prevalent in various workplaces they worked at. The implications for policy and practice are discussed.

Participation is a key indicator of health and well-being and a critical rehabilitation goal for individuals with disabilities. Despite the numerous participation measures that have been developed, there is still an absence of agreement on the definition, domains, and dimensions of this construct. The result is that instruments intending to measure the same construct may actually measure quite different aspects of daily life and therefore yield significantly different findings. A solid conceptual model is needed to provide consistent guidance for measurement selection and development. In this article we identify the relevant content areas of participation and propose a conceptual model for adults that is intended to apply across diagnoses, conditions, and settings. We classified participation into 3 main domains: work and education, household, and community. Subdomains are defined within each. The model was reviewed using a semistructured survey by 8 rehabilitation measurement experts. Their feedback regarding the relevance, clarity, and comprehensiveness of the model led to the creation of an alternative structure in which the 3 main domains were recategorized as productivity, social, and community. The proposed conceptual model provides a clear framework for practitioners and researchers to understand the concept of participation and to guide selection or development of measures.