The World Health Organization International Classification of Functioning, Disability, and Health (!CF) (WHO, 2001) has recently called for research to investigate the environmental factors that influence the participation of individuals with various health conditions. Participation in life may be hindered if society creates negative environmental factors (barriers) or fails to provide positive environmental factors (facilitators). To date, most of the research in this area has focused on individuals with physical disorders. This qualitative research investigation addresses the gap in the literature in relation to the communication disorder of aphasia. The aim of the study was to explore the environmental factors that hinder or support the community participation of adults with aphasia.
Two studies, underpinned by the constructivist paradigm and following the qualitative description research strategy, were conducted to address this aim. In the first phase, 25 adults with aphasia participated in semistructured in-depth interviews. All participants had aphasia caused by a stroke, lived in the community (i.e., in their own homes or a retirement village), and were at least six months poststroke. Informants were 34 to 85 years old with varied aphasia severity as measured by the Western Aphasia Battery (Kertesz, 1982). The participants were also purposefully selected using maximum variation sampling for variables such as gender, time postonset of aphasia, and education. Qualitative content analysis of the interview transcripts revealed 156 barriers and 206 facilitators. These factors were categorised into 36 subtypes of environmental factors (e.g., Facilitators- Procedures) and six types of environmental factors (i.e., Barriers Related to other People, Physical Barriers, Societal Barriers, Facilitators Related to Other People, Physical Facilitators, and Societal Facilitators). The study also revealed seven themes: Awareness of Aphasia, Opportunity for Participation, Familiarity, Time Available for Communication, Communication Complexity, Message Clarity, and Availability of Extra Support for Communication. A few participants identified environmental factors related to their physical difficulties ( e. g., Iack of stair railings) during the interviews, while all participants reported some other influences ( e.g., "The BARRIERS ... got nothin' to do with it ... I just can't TALK") on their community participation, in addition to environmental factors.
In the second phase, 10 participants from the first study were observed participating in community environments, using the method of participant observation. The participants, aged 35 to 72, were purposefully selected using maximum variation sampling for a variety of variables such as gender, aphasia severity, and living situation. Qualitative content analysis of the field notes revealed 44 barriers and 59 facilitators, as well as 19 subtypes of environmental factors ( e.g., Barriers- Other People's Actions) and the same six types of environmental factors generated by the first study. The investigation identified four of the themes that were revealed in the first study (i.e., Familiarity, Communication Complexity, Time Available for Communication, and Availability of Extra Support for Communication) and two themes that were not revealed by the first study (i.e., Referents and Interaction).
The results of the two phases suggested that the participants faced a wide range of barriers to community participation, many of which have not been reported previously. The research also identified a number of existing facilitators and potential facilitators for overcoming these barriers. A preliminary framework for evaluating environmental factors is proposed, involving the themes and environmental factor types and subtypes generated by the two studies. The results of the two investigations share some similarities with the ICF's Environmental Factor domains; however, there are also some key differences. Future versions of the ICF may need to incorporate a broader range of environmental factors into the classification system in order to be relevant for people with aphasia.