Home and Community Environment
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Home and Community Environment

Last Updated

Purpose

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

Link to Instrument

Acronym HACE

Area of Assessment

Activities of Daily Living
Functional Mobility
Social Relationships

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

CDE Status

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

Diagnosis/Conditions

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

Populations

Osteoarthritis
Older Adults and Geriatric Care
Mixed Populations
Wheelchair Usage

Key Descriptions

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

Number of Items

36

Time to Administer

6-30 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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

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

ICF Domain

Participation
Environment

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

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

For detailed information about how recommendations were made, please visit: 

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 for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

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

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

No

No

Not reported

Considerations

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

Mixed Populations

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Normative Data

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

HACE Norms

HACE Domain

Range

Mean (SD)

Home mobility barriers

0 to 9

3.0 (2.1)

Community mobility barriers

0 to 4

0.7 (0.9)

Mobility technology facilitators

0 to 9

3.9 (2.0)

Communication technology facilitators

0 to 4

1.0 (1.0)

Transportation facilitators

0 to 5

3.2 (1.2)

Social support

0 to 100

83 (19)

 

 

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

 

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

HACE Domain (n)

Mean (SD)

Transportation (568)

3.64 (1.6)

Community (560)

1.13 (0.9)

Negative Attitudes (567)

0.26 (0.6)

Technology Communication (568) 

1.83 (0.7)

Technology Mobility (568)

2.35 (2.1)

Home (568)

1.66 (1.8)

 

 

Test/Retest Reliability

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

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

Internal Consistency

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

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

 

Construct Validity

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

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

Correlation coefficients between HACE domains and other environmental measures

HACE Domain

CHIEF

MQE Barrier

MQE Facilitator

HACE Transportation

-.19

.13

-.07

HACE Community

.30a

-.09

.03

HACE Negative Attitudes

.22a

-.15

-.04

HACE Technology Communication

.05

.03

.11

HACE

Technology Mobility

.28a

-.27a

.18a

HACE Home 

-.15

.13

-.15

      

HACE Domain

EFIB Built and Natural Environment

EFIB Systems, Services, and Policies

EFIB Social Barriers

EFIB Social Facilitators

EFIB Access to Information and Technology

HACE Transportation

-.24

.27b

.16

.18

.27b

HACE Community

.28b

-.32b

-.15

-.23

-.26b

HACE Negative Attitudes

.23b

-.12

-.29b

-.18

-.18

HACE Technology Communication

-.08

.20

.05

.09

.34b

HACE

Technology Mobility

.48b

-.08

-.33b

-.11

-.08

HACE Home 

-.21

-.05

.21

.02

-.06

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

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

 

 

 

Content Validity

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

 

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

Face Validity

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

Older Adults and Geriatric Care

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Test/Retest Reliability

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

HACE Test retest reliability:

 

 

 

 

Domain

Items

Median percent agreement (Range)

Median Kappa (range)

Home mobility

9

89% (71–100)

0.66 (0.28–1.0)

Community mobility

5

75% (58–92)

0.47 (0.20–0.64)

Basic mobility devices

9

92% (75–100)

0.65 (0.45–1.0)

Communication devices

4

94% (88–96)

0.79 (0.75–0.83)

Transportation

5

100% (67–100)

1.0 (0.29–1.0)

Attitudes

4

88% (84–95)

0.62 (0.51–0.77)

Construct Validity

Elderly Adults: (Keysor et al, 2005):

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

 

Home mobility

Items

Total Sample

Percent (n)

Single or multi-family home

Percent (n)

Multi-unit complex dwelling

Percent (n)

p

 

(n = 62)

(n = 19)

(n = 43)

 

1 or more obstacle at the main door

48 (30)

100 (19)

100 (19)

<0.001

1 or more obstacle from the main door to main living area

10 (6)

26 (5)

2 (1)

0.009

1 or more obstacle inside main living area barriers

16 (10)

56 (10)

0 (0)

<0.001

1 or more home mobility obstacle (summary score)

48 (30)

100 (19)

26 (11)

<0.001

 

Osteoarthritis

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Normative Data

 

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

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

Use of parks and walking areas

Country

LLOA

No LLOA

Sweden 

89.1

95.2

UK

62.3

63.8

The Netherlands 

58.8

74.3

Germany

90.3

91.2

Italy 

56.1

56.4

Spain 

69.0

73.1

 

Use of places to sit and rest

Country

LLOA

No LLOA

Sweden 

46.5

78.3

UK

38.9

60.2

The Netherlands 

37.3

46.0

Germany

35.8

69.5

Italy 

19.7

11.2

Spain 

63.4

82.0

 

Use of public transportation

Country

LLOA

No LLOA

Sweden 

78.3

85.6

UK

60.2

50.6

The Netherlands 

46.0

50.2

Germany

69.5

66.5

Italy 

11.2

10.4

Spain 

82.0

86.3

 

Use of Car

Country

LLOA

No LLOA

Sweden 

58.2

69.8

UK

56.5

71.8

The Netherlands 

45.1

66.6

Germany

69.8

80.9

Italy 

68.0

74.4

Spain 

18.5

42.1

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

 

 

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

Percentage of study subjects reporting HACE neighborhood features 

Feature

Present (% of 436)

Don’t know (% of 436)

Uneven sidewalks or other walking areas

79

4

No parks and walking areas that are easy to get to and easy to use 

12

2

No safe parks or walking areas

12

4

No places to sit and rest at bus stops, in parks, or in other places where people walk 

21

8

No curbs with curb cuts

20

5

Public transportation that is close to your home

58

18

Public transportation with adaptations for people who are limited in their daily activities 

92

1

Adequate handicap parking

45

5

Have a car available to you at your home 

98

0

Able to drive 

96

0

 

 

 

Internal Consistency

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

  • Adequate internal consistency (Cronbach's alpha = 0.70) 

Construct Validity

Osteoarthritis: (Abdelnasser et al., 2019)  

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

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

Factor

Stand. coeff. Beta

Significance

Home Mobility 

0.004

0.947

Community Mobility 

0.004

0.946

Social environment 

0.154

0.015*

Assistive & mobility devices 

-0.003

0.956

Communication devices 

-0.383

0.000*

Transportation 

0.350

0.000*

Attitude 

-0.016

0.801

 

Wheelchair Usage

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Normative Data

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

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

 

Construct Validity

Convergent validity: 

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

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

 

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

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

 

Wheelchair users: (Sakakibara et al., 2015)

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

 

Bibliography

Abdelnasser, N. O. E., Moneim, S. A., & Fouad, R. A. (2019). The relationship between environmental factors and health-related functional disability of older adults with osteoarthritis. International Scientific Meeting on Public Health and Sports, 26(30), 2468-5739. 

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

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

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

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

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

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

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

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

 

 
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