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International Journal of Speech-Language Pathology , 2008; 10(1 – 2): 27 – 37

of Speech-Language Pathology , 2008; 10(1 – 2): 27 – 37 The ICF Contextual Factors related

The ICF Contextual Factors related to speech-language pathology


The University of Queensland, Australia

Abstract The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) conceptualizes functioning and disability as a dynamic interaction between a person’s health condition and their contextual factors. Contextual factors ‘‘represent the complete background of an individual’s life and living’’ and comprise two components:

Environmental Factors and Personal Factors. This review aims to: (1) discuss why contextual factors are important for speech-language pathologists to address in their clinical practice, (2) describe how environmental factors are coded in the ICF, (3) identify environmental factors that are relevant for people with communication disorders, and (4) identify personal factors that are relevant for people with communication disorders. Research on environmental factors that can influence the functioning of individuals with various communication disorders is presented, in addition to studies on personal factors that are important for speech-language pathologists to consider. The paper concludes that speech-language pathologists need to address contextual factors routinely, in order to provide a holistic approach to intervention for their clients. Furthermore, although a number of contextual factors that are relevant for people with communication disorders have been reported in the literature, more research is needed in this area.

Keywords: ICF, World Health Organization, speech-language pathology, Contextual Factors, Environmental Factors, Personal Factors.


The World Health Organization’s (WHO) Interna- tional Classification of Functioning, Disability and Health (ICF) conceptualizes functioning and dis- ability as a dynamic interaction between a person’s health condition and their Contextual Factors (WHO, 2001). The Contextual Factors part of the ICF is, therefore, a key feature of the classification. Contextual factors ‘‘represent the complete back- ground of an individual’s life and living’’ (WHO, 2001, p. 16) and comprise two components:

Environmental Factors and Personal Factors. While Environmental Factors refer to all aspects of the external world of an individual’s life that may have an impact on his or her functioning, Personal Factors involve ‘‘features of the individual that are not part of the health condition’’ such as gender, age, and coping styles (WHO, 2001, p. 17). This review aims to: (1) discuss why Contextual Factors are important for speech-language pathologists to address in their clinical practice, (2) describe how Environmental Factors are coded in the ICF, (3) identify Environ- mental Factors that are relevant for people with communication disorders, and (4) identify Personal

Factors that are relevant for people with commu- nication disorders.

Why are Contextual Factors important for speech-language pathologists?

The inclusion of Contextual Factors in the ICF highlights the integral role that Environmental and Personal Factors play in influencing the functioning of people with health conditions such as commu- nication disorders. Therefore, a holistic approach to maximizing a client’s communication functioning requires that speech-language pathologists routinely address these factors as part of their clinical practice. In addition, there are a number of specific reasons why it is particularly important for speech-language pathologists to focus on Environmental and Personal Factors. First, speech-language therapy aims to improve clients’ communication in their everyday environments, not just within the clinic (Owens, Metz, & Haas, 2007). Ensuring that an individual’s communication skills are generalized to settings outside the clinic, however, can be difficult (Finn, 2003; Hughes, 1985; van den Broek, 2005). One reason for this difficulty may be that some clinicians

28 T. J. Howe

fail to address Contextual Factors adequately in therapy, hoping rather that the communication skills will ‘‘magically’’ transfer to use outside the clinic (Threats & Worrall, 2004). Secondly, communica- tion is a collaborative process and generally one cannot communicate without a communication partner (Eadie, 2003), in other words an environ- mental factor. Since Environmental Factors are an integral part of communication (Threats, 2000), it is important that speech-language pathologists address them. Thirdly, the speech-language pathologist has specialist knowledge about communication and communication disorders that can be used to address Environmental Factors that influence the function- ing of people with speech and language difficulties. As Simmons-Mackie (2000, p. 180) states, ‘‘The speech-language pathologist is uniquely qualified to analyse the communication requirements of activ- ities, identify potential communication adaptations, and collaborate with involved parties to enhance participation’’. The speech-language pathology scope of practice in countries such as the United States (American Speech-Language-Hearing Asso- ciation, 2001) and Australia (Speech Pathology Australia, 2002) now includes focusing on Environ- mental Factors as part of the clinician’s role. The inclusion of Environmental Factors in the ICF can also help speech-language pathologists to document and/or be reimbursed for activities that they may have undertaken in the past, but that were outside the traditional therapy model (Threats & Worrall, 2004). An example is a speech-language pathologist who focuses on the Environmental Factor of training family members to communicate better with an individual who has severe chronic aphasia. The clinician can use the ICF framework to demonstrate that the training is a worthwhile use of time because it has a greater impact on the client’s everyday communication functioning than if the same amount of time was spent working only directly with the client (Threats & Worrall, 2004). Furthermore, the ICF Environmental Factors component provides speech-language pathologists with standard terminology to use within the disci- pline, as well as across disciplines and countries. For example, there are currently at least four non-ICF classifications for Environmental Factors that are relevant for people with aphasia. Each of these classifications uses different labels to refer to similar types of factors. For example, while Parr, Byng, Gilpin, and Ireland (1997) included factors involving the attitudes of others in a broad category labelled, ‘‘Attitudinal’’, Garcia, Barrette, and Laroche (2000) included these factors in a higher level classification called, ‘‘Societal’’. In contrast, Howe, Worrall, and Hickson (in press a) classified attitudes of other people within a broader category labelled, ‘‘Related to other people’’, while Brown et al. (2006) categorized them as ‘‘People environmental factors’’. This inconsistency is confusing and could result in

miscommunication. The ICF, in contrast, offers a standard set of terms that are recognized interna- tionally and that have been translated into a number of languages. Although the categories within the current version of the ICF do not provide enough detail in some areas that are particularly important for people with communication disorders such as aphasia (Howe, 2006), the classification provides a foundation for the development of more relevant terms in the future. In addition, the various specific

classifications could be used clinically; they could be translated into the standard terms used by ICF terms in communication with organizations such as gov- ernments and third party payers. In addition, the inclusion of Environmental Factors

in the ICF provides speech-language pathologists with

a social policy tool that they can use to help them

advocate for greater community access for their clients (Hurst, 2003; Threats, 2000). The availability of an Environmental Factor classification system makes it easier to identify the specific barriers that need to be considered. For example, speech-language patholo- gists can use the classification to help them identify and reduce negative Environmental Factors or bar- riers to communication (e.g., poor communication strategies used by the communication partner of an individual with dementia). The classification also provides clinicians with a framework for advocating for positive Environmental Factors or facilitators (e.g., modified written information for an individual with aphasia) for their clients. A barrier-free environment is not necessarily enough to support the participation of people with communication disorders (Threats, 2007). Facilitators must also be addressed. Systematic consideration of the Personal Factors component for each client is also important in speech-language therapy. Client-centredness or per- son-centredness is increasingly becoming a priority in health and rehabilitation service delivery (Cott, 2004) and includes demonstrating respect for clients and involving them in decision – making (Townsend et al., 2002). Another aspect of person-centredness involves therapists focusing on the Personal Factors of clients by developing individualized rehabilitation programs (Cott, 2004). For example, by considering unchangeable Personal Factors such as ethnic back- ground, gender, and previous experiences, clinicians can better understand their clients and adapt services to meet their clients’ needs (Threats, 2007). Furthermore, the identification of potentially changeable Personal Factors such as coping styles and other health conditions can help speech- language pathologists to advocate for other services that their clients may require (Threats, 2003).

How are Environmental Factors coded within the ICF?

Environmental Factors are defined as ‘‘the physical, social, and attitudinal environment in which people

live and conduct their lives’’ (WHO, 2001, p. 10). These factors can be negative, positive, or have no effect. An individual’s functioning may be hindered and disability created, if society creates negative Environmental Factors (barriers) or fails to provide positive Environmental Factors (facilitators). In contrast, a person’s functioning may be supported, if society removes barriers and provides facilitators. Within the ICF, Environmental Factors target two

different levels: the individual and the societal level. While the individual level involves a person’s immediate environment such as a home, workplace,

or school, the societal level refers to overarching

systems such as services and formal and informal rules. Furthermore, the Environmental Factors component is divided into five chapters or domains:

(1) Products and technology; (2) Natural environ- ment and human-made changes to environment; (3) Support and relationships; (4) Attitudes; and (5) Services, systems, and policies. Each chapter con- tains a detailed list of Environmental Factors organized hierarchically into second- or third-level categories. In addition to a heading, every category has an alphanumeric code, beginning with the letter ‘‘e’’ to denote ‘‘Environmental Factors’’, followed by a one-digit number to represent the chapter number, and a two-digit number to represent the second-level category. For example, Chapter Two Natural en- vironment and human-made changes to environ- ment includes the second-level category ‘‘Light’’ (e240). Third-level categories have an additional one digit number (e.g., ‘‘Light quality’’ (e2401)). To help the rater to select an appropriate Environmental Factor, categories also include an operational defini- tion and, where applicable, category inclusions and exclusions. Environmental Factors are coded with respect to the perspective of the person with the communication disorder. Because it is recognized that an Environ- mental Factor such as kerb cuts may be a facilitator for one individual (e.g., a person who uses a wheel- chair), yet a barrier for another person (e.g., a person

who is blind), the factors are written in neutral terms.

A specific Environmental Factor such as support

from another person may even be a barrier or a facilitator for individuals with the same communica-

tion disorder (Howe, Worrall, & Hickson, in press b). The impact of a particular Environmental Factor


a specific person’s life is indicated by the inclusion


qualifiers. Barriers are coded by placing a point (.)

after the factor, followed by a number qualifier that indicates the extent of the barrier (i.e., .0 for no

barrier, .1 for a mild barrier, .2 for a moderate bar- rier, .3 for a severe barrier, or .4 for a complete barrier). Background noise that is a mild barrier for

an individual with dysarthria in a specific situation,

for example, would be coded using the neutral category of ‘‘Sound quality’’ (e2501) followed by a point and a 1 to indicate that its effects are mild (i.e., e2501.1). A factor can be a barrier because it is

ICF Contextual Factors


present or because it is absent. For example, back- ground noise for an individual with a voice problem may be barrier because of its presence, while specialized workplace training for people with trau- matic brain injury may be a barrier because of its absence. Facilitators are coded by placing a þ sign after the factor, followed by a number qualifier that identifies the extent of the facilitator (i.e., þ 0 for no facilitator, þ 1 for a mild facilitator, þ 2 for a moderate facilitator, þ 3 for a substantial facilitator, and þ 4 for a complete facilitator). A communication board that is a moderate facilitator would, therefore, be coded by using the neutral category of ‘‘Assistive products and technology for communication’’ (e1251), followed by a þ sign and a 2 to indicate that its effects are moderate (i.e., e1251 þ 2). A second qualifier for Environmental Factors is to be developed in the future. Environmental Factors may be coded in one of three ways. First, they can be coded overall for the person, without relating them specifically to the Body Functions and Structures component or the Activ- ities and Participation component. The second option is to code Environmental Factors in relation to the Body Functions and Structures component and the Activities and Participation component. The final option is to code Environmental Factors for capacity and performance qualifiers in the Activities and Participation component for each item (see O’Halloran & Larkin (2008) for more information about the capacity and performance qualifiers). The selection of one of these three coding options will depend on the user’s requirements. For example, rather than identifying that a family member of someone with a traumatic brain injury is generally a barrier or facilitator, it may be important to highlight that the family member is a facilitator in relation to helping the individual return to work, but a barrier in relation to the person developing a romantic relation- ship. Environmental Factors are intended to be coded in relation to a certain point in time; however, a longer timeframe may be used, if specified.

What Environmental Factors are relevant for individuals with communication disorders?

Each of the five chapters or domains in the Environmental Factors component is described below. Specific examples of Environmental Factors that are relevant for individuals with various com- munication disorders within each chapter are also provided.

Chapter One: Products and Technology

The products and technology chapter comprises ‘‘natural or human-made products or systems of products, equipment, and technology’’ (WHO, 2001, p. 173). The chapter includes items designed

30 T. J. Howe

specifically for individuals with communication disorders, products used by the general public, signage, and drugs.

Assistive products and technology for communication. There is a wide range of products designed speci- fically for people with communication disorders that support participation. Facilitators include products that improve speech such as palatal lifts for indivi- duals with dysarthria (Roth, Poburka, & Workinger, 2000), altered auditory feedback devices for indivi- duals who stutter (Zimmerman, Kalinowski, Stuart, & Rastatter, 1997), voice amplifiers for individuals with voice disorders (Roy et al., 2002), and electro- larynxes and tracheosophageal voice prostheses for individuals who have had a laryngectomy or phar- yngolaryngectomy (Ward, Koh, Frisby, & Hodge, 2003). Electronic augmentative and alternative communication systems such as synthesized speech devices used by people with dysarthria (Drager, Hustad, & Gable, 2004) and the TalksBac computer system used by people with aphasia (Waller, Dennis, Brodie, & Cairns, 1998) would also be classified as facilitators within this chapter. In addition, this domain includes low technology aids that support verbal expression such as remnant books (Ho, Weiss, Garrett, & Lloyd, 2005) and Talking Mats for individuals with aphasia (Murphy, 2000), and memory wallets for individuals with dementia (Bourgeois, 1992). Finally, assistive products for people with hearing disorders such as hearing aids (Vuorialho, Karinen, & Sorri, 2006), cochlear implants (Lassaletta, Castro, Bastarrica, de Sarria, & Gavilan, 2005), and telephone amplifiers (Stephens, Gianopolous, & Kerr, 2001) are also examples of facilitators that would be categorized within this chapter. Assistive products and technology facilitators include modifications to written materials that are specifically for people with reading difficulties. For example, the use of simple words, short sentences, and increased white space around the text can facilitate reading comprehension in individuals with aphasia (Rose, Worrall, & McKenna, 2003). Furthermore, modifications such as using supportive graphic information and dot points can help people with complex communication needs to understand written information (Owens, 2006). Although several assistive products are facilitative for people with communication disorders, some specific features of these devices hinder participation. For example, battery problems when using electro- larynxes (Carr, Schmidbauer, Majaess, & Smith, 2000) and augmentative communication devices that are not reliable (Bailey, Parette Jr., Stoner, Angell, & Carroll, 2006) have been identified as barriers. In addition, if the device is especially cumbersome for the person to use, then it could potentially be more of a barrier to communication participation than a facilitator.

General products and technology. Products used by the general public may also hinder or facilitate the participation of individuals with communication disorders. Telephones, for example, have been reported to be a barrier for people with aphasia (Howe et al., in press b; Murphy, 2006), dysarthria (Ball, Beukelman, & Pattee, 2004), and spasmodic dysphonia (Baylor, Yorkston, & Eadie, 2005), while intercoms have been identified as a hindrance for individuals with laryngectomies (Sullivan, Beukelman, & Mathy-Laikko, 1993). In addition, communicating in cars has been reported to be difficult for people with laryngectomies (Sullivan et al., 1993), spasmodic dysphonia (Baylor et al., 2005), and dysarthria (Ball et al., 2004). In contrast, general products such as bus passes, video monitors at train stations, and computerized scoring systems at bowling alleys have been identified as facilitators for people with aphasia (Howe et al., in press b). Specific features of general products can also hinder participation. For example, telephone voice record- ings, telephone voice recognition systems, and non- standardized automated teller banking machines have been identified as barriers by individuals with aphasia (Howe, 2006; Howe et al., in press b).

Signage. Features of signs such as unclear pictures can be barriers for some individuals with aphasia, while colour coded and clear signage have been reported to be facilitative (Howe, 2006; Howe et al., in press b). Furthermore, labels with photographs and names can help individuals with dementia to identify their belongings (Gross et al., 2004).

Products and substances for personal consumption. Substances that are consumed such as drugs and liquids are also included in the Products and Technology chapter. An example of a drug that is a facilitator for some individuals with communication disorders is Botulinum Toxin A (Botox). Injection of Botox into specific laryngeal muscles has been used to improve the voice of individuals with spasmodic dysphonia (Zwirner, Murry, Swenson, & Woodson, 1991). A Cochrane systematic review (Greener, Enderby, & Whurr, 2001) found that another drug, piracetam, may be effective in the treatment of aphasia after stroke; however, larger research trials are needed to provide further evidence of the drug’s effectiveness. Although many studies have investi- gated the effect of drugs on reducing stuttering, a recent systematic review concluded that none of the pharmacological agents tested to date can be recom- mended to improve fluency in people who stutter (Bothe, Davidow, Bramlett, Franic, & Ingram, 2006). Drugs may also be barriers, negatively influencing the functioning of people with communication disorders. Some anticonvulsant medications, for example, may negatively affect speech production, while other medications can produce drowsiness, anxiety, confu- sion, or depression (Vogel & Carter, 1995).

Daily hydration treatment involving drinking eight or more glasses of water, in addition to 2 hours of exposure to high humidity environments and con- sumption of a mucolytic medication, was found to produce significantly greater improvements in voice and in laryngeal appearance than a placebo condition in individuals with laryngeal nodules or polyps. Some benefits, however, were also reported for the placebo condition (Verdolini-Marston, Sandage, & Titze, 1994).

Chapter Two: Natural Environmental and Human-made Changes to Environment

The domain of natural environment and human- made changes to environment includes elements of the physical environment that are either natural or modified by people. Sound is one factor in this domain that is particularly relevant for people with communication disorders.

Sound. Background noise has been identified as a barrier to communication for individuals with spas- modic dysphonia (Baylor et al., 2005), voice disorders (Thomas, de Jong, Kooijman, Donders, & Cremers, 2006), dementia (Orange, 1995), laryngectomies (Carr et al., 2000; Sullivan et al., 1993), aphasia (Garcia et al., 2000; Howe et al., in press b), and dysarthria caused by amyotrophic lateral sclerosis (Ball et al., 2004). Conversely, noise in one study was identified as a facilitator to communication for individuals with reduced vocal loudness due to Parkinson’s disease (Adams, Moon, Dykstra, Abrams, Jenkins, & Jog, 2006), with people with Parkinson’s disease consistently increasing their loudness level as the level of the background noise increased.

Other Environmental Factors. A variety of other physical factors are also relevant for people with communication disorders. For example, temperature changes, environmental irritants in the air, and humidity have been found to have a negative influence on individuals with voice disorders (Thomas et al., 2006). In contrast, as reported previously, hydration treatment that included expo- sure to humid environments resulted in significant improvements in voice and in laryngeal appearance for individuals with laryngeal nodules or polyps (Verdolini-Marston et al., 1994). The presence of visual distractions has also been reported to hinder the participation of individuals with aphasia (Howe et al., in press b). In contrast, modifying the physical environment by brightening the lighting, seating individuals around small tables, rather than along the walls of a ward, and setting up items so individuals could serve themselves resulted in significant improvements in the communication of individuals with dementia during their coffee time (Melin & Gotestam, 1981). Finally, environments that are familiar and constant have been identified as

ICF Contextual Factors


facilitative for people with aphasia (Howe, 2006) and dementia (Orange, 1995).

Chapter Three: Support and Relationships

The support and relationships domain is a key area for individuals with communication disorders. It includes the relationships of other people and animals and the amount of assistance provided by the individuals, but excludes the attitudes of other people. The categories within this domain are classified according to the relationship that the individual has with the person who has the commu- nication disorder (e.g., ‘‘Immediate family’’ (e310), ‘‘Personal care providers and personal assistant’’ (e340), and ‘‘Health professionals’’ (e355)). In the ICF, professionals who provide services such as transportation and economic services may be coded within Chapter Five: Services, systems, and policies. For example, a bus driver may be coded under the services, systems, and policies category of ‘‘Trans- portation services’’ (e5400). There is overlap, there- fore, between categories within the Support and relationships domain and the Services, systems, and policies domain (e.g., a health professional could be categorized as ‘‘Health professionals’’ (e355) within the Support and relationships chapter or as ‘‘Health services’’ (e5800) within the Services, systems, and policies chapter).

General support and relationships. The availability of other people in the environment for support during communication has been identified in a number of studies. Siblings, for example, can facilitate the participation of children with speech impairments by protecting and interpreting for their family member (Barr, McLeod, & Daniel, in press), while the presence of family members is an important support for people with dementia (Muo et al., 2005), aphasia (Howe et al., in press b), and complex communication needs (Hemsley & Balandin, 2004). Furthermore, the level of support provided by family and friends was identified as an important facilita- tor for individuals who had had a laryngectomy (Richardson, Graham, & Shelton, 1989). Finally, the availability of support from other people with the same communication disorder has been reported to be facilitative for people with laryngectomies (Richardson et al., 1989), aphasia (Howe et al., in press b), and fluency disorders (Yaruss et al., 2002). The presence of other individuals in the environ- ment can also be barrier. For example, having other individuals available to speak for the individual can be a barrier to participation for individuals with aphasia (Howe et al., in press b) and children with speech impairment (Barr et al., in press). Instead of providing the individual with a communication disability with the chance to speak for him or herself, other people may tend to communicate only with the person accompanying the individual.

32 T. J. Howe

Specific communication behaviours of other people. Specific behaviours of communication partners can hinder participation. For example, other people speak- ing too fast was reported to be a barrier for people with aphasia, young people with developmental language difficulties, and adults with learning difficulties (Howe et al., in press b; Law, Bunning, Byng, Farelly, & Herman, 2005; Murphy, 2006). Other barriers for people with a variety of communication disorders include conversation partners not providing enough time for the individual to communicate and not speaking directly to the person with the communica- tion disorder (Howe et al., in press b; Law, Bunning, Byng, Farelly, & Herman, 2005; Murphy, 2006; Nordehn, Meredith, & Bye, 2006). A study using virtual reality technology found that individuals with fluency disorders stuttered more when the virtual interviewer interrupted them, spoke fast, had reduced eye contact, and increased the time pressure (Brundage, Graap, Gibbons, Ferrer, & Brooks, 2006). Conversely, communication partners who demonstrate patience when communicating have reported to be facilitative for people with aphasia (Howe et al., in press b) and dementia (Orange, 1995). Concentrating on the person with the commu- nication disorder was also identified as a facilitator for conversation partners to use when listening to individuals with aphasia (Howe, 2006) and with dysarthria caused by Huntington’s disease and amyotrophic lateral sclerosis (Klasner & Yorkston, 2005). Other examples of facilitators for people with communication disorders post-stroke included other people asking individuals how best to communicate with them and health professionals writing down key points during health consultations for individuals to take home with them (Nordehn et al., 2006).

Communication partner training for other people. Com- munication partner training has been found to facilitate the participation of people with a variety of communication disorders. Training others to modify their behaviours when interacting with individuals with communication difficulties has had a positive effect on the communication of preschoolers with language disorders (Crowe, Norris, & Hoffman, 2004) and autism spectrum disorder (McConachie, & Diggle, 2007) and adults with aphasia (Kagan, Black, Duchan, Simmons-Mackie, & Square, 2001), traumatic brain injury (Togher, McDonald, Code, & Grant, 2004), and verbal apraxia (Florance, Rabidoux, & McCauslin, 1980). Communication partner instruction has included a variety of conversa- tion partners such as family members (Correll, van Steenbrugge, & Scholten, 2004), medical students (Legg, Young, & Bryer, 2005), police officers (Togher et al., 2004), and volunteers (Kagan et al., 2001).

Characteristics of other people. The characteristics of conversation partners, unlike specific communica- tion behaviours of other people discussed earlier,

involve general qualities of individuals that can influence the communication of people with various speech and language disorders. For example, a familiar listener can be more facilitative than an unfamiliar listener with individuals who have spas- modic dysphonia (Baylor et al., 2005), laryngec- tomies (Carr et al., 2000), aphasia (Howe et al., in press b), dysarthria (DePaul, & Kent, 2000), and dementia (Orange, 1995). Familiar partners may have a shared understanding of some events that facilitates the communication of the individual with the communication disorder (Murphy, 2004). Even brief familiarization with the speech of individuals with dysarthria has been shown to enhance listeners’ understanding of the individuals’ communication (Hustad & Cahill, 2003). The presence of a foreign accent or a hearing difficulty is an additional characteristic of other people that can influence the participation of individuals with communication disorders. For ex- ample, conversation partners who speak with a foreign accent can be more difficult for people with aphasia to understand (Howe et al., in press b; Le Dorze, Brassard, Larfeuil, & Allaire, 1996), while individuals with hearing difficulties have been identified as being more difficult for people with spasmodic dysphonia (Baylor et al., 2005) and laryngectomies (Carr et al., 2000) to commu- nicate with.

Number of other people. The number of communica- tion partners the individual has to communicate with at one time has also been reported to be an important Environmental Factor for people with a variety of communication disorders. Being required to speak in larger groups is a barrier for individuals with dysarthria (Ball et al., 2004), dementia (Orange, 1995), and aphasia (Howe et al., in press b; Le Dorze et al., 1996). Conversely, one-to-one conversations or small group conversations have been identified as a facilitator for people with dementia (Orange, 1995) and aphasia (Howe et al., in press b).

Animals. Animals can also be facilitators for people with communication disorders. Hearing dogs can support the participation of people with hearing loss (Guest, Collis, & McNicholas, 2006), while the presence of dogs can be facilitative for the commu- nication of people with aphasia (Howe et al., in press b; LaFrance, Garcia, & Labreche, 2007).

Chapter Four: Attitudes

The Attitudes chapter focuses on the attitudes of other individuals and society in general. Attitudes

refer to ‘‘the observable consequences of customs, practices, ideologies, values, norms, factual beliefs,

and religious beliefs

influence individual


behaviour and social life at all levels’’ (WHO, 2001, p. 190). The organization of this chapter is similar to

that of Support and Relationships in that the categories refer to the relationship of the individual to the person with the communication disorder (e.g., ‘‘Individual attitudes of immediate family members’’ (e410) or ‘‘Individual attitudes of friends’’ (e420)).

Attitudes of other people. Negative attitudes of other people can hinder the participation of individuals with a variety of communication disorders. For example, other people’s negative attitudes have been identified as a hindrance for people with aphasia (Howe et al., in press b) and as a barrier to workplace participation for people who have dysarthria, laryn- gectomy, hearing loss, fluency disorders, and aphasia (Garcia, Laroche, & Barrette, 2002). Furthermore, children with a specific language impairment (Knox, & Conti-Ramsden, 2003) and adolescents who stutter (Blood & Blood, 2004) reported that they were at greater risk of bullying than individuals without these disorders. A number of studies have identified negative attitudes of others towards people with various communication disorders such as dysarthria (Fox & Pring, 2005) and stuttering (Lass et al., 1992). In contrast to negative attitudes, positive attitudes towards individuals with communication disorders can be facilitative. Positive attitudes of family mem- bers, for example, are a facilitator for people with Alzheimer’s disease (Muo et al., 2005). Further- more, health care providers having a respectful attitude was identified as a key facilitator by people with communication disorders post-stroke (Nordehn et al., 2005). It is noted that the ICF includes a code that specifically refers to the individual attitudes of health professionals (WHO, 2001).

Societal attitudes. In addition to individual attitudes, more general attitudes in society can also influence the functioning of people with communication disorders. For example, Brown et al. (2006) reported that an organizational attitude in a bank of dealing with customers as fast as possible may be a barrier for individuals with aphasia who need more time to communicate.

Other people’s awareness of the communication disorder. Other people’s awareness of the communication disorder is subsumed under the categories of the Attitudes chapter as it is assumed that values and beliefs are the ‘‘driving forces behind the attitudes’’ (WHO, 2001, p. 190). Awareness of aphasia in general was identified as a key facilitator, while lack of awareness of aphasia was reported to be an important barrier for people with aphasia (Howe et al., in press b; Parr et al., 1997). In another example, teachers who participated in a course that focused on speech and language development had more accurate perceptions of the ability levels of students with communication disorders than tea- chers who did not receive training (Ebert & Prelock,

ICF Contextual Factors


1994). Furthermore, negative attitudes of family members were found to be a key barrier for individuals with Alzheimer’s disease (Muo et al., 2005). Family members, however, were found to have a facilitative influence, if they were informed about the progress of the disease and how to cope with it (Muo et al., 2005). Service providers have also identified lack of awareness of aphasia as a key barrier to participation in community settings for people with aphasia (Brown et al., 2006). Although awareness by itself may not necessarily change people’s attitudes, it may be a key precursor for enabling people to develop more positive attitudes toward individuals with various communication disorders. Furthermore, awareness of communication dis- orders such as aphasia may underpin some of the other Environmental Factors. Awareness can influ- ence society’s provision of appropriate services and resources for participation (Elman, Ogar, & Elman, 2000; Simmons-Mackie, Code, Armstrong, Stiegler,

& Elman, 2002). Furthermore, if other people are

not aware that disorders such as aphasia exist, they will not know how to facilitate communication with people who have the disorder (Simmons-Mackie

et al., 2002).

Chapter Five: Services, Systems, and Policies

Services, systems, and policies refer to the social structures, services, and overarching systems that have an impact on individuals. While the other chapters focus mainly on the person’s immediate environment, this domain comprises factors in the broader environment of society. This domain in- cludes work, community, government, transporta- tion, health, and communication services and organizations, as well as the administrative systems that organize, control and monitor services, and laws and formal and informal rules.

Services. Services refer to ‘‘structured programmes,


ployers, associations, organizations, agencies, or government in order to meet the needs of individuals

operations, and services



and includes the persons who provide these services’’


(Schneidert, Hurst, Miller, & U stu¨ n, 2003, p. 591).

A number of services have been identified as being

particularly important for facilitating the parti- cipation of people with communication disorders, including the provision of support groups for people who stutter (Yaruss et al., 2002), and for individuals with aphasia, the availability of driving instructors who are specially trained to communicate with

individuals with aphasia, and the provision of advocates to support the communication of indivi- duals with aphasia in the legal system and in government departments (Howe, 2006; Howe et al., in press b). Furthermore, the provision of rehabilitation and vocational support services is

34 T. J. Howe

associated with positive employment outcome for individuals with traumatic brain injury (Ownsworth & McKenna, 2004). Finally, the avail- ability of speech therapy services has been identi- fied as a facilitator for people with laryngectomies (Richardson et al., 1989) and individuals with aphasia (Howe et al., in press b).

Systems and policies. Systems refer to mechanisms designed to ‘‘organize, control, and monitor ser- vices’’ (WHO, 2001, p. 192). A number of barriers to and facilitators for people with aphasia using public transport systems have been identified. Barriers include being required to communicate the destination and ticket type to obtain a ticket on public transport and having to speak to someone on a telephone to book a taxi (Ashton et al., in press). In contrast, facilitators such as being required to use only one ticket for the whole journey (Ashton et al., in press) or the use of a ticketing system that does not require the person to talk to the bus driver (Howe et al., in press b) have been identified as facilitators. Workplace systems can also influence the func- tioning of people with communication disorders. These systems include procedures necessary to participate in a specific job such as being required to speak over loud noise when teaching. For example, one study found that 38% of teachers indicated that the requirements of teaching had negatively affected their voice (Smith, Lemke, Taylor, Kirchner, & Hoffman, 1998). Environmental Factors in workplaces such as the interview process and costs related to adaptations have also been reported to influence the participation of people with various communication disorders (Garcia et al., 2002). Policies refer to rules and standards that ‘‘govern and regulate the system’’. An example of a policy that is a barrier for people with aphasia is a banking policy that requires that clients be served within a short time period (Howe et al., in press b). An example of a facilitator would include a government policy for providing sufficient funding for people with aphasia after they have had a stroke (Howe et al., in press b).

What Personal Factors are relevant for people with communication disorders?

Personal factors refer to an individual’s features that are not associated with or caused by the person’s health condition (Threats, 2007), but that may have an impact on their experience of the health condition (Bornman, 2004). These factors include gender, race, other health conditions, ethnicity, coping styles, profession, and individual psychological assets (WHO, 2001). Because of the wide social and cultural variation associated with Personal Factors, they are not classified in the ICF. The World Health Organization, however, has called for development of this component in the future (WHO, 2001).

Threats (2007) reports that there has been some confusion in the literature regarding the difference between Personal Factors and Body Functions components in the ICF, particularly in relation to mental functions such as confidence and optimism. The author suggests that one way to differentiate between Personal Factors and Body Functions components in individuals with acquired commu- nication disorders is to determine if the characteristic existed premorbidly. For example, if a spouse indicates that his wife with aphasia was not confident about communicating prior to her stroke and that she continues to lack confidence, this trait may be considered a personal factor. However, if the woman’s husband reported that his wife’s reduced confidence is associated with the onset of her aphasia, this factor may be categorized within the Body Function component. Personal Factors can be divided into potentially changeable and more difficult to change or un- changeable factors. Potentially changeable factors include other health conditions, fitness, lifestyle, habits, coping styles, social background, education, profession, current experiences, overall behaviour pattern and character style, and individual psycho- logical assets. Factors that are unchangeable or difficult to change include age, race, gender, ethnicity, nationality, upbringing, and past experi- ences. Another way to divide these factors is by grouping them broadly into demographic infor- mation (e.g., age, ethnicity, and socioeconomic level) and personality traits (e.g., coping styles) (Threats, 2007). Investigations of Personal Factors in relation to communication disorders are limited relative to Environmental Factor research. Some difficult to change or unchangeable factors that have been investigated include age and gender in individuals with traumatic brain injury, aphasia, and head and neck cancer. The results of these studies, however, are conflicting or inconclusive (Cherney & Robey, 2001; de Graeff et al., 2000; Fleming, Tooth, Hassell, & Chan, 1999; Grosswasser, Cohen, & Keren, 1998; Terrell et al., 2004; Winkler, Unsworth, & Sloan, 2006). Another unchangeable personal factor, pre-injury occupational status, is associated with employment outcome for people with traumatic brain injury. Individuals with higher qualifications and higher pretraumatic brain injury occupational level were more likely to return to competitive employment (Ownsworth & McKenna, 2004). Potentially changeable Personal Factors that have been investigated in individuals with communication disorders include the presence of other health conditions, coping styles, and personality traits. The presence of other health conditions can be a negative influence on the functioning of people with aphasia (Cherney & Robey, 2001) and on the functioning and quality of life of people with head

and neck cancer (de Graeff et al., 2000; Terrell et al., 2004). Coping styles and personality traits are potentially changeable Personal Factors that have been investigated in relation to people who stutter. Individuals who stutter reported that making the transition from unsuccessful to successful manage- ment of their stuttering was associated with variables such as high levels of motivation or determination (Plexico, Manning, & DiLollo, 2005). Continued successful management of stuttering was reported to be associated with psychological assets such as optimism and self acceptance, while unsuccessful management of stuttering was reported to involve themes such as avoidance (Plexico et al., 2005). Clinicians also need to consider how Personal Factors interact with Environmental Factors in a particular individual (Threats, 2007). For example, a personality trait, an example of a personal factor, can influence a person’s self-perception of the benefit of having a hearing aid, an Environmental Factor. In one study, extroverted individuals reported greater hearing aid benefits than individuals with other personality characteristics (Cox, Alexander, & Gray,



Speech-language pathologists need to address both components of Contextual Factors, namely Environ- mental Factors and Personal Factors, in order to provide a holistic approach to intervention for their client’s disability. Although a number of Environ- mental and Personal Factors that are relevant for people with communication disorders have been reported in the literature, further research is needed in this area (Howe, Worrall, & Hickson, 2004; Threats, 2007).


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