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Importance of Environmental Assessment in Health Care of Old and Disabled Persons

Hana M. Hermanova, WHO Regional Office for Europe, Copenhagen, Denmark

Introduction

The World Health Organization launched a worldwide policy "Health for All by the Year 2000", aimed at enabling everybody to lead socially and economically productive lives by the end of this century. The old and the disabled, who are often deprived of full enjoyment of life, are the groups given particular attention in this movement. The WHO Regional Office for Europe has a modified strategy for Health for All, supported by 38 regional targets. One of the targets (Target 3) bearing the slogan "Better opportunities for disabled persons" aims at the equalization of opportunities for disabled persons and their full participation.

To support the monitoring process, a list of regional indicators has been proposed to measure progress in the European Region towards health for all and more specifically towards the attainment of the regional targets. Many of the proposed indicators are already part of health information systems in most countries. Data on others may be missing. Some indicators call for special data collection through sample surveys, some indicators require development of basic methodologies for data collection. The field of disablements (regardless of age) is one of the areas where relevant information is missing.

Information Strategy

The World Health Organization developed an experimental International Classification of Impairments, Disabilities and Handicaps (WHO, Geneva 1980). The underlying concept of this classification of impairment (at organ level), disability (at functional level) and handicap (at social level - disadvantage for the individual) has been found useful. The environment, both physical and social, determines the degree of disability and, almost entirely, the extent of the handicap. Methodologies currently available usually assess the affected individual only, and do not take into account the parameters of the physical and social environments.

System "Man-Environment" - Social Homeostasis

Every human being, in health and/or in disease, is a personality determined by the environment in which he or she grows up and lives. Only the person, who adapts to the requirements of the environment, is independent. In other words, there is a system of balance between the needs of a person and the requirements of his/her physical and social environment, identified as "social homeostasis"

If a person is unable to respond to the requirements of the environment due to disease or disability, the system deteriorates (crisis). Both components, man and environment, are in a permanent state of change and development. A methodology assessing this dynamic coexistence has not yet been developed.

Assessments in General

In order to assess the disablement of an individual, a whole series of information is needed, in particular:

a) About the individual:

• State of health (clinical).
  State of health as reflected in the functioning of systems important for independent life (e.g. intellectual, vision, hearing, speech, mobility).

b) Performance of activities of daily living (interaction man-environment) .

c) Socio-economic circumstances.

d) Environmental constraints (interior and exterior of household).

Physical Environment in General

A new discipline, ecology and ecological psychology, has evolved in the last decade. It tries to interpret environmental influences upon human lives.

Every individual has close ties with the environment. The environment of an infant is reduced to a few square meters. Personality development is accompanied by a broader environmental exploration and the home becomes a refuge. This situation persists up until the age of 70-74. After this age the functional capacities of a person deteriorate due to the aging process. The environment is reduced to a few square meters again. The environment can be stimulus, source of orientation and security, but also enemy.

Physical Macro-Environment and Micro-environment

Availability of services, particularly shops and transport, are important characteristics of the macro-environment and influence activities of daily living. Simple standard guidelines on the assessment of the exterior of the household in urban and rural areas are missing in most schemes.

The interior of the household is getting more attention. The following information is usually available:

Type of residence such as rental apartment, own house, single or shared accommodation. Living in and maintaining one’s own house can exceed the functional abilities of a disabled or old person. A big apartment or house brings a lot of work. Too small an apartment or shared accommodation could lead to a loss of privacy.

Electricity, mainstream water, indoor toilet are recognized as vital for the existence of an individual in a given environment. Bathroom, telephone, refrigerator have become just as vital during the second half of the 20th century.

Heating should be given great attention. Central heating enables survival in households of very disabled people.

Lifts are vital for persons with mobility problems, internal diseases, cardiovascular or respiratory conditions, etc. A disabled person could easily become a prisoner in his own home if a lift is not available!

Macro-environment:

steep streets, poor surface, high steps, no ramps, busy crossings with heavy traffic, flight of stairs without railings, poor lighting , noise.

Micro-environment:

poor lighting, high humidity, dust, slippery floors, thresholds, poor electrical installations, inadequate storage of food. Too much space, too little space. Vital equipment missing.

Some Suggestions for Future Action

The implementation of the slogan "Better Opportunities for Disabled Persons" has to be supported by an adequate information base. Important information is generated by assessing health and functional status of the disabled/old client, ADL performance, and physical and social environment.

While there are many evaluation schemes of the functioning of the old and/or disabled person, there are literally no schemes for assessing the physical environment. Simple guidelines for evaluating the macro-and micro-environment should be offered to providers of health and social services in the near future.

Methods for interpreting the interaction between the individual and his environment have to be developed. (A checklist of environmental components, to be taken into account is attached in the appendix for discussion). Creating a simple standard tool in environmental assessment universally applicable in most Member states remains one of the important tasks for the near future.

Appendix: Checklist of Environmental Components Important in Assessing Disability

Physical environment - household interior:

Residence - owner, tenant

Type of residence

Number of persons per room

Cold water

Electricity

Indoor toilet

Gas

Heating - central, electrical, gas, coal

Refrigerator

Bathroom - cold/hot water, shower, bath

Telephone.

Steps/flights of stairs

Lift

Shopping - within walking distance (5-15 minutes)

Neighbor/family on same floor

Ability to handle income

Social environment (neutral, friendly, supportive, hostile, overprotective)

Assistance available for cleaning, shopping, laundry, meals

Frequency of assistance