Abstract
The main objective of this study was to evaluate the measurement structure of the Multiple Sclerosis Environmental Supports Scale (MSESS) with 248 individuals with multiple sclerosis (MS). Exploratory factor analysis yielded three reliable factors (health and mental health services; rehabilitation, social, and support services; and independent living supports). The MSESS appears to be a promising rehabilitation assessment tool for individuals with MS, one that can be used by rehabilitation counselors to evaluate environmental support factors in their interview, assessment, and rehabilitation planning protocols.
Keywords
Community integration and participation are fundamental human rights and important to the health and well-being of people with multiple sclerosis (MS) and other forms of chronic illness and disability (CID; Chan, Sasson, Ditchman, Kim, & Chiu, 2009; Chan, Tarvydas, Blalock, Strauser, & Atkins, 2009; Kratz et al., 2016). Due to the progressive, unpredictable, and disabling nature of MS and its negative impact on physical functioning, mental health, and social participation (Kwiatkowski et al., 2014; Ng, Amatya, & Khan, 2013), individuals with MS have lower community participation in comparison with the general population (Khan & Pallant, 2007). Chan, Tarvydas, et al. (2009) suggested that the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), with its emphasis on the importance of personal and environmental contextual factors on community participation and health-related quality of life, can be used as a rehabilitation assessment, plan development, and intervention model for people with CID. They underscored the need to consider environmental factors as mediator and moderator variables in the development of effective health self-management, psychosocial, and vocational interventions and outcomes to promote community participation.
Environmental factors, such as the physical, social, and attitudinal environments, can influence community participation for individuals with MS (Coenen et al., 2011; Hamed, Tariah, & Hawamdeh, 2012; Jones & Amtmann, 2014; Plow, Finlayson, Gunzler, & Heinemann, 2015). Specifically, there is a positive relationship between social support and higher levels of community participation and integration (Yamout et al., 2013). Similarly, assistive technology reduces the negative impact of cognitive and physical impairments on everyday functioning (Johnson, Bamer, Yorkston, & Amtmann, 2009), and environmental supports such as accessible health care, psychological counseling, and vocational rehabilitation interventions are core facilitators of employment participation for individuals with MS (Chiu, Chan, Bishop, da Silva Cardoso, & O’Neill, 2013; MS International Federation, 2016). Hence, maximizing community participation outcomes of people with MS requires an assessment of their environmental support needs as an essential component of the rehabilitation process (Heinemann et al., 2014). However, there is a paucity of environmental support measures developed and validated specifically for people with MS. To date, there is no well-validated, comprehensive measure of environmental support for people with MS.
Purpose of the Study
The purpose of this study was to validate the measurement structure and psychometric properties of the Multiple Sclerosis Environmental Supports Scale (MSESS) using exploratory factor analysis (EFA). A reliable and valid measure of environmental supports will aid rehabilitation counselors working with people with MS in evaluating this important determinant of community participation and, thereby, in developing tailored rehabilitation interventions to facilitate more active community participation.
Method
Participants
Two hundred forty-eight individuals with MS (36 men and 212 women) were recruited for this study. Participants ranged in age from 23 to 69 years (M = 44.85, SD = 11.19).
Procedures
Adults with MS were recruited from the Washington, D.C., and Wisconsin chapters of the National Multiple Sclerosis Society (NMSS). Inclusion criteria consisted of individuals being 18 years or older and with a diagnosis of MS. The study was advertised via monthly electronic newsletters, and a single round of direct email solicitation to NMSS members. Participants were provided a link to an anonymous online survey via Qualtrics, or an option to complete the survey by paper and pencil, or over the phone. The survey included an informed consent in accordance with the University of Wisconsin–Madison Institutional Review Board requirements. Participants who completed the online survey received a US$15 gift card upon completion of the study.
Measures
MSESS
The MSESS was developed specifically for assessing the environmental support needs of people with MS based on a comprehensive review of the ICF and MS literature. Following Crocker and Algina’s (2006) and Kline’s (1986) recommended test construction procedures for developing and validating clinical assessment instruments, three rehabilitation researchers with expertise in MS developed the test specifications. The test specifications were used by the researchers to define the environmental support domains, who wrote items for each domains in the specifications, reviewed and revised items, collected data to test the items, and determined statistical properties of item scores. Researchers also performed EFA following Floyd and Widaman’s (1995) procedures to identify the number of underlying dimensions in the data. The test specifications of the MSESS composing of five a priori categories/domains were created and each category was populated with items representing each construct; they are, (a) health care and related services, (b) social services, (c) mental health services, (d) vocational rehabilitation services, and (e) community living supports (Chan & Pfaller, 2016). The initial draft of the MSESS was composed of 20 items. Item analyses and EFA indicated three items can be eliminated. The final version of the MSESS comprised 17 items and each item is rated on a 5-point Likert-type agreement scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Impact on Participation and Autonomy Questionnaire (IPA)
The IPA was developed by Cardol, Haan, van den Bos, de Jong, and de Groot (2001) to assess the concept of community participation as defined by the ICF. It is comprised of 32 items and has five subscales (e.g., “my chances of getting around in my house where I want to are” and “my chances of visiting relatives and friends when I want to are”). The five subscales include (a) Autonomy Indoors, (b) Family Role, (c) Autonomy Outdoors, (d) Social Life and Relationships, and (e) Work and Education. Each item is rated on a 5-point Likert-type scale ranging from 0 (very good) to 4 (very poor). Items are reverse-scored so that high scores indicate high levels of participation. Internal consistency reliability coefficient estimates (Cronbach’s α) range from .81 to .91 (Cardol et al., 2001).
Results
EFA
Based on the recommendation of Floyd and Widaman (1995), a principal components analysis of the 17 × 17 MSESS correlation matrix was performed to evaluate the factorial validity of the MSESS. The Kaiser–Meyer–Olkin test resulted in a sampling adequacy of .87, and the Bartlett’s test of sphericity was significant, χ2(136, N = 248) = 1,807.33, p < .001, indicating that it was appropriate to proceed with EFA. Kaiser–Guttman’s “eigenvalues greater than one” rule and Cattell’s scree test (Nunnally & Bernstein, 1994) both indicated a three-factor measurement structure that accounted for 54% of the variance. The three-factor solution was rotated to simple structure using the promax procedure. Items with factor loadings greater than .40 in one factor and less than .30 in other factors were retained. Means, standard deviations, and factor loadings for the MSESS are presented in Table 1. As can be observed, these factors were parsimonious, interpretable, and meaningful and were labeled as follows:
Means, Standard Deviations, Factor Loadings and Communalities for the Multiple Sclerosis Environmental Supports Scale.
Note. Factor loadings ≥ .40 are bold-faced. MS = multiple sclerosis; Factor A = health and mental health services; Factor B = rehabilitation, social, and support services; Factor C = community living supports; SSDI = Social Security Disability Income.
Factor A—Health and mental health services
Factor A comprises seven items representing a combination of the health care and related services and mental health services categories. This factor reflects health care access and quality, accounting for 37.39% of the total variance. The internal consistency reliability coefficient (Cronbach’s α) was .88.
Factor B—Rehabilitation, social, and support services
Factor B comprises five items representing a combination of the social and vocational rehabilitation services categories. This factor reflects individuals’ perceived support and access to rehabilitation and social services, accounting for 8.42% of the total variance. Cronbach’s alpha was .72.
Factor C—Community living supports
Factor C comprises five items representing the community living support categories. This factor reflects individuals’ perceived levels of support in their living environments, accounting for 8.05% of the total variance. Cronbach’s alpha was .64.
External Correlates
A correlational analysis was conducted to examine the relationship of the three factors with community participation. Community living supports (r = .53, p < .01); rehabilitation, social, and support services (r = .36, p < .01); and health and mental health services (r = .33, p < .01) were all positively associated with community participation.
Discussion
Individuals with MS experience difficulties in multiple life domains, including physical, cognitive, psychosocial, behavioral, and environmental challenges (Ng et al., 2013). For example, mobility can be a barrier for individuals with MS and limit social activities in the community (Kratz et al., 2016). People with MS report limited community participation (Khan & Pallant, 2007), which stands as a threat to their long-term health. Conversely, community participation and integration promote health and well-being. Reducing environmental barriers and providing supportive environments can improve participation in individuals with CID (Whiteneck et al., 2004). Presently, the multisymptomatic effects of MS and the capricious disease process leave far too many people with MS unemployed, isolated from friends and family members, and disengaged from their communities (Rumrill, 2015). Within the ICF framework, environmental supports are essential to support people with MS to participate actively in their communities. Research has suggested that environmental factors are important to measure one’s participation because they indicate how people interact with the environment when performing life activities (Noreau & Boschen, 2010). In addition, increased environmental barriers were associated with lower participation in individuals with MS (Plow et al., 2015). Therefore, rehabilitation counselors can provide more effective services by considering the environmental support factors in people with MS. In this study, we validated the MSESS as an assessment of environmental support needs of people with MS. EFA results indicated that the five a priori categories could be better represented by three underlying factors in the data. Each factor of the MSESS was significantly associated with community participation suggesting that individuals with MS can benefit from receiving these environmental support services to improve their community integration and participation. Because the MSESS was developed based on the ICF framework, it can also be utilized by rehabilitation researchers to evaluate the contribution of environmental supports in the ICF vocational rehabilitation model. The main limitation of this study was that a convenience sample of individuals with MS who belonged to NMSS chapters was used that may limit generalizability. In addition, although the internal consistency reliability of the three NMSS subscales are within the acceptable range for brief psychometric measures, additional items should be considered in future research to increase the MSESS’ reliability and validity for use in developing and evaluating environmental supports for persons with MS.
Footnotes
Authors’ Note
The ideas, opinions, and conclusions expressed are those of the authors and do not represent recommendations, endorsements, or policies of the U.S. Department of Health and Human Services.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The contents of this article were developed with support from the Rehabilitation Research and Training Center (RRTC) on Employment of People with Physical Disabilities. The RRTC was funded by the National Institute on Disability, Independent Living and Rehabilitation Research Grant H133B13001 to Virginia Commonwealth University.