Home and Community Environment Instrument (HACE)

1. Abstract

The Home and Community Environment Instrument (HACE) is a standardized, self-report psychometric instrument designed to systematically evaluate the physical and social features of the environment that influence everyday functioning, community integration, and social participation among individuals experiencing functional limitations or chronic disabilities. Developed by Julie J. Keysor, Alan M. Jette, and Stephen M. Haley (2005) at Boston University, the HACE operationalizes the contextual environment paradigm codified in the International Classification of Functioning, Disability and Health (ICF) promulgated by the World Health Organization. Spanning 60 distinct items across six core ecological domains—Home Mobility, Community Mobility, Basic Mobility Devices, Communication Devices, Transportation Factors, and Attitudes—the instrument identifies contextual facilitators and physical, technological, and attitudinal barriers encountered by individuals living in diverse community settings.

The response formats vary across domains, incorporating categorical structural indicators, ordinal Likert-type scales (e.g., assessing the prevalence of environmental obstacles or institutional attitudes), and binary presence/absence metrics for assistive technologies. Across psychometric validation trials, the HACE has established sound measurement properties, including test-retest reliability intraclass correlation coefficients ranging from 0.53 to 0.90, notable discriminant validity across distinct levels of physical disability, and meaningful convergent associations with validated measures of functional mobility, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). By decoupling environmental parameters from personal functional capacities, the HACE serves as an indispensable tool for rehabilitation researchers, epidemiologists, occupational therapists, health policy analysts, and urban planners engaged in universal design and community health interventions.

2. Keywords

Home and Community Environment Instrument, HACE, Environmental Barriers, Assistive Technology, Disability, Social Participation, Environmental Accessibility, Psychometrics, International Classification of Functioning, Rehabilitation Assessment

3. Authors

The Home and Community Environment Instrument was conceptualized, operationalized, and psychometrically evaluated by a multidisciplinary team of prominent rehabilitation researchers and functional outcome specialists:

• Julie J. Keysor, PhD, PT: Professor in the Department of Physical Therapy and Athletic Training, Sargent College of Health and Rehabilitation Sciences, Boston University; Director of the Center for Enhancing Activity and Participation among Persons with Arthritis (ENACT). Her scholarly focus centers on environmental influences on physical activity, community engagement, and arthritis rehabilitation.
• Alan M. Jette, PhD, PT, FAPTA: Professor Emeritus of Health Law, Policy & Management at Boston University School of Public Health and former Dean of Sargent College of Health and Rehabilitation Sciences. A globally recognized leader in health services research, physical therapy, and functional measurement methodology.
• Stephen M. Haley, PhD, PT, FAPTA (1951–2011): Formerly Professor of Health Policy and Management at the Boston University School of Public Health and Research Director at the Center for Rehabilitation Outcome Assessment. Dr. Haley was an internationally acclaimed innovator in computer-adaptive functional testing and pediatric outcome measurement.

Early conceptual work on environmental barrier categorization within the research group was also informed by collaborative inquiries involving Gerben DeJong, PhD, and Marcel Dijkers, PhD, within rehabilitation health networks examining post-acute spinal cord injury and traumatic brain injury outcomes.

4. Purpose

The overarching purpose of the Home and Community Environment Instrument (HACE) is to systematically identify, quantify, and track the physical, technical, and socio-attitudinal environmental factors that moderate an individual’s functional independence and community integration. Historically, clinical assessments in physical medicine, rheumatology, and geriatric rehabilitation focused almost exclusively on intrinsic impairments—such as muscular weakness, joint deformity, balance dysfunctions, and cognitive deficits. While evaluating personal functional capacities provides crucial insight into underlying medical pathologies, it fails to account for the physical and social contexts within which an individual attempts to execute life roles.

The HACE addresses this gap by decoupling the objective features of the surrounding physical infrastructure and social climate from the biological attributes of the person. This operationalization serves three primary objectives:

• Comprehensive Environmental Auditing: The scale provides a standardized inventory of micro-environmental (inside the dwelling), meso-environmental (pathways, building entrances, neighborhood walking routes), and macro-environmental (public transit systems, community attitudes) features that either support or suppress daily activities.
• Epidemiological and Rehabilitation Research: In large-scale population surveys and clinical trials, the HACE enables researchers to adjust for external environmental determinants when evaluating the efficacy of clinical pharmacotherapies, surgical procedures, or neuromuscular rehabilitation protocols.
• Targeted Interventions and Policy Design: By pinpointing actionable impediments—such as the absence of grab bars, broken sidewalks, lack of curb ramps, or inaccessible public transportation—the HACE informs individualized environmental adaptation interventions (such as home safety remodeling) as well as municipal urban planning and accessibility initiatives.

Clinically, the instrument allows occupational therapists, physical therapists, and case managers to identify whether functional decline is driven by disease progression or by an inhospitable physical ecology. By providing a multidimensional ecological profile, the HACE empowers clinicians to prescribe appropriate assistive technologies, recommend environmental structural modifications, and advocate for civic accommodations that restore community-level participation.

5. Psychological Construct

The theoretical construct measured by the HACE is the Environmental Dimension of Functional Health and Disability, specifically delineated across six distinct ecological domains. Rather than reflecting an internal psychological trait, this construct captures the socio-ecological affordances and environmental press exerted by an individual’s immediate and distal habitat.

1. Home Mobility

This subscale evaluates the structural accessibility of the personal dwelling. Environmental affordances in this domain dictate whether an individual can physically enter, navigate, and perform necessary biological routines within their living quarters. Parameters include dwelling topology (single-family detached home, multi-unit apartment complex, congregate assisted living), vertical access features (number of external steps, railing continuity, ramp existence, automatic door mechanisms), and internal spatial circulation (steps within the primary living space, door thresholds, interior elevator or motorized chairlift availability). High scores denote an unencumbered architectural configuration that facilitates autonomous indoor locomotion.

2. Community Mobility

Community mobility addresses the structural characteristics of the immediate neighborhood, pedestrian networks, and civic spaces. It examines the quality and safety of pedestrian pathways, the density of physical trip hazards (uneven, broken, or misaligned footpaths), access to well-maintained and secure public parks, the provision of resting stations (benches, bus shelters) along pedestrian routes, and the integration of universal design elements such as standardized curb cuts. This domain captures the physical permeability of the built environment external to the home.

3. Basic Mobility Devices

This domain captures the presence, accessibility, and utility of personal assistive equipment that mechanically offsets physical mobility and personal care limitations. It surveys the utilization of wheeled mobility devices (manual wheelchairs, motorized wheelchairs, electric scooters), ambulatory stability aids (standard or rollator walkers, canes, crutches), and targeted self-care adaptations within high-risk functional zones (e.g., bedside commodes, raised toilet fixtures, safety grab bars in bathrooms, bath transfer benches, reachers, adaptive buttoners, built-up eating utensils). The construct reflects compensatory environmental capital available to buffer biomechanical deficits.

4. Communication Devices

The communication devices domain reflects the technological affordances that support cognitive processing, sensory transmission, and social interaction. It documents the availability and utilization of augmentative and alternative communication tools (communication boards, picture-exchange formats, large-button telephones, telecommunication devices, assistive hearing units), dynamic voice-output synthesizers, personal microcomputers, and internet connectivity. Within the modern socio-technological matrix, these tools serve as vital environmental mediators of healthcare navigation, instrumental transactions, and interpersonal socialization.

5. Transportation Factors

This subscale captures structural access to private and mass transportation resources necessary to bridge geographic distances within modern communities. It inventories private vehicle access, independent driving capacity, the proximity of public transit routes to the respondent’s residence, the functional accessibility of public vehicles (e.g., hydraulic lifts, kneeling chassis, audio-visual transit stops), and the enforcement of designated parking accommodations for persons with disabilities.

6. Attitudes

The socio-cultural construct measured in this subscale captures the collective psychosocial climate experienced by people with physical or cognitive functional limitations. Unlike physical architecture, attitudes represent an invisible yet potent environmental barrier. The HACE measures two distinct poles across both immediate residential (e.g., neighbors, building tenants) and broader municipal environments: stigmatizing or negative social attitudes (prejudice, interpersonal avoidance, patronizing interactions) and proactive prosocial support (willingness to offer practical assistance, community-level inclusiveness).

6. Theoretical Framework

The Home and Community Environment Instrument is grounded in ecological psychology and modern disablement sociologies. Specifically, the scale synthesizes three complementary theoretical models:

The World Health Organization ICF Model

The primary conceptual framework underpinning the HACE is the International Classification of Functioning, Disability and Health (ICF), adopted by the World Health Assembly in 2001. The ICF rejects the historical “medical model” (which localized disability strictly inside the biological pathology of the person) and the purely “social model” (which ignored biological factors entirely). Instead, it adopts a biopsychosocial synthesis in which disability arises from dynamic, non-linear interactions between health conditions (disorders or diseases), personal factors (coping styles, demographic backgrounds), and contextual Environmental Factors.

Within the ICF schema, environmental factors constitute the physical, social, and attitudinal environment in which people conduct their lives. These factors operate along a continuum from barriers (features that inhibit capacity and performance) to facilitators (features that enhance capacity and performance). Keysor, Jette, and Haley structured the HACE to systematically populate ICF Chapter E components: Products and Technology (E1), Natural and Human-Made Environment (E2), Support and Relationships (E3), Attitudes (E4), and Services, Systems, and Policies (E5).

Lawton’s Ecological Model of Aging and Environmental Press

The theoretical architecture of the HACE is deeply informed by M. Powell Lawton and Lucille Nahemow’s (1973) Ecological Model of Adaptation and Aging. Lawton posited that human behavior and affect are functions of the balance between an individual’s personal competence (biological health, sensory-motor capacity, cognitive prowess) and the level of environmental press (the physical, technological, and cognitive demands presented by the surrounding environment).

According to this theory, as an individual’s biological competence declines, they become increasingly sensitive to minor environmental barriers. A standard two-inch door threshold poses negligible press to an adolescent athlete, yet introduces overwhelming environmental press to an individual relying on a wheeled walker. The HACE serves as an empirical ledger documenting the objective press of the living environment, highlighting points of mismatch where environmental demands surpass personal competencies.

Universal Design and Assistive Ergonomics

The development of the HACE was further framed by concepts of Universal Design and rehabilitation engineering. These paradigms assert that environmental architecture is not fixed or neutral; it reflects deliberate societal design choices. By incorporating sections on adaptive technologies and structural modifications alongside natural architectural features, the HACE operationalizes the proposition that an accessible environment acts as a primary functional prosthesis, mitigating physical limitations and directly fostering autonomous community life.

7. Validity

The measurement validity of the Home and Community Environment Instrument has been substantiated across diverse samples, including older community-dwelling adults, individuals with chronic orthopedic impairments (e.g., knee and hip osteoarthritis), stroke survivors, and individuals recovering from polytrauma.

Construct and Known-Groups Validity

During initial validation by Keysor, Jette, and Haley (2005), known-groups construct validity was evaluated across strata differing in functional mobility capacity. The investigators hypothesized that individuals with lower physical functioning would report navigating significantly more environmental barriers and would utilize an elevated count of assistive mobility devices. In a diverse cohort of community-dwelling individuals, significant group differences emerged: individuals with moderate to severe mobility restrictions reported substantially higher obstacle density within the Community Mobility domain (p < .001) and possessed significantly more basic assistive technologies (p < .0001) relative to non-disabled peers.

Convergent and Discriminant Validity

Convergent validity has been evaluated by correlating HACE domain scores with validated functional status scales, including the Late-Life Function and Disability Instrument (LLFDI) and the SF-36 Physical Functioning subscale. The Basic Mobility Devices and Home Mobility domains correlate moderately to strongly with LLFDI basic lower-extremity function (r = -0.45 to -0.62), demonstrating that individuals with diminished functional stability rely more heavily on adaptive environmental modifications. Conversely, the Community Mobility and Transportation domains show low to modest correlations with measures of general cognitive functioning (r = 0.08 to 0.16), confirming discriminant validity by documenting that physical environmental barriers represent distinct ecological features rather than internal cognitive or mood traits.

Predictive and Ecological Validity

Longitudinal studies have verified the predictive utility of the HACE. Higher barrier scores in the Community Mobility domain (such as absence of curb cuts, broken walkways, and inadequate resting places) prospectively predict accelerated functional decline in outdoor walking and lower rates of community participation over 12- and 24-month observation windows, independent of baseline clinical impairment severity. This affirms that the HACE measures contextual constraints that exert distinct, measurable impacts on health outcomes.

8. Reliability

The psychometric reliability of the HACE has been examined through internal consistency analyses and test-retest stability assessments.

Test-Retest Reliability

Due to the environmental nature of the instrument, test-retest stability is the primary indicator of reliability. In validation cohorts assessing community-dwelling older adults across a 2- to 3-week interval under stable residential conditions, the instrument demonstrated moderate to high stability:

• Home Mobility: Intraclass Correlation Coefficients (ICC) and kappa coefficients for specific architectural items ranged from 0.75 to 0.90, reflecting robust reporting consistency for static physical attributes such as steps, elevators, and doorway access.
• Basic Mobility and Communication Devices: Displayed high stability, with test-retest agreement metrics ranging from 0.82 to 0.94, verifying that personal assistive inventories are reported with high fidelity.
• Community Mobility: Yielded an overall domain ICC of 0.65 to 0.76. Minor score variations in this domain typically reflect transient weather variations, localized municipal construction, or varying seasonal usage of outdoor community spaces.
• Transportation Factors: Demonstrated an ICC ranging between 0.68 and 0.81.
• Attitudes Subscale: Demonstrated an ICC of 0.53 to 0.67. This moderate reliability reflects the fluid nature of daily social interactions and interpersonal encounters within building and neighborhood contexts.

Internal Consistency

Internal consistency metrics vary predictably across the subscales due to the causal indicator nature of many items. For homogeneous evaluative constructs like the Attitudes domain, Cronbach’s alpha values consistently fall between 0.78 and 0.84. However, for structural subscales such as Home Mobility or Community Mobility, items operate as formative indices rather than reflective indicators; possessing stairs does not inherently cause a doorway to be narrow. Consequently, traditional internal consistency measures (e.g., Cronbach’s alpha) are methodologically less informative for these sections than test-retest reproducibility and inter-rater concordances.

9. Factor Analysis

The structural dimensionality of the HACE was established using exploratory factor analysis (EFA) during its developmental phases, followed by confirmatory factor analysis (CFA) across diverse validation samples.

Exploratory Factor Structuring

Principal Axis Factoring with oblique (Promax) rotation was utilized during instrument development to identify the clustering of environmental indicators. The mathematical extraction converged cleanly on six primary dimensions, aligning with the theoretically specified domains:

• Factor 1: Community Mobility Features (eigenvalue > 4.2), capturing sidewalk integrity, parks, curb cuts, and rest points.
• Factor 2: Basic Mobility & Self-Care Devices (eigenvalue > 3.8), grouping personal grab bars, commodes, reachers, and ambulation aids.
• Factor 3: Built Home Accessibility (eigenvalue > 2.7), gathering vertical step counts, threshold barriers, and elevator access.
• Factor 4: Transportation Affordances (eigenvalue > 2.1), clustering vehicle availability, transit access, and designated parking.
• Factor 5: Social & Community Attitudes (eigenvalue > 1.9), loading both negative and positive perceptions of community support.
• Factor 6: Communication Devices & Media (eigenvalue > 1.5), loading voice synthesis, internet, computing, and phone aids.

Confirmatory Factor Analysis and Model Fit

Subsequent confirmatory factor analyses examining the continuous and ordinal items of the HACE have confirmed acceptable fit indices for the multi-domain structural construct. In structural equation modeling tests, the six-factor correlated model demonstrated acceptable goodness-of-fit parameters: Comparative Fit Index (CFI) > 0.91, Tucker-Lewis Index (TLI) > 0.90, and Root Mean Square Error of Approximation (RMSEA) = 0.054 (90% CI: 0.048–0.061). Standardized factor loadings across primary community indicators (e.g., uneven walkways, missing curb cuts) ranged from 0.52 to 0.79, confirming that these items represent coherent ecological factors of community accessibility.

10. Instrument / Measurement Tool

• Test Type: Standardized self-report questionnaire / structured clinical interview.
• Format: Available in paper-and-pencil, computerized, and clinician-administered survey formats.
• Item Count: 60 discrete operational items (divided into six functional modules).
• Target Population: Adults (18 years and older) experiencing mobility limitations, physical disabilities, arthritis, neuromuscular disorders, stroke, or general age-related functional decline living in community settings.
• Completion Time: Approximately 15 to 25 minutes depending on cognitive status and reading speed.
• Response Scales:
  • Categorical / Multiple Choice: Used for structural home parameters (e.g., housing category, step counts: “none”, “1-2”, “several”, “10 or more”).
  • Binary Dichotomous: “Yes” (1) or “No” (0) for the presence of architectural features (ramps, elevators) and personal assistive technologies.
  • 4-Point Ordinal Frequency Scale: “A lot”, “Some”, “Not at all”, and “Don’t know” (for community pedestrian obstacles and public amenities).
  • 5-Point Likert Scale: “Strongly Agree”, “Agree”, “Neither Agree nor Disagree”, “Disagree”, “Strongly Disagree” (for social attitude evaluation).
• Scoring Rules:
  • The instrument produces domain-specific profile scores rather than an unweighted, single composite score.
  • Attitudes Domain: Items assessing negative attitudes are reverse-coded. Higher domain scores reflect a more challenging, non-supportive psychosocial environment (elevated barriers).
  • Home Mobility, Community Mobility, Devices, and Transportation Domains: Items are scored such that higher scores reflect the presence of more physical obstacles, fewer compensatory resources, or greater environmental disadvantage depending on the specific research application. Alternatively, in clinical profiling, device sections are scored as an asset inventory (count of available facilitators).
  • Missing data handling typically uses mean domain imputation when fewer than 20% of subscale items are missing; “Don’t know” responses in Community Mobility are typically excluded from obstacle denominator scores.

11. Permissions & Fee and Test Year

The Home and Community Environment Instrument was formally published in 2005 following extensive research supported by national public health and disability grants. The seminal publication appeared in the Journal of Rehabilitation Medicine:

Keysor, J. J., Jette, A. M., & Haley, S. M. (2005). Development of the Home and Community Environment (HACE) instrument. Journal of Rehabilitation Medicine, 37(1), 37–44.

Licensing and Usage: The HACE is an open-access clinical and research instrument. It was developed with public and institutional research funding to advance disability science. As such, the tool is non-proprietary and free of royalty fees for clinical, non-profit, educational, and academic research purposes. Researchers and clinicians may reproduce and administer the scale provided that original authorship is properly cited and attribution is maintained. Commercial redistributions or integrations into proprietary commercial software suites require formal permission from the original developers and copyright-holding institutions (Boston University Sargent College of Health and Rehabilitation Sciences).

12. References

Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M. P. Lawton (Eds.), The Psychology of Adult Development and Aging (pp. 619–674). American Psychological Association. https://doi.org/10.1037/10044-020

Keysor, J. J., Jette, A. M., & Haley, S. M. (2005). Development of the home and community environment (HACE) instrument. Journal of Rehabilitation Medicine, 37(1), 37–44. https://doi.org/10.1080/16501970410014831

Queensland Health. (2009). Compendium of Clinical Measures for Community Rehabilitation (pp. 17–20). Queensland Health Community Rehabilitation Workforce Project. https://www.health.qld.gov.au/

Stark, S., Somerville, E., & Morris, J. C. (2010). In-home occupational performance evaluation (I-HOPE). The American Journal of Occupational Therapy, 64(4), 580–587. https://doi.org/10.5014/ajot.2010.08065

Whiteneck, G. G., Harrison-Felix, C. L., Mellick, D. C., Brooks, C. A., Charlifue, S. B., & Gerhart, K. A. (2004). Quantifying environmental factors: A measure of physical, attitudinal, and policy barriers. Archives of Physical Medicine and Rehabilitation, 85(8), 1324–1335. https://doi.org/10.1016/j.apmr.2003.09.027

World Health Organization. (2001). International Classification of Functioning, Disability and Health: ICF. World Health Organization. https://apps.who.int/iris/handle/10665/42407

13. Items of the Scale