Relationships and gender differences within and between assessments used in Swedish home rehabilitation – a cross-sectional study

Home rehabilitation programmes are increasingly used around the world to reduce disability in everyday life due to ageing or health conditions and to promote independent living [1‐5]. A home rehabilitation programme is usually a person-centred intervention that includes a comprehensive assessment and is led by multidisciplinary teams [6‐8]. As health conditions addressed in home rehabilitation vary, practitioners gain from comprehensive assessments in their daily practice, which allow them to evaluate the progress and effects of rehabilitation interventions [4, 9, 10]. Assessment of functioning is a complex and multifaceted process, since diagnoses, tasks and environments interact and impact on function and activities in different ways [9]. Several gendered factors can also cause differences in health conditions for men and women, especially in old age [11‐13], and this could influence assessment outcomes through measurement methods. For example, women are generally at higher risk than men of developing chronic conditions, with subsequent long-term physical impairments and limitations in functioning [14‐16]. Self-reported assessments could also be influenced by gender roles, so it is argued that objective measures (i.e. physical performance as observed by staff) are more likely to present gender-neutral assessments [17]. A study found that while there were no significant differences in the physical performance of men and women based on staff assessments, women self-reported a higher incidence of disability in activities of daily living (ADL) and mobility than men over time [18].

To ensure that assessments are valid, reliable and in line with evidence-based practice, standardised assessment instruments should be used [9]. There are three categories of assessment that are commonly used in home rehabilitation programmes to examine a person’s functioning and need for rehabilitation: 1) standardised examinations and tests (hereafter standardised tests), where staff assess the person’s functioning through observation, using specific pre-determined criteria, 2) questionnaires, where standardised self-assessment questions are used, and 3) patient-specific instruments, where the person identifies his or her own rehabilitation goals as well as assesses the outcome of the interventions [4, 19]. Unstructured observations are however still commonly used by occupational therapists and physiotherapists [10, 20‐22]. Lack of knowledge, confidence and support regarding which assessment instruments to choose in different clinical settings [10, 11] may explain the use of unstructured rather than structured assessments. Moreover, there is no overall agreement on which specific instruments that should be used within home rehabilitation programmes [6, 21].

When using a range of instruments, it is vital to know how the instruments relate to each other and the different aspects covered by each. Gender differences in functioning and possible differences between self-reported and standardised tests need to be considered when planning which assessment instruments and evaluation methods to use in home rehabilitation practice [15, 16, 21, 23]. In this study, we aimed to explore relationships between standardised tests and a questionnaire used in a municipal home rehabilitation context, and we specifically studied whether there were gender differences within and between assessments.

The aim of this study was to investigate relationships between assessments from standardised tests and a questionnaire and to determine if there were gender differences, both within and between the assessment instruments used. We found that women were assessed to be more independent regarding the IADLs of cooking and housework compared to men. We argue that this may not only be due to differences in functioning but may also be an effect of traditional gender roles. Other studies likewise show that women are still more often engaged in these IADLs than their male partners [37, 38]. The fact that we found no such gender differences between men and women living alone and that cohabiting women were more independent in IADL cooking, could also support this explanation. In our study, like previous studies [38‐40], the majority of men lived with someone (for example a wife taking care of cooking) while the female participants mostly lived alone. Bias could therefore have played a role in the score setting, if women were assessed by their functioning and men by their knowledge or skills in certain household activities [17]. A similar finding was observed in a study that concluded that men and women were not equivalently observed on IADLs [41]. The ADL test used in the intervention did not include traditional “male chores” (e.g., car care and minor household repairs). Our findings call for using instruments that target a wider range of daily chores, to avoid gender-biased results in assessments of ADL ability, and to support gender-equal practice in line with health and social service policies [42]. It is important to take in consideration that gender differences in household activities are expected to decrease through generations. Further research should therefore analyse whether different age cohorts lead to different results.

Another interesting result in our study is that the staff’s assessment of IADL was consistent with women’s self-assessment in the EQ-5D-5 L dimension usual activities but not the men’s self-assessments. This may indicate that men thought of other activities outside IADL when responding to the EQ-5D-5 L dimension usual activities. For example, a previous study found differences in how older persons use their mobility outside the home. They found that men engaged in more leisure activities such as sports, whereas women were more engaged in IADL [37]. It has also been suggested that older women find household activities more interesting and meaningful than men do [38]. What typical “meaningful activities” can be may be gendered. Thus, the gendered dimensions of the IADLs measured in standardised tests highlight the importance of individual goal-setting, for example with patient-specific instruments, where goals related to the person’s own context also are likely to be identified in the home rather than in the clinical context. For example, Canadian Occupational Performance Measure (COPM) is a patient-specific instrument relevant to use in home rehabilitation programs that helps the person to identify meaningful, everyday activities during the goal-setting process [4].

We found that correlations between the three assessment instruments were weak to moderate. For example, the concordance between Sunnaas ADL and GMF upper limb functions was particularly low, and with the Bonferroni correction test most of the significant relationships disappeared. An explanation could be that the participants had physical impairments but still managed to be independent in ADL. If so, this indicates that a performance-based standardised test of physical function poorly predicts the performance of more complex ADL situations [12]. In addition, we found a gender difference in motor functioning in reaching down and touching one’s toes during PADL and climbing stairs, to the men’s advantage. This could be explained by the fact that most women in our study suffered from orthopaedic conditions and multimorbidity, which also included long-term chronic diseases affecting their motor functioning to a greater extent than for men [15, 16]. When it comes to the two standardised tests measuring ADL and motor functions, the mobility variables tend to overlap each other. A suggestion for the home rehabilitation team could therefore be to choose broad standardised tests that covers more than just mobility aspects.

We found no differences in how men and women self-report their perceived health in three of the EQ-5D-5 L dimensions. Our results contrast with the notion that women generally over-report and men under-report health problems, but is in line with a recent study suggesting otherwise [43]. However, we found a difference between EQ-5D-5 L and the standardised assessment with GMF, with a few weak statistically significant correlations between them. This result is in line with previous studies which suggest that physical functioning measured by staff on the one hand, and self-reported measures of physical functioning on the other hand do not measure the same construct [12, 13]. Another possible explanation for the difference could be that self-reported estimates are influenced by emotional, psychological and environmental factors that are not present in standardised tests assessing more specific aspects of functioning [13]. Additionally, not all physical impairments lead to functional limitations or experienced disability. There is thus an added value to measuring people’s subjective experience of health besides objective measurements of function and activity. Our results suggest the importance of combining all the three types of assessments (standardised examinations, self-assessment questionnaires and patient-specific instruments) in home rehabilitation, to ensure complementary information is obtained. This would provide a wider overall picture of the person’s situation [4] and to capture functional improvements that are not self-reported [11].

In our study we have analysed data from a real-life setting with a comprehensive structured assessment implemented in everyday practice. However, as previously described, there are factors that hinder the use of standardised assessment instruments in practice [10, 11] and this needs to be addressed when implementing home rehabilitation programs. In our study, we have also analysed data from assessments instruments used by an interdisciplinary team. Together, the instruments target body functions, activity, and participation in line with The Geriatric ICF Core Set. The Geriatric ICF Core Set is developed from WHO’s International Classification of Functioning, Disability and Health (ICF) to reflect the most relevant health-related problems of community-dwelling older adults [44]. Home rehabilitation programs often also include assessments from other health care/care providers. Thus, to avoid fragmented care, The Geriatric ICF Core Set could be used as a framework to unify the assessments of older adults’ functioning and disability as their health is a multidimensional construct [44]. Further research on the associations between The Geriatric ICF Core Set and instruments used in home rehabilitation settings is needed.

The use of comprehensive assessments, especially when gender aspects are considered, allows subtle differences in functional abilities in the older population to be better captured [4, 40]. Our result indicates that standardised tests alone do not capture all dimensions of functioning. The differences between the self-reported questionnaire and standardised test outcomes shows the importance of combining these categories of assessments instruments to capture different perspectives. To obtain a person-centred intervention focusing on meaningful activities a patient-specific instrument should also be included in the assessment battery. Further research is needed on which specific instruments within the categories to use in home rehabilitation programs for a gender-neutral practice.