Environmental barriers and facilitators: impacts on the functionality of institutionalized and community-dwelling older adults

Abstract

Objective  "Individual attitudes of acquaintances, peers, colleagues, neighbors, and community members" were predictors of disability in NI individuals (OR 5.25; CI 1.40–20.72; p=0.01). Pain was a predictor in both groups (NI- OR 3.65; CI 1.22–8.21; p=0.01 and I- OR 10.06; CI 2.47–40.93; p<0.001). Polypharmacy increased the likelihood of disability in I individuals (OR 4.59; CI 1.05–20.05; p=0.04), while self-rated health was a predictor for NI individuals (OR 3.10; CI 1.01–9.51; p=0.04).

Method  "Individual attitudes of acquaintances, peers, colleagues, neighbors, and community members" were predictors of disability in NI individuals (OR 5.25; CI 1.40–20.72; p=0.01). Pain was a predictor in both groups (NI- OR 3.65; CI 1.22–8.21; p=0.01 and I- OR 10.06; CI 2.47–40.93; p<0.001). Polypharmacy increased the likelihood of disability in I individuals (OR 4.59; CI 1.05–20.05; p=0.04), while self-rated health was a predictor for NI individuals (OR 3.10; CI 1.01–9.51; p=0.04).

Results  "Individual attitudes of acquaintances, peers, colleagues, neighbors, and community members" were predictors of disability in NI individuals (OR 5.25; CI 1.40–20.72; p=0.01). Pain was a predictor in both groups (NI- OR 3.65; CI 1.22–8.21; p=0.01 and I- OR 10.06; CI 2.47–40.93; p<0.001). Polypharmacy increased the likelihood of disability in I individuals (OR 4.59; CI 1.05–20.05; p=0.04), while self-rated health was a predictor for NI individuals (OR 3.10; CI 1.01–9.51; p=0.04).

Conclusion  Institutionalized older adults face greater functional challenges in mobility, self-care, and social participation but benefit from structured routines and professional care. Non-institutionalized individuals, despite being more autonomous, encounter barriers such as social isolation and limited access to healthcare, negatively impacting their functionality.

Keywords
Older Adults; Homes for the Aged; Independent Living; International Classification of Functioning; Disability; and Health

Resumo

Objetivo  Comparar a influência de fatores ambientais na funcionalidade de pessoas idosas institucionalizadas (I) e não institucionalizadas (NI).

Método  Estudo transversal com 208 pessoas realizado entre 2020 e 2021. A caracterização sociodemográfica incluiu: sexo, idade, estado civil, escolaridade, peso, altura e hábitos de saúde; a funcionalidade, avaliada pelo WHODAS 2.0 de 36 itens, incluiu os domínios: cognição, mobilidade, autocuidado, relações interpessoais, atividades de vida e participação social; e o impacto ambiental foi mensurado por um formulário baseado em 20 categorias dos Fatores Ambientais da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF), validado por especialistas. As análises estatísticas envolveram testes Qui-quadrado, Exato de Fisher e U de Mann-Whitney. Modelos de regressão logística univariada e multivariada identificaram preditores de incapacidade, com p<0,2 para inclusão e significância de 5%

Resultados  As "atitudes individuais de conhecidos, companheiros, colegas, vizinhos e membros da comunidade" foram preditoras de incapacidade nos NI (OR 5,25; IC 1,40-20,72; p=0,01). A dor foi preditora nos dois grupos (NI- OR 3,65; IC 1,22–8,21; p=0,01 e I- OR 10,06; IC 2,47–40,93; p<0,001). A polifarmácia aumentou a chance de incapacidade para I (OR 4,59; IC 1,05–20,05; p=0,04), enquanto a autoavaliação de saúde para NI (OR 3,10; IC 1,01–9,51; p=0,04

Conclusão  Pessoas idosas institucionalizadas têm maiores dificuldades funcionais em mobilidade, autocuidado e participação social, mas se beneficiam de rotinas estruturadas e cuidados profissionais. Não institucionalizados, embora mais autônomos, enfrentam barreiras como isolamento social e acesso limitado a cuidados de saúde, impactando negativamente sua funcionalidade.

Palavras-Chave:
Pessoa Idosa; Instituição de Longa Permanência Para Idosos; Vida Independente; Classificação Internacional de Funcionalidade; Incapacidade e Saúde

INTRODUCTION

As people age, their ability to maintain functional independence becomes increasingly shaped by environmental factors¹. Environmental barriers in homes and public spaces have been shown to negatively influence the health and well-being of older adults. Examples include architectural obstacles, property deterioration, lack of accessibility, unsafe streets, inadequate transportation, and difficulties accessing healthcare services².

In older populations, particularly those in institutionalized settings, barriers such as limited mobility, restricted access to healthcare, and social isolation can significantly reduce quality of life. Conversely, facilitators such as strong family support, positive societal attitudes, and accessible infrastructure can mitigate these challenges and promote autonomy³,⁴. Understanding the diverse impacts of environmental factors on functionality and how they affect older adults in different settings, such as those living in institutions or within the community, is essential for developing strategies that enhance their functionality and overall well-being, enabling them to live safely and independently⁵.

In Brazil, the accelerated population aging presents a unique challenge. While many older adults remain in community settings, a significant portion is institutionalized due to poor health, lack of family support, or financial constraints⁶. Institutionalization often results in greater dependence on caregivers and reduced daily autonomy, negatively affecting social engagement and self-care⁷. However, the environmental conditions in these settings, such as structured routines and professional care, can provide significant support that is often absent in community environments. Structured routines and management support in institutions promote better care outcomes, offering personalized and humanized attention that can alleviate the challenges faced by older adults⁸.

The International Classification of Functioning, Disability and Health (ICF), published by the World Health Organization (WHO) in 2001, provides a standardized framework for documenting human functionality. Organized into components such as body functions, body structures, activities and participation, and environmental factors, it employs a universal coding system and quantifiable scales to classify functionality across the lifespan⁹. Unlike traditional health models, the ICF emphasizes that disability arises from the interaction between intrinsic health conditions (e.g., body functions, body structures, and activities and participation) and extrinsic factors (e.g., environmental and personal factors)¹⁰,¹¹. This approach has become an essential tool for understanding functionality in older adults, offering critical insights into how elements such as nutrition, mobility aids, and access to care shape daily life and the quality of care in institutionalized and non-institutionalized populations¹²-¹⁴.

This study aims to compare the impact of environmental barriers and facilitators on the functionality of institutionalized and non-institutionalized older adults in Brazil. Using the ICF framework, the research seeks to identify the environmental factors that most affect functionality, with the goal of informing future interventions and policies to improve the quality of life and autonomy of older adults in different living contexts.

METHOD

This cross-sectional study included 208 older adults (aged over 60 years old) residing either in Homes for the Aged or community settings in southern Brazil, specifically in the municipality of Curitiba and its metropolitan region. Participants were selected through convenience sampling. For the non-institutionalized group, a list of 308 participants from a community center in the metropolitan region was used. After contact attempts and refusals, 104 non-institutionalized older adults were recruited. To balance the groups, an equal number of 104 institutionalized participants were selected from 13 Homes for the Aged in the same region.

Data were collected using a structured questionnaire designed to capture sociodemographic information, individual characteristics, functionality, and environmental factors. Cognitive screening was conducted using the Mini-Mental State Examination (MMSE), with eligibility criteria set at a score equal to or greater than 19 for illiterate individuals and equal to or greater than 23 for elderly people with 5 or more years of schooling to ensure participants had adequate cognitive capacity to respond to the study instruments¹⁵. This range was chosen to ensure that participants could comprehend and accurately respond to the questionnaire. Older adults with moderate or severe cognitive impairment affecting perception, reasoning, or language were excluded.

Sociodemographic variables included sex (male, female), age (in years), weight (in kilograms), height (in meters), marital status (married, single, separated/divorced, widowed), living arrangements (living alone or with others), and educational level (in years). Individual characteristics assessed included smoking status (non-smoker, former smoker, smoker), alcohol consumption (does not consume or consumes at least once a week), regular physical activity (none, aerobic/resistance training), and self-perceived health status (poor/fair, good/excellent).

Body Mass Index (BMI) was calculated using self-reported weight and height and categorized according to Lipschitz's standards for older adults: underweight (<22 kg/m²)¹⁶, normal weight (eutrophic) (23–27 kg/m²), and overweight (>27 kg/m²). Data on comorbidities (e.g., hypertension, diabetes, heart disease, chronic lung diseases, cerebrovascular diseases, osteoporosis, and joint diseases) were also recorded, along with reports of pain in the past month and polypharmacy (defined as the use of six or more medications¹⁷).

Functionality was assessed using the WHODAS 2.0, a 36-item questionnaire that measures difficulties in daily activities across six domains: cognition, mobility, self-care, interpersonal relationships, daily activities, and social participation. Standardized scores were calculated for each domain, ranging from 0 (no difficulty) to 100 (maximum difficulty). Participants were dichotomized based on the presence or absence of specific functional difficulties in each domain¹⁸.

Environmental factors were assessed using a structured questionnaire developed by the researchers and validated by five experts¹⁹. These experts, invited via email, evaluated the construct, content, and clarity of each question on a 10-point scale (0 = invalid or unclear; 10 = valid and clear). Items that achieved at least 80% agreement among the experts were retained²⁰. The experts were selected based on Fehring's criteria²¹, with adaptations from Melo et al.²², requiring a master's degree and expertise in the ICF.

Regarding the application to participants, older adults were instructed to reflect on the past 30 days and indicate whether each environmental factor acted as a facilitator, barrier, or had no impact on their daily lives. The magnitude of each factor was assessed using a qualifier scale: 4 - complete barrier; 3 - severe barrier; 2 - moderate barrier; 1 - mild barrier; 0 - neither barrier nor facilitator; +1 - mild facilitator; +2 - moderate facilitator; +3 - severe facilitator; +4 - complete facilitator. For statistical analysis, the environmental variables were dichotomized as "facilitators" or "barriers."

Data were collected between August 2020 and May 2021 through interviews conducted via phone or live video call, led by a single researcher to ensure consistency. The interviews lasted 30–45 minutes. This remote approach was adopted due to the restrictions imposed by the COVID-19 pandemic. All participants provided informed consent after being briefed on the study's objectives and procedures.

Categorical variables were summarized using absolute and relative frequencies, while continuous variables were presented as means with confidence intervals (CIs). The Shapiro-Wilk test was used to assess normality. Comparisons between groups for categorical variables were made using the Chi-square or Fisher's Exact tests, while the Mann-Whitney U test was applied for non-parametric continuous variables. Univariate and multivariate logistic regression models were used to explore associations between functional disability and independent variables, including sociodemographic, individual, and environmental factors. Variables with p-values <0.2 were included in the multivariate models, and statistical significance was set at 5% (p < 0.05).

This study followed the ethical guidelines of Resolutions No. 466/2012 and No. 510/2016 for research involving human subjects and was approved by the Research Ethics Committee of the Pontifícia Universidade Católica do Paraná under approval number 4.209.905.

RESULTS

The study included 208 older adults, equally divided between the institutionalized and non-institutionalized groups. Their sociodemographic and health characteristics are summarized in Table 1.

Table 1
Sociodemographic characteristics of participants by group (n=208). Curitiba, PR, 2021.

Variables	Total (n=208)	Non-Institutionalized (n=104)	Institutionalized (n=104)	p-value
Sex, n (%)				1.0*
Male	80 (38.5)	40 (38.5)	40 (38.5)
Female	128 (61.5)	64 (61.5)	64 (61.5)
Age (years), mean (CI)	72.5 (65.0-77.5)	71.0 (65.0-75.0)	74.0 (65.2-81.7)	0.009***
Age (years), n (%)				0.003*
60-69	81 (38.9)	45 (43.3)	36 (34.6)
70-79	88 (42.3)	48 (46.2)	40 (38.5)
≥80	39 (18.8)	11 (10.6)	28 (26.9)
Marital Status, n (%)				<0.001**
Single	154 (74.0)	9 (8.7)	43 (41.3)
Married	54 (26.0)	54 (51.9)	0 (0.0)
Separated/Divorced	35 (16.8)	8 (7.7)	27 (26.0)
Widowed	67 (32.2)	33 (31.7)	34 (32.7)
Educational Level (years), n (%)				0.4*
Illiterate	21 (10.1)	8 (7.7)	13 (12.5)
≤9	124 (59.6)	67 (64.4)	57 (54.8)
10-12	38 (18.3)	17 (16.3)	21 (20.2)
≥13	25 (12)	12 (11.5)	13 (12.5)
Personal Income (minimum wage), n (%)				<0.001 **
No income	13 (6.3)	7 (6.7)	6 (5.8)
<1	17 (8.2)	1 (1)	16 (15.4)
1–2	134 (64.4)	67 (64.4)	67 (64.4)
3–4	28 (13.5)	22 (21.2)	6 (5.8)
≥5	16 (7.7)	7 (6.7)	9 (8.7)
Lives Alone, n (%)				-
No	181 (87.0)	77 (74.0)	104 (100.0)
Yes	27 (13.0)	27 (26.0)	0 (0.0)
Number of household members, mean (CI)	-	2.35 ± 1.27	-
Number of children, mean (CI)	2.2 ± 1.76	2.9 3± 1.63	1.4 ± 1.56	<0.001**
BMI. kg/m², mean (CI)	26.7 (23.6-30.1)	27.3 (25.7-30.7)	25.1 (22.8-28.8)	<0.001***
BMI. kg/m2, n (%)				<0.001**
Underweight	27 (13)	7 (6.7)	20 (19.2)
Normal weight	89 (42.8)	37 (35.6)	52 (50)
Overweight	92 (44.2)	60 (57.7)	32 (30.8)
Regular physical activity, n (%)				0.008*
No	111 (53.3)	41 (39.5)	70 (67.3)
Yes	97 (46.6)	63 (60.5)	34 (39.7)
Smoking, n (%)				<0.001**
Não	180 (87.4)	101 (97.1)	81 (77.9)
Yes	26 (12.6)	3 (2.9)	23 (22.1)
Alcohol consumption, n (%)				1.0**
No	207 (99.5)	104 (100.0)	103 (99.0)
Yes	1 (0.5)	0 (0.0)	1 (1.0)
General health status				0.003**
Poor/Fair	15 (7.2)	2 (1.9)	13 (12.5)
Moderate	55 (26.4)	24 (23.1)	31 (29.8)
Good/Excellent	138 (66.4)	78 (75)	60 (57.7)
Comorbidities, n (%)				0.4*
No	8 (3.9)	9 (4.8)	3 (2.9)
Yes	200 (96.1)	99 (95.2)	101 (97.1)
Number of diseases				0.7*
0	24 (11.5)	14 (13.4)	10 (9.6)
1-2	36 (17.3)	15 (14.4)	22 (21.2)
3-4	22 (10.5)	14 (13.4)	8 (7.7)
4+	118 (56.7)	56 (53.8)	61 (58.7)
Pain				0.008*
No	101 (48.6)	60 (57.6)	41 (39.4)
Yes	107 (51.4)	44 (42.3)	63 (60.5)
Medication				0.3**
No	10 (4.8)	7 (6.7)	3 (2.9)
Yes	198 (95.2)	97 (93.3)	101 (97.1)
Polypharmacy, n (%)				<0.001**
No	116 (55.8)	71 (68.3)	45 (43.2)
Yes	79 (38)	33 (31.7)	46 (44.2)
Did not know how to answer	13 (6.2)	0 (0)	13 (12.5)
MMSE score	26.0 (10.7)	27.0 (4.0)	25.0 (6.0)	0.005***

• *Chi-square; ** Fisher's Exact Test; *** Mann–Whitney U Test; Significant variables (p<0.05) are highlighted in bold; n: number of participants; CI: confidence interval; BMI: body mass index; MMSE: Mini-Mental State Examination.

The institutionalized participants were generally older, predominantly single or widowed, and exhibited lower cognitive performance compared to the non-institutionalized participants. Both groups had similar educational levels, with most reporting up to nine years of schooling.

Health and lifestyle differences were evident: institutionalized participants reported a higher frequency of musculoskeletal pain, higher rates of polypharmacy, lower Body Mass Index (BMI), and reduced engagement in physical activity. Conversely, non-institutionalized participants exhibited healthier behaviors, such as a lower prevalence of smoking and greater participation in physical activities, highlighting the impact of the environment on health status and functionality.

Table 2 presents the standardized scores of the WHODAS 2.0 across all domains for the non-institutionalized and institutionalized groups. Institutionalized participants demonstrated significantly more difficulties in activities of daily living than the non-institutionalized participants, with statistically significant differences in all domains except for cognition.

Table 2
Comparison of disability between community-dwelling and institutionalized older adults based on WHODAS 2.0 domains and summary scores (n=208). Curitiba, PR, 2021.

Variables	Total Mean (CI)	Non-Institutionalized Mean (CI)	Institutionalized Mean (CI)	p-value*
Domain 1: Cognition	8.3 (0.0-20.8)	8.3 (0.0-20.8)	8.3 (0.0-20.8)	0.722
Domain 2: Mobility	10.0 (0.0-40.0)	0.0 (0.0-10.0)	25.0 (0.0-60.0)	<0.001**
Domain 3: Self-care	0.0 (0.0-25.0)	0.0 (0.0-0.0)	21.8 (0.0-43.7)	<0.001 **
Domain 4: Interpersonal Relationships	5.0 (0.0-20.0)	0.0 (0.0-10.0)	20.0 (0.0-25.0)	<0.001**
Domain 5: Daily Activities	6.2 (0.0-50.0)	0.0 (0.0-5.4)	50.0 (14.0-50.0)	<0.001**
Domain 6: Social Participation	6.2 (0.0-18.7)	3.1 (0.0-12.5)	15.6 (3.1-30.4)	<0.001**
Overall Score	9.3 (3.2-25.8)	4.8 (1.7-9.0)	22.3 (11.1-39.7)	<0.001 **

• *Mann-Whitney U Test; ** Statistically significant variables (p < 0.05) – highlighted in bold. CI: confidence interval; WHODAS 2.0: World Health Organization Disability Assessment Scale, second edition.

Table 3 compares the perception of barriers and facilitators related to environmental factors between the groups.

Table 3
Comparison of the presence of a barrier or facilitator in daily life to access environmental factors between community-dwelling and institutionalized older adults (n=208). Curitiba, PR, 2021.

Environmental Factors of the ICF	Non-Institutionalized n(%)	Institutionalized n(%)	p-value
Products or substances for personal consumption	103 (99.0)	104 (100.0)	0.3
Products and technologies for personal mobility in indoor and outdoor environments	103 (99.0)	103 (99.0)	1.0
Products and technologies for communication	103 (99.0)	103 (99.0)	1.0
Products and technologies for culture, recreation, and sports	69 (66.3)	86 (82.7)	0.007**
Products and technologies for religious and spiritual practices	96 (92.3)	91 (87.5)	0.2
Climate	77 (74.1)	90 (86.6)	0.02 **
Lighting	95 (91.4)	99 (95.2)	0.2
Weather-related changes	43 (41.3)	37 (35.6)	0.3
Immediate family	100 (96.2)	81 (77.9)	< 0.001**
Friends	93 (89.4)	88 (84.6)	0.3
Acquaintances, colleagues, neighbors, and community members	84 (80.8)	81 (77.9)	0.6
People in positions of authority	79 (76)	87 (83.7)	0.1
Personal care providers and personal assistants	54 (52)	101 (97.1)	<0.001**
Healthcare professionals	103 (99)	103 (99)	1.0
Individual attitudes of acquaintances, colleagues, neighbors, and community members	82 (78.8)	93 (89.4)	0.03 **
Individual attitudes of healthcare professionals	98 (94.2)	104 (100)	0.01 **
Social attitudes	69 (66.3)	97 (93.3)	<0.001**
Social norms, practices, and ideologies	65 (62.5)	91 (87.5)	<0.001**
Social security services, systems, and policies	93 (89.4)	98 (94.2)	0.2
Health services, systems, and policies	102 (98.1)	104 (100)	0.1

• Mann-Whitney U Test; **Statistically significant variables (p < 0.05) – highlighted in bold; ICF: International Classification of Functioning, Disability, and Health.

Table 4 presents the distribution of qualifiers from the environmental factors’ questionnaire, using a scale ranging from 4 (complete barrier) to +4 (complete facilitator). The data are presented separately for non-institutionalized (NI) and institutionalized (I) older adults.

Table 4
Distribution of ICF qualifiers between Non-Institutionalized and Institutionalized individuals for each category of the environmental factors’ questionnaire. Curitiba, PR, 2021.

Categories of Environmental Factors	Groups	ICF Qualifiers n (%)
		.4	.3	.2	.1	0	+1	+2	+3	+4
Products or substances for personal consumption	NI	0(0)	1(1)	2(1.9)	1(1)	1(1)	2(1.9)	20(19.2)	9(8.7)	68(65.4)
	I	0(0)	1(1)	3(2.9)	3(2.9)	0(0)	1(1)	18(17.3)	13(12.5)	65(62.5)
Products and technologies for personal mobility in indoor and outdoor environments	NI	2(1.9)	3(2.9)	2(1.9)	0(0)	1(1)	5(4.8)	5(4.8)	7(6.7)	79(76)
	I	1(1)	3(2.9)	6(5.8)	2(1.9)	1(1)	2(1.9)	11(10.6)	11(10.6)	67(64.4)
Products and technologies for communication	NI	0(0)	0(0)	1(1)	0(0)	1(1)	1(1)	15(14.4)	15(14.4)	71(68.3)
	I	3(2.9)	3(2.9)	3(2.9)	2(1.9)	1(1)	3(2.9)	12(11.5)	13(12.5)	64(61.5)
Products and technologies for culture, recreation, and sports	NI	0(0)	1(1)	1(1)	1(1)	35(33.7)	0(0)	7(6.7)	6(5.8)	53(51)
	I	0(0)	5(4.8)	1(1)	3(2.9)	18(17.3)	2(1.9)	7(6.7)	2(1.9)	66(63.5)
Products and technologies for religious and spiritual practices	NI	0(0)	1(1)	1(1)	0(0)	8(7.7)	0(0)	2(1.9)	3(2.9)	89(85.6)
	I	2(1.9)	8(7.7)	3(2.9)	4(3.8)	13(12.5)	0(0)	5(4.8)	6(5.8)	63(60.6)
Climate	NI	4(3.8)	4(3.8)	13(12.5)	8(7.7)	27(26)	0(0)	19(18.3)	5(4.8)	24(23.1)
	I	3(2.9)	7(6.7)	13(12.5)	6(5.8)	14(13.5)	3(2.9)	11(10.6)	2(1.9)	45(43.3)
Lighting	NI	0(0)	2(1.9)	4(3.8)	3(2.9)	9(8.7)	0(0)	4(3.8)	2(1.9)	80(76.9)
	I	2(1.9)	1(1)	1(1)	1(1)	5(4.8)	1(1)	9(8.7)	1(1)	83(79.8)
Weather-related changes	NI	1(1)	1(1)	5(4.8)	2(1.9)	61(58.7)	1(1)	4(3.8)	2(1.9)	27(26)
	I	2(1.9)	3(2.9)	1(1)	3(2.9)	67(64.4)	2(1.9)	2(1.9)	0(0)	24(23.1)
Immediate Family	NI	1(1)	0(0)	0(0)	1(1)	4(3.8)	0(0)	9(8.7)	6(5.8)	83(79.8)
	I	7(6.7)	3(2.9)	4(3.8)	5(4.8)	23(22.1)	3(2.9)	11(10.6)	10(9.6)	38(36.5)
Friends	NI	1(1)	1(1)	0(0)	1(1)	11(10.6)	2(1.9)	21(20.2)	7(6.7)	60(57.7)
	I	2(1.9)	2(1.9)	2(1.9)	5(4.8)	16(15.4)	8(7.7)	16(15.4)	10(9.6)	43(41.3)
Acquaintances, colleagues, neighbors, and community members	NI	3(2.9)	1(1)	1(1)	0(0)	20(19.2)	4(3.8)	16(15.4)	15(14.4)	44(42.3)
	I	2(1.9)	3(2.9)	2(1.9)	4(3.8)	23(22.1)	7(6.7)	22(21.2)	10(9.6)	31(29.8)
Individual attitudes of acquaintances, colleagues, neighbors, and community members	NI	4(3.8)	2(1.9)	3(2.9)	0(0)	22(21.2)	2(1.9)	17(16.3)	11(10.6)	43(41.3)
	I	5(4.8)	2(1.9)	5(4.8)	3(2.9)	11(10.6)	3(2.9)	30(28.8)	10(9.6)	35(33.7)
People in positions of authority	NI	0(0)	0(0)	3(2.9)	1(1)	25(24)	5(4.8)	13(12.5)	8(7.7)	49(47.1)
	I	4(3.8)	3(2.9)	2(1.9)	2(1.9)	17(16.3)	6(5.8)	26(25)	12(11.5)	32(30.8)
Personal in positions of authority	NI	0(0)	0(0)	1(1)	0(0)	50(48.1)	2(1.9)	2(1.9)	4(3.8)	45(43.3)
	I	1(1)	1(1)	0(0)	0(0)	3(2.9)	2(1.9)	12(11.5)	15(14.4)	70(67.3)
Healthcare Professionals	NI	2(1.9)	0(0)	0(0)	1(1)	1(1)	3(2.9)	11(10.6)	16(15.4)	70(67.3)
	I	0(0)	1(1)	2(1.9)	0(0)	1(1)	6(5.8)	15(14.4)	13(12.5)	66(63.5)
Individual attitudes of healthcare professionals	NI	1(1)	1(1)	2(1.9)	0(0)	6(5.8)	1(1)	7(6.7)	16(15.4)	70(67.3)
	I	0(0)	1(1)	3(2.9)	0(0)	0(0)	1(1)	17(16.3)	13(12.5)	69(66.3)
Social attitudes	NI	2(1.9)	6(5.8)	14(13.5)	4(3.8)	35(33.7)	3(2.9)	19(18.3)	10(9.6)	11(10.6)
	I	2(1.9)	17(16.3)	10(9.6)	2(1.9)	7(6.7)	2(1.9)	19(18.3)	10(9.6)	35(33.7)
Social norms, practices, and ideologies	NI	1(1)	16(15.4)	10(9.6)	0(0)	39(37.5)	2(1.9)	11(10.6)	10(9.6)	15(14.4)
	I	1(1)	15(14.4)	12(11.5)	2(1.9)	13(12.5)	4(3.8)	16(15.4)	11(10.6)	30(28.8)
Social security services, systems, and policies	NI	5(4.8)	2(1.9)	4(3.8)	2(1.9)	11(10.6)	5(4.8)	9(8.7)	8(7.7)	58(55.8)
	I	6(5.8)	9(8.7)	12(11.5)	1(1)	6(5.8)	6(5.8)	17(16.3)	9(8.7)	38(36.5)
Healthcare services, systems, and policies	NI	1(1)	0(0)	3(2.9)	0(0)	2(1.9)	0(0)	11(10.6)	11(10.6)	76(73.1)
	I	1(1)	1(1)	5(4.8)	1(1)	0(0)	2(1.9)	14(13.5)	8(7.7)	72(69.2)

• NI: Non-Institutionalized, I: Institutionalized

The results indicate a predominance of facilitating environmental factors in all categories for both groups. However, notable differences between the groups arise in Chapter 1 of this component of the ICF, which includes categories related to products and technology. Institutionalized participants more frequently identified products and technologies for cultural, recreational, and sports activities as facilitators. In contrast, non-institutionalized participants were more likely to perceive products and technologies related to religious practices and spiritual life as facilitators.

Significant differences were observed in perceptions of immediate family support. Non-institutionalized participants were more likely to select the +4 qualifiers, reflecting stronger perceptions of complete family support. In contrast, institutionalized participants reported higher levels of support from caregivers and personal assistants, highlighting the importance of professional care in institutional settings. Support from friends, acquaintances, and community members also varied, with non-institutionalized participants expressing stronger perceptions of these relationships as facilitators.

The univariate regression analysis, presented in Table 5, showed a statistically significant association for the environmental factor "individual attitudes of acquaintances, peers, colleagues, neighbors, and community members" in the non-institutionalized group. In addition to this variable, age, BMI, pain, and general health status were significant sociodemographic risk factors for functional disability in older adults living in the community. For institutionalized older adults, pain, comorbidities, and polypharmacy were identified as influential risk factors.

Table 5
Binary Logistic Regression Analysis (Univariate and Multivariate) for Factors Associated with WHODAS 2.0 in Institutionalized and Non-Institutionalized Older Adults. Curitiba, PR, 2021.

Independent Variables	Univariate Model		Multivariate Model
	Non-Institutionalized OR (95% CI) p-value	Institutionalized OR (95% CI) p-value	Non-Institutionalized OR (95% CI) p-value	Institutionalized OR (95% CI) p-value
Individual attitudes of acquaintances, companions, colleagues, neighbors, and community members
Neither barrier nor facilitator	1	1	1	-
Barrier/Facilitator	6.07 (1.44-25.61) 0.01	2.30 (0.54-9.84) 0.25	5,28 (1.40-20.72) 0.01
Age (years)
60-69	1	1	1
70-79	0.36 (0.15-0.84) 0.01	0.94 (0.28-3.12) 0.92	0.41 (0.15-1.10) 0.07	-
> 80	0.50 (0.13-1.91) 0.31	1.66 (0.37-7.35) 0.50	0.69 (0.15-3.08) 0.63
BMI
Underweight	1	1	1
Normal weight	6.33 (0.69-57.9) 0.10	1.59 (0.46-5.51) 0.46	6.88 (0.51-92.78) 0.14	-
Obesity	6.41 (0.72-56.55) 0.09	5.0 (0.86-28.86) 0.7	10.17 (0.76-134.5) 0.07
Pain
No	1	1	1	1
Yes	3.98 (1.74-9.09) 0.001	9.28 (2.44-35.21) 0.001	3.16 (1.22-8.21) 0.01	10.06 (2.47-40.93) 0.001
Comorbidities
No	1	1	-	1
Yes	1.72E+09 (0.00-0.00) 0.99	12.42 (1.05-146.33) 0.04		6.29 (0.34-114.30) 0.21
Number of Medications
< 5	1	1		1
≥ 5	1.38 (0.60-3.16) 0.44	4.63 (1.19-17.95) 0.02		4.59 (1.05-20.05) 0.04
Don’t know / No response	-	1.77 (0.34-9.29) 0.49	-	1.96 (0.32-12.04) 0.46
General health status
Poor/fair	1	1	1
Moderate	2.72 (1.04-7.12) 0.04	5.87E+08 (0.00-0.00) 0.99	3.10 (1.01-9.51) 0.04	-
Good/Excellent	2.20E+09 (0.00-0.00) 0.99	5.87E+08 (0.00-0.00) 0.99	1.36E (0.00-0.00) 0.99

• The independent variables with p≤0.2 were included in the multivariate modeling process. Only the variables with significant results (p<0.05) are presented. Summary of the Non-Institutionalized Model: χ² (8) = 29.81, p<0.001, Nagelkerke R² = 0.33; Hosmer-Lemeshow Test p = 0.12. No significant outliers were identified. Summary of the Institutionalized Model: χ² (4) = 21.91, p<0.001, Nagelkerke R² = 0.79; Hosmer-Lemeshow Test p = 0.79. Residuals within expected limits (below 3.55). OR: Odds Ratio, CI: 95% Confidence Interval, BMI: Body Mass Index, NI: Non-Institutionalized, I: Institutionalized.

In the multivariate logistic regression, the predictors of functional disability for non-institutionalized individuals were the aforementioned environmental factor, pain, and self-perception of health. For institutionalized individuals, pain and polypharmacy were identified as predictors.

Pain increased the likelihood of functional disability by 3.16 times in the non-institutionalized group, while for the institutionalized group, the increase was 10.06 times. Polypharmacy was a risk factor for disability among non-institutionalized older adults, with an adjusted odds ratio (OR) of 4.59. Among environmental factors, individual attitudes of acquaintances, peers, colleagues, neighbors, and community members increased the likelihood of functional disability in non-institutionalized older adults by 5.28 times.

DISCUSSION

This study analyzed how environmental factors impact the functionality of institutionalized and non-institutionalized older adults in Brazil. Among the non-institutionalized participants, the individual attitudes of acquaintances, partners, colleagues, neighbors, and community members emerged as the only statistically significant environmental factor in the multivariate logistic regression model. Participants who perceived these attitudes as barriers highlighted the lack of positive interactions, which were considered avoidable or modifiable. In contrast, those who saw them as facilitators emphasized the importance of supportive behaviors in times of need, both in the past and in the future.

Environmental factors are crucial for promoting healthy and active aging, encompassing more than just physical or technological aspects. They include elements such as natural settings, human-made modifications, social networks, attitudes, and public policies²³. Recognizing the importance of these factors is essential for reducing disability and fostering participation among older adults¹⁸. This study identified cultural, recreational, and sports products and technologies as significant facilitators for both groups, reinforcing the value of social and cultural engagement in maintaining functionality.

Pain emerged as a prominent factor differentiating the groups. Institutionalized older adults reported higher levels of pain, which were strongly associated with increased disability. Chronic pain, particularly musculoskeletal pain, is prevalent among older adults in Brazil and is consistently linked to a reduction in independence and quality of life²⁴,²⁵. In this study, the lumbar spine and lower limbs were the most commonly reported areas of pain, consistent with findings identifying these areas as critical contributors to functional limitations²⁶,²⁷. Effective pain management is essential to improve functionality, highlighting the importance of healthcare professionals addressing this issue in both community and institutional settings.

Another significant finding was polypharmacy, which increased the likelihood of disability among institutionalized participants. This aligns with evidence linking polypharmacy to adverse outcomes, such as a higher number of comorbidities, poorer self-rated health, reduced physical activity, and greater risks of falls, depression, and pain²⁸. Optimizing medication management is therefore crucial to mitigate these risks and preserve the functionality and quality of life of this population.

Self-rated health was notably better among non-institutionalized participants, possibly reflecting the benefits of community engagement in activities conducted at community centers. These activities promote well-being, confidence, adaptability, and resilience. Educational programs, physical activities, and cultural workshops also contribute to functionality by enabling older adults to actively participate in social and collaborative initiatives, which enhances their autonomy and self-esteem²⁹.

Living conditions played an important role in functionality. Institutionalized participants benefited from structured routines and professional care, which helped mitigate some functional limitations. However, they faced challenges such as social isolation and lack of family presence, negatively impacting their emotional well-being. Conversely, non-institutionalized participants, although generally more autonomous, faced barriers such as limited access to healthcare and social isolation, which adversely affected their functionality and quality of life.

Functionality, assessed by the WHODAS, revealed moderate levels of disability among institutionalized participants and mild levels among non-institutionalized participants. These findings align with previous research reporting higher levels of disability in institutionalized populations, although contextual differences in methodologies should be considered²⁸,³⁰. In this study, participation in community center activities, focused on physical, cultural, and recreational engagement, likely contributed to the lower levels of disability observed among non-institutionalized participants.

Cognitive performance, measured by the WHODAS, did not differ significantly between the groups. However, institutionalized participants scored lower on the Mini-Mental State Examination (MMSE), consistent with studies reporting higher rates of cognitive impairments, such as dementia and depression, among institutionalized older adults in Brazil²⁶,²⁷. This highlights the importance of creating supportive environments that promote cognitive engagement and recreational activities to mitigate cognitive decline³¹.

Supportive relationships were identified as critical facilitators in both groups. Non-institutionalized participants mainly relied on family support, while institutionalized participants cited caregivers and personal assistants as their primary sources of support. However, negative social attitudes toward aging were identified as barriers in both groups, particularly among institutionalized participants. Ageist views and stereotypes about older adults not only reinforce discrimination but also diminish the perception of autonomy and independence³². Public awareness campaigns and educational initiatives are urgently needed to combat these prejudices, promoting more positive social perceptions of aging and older adults.

This study has several limitations. The cross-sectional design restricts causal inferences between disability and associated factors, limiting the understanding of their temporal relationships. Additionally, the reliance on self-reported data, such as weight and height, introduces potential recall bias. The use of a convenience sample and the geographic restriction to the city of Curitiba may also limit the generalizability of the findings to other regions of Brazil with different socioeconomic contexts. Future research with larger, more diverse samples and longitudinal designs is recommended to better understand the causal pathways influencing functionality in older adults.

This present study highlights how sociodemographic and environmental factors influence disability among older adults in Brazil, contributing to targeted interventions that prevent functional decline and promote healthier living environments for both community-dwelling and institutionalized individuals. The environment plays a vital role in shaping functionality, especially as older adults prioritize simplicity and comfort in their surroundings. Comprehensive intervention strategies that address facilitators and mitigate barriers can improve quality of life, support aging in place, and enhance access to care.

CONCLUSION

This study highlights the fundamental role of environmental factors in influencing the functionality of institutionalized and non-institutionalized older adults. Institutionalized individuals have higher levels of disability in the domains of mobility, self-care, and social participation. However, they benefit from structured routines and professional care, which help mitigate some challenges. Alternatively, non-institutionalized older adults, although generally more autonomous, face significant barriers, including social isolation and limited access to healthcare, which negatively impact their functionality.

The main contribution of this study lies in identifying specific environmental barriers and facilitators that influence functionality. Facilitators such as family support, positive social attitudes, and accessible services promote independence and participation. In contrast, barriers such as inadequate accessibility and insufficient healthcare infrastructure represent significant challenges to the autonomy of older adults. These findings provide valuable insights for policymakers and healthcare professionals, emphasizing the need for targeted interventions that address environmental barriers while leveraging facilitators to promote quality of life and autonomy among older adults in different living contexts.

ACKNOWLEDGEMENTS

We would like to thank the institutions that participated in the study, the Center for Older Adults, and the various professionals who facilitated contact with participants, making data collection possible.

• Research funding: – Coordination of Superior Level Staff Improvement – Brazil (CAPES). Codes: 001, 88887.357872/2019-00 and 88887.339996/2019-00.
• DATA AVAILABILITY
  The dataset supporting the results of this study can be made available upon request to the corresponding author Maria Isabel Barboza Silveira, subject to the applicable ethical and legal criteria.

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Edited by

• Edited by: Camila Alves dos Santos

Data availability

The dataset supporting the results of this study can be made available upon request to the corresponding author Maria Isabel Barboza Silveira, subject to the applicable ethical and legal criteria.

Publication Dates

• Publication in this collection
  24 Mar 2025
• Date of issue
  2025

History

• Received
  24 Sept 2024
• Accepted
  02 Jan 2025