Exploring housing policies in five Swedish municipalities: alternatives and priorities.

INTRODUCTION: Housing shortage due to population growth within metropolitan areas, combined with an ageing population, has put pressure on current housing provision in Sweden. Thus, there is an urgent need to develop sustainable housing policies to accommodate the growing number of seniors in accessible home environments. This study aimed to gain an in-depth understanding of how municipalities currently address housing accessibility issues and to explore what types of policy solutions they consider for the future. MATERIAL AND METHODS: Five Swedish municipalities were selected to represent a diversity of the population, housing provision approaches, and geographical areas. To understand current housing policies, two key actors (e.g. public officials, housing adaptation grant managers, city architects, etc.) from each municipality participated in semi-structured interviews (N = 10). Subsequently, those key actors, two senior citizens, and three researchers participated in a research circle to explore future policy solutions. Data were analyzed using content analysis. RESULTS: The interviews revealed common approaches to deal with housing accessibility issues such as regular renovations and maintenance, individual adaptations based on specific needs, and seeking collaboration with private housing actors on housing provision matters. Possible measures suggested for the future included increasing the national coordination of housing accessibility policies, amending legislation to only allow the construction of housing according to strengthened accessibility standards, and introducing economic incentives for seniors to move from housing with poor accessibility to more accessible accommodations. CONCLUSIONS: Municipalities struggle with the lack of accessible and affordable housing for their ageing population, despite a large variety of policies from economic incentives to research and development policies. The results suggest that collaboration needs to be improved between all actors involved in housing policies. Preventive measures within the current laws may be needed to strengthen the construction of more accessible and affordable housing for populations ageing in place.

Old Overnight: Experiences of Age-Based Recommendations in Response to the COVID-19 Pandemic in Sweden.

The Swedish response to the COVID-19 pandemic included age-based recommendations of voluntary quarantine specifically for those 70 years of age or older. This paper investigates the experiences of a sudden change of policy in the form of an age restriction that trumped the contemporary active aging ideal. A web-based qualitative survey was conducted in April 2020. Through manual coding of a total of 851 responses, six different ways of relating to the age-based recommendations were identified. The results show that age is not an unproblematic governing principle. Instead, in addition to protecting a vulnerable group, the age-based recommendation meant deprivation of previously assigned individual responsibility and, consequently, autonomy. It is shown how respondents handled this tension through varying degrees of compliance and resistance. Findings highlight the importance of continuously tracking the long-term consequences of age-based policy to avoid negative self-image and poorer health among older adults.

Cohabitants' perspective on housing adaptations: a piece of the puzzle.

As part of the Swedish state-funded healthcare system, housing adaptations are used to promote safe and independent living for disabled people in ordinary housing through the elimination of physical environmental barriers in the home. The aim of this study was to describe the cohabitants' expectations and experiences of how a housing adaptation, intended for the partner, would impact their everyday life. In-depth interviews were conducted with cohabitants of nine people applying for a housing adaptation, initially at the time of the application and then again 3 months after the housing adaptation was installed. A longitudinal analysis was performed including analysis procedures from Grounded Theory. The findings revealed the expectations and experiences in four categories: partners' activities and independence; cohabitants' everyday activities and caregiving; couples' shared recreational/leisure activities; and housing decisions. A core category putting the intervention into perspective was called 'Housing adaptations - A piece of the puzzle'. From the cohabitants' perspective, new insights on housing adaptations emerged, which are important to consider when planning and carrying out successful housing adaptations.

A cluster randomized controlled trial of a client-centred, activities of daily living intervention for people with stroke: one year follow-up of caregivers.

OBJECTIVE: Compare caregiver burden, provision of informal care, participation in everyday occupations and life satisfaction of caregivers to people with stroke, who either had received a client-centred, activities of daily living intervention or usual activities of daily living interventions. DESIGN: A multicentre cluster randomized controlled trial in which 16 rehabilitation units were randomly assigned to deliver a client-centred, activities of daily living intervention or usual activities of daily living interventions. Caregiver outcomes were compared cross-sectionally at 12 months and changes in outcomes between three and 12 months after people with stroke were included in the study. SETTING: Inpatient and outpatient rehabilitation. PARTICIPANTS: Caregivers of people with stroke enrolled in the trial. INTERVENTION: A client-centred, activities of daily living intervention aiming to increase agency in daily activities and participation in everyday life for people after stroke. MAIN MEASURES: Caregiver Burden Scale, Occupational Gaps Questionnaire, LiSat-11. RESULTS: There were no differences in outcomes between caregivers in the client-centred, activities of daily living (n = 88) and the usual activities of daily living (n = 95) group at 12 months. The caregiver burden score was 42.7 vs. 41.8, p = 0.75, mean occupational gaps were 3.5 vs. 4.0, p = 0.52 and satisfaction with life was 53% vs. 50%, p = 0.87. There were no differences in changes between three and 12 months. However, within groups there were significant differences in caregiver burden, factor general strain, for caregivers in the client-centred, activities of daily living group, and in provision of informal care for the usual activities of daily living group. CONCLUSION: The client-centred intervention did not bring about any difference between caregiver-groups, but within groups some difference was found for caregiver burden and informal care.

A research-based strategy for managing housing adaptations: study protocol for a quasi-experimental trial.

BACKGROUND: The primary aim of this paper is to describe the design of a project evaluating the effects of using a research-based strategy for managing housing adaptations (HAs). The evaluation targets clients' perspectives in terms of activity, participation, usability, fear of falling, fall incidence, use of mobility devices, and health-related quality of life, and determines the societal effects of HAs in terms of costs. Additional aims of the project are to explore and describe this strategy in relation to experiences and expectations (a) among clients and cohabitants and (b) occupational therapists in ordinary practice. METHODS/DESIGN: This study is a quasi-experimental trial applying a multiphase design, combining quantitative and qualitative data. At the experimental sites, the occupational therapists (OTs) apply the intervention, i.e. a standardized research-based strategy for HA case management. At the control site, the occupational therapists are following their regular routine in relation to HA. Three municipalities in south Sweden will be included based on their population, their geographical dispersion, and their similar organizational structures for HA administration. Identical data on outcomes is being collected at all the sites at the same four time points: before the HA and then 3, 6, and 12 months after the HA. The data-collection methods are semi-structured qualitative interviews, observations, clinical assessments, and certificates related to each client's HA. DISCUSSION: The intervention in this study has been developed and tested through many years of research and in collaboration with practitioners. This process includes methodological development and testing research aimed at identifying the most important outcomes and research targeting current HA case-management procedures in Swedish municipalities. When the study is completed, the results will be used for further optimization of the practice strategy for HA, in close collaboration with the data-collecting OTs. TRIAL REGISTRATION: No: NCT01960582.

Psychometric properties of the arabic version of occupational value with pre-defined ítems.

BACKGROUND: Perceived occupational value is closely linked with well-being and there is need worldwide for assessment tools that target this phenomenon. The Occupational Value with pre-defined items (OVal-pd), measuring three dimensions of occupational value; concrete, socio-symbolic and self-rewarding, was designed for that purpose. AIM: To pilot an Arabic version of OVal-pd and evaluate its psychometric properties in terms of content validity, factor structure, homogeneity, construct validity, test-retest stability, floor and ceiling effects, and measurement error. METHODS: Snowball sampling was used to recruit Arabic-speaking persons living in Sweden (n = 55). They completed the OVal-pd and questionnaires addressing background factors, content validity and feasibility. Confirmatory factor analysis, Spearman's rank correlation, Cronbach's α, intraclass correlation coefficients, and minimum detectable change were calculated. RESULTS: A 22-item version of the Arabic OVal-pd was found to have acceptable content validity and feasibility and the proposed three occupational value dimensions were confirmed. Good properties in terms of construct validity, internal consistency and test-retest stability were also established. No floor or ceiling effects were observed. CONCLUSION: The Arabic OVal-pd showed good validity and reliability on various psychometric aspects. SIGNIFICANCE: In today's multicultural societies, the Arabic OVal-pd can be an important tool for occupational therapists working with Arabic-speaking clients.

The Relationship Between Physical Housing Characteristics, Housing Accessibility and Different Aspects of Health Among Community-Dwelling Older People: A Systematic Review.

Objectives: To synthesize the evidence on the relationships between physical housing characteristics or housing accessibility and different aspects of health among community-dwelling people 60 years and older. Methods: A systematic review of recent evidence with a narrative synthesis was conducted. Results: We included 15 studies and found three themes covering physical housing characteristics or housing accessibility that are associated with aspects of health among community-dwelling older adults: (1) interventions by home modifications targeting housing features both at entrances and indoors; (2) non-interventions targeting indoor features; (3) non-interventions targeting entrance features, that is, the presence of an elevator or stairs at the entrance. The overall quality of evidence across studies was assessed as very low. Discussion: The findings highlight the need for studies with a stronger research design and higher methodological quality that address the physical housing environment in relation to health among older adults to strengthen the body of evidence.

Conditions for uptake of evidence-based knowledge in municipal care for older people in Sweden: a developmental evaluation.

OBJECTIVE: The objective of this paper is to describe the initial phase of a long-term collaboration initiative between a municipality and the Faculty of Medicine at a university in Sweden. The overall ambition of the collaboration is to strengthen the quality of care for older people. The concrete goal is to equip academically trained registered health care professionals (HCP) with tools for transferring evidence-based knowledge into practice. As municipal healthcare for older people is mainly carried out by staff lacking academic education, reg. HCP are key actors to bring in and consolidate an evidence-based approach in this setting. Developmental evaluation (DE) has been used to evaluate four separate activities in the initial phase. The activities where sequenced in a cumulative design to provide knowledge for further development of adequate tools. RESULTS: The cumulative design originally planned did not fit the internal logic of the municipality. Therefore, workflow and pace adjustments were made to proceed towards the joint ambition; the creation of fruitful conditions for the uptake of evidence-based knowledge. Long-term collaboration between academia and organizations outside academia demands a sensitive and flexible research approach, recognizing that collaboration implies mutuality and restricts the sovereignty of academia in designing research.

Enabling Long-term Predictions and Cost-benefit Analysis Related to Housing Adaptation Needs for a Population Aging in Place: Protocol for a Simulation Study.

BACKGROUND: Policies that promote aging in place are common in Sweden and many other countries. However, the current housing stock cannot sufficiently accommodate a population aging in place considering how functional capacity and housing needs change as people age. To be suitable for all regardless of their functional ability, housing should be designed or adapted to facilitate the performance of activities of daily living. Long-term planning and plausible projections of development 20 to 30 years into the future are needed. OBJECTIVE: The overall aim is to develop simulation models that enable long-term predictions and analysis of potential consequences in terms of societal gains and costs for different large-scale measures and interventions in the ordinary housing stock. METHODS: This study is designed as a simulation study and will broadly apply health impact assessment methods in collaboration with five municipalities in Sweden. Individual interviews and research circles were used to identify current and prioritize potential new policies to improve the accessibility of the housing stock. We will run a series of simulations based on an estimated willingness to pay from discussions with the municipalities. Two to three different prioritized policies will be compared simultaneously using Markov cohort analysis to estimate the potential costs and health impact on the population. Using data from a systematic review and existing population-based data sets with individual-level data on home and health variables, we will calculate parameter estimates for the relations between housing accessibility and health outcomes. The potential impact of selected policy interventions will be estimated in several microsimulations representing people living in the community. Sensitivity analyses will be conducted for each simulation. RESULTS: As of April 2022, open access data was collected, and a systematic review was underway and expected to be completed by November 2022. Collaboration with five municipalities was established in autumn 2020. In spring 2021, the municipalities developed a list of prioritized policy interventions to be tested and used in the simulation models. Inventories of barrier frequencies in ordinary housing started in spring 2022 and are expected to be completed in autumn 2022. Data gathering and analyses for simulation inputs will be completed during 2022 followed by the simulation modeling analyses to be completed in 2023. CONCLUSIONS: Improved accessibility of the ordinary housing stock has the potential to maintain or improve the health of the aging population. This study will generate tools that enable long-term predictions and reliable cost-benefit estimates related to the housing adaptation needs for a population aging in place, thus providing support for the best-informed policy decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39032.

Identifying and validating housing adaptation client profiles - a mixed methods study.

Purpose: An increasing number of people will live with disabilities in their homes and consequently, the need for home-based interventions will increase. Housing adaptations (HAs) are modifications to the physical home environment with the purpose to enhance independence for a heterogeneous group of people. Increasing the knowledge of the characteristics of HA clients by exploring their heterogeneity, could facilitate the planning of interventions and allocation of resources. The purpose of this article was to identify and validate HA client profiles.Materials and methods: This cross-sectional study applied a mixed methods design to identify profiles of HA clients through cluster analysis confirmed by qualitative interview data. The sample consists of 241 HA clients in Sweden with a mean age of 75.1 years.Results: A classification into five groups emerged as the one best describing the heterogeneity of characteristics among this sample of clients. Five client profiles were outlined based on their age and level of disability, and the variation between the profiles was confirmed through the qualitative interview data.Conclusions: The identified client profiles are a step towards a better understanding of how home-based interventions could be delivered more effectively to groups of HA clients, based on their different characteristics.Implications for rehabilitationHousing adaptations are structural modifications to the physical home environment with the purpose to enhance independence for people with disabilities.People applying for housing adaptations are a heterogeneous group with different needs.This study outlines five client profiles which can guide professionals on how to differentiate home-based interventions and follow-up processes among housing adaptation clients.

Pushing for miracles, pulling away from risk: An ethnographic analysis of the force dynamics at Senior Summer Camps in Sweden.

With an ageing population and a discourse of active ageing guiding welfare policies, initiatives to engage older people in health promoting activities have been established. One growing phenomenon is Senior Summer Camps, arranged all over Sweden in beautiful natural environments close to water. Their main purpose is to enable older people to participate in outdoor activities in an institutionalized setting. Although many professionals consider acts of infantilization as highly inappropriate, research has shown that still this is frequently done in institutional settings targeting older people. This paper wish to contribute to this field of research. The objective is to study how the camp leaders handle the dilemma of on the one hand, wanting to push senior campers into participating in challenging activities, and on the other, needing to pull them away, to reduce risk and ensure their safety, as well as how senior campers experience alternately being pushed into and pulled away from activities. What strategies are used by the camp leaders to push the campers to challenge themselves without taking unnecessary risks, and what consequences do these strategies have for the campers? The study was conducted in the form of ethnographic observations at two different camps. During one week at each camp we stayed with the participants, alternately being a silent observer and listener in the background, and an active participant in conversations and activities. Narratives, direct quotes, descriptions and reflections were written down in a field diary that forms the empirical basis for the analysis. Various modes of pushing and pulling were identified and defined as cheering, tricking, compelling, monitoring and restricting. These different modes of pushing and pulling were analyzed as manifestations of force, exerted by the camp leaders within a certain age-based force dynamic that resulted in different responses among the campers, especially in terms of how they "did age" in relation to notions on autonomy and vulnerability. It is shown that manifestations of force involve the risk of putting the campers in a position of vulnerability, regardless of whether or not they are actually vulnerable. The main argument in this paper is that initiatives that in an institutionalized context aim to promote a prolonged health and well-being, targeting "older people" in a general sense, run the risk of getting the exact opposite result, namely instead learned vulnerability is implicitly promoted by removing or downplaying the agency and autonomy of the campers.

Health-Related Quality of Life among People Applying for Housing Adaptations: Associated Factors.

Housing adaptations (HA) clients are a heterogeneous group of people with disabilities experiencing restricted performance and participation in everyday life. While health-related quality of life is a common and relevant outcome in health care research, associated factors among HA clients are largely unknown. Thus, the aim of this study was to investigate which factors are associated with health-related quality of life among HA clients in Sweden. The study has a cross-sectional design, using baseline data collected among 224 participants in three municipalities in Sweden. The main outcome was health-related quality of life measured by the EQ-5D. Factors investigated as potentially associated were age, sex, living conditions, cognitive impairment, usability of the home, activities of daily living (ADL) dependence, participation, and fear of falling. The associations were explored using multiple linear regression analysis. Younger age and higher dependence in ADL were associated with lower scores on the EQ-5D. The social aspect of usability in the home had a positive association with the EQ VAS. Results suggest that certain groups of HA clients might be at risk for low health-related quality of life. Knowledge of their characteristics can potentially improve development and implementation of tailored interventions aiming at increasing their health-related quality of life.

Relationship between awareness of disability and occupational performance during the first year after a stroke.

OBJECTIVES: This study examined the relationship between awareness of disability and occupational performance in a group of elderly persons during the year after stroke. METHOD: Data on awareness of disability and occupational performance (i.e., activities of daily living [ADL] motor and process ability) were collected 1, 3, 6, and 12 months after stroke. A mixed-linear-effects model was implemented to examine the relationship between awareness of disability and ADL motor and process ability over time. RESULTS: Increased awareness of disability was related to improvements in occupational performance (ADL motor and process ability). The 2 relationships were different, with a positive linear relationship between awareness of disability and ADL motor ability, and a stronger, positive, nonlinear relationship between awareness of disability and ADL process ability. CONCLUSION: Clients' awareness of disability and their ability to perform occupations should be assessed several times during a rehabilitation process so that interventions can be adjusted to match each client's potential to benefit from them.

Falls and Fear of Falling among Persons Who Receive Housing Adaptations-Results from a Quasi-Experimental Study in Sweden.

While health might deteriorate through the ageing and disablement process, the impacts of disability can be reduced by adapting the environment. This study aimed to investigate the effects of applying a standardized research-based strategy to housing adaptation as compared to ordinary practice with respect to falls and fear of falling. Another aim was to investigate the overall effects of housing adaptations on fall-related outcomes over time. In total, 196 clients were included at baseline, with follow-up at 3 and 6 months after the housing adaptation was implemented. The only significant difference between the two approaches was identified with respect to fear of falling at 3 months after the housing adaptation, but not after 6 months. The number of clients reporting actual falls increased over time in both sites, whereas the number of reported near-falls decreased most in the intervention site, but without significant differences. Thus, the patterns of differences between the sites are inconsistent, as are the patterns of change in fall-related outcomes. An overall conclusion is that if the goal is to improve fall-related outcomes, housing adaptation should be complemented with other interventions preventing falls and explicitly address the clients' activity limitations. In addition, longer follow-up times are necessary.

Factors associated with participation frequency and satisfaction among people applying for a housing adaptation grant.

BACKGROUND: People applying for a housing adaptation (HA) grant are at great risk of participation restrictions due to declining capacity and environmental barriers. AIM: To investigate the association of person-, environment-, and activity-related factors with participation frequency and satisfaction among people applying for a housing adaptation grant. MATERIAL AND METHODS: Baseline cross-sectional data were collected during home visits (n = 128). The association between person-, environment-, and activity-related factors and participation frequency and satisfaction was analysed using logistic regressions. RESULTS: The main result is that frequency of participation outside the home is strongly associated with dependence in activities of daily living (ADL) and cognitive impairments, while satisfaction with participation outside the home is strongly associated with self-reported health. Moreover, aspects of usability in the home were associated with frequency of participation outside the home and satisfaction with participation in the home and outside the home alone. CONCLUSION: Dependence in ADL, cognitive impairments, self-rated health, and aspects of usability are important factors contributing to participation frequency and satisfaction among people applying for a housing adaptation grant, particularly outside the home. SIGNIFICANCE: Our findings indicate that more attention should be directed towards activity-related factors to facilitate participation among HA applicants, inside and outside the home.

Heterogeneity of Characteristics among Housing Adaptation Clients in Sweden--Relationship to Participation and Self-Rated Health.

The aim of the paper was to explore the heterogeneity among housing adaptation clients. Cluster analysis was performed using baseline data from applicants in three Swedish municipalities. The analysis identified six main groups: "adults at risk of disability", "young old with disabilities", "well-functioning older adults", "frail older adults", "frail older with moderate cognitive impairments" and "resilient oldest old". The clusters differed significantly in terms of participation frequency and satisfaction in and outside the home as well as in terms of self-rated health. The identification of clusters in a heterogeneous sample served the purpose of finding groups with different characteristics, including participation and self-rated health which could be used to facilitate targeted home-based interventions. The findings indicate that housing adaptions should take person/environment/activity specific characteristics into consideration so that they may fully serve the purpose of facilitating independent living, as well as enhancing participation and health.

The combined perceptions of people with stroke and their carers regarding rehabilitation needs 1†year after stroke: a mixed methods study.

OBJECTIVES: The aim of the study was to explore the associations between the dyad's (person with stroke and informal caregiver) perception of the person with stroke's rehabilitation needs and stroke severity, personal factors (gender, age, sense of coherence), the use of rehabilitation services, amount of informal care and caregiver burden. Further, the aim was to explore the personal experience of everyday life changes among persons with stroke and their caregivers and their strategies for handling these 1 year after stroke. DESIGN: A mixed methods design was used combining quantitative and qualitative data and analyses. SETTING: Data were mainly collected in the participants' homes. OUTCOME MEASURES: Data were collected through established instruments and open-ended interviews. The dyad's perceptions of the person with stroke's rehabilitation needs were assessed by the persons with stroke and their informal caregivers using a questionnaire based on Ware's taxonomy. The results were combined and classified into three groups: met, discordant (ie, not in agreement) and unmet rehabilitation needs. To assess sense of coherence (SOC) in persons with stroke, the SOC-scale was used. Caregiver burden was assessed using the Caregiver Burden Scale. Data on the use of rehabilitation services were obtained from the computerised register at the Stockholm County Council. PARTICIPANTS: 86 persons with stroke (mean age 73 years, 38% women) and their caregivers (mean age 65 years, 40% women). RESULTS: Fifty-two per cent of the dyads perceived that the person with stroke's need for rehabilitation was met 12 months after stroke. Met rehabilitation needs were associated with less severe stroke, more coping strategies for solving problems in everyday activities and less caregiver burden. CONCLUSIONS: Rehabilitation interventions need to focus on supporting the dyads' process of psychological and social adaptation after stroke. Future studies need to explore and evaluate the effects of using a dyadic perspective throughout rehabilitation.

Changes in daily occupations and the meaning of work for three women caring for relatives post-stroke.

STUDY AIM: This qualitative study explored how some working Austrians experienced and coped with changes in their daily occupations after becoming informal carers of persons who had had a stroke. The study provides insights into the working carers' occupational experiences and strategies during a period of pronounced life changes. METHODS: Three participants, who were employed in full- or part-time work, as well as being informal carers of persons who had had a stroke, were interviewed on two occasions. The data from these interviews were analysed using Interpretative Phenomenological Analyses. RESULTS: Carers found themselves in an ongoing process, ranging from the disruption of daily occupations to their eventual restructure. First, the stroke led to involuntary changes in the carers' daily life, which resulted in challenges in their own, and in shared, occupations. Second, carers actively changed their values and performance of occupations, which appeared to be a strategy to shape their well-being. Paid work was found to be a stabilizing and balancing occupation, which contributed to coping and the well-being of carers. CONCLUSIONS: The authors' findings demonstrate the benefits of paid work and engagement in meaningful occupation for the carers' well-being. These results should encourage occupational therapists to be sensitive to the complexity of the lives of working informal carers.

Changes in the impact of stroke between 3 and 12 months post-stroke, assessed with the Stroke Impact Scale.

OBJECTIVE: To examine data collected using the Stroke Impact Scale 3.0 (SIS) at 3 and 12 months post-stroke, and to explore any clinically meaningful changes in everyday life in relation to age, gender and stroke severity. DESIGN: Prospective longitudinal study. METHODS: A total of 204 persons were assessed using the SIS at 3 and 12 months after onset of stroke. Changes in domain scores were calculated over time and in relation to age, gender and stroke severity. RESULTS: The Strength, Hand Function and Participation domains had the highest perceived impact at 3 and 12 months, indicating problems in everyday life. Stroke recovery was perceived to be significantly higher at 12 than at 3 months irrespective of stroke severity, age or gender. The impact on the Strength and Emotion domains was significantly lower at 12 months than at 3 months. Most clinically meaningful changes, both positive and negative (± 15 points), were seen in the Participation domain and in Stroke recovery. Few changes were associated with age, gender or stroke severity. CONCLUSION: Both positive and negative clinically meaningful changes related to impact of stroke were found between 3 and 12 months post-stroke. Therefore it is important to pay close attention to patients' perceptions of their everyday life situation during rehabilitation and at discharge.

Differences in awareness between persons with left and right hemispheric stroke.

AIM: The aim of this study was to investigate whether there are any differences in awareness of ability between persons with left and right hemispheric stroke. METHODS: The sample consisted of data from the Assessment of Awareness of Ability (A³) database, primarily consisting of clients admitted to occupational therapy services. In total the study included 183 data records from clients, 78 with left and 105 with right hemispheric stroke. Awareness of ability was assessed using the Assessment of Awareness of Ability (A³). Differences in awareness were investigated using t-tests, CI, effect size, and differential item functioning. RESULTS: No significant overall mean difference (t-test = 1.31, p = 0.19) in awareness between left and right hemispheric stroke was identified. However, significant differences (p < 0.05) were identified on three specific items included in the A³. In these cases, persons with right hemispheric stroke showed a more limited awareness. CONCLUSION: Persons with right hemispheric stroke have more pronounced problems with being aware of limitations in specific ADL performance skills compared with persons with left hemispheric stroke.