International Journal of Speech-Language Pathology, 2008; 10(1 2): 27 37

The ICF Contextual Factors related to speech-language pathology

TAMI J. HOWE

The University of Queensland, Australia

Abstract
The World Health Organizations International Classification of Functioning, Disability and Health (ICF) conceptualizes
functioning and disability as a dynamic interaction between a persons health condition and their contextual factors.
Contextual factors represent the complete background of an individuals life and living and comprise two components:
Environmental Factors and Personal Factors. This review aims to: (1) discuss why contextual factors are important for
speech-language pathologists to address in their clinical practice, (2) describe how environmental factors are coded in the
ICF, (3) identify environmental factors that are relevant for people with communication disorders, and (4) identify personal
factors that are relevant for people with communication disorders. Research on environmental factors that can influence the
functioning of individuals with various communication disorders is presented, in addition to studies on personal factors that
are important for speech-language pathologists to consider. The paper concludes that speech-language pathologists need to
address contextual factors routinely, in order to provide a holistic approach to intervention for their clients. Furthermore,
although a number of contextual factors that are relevant for people with communication disorders have been reported in the
literature, more research is needed in this area.

Keywords: ICF, World Health Organization, speech-language pathology, Contextual Factors, Environmental Factors,
Personal Factors.

Factors that are relevant for people with commu-

Introduction
The World Health Organizations (WHO) Interna-
tional Classification of Functioning, Disability and
Health (ICF) conceptualizes functioning and dis-
ability as a dynamic interaction between a persons
health condition and their Contextual Factors
(WHO, 2001). The Contextual Factors part of the
ICF is, therefore, a key feature of the classification.
Contextual factors represent the complete back-
ground of an individuals life and living (WHO,
2001, p. 16) and comprise two components:
Environmental Factors and Personal Factors. While
Environmental Factors refer to all aspects of the
external world of an individuals life that may have an
impact on his or her functioning, Personal Factors
involve features of the individual that are not part of
the health condition such as gender, age, and
coping styles (WHO, 2001, p. 17). This review aims
to: (1) discuss why Contextual Factors are important
for speech-language pathologists to address in their
clinical practice, (2) describe how Environmental
Factors are coded in the ICF, (3) identify Environ-
mental Factors that are relevant for people with
communication disorders, and (4) identify Personal
nication disorders.
Why are Contextual Factors important
for speech-language pathologists?
The inclusion of Contextual Factors in the ICF
highlights the integral role that Environmental and
Personal Factors play in influencing the functioning
of people with health conditions such as commu-
nication disorders. Therefore, a holistic approach to
maximizing a clients communication functioning
requires that speech-language pathologists routinely
address these factors as part of their clinical practice.
In addition, there are a number of specific reasons
why it is particularly important for speech-language
pathologists to focus on Environmental and Personal
Factors. First, speech-language therapy aims to
improve clients communication in their everyday
environments, not just within the clinic (Owens,
Metz, & Haas, 2007). Ensuring that an individuals
communication skills are generalized to settings
outside the clinic, however, can be difficult (Finn,
2003; Hughes, 1985; van den Broek, 2005). One
reason for this difficulty may be that some clinicians

Correspondence: Tami Howe, Communication Disability Centre, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane,
Queensland, 4072, Australia. Tel: 617 3346 7494. Fax: 617 3365 1877. E-mail: t.howe@uq.edu.au
ISSN 1754-9507 print/ISSN 1754-9515 online The Speech Pathology Association of Australia Limited
Published by Informa UK Ltd.
DOI: 10.1080/14417040701774824
28 T. J. Howe
fail to address Contextual Factors adequately in
therapy, hoping rather that the communication skills
will magically transfer to use outside the clinic
(Threats & Worrall, 2004). Secondly, communica-
tion is a collaborative process and generally one
cannot communicate without a communication
partner (Eadie, 2003), in other words an environ-
mental factor. Since Environmental Factors are an
integral part of communication (Threats, 2000), it is
important that speech-language pathologists address
them. Thirdly, the speech-language pathologist has
specialist knowledge about communication and
communication disorders that can be used to address
Environmental Factors that influence the function-
ing of people with speech and language difficulties.
As Simmons-Mackie (2000, p. 180) states, The
speech-language pathologist is uniquely qualified to
analyse the communication requirements of activ-
ities, identify potential communication adaptations,
and collaborate with involved parties to enhance
participation. The speech-language pathology
scope of practice in countries such as the United
States (American Speech-Language-Hearing Asso-
ciation, 2001) and Australia (Speech Pathology
Australia, 2002) now includes focusing on Environ-
mental Factors as part of the clinicians role.
The inclusion of Environmental Factors in the
ICF can also help speech-language pathologists to
document and/or be reimbursed for activities that
they may have undertaken in the past, but that were
outside the traditional therapy model (Threats &
Worrall, 2004). An example is a speech-language
pathologist who focuses on the Environmental
Factor of training family members to communicate
better with an individual who has severe chronic
aphasia. The clinician can use the ICF framework to
demonstrate that the training is a worthwhile use of
time because it has a greater impact on the clients
everyday communication functioning than if the
same amount of time was spent working only directly
with the client (Threats & Worrall, 2004).
Furthermore, the ICF Environmental Factors
component provides speech-language pathologists
with standard terminology to use within the disci-
pline, as well as across disciplines and countries. For
example, there are currently at least four non-ICF
classifications for Environmental Factors that are
relevant for people with aphasia. Each of these
classifications uses different labels to refer to similar
types of factors. For example, while Parr, Byng,
Gilpin, and Ireland (1997) included factors involving
the attitudes of others in a broad category labelled,
Attitudinal, Garcia, Barrette, and Laroche (2000)
included these factors in a higher level classification
called, Societal. In contrast, Howe, Worrall, and
Hickson (in press a) classified attitudes of other
people within a broader category labelled, Related
to other people, while Brown et al. (2006)
categorized them as People environmental factors.
This inconsistency is confusing and could result in
miscommunication. The ICF, in contrast, offers a
standard set of terms that are recognized interna-
tionally and that have been translated into a number
of languages. Although the categories within the
current version of the ICF do not provide enough
detail in some areas that are particularly important
for people with communication disorders such as
aphasia (Howe, 2006), the classification provides a
foundation for the development of more relevant
terms in the future. In addition, the various specific
classifications could be used clinically; they could be
translated into the standard terms used by ICF terms
in communication with organizations such as gov-
ernments and third party payers.
In addition, the inclusion of Environmental Factors
in the ICF provides speech-language pathologists with
a social policy tool that they can use to help them
advocate for greater community access for their clients
(Hurst, 2003; Threats, 2000). The availability of an
Environmental Factor classification system makes it
easier to identify the specific barriers that need to be
considered. For example, speech-language patholo-
gists can use the classification to help them identify
and reduce negative Environmental Factors or bar-
riers to communication (e.g., poor communication
strategies used by the communication partner of an
individual with dementia). The classification also
provides clinicians with a framework for advocating
for positive Environmental Factors or facilitators (e.g.,
modified written information for an individual with
aphasia) for their clients. A barrier-free environment is
not necessarily enough to support the participation of
people with communication disorders (Threats,
2007). Facilitators must also be addressed.
Systematic consideration of the Personal Factors
component for each client is also important in
speech-language therapy. Client-centredness or per-
son-centredness is increasingly becoming a priority
in health and rehabilitation service delivery (Cott,
2004) and includes demonstrating respect for clients
and involving them in decision making (Townsend
et al., 2002). Another aspect of person-centredness
involves therapists focusing on the Personal Factors
of clients by developing individualized rehabilitation
programs (Cott, 2004). For example, by considering
unchangeable Personal Factors such as ethnic back-
ground, gender, and previous experiences, clinicians
can better understand their clients and adapt services
to meet their clients needs (Threats, 2007).
Furthermore, the identification of potentially
changeable Personal Factors such as coping styles
and other health conditions can help speech-
language pathologists to advocate for other services
that their clients may require (Threats, 2003).
How are Environmental Factors coded
within the ICF?
Environmental Factors are defined as the physical,
social, and attitudinal environment in which people

live and conduct their lives (WHO, 2001, p. 10).
These factors can be negative, positive, or have no
effect. An individuals functioning may be hindered
and disability created, if society creates negative
Environmental Factors (barriers) or fails to provide
positive Environmental Factors (facilitators). In
contrast, a persons functioning may be supported,
if society removes barriers and provides facilitators.
Within the ICF, Environmental Factors target two
different levels: the individual and the societal level.
While the individual level involves a persons
immediate environment such as a home, workplace,
or school, the societal level refers to overarching
systems such as services and formal and informal
rules. Furthermore, the Environmental Factors
component is divided into five chapters or domains:
(1) Products and technology; (2) Natural environ-
ment and human-made changes to environment; (3)
Support and relationships; (4) Attitudes; and (5)
Services, systems, and policies. Each chapter con-
tains a detailed list of Environmental Factors
organized hierarchically into second- or third-level
categories. In addition to a heading, every category
has an alphanumeric code, beginning with the letter
e to denote Environmental Factors, followed by option is to code Environmental Factors in relation
a one-digit number to represent the chapter number,
and a two-digit number to represent the second-level
category. For example, Chapter Two Natural en-
vironment and human-made changes to environ-
ment includes the second-level category Light
(e240). Third-level categories have an additional one
digit number (e.g., Light quality (e2401)). To
help the rater to select an appropriate Environmental
Factor, categories also include an operational defini-
tion and, where applicable, category inclusions and
exclusions.
Environmental Factors are coded with respect to
the perspective of the person with the communication
disorder. Because it is recognized that an Environ-
mental Factor such as kerb cuts may be a facilitator
for one individual (e.g., a person who uses a wheel-
chair), yet a barrier for another person (e.g., a person
who is blind), the factors are written in neutral terms.
A specific Environmental Factor such as support
from another person may even be a barrier or a
facilitator for individuals with the same communica-
tion disorder (Howe, Worrall, & Hickson, in press b).
The impact of a particular Environmental Factor
on a specific persons life is indicated by the inclusion
of qualifiers. Barriers are coded by placing a point (.)
after the factor, followed by a number qualifier that
indicates the extent of the barrier (i.e., .0 for no
barrier, .1 for a mild barrier, .2 for a moderate bar-
rier, .3 for a severe barrier, or .4 for a complete
barrier). Background noise that is a mild barrier for
an individual with dysarthria in a specific situation,
for example, would be coded using the neutral
category of Sound quality (e2501) followed by a
point and a 1 to indicate that its effects are mild (i.e.,
e2501.1). A factor can be a barrier because it is
ICF Contextual Factors 29
present or because it is absent. For example, back-
ground noise for an individual with a voice problem
may be barrier because of its presence, while
specialized workplace training for people with trau-
matic brain injury may be a barrier because of its
absence.
Facilitators are coded by placing a sign after the
factor, followed by a number qualifier that identifies
the extent of the facilitator (i.e., 0 for no facilitator,
1 for a mild facilitator, 2 for a moderate
facilitator, 3 for a substantial facilitator, and 4
for a complete facilitator). A communication board
that is a moderate facilitator would, therefore, be
coded by using the neutral category of Assistive
products and technology for communication
(e1251), followed by a sign and a 2 to indicate
that its effects are moderate (i.e., e1251 2). A
second qualifier for Environmental Factors is to be
developed in the future.
Environmental Factors may be coded in one of
three ways. First, they can be coded overall for the
person, without relating them specifically to the Body
Functions and Structures component or the Activ-
ities and Participation component. The second
to the Body Functions and Structures component
and the Activities and Participation component. The
final option is to code Environmental Factors for
capacity and performance qualifiers in the Activities
and Participation component for each item (see
OHalloran & Larkin (2008) for more information
about the capacity and performance qualifiers). The
selection of one of these three coding options will
depend on the users requirements. For example,
rather than identifying that a family member of
someone with a traumatic brain injury is generally a
barrier or facilitator, it may be important to highlight
that the family member is a facilitator in relation to
helping the individual return to work, but a barrier in
relation to the person developing a romantic relation-
ship. Environmental Factors are intended to be
coded in relation to a certain point in time; however,
a longer timeframe may be used, if specified.
What Environmental Factors are relevant for
individuals with communication disorders?
Each of the five chapters or domains in the
Environmental Factors component is described
below. Specific examples of Environmental Factors
that are relevant for individuals with various com-
munication disorders within each chapter are also
provided.
Chapter One: Products and Technology
The products and technology chapter comprises
natural or human-made products or systems of
products, equipment, and technology (WHO,
2001, p. 173). The chapter includes items designed
30 T. J. Howe
specifically for individuals with communication
disorders, products used by the general public,
signage, and drugs.
Assistive products and technology for communication.
There is a wide range of products designed speci-
fically for people with communication disorders that
support participation. Facilitators include products
that improve speech such as palatal lifts for indivi-
duals with dysarthria (Roth, Poburka, & Workinger,
2000), altered auditory feedback devices for indivi-
duals who stutter (Zimmerman, Kalinowski, Stuart,
& Rastatter, 1997), voice amplifiers for individuals
with voice disorders (Roy et al., 2002), and electro-
larynxes and tracheosophageal voice prostheses for
individuals who have had a laryngectomy or phar-
yngolaryngectomy (Ward, Koh, Frisby, & Hodge,
2003). Electronic augmentative and alternative
communication systems such as synthesized speech
devices used by people with dysarthria (Drager,
Hustad, & Gable, 2004) and the TalksBac computer
system used by people with aphasia (Waller, Dennis,
Brodie, & Cairns, 1998) would also be classified as
facilitators within this chapter. In addition, this
domain includes low technology aids that support
verbal expression such as remnant books (Ho, Weiss,
Garrett, & Lloyd, 2005) and Talking Mats for
individuals with aphasia (Murphy, 2000), and
memory wallets for individuals with dementia
(Bourgeois, 1992). Finally, assistive products for
people with hearing disorders such as hearing aids
(Vuorialho, Karinen, & Sorri, 2006), cochlear
implants (Lassaletta, Castro, Bastarrica, de Sarria,
& Gavilan, 2005), and telephone amplifiers
(Stephens, Gianopolous, & Kerr, 2001) are also
examples of facilitators that would be categorized
within this chapter.
Assistive products and technology facilitators
include modifications to written materials that are
specifically for people with reading difficulties. For
example, the use of simple words, short sentences,
and increased white space around the text can
facilitate reading comprehension in individuals with
aphasia (Rose, Worrall, & McKenna, 2003).
Furthermore, modifications such as using supportive
graphic information and dot points can help people
with complex communication needs to understand
written information (Owens, 2006).
Although several assistive products are facilitative
for people with communication disorders, some
specific features of these devices hinder participation.
For example, battery problems when using electro-
larynxes (Carr, Schmidbauer, Majaess, & Smith,
2000) and augmentative communication devices that
are not reliable (Bailey, Parette Jr., Stoner, Angell, &
Carroll, 2006) have been identified as barriers. In
addition, if the device is especially cumbersome for
the person to use, then it could potentially be more
of a barrier to communication participation than a
facilitator.
General products and technology. Products used by the
general public may also hinder or facilitate the
participation of individuals with communication
disorders. Telephones, for example, have been
reported to be a barrier for people with aphasia
(Howe et al., in press b; Murphy, 2006), dysarthria
(Ball, Beukelman, & Pattee, 2004), and spasmodic
dysphonia (Baylor, Yorkston, & Eadie, 2005), while
intercoms have been identified as a hindrance
for individuals with laryngectomies (Sullivan,
Beukelman, & Mathy-Laikko, 1993). In addition,
communicating in cars has been reported to be
difficult for people with laryngectomies (Sullivan
et al., 1993), spasmodic dysphonia (Baylor et al.,
2005), and dysarthria (Ball et al., 2004). In contrast,
general products such as bus passes, video monitors
at train stations, and computerized scoring systems
at bowling alleys have been identified as facilitators
for people with aphasia (Howe et al., in press b).
Specific features of general products can also hinder
participation. For example, telephone voice record-
ings, telephone voice recognition systems, and non-
standardized automated teller banking machines
have been identified as barriers by individuals with
aphasia (Howe, 2006; Howe et al., in press b).
Signage. Features of signs such as unclear pictures
can be barriers for some individuals with aphasia,
while colour coded and clear signage have been
reported to be facilitative (Howe, 2006; Howe et al.,
in press b). Furthermore, labels with photographs
and names can help individuals with dementia to
identify their belongings (Gross et al., 2004).
Products and substances for personal consumption.
Substances that are consumed such as drugs and
liquids are also included in the Products and
Technology chapter. An example of a drug that is a
facilitator for some individuals with communication
disorders is Botulinum Toxin A (Botox). Injection of
Botox into specific laryngeal muscles has been used to
improve the voice of individuals with spasmodic
dysphonia (Zwirner, Murry, Swenson, & Woodson,
1991). A Cochrane systematic review (Greener,
Enderby, & Whurr, 2001) found that another drug,
piracetam, may be effective in the treatment of
aphasia after stroke; however, larger research trials
are needed to provide further evidence of the drugs
effectiveness. Although many studies have investi-
gated the effect of drugs on reducing stuttering, a
recent systematic review concluded that none of the
pharmacological agents tested to date can be recom-
mended to improve fluency in people who stutter
(Bothe, Davidow, Bramlett, Franic, & Ingram, 2006).
Drugs may also be barriers, negatively influencing the
functioning of people with communication disorders.
Some anticonvulsant medications, for example, may
negatively affect speech production, while other
medications can produce drowsiness, anxiety, confu-
sion, or depression (Vogel & Carter, 1995).

Daily hydration treatment involving drinking eight
or more glasses of water, in addition to 2 hours of
exposure to high humidity environments and con-
sumption of a mucolytic medication, was found to
produce significantly greater improvements in voice
and in laryngeal appearance than a placebo condition
in individuals with laryngeal nodules or polyps.
Some benefits, however, were also reported for the
placebo condition (Verdolini-Marston, Sandage, &
Titze, 1994).
Chapter Two: Natural Environmental and
Human-made Changes to Environment
The domain of natural environment and human-
made changes to environment includes elements of
the physical environment that are either natural or
modified by people. Sound is one factor in this
domain that is particularly relevant for people with
communication disorders.
Sound. Background noise has been identified as a
barrier to communication for individuals with spas-
modic dysphonia (Baylor et al., 2005), voice disorders
(Thomas, de Jong, Kooijman, Donders, & Cremers,
2006), dementia (Orange, 1995), laryngectomies
(Carr et al., 2000; Sullivan et al., 1993), aphasia
(Garcia et al., 2000; Howe et al., in press b), and
dysarthria caused by amyotrophic lateral sclerosis
(Ball et al., 2004). Conversely, noise in one study was
identified as a facilitator to communication for
individuals with reduced vocal loudness due to
Parkinsons disease (Adams, Moon, Dykstra, Abrams,
Jenkins, & Jog, 2006), with people with Parkinsons
disease consistently increasing their loudness level as
the level of the background noise increased.
Other Environmental Factors. A variety of other
physical factors are also relevant for people with
communication disorders. For example, temperature
changes, environmental irritants in the air, and
humidity have been found to have a negative
influence on individuals with voice disorders
(Thomas et al., 2006). In contrast, as reported
previously, hydration treatment that included expo-
sure to humid environments resulted in significant
improvements in voice and in laryngeal appearance
for individuals with laryngeal nodules or polyps
(Verdolini-Marston et al., 1994).
The presence of visual distractions has also been
reported to hinder the participation of individuals
with aphasia (Howe et al., in press b). In contrast,
modifying the physical environment by brightening
the lighting, seating individuals around small tables,
rather than along the walls of a ward, and setting up
items so individuals could serve themselves resulted
in significant improvements in the communication of
individuals with dementia during their coffee time
(Melin & Gotestam, 1981). Finally, environments
that are familiar and constant have been identified as
ICF Contextual Factors 31
facilitative for people with aphasia (Howe, 2006) and
dementia (Orange, 1995).
Chapter Three: Support and Relationships
The support and relationships domain is a key area
for individuals with communication disorders. It
includes the relationships of other people and
animals and the amount of assistance provided by
the individuals, but excludes the attitudes of other
people. The categories within this domain are
classified according to the relationship that the
individual has with the person who has the commu-
nication disorder (e.g., Immediate family (e310),
Personal care providers and personal assistant
(e340), and Health professionals (e355)). In the
ICF, professionals who provide services such as
transportation and economic services may be coded
within Chapter Five: Services, systems, and policies.
For example, a bus driver may be coded under the
services, systems, and policies category of Trans-
portation services (e5400). There is overlap, there-
fore, between categories within the Support and
relationships domain and the Services, systems, and
policies domain (e.g., a health professional could be
categorized as Health professionals (e355) within
the Support and relationships chapter or as Health
services (e5800) within the Services, systems, and
policies chapter).
General support and relationships. The availability of
other people in the environment for support during
communication has been identified in a number of
studies. Siblings, for example, can facilitate the
participation of children with speech impairments
by protecting and interpreting for their family
member (Barr, McLeod, & Daniel, in press), while
the presence of family members is an important
support for people with dementia (Muo et al., 2005),
aphasia (Howe et al., in press b), and complex
communication needs (Hemsley & Balandin, 2004).
Furthermore, the level of support provided by family
and friends was identified as an important facilita-
tor for individuals who had had a laryngectomy
(Richardson, Graham, & Shelton, 1989). Finally,
the availability of support from other people with
the same communication disorder has been reported
to be facilitative for people with laryngectomies
(Richardson et al., 1989), aphasia (Howe et al., in
press b), and fluency disorders (Yaruss et al., 2002).
The presence of other individuals in the environ-
ment can also be barrier. For example, having other
individuals available to speak for the individual can
be a barrier to participation for individuals with
aphasia (Howe et al., in press b) and children with
speech impairment (Barr et al., in press). Instead of
providing the individual with a communication
disability with the chance to speak for him or herself,
other people may tend to communicate only with the
person accompanying the individual.
32 T. J. Howe
Specific communication behaviours of other people.
Specific behaviours of communication partners can
hinder participation. For example, other people speak-
ing too fast was reported to be a barrier for people with
aphasia, young people with developmental language
difficulties, and adults with learning difficulties (Howe
et al., in press b; Law, Bunning, Byng, Farelly, &
Herman, 2005; Murphy, 2006). Other barriers for
people with a variety of communication disorders
include conversation partners not providing enough
time for the individual to communicate and not
speaking directly to the person with the communica-
tion disorder (Howe et al., in press b; Law, Bunning,
Byng, Farelly, & Herman, 2005; Murphy, 2006;
Nordehn, Meredith, & Bye, 2006). A study using
virtual reality technology found that individuals with
fluency disorders stuttered more when the virtual
interviewer interrupted them, spoke fast, had reduced
eye contact, and increased the time pressure
(Brundage, Graap, Gibbons, Ferrer, & Brooks,
2006). Conversely, communication partners who
demonstrate patience when communicating have
reported to be facilitative for people with aphasia
(Howe et al., in press b) and dementia (Orange, 1995).
Concentrating on the person with the commu-
nication disorder was also identified as a facilitator
for conversation partners to use when listening to
individuals with aphasia (Howe, 2006) and with
dysarthria caused by Huntingtons disease and
amyotrophic lateral sclerosis (Klasner & Yorkston,
2005). Other examples of facilitators for people with
communication disorders post-stroke included other
people asking individuals how best to communicate
with them and health professionals writing down key
points during health consultations for individuals to
take home with them (Nordehn et al., 2006).
Communication partner training for other people. Com-
munication partner training has been found to
facilitate the participation of people with a variety of
communication disorders. Training others to modify
their behaviours when interacting with individuals
with communication difficulties has had a positive
effect on the communication of preschoolers with
language disorders (Crowe, Norris, & Hoffman,
2004) and autism spectrum disorder (McConachie,
& Diggle, 2007) and adults with aphasia (Kagan,
Black, Duchan, Simmons-Mackie, & Square,
2001), traumatic brain injury (Togher, McDonald,
Code, & Grant, 2004), and verbal apraxia (Florance,
Rabidoux, & McCauslin, 1980). Communication
partner instruction has included a variety of conversa-
tion partners such as family members (Correll, van
Steenbrugge, & Scholten, 2004), medical students
(Legg, Young, & Bryer, 2005), police officers (Togher
et al., 2004), and volunteers (Kagan et al., 2001).
Characteristics of other people. The characteristics of
conversation partners, unlike specific communica-
tion behaviours of other people discussed earlier,
involve general qualities of individuals that can
influence the communication of people with various
speech and language disorders. For example, a
familiar listener can be more facilitative than an
unfamiliar listener with individuals who have spas-
modic dysphonia (Baylor et al., 2005), laryngec-
tomies (Carr et al., 2000), aphasia (Howe et al., in
press b), dysarthria (DePaul, & Kent, 2000), and
dementia (Orange, 1995). Familiar partners may
have a shared understanding of some events that
facilitates the communication of the individual with
the communication disorder (Murphy, 2004). Even
brief familiarization with the speech of individuals
with dysarthria has been shown to enhance listeners
understanding of the individuals communication
(Hustad & Cahill, 2003).
The presence of a foreign accent or a hearing
difficulty is an additional characteristic of other
people that can influence the participation of
individuals with communication disorders. For ex-
ample, conversation partners who speak with a
foreign accent can be more difficult for people with
aphasia to understand (Howe et al., in press b; Le
Dorze, Brassard, Larfeuil, & Allaire, 1996), while
individuals with hearing difficulties have been
identified as being more difficult for people with
spasmodic dysphonia (Baylor et al., 2005) and
laryngectomies (Carr et al., 2000) to commu-
nicate with.
Number of other people. The number of communica-
tion partners the individual has to communicate with
at one time has also been reported to be an important
Environmental Factor for people with a variety of
communication disorders. Being required to speak in
larger groups is a barrier for individuals with
dysarthria (Ball et al., 2004), dementia (Orange,
1995), and aphasia (Howe et al., in press b; Le Dorze
et al., 1996). Conversely, one-to-one conversations
or small group conversations have been identified as
a facilitator for people with dementia (Orange, 1995)
and aphasia (Howe et al., in press b).
Animals. Animals can also be facilitators for people
with communication disorders. Hearing dogs can
support the participation of people with hearing loss
(Guest, Collis, & McNicholas, 2006), while the
presence of dogs can be facilitative for the commu-
nication of people with aphasia (Howe et al., in press
b; LaFrance, Garcia, & Labreche, 2007).
Chapter Four: Attitudes
The Attitudes chapter focuses on the attitudes of
other individuals and society in general. Attitudes
refer to the observable consequences of customs,
practices, ideologies, values, norms, factual beliefs,
and religious beliefs . . . [that] . . . influence individual
behaviour and social life at all levels (WHO, 2001,
p. 190). The organization of this chapter is similar to

that of Support and Relationships in that the
categories refer to the relationship of the individual
to the person with the communication disorder (e.g.,
Individual attitudes of immediate family members 2005). Family members, however, were found to
(e410) or Individual attitudes of friends (e420)). have a facilitative influence, if they were informed
Attitudes of other people. Negative attitudes of other
people can hinder the participation of individuals
with a variety of communication disorders. For
example, other peoples negative attitudes have been
identified as a hindrance for people with aphasia
(Howe et al., in press b) and as a barrier to workplace
participation for people who have dysarthria, laryn-
gectomy, hearing loss, fluency disorders, and aphasia
(Garcia, Laroche, & Barrette, 2002). Furthermore,
children with a specific language impairment (Knox,
& Conti-Ramsden, 2003) and adolescents who
stutter (Blood & Blood, 2004) reported that they
were at greater risk of bullying than individuals
without these disorders. A number of studies have
identified negative attitudes of others towards people
with various communication disorders such as
dysarthria (Fox & Pring, 2005) and stuttering (Lass
et al., 1992).
In contrast to negative attitudes, positive attitudes
towards individuals with communication disorders
can be facilitative. Positive attitudes of family mem-
bers, for example, are a facilitator for people with
Alzheimers disease (Muo et al., 2005). Further-
more, health care providers having a respectful
attitude was identified as a key facilitator by people
with communication disorders post-stroke (Nordehn
et al., 2005). It is noted that the ICF includes a code
that specifically refers to the individual attitudes of
health professionals (WHO, 2001).
Societal attitudes. In addition to individual attitudes,
more general attitudes in society can also influence
the functioning of people with communication
disorders. For example, Brown et al. (2006) reported
that an organizational attitude in a bank of dealing
with customers as fast as possible may be a barrier for
individuals with aphasia who need more time to
communicate.
Other peoples awareness of the communication disorder.
Other peoples awareness of the communication
disorder is subsumed under the categories of the
Attitudes chapter as it is assumed that values and
beliefs are the driving forces behind the attitudes cipation of people with communication disorders,
(WHO, 2001, p. 190). Awareness of aphasia in
general was identified as a key facilitator, while lack
of awareness of aphasia was reported to be an
important barrier for people with aphasia (Howe
et al., in press b; Parr et al., 1997). In another
example, teachers who participated in a course that
focused on speech and language development had
more accurate perceptions of the ability levels of
students with communication disorders than tea-
chers who did not receive training (Ebert & Prelock,
ICF Contextual Factors 33
1994). Furthermore, negative attitudes of family
members were found to be a key barrier for
individuals with Alzheimers disease (Muo et al.,
about the progress of the disease and how to cope
with it (Muo et al., 2005). Service providers have
also identified lack of awareness of aphasia as a key
barrier to participation in community settings for
people with aphasia (Brown et al., 2006). Although
awareness by itself may not necessarily change
peoples attitudes, it may be a key precursor for
enabling people to develop more positive attitudes
toward individuals with various communication
disorders.
Furthermore, awareness of communication dis-
orders such as aphasia may underpin some of the
other Environmental Factors. Awareness can influ-
ence societys provision of appropriate services and
resources for participation (Elman, Ogar, & Elman,
2000; Simmons-Mackie, Code, Armstrong, Stiegler,
& Elman, 2002). Furthermore, if other people are
not aware that disorders such as aphasia exist, they
will not know how to facilitate communication with
people who have the disorder (Simmons-Mackie
et al., 2002).
Chapter Five: Services, Systems, and Policies
Services, systems, and policies refer to the social
structures, services, and overarching systems that
have an impact on individuals. While the other
chapters focus mainly on the persons immediate
environment, this domain comprises factors in the
broader environment of society. This domain in-
cludes work, community, government, transporta-
tion, health, and communication services and
organizations, as well as the administrative systems
that organize, control and monitor services, and laws
and formal and informal rules.
Services. Services refer to structured programmes,
operations, and services . . . established . . . by em-
ployers, associations, organizations, agencies, or
government in order to meet the needs of individuals
and includes the persons who provide these services
(Schneidert, Hurst, Miller, & Ustun, 2003, p. 591).
A number of services have been identified as being
particularly important for facilitating the parti-
including the provision of support groups for people
who stutter (Yaruss et al., 2002), and for individuals
with aphasia, the availability of driving instructors
who are specially trained to communicate with
individuals with aphasia, and the provision of
advocates to support the communication of indivi-
duals with aphasia in the legal system and in
government departments (Howe, 2006; Howe
et al., in press b). Furthermore, the provision of
rehabilitation and vocational support services is
34 T. J. Howe
associated with positive employment outcome
for individuals with traumatic brain injury
(Ownsworth & McKenna, 2004). Finally, the avail-
ability of speech therapy services has been identi-
fied as a facilitator for people with laryngectomies
(Richardson et al., 1989) and individuals with
aphasia (Howe et al., in press b).
Systems and policies. Systems refer to mechanisms
designed to organize, control, and monitor ser-
vices (WHO, 2001, p. 192). A number of barriers
to and facilitators for people with aphasia using
public transport systems have been identified.
Barriers include being required to communicate the
destination and ticket type to obtain a ticket on
public transport and having to speak to someone on a
telephone to book a taxi (Ashton et al., in press). In
contrast, facilitators such as being required to use
only one ticket for the whole journey (Ashton et al.,
in press) or the use of a ticketing system that does not
require the person to talk to the bus driver (Howe
et al., in press b) have been identified as facilitators.
Workplace systems can also influence the func-
tioning of people with communication disorders.
These systems include procedures necessary to
participate in a specific job such as being required
to speak over loud noise when teaching. For
example, one study found that 38% of teachers
indicated that the requirements of teaching had
negatively affected their voice (Smith, Lemke,
Taylor, Kirchner, & Hoffman, 1998). Environmental
Factors in workplaces such as the interview process
and costs related to adaptations have also been
reported to influence the participation of people
with various communication disorders (Garcia
et al., 2002).
Policies refer to rules and standards that govern
and regulate the system. An example of a policy that
is a barrier for people with aphasia is a banking policy
that requires that clients be served within a short time
period (Howe et al., in press b). An example of a
facilitator would include a government policy for
providing sufficient funding for people with aphasia
after they have had a stroke (Howe et al., in press b).
What Personal Factors are relevant for people
with communication disorders?
Personal factors refer to an individuals features that
are not associated with or caused by the persons
health condition (Threats, 2007), but that may have
an impact on their experience of the health condition
(Bornman, 2004). These factors include gender,
race, other health conditions, ethnicity, coping styles,
profession, and individual psychological assets
(WHO, 2001). Because of the wide social and
cultural variation associated with Personal Factors,
they are not classified in the ICF. The World Health
Organization, however, has called for development of
this component in the future (WHO, 2001).
Threats (2007) reports that there has been some
confusion in the literature regarding the difference
between Personal Factors and Body Functions
components in the ICF, particularly in relation to
mental functions such as confidence and optimism.
The author suggests that one way to differentiate
between Personal Factors and Body Functions
components in individuals with acquired commu-
nication disorders is to determine if the characteristic
existed premorbidly. For example, if a spouse
indicates that his wife with aphasia was not confident
about communicating prior to her stroke and that
she continues to lack confidence, this trait may be
considered a personal factor. However, if the
womans husband reported that his wifes reduced
confidence is associated with the onset of her
aphasia, this factor may be categorized within the
Body Function component.
Personal Factors can be divided into potentially
changeable and more difficult to change or un-
changeable factors. Potentially changeable factors
include other health conditions, fitness, lifestyle,
habits, coping styles, social background, education,
profession, current experiences, overall behaviour
pattern and character style, and individual psycho-
logical assets. Factors that are unchangeable or
difficult to change include age, race, gender,
ethnicity, nationality, upbringing, and past experi-
ences. Another way to divide these factors is by
grouping them broadly into demographic infor-
mation (e.g., age, ethnicity, and socioeconomic
level) and personality traits (e.g., coping styles)
(Threats, 2007).
Investigations of Personal Factors in relation to
communication disorders are limited relative to
Environmental Factor research. Some difficult
to change or unchangeable factors that have been
investigated include age and gender in individuals
with traumatic brain injury, aphasia, and head and
neck cancer. The results of these studies, however,
are conflicting or inconclusive (Cherney & Robey,
2001; de Graeff et al., 2000; Fleming, Tooth,
Hassell, & Chan, 1999; Grosswasser, Cohen, &
Keren, 1998; Terrell et al., 2004; Winkler,
Unsworth, & Sloan, 2006). Another unchangeable
personal factor, pre-injury occupational status, is
associated with employment outcome for people
with traumatic brain injury. Individuals with
higher qualifications and higher pretraumatic
brain injury occupational level were more likely to
return to competitive employment (Ownsworth &
McKenna, 2004).
Potentially changeable Personal Factors that have
been investigated in individuals with communication
disorders include the presence of other health
conditions, coping styles, and personality traits.
The presence of other health conditions can be a
negative influence on the functioning of people with
aphasia (Cherney & Robey, 2001) and on the
functioning and quality of life of people with head

and neck cancer (de Graeff et al., 2000; Terrell et al.,
2004). Coping styles and personality traits are
potentially changeable Personal Factors that have
been investigated in relation to people who stutter.
Individuals who stutter reported that making the
transition from unsuccessful to successful manage-
ment of their stuttering was associated with variables
such as high levels of motivation or determination
(Plexico, Manning, & DiLollo, 2005). Continued
successful management of stuttering was reported to
be associated with psychological assets such as
optimism and self acceptance, while unsuccessful
management of stuttering was reported to involve
themes such as avoidance (Plexico et al., 2005).
Clinicians also need to consider how Personal
Factors interact with Environmental Factors in a
particular individual (Threats, 2007). For example, a
personality trait, an example of a personal factor, can
influence a persons self-perception of the benefit of
having a hearing aid, an Environmental Factor. In
one study, extroverted individuals reported greater
hearing aid benefits than individuals with other
personality characteristics (Cox, Alexander, & Gray,
1999).
Conclusion
Speech-language pathologists need to address both
components of Contextual Factors, namely Environ-
mental Factors and Personal Factors, in order to
provide a holistic approach to intervention for their
clients disability. Although a number of Environ-
mental and Personal Factors that are relevant for
people with communication disorders have been
reported in the literature, further research is needed
in this area (Howe, Worrall, & Hickson, 2004;
Threats, 2007).
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