How does the environmental inadequacy mediate the effect of functional limitations on participation restrictions in young adults with cerebral palsy?

Background: Adults with cerebral palsy (CP) face various functional limitations and comorbidities, that prevent them from participating fully in social life. Disability models suggest that an environment not tailored to their needs could partly explain the link between functional limitations and participation restrictions. However, there is still insufficient knowledge about how the environment hinders participation.

Objective: To investigate the mediating role of environmental inadequacy in the relationship between functional limitations and participation restrictions in young adults with CP.

Methods: Cross-sectional study, which included 310 young adults with CP, aged 22-27 years at interview (2018-2020) and recruited in well-defined geographical areas in France, Germany, Italy, Portugal and Sweden. Environmental inadequacy was assessed using the EAEQ and participation restrictions using the QYPP-YA. A theorical model was tested with a partial least squares structural equation model.

Results: Functional limitations had a significant direct effect on participation restrictions (β = 0.62, p < 0.001). A small part of the total effect was mediated by the "inadequacy of services, systems and policies" environmental latent variable (β = 0.10, p < 0.001). "Inadequacy of support and relationships" and "inadequacy of attitudes" environments demonstrated no mediating effect. Unexpectedly, a higher "inadequacy of products and technology" environmental score appeared to reduce participation restrictions (β = -0.10, p = 0.025).

Conclusions: The environment considered as suggested by the ICF had only a minimal mediating effect in our study. However, public health policies must give priority to improvements at the macro-environmental level, particularly in terms of availability and access to the "services, systems and policies".