Refactoring of the SAFER-HOME to represent

the occupational context of a person

Li Ruijie (RJ), MSc OT
Senior Research Analyst
HSOR@NHG
The evi dence behi nd your deci si ons
A short story
First, a short story
A policeman, Javert, was in the area when Valjean stole a
loaf of bread. Valjean was caught by Javert.


Valjean : I stole a loaf of bread.
My sisters child was close to death
Javert
(Policeman)
: My dutys to the law
In daily clinical practice
We often come across patients with diverse needs.
It is possible or even necessary to use different models to
consider the needs of these patients
- No model is perfect
- Different models enable us to think from different
perspectives
If we can do that for patients, can
we do the same for instruments?
Background
Background
Current study is part of a larger programme
(Community Health Engagement Programme, CHEP).
Programme aims to engage seniors staying in 1-room
flats in an active lifestyle.
The interventions include:
- Self-management of chronic diseases
- Falls prevention
Background
SAFER-HOME
Safety Assessment of Function and the Environment for
Rehabilitation Health Outcome Measurement and
Evaluation (SAFER-HOME)
- Used to evaluate changes following home safety
interventions.
- Used the Person-Environment-Occupation (PEO) model to
guide its development.
- Currently in its 3
rd
revision
Background
The PEO model
SAFER HOME conceived
using Person-Environment-
Occupation (PEO) model.
Influence of PEO can be
seen in the subscales of the
instrument (e.g. Kitchen,
Personal care etc.)
Occupation
Person Environment
Aim
To determine if it is possible to use
an alternative model to consider the
construct of an instrument.
The alternative model
The Model of Human Occupation (MOHO)
Environment
PERFORMANCE
CAPACITY
Occupational
Adaptation
Performance
Participation
Skill
Occupational
Competence
Occupational
Identity
HABITUATION
Habits
Roles
VOLITION
Values
Interests
Personal causation
Methods
Methods
Refactoring
The refactoring process would put the items from the
SAFER-HOME and put them into constructs of the
MOHO.
Refactoring process would be guided by
- The theoretical constructs of MOHO
- Expert opinions (survey of OTs)
Methods
Refactoring
Surveyed 5 occupational therapists (average 5.18 years of
experience, > 2 years in CHEP)
The OTs were asked to classify each item to determine if it is
more amendable to:
- Environmental modification
- Performance capacity modification
- Both
An additional option was available if the OTs deem the item
unnecessary and could be deleted.
Methods
Refactoring
After refactoring, the original SAFER-HOME was
compared with the refactored model using CFA.
- Fit indices were used to determine if the 2 models are
comparable

Methods
Confirmatory factor analysis
I01
.
.
.
.
I72
I02
Error I01
Error I02
Error I72
Living situation
Wandering
.
.
.
.
Methods
Confirmatory factor analysis
I01
.
.
.
.
I72
I02
Error I01
Error I02
Error I72
Environment
Performance
capacity
For illustration purposes only, the items do not correspond to assigned categories.
Results
Results
Sample characteristics (n = 539)
Age in years 73.14 (8.09)
Female gender, n (%) 371 (70.94)
Ethnic Group, n (%)
Chinese 421 (80.50)
Malay 66 (12.62)
Indian 28 (5.35)
Others 8 (1.53)
Results
Sample characteristics (n = 539)
Living arrangements, n (%)
Alone 108 (20.65)
With spouse only 109 (20.84)
With immediate family 219 (41.87)
Others 85 (16.25)
Missing 2 (0.38)
Number of falls in past 1 year 0.30 (0.51)
Results
Refactored results
Refactored results presented in the form of a co-
occurrence matrix.
Establish relationships with the original model.
Delete Both Environment
Performance
capacity
Bathroom & toilet 0 3 5 3
Communication & scheduling 0 2 1 0
Eating 0 0 0 2
Environmental hazards 2 1 10 0
Household 0 2 0 7
Kitchen 0 6 0 2
Leisure 0 0 0 1
Living situation 0 0 2 1
Medication, addiction &
abuse
0 0 0 3
Mobility 0 2 3 5
Personal care 0 0 0 8
Wandering 2 0 1 0
Results:
Confirmatory factor analysis (Fit indices)
The fit indices suggest that the data fit the models well.

2 (df) RMSEA SRMR
Recommended
(Hu & Bentler, 1999)
- < 0.060 < 0.080
Original structure 3451.859
(1657)
0.046 0.006
Refactored structure 3738.375
(1654)
0.048 0.062
Discussion
Discussion
Refactoring
Results suggests that refactoring can produce a model
that is comparable to the original model
2 issues remain
- There can be infinite number of models that can be
comparable to the original model
- What is the value of such refactoring?
Discussion
Infinite comparable models
Technically, true. If
- The only criteria in which I consider comparable is fit
indices and the various diagnostics in CFA.
However, any comparable model will only hold meaning
when supported by:
- Theoretical underpinnings
- Expert knowledge
Discussion
Value of refactoring
The value lies in the
- A different way to summarise the state of the patients
functioning
- Possibly new insights into what each factor structure mean
- Different predictability of future falls
> Environment was found to be a significant predictor of falls in
the refactored model.
Conclusion
The new refactored SAFER HOME is a structurally valid
alternative way of conceptualising the instrument.
The refactored instrument suggests that environmental
modifications has a significant impact on falls.
Questions?
Ruijie (RJ)
ruijie@gmail.com