THERAPEUTIC RECREATION JOURNAL Vol. XLII, No. 4, I\l-ll6, 2008

Contribution of Community Integration toQuality of Life for Participants of Community-Based Adaptive Sport ProgramsSanghee Chun, Youngkhill Lee, Neil Lundberg, Bryan McCormick, and Jinmoo Heo

Abstract

The purpose of this study was to examine the contrihution of community integration toquality of life (QOL) for people with disahilities who were the participants of community-basedadaptive sport programs. Specifically, it was hypothesized that community integration contributesto physical, psychological, social, and environmental QOL. Out of 240 individuals from the mail-ing list of the Adaptive Sports Center (ASC) in Crested Butte, Colorado, a total of 93 individualsresponded to the questionnaire that measured community integration and quality of life. TTiemultiple regression analysis controlling for age, gender, and marital status was conducted to assessthe predictors for QOL domains. Community integration was the only factor that significantlypredicted psychological domain, social relationships, and environment domain. However, com-munity integration did not predict to an overall QOL. This study showed connections betweencommunity integration and QOL for participants of community-based adaptive sport programs.Further investigation on the relationships between community integration and the specific do-mains of QOL is necessary in the future for a better understanding of the phenomena.

KEYWORDS: Community Integration, Reintegration, Qudity of Life, Adaptive Sports,Therapeutic Recreado

Sanghee Chun is an Assistant Professor in the Department of Recreation and Leisure Studies at Brock University.

Youngkhill Lee is an Associate Professor in the Department of Health, PE.. Recreation. Dance, and Sport at Calvin College.

Neil Lundberg is an Assistant Professor in the Department of Recreation Management and Youth Leadership at BrighamYoung University.

Bryan McCormick is an Associate Professor in the Department of Recreation. Park, and Tourism Studies Indiana University.

Jinmoo Heo is an Assistant Professor in the Department of Tourism. Conventions, and Event Management IndianaUniversity—Indianapolis.

CHUN, LEE, LUNDBERG, MCCORMICK, AND HEO 217

Quality of life (QOL) for individuals withdisabilities has been recognized as an impor-tant issue in the health care field. Thus, im-proving QOL has become a major goal as wellas an important outcome in providing servicesfor this population (e.g., Dawson, Markowitz,& Stuss, 2005; Fabian, 1991; Pain, Dunn, An-derson, Darrah, & Kratochvil, 1998; WorldHealth Organization, 2001). Although defini-tions of QOL vary, there is general agreementthat individuals' statements of satisfactionwith major aspects of daily functioning are thecrucial indicators of subjective QOL (Priebe,Roeder-Wanner, & Kaiser, 2000). As the ex-perience of disabilities is multifaceted (Swan-son, Swartz, Elbogen, Wagner, & Burns, 2003),researchers examining QOL have focused onmeasuring various aspects of life such as work,health, leisure, and community integration(e.g., Anderson & Lewis, 2000; Brown, Gor-don, & Haddad, 2000; Gaite et al., 2002; Lee& McComick, 2004, 2006; Ritsner, 2003).Active engagement in activities and commu-nity integration, the latter of which has beendefined in terms of successful engagement inoccupational, social, and community activities(e.g., Dijkers, 1999; Felce & Emerson, 2001),have been identified as important factors pre-dicting QOL (e.g., Huebner, Johnson, Ben-nett, & Schneck, 2003; Schonherr, Groothoff,Mulder, Schoppen, & Eisma, 2005).

Engagement in Activity and QOLPrevious research suggests that active en-

gagement in social activities is strongly associ-ated with highQOLof individuals with disabil-ities (e.g., Huebner et al., 2003; Kennedy, Lude,Taylor, 2006; Levasseur, Desrosiers, & Noreau,2004; Schonherr, Groothoff, Mulder, & Eisma,2005; Warr, Butcher, & Robertson, 2004).Warr et al. reported that engagement in socialactivity among older adults facilitated a senseof confidence and that higher activity level wasmore highly correlated with increased levels ofpsychological well-being. Likewise, Lucas andFujita (2000) reported that people engaging insocial activity more frequently demonstratedbetter well-being than those who enjoyed soli-tary activities. More importantly, a number ofleisure studies have shown that leisure activi-ties play an important role in improving QOL(e.g., Duvdevany & Arar, 2004; Labronici,Cunba, Oliveira, & Gabbai, 2000; Tasiemski,

Kennedy, Gardner, & Taylor, 2005). Tasiemskiet al, for example, examined the relationshipsbetween recreational sports participation andlife satisfaction and found that respondentswith spinal cord injuries (SCI), who were in-volved in sports or physical recreation, demon-strated higher satisfaction with life in generalthan those not participating in physical activi-ties. Another study using a sample of 85 adultswith intellectual disability explored the role ofleisure activities and friendships on QOL andfound that participants with more frequent lei-sure activity involvement and more friendshipsexperienced higher QOL than those with lessleisure participation and less friendships (Du-vdevany & Arar).

Researchers in the field of therapeuticrecreation have also noted the important re-lationship between leisure engagement, com-munity integration, and QOL. As healthcareservices continue to transition form traditionalinpatient services toward offerings within thecommunity, the importance of leisure is be-ing further acknowledged (Hutchinson &NcGill, 1998). In fact, ensuring opportunitiesfor leisure engagement is being promoted as animportant goal for a wide variety of rehabilita-tive services (Sylvester, Voelkl, & Ellis, 2001).The effectiveness of community integrationprograms has been observed in populationssuch as older adults with mental health issues(Hebblethwaite & Pedlar, 2005), refugees fromvarious countries (Kensinger, Gearig, Boor, Ol-son, & Gras, 2007), and individuals with SGI(Dattilo, Galdwell, Lee, & Kleiber, 1998). Itcan be assumed that therapeutic recreationpractitioners will see a steady growth in oppor-tunities to provide community integration asan important rehabilitative service.

Community Integration and QOLIn addition to the relationships between

engagement in leisure activity and QOL, pre-vious literature has demonstrated that com-munity integration is an important factor forthe experience of life satisfaction and highQOL. Some researchers reported a statisticallysignificant relationship between communityintegration and life satisfaction (e.g., Bram-ston, Bruggerman, & Pretty, 2002; Dijkers,1999; Reistetter, Spencer, Trujillo, & Abreu,2005; Stalnacke, 2007; Stancliffe, Emerson, &Lakin, 2001). An empirical study on intellec-

218 COMMUNITY INTEGRATION

tuai disability showed that community integra-tion is the most effective means of promotingpositive life experiences for people with dis-ahility (Stancliffe et al). Specifically, Bramstonet al. reported that high sense of communitywas associated with high life satisfaction for in-dividuals with intellectual disability. Anotherstudy supported that higher levels of commu-nity integration were associated with higherlife satisfaction for people with SCI (Dijkers).One the other hand, in a longitudinal study,Charlifue and Gerhart (2004) reported thatdeclined community réintégration over timewas associated with decreased QOL. In addi-tion, Duvdevany and Arar (2004) emphasizedthe importance of involvement in relevant lei-sure programs and social skill development forsuccessful community integration. Communityintegration has been considered an importantintervention goal for improving QOL (Brownet al., 2000; Reistetter et al.).

Previous literature provides evidence thatlife satisfaction and QOL of individuals withdisabilities are strongly related to communityintegration (e.g., Bramston et al.; Dijkers; Gal-ski, Tompkins, & Johnston, 1998; Huebner etal., 2003; Levasseur et al., 2004); however, fewstudies have explored the role of communityintegration on the specific domains of QOLfor people with disabilities. Because chronichealth problems restrict work and negativelycontribute to QOL (Levasseur et al.), commu-nity integration through active engagement inleisure activities appears to be a critical ele-ment in improving QOL, which is a commongoal among both inclusive and therapeutic rec-reation practitioners.

Purpose Statement and ResearchHypothesis

The purpose of this study was to exam-ine the contribution of community integrationto QOL for people with disabilities who werethe participants of community-based adaptivesport programs. Specifically, it was hypoth-esized that higher scores in self-reported com-munity integration would be related to higherscores in physical, psychological, social, andenvironmental QOL.

Methods

RespondentsThe sample of this study was drawn from

mailing lists of former and current partici-pants of the Adaptive Sports Center (ASC)in Crested Butte, Colorado. Two criteria wereused in selecting participants for the study; (a)individuals had a physical or cognitive illnessesor disability, and (b) they were required to haveappropriate cognitive ability to complete theinstruments. A recreation therapist workingat the center identified 240 potential partici-pants who met the study inclusion criteria. Aresearch information packet including a coverletter explaining the purpose of the study, aresearch questionnaire, a self-addressed enve-lope, and a consent form was sent to the 240potential research respondents. To ensure con-fidentiality, staff at the ASC affixed the mail-ing labels to envelopes and sent the packet tothe potential respondents. Follow-up remind-ers were sent to the participants 4 weeks afterthe questionnaires had been distributed.

The final sample consisted of 93 respon-dents with the response rate of 39%. The ma-jority of respondents were male (61.3%) andCaucasian (96.8%) with a mean age of 43 yearsold (range = 18-78, SD = 13.7). Approximately45.2% of the individuals were single and 36.6%were married. A total of 44.1% of the samplehad full-time jobs. The respondents completedan average of 15.6 years education (range =11-19, SD = 2.86), indicating undergraduateeducation as an average academic background.With regard to disability types, 36.6% of therespondents had SCI, 31.7% had developmen-tal disabilities, and another 31.7% had ortho-pedic-related impairment. The average lengthof time since the injury was 21years (range = 1to 56 years, SD = 15.31), which shows that therespondents do have chronic illness.

InstrumentationQuality of life. Quality of life was mea-

sured using the World Health Organization'sQuality of Life Assessment (WHOQOL). TheWHOQOL is a generic quality of life instru-ment in that it was designed to be applicableto people living under different circumstances,conditions, and cultures (WHOQOL Group,1998). The WHOQOL-BREF contains 26items belonging to four domains: physical

CHUN, LEE, LUNDBERG, MCCORMICK, AND HEO 2t9

health, psychological health, social relation-ships and environment. It also includes asection on overall quality of life and generalhealth. The WHOQOL-BREF domain scoresdemonstrate good discriminant validity, crite-rion validity, content validity, test-retest reli-ahility, and internal consistency (e,g,, Aigneret al„ 2006; WHOQOL Group, 1998), The in-ternal consistency of the WHOQOL- BREF do-mains in this study (Cronbach's alpha: ,81 onphysical health; ,68 on psychological health;,69 on social relationships; ,and ,72 on envi-ronment) were similar to research supportedby the WHOQOL Group (Gronbach's alpha:,80 on physical health; ,76 on psychologicalhealth; ,66 on social relationships; and ,80 onenvironment; WHOQOL Group, 2005), Forreliability purposes the WHOQOL-BREF do-main scores were converted to a 0 to 100 scaleas recommended by the WHOQOL Group(2005) for easy comparisons to other validatedquestionnaires.

Community integration. Gommunity inte-gration was measured using the GommunityIntegration Measurement (GIM), which as-sesses people's perceived connections withintheir community (Reistetter et al,, 2005), Re-spondents rated aspects of 10 Likert-type ques-tions on a 5-point scale, where 1 represents "al-ways disagree" and 5 represents "always agree,"The average of domain items was calculatedfrom scale scores, Gronbach's alpha of commu-nity integration scores (a =,81) was similar toprevious studies (Minnes et al,, 2003; Re-istetter et al,). Along with these measures,demographic variables such as age, gender,education, marital status, and other personalcharacteristics were also collected.Data Analysis

Descriptive statistics (e,g., mean, stan-dard deviation, percentile) were used to exam-ine the nature and relationships of study vari-ables, Gorrelation coefficients were calculatedto examine to the relationships between com-munity integration, QOL, and all demographicvariables before entering all the variables intoregression analyses. This analysis was used toidentify underlying associations prior to includ-ing variables in a hierarchical regression analy-sis, which allows variables with greater theo-retical importance to be entered earlier thanother variables in the analysis (Tabachnick &

Fidell, 2001), For the assessment of the impactof community integration on QOL, hierarchi-cal regression analysis controlling for age, gen-der, and marital status was computed for eachof the domains of the WHOQOL-BREF Twoblocks of independent variables were enteredsequentially to examine the contribution ofeach block to explained variance {R') in eachof the QOL domains. The three demographicvariables (i,e,, age, gender, marital status) wereentered into the first block analysis, and thenthe community integration variable was addedinto the second block in order to examine theunique contribution of community integration.

ResultsDescriptive statistics (see Table 1) show

the mean distribution of the community inte-gration and the WHOQOL-BREF domains.The mean of GIM was 4.45 {SD = 0,51) witha range of 2,80 to 5,00, On average, respon-dents strongly felt that they had connectionswithin their communities. In addition, respon-dents experienced satisfaction in the four do-mains of QOL, The mean of the environmen-tal dortiain was the highest (M = 78.89, SD =11.96), followed by overall QOL (M = 77.20,SD = 15,09), psychological QOL (M = 74.20,SD = 12.70), physical QOL (M = 73.42, SD= 16,30), and social QOL (M = 65,62, SD =20,64), The sample reported highest satisfac-tion on condition of their living place (M =4.45, SD = ,63) and the lowest satisfaction onsex life (M = 3.06, SD = 1.16),

The correlation matrix (see Table 2)identified a number of statistically significantrelationships between demographic variables,community integration, and each domainof QOL (i.e., physical health, psychologicalhealth, social relationship, and environment).Two socio-demographic variables showedsignificant relationships with other researchvariables. Age was significantly inversely cor-related with marital status (r = ".49, p < .01)and physical health (r = ".33, p < .01), suggest-ing that older respondents were less likely to bemarried and more likely to report lower levelsof physical QOL. Interestingly, gender was sig-nificantly associated with environmental do-main indicating that women tended to reporthigher level of environmental QOL than mendid, although gender was not associated withother QOL domains, Gommunity integration

220 COMMUNITY INTEGRATION

TABLE 1

Descriptive Statistics for Study Variables

Variables

Community Integration

Physical QOL

Psychological QOL

Social QOL

Environmental QOL

Overall QOL

n

90

88

89

88

90

91

min

2.80

28.57

41.67

16.67

43.75

20.00

max

5

100

100

100

100

100

mean

4.45

73.42

74.20

65.62

78.89

77.20

SD

.51

16.30

12.70

20.64

11.96

15.09

TABLE 2

Zero-order Correlation Coefficients of ¡ndeperuient and Dependent Variables

Variables

Age

Gendet

MaritalStatus

CommunityIntegration

PhysicalQOL

Psychol.QOL

Social QOL

Environ.QOL

Overall QOL

Age

1.00

Gender

.02

1.00

Marital

.49**

.17

1.00

CI

.12

.10

.03

1.00

Physical

-.33**

-.15

-.21*

.23*

1.00

Psychol.

-.13

-.04

.08

.38**

.56**

1.00

Social

.07

.13

.12

.48**

.20

.50**

1.00

Environ.

.07

.25*

.19

.46**

.45**

.52**

.50**

1.00

Overall

-.24*

.01

-.18

.18

.57**

.63**

.34**

.35**

1.00

Note. *!>< .05, ** /)< .01, **• f) < .001 ; Psychological QOL »Psychol. QOL; Community Integration = IC

CHUN, LEE, LUNDBERG, MCCORMICK, AND HEO 221

was positively related to all of the QOL do-tnains (physical, r = .22, p < .05; psychological,r = .38, p< .01; social, r = .48, p <. 01; environ-mental, r = .46, p < .01): however, it was notsignificantly associated with overall QOL. Thisresult demonstrates that the respondents whoreported higher CIM scores were more likelyto experience higher QOL on each of the do-mains, but CIM was unrelated to overall QOL.In addition, intercorretations of WHOQOL-BREF domains indicated that scale values onthese domains are not independent althougheach domain measures different perspectivesof QOL.

Multiple regression analysis (see Table3) was conducted to assess the predictors forQOL domains. Although gender and maritalstatus were significantly related to two of theQOL domains when examining simple cor-relations, they were not significant predictorsof any particular QOL domains in the regres-sion analyses. Results did indicate that ageand community integration significantly con-tributed to the physical domain of QOL (R' =.20, p< .01 ). Community integration (ß = .28,p < .05) was positively associated with physi-cal QOL, while age (ß = ".33, p < .05) was

negatively associated with physical QOL. Inaddition, community integration was the onlystatistically significant predictor in explainingthe environment domain (ß = -.45; R^ = .28,p < .001), social relationships (ß = -.45; R' =.21, p < .01 ), and the psychological domain (ß= ".40; R^= .18, p < .01). Overall, the patternof findings from the regression analyses appearsto indicate that in this sample, community in-tegration has a stronger relationship to thoseQOL domains relevant to social and environ-mental domains, a weaker relationship to psy-chological QOL and a weaker still relationshipwith physical QOL (as measured by the CIM).Finally, community integration was not a sig-nificant predictor of overall QOL (R'= .10).

DiscussionThe purpose of this study was to examine

the contribution of community integration toQOL for people with disabilities participatingin an adaptive sports program. Based on theidea that community integration plays an im-portant role in experiencing QOL, this presentstudy hypothesized that community integrationcontributes to the experience of high physical,psychological, social, and environmental QOL.

TABLE 3

Hierarchical Regression Anal'^sis of Quality of Life

Variables

Constant

Age

Gender

Marital Status

CommunityIntegration

R'

N

Physical

B(SE)

58.19(15.17)

-.40(.14)

-4.75(3.50)

-.734(2.38)

8.96(3.25)

ß

-.33

-.14

-.04

. 2 0 "

88

Phychologica!

B(SE)

37.76(11.90)

-.20(.11)

-1.42(2.66)

2.06(1.80)

9.91(2.56)

ß

-.23

-.06

.14

.40

.18

89

Social

B(SE)

-16.49(18.23)

-.01(.17)

1.94(4.24)

1.12(3.01)

17.66(3.96)

ß

-.01

.05

0.4

.45

.22**

88

Enviton

B(SE)

24.60(10.44)

-.07(.10)

4.47 •(2.42)

2.80(1.62)

10.49(2.24)

ß

-.08

.18

.19

.45

.28***

90

Overall

B(SE)

62.96(12.19)

-.24(.14)

.91(3.37)

-1.69(2.28)

5.90(3.27)

ß

-.21

.03

-.09

.20

.10

91

Note. * p < .05, ** p < .01, *** p < .001

222 COMMUNITY INTEGRATION

Results of tbe regression analyses supported tberesearch hypothesis concerning tbe contribu-tion of community integration to physical, psy-chological, social, and environmental QOL.Findings in this study showed that commu-nity integration is a critical factor predictingthe four domains of QOL, which is congruentwitb extensive previous literature on life satis-faction (e.g., Levasseur et al., 2004; Reistetteret al., 2005; Stalnacke, 2007; Stancliffe et al.,2001). In terms of social participation throughengagement in activities, Harlow et al. statedthat social participation and community-basedactivities predicted life satisfaction, whereassedentary and solitary activities such as watch-ing television or reading were not associatedwith well-being. Similarly, Tasiemsk, Kennedy,Gardner, and Taylor (2005) reported tbat anactive sporting life-style is positively associatedwith general life satisfaction. TTiey also foundthat people engaging in sports or physical ac-tivities demonstrated higher life satisfactionthan those not participating in physical recre-ation. More specifically, another study foundthat playing basketball regularly helped peoplewith physical disability with social integration,leading to higher levels of QOL (Labronici etal., 2000).

Although community integration was asignificant predictor on specific QOL domains,it did not significantly contribute to overallQOL. The result of tbis study indicates thatcommunity integration for this sample was abetter predictor of satisfaction witb specificaspects of daily functioning ratber than over-all QOL. Previous research has indicated thatindividuals with disabilities frequently, reportlower levels of QOL and life satisfaction (U.S.Department of Healtb and Human Services(HHS], 2001). This general trend might ac-count for lower QOL scores in this sampleand the nonsignificant relationship betweencommunity integration and overall QOL. Forinstance, asking individuals about their over-all QOL may be an overly broad approach thatmight ignore specific strengths and needs.

In terms of demographic factors, the role ofage in the present study is consistent with find-ings by Kilian, Matschinger, and Angermeyer(2001) in that it was significantly associatedwith physical QOL. Kilian et al. examined theimpacts of chronic illnesses on subjective QOLand reported that age significantly contributed

to QOL cbange. In addition, gender has beenknown as a critical factor relating to individu-als' QOL. For example, Kilian et al. stated thatmales rate tbeir physical QOL higher as com-pared to females. Another study showed thatmales' perceived well-being was more positive-ly affected by family and social activities whencompared with a group of females (Warr et al.,2004). While gender was not a significant pre-dictor of QOL in this study, it was correlated toenvironmental QOL, suggesting a relationshipneeding further investigation.

Although extensive research has exploredthe relationships between community integra-tion and life satisfaction for people witb dis-abilities, few studies support the finding thatcommunity integration predicts specific as-pects of QOL. Tliis study showed connectionsbetween community integration and QOL.Furtber investigation is necessary on tbe rela-tionships between community integration onspecific QOL domains.

Implications for Therapeutic RecreationSpecialists

Therapeutic recreation specialists andrecreational therapists clearly recognize com-munity integration as an important compo-nent of successful rehabilitation (Sylvester etal., 2001). Brown et al. (2000) argued thatcommunity integration is a viable rehabilita-tion goal for improving QOL for people withdisabilities. The current study verifies this ar-gument with findings that community integra-tion was significantly associated with all fourdomains of QOL. Successful community inte-gration is clearly an important and worthwhilegoal for individuals with illness and disabilityand should be an important priority for recre-ational therapists.

Recreational therapists should also con-sider the importance of community integrationthroughout the TR process. When consideringthe potential impact of community integrationand how it might influence various domainsof QOL, it seems critical that recreationaltherapists develop more effective strategies forassessing needs and evaluating changes thatresult from such programs. The CI M used inthis study could be used to accomplish thistask. Furthermore, recreational therapistsshould continue to explore bow the provisionof various types of recreational activities and

CHUN, LEE, LUNDBERG, MCCORMICK, AND HEO 223

interventions most powerfully affect commu-nity integration and any resulting changes inquality of life.

The possible inter-relationships hetweenthe specific domains should also be consideredby practitioners and studied by researchers. Forexample, Schalock (1999) has suggested that,while physical exposure to the community orsimply living in the community does not au-tomatically guarantee positive experiences, itis necessary for the development of a sense ofcommunity. Developing a sense of communitycan then provide a feeling of shard emotionalconnection, memberships, and sense of be-longing (McMillan & Chavis, 1986). Under-standing such interactions can provide insightinto how to develop and deliver effective com-munity integration programs.

A final, but related, implication is thatrecreational therapists should consider the factthat the impact of community integration onQOL in this study was observed within thespecific domains, but not in the overall QOLmeasure. This is important because it rein-forces the need to acknowledge these differentareas of community integration in program de-velopment, treatment or inclusion planning,and evaluation of outcomes. Understandingspecific areas of need regarding quality of lifeand targeting these areas through communityintegration is an approach to programmingthat has the potential to revolutionize how ser-vices are delivered across a variety of popula-tions and settings.

LimitationsSome methodological issues must be con-

sidered when interpreting the results of thisstudy. First, the findings of this study are lim-ited by the nature of the sample. The respon-dents in this study were participants of onecommunity-based program in a particular area.Involvement in the Adaptive Sports Centerprograms was an inherent criterion for beingselected to participate in the study, which ex-cludes nonparticipants from the study popula-tion. The reasons for not participating in theAdaptive Sports Center programs are also po-tential barriers to community integration, suchas level of disability or lack of social supports.Thus, it is possible that those excluded fromthe study by these factors would have different

response patterns with regard to their percep-tions to community integration and QOL.

In addition, this study showed possiblerelationships between community integrationand QOL based on a sample with a variety ofdifferent types of disabilities. Because the re-spondents in this study experienced varioustypes of physical disability, any unique patternsassociated with disability type were not ableto be detected. It is recommended that futurestudies explore the contribution of communityintegration to QOL focusing on a specific dis-ability types for better understanding of thephenomena.

When considering these limitations, aswell as the low response rate from this study(39%), it is imperative that results be gener-alized with caution. It is also imperative thatfuture research examine the diverse subgroupsthat are within the targeted study population,but that were not specifically considered in thecurrent study sample.

References

Aiyner, M., Forster-Streffleur, E, Prause, W., FreidI, M.,Weiss, M,,& Bach, M. (2006).

Anderson, R. L., & Lewis, D. A. (2000). Quality of life ofpersons wirh severe mental illness living in an inter-mediare care facility. Joumal of Clinical Psychoiogy,56(4), 575-581.

Bramsron, P., Bruggerman, K., & Pretty, G. (2002). Com-munity perspecrives and subjective quality of life.lmen\ational Journal of Disability. Development, &Education, 49(4), 385-397.

Btown, M., Gordon, W. A., & Haddad, L. (2000). Modelsfor predicting subjective quality of life in individualswitb traumatic brain injury. Brain injury. Í4, 5-19.

Cbarlifue, S-, & Gerbart, K. (2004). Community integra-tion in spinal cotd injury of long dutation. NeuroRe-habilitation, 19(2), 91-101.

Dattilo, J., Caldwell, L., Lee, Y., iSi Kleiber, D. (1998). Re-tutning to the community witb a spinal cord injury:Implications for tberapeutic recreation specialists.

Kutic Recreation Joumai, 32(1), 13-27.

Dawson, D. R., Markowitz, M., & Stuss, D. T (2005).Community integration status 4 years after traumat-ic brain injury; Participant-proxy agteement. JournalufHead Trauma Rehabilitation, 20(5), 426-435.

Dijkers, M. P. (1999). Correlates of life satisfaction an-mong petsons witb spinal cord injury. Archives ofPhysical Medicine & Rehahiltiaticm, 80(8), 867-876.

224 COMMUNITY INTEGRATION

Duvdevany, I., Si Arar, E. (2004). Leisure activities, friend-ships, and quality of life of persons with intellectualdisability: Foster homes vs community residentialsettings. International Journal of Rehabilitation Re-search. 27(4), 289-296.

Fabian, F. S. (1991). Using quality-of-life indicators inrehabilitation program evaluation. RehabilitationCounseling Bulietin, 34, 344-356.

Felce, D., & Fmerson, F. (2001 ). Living with support in ahome in the community: Predictors of behaviouraldevelopment and household and community activ..ity. Menral Retardation & Developmental DisabilitiesResearch Reviews, 7(2), 75-83.

Gaite, L., Vázquez-Barquero, J. L., Borra, C , Ballesteros, J.,Schene, A., Welcher, B.,

Thornicroft, G., Becker, T, Ruggeri, M., Herran, A., &The FPSILON Study Group. (2002). Quality oflife in patients with schizophrenia in five Furopeancountries: the EPSILON study. Acta PsychiatricaScandinavica, ¡05, 283-292.

Galski, T, Tompkins, C , & Johnston, M. V. ( 1998). Com-petence in discourse as a measure of social integra-tion and quality of life in persons with traumaticbrain injury. Brain Injury, 12(9), 769-782.

Hebblethwaite, S. & Pedlar, A. (2005). Community inte-gration for older adults with mental health issues:Implications for therapeutic recreation. TherapeuticRecreation Joumal, 39(4), 264-276.

Huebner, R. A., Johnson, K., Bennett, C. M., & Schneck,C. (2003). Community participation and qualityof life outcomes after adult traumatic brain injury.American Jotimal o/Occupationa! Therapy, 57, 177-185.

Hutchinson, P. & McGill, J. (1998). Leisure, integration,and community. Toronto, ON: Leisurability Publica-tions.

Kennedy, P., Jude, P, & Taylor, N. (2006). Quality of life,social participation, appraisals and coping post spi-nal cord injury: A review of four community sam-ples. Spinal Cord, 44, 95-105.

Kensinger, K., Gearig, J., Boor, J., Olson, N., & Gras, T.(2007). A therapeutic recreation program for inter-national refugees in a Midwest community. Thera-peutic Reaeation Joumal, 41(2) , 148-157.

Kilian, R., Matschinger, H., & Angermeyer, M. C. (2001 ).The impact of chronic illness on subjective qualityof life: A comparison between general populationand hospital impatiens with somatic and psychiat-ric disease. Clinical Psychobgj & Psychotherapy, 8,206-213.

Labronici, R. H. D., Cunha, M. C. B., Oliveira, A., &Gabbai, A. A. (2000). Sport as integration factor ofthe physically handicapped in our society. Ari>ui«)sde Neuro-PsiquialTia, 50(4), 1092-1099.

Lee, Y., & McCormick, B. P. (2004). Subjective well-beingof people with spinal cord injury: Does leisure con-tribute?Joumal of Rehabilitation, 70(3), 5-12.

Lee, Y., & McCormick, B. P (2006). Examining the roleof self-monitoring and social leisure in the life qual-ity of individuals with spinal cord injury. Joumal ofLeisure Research, 38(1), 1-19.

Levasseur, M., Desposiers, J., tSi Noreau, L. (2004). Is socialparticipation associated witb quality of life of olderadults with physical disabilities? Disability and Reha-bilitation, 26(20), 1206-1213.

Lucas, R. E., & Fujita, E (2000). Factors influencing therelation between extraversion and pleasant affect.Joumal of Personality & Social Psychology, 79, 1039-1056.

McMillan, D., & Chavis, D. (1986). Sense of community:A definition and theory. Journal o/Community Psy-chology, 14(0,6-23.

Minnes, P, Carlson, P, McColl, M. A., Nolte, M. L.,Johnston, J., & Buell, K. (2003). Community inte-gration: A useful construct, but what does it reallymean? Brain Injury, 27 (2), 149-159.

Pain, K., Dunn, M., Anderson, G., Darrah, J., & Kratoch-vil, M. (1998). Quality of life: What does it meanin rehabilitation? Joumal of Rehabilitation, 64(2),5-11.

Priebe, S. 1., Roeder-Wanner, U. U., & Kaiser, W. (2000).Quality of life in first-admitted schizophtenia pa-tients: A follow-up study. Psychological Medicine, 30,225-230.

Reistetter, T. A., Spencer, J. C , Trujillo, L., & Abreu, B.C. (2005). Examining the community integrationmeasure (CIM): A replication study with life satis-faction. NeuroRehahilitation, 20, 139-148.

Ritsner, M. (2003). Predicting changes in domain-specificquality of life of schizophtenia patients. Journal ofNervous and Mental Disease, 19 / (5 ) , 287-294.

Schalock, R. L. (1999). The promises and challenges ofthe concept of quality of life. Exceptionality Educa-tionGanaila,9(l&2), 61-82.

Schonberr, M. C , Groothoff, J. W., Mulder, G. A., &Eisma, W. H. (2005). Participation and satisfactionafter spinal cord injury: Results of a vocational andleisure outcome study. Spinal Cord, 43, 241-248.

Stalnacke, B. M. (2007). Community integration, socialsupport, and life satisfaction in relation to symptoms3 years after mild traumatic brain injury. Brain In-jury, 21(9), 933-942.

Stancliffe, R. J., Fmerson, F., & Lakin, K. C. (Fds.) (2001 ).Community living and people witb intellectual dis-ability (special Issue]. Joumal of /ntellectuaJ & Devel-opmental Disability, 26{ 1 ), 5-13.

CHUN, LEE, LUNDBERG, MCCORMICK, AND HEO 225

Swanson, J. W., Swartz, M. S., Elbogen, E. B., Wagner,H. R., & Burns, B. J. (2003). Effects of involuntaryoutpatient commitment on subjective quality of lifein persons with severe mental illness. Behavioral Sci-ences and the Law, 21, 473-491.

Sylvester, C , Voelkl, J., 6i Ellis, G. (2001). Therapeuticrecreation programming: Thecrry and practice. StateCollege, PA: Venture Publishing, Inc.

Tabachnick, B G., & Fidell, L. S. (2001). Usingmuhivan-ate statistics. Needham Heights, MA: Pearson Educa-tion Company.

Tasiemski, T, Kennedy, P., Gardner, B. P., iSi Taylor, N.(2005). The association of sports and physical recre-ation with life satisfaction in a community sample ofpeople with spinal cord injuries. NeuroRehabilitation,20, 253-265.

U.S. Department of Health and Human Services (2001,December). Healthy People 2010: Underslanding andImproving Health. 2nd ed. Washington, DC: U.S.Government Printing Office. Retrieved June 22,2004 from http://www.healthypeople.gov/

Warr, P., Butcher, V, & Robertson, I. (2004). Activity andpsychological well-being in older people. Agi'ng &Mental Health, 8{2), 172-183.

WHOQOL Group. (1998). Development of the WorldHealth Organization WHOQOL-BREF quality oflife assessment. Psycholo^cal Medicine, 28, 551-558.

WHOQOL Group. (2005), The World Health Organiza-tion Quality of Life instruments: US version WHO-QOL'¡00 and importance items user's manual andinteriïrewtion Guid£. WA: WHOQOL Group.

World Health Organization. (2001 ). International classifica-tion of functioning, disability, and health (¡CF). Ge-neva, Switzerland: Author.

226 COMMUNITY INTEGRATION