In addition, functional limitations often make it difficult, if not impossible, for adults with disabling conditions to return to their old jobs without training and modification of the work environment. Some will not be able to return to their previous occupation at all, necessitating training in a new skill or profession. Thus vocational training is often critical to ensuring one's return to the work force.

Environmental Considerations

The quality of life of a person with a disabling condition is closely linked to the person's social and physical environment, on both large and small scales. Because of the multifaceted nature of this relationship, trade-offs may be necessary. Someone who uses a wheelchair and lives in a northern state, for example, may be forced to limit his or her outdoor activities during the winter months because of icy conditions and low temperatures. A person who has the same limitation but lives in the South or Southwest will confront far fewer weather-related barriers. For many people, however, relocating to an area with a more benign climate is not financially feasible or even desirable. Moving may entail loss of friends and family contacts, loss of job, and other costs that outweigh climate-related advantages.

When the focus shifts to the individual's general surroundings, other important variables come into play, such as proximity to health services, work, stores, recreational establishments, and family and friends; accessibility to buildings and public transportation; availability of housing; and opportunities for employment. Not all of these variables are under the control of the individual. For example, social attitudes and public policy are the primary determinants of whether public buildings are accessible to people in wheelchairs or whether local employers are willing to invest in the workplace modifications that may be required by people with disabling conditions.

Distance to needed services, however, may be within the control of the individual. Generally, the greater the distance to services, the more dependent a person with a disabling condition is on the assistance of others. Thus a person who lives in an urban environment may be more autonomous in his or her personal affairs than someone who lives in a rural area and must depend on others for transportation and to make necessary purchases.

The home environment introduces new considerations that are primarily related to safety and to the performance of basic living activities. Financial resources and the reimbursement policies of public and private insurers are the primary determinants of whether the immediate living environment is adapted to the needs and capabilities of the person with a disabling condition. Many "off-the-shelf" assistive technologies can be instrumental in promoting greater autonomy. But, as discussed previously, these technologies often do not qualify for insurance coverage.

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