Workshop on Disability in America A New Look: Summary and Background Papers (2006) / Chapter Skim
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Appendix B Conceptual Models of Disability: Past, Present, and Future--Gale Whiteneck
Appendix B Conceptual Models of Disability: Past, Present, and Future--Gale Whiteneck
Pages 50-66
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From page 50... ...
The WHO International Classification of Impairments, Disabilities, and Handicaps (ICIDH) ,1 published in 1980, suggested conceptual distinctions among three levels of performance -- impairment at the organ level, disability at the person level, and handicap at the societal level.
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From page 51... ...
Researchers focused their attention on the development of participation and environmental measures, including the Craig Handicap Assessment and Reporting Technique,6, 7 the Community Integration Questionnaire,8 and the Craig Hospital Inventory of Environmental Factors.9, 10 Although the models theoretically incorporated the importance of environmental factors, little empirical evidence exists to support the theory. For example, spinal cord injury (SCI)
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From page 52... ...
Personal factors may appear to be separate features of the individual distinct from a particular health condition or health state, yet they may influence the disability process. Such factors may also include variables such as habits, lifestyles, experiences, coping styles,
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From page 53... ...
The model conceives these components as separate but related constructs with dynamic interactions between health conditions, like disease, disorders, and injuries, and contextual factors, such as personal and environmental factors. Describing the model component body functions and structure, ICF refers to the "body" as the human organism.
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From page 54... ...
54 TABLE B.1 Concepts and Terminology Used by Models of Disability Organ Person Societal Model, Year Origin Level Level Level Other Domains Nagi, Pathology Impairment Functional Disability 197615 limitations WHO, Disease Impairment Disability Handicap 19801 IOM, Pathology Impairment Functional Disability 199117 limitations NCMRR, Patho- Impairment Functional Disability Societal limitations 199218 Physiology limitations IOM, Pathology Impairment Functional Disability Environmental factors 19975 limitations quality of life WHO, Health Body structure Activity Participation Environmental factors, 20012 Condition and function personal factors
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From page 55... ...
Societal factors include formal and informal services and systems in the community that affect a person's life. Societal factors encompass organizations and services related to work, community activities, government agencies, communication services, and transportation services.
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SUMMARY AND CRITIQUE OF ICF This author's assessments of ICF compared with past models and the models of disability that are needed in the future can be summarized in the following title used in a recent presentation: "The ICF, one step forward, one step back, and a few steps yet to go for a complete model."25 The one step forward was the inclusion of environmental factors; the one step back was the blurring of activities and participation; and the needed steps include the differentiation of activities and participation, the addition of quality of life to the model, elaboration of the impact of environmental factors, the development of personal factors, refinement of the graphic depiction of the model, definition of research strategies to better measure the domains of disability, and validation of the model. Background on the Revision of ICF ICF lists hundreds of people from scores of countries who were involved in the decade-long revision process.
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From page 57... ...
Eventually, they were maintained, and in the author's view, that was probably the major step forward in the conceptualization of disability outcomes. The Step Backward The loss of a clear distinction between activity and participation was the step backward.
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From page 58... ...
Both conceptual and empirical advances are needed to move the disability field forward. These advances are envisioned as iterative processes, in which the conceptual model guides research and empirical evidence informs theory, which culminate in a revised and validated Model of Disability (ICF-2)
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From page 59... ...
This early conceptual focus on roles as the defining characteristic of performance at the societal level may offer an effective way to differentiate activities and participation in ICF-2. Step 2: Quality of Life, a Key Missing Component of ICF ICF offers a comprehensive model of objective disability outcomes and provides rehabilitationists and researchers with a system for categorizing disability.
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From page 60... ...
Only the actual addition of a new quality-of-life domain acknowledges the validity of the subjective perceptions of people with disabilities and that those perceptions are distinct outcomes of the disability process. Quality of life could be measured simply by using a standardized assessment of global life satisfaction29 or an instrument that assesses satisfaction with domains of life;30 but it should not be a composite measure of Health-Related Quality of Life (HRQOL)
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From page 61... ...
32 and one in SCI.24 The TBI study surveyed 73 participants from one TBI model system program at their first anniversary of injury, with respondents reporting a greater impact from environmental barriers also reporting lower levels of participation and life satisfaction.32 The SCI study surveyed 2,726 participants from the 16 federally designated SCI model systems as they crossed their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury. Environmental barriers accounted for only 4 percent of the variation in participation, but they accounted for 10 percent of the variation in quality of life.
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From page 62... ...
However, this step is controversial. The current conceptual model acknowledges that contextual factors, including both environmental and personal factors, play a major role in disability outcomes.
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From page 63... ...
A prerequisite of that task is the availability of psychometrically sound measures of the ICF concepts. Although many measures of impairment and activities of daily living have been developed, the measurement of participation is a relatively new field and the measurement of environmental factors is in its infancy.
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From page 64... ...
WHO's ICF has incorporated a major concept advocated by Enabling America -- environmental factors -- and ICF, as the currently accepted international model, should be the starting point for advocating future conceptual revisions. Seven steps have been outlined to improve the ICF conceptualization, including the differentiation of activities and participation, the addition of quality of life to the model, elaboration of the impact of environmental factors, the development of personal factors, refinement of the graphic depiction of the model, definition of research strategies to better measure the domains of the model, and validation of the model by testing the interrelationships among its concepts and deriving interventions to improve the lives of people with disabilities.
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From page 65... ...
Environmental factors and their role in participation and life satisfaction after spinal cord injury. Archives of Physical Medicine and Rehabilitation 2004; 85(11)
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From page 66... ...
Identifying environmental factors that influence the outcomes of people with traumatic brain injury. Journal of Head Trauma Rehabilita tion 2004; 19(3)
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