Trends in Rehabilitation and Disability: Transition from a Medical Model to an Integrative Model (part 3)

The Integrative Model
The Integrative Model has a broad knowledge base ranging from medicine to literature which is informed by the experience of people with disabilities. The Integrative Model is "under construction". From the integrative perspective, individuals with disabilities have many roles, including citizen and patient, among many others. There are a number of evolving policies and practices that are representative of this model. Some of them are represented in the World Health Organization International Classification of Functioning, Disability and Health, the U.S. Institute of Medicine's Enabling America: Assessing the Role of Rehabilitation Science and Engineering, and the NIDRR Long-Range Plan (Brandt & Pope, 1997; National Institute on Disability and Rehabilitation Research, 1999; World Health Organization, 2001).

Policies and Practices
While retaining general health, welfare, special education, and employment policies and practices of the first and second stages, countries are in various stages of transition to a civil rights approach and related universality of design applications in systems and markets. International organizations, such as the World Health Organization, have developed a more universal approach to disability. The following interpretation of the ICF illustrates its universality and integrative characteristics (Schneider, 2001):

Universal Model - not a minority model
Integrative Model - not merely medical or social
Interactive Model - not linear progressive
Parity - not etiological causality
Inclusive - contextual, environment & person
Cultural applicability - not western concepts alone
Operational - not theory driven alone
Life span coverage - not adult driven (children-elderly)
Human Functioning - not merely disability

The components of the ICF encourage a broad and integrative classification. The three components of the ICF are body components, activities and participation, and environment. ICF researchers will be challenged to identify the relationships among the components.

The Disability Movement is pressing a number of international organizations for conventions and statements of principle committed to full integration of people with disabilities in society. The UN is being pressed to adopt a convention on the rights of people with disabilities (http://www.dpi.org/en/resources/topics/topics-convention.htm). The World Summit on the Information Society is being pressed to adopt a section on disability within the draft Declaration of Principles (http://www.dpi.org/en/resources/topics/topics-convention.htm). Many of these initiatives have precedent in U.S. law. The Americans with Disabilities of 1990 (ADA) recognizes the full civil rights of people with disabilities (http://usdog.gov/crt/ada/adahom1.htm). The ADA also provides assistive technology and accessibility of communications with important roles in the realization of rights and opportunities. The United States has regulated the communications industry to assure access. The original Communications Act of 1934 recognized universal access for all people in the United States. In 1996, the new Telecommunications Act was amended to include rules requiring telecommunications manufacturers and service providers to make their products and services accessible to people with disabilities, if readily achievable (http://www.access-board.gov/telecomm/html/telfinal.htm). The United States has also created market incentives to motivate industry to make its systems and products accessible (http://www.section508.gov/). As Section 508 of the Rehabilitation Act requires, the United States government constitutes a large market for accessible technology and employs the federal procurement system to purchase it (http://www.ittatc.org/laws/255.cfm). Section 508 requires access to electronic and information technology provided by the Federal government. The law applies to all federal agencies when they develop, procure, maintain or use electronic and information technology. Federal agencies must ensure that technology is accessible to employees and members of the public with disabilities to the extent it does not impose an "undue burden". Section 508 speaks to various means for disseminating information, including computers, software and electronic office equipment. It applies to, but is not solely focused on federal pages on the Internet or the World Wide Web. It does not yet apply to web pages of private industry.

Applications of technology within the integrative model appear below. The first example is a mammogram at Magee Women's Hospital in Pittsburgh made accessible for patients with disabilities:

Other examples show President Clinton viewing an accessible voting kiosk and the CEO of Microsoft viewing accessible equipment:

Measurement Tools and Principles
Disability is not inherent in measurement tools designed with the integrative model in mind. Psychological, social and environmental factors must be incorporated into assessments that are based on an integrative model. Assessment measures that are consistent with the integrative model assume a real world context of school, family, employment. Health service performance measures should be based on consumer outcomes. S ome measures of disability may be disability specific in which case they may change the perception of the capability of the individual. David Gray illustrates this point below (grayda@msnotes.wustl.edu):

Researchers at the RERC at the University of Buffalo (http://www.ap.buffalo.edu) have developed a prototype database on anthropometry of wheelchair users.

Researchers at the Department of Rehabilitation Sciences and Technology, School of Health and Rehabilitation Sciences have developed a Virtual Reality Tele-Rehabilitation System for Analyzing the Accessibility of the Physical Environment.

The slide below shows the need for research in outcomes for assistive technology.

Education and Training
The ICF has become a useful framework on which to base coursework for individuals across a wide number of fields, including the health professions, social work, psychology, and Disability Studies. Over thirty ICF-related courses have been identified in universities in the United States and Canada (icf_clearinghouse@listserv.cdc.gov). For example, the University of Pittsburgh Department of Occupational Therapy has adopted the ICF as the foundation for curriculum design.

Conclusion, Opportunities, and Challenges
In the international area, the following policy, research and practice opportunities and challenges exist:

• Monitor UN Implementation of the Standard Rules and enact a UN Disability Human Rights Convention
• Incorporate a statement on accessibility for people with disabilities into the World Summit on the Information Society draft principles
• Support developing countries in provision of programs and participation for people with disabilities
• Develop the ICF measures for social and environmental factors so that assessment measures assume a real world context of school, family, employment
• Base health service performance on consumer outcomes
• Generate global marketplace incentives and standards to support universal design, usability and accessibility in product design and sale
• Add disability to surveys of health, income, employment and education

In addition to the above the domestic area provides the following opportunities and challenges:

• Commit public and private research and development funding to technological inclusion of people with disabilities
• Promote technological inclusion by linking technology policy to civil rights
• Monitor research policies to protect people with disabilities in research conducted abroad with domestic research funding
• Create a government marketplace for usable and accessible systems and products
• In the practice area, the following opportunities and challenges exist:
• Promote science, technology and education and training opportunities for people with disabilities
• Integrate the perspective of people with disabilities and social and environmental factors into curricula
• Broaden the range of disciplines that address disability to include engineers, designers, lawyers
• Adopt the ICF as a framework to develop health-related professional education

In research, the following opportunities and challenges exist:

• Develop measures of social factors and environmental domains
• Develop accessible survey research process and questions about social behavior and environmental accessibility
• Develop evidence-based practice
• Develop assistive technology outcome measures

Opportunities for collaboration exist:

• Develop strategies based on the Tokushima Agreement between Japan, the United States, Australia and Europe

References
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Barnes, C., & Mercer, G. (2003). Disability. Cambridge, UK: Polity Press.

Basnett, I. (2001). Health Care Professionals and Their Attitudes toward Decisions Affecting Disabled People. In G. L. Albrecht, K. D. Seelman & M. Bury (Eds.), Handbook of disability studies (pp. 450-467). Thousand Oaks, Calif.: Sage Publications.

Brandt, E. N., & Pope, A. M. (Eds.). (1997). Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, D.C.: National Academy Press.

Coleridge, P. (1993). Disability, Liberation and Development. United Kingdom and Ireland: Oxfam.

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Scherer, M. J. (Ed.). (2002). Assistive Technology: Matching Device and Consumer for Successful Rehabilitation. Washington, D.C.: American Psychological Association.

Schneider, M. (2001, June). Participation and Environment in the ICF and measurement of disability: Classification, Assessment, Surveys and Terminology. Paper presented at the World Health Organization United Nations Meeting on Measurement of Disability, New York.

Seelman, K. D. (2002, October 24). Disability Studies and the Disciplines: Bridges and Chasms. Paper presented at the Invest in Disability Week, Ann Arbor, Michigan.

Strax, T. E. (2003). Consumer, Advocate, Provider: A Paradox Requiring a New Identity Paradigm. Archives of Physical Medical Rehabilitation, 84: 943-5.

Van Oorscot, W., & Hvinden, B. (2001). Disability Policies in European Countries. Dordrecht, The Netherlands: Kluwer Law International.

World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva,: World Health Organization.

Zeitzer, I. (2002). The Challenges of Disability Pension Policy: Three Western European Case Studies of the Battle against the Numbers. In E. Fultz & R. Marcus (Eds.), Reforming Worker Protections: Disability Pensions in Transformation. Budapest: International Labor Organization.

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