Disability in America Toward a National Agenda for Prevention (1991) / Chapter Skim
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3 A Model for Disability and Disability Prevention
3 A Model for Disability and Disability Prevention
Pages 76-108
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From page 76... ...
CONCEPTUAL FRAMEWORK There are two major conceptual frameworks in the field of disability: the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) , and the "functional limitation," or Nagi, framework, which is not accompanied by a classification system.
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From page 77... ...
Handicap sometimes has been used to imply an absolute limitation that does not require for its actualization any interaction with external social circumstances. In recent years, the term has fallen into disuse in the United States, primarily as a result of a feeling on the part of people with disabling conditions that handicap is a negative term.
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From page 78... ...
It notes the opportunity and calls attention to the need for its pending revision, prefers not to use the term handicap in this context, and offers an alternative framework that does not focus on the consequences of disease. The committee's alternative framework draws on the widespread acceptance and success of the ICIDH and the conceptual clarity and terminology of the Nagi framework, and then adds risk factors and quality of life into a model of the disabling process.
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From page 79... ...
Many chronic diseases have multiple or uncertain etiologies. High serum cholesterol, hypertension, and smoking, for example, all increase the risk of heart disease, but not all people with these traits develop heart disease.
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From page 80... ...
. All functional limitations result from impairments, but not all impairments lead to functional limitation (Figure 3-21.
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From page 81... ...
These roles and tasks are organized in spheres of life activities such as those of the family or other interpersonal relations; work, employment, and other economic pursuits; and education, recreation, and self-care. Not all impairments or functional limitations precipitate disability, and similar patterns of disability may result from different types
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From page 82... ...
For example, whether a person with an impairment is able to work depends not only on the nature and severity of his or her impairment and resulting functional limitation but also on such factors as the state of the economy, characteristics of the workplace, availability of transportation, and the individual's particular work skills and training. Whether a person with a functional limitation lives independently may be determined by supportive social contacts and the architectural features of his or her home.
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From page 83... ...
Capacities are the means; expected activities are the ends. One reason why impairments and functional limitations do not necessarily lead to disability is that individuals with a given impairment may overcome specific functional limitations by compensating with other functional capacities to avoid disability.
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From page 84... ...
lists the following 16 causes of disabling conditions: · Genetic disorders · Acute and chronic illness · Violence · Lack of physical fitness · Tobacco use · Educational deficiency · Familial-cultural deleterious beliefs · Inaccessibility to adequate health care · Perinatal complications · Unintentional and intentional injuries · Environmental quality problems · Alcohol and drug abuse · Nutritional disorders · Deleterious child-rearing practices · Unsanitary living conditions · Stress Whether through injury, disease, personal-choice behaviors, genetic traits, or some other causal mechanism, multiple risk factors of various types can converge to predispose an individual to the disabling process, as shown in Figure 3-3. In addition, risk factors interact at the different stages of the disabling process (note the circles between the stages that represent the
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From page 85... ...
\ 1 1~ . 1 1 1 1 , 1 ~ , Events e.g., falls, infections The Disabling Process Pathology Impairment Functional Limitation Disability Quality of Life 85 FIGURE 3-3 Model of disability showing the interaction among the disabling process, quality of life, and risk factors.
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From page 86... ...
Biological risk factors associated with disabling conditions are often the same as those associated with specific diseases because the disabling condition often results from the disease (e.g., arthritis, diabetes, atherosclerosis)
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From page 87... ...
Inadequate public transportation also can put individuals with impairments or functional limitations at increased risk for disability.
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From page 88... ...
and interventions designed to assist people with disabling conditions in adjusting to the environment (e.g., rehabilitation and retraining)
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From page 89... ...
These behaviors also resulted in a decrease in the morbidity associated with many disorders, such as heart disease, lung cancer, and hypertension illnesses that cost society substantial medical care dollars and losses resulting from forgone productivity. Health-related behaviors such as those described above greatly influence the onset and progression of disabling conditions.
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From page 90... ...
Within the disabling process, each stage interacts with an individual's quality of life; it is not an endpoint of the model but rather an integral part. There is no universal threshold- no particular level of impairment or functional limitation at which people perceive themselves as having lost their personal autonomy
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From page 91... ...
Similarly, environmental modification (e.g., elimination of physical obstacles and barriers) is an important form of disability prevention, as is legislation such as the recently enacted Americans with Disabilities Acta landmark in antidiscrimination legislation directed toward ensuring the rights of people with disabling conditions.
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From page 92... ...
Skin infections and contractures, in turn, can lead to additional impairment and functional limitation. Psychological Status Successful management of potentially disabling conditions and prevention of secondary conditions depends greatly on the psychological status of the individual with the condition.
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From page 93... ...
Although health and welfare programs defray expenses and help offset income losses for persons with disabling conditions, they do so only for those with the most severe disabilities. Even for these people, however, some acute and longterm care needs go unaddressed.
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From page 94... ...
Those with easily transferable skills are more likely to return to work than those who have narrow job experience and who, because of their functional limitations, cannot return to their previous employment. Thus people who were involved in physically demanding occupations usually are less able to return to their former job than those who were engaged in sedentary, white-collar jobs prior to the initiation of the disabling condition.
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From page 95... ...
In addition, persons with multiple disabling conditions are more likely to have severe limitations in activity. Thus prevention of secondary conditions is an important aspect of reducing disability and improving the quality of life.
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From page 96... ...
Epidemiological methods can be used to describe these distributions, help identify risk factors, and, in turn, guide development of disability prevention programs. The challenge is to recognize the shortcomings of traditional methods for addressing disability and then develop the tools and data networks necessary to identify the causes of disabilities and their associated risk factors.
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From page 97... ...
In short, the paths of the model in Figure 3-3 must be explored and quantified, the mechanisms described, and intervention strategies developed. Questions that must be addressed if we are to set priorities for disability prevention include the following: Do conditions with the highest risks of disability also pose the highest risks of functional limitation and impairment?
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From page 98... ...
As the model of the disabling process illustrates, knowledge of risk factors is central to disability prevention. Indeed, a comprehensive understanding of risks is critical to answering three fundamental questions: · Given exposure to environmental agents or other provocations, why do some persons develop potentially disabling conditions and others do not?
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From page 99... ...
In addition, although potentially disabling conditions are dynamic and can improve as well as deteriorate, existing data systems can neither measure the dynamics of disability progression nor identify risk factors that accelerate progression from impairment to functional limitation to disability. More specific epidemiological data are needed on the incidence and prevalence offuncfional limitation and disability and their attendant risk factors.
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From page 100... ...
Existing national data sets that track the prevalence of chronic conditions over time are useful for disability surveillance. The lack of data on incidence rates, however, is a serious void in disability surveillance and an impediment to fundamental understanding of the disabling process.
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From page 101... ...
Thus populations with equal risks of developing TABLE 3-2 Risk Factors in Chronic Disease and Disability Risk Factor Some Related Conditions Smoking Alcohol abuse Lack of prenatal care Socioeconomic status Lung cancer Emphysema Bronchitis Other respiratory diseases Coronary artery disease Burns (especially home fires) Injuries sustained in motor vehicle accidents,especially head injuries and pedestrian injuries Cirrhosis Fetal alcohol syndrome Mental retardation Cerebral palsy Congenital heart abnormalities (via rubella)
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From page 102... ...
Collecting data on the incidence and duration of pathology, impairment, and functional limitation as well as secondary conditions is an important component of the disability surveillance effort that is needed. Although the NHIS includes some disability-related questions, it is quite limited in scope because it is a general-purpose survey of the health of the nation and not designed to investigate efficiently the causes and risks of disability.
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From page 103... ...
Priority setting must include an analysis of epidemiological data pertaining to the causes and natural history of various disabling conditions. As noted in Chapter 2, some of the less prevalent potentially disabling conditions (e.g., spinal cord injury)
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From page 104... ...
, the committee believes that specific conditions may not always be the most appropriate or effective means for setting priorities or identifying targets for the development of preventive intervention strategies. An alternative method for consideration is to focus on risk factors or causes that are generic to the etiology of several disabling conditions.
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From page 105... ...
Unfortunately, and incorrectly, people with potentially disabling conditions often are not recognized as a target population for primary prevention efforts, despite the fact that having a potentially disabling condition frequently increases the need for good health promotion and disease prevention practices. With respect to disability, primary prevention usually means preventing the initiation of a potentially disabling condition such as spinal cord injury.
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From page 106... ...
Secondary prevention can in many cases cure a specific pathology, but in other cases secondary prevention merely slows the progression of a pathology toward becoming a clinical condition. People with chronic diseases and those with disabling conditions can benefit significantly from secondary prevention efforts, and, as noted earlier, much of this report focuses on secondary and tertiary prevention.
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From page 107... ...
Tertiary prevention, as well as secondary prevention, has not received as much emphasis in public health as the health-promoting, disease-preventing measures of primary prevention. However, the fact that more than 35 million people already have some type of disabling condition underscores the need to develop and implement secondary and tertiary prevention strategies that are directed toward people with disabling conditions, and that will reduce the risks of additional limitation and prevent disability and secondary conditions.
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From page 108... ...
Given the existence of predisposing functional limitations, the predominant means of disability prevention and amelioration are often social and economic.
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