Comparing the Disability Creation Process and International Classification of Functioning, Disability and Health Models Mélanie Levasseur
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Johanne Desrosiers
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Denise St-Cyr Tribble
Key words ■
participation Health
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Disability Creation Process
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International Classification of Functioning, Disability and
Mots clés ■
Participation ■ Processus de production du handicap du handicap et de la sante
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Classification internationale due fonctionnement,
Abstract Background. The conceptualisation of participation is important for both clinicians and researchers. Purpose. Analyse and compare two conceptual models, the Disability Creation Process (DCP) and the International Classification of Functioning, Disability and Health (ICF), with particular emphasis on the participation component. Method. Conceptual comparative analysis of the DCP and ICF models focused on participation. Results. We found more differences than similarities between the DCP and ICF models. Similarities concerned approaches, objectives, elements of the models’ components, and, to some extent, the participation component itself. Differences were mainly in the underlying models, conceptualisation of components including participation, and the measurement tools of participation. Practice Implications. Based on the results of this conceptual comparison, occupational therapists working in clinical and research settings are encouraged to consider using the DCP, which is an excellent model to choose in regard to participation. Empirical studies are still needed to clarify the concept of participation.
Résumé Description. La conceptualisation de la participation est importante à la fois pour les cliniciens et les chercheurs. But. Analyser et comparer deux modèles conceptuels, soient le Processus de production du handicap (PPH) et la Classification internationale du fonctionnement, du handicap et de la santé (CIF), en mettant un accent particulier sur la composante de la participation. Méthodologie. Analyse conceptuelle comparative des modèles du PPH et de la CIF, axée sur la participation. Résultats. Nous avons trouvé plus de différences que de similarités entre les modèles du PPH et de la CIF. Les similarités que nous avons trouvées concernaient les approches, les objectifs, les éléments des composantes des modèles et, dans une certaine mesure, la composante de la participation en soi. Les différences étaient principalement dans les modèles sous-jacents, la conceptualisation des composantes, y compris la participation, et les instruments de mesures de la participation. Conséquences pour la pratique. Si l’on se fie aux résultats de cette comparaison conceptuelle, les ergothérapeutes travaillant dans des milieux cliniques et de recherche auraient avantage à utiliser le PPH, qui est un excellent modèle en ce qui a trait à la participation. Il faudra poursuivre d’autres études empiriques pour clarifier le concept de la participation. articipation is a recent concept that is very important for clinicians and researchers, especially in occupational therapy (Desrosiers, 2005). It is now considered an outcome measure of rehabilitation success. However, there is no consensus in the scientific literature regarding the conceptual or operational definition of participation. The two best known models that include the concept of participation are the Disability Creation Process model (DCP) (Fougeyrollas et al., 1998) and the International Classification of Functioning, Disability and Health model (ICF) (World Health Organization, 2001). The fact that these two models are currently used has important consequences: 1) communication difficulties between those using the con-
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cept of participation; 2) problems in development and identification of instruments to measure participation; 3) differing analyses of participation situations; 4) different intervention plans (some might be incomplete); and 5) variation in design of research projects studying participation (e.g., underlying conceptual model, definition and identification of the variables under study, data collection, etc.). The aims of this conceptual paper are 1) to describe the DCP and ICF and define the participation components of each model and, 2) to discuss similarities and differences between the two approaches. Strengths and weaknesses of each model are discussed from an occupational therapy perspective.
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The DCP Model
Social participation is the interactive result of factors intrinsic to the individual (e.g., personal characteristics, organic systems, and capabilities) and extrinsic factors in the physical and social environment (Fougeyrollas, 2002). Capability means the intrinsic ability of an individual to accomplish a physical or mental activity regardless of the environment. In the DCP, social participation includes 12 life domains, half of which refer to daily activities (nutrition, fitness, personal care, communication, housing, and mobility) and the other half to social roles (responsibility, interpersonal relationships, community life, education, employment, and recreation). It is important to note that in this model, social roles are not defined in the usual way, such as the role of mother, student, worker, etc. (Desrosiers, 2005). These activities or roles ensure the individual’s survival and development in soci-
The DCP (Fougeyrollas et al., 1998) is an explanatory model of the causes and consequences of disease, trauma, or other damage to the individual’s integrity or development. The work of the Quebec International Classification of Impairments, Disabilities and Handicaps (ICIDH) Committee led to the revision of a previous version of the ICF, the ICIDH (Fougeyrollas, 2002). The DCP is based on the interaction between individuals and their environment (see Figure 1). Social participation is operationalised via the concept of life habits, which are defined as daily activities and social roles valued by the person corresponding to his or her age, gender, and sociocultural identity (Fougeyrollas et al., 1998). A life habit, which could also be called a life situation, is thus the performance of a daily activity or a social role in real life situations.
FIGURE 1 Disability Creation Process (DCP) model
Risk Factors 1. Biological risks 2. Physical environment risks 3. Social organization risks 4. Social and individualbehaviour risks
Cause
Personal Factors Organic Systems 1. 2. 3. 4. 5. 6. 7.
Nervous system Auricular system Ocular system Digestive system Respiratory system Cardiovascular system Hematopotic and immune system
Integrity
Environmental Factors Capabilities
1. Intellectual capabilities 2. Language capabilities 3. Behaviour capabilities 4. Sense and Perception capabilities 5. Motor activity capabilities 6. Breathing capabilities 7. Digestion capabilities 8. Excretion capabilities 9. Reproduction capabilities 10. Protection and resistance capabilities
8. Urinary system 9. Endocrine system 10. Reproductive system 11. Cutaneus system 12. Muscular system 13. Skeletal system 14. Morphology
Impairment
Abilitu
1. Social Factors 1.1 - Political economic factors 1.2 - Sociocultural factors 2. Physical factors 2.1 - Nature 2.2 - Development
Disability
Facilitator
Obstacle
Interaction Life Habits 1. Nutriction 2. Fitness 3. Personal care 4. Communication 5. Housing 6. Mobility 7. Responsability
Social participation
8. Interpersonnal relationships 9. Community life 10. Education 11. Employment 12. Recreation 13. Other habits
Handicap Situation
Adapted with permission from: Fougeyrollas, P., Cloutier, R., Bergeron, H., Côté, J., St-Michel, G. (1998). The Quebec Classification: Disability Creation Process. Lac St-Charles, Quebec, Canada: International Network on the Disability Creation Process; Canadian Society for the International Classification of Impairments, Disabilities and Handicaps.
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FIGURE 2 International Classification of Functioning, Disability and Health (ICF) model
Health condition (disorder or diseas)
Body funtions and structures
Activities
Participation
Environmental Factors
Personal Factors
Reprinted with permission from: World Health Organization (WHO) (2001). International Classification of Functioning, Disability and Health. WHO, Geneva, Switzerland
ety throughout his or her life (Fougeyrollas et al., 1998). The accomplishment of daily activities and social roles is measured on a continuum from optimal social participation to total participation restriction (total handicap situation).
The ICF Model The origins of the ICF date back to the 1980s with the publication of the ICIDH by the World Health Organization (WHO) (WHO, 1980). At that time, the WHO was innovative in proposing a universal nomenclature to describe and measure the consequences of diseases and traumas. The ICIDH model introduced linearly the concepts of impairment, disability, and handicap in response to the limitations of biomedical models that focused mainly on diagnoses and pathologies. Following criticisms regarding the concept of handicap and the work of the Quebec ICDIH Committee, the WHO made significant changes to its model and incorporated the term participation. The most recent version of the WHO’s model, the ICF (WHO, 2001), illustrates the complex and dynamic interaction between, on one hand, health conditions (e.g., diseases, disorders, injuries, traumas, etc.), body functions, activities, and participation and, on the other hand, extrinsic factors that represent the circumstances in which the VOLUME
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individual lives (see Figure 2). The term participation is used in the ICF and refers to social participation in the DCP. Participation is the result of the interaction between the individual’s health condition and contextual factors that include both personal and environmental factors. The ICF defines participation as involvement of the person in life situations. In the ICF, participation includes nine domains: 1) learning and applying knowledge, 2) general tasks and demands, 3) communication, 4) mobility, 5) self-care, 6) domestic life, 7) interpersonal interactions and relationships, 8) major life areas, and 9) community, social, and civic life. These domains are used to operationalise both the participation component and the activities component. According to the ICF, each domain can be used to denote activities, or participation, or both. The term activities used in the ICF refers to capabilities in the DCP. While participation is defined as what an individual is doing in a real life situation, activities denote the individual’s ability to perform a task or action. According to the ICF, the gap between activities and participation reflects the different impacts between standardized environments and real environments. Expected participation is the population norm, which represents the experience of people without the specific health condition (WHO, 2001).
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Similarities between the DCP and ICF
3. For example, the DCP domains Housing, Mobility, and Interpersonal relationships are similar to the Domestic life, Mobility, and Interpersonal interactions and relationships domains of the ICF. Finally, the great majority of the elements in the participation domains are similar in both models (see Tables 2 and 3). For example, the element Food preparation in the DCP has the same meaning as Preparing meals in the ICF.
There are a number of similarities between the models’ approaches, objectives, and components including the participation component of the DCP and ICF (see Table 1). First, both models describe their approaches as systematic and universal, in that they apply to all human beings, not just those with impairments and disabilities. Second, the main objective of both models is to describe the complex and dynamic process of human functioning. They also try to establish a common language, understood by all the different health disciplines, clients, and families, to describe this process. In addition, they provide a scientific foundation for studies in this field. Third, the wording and components of these two models have some similarities. First, the terms used for the components are positive or neutral, which allows human functioning to be classified and measured in a non-pejorative way (Bickenbach, Chatterji, Badley, & Üstün, 1999). For example, the term participation is used rather than handicap. There are also similarities between the models’ components and their relationship. Both models recognize the role of activities and involvement in the environment as an important health indicator, which is one of the foundations of occupational therapy (Desrosiers, 2005). In fact, both the DCP and ICF recognize the importance of not looking only at organic systems and their functional uses; they consider that personal and environmental factors affect participation. The DCP and ICF share a multidimensional view of participation as an interactive and evolving process. The two-way, dynamic interaction between the models’ components implies that interventions targeting one of them may have an effect on one or more of the other components. These interactions are specific and the direct link between the components cannot always be foreseen (WHO, 2001). Since the interactions operate in both directions, the health condition may modify or be modified by participation. To fully describe a health experience, all the components are necessary. For example, participation restriction cannot be assumed solely on the basis of the presence of disabilities. Finally, for the participation component of the two models, we found three similarities in the definition of the concept, the domains, and the elements that make up the domains. First, the definitions of participation in the two approaches consider the individual’s real life situations. The concept of social participation in the DCP and its counterpart, participation, in the ICF both take into account the performance in daily activities and social roles. Despite different terminology, there are also some similarities between the nine domains of the ICF and the 12 domains of the DCP used to conceptualise the participation component. Generally, seven of the nine ICF domains correspond to the 12 DCP domains. The ICF domains that completely or partially match the DCP domains are compared in Tables 2 and 236
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Differences between the DCP and ICF There are also a number of differences between the DCP and ICF (see Table 1), especially in the underlying conceptual models, the conceptualisation of the models’ components (the participation component, in particular), and the measurement tools of participation. First, various conceptual models have been proposed to understand and explain disability and human functioning. The model or paradigm on which the development of a classification is based dictates its orientation, its general perspective. The DCP and ICF are based on different conceptual models. The DCP is based on the anthropological model of human development and disability (Fougeyrollas et al., 1998), which maintains that the disability process does not exist independently of the dynamic and interactive process between personal (intrinsic) factors and environmental (extrinsic) factors. This process determines the situational result of the performance of life habits corresponding to the individual’s age, gender, and sociocultural identity. There is an infinite number of possible variations in relation to biological, functional, and social normative references. The DCP’s definition of social participation is based on the anthropological model and is indicative of its holistic, ecological, and systematic orientation respecting human rights and the ideology of equality. The influence of the anthropological model is reflected in the importance of environmental factors found in the definition of participation in the DCP. The ICF is based on the integration of two opposing models: the medical model and the social model (WHO, 2001). The medical model views disability as a problem of the person and as being directly caused by disease, trauma, or other health conditions. In the social model, however, participation restriction is viewed mainly as a socially created problem, and as a matter of the full integration of individuals into society (WHO, 2001). Participation restriction is not an attribute of an individual but rather a complex collection of conditions, many of which are created by the social environment. In order to capture the integration of the various perspectives of functioning, the ICF used a biopsychosocial approach, and attempts to provide a coherent view of the different perspectives of health from a biological, individual, and social perspective. Thus, the definition of participation in the ICF is influenced by these medical and social models. ■
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LEVASSEUR ET AL. The influence of the medical model is reflected in the importance given to health conditions in the model, and the way normative differences are explained by the degree of variation in human development and adaptation (WHO, 2001). Although the ICF model is meant to be applicable to anyone (not only to persons with disabilities) the model’s Health condition component is an important factor that influences many other components. The illustration of the ICF suggests that the health condition is the starting point of the model and,
thus, of human functioning. The social model’s influence is seen in the consideration given to environmental factors. Second, the conceptualisation of the components in the DCP is significantly different from that in the ICF. In the DCP, social participation is the outcome of the interaction between the individual and his or her environment. Personal factors, social participation, and the environment are conceptually distinct (i.e., mutually exclusive nomenclatures). In the ICF, on the other hand, participation is the outcome of
TABLE 1 Similarities and differences between the DCP and ICF models DCP
ICF
SIMILARITIES Approaches
Systematic and universal
Systematic and universal
General objective
Describe the complex and dynamic process of human functioning
Describe the complex and dynamic process of human functioning
Wording of the components
Positive or neutral
Positive or neutral
Components of the models
Personal factors (including organic systems and capabilities), environmental factors and social participation
Personal factors, body functions and structures, activities, environmental factors and participation
Definition of the participation component
Performance of daily activities and social roles in real life situations
Involvement of the individual in life situations (real environment)
Participation domains and elements
See Tables 2 and 3
See Tables 2 and 3
Terminology
“social participation” and “capabilities”
“participation” and “activities”
Underlying conceptual models
Anthropological model of human development and disability
Medical model and social model
Conceptualization of participation
Result of the interaction between intrinsic individual factors and extrinsic environmental factors
Result of the interaction between the individual’s health condition and contextual factors that include both personal and environmental factors
Conceptualization of personal factors
Grouped with the individual’s health conditions, capabilities and organic systems
Distinct from health conditions, activities and body functions
Conceptualization of the environment
Directly influences social participation, incorporated as a determinant
Mitigated, influence of the environment not clearly identified conceptually
Classification of capabilities and participation
Mutually exclusive
With or without overlap, at the discretion of the ICF user
Participation domains and elements
See Tables 2 and 3
See Tables 2 and 3
Measurement tools of participation
Life-H (performance, type of help required and satisfaction)
ICF Checklist (performance)
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TABLE 2 Comparison of the DCP and ICF daily activities domains and elements DCP
ICF
NUTRITION - Diet1 - Food preparation2 - Meals3 FITNESS - Sleep - Physical fitness4 - Mental fitness PERSONAL CARE - Hygiene5 - Excretory hygiene6 - Dressing7 - Health care8
SELF-CARE [Eating3, Drinking3, Washing oneself5, Caring for body parts5, Toileting6, Dressing7, Looking after one's health8 (including managing diet1 and fitness4), etc.] COMMUNICATION - Receiving9, 10 (including comprehending the meaning represented by signs and symbols12) - Producing9, 10 - Conversation and use of communication devices and techniques11
COMMUNICATION - Oral and sign communication9 - Written communication10 - Telecommunication11 - Signs12 HOUSING - Housing13 - Maintenance14 - Furnishing and other household appliances15
DOMESTIC LIFE - Acquisition of necessities (including a place to live13, goods and services21*) - Household tasks [preparing meals2, doing housework14 (including using household appliances15), etc.] - Caring for household objects14 and assisting others20*
MOBILITY - Limited mobility16 - Transportation17
MOBILITY - Changing and maintaining body position - Carrying, moving and handling objects - Walking and moving16 - Moving around using transportation17 LEARNING AND APPLYING KNOWLEDGE - Purposeful sensory experiences - Basic learning - Applying knowledge GENERAL TASKS AND DEMANDS [Undertaking a single or multiple tasks, Carrying out daily routine, Handling stress and other psychological demands (including handling responsibilities18*, 19*, 20*)]
1-20 Similar elements of the DCP and ICF domains are indicated with a reference number. Shading indicates elements that do not have an equivalent in the other model. The asterisk (*) identifies elements which, according to the DCP, should be included in social roles.
the interaction between the individual’s health condition, activities, body functions, and contextual factors, which include both personal and environmental factors. This different conceptualisation is built on three main foundations: 1) personal factors, 2) environmental factors, and 3) activities and participation. More specifically, the DCP and ICF do not conceptualise personal factors in the same way. In the ICF, health conditions, activities, and body functions/personal factors are three 238
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conceptually distinct components, while in the DCP, personal factors include the individual’s health problems, capabilities, organic systems, and personal characteristics. The way personal factors are conceptualised in the ICF makes it difficult to clearly distinguish between components intrinsic and extrinsic to the individual. The influence of environmental factors is also conceptualised differently in these two models. In the DCP, the environment has a direct effect on and is incorporated as a ■
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LEVASSEUR ET AL. determinant of social participation in the same way as personal factors (see Figure 1). In the ICF, the influence of the environment is mitigated, that is, not clearly identified conceptually (see Figure 2). As with the ICIDH, the ICF predominantly focuses on the individual rather than on a broader view that takes into account the environment’s key role in the disability creation process (Fougeyrollas, Noreau, & Boshen, 2002). In short, the impact of environment is not considered an explanatory element of participation (Noreau & Fougeyrollas, 1996). However, when we look at the participation component as an outcome, it is important to distinguish between what is intrinsic versus extrinsic to the individual. Indeed, this distinction is fundamental because interventions targeting personal factors are very different from interventions targeting the environment. Finally, capabilities and social participation in the DCP are two, operationally distinct components, while in the ICF the same domains may correspond to activities and participation. The ICF suggests distinguishing between these two concepts solely by using qualifiers: Activities represent what the individual can do in a “uniform” or “standardized” environment, while participation is the performance of the same activities in the “real” environment. Users of the ICF have to decide if they want to use the activities and participation domains with or without overlapping. Since the activities and participation domains and their elements are included in the same list, the users themselves categorise what they consider as being part of the activities, participation, or both. International variations and the different approaches of professionals and theoretical frameworks explain the WHO’s difficulty in distinguishing between the activities and participation components (WHO, 2001). Also, according to the WHO (2001), it would also not be useful to classify social situations since their relevance differs from one person to another and there is an infinite number and types of social situations. Fougeyrollas (2002, p. 25) maintains: Thus, the ICF gets away from the central clarification made by the DCP, namely the distinction between 1) what relates specifically and intrinsically to the individual and 2) the performance of socially defined, more complex activities resulting from the interaction between personal factors and environmental factors. In the DCP, it is not possible to use a single nomenclature mixing up functional capacities (capabilities) such as prehension or oral comprehension with life habits such as food preparation and interpersonal relationships … [translation] The ICF categorisation of the activities and participation domains leads to significant difficulties in operational interpretation, applications, and usefulness. For example, as mentioned by Dijkers, Whiteneck, and El-Jaroudi (2000), if a participation instrument includes activity elements, it cannot be used to test theories concerning the relationship between participation and activities. According to Fougeyrollas VOLUME
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(2002), the performance of intellectual or behavioural activities must be transferred to the dimension of capabilities, defined in the DCP as exteriorised functions stemming from structural integrity or internal functions of the organs, but belonging to a conceptually distinct dimension. The distinction between capabilities and participation is a fundamental operational issue (Fougeyrollas et al., 2002; Stewart & Carswell, 2004). Capabilities and participation may be related, but we cannot assume that doing a certain activity will lead to a participation restriction without considering the environmental variables of real life situations. The environmental factor of the DCP is thus a key variable that contributes to distinguish personal capabilities and performance in regard to social participation. By definition, social participation is always variable, subject to change, and modifiable by both personal and environmental factors. Although the performance may vary across environments, participation can still be conceptualised separately from capabilities. Third, despite their similarities, the participation components of the DCP and ICF present some differences, mainly between their respective domains and the elements that make up these domains (see Tables 2 and 3). The Nutrition, Fitness, and Responsibility domains of the DCP do not have an equivalent in the ICF domains. However, some of the other domains in the ICF contain some elements that relate to these DCP domains: the Self-care ICF domain includes Eating and drinking and Managing fitness while the General tasks and demands ICF domain includes Handling responsibilities. Two of the participation domains of the ICF, Learning and applying knowledge and General tasks and demands, do not have an equivalent in the social participation domains of the DCP (see shaded areas of the ICF in Tables 2 and 3). When we take a closer look, we see that these domains of the ICF are more related to capabilities in the DCP. Thus the Learning and applying knowledge domain of the ICF corresponds to the DCP’s Intellectual capabilities while the General tasks and demands domain of the ICF is similar to the DCP’s Behaviour capabilities. For example, the act of thinking, which is an element in the Learning and applying knowledge domain, is inherent to the individual and not the result of an interaction with the environment. In fact, these ICF domains were omitted from the new participation instrument developed by Gandek and colleagues (Jette, Keysor, Coster, Ni, & Haley, 2005). Two other ICF domains, Mobility and Interpersonal interactions and relationships, also include elements of capabilities or activities rather than participation (see shaded areas of the ICF in Tables 2 and 3). Finally, there are some differences between the ICF and DCP in regard to the elements included in the participation domains. The DCP contains two elements that do not have an equivalent in the ICF: Mental fitness and Counseling (see shaded areas of the DCP in Tables 2 and 3). Also, in the ICF, sleep is put in the Global mental functions domain of the Body
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TABLE 3 Comparison of the DCP and ICF social roles domains and elements DCP
ICF
RESPONSIBILITY - Financial responsability18 - Civil responsability19 - Family responsability20 COMMUNITY LIFE - Consumption21 - Voluntary associations22 - Religious groups23 RECREATION - Sports and games24 - Arts and culture25
COMMUNITY, SOCIAL AND CIVIC LIFE [community life22, recreation and leisure (including play24, sports24, arts and culture25), religion and spirituality23, human rights19, political life and citizenship19, etc.]
INTERPERSONAL RELATIONSHIPS - Sexual relations26 - Affective relations27 - Social relations 28
INTERPERSONAL INTERACTIONS AND RELATIONSHIPS - General interpersonal interactions (showing respect, warmth, appreciation, and tolerance in relationships, etc.) - Particular interpersonal relationships [formal or informal social relationships28, family relationships27, intimate relationships27 (including sexual relationships26), etc.]
EDUCATION - Preschool29 - Academic education30 - Occupational Training31 - Other training32 EMPLOYMENT - Guidance - Job search33 - Paid employment34 - Unpaid employment35
MAJOR LIFE AREAS - Education (preschool education29, school education30, vocational training31, others32) - Work and employment [Acquiring, keeping and terminating a job (including seeking employment33), remunerative employment34, non-remunerative employment35, etc.] - Economic life18
18-35 Similar elements of the DCP and ICF domains are indicated with a reference number. Shading indicates elements that do not have an equivalent in the other model.
functions component, since sleep is influenced by personal and environmental factors. The ICF groups elements less naturally than the DCP across the different domains. For example, the ICF’s Domestic life domain includes the element Assisting others, which would probably have been better placed in the Interpersonal interactions and relationships domain. Finally, the measurement tools of participation in the DCP and ICF are also very different. First, the ICF Checklist is the measuring instrument used to operationalise the ICF (WHO, 2001). This instrument considers the individual’s performance in certain tasks, activities, and roles. On the other hand, the Assessment of Life Habits (Life-H) (Fougeyrollas & Noreau, 2003) was developed along with the DCP to operationalise this model. The Life-H quantifies 1) the degree of accomplishment and type of help used, and 2) satisfaction with the accomplishment of daily activities and social roles. The perception of the individual, which is essential in understanding specific needs and problems faced socially (Canadian Association of Occupational Therapists, 1991; Whiteneck, 1994), is considered by the Life-H instru240
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ment. Also, satisfaction with the accomplishment of daily activities and social roles, which is a crucial aspect of needs assessments (Renwick & Friefeld, 1996), is also taken into account by the Life-H.
Which model to choose? Given the differences between the DCP and ICF, we may well ask which is the best approach. The ICF cannot be ignored since it has been the subject of international consultations, although without much input from people with disabilities (McLaughlin Gray, 2001), and is recognized internationally. The ICF was also issued after the elaboration of the DCP and is partially based on it. However, a lack of clarity makes the ICF a complex conceptual model. This lack of clarity is mainly found in three areas: 1) identification of what is intrinsic to the individual versus what is extrinsic, 2) interactions between the components, and 3) the operational distinction between activities and participation. As we mentioned, since the ICF’s contextual factors include both personal and environmental factors, the factors intrinsic and ■
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LEVASSEUR ET AL. extrinsic to the individual are not clearly identified. Grouping body functions and structures, the health condition, activities, and personal factors in the same component specific to the individual might make it easier to understand. Second, although the ICF model purports to be circular, the arrangement of the body functions, activities, and participation components recall the linear, hierarchical, and causal relationship between the ICIDH components impairment, disability, and handicap. The arrows indicating the interactions between the model’s components are also not clear. They could easily confuse anyone who may not see any link, for example, between participation and environmental factors (see Figure 2). Finally, the main purpose of the ICF was to establish a common language to describe human functioning; it is essential that distinguishing between the domains that operationalised activities and those that operationalized participation are not left to the user’s discretion. Making a distinction between the execution of an action and the involvement of the individual in a real life situation is fundamental, for example, to refine the evaluation of these aspects. The DCP model was developed in Quebec by a small group mandated by the WHO to propose a revision of the ICIDH’s concept of handicap. The DCP model (developed in both French and English versions) is well-known and used in the province of Quebec as well as in some European countries (Desrosiers, 2005), although less so in English Canada. From a conceptual standpoint, the DCP illustrates in a precise, circular, and practical way the dynamic and interactive process of disability and human functioning (Fougeyrollas et al., 2002). The DCP’s perspective is global, holistic, and ecological, it illustrates a destigmatisation of the disability process and reflects the ideology of human rights and equality. It describes in an innovative way the links between personal (intrinsic) and environmental (extrinsic) factors that determine the situational result of the performance of daily activities and social roles (social participation). The DCP makes a distinction between capabilities and social participation. In addition, it enables users to clearly document individual changes and distinguish them from environmental and social changes (Fougeyrollas et al., 2002). Finally, the DCP makes it easier to identify independent and dependent variables, choose the measuring instrument, and identify the causes and consequences of changes. To know which of the two models best represents reality, two studies were done: a case study and a factor analysis. The Canadian Institute for Health Information, in collaboration with France, did a validation study of the two models using case studies to compare the content validity and reliability of the ICF’s concepts of activities and participation and the DCP’s concepts of capabilities and social participation. This study (done in both English and French), showed the conceptual and general practical superiority of the DCP (Canadian Institute for Health Information, 2002). Jette, VOLUME
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Haley, and Kooyoomjian (2003) did a factor analysis based on a self-assessment measuring performance in physical actions, activities of daily living, and vocational and community activities. These researchers concluded that it was important to make a distinction between the activities and participation concepts.
Future perspectives Conceptual models that include the concept of participation might be reviewed based on the results of our comparison of the ICF and DCP models. Moreover, quality of life, one of the more important health outcomes found to be associated with participation (Elliott & Barris, 1987; Levasseur, Desrosiers, & Noreau, 2004; Maguire, 1983; Patrick, Kinne, Engelberg, & Pearlman, 2000; Smith, Kielhofner, & Watts, 1986) should be considered for inclusion in the ICF and DCP models. Occupational therapists’ expertise is important in contributing to the evolution of a conceptual universal model including participation such as the ICF and DCP (Desrosiers, 2005). Finally, empirical studies are still needed to clarify the concept of participation.
Conclusion Participation is a very interesting concept and the focus of current research, especially in occupational therapy. The ICF and DCP, two conceptual models that include participation, have a number of similarities, especially in their approaches, objectives, and components. However, some important differences make the DCP an interesting model because of its conceptualisation and operationalisation of social participation. The dissemination and use of the DCP in empirical studies will continue to further the study of the process of human functioning internationally. Over time, we may be able to reach a consensus regarding a common language, which will make it possible to compare the results of participation studies and further clarify the concept.
Acknowledgements The authors received funding from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). Mélanie Levasseur is an FRSQ scholarship student and Johanne Desrosiers is a CIHR Research Fellow. The authors wish to thank Nathalie Bier, OT, and Nadine Larivière, OT, for their suggestions and comments on a preliminary version of this article.
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Authors Mélanie Levasseur, MSc, OT(C), is a doctoral student in Clinical Sciences at the Faculty of Medicine and Health Sciences, Université de Sherbrooke, and at the Research Centre on Aging, Health and Social Services Centre–University Institute of Geriatric of Sherbrooke (CSSS-IUGS), 1036 Belvédère South, Sherbrooke, QC, J1H 4C4. E-mail:
[email protected] Johanne Desrosiers, PhD, OT, FCAOT, is Professor and director of the Department of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and a researcher at the Research Centre on Aging, CSSS-IUGS, 1036 Belvédère Sud, Sherbrooke, QC, J1H 4C4. Denise St-Cyr Tribble, PhD, RN, is Professor in the Department of Nursing Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Scientific Director, CSSS-IUGS [Local Community Service Centre (CLSC) component], 50 Camirand, Sherbrooke, QC, J1H 4J5.
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