The main objective of the Italian project was to propose a suitable solution for a common framework for disability as a systemic attribute, therefore incorporating an interactive definition of disability, an evaluation methodology, and proper instruments for the representation of this interaction. Considering the complexities of the tasks and the limits of the current research on the analyzed issues, the project tried to find a “practicable compromise” to be improved, integrated and refined over time. It aimed to propose a “prototype” incorporating a “new vision” that works even though it has to be improved .
Although the results are preliminary and the statistical procedure can be further refined, some considerations can be made:
it is possible to describe disability as a continuum according to a person-environment evaluation framework using ICF; and
it is possible to identify meaningful groups that could be used to define different profiles of intervention, or case-mix representation, no more based on personal characteristics but on the type of person-environment relationship.
Disability is multifactorial and complex . If it is conceptualised using a complex model as ICF proposes and the UN Convention stresses, it is not possible to describe it in a single measure . Mainly due to this initial state of the theorization, the assessment of disability in a systemic framework is also quite a difficult task . The traditional approach to disability assessment is distant from that of an interactive model, as well documented by Rust & Smith ; in order to guarantee the comparability of results, common disability assessment instruments are poor in defining the conditions and characteristics of the environment in which the evaluation has to be realized. In contrast, in an interactive model, there is no more room for the idea of measuring disability as “an intrinsic characteristic” of the person and the environment plays an important role. This study shows that a conceptual refinement of the constructs and concepts guiding the definition of the disability assessment process, particularly the way in which the environment is taken into consideration, is possible and allows to read the role of environment in the functioning of persons with bad health conditions. As Salvador proposed , we could adopt the concept of environmental dependence to describe the situation of people whose functioning is classified by the person-environment interactions classification tree.
The possibility of summarizing the person-environment interaction allows us to consider the individual scenario as a base for intervention. It is not enough, of course, to make a decision but it could be used as a common and shareable reference for defining potential areas of intervention within a systemic framework and with a specific orientation to the dynamic of the system. Furthermore, the individual scenario represents a reference for monitoring the situation over time and evaluating the impact of interventions at personal and contextual level. The aggregated scenario instead is an interesting perspective to monitor the health status of the population and, at the same time, the efficacy of disability policies and their heterogeneous impact on different areas of human life. As underlined earlier, the sample cannot be considered representative of a specific population of persons with disability. Having this in mind, it is interesting to note that the representation of A&P data associated with EFs gives an immediate view of the disability profiles at aggregate level, distinguishing between areas of relatively good performance and good capacity, areas of good performance in the presence of effective and reactive environments, and areas with “open problems” and “persisting difficulties”.
The descriptive data show the heterogeneous presence of the environment in the different A&P domains. The fact that Self Care is better supported than Mobility can be explained by a traditionally consolidated attention to an area that refers more directly to health and social care.
The great difference between facilitators and barriers, taking into account the overall amount of these coded factors, may be due to the nature of the studied population, which experiences severe functioning problems within a complex system of supporting interventions.
As seen in the premises, the UN Convention on rights of people with disability itself takes into consideration only barriers. In addition to that, the way in which the Italian system is organized, could be also considered. In Italy the services are traditionally provided by the National and Regional Health systems and therefore considered as granted by the citizens that are not used to an “insurance” logic. In this sense, the health services provided by the Public health systems are considered as barriers only when they are not efficiently working. Furthermore, the evaluators that have made the assessments and compiled the protocols in this national project belong to the same health system that they were evaluating and are therefore not used to consider themselves as part of the environment surrounding the evaluated person.
These factors have all to be considered in order to understand the possible difficulties in detecting and evaluating the role and importance of barriers in everyday life of persons with disability.
With regard to the distribution of the environmental factors, the peak of Products and technology registered in the Mobility area is probably due to the simplicity of detecting assistive devices as a facilitator. Moreover, in the Italian system, Support and relationships are a strategic resource in any A&P domain and cover, in each domain, the majority of the specific A&P evaluated areas.