Assessing changes in life skills and quality of life resulting from rehabilitation services. (Assessing Rehabilitation Outcomes).

In addressing the goals of the rehabilitation process, Murphy and Williams (1999) state:

   The rehabilitation process is seen as a systematic
   approach to assessing and addressing the total
   needs of a person with disabilities. Each person is
   seen as a unique individual with assets that can be
   developed. The ultimate goal of the rehabilitation
   process is to promote functional independence
   where the individual is capable of economic self-sufficiency
   and integration into society. (p. 29)

A major accountability mandate for rehabilitation services to achieve those goals dates back to the passage of the Rehabilitation Act of 1973. That mandate required rehabilitation service programs to demonstrate that they have met expected service outcome goals and have done so in an efficient manner (Rubin & Roessler, 2001). Meeting and exceeding expected service outcome goals is one method of demonstrating the success and effectiveness of services provided and of justifying the continued funding of rehabilitation services.

Historically, the evaluation of the effectiveness of rehabilitation services has been heavily focused on short-term employment outcomes (Gilbride, Stensrud, & Johnson, 1994; Gilbride, Thomas, & Stensrud, 1998). However, limiting the assessment of service effectiveness to short term employment outcome data may provide an insufficient and sometimes misleading picture of the benefits to consumers from rehabilitation services (General Accounting Office, 1993). It is difficult to determine the meaning of short-term employment outcome data as an index of service effectiveness without also having a clear picture of how the competencies of the individual and the individual's perception of the desirability of his/her life situation has changed following rehabilitation services. Unless the post-services employment status of the individual can be explained as resulting from the changes produced in the individual or his/her life situation by the rehabilitation services provided, there is little reason to believe that either the current employment will be sustained for any meaningful period of time or that the current job could not have been acquired without the rehabilitation services provided.

To acquire a valid picture of desired benefits from complex packages of services, measurement tools for the comprehensive assessment of client outcomes are needed (Johnston, Stineman, & Velozo, 1997; Schalock, Keith, Hoffman, & Karan, 1989). It can be argued that in addition to assessing changes in vocational status, changes in areas of life skills and areas of sense of well being (i.e., self perceived quality of life) in consumers who have received vocational rehabilitation services would be valid measures of the impact of services received. Several health care and rehabilitation researchers have been advocating for the inclusion of quality of life in the framework for assessing rehabilitation health outcomes (Murphy & Williams, 1999; Renwick & Friefeld, 1996). For example, the Medical Outcomes Study (MOS) project has underscored the concept of measuring well being, as well as functioning in order to examine the relationship between improvement in functioning and changes in patients' well-being as indicators of successful outcomes (Stewart & Ware, 1992).

The purpose of this paper is to discuss the relevance of addressing both life skills and quality of life when attempting to assess the effects of rehabilitation services. The purpose of such measures is to provide the service provider with (a) a clear over-all pre vs post picture of the level of functioning of the individual, (b) clear evidence of the effects of services on the sense of well being of the consumer and, (c) a means with which to monitor his or her own effectiveness (Ware, 1992). Moreover, such measures can be used to generate service outcome data for a large group of counselors as well as for the individual counselor (Keith, 1999). In regard to the former, the service outcome database provided would be potentially useful for program evaluation initiatives directed at identifying best (service delivery) practices.

The importance of focusing on quality of life as well as on the consumer's life skills in assessment of service outcomes cannot be overstressed. This is based on the assumption that the extent of consumer motivation to participate in rehabilitation services is determined by the anticipated effect of those services perceived by the consumer on his/her quality of life (Dijkers, 1997; Wienberg, 1984). Therefore, in designing an outcome assessment system for rehabilitation service, one must be able to not only see the connection between the specific design of services and specific gains in life skills (e.g. Maintain good grooming, Dress appropriately for work), but also the relationship between gains in life skills and positive changes in the perceived quality of life of the individual (e.g. Other people react toward me in a positive way) (Dijkers, 1997; Murphy & Williams, 1999).

This paper will examine the two important components of a comprehensive outcome measurement system noted above, life skills, and quality of life. The life skills aspect, which addresses the functioning level of an individual, will be defined and discussed. Following that the quality of life aspect will be defined and discussed. Some examples of potential content coverage of the measures also are provided.

Life Skills Defined

Life skills can be defined as those skills used in everyday living, in work situations, and for lifestyle maintenance (Murphy & Williams, 1999). Cronin (1996) has defined life skills as "those skills or tasks that contribute to the successful independent functioning of an individual in adulthood" (p. 54). Overall, they "are conceptualized as all those things needed for effective living" (Darden, Gazda, & Ginter, 1996, p. 140), including success in employment (Brolin, 1982; Vogel, 1974). Typically, the construct of life skills refers to a group of skills which can be learned (Darden et al., 1996). Sufficient mastery of fundamental life skills is seen as necessary for the individual to function optimally in society (Darden et al., 1996). Deficits in the types of life skills found on Table 1 can preclude optimal functioning, thereby preventing the individual from fulfilling his/her current or anticipated role in society. Rehabilitation services can play a major role in reducing such deficits in people with disabilities.

A comprehensive picture of the life skills deficits of an individual provides a better guide to the type of rehabilitation services needed than does the typical diagnostic label. While the life skills on Table 1 have been sorted by areas, the effect of changes in any given area cannot be viewed as only affecting performance within that area. For example, positive changes in communication skills on Table 1, (e.g. "Initiate a conversation," "Maintain a conversation") can positively affect the individual's ability to "Make new friends" (under Interpersonal Skills), "Interview effectively for available jobs" (under Job Seeking Skills) and "Get along with co-workers" (under Vocational Adjustment Skills). Conversely, failure to address significant deficits via rehabilitation services in the communication skills of the individual could reduce the likelihood of significantly changing the level of those aspects of the individual's interpersonal skills, job seeking skills, and vocational adjustment skills via other targeted rehabilitation services. Therefore, generalized influences can be viewed as pervading the life skills domain. That is, changes in a positive or negative direction in one life skills area can produce changes in other life skills areas to varying degrees (Darden et al., 1996). Consequently, failure to adequately assess the consumer in all life skills areas and to address all significant deficits in the rehabilitation plan could lead to a failure to achieve desired rehabilitation service outcome goals.

Life Skills Assessment

Life skills assessment as an outcome measure in rehabilitation relates to any systematic attempt to objectively measure the life skills of an individual in any of a variety of areas, such as self-care skills, mobility skills, communication skills, interpersonal skills, health management skills, job seeking skills, and vocational adjustment skills (Murphy & Williams, 1999; Stewart & Ware, 1992). Life skills assessment relates to an assessment of those skills necessary for adequately performing the tasks associated with daily activities, such as self-care, social interactions, vocational pursuits, and leisure pursuits. Therefore, life skills assessment should address the ability of an individual with a disability to perform across many different categories of life skills (Johnston, Keith, & Hinderer, 1992). Table 1 provides a list of life skill areas that are relevant to consider in the rehabilitation plan development and outcome assessment process.

In the rehabilitation process, diagnosis of the disability as it might affect the life skills of the individual is important for determining which rehabilitation services will be necessary to optimize the daily functioning of that individual (Johnston et al., 1997; Willer, Button, & Corrigan, 1997). Life skills assessment can serve to provide both subjective and objective views of an individual's level of functioning in the life skills areas found on Table 1. For example, a consumer can provide a subjective self-assessment of the extent of deficit (if any) in any of the life skills found on Table 1 while the professional service provider can attempt to objectively assess the functioning levels of the individual in those same life skill areas. Such assessments can occur just prior to the initiation of and directly following the completion of rehabilitation services to determine the effect of such services on consumer functioning.

In U.S. society it might be easy, yet erroneous, to assume that all individuals seeking rehabilitation services desire to maximize their level of independence. Such an expectation could lead to an equally potentially erroneous assumption that any given consumer of rehabilitation services would value an opportunity to upgrade his/her level of independent functioning in regard to every life skill found in Table 1. Individuals can value both states of independence and interdependence in their lives depending on the particular functional domain being addressed (Dennis, Williams, Giangreco, & Cloninger, 1993). How important they perceive the need for change across life skill areas can vary. That variability can be somewhat explained by factors such as type of disability, personal background, age, culture, social situation, and environment (Zhan, 1992). Consequently, the goals of and the services to be provided by any rehabilitation plan should be somewhat dependent on the importance the consumer places on each life skill as well as on the extent of the deficit observed in any given life skill. Such varying levels of importance also should be given sufficient consideration in any pre to post evaluation of the effect of rehabilitation services on life skill functioning.

Quality of Life Defined

The prevalence of individuals with chronic disabilities has greatly increased in the last 50 years. While a cure for these conditions is not attainable, the quality of life of the individuals so affected can be positively impacted via rehabilitation services that promote gains in overall physical, psychological, social, vocational, or material well-being (Dijkers, 1997). Such gains are a paramount objective of rehabilitation services (Murphy & Williams, 1999). Therefore, many rehabilitation facilities in the United States "have some variation of 'adding life to years' as their slogan, which may be contrasted with the 'years added to life' characteristic of many other branches of health care" (Dijkers, 1997, p. 153). Consequently, consumers of rehabilitation services should expect to have a better quality of life after receiving rehabilitation services.

Quality of life is a term generally used to describe the perceived well-being of people (Murphy & Williams, 1999; Zautra, Beier, & Cappel, 1977), however, it has been defined in numerous ways (Dennis et al., 1993; Dijkers, 1997; Felce & Perry, 1995; Goodinson & Singleton, 1989; Zhan, 1992). Broad definitions of quality of life tend to address freedom of action, sense of purpose for one's life, achievement regarding work, family or social/recreational life, self-preservation of esteem and integrity, and physical and material well-being (Felce & Perry, 1996; Flanagan, 1978; Goodinson & Singleton, 1989; Murphy & Williams, 1999; Stewart & Ware, 1992). Many aspects of this broad definition have been supported by empirical research. For example, in a national study of 30, 50, and 70 year old males and females, Flanagan (1978) found strong positive relationships between self-reported level of overall quality of life and self-report of how well the needs and wants of these individuals were being met in areas of "material comforts, health, work, active recreation, learning, and creative expression" (p. 143). Results of a survey in which a random sample of 2,000 adults in Great Britain were asked to list, in priority order, the five most important things in their lives, suggested that people judge the quality of their lives on the basis of their "finances/standard of living/housing, followed by relationships with family and friends, own health, the health of close others, and social life/leisure activities" (Bowling, 1995, p. 1459). Regardless of the particular aspects covered in any specific conceptualization of quality of life, its validity will depend on the extent to which its formulation is "equally applicable across disability groups, other special populations, and society as a whole" (Felce & Perry, 1996, p. 60).

Quality of Life Assessment

Past literature on quality of life for persons with disabilities has basically emphasized three broad categories of measures of quality of life: (a) measures of one's satisfaction with life within multiple domains such as health, hou=sing, social activities, and work, (b) measures of the level of functioning of the individual in his/her environment, and (c) social indicators (group statistics as a measure) such as unemployment rates, access to health care, and socioeconomic status (Bowling, 1995; Evans, Burns, Robinson, & Garrett, 1985; Fabian, 1991). The validity of the latter two areas of measurement as indices of the quality of life of the individual has been seriously questioned (Fabian, 1991; Zahn, 1995). For example, in regard to level of functioning, there is a general lack of empirical data showing a positive relationship between how well people with disabilities adapt to their environment and their perception of their level of quality of life (Fabian, 1991). In regard to questioning the validity of social indicators as an index of quality of life, Zhan (1992) has pointed out that while socioeconomic indicators became more positive between 1957 and 1972, 'happiness' steadily declined in the U.S. population during that period. Furthermore, investigations of the relationships between objective social indicators and the individual's expressed satisfaction with life have yielded only modest correlations between the two (Fabian, 1991; Murphy & Williams, 1999).

Regardless of method, quality of life assessment often focuses on the perceived well-being of the individual in physical, psychological, social and material areas (Cella & Tusky, 1993; Felce & Perry, 1996; Murphy & Williams, 1999; Padilla, Grant & Ferrell, 1992). Physical well-being tends to address basic life domains such as physical health and fitness (Felce & Perry, 1996). Psychological well being typically addresses mental health in regard to levels of personal adjustment (Stewart Ware, Sherbourne & Wells, 1992). Social well-being typically focuses on the extent and quality of personal relationships, spiritual fulfillment, community involvement, and extent of involvement in active and participatory recreational activities. (Dennis et al., 1993; Diener, 1984; Felce & Perry, 1996; Murphy & Williams, 1999). Material well-being tends to focus on financial and quality of environment factors. However, given that "work is still the overarching value and that research indicates that there is a dynamic interaction between quality of work life and quality of life in general" (Murphy & Williams, 1999, p. 3), quality of life assessment also should focus on occupational or career development sense of well-being. It also can be noted that while people receive monetary compensation from employment, they receive many nonmonetary benefits from work as well (Murphy & Williams, 1999). Therefore, it is likely that perceived changes in the psychological and social well being areas of quality of life (e.g. my life is under control, I feel hopeful about the future, I seldom feel lonely, others turn to me for help) may often coincide with perceived changes in the Occupational/Career Development Well Being area of quality of life (e.g. I am happy with my employment situation). Table 2 provides a picture of the type of items that could be included under the physical, psychological, social, occupational/career development and material areas in a subjective quality of life measure. To assess the effectiveness of rehabilitation services, consumers of rehabilitation services could rate the extent to which quality of life items such as those found on Table 2 are descriptive of themselves both pre and post service delivery. In order to guard against the tyranny of the values of others, consumers also could rate how much effort (e.g., much, some, little) they would be willing to put forth to maintain or change any quality of life item. The validity of the weighted qualities of life scores yielded by such a two rating system would rest on the validity of the following assumption: consumers are the best judges of what factors contribute to their satisfaction with life.

Subjectively measured, good quality of life could be seen as synonymous with positive sense of well being, i.e., a high positive self-appraisal of oneself and one's circumstances. Poor quality of life could be seen as synonymous with a negative sense of well being, i.e., a negative self-appraisal of oneself and one's circumstances (Diener, 1994).

To date, many instruments developed to measure quality of life have been designed for self-assessment of one's state of affairs (Murphy & Williams, 1999; Renwick, Brown & Nagler, 1996; Stewart & Ware, 1992). Therefore, the history of activity in this area suggests that any overall appraisal of quality of life should centrally focus on the consumer's perception of his or her well being in areas regarded as important by him or her (Cella & Tusky, 1993).

When assessing quality of life, the level of importance placed by consumers on well being in various aspects of their lives should be the key consideration (Felce & Perry, 1995; Zahn, 1992). Assessment of quality of life should address life satisfaction in relation to personally determined standards of what consumers consider desirable or undesirable for their life. Such an assessment should suggest the services that are needed to either restore, maintain, or enhance aspects of the individual's functioning or life situation necessary for optimizing quality of life.

Conclusion

It is important to accurately assess the deficits in life skills of persons seeking rehabilitation services at both rehabilitation plan development to determine the types of services needed, and at case closure to determine the extent to which their life skills deficits have been reduced by those rehabilitation services (Dittmar, 1997). As deficits diminish, the individual's capacity for independent functioning and level of self-esteem are likely to increase. As those gains are experienced, the subjective perception that individuals have of their quality of life is likely to become more positive (Cronin, 1996). To the extent that rehabilitation services are effective, one should see a reduction in significant life skills deficits of the individual. That reduction should, in turn, lead to greater self-esteem and capacity for independent functioning, which should be associated with a more positive perception of one's quality of life (Dennis et al., 1993). In fact, it might be assumed that the likelihood of individuals with disabilities optimally complying with recommended rehabilitation service interventions is greatly dependent on their expectation of such services positively affecting their sense of well being or life satisfaction (Murphy & Williams, 1999).

Through the use of a valid system for assessing changes in life skills and quality of life resulting from the services they provide, rehabilitation professionals can obtain feedback on which services are most effective, and over time, such a system may further provide a differential blueprint of effective service provision. Overall, such a system could identify the "best practices" in the rehabilitation service delivery process, information which in turn can play a major role in facilitating the effectiveness of rehabilitation services (Cronin, 1996).

Table 1 *

Examples of Life Skills Sorted by Areas

Self-Care Skills

a. Dress oneself

b. Bathe oneself

c. Clean home

d. Cook meals

e. Maintain good grooming

f. Manage personal finances

Mobility Skills

a. Use public transportation

b. Drive a car

c. Use an elevator

d. Get around all areas of one's home

Communication Skills

a. Initiate a conversation

b. Maintain a conversation

c. Communicate one's needs to others

Interpersonal Skills

a. Make new friends

b. Maintain old friendships

c. Act appropriately in various social situations

d. Have a sensitivity to how others are feeling

e. Express dissatisfaction effectively when mistreated

Health Management Skills

a. Acquire sufficient exercise

b. Maintain a healthy diet

c. Take medication appropriately

d. Avoid situations which will exacerbate one's disability

e. Seek out medical care when needed

f. Seek out psychological services when needed.

Job Seeking Skills

a. Identify available jobs in one's geographic area

b. Complete a job application blank

c. Interview effectively for available jobs

d. Write a resume

Vocational Adjustment Skills

a. Show up regularly for work

b. Dress appropriately for work

c. Get along with co-workers

d. Get along with supervisors

e. Stay on task in work situations

f. Adjust to unexpected changes in the daily routine of a job

g. Handle the physical demands of jobs available to oneself

Table 2 *

Examples of Quality of Life Indicators Sorted by Areas

Quality of Life Area

Physical Well Being

a. My health is good

b. I seldom need hospitalization

c. I have adequate energy

d. I have good medical services

Psychological Well Being

a. I am in control of my life

b. I am seldom depressed

c. I feel hopeful about the future

d. I enjoy life

e. I have many good reasons to live

f. I feel good about myself

g. I am well adjusted to my disability

h. I can usually laugh at myself

i. I often feel happy

j. I am an important member of my family

k. I am seldom bored

l. I am satisfied with my personal appearance

Social Well Being

a. I have friends who care about me

b. I have an active social life

c. I am treated well by others

d. I feel comfortable in social situations

e. I seldom feel lonely

f. I receive emotional support from my family

g. I have someone that I can talk to about my problems

h. My recreational activities often involve interacting with others

i. I have many satisfying leisure activities

Occupational/Career Development Well Being

a. I am happy with my job options

b. I am happy with my job skills

c. My career is developing satisfactorily

d. I am happy with my employment situation

e. I have job advancement opportunities

Material Well-Being

a. I seldom worry about money

b. I can afford the medical services I need

c. I can afford to buy my favorite foods

d. I can afford decent housing

e. I can afford decent clothing

f. I feel good about my financial future

* Items in Tables 1 and 2 were generated via a multistage process contained in a field-initiated research project (H133G990137), funded by the National Institute on Disability and Rehabilitation Research (NIDRR), for identifying life skills and indices of quality of life which can be affected by rehabilitation services. The multistage process involved a comprehensive literature review as well as focus groups, a delphi study, and item refinement workshops through which input from rehabilitation professionals and consumers on relevant life skills and quality of life indices was acquired. More detailed information on the process can be obtained from the second author who is the project director on the NIDRR field initiated research grant.

References

Bowling, A. (1995). What things are important in people's lives? A survey of the public's judgment to inform scales of health related quality of life. Social Science and Medicine, 41, 1447-1462.

Brolin, D. (1982). Life skills for independent living. Washington, D.C.: American Association of Colleges for Teacher Education.

Cella, D., & Tusky, D. (1993). Quality of life in cancer: Definition, purpose, and method of measurement. Cancer Investigation, 11,327-336.

Cronin, M. (1996). Life skills curricula for students with learning disabilities: A review of the literature. Journal of Learning Disabilities, 29(1), 53-68.

Darden, C., Gazda, G., & Ginter, E. (1996). Life skills and mental health counseling. Journal of Mental Health Counseling, 18(2), 135-141.

Dennis, R., Williams, W., Giangreco, M., & Cloninger, C. (1993). Quality of life as context for planning and evaluation of services for people with disabilities. Exceptional Children, 59(6), 499-512.

Diener, E. (1984). Subjective well being. Psychological Bulletin, 95(3), 542-575.

Diener, E. (1994). Assessing subjective well being: Progress and opportunities. Social Indicators research, 31, 103-157.

Dijkers. M. (1997). Measuring quality of life. In M. J. Fuhrer (Ed.), Assessing medical rehabilitation practices: The promise of outcome research (pp. 153-179). Baltimore, MD: Paul H. Brookes Publishing Co.

Dittmar, S. (1997). Overview: A functional approach to measurement of rehabilitation outcomes. In S.S. Dittmar & G.E. Gresham (Eds.), Functional assessment and outcome measures for the rehabilitation health professional. (pp. 1-10). Gaithersburg, MD: Aspen Publishers, Inc.

Evans, D., Burns, J., Robinson, W., & Garrett, O., (1985). The quality of life questionnaire: A multidimensional measure. American Journal of Community Psychology, 13, 305-322.

Fabian, E. (1991). Using quality of life indicators in rehabilitation program evaluation. Rehabilitation Counseling Bulletin, 34, 344-356.

Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16(1), 51-74.

Felce, D., & Perry, J. (1996). Exploring current conceptions of quality of life. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation (pp. 51-62). Thousand Oaks, CA: Sage Publications

Flanagan, J. (1978). A research approach to improving our quality of life. American Psychologist, 33(2), 138-147.

General Accounting Office. (1993). Vocational rehabilitation: Evidence for federal program's effectiveness is mixed (GAO-PEMD-93-19). Washington, DC: Author.

Gilbride, D., Stensrud, R., & Johnson, M. (1994). Current models of job placement and employer development: Research competencies and educational considerations. Rehabilitation Education, 7, 215-239.

Gilbride, D.D., Thomas, J.R., & Stensrud, R. (1998). Beyond status code 26: Development of an instrument to measure the quality of placements in the state VR program. Journal of Applied Rehabilitation Counseling, 29(1), 3-7.

Goodinson, S., & Singleton, J. (1989). Quality of life: A critical review of current concepts, measures and their clinical implications. International Journal of Nursing Students 26(4), 327-341.

Johnston, M., Keith, R., & Hinderer, S. (1992). Measurement standards for interdisciplinary medical rehabilitation. Archives of Physical Medicine and Rehabilitation, 73, 53-523.

Johnston, M. V., Stineman, M., & Velozo, C. (1997). Outcomes research in medical rehabilitation: Foundations from the past and directions for the future. In M J. Fuhrer (Ed.), Assessing medical rehabilitation practices: The promise of outcome research (pp. 1-41). Baltimore, MD: Paul H. Brookes Publishing Co.

Keith, R.A. (1999). Comprehensive rehabilitation: Themes, models, and issues. In M.B. Eisenberg, R.L. Glueckauf, & H.H. Zaretsky (Eds.), Medical aspects of disability: A handbook for the rehabilitation professional (pp. 3-25). New York: Springer Publishing Company, Inc.

Murphy, O., & Williams, J. (1999). Assessment of rehabilitative and quality of life issues in litigation. Boca Raton, FL: CRC Press.

Padilla, G.V., Grant, M.M., Ferrell, B. (1992). Nursing research in quality of life. Quality of Life Research, 1, 341-348.

Renwick, R., Brown, L., & Nagler, M. (1996). Quality of life in health promotion and rehabilitation: Conceptual approaches, issues, and applications. Thousand Oaks, CA: Sage Publications.

Renwick, R., & Friefeld, S. (1996). Quality of life and rehabilitation. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation: Conceptual approaches, issues, and applications (pp. 26-36). Thousand Oaks, CA: Sage Publications.

Rubin, S.E., & Roessler, R.T. (2001). Foundations of the vocational rehabilitation process (5th ed.). Austin, TX: PRO-ED.

Schalock, R., Keith, K., Hoffman, K., & Karan, O. (1989). Quality of life: Its measurement and use. Mental Retardation, 27 (1), 25-31.

Stewart, A.L., & Ware Jr., J. E. (1992). Measuring functioning and well-being: The medical outcomes study approach. Durham, NC: Duke University Press.

Stewart, A. L., Ware Jr., J. E., Sherbourne, C. D., & Wells, K. B. (1992). Psychological distress/well-being and cognitive functioning measures. In A. L. Stewart & J. E. Ware Jr. (Eds.), Measuring functioning and well-being: The medical outcomes study approach (pp. 102-142). Durham, NC: Duke University Press.

Vogel, H. (1974). A follow-up study of former student-patients at the Crippled Children's Hospital and School, Sioux Falls, South Dakota. Unpublished doctoral dissertation, University of South Dakota, Sioux Falls.

Ware Jr., J. E. (1992). Measures for a new era of health assessment. In A. L. Stewart & J. E. Ware Jr. (Eds.), Measuring functioning and well-being: The medical outcomes study approach (pp. 3-24). Durham, NC: Duke University Press.

Weinberg, N. (1984). Physically disabled people assess the quality of their lives. Rehabilitation Literature, 45, 12-15.

Willer, B., Button, J., & Corrigan, J. D. (1997). The concept of handicap in rehabilitation and research. In M. J. Fuhrer (Ed.), Assessing medical rehabilitation practices: The promise of outcomes research (pp. 127-151). Baltimore, MD: Paul H. Brookes Publishing Co.

Zhan, L. (1992). Quality of life: Conceptual and measurement issues. Journal of Advanced Nursing, 17, 795-800.

Zautra, A., Beier, E., & Cappel, L. (1977). The dimensions of life quality in a community. American Journal of Community Psychology, 5(1),85-97.

Stanford E. Rubin, Ed.D., CRC, Rehabilitation Institute, Southern Illinois University Carbondale, Carbondale, IL 62901-4609

Stanford E. Rubin

Southern Illinois University Carbondale

Fong Chan

University of Wisconsin-Madison

Deborah L. Thomas

Southern Illinois University Carbondale