DISABILITY AND DEVELOPMENT: IS THE RIGHTS MODEL OF DISABILITY VALID IN THE ARAB REGION? AN EVIDENCE-BASED FIELD SURVEY IN LEBANON AND JORDAN

Kozue Kay Nagata*

ABSTRACT

This paper reviews the process and outcome of constructing a "rights model of disability" which is culturally specific to Jordan and Lebanon. The objective of the empirical part was, to survey the current level of attitudes of non-disabled people towards their disabled fellows in Jordan, and to compare the attitudes of Lebanon's university students towards five different categories of disabled people (mentally disabled people, psycho-socially disabled people, physically disabled people, hearing impaired people and visually impaired people) to highlight the variations and diversity among them. It also examined the relationship between the attitudes and various demographic and social characteristics of the respondents. The set of findings was further tested and triangulated through meta-analysis of individual views expressed in the qualitative studies.

In Jordan, the attitude of 191 randomly selected non-disabled people was studied, using a Scale of Attitudes towards Disabled Persons (SADP). The participants from 4 communities of Jordan, exhibited overall negative attitudes towards disabled people. Socio-economic-demographic characteristics showed almost no difference regarding their attitudes towards disabled people.

In Lebanon, a more complex scale, composed of four sub-scales, namely a, "Baseline Survey of Student Attitudes towards People with a Disability" was used, to survey 94 university students' attitudes towards five different categories of disabled people, and a set of indices for future comparison was constructed. The results indicated the same pattern of gradations of attitude differences (found in other countries) towards persons with physical or sensory impairments (better), intellectual impairment (middle) and mental illness (worse). The main findings of this empirical field research showed particularly negative public attitudes towards people with intellectual impairment and mental illness in Lebanon.

Finally, the validity of the proposed rights model of disability and the empirical findings of this study, were further examined and co-validated through analysis of the collective views of those who took part in the questionnaire surveys and the participatory focus group discussions, which took place in Lebanon in 2005 and 2007, and in Jordan in 2005, as well as a series of intensive on-line and/or telephone interviews of a few informants comprising of disabled persons and experts. The policy implications of the findings are discussed.

INTRODUCTION

A variety of models has been promoted to explain disability and disabled persons, which may be expressed in the dialectic of the medical model vs. the social model. The former model views "disability" as a problem of the individual, which is caused by impairment (including disease and trauma), so that the management of disability requires medical intervention and/ or rehabilitation of the individual. Rehabilitation is viewed as the main intervention, and the principal political response is often reform of the rehabilitation or health care system. The social model of disability views the issue mainly as a social barrier (e.g. negative attitudes, physical barriers, institutional and legal barriers), created by the environment, and it is thus a collective social responsibility to make the environment barrier-free. The issue here, is whether to adopt attitudinal intervention, requiring social change which at the political level, becomes an issue of human rights and anti-discrimination.

The social model is becoming widely accepted by many in academic circles, as well as within the community of both developed and developing countries. The strength of the social model is due to its seeing beyond the specific impairment of individuals. It can encompass socio-economic, cultural and legal dimensions of disability from human rights perspectives. This complexity of the model will mandate a coherent action for carrying out research, on the existing level of social barriers and legislation/policy, and campaigning to confront social prejudice and discrimination (1).

However, some cautious Arab researchers argue that the social model may not be directly relevant to the daily life of grass-roots disabled Arab women and men, and the model's contribution may be limited to the provision of an insightful view towards a conceptual understanding of disability, in those developing countries (2).

However, these days most people may refer to the social models of disability in a much more dynamic manner, which may be alien even to its original radical version. For example, Hurst (3) refers to the social rights model of disability. Indeed, the radical social model of disability provides one with the insight to describe the way in which society is constructed, to make people with disabilities "disabled".

In middle-income Arab countries like Jordan and Lebanon, a more integrated, comprehensive and developmental model? which captures the complex integration of various perspectives ? may be necessary. Such a conceptual model was constructed by the author (Figure 1). It is similar to the updated and revised social model of disability, adopted by the Greater London Action on Disability GLAD (4). It also embraces the WHO-ICF integrated approach to disability (5).

The proposed conceptual model of disability, the rights model, is comprehensive, and is based on an integration of three key perspectives, namely, (1) the mutual and dynamic interaction between a disabled individual and his/her social environments (e.g. social barriers, attitudes, accessibility, etc.); (2) the diversity existing among different types and categories of disabled persons, and thus the difference in their needs and priorities; and (3) the relevance of the human rights-based approach to individual disability experiences in Jordan and Lebanon.

Figure 1: Diagram of the Rights Model of Disability from development Perspective

Though the process and mechanism of discrimination and prejudice is mutual and dynamic between a disabled individual and his environment, a mechanism for reinforcing positive public attitudes is a vital key for the success of any interventions for creating an inclusive,Cultural Relativism Collectivism vs Individualism barrier-free and rights-based society (6) . Based on this model, for designing an appropriate national policy and legislation on disability and development, it is critical to first establish a baseline of the current level of social attitudes including discrimination, prejudice, misconception, acceptance and recognition, in a given society. Such a baseline must be established as prerequisite prior to assessing the effectiveness of any kind of rights-based interventions (for changing society and removing social barriers) in the future, with the ultimate goal of institutionalising the equal opportunity concept and inclusion among people in those countries.

With due respect to cultural relativism, each community should study its own attitudes towards people with disability. The attitudes of non-disabled people have been empirically studied world-wide, but almost no studies have been carried out in Jordan and Lebanon.

AIM OF THE STUDY

The study aimed to explore evidence-based information on the current level of social barriers, as well as disabled people's preference of disability approach and model, domestic disability policies and priorities for service delivery in Jordan and Lebanon. Concurrently, the empirical finings were compared to the illustration of individual disability experiences of Arab women and men in the case studies and participatory focus groups. As the ultimate purpose of this study, the proposed rights model of disability was field tested and co-validated in two countries.

METHODOLOGY

The data sources of this study were very comprehensive, which included extensive review of literature, statistics and other documented materials, the quantitative data from two set of questionnaire forms (about attitudes and opinions), the qualitative data from the participatory focus group sessions, the face-to-face interviews, the telephone and on-line interviews, the field visits and the direct experience with and exposure to disabled people of this author, in the region (7 years in Jordan and 4 years in Lebanon respectively).

In Jordan, the Arabic version of Scale of Attitudes toward Disabled People (SADP) was administered by the author, with a total sample of 191 valid data. Details are presented in another paper (7) The data were collected from four communities, namely, Amman (the capital), Karak, Irbed, and Madaba of Jordan (with almost the same proportion of 25 per cent from each community). The research employed a stratified proportional sampling method, to balance the socio-economic characteristics of the respondents. The sample size was spread across different socio-economic characteristics. For instance, the gender balance was almost equal. The mean age was 33 years with SD of 13.3. To eliminate the sampling bias, people of each community passing-by on the street, were selected and asked to answer the questionnaire, in a systematic manner, thus maintaining a certain level of random selection.

SADP is a reliable self-report scale that consists of 24 items, developed by Antonak (8, 9). The 24 items of the SADP are expressed as statements to which respondents answer on a Likert-type scale. Any incomplete questionnaire was eliminated from the study. The total score ranges from 0, indicative of a very negative attitude, to 144, indicative of a very favourable attitude. Descriptive statistics, the Mann-Whitney Test and the Kruskal-Wallis Test were used to analyse the data using SPSS statistical software. The reliability alpha showed a moderate level of reliability (0.56).

In Lebanon, the "Baseline Survey of Students' Attitudes towards People with a Disability" which was developed by the Equal Opportunity Commission of Hong Kong in 2000 (10), was selected as an instrument. A total of 94 valid questionnaires were collected from three major universities in Beirut, Lebanon. More details are presented in another paper (11).

The Arabic version of the Survey, which was developed in English as the original language, with a total of 5069 samples, by the Equal Opportunity Commission (EOC) of Hong Kong in April 2000, was selected for this research. The Survey's conceptual construct, is based on widely used attitudes scales, including SADP developed by Antonak (8.9). The scale of 47 self-reporting questions is composed of four sub-scales, namely, optimism-human rights (8 items), behavioural misconceptions (13 items), pessimism-hopelessness (9 items) and social acceptance (17 items). In the optimism-human rights component, the statements express positive, optimistic views of people with disabilities and affirmed their human rights to live and work as citizens of society. The behavioral misconceptions component describes common misconceptions about the behaviuor of people with a disability, such as, "they enjoy repetitive work". The pessimism-hopelessness component is about negative beliefs about disabled people and the social acceptance component, is to examine possible reactions of the subjects towards people with a disability in daily social contexts. The EOC-reported sub-scales' reliability ranged from 0.69 to 0.85, and a modest level of the concurrent validity with another (vignette) test was also reported.

In Lebanon, the research employed a convenience sampling method, collecting data from the pre-selected classes from 3 main universities in Beirut, Lebanon, namely American University in Beirut (AUB), St. Joseph University (SJU) and Lebanese University (LU). To maintain a certain level of randomness of sampling and to reduce sampling bias as much as possible, in each class 50 per cent of the students were randomly selected and asked to participate in the research and the rest were eliminated. Among the selected half of each class, the participating students were randomly assigned to the five questionnaire forms for five categories of disabled persons. Out of the total of 120 questionnaire returns, only 94 data were considered valid after elimination of all the ones that were incomplete and inconsistent ones. The gender balance of the sample was about 4-6 (males - females).

Descriptive statistics and ANOVA were used to analyse this set of data using SPSS statistical software. Cronbach's Alphas were computed for the four earlier mentioned attitude sub- scales. All sub-scales had good reliability scores ranging from 0.867 (behavioural misconception) to 0.834 (pessimism-hopelessness). The Correlation Matrix of attitude component sub-scales showed a moderate level of consistency, ranging from 0.53 to 0.68 thus showing the interrelatedness or overlapping among the four conceptual constructs. The concurrent validity of this instrument was tested with a collective opinion expressed in a participatory focus group session held in Lebanon, in January, 2005.

To further validate other components of the proposed rights model of disability, a questionnaire, composed of 57 questions with 35 sub-items on disability approach and model, adequacy of the current domestic disability law and policy, and priorities for service delivery was prepared by the author in English and translated into Arabic by a group of Arab experts. All questions were given as bi-nominal choice of yes/no, tri-nominal multiple choice, or 4 ?scale choice. Data collection was based on convenience sampling, i.e., respondents were invited by a field worker to answer the questionnaire on a voluntary basis in Jordan and Lebanon. Over a period of 7 months (June ? December 2005), a total of 113 valid data (from 120 collected) from Jordan and 74 valid data (from 85 collected) from Lebanon were used for this analysis.

To triangulate these empirical findings, the qualitative data were collected in a participatory manner, using the selected appropriate tools of participatory rural appraisal (PRA) in Lebanon and Jordan.

The combined data were analysed as typology, comparison and analytical induction. The data from the above-mentioned two sets of questionnaires were verified and analysed, using the SPSS software package for windows, as frequency, percentages, T-test, F-test, Chi- square test, etc. as appropriate.

RESULTS

The results of the questionnaire surveys in Jordan

Two hundred and five people responded to the SADP, out of which, 191 data sets were complete and valid, with 95 males and 96 females with a mean age of 33, with SD of 13.37. The respondents showed overall negative attitudes towards disabled persons with the mean score of 88.67 with SD of 14.63. This score is lower than some other research findings. For instance, Al-Abdulwahab, et. al. (12), reported the equivalent score of 102 + -3.5 for Saudi speech pathologists and 102 + 3.4 for Saudi family medicine physicians. Arab professionals seem to show more positive attitudes towards disability.

The only characteristics to which a difference in attitudes could be attributed, were the participants' residential communities, and their personal experience of interaction with disabled people as a family member. With respect to communities, the mean score of the respondents from the capital city, Amman (with the population size of some 1.33 millions out of 5.8 million of the Jordan's total population), was rated the highest (meaning the most positive attitude score, M=95.63, SD=14.80) in contrast with the equivalent score (M=82.94, SD=12.77) of the town of Karak (most suburban and rural community among the four pilot places, with the population size of some 23 thousands), and the difference among all 4 cities was statistically significant at p < 0.01 (ANOVA, F=6.846, p < 0.01). Further, a post hoc analysis was conducted. With both Scheffe Post Hoc analysis and Turkey HSD analysis, the statistically significant difference was found for Amman-Karak and Amman-Madaba (a suburban city with the population of some 88 thousands), but there was no difference between Amman and Irbed (the secondary city with the population of some 328 thousands). Madaba scored M=87.2 with SD=13.08, and Irbed scored M=95.47 with SD=15.22).

The findings supported the common and global view, that disabled people living in rural communities tend to face more serious discrimination and prejudice. So - called CNN and the satellite TV effect (i.e. cultural globalisation) and urban population's relative exposure to international developments and the universal human rights concept, as well as openness may have had some positive impact on creating the positive attitude of non-disabled population in the urban cities of Jordan.

The respondents in interaction with disabled persons as a family member, scored higher (94.38) than those without (87.53) (p < 0.001). Those who had watched or participated in some disability awareness programme/campaigns also scored higher (93.01), than those who had not (86.44) (p < 0.001). All other public education schemes had no impact on their attitudes. Also, those whose impression about disabled people came from personal experiences with disabled people, scored higher than those who did not (p < 0.05).

RESULTS OF THE QUESTIONNAIRE SURVEY IN LEBANON

The results, shown in Table 1 indicated the same pattern of gradations of attitude differences toward hearing impaired persons, physically disabled persons, and visually impaired persons (better), and those with intellectual impairment and mental illness (worse).

The main findings showed particularly negative attitudes of the respondents towards people with intellectual disability and with mental illness (including the survivours). Among the four sub-scales, all except the behavioural misconception component indicated a statistically significant difference (p < 0.05) with the same gradation pattern. The sub-scale of behavioural misconceptions also showed a similar pattern of variation, but it was not statistically significant. Though not statistically significant due to the small sample size, students with previous exposure to and contact with disabled people, namely, those with a disabled family member (mean score of 84.12 vs. 90.57), with a disabled friend (mean score of 85.90 vs. 90.41) and those who had watched a TV awareness programme before (88.40 vs. 90.12) showed slightly more positive attitudes. Other socio-economic characteristics did not support a statistically significant variation, for this small sample size.

The survey was able to differentiate between students' attitudes, both, among different universities and also towards people with different types of disabilities. The scale showed that the students had less favorable attitudes towards people with intellectual impairment and those with mental illness or the survivours. This is the same pattern as the findings in Hong Kong, in 2000 and several other countries. The scores of the survey were also highly correlated with the collective opinion expressed by the focus group which took place in August 2007 and January 2005, and other informed opinions. The participating Lebanese university students were more differentiating than the Hong Kong students, towards people with disabilities.

^*Lower score indicates more positive attitudes and higher score indicates more negative attitudes.

^** ANOVA: F=2.646 p < 0.05

TESTIMONIES OF INDIVIDUAL DISABILITY EXPERIENCES: CASE STUDIES

Case study 1. Dynamism of prejudice between society and an individual

"Arab societies always treated certain categories of disabled persons as a negligible quantity, treating them as though it was the end of the road. Disability in Arab culture has traditionally been seen as something shameful, an ordeal to be endured by the family. How to eliminate the negative social attitudes? The only answer is to promote and protect the human rights and civil rights of disabled citizens. Jordan already signed the new International Convention on the rights of disabled persons. Now, we must swiftly ratify and implement its principles. Rights now, Jordan needs an antidiscrimination law and its enforcement mechanism. We must review and modify the current out-dated law on social welfare of disabled persons (Law No. 12), which is based on the concept of charity and pity." (Author's note: In April 2007, Jordan amended Law No. 12 to introduce the rights-based principle. The revision included a set of anti- discrimination measures and remedy mechanisms in various sectors.)

You know, our fellow citizens who are exposed to disabled people are relatively positive, and this is why the role of public education programmes and mass media is so important, to eliminate our prejudice and misconception. We need both, we need a twin-track approach of non-discrimination and proactive campaign. I think however it is critical to accept the dynamism of prejudice and discrimination of human beings and human nature, so an effort to empower people with disabilities is equally important; we disabled people must be changed. We, disabled people too, must be rehabilitated, educated and empowered. A good leadership training course, for instance, is a very effective tool, as non-disabled people can be influenced by an outstanding leadership and the caliber of a disabled fellow. Nobody will be listening to just nagging and complaining persons in this world. I am taking pride that I myself must have influenced so many non-disabled counterparts through my advocacy work, simply because they were very impressed by me and my achievements. No doubt, I am a charming person, and many people like me. You know I enjoy my family life with 11 kind children ? a big family, which is an important achievement in our culture. " (a physically disabled male Jordanian activist).

Case study 2. Diversity among disabilities: Challenges faced by people with intellectual disabilities and the parents

"The diversity among different disabilities exists in this war-torn, sectarian society of Lebanon. There appear to be more differences among the disabled population than similarities in my opinion, disabled women and men, poor and rich, rural and urban, educated and illiterate, disabled veterans and otherwise, you can name it. As a father of two children with severe intellectual impairment, I do not know whether the trust among different disabled groups is higher than between mainstream society and the unified "disability group". In my opinion, there is nothing like a unified disability culture in Lebanon, but there are many disability subcultures in this sectarian society with wide income disparity. I myself am a pioneer and founder of a self-help group of parents of intellectually disabled children, but I have so many times faced tension in coalition with so-called cross-disability self-help groups (which are often dominated by a group of physically disabled Western-educated elite men), as they do not see us, the parents' group as a self-help group. But, our children need parents' advocacy and support (they may not be able to articulate their own voice and who will represent their own voice?). Our children are facing a completely different kind and level of discrimination by our society (the able-bodied), and our children have different needs. Yes, an alternative form of education should be made available for our children, as long as it is the choice of the child and/or his/her parents, as inclusive education in our country is not well equipped with support system. Able-bodied students can choose their school, commuting or residential, co-education of single-sex education, why our children must be denied the same choice?" (a medical doctor and father of 2 children with intellectual disability in Beirut).

Case study 3. Gender dimension of disability: the Impact of armed conflicts on Arab women

"Several countries in the Arab region including Lebanon are war-torn or under civil unrest.From perspective of us, Arab people, Lebanon is regarded as a country which has been occupied by a foreign power for a long time, and devastated by a foreign invasion. Negative perceptions towards physical disability were changed during the civil war and subsequent conflicts in Lebanon, with the fighting of various sectarian groups within this country and the continuing national resistance against the foreign control for our own national cause. The issue of disability became an important political agenda all of sudden. The conflicts increased the number of people with permanent physical disabilities. The disability was a mere stigma traditionally and it now became heroic, at least as a symbol of active resistance. Disability is now perceived as martyrdom where young men or teen-agers sacrificed their lives to live in wheel chairs, or poor young children stepped on landmines to live with prosthetics. However, unfortunately, this new focus diverted attention away from Lebanese women with disabilities, who have been most discriminated against traditionally, and who suffered equally from the civil unrest. It also worked against women and men with congenital and non-physical disabilities, such as women with intellectual disabilities. We disabled women are sacrificed in favor of a small number of disabled war veterans" (a physically disabled activist woman in Beirut).

RESULTS OF THE QUESTIONNAIRE SURVEY ON COLLECTIVE OPINIONS OF DISABLED PEOPLE

Of the total of 74 valid data from Jordan, 59.5 per cent were physically disabled persons, 23.0 per cent blind persons, 5.4 per cent deaf persons, 6.8 per cent persons with intellectual disability, 2.7per cent persons with mental illness, and 2.7 per cent multiply disabled persons. Of the total of 113 valid data from Jordan, 18.6 per cent were physically disabled persons, 19.5 per cent blind persons, 15.9 per cent deaf persons, 11.5 per cent persons with intellectual disability, 17.7 per cent persons with mental illness, and 16.8 per cent multiply disabled persons. These two sets of samples are different (p < .01). However, the educational backgrounds of the two sets of samples are very similar (with 44.6 per cent of Lebanese participants being primary school educated or below and 36.3 per cent of Jordanian participants being primary school educated or below). The mean age for Lebanon was 35.41 and that of Jordan was 31.61. In Lebanon, 49 per cent of respondents were Moslem, and 51 per cent were Christians, but in Jordan, the Christian population represents only 22 per cent and the rest was Moslem.

Concerning the question regarding the additional disabled family member, 23.0 per cent of the Lebanese respondents and 34.5 per cent of the Jordanian respondents answered that they had one additional disabled member in the family. Also, 4.1 per cent of Lebanese and 15.0 per cent Jordanians responded that they had two or more additional disabled family members (p < .01), implying the strong possibility of congenital disability which may be related to the consanguinity practice. Regarding the question of, "do you support the social welfare and charity- based approach to disability, or the rights-based approach to disability, or the combination of both approaches", there was a statistically significant difference between two countries (p < 0.1).

In Lebanon, only 4.1 per cent of the respondents supported the social welfare/charity approach, 66.2 per cent supported the rights-based approach, and the remaining 29.7 per cent supported the combination of both approaches. On the other hand, in Jordan, 26.5 per cent supported the social welfare/charity approach, 59.3 per cent supported the rights-based approach, and the 14.2 per cent supported the combination. One may attribute this difference to the level of maturity of democracy in Lebanon and the overall rights-based and individualistic style of the Lebanese people in general. Concerning the question of the disability model (social model vs. medical model) and the domestic disability policy in each country, 95 per cent of Lebanese supported the combined socio-medical model, and only a minority supported either the pure medical model or pure social model. However, 27 per cent of the respondents criticised the current Lebanese disability policy, as based on the outdated medical model.

In contrast, in Jordan, 20.4 per cent of the respondents supported the medical model, and 25.7 per cent supported the social model and the majority, 50.4 per cent supported the combined, socio-medical model. This result corresponds to the previous empirical study, in which, the majority of Jordanian disabled people choose the socio-medical model (2). Furthermore, Jordanians fairly evaluated their domestic disability law, as being based on the socio-medical model of disability, the model of their own choice.

Thus, concerning their preference about the disability model as the basis for national policy, there was a statistically significant difference between the two countries (p < 0.01). Though Jordanians tend to be more conservative, both Jordanian and Lebanese disabled people supported the rights-based approach to disability over the social welfare approach, and disapproved the medical model of disability, as a basis for national policy.

As anticipated, concerning the knowledge about the domestic disability law, there was a significant correlation between the respondents' knowledge and their educational attainment, both in Lebanon and Jordan.

THE RESULT OF PARTICIPATORY FOCUS GROUP SESSIONS IN JORDAN AND LEBANON

The following is a brief summary of the results of a one gender-balanced focus group composed of 6 disabled persons and 3 professionals, held in Amman, Jordan in January 2005, and another focus group composed of 9 disabled persons (5 disabled women and 4 disabled men) and 3 parents (2 mothers and 1 father), held in Beirut, Lebanon in January 2005, in addition to the data collected from the latest focus group held in Beirut, in August 2007, composed of 29 PRA participants with individual disability experience (4 blind, 7 deaf, 7 physical disability, 8 parents, 2 intellectual disability, 1 survivor of mental illness).

• The participants showed a preference for "rights approach," over "charity-based social welfare approach" to disability (in both countries, more so in Lebanon).
• Overall preference was for the "social model" or "socio-medical model" of disability over the "medial model of disability" (in both countries, more so for men).
• There was recognition of the diversity among different disabilities (with particular discrimination against people with intellectual disability and/or psycho-social disability, as well as disabled Arab women) in degree and nature.
• More differences than similarities were found among the disabled population in Lebanon
• Lack of trust was found among disabled groups, which is as high as that between mainstream society and the "disability group," in Lebanon.
• There is no single disability culture in Lebanon and there are many disability sub-cultures (depending on disability type, social class, difference in religions, gender, disabled veterans, wealth or poverty, etc).
• The participants acknowledged the preference and priority given to the war victims (often males) as a political agenda, over the rest, particularly those with congenital disability and disabled women (more so in Jordan and Palestine) and some even feel that the majority of disabled persons are sacrificed in favor of the small size of veterans.
• Severe discrimination and prejudice are faced by children with intellectual disabilities and psycho-social disabilities, as voiceless and vulnerable people (they are not well represented in the national forum of cross-disability groups).
• There is lack of recognition of psycho-social disability and the survivours as "disability, disabled" by both non-disabled and other disabled people.
• There is tension in the process of coalition with grass-roots self-help groups and a national forum of multi-disability group, often represented by the urban elites, English-educated men in wheel-chairs (in Lebanon).
• The self-help group of parents of intellectually challenged children have a unique identity (in both countries).
• The importance of self-help groups for striking the balance between their advocacy work and development programme (e.g. micro-credit, income generation, etc.) for their own survival, is stressed in Lebanon.
• There is recognition of the overall effectiveness and relevance of CBR programmes, over other modalities (e.g. institutional model or independent living model), as the most effective tool, to achieve the independence and happiness within the family and the community, as well as to alleviate the negative public attitudes (in both countries, more so in Jordan).
• There is a recognition of the need for comprehensive rehabilitation (particularly the provision of timely and appropriate medical rehabilitation immediately after minor physical operations and interventions, which is critical) as well as adequate medical services.
• There is urgent need for sports rehabilitation to be made easily accessible to women and men at low cost, as early intervention of preventable disabilities (more so in Jordan). Often, disabled Arab women's access to sports, exercise and sports rehabilitation is limited.
• There is natural acceptance of the importance of prevention of the negative causes of disability (including poverty, armed conflicts, lack of micro-nutrients, very high traffic accident rate, too many children and lack of spacing, as well as a cultural factor - consanguinity - which is still common in the Arab region), as a part of the overall development strategy.
• There is need for reviewing the existing comprehensive law on disability in Lebanon and Jordan, in line with the newly adopted international convention on the right of persons with disabilities and its optional protocol.
• There is need for initiating a public debate about the possibility of formulating a Lebanese anti-discrimination law and setting up its national monitoring mechanism ("reactive measure" to enforce non-discrimination).
• There is urgent need to strengthen the public awareness campaigns to improve the prevailing negative public attitudes towards disabled persons ("proactive measure" to remove the attitudinal barrier), using mass media campaigns and inclusion of disability concerns into the school and summer camp curriculum.
• There is need for drastic measures to eliminate the negative cultural elements and traditions to ensure non-discrimination (preference of non-discrimination over perpetuation of the culture).
• Inclusive education (as the idealistic form of education), was accepted as a matter of principle at all levels including tertiary education.
• The concurrent need for alternative forms of education, for some categories of disabled persons (e.g. deaf people, severely and multiply disabled people, people with intellectual disability), by their (or parents') own choice, was recognised.
• There is need for transitional and support measures between alternative education and mainstream education.
• There is recognition of the need for maintaining the "positive measures" such as employment quota scheme (3 per cent in Lebanon, 2 per cent in Jordan), or tax concessions as transitional provisions, until the concept of "reasonable accommodation" is established in both countries.
• There is a high recognition of the validity and relevance of the twin-track approach of disability mainstreaming into development, and empowerment of persons with disabilities through targeted projects.
• The need to adopt universal design (or barrier-free design) in the process of reconstruction and rehabilitation of the war torn Lebanon, was fully recognised as a challenge and opportunity for creating accessible infrastructure. As the devastated areas are in the Hizbollah controlled area, a strong public-private partnership was recommended.

DISCUSSION AND RECOMMENDATIONS

The findings of the study echoed previous research, in that they demonstrate that attitudes should be treated as a multidimensional construct, consisting of the interlocking facets of cognitive, cultural, behavioural and economic factors. The findings also found diversity existing among disabilities and different types of disabled people.

The findings of the present (both from the questionnaire survey and the focus group sessions) may inform policy makers, educators, social workers, and mass-media experts about careful re-thinking of the core messages to be delivered in public awareness programmes and disability- related services. In particular, it is important that due attention be paid to the needs of those with intellectual and psycho-social impairments (mentally ill) and disabled women in Lebanon and Jordan, to rectify the deep-rooted misconceptions about genetic inferiority. To alleviate discrimination, both pro-active measures (e.g. public awareness) and a reactive measure (e.g. law enforcement) may be required.

This study also validated the proposed rights-based model of disability, in which both civil- political and socio-economic rights are to be promoted, in the region. The importance of disabled persons' inclusion, participation and access to services, including education, training, rehabilitation, CBR, medical services, etc. was recognised. Also, the need for prevention of negative causes of impairment, particularly poverty, armed conflict and consanguinity, was singled out. Indeed, prevention may be considered to be a critical element of disability inclusive development cooperation policy.

The limitation of the empirical part of this research includes a small sample size in these two countries of the region, potential sample bias towards voluntary participants, lack of randomness, and a question regarding the accuracy of the Arabic translation of the two instruments. The participatory focus groups were conducted partially with an interpreter (Arabic and English), so a cultural and linguistic shortcoming is another limitation. Following the findings of this small-scale pilot study, a nation-wide public-funded survey with a bigger, less biased and more representative sample should be conducted in Jordan and Lebanon, and elsewhere in the Arab region. However, adoption of the twin-track approach, of disability mainstreaming and empowerment of persons with disabilities is urgently needed.

^*Senior Economic Affairs Officer
Development Cooperation Policy Branch
Office of ECOSOC Support and Coordination
United Nations Department of_Economic and Social Affairs
United Nations HQ, New York, NY 10017, USA
e-mail:nagata@un.org

ACKNOWLEDGEMENT

This article is based on a doctoral dissertation of the author. The author is currently a senior economic affairs officer in charge of generic development cooperation policy of the United Nations. Prior to her current position at the UN HQ, the author served as a focal point for disability matters, from 1988 to 2002, at United Nations Economic and Social Commission for Western Asia (ESCWA) in Beirut, Amman and Baghdad, and from 2003 to 2006, at United Nations Economic and Social Commission for Asia and the Pacific (ESCAP), in Bangkok. However, the views expressed in this article are those of the author and do not necessarily reflect the views of the United Nations or its regional commissions.

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