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Conceptions of disability among health professionals in training and in practice: a qualitative study

Abstract
Health professionals wield significant influence over public knowledge and responses to disability, based on their own conceptions. This study aimed to examine the conceptions of disability among thirty professionals in training or practice, representing fourteen distinct health professions, through individual interviews. A committee of experts developed thirty-four representative statements encompassing religious-moral, medical, social, and affirmative perspectives on disability. The participants provided justifications for their positions on each statement, unveiling a coexistence of understandings that encompassed both medical and social perspectives on disability. A recurring argument emphasized bodily impairments as the origin of social inequalities, advocating for health practices that aim to normalize individuals. Simultaneously, the need for societal transformation to dismantle barriers, foster inclusion, and ensure rights was also acknowledged. Some justifications critically addressed ideologies that individualize disability and social processes that contribute to inequality. Moral and/or religious interpretations were frequently used by the participants. However, the study highlighted the limited comprehension of disability as a complex and multidimensional phenomenon, indicating a pressing need for enhanced attention to professional training in this area.
Key words: Disabled Persons, Disability Studies, Social Discrimination; Health Personnel

INTRODUCTION
The conceptions of disability held by health professionals, who play a crucial role in enabling access to various services and benefits for people with disabilities, can have a significant social impact. These professionals wield considerable power to influence language, knowledge, and public and institutional responses to disability1. According to the Brazilian Inclusion Law2, a person with a disability is defined as " those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others." To what extent do the conceptions of professionals in training and in practice diverge or align with this definition? This original study aimed to identify the conceptions of disability articulated by students and professionals in the health field, relating them to the main explanatory perspectives of disability identified in the literature of Disability Studies1, 3-21.
The oldest perspective on understanding disability is the religious or moral perspective, which remains extremely prevalent worldwide 3-5. Its influences, though subtle, are still pervasive5. This perspective views disability as a trial with ambiguous interpretations: a special teaching experience and a noble life mission, as well as a punishment for morally reprehensible conduct. People with disabilities are sometimes seen as exceptional and elevated, and at other times as unfortunate objects of pity (which implies both compassion and contempt). Grace and redemption can promote the restoration of normality3,4. The moral perspective has historically invoked a duty of charity, being responsible for the creation of protective (segregated) institutions while also strengthening discourses of invalidity and incapacity5.
From the 16th century onwards, with the development of medicine, various forms of disability began to be explained by physical-biological abnormalities5. The medical perspective posits that all negative experiences of disability result from a negative bodily characteristic—some injury, absence, failure, or dysfunction—that hinders adequate performance in important daily tasks, leading to social disadvantages22. Disability is viewed as an inherent deficit or loss, a matter of luck or personal tragedy3,4,6. The solution lies in curative and rehabilitative medical treatments aimed at normalising and preparing individuals to meet social demands6-8,23.
In the second half of the 20th century, people with disabilities began to articulate politically and raised serious questions about the medical conception, giving rise to the social model of disability. This perspective explains disability not by individual causes, but by social ones: it is the collective arrangements hostile to diversity that produce situations of disability. The social model sees disability as a system of oppression that affects people with certain bodily differences. Thus, disability is not something that the individual has, but something imposed upon them by unjust and exclusionary social structures. The solution lies in the struggle for social reform and the guarantee of rights.
The social model opened perspectives that allowed for the appreciation of bodily and functional differences among people with disabilities. From an affirmative perspective, these differences, rather than being seen as aberrations or tragedies, are integral parts of human diversity, unique ways of being in the world, and can be sources of pride, dignity, and personal richness9,24,25. Some individuals reject cure as a solution; instead, they want changes in the people, values, and resources around them, including the attitudes of health professionals, so that differences are celebrated26.
These four explanatory strands are not necessarily antagonistic or irreconcilable. In reality, elements of the moral/religious, medical, social, and affirmative perspectives often mix, giving rise to individual conceptions that may be consolidated, uncertain, ambiguous, or conflicting, reflecting the complex nature of the phenomenon of disability27, 28. Thus, understanding individual conceptions requires considering the historical and political context and how these elements interact, putting different explanatory strands into perspective and destabilizing the meaning of disability27, 28.
When prompted to take a stance and justify their position on a complex issue, individuals are encouraged to cognitively process their personal experiences and cultural contexts to communicate their interpretations and seek mutual understanding29,30. Thus, when asked about beliefs and definitions (often previously unarticulated) about disability, students and healthcare professionals may express certainties as well as attempts at redefinition, typical of concept processing. They may question previously unquestioned views or confront uncertainties and ambiguities.
To capture these different nuances, we explored a set of statements representative of various conceptions of disability, inviting students and healthcare professionals to justify their agreement or disagreement with each to reflect on different perceptions. Given the impact of these conceptions on the practice of healthcare professionals, we used a combination of qualitative methods to investigate the conceptions of disability among professionals in training and in practice. The contents identified in the interviews were discussed considering the national and international guidelines that currently guide healthcare for people with disabilities.
METHODS
Study Design
A qualitative study was conducted aiming to interview students and professionals from 14 healthcare professions, using mixed individual interviews (structured and semi-structured). The targeted professions were medicine, dentistry, psychology, nursing, physical education, speech therapy, nutrition, veterinary medicine, pharmacy, occupational therapy, healthcare management, biomedicine, radiology technology, and physiotherapy. The study utilized the theoretical framework of communicative action29,30 and employed content analysis according to Bardin31 to systematize the data. Content analysis is a set of research techniques aimed at coding the main textual signifiers that, when grouped, reveal meanings and patterns related to values and ideas about disability. Data collection took place from August to December 2020. All procedures of this study were approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (CAAE: 09674819.9.0000.5149). The reporting of this work adheres to all criteria of the Standards for Reporting Qualitative Research32.
Participants
Students and healthcare professionals residing in Minas Gerais, Brazil, were selected. Intentional sampling aimed to achieve maximum variation across healthcare fields, among students and professionals, with a snowball sampling approach: initial participants were contacted through referrals from acquaintances via WhatsApp, and subsequent participants were referred by the initial interviewees. All participants signed an Informed Consent Form, agreeing to participate. Additionally, they consented to the recording and transcription of the interviews while maintaining anonymity.
Thirty volunteers comprising 18 students (6 males and 12 females, one of whom was a person with a disability) with a mean age of 21.5 (±2.64 years), and 12 healthcare professionals (6 males and 6 females) with a mean age of 27.25 (±4.34) years were selected. Among the 30 participants, 18 identified as white (60%), 10 as mixed race (33.33%), and 2 as black (6.66%), and 11 reported living with people with disabilities (36.6%). For all professions, at least 1 student and 1 professional were included, except for radiology (only 1 student) and physiotherapy (only 2 students). Most participants did not know the authors of the study. The authors had no supervisory, teaching, or authoritative relationship with the participants.
Procedures
Following the approach of Mackenzie et al.33, in a first stage, a panel of disability rights activists and specialists was formed through invitations from the researchers. The panel consisted of 8 people with disabilities and 4 without disabilities, including 9 academics from various fields of knowledge (sociology, social communication, law, education, literature, sign language) and 3 activists. These individuals evaluated statements found in international literature1,3-6,8-21, with the aim of adapting them to create a bank of statements representing different perspectives on disability in the Brazilian context18. This process resulted in the definition of 34 statements (described in Tables 1 to 4) that express elements of the moral/religious, medical, social, and affirmative perspectives.
In the individual interviews, participants were asked to define their position on each statement on a linear scale ranging from 1 (completely disagree) to 5 (completely agree). The presentation order of the statements was determined by random draw and kept consistent for all participants. Following each rating, participants were asked to justify their position. Transcribed responses from all participants were organized in a spreadsheet to allow comparisons between the responses of all interviewees, based on their level of agreement.
Analysis
To define the analysis corpus, exploratory readings were initially conducted to identify, for all 34 statements, the degree of agreement and disagreement, as well as the explicit justifications provided for each position. Pronouncements that did not consist of a description of reasons for the participant\'s position regarding the presented statement were disregarded (e.g., those that merely repeated the statement). Subsequently, recurring arguments were identified, and exemplary arguments used to justify participants\' opinions were selected. This analysis was conducted by LADA (Ph.D. in sociology) and HAS (physiotherapy student). The justifications provided by the participants were interpreted considering the literature on Disability Studies. The analysis was further carried out by LADA, HAS, RLG (Ph.D. in Social Communication), and DVV (Ph.D. in experimental psychology) reflectively, through discussions and questioning of established assumptions. Based on this analysis, descriptions of the results obtained were made, including percentages by degree of agreement and exemplary justifications for each statement, using expressions used by the participants indicated in double quotation marks. Finally, the data obtained were examined and discussed in light of the literature and the knowledge and experience of the authors.
RESULTS
The percentages by degree of agreement and exemplary justifications for agreeing or disagreeing with each statement are presented in Tables 1 to 4. Overall, the positions of the interviewees on statements representing the moral/religious perspective (Table 1) were well distributed, with a slight predominance of agreement. None of the statements elicited more than 40% disagreement. Two statements obtained 50% or more agreement: one attributing a special or exemplary mission in life to people with disabilities, and another stating that “God writes straight with crooked lines”. Through their justifications, participants interpreted disability as a condition generating "insufficiency," chosen in just measure for those who have it; necessary for the learning of the person with a disability and others in their surroundings and needing to be overcome by the individual with the help of charity. The existence of people with disabilities was also interpreted as a means for people to recognize the privilege they possess and to be more grateful for their health and their "perfection." Counterpoints included stating that there is nothing exemplary in a person with a disability performing basic daily activities, or that disability can be attributed to chance rather than to a higher divine purpose. There were also criticisms with a political bias: the view of people with disabilities as "angels" with a special mission, targets of "divine punishment," objects of pity, or instruments for others to become better was considered reductive, demeaning, and "ableist." Instead of charity initiatives, participants pointed out the need for state accountability and social reform.
Regarding statements from the medical perspective (Table 2), most were endorsed by the interviewees. Six out of nine statements obtained agreement rates ranging from 56% to 80%. In exemplary justifications, disability was interpreted as an evidently unwanted phenomenon for all; resulting from problems that affect the body; requiring medical definition for legitimacy; and differentiating people with disabilities from others by their "limitations" and "difficulties." The differentiation between "extreme", "totally incapacitating" cases and other "milder" cases was pointed out as a factor that could compromise quality of life. The possibility of curing and preventing disabilities through science was well-received by the majority, seen as a means to make people more equal, thus advancing in solving the "world\'s problem." Only three statements did not obtain more than 50% agreement. Forty-six percent of participants stated that disabilities need to be treated, either as a form of "palliative care", or to be "minimized" or "reversed." A minority of participants agreed with the need for rehabilitation for adjustment to social demands or the need to seek normalcy, arguing that "unfortunately" this is the condition for acceptance in a "standardized society," and stating that anyone who fights against disability has the "healthy person" as an ideal.
Among the reasons for disagreeing with the medical statements, used by a minority of participants, were arguments that disability is undesirable but not tragic if resources are available; that the difference between people with disabilities and others lies in how they are treated and the opportunities accessible to them; that treatments should only be pursued if desired; and that disability is not a disease, therefore it does not require a cure or effort for correction, but rather acceptance of differences and inclusion. For some participants, it is society that "needs rehabilitation," and scientific advancement should promote access rather than the elimination of disabilities.
The statements from the social model (Table 3) also received significant endorsement from the participants. Agreement was greater than disagreement or neutrality in 10 out of 12 statements. The need for social change to ensure inclusion and guarantee rights for people with disabilities was endorsed by 96% and rejected by 0% of the interviewees, and 86% agreed that quality of life is more affected by social obstacles than by physical impairments. In general, participants argued that environmental barriers can worsen disability situations; that the difficulties faced in non-inclusive environments are unjust and constitute a violation of rights; that exclusion can be more disabling than physical impairments; and that the person with a disability is the one who should assess whether their condition is good or bad. Among the reasons for disagreeing with the social perspective, participants pointed out that some types of impairments (mental, for instance) can be inherently negative and limiting, causing significant suffering; that correction or cure may be desired and promote better quality of life; that some severe disabilities cannot be alleviated by social guarantees; and that people with disabilities have already achieved formal equality of rights. Two statements were rejected by more than half of the participants, who argued that disability is pre-existing to and independent of social choices and arrangements, with social exclusion being a consequence, not a cause, of disability. Agreement ratings well distributed for defining disability as a restriction on participation or describing it as something that varies among different cultures.

Four out of the 8 sentences from the affirmative perspective (Table 4) obtained more than 50% agreement. In general, through their justifications, the interviewees pointed out that we are all susceptible to becoming disabled individuals or to living with someone who has a disability; that we all have weaknesses or difficulties like people with disabilities; that being a person with a disability can be a source of pride to the extent that one overcomes the difficulties it imposes; and that the existence of disability is valuable to the world as a source of inspiration and motivation. As counterpoints, the interviewees argued that pride and happiness do not lie in disability, but in its cure or treatment; that disability is not a natural part of everyone\'s life because it is socially concealed; and that it would be ideal for all of us to have no disabilities and thus be equal. For the remaining sentences, the positions were evenly distributed. The arguments pointed to the fact that everyone, whether disabled or not, needs help from others and that it is necessary to demarcate who is a \'person with a disability,\' understood as a medical and political category, in order to ensure specific rights which could be compromised without this demarcation.
DISCUSSION
This study investigated the conceptions of disability among 30 interviewees, based on the definition of the Brazilian Inclusion Law, which was elaborated from the United Nations Convention on the Rights of Persons with Disabilities34. States that ratified the Convention committed to conduct training activities to raise awareness among healthcare professionals about human rights, dignity, autonomy, and the needs of persons with disabilities34. Both the Convention and the LBI promote the idea that disability is not merely about bodily impairments but rather the negative result of the interaction between a body with impairments and environments that are insensitive to the diversity of individuals9. Disability is a matter of unequal social participation resulting from the barriers imposed on individuals with certain bodily impairments35. Thus, the social disadvantages often experienced by people with disabilities are not natural or inherent to the characteristics of the body but rather the result of values, attitudes, and practices that discriminate against bodies with impairments9.
As anticipated, our analysis of the interviewees\' justifications revealed the coexistence of understandings involving different perspectives of disability. For example, while the definition of disability as unequal participation restriction was relatively accepted, the idea that bodily impairments are the origin of inequalities among individuals was also frequent, with its cure being seen as a way to address the "world\'s problem". Overall, the interviewees showed great adherence to both biomedical and social elements of disability. In a minority of justifications, criticisms of individualizing ideologies and processes of exclusion emerged. It was also clear that disability was assimilated as a moral and/or religious determination in many of the justifications. This suggests that a socio-historical context where legislation includes social components of disability and where people with disabilities themselves have more opportunities to express their capabilities may have challenged more traditional perspectives, such as the medical and moral/religious ones27.
However, the medical perspective still seems to have hegemony among healthcare professionals4,10-13,36-38, despite efforts by the World Health Organization, for more thatn 20 years, to disseminate and universally implement the International Classification of Functioning, Disability, and Health (ICF) 40. The ICF challenges the medical model by incorporating an interactionist understanding of the socio-political and biomedical mediators of disability7,39,40. In Brazil, a resolution by the National Health Council41 determines that the ICF be used in the Unified Health System and as a pedagogical tool in the development of educational programs. However, while there is ample literature on the use of the ICF in the training of physiotherapists and occupational therapists42-45, this is rare for other health professions. Therefore, conceptions that bodily impairments naturally lead to social inequalities remain common. Impairments are conflated with inequalities, making them "logically" undesirable39. In the view of most interviewees, healthcare practices should prevent, repair, or reverse signs of abnormality in order to ensure that all individuals meet a standard of functioning typical of the species23,46, compatible with moral precepts of productivity and conformity to social norms9, in an "unfortunately" "standardized" society. The closer to the simulacrum of normality, the greater the success of medicalization of impairments9. It seems evident, therefore, as one exemplary justification suggests, that "every person who struggles against disability is trying to become as close as possible to a healthy person who does not have a disability."
Nevertheless, statements from the social perspective were widely accepted. This perspective became popular in the country with cultural changes over several decades driven by the activism of people with disabilities14. The increasing presence of these individuals in schools, universities, and the job market due to quota systems and other inclusion policies; the participation of people with disabilities in political instances, such as councils and political conferences48; and the increasing impact of their struggles through various internet platforms, all are elements that must be considered in this shift in political culture regarding disability. A study of Brazilian mass print media from 1960 to 2008 revealed extensive transformations15 as a result of these struggles. Until 1980, disability was predominantly framed as an individual problem to be addressed with charity and medical treatments. However, from 1980 onwards, human rights, accessibility, social participation, and quality of life framings of disability gained influence, transferring the responsibility for addressing disability-related issues to society as a whole15.

Thus, the acceptance of social perspectives among the participants can be interpreted as a sign of the progressive social recognition of people with disabilities through collective learning15. That is, there seems to have been a generalization of accumulated values and knowledge that provided the interviewees with understandings that were internalized to varying degrees as common sense49. However, based on the different justifications provided, the acceptance of social precepts seems to have been superficial, without integration into a multidimensional synthesis that considers the conception of disability expressed in the Convention, Brazilian Law and the ICF39. For example, disability was still interpreted as a natural fact, prior to social arrangements47. Repeatedly, interviewees stated that inequality (such as social participation restrictions) does not cause or constitute disability but merely results from it. Moreover, the frequently expressed ideal of standardizing individuals through health interventions23,46 implies reducing social inequality to individual differences.
Moralizing views of disability were common and can be understood from two perspectives. Firstly, there is a reinforcement of the morality of efficiency50 when disability is related to "insufficiency," "difficulty," "inability," or "fragility" that "no one wants" or "is happy to see." The sphere of work and performance is one of the great definers of the moral hierarchy that has emerged in modernity, responsible for defining what and who is valuable51. Thus, disability would be associated with something negative that does not contribute to the social expectations of the productivity world. Secondly, there is a morality inherited from religiosity that relates disability to something just and necessary for the realization of a life example and learning mission: for those who experience it, of "overcoming"; for others, of "inspiration," of gratitude for being "perfect," and of an opportunity to "help." The attribution of disability to a greater reason also relies on the idea that there is value in disability as it can contribute to society by providing inspiration and gratitude.
Historically, the contestation of the moral and/or religious narrative by the biomedical narrative was seen as an important step towards ensuring equality52,53. Later, social criticism shifted the disability issue from the individual to the societal level, from misfortune to justice, from nature to politics16. A few participants criticized the moralizing view as prejudiced and pointed out the need to reform society and hold the state accountable. Meanwhile, affirmative statements were sometimes challenged, sometimes accepted as a means to reaffirm moral/religious perspectives. For example, the idea that disability could be a source of happiness, pride, and personal fulfillment was both denied and endorsed with the same justification that these feelings would emerge from overcoming the disability. Self-realization would only be possible if disability was considered potentially useful to society but would not arise from disability itself. The existence of bodily or mental differences among people with disabilities was positively valued as something that would have "motivational" value and also negatively valued as a problem that "no one likes to have" and that makes us unequal. The equation between differences and inequalities was quite common, revealing a reductionist and naturalizing understanding of complex and unjust socio-political dynamics.
The conceptions expressed by healthcare professionals reveal the need for criticism and attention to education, given that they can either facilitate or hinder healthcare for individuals with disabilities10,12,13,17,19. Care practices fall far short of guidelines committed to inclusion, attitudinal and cultural changes regarding this population. A World Health Organization study found that people with disabilities were twice as likely to find healthcare professionals\' skills and equipment inadequate for meeting their needs, three times more likely to have care denied, and four times more likely to be mistreated by service providers17,54. We speculate, in agreement with Andrada18, that ideological barriers are at the root of this problem. Part of the difficulty in implementing truly inclusive care actions lies in the resistance of conceptions of disability as a "personal tragedy," common in the healthcare field17. The diffusion of an understanding of disability as a complex, multidimensional phenomenon (biological, psychological, and social) remains limited in Brazilian academic production18, in the education of health professionals nationally and internationally12,13, as well as in the discourse of the interviewees.

CONCLUSIONS
This study is inherently limited in terms of the depth of investigation into the interviewees\' conceptions, given the format of the interview, which was unique and brief, based on the formulation of justifications for the degree of agreement with predefined statements. Other interview formats could have provided greater insight into the intersection between perspectives developed in the interaction of the individual with their culture, life history, and university education. However, the results confirm previous findings regarding the conceptions of healthcare professionals4,10-13,55. We believe that a complex approach to disability in professional training – as suggested by the Disability Studies literature – has the potential to highlight shortcomings in the protection and promotion of the rights of people with disabilities in healthcare and generate concrete changes. For comprehensive and integrated learning, scholars in the field suggest that forming authentic partnerships with people with disabilities – both as healthcare students or as experts from whom professionals can learn – may be the most transformative type of training17,19. Encouraging students to critically reflect on their experiences, including their emotional reactions to disability, is also fundamental to learning17,20,55. With access to critical education that goes beyond biomedical knowledge, including psychosocial, political, and justice issues, professionals could assume a key role as allies in the fight against social structures that oppress people with disabilities21.

ACKNOWLEDGMENTS
To the National Council for Scientific and Technological Development (CNPq) for the scholarship granted for the realization of this research.

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