Disability in Older Adults comprises public domain material fr

Disability in Older Adults comprises public domain material
from the National Institutes of Health.
http://report.nih.gov/nihfactsheets/Pdfs/DisabilityinOlderAdults
(NIA).pdf
Disability in Older Adults
FACT SHEET - Disability in Older Adults
National Institutes of Health
Updated October 2010
1
Yesterday
approximately 26.1 million people were 65 years of age or
older, compared with 3 million in 1900. And Americans
were living notably longer than they had in the past –

average life expectancy for a child born in 1980 was 73.7
years, up from 47.3 years in 1900. Disability was on the
rise among older people. Studies from the 1970s and early
1980s pointed to modest increases in the prevalence of
disability. For example, in 1976, 4.8 million older people
reported limitations in the number or kinds of major
activities they could undertake.
ly brought with it
frailty and loss of independence. One study, for example,
predicted that technology would save people’s lives, but
still leave them disabled and an increasing burden on
society. However, groundbreaking research from projects
such as the Baltimore Longitudinal Study of Aging
(http://www.grc.nia.nih.gov/branches/blsa/blsanew.htm),
initiated in 1958, began to suggest that disease and
disability were not inevitable consequences of aging.
rease in life
expectancy, and concerns about disability led to the
founding in 1974 of the National Institute on Aging (NIA)
within the National Institutes of Health (NIH). The Institute
was charged with “the conduct and support of biomedical,
social, and behavioral research, training, health
information dissemination, and other programs with
respect to the aging process and diseases and other
special problems and needs of the aged.”
Today
n is
increasingly older. The leading edge of the Baby Boom
turns 65 in 2011, part of a rapid growth in population
aging in the United States – and worldwide. 39 million
people in the United States are age 65 or older, and life

expectancy at birth has reached 78.3 years. Most notable
is the growth in the population of individuals age 85 and
older who are at highest risk for disease and disability.
an inevitable part of aging. Disability rates can be reduced,
as evidenced by data from the National Long Term Care
Survey (http://www.nltcs.aas.duke.edu/), which found
that between 1982 and 1999, the prevalence of physical
disability in older Americans decreased from 26 percent to
20 percent. Additionally, there is evidence from the Health
and Retirement Study (http://hrsonline.isr.umich.edu/)
that the probability of being cognitively impaired at a
given age has been decreasing (from the mid-1990s up
until at least 2004), although the rapidly increasing
population of older adults means that the absolute
number of cognitive impaired individuals is still increasing.
of disability has continued since 1999, and researchers are
analyzing multiple data sources to ascertain the trend.
There is some evidence suggesting that while the decline
in disability may have continued among the oldest old
(those age 85+), the decline in disability ended or was
reversed in the new cohorts recently entering old age.
disability rates include improved medical treatment
(particularly treatments such as beta blockers and ACE
inhibitors for cardiovascular disease), positive behavioral
changes, more widespread use of assistive technologies,
rising education levels, and improvements in
socioeconomic status. The NIH supports research to
understand the underlying causes of this decline in order
to develop behavioral and multi-level interventions to
maintain and accelerate this trend.

healthier aging and longer life expectancy. Epidemiologic
studies suggest that lifespan and health are determined by
both genetic and environmental influences, with genetics
accounting for about 35 percent of lifespan and modifiable
environmental factors contributing most to this complex
interaction.
people function. Researchers at the NIH-supported Claude
D. Pepper Older Americans Independence Centers
(https://www.peppercenter.org/public/home.cfm), for
example, have developed effective ways to prevent falls,
FACT SHEET - Disability in Older Adults
National Institutes of Health
Updated October 2010
2
improve muscle function (size, strength and power), and
reduce delirium related to hospital stays. One NIH study
dramatically demonstrated that even 90-year-olds can
improve muscle strength and mobility with simple weight
training exercises.
threatened by recent increases in obesity levels. According
to the National Health Interview Survey
(http://www.cdc.gov/nchs/nhis.htm), the disability rate

among people ages 18 to 59 rose significantly from the
1980s through the 1990s, with the growing prevalence of
obesity factoring into the trend. Obesity and overweight
put people at increased risk for potentially disabling
chronic diseases such as heart disease, type 2 diabetes,
high blood pressure, stroke, osteoarthritis, respiratory
problems, and some forms of cancer.
Tomorrow
for specific types of disability. NIH investigators have
identified several markers, including grip strength, gait
(walking) speed, circulating levels of the protein IL-6, and
measures of lung function, that can be used to predict the
onset of limitations in mobility. Researchers are currently
conducting a genome-wide association study to identify
genes and genomic regions associated with trajectories of
change in each of these markers.
(http://web.jhu.edu/popaging/nhats.html), a new
nationwide NIH-funded study of 12,000 people age 65 and
older, will provide data to disentangle the physical, social,
technological and environmental factors in disability
prevalence, onset, and recovery. The study will also help
us understand the social and economic consequences of
late-life disability for individuals, families and society.
(http://hrsonline.isr.umich.edu/), a nationwide NIH-
funded survey of more than 22,000 people age 50 and
older, is allowing researchers to examine the interactions
among physical and mental health, insurance coverage,
financial well-being, family support, work status,

retirement planning and the impact of these variables on
disability. Improved ability to forecast disability trends will
help give policymakers more accurate projections of
national expenditures for the Social Security and Medicare
programs. Researchers will also assess disability risks in
understudied populations within the United States,
minorities, and the medically underserved.
arch may bring new treatments to prevent or
minimize disability from stroke, diabetes, and other acute
and chronic health problems. For example, NIH-supported
researchers are developing interventions to improve
quadriceps muscle function after total knee replacement
and muscle conditioning (muscle size, strength and power)
in community dwelling individuals at high risk for falls and
mobility disability. Other studies are evaluating the ability
of an exercise and health promotion intervention to
facilitate maintenance of physical and cognitive function in
older adults with mild cognitive impairment (often a
precursor condition to Alzheimer’s disease). In addition,
researchers are conducting a clinical trial of testosterone
in men with impaired physical functioning.
older people. For example, the ongoing Lifestyle
Interventions and Independence for Elders (LIFE) Study
(https://www.thelifestudy.org/public/index.cfm) will
assess the effect of an exercise intervention to prevent
mobility disability in older adults. NIA also funds a
randomized trial of a social engagement intervention, the
Experience Corps
(http://www.experiencecorps.org/index.cfm), which
places older volunteers, mostly inner-city residents, in
elementary schools in cognitively demanding and socially
productive roles. Preliminary data have shown

improvements in both mental and physical health for
seniors, as well as benefits for the schools.
Contact:
Medical aspects of disability: Lyndon Joseph, Ph.D.,
[email protected]
Disability trends: Richard Suzman, Ph.D.,
[email protected]
National Institute on Aging (NIA) website:
http://www.nia.nih.gov
First Principles by Merrill_Week 3.pdf
First Principles of Instruction
M. David Merrill
For the past several years the author has been
reviewing instructional design theories in an
attempt to identify prescriptive principles that
are common to the various theories. This paper
is a preliminary report of the principles that
have been identified by this search. Five first
principles are elaborated: (a) Learning is
promoted when learners are engaged in
solving real-world problems. (b) Learning is
promoted when existing knowledge is
activated as a foundation for new knowledge.
(c) Learning is promoted when new knowledge
is demonstrated to the learner. (d) Learning is
promoted when new knowledge is applied by
the learner. (e) Learning is promoted when

new knowledge is integrated into the learner’s
world.
Representative instructional design
theories are briefly examined to illustrate how
they include these principles. These include:
Star Legacy by the Vanderbilt Learning
Technology Center, 4-Mat by McCarthy,
instructional episodes by Andre, multiple
approaches to understanding by Gardner,
collaborative problem solving by Nelson,
constructivist learning environments by
Jonassen, and learning by doing by Schank.
It is concluded that, although they use a
wide variety of terms, these theories and
models do include fundamentally similar
principles.
Recent years have seen a proliferation of in-
structional design theories and models. Ten-
nyson, Schott, See, and Dijkstra (1997) and
Reigeluth (1999) summarize a number of these
different positions. Instructional design theory,
as represented in Reigeluth, varies from basic
descriptive laws about learning to broad cur-
riculum programs that concentrate on what is
taught rather than on how to teach. Are all of
these design theories and models merely alter-
native ways to approach design? Do all of these
design theories and models have equal value?
Do these design theories and models have fun-
damental underlying principles in common? If
so what are these underlying first principles?
The purpose of this paper is to identify and ar-
ticulate the prescriptive design principles on
which these various design theories and models
are in essential agreement.

Reigeluth (1999) distinguishes two major
kinds of instructional methods: basic methods
and variable methods. This paper identifies
what Reigeluth calls basic methods but which I
prefer to call first principles of instruction. This
paper refers to variable methods as programs
and practices. A principle (basic method) is a
relationship that is always true under ap-
propriate conditions regardless of program or
practice (variable method). A practice is a specific
instructional activity. A program is an approach
consisting of a set of prescribed practices. Prac-
tices always implement or fail to implement un-
derlying principles whether these principles are
specified or not. A given instructional approach
may only emphasize the implementation of one
or more of these instructional principles. The
same principles can be implemented by a wide
variety of programs and practices. A given
ETR&D, Vol. 50, No. 3, 2002, pp. 43–59 ISSN 1042–1629 43
AAH GRAPHICS, INC. / (540) 933-6210 / FAX 933-6523 / 09-
30-2002 / 11:57
theory may specify both principles and practices
for implementing these principles. For some ex-
amples in Reigeluth (1999) a program is
specified but the underlying first principles are
not specified. Parsimony would dictate that
there should be only a few first principles of in-
struction that can support a wide variety of in-
structional programs and practices (design

theories, models, and methods).
What are the properties of first principles of
instruction? First, learning from a given pro-
gram will be promoted in direct proportion to its
implementation of first principles. Second, first
principles of instruction can be implemented in
any delivery system or using any instructional
architecture. Third, first principles of instruction
are design oriented or prescriptive rather than
learning oriented or descriptive. They relate to
creating learning environments and products
rather than describing how learners acquire
knowledge and skill from these environments or
products.
In this paper, I have identified the principles
that are included in a variety of design theories
and models. There is no attempt in this paper to
identify the empirical support for these prin-
ciples. I assume, perhaps without sufficient jus-
tification, that if a principle is included in several
instructional design theories, the principle has
been found either through experience or empiri-
cal research to be valid. My associates and I are
involved in a review effort to identify empirical
research that supports or fails to support these
design principles. The present report merely
identifies the principles that have been iden-
tified by a variety of theorists and model
builders.
The premise of this paper is that there is a set
of principles that can be found in most instruc-
tional design theories and models and even
though the terms used to state these principles

might differ between theorists, the authors of
these theories would agree that these principles
are necessary for effective and efficient instruc-
tion. This premise also assumes that these
design principles apply regardless of the in-
structional program or practices prescribed by a
given theory or model. If this premise is true,
there will be a decrement in learning and perfor-
mance when a given instructional program or
practice violates or fails to implement one or
more of these first principles. Obviously, the
support for this hypothesis can only come from
evaluation studies for a given instructional
product or research studies comparing the use
and misuse of these principles.
The theories cited in this paper are illustra-
tive of our approach rather than exhaustive. Not
all of the principles stated in this paper are in-
cluded in the theories that are very briefly
described. The vocabulary used to describe
these theories and their implementation details
varies significantly. Each of the theories and
models reviewed here tends to emphasize dif-
ferent principles.
This paper will provide a concise statement
of these first principles of instruction and then
review selected theories to see how these prin-
ciples are incorporated by each of these theories.
As each theory is reviewed, there will be an at-
tempt to translate the vocabulary of the theory to
the vocabulary of the first principles as stated.
INSTRUCTIONAL PHASES

Many current instructional models suggest that
the most effective learning products or environ-
ments are those that are problem-centered and
involve the student in four distinct phases of
learning: (a) activation of prior experience, (b)
demonstration of skills, (c) application of skills,
and (d) integration of these skills into real-world
activities. Figure 1 illustrates these four phases.
Much instructional practice concentrates
primarily on the demonstration phase and ig-
nores the other phases in this cycle of learning.
Most of the theories reviewed in this paper
stress problem-centered instruction and include
some (if not all) of these four phases of effective
instruction. Figure 1 provides a conceptual
framework for stating and relating the first prin-
ciples of instruction. The first principle relates to
problem-centered instruction. Four more prin-
ciples are stated for each of the four phases for
effective instruction. These five first principles
stated in their most concise form are as follows:
1. Learning is promoted when learners are
engaged in solving real-world problems.
2. Learning is promoted when existing
30-2002 / 11:57
44 ETR&D, Vol. 50, No. 3

knowledge is activated as a foundation for
new knowledge.1
3. Learning is promoted when new knowledge
is demonstrated to the learner.
is applied by the learner.
is integrated into the learner’s world.
FIRST PRINCIPLES OF INSTRUCTION
In the following paragraphs, I elaborate the five
prescriptive design principles for problem-
centered instruction and for each of the four in-
structional phases. First, I state each principle
and its corollaries including a short descriptor
for each principle or corollary. After this concise
statement, I elaborate and explain the principle
and its corollaries in more detail citing some rep-
resentative theorists or investigators who have
suggested the principle.
Principle 1—Problem-centered: Learning is
promoted when learners are engaged in solving
real-world problems.
• Corollary—Show task: Learning is promoted
when learners are shown the task that they
will be able to do or the problem they will be
able to solve as a result of completing a
module or course.
• Corollary—Task level: Learning is promoted

when learners are engaged at the problem or
task level, not just the operation or action
level.
• Corollary—Problem progression: Learning is
promoted when learners solve a progression
of problems that are explicitly compared to
one another.
Problem-centered
Much of the current work in cognitive psychol-
ogy has shown that students learn better when
engaged in solving problems (Mayer, 1992a).
Problem-centered learning is well represented
by a number of recent instructional models in-
cluding: Collins, Brown and Newman (1989),
Cognitive Apprenticeship; Schank, Berman, and
Macperson (1999), Goal Based Scenarios; Jonassen
(1999), Constructivist Learning Environments;
Savery and Duffey (1995), Problem-Based Learn-
ing; Clark and Blake (1997), Novel Problem Solv-
ing; and van Merriënboer (1997), Whole Task
Practice in 4C/ID Model.
The definition of a problem varies among
theorists. For some, a problem is engaging in
some form of simulation of a device or situation.
For others, it merely means being involved in
some form of real world task. I use the word
problem to include a wide range of activities,
with the most critical characteristics being that
the activity is some whole task rather than only
components of a task and that the task is repre-
sentative of those the learner will encounter in

the world following instruction. Problem-
centered instruction is contrasted with topic-
centered instruction where components of the
task are taught in isolation (e.g., “You won’t un-
derstand this now but later it will really be im-
portant to you”) before introducing the real
world task to the students.
Figure 1 Phases for Effective Instruction
1. I used the word knowledge in its broadest connotation to
include both knowledge and skill, and to represent the
knowledge and skill to be taught as well as the knowledge
and skill acquired by the learner.
30-2002 / 11:57
FIRST PRINCIPLES 45
Show task
It has become common practice to state learning
objectives at the beginning of module or lesson
material. These objectives are usually some form
of: “The learner will be able to . . . .” Objectives
of this form are abstract and often only under-
stood following the instruction. Most theorists
suggest that a specific demonstration of the par-
ticular whole task similar to those the learners
will be able to do following instruction provides
a better orientation to the instructional material
to follow than a list of abstract objective state-
ments. Van Merriénboer (1997) recommended

that the first problem in a sequence should be a
worked example that shows students the type of
whole task that they will learn to complete.
Task level
Much available instruction teaches commands
or individual actions and assumes that the
learner will be able to put these individual com-
ponents together to do real world tasks. Too
much traditional instruction is topic based,
teaching all the prerequisites before introducing
the real world whole task or problem. Learning
to complete a whole task involves four levels of
instruction: (a) the problem, (b) the tasks re-
quired to solve the problem, (c) the operations
that comprise the tasks, and (d) the actions that
comprise the operations. Effective instruction
should engage students in all four levels of per-
formance: the problem level, the task-level, the
operation-level, and the action-level. Schank et
al. (1999) stressed that one shortcoming of tradi-
tional instruction is the emphasis on decontex-
tualized skills. Jonassen (1999) stressed that
learners will assume ownership only if the
problems to be solved are interesting, relevant
and engaging. Other theorists have stressed that
effective learning requires engaging the learners
in authentic problems (Savery & Duffy, 1995;
Nelson, 1999).
Problem progression
Some of the problems or whole tasks that
learners must complete are very complex. Most
theorists would agree that solving a single prob-

lem or receiving little or no guidance (sink-or-
swim) is not effective. To master a complex
problem students must first start with a less
complex problem. When the first problem is
mastered, students are then given a more com-
plex problem. Through a progression of increas-
ingly complex problems, the students’ skills
gradually improve until they are able to solve
complex problems. Problem progression is ad-
vocated by Elaboration Theory (Reigeluth, 1999),
4C/ID Model (van Merriënboer, 1997), work model
progression (Gibbons, Bunderson, Olsen, &
Robertson, 1995), scaffolding (Collins, et al.,
1989), and understanding-performances (Perkins &
Unger, 1999).
Activation Phase
Principle 2—Activation: Learning is promoted
when relevant previous experience is activated.
• Corollary—Previous experience: Learning is
promoted when learners are directed to
recall, relate, describe, or apply knowledge
from relevant past experience that can be
used as a foundation for the new knowledge.
• Corollary—New experience: Learning is
promoted when learners are provided
relevant experience that can be used as a
foundation for the new knowledge.
• Corollary—Structure: Learning is promoted
when learners are provided or encouraged to
recall a structure that can be used to organize

the new knowledge.
Activation
It has long been a tenet of education to start
where the child is. It is therefore surprising that
many instructional products jump immediately
into the new material without laying a sufficient
foundation for the students. If students have had
relevant experience, then the first phase of learn-
ing is to be sure that this relevant information is
activated ready for use as a foundation for the
new knowledge. If students have not had suffi-
cient relevant experience, then the first phase of
learning a new skill should be to provide three-
dimensional experience that they can use as a
foundation for the new knowledge. Too much
instruction starts with abstract representations
30-2002 / 11:57
46 ETR&D, Vol. 50, No. 3
for which learners have insufficient foundation.
This paper borrowed the term activation from
Andre (1997) who provided one of the best
recent discussions of this principle.
Previous experience
When learners think that they already know
some of the material to be taught, then their ex-
isting experience can be activated by an ap-

propriate opportunity to demonstrate what they
already know. This activity can be used to help
direct students to the yet-to-be-learned new
material and thus result in more efficient in-
struction. Requiring students to complete the
usual information-oriented pretest of the
material to be taught when they don’t feel that
they know the material is frustrating and not
productive in activating prior experience. A
simple recall of information is seldom effective
as an activating experience. Andre (1997) cited
theory and research supporting schema activa-
tion and advance organizers.
Provide experience
Often the new learning may be foreign to the
previous experience of the learner. When in-
struction jumps immediately to this new
material the learner feels overwhelmed. Elemen-
tary school teachers understand this
phenomenon and spend considerable time
providing experiences upon which later learn-
ing can be built. As learners mature the educa-
tional system seems to feel that providing
relevant experience prior to instruction is no
longer necessary. Consequently students must
resort to memorizing the material presented be-
cause they lack previous mental models based
on experience that can be used to structure the
new knowledge.
Structure
Activation is more than merely helping students
recall previous experience or providing relevant

experience. Activation also involves stimulating
those mental models that can be modified or
tuned to enable learners to incorporate the new
knowledge into their existing knowledge. Andre
(1997) cited theory and research showing that
themes can serve as an organizing structure if
they are relevant to the content being taught.
There is a current emphasis on introducing
motivational themes into instruction, for ex-
ample, playing golf, flying a space ship, and so
forth. When these themes are irrelevant to the
content of the instruction, they activate inap-
propriate mental models and may actually inter-
fere with, rather than promote instructional
effectiveness. In an attempt to promote motiva-
tion, these themes may actually increase the cog-
nitive load required to acquire the target
knowledge. If learners have a mental model that
can be used to organize the new knowledge,
they should be encouraged to activate this men-
tal model. However, if the mental model is in-
sufficient to adequately organize the new
knowledge, then learning is promoted if the in-
struction provides a structure that the learner
can use to build the required organizational
schema for the new knowledge. Andre (1997)
discussed the role of advance organizers in
providing structure for later learning. Mayer
(1975) indicated that providing learners with a
conceptual model can facilitate the acquisition of
problem solving. Clark and Blake (1997) recom-
mended presenting dynamic schema and analog
models to promote far transfer.
Demonstration Phase

Principle 3—Demonstration (Show me): Learning
is promoted when the instruction demonstrates
what is to be learned rather than merely telling
information about what is to be learned.
• Corollary—Demonstration consistency: Learn-
ing is promoted when the demonstration is
consistent with the learning goal: (a) ex-
amples and nonexamples for concepts, (b)
demonstrations for procedures, (c) visualiza-
tions for processes, and (d) modeling for be-
havior.
• Corollary—Learner guidance: Learning is
promoted when learners are provided ap-
propriate learner guidance including some of
the following: (a) learners are directed to
relevant information, (b) multiple repre-
sentations are used for the demonstrations, or
(c) multiple demonstrations are explicitly
compared.
30-2002 / 11:57
FIRST PRINCIPLES 47
• Corollary—Relevant media: Learning is
promoted when media play a relevant in-
structional role and multiple forms of media
do not compete for the attention of the
learner.

Demonstration (Show me)
Knowledge to be learned exists at two levels: (a)
information and (b) portrayal. Information is
general and inclusive and refers to many cases
or situations. Portrayal is specific and limited
and refers to a single case or a single situation.
Presenting information is by far the most com-
mon form of instruction. Often instruction is
merely information followed by a few remem-
ber-what-you-were-told questions. This tell-
and-ask instruction by itself is seldom effective
instruction. Instruction is far more effective
when it also includes the portrayal level in that
the information is demonstrated via specific
situations or cases. Learners remember and can
apply information far more readily when the in-
formation includes specific portrayals. Van Mer-
rienboer (1997) identified a number of different
problem formats. He indicated that showing a
learner what to do via a worked-out example
and modeling examples, which show the learner
how to do the problem, are important first steps
in an instructional sequence. Merrill (1994) cited
research that shows that presenting examples is
more effective than merely presenting informa-
tion; presenting examples in addition to practice
promotes better learning than practice alone.
Demonstration consistency
Gagné (1985) identified categories of learning
and suggested that effective learning occurs
when the conditions of learning were consistent
with the desired category of learned perfor-
mance. Merrill (1994) elaborated the categories

of Gagné and prescribed primary and secondary
presentation forms consistent with each out-
come category. Merrill (1997) identified the
knowledge structure, presentation, practice, and
learner guidance that are consistent for each of
these different kinds of learning outcomes.
Dijkstra & van Merriënboer (1997) identified
three classes of problems: (a) problems of
categorization, (b) problems of design (plans
and procedures), and (c) problems of interpreta-
tion (principles, models, and theories). Each of
these different classes of problems require dif-
ferent knowledge structures (corresponding to
the desired cognitive structure) and different
constituent skills (concepts, activities, and
processes) if learning is to be efficient and effec-
tive. Van Merriënboer (1997) has extended this
work in the context of problem-centered instruc-
tion. These theorists agree that if demonstrations
are inconsistent with the intended learning out-
comes then learning will be ineffective. The con-
sistency criterion should be applied first since if
the presentation is inconsistent with the in-
tended learning outcome then it doesn’t matter
if there is learner guidance or if the media is
relevant.
Learner guidance
Clark & Blake (1997) indicated that problem
solving (far transfer) is promoted when the
structural features are carefully identified and
explicitly mapped for the student. This explicate
guidance focuses the learner’s attention on
relevant information in the task. Early in an in-

structional presentation this attention-focusing
function facilitates knowledge acquisition.
However, as the instruction progresses this in-
formation focusing role should be faded and
students expected to attend to and focus their
own attention on the relevant aspects of the in-
formation (Andre, 1997).
Another form of guidance is to provide
learners with multiple representations of the
ideas being taught and the demonstration being
provided. Spiro and Jehng (1990), Schwartz, Lin,
Brophy, and Bransford (1999), and Clark and
Blake (1997) all stressed the importance of alter-
native points of view, especially for ill-defined
domains and nonrecurrent skills. Spiro, Fel-
tovich, Jacobson and Coulson (1992), in cogni-
tive flexibility theory, stressed the importance of
coming at a given topic from multiple perspec-
tives.
Gentner and Namy (1999) have demon-
strated that merely presenting alternative repre-
sentations is not sufficient. When learners are
explicitly directed to compare different view-
30-2002 / 11:57
48 ETR&D, Vol. 50, No. 3
points they are forced to tune their mental
models to provide a broader perspective.

Relevant media
Mayer (1992b, 2001) has demonstrated that
gratuitous illustrations make little or no instruc-
tional contribution and are often ignored by
learners or may actually interfere with efficient
learning He has also demonstrated that some
combinations of multimedia (e.g., text and a
graphic) compete for attention and therefore in-
crease the cognitive load for the student. Other
combinations of media, such as audio and
graphics, support one another and promote
more effective learning.
Application Phase
Principle 4—Application (Let me): Learning is
promoted when learners are required to use
their new knowledge or skill to solve problems.
• Corollary—Practice consistency: Learning is
promoted when the application (practice)
and the posttest are consistent with the stated
or implied objectives: (a) information-about
practice—recall or recognize information, (b)
parts-of practice—locate, and name or
describe each part, (c) kinds-of practice—
identify new examples of each kind, (d) how-
to practice—do the procedure and (e)
what-happens practice—predict a conse-
quence of a process given conditions, or find
faulted conditions given an unexpected con-
sequence.
• Corollary—Diminishing coaching: Learning is
promoted when learners are guided in their

problem solving by appropriate feedback
and coaching, including error detection and
correction, and when this coaching is
gradually withdrawn.
• Corollary—Varied problems: Learning is
promoted when learners are required to
solve a sequence of varied problems.
Application (Let me)
Merrill (1994) cited research demonstrating that
adding practice to information and examples in-
creases learning. Most instructional design
theories advocate application of knowledge and
skill as a necessary condition for effective learn-
ing. Gagné (1985) stated eliciting performance
and providing feedback as necessary instruc-
tional events. Gardner (1999) and Perkins and
Unger (1999) both emphasized the necessity of
many opportunities for performance. All of the
problem-based models (Clark & Blake, 1997;
Jonassen, 1999; Nelson, 1999; Savery & Duffy,
1995; Schank et al., 1999; Schwartz et al., 1999;
van Merriënboer, 1997) emphasized the impor-
tance of being involved in doing real-world
tasks or problems. It is astounding that with this
almost universal agreement on the importance
of applying knowledge to real-world tasks, so
much instruction merely includes a few multi-
ple-choice questions that are labeled practice.
Such remember-what-you-were-told questions
do little to promote learning.
Practice consistency

Just as there are different components of
knowledge, presentation, and learner guidance
appropriate for different kinds of instructional
goals, so there are different kinds of practice ap-
propriate for different instructional goals. En-
gaging in practice that is inconsistent with the
desired instructional goal will do little to im-
prove performance. Gagné (1965, 1985) and
Merrill (1994, 1997) identified appropriate prac-
tice for each of the kinds of knowledge and skill
identified. Learning is promoted when the prac-
tice is consistent with the learning goal. The con-
sistency criterion should be applied first. If the
application is inconsistent with the intended
goals of the instruction, then it will be ineffective
and it won’t matter whether or not there is ap-
propriate coaching and feedback or a sequence
of problems.
Diminishing coaching
One theory of effective instruction is scaffolding
(Burton & Brown, 1979; Collins et al., 1989). The
idea is that early in learning students need con-
siderable support, but as the learning progresses
this support is gradually taken away leaving the
students eventually on their own. Scaffolding in-
30-2002 / 11:57
FIRST PRINCIPLES 49

volves performing parts of the task that the stu-
dents cannot perform and gradually reducing
the amount of guidance and shifting the control
to the student.
Feedback has long been recognized as the most
important form of learner guidance. All theories
advocate some form of feedback as a necessary
condition for learning. Gagné (1985) included
feedback as one of the events for instruction.
Andre (1997) included feedback as one of his three
phases of effective instruction. Numerous research
studies have demonstrated the importance of feed-
back while investigating a number of variables
about what type of feedback is most effective (Kul-
havy, 1977; Kulhavy & Stock, 1989).
Making errors is a natural consequence of
problem solving. Most learners learn from the
errors they make, especially when they are
shown how to recognize the error, how to
recover from the error, and how to avoid the
error in the future. Error diagnosis and correc-
tion is a fundamental principle of minimialism
(van der Meij & Carroll, 1998).
Varied problems
Applying knowledge to a single problem is in-
sufficient for learning a cognitive skill. Adequate
practice must provide multiple opportunities for
learners to use their new knowledge or skill for a
variety of problems. Andre (1986) indicated the
importance of providing learners with a range of
examples. Merrill, Tennyson, and Posey (1992)
indicated that a necessary condition for effective

concept instruction was a range of divergent ex-
amples. Tennyson & Park (1980) and Tennyson
& Cocchierella (1986) reviewed research
demonstrating the value of a sequence of varied
examples in concept instruction, and van Mer-
rienboer (1997) stressed variability of practice.
Integration Phase
Principle 5—Integration: Learning is promoted
when learners are encouraged to integrate
(transfer) the new knowledge or skill into their
everyday life.
• Corollary—Watch me: Learning is promoted
when learners are given an opportunity to
publicly demonstrate their new knowledge
or skill.
• Corollary—Reflection: Learning is promoted
when learners can reflect on, discuss, and
defend their new knowledge or skill.
• Corollary—Creation: Learning is promoted
when learners can create, invent, and explore
new and personal ways to use their new
knowledge or skill.
Integration
McCarthy (1996) suggested that the fourth
phase of effective instruction is creating per-
sonal adaptations of the new knowledge and
skill. The Vanderbilt group (Schwartz et al.,
1999) included reflecting back on the experience

as a step in their Star Legacy system. Current in-
struction literature has much to say about the
importance of motivation. Often glitz, anima-
tion, multimedia, and games are justified as
motivational elements of an instructional
product. However, for the most part, these
aspects have a temporary effect on motivation.
The real motivation for learners is learning.
Learners have integrated instruction into their
lives when they are able to demonstrate im-
provement in skill, to defend their new
knowledge, and to modify their new knowledge
for use in their everyday lives.
Watch me
Whenever learners acquire new skills, their first
desire is to show a close friend or associate their
newly acquired ability. Learning is the most
motivating of all activities when the learner can
observe his or her own progress. One of the
main attractions of computer games is the in-
creasing skill level that is apparent to the player.
Effective instruction must provide an oppor-
tunity for learners to demonstrate their newly
acquired skills. This principle of going public
with their newly acquired knowledge is em-
phasized in Teaching for Understanding (Gardner,
1999; Perkins & Unger, 1999) and for Vander-
bilt’s Star Legacy (Schwartz et al., 1999).
30-2002 / 11:57
50 ETR&D, Vol. 50, No. 3

Reflection
Learners need the opportunity to reflect on,
defend, and share what they have learned if it is
to become part of their available repertoire. Nel-
son (1999) cites a number of problem-solving
models that include synthesize and reflect as an
important process activity for collaborative
problem solving. Laurillard (1993) stressed the
role of reflection in her Conversational Framework
model of instruction. Boud, Keogh, and Walker
(1985) presented a model for reflection in learn-
ing.
Creation
Modifying new knowledge to make it one’s own
is where a learner moves beyond the instruction-
al environment and takes the new knowledge
and skill into the world beyond. McCarthy
(1996) stressed creating, revising, editing, syn-
thesizing, and refocusing as important final
phases of a learning experience.
AN ANALYSIS OF REPRESENTATIVE
INSTRUCTIONAL THEORIES
This section briefly reviews several instructional
theories. The theories described in this section
all implement some of the first principles and
their corollaries. Since the vocabulary is often
different, this paper attempts to do some transla-
tion of theorist’s terms to be consistent with the
terms used in the above statement of the prin-

ciples. I have sometimes quoted these authors to
provide the reader with the vocabulary of the
theorists so that the reader can see first hand
how the statements have been interpreted as
representative of the first principles outlined in
this paper. This overview is representative only
and does not present all of the principles
specified by the theory, but only enough to give
the reader a feel for the correspondence with the
first principles stated. The reader is encouraged
to examine these and other theories in detail to
determine whether or not the theory reflects the
first principles as stated.
Herbart (1776 – 1841)
The first principles of instruction presented in
this paper are not new. Johann Friedrich Herbart
is often identified as the father of scientific peda-
gogy. He recommended that the teacher should
first prepare the pupils to be ready for a new les-
son. Further, he suggested that the pedagogy
should associate the new lesson with ideas
studied earlier. Both of the recommendations
are consistent with the principle of activation.
He also recommended that the pedagogy should
use examples to illustrate the lesson’s major
points. Clearly, he also emphasized demonstra-
tion in addition to the presentation of informa-
tion. Finally he recommended that the pedagogy
should test pupils to ensure they have learned
the new lesson. This is the principle of applica-
tion (Hilgenheger, 1993).
Vanderbilt Learning Technology
Center—Star Legacy

The Learning Technology Center at Vanderbilt
(Schwartz et al., 1999) described Star Legacy, a
software shell for instruction. The Vanderbilt
approach is a good illustration of the phases of
instruction and the five general principles that
have been identified. They describe a learning
cycle that, they believe, involves important, yet
often implicit, components of effective instruc-
tion. They emphasize making the learning cycle
explicit. Their learning cycle is illustrated in Fig-
ure 2.
Look ahead provides the learning context and
learning goals. The challenges are problems to be
solved. The Vanderbilt group (Schwartz et al.,
1999) uses the metaphor of successively higher
mountains to represent a progression of increas-
ingly difficult problems. Generate ideas is an ac-
tivation activity where learners interact with
other learners to share experience and to share
what they already know related to the challen-
ges. Multiple perspectives is an opportunity for
students to compare their view of the problem
and possible solutions with the view of other
students and, more importantly, with the view
of experts. During multiple perspectives con-
cepts, procedures and principles that the student
30-2002 / 11:57
FIRST PRINCIPLES 51

may need in order to solve the problem are
demonstrated. Research and revise continues the
demonstration phase and moves into the ap-
plication phase; students gather numerous dif-
ferent ideas and try them out to see how they
might solve the problem. Check your mettle is an
opportunity for students to apply their ideas
and receive feedback before they go public with
their solutions. Go public is a chance for the stu-
dents to demonstrate their solutions and to
defend their ideas. This is an important com-
ponent of the integration phase of instruction.
Reflect back is an opportunity for the students to
review their learning activities and is another
important aspect of integration. Because the
authors believe that the learning cycle should be
made explicit, Star Legacy is one of the most ex-
plicit representations of the learning cycle that
forms the structure for the first principles of in-
struction. This same cycle of learning is also
found in other theories and models, but it is fre-
quently more subtle and not as explicit as in Star
Legacy.
McCarthy—4-MAT
McCarthy (1996) represented a model used by
many teachers in K–12 education. McCarthy is
seldom cited in the instructional technology
literature. Her work is important to our con-
sideration of first principles because she made
the learning cycle explicit. McCarthy ap-
proached this idea from a consideration of stu-
dent learning styles but concluded that,
although learners may have preference for

various approaches to learning, effective in-
struction requires them to be involved in the
whole cycle of learning activities. Figure 3 il-
lustrates some of the ideas that she emphasized
in her 4-MAT approach.
McCarthy did not emphasize problem solv-
ing as much as did the Learning Technology
Center. Her emphasis was on the various types
of activities that might be appropriate for each of
the learning phases and how these learning ac-
tivities reflect learning preferences of various
types of learners. Her Phase 1 serves the role of
activation, in which the learners share what they
know and try to find meaning related to the new
material they will learn. 4-MAT Phase 1 is
similar to Star Legacy’s generate ideas, but em-
phasizes a more learner-centered approach,
whereas the Vanderbilt group is more problem
focused. 4-MAT Phase 2 is the demonstrate
phase, where the learners acquire new
knowledge and relate it to what they already
know. McCarthy (1996) included subphases, the
description of which is beyond the scope of this
Figure 2 Learning Cycle of Star Legacy (Schwartz et al., 1999)
30-2002 / 11:57
52 ETR&D, Vol. 50, No. 3
presentation, but which provide practices and
theory for making the transition from one phase

to the next. Phase 3 is clearly the application
phase, where learners use what they know to do
something, make something, or play with the
ideas. This phase is also related to the Star
Legacy research and revise and test your mettle
components. McCarthy Phase 4 is where
learners make the knowledge their own. This is
the integration phase of first principles, and I
borrowed McCarthy’s term integration for this
phase. The formulation of the learning cycle for
first principles and the graphic representation of
these phases were influenced by McCarthy’s
work. She provided perhaps the most explicit
articulation of the cycle of learning and the
phases required for effective instruction.
Andre—Instructional Episode
Andre’s (1997) work was focused on the research
supporting instruction rather than a theory per
se. He described an instructional episode consist-
ing of three major phases: (a) activation phase
(from which first principles borrowed the term),
(b) instructional phase, and (c) feedback phase.
For Andre the instructional phase consisted of
presentation, discovery and practice (the first
principles demonstration and application phase).
His feedback phase was only part of the first
principles application phase as described above.
Andre did not emphasize problem solving or in-
tegration following the practice-feedback phase.
Andre described research findings that support a
number of the corollaries stated above.
Figure 3 McCarthy 4-MAT Cycle of Learning (McCarthy, 1996)

30-2002 / 11:57
FIRST PRINCIPLES 53
Gardner—Multiple Approaches to
Understanding
Gardner’s (1999) performance approach to under-
standing emphasized understanding content
(“important questions and topics of the world”
p. 73) rather than problem solving, but his ap-
proach did embrace each of the four phases of
instruction as described in this paper. He
stressed that understanding can only be ob-
served when students engage in “performances
that can be observed, critiqued, and improved”
(p. 73). He organized his theory around phases
he identified as entry points, telling analogies, and
approaching the core.
Entry points are a form of activation. “One
begins by finding a way to engage the students
and to place them centrally within the topic. I
have identified at least six discrete entry points,
which can be roughly aligned with specific intel-
ligences” (p. 81). He then described entry points
from these six viewpoints: (a) narrational, (b)
quantitative-numerical, (c) foundational-exis-
tential, (d) aesthetic, (e) hands-on, and (f) social.
Telling analogies forms a transition from ac-
tivation to demonstration. “[C]ome up with in-
structive analogies drawn from material that is

already understood, and that can convey impor-
tant aspects of the less familiar topic” (p. 82).
Approaching the core includes some of the
prescriptions for demonstration. “[P]ortray the
topic in a number of ways . . . [use] multiple ap-
proaches [that] explicitly call upon a range of in-
telligences, skills, and interests” (p. 85).
He also stressed application. “[M]ultiple repre-
sentations is one component of effective teaching;
the complementary component entails the
provision of many opportunities for performance,
which can reveal to the student and to others the
extent to which the material has been mastered”
(p. 86). “Although it is easy to fall back on the tried-
and-true—the short answer test, the essay ques-
tion—there is no imperative to do so.
Performances can be as varied as the different
facets of the topic, and the diverse sets of skills of
students” (p. 87). Gardner did emphasize entry
points and multiple approaches to the topic consis-
tent with different kinds of intelligences, however,
in his paper, he did not explicitly identify practice
consistency with these different intelligences.
Perhaps the primary emphasis of Gardner
was on those prescriptions for integration that
involve going public. “When students realize
that they will have to apply knowledge and in-
sights in public form, they assume a more active
stance vis-à-vis material, seeking to exercise
their ‘muscles of performance’ whenever pos-
sible” (p. 74).
Nelson—Collaborative Problem Solving

Nelson’s (1999) theory emphasized problem
solving and included all of the phases, but with
more emphasis on application and less em-
phasis on demonstration. She attempted to pro-
vide “an integrated set of guidelines . . . to
design and participate in authentic learning en-
vironments which invoke critical thinking,
creativity, and complex problem solving while
developing important social interaction skills”
(p. 246). She provided an extensive list of
guidelines, and the source for these guidelines,
organized under nine process activities:
1. Build readiness.
2. Form and norm groups.
3. Determine a preliminary problem definition.
4. Define and assign roles.
5. Engage in an iterative collaborative problem-
solving process.
6. Finalize the solution or project.
7. Synthesize and reflect.
8. Assess products and processes.
9. Provide closure. (Nelson, 1999, Table 11.2, p.
258)
Some of these activities are clearly related to col -
laboration and, as such, are not included in our

set of first principles (see especially numbers 2,
4, and 9). I view collaboration as one way to im-
plement first principles; thus the activity
guidelines for collaboration provided by Nelson
are viewed as implementation guidelines rather
than first principles.
Nelson (1999) was clearly problem oriented
as demonstrated by the following guideline:
“Develop an authentic problem or project
scenario to anchor instruction and learning ac-
tivities” (p. 258).
30-2002 / 11:57
54 ETR&D, Vol. 50, No. 3
She promoted activation via the following
learning activities: “[a] Negotiate a common un-
derstanding of the problem, [b] Identify learning
issues and goals, and [c] Brainstorm preliminary
solutions or project plans” (Nelson, 1999, p. 258).
She provided guidelines for gathering infor-
mation that may be required for the problem-
solving process. I view these activities as part of
application rather than demonstration per se:
“[a] Identify sources of needed resources, [b]
Gather preliminary information to validate the
design plan, [c] Acquire needed information,
resources, and expertise, and [d] Collaborate
with instructor to acquire additional resources
and skills needed” (Nelson, 1999, p. 258).

Application activities include: “[a] Select and
develop initial design plan, [b] Refine and
evolve the design plan, [c] Engage in solution or
project development work, [d] Conduct forma-
tive evaluations of the solution or project, [e]
Draft the preliminary final version of the solu-
tion or project, [f] Conduct the final evaluation
or usability test of the solution or project, [g]
Revise and complete the final version of the
solution or project, and [h] Evaluate the
products and artifacts created” (Nelson, 1999, p.
258).
Integration activities include: “[a] Identify
learning gains, [b] Debrief experiences and feel-
ings about the process, and [c] Reflect on group
and individual learning processes” (Nelson,
1999, p. 258).
Jonassen—Constructivist Learning
Environments (CLE)
Jonassen’s (1999) approach emphasized prob-
lem solving and included all four phases of in-
struction. The primary emphasis of CLE is
problem solving as reflected in the following
statements: “The goal of the learner is to inter-
pret and solve the problem or complete the
project” (p. 217), “. . . the problem drives the
learning” (p. 218), “Students learn domain con-
tent in order to solve the problem, rather than
solving the problem as an application of learn-
ing” (p. 218), and “. . . you must provide inter-
esting, relevant, and engaging problems to
solve. . . . The problem should not be overly cir-

cumscribed. Rather, it should be ill defined or ill
structured, so that some aspects of the problem
are emergent and definable by the learners” (p.
219). Jonassen recommended problem progres-
sion: “Start the learners with the tasks they
know how to perform and gradually add task
difficulty until they are unable to perform
alone” (p. 235).
Some attention was directed toward activa-
tion. “What novice learners lack most are ex-
periences. . . . Related cases [demonstrations]
can scaffold (or supplant) memory by providing
representations of experiences that learners
have not had” (Jonassen, 1999, p. 223).
Demonstration was stressed: “Carefully
demonstrate each of the activities involved in a
performance by a skilled (but not an expert) per-
former. . . . Modeling provides learners with an
example of the desired performance. . . . Two
types of modeling exist: . . . Behavioral modeling
. . . demonstrates how to perform the activities
identified. . . . Cognitive modeling articulates
the reasoning . . . that learners should use while
engaged in the activities” (Jonassen, 1999, p.
231). “A widely recognized method for model-
ing problem solving is worked examples” (p.
232).
Application was also stressed, with an em-
phasis on coaching and scaffolding. “[I]n order
to learn, learners will attempt to perform like the
model, first through crude imitation, advancing
through articulating and habituating perfor-

mance, to the creation of skilled, original perfor-
mances. At each of these stages the learner will
likely improve with coaching” (Jonassen, 1999,
p. 232). “The most important role of the coach is
to monitor, analyze, and regulate the learners’
development of important skills” (p. 233). Jonas-
sen “. . . suggests three separate approaches to
scaffolding of learning: adjust the difficulty of
the task to accommodate the learner, restructure
the task to supplant a lack of prior knowledge,
or provide alternative assessments” (p. 235).
The reflection aspect of integration was sug-
gested as one role of coaching. “[A] good coach
provokes learners to reflect on (monitor and
analyze) their performance” (p. 233).
30-2002 / 11:57
FIRST PRINCIPLES 55
Van Merriënboer—Four Component
Instructional Design Model (4C/ID)
Van Merriënboer (1997) provided perhaps the
most comprehensive recent model of instruc-
tional design that is problem-centered and in-
volves all of the phases of instruction identified
in this paper. His model integrated more direc-
tive approaches to instruction with problem-
based approaches all in the context of what is
known about cognitive processing. The model
described multiple approaches to analysis and

how the products of these various analysis tech-
niques lead to instructional designs that focus on
whole task practice. This short summary is in-
adequate to illustrate the comprehensive nature
of the 4C/ID model.
The model was clearly problem-based. “At
the heart of this training strategy is whole-task
practice, in which more and more complex ver-
sions of the whole complex cognitive skill are
practiced. . . . In . . . the analysis phase . . . the
skill is decomposed in a hierarchy of constituent
skills; . . . classified as recurrent constituent
skills, which require more-or-less consistent per-
formance over problem situations, or nonrecur-
rent constituent skills, which require highly
variable performance over situations” (van
Merriënboer, 1997, p. 8). “While learners prac-
tice simple to complex versions of a whole task,
instructional methods that promote just-in-time
information presentation are used to support the
recurrent aspects of the whole task while, at the
same time, instructional methods that promote
elaboration are used to support the nonrecurrent
aspects of the task” (p. 10).
Van Merriënboer’s (1997) model did not ex-
plicitly address the issue of activation. However,
his detailed attention to analysis and the various
kinds of knowledge that comprise an instruc-
tional sequence certainly addressed some of the
concerns of activation.
Demonstration was addressed at several
levels. The first problems in a sequence should
be worked-out examples of how to perform the

task. As the student progresses through the se-
quence of problems other information is
presented or demonstrated. These include part-
task practice for development of “situation
specific, automated rules . . .” (van Merriënboer,
1997, p. 12). For just-in-time information,
“Demonstration is usually needed to illustrate
the application of rules or procedures and to ex-
emplify concepts, principles, or plans that are
prerequisite to a correct application of those
rules or procedures [in solving the problem]”
(p.13). The heuristic methods used by skilled
performers were modeled for the student. It
should be noted that all of this demonstration
occured in the context of having the student
engage in whole-task performance or problem
solving.
Application and integration were at the cen-
ter of the model. “The heart of the 4C/ID model
concerns the design of whole-task practice. . . .
The design of information presentation
[demonstration] is always subordinate to, al-
though integrated with, the design of practice”
(van Merriënboer, 1997, p. 170). The emphasis of
the model was on a sequence of problems so that
demonstration and application are an integrated
whole rather than distinct phases. The model
described in some detail both product-oriented
problem formats and process-oriented problem
formats. The model suggested that appropriate
practice involves scaffolding of problems, but
rather than leaving the definition of scaffolding
somewhat unspecified, the model suggested
how different types of problem formats relate to

cognitive load and practice sequences that were
likely to promote the most effective skill
development. The whole-task practice model
led the student toward a real-world task that
van Merrienboer thought should promote maxi-
mum integration.
Schank—Learning by Doing
Shank’s (Schank et al., 1999) model was clearly
problem-centered with a very strong emphasis
on the application phase of instruction. In this
model there was limited emphasis on activation
and demonstration and, while integration was
certainly the goal, there was very little in the
model to direct the integration process per se.
“GBS [goal-based scenario] is a learn-by-doing
simulation in which students pursue a goal by
practicing target skills and using relevant con-
tent knowledge to help them achieve their goal”
30-2002 / 11:57
56 ETR&D, Vol. 50, No. 3
(p. 165). “There are seven essential components
of a GBS: the learning goals, the mission, the
cover story, the role, the scenario operations, the
resources, and the feedback, including coaches
and experts” (p. 173).
Scenarios (problems) were carefully defined.
“[T]he first step in creating a GBS is determining

a goal or mission that will be motivational for
the student to pursue. . . . The cover story is the
background story line that creates the need for
the mission to be accomplished. . . . the most im-
portant thing to consider is whether the story
will allow enough opportunities for the student
to practice the skills and seek the knowledge you
wish to teach. . . . The role defines who the stu-
dent will play within the cover story. . . . it is im-
portant to think about what role is the best in the
scenario to practice the necessary skills” (Schank
et al., 1999, p. 173–175).
Schank et al., stressed that new cases
(memories) are developed from existing cases
(memories). Activation is elicited via stories.
“The memories that contribute to our library of
cases [memories] are of specific events in the
form of stories. . . . the best way to convey infor-
mation is . . . to embed lessons in stories
[portrayal] that the learner can understand as an
extension of the stories he or she already knows
[activation]” (1999, p. 177).
Demonstration was provided within the con-
text of the scenario. “[T]he resources we provide
are usually experts telling stories about the in-
formation the student needs [demonstration]”
(Schank et al., 1999, p. 177). “Information is
provided primarily via feedback during the
operation of the scenario in three ways: . . . con-
sequence of actions . . . coaches . . . [who] pro-
vide . . . a just in time source to scaffold the
student through tasks . . . and domain experts
who tell stories that pertain to similar experien-
ces” (p. 178).

“The scenario operations [application] com-
prise all of the activities the student does in
order to work toward the mission goal” (Schank
et al., 1999, p. 175). “The scenario operations
should . . . have consequences that become evi-
dent at various points throughout the student
interaction. . . . It is important that . . . little time
be spent talking to the student about the
scenario, and much more time be spent with the
student practicing the skills and learning the in-
formation that comprise the learning goals” (p.
176).
The model did not address integration direct-
ly but assumed that, if the mission is motivating
and of interest to the student, the student will in-
ternalize the case (memories) and it will be avail-
able in later real-world or other instructional
scenarios.
CONCLUSION
Do the theories and models reviewed in this
paper involve fundamentally different first prin-
ciples? The answer appears to be no.
• All the theories and models reviewed incor-
porate some of these principles.
• No theory or model reviewed includes all of
these principles.
• Some theories and models reviewed include
principles or prescriptions that are not

described in this paper. These represent areas
for further investigation.
• No theory or model reviewed includes prin-
ciples or prescriptions that are contrary to
those described in this paper.
How do these theories and models differ?
The vocabulary used to describe these
theories and their implementation details vary
significantly.
These theories and models tend to emphasize
different principles. Gardner (1999) stressed
public exhibition of understanding (integration)
and different kinds of intelligence (which is not
included in the prescriptions of this paper). Nel-
son (1999) emphasized collaboration (which is
not included in the prescriptions of this paper).
Collaboration is emphasized by a number of
current models, especially constructivist
models. I agree that collaboration is a very im-
portant implementation of activation and in-
tegration but I am not yet convinced that
collaboration is a first principle. Jonassen (1999)
emphasized problem solving in learning en-
vironments. Van Merriënboer (1997) em-
phasized problem sequence and the sequence of
supporting information. Schank (Schank et al.,
1999) emphasized stories (a form of demonstra-
tion) and problem solving (cases).
30-2002 / 11:57

FIRST PRINCIPLES 57
This survey of instructional theories and
models demonstrates that these theories do in-
clude first principles of instruction that are
similar, regardless of theory or philosophical
orientation.
M. David Merrill [[email protected]] is a Professor
in the Department of Instructional Technology at
Utah State University.
REFERENCES
Andre, T. (1986). Problem-solving in education. In
G.D. Phye & T. Andre (Eds.). Cognitive classroom
learning (pp. 169–204). New York: Academic Press.
Andre, T. (1997). Selected microinstructional methods
to facilitate knowledge construction: implications
for instructional design. In R.D. Tennyson, F. Schott,
N. Seel, & S. Dijkstra, Instructional design: Internation-
al perspective: Theory, research, and models (Vol. 1) (pp.
243–267). Mahwah, NJ: Lawrence Erlbaum As-
sociates.
Boud, D., Keogh, R., & Walker, D. (1985). Promoting
reflection in learning: A model. In D. Boud, R.
Keogh, & D. Walker (Eds.) Reflection: Turning ex-
perience into learning (pp. 18–40). London: Kogan
Page.
Burton, R.R., & Brown, J.S. (1979). An investigation of
computer coaching for informal learning activities.

International Journal of Man-Machine Studies, 11, 5–24.
Clark, R.E. & Blake, S.B. (1997). Designing training for
novel problem-solving transfer. In R.D. Tennyson, F.
Schott, N. Seel, & S. Dijkstra. Instructional design: In-
ternational perspective: Theory, research, and models
(Vol. 1) (pp. 183–214). Mahwah, NJ: Lawrence
Erlbaum Associates.
Collins, A., Brown, J.S., & Newman, S.E. (1989). Cogni-
tive apprenticeship: Teaching the crafts of reading,
writing, and mathematics. In L.B. Resnick (Ed.)
Knowing, learning and instruction: Essays in honor of
Robert Glaser (pp. 453–494). Hillsdale, NJ: Lawrence
Erlbaum Associates.
Dijkstra, S., & van Merriënboer, J.J.G. (1997). Plans,
procedures, and theories to solve instructional
design problems. In S. Dijkstra, N. Seel, F. Schott &
R.D. Tennyson (Eds.) Instructional design internation-
al perspective: Solving instructional design problems
(Vol. 2) (pp. 23–43). Mahwah, NJ: Lawrence
Erlbaum Associates.
Gagné, R.M. (1965). The conditions of learning. New
York: Holt, Rinehart and Winston.
Gagné, R.M. (1985). The conditions of learning and theory
of instruction (4th Ed.). New York: Holt, Rinehart and
Winston.
Gardner, H. (1999). Multiple approaches to under-
standing. In C.M. Reigeluth (Ed.), Instructional
design theories and models: A new paradigm of instruc-
tional theory (Vol. II) (pp. 69–89). Mahwah, NJ:

Lawrence Erlbaum Associates.
Gentner, D. & Namy, L. (1999). Comparison in the
development of categories. Cognitive Development,
14, 487–513.
Gibbons, A.S., Bunderson, C.V., Olsen, J.B. &
Roberston, J. (1995). Work models: Still beyond in-
structional objectives. Machine-Mediated Learning,
5(3&4), 221–236.
Hilgenheger, N. (1993). Johann Friedrich Herbart.
Prospects: The Quarterly Review of Comparative Educa-
tion. 23(3&4), 649–664.
Jonassen, D. (1999) Designing constructivist learning
environments. In C.M. Reigeluth (Ed.), Instructional
design theories and models: A new paradigm of instruc-
tional theory (Vol. II) (pp. 215–239). Mahwah, NJ:
Lawrence Erlbaum Associates.
Kulhavy, R.W. (1997). Feedback in written instruction.
Review of Educational Research, 47, 211–232.
Kulhavy, R.W., & Stock, W.A. (1989). Feedback in writ-
ten instruction: The place of response certitude.
Educational Psychology Review, 1, 279–308.
Laurillard, D. (1993). Rethinking university teaching: A
framework for the effective use of educational technology.
New York: Routledge.
Mayer, R.E. (1975). Different problem-solving com-
petencies established in learning computer
programming with and without meaningful
models. Journal of Educational Psychology, 67, 725–

734.
Mayer, R.E. (1992a). Thinking, problem solving, cognition
(2nd Ed.). New York: W.H. Freeman.
Mayer, R.E. (1992b). Illustrations that instruct. In R.
Glaser (Ed.), Advances in instructional psychology.
Hillsdale, NJ: Lawrence Erlbaum Associates.
Mayer, R.E. (2001). Multimedia learning. London:
Cambridge University Press.
McCarthy, B. (1996). About learning. Barrington, IL: Ex-
cell Inc.
Merrill, M.D. (1994). Instructional design theory.
Englewood Cliffs: Educational Technology Publica-
tions.
Merrill, M.D. (1997). Instructional strategies that teach.
CBT
Solution
s, Nov./Dec., 1–11.
Merrill, M.D., Tennyson, R.D. & Posey, L.O. (1992).
Teaching concepts: An instructional design guide (2nd
Ed.). Englewood Cliffs, NJ: Educational Technology
Publications.

Nelson, L.M. (1999). Collaborative problem solving. In
C.M. Reigeluth (Ed.), Instructional design theories and
models: A new paradigm of instructional theory (Vol. II)
(pp.241–267). Mahwah, NJ: Lawrence Erlbaum As-
sociates.
Perkins, D.H., & Unger, C. (1999). Teaching and learn-
ing for understanding. In C.M. Reigeluth (Ed.), In-
structional design theories and models: A new paradigm
of instructionsl theory (vol. II) (pp. 91–114). Mahwah,
NJ:Lawrence Erlbaum Associates.
Reigeluth, C.M. (1999). Instructional design theories and
models: A new paradigm of instructional theory (Vol. II).
30-2002 / 11:57
58 ETR&D, Vol. 50, No. 3
Mahwah, NJ: Lawrence Erlbaum Associates.
Reigeluth, C.M. (1999). The elaboration theory:

guidance for scope and sequence decisions. In C.M.
Reigeluth (Ed.), Instructional design theories and
models: A new paradigm of instructional theory (Vol. II)
(pp. 425–453). Mahwah, NJ: Lawrence Erlbaum As-
sociates.
Savery, J., & Duffy, T. (1995). Problem based learning:
an instructional model and its constructivist
framework. In B.G. Wilson (Ed.), Designing construc-
tivist learning environments (pp. 135–148).
Englewood Cliffs: Educational Technology Publica-
tions.
Schank, R.C., Berman, T.R. & Macperson, K.A. (1999).
Learning by doing. In C.M. Reigeluth (Ed.), Instruc-
tional design theories and models: A new paradigm of in-
structional theory (Vol. II) (pp. 161–181). Mahwah,
NJ: Lawrence Erlbaum Associates.
Schwartz, D., Lin, X., Brophy, S., & Bransford, J.D.
(1999). Toward the development of flexibly adaptive
instructional designs. In C.M. Reigeluth (Ed.), In-
structional design theories and models: A new paradigm
of instructional theory (Vol. II) (pp. 183–213). Mah-
wah, NJ: Lawrence Erlbaum Associates.

Spiro, R.J., & Jehng, J.C. (1990). Cognitive flexibility
and hypertext: Theory and technology for the non-
linear and multidimensional traversal of complex
subject matter. In D. Nix & R. Spiro (Eds.), Cognition,
education, and multimedia (pp. 163–205). Hillsdale,
NJ: Lawrence Erlbaum Associates.
Spiro, R.J., Feltovich, P.J., Jacobson, M.J., & Coulson,
R.L. (1992). Cognitive flexibility, constructivism,
and hypertext: Random access instruction for ad-
vanced knowledge acquisition in ill-structured
domains. In T.M. Duffy & D.H. Jonassen (Eds.) Con-
structivism and the technology of instruction: A conver-
sation. Hillsdale NJ: Lawrence Erlbaum Associates.
Tennyson, R.D., & Park, O. (1980). The teaching of con-
cepts: A review of instructional design literature.
Review of Educational Research, 50, 55–70.
Tennyson, R.D., & Cocchierella, M.J. (1986). An em-
pirically based instructional design theory for teach-
ing concepts. Review of Educational Research, 56,
40–72.

Tennyson, R., Schott, F., Seel, N., & Dijkstra, S. (1997).
Instructional design: International perspective: Theory,
research, and models. (Vol. 1). Mahwah, NJ: Lawrence
Erlbaum Associates.
van Merriënboer, J.J.G. (1997). Training complex cogni-
tive skills. Englewood Cliffs: Educational Technol-
ogy Publications.
Van der Meij, H., & Carroll, J.M. (1998). Principles and
heuristics for designing minimalist instruction. In
J.M. Carroll (Ed.) Minimalism beyond the Nurnberg
funnel (pp. 19–53). Cambridge, MA: MIT Press.
30-2002 / 11:57
FIRST PRINCIPLES 59
Week 1 Notes.html
An open system continuously interacts with its environment. If
you think of training as an open system, we can see that the
needs of the trainees must be considered by the training

development process. Training needs would be input of the
process, and the output would be the training. A training
process that does not interact with its environment would
probably not be able to meet the training needs because it has
no way of knowing what the training needs are.
An open system model:
•Depends on the environment for inputs
•Environmental inputs are transformed into outputs
•In effective systems, the system output influences the
environment to supply new supportive inputs
A system must be responsive to the needs and demands of its
environment because environment provides the input needed for
the system to continue and replenish itself. Training is a
subsystem within a larger human resource unit.
Inputs: Organizational Needs, Training budget, Staff,
Equipment
Outputs: Improved knowledge, skills, and attitudes, Job
performance
Looking at training from an open systems perspective shows
how interconnected training activities are with what is
happening elsewhere in the organization.

Training Process Model: ADDIE
All training processes are critical to the success of training. An
effective training system is a set of processes designed to
transform organizational inputs into outputs that meet the
organizational needs. Training should be viewed as a set of
integrated processes in which organizational and employee
needs are analyzed and responded to in a rational, logical and
strategic manner.
The ADDIE training process model is a 5 step process for
developing effective training programs. The acronym ADDIE
stands for Analyze, Design, Develop, Implement, and Evaluate.
Each stage of the model has a specific purpose, and serves as a
foundation and input for the next phase, ensuring an effective
and comprehensive approach to training.
Click here to learn more about the ADDIE model

Addie_model.png
Table of Contents.htmlHRMN 406 7381 Employee Training and
Development (2212) - Week 3: March 31 - April 6 2021
1. First Principles by Merrill_Week 3
2. Week 3 Notes
State Strategies for Promoting Wellness and Healthy
Lifestyles for People with Disabilities

© Association of State and Territorial Health Officials 2013
2231 Crystal Drive, Ste 450, Arlington, VA
(202) 371-9090 www.astho.org
Inadequate access to preventive health and other health
promotion services among people with
disabilities compared to the general population is a public
health concern. More than 54 million
people—one in five Americans—have a disability with which
they were either born or acquired through
injury, age, or illness.2,3 In 2006, disability-associated
healthcare expenditures for adults in the United
States totaled $397.8 billion (26.7% of all expenditures).4 Of
this national total, $118.9 billion was for the Medicare
population, $161.1 billion for Medicaid recipients, and $117.8
billion for non-public (privately insured or uninsured) sources.5
Medicaid serves an estimated 9.9 billion children and adults
with disabilities and is the primary way of providing healthcare
services to people with disabilities.6
A disability is a feature of the body, mind, or senses that can
affect a person’s daily life. People with disabilities need
healthcare and health promotion programs for

the same reasons that the general population does. Despite this
knowledge, people with disabilities
experience barriers to preventive healthcare services, which can
lead to poor health status, delayed
treatment of chronic illnesses, and failure to prevent secondary
conditions or health problems related to
a disability. Research indicates that people with disabilities may
be disproportionately affected by excess
weight or obesity; increased risk for diabetes, hypertension,
substance abuse, injury, depression, and
stress; and receive less frequent cancer screenings compared to
people without disabilities.7 Health
disparities for people with disabilities vary by ethnicity, age,
gender, and income level.8
Several national initiatives are focused on people with
disabilities and provide leadership for an
increased public health focus on the health issues that affect
people with disabilities. Some of these
include:
• The American Public Health Association (APHA) Disability
Section.9
• The Healthy People 2020 inclusion of a focus area on
disability and health.10

• The U.S. Surgeon General’s Call to Action to Improve the
Health and Wellness of Persons with
Disabilities.11
• HHS’s National Partnership for Action to End Health
Disparities.12
In addition, CDC’s National Center on Birth Defects and
Developmental Disabilities (NCBDDD)13 supports
18 state-based programs to ensure that individuals with
disabilities are included in ongoing state disease
prevention, health promotion, and emergency response
activities.
More people with disabilities are living longer, higher-quality
lives due to the positive impact of public
health, medical, and other interventions. State and territorial
health agencies play a key role in ensuring
people with disabilities have access to these healthcare and
health promotion services. This issue brief
provides some background on the barriers and challenges to
accessing preventive healthcare and health
promotion services and highlights some of the initiatives that
state public health agencies have
undertaken to remove those barriers.

A disability is a feature of the body,
mind, or senses that can affect a
person’s daily life. People with
disabilities need healthcare and
health promotion programs for the
same reasons that the general
population does.1

(202) 371-9090 www.astho.org
Barriers to Preventive Health and Health Promotion Activities
and Services
There are significant health inequities that lead to inadequate
access to preventive health and other
health promotion services among people with disabilities.
People with disabilities are more likely to
experience disadvantages in health and well-being compared to
the general population, and barriers to
preventive health services can often delay treatment of chroni c
conditions and failure to prevent
secondary conditions. Widespread challenges to accessing
healthcare services and health promotion
activities for people with disabilities include physical,
environmental, programmatic, and attitudinal and
cultural barriers. To begin removing these barriers, public
health needs to consider a new approach where accessibility
and accommodation for people with disabilities is part of the
overall agenda. Public health can also help eliminate health
inequities by addressing social determinants of health (e.g.,
education and poverty) that exist among people with
disabilities.

Physical Barriers
Due to the lack of accessible places to be physically active
(e.g., sidewalks, parks, fitness centers, green
spaces), individuals with disabilities are more likely to be less
physically active than people without
disabilities. In 2008, the National Health Interview Survey
reported that 27.3 percent of people with
disabilities met the 2008 Physical Activity Guidelines for
Americans, whereas 46.9 percent of the general
population met the same guidelines. Engaging in regular
physical activity is one of the most important
things that people of all ages and abilities can do to improve
their health, well-being, and quality of life.
Although the causes of obesity are diverse and complex, lack of
accessible places to be physically active,
combined with other food access factors (e.g., difficulty
preparing and shopping for healthy foods),
create additional barriers for people with disabilities. Having
access to places and spaces to be physical
active may also help to prevent some secondary conditions.
Consequently, when public spaces—
schools, offices, healthcare facilities, and parks—are built, they
should be designed using the Universal
Design14 principles so they can be used by all people,

regardless of age and ability.
People with disabilities also often lack access to basic primary
and preventive health services due to
medical equipment that is not accessible.15, 16 Despite being at
higher risk of developing certain chronic
and secondary conditions, these individuals are frequently
prevented from receiving routine physical
exams and weigh-ins, dental exams, x-rays, mammographies,
Pap tests, colonoscopies, and vision
screenings.
Environmental Barriers
Environmental features affect a person’s ability to participate in
various preventive health and health
promotion activities and services. The built environment
includes a community’s physical form (e.g.,
urban design, land use patterns, and the transportation system)
as well as the accessibility of public
buildings, facilities, and housing. When communities are not
walkable/bikable/rollable, it contributes to
inadequate healthcare service access, levels of physical
inactivity, and social isolation of people with
disabilities. In addition, finding accessible housing can be a
challenge for people with disabilities who

want to live independently. When a home is not accessible,
there is greater potential for falls, decreased
independence, and isolation. 17
To begin removing the health
barriers that people with disabilities
face, public health needs to consider
a new approach where accessibility
and accommodation for people with
disabilities is part of the overall
agenda.
(202) 371-9090 www.astho.org

Programmatic Barriers
Programmatic access to primary and preventive healthcare
services can refer to both the practices and policies that
are part of the delivery system. Medical equipment that is
not accessible, healthcare professionals who are not
appropriately trained, lack of interpreters during exams,
and lack of individual accommodations prevent many
people with disabilities from accessing basic medical
services.21,22 Access can be particularly challenging in rural
areas where workforce challenges are more prevalent. In
addition, people with disabilities often lack health
insurance or coverage for specialty care services, including
long-term care, care coordination, prescription
medications, durable medical equipment, and assistive
technologies.23
Obtaining treatment and achieving recovery can be
challenging for anyone struggling with substance abuse,
but people with disabilities are often inhibited by
additional obstacles. A number of risk factors, including
lack of access to prevention and treatment services, make
people with disabilities more vulnerable to encountering
problems associated with substance abuse.24 Research
shows that substance abuse prevalence rates are higher

for people with disabilities (e.g., traumatic brain inj uries,
spinal cord injuries, or mental illness) compared to the
general population.25,26
Attitudinal and Cultural Barriers
Attitudinal and cultural barriers related to healthcare
services often lead to discrimination toward people with
disabilities and can be more challenging to overcome than
physical, environmental, and programmatic barriers.
Healthcare providers may overlook mental health and
substance abuse needs because they are focused on a
patient’s disability, often leading to misdiagnosis or not
being diagnosed at all.27 If left untreated, non-disability-
related health conditions could exacerbate other
secondary conditions.
Providers may also mistakenly assume that people with
disabilities are not sexually active, especially i f the disability is
severe or disfiguring. Therefore, this
population often is not screened for sexually transmitted
diseases (STDs), and women are not given
regular gynecological exams or advised about preconception
health and healthy pregnancies.28
Women with Disabilities

About 27 million women in the United
States have disabilities. Research
indicates that women with disabilities
may not receive health screenings
regularly or screenings that adhere to the
recommended guidelines.18 Failure to
provide comprehensive services for
women with disabilities can have
significant implications on their health.
Breast Health
• Women with disabilities may have
delayed diagnosis or treatment of
breast cancer due to inaccessible
mammography equipment. Self-
reported mammography use is lower
for women with a disability (72.2%
for 40 years of age or older; 78.1%
for 50-74 years of age) than women
without a disability (77.8% and
82.6%, respectively).19

Reproductive Health
• Women with disabilities are less
likely than women without
disabilities to report having a Pap test
in the past three years.20 Inadequate
service utilization may be due to: not
being aware of the importance of
having the exam, difficulty getting on
the exam table, or finding a provider
who is knowledgeable about their
specific disability. In addition, women
with disabilities may not receive
regular gynecological exams or STD
screenings due to providers assuming
they are not sexually active.

(202) 371-9090 www.astho.org
Strategies for State and Territorial Health Agencies
State and territorial health agencies play an important role in
expanding health promotion and wellness
activities for people with disabilities. CDC currently supports
18 states with implementing disability and
health programs, 11 of which are a collaboration with or housed
within the state health agency. Even
when states do not have specific disability and health programs,
state health agencies can include
people with disabilities in health promotion services and
activities. Strategies that states may consider
to reduce the barriers for people with disabilities include the
following:
• Work with healthcare providers to ensure medical equipment
(e.g., exam tables, scales),
facilities, and buildings are accessible to increase the utilization
of preventive services.
• Encourage providers to advocate for their patients with

disabilities and ensure that all available
resources are used to treat a patient.
• Work with healthcare providers to ensure that staff are
adequately trained to provide
preventive services to people with disabilities.
• Develop policies to encourage health insurers to provide
provisional transition services to
ensure continuity of care in the event of provider or service plan
change.
• Develop, strengthen, and enforce policies that further the
Americans with Disabilities Act’s
scope. Many healthcare providers lack awareness of what is
required to ensure patients with
disabilities have access to culturally-appropriate care.
• Include people with disabilities in the planning, reporting, and
evaluation of topics such as
medical reimbursement, health service delivery, community
planning, communication, and
transportation.
• Include people with disabilities in the design, planning, and

implementation of community
interventions. Have individuals with disabilities conduct staff
trainings.
• Target people with disabilities in all health promotion,
preventive health, mental health, and
substance abuse outreach and programs.
• Partner with organizations that advocate and serve people with
disabilities to leverage the work
they are already doing, expand efforts, and create greater reach.
• Educate people with disabilities about the importance of
preventive health services. Encourage
them to advocate for their health needs and speak up when they
are not being met.
• Work with wellness and fitness centers to reduce the barriers
to physical activity programs by
ensuring access to facilities and equipment. Encourage
implementation of programs that target
individuals with disabilities.
• Facilitate partnerships with a variety of state, local, and
private agencies (including mental

health services, social services, Medicaid, transportation, and
other programs) to coordinate
efforts to increase services and decrease physical,
environmental, attitudinal, and cultural
barriers for all programs and interventions.
• Develop materials in accessible formats (e.g., braille, large
print, audio tape, e-text) that are at
the appropriate reading level and available in different
languages.
• Include pictures of people with disabilities and of different
ethnicities in program materials and
messaging (posters, flyers, brochures, PSAs, videos) to
encourage participation.

(202) 371-9090 www.astho.org
State Disability and Health Activities
State disability and health programs are collaborating with other
state and local agencies to promote
wellness and healthy lifestyles for people with disabilities.
These programs have developed a variety of
initiatives around issues related to access, women’s health,
health promotion training and curricula for
consumers and providers, emergency preparedness, physical
activity, and worksite health promotion.
The following state examples highlight some of these activities.
The Illinois Disability and Health Program
collaborated with the Illinois Department of
Public Health’s Office of Women’s Health to
include language in its Women’s Health Mini-
Grant Program application, encouraging
grantees to include women with disabilities as a
target group. There are three different health

promotion programs offered through the mini-
grants: Women Walking Out, Building Better
Bones, and Life Smart for Women. Specific
disability-related questions were also added to
the mini-grant quarterly reports in fiscal year
2013 to identify the number of women with
disabilities who participate in the programs. By
continuing to collect this data in 2014 and
beyond, the programs will learn how many
women with disabilities participate in women’s
health programs and increase disability
awareness among grantees.
The Massachusetts Department of Public
Health promotes and provides sensitivity
training to healthcare providers on the unique
health needs of people with disabilities. With
CDC funding, the state Health and Disability
Program (HDP) adapted its “Welcoming
Workshops” presentation to include
“Navigating the Patient with a Disability” for
patient navigators. This modification includes
information on the Massachusetts Facility
Assessment Tool, accessible print materials, and
planning accessible meetings. HDP also tailors

its workshops to include audience-specific
information to achieve high impact. By
strengthening ties to other programs within the
state, HDP has a direct impact on healthcare
providers working with people with disabilities.
The Michigan Department of Community
Health (MDCH) has been promoting the
evidence-based, chronic disease self-
management, Personal Action Toward Health
(PATH) program to people with disabilities, so
about half of the PATH participants have a
disability. This goal has been achieved by
offering workshops at disability-friendly
locations throughout the state; collaborating
with disability service, advocacy, and behavioral
health organizations; training people with
disabilities as PATH leaders; and targeting
marketing. In addition, MDCH developed a
postcard to market disability-friendly physical
activity options to people with disabilities. The
postcards are placed in disability advocacy and
service locations statewide. MDCH has also
worked with the state American Cancer Society
chapter and the state’s Breast and Cervical

Cancer Prevention Program to determine the
building and equipment accessibility of
mammography facilities throughout the state.
Through an online portal, women with
disabilities are able to search for accessible
facilities in their county.29
The Montana Disability and Health Program
(MTDH) works to infuse disability health and
wellness goals into the plans, policies,
programs, and procedures of state agencies and
community service providers by having people
with disabilities serve as “disability advisors” in
public health standing committees. As part of
the planning process, disability advisors identify
disability-specific resources to protect and
promote or barriers to remove. MTDH has
created practice guidelines that offer
suggestions on how to involve people with

(202) 371-9090 www.astho.org
disabilities as members of advisory groups.30 In
addition, MTDH and the Montana Housing Task
Force support and advocate for visitability in
home design through a statewide educational
campaign. To date, approximately 8,300
consumers, builders, architects, policymakers,
and other stakeholders have been educated
about visitability in home design.31
The New York State Department of Health
(NYSDOH) Disability and Health Program (DHP)
developed an inclusion policy that requires all
NYSDOH requests for proposals and
applications to incorporate strategies to ensure
people with disabilities are integrated into
public health programs and services. In
addition, all programs must include an
evaluation component to assess the policy’s

effect and reach. DHP also developed a
Medicaid Buy-In Program for Working People
with Disabilities (MBI-WPD),32 which allows
working people with disabilities to earn
additional income without the possibility of
losing critical healthcare coverage. A toolkit has
also been created to help New Yorkers
determine if they would like to apply for MBI-
WPD and assist with the application process.33
The North Carolina Office on Disability and
Health (NCODH) collaborated with the Center
for Universal Design to develop “Removing
Barriers to Health Clubs and Fitness Facilities: A
Guide for Accommodating All Members,
Including People with Disabilities and Older
Adults”.34 NCODH developed a community-
centered training model based on this guide
with the goal of creating fitness environments
that are accessible, safe, and support people of
all abilities. NCODH also offers the Work
Healthy, Live Healthy program, which focuses
on providing environmental supports for health
promotion at worksites to promote healthy

lifestyle choices. The program targets adults
with disabilities who receive services at
community rehabilitation agencies.
The South Carolina Interagency Office of
Disability and Health (SCIODH) has partnered
with the University of South Carolina to teach
future medical professionals and
paraprofessionals about the specials needs of
people with disabilities. Students are taught
how to lift patients from wheelchairs and onto
an examination table, how to communicate in a
sensitive way, and what it means to have a
disability. SCIODH also partnered with the state
Department of Disabilities and Special Needs
and the state health agency to develop the
Steps to Your Health program, which is
designed for people with intellectual
disabilities. Program participants reported
increased knowledge, healthier self-reported
diet, more frequent physical activity, and
reduction in body mass index following the
program.35 SCIODH follows up with class
attendees after one year to see if they have
maintained the healthy lifestyles they learned.

Conclusion
State health agencies are increasingly focusing on health and
wellness promotion initiatives for people
with disabilities. However, these programs currently exist in a
limited number of states, indicating room
for growth at the national and state levels. Research indicates
that disability and health programs are
beneficial not only for people with disabilities, but for the
population and economy as a whole because
these programs decrease healthcare expenditures due to
preventable illness, reduce disparities, and
promote inclusiveness and access for all. As public health
moves toward integrating disability into its
overall agenda, state health agencies need to continue to
prioritize accessibility; accommodations and
alternative formats; messaging and communications; and
disability sensitivity, cultural awareness, and
etiquette to ensure that people with disabilities can participate
to their full extent.

(202) 371-9090 www.astho.org
Resources
American Association on Health and Disability (AAHD)
www.aahd.us
AAHD Health Promotion Resource Center
http://www.aahd.us/resource-center/
AAHD Susan G. Komen Race for the Cure Grants
http://www.aahd.us/initiatives/susan-g-komen-grants/
Amputee Coalition
http://www.amputee-coalition.org/
ASTHO Disability Case Studies

Disability in Older Adults comprises public domain material fr

Disability in Older Adults comprises public domain material fr

Recommended

Recommended

More Related Content

Similar to Disability in Older Adults comprises public domain material fr

Similar to Disability in Older Adults comprises public domain material fr (15)

More from AlyciaGold776

More from AlyciaGold776 (20)

Recently uploaded

Recently uploaded (20)

Disability in Older Adults comprises public domain material fr