Community Integration of Disability: A Bibliometric and Knowledge-Map Analysis

Introduction

Disability is a public health issue of global concern and a priority for development, as defined by World Health Organization(WHO): Individuals with disabilities are not only those who are born with an impairment for any reason but also those who suffer from a range of functional impairments due to illness, injury or natural aging.¹ According to WHO, there are currently 1.3 billion people with severe disabilities worldwide, which represents 16% of the world’s population, or 1 in 6 people.^2,3

Individuals with disabilities are part of the human condition. Persons with disabilities should be afforded equal rights to engage in all activities, just as individuals without disabilities. However, individuals with disabilities often encounter social barriers, including limited access to healthcare resources, as well as stigmatization, discrimination, and violations of their rights, which is particularly prevalent among those living in low- and middle-income countries, where an estimated 80% of people with disabilities reside.⁴

The community serves as the primary living environment for residents, including individuals with disabilities. Patients who have experienced conditions such as stroke, traumatic brain injury, and spinal cord injury may initially receive specialized treatment in hospitals following their illness. After completing hospital treatment, these survivors eventually returned to their community for a prolonged rehabilitation exercise, and became members of their community and home again. However, these survivors are dissatisfied with their reintegration into the community as “individuals with disabilities”.^5,6 For example, concerning community medical resources,⁷ psychological factors,⁸ engagement in community activities,⁹ and the community environment and facilities, which hindered individuals with disabilities from successfully reintegrating into their communities and family life as ordinary members.¹⁰

Community integration(CI) is a worldwide trend for individuals with disabilities. The Convention on the Rights of Persons with Disabilities(CRPD) mandated state parties to facilitate the equal right of individuals with disabilities to reside in the community, make choices together with others, and ensure their rights and opportunities for full inclusion and participation in society.¹¹ In 2023, the United Nations(UN) made another significant contribution to advancing the integration of individuals with disabilities into the community.¹² Furthermore, WHO has emphasized that advancing health equity contributes to broader social integration and participation of individuals with disabilities, and that international support for the community integration of persons with disabilities is crucial.¹³ Meanwhile, it is essential to assist individuals with disabilities in reintegrating and returning to their communities as functioning members of society. Facilitating the reintegration of individuals with disabilities into their communities and families can create the potential to contribute to additional social wealth and enhance their quality of life. In addition, increased research on the community integration of individuals with disabilities could benefit the future provision of sustainable personalized medicine and health services for them at the community level.¹⁴

Scholars have different views on the definition of community integration. Willer et al^15–17 argued that community integration should include family integration, social integration, and productive activities, therefore, community integration is the active and extensive community participation of individuals with disabilities. McColl et al¹⁸ expanded the concept of community integration and argues that community integration should include four dimensions: home integration, social support, vocational, and independent living ability. However, it is worth noting that both Willer and McColl focused only on the objective level of community integration for individuals with disabilities and do not consider the subjective level. Wong and Solomon¹⁹ argued that community integration should not be limited to the physical level but should also include the social and psychological dimensions, which further enriched and expanded the concept of community integration by including the subjective level of community integration. Parvaneh and Cocks²⁰ proposed that community integration should include the seven dimensions: interpersonal relationships, community participation, community belonging, occupation, being at home, reclaiming life, increased risk, and vulnerability, and formed the Community Integration Framework (CIF). In addition, Shaikh et al²¹ argued that community integration differs from participation, and the concept of community integration should be clarified further. In summary, according to the views of the above scholars, the essence of community integration is to enable individuals with disabilities to reintegrate into the communities and families that they are familiar with as normal as possible after they have gone through the painful events, enjoy the same rights as ordinary people, and participate in all kinds of community life as ordinary people do.

Publications related to community integration are increasing.^22–24 However, studies have yet to utilize bibliometric methods to analyze and visually present this topic to the best of our knowledge. In addition, our team is focusing on community integration, and we urgently need to conduct a review on community integration to provide direction for our team’s subsequent research. Therefore, this study can answer the following questions: What is the current status of research on community integration of people with disabilities? Who are the most influential authors in community integration? Who are the authors most contributing to community integration? Which is the most important literature on community integration? In which journals have most community integration research findings been published? How is their quality? Moreover, How is the citation relationship among different journals?

Bibliometrics uses scientific methods to systematically study the quantity, distribution, structure, characteristics, and patterns of published academic findings. It also involves using information visualization techniques and methods to visually display a specific topic’s research development background, status, hotspots, and development trends.^25,26 The utilization of bibliometric methodology in this study is essential and valuable. Firstly, bibliometrics is scientific and widely employed in researching various subject areas. Secondly, the results obtained through bibliometrics are objective and do not rely on individual subjective judgment. Finally, the peers acknowledged and accepted the findings of researchers in the medical field who have utilized bibliometrics in their research. CiteSpace was developed by Chao-Mei Chen, a professor at Drexel University, USA.²⁷ It is a powerful tool for visualizing and analyzing research progress and current frontiers in a specific subject area. The software has robust co-citation and research frontier analysis capabilities.²⁸ We aimed to: (1) conduct a literature review about community integration of disabilities. (2) to clarify the knowledge, hotspots, and trends through CiteSpace.

Methods

Data Sources and Data Collection

All data was retrieved from The Web of Science Core Collection (WOSCC), including the Science Citation Index Expanded (SCIE) and Social Science Citation Index(SSCI). WOSCC was chosen for the following reasons: The Core Journals Citation Database database of the Institute for Scientific Information (ISI) contained thousands of high-quality, peer-reviewed journal literature with worldwide impact. Additionally, data obtained from WOSCC can be directly analyzed with popular bibliometric software, eliminating potential problems associated with corrupted data or missing fields and ensuring the integrity of the analysis.

The specific search strategy in WOSCC was as follows: Topic=(“community integration”) OR Topic =(“community reintegration”) OR Topic=(“community reentry”). Additional search constraints included document type=article and review, language=english, and publication timespan=1990.01.01–2023.12.31. The data retrieval process involved two researchers working consecutively to ensure the accuracy of the search results. We did not include disability-related terms in our search formula for the following considerations: First, community integration is a complex concept, and broader search criteria can reveal more relevant literature; Second, the concept of community integration seems closely associated with disability in general perception; And third, the concept of disability is too big to be well defined. Therefore, the search formula we made can include as much literature as possible with essential insights into the community integration of individuals with disabilities, which will help us uncover interdisciplinary research findings critical to understanding the complexity of community integration. A total of 2242 articles were initially retrieved, with 3 articles being excluded. Ultimately, 2239 relevant hits were obtained (Details in Figure 1).

Figure 1 The flowchart for data collection, analysis and visualization.

Data Analysis and Visualization

CiteSpace 6.2.R4 and Microsoft Office Excel 2019 were used in. CiteSpace was primarily utilized for keyword and co-citation network analysis, including cited references, authors, and journal analysis. We also employed CiteSpace’s journal dual map overlay function to enhance our research findings. The parameters for CiteSpace were configured as follows: the timespan from 1990 to 2023, with year per slice chosen as 1, and pruning was applied using both the Pathfinder and Pruning sliced networks methods. The selection criterion was set to the g-index (k=25). All other settings remained defaults. The Log-likelihood rate(LLR) algorithm was utilized for clustering.

Microsoft Office Excel 2019 (Microsoft Corp., Redmond, WA, USA) was used to draw the trend of the members of the publication and make tables of co-cited authors, co-cited journals, co-cited references, and keyword frequencies.

Results

Results of Publications Every year

The number of publications is a crucial indicator for measuring a field’s developmental trend. It is also significant in analyzing and predicting its future development trend. There is a fluctuating upward trend in the annual number of community integration publications. The trend can be divided into three stages: First (starting stage) occurred before 1992, during which the annual number of community integration articles was below 10. Second (rising stage) occurred from 1992 to 2014, when the annual number of community integration articles remained under 100. Third (further development stage) spans from 2015 to 2023, when the number of articles on community integration exceeded 100 per year. In addition, it took 25 years (1990–2014) to reach more than 1000 cumulative publications. However, it only took roughly 9 years (2014–2022) to reach 2000 cumulative publications from 1000. The cumulative number of publications is fitted to the equation: y=2.3399x²-17.544x+75.656, R²=0.9984 (Details in Figure 2).

Figure 2 Research publications trends on community integration from 1990 to 2023.

Keywords

The high-frequency keywords in CiteSpace reflected the research foundation within community integration. We have compiled keywords of community integration topics. It is evident that from 1990 to 2023, the three most frequently occurring keywords are brain injury (571, 13%), individuals (488, 11%), and quality of life (434, 10%). The more frequently a keyword appears, the more critical it is to the research foundation of community integration. We presented the top 20 keywords based on frequency (Details in Figure 3).

Figure 3 Top 20 keywords on community integration.

Then, we generated a keyword clustering map, and eight clusters were generated. Modularity(Q) and silhouette(S) are crucial indicators for evaluating the clustering level. Generally, the Q greater than 0.3 and S greater than 0.5 indicate a reasonable cluster structure and convincing results. After the clustering, the following parameters were obtained: Q=0.37>0.30 and S =0.70>0.50, indicating reasonable clustering and high confidence. In the keyword cluster map, we display 8 large-scale clusters. The clustering labels start from 0; the smaller the value, the larger its size. The three most significant clusters are #0 traumatic brain injury, #1 mental health, and #2 stroke. We further combined the cluster names and browsed the keywords contained in the eight clusters to further summarize the eight clusters into three main clusters, namely cluster 1 (#0 traumatic brain injury, #1 mental health, #2 stroke, and #6 spinal cord injuries): the main scope of the community integration study. Cluster 2 (#3 children and #5 veterans): the relevant population of the community integration, and cluster 3 (#7 meditation): the assessment tools of the community integration (Detailed in Figure 4a). Subsequently, a keyword timeline map was created based on the keyword clustering map. The timeline view illustrates each cluster keyword’s temporal evolution trend and mutual influence, explaining research dynamics and evolution trends by visualizing the number of clusters, temporal distribution, and knowledge flow. The position of nodes on the horizontal axis indicates their first appearance while connecting lines represent co-citation relationships.As seen in the timeline, research on community integration emerged along with research on children’s issues from 1990 to 2023 and then received much in-depth research in traumatic brain injury. So far, the research areas that are still active are #0 traumatic brain injury, #2 stroke, #3 children, and #6 spinal cord injuries, which indicates that these may be the main research topics at present (Detailed in Figure 4b). Keyword citation burst refers to the sudden increase in the frequency of keywords within a short period, which is utilized to illustrate the hotspots and trends in a specific field. The two keywords, mental retardation (10.4, 18) and developmental disabilities (8.1, 18), had the strongest burst and the most extended duration. So far, the five keywords with the strongest burst are social participation (5.6, 7), substance use (5.9, 5), experiences (7.56, 4), interventions (7.15, 4), and Afghanistan (5.6, 3). In addition, among the four keywords, experiences and interventions have the strongest intensity, greater than 7, which indicates that experiences and interventions related to community integration should receive more attention for they may represent a hotspot and direction of future study (Detailed in Figure 5).

Figure 4 (a) and (b) Co-occurrence analysis of keywords in community integration. (a) keyword cluster map in community integration. (b) Timeline view map of keywords in community integration.

Figure 5 Top 25 keywords citation bursts map in community integration.

Distribution of Cited Authors and Cited References

Frequently cited authors are the most influential scholars within a field, reflecting the pinnacle of knowledge innovation in that particular area. Willer is the author with the most citations, with 405 counts, followed by WHO and Sander, with 380 and 262 citations, respectively. In addition, McColl has a relatively high centrality (0.8) but is still less than 0.1, indicating relatively little contact and cooperation between scholars in community integration. This study presented the top 10 authors with high citation frequency (Details in Table 1).

Table 1 Top 10 Cited References in Community Integration

Frequency cited references serve as the foundation of knowledge for a research field, which is vital in advancing the research. As can be seen from Table 2, the article with the highest number of citations is: “The International Classification of Functioning, Disability and Health (ICF)” with a total of 33 citations, followed by two articles by Sander: “The Community Integration Questionnaire revisited: an assessment of factor structure and validity” and “What is community integration anyway?: defining meaning following traumatic brain injury”. It is worth noting that another scholar, also a highly cited scholar in this study, Willer, also has two articles with high citation frequencies. This study presented ten highly cited references, each with 15 or more citations (Details in Table 2).

Table 2 Top 10 Cited Author in Community Integration

Distribution of Cited Journal

Journal co-citation refers to a network structure that reflects the citation relationships between journals. Scholars can gain insights into the field and assess the quality of journals with articles published on community integration.In this study, the journal with the highest number of citations was Archives of Physical Medicine and Rehabilitation (1122, Q1), followed by The Journal of Head Trauma Rehabilitation (744, Q1) and Brain Injury (732, Q3). The journal with the highest impact factor is Social Science & Medicine, with an impact factor of 4.9. Among the top ten journals, eight are ranked in Journal Citation Reports (JCR) Q1 or Q2 in 2023 (n=10, 80%). A total of eight journals are from the field of rehabilitation(n=10, 80%). This study presents the top ten journals with the highest number of journal co-citations (Details in Table 3).

Table 3 Top 10 Cited Journals in Community Integration

Journal Dual-Map Overlay

Dual-map overlay of journals can analyze the diffusion direction of knowledge in community integration research. This method embodies the analytical objects on a single map and clearly shows the knowledge flow process and the citation relationship between journals. The results of the dual-map overlay analysis of the journals show that there are four main citation paths in the journals on community integration. The citing journals are concentrated in “neurology, sports, ophthalmology”, “psychology, education, social”, and the cited journals are concentrated in “health, nursing, medicine”, “psychology, education, social”. This study analyzed the distribution of journals by field of specialization using the dual-map overlay of journals. In Figure 6, the citing journals are on the left, and the cited journals are on the right (Details in Figure 6).

Figure 6 The dual-map overlay of journals in community integration.

Discussion

This review used CiteSpace, the most commonly used bibliometric analysis software worldwide, to visually analyze research on community integration of individuals with disabilities from 1990 to 2023. It objectively described the current status, development trends, and future research hotspots of community integration. This review can help researchers better understand the current research status and development trends in community integration. To our knowledge, no studies have yet employed a bibliometric method to explore community integration.

From 1990 to 2023, the number of publications focusing on community integration has been on an upward trend. This trend became particularly pronounced after 2015, with the annual publication count exceeding 100, indicating a positive development.This increase may be related to the implementation of disability-related legislation and policies in various countries,²⁹ and the reform and development of long-term care and continuous care worldwide.^30,31 The current trend predicts that research related to community integration will continue to grow and increase in both the level and content, which suggests that more and more scholars are recognizing the importance of community integration.

Many keywords with medical characteristics appeared in the top 20, such as “brain injury”, “quality of life”, “rehabilitation”, “disability”, “recovery”, and “care.”they formed the research basis for community integration. In addition, the top 20 high-frequency keywords can give a general impression of community integration, which is of great significance for researchers to grasp the main content of research on community integration.³²

We have divided the keyword cluster map into three clusters (Figure 4a). Cluster 1 is the largest and most important. We have discovered that the community integration study population includes those with traumatic brain injury, spinal injury, stroke, intellectual disability, and mental retardation. The common thread among them is the presence of neurological problems. After consulting the literature, we found a clue: the deinstitutionalization movement. This movement gained after the 1950s and shifted the focus of psychiatric rehabilitation towards a community-based model. Deinstitutionalization involves relocating individuals with mental illness from large, closed hospital institutions to the community in order to facilitate their better integration into society.³³ Subsequently, deinstitutionalization swept through the United States³⁴ ultimately leading to the enactment of the Americans with Disabilities Act. This historical context highlights why studying mental illness is essential to community integration. An analysis conducted by The Lancet reveals that neurological disorders are now the leading cause of ill health and disability worldwide. Since 1990, there has been an 18% increase in disabilities, illnesses, and premature deaths attributed to neurological disorders.³⁵ It has become imperative to provide people with neurological disorders access to targeted high-quality care, treatment, and rehabilitation services. Consequently, the issue of community integration for people with disabilities has become increasingly important since 1990.

From the timeline view, community integration was first studied in children around 1990. Graphically, research on the community integration of children has yet to develop rapidly and extensively, which may be limited to the fact that the timespan of the data we included began in 1990. A few years later, community integration of traumatic brain injury (TBI) was studied on a large scale. Although the research scale has declined over time, it is still a topic worthy of research.^21,36 However, our study cannot effectively answer why and how community integration research would shift from the children’s research field to the research of TBI patients. Therefore, more research is needed to investigate this diffusion or transfer of knowledge thoroughly. Meanwhile, it is also essential to pay attention to the community integration of stroke, children, and spinal cord injury patients, which represent the current topics of focus for community integration scholars.

The first to burst keywords were mental retardation and developmental disabilities, and they appeared with the highest intensity and most prolonged timespan. Bouras and Szymanski³⁷ compared the services provided to mental retardation and patients in the United States and the United Kingdom and concluded that the mental health services for mental retardation and patients were attributed to the influence of the deinstitutionalization movement and normalization movement in the United States, the renewal of care philosophy, and the advancement of mental illness assessment and diagnosis techniques. The keywords that are still burst and may continue to burst are “social participation”, “substance use”, “experiences”, “interventions”, and “Afghanistan”.

Levasseur et al³⁸ summarized social participation as the process by which individuals interact with others in the community or society. Cooper et al³⁹ mentioned in a study on the social participation of people with cerebral palsy that there is no clear definition of social participation, and the boundaries with social/community integration are often blurred. Shaikh et al²¹ also mentioned in their research that although there are some similarities between social participation and community integration, the latter should be explored as a concept distinct from participation. Therefore, more clarification about community integration and social participation is needed.

Substance Use among adolescents is also a direction that deserves attention in the future. Substance Use Disorder (SUD) is a medical condition involving the abuse or dependence on a substance (such as alcohol, nicotine, opioids, stimulants, sedatives, etc)., which often leads to significant problems in an adolescent’s physical, psychological, and social functioning, and it remains a severe public health problem worldwide.⁴⁰ A survey showed that 20.4 million people aged 12 or older in the United States were diagnosed with SUD in the previous year, but less than 11% of them received treatment. Therefore, responses to SUD require more attention and intervention. In the future, it is possible to explore the development of effective integrated care interventions and the role of integrated care models in promoting the community integration of substance abusers at the community level.⁴¹

Starting in 2020, issues related to the community integration of Afghan veterans have begun to increase. These issues focus on the psychological community integration of veterans and the factors influencing community integration. Bernstein et al⁴² studied predictors of driving status in veterans within 1 year of traumatic brain injury, and their conclusion was reached that rehabilitation efforts to improve function and reduce negative impacts may positively impact driving and community reintegration. Fogle et al⁴³ used the National Health and Resilience in Veterans Study to review the mental health and physical health outcomes of veterans and several critical risk and protective factors. They also discussed how to promote veterans’ mental health and resilience through social support, psychosocial characteristics (such as resilience, gratitude, and meaning in life), and social connectedness (such as secure attachment, community integration, and social participation).

Experiences and Interventions are the two strongest keywords in the five burst keywords. Combined with the timeline chart, research on the experiences and interventions of community integration for people with different disabilities should receive more attention in the future. Ownsworth et al⁴⁴ conducted a longitudinal study to understand the psychological state and degree of community integration of patients with traumatic brain injury after discharge. They concluded that stigma may still negatively impact an individual’s community reintegration a few months after discharge. Becker et al⁴⁵ conducted a qualitative study to explore the community reintegration experiences of stroke survivors in New Zealand and identified four themes associated with successful community reintegration.

The content of community integration research has gradually migrated from its earliest focus on disabilities caused by neurological disorders such as intellectual disabilities and head/brain injuries to a focus on social participation among diverse populations,^46–48 and substance abuse issues among homeless people and offenders,^49–51 and community integration for veterans associated with the wars in Afghanistan.^52,53 Studying diverse populations’ experiences and finding effective interventions to promote community integration has become a popular approach.^54–57 These are the focus and trend of future research on community integration.

Willer led the rankings and developed the community integration questionnaire (CIQ), an assessment tool widely utilized by academics and making significant contributions to community integration. McColl’s centrality reaches 0.8<0.1. McColl et al¹⁸ developed the community integration measure (CIM) in 2001 based on qualitative research with patients with acquired brain injury. The CIM can measure a person’s level of participation in community activities, level of contact with the community, and sense of belonging.

The most frequently cited reference is ICF issued by the WHO in 2001. The ICF provides a theoretical framework and classification system that considers the impact of disease, disability, and other health conditions on the structure and function of the human body, mobility, and participation. It integrates biological, psychological, social, and environmental aspects, aligning with the core goal of modern rehabilitation medicine to improve and restore function.⁵⁸ The ICF is crucial in recognizing and studying health and health-related conditions. To some extent, it also provides a more robust framework for studying the community integration of patients with disabilities. Regarding cited individuals, Willer and Sanders had two documents with many co-citations. Willer et al¹⁵ developed the CIQ in 1993 and validated it with psychological measures. In 1994, Willer et al⁵⁹ utilized the CIQ for further validation in patients with acquired brain injury. The CIQ has been continuously refined and has emerged as one of the most widely used assessment tools for measuring community integration. In 1999, Sander et al⁶⁰ investigated the Questionnaire’s factor structure and concurrent validity, further refining the scoring system for enhanced completeness in evaluating community integration. In 2010, Sander et al⁶¹ further contemplated the definition and concept of community integration, analyzed the challenges encountered by researchers and rehabilitation practitioners, and indicated the direction for future research on community integration. In 2001, Novack et al⁶² conducted a prospective study that identified multiple factors influencing outcomes in patients with acquired brain injury, laying the groundwork for further interventions in this patient population. The paper of Moher is a statement on Preferred reporting items for systematic review and meta-analysis.⁶³ His citation count is among the highest in the field of community integration, which suggests that there has been some increase in evidence-based types of articles in the field of community integration, possibly after 2015. In 2004, Cicerone et al⁶⁴ conducted a non-randomized controlled trial of TBI patients to validate the intervention effects of two interventions, and they found that both interventions had a significant effect on patients with TBI and contributed to the improvement of patients’ community integration.

Using the dual map of journals overlay, we found that the journals cited by the community integration come from multiple fields. This suggests that community integration is a complex social phenomenon that involves psychological, educational, and health domains. The cross-disciplinary citation pattern implies that researchers from different disciplines explore community integration from multiple perspectives, leading to broader interdisciplinary exchange and cooperation. Furthermore, frequent journal citations focus on interrelated and complementary aspects of community integration. This reflects the complementary nature of research themes. As community integration research deepens, methods and theories from different fields influence each other, indicating a new trend in the field’s development - cross-fertilization between disciplines becoming an important direction for future research.

Limitations

Despite the progress we have made, our research inevitably has some limitations. Firstly, our data only includes more than two thousand results from the WOSCC database but does not encompass results from other databases, which may affect the stability of the conclusions. Second, for the sake of comprehensively searching for relevant community integration research, we did not include search terms related to people with disabilities. However, this may prevent us from studying the results of community integration at a more subtle level. Community integration is a complex concept, and our research has pointed the way for future research on community integration: in future research, community integration research should be limited to a single field, such as stroke, children, traumatic brain injury, etc. Finally, we did not analyze the content of authors, institutions, and countries and lacked sophisticated graphics to show the relationships between nodes. In the following study, we will consider an analysis based on graph theory to study community integration comprehensively.

Conclusion

Community integration is gradually becoming a popular research topic, and the annual number of publications in this field is expected to grow in the future. Research on community integration related to traumatic brain injury, stroke, children, and spinal cord injuries is currently the focus of this work. Future research should explore the experiences and feelings of different groups of individuals regarding community integration and develop more effective interventions for community integration. Barry Willer is the most prominent contributing author in community integration. McColl is the most influential scholar. The most authoritative cited reference is the ICF framework published by WHO. Rehabilitation journals, led by the Archives of Physical Medicine and Rehabilitation, are authoritative journals on community integration. More multidisciplinary cooperation in community integration should be conducted. Furthermore, more profound research is needed on community integration in the future.