Workshop on Improving Disability Data for Policy Use
23-26 September 2003, Bangkok, Thailand

International Classification of Functioning, Disability and Health (ICF)

Text version of a Powerpoint Presentation
Presented by WHO on 24 September 2003, 9:00am

Slide 1

UNESCAP Workshop on Improving Disability Data for Policy Use
Bangkok, 23 - 26. September 2003

International Classification of Functioning, Disability and Health (ICF)

2

Framework and Concept

Why do we need disability data?
Disability accounts for 500 Mio healthy live year lost p.a.

Diagnosis alone fails to predict
Service needs
Utilization patterns
Outcomes
Costs

3

Disability Statistics

What is wrong?

• lack of common language
• limited focus & domain coverage
• a priori definition of disability
• no linkage with health surveys

4

Implications of NOT using a common & comprehensive language

(chart showing wide range of percentages of disability within the population of a country)

5

Implications of NOT using a common & comprehensive language

1 Information lack on:

• identifying people with disabilities most in need
• functioning problems that matter most for people
• effective interventions strategies for
  • assistance
  • treatment
  • rehabilitation
  • prevention

2 Equalisation of opportunities

6

WHO Family of International Classifications

(Chart showing relationships)

7

ICF in Health & Disability Statistics

What difference does it make?

8

Universal Model vs. Minority Model

UNIVERSAL MODEL

• Everyone may have disability
• Continuum
• Multi-dimensional

MINORITY MODEL

• Certain impairment groups
• Categorical
• Uni-dimensional

9

Common 'language' endorsed by 191 WHO Member States in the 54th WHA

• Endorse and publish ICF
• Use the ICF in Member States in:
  • research
  • surveillance
  • reporting
• Joint use with ICD
• Operational subsets:
  • surveys
  • clinical encounters
• Periodic revision

10

Inclusive focus & comprehensive domain coverage

(table)

11

Disability as a multi-dimensional & universal experience (a posteriori definition)

• no need for a definition of who counts as disabled and who does not
• choices for threshold can be explicitly stated (at point of analysis)
• measurement can be tailored to suit the purpose

12

Linking Health and Disability Statistics

Health surveys

• Health condition
• Level of functioning
• Risk factors
• Prognosis
• Health system interventions
• Satisfaction

Disability surveys

• Type of disability
• Severity of disability
• Cause of disability
• Impact of disability
• Assistance required
• Other facilitators and barriers
• Satisfaction

13

WHO Surveys: Overall level of health

(chart)

14

WHO framework for measuring health

• places disability as an issue of a threshold on a continuum of health for defining decrement
• clearly recognises the impact of the environment on levels of functioning
• destigmatises 'ill-health' and 'disability' by accepting it as a universal human experience

15

Medical and Social Model

• PERSONAL problem & SOCIAL problem
• medical care & social integration
• individual treatment & social action
• professional help & individual & collective responsibility
• personal & environmental adjustment manipulation
• behaviour & attitude
• care & human rights
• health care policy & politics
• individual adaptation & social change

16

Unidirectional Flow of Concepts

ICIDH 1980

• Disease or disorder
• Impairments
• Disabilities
• Handicaps

17

Interaction of Concepts
ICF 2001

18

Equity / Parity

• Loss of limb
  landmines = diabetes = thalidomide
• Missed days at usual activities
  flu = depression = back pain = angina
• Stigma
  leprosy = schizophrenia = epilepsy = HIV

19

Contextual Factors

Person

• gender
• age
• other health conditions
• coping style
• social background
• education
• profession
• past experience
• character style

Environment

• Products
• Close milieu
• Institutions
• Social Norms
• Culture
• Built-environment
• Political factors
• Nature

20

ICF Field Testing

• 7 years 1994-2001
• 61 countries
• ICF drafts translated into / tested in 27 languages
• 38 National Consensus Conferences
• 7 International Consensus Conf.
• 2000 Live Case evaluations
• 3500 Case Summary evaluations

21

Common 'language' developed in a cross-culturally applicable manner

• Conceptual and functional equivalence of Classification
• Translatability
• Usability
• International Comparisons

22

Foundations of ICF

• Human Functioning - not merely disability
• Universal Model - not a minority model
• Integrative Model - not merely medical or social
• Interactive Model - not linear progressive
• Parity - not etiological causality
• Context - inclusive - not person alone
• Cultural applicability - not western concepts
• Operational - not theory driven alone
• Life span coverage - not adult driven

23

ICF

(ICF Chart up to 1st level)

24

1st level Classification

Body Functions (b) Body Structures (s)

(table of functions vs. structures)

25

1st level Classification

Activities and Participation (d)

1 Learning & Applying Knowledge
2 General Tasks and Demands
3 Communication
4 Movement
5 Self Care
6 Domestic Life Areas
7 Interpersonal Interactions
8 Major Life Areas
9 Community, Social & Civic Life

26

1st level Classification Environmental Factors (e)

1. Products and technology
2. Natural environment and human-made changes to the environment
3. Support and relationships
4. Attitudes
5. Services, systems and policies

27

ICF

(ICF Chart up to 2nd level)

28

2nd level Classification - Example

Chapter 5 Functions of the digestive, metabolic and endocrine systems

Functions related to the digestive system (b510-b539)

b510 Ingestion functions
b515 Digestive functions
b520 Assimilation functions
b525 Defecation functions
b530 Weight maintenance functions
b535 Sensations associated with the digestive system
b539 Functions related to the digestive system, other specified and unspecified

29

Detailed Classification with Definitions - Example

Chapter 5 Functions of the digestive, metabolic and endocrine systems

Functions related to the digestive system (b510-b539)

b 510 Ingestion functions
io Functions related to taking in and manipulating solids or liquids through the mouth into the body.

• Inclusions: functions of sucking, chewing and biting, manipulating food in the mouth, salivation, swallowing, burping, regurgitation, spitting and vomiting; impairments such as dysphagia, aspiration of food, aerophagia, excessive salivation, drooling and insufficient salivation
• Exclusion: sensations associated with digestive system (b535)
• b 5105 Swallowing
  • Functions of clearing the food and drink through the oral cavity, pharynx and oesophagus into the stomach at an appropriate rate and speed.
  • Inclusions: oral, pharyngeal or oesophageal dysphagia; impairments in oesophageal passageof food
• b 51050 Oral swallowing
  • Function of clearing the food and drink through the oral cavity at an appropriate rate and speed.

30

ICF

(ICF Chart up to 3rd and 4th levels)

31

Qualifiers: Body Functions

(diagram)

32

Use of ICF framework

Body Functions & Structures

• IMPAIRMENT of Functions & Structure
• Medical treatment

Activities & Participation

• CAPACITY/ PERFORMANCE PROBLEM
• Rehab, back to work programme, education

Environmental Factors

• Barriers
• Facilitators
• Destigma. Campaign Support informal care

33

ICF Implementation

Information Gap

34

ICF Implementation

1. Population measures
   • Census questions on health and disability
   • Health and Disability Surveys
   • HIS
2. Specific Applications
   • Clinical Encounters
   • Specific populations
     • Elderly
     • Administrative Records
3. Other uses
   • Legal
   • Insurance
   • Education

35

ICF in Health Information Systems

(Chart showing global ICF database and Intervention strategies)

36

Simplification & Parsimoniousness

(circular diagram showing "full version", "checklist")

37

ICF Checklist

• One component- One page "at-a-glance"
• Salient Categories (152 out of 1494)
  • Body Functions
  • Body Structures
  • Activity and Participation
  • Environmental Factors
• Other Contextual information
• Diagnostic information
• Interviewing Guidelines
• Available for:
  • Clinicians & providers

38

Simplification & Parsimoniousness

(circular diagram showing "full version", "checklist", "WHO-DAS")

39

WHO-Disability Assessment Schedule (WHO-DAS) II

• Developed after extensive cross-cultural and psychometric testing
• 6 Domains
  • Understanding the world around you
  • Getting Around
  • Self-Care
  • Getting along with people
  • Life activities (household, work)
  • Participation in Society
• Advanced Scoring
  • Difficulty Ratings
  • Frequency Ratings
• No. of disability days in last month
• Available as
  • Survey version (12 or 36 items)
  • Proxy versions

40

Simplification & Parsimoniousness

(circular diagram showing "full version", "checklist", "WHO-DAS" and two "core sets")

41

Further information:

Visit the ICF website
www.who.int/classifications/icf

Contact us via e-mail:

(email accounts not shown to prevent unsolicited email)

Contact WHO Collaborating Centers for the Family of International Classifications

www.who.int/classifications/icf

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Copyright (c) 2003 UNESCAP
Last Updated 12/11/2003. Contact: stat.unescap@un.org