Slide
1 International
Classification of Functioning, Disability and
Health (ICF)
Structure of ICF
and its use in health and disability statistics
Nenad Kostanjsek
Department of Measurement and Health Information
Systems
World Health Organization
www.who.int/classification/icf
Slide 2
Model of Functioning
and Disability
Health Condition
(disorder/disease)
Slide
3 Health Condition
- A health condition is
an umbrella term for disease, disorder, injury
or trauma
- A health condition may
also include other circumstances, such as
ageing, stress, congenital anomaly, or genetic
presdisposition
- Health conditions are
coded using ICD-10 (e.g. Parkinson’s
Disease G20)
Slide
4 Model
of Functioning and Disability
Slide
5 Characteristics
Body Functions, Structures and Impairmentsp
- Definition
- BF: physiological
& psychological functions of body
system
- BS anatomical parts
of body system
- Impairment: problem
in BF or BS
Slide
6 Parkinson’s
Patient – Example
Impaired Body Functions
- Involuntary movements
(b 765)
- Energy functions (b 130)
- Emotional functions (b
152)
Slide
7 Parkinson’s
Patient – Example
Impaired Body Functions
- Brain (s 110)
- Structures of upper extremity
( s 730)
Slide
8 Model
of Functioning and Disability
Slide
9 Characteristics
activities and participation
- Definition
- Activity: execution
of task
- Participation:
involvement in life situation
- Activity limitation:
difficulties in executing activities
- Participation restriction:
problems of involvement in life situation
Slide
10 Parkinson’s
Patient – Example
Activity limitation & Participation restriction
- Fine hand use (d 440)
- Moving around (d 455)
- Eating (d 550)
- Dressing (d 540)
- Speaking (d 330)
- Community life (d 910)
- Recreation and leisure
(d 920)
- Employment (d 850)
Slide
11 Model of Functioning
and Disability
Slide
12 Environmental
Factors
Environmental factors make up the physical,
social and attitudinal environment in which
people live and conduct their lives.
Slide
13 Parkinson’s
Patient – Example
Environmental Factors
- Extended family (e 310)
– facilitator
- Individual attitudes
of people in subordinate position (e 430)
– facilitator
- Labour and employment
services, systems and policies (e 590) –
barrier
Slide
14 Model of Functioning
and Disability
Slide
15 Parkinson’s
Patient – Example
Personal Factors
- 60 year old man
- Highly educated
- Patient character
Slide
16 Disability
Slide
17 Functioning
Slide
18 Same diagnosis
but different levels of functioning
ICD-10 S 83.3 Tear of articular cartilage of
knee
Slide
19 
Slide
20 1st level
Classification
| Body Functions (b) |
Body Structures (s) |
| Mental functions |
Structures of the nervous system |
| Sensory functions and pain |
The eye, ear and related structures |
| Voice and speech functions |
Structures involved in voice and speech |
| Functions of the cardiovascular, haematological,
immunological and respiratory systems |
Structures of the cardiovascular, immunological
and respiratory systems |
| Functions of the digestive, metabolic
and endocrine systems |
Structures related to the digestive, metabolic
and endocrine systems |
| Genitourinary and reproductive functions |
Structures related to the genitourinary
and reproductive systems |
| Neuromusculoskeletal and movement-related
functions |
Structures related to movement |
| Functions of the skin and related structures |
Skin and related structures |
Slide
21 1st level
Classification Activities and Participation
(d)
- Learning & Applying
Knowledge
- General Tasks and Demands
- Communication
- Movement
- Self Care
- Domestic Life Areas
- Interpersonal Interactions
- Major Life Areas
- Community, Social &
Civic Life
Slide
22 1st level
Classification Environmental Factors (e)
- Products and technology
- Natural environment
and human-made changes to the environment
- Support and relationships
- Attitudes
- Services, systems and
policies
Slide
23 
Slide
24 2nd level
Classification – Example
Activities and Participation (d)
Chapter 5 Self-care
d510 Washing oneself
d520 Caring for body parts
d530 Toileting
d540 Dressing
d550 Eating
d560 Drinking
d570 Looking after one’s health
d598 Self-care, other specified
d599 Self-care, unspecified
Slide
25 Detailed Classification
with Definitions – Example
Activities and Participation (d)
| d 540 |
Dressing |
| |
Carrying out the coordinated actions and
tasks of putting on and taking off clothes
and footwear in sequence and in keeping
with climatic and social conditions, such
as by putting on, adjusting and removing
shirts, skirts, blouses, pants, undergarments,
saris, kimono, tights, hats, gloves, coats,
shoes, boots, sandals and slippers.
Inclusions: putting on or taking off clothes
and footwear and choosing appropriate clothing |
| |
|
| d 5400 |
Putting on clothes |
| |
Carrying out the coordinated tasks of
putting clothes on various parts of the
body, such as putting clothes on over the
head, over the arms and shoulders, and on
the lower and upper halves of the body;
putting on gloves and headgear. |
| |
|
| d 5401 |
Taking off clothes |
| |
Carrying out the coordinated tasks of
taking clothes off various parts of the
body, such as pulling clothes off and over
the head, off the arms and shoulders, and
off the lower and upper halves of the body;
taking off gloves and headgear. |
| |
|
| d 5402 |
Putting on footwear |
| |
Carrying out the coordinated tasks of
putting on socks, stockings and footwear. |
| |
|
| d 5403 |
Taking off footwear |
| |
Carrying out the coordinated tasks of
taking off socks, stockings and footwear. |
| |
|
| d 5404 |
Choosing appropriate clothing |
| |
Following implicit or explicit dress codes
and conventions of one's society or culture
and dressing in keeping with climatic conditions. |
| |
|
| d 5408 |
Dressing, other specified |
| |
|
| d 5409 |
Dressing, unspecified |
Slide
26 
Slide
27 Qualifiers:
Body Functions
Slide
28 Qualifiers:
Body Structure
Slide
29 Qualifiers:
Activities & Partizipation
Slide
30 Qualifiers:
Enivironmental Factors
Slide
31 Using ICF
in disability statistics
Design and implementation choices
WHAT choices have to be made?
- Policy consideration
- Practical consideration
- Disability indicators
- selection &
item reduction
- expected requirement
of indicators: feasibility, reliability,
relevance, sensitivity, specificity, validity
- Measurement approach
- Screening/Filter questions
- Main survey questionnaire
- Threshold setting
HOW to make choices?
- Consultation and
implementation process
Slide
32 Using ICF
in disability statistics
How to design a disability survey?
- Sampling
- Questions
- Screening : 4- 5
short questions
- Full set : 8 –30
questions
- Additional Information:
- Health condition
- Assistance needed
- Other Environmental
Factors
- Response Scale
- Five point scale
linked to ICF coding
Slide
33 Using ICF
in disability statistics
Criteria for Selection of survey domains
- Linked to the conceptual
framework of ICF
- Suitable for self report
- Reliability and Validity
- Comprehensive enough
to reflect major health conditions (in terms
of prevalence and severity)
- Build on existing knowledge
base of common questionaires
- Cross-Population Comparability
- Ensure sensitivity (ability
to pick up positive cases) and specificity
(ability to differentiate true from false
cases) for Screening/Filter questions
- Possible link to a calibration
test
Slide
34 Using ICF
in disability statistics
Recommended ICF item pool (see Annex 9 ICF)
- Vision
- Hearing
- Speech
- Digestion
- Bodily excretion
- Fertility
- Sexual activity
- Skin & disfigurement
- Breathing
- Pain
- Affect
- Sleep
- Energy
/ vitality
- Cognition
- Communication
- Mobility
|
- Self-care:
Including eating
- Usual activities:
household activities; work or school
activities
- Social functioning:
interpersonal relations
- Participation:
societal participation including discrimination/stigma
|
Slide
35 Using ICF
in disability statistics
ICF item pool used in 71 countries
- Population norms for
selected ICF domains are available for countries
which participated in the World Health Survey
2002/03 and the Multi Country Survey Study
2000/01
- Among those are the following
UN-ENSCAP countries
Australia
Bangladesh
China
India
Lao (PDR)
Malaysia
Myanmar
Nepal
Sri Lanka
Philippines
Vietnam |
|
Slide
36 Using ICF
in disability statistics
Linking Health and Disability Statistics
| Health surveys |
Disability surveys |
- Health condition
- Level of
functioning
- Risk factors
- Prognosis
- Health system interventions
- Satisfaction
|
- Type of
disability'
- Severity
of disability
- Cause of
disability
- Impact of disability
- Assistance required
- Other facilitators
and barriers
- Satisfaction
|
Slide
37 ICF based
Assessment Instrument
Measurement Domains
- Understanding and communicating
with the world (cognition)
- Moving and getting
around (mobility)
- Self care (attending
to one's hygiene, dressing, eating and staying
alone)
- Getting along with
people (interpersonal interactions)
- Life activities (domestic
responsibilities, leisure, and work)
- Participation in society
(joining in community activities)
Days out of role (work, education etc.)
Slide
38 Functioning
(WHO-DAS II)
Questions (12 item version)
In the last 30 days how much difficulty did
you have in:
- Standing for
long periods such as 30 minutes?
- Taking care of your
household responsibilities?
- Learning a new
task, for example, learning how to get
to a new place?
- How much of a problem
did you have joining in community activities
(for example, festivities, religious or other
activities) in the same way as anyone else
can?
- How much have you been
emotionally affected by your health
problems?
- Concentrating on doing
something for ten minutes?
- Walking a long distance
such as a kilometre [or equivalent]?
- Washing your
whole body?
- Getting dressed?
- Dealing with people
you do not know?
- Maintaining a friendship?
- Your day to day work?
Slide
39 WHO-DAS II
use and administration
 |
- WHO-DAS survey
version used in 71 countries
- WHO-DAS clinical
version used in multiple settings
incl. HIV/AIDS to study
- sensitivity to change
- cost-effectiveness
- time to administer:
8 min
- training requirements
minimum for lay interviewers
- available in 20
languages
|
Slide
40 WHO-DAS
Software
- Configuration of different
WHO-DAS version
- CAPI minimises interview
error by
- checking entered
values
- managing skipping
pattern
- supports data entry from
paper & pencil version
- operates on desktop,
laptop and PDA
Slide
41 WHODAS II
norms general population
Slide
42 Using ICF
in disability statistics
Setting disability prevalence
rates –
- limited vs. comprehensive
domain coverage
- a priory vs. posteriori
approach
Slide
43 Further information:
Slide
44 ICF based
Disability Survey approach
- Application of WHO-DAS
Short version (12 question) in general population
- Application of remaining
14 question in sub-set
- Branching structure
for questions on impairments and environmental
factors
Slide
45 ICF Implementation
Areas
- Population level
- Census questions
on health and disability
- Health and Disability
Surveys
- Indicators and
reporting systems in health care, rehab,
disability evaluation
- Outcome measure
- Individual level
- Clinical functional
status assessment
- Treatment planning
- Outcome measure
- Other uses
- Legal
- Insurance
- Education
Slide
46 ICF Implementation
Steps
- Specify the purpose
- Select ICF data
set
- Set thresholds
- Decide on measurement
approach
- Develop implementation
strategy
Slide
47 ICF Core Sets
Slide
48 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:
Slide
49 What is Disability
Data?
Disability vs. Health Measurement
| |
DISABILITY |
No |
Yes |
| Health problem |
No |
|
|
| Yes |
|
|
| Case 1: |
Blind person |
| Case 2: |
Person with flu – cannot work for
10 days |
| Case 3: |
Heavy smoker – risk to develop lung
cancer |
| Case 4: |
Person with epilepsy – not allowed
to drive |
| Case 5: |
HIV positive person (a- symptomatic) –
work denied |
| Case 6: |
Person living in polluted environment
- risk to develop respiratory problems |
| Case 7: |
Coronary Infarct - cannot walk +200 meters |
| Case 8: |
Paraplegic person - using wheelchair to
move around |
| Case 9: |
Person with one eye loss – no driving
licences |
| Case 10: |
Ex-Depression patient – difficulties
in engaging in community activities |
Slide
50 Using ICF
in disability statistics
Design and implementation choices
- Domain and their definition
should be linked to ICF
- Wording and sequence
of questions
- ‘What difficulty do you have in….?’
- ‘What happens in your usual/current
environment?’
- ‘What features of the environment
make it easier or more difficult for you
to…?’
- Cognitive testing of what
context people have in mind when reporting
difficulties
- Ask about a wider range
of domains and environmental factors
- involvement in civil
society, friendships, caring for others,
etc.
- attitudes, natural
environment, design of land areas, systems
and policies, services such as housing,
political, legal, etc.
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