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					       World Health Organization
Assessment Classification & Epidemiology
                Group


International Classification
              of
 Functioning and Disability

            ICIDH-2
WHO Family of International Classifications


 PRIMARY CARE               ICD           SPECIALITY-BASED
                                          ADAPTATIONS

                         International
 . Lay reporting
 . Community-based       Classification       IND
   information schemes         of         Nomenclature of
                           Diseases          Diseases


 Procedures
                          ICIDH
                         International
                                          SPECIALITY-BASED
 Reasons for encounter   Classification   ADAPTATIONS
                               of
                          Functioning
                         and Disability
      Need for the ICIDH
 Change   in the Health Care Scene: from
  acute to chronic disease
 Change from disease focus to
  consequences focus
 Need for an international „common
  language’ of consequences
 To serve the needs of people with
  disability
      Foundations of ICIDH-2
   Human Functioning - not merely disablement

   Universal Model     - not a minority model

   Integrative Model   - not merely medical or social

   Interactive Model   - not linear progressive

   Parity              - not etiological causality

   Inclusive           - contextual:environment & person

   Cultural applicability- not western concepts
    The “Bridged” Model of Disablement
          Medical AND Social Models

   PERSONAL problem        AND   SOCIAL problem
   medical care            AND   biopsychosocial
                                  integration
   individual treatment    AND   social action
   professional help       AND   individual &
                                  collective
                                  responsibility
   personal                AND   environmental
    adjustment                    manipulation
   behavior                AND   attitude
   care                    AND   human rights
   health care policy      AND   politics
   individual adaptation   AND   social change
UNIVERSAL vs MINORITY
    Cultural Applicability




• Conceptual equivalence of Classification
• Translatability
• Usability
• International Comparisons
Functioning & Context


          Environment




       Person
          ICIDH levels:
forest - tree - stem - branch - leafs
International                 ICIDH- 2
Classification
of
Impairments,             1. Main volume with
Activities, and             glossary
Participation
                         2. Clinical Descriptions
           A manual of
         Dimensions of
                            & Assessment
           Functioning
       and Disablement      Guidelines

                         3. Assessment Criteria
                            for Research

     WORLD HEALTH
     ORGANIZATION
                         4. Dedicated
     GENEVA
     2000
                            Assessment Tools
       Principles of Revision

   Multi-center network support for development
    and later training
   WHO being the client server
   Multiple versions for different users at
    different sectors and levels of health care
   Field trials: applicability is the key
   Empirical work serves the conceptual
    position and comes before ideological
    position
          Revision Structure
                                               Argentina
                                          Brazil
                                                                                     Level 3
  ALL WHO                        Chile

   Member              China                     Australian CC
   States                                       Dutch CC                             Level 2
                Denmark                                           Health Promotion
                                         French CC                     DPR           Level 1
                  Egypt                                    Mental Health
                                   Japan CC                Substance
Islamic Republic of Iran                                      Abuse
                                  Nordic CC                 Ageing
                Malaysia                                                               WHO
                                                               EBD                     ACE
                                         NACC
                      Pakistan            UK CC              CEQ
                                             MH TF             OHS
                           Philippines
                                              Children’s T F    Other Clusters
                                 South Africa
                                                 Environment T F
      Collaborating Centers
   French - I focus - Mind is not Body - Quebec Model
   Netherlands -Taxonomy - Moment vs Process
   USA - Handicap, Environment,
   Canada - A/P distinction: Person vs Environment
   Australia: PWD - DDRAG
   Japan: Subjective dimensions
   UK: Morbidity coding, DPI
   Spanish Network: Cultural sensitivity
   Finnish: terms, words, ...
         Overall Objective of
          ICIDH-2 Revision
To develop an operational classification system on
        human functioning and disability

   that is applicable to every human being: universality
   addresses multiple dimensions regarding the „person‟
    and „environment‟ (at body, person and society levels)
   international practices that are culture sensitive
   based on user needs
   empirical field trials on applicability, reliability and
    utility
        Significant Changes:
               Overall
   Focus: Disabilities   Functioning & Disability
   Impairments           Body Functions & Structures
   Disabilities          Activities
   Handicaps             Participation
   No environment        Environmental Factors
   Causal - linear       Interactive-integrative
   No Definitions        Operational Definitions
   No Assessment         Linked Instruments
      ICIDH-1                  ICIDH-2

 Conceptual     transformation
 Userneeds
 Advocacy --> science
   – Summary health measures: evidence to inform
     policy
   – Causality: multi-linear web
 Polarization:
   – medical vs social
   – global vs local
   – universal vs minority models
 Models
      Sequence of Concepts
                 ICIDH 1980



Disease
   or      Impairments   Disabilities   Handicaps
disorder
      Interaction of Concepts
                             1999
                        Health Condition
                        (disorder/disease)


Body Function               Activities               Participation
(Impairments)            (Activity Limitation)   (Participation Restriction)




                Environmental            Personal
                Factors                  Factors
Functioning & Disability
    as a Spectrum
 Functioning & Disability
as a multidimensional construct

   Body
    F+S




                Person level (activity)
Hidden Logic of Classification
          Common Sense - Science Link
   Universe
   Interconnectedness with other     Natural
    classifications                   classifications -
   Dimension (s)                     primary (symbolic)
     – uni-dimensional
     – multi-dimensional
   Extendibility
     – downwards / upwards
     – hierarchical relations
   Categories-mutually exclusive
   Categories- jointly exhaustive    Scientific
   Taxonomic Unit                    Classifications-
   Systematic approach               secondary (logical)
   Boundaries vs Core
            Equity / Parity

   Loss of limb
    landmines = diabetes = thalidomide


   Missed days at usual activities
    flu = depression = back pain = angina


   Stigma
    leprosy = schizophrenia = epilepsy = HIV
Images of Disability:
   Forrest Gump
Activity
Limitation
(Disability)
Impairment   Activity
             Limitation
             (Disability)
Impairment    Activity      Participation
             Limitation      Restriction
             (Disability)    (Handicap)
  ICIDH in simple terms

Your body doesn‟t
function properly
You  are limited in your
activities
You   face barriers in society
    Components of ICIDH-II

   Body Functions
   Body Structure
   Activity
   Participation
   Environmental Factors
                    ICIDH-II

   Body Functions are the physiological or
    psychological functions of body systems.

   Body Structures are anatomic parts of the body
    such as organs, limbs and their components.

   Impairments are problems in body function or
    structure such as a significant deviation or loss.
                    ICIDH-II

   Activity is the performance of a task or action by an

    individual.


   Activity Limitations are difficulties an individual may

    have in the performance of activities.
                     ICIDH-II

   Participation is an individual's involvement in life
    situations in relation to Health Conditions, Body
    Functions and Structure, Activities, and Contextual
    factors.

   Participation Restrictions are problems an
    individual may have in the manner or extent of
    involvement in life situation
                 ICIDH-II

Environmental Factors make up the physical, social


 and attitudinal environment in which people live and


 conduct their lives
        Dimensions of
    Functioning & Disability

 Body           ACTIVITIES    PARTICIPATION



BODY            PERSON         SOCIETY
Function/       Activities    Participation
Structure
(impairment)   (limitation)   (restriction)
              Schizophrenia

Body               ACTIVITIES     Participation

Information      Deficit in         Occupational
processing       parental functions hindrance,
                 Work dysfunction Stigmatization
                    Epilepsy

IMPAIRMENTS         ACTIVITY      PARTICIPATION
                    LIMITATIONS    RESTRICTION

Transient loss of   none          denial of a
Consciousness                     driving licence
         Multiple Sclerosis

IMPAIRMENTS     ACTIVITY           PARTICIPATION
                LIMITATIONS        RESTRICTION

Fatigue         self-care          Community part.
Speech          doing housework    Employment
Weakness in     handling objects   lack of special
      muscles                         devices
                   ICIDH-II
    Classification of Each Component

   Chapter e.g., Activities of moving around
   Block e.g., Walking and related activities
   Two-Level category e.g., Walking activity
   Three-Level category e.g., Walking short
       distances
   Four-Level category, if needed
             ICIDH-II
        Uniform Qualifier
0 NO problem         0-4 %

1 MILD problem       5-24 %

2 MODERATE problem   25-49 %

3 SEVERE problem     50-95 %

4 COMPLETE problem   96-100 %

8 not specified

9 not applicable
             ICIDH 2 Codes


                                        Second qualifier

            a 4 10 0 X . 2 0
                         Three level      First qualifier
Dimension
             Chapter
                                       Four level
                       Two level
                 ICIDH-II
             Qualifiers for EF
-0 NO barriers             (none, absent, negligible… ) 0-4 %
-1 MILD barriers           (slight, low…)           5-24 %
-2 MODERATE barriers       (medium, fair...)        25-49 %
-3 SEVERE barriers         (high, extreme, …)       50-95 %
-4 COMPLETE barriers       (total…)                 96-100 %


+0 NO facilitators         (none, absent, negligible… ) 0-4 %
+1 MILD facilitators       (slight, low…)           5-24 %
+2 MODERATE facilitators   (medium, fair...)        25-49 %
+3 SEVERE facilitators     (high, extreme, …)       50-95 %
+4 COMPLETE facilitators   (total…)                 96-100 %
www.who.ch/icidh
Multi-level ICIDH Database
User Comments
Interaction of E with B, A, P
    ISO Standards Application

   Terminology
     – Harmonization of terms and clarification of semantic
       principles
     – Translation
     – Operationalization
     – Computerization
   Standardization for a multi-view and multi
    version approach
     – Compatibility
     – Standard classification procedures: Parent-child categories
              Use of ICIDH

   Scientific :   Impact of illness
   Services :     Interventions and outcomes
   Individual :   Specify needs
   Economic :     Planning

   Social:        Rights of the individual-duties
                   of the society
    Future Directions with
           ICIDH-2
 Use   of the ICIDH-2 at country level
               international data set
 Establishing an
 and comparisons
 Algorithms   for eligibility benefits, etc.
 Assessment instruments

 Computerization &    case-recording forms
Links of ICIDH and DALYs

           I
           C
           I
           DALY
           H
Activity/Participation


                     Good example
   GOOD
                     Learn from it
                     Identify facilitators

   Remove Barriers   Awareness
                     R&D
       Links between
  Disability & Quality of Life
               Disablements
              None   Present
          G
Quality   o
          o
 of       d
 Life     B
          a
          d
       World Health Organization
Assessment, Classification & Epidemiology Group




        ICIDH 2
         Beta 2
  Field Trial Studies
  ICIDH 2 Beta 2 Field Trial Studies
                 Goals
 totest the feasibility of the use of the
 classification in different settings
 totest the reliability of the classification
 in different settings, formats and
 versions
 toaddress some basic questions
 related to constructs and validity
        ICIDH-2 Checklist

 Easy tofill short list of ICIDH-2
 categories
 Available     in several versions
  – Clinician
  – Self-administered
  – Informant

 Canbe used for Activity limitations
 alone
            ICIDH-2 Beta 2
              Field Trials
 Core   Studies
  – Translation and Linguistic Evaluation
  – Basic Questions
  – Feasibility and Reliability for Cases
 Additional   Studies
  – Feasibility and Reliability for Health Records
  – Feasibility and Reliability for Surveys
  – Face validity and predictive validity
  – Utility for Intervention planning and evaluation
  – Individual Centre & Task Force studies
            Translation &
        Linguistic Evaluation
   Translation - must for non-english speaking countries
   Linguistic Evaluation - for all countries

Process
   Translation of the short version (two-level)
   Back-translation and linguistic evaluation of key
    terms
   Evaluation by a bi-lingual expert panel
   Modifications made based on its recommendations
   The translation, back-translation and linguistic
    evaluation of key terms and a report on this exercise
         Linguistic Evaluation
         for English Speakers
   English term has different or modified meaning
   Term has specific meaning in a specialty
   Definitions and inclusion/exclusion terms do
    not meet the operational requirements
   improvements suggested in:
     – terminology
     – definitions
     – operationalizations
     – links with assessment and evaluation tools

   better translatable terms for other languages
        Basic Questions

 New Basic Questions for Beta 2
 Response Possibilities:
  –Individuals
  –Consensus Conferences
  –Feedback form
 Qualitative   and Quantitative
 analysis
               Examples of
              Basic Questions
   Title of of ICIDH-2
   Changes in the Definitions & terminology
   Conceptualizations of B,A,P and E
   Structure of the Classification
   Operationalizations
   Qualifiers
   Guidelines and application notes
   Philosophy
     – Have changes been effective, if not identify problems, recommend
       changes?
     – Are the current structures acceptable, accurate ? Any better
       approach?
Feasibility in Live Evaluations

 Familiarisation ofusers
 Test coding with actual clients
 systematic feedback on
  – use of codes
  – ease of use
  – confidence in coding
  – meaningfulness
  – time to do coding
  – missing areas
Reliability in Live Evaluations

   Rater-observer in one evaluation
   Repeat assessment after one week
   Reliability calculated for
     –2 level categories
     –3 and 4 level categories
     –qualifiers
   Reliability on Case Summaries
              (Vignettes)

 Vignettes collected   from centres
 Standard vignettes    developed
 Accepted coding   developed
 Rated   across centres
 Comparisons made
            CASE 1

Ms. A, with a diagnosis of ICD 10 mild
mental retardation, can understand
the basic need to maintain her health.
Yet, because no physician in her area
provides care for people with mental
retardation, she does not receive the
preventive and basic care she
requires to maintain good health.
         CASE 1 -- coding
 Ms. A: mild mental retardation; can understand the need
 to maintain her health; no physician provides care; she
 does not receive health care


B:   Intellectual functions (b120) – impaired
A:   Activities of looking after one‟s health
           (a580) – not limited
P:   Participation in health (p140) – restricted
EF: Health service providers (e345) – barrier
             CASE 2


Mr. B has a paraplegic condition, as a
result of a severe neck injury, and
cannot perform the basic movements
required to drive a standard car;
however, with a suitably modified
vehicle, he can drive safely.
Unfortunately, there is a law in his
province that prohibits him from driving.
              CASE 2-- coding

     Mr. B: paraplegic condition; cannot drive standard car,
     but can drive modified vehicle; law prohibits driving.

B:       Muscles power functions (b730) – impaired
A:       Activities of using transportation as a driver (a450) –
                 not impaired
P:       Participation in mobility with transportation
                 (p240) – restricted
EF:      Products for personal mobility and transportation
               (e140) – facilitator
         Transportation systems and policies (e635) – barrier
             CASE 3

Mr. C has cerebral palsy can not speak
clearly, but has improved with the help
of a speech therapist. Around friends or
close colleagues at work he has no
difficulty with conversations. However,
most strangers do not take the time to
listen carefully to understand him. So,
Mr. C does not always get what he
wants in stores and restaurants.
              CASE 3 -- coding

Mr. C: has cerebral palsy; with speech therapy can speak clearly around friends
  or close colleagues at work; not strangers; doesn’t get service in stores.

B:       Articulation functions (b320) – impaired
A:       Activities of producing spoken messages (a230) – limited
         Activities of maintaining interaction (a740) – not limited
P:       Participation in spoken exchange of information (p310) –
                  restricted
         Participation in necessities for oneself (p130) – restricted
         Participation in informal social relationships (p430) –
                  not restricted
EF:      Health services (e575) – facilitator
         Friends (e320) – facilitator     Strangers (e355) – barrier
               CASE 4

A mentally retarded couple have been married
for several years and have always wanted to
have children. There are no medical reasons
why they cannot, and they believe that they
will not have any problems in the day-to-day
care of a child. Yet, they have decided not to
have a child because they believe that people
will think they are bad parents and their child
will be shunned by other children and made
fun of.
           CASE 4-- coding

 Mentally retarded couple: want and can care for children; fear
 attitudes of others, so have decided not to have children.

B:    Intellectual functions (b120) – impaired
      Procreation functions (b660) – not impaired
A:    Activities of assisting others (a660) – not limited
P:    Participation in family relationships (p410) –
             restricted
      Participation in caring for others (p530) –
             restricted
EF:   Societal attitudes and beliefs (e420) – barrier
               CASE 5

A child born deaf and blind but with normal
intelligence, is covered by strict educational
mainstreaming laws and is a student in a
regular public school. Her teacher has access
to support staff trained to teach children with
multiple sensory impairments, the child uses
a computer with a Braille adaptation, and is
fully accepted by other children in the class.
Unfortunately, despite the assistance, she is
having considerable difficulty learning basic
reading skills.
                CASE 5 -- coding

     Child: deaf , blind, normal intelligence; mainstreamed with good
     support in public school; difficulty learning reading .


B:         Seeing functions (b210) – impaired; Hearing functions (b230) – impaired;
           Intellectual functions (b120) – not impaired

A:          Purposeful sensory activities (a110) – limited; Activities of learning to
            read (a115) – limited; Activities of understanding spoken messages
     (a210)          – limited; Activities of understanding written messages (a225) –
     limited;        Basic interpersonal activities (a710) – not limited; Complex
     interpersonal activities (a720) – not limited
P:         Participation in education in school (p630) – restricted

EF:        Products for communication (e135) – facilitator; Products for education
           e145) – facilitator; Friends (e320) – facilitator; People in positions of
           authority (e330) – facilitator
     Applicability on Records


 Use   of routine health or other records
 Information   extracted using checklist

 Feasibility and   Reliability of
 classification tested
       Applicability in Surveys


 Back-coding of     existing survey records
 Application     in new surveys
  – Feasibility
  – Reliability
  – Meaningfulness of information
      Face and Predictive Validity

   Information on functioning and disability
     – ICIDH-2
     – ICIDH-2 checklist
     – Other assessment instruments

   Other information collected on
     – diagnosis, severity
     – health care utilisation
     – loss of work days, etc...

   Correlation for cross-sectional measures
   Predictive power for longitudinal measures
Utility for Interventions

 Intervention   matching
  – indications, outcomes

 Intervention   planning based on ICIDH-2
 Evaluation   by intervention personnel
  – Review of advantages and disadvantages
  – Multiple informant feedback
  Centre and Task Force
  Recommended Studies
 For A and P overlap
 Formal Reference Model of the
  ICIDH-2
 Any others
        ICIDH-2 Material

 Available   from the WHO Website



http://www.who.int/icidh

				
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