Draft Icf Practical Manual

7/27/2019 Draft Icf Practical Manual

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How to use the

ICF

A Practical Manualfor using the

International Classication of

Functioning, Disability and Health

(ICF)

Exposure draft for comment

October 2013

World Health OrganizationGeneva


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How to use theICFA Practical Manual

for using the

Internaonal Classicaon of

Funconing, Disability and Health

(ICF)

Exposure dra for comment

Suggested citaon

World Health Organizaon. How to use the ICF: A praccal manual for using the InternaonalClassicaon of Funconing, Disability and Health (ICF). Exposure dra for comment. October2013. Geneva: WHO


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ContentsPreface to the ICF Praccal Manual 1

Why should I read this Praccal Manual? 1

What will I learn from reading this Praccal Manual? 1

How is this Praccal Manual organised? 2

Why was this Praccal Manual wrien? 2

1 Geng started with the ICF 3

1.1 What is the ICF? 3

1.2 How can I use the ICF? 7

1.3 What does the ICF classify? 12

1.4 How does a classicaon such as the ICF relate to electronic records? 14

2 Describing funconing 15

2.1. How can I use the ICF to describe funconing? 15

2.2 What is the ICF coding structure? 18

2.3. How can I describe Body Funcons and Body Structures using the ICF coding

structure? 20

2.4 How can I describe Acvies and Parcipaon using the ICF? 22

2.5 How can I describe the impact of the Environment using the ICF? 25

2.6. How can I use the personal factors? 26

2.7 How can I use the ICF with exisng descripons of funconing? 27

3 Using the ICF in clinical pracce and the educaon of health professionals 29

3.1 Can the ICF be used to enhance the training of health professionals? 29

3.2 How can the ICF be used in the educaon of health professionals? 31

3.3 How can I use the ICF to describe funconing in clinical pracce? 34

3.4. How does the ICF relate to medical diagnosis? 41

3.5. What are the benets of using the ICF as a common language in clinical

sengs? 43

3.6. How can ICF be used to evaluate the outcomes of intervenons? 45

4 Using the ICF for community support services and income support 46

4.1 Why use the ICF for support servicesand income support? 46

4.2 How can the ICF assist service planning? 47

4.3 How can the ICF be used to establish eligibility? 48

4.4 Can the ICF support improved service integraon and management? 50

4.5 Why is the ICF a useful framework to assess service quality? 51

5 Using the ICF for populaon-based, census or survey data 53

5.1. Can the ICF be used to inform populaon-based data collecons? 53

5.2. What is the dierence between collecng survey data and clinical data? 55

5.3. What is the starng point for using the ICF in censuses and surveys? 56


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5.4. How can survey purposes be related to the ICF? 57

5.5. Can standard queson sets be used? 58

5.6. What is involved in the design and tesng of relevant survey quesons? 60

5.7. Should analysis of data and interpretaon of results also refer to the ICF? 61

5.8. What relevant queson sets currently exist? 62

5.9 How can populaon data help examine equal opportunity outcomes? 65

6 Using ICF in educaon systems 66

6.1. Is the ICF useful in educaonal sengs? 66

6.2 Can ICF help to bridge diagnosc and educaonal informaon? 67

6.3 Can the ICF be used for assessment in educaon? 68

6.4 Can ICF be used to understand parcipaon in educaon? 69

6.5 Can ICF be used to analyse educaonal environments? 70

6.6 Can ICF be used to establish eligibility in educaon sengs? 71

6.7. Can the ICF be used for goal-seng? 72

6.8. How can ICF be used to evaluate student outcomes? 73

6.9 Can ICF facilitate cooperaon and integrate dierent perspecves? 74

7 Using the ICF for policy and program purposes 75

7.1 Why is it important to use standard disability concepts across dierent policy areas? 75

7.2 Why use the ICF in policy-making? 76

7.3 How can the ICF help raise awareness and idenfy problems? 78

7.4 Can the ICF help in the policy development process? 797.5 How can the ICF assist planning at systems level? 81

7.6 How can the ICF facilitate policy implementaon? 82

7.7 Can the ICF help evaluate and monitor the eects of policies? 83

8 Using the ICF for advocacy and empowerment purposes 84

8.1 Can ICF be used for advocacy? 84

8.2 Can the ICF be used to measure atudes and atude changes? 85

8.3 Can the ICF support empowerment and independent living? 86

8.4 Can the ICF be used for peer counselling? 87Bibliography 88

Annex 1: List of Acronyms 92

Annex 2: List of Boxes 93

Annex 3: Acknowledgments 94


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Preface to the ICF Praccal Manual

Why should I read this Praccal Manual?

Anyone interested in learning more about use of theInternaonal Classicaon of Funconing, Disability andHealth (ICF, WHO 2001) may benet from reading thisPraccal Manual. The ICF is presently used in many dierentcontexts and for many dierent purposes around the world.It can be used as a tool for stascal, research, clinical, socialpolicy, or educaonal purposes and applied, not only in thehealth sector, but also in sectors such as insurance, socialsecurity, labour, educaon, economics, policy or legislaondevelopment, and the environment.

People interested in funconing and disability and seeking ways to apply the ICF shouldnd the contents of this Praccal Manual helpful. The Praccal Manual provides a range ofinformaon on how to apply ICF in various situaons. It is built on the acquired experse,knowledge and judgement of users in their respecve areas of work, and is designed to beused alongside the ICF itself, which remains the primary reference.

What will I learn from reading this Praccal Manual?

The Praccal Manual provides guidance on how to apply theICF concepts and framework in pracce, for example in:

Coding and stascal use

Clinical documentaon

Educaon

Social Policy and Programmes

Advocacy and Empowerment.

The Praccal Manual describes use casesof the ICF developed since 2001, and brings togetherexperiences from applying the classicaon and framework in various countries and sengssince ICF was published.

The reader is expected to gain an overview of quesons to consider when applying the ICF,common issues associated with ICF use, and examples of how ICF has been applied by others.

This Praccal Manual assumes basic knowledge about ICF, its philosophy, and its principles,as well as the necessary skills and experiences relevant for specic applicaons, such ascoding using ICF. The Praccal Manual complements exisng informaon, recommendaonsand tools, by relang applicaons to the ICF. It does not replace guidelines related tobest pracce and up-to-date methodological standards for parcular user groups, such asclinicians, stascians and educators.

The ICF Practical Manual

provides information on how to

use ICF.

The ICF Practical Manual shares

many examples of how the ICF

has been used.


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How is this Praccal Manual organised?

The Praccal Manual is organised in a Queson & Answerformat to help locate the informaon the reader is seeking.

The Praccal Manual gives a range of informaon to support

ICF use and may refer the reader to related sources.The rst secon, Geng started with ICF, includes basicinformaon about ICF and its usage that users should beaware of.

Similarly, the secon Describing funconing providesdetail on the coding structure of ICF and how to use it, whilepoinng out common issues users may want to note when documenng funconing anddisability.

Subsequent secons provide informaon on using ICF for a range of purposes, in varioussengs, and involving various stakeholders. These secons focus on specic areas of

applicaon, such as in clinical sengs

community support services

income support

populaon-based applicaons

educaon systems

policy and programme development

advocacy.

Boxes are used throughout the Praccal Manual to illustrate how the ICF has been usedaround the world.

Why was this Praccal Manual wrien?

At the me of the rst edion of this Praccal Manual, ICFhas been in use for just over a decade. During this mevarious experiences have been collected, and it may behelpful to new users to be able to access and learn fromthese experiences.

The Praccal Manual also highlights some pialls to avoidand provides examples of successful applicaons, so thatknowledge of ICF use is spread as broadly as possible acrossa wide range of users.

Commenng on the Exposure dra

This exposure dra Manual will be reviewed and nalised in 2014. If you wish to suggest

amendments to the current dra, please contact WHO sta at [email protected]. Comment

received by the end of May 2014 will be considered in producing the ICF Praccal Manual 2014


is organized to answercommonly posed questions in a

knowledge base format.


provides real life examples

of ICF implementation
mailto:[email protected]:[email protected]


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1 Geng started with the ICF

1.1 What is the ICF?

The Internaonal Classicaon of Funconing, Disability andHealth (ICF) is a framework for organising and documennginformaon on funconing and disability (WHO 2001).It conceptualises funconing as a dynamic interaconbetween a persons health condion, environmental factorsand personal factors.

ICF provides a standard languageand conceptual basisforthe denion and measurement of disability, and it providesclassicaons and codes. It integrates the major models ofdisability - the medical model and the social model - as a bio-psycho-social synthesis. It

recognises the role of environmental factors in the creaon of disability, as well as the roleof health condions(stn et al. 2003).

Funconing and disability are understood as umbrella terms denong the posive andnegave aspects of funconing from a biological, individual and social perspecve. TheICF therefore provides a mul-perspecve, biopsychosocial approach which is reected inthe muldimensional model. Denions and categories in the ICF are worded in neutrallanguage, wherever possible, so that the classicaon can be used to record both theposive and negave aspects of funconing.

In classifying funconing and disability, there is not an explicit or implicit disncon betweendierent health condions. Disability is not dierenated by aeology. ICF claries that wecannot, for instance, infer parcipaon in everyday life from medical diagnosis alone. In thissense ICF is aeology-neutral: if a person cannot walk or go to work it may be related to anyone of a number of dierent health condions. By shiing the focus from health condionto funconing, the ICF places all health condions on an equal foong, allowing them tobe compared, in terms of their related funconing, via a common framework. For instance,arthris has been found to have very high frequency among people in Australia with a healthcondion and with a disability; that is, arthris accounts for much of the disability in thepopulaon. In contrast, condions such as ausm, demena, Down syndrome and cerebralpalsy are much higher ranked in terms of the likelihood of severe disability (AIHW 2004).The ICF covers the enre life span. An on-going process of updang the ICF is managed byWHO and its classicaons network to enhance ICF relevance for the populaon at all ages.

The ICF provides a common

language for disability.


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How is the ICF used in health?

Health has been dened in the WHO Constuon as a stateof complete physical, mental, and social well-being and notmerely the absence of disease or inrmity (Constuon ofthe World Health Organizaon, WHO 1948).

The ICF provides a scienc, operaonal basis for describing,understanding and studying health and health-relatedstates, outcomes and determinants. The health and health-related states associated with any health condion can bedescribed using ICF.

Health condions (i.e., diseases, disorders, injuries or related states) are classied primarily inthe Internaonal Classicaon of Diseases(ICD) which provides an aeological framework.The ICF and ICD are two complementary WHO reference classicaons; both members ofthe WHO Family of Internaonal Classicaons. ICF is not associated with specic health

problems or diseases; it describes the associated funconing dimensions in mulpleperspecves at body, person and social levels.

The ICF conceptualises funconing and disability in the context of health, and therefore doesnot cover circumstances that are brought about solely by socioeconomic or cultural factors.Nevertheless, if poverty results in a health condion such as malnutrion, related funconingdicules can be described using the ICF. A health condion whether diagnosed or not isalways understood to be present when ICF is applied.

How is the ICF organised?

ICF organises informaon in two parts. Part 1 deals withfunconing and disability while part 2 covers contextualfactors. Each part has two components:

Funconing and Disability:

o Body Funcons and Body Structures

o Acvies and Parcipaon

Contextual Factors:

o Environmental Factors

o Personal Factors.

The funconing of an individual in a specic domain reects an interacon betweenthe health condion and the contextual: environmental and personal factors . Thereis a complex, dynamic and oen unpredictable relaonship among these enes. Theinteracons work in two direcons, as illustrated. To make simple linear inferences fromone enty to another is incorrect; e.g. to infer overall disability from a diagnosis, acvitylimitaons from one or more impairments, or a parcipaon restricon from one or morelimitaons. It is important to collect data on these enes independently and then exploreassociaons between them empirically.

A persons health can be

operationally deined

using ICF.

ICF puts every person in a

context:

functioning and disability

are resultsof the interaction

between the health conditions

of thepersonand their

environment.


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Each ICF component consists of mulple domains, and each domain consists of categoriesthat are the units of the classicaon. The ICF provides textual denions as well as inclusionand exclusion terms for each class.

Box 2: Denions

In the context of health:

Funconing is an umbrella term for body funcons, body structures, acvies and parcipaon.It denotes the posive aspects of the interacon between an individual (with a health condion)and that individuals contextual factors (environmental and personal factors).

Disabilityis an umbrella term for impairments, acvity limitaons and parcipaon restricons.It denotes the negave aspects of the interacon between an individual (with a health condion)and that individuals contextual factors (environmental and personal factors).

Body funcons- The physiological funcons of body systems (including psychological funcons).Body structures- Anatomical parts of the body such as organs, limbs and their components.

Impairments- Problems in body funcon and structure such as signicant deviaon or loss.

Acvity- The execuon of a task or acon by an individual.

Parcipaon- Involvement in a life situaon.

Acvity limitaons- Dicules an individual may have in execung acvies.

Parcipaon restricons - Problems an individual may experience in involvement in lifesituaons.

Environmental factors - The physical, social and atudinal environment in which people liveand conduct their lives. These are either barriers to or facilitators of the persons funconing.

WHO 2001, 212-213

Box 1: The ICF Model: Interacon between ICF components

WHO 2001, 18

Environmental

Factors

Personal

Factors

Activities ParticipationBody Functions

and Structures

Health condition

(disorder or disease)


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Box 3: Example of denion with inclusion and exclusion statements

Chapter 2 of Acvies and Parcipaon, General tasks and demands, is about general aspects

of carrying out single or mulple tasks, organizing rounes and handling stress. These items can

be used in conjuncon with more specic tasks or acons to idenfy the underlying features of

the execuon of tasks under dierent circumstances. Within this chapter there is the following

category:

d220 Undertaking mulple tasks

Carrying out simple or complex and coordinated acons as components of mulple, integrated

and complex tasks in sequence or simultaneously.

Inclusions: undertaking mulple tasks; compleng mulple tasks; undertaking mulple tasks

independently and in a group

Exclusions: acquiring skills (d155); solving problems (d175); making decisions (d177);

undertaking a single task (d210)

WHO 2001, 130

The funconing and disability of an individual may be recorded by selecng the appropriatecategory and its corresponding code and then adding the numbers or qualiers, thatspecify the extent of the funconing or disability in that category, or the extent to which anenvironmental factor is a facilitator or a barrier. The ICF model and conceptual framework thusprovide the plaorm for a common language and the high level structure of the classicaon

that, in its ner details, allows for specic descripon and quancaon. In this way, the ICFoers users the building blocks for stascal informaon.


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1.2 How can I use the ICF?

Why should I use the ICF?

The ICF is the world standard for conceptualising andclassifying funconing and disability, agreed by the WorldHealth Assembly in 2001. It provides a freely availabletechnical resource which is the internaonal referenceframework for health and disability informaon:

The ICF supports rights-based policies (UN 2006,Bickenbach 2009) and provides a framework andmodel that assist planning and communicaonacross government and other sectors.

ICF provides acommon language, terms and conceptsfor use by people experiencing disability, providing relevant services, or working withdisability data and informaon. This is important because people with funconingdicules may interact with many professionals and systems, for example health,educaon and social care. Processes are more ecient if all those involved are basingtheir approaches and communicaon on the common language and concepts. This isparcularly the case now that some health and human services and systems providelong term services and support for the growing number of people aected by chroniccondions. A common language is essenal to support this integrated care.

ICF provides an organised data structure that can underpin informaon systemsacross dierent areas of policy and services and for policy-relevant populaon data.If records, research and stascs about funconing and disability are based on the

ICF model and framework, they will more eciently contribute to a coherent naonaland internaonal understanding of funconing and disability and data comparableacross sengs and me.

The ICF is a mul-purpose toolwhich allows for a wide range of use cases, some ofwhich are described in this manual.It can also be viewed as meta-language to helpclarify the relaonship between data, informaon and knowledge, and to build ashared understanding and interpretaon of concepts. This will be especially importantif the ICF is to help to ensure consistency of applicaon across sectors and levels ofhealth, social and educaon systems.

ICF is the world standard

for conceptualising and

classifyingfunctioning

and disability, agreed

by the World Health

Assembly in 2001


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Where can I apply the ICF?

The ICF can be used in various ways across many elds ofapplicaon. This Praccal Manual will illustrate some majoruses in Secons 3 to 8. In brief, these are:

Clinical pracce:The ICF is relevant to many acviesin clinical pracce such as the consideraon of healthand funconing, seng goals, evaluang treatmentoutcomes, communicang with colleagues or theperson involved. It provides a common languageacross clinical disciplines and with paents or clients.The ICF is complementary to the ICD the globalstandard for classifying diseases and, when usedtogether, they present a full picture of the healthstatus of an individual.

Support services and income support:The ICF model and classicaon can support

eligibility assessment, service planning, and system-based data generated byadministrave processes. In parcular, the focus on environmental factors makes itpossible to arculate clearly whether the needs of the individual require environmentalchanges or the provision of personal support.

Populaon stascs: Classicaon systems have been described as the buildingblocks of stascal informaon (Madden et al 2007). When populaon data suchas from censuses and surveys as well as administrave and service data are basedon the same concepts and frameworks, a strong, integrated naonal informaonarray can be developed. This informaon resource can then be used to compare thenumbers of people in need of various services to the number receiving them, orcan indicate which areas of the social environment are most disabling for people

experiencing funconing dicules, as just two examples.

Educaon: The same general advantages apply in the eld of educaon as withother policy and programme areas. The ICF, as a common language, can assist withintegrang perspecves from the child, the family, the school, and service systems.

Policy and programmes: The ICF supports clear, conceptual thinking aboutdisability and health related policies at a high level. The classicaon can furthersupport eligibility assessment, service planning and system-based data generatedby administrave processes. If the ICF is used for these purposes across policy andprogramme areas as well as in populaon stascs, then coherent, interconnectednaonal and internaonal data on funconing and disability can be assembled

within the populaon. This, in turn, facilitates planning, managing, cosng, resourceallocaon and monitoring within and across programmes.

Advocacy and Empowerment:The term advocacy may include both advocacy by aperson on their own behalf or on behalf of someone else, as well as broad advocacywhich seeks to inuence system and environmental change. The ICF, as a conceptualframework for funconing and disability related to the UN Convenon on the Rightsof Persons with Disabilies, supports logical arguments based on internaonalstandards, and on related informaon and data.


provides examples of how ICF

may be used in different ways inmany different ields.


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People interested in any of these uses may nd it useful to reference several relevant areasof the manual. For example, people with an interest in survey design reading Secon 5 mayalso nd useful the general principles in Secons 1 and 2, informaon on assessment andmeasurement from Secon 3, as well as details of other exisng quesonnaires such as in

Secon 4.There are many other areas where ICF might be used, such as in the elds of research ortraining (e.g. of health professionals). While these areas of applicaon are not discussed indetail in this Manual, it is expected that the informaon in this manual will sll be useful andmay be extrapolated to other elds of interest.

What data can be organised with the ICF?

Both quantave and qualitave data can be organisedwith the ICF. The ICF provides a valuable framework for

funconing and disability in qualitave studies, in planninga study or in organising qualitave responses. The highlevel arculaon of components and the chapter headingsmay provide useful structuring for these purposes.

The ICF framework and classicaon is similarly useful inplanningquantave studiesand surveys, as its hierarchicalstructure also supports creang adequate data formatsfor dierent purposes at the desired level of detail (e.g. asurvey queson covering an enre domain vs. stascaldata linked to one ICF item). ICF qualiers can be obtained to document the extent of aproblem when used in combinaon with any level of detail selected. Informaon is then

ready for stascal aggregaon or analysis across me and sengs. More detail is given inthe following secons.

Pre-exisng data can be retroacvely related to the ICF, as well. This may be done via aprocess of mapping or linking whereby the high level concepts or components of measures(e.g. assessment or outcome measures) are mapped or linked to ICF components (Cieza et al.2005). In certain situaons, this mapping may enable automac recoding of data.

Data to be obtained from new collecons can readily be based on the ICF framework andclassicaon using ICF based assessment instruments. The necessary steps, along withillustraon of major applicaons, are provided in the following secons.

How can ICF be applied ethically?

It is essenal that the use of the ICF respect the rights ofeveryone, including people with disabilies. ICF providesethical guidelines for the use of the ICF; these are in line withthe principles of the UN Convenon and require involvementof the person concerned in the design of research and datasystems.

Annex 6 of the ICF sets out ethical guidelines for its use (Box4).

ICF structure enables users todesign both:

- measurement data

(quantitative studies) and

- descriptive data

(qualitative studies).

ICF respects the rights of every

person and actively avoids

labelling, stigmatisation and

discrimination.


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Box 4: Ethical guidelines for the use of ICF

Respect and condenality

(1) ICF should always be used so as to respect the inherent value and autonomy of individualpersons.

(2) ICF should never be used to label people or otherwise idenfy them solely in terms of one or

more disability categories.

(3) In clinical sengs, ICF should always be used with the full knowledge, cooperaon, and

consent of the persons whose levels of funconing are being classied. If limitaons of an

individuals cognive capacity preclude this involvement, the individuals advocate should be

an acve parcipant.

(4) The informaon coded using ICF should be viewed as personal informaon and subject to

recognized rules of condenality appropriate for the manner in which the data will be used

Clinical use of ICF

(5) Wherever possible, the clinician should explain to the individual or the individuals advocate

the purpose of the use of ICF and invite quesons about the appropriateness of using it to

classify the persons levels of funconing.

(6) Wherever possible, the person whose level of funconing is being classied (or the persons

advocate) should have the opportunity to parcipate, and in parcular to challenge or arm

the appropriateness of the category being used and the assessment assigned.

(7) Because the decit being classied is a result of both a persons health condion and the

physical and social context in which the person lives, ICF should be used holiscally.

Social use of ICF informaon

(8) ICF informaon should be used, to the greatest extent feasible, with the collaboraon of

individuals to enhance their choices and their control over their lives.

(9) ICF informaon should be used towards the development of social policy and polical change

that seeks to enhance and support the parcipaon of individuals.

(10) ICF, and all informaon derived from its use, should not be employed to deny established

rights or otherwise restrict legimate entlements to benets for individuals or groups.

(11) Individuals classed together under ICF may sll dier in many ways. Laws and regulaons

that refer to ICF classicaons should not assume more homogeneity than intended and

should ensure that those whose levels of funconing are being classied are considered as

individuals.

WHO 2001; 244-245


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What are the main consideraons in using the ICF?

There are many ways to outline the main steps in applyingthe ICF. Here, the process is outlined in terms of some basicquesons that must be answered.

Why:Dene the purpose of the undertaking: for instance, toesmate the need for services or to evaluate outcomes fromintervenons.

What: Idenfy what informaon is sought, relevant to theWhy.Specify informaon items relang to funconing anddisability and relate them to ICF components, domains andcategories, including Environmental Factors. Consider all components for inclusion, and useall chapters (domains) of Acvies and Parcipaon for diverse populaons.

How:What methods will be used?

Methods may include standard survey, data system design, research, ormeasurement methods, but there may also be addional specic consideraonsrelevant to funconing. Some examples of these specic consideraons areincluded in this Praccal Manual.

Design analyses and check that planned analyses will answer the key quesonsand meet the main aims.

Check whether there is exisng informaon available or whether new informaonmust be sought. If using exisng informaon, plan to map to or recode theinformaon in ICF.

If new informaon is needed, idenfy potenal sources and methods of obtainingthat informaon. This may involve consideraons of sampling, queson design, orother standard quesons.

Check whether the planned collecon may serve more than just your own purposes,i.e. whether there are opportunies to combine resources or collaborate acrossprojects or sectors.

What measurement tools will be used? How do these relate to the ICF? Mappingor linking may be required to answer this queson and to enable pre-exisng datato be used in ICF-compable analyses.

Are the methods ethical? Both the UN Convenon and the ICF itself, as well as

many current research procedures, require involvement of the person or personsconcerned in the design of the research and data systems, and in the process ofmeasurement or assessment (see Annex 6 of ICF, or Box 4 in this Manual).

Where and when: In what sengs will the informaon be obtained or the measurementsmade? When should they be made? At what me will assessment be of most benet to theperson concerned? What repeat measurements will best inform outcomes measurement?

Who: Whose perspecves must inform what is recorded? How does the involvement ofdierent perspecves relate to the validity of the data being recorded and its relaonshipto the aim? Many professionals and family members may have views on the funconingand disability of a specic individual, but the ICF recommends that the involvement of theperson in queson is important for validity as well as for ethical reasons. More informaonon all these steps is provided in Secon 2 on describing funconing, and specic guidanceon some applicaons may be found in other secons of the Manual.

Use of the ICF requiressystematic thought and

planning.


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1.3 What does the ICF classify?

Does the ICF dene disability?

The ICF provides denions for funconing and disability(see Box 2 Secon 1.1). However the ICF does not dictate

who is normal and who is disabled. Using the ICF a personor a group can be idened as having disability withineach seng or use. What are universal and standard are theunderlying concept and the dimensions of funcons; thethresholds may change according to the purpose of the usecase. For example, thresholds for a clinical intervenon forvision may dier from those of a social support programme.

In this sense, there are some guidelines; for instance, disability for policy and researchpurposes may be dened, using the ICF, either a priori (e.g. dening a target group for anintervenon) or post facto (e.g. selecng a subgroup by seng a threshold in populaon-baseddatasets). Disability dened for specic purposes will consequently only apply for peoplethat t this denion. The term disability may therefore refer to dierent characteriscsin dierent policy sectors or countries. By using the ICF, dierences in denions can berecognised and people with disabilies who have been excluded or are underrepresentedunder a specic denion may be idened.

Does the ICF classify people?

ICF classies funconing and disability, NOT the people,themselves.

The units of ICF classicaon are categories within healthand health-related domains. The ICF classies physiological(including psychological) funcons, anatomical structures,acons, tasks, areas of life, and external inuences. The ICFdoes not classify people and it is not possible to assign peopleto a category within the ICF.

ICF provides a framework for the descripon of humanfunconing and disability and for the documentaon,organisaon and analysis of this informaon.

To whom does the ICF apply?

The ICF is applicable to all people, to describe their funconingand level of health. As anyone may experience disability atsome point in their lives, whether permanent or temporary,intermient or connuous, ICF can be used to document thedecrements in funconing domains as disability.

ICF was not designed, nor should it be used, to label personswith disabilies as a separate social group. The ICF is applicableto all people, irrespecve of specic health condions, in allphysical, social and cultural contexts.

ICF provides deinitions andconcepts for functioning and

disability which may be used to

inform speciic deinitions in

different settings.

ICF classiies functioningand disability, NOT the

people, themselves.

ICF can be applied to anyone.


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The denionsused in the ICF have inclusionsthat provide specicaons, synonymsandexamplesthat take into account cultural variaon and dierences across the life span. It istherefore suitable to be used in dierent countries and cultures. The ICF can be appliedacross the enre life spanand is suitable for all age-groups.

Can the ICF be used for specic groups and sub-populaons?

The ICF may be used both to dene sub-groups and to describethe funconing or disability of specic groups, idened byage, gender, naonality or any other variable.

Parcular groups can be specied by selecng certaincategories in the ICF and dening threshold levels for groupinclusion or exclusion. For example, it may be of interest tocarry out collaborave research with people experiencing

mobility limitaons above an agreed level of diculty. Othergroupings may be used by service providers to dene theirtarget groups, such as individuals who require personalassistance to enable their parcipaon in a specied area of life. In doing so users shouldbe aware that grouping people with disabilies can be discriminatory if it is done as araonale for treang people dierently. Every human being, irrespecve of any dierence ofdevelopment, funconing or health condion, is equal in dignity and rights.

The ICF can be used to idenfy populaons of interest for the purpose of monitoring whetherall persons with disabilies are fully parcipang in society as required by the Convenon onthe Rights of Persons with Disabilies. Sub-groups, for example people with specic types offunconal limitaon, may need to be idened for specic monitoring purposes, e.g. whether

the deaf community is given adequate recognion and support, or whether children who areblind have access to appropriate means of communicaon in schools. Categories or clustersof categories from ICF can be selected and used to aggregate informaon on funconing anddisability for a group or populaon, such as to illustrate the higher rates of disability in olderpopulaons (e.g. WHO & World Bank 2011). Surveys and censuses may include quesons onfunconing and disability, thus providing informaon for populaon stascs.

ICF could be used to specify

a group based on aspects of

functioning and disability.


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1.4 How does a classicaon such as the ICF relate to electronic records?

Records in various formats in the health eld may be based onclassicaons of all kinds. For instance the use of the ICD andits predecessors worldwide for hundreds of years has enableddata on life expectancy, causes of death, and health serviceuse to be collected and used to inform health decisions inmany countries. In more recent years, populaon surveysand disability support services collecons have been basedon the ICF (see Secons 4 and 5).

Funconal status informaon is increasingly recognizedas an integral part of the electronic health records (EHR)architecture. The ICF as it is (with its class hierarchy withtextual denions) helps to standardize funconal status informaon in EHRs. To ease theincorporaon of ICF into EHRs, work is being undertaken to

formalize the knowledge representaon in ICF (ontology development) and

build linkages with clinical terminologies (e.g. SNOMED-CT)

Work is also proceeding on an ontological representaon of the ICF so as to facilitate its usein, or relaonships to, e-Health systems.

Box 5: Ontological Model of the ICF

Since 2008 the WHO-FIC Network has been working to provide an ontological representaon of

the ICF, to achieve semanc interoperability for the e-Health informaon systems. Organizing

knowledge domains in ontologies permits the creaon of a common framework that allows data

to be shared and reused across applicaons, enterprises, and communies. Addionally, the

informaon can be processed not only manually, but also by automac tools, including revealing

possible new relaonships among pieces of data (Andronache et al 2012).

There are indicaons that ICF, as it now is, does not show a clear ontological structure. For

example, there are constructs within Acvies and Parcipaon (e.g. d210: undertaking mulple

tasks) which can be considered as parent concepts to other constructs in the same component

(e.g. d630 preparing meals), some constructs with similar meaning (e.g. b16711 expression

of wrien language and d345 wring messages) and hard to dierenate by observaon

are posioned in dierent components of the classicaon, with not mutually exclusive

aributes. Further, aempts to map ICF constructs with SUMO (Suggested Upper Merged

Ontology) or to complete a gap analysis with a clinical terminology (SNOMED CT) showed

misalignment. A more stringent and logical re-denion of the ICF categories would:a) reduce ambiguity of concepts and improve ICF use ecacy;

b) facilitate semanc inter-changeability among the major WHO classicaons;

c) ease the process of ICF update and maintenance.

It can be ancipated that future updates of the ICF will move it in this direcon.

See: Della Mea & Simoncello 2010; Simoncello & Della Mea 2011; Della Mea & Simoncello 2012.

ICF may add important valueto the clinical information in

electronic health records to

deine health status.


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2 Describing funconing

2.1. How can I use the ICF to describe funconing?

Can I use the ICF to measure funconing?

The ICF framework and item pool can be used for thedescripon and measurement of funconing. The ICFprovides the building blocks of measurement and stascsin terms of concepts, denions, categories and codes forfunconing and disability as well as related environmentalfactors inuencing them.

The ICF is a resource with mulple uses. This PraccalManual is a complement to the ICF and assumes that readershave a sound basic understanding of ICF. The main steps for

applying the ICF are set out in Secon 1.1, and these alsoare assumed to be understood. This secon goes into further detail relevant to using theseprocesses and undertaking these steps, following on from the more general overview inSecon 1.

Should I use the codes to describe funconing?

In brief, the answer is yes, although in applying the ICF onecan disnguish between (a) using the ICF model and theconcepts and terms of ICF, and (b) codifying funconinginformaon using ICF.

If the ICF is used as only a conceptual model, its dimensionsand domains may be used to describe funconing withoutusing the individual ICF categories or codes. Domains can beunderstood as meaningful sets of body funcons, acons,tasks, or area of life which capture a specic phenomenonor the experiences of an individual.

Which sources of informaon should I use?

The ICF is a framework for disability stascs and health

informaon (Kostanjsek 2011) and an informaon systemwhich enables the integraon of data from many dierentsources. Informaon that can be organised in the ICFmay come from primary sources (person experiencingdisabilies) or secondary data sources (e.g. pre-exisngdocumentaon or stascs). The person experiencing oneor more disabilies may provide direct informaon in aninterview, through a quesonnaire, or through other formsof self-reporng. Relevant professionals or proxies (e.g.parent, partner) may use observaon, quesonnaires, ormeasurement tools and procedures to collect informaon.

The best source of informaon to choose depends on the specic categories of funconingand disability that are to be captured. A professional such as a trained interviewer may have

The ICF framework allows

multiple measurement

strategies. ICF categories may

be measured by levels using

qualiiers.

Functioning is described with a

combination of ICF codes and

ICF qualiiers.

Information that can be

organised using the ICF may

come from primary or secondary

data sources.


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good experse in recording and classifying a specic area, but may not be in the best posionto understand the full experience of disability as it aects other life domains. Therefore, it isimportant to consider the issue of who is best qualied and posioned to record and classifyfunconing and disability informaon.

Some aspects of funconing (e.g. intellectual funcons) cannot be observed directly, but

must be inferred through standardised tesng. For other aspects, self-reported data may bethe most reliable and meaningful (e.g. recreaon and leisure). In some circumstances, it maybe adequate to use mulple data sources for the purpose of cross-validaon. Choice of datasource may also depend on the age of the individual in queson, and on the specic purposefor which the informaon is to be used. For eligibility purposes, there may be a need toestablish severity levels comparable across sengs independent of the specic experienceof disability of one individual, while a study on social well-being might be more interested inthe experience of the individual in the specic life situaon.

Which methods should I use to obtain informaon related to ICF?

There are many dierent approaches that may be used toobtain informaon relevant to categories or domains inthe ICF. For some categories in the ICF, there are specicprofessional standards and procedures, e.g. to measureseeing funcons. For others, assessment instruments maybe available that can be directly linked to contents in the ICF.

Informaon may also be gained through observaon by anexperienced professional. Observaons are subsequentlyorganised into the framework of the ICF. Clinical judgementor professional reasoning is used to idenfy the target category and dene the severity level.

Observaons from proxies may be obtained as well; in this case, the professional may askaddional quesons to be able to establish the severity level.

Informaon can also be gathered through interviews either directly with the person with adisability or with a proxy. This approach is parcularly useful in situaons where funconingcannot be measured directly, or where the experience of disability is of greater interestthan a clinical measurement. Another method may use standardised or non-standardisedquesonnaires or other wrien material provided by the person with disabilies or by aproxy. The role of the individual or individuals involved must be considered at all mes.

Are qualiers an integral part of the descripon of funconing?

A code is complete only when a qualier is present, and aminimum of one qualier must be indicated for each code.The qualier is placed aer the ICF code, separated by adecimal or + sign, and this eecvely closes the code. Thequalier or qualiers specify informaon about funconingstatus: the magnitude, the locaon and the nature of anyproblem.

The rst, common qualier species the extent of a problem,whether the impairment of a body funcon or structure, alimitaon in acvies, or a restricon in parcipaon. The rst qualier may also be used

to convey informaon when there is no funconing problem (qualier 0), consistent witha neutral descripon of human funconing as advocated by ICF. For environmental factors,

The ICF can be used to inform the

collection of information using a

range of methods.

ICF domains indicate the area of

functioning; qualiiers indicate

the extent of functioning or

disability.


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the rst qualier species either the extent of a negave eect (the size of a barrier), or ofa posive eect (how strong that factor is as a facilitator); in the laer case the decimal aerthe code is replaced with the + sign. Important informaon on coding is provided in ICF itself,see Annex 2.

Box 6: The generic qualier and an example of an ICF-code

ICF codes require the use of one or more qualiers which denote the magnitude or severity ofthe problem in queson. The problem refers to an impairment, limitaon, restricon, or barrierwhen used in combinaon with b, s, d or e codes, respecvely. Qualiers are coded as one ormore numbers aer a decimal point.

xxx.0 NO problem (none, absent, negligible, ) 0-4%

xxx.1 MILD problem (slight, low, ) 5-24%

xxx.2 MODERATE problem (medium, fair, ) 25-49%

xxx.3 SEVERE problem (high, extreme, ) 50-95%

xxx.4 COMPLETE problem (total, ) 96-100%xxx.8 not specied

xxx.9 not applicable

The leers b, s, d, and e represent the dierent components and are followed by a numeric codethat starts with the chapter number (one digit), followed by the second level (two digits), aswell as third and fourth levels (one extra digit each). For example, the following codes indicatea mild problem in each case.

b2.1 Sensory funcons and pain (rst-level item)

b210.1 Seeing funcons (second-level item)

b2102.1 Quality of vision (third-level item)

b21022.1 Contrast sensivity (fourth-level item)

WHO 2001

What is the meaning and use of the digits 8 and 9 as qualiers?

When the digits 8 and 9 are used as qualiers, they havedierent meanings from when they are used in codes.Qualier 8 means not specied, and is used when theinformaon provided about the category is insucient toguide the choice of an appropriate qualier; e.g. I knowthere is a problem in seeing, but I do not know whetherthat problem is mild or severe. Qualier 9 means notapplicable, and is used when no specicaon can be givenabout that category. The use of the qualier 9 will mostoen occur when use of the category is inappropriate forthat individual, such as when coding d850 remuneraveemployment for a rered person, or b650 menstruaonfuncons for a male.

The use of qualiers in clinical contexts is further detailed in Secon 3.3.

The digits 8 and 9 as qualiiers

mean not speciied or notapplicable (respectively).


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2.2 What is the ICF coding structure?

How is the ICF organised?

The ICF is a hierarchical classicaon. This means that theinformaon coded at a more granular level is preservedat the broader level, as well. Following each branch of theclassicaon it is possible, from very general categoriesencompassing enre domains of funconing, to reach verydetailed descripons of specic aspects of funconing. Thestructure of ICF is illustrated in Box 7.

Box 7: Structure of ICF

WHO 2001; 215

The classicaon is organised in two parts, each comprising two components. Part 1 -Funconing and Disability - includes Body Funcons and Structures and Acvies andParcipaon; Part 2 Contextual Factors incorporates Environmental Factors and PersonalFactors, though Personal Factors are not yet classied in the ICF. Each component issubdivided into domains and categories at varying levels of granularity (up to four levels),each represented by a numeric code.

The prex to an ICF code is a single leer (b, s, d, or e) represenng the component inICF where the code appears. For example, the prex d represents the Acvies andParcipaon component, although the user may choose to use the more granular, oponal a(for Acvies), or p (Parcipaon), depending on their specic user needs.

Aer this inial leer, the number of digits which make up the code indicates the categoryand its level. The rst digit is used for rst-level categories (chapters 1 to 8 for body funconsand structures, 1 to 9 for acvies and parcipaon, and 1 to 5 for environmental factors).A total of 3 digits are used for second-level categories, 4 digits for third-level and 5 digits

for fourth-level categories. By reading the digits from right to le, one may easily look backfrom a specic code to the broader category within which it is located, moving all the way

The ICF is a hierachical

classiication, arranged in

increasing levels of detail.


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to the domain or chapter. Conversely, when trying to select the most appropriate categoryto describe an aspect of funconing, one should rst allocate the item to the appropriatecomponent, then to the domain and chapter. Finally, within a given block of that chapter,one should select the category best describing that aspect of funconing with the desiredlevel of detail.

At each level of the classicaon there are categories ending with either 8 or 9. Thesecategories may be used to signal either that the aspect of funconing is not covered bythe exisng denions but is suciently specied to be described (- 8: other specied), orthat there is an aspect present for which the informaon available is insucient for furtherspecicaon (- 9: not specied). Users are advised to study Annex 1 (taxonomy) and Annex 2(coding) of the ICF for addional basics on these topics.

How can the dierent levels of the ICF categories be used?

There is no set rule for the level of detail to be used whenusing ICF, but the scope and purpose of the applicaon

should dictate the granularity required. Once informaon isgathered and coded at a given level of detail (e.g. with a thirdlevel code), it will always be possible to roll the informaonup to a broader category, but it will not be possible tocapture greater specicity (e.g. fourth level) without tappingthe informaon source again. Granularity (or level of detail)must be t for purpose. If in doubt, a prudent approachmay be to gather and code the informaon at the greatestspecicity allowed by cost and data management capacity.

The level of detail used should

be it for purpose, and accord

with the quality of information

possible to collect.


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2.3. How can I describe Body Funcons and Body Structures using the ICFcoding structure?

Aspects of physiology and anatomy are described with

categories from part 1 of ICF: body funcons and structures.The body is an integral part of human funconing and thebiopsychosocial model considers it in interacon with othercomponents.

The chapters on structure and funcon anatomy andphysiology respecvely are organized in parallel. Forexample, in Body Funcons, funcons of the genitourinaryand reproducve system are in chapter 6 while the anatomyof that same system is represented in chapter 6 of BodyStructures.

The molecular and cellular details of funcon and structureare not captured by the ICF For example, the presence of an extra chromosome 21 in Downsyndrome is not captured by ICF, but the consequences of that anomaly at the organ andfuncon level are described.

What is the dierence between Body Funcons and Structures?

Body funcons are the physiological aspects of bodysystems, while structures are the anatomical support. Forexample, sight is a funcon while the eye is a structure;force is a funcon, while muscles are structures. In some

chapters, this dierence may be less obvious: e.g. baldnessis a problem of skin funcon (b850 funcons of hair), notin its structure. The user should always check the denionand the inclusion and exclusion specicaons aached toeach category before deciding which code to use.

The integrity in a funcon or a structure should not be used as an indicator that the supporngstructure or funcon is intact, as well. Conversely, impairment in a funcon or structureshould not be used to infer or assume impairment in a supporng structure or funcon.For example, a severe impairment in intellectual funcons (b117.3) may be associated withan anatomically intact brain (s110.0), or an atrial defect in the heart (s41000.35) may be

associated with a normal heart funcon (b410.0).As all categories of body funcons and structures may be applied to a single individual,simultaneously, it becomes especially important to dene the areas of interest to bedescribed or the level of detail in each domain. Again, scope and purpose should guide theuser in making the most appropriate choice.

The ICF chapters on body

structure and function relate

to anatomy and physiology

respectively, and are organised

in parallel.

Body functions are the

physiological aspects of body

systems, while structures are theanatomical support.


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What are the qualiers for Body Funcons and Structures?

Body structures are coded with a generic qualier, an oponal

second qualier which species the nature of impairment,and an oponal third qualier which indicates the locaon,such as le or right. The second qualier reects the nature ofthe change as it is registered macroscopically. It may happenthat a condion is associated with more than one type ofstructural change. In that case, it may be possible to selectthe qualier describing the type of change most relevant tothe person (the rule for doing so would need to be locallydened) or it may be possible to record all impairmentsrelated to the health condion. The third qualier (locaon)should be related to the category being used (e.g. the dislocaon of a lower cervical vertebra

would be described with the third qualier 6-proximal if the code used is s7600 vertebralcolumn, but with the qualier 7-distal if the code used is s76000 cervical column).

Impairments in body funcons or structures are not always permanent or chronic. Forexample, pain might occur only on some days or during part of the day. In such cases,frequency, intensity and duraon of the impairment should be considered as expressionsof severity when coding the extent of impairment. During childhood and adolescence,impairments may also take the form of delays in the emergence of body funcons duringdevelopment.

In describing body funcons and structures the reference point should be the expectedphysiology and anatomy for an average person of the same age and gender. When describing

children, this might involve comparison with milestones in development achieved in thegeneral populaon at a specic age.

What is the relaonship between an ICF body component and an ICD code?

Some of the categories in body funcons or structuresmay reect a health condion as it is described and codedby the ICD. For example, b4200: increased blood pressurefully corresponds to the ICD code for hypertension). Theserelaonships will be addressed in the current ICD revision.However, it should be kept in mind that ICF describes human

funconing as a snapshot with none of the prognoscimplicaons a clinical diagnosis may entail. Also, descriponof a specic impairment does not mean that the impairmentis permanent or equate to a diagnosc conclusion.

Body structure may have up

to 3 qualiiers, relating to

extent, nature and location of

impairment. Body Funtion has

one qualiier, to indicate the

extent of impairment.

Some ICF body categories

relect

health conditions.


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2.4 How can I describe Acvies and Parcipaon using the ICF?

Acons and tasks executed by individuals are dened asAcvies, and involvement in life situaons is dened as

Parcipaon. The chapters and categories of ICF coverall aspects of life, from basic acons such as walking andmoving, to complex and socially collaborave situaonssuch as interacng with others, or parcipang in school orin community life.

Chapters (domains) are organized in blocks in which thecategories are clustered in an ordered way, either fromsimpler to more complex, such as in the domain 4 (Mobility)or from general to more parcular, such as in the domain 7(Interpersonal Relaonships).

The categories or blocks of acvies and parcipaon may be composed of mulpleelements which relate to each other. For instance, parcipang in school educaon entailsthe organizaon of daily roune, undertaking single and mulple tasks, managing stress anddemands and so on. In selecng the most appropriate set of categories to describe an acvityor area of parcipaon, one should focus on the set best represenng its crical aspects andrelang to the purpose of recording the informaon.

What are the opons for delineang Acvies and Parcipaon?

ICF presents the 9 domains of acvies and parcipaon asa single list. Every acon, parcularly when executed in a

social environment, may be considered parcipaon, andparcipaon always entails the execuon of an acon ortask. Despite this relaonship, the denions of acviesand parcipaon are clearly dierent and disnguishingacvies and parcipaon will require careful consideraon.

When evaluang Acvies and Parcipaon, the ocialWHO coding style uses a single, fully overlapping list ofcategories. However, the user may consider any of the fouropons shown in ICF annex 3:

Disnct non overlapping sets of Acvies (e.g. domains 1-4) and Parcipaon

(e.g. domains 5-9) Parally overlapping sets (e.g. Acvies domains 1-6 and Parcipaon domains

3-9)

All rst and second level categories as Parcipaon, and all categories at higherlevel as Acvies

A single fully overlapping list of categories (ocial WHO coding style asmenoned above)

Recording the reasons for the choice and experience each me the ICF is used is of general

interest to other users. Such recording is explicitly advised in Annex 3 where it is notedthat with the connued use of ICF and the generaon of empirical data, evidence will

The Activities and Participation

chapters of the ICF

allow the description

of all areas of life for all people.

There are four options inAnnex 3 of the ICF, with the

fourth option a single,

fully overlapping list now

recommended by WHO.


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become available as to which of the above opons are preferred by dierent users of theclassicaon. Empirical research will also lead to a clearer operaonalizaon of the noonsof acvies and parcipaon. Data on how these noons are used in dierent sengs, indierent countries and for dierent purposes can be generated and will then inform furtherrevisions to the scheme.

What are the qualiers for Acvies and Parcipaon?

Two qualiers may be used to describe Acvies andParcipaon, based on the generic qualier and theconstructs of performance and capacity. The rst describeswhat a person does in their actual environment. The seconddescribes what a person does in a situaon in which theeect of the context is absent or made irrelevant (such as ina standardized evaluaon seng). The performance of theacvity or level of parcipaon should always be observable

as it reects the actual funconing in the real life seng.However, since the performance qualier describes theinteracon between the person and the context, it may change in dierent environments(e.g. the funconing of an individual may change signicantly when at home as comparedto when at work). Opons to account for this variance include coding separate proles ofperformance for dierent environments, or making an appraisal of the performance in themost relevant seng for the purpose of the current ICF use.

In some instances, capacity may be easily observed by simply removing a specicallyrelevant environmental factor (e.g. capacity of walking could be observed for a person whouses a walking sck by taking away the sck, in a standard environment). In other situaonscapacity may be impossible to evaluate objecvely, either because the contextual factor

cannot be safely removed (e.g. a medicaon or an implanted medical device) or because thecontext is, in fact, part of the acon being described (e.g. in interpersonal relaonships orhousehold acvies). In these situaons, capacity may be inferred by approximaon, referralto previously collected data, or repeated evaluaons in dierent sengs to esmate theeect of a specic environment on the level of funconing (e.g. to note the dicules aperson has in relaonships with dierent friends in dierent environments).

The combined coding of performance and capacity is a powerful technique to understandthe nal eect of the environment on a person, as well as allowing the user opportuniesto eect changes to the environment to enhance funcon. The gap between capacityand performance reects the dierence between the impacts of current and uniform

environments, and thus provides a useful guide as to what can be done to the environmentof the individual to improve performance (WHO 2001, 15).

What are the addional qualiers for Acvies and Parcipaon?

There is a variety of oponal or addional qualiers thatmay be useful, including qualiers for performance withoutassistance and capacity with assistance, both of whichmay be useful in instuonal sengs. The use of theseaddional qualiers may allow the dierenal evaluaonof modicaons to the environment, such as assisve

technology, personal assistance, or policies related toequitable access.

Two qualiiers are described

in the ICF performance and

capacity; the difference between

them indicates the effect of the

persons environment.

There are additional optional

qualiiers, in different stages

of development and use.


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It is possible that, in the future, WHO may develop a qualier for involvement or subjecvesasfacon for the acvies and parcipaon component (WHO 2001, 230-231). Such aqualier (sasfacon with parcipaon) has been developed for use in Australia, to helpwith delineang Acvies and Parcipaon (AIHW 2006, AIHW 2003). Based on ndingsfrom ICF-based populaon surveys done in Japan, a disncon is made in that country

between two indicators of performance of acvies: universal independence and limitedindependence (Okawa et al 2008).

What is the dierence between Acvies and Body Funcons?

Acvies may relate to the interplay of mulple funconsand structures. For example, speaking (d330) requiresmental funcons of language (b167), plus voice (b310),plus arculaon (b320), all supported by the associatedstructures (s3). Essenals of walking (d450) include thecombinaon of orientaon (b114), balance (b235), control

of voluntary movement (b760), muscle force (b730), tone(b735), mobility of joints (b710), structural support ofbones (s7700), ligaments and tendons (s7701) as well asenabling environmental factors such as well-built roads andfootpaths. It is oen possible to observe the specic bodyfuncons and the more complex related acons separately.

In other cases, such as for many mental funcons, the acvity is the only way in which abody funcon may be assessed. For example, to evaluate aenon funcons (b140), the onlyavailable method is to observe the acvity of focusing aenon (d160).

Activities relate to the whole

person and may relate to

multiple functions and

structures.


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2.5 How can I describe the impact of the Environment using the ICF?

What are barriers and facilitators and how do I code them?

The physical, social, and atudinal environment in whichpeople live inuences their funconing in a substanal way.

If that inuence is posive, the resulng performance willbe above the expected capacity; if that inuence is negave,the individual will perform below his or her capacity. Whenan environmental factor improves performance, it is codedas a facilitator; when it lowers the level of performance, it iscoded as a barrier.

The socio-cultural context in which an individual lives shouldbe taken into consideraon when coding the absence of aspecic environmental factor as a barrier. This may require making a judgment about what itis reasonable to expect. Is the absence of an electronic wheelchair or public transportaona barrier because it is not available in a specic rural context? In such cases, should codes in

Chapters 1 (Products and Technology) and 5 (Services, Systems and Policies) be recorded asbarriers? How can improvements in services be idened if these factors are not recordedas barriers?

What are the dierent coding opons for Environmental Factors?

Environmental factors can be coded as a separate list, and inthis case the weighng of their inuence should be againstthe eect they have on the funconing of the whole person.Environmental factors can also be coded in parallel to thecategory on which they exert their eect. In this case, thequalier should consider the eect that the factor has on

that specic item; for example, peer atudes may aectschooling, or technology may aect employment.

Environmental factors are to be coded as they relate to theindividual whose situaon is being described. Facilitatorsand barriers should be coded with reference to the inuence they have on the funconingof that individual, and the qualier should be applied to describe the extent to which anenvironmental factor is inuencing the funconing of that individual. The perspecve ofthe individual whose funconing is being evaluated or described represents importantinformaon and should be included in the evaluaon of environmental factors whereverpossible. External observers may make valuable contribuons to the understanding of theeects of environmental factors and the improvements that can be made

It is not infrequent that an environmental factor acts both as a facilitator and a barrier(e.g. a drug improving some symptoms but causing adverse eects; a mother providingsupport for a child in one area of life but at the same me prevenng the development ofhis autonomy in interpersonal relaons; specialised transportaon services that facilitateusing transportaon, but are a barrier as their availability is limited and they prevent publictransportaon services from becoming fully accessible). If the opposite eect is exertedon dierent aspects of funconing, it is possible to dierenate the opposing inuenceby aaching the environmental factor code to the aected category with the appropriatequalier indicang its posive or negave eect (e.g. the mother facilitates self-care of thechild but is a barrier to the personal interacons of that child). If the inuence is observed

on the same category, then one could either make an esmate of the nal total eect thatenvironmental factor has on the specic aspect of funconing, or repeang the categorywith a dierent qualier measure.

The environment may have asigniicant effect on a persons

functioning and it is essential

to record the degree to which it

enables or disables the person.

There are three options for

coding Environmental factors (in

Annex 2): relating to the person

overall, to each ICF component,

or to performance and capacity.


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2.6. How can I use the personal factors?

What are the personal factors?

Personal factors may include gender, age, race, lifestyles,habits, educaon and profession. They represent inuenceson funconing parcular to the individual which are notrepresented elsewhere in ICF. An example of this is whenan individual cannot get a job due to lack of qualicaons,rather than any diculty in funconing or problem inthe environment. One way to include personal factors inthe funconing prole is by annotaon and descripon.Populaon surveys rounely gather such informaon as partof the survey.

Why are personal factors not yet classied?

Personal factors are not currently classied in the ICF. This isdue to the large societal and cultural variance, as well as thelack of clarity in the scope of such factors.

ICF was developed as a universal tool to describe humanfunconing, health and disability. Extreme variaon andcontextual dependency of personal factors has so farprevented a shared approach to their classicaon. Manyelements of personal factors (e.g. economic, educaon andemployment status) have been described and classied

by other systems, such as those of internaonal and naonal stascal organisaons, andappropriate use of these sources may be made when including personal factors. Further,some factors that could be considered personal may be already classied in ICF itself.Examples of this are b126 Temperament and personality funcons or b1301 Movaon.

The development of a classicaon of personal factors is recognised as both a challenge andan opportunity. By including such informaon in data collecon, an invesgator may provideempirical background for the future development of personal factors in the ICF.

Personal factors represent

inluences on functioning

particular to the individual.

There is as yet a lack of clarity

about the scope of personal

factors.


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2.7 How can I use the ICF with exisng descripons of funconing?

How can I link the ICF to dierently structured informaon systems?

The organisaon of the ICF as a classicaon is based on the ICF model and follows specictaxonomic principles. Disability-related informaon generated independently of the ICFmodel and classicaon may or may not be easily linked to individual categories or codeson a one-to-one basis. For example, disability categories used by educaon systems andanalysed according to the ICF model may represent:

a health condion as represented in the ICD (e.g. Aenon Decit HyperacvityDisorder, Ausm); or

an impairment (e.g. in aenon funcons or structure of the inner ear); or

a cluster of funconal problems with idencaon of an underlying healthcondion (e.g. intellectual disabilies, physical disabilies); or

a cluster of funconal problems without idencaon of an underlying healthcondion (e.g. developmental delay, learning disabilies).

The main purpose of any cross-walk should be to clarify and idenfy concepts and contentusing ICF. Cross-walks can be established to exisng databases, other classicaons, ordisability-related nomenclatures as well as to assessment tools. Linking rules (Cieza et al2005) are used wherever applicable.

Box 8: Informaon systems learn to speak ICF: the FABER soluon

A web applicaon named FABER was developed by the WHO-FIC Collaborang Centre in Italy tocollect informaon using a mul-axial assessment framework consistent with ICF. ICF and othermedical terminology systems are used to record informaon. The web applicaon includesan informaon model and a descripon model. The informaon model contains concreterecord entries. The descripon model provides templates for the bio-psycho-social record. Thetemplates describe the informaon that may be entered, all referenced to the ICF conceptualmodel. Parcular emphasis was placed on collecng informaon on environmental factors (EFs)to describe the interacon between an individual and their environment.

The FABER conceptual design was developed, and implementaon of a minimum dataset forindividual records was implemented, in accordance with an ad hoc biopsychosocial assessmentprotocol tested with more than 1,300 Italian outpaents in a naonal project during the period

2008-2010. FABER was populated in dierent steps and by dierent professionals who workedcooperavely. The web applicaon releases specic outputs useful to disnguish betweenfunconing and disability in the same funconing prole, to highlight the EFs involved, andto plan reasonable adaptaons to overcome disability. A specic algorithm was designed todisnguish between posive and negave aspects of the interacon between an individual andtheir EFs. Two eld trials were carried out in 2011 and 2012, respecvely, on 400 individuals witha variety of health condions and from dierent age groups. The alpha version, in Italian, wasadapted to the Italian welfare system, services, and policies. An internaonal version working inother languages and dierent systems is planned.

hp://www.reteclassicazioni.it
http://www.reteclassificazioni.it/http://www.reteclassificazioni.it/


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Can the ICF help to clarify how people think about disability?

It is possible to gain insight into the way people thinkabout disability by comparing statements and underlyingpremises and by asking quesons and analysing textualinformaon in the context of the ICF model, framework andclassicaon. In some situaons, the term disability maybe used without strict understanding or awareness of thepotenal underlying concepts, beliefs or theories. However,ICF is based on an integraon of medical and social modelsto provide a coherent view of dierent perspecves ofhealth and disability from a biological, individual and socialperspecve.

In all contexts, consideraon should be given to the complexity of combining informaoncreated in dierent philosophical, scienc, instuonal or cultural sengs by individuals

with dierent levels of personal involvement or professional interests. For example, clinicaldata based on informaon collected by a specic professional group may yield very dierentndings from informaon from a populaon survey based on self-reported data. Reliableknowledge upon which to take far-reaching decisions should be based on a meaningfulintegraon of all available informaon.

ICF provides an integrated,

coherent view of health and

disability.


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3 Using the ICF in clinical pracce and the educaon ofhealth professionals

3.1 Can the ICF be used to enhance the training of health professionals?

What is the current status of health professions educaon?

A global independent commission on the educaon ofhealth professionals for the 21st century concluded thatundergraduate students are currently not adequatelyequipped to strengthen health systems and to address thehealth needs of populaons (Frenk et al 2010). Healthcareadvances in the last century benet relavely few people,resulng in a widening of inequies in healthcare. This Lancet

Commission report made recommendaons for instruconaland instuonal reform of educaonal instuons, includingstrategies emphasising person-centred and community-based training to reduce this gap. This could be achievedby introducing competency-based curricula that facilitate transformave learning to equipstudents as agents of change. The harmonisaon between the educaon and health systems isanother crucial component that was idened. This interdependence could be strengthenedthrough inter- and trans-professional teaching and learning (Frenk, et al., 2010).

The use of the ICF framework as an approach to paent care can play a strategic role intransforming the educaon of health professionals (Geertzen et al., 2011) and improvinginter-professional collaboraon (Allan, et al., 2006). This process can contribute to the

strengthening of health systems and the health status of individuals.

Which health professionals should be educated to use ICF and why?

The ICF can be used in undergraduate and post-graduatetraining of any health professional, as well as in primarycare sengs and by community care workers (Snyman et al.,2012). The advantages of integrang ICF in educaon in thisway include:

The framework acts as a catalyst for change

management as educators start modelling a holiscapproach to paent care

The tradional hierarchical structure of the teamchanges. Team members become equal partners inthe team where their contribuons are valued and an environment is createdin which any appropriate team member may coordinate the management of apaent.

ICF can be used to structure a holisc approach to management of any paent with anyhealth condion, ensuring person-centred care. ICF does not belong to any single discipline,but is neutral. It is therefore an ideal tool to link and integrate informaon taught to dierent

health professionals. The use of the ICF framework as a common approach in teaching theassessment and management of paents can result in:

The incorporation of the ICF

framework in the education of

health professionals can improve

approaches to patient care and

inter-professional collaboration.

ICF may be applied by any

health professional, and thus

may serve as a foundation for

inter-professional education,

collaboration and practice.


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Beer paent experience,

A bio-psycho-social-spiritual approach to paent care, Improved health outcomes,

The strengthening of health systems,

Improved inter-professional educaon, collaboraon and pracce and

Task sharing and task shiing.

The ICF framework can provide a guide for teaching public health and development of publichealth competencies. The environmental factors domains can provide a framework forstudents to collect, analyse, interpret and communicate informaon pertaining to: publichealth outcomes, social determinants of health, health promoon and disease prevenonacvies in collaboraon with community partners, and mapping of community assets.

Does the use of ICF enhance the clinical performance of students?

There is research evidence to suggest that the use ofthe ICF can lead to a more holisc and comprehensiveassessment and management of paents. This wasfound to be so when a funconal model, rather than atradional, solely diagnosis-based model, was used toassess paents with mulple sclerosis; the assessments

were more comprehensive and more items requiringintervenon were idened (Stallinga et al., 2012).

The introducon of the model in training physiotherapystudents to manage children with developmentaldisorders resulted in intervenon plans whichdemonstrated a greater awareness of the impact of contextual factors and a beerunderstanding of parcipaon and social interacon (Jelsma & Sco, 2011).

When medical students used the ICF framework within a primary healthcare context itenhanced transformave learning and facilitated interdependence and contributed to thestrengthening of the health system (Snyman et al., 2012).

The use of ICF can lead to a

more comprehensive approach

to disability.


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Students will not compartmentalise the management of dierent healthcondions. Instead, they will be taught to integrate informaon from acrossdierent disciplines (e.g. anatomy, physiology, pathology, sociology), systems(e.g. cardiovascular, musculoskeletal) and professions or speciales (e.g. surgery,public health and medicine).

(Stephenson & Richardson, 2008).

It has been found that the more familiar a student is with the ICF, the more comprehensivetheir assessment and management of their paents. Clinical reasoning is enhanced, allowingthe student to develop a full and complete clinical and contextual prole of paents (Edwardset al., 2004).

The conceptual framework of the ICF, which emphasises that there is not a linear causalrelaonship between a specic health condion and the funconal outcomes, is an idealtool to encourage students to invesgate and integrate the relaonship between thedierent components.

What items of ICF should be included and at what level?

Students should be introduced to the conceptual frameworkof the ICF early in their training so they become familiarwith the broad structure of components, interacons anddomains. The student should learn how to gather all relevantdata, but also how not to waste me gathering informaonthat his not relevant to the paents management (Sackeet al., 1985). It may be that all health professionals shouldhave the ability to assess funconing and health at a very highlevel, while dierent health professionals may have dierentrequirements with regard to the use of the more granularcodes, i.e. at a three or four level. The amount of informaonrequired may also depend on the funconal status and healthcondion of the paent.

Can the ICF assist students in pracsing evidence-based healthcare?

ICF has been found useful in generang outcome-based

assessments (Peterson & Rosenthal, 2005). The incorporaonof ICF outcome measures into the assessment of a paentcan be a valuable teaching tool, as it allows the consistentevaluaon of the impact of intervenons, and builds upbest pracce skills based on rst-hand experience.

The introduction of ICF in the

students curriculum should

start early with the general

framework and later proceed to

the granular coding.

The ICF enables consistent

evaluation of interventions,

building evidence for

effectiveness.


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Can ICF assist in developing ethical clinical pracce in students?

Health professional students should develop respect for theautonomy and dignity of their paents. ICF has eleven ethicalprovisions, on respect and condenality, clinical use of ICFand social use of ICF informaon (WHO 2001:244245; Box 4of this Manual).

The person-centred approach to assessment andmanagement can ensure that the contextual background ofeach person is taken into account during interacons andwhen assisng in the management of health and funcon.This is parcularly applicable in mulcultural sociees(Ramklass, 2009). In one study, when students applied theICF framework, it was found that they were able to idenfyand take greater ownership in addressing ethical challenges

related to the case (Snyman et al., 2012).

By following the ethicalguidelines of the ICF the student

will be guided towards a patient

oriented approach respectful of

cultural diversities.


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3.3 How can I use the ICF to describe funconing in clinical pracce?

How can I use an ICF-based paent prole?

An ICF-based funconal prole may be used to complement the diagnosc informaon of apaent or a cohort of paents with informaon on funconing. This addional informaonprovides a more robust picture of the overall health status of the individual. Such a pictureis relevant and useful for all condions, but oen of parcular interest in chronic condionsand non-communicable diseases. Examples of possible uses of an ICF-based paent proleinclude:

Snapshot prole of a single individual to detect areas of needs, problems andstrengths;

Dynamic prole of the funconal status of an individual or group to track changes,

such as those due to natural history, intervenons, or environmental modicaons; Funconal prole of a cohort grouped by some criteria (e.g. diagnosis, age, or

gender); or

Planning treatment or management.

What does an ICF-based paent prole focus on?

The ICF-based paent prole will always focus on the wayin which the person funcons at a given me, taking scopeand purpose into account. Choosing a me interval and an

environment that will provide a stable representaon of thefunconing of an individual is also advisable, for praccalpurposes. Examples of a me period might be one week to amonth. An example of a suitable environment would be theone where the individual spends the most me, such as workor home. Seng these parameters is even more importantwhen recording intermient, cyclical, episodic aspects offunconing, such as sleeping, menstruaon funcons, driving,recreaon, or parcipaon in social events. This can also showchanges over the interval, or between one environment andanother.

Special focus may be given to specic aspects of funconing which are relevant to thescope of the prole. Therefore the granularity of the prole might be non-homogeneousif a specic area is of special interest and movates the proling. In all instances, evenwithin the asymmetry of a prole focusing on specic chapters or domains, it will alwaysbe possible to roll up from a more granular set of codes to a higher level within theclassicaon, such as the second level or the chapter level, to represent that prole as ahomogeneous dataset.

An ICF-based patient proile

focuses on the way in which theperson functions at a given time.


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o Shortlist 3 ICF Core sets for specic condions: These are checklistsdeveloped through a scienc process that includes conducng asystemac literature review, a mul-centre cross-seconal study,an expert survey, a qualitave study and an internaonal consensusconference (stn 2004, Stucki 2004, Finger 2012) to best represent

the typical funconing prole of persons with a specic healthcondion or within a specic context (e.g. vocaonal rehabilitaonprogram). Examples include spinal cord injury, arthris, diabetes,stroke, depression, and obesity. There have been further renementsto represent the funconing of individuals with a given medicaldiagnosis in specic stages of the clinical process, such as post-acutevs. chronic. However, co-morbidies are not specically accountedfor in the core sets and use of these can reduce the specicity of thefunconal prole.

How do I assess the environment of an individual?

Environmental factors can aect acvies and parcipaonas well as body funcons and structures (e.g. diurecs aectb610 urinaon excretory funcons or an intravascular stentchanges a vessel lumen). While aids and equipment are byfar the most common environmental factors to considerin the use of ICF, others deserve equal consideraon evenif they are less obvious. Examples include air quality fora person with asthma or sgma associated with a mentalhealth diagnosis. Another example might be a clinician in astandardized environment such as a hospital overlooking

the environment as a source of variaon signicantly aecng funconing. In truth, thepresence of person

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Draft Icf Practical Manual