International Classifications World Health Organization Classification Assessment Surveys & Terminology Group ICF as the New Member in the WHO Family of International Classifications Greetings , I am happy to greet you on behalf of the World Health Organization and it is my pleasure to provide you with this introduction on the WHO Family of International Classifications (WHO- FIC) We are now in an upgrading process and moving towards the a unified concept of integrated classification systems for health information. In this presentation, I would like to address the following points: What is the WHO Family of International Classifications ? Why is there a need for the WHO FIC ? What are the key concepts of WHO FIC And the underlying principles of family ? How can we use the WHO FIC to improve people’s health? For your information, a copy of the slides used in this presentation is available from WHO or over the INTERNET. The contact addresses are found at the end of this presentation. www.who.int/classification/icf

Basic Messages ICF has been systematically revised in the last decade large international and multidisciplinary participation extensive field testing guided by scientific principles taxonomic guidelines: logic and terminology practical utility: feasibility, ease of use, ethical guidelines reliability, validity and comparability When the rubber hits the road... ICF can serve as a useful tool for Health Information Systems evaluation: needs, outcomes, costs, quality, satisfaction service provision, social policy Application guidelines, training, tools are needed

استاديار دانشکده علوم توانبخشی ؛ دانشگاه علوم پزشکی ايران دکتر محمد کمالی استاديار دانشکده علوم توانبخشی ؛ دانشگاه علوم پزشکی ايران www.mkamali.com kamali@mkamali.com http://rehabiran.blogspot.com صندوق پستي 183-17445 دی ماه هشتاد ودو

[Keywords] ###[Narration] ### World Health Assembly Endorse and publish ICF use the ICF in Member States in: research surveillance reporting Joint use with ICD Operational subsets: surveys clinical encounters Periodic revision [Keywords] ###[Narration] ###

WHO Family of International Classifications ICD-10 International Statistical Classification of Diseases & Related Health Problems Interventions procedures Primary care adaptations Reasons for encounter ICF International Classification of Functioning, Disability and Health Speciality adaptations IND Nomenclature of Diseases [Keywords] context###[Narration] ### Associated Products Main Classifications Adaptations

ICF Publications 1. Main volume with glossary - Full version 9999 cat. - Short version 99 cat. 2. Clinical Descriptions & Assessment Guidelines 3. Assessment Criteria for Research 4. Other versions - Specialty adaptations Children and Youth 5. Dedicated Assessment Tools The International Classification of Impairment, Disabilities and Handicaps was developed as a tool for classifying the consequences of disease. The revised classification, ICF (see paragraph 9 in the main document above), aims to provide a unified and standard language and framework for the description of health states and is based on dimensions of functioning with categories, or domains, within each dimension. These dimensions are (1) body functions and structure, (2) activities at the individual level and (3) participation in society. It systematically groups different health domains and health-related domains (e.g. what a person can do or does do when he or she has a given health condition). It covers all possible health domains described at body, individual and society dimensions. In this way, the universe of ICIDH encompasses health and health-related outcomes (including non-fatal health outcomes – see Annex 3).

[Keywords] context###[Narration] ### ICF Checklist One component- One page “at-a-glance” Salient Categories (169 out of 1494) Impairments with: Body Functions Body Structures Activity and Participation Environmental Factors Other Contextual information Available for: Clinicians & providers Consumers [Keywords] context###[Narration] ###

Aims to provide a scientific basis for consequences of health conditions to establish a common language to improve communications to permit comparison of data across: countries health care disciplines services time to provide a systematic coding scheme for health information systems [Keywords] context###[Narration] to provide a scientific basis for consequences of health conditions to establish a common language for describing consequences of health conditions in order to improve communications between health care workers, other sectors and people with disabilities to stimulate better care and services to improve the participation in society of people with disablements - this is central to improving quality of life and facilitating the autonomy of persons with disablements to permit comparison of data across countries, health care disciplines, services and time - the need for such an international language has long been felt to provide a systematic coding scheme for health information systems - international comparisons of epidemiological and other data has suffered from a lack of uniform systems to stimulate research on the consequences of health conditions - this will facilitate the development of more effective interventions to collect data on facilitators and inhibitors in society that affect the participation of people with disablements - this is crucial to influence policy change###

Foundations of ICF Human Functioning - not merely disability Universal Model - not a minority model Integrative Model - not merely medical or social Interactive Model - not linear progressive Parity - not etiological causality Context - inclusive - not person alone Cultural applicability - not western concepts Operational - not theory driven alone Life span coverage - not adult driven [Keywords] concept###[Narration] ###

Human Functioning not disability alone Body functions vs impairments Body Structures Activities vs activity limitation 1980 disability Participation vs handicap

Participation or Handicap? neutral language “politically correct” correct use intervention opportunity positive aspects ICF does not only describe negative health experiences, but neutral health domains in which the state can be described as both positive and negative. For example: read slide

Universal Model vs. Minority Model Everyone may have disability Continuum Multi-dimensional Certain impairment groups Categorical Uni-dimensional [Keywords] concept###[Narration] ICIDH applies to 100 % disablement applies to nearly all###

Medical versus Social Model PERSONAL problem vs SOCIAL problem medical care vs social integration individual treatment vs social action professional help vs individual & collective responsibility personal vs environmental adjustment manipulation behaviour vs attitude care vs human rights health care policy vs politics individual adaptation vs social change The various models proposed to explain and classify disablements may be expressed in a dialectic of “medical model” versus “social model”. The medical model views the disablement phenomenon as a “personal” problem, directly caused by disease, trauma or health conditions, which requires medical care provided in the form of individual treatment by professionals. Management of disablement is aimed at the person’s better adjustment and behaviour change. Health care is viewed as the main issue and at the political level it is health care policy that needs to be modified. The social model of disablement, on the other hand, sees the issue mainly as a “societal” problem from the viewpoint of integration of persons with disabilities into society. Disablement is not an attribute of a person, but a complex collection of conditions many of which are created by the social environment. Hence the management of the problem requires social action and it is the collective responsibility of society to make the environmental modifications necessary for the full participation of people with disabilities into all areas of social life. The issue is, therefore, an attitudinal or ideological one which requires social change, while at political level it is a question of human rights. Hence the issue is highly political for all intents and purposes.

Sequence of Concepts ICIDH 1980 Disease or disorder Impairments Disabilities Handicaps

Interaction of Concepts ICF 2001 Health Condition (disorder/disease) Body function&structure (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors

Equity / Parity Loss of limb Missed days at usual activities Stigma landmines = diabetes = thalidomide Missed days at usual activities flu = depression = back pain = angina Stigma leprosy = schizophrenia = epilepsy = HIV [Keywords] concept###[Narration] ###

Contextual Factors Person Environment gender Products age Close milieu other health conditions coping style social background education profession past experience character style Environment Products Close milieu Institutions Social Norms Culture Built-environment Political factors Nature [Keywords] structure###[Narration] ###

Cultural Applicability [Keywords] concept###[Narration] ### Conceptual and functional equivalence of Classification Translatability Usability International Comparisons

Comparability: equivalence across cultures Conceptual equivalence: similar understanding /meaning of concepts Functional equivalence: similar domains Metric equivalence: similar measurement characteristics

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

Functioning and Disability Structure ICF Classification Part 1: Functioning and Disability Part 2: Contextual Factors Parts Body Functions and Structures Activities and Participation Environmental Factors Personal Factors Components Change in Body Functions Change in Body Structures Capacity Performance Facilitator/ Barrier Constructs/ qualifiers ICIDH categories are organized in a "nested" approach Broader Category  detailed subcategory The classification has two parts, each with two components. [An example may help to illustrate the point: The universe of health and disability is being classified (this is the forest). Within that forest we classify the dimensions of Impairments, Activities and Participation (the trees). In the Activities dimension we have several chapters or domains ranging from simple to complex activities - from sensing and recognizing to interpersonal behaviors (the trunks). Within, for example, the chapter on Interpersonal Behaviors are included activities such as general interactive skills (the branch) and included in that broad category are behaviors such as initiating social contact, responding to cues and so on (the leaves).] Item levels: 1st 2nd 3rd 4th Item levels: 1st 2nd 3rd 4th Item levels: 1st 2nd 3rd 4th Item levels: 1st 2nd 3rd 4th Item levels: 1st 2nd 3rd 4th Domains and categories at different levels

Body Functions and Structures Mental functions Structures of the nervous system Sensory functions and pain The eye, ear and related structures Voice and speech functions Structures involved in voice and speech Functions of the cardiovascular, haematological, immunological and respiratory systems Structures of the cardiovascular, immunological and respiratory systems Functions of the digestive, metabolic and endocrine systems Structures related to the digestive, metabolic and endocrine systems Genitourinary and reproductive functions Structures related to the genitourinary and reproductive systems Neuromusculoskeletal and movement-related functions Structures related to movement Functions of the skin and related structures Skin and related structures

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

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

ICF Applications Health sector Social security Education sector Labour sector Economics & development sector Legislation & law Other …. Though the ICIDH is a classification of disability's and functioning within a health context it is also intended that it will have a much wider applicability. The ICIDH could be used to inform the development of social security guidelines, special education facilities and policies and compensation in the labour sector. It could be used to identify investments into overall development and serve as the framework for developing national and international laws that address the area of disability in particular and discrimination in general.

ICF in health & disability statistics Common Domains Mobility - Cognition - Mood Self Care - Usual Activities ... link data from both health and disability Multiple Components overcomes the “impairment” focus Environmental Factors Comparability Another principle that underlies ICIDH is that of parity. There is no distinction, at the level of impairment, activity limitation or participation restriction, between different health conditions (e.g. mental and physical). In other words, disablement is not differentiated by etiology. ICIDH is etiologically neutral.

ICF in clinical practice & management Needs assessment Outcome assessment Utilization patterns Comparison of different interventions Consumer satisfaction Service performance outcomes cost-effectiveness Electronic records Clinical terminology (Vorhersage des Inanspruchnahmeverhaltens & Länge der Hospitalisierung)

ICF in policy making assessment of population health impact of disability economic social evidence-base for policy makers on different policy interventions responsiveness of services efficiency performance assessment Gesundheitspolitik, Sozialpolitik, Behindertenpolitik and Menschenrechtspolitik (keine Entsprechung von Bedurfnisslagen, Problemlagen, Ressourcenvereilung)

ICF research applications joint assessment of disease and functioning description of association intervention response & synchrony of change explanatory power on: utilization needs costs outcomes Cost-effectiveness of interventions Unified approaches Another principle that underlies ICIDH is that of parity. There is no distinction, at the level of impairment, activity limitation or participation restriction, between different health conditions (e.g. mental and physical). In other words, disablement is not differentiated by etiology. ICIDH is etiologically neutral.

ICF Domains used in International WHO Surveys Health Domains Vision Hearing Speech Digestion Bodily excretion Fertility Sexual activity Skin & disfigurement Breathing Pain Affect Sleep Energy / vitality Cognition Communication Mobility and Dexterity Health Related Domains Self-care: Including eating Usual activities: household activities; work or school activities Social functioning: interpersonal relations Participation: societal participation including discrimination/stigma