ICF Australian User Guide V1.0

Contents

5.    Activities and Participation: application in Australia

5.1    Activities and Participation in the ICF

Key definitions are:

• Activity is the execution of a task or action by an individual.

• Participation is involvement in a life situation.

• Activity limitations are difficulties an individual may have in executing activities.

• Participation restrictions are problems an individual may experience in involvement in life situations.

The ICF provides a single list of Activities and Participation domains, or life areas, with options for use. This approach reflects the inability of ICF developers to reach consensus on devising two separate lists of domains for Activities and Participation (WHO 2001:16):

It is difficult to distinguish between Activities and Participation on the basis of domains.Therefore ICF provides a single list that can be used if users wish to do so to differentiate Activities (A) and Participation (P) in their own operational ways.Basically there are four possible ways of doing so:

(a) to designate some domains as Activities and others as Participation, not allowing any overlap;

(b) same as (a) above, but with partial overlap;

(c) to designate all detailed domains as A and use the broad category headings as P;

(d) to use all domains as both A and P.

Based on experience in Australia during the testing of the draft ICF, options (b) and (d) appear the most useful approaches. Option (a) may also be useful for specific applications where agreement can be achieved among stakeholders.

This section outlines the basis for these suggestions, and recommends how to proceed during application.

Option (c) appears to be untried, and at this stage this User Guide contains no advice on its use.

Qualifiers are measures coded after the relevant category code of any component (Body Structures or Functions, Activities and Participation, Environmental Factors). Qualifiers are recognised as essential to the meaningful use of the ICF classification because the domains themselves are neutral:

The ICF codes are only complete with the presence of a qualifier, which denotes a magnitude of the level of health (e.g. severity of the problem) (WHO 2001:21). Without qualifiers codes have no inherent meaning (WHO 2001:222).

The instructions in the ICF allow considerable discretion in the hands of the user. Both Activities and Participation, for instance, are to be used with a 'generic qualifier', which indicates the extent of difficulty, using the scale:

0    No difficulty

1    Mild difficulty

2    Moderate difficulty

3    Severe difficulty

4    Complete difficulty

8    Not specified

9    Not applicable

WHO recognises that the scale requires calibration.

All three components in the ICF (Body Functions and Structures, Activities and Participation, and Environmental Factors) are quantified using the same generic scale.For this quantification to be used in a universal manner, assessment procedures need to be developed through research.The percentages are to be calibrated in different domains with reference to relevant population standards as percentiles (WHO 2001:22).

Two constructs - 'performance' and 'capacity' - can also be used, together with the generic qualifiers, for the Activities and Participation domains. These constructs indicate the environment in which measurement is taking place (see Section 2.2). Performance relates to the 'current' environment. Capacity relates to a 'standardised' environment (either an actual test environment or an assumed one) - and also an 'optimum' environment, in that the ICF also states that:

The gap between capacity and performance reflects the difference between the impacts of current and uniform environments, and thus provides a useful guide as to what can be done to the environment of the individual to improve performance (WHO 2001:15).

It is suggested that the performance-related qualifier be coded first, after the category code and a decimal point that separates the domain or category from the qualifying measurement; and any capacity-related qualifier is coded second (WHO 2001:229). Thus, the officially recommended coding style is illustrated in the following example:

In this example, the performance qualifier indicates moderate difficulty (2) with performance, in this case changing basic body position, and the capacity qualifier indicates that capacity is not specified (8).

The prefix d may be used to denote the component 'Activities and Participation' or 'a' or 'p' may be used to denote an activity or participation respectively (WHO 2001:14). This coding convention is also relevant to the discussion in the ICF of an 'information matrix' (see Section 5.6).

The ICF (WHO 2001:15) states that both capacity and performance:

• are 'assessed against a generally accepted population standard' i.e. to record the 'discordance' between the observed level and what is expected of a similar individual without a similar 'health condition'; and

• can be measured with or without assistance (personal or assistive devices).

In developing approaches to these qualifiers, it is helpful to consider three typical coding situations (using Activities domains).

1. The person has moderate difficulty in their current environment with the aid of some equipment, and severe difficulty in their current environment without it.

2. The person has moderate difficulty in their current environment with the aid of equipment (e.g. a walking stick). An assessment of 'capacity' in a clinic results in a recommendation that the person gets a new aid (e.g. a walking frame).

3. The person has moderate difficulty in their current environment with the equipment, severe difficulty in this environment without it, and expresses the need for both new equipment and a better environment in order to experience only mild difficulty (e.g. a walking frame, home modifications, additional personal assistance - i.e. three environmental enhancements).

To code all the information in each example, using what is given in the ICF, the following must be recorded:

• difficulty with the activity;

• environmental factors that are in use (or predicted or recommended to be in use); and

• the type of environment (whether current or standardised/optimum).

This amounts to coding convention 3 for Environmental factors (see Section 6 and WHO 2001:225-6):

Convention 3

Environmental factors are coded for capacity and performance qualifiers in the Activities and Participation component for every item.

Performance qualifier_________________ E code______________________

Capacity qualifier____________________ E code______________________

In addition, however, examples 2 and 3 illustrate the 'predictive' concept of 'need', i.e. it is predicted that different environmental circumstances could enhance performance. This prediction may be made by various people, for instance, the person expressing their own needs, or a clinician, possibly in a 'standard environment'.

To recapitulate, the following points are relevant in operationalising the concepts of performance and capacity in the Australian context:

• Performance relates to the usual or current environment.

• Capacity relates to the standardised or uniform environment (see second ICF qualifier). Capacity also appears to relate to an 'optimum' environment as the ICF describes capacity in terms of indicating 'the highest probable level of functioning that a person may reach in a given domain at a given moment' (WHO 2001:15).³

• Need relates to the environmental factors (such as personal assistance, equipment, environmental modifications) that are present in the standardised or 'optimum' environment (where maximum capacity is achieved) but are not in the current environment (where current performance is achieved); that is, 'need' relates to closing the 'performance gap' between the current and the optimum environments for the person.

The possibility of coding further qualifiers is recognised in Annex 2 of the ICF (WHO 2001:230 - 32). The advice given is as follows:

• Qualifiers indicating the use of assistance: Performance (or capacity) may be measured with and without assistance (assistive devices or personal assistance). WHO specifies an order for recording them using four successive qualifiers: (1) performance with assistance; (2) capacity with no assistance; (3) capacity with assistance; (4) performance without assistance (WHO 2001:230).

• Qualifiers indicating involvement: 'The fifth digit position is reserved for qualifiers that may be developed in the future, such as a qualifier for involvement or subjective satisfaction' (Annex 2, WHO 2001:231).

3 The construct of 'capacity' appears to relate to a conceptualisation of health that distinguishes between what is sometimes called 'within the skin' factors and external factors. This distinction in turn relies on the notion of a separate individual with intrinsic capacity, where better health outcomes can be promoted by health interventions and environmental modifications. This approach is based in an egalitarian, human rights philosophy and has much to commend it in theory.

The need to introduce the idea of 'capacity' into the classification appears to be driven at least in part by the desire to measure the performance of health systems and how well they are closing the gap between capacity and performance. This purpose brings with it the need to define and confine the scope of the health system, not holding it accountable for measures that, while promoting good human health and functioning, are beyond the scope of many health systems. This aim, of assessing health systems, thus may require a measurement of 'capacity', but also requires the measurement of the level of health and human functioning (to indicate the 'performance gap').

Contents