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The Environmental factor qualifier indicates the extent to which an environmental factor acts as a facilitator or a barrier. There is a negative 5-point scale to indicate the degree to which a particular environmental factor is a barrier to a person's successful functioning, and a positive 5-point scale to indicate the degree to which a particular environmental factor is a facilitator (WHO 2001:172).
WHO (2001:225 - 26) offers three coding conventions for environmental factors, essentially to code factors:
as they affect the person overall, without relating the rating to any particular component;
as they broadly affect each of body structure, body function, activity and participation; or,
against every single body structure, body function, activity or participation code used.
Testing using 'vignettes' during ICF development in Australia generally revealed reluctance for option 3, not only because it was very labour intensive, but also because of the duplication involved. A number of environmental factors occurred repeatedly as affecting more than one code. For instance, a highly accessible physical built environment may facilitate a range of activities in the area of mobility, as well as participation in the areas of employment and community life.
Nevertheless, there may be applications where it will be important to relate each environmental factor to each individual impairment, activity limitation or participation restriction. There may be other applications where one of the other two options may provide information adequate to the purpose (or where data design will be required to obtain summary information to minimise 'provider burden').
Within the one application, it could be possible to use more than one option. For instance, in the case of disability support services the following possibilities could be used:
the use of environmental factors (personal assistance and equipment) to help describe support needs in areas of activity and participation, an example of (3)
the presence of a family member or friend who regularly assists, as an overall environmental descriptor, an example of (1)
the need for equipment or environmental modifications as indicators of specific unmet needs, again essentially (1). (This is a way of investigating the 'gap' between the ideal environment and the actual one.)
These would be relatively minor adjustments of a national data set to incorporate the classification, but they would still represent progress compared to a collection containing no recognition of some key ICF concepts (see also Section 10.1).
The qualifiers of the Environmental factors are well conceptualised. Because of their newness, it will be important to systematically record and share information and experience about the qualifiers as they come into more common use. As practice builds up, calibration will also become important.
The more general challenge is to ensure that we use this new aspect of the classification to its full extent. Each time we use the classification, we need to check that we have adequately incorporated environmental factors into our applications.
Table 6.1 provides a template for recording use of these factors.
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