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World Health Organization Assessment Classification

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Title: World Health Organization Assessment Classification


1
World Health OrganizationAssessment
Classification Epidemiology Group
  • International Classification of
  • Functioning and Disability
  • ICIDH-2

2
WHO Family of International Classifications
ICD International Classification of Diseases
SPECIALITY-BASED ADAPTATIONS
IND
Nomenclature of Diseases
Procedures
ICIDH
International Classification of Functioning and
Disability
SPECIALITY-BASED ADAPTATIONS
Reasons for encounter
3
(No Transcript)
4
Need for the ICIDH
  • Change in the Health Care Scene from acute to
    chronic disease
  • Change from disease focus to consequences focus
  • Need for an international common language of
    consequences
  • To serve the needs of people with disability

5
Foundations of ICIDH-2
  • Human Functioning - not merely disablement
  • Universal Model - not a minority model
  • Integrative Model - not merely medical or social
  • Interactive Model - not linear progressive
  • Parity - not etiological causality
  • Inclusive - contextualenvironment person
  • Cultural applicability - not western concepts

6
The Bridged Model of Disablement
Medical AND Social Models
  • PERSONAL problem AND SOCIAL problem
  • medical care AND biopsychosocial
    integration
  • individual treatment AND social action
  • professional help AND individual
    collective responsibility
  • personal AND environmental adjustment
    manipulation
  • behavior AND attitude
  • care AND human rights
  • health care policy AND politics
  • individual adaptation AND social change

7
UNIVERSAL vs MINORITY
8
Cultural Applicability
  • Conceptual equivalence of Classification
  • Translatability
  • Usability
  • International Comparisons

9
Functioning Context
Environment
Person
10
ICIDH levelsforest - tree - stem - branch -
leafs
11
ICIDH- 2
International Classification of
Impairments, Activities, and Participation
ICIDH - 2
1. Main volume with glossary 2.
Clinical Descriptions Assessment Guidelines 3.
Assessment Criteria for Research 4.
Dedicated Assessment Tools
A manual of Dimensions of Functioning and
Disablement
WORLD HEALTH ORGANIZATION GENEVA 2000
12
Principles of Revision
  • Multi-center network support for development and
    later training
  • WHO being the client server
  • Multiple versions for different users at
    different sectors and levels of health care
  • Field trials applicability is the key
  • Empirical work serves the conceptual position and
    comes before ideological position

13
Revision Structure
Brazil
Level 3
ALL WHO Member States
Chile
Australian CC
China
Level 2
Dutch CC
Denmark
Health Promotion
Level 1
French CC
DPR
Egypt
Mental Health
Japan CC
Substance Abuse
Islamic Republic of Iran
Nordic CC
Ageing
WHO ACE
Malaysia
EBD
NACC
CEQ
Pakistan
UK CC
MH TF
OHS
Philippines
Childrens T F
Other Clusters
South Africa
Environment T F
14
Collaborating Centers
  • French - I focus - Mind is not Body - Quebec
    Model
  • Netherlands -Taxonomy - Moment vs Process
  • USA - Handicap, Environment,
  • Canada - A/P distinction Person vs Environment
  • Australia PWD - DDRAG
  • Japan Subjective dimensions
  • UK Morbidity coding, DPI
  • Spanish Network Cultural sensitivity
  • Finnish terms, words, ...

15
Overall Objective of ICIDH-2 Revision
  • To develop an operational classification system
    on
  • human functioning and disability
  • that is applicable to every human being
    universality
  • addresses multiple dimensions regarding the
    person and environment (at body, person and
    society levels)
  • international practices that are culture
    sensitive
  • based on user needs
  • empirical field trials on applicability,
    reliability and utility

16
Significant Changes Overall
  • Focus Disabilities Functioning Disability
  • Impairments Body Functions Structures
  • Disabilities Activities
  • Handicaps Participation
  • No environment Environmental Factors
  • Causal - linear Interactive-integrative
  • No Definitions Operational Definitions
  • No Assessment Linked Instruments

17
ICIDH-1 ICIDH-2
  • Conceptual transformation
  • User needs
  • Advocacy --gt science
  • Summary health measures evidence to inform
    policy
  • Causality multi-linear web
  • Polarization
  • medical vs social
  • global vs local
  • universal vs minority models
  • Models

18
Sequence of Concepts ICIDH 1980
Disease or disorder
Impairments Disabilities
Handicaps
19
Interaction of Concepts1999
Health Condition (disorder/disease)
Body Function Activities
Participation (Impairments)
(Activity Limitation) (Participation
Restriction)
Environmental Personal Factors
Factors
20
Functioning Disabilityas a Spectrum
B A P
21
Functioning Disabilityas a multidimensional
construct
22
Hidden Logic of Classification Common Sense -
Science Link
  • Universe
  • Interconnectedness with other classifications
  • Dimension (s)
  • uni-dimensional
  • multi-dimensional
  • Extendibility
  • downwards / upwards
  • hierarchical relations
  • Categories-mutually exclusive
  • Categories- jointly exhaustive
  • Taxonomic Unit
  • Systematic approach
  • Boundaries vs Core
  • Natural classifications - primary (symbolic)
  • Scientific Classifications- secondary (logical)

23
Equity / Parity
  • Loss of limb
  • landmines diabetes thalidomide
  • Missed days at usual activities
  • flu depression back pain angina
  • Stigma
  • leprosy schizophrenia epilepsy HIV

24
Images of Disability Forrest Gump
25
Activity
Limitation
(Disability)
26
Impairment Activity
Limitation (Disability)
27
Impairment Activity
Participation
Limitation
Restriction (Disability)
(Handicap)
28
ICIDH in simple terms
  • Your body doesnt function properly
  • You are limited in your activities
  • You face barriers in society

29
Components of ICIDH-II
  • Body Functions
  • Body Structure
  • Activity
  • Participation
  • Environmental Factors

30
ICIDH-II
  • Body Functions are the physiological or
    psychological functions of body systems.
  • Body Structures are anatomic parts of the body
    such as organs, limbs and their components.
  • Impairments are problems in body function or
    structure such as a significant deviation or loss.

31
ICIDH-II
  • Activity is the performance of a task or action
    by an individual.
  • Activity Limitations are difficulties an
    individual may have in the performance of
    activities.

32
ICIDH-II
  • Participation is an individual's involvement in
    life situations in relation to Health Conditions,
    Body Functions and Structure, Activities, and
    Contextual factors.
  • Participation Restrictions are problems an
    individual may have in the manner or extent of
    involvement in life situation

33
ICIDH-II
  • Environmental Factors make up the physical,
    social and attitudinal environment in which
    people live and conduct their lives

34
Dimensions of Functioning Disability
35
Schizophrenia
Body ACTIVITIES Participation
Information Deficit in Occupational process
ing parental functions hindrance, Work
dysfunction Stigmatization
36
Epilepsy
IMPAIRMENTS ACTIVITY PARTICIPATION
LIMITATIONS
RESTRICTION
Transient loss of none denial of a
Consciousness driving licence


37
Multiple Sclerosis
38
ICIDH-IIClassification of Each Component
  • Chapter e.g., Activities of moving around
  • Block e.g., Walking and related activities
  • Two-Level category e.g., Walking activity
  • Three-Level category e.g., Walking short
    distances
  • Four-Level category, if needed

39
ICIDH-IIUniform Qualifier
  • 0 NO problem 0-4
  • 1 MILD problem 5-24
  • 2 MODERATE problem 25-49
  • 3 SEVERE problem 50-95
  • 4 COMPLETE problem 96-100
  • 8 not specified
  • 9 not applicable

40
ICIDH 2 Codes
  • a 4 10 0 X . 2 0

Second qualifier
First qualifier
Three level
Dimension
Chapter
Four level
Two level
41
ICIDH-IIQualifiers for EF
  • -0 NO barriers (none, absent, negligible )
    0-4
  • -1 MILD barriers (slight, low) 5-24
  • -2 MODERATE barriers (medium, fair...) 25-49
  • -3 SEVERE barriers (high, extreme, ) 50-95
  • -4 COMPLETE barriers (total) 96-100
  • 0 NO facilitators (none, absent, negligible
    ) 0-4
  • 1 MILD facilitators (slight, low) 5-24
  • 2 MODERATE facilitators (medium,
    fair...) 25-49
  • 3 SEVERE facilitators (high, extreme,
    ) 50-95
  • 4 COMPLETE facilitators (total) 96-100

42
www.who.ch/icidh
43
Multi-level ICIDH Database
44
User Comments
45
Interaction of E with B, A, P
46
ISO Standards Application
  • Terminology
  • Harmonization of terms and clarification of
    semantic principles
  • Translation
  • Operationalization
  • Computerization
  • Standardization for a multi-view and multi
    version approach
  • Compatibility
  • Standard classification procedures Parent-child
    categories

47
Use of ICIDH
  • Scientific Impact of illness
  • Services Interventions and outcomes
  • Individual Specify needs
  • Economic Planning
  • Social Rights of the individual-duties
    of the society

48
Future Directions with ICIDH-2
  • Use of the ICIDH-2 at country level
  • Establishing an international data set and
    comparisons
  • Algorithms for eligibility benefits, etc.
  • Assessment instruments
  • Computerization case-recording forms

49
Links of ICIDH and DALYs
  • I
  • C
  • I
  • D A L Y
  • H

50
Activity/Participation
51
Links between Disability Quality of Life
Disablements
None Present
G o o d
Quality of Life
B a d
52
World Health Organization Assessment,
Classification Epidemiology Group
  • ICIDH 2
  • Beta 2
  • Field Trial Studies

53
ICIDH 2 Beta 2 Field Trial Studies Goals
  • to test the feasibility of the use of the
    classification in different settings
  • to test the reliability of the classification in
    different settings, formats and versions
  • to address some basic questions related to
    constructs and validity

54
ICIDH-2 Checklist
  • Easy to fill short list of ICIDH-2 categories
  • Available in several versions
  • Clinician
  • Self-administered
  • Informant
  • Can be used for Activity limitations alone

55
(No Transcript)
56
ICIDH-2 Beta 2Field Trials
  • Core Studies
  • Translation and Linguistic Evaluation
  • Basic Questions
  • Feasibility and Reliability for Cases
  • Additional Studies
  • Feasibility and Reliability for Health Records
  • Feasibility and Reliability for Surveys
  • Face validity and predictive validity
  • Utility for Intervention planning and evaluation
  • Individual Centre Task Force studies

57
Translation Linguistic Evaluation
  • Translation - must for non-english speaking
    countries
  • Linguistic Evaluation - for all countries
  • Process
  • Translation of the short version (two-level)
  • Back-translation and linguistic evaluation of key
    terms
  • Evaluation by a bi-lingual expert panel
  • Modifications made based on its recommendations
  • The translation, back-translation and linguistic
    evaluation of key terms and a report on this
    exercise

58
Linguistic Evaluation for English Speakers
  • English term has different or modified meaning
  • Term has specific meaning in a specialty
  • Definitions and inclusion/exclusion terms do not
    meet the operational requirements
  • improvements suggested in
  • terminology
  • definitions
  • operationalizations
  • links with assessment and evaluation tools
  • better translatable terms for other languages

59
Basic Questions
  • New Basic Questions for Beta 2
  • Response Possibilities
  • Individuals
  • Consensus Conferences
  • Feedback form
  • Qualitative and Quantitative analysis

60
Examples of Basic Questions
  • Title of of ICIDH-2
  • Changes in the Definitions terminology
  • Conceptualizations of B,A,P and E
  • Structure of the Classification
  • Operationalizations
  • Qualifiers
  • Guidelines and application notes
  • Philosophy
  • Have changes been effective, if not identify
    problems, recommend changes?
  • Are the current structures acceptable, accurate ?
    Any better approach?

61
Feasibility in Live Evaluations
  • Familiarisation of users
  • Test coding with actual clients
  • systematic feedback on
  • use of codes
  • ease of use
  • confidence in coding
  • meaningfulness
  • time to do coding
  • missing areas

62
Reliability in Live Evaluations
  • Rater-observer in one evaluation
  • Repeat assessment after one week
  • Reliability calculated for
  • 2 level categories
  • 3 and 4 level categories
  • qualifiers

63
Reliability on Case Summaries (Vignettes)
  • Vignettes collected from centres
  • Standard vignettes developed
  • Accepted coding developed
  • Rated across centres
  • Comparisons made

64
Coding Cases Mr A 27 y.o. engineer
  • lacks hands due to birth defect thalidomide
  • difficulty with fine movements
  • can and does drive a standard car
  • law in his country prohibits him from driving.

65
Mr. A. ICIDH-2 coding
  • B Muscles power functions
  • (b730) no impairment
  • A Activities of using transportation as a driver
    (a450) no limitation
  • P Participation in mobility with transportation
    (p240) restricted
  • E Transportation systems and policies
  • (e635) barrier

66
CASE 1
  • Ms. A, with a diagnosis of ICD 10 mild mental
    retardation, can understand the basic need to
    maintain her health. Yet, because no physician in
    her area provides care for people with mental
    retardation, she does not receive the preventive
    and basic care she requires to maintain good
    health.

67
CASE 1 -- coding
  • Ms. A mild mental retardation can understand
    the need to maintain her health no physician
    provides care she does not receive health care
  • B Intellectual functions (b120) impaired
  • A Activities of looking after ones health
    (a580) not limited
  • P Participation in health (p140) restricted
  • EF Health service providers (e345) barrier

68
CASE 2
  • Mr. B has a paraplegic condition, as a result of
    a severe neck injury, and cannot perform the
    basic movements required to drive a standard car
    however, with a suitably modified vehicle, he can
    drive safely. Unfortunately, there is a law in
    his province that prohibits him from driving.

69
CASE 2-- coding
  • Mr. B paraplegic condition cannot drive
    standard car, but can drive modified vehicle law
    prohibits driving.
  • B Muscles power functions (b730) impaired
  • A Activities of using transportation as a
    driver (a450) not impaired
  • P Participation in mobility with transportation
    (p240) restricted
  • EF Products for personal mobility and
    transportation (e140) facilitator
  • Transportation systems and policies (e635)
    barrier

70
CASE 3
  • Mr. C has cerebral palsy can not speak clearly,
    but has improved with the help of a speech
    therapist. Around friends or close colleagues at
    work he has no difficulty with conversations.
    However, most strangers do not take the time to
    listen carefully to understand him. So, Mr. C
    does not always get what he wants in stores and
    restaurants.

71
CASE 3 -- coding
  • Mr. C has cerebral palsy with speech therapy
    can speak clearly around friends or close
    colleagues at work not strangers doesnt get
    service in stores.
  • B Articulation functions (b320) impaired
  • A Activities of producing spoken messages
    (a230) limited
  • Activities of maintaining interaction (a740)
    not limited
  • P Participation in spoken exchange of
    information (p310) restricted
  • Participation in necessities for oneself (p130)
    restricted
  • Participation in informal social relationships
    (p430) not restricted
  • EF Health services (e575) facilitator
  • Friends (e320) facilitator Strangers
    (e355) barrier

72
CASE 4
  • A mentally retarded couple have been married for
    several years and have always wanted to have
    children. There are no medical reasons why they
    cannot, and they believe that they will not have
    any problems in the day-to-day care of a child.
    Yet, they have decided not to have a child
    because they believe that people will think they
    are bad parents and their child will be shunned
    by other children and made fun of.

73
CASE 4-- coding
  • Mentally retarded couple want and can care for
    children fear attitudes of others, so have
    decided not to have children.
  • B Intellectual functions (b120) impaired
  • Procreation functions (b660) not impaired
  • A Activities of assisting others (a660) not
    limited
  • P Participation in family relationships (p410)
    restricted
  • Participation in caring for others (p530)
    restricted
  • EF Societal attitudes and beliefs (e420)
    barrier

74
CASE 5
  • A child born deaf and blind but with normal
    intelligence, is covered by strict educational
    mainstreaming laws and is a student in a regular
    public school. Her teacher has access to support
    staff trained to teach children with multiple
    sensory impairments, the child uses a computer
    with a Braille adaptation, and is fully accepted
    by other children in the class. Unfortunately,
    despite the assistance, she is having
    considerable difficulty learning basic reading
    skills.

75
CASE 5 -- coding
  • Child deaf , blind, normal intelligence
    mainstreamed with good support in public school
    difficulty learning reading.
  • B Seeing functions (b210) impaired Hearing
    functions (b230) impaired Intellectual
    functions (b120) not impaired
  • A Purposeful sensory activities (a110)
    limited Activities of learning to read (a115)
    limited Activities of understanding spoken
    messages (a210) limited Activities of
    understanding written messages (a225) limited
    Basic interpersonal activities (a710) not
    limited Complex interpersonal activities (a720)
    not limited
  • P Participation in education in school (p630)
    restricted
  • EF Products for communication (e135)
    facilitator Products for education e145)
    facilitator Friends (e320) facilitator People
    in positions of authority (e330) facilitator

76
Applicability on Records
  • Use of routine health or other records
  • Information extracted using checklist
  • Feasibility and Reliability of classification
    tested

77
Applicability in Surveys
  • Back-coding of existing survey records
  • Application in new surveys
  • Feasibility
  • Reliability
  • Meaningfulness of information

78
Face and Predictive Validity
  • Information on functioning and disability
  • ICIDH-2
  • ICIDH-2 checklist
  • Other assessment instruments
  • Other information collected on
  • diagnosis, severity
  • health care utilisation
  • loss of work days, etc...
  • Correlation for cross-sectional measures
  • Predictive power for longitudinal measures

79
Utility for Interventions
  • Intervention matching
  • indications, outcomes
  • Intervention planning based on ICIDH-2
  • Evaluation by intervention personnel
  • Review of advantages and disadvantages
  • Multiple informant feedback

80
Centre and Task Force Recommended Studies
  • For A and P overlap
  • Formal Reference Model of the ICIDH-2
  • Any others

81
ICIDH-2 Material
  • Available from the WHO Website
  • http//www.who.int/icidh
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