20 Years of ICF-International Classification of Functioning, Disability and Health: Uses and Applications around the World

The International Classification of Functioning Disability and Health (ICF) was approved in 2001 and, since then, several studies reported the increased interest about its use in different sectors. A recent overview that summarizes its applications is lacking. This study aims to provide an updated overview about 20 years of ICF application through an international online questionnaire, developed by the byline authors, and sent to each World Health Organization Collaborating Centers of the Family of International Classifications (WHO-FIC CCs). Data was collected during October 2020 and December 2021 and descriptive content analyses were used to report main results. Results show how, in most of the respondent countries represented by WHO-FIC CCs, ICF was mainly used in clinical practice, policy development and social policy, and in education areas. Despite its applications in different sectors, ICF use is not mandatory in most countries but, where used, it provides a biopsychosocial framework for policy development in health, functioning and disability. The study provides information about the needs related to ICF applications, that can be useful to organize targeted intervention plans. Furthermore, this survey methodology can be re-proposed periodically to monitor the use of the ICF in the future.

Expanding on the use of The International Classification of Functioning, Disability and Health: Examples and resources

Most physiotherapists today are familiar with the abbreviation ICF and know that it stands for the International Classification of Functioning, Disability and Health; the title of the World Health Organization’s international standard for describing health and health related states. Most universities in South Africa and globally have adopted the framework of the ICF in their curricula especially in promoting clinical reasoning, however, translating that knowledge for recording and monitoring has been slow in coming. Less well known, is how the ICF is and can be used and how it can inform physiotherapy practice, research, education and administration. Our article outlines the importance of the ICF to physiotherapy and recommends resources to facilitate expanded ICF use by physiotherapists. Examples are given of how to use coding and the importance of aggregating data and concluding with resources that can assist with the expanded use. Sufficient evidence and resources are available to support the expanded use of the ICF for data collection and clinical coding.

Avoiding the Banality of Evil in Times of COVID-19: Thinking Differently with a Biopsychosocial Perspective for Future Health and Social Policies Development

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Trojan horse to achieve some of the sustainable development goals such as universal health coverage and equity in access, thus acting on environmental factors is the key for global health improvement.

Disability prevalence-context matters: A descriptive community-based survey

BACKGROUND

There is increasing interest in the collection of globally comparable disability data. Context may influence not only the rates but also the nature of disability, thus locally collected data may be of greater use in service delivery planning than national surveys.

OBJECTIVES

The objective of this article was to explore the extent to which two areas, both under-resourced but geographically and socially distinct, differed in terms of the prevalence and patterns of disability.

METHOD

A cross-sectional descriptive survey design was utilised, using stratified cluster sampling in two under-resourced communities in the Western Cape, South Africa. Nyanga is an informal urban settlement in Cape Town and Oudtshoorn is a semi-rural town. The Washington Group Short Set of questions was used to identify persons with disabilities (PWD), and a self-developed questionnaire obtained socio-demographic information.

RESULTS

The overall prevalence of disability was 9.7% (confidence intervals [CIs] 9.7-9.8) and the proportion of PWD was significantly different between the two sites (Chi-Sq = 129.5, p < 0.001). In the urban area, the prevalence rate of any disability was 13.1% (CIs 12.0-14.3) with 0.3% (CIs 0.1-0.6) reporting inability to perform any function at all. In contrast, the semi-rural community had a lower overall prevalence rate of 6.8% (CIs 6.0% - 7.8%) but a higher rate of those unable to perform any function: 1% (CIs 0.07-1.4). Disability was associated with gender, age, unemployment and lower income status in both areas.

CONCLUSION

Deprived areas tend to show higher disability prevalence rates than the National Census estimates. However, the discrepancy in prevalence and patterns of disability between the two under-resourced areas indicates the need for locally specific data when planning health interventions.

Addressing change in physiotherapy education in South Africa

Background

Recent demands for the decolonisation of curriculum in South Africa present challenges to students, academics and other stakeholders. This resulted in tensions in tertiary institutions, cumulating in student-led protests. The authors hypothesised that the lack of shared understanding of what this unexplored process may entail contributed to the dilemma.

Objective

The aim of this opinion article is to highlight some of the possible contributors to the uncertainties in addressing this critical issue, especially as it relates to the demands for change in physiotherapy education.

Method

To formulate our opinion, the authors reviewed literature relating to transformation in education in South Africa generally, and physiotherapy education specifically.

Results

While there is an opportunity to address the demand for change in physiotherapy education in South Africa, there is the possibility that the use of words, such as transformation, decolonisation and decoloniality, present different connotations to students and academics.

Conclusion

It is of vital importance to create formal discourse which includes students, academics and other stakeholders that will facilitate shared understanding about what the previously unexplored and unmapped processes of engagement entail. The change process in physiotherapy education is envisaged to be a partnership between students and academic staff having common understanding about the processes and responsibilities, and must be addressed comprehensively.

Clinical implications

Aligning the change process in physiotherapy education with the decolonisation agenda will strengthen the South African health care system by ensuring that physiotherapy students are adequately prepared to provide service to patients within a context that acknowledges the uniqueness of South African communities.

Should additional domains be added to the EQ-5D health-related quality of life instrument for community-based studies? An analytical descriptive study

Background

There is increasing interest in monitoring the health-related quality of life (HRQoL) of populations as opposed to clinical populations. The EQ-5D identifies five domains as being most able to capture the HRQoL construct. The question arises as to whether these domains are adequate within a community-based population or whether additional domains would add to the explanatory power of the instrument.

Methods

As part of a community-based survey, the responses of 310 informants who reported at least one problem in one domain filled in the EQ-5D three-level version and the WHOQOL-BREF (World Health Organization Quality of Life Scale – Abbreviated version). Using the EQ-5D visual analogue scale (VAS) of rating of health as a dependent variable, the five EQ-5D and four selected WHOQOL-BREF items were entered as dummy variables in multiple regression analysis.

Results

The additional domains increased the explanatory power of the model from 52 % (EQ-5D only) to 57 % (all domains). The coefficients of Self-Care and Usual Activities were not significant in any model. The most parsimonious model included the EQ-5D domains of Mobility, Pain/Discomfort, Anxiety/Depression, Concentration, and Sleep (adjusted r² = .57).

Conclusions

The EQ-5D-3L performed well, but the addition of domains such as Concentration and Sleep increased the explanatory power. The user needs to weigh the advantage of using the EQ-5D, which allows for the calculation of a single summary index, against the use of a set of domains that are likely to be more responsive to differences in HRQoL within community living respondents. The poor predictive power of the Self-Care and Usual Activities domains within this context needs to be further examined.

Attitudes, knowledge and treatment of low back pain amongst nurses in the Eastern Cape, South Africa

Background: One of the high-risk professions for the development of musculoskeletal problems is nursing. Studies have reported that there is a high prevalence of low back pain (LBP) amongst South African nurses, but very little is known regarding the prevention and self-treatment principles for LBP in this group.Objectives: The objective of this study is to evaluate the knowledge, attitudes and beliefs about the prevention and self-treatment principles for LBP amongst nursing staff in Cecilia Makiwane Hospital, Eastern Cape.Methods: The study population consisted of all qualified nurses employed at the hospital. A cross-sectional survey with a purposive convenience sampling method was used. A questionnaire was designed using literature from established sources. The questionnaire was distributed manually and data obtained were analysed using EPI-INFO4.Results: The study found that the majority of the participants experienced LBP on a regular basis. The participants could identify the most important physical risk factors associated with the development of LBP, but neglected the psychological risk factors. Action taken after the development of LBP included professional consultations as well as medication and bed rest.The participants identified the different components of a preventative exercise programme but only focused on the physical and not psychological components associated with LBP.Conclusions: LBP is a serious problem amongst the nurses at the hospital, but no proactiveapproach is taken in order to address this problem. Policy guidelines and a comprehensive prevention and treatment programme need to be designed and implemented to address this issue.

Disability and access to health care - a community based descriptive study

PURPOSE

The World Disability Report highlighted the need for adequate access to health and medical rehabilitation services for those with disability. Participants in a large community based survey in a low-income area were asked questions relating to their use of health related services.

METHOD

Using random, cluster sampling a representative sample of 1083 households in a deprived area of Cape Town were approached and 152 people with disability were interviewed.

RESULTS

Those with disability were more likely to be male (χ² = 4.24, p = 0.03) and unemployed (χ² = 66.89, p > 0.001) compared to those without disability. The percentages reporting unmet needs were respectively: 54% for home-based care; 34.5% for assistive devices, 28.9% for medical rehabilitation services; and 2.5% for health services. Those over 65 years of age were less likely to have had the medical rehabilitation that they required (χ² = 8.00, p = 0.018). There were fewer respondents with sensory and language disorders but these groups reported proportionately more unmet needs. The main problems with accessing services included inadequate finances (71%) and transport problems (72%).

CONCLUSION

It is recommended that all efforts be expended to extend appropriate rehabilitation services, including home based-care and appliances to those identified as having disability, particularly to those older than 65 years. In addition, the services need to be affordable and accessible in terms of suitable transport, particularly in the light of the high unemployment rate and the large number of respondents with mobility problems. Implications for Rehabilitation People with disability may be the most in need of additional health related care and the least able to access it. Transport and financial considerations were found to limit the ability to access appropriate care. Rehabilitation and health services need to reach out through home-based care and appropriate forms of rehabilitation delivery to ensure that those who are most in need of care, such as the elderly and those with more neglected forms of disability, are provided with the services that they require.

Undergraduate physiotherapy education in Malawi--the views of students on disability

BACKGROUND

The College of Medicine in Malawi offers an undergraduate physiotherapy programme which started in 2010. The programme aims at training competent physiotherapists who can address the needs of people with disabilities. Therefore it is important to ensure that the perceptions of physiotherapy students towards disability are appropriate.

OBJECTIVES

The study explored the views of the first cohort of physiotherapy students (n=19) in the pre-medical class in the College of Medicine, University of Malawi, on disability.

METHODS

An audit of the views of premedical physiotherapy students was carried out in 2010 using the Q methodology.

RESULTS

Two independent factors emerged which captured the views of 19 students on disability. Most of the views expressed suggest that the students empathised with people with disabilities. Participants perceived that people with disabilities can have a good quality of life like everyone else, and are as intelligent as people without disabilities. However, some participants also expressed some discomfort when around people with disabilities.

CONCLUSION

While there was consensus on some positive views, the negative viewpoints have the potential to act as a barrier to the rehabilitation of people with disabilities. The curriculum should ensure that the positive views are reinforced throughout the training programme, while the negative viewpoints are reversed.

The impact of an employee wellness programme in clothing/textile manufacturing companies: a randomised controlled trial

Background

The prevalence of health risk behaviours is growing amongst South African employees. Health risk behaviours have been identified as a major contributor to reduced health related quality of life (HRQoL) and the increased prevalence of non-communicable diseases. Worksite wellness programmes promise to promote behaviour changes amongst employees and to improve their HRQoL. The aim of this study was to evaluate the short-term effects of an employee wellness programme on HRQoL, health behaviour change, body mass index (BMI) and absenteeism amongst clothing and textile manufacturing employees.

Methods

The study used a randomised control trial design. The sample consisted of 80 subjects from three clothing manufacturing companies in Cape Town, South Africa. The experimental group was subjected to a wellness programme based on the principles of cognitive behaviour therapy (CBT) as well as weekly supervised exercise classes over six weeks. The control group received a once-off health promotion talk and various educational pamphlets, with no further intervention. Measurements were recorded at baseline and at six weeks post-intervention. Outcome measures included the EQ-5D, Stanford Exercise Behaviours Scale, body mass index and absenteeism.

Data was analysed with the Statistica-8 software program. Non-parametric tests were used to evaluate the differences in the medians between the two groups and to determine the level of significance. The Sign test was used to determine the within group changes. The Mann–Whitney U test was used to determine the difference between the two groups.

Results

At six weeks post intervention the experimental group (39 subjects) demonstrated improvement in almost every parameter. In contrast, apart from an overall decrease in time off work and a reduction in BMI for all study participants, there was no significant change noted in the behaviour of the control group (41 subjects). Seventy percent of the experimental group had improved HRQoL EQ-5D VAS scores post intervention, indicating improved perceived HRQoL. In comparison, only 58% of the control group had improved HRQoL EQ-5D VAS scores post intervention. There was no significant difference between the two groups at baseline or at six weeks post intervention.

Conclusion

An employee wellness programme based on the principles of CBT combined with weekly aerobic exercise class was beneficial in improving the perceived HRQoL and changing health-related behaviours of clothing manufacturing employees. However, it cannot be concluded that the EWP was more effective than the once off health promotion talk as no significant changes were noted between the two groups at 6-weeks post intervention.This trial has been registered with ClinicalTrials.gov (trial registration number NCT01625039).

Widening access to un dergraduate physiotherapy education in South Africa - pointers from students’ records

In response to the state mandate to improve access and equityin higher education, the admission policy of universities in South Africa (SA)currently employs measures for the redress of past inequalities and racialinjustices. As there is no information on the processes to widen access toundergraduate physiotherapy education program in SA, the aim of this reportedstudy was to search for pointers from students’ records in one local university,situated in the Western Province of SA, that would inform the development ofstrategies that will widen the access for previously disadvantaged populationgroups and ensure successful academic outcomes. The records of six cohorts of students who earlier applied for andlater enrolled in the undergraduate physiotherapy program between the years 2000 and 2005 were retrospectivelyreviewed. Information pertaining to access, student characteristics, and academic persistence was extracted, reviewedand analysed descriptively. During the period reviewed, approximately equal numbers of Black and non-Black studentsapplied for admission to the program. The proportion of Black applicants meeting minimum admission requirementswas less than half of the White/Asian applicants. Less than 50% (105/212) of the offers made to Black applicantswere accepted. Forty one percent (43/105) of the enrolled Black students successfully completed the program withinthe minimum 4 years compared to 75.5% (145/192) of the White/Asian students. Strategies should be implementedto increase awareness and recruitment, improve enrolment rates, and improve retention and throughput for Blackstudents in the undergraduate physiotherapy program of a historically “white” SA university.

Exploring ICF components in a survey among Xhosa speakers in Eastern & Western Cape, South Africa

PURPOSE

To contribute to the testing and development of the ICF model by exploring the relationship between activity limitations, participation restrictions and environmental barriers.

METHOD

Structured questionnaire-based interviews were carried out among a convenience sample of 950 households counting 4917 individuals in Eastern and Western Cape, South Africa. Approximately half of the households had at least one individual with disability, while the other half represented controls in the study. Activity limitations, participation restrictions and environmental barriers were operationalized by means of questions drawn directly from the ICF checklist.

RESULTS

Principal component analyses supported a four-component solution for the activity and participation variables, and a two-component solution for the barrier variables. Scales for each sub-component were produced by adding the individual items under each sub-component. Male respondents are more restricted than females when it comes to social activities, individual care, education and mobility barriers. While respondents in Western Cape scored higher (more limitations and restrictions) on the activity and participation sub-scales individual care, daily activities and education, Eastern Cape respondents scored higher on both the environmental barrier sub-scales.

CONCLUSIONS

A viable structure of sub-components under the broader ICF concepts has been demonstrated. The study has provided some support to viewing activity limitations and participation restrictions as two independent dimensions, but also invites further studies and refinement of the model.

Who gets the disability grant in South Africa? An analysis of the characteristics of recipients in urban and rural areas

BACKGROUND

This study was to establish whether there was a difference in the characteristics of people who received a disability grant and those who did not in rural and urban samples of isiXhosa-speaking people with disability in South Africa.

SAMPLE

The sample was a convenience sample and was identified through a 'snowballing' process.

INSTRUMENTATION

A demographic survey and isiXhosa versions of the International Classification of Functioning, Disability and Health (ICF) and EQ-5D, a health-related quality of life measure were utilized.

RESULTS

The sample consisted of 244 rural and 61 urban respondents, demonstrating a preponderance of physical disabilities. The groups who received or did not receive grants were equivalent in terms of age, gender, marital status and employment status. A significantly higher proportion of rural dwellers accessed the grant. The grant holders displayed significantly more problems related to mobility and to technology and policies and services relating to mobility and transport. Those who did not receive grants reported more barriers with regard to the attitudes of health workers but not with regard to any other aspect of social support.

CONCLUSIONS AND RECOMMENDATIONS

The majority of men and women with disability identified in this study received the grant, whether or not they lived in remote rural or in urban areas. As there were few differences between the groups, it is likely that several non-grant holders might qualify if they were informed of the grant and applied. The role of medical doctors as 'gatekeepers' to the grant might need to be examined.

How compliant are beverage employees to occupational health and safety regulations?

This observational study was undertaken to identify thehealth and safety violations of employees at a specific beverage manufac-turing company.  A  site inspection and observation of all employees employedat this specific beverage company was conducted by the researcher over 2 days. Employees were observed for 12 hours per day with the morningshift on Day 1 and the afternoon shift on Day 2. A  sample of conveniencewas used in that every employee who was present on those days was included. Descriptive statistics were used to analyze the data set. There were a total of 212 employees and 332 behaviours observed during thisstudy period. Unsafe handling and behaviour was observed in 55% of observations. Incorrect manual lifting techniques was the most frequent health and safety violation observed. In the 48 manual lifting behaviours observed, correct practice was observed in only three cases.  It is clear thatmore healthcare education and practical training is required in the area of manual lifting techniques. It is clear that more practical training is required in the area of manual handling.

The determinants of health-related quality of life in urban and rural isi-Xhosa-speaking people with disabilities

This study aimed to establish the determinants of health-related quality of life in a rural and an urban sample of Xhosa-speaking people with disability. The sample was a convenience sample and was identified through a 'snowballing' process initiated by enumerators who were all members of Disabled People South Africa. The Xhosa version of the EQ-5D was utilized and the visual analogue scale which ranges from 0 (worst imaginable health state) to 100 (best imaginable health state) was used as the dependent measure. The sample consisted of 244 rural and 61 urban respondents, demonstrating a preponderance of physical disabilities. The urban sample reported more problems in each of the descriptor domains. The visual analogue scale score showed a bimodal distribution. The results of the multiple regression analysis indicated that the presence of pain detracted most from health-related quality of life (-20%), followed by anxiety and depression (-10%), and difficulty with performance of usual activities (-10%). Rural participants, with the same impairment level, reported 8% poorer health-related quality of life. The mean visual analogue scale scores were low (in the 60s), and would indicate that the majority of people living with disability do not necessarily adapt to their functional limitations and continue to experience diminished health-related quality of life. The bimodal distribution, however, did indicate that some respondents enjoyed good health-related quality of life. There is a need to manage symptoms, particularly pain and depression, as these have a severe negative impact on health-related quality of life. The rural setting seemed to contribute to a worse perceived health-related quality of life. This effect needs to be factored in when evaluating programmes.

Injury profile of employees at a specific beverage manufacturing company: a retrospective study

This article reports on important information pertaining tothe prevalence of occupational injuries. At present very little data existson the prevalence of occupational injuries in South Africa.  A retrospective study was undertaken to detail the occupational injuries sustained by employees at a specific beverage manufacturing company.The aim of this study was to determine the mechanisms, type, classification, anatomical site, frequency and time of injuries at this beverage company.The sample consisted of all employees that reported to the occupational health clinic with occupational injuries during the six-month review period i.e. July 2004-December 2004. Results of this review were computed in a self-complied injury data spreadsheet. The data was presented descriptively and the level of significance was set at 0.05.  Incorrect lifting of manual materials was reported as the most common mechanism of injury. Repetitive strain injuries were the most common type of injury. The spine/trunk was the site of 48 (66.7% of regions) injuries with the most frequently injured regions being the back (43.1%) and neck (22.2%). Most of the injuries were sustained during the month of December (27.8%). It is recommended that aggressive health promotion and injury prevention strategies be implemented to reduce the burden of occupational injuries at this specific beverage manufacturing company.