Attention Deficit Hyperactivity Disorder (ADHD) is considered a major public health problem, not only for its high prevalence but also because the symptoms have an impact on activities in daily life at both fa- milial and school levels as well as on a general social level. Clinical evaluation of ADHD was based on the diagnostic criteria of the International Classification of Diseases ICD 10, Diagnostic and Statistical Manual of Mental Disorders DSM IV and comorbidity phe- nomena. Therefore, it has not yet developed into evaluations any more comprehensive than activity limitations and participation restrictions from a bio- psychosocial model of disability, as proposed by the International Classification of Functioning, Disability and Health ICF. Thus, it is necessary to start assess- ment processes of children with ADHD using the functionality and performance components proposed by the ICF, allowing a new approach and a greater understanding of the health status of this population from a more holistic perspective in relation to the disability. Objective: To identify the theoretical ele- ments that justify the importance of addressing ADHD from a bio-psychosocial perspective as pro- posed by the evaluation of the ICF model, ensuring comprehensive assessment processes. This article is the result of a theoretical review addressed in re- search projects around the design, validity and relia- bility of assessment instruments of activity limitations and participation restrictions in children with ADHD.
Qualitative methodology provides the possibility to explore the perspective of those who experience a health problem, that is, the so-called patient perspective [24,25]. Qualitative methods are now widely used and increasingly accepted in health research and health-related sciences [26-28]. One of the most broadly used techniques in qualitative research is the focus group methodology [29-31]. Focus groups are "care- fully planned series of discussions designed to obtain percep- tions on a defined area of interest in a permissive, non- threatening environment" . They are especially useful for studies that involve complex issues that entail many levels of feeling and experience . "The basic goal in conducting focus groups is to hear from the participants about the topics of interest to the researcher" . The idea behind this meth- odology is that group processes can help people to explore and clarify their views . The non-directive nature of focus groups affords participants an opportunity to comment, explain, disagree and share experiences and attitudes . The objective of the present study was twofold: first, to come forward with a proposal for the most appropriate focus group approach to validate Comprehensive ICF Core Sets from the patient perspective; and second, to add evidence to the vali- dation of the Comprehensive ICF Core Set for RA from the perspective of patients with RA based on a group of German patients. The specific aims were to explore the aspects of functioning and health important to patients with RA using two different focus group approaches and to examine to what extent these aspects are represented by the current version of the Comprehensive ICF Core Set for RA.
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that, in this analysis, only the variables sex, age and number of concomitant diseases were included. Future studies should also include further personal factors as rel- evant independent variables. Third, no interaction terms were included in the models since the purpose of the study was simply to propose a method to select ICF cate- gories and to identify candidate ICF categories for a Generic ICF Core Set. However, it is possible that interac- tion terms including, for example, b130 energy and drive functions and b280 sensation of pain, contribute to general health as measured by the item 1 of the SF-36. The inter- action terms should be included in future studies. Four, and probably most important, in our patient sample there was not much variance in most of the categories, i.e., in many categories most people had no limitations. Accord- ing to the guidelines that establish what kind of patients have access to rehabilitation after discharge from an acute hospital in Germany, all the patients have to be able to eat and wash themselves without external support, as well as be able to move independently on the ward. Therefore, one can assume that the limitations in functioning suf- fered by the patients included in this study do not repre- sent the whole spectrum of severity of limitation in functioning of patients suffering from chronic conditions. This limitation points out an additional limitation of the study – the generalization of the results. Only patients treated in rehabilitation centers in Germany were included in this study. Thus, patients treated in acute hos- pitals, day clinics and outpatients and inpatients in coun- tries other than Germany are not represented. This again emphasizes the importance of performing similar analy- ses with patients in different countries who are being treated in different settings. This will be possible with the data collected in the international validation study of the ICF Core Sets involving over 50 countries and 270
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Previous reviews of the ICF have found an increase in publications reporting on its use in healthcare since its endorsement in 2001 [34,35]. A review by Jelsma (2009) found that the ICF has been used across disciplines, health conditions, sectors and settings and that it has made an impact on data collection and analysis of people with disabilities. Cerniauskaite et al. (2011) performed a review of the literature on the ICF from 2001 to 2009 and also found a significant increase in the quantity of globally published literature during this time with one third of identified articles published in 2008 and 2009. It was found that the ICF has been used in both clinical and non-clinical contexts, including legisla- tion, labour, education and policy development . Fayed et al. (2011) performed a systematic review on the use of ICF linking rules for linking health and health- related information to the ICF and found evidence that this method was used for describing and comparing infor- mation from outcome measures, results from qualitative research and clinical patient reports . However none of the reviews made reference to Indigenous healthcare or other minority populations so it is not known whether the ICF has been applied in an Indigenous context.
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PFs have played a tangential part in relation to ICF- based health outcome research. In the ICF, PFs are de- fined as internal factors that determine functioning and the individuals’ experience of disability. PFs comprise “features of the individual” such as coping, social back- ground and psychological factors impacting health out- comes . However, even if a few researchers have explored PFs through consensus processes , system- atic reviews  or qualitative interviews with patients , they are not yet classified according to the ICF “taxonomy” [6,7].
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The present study presented some limitations such as: the subjects' profile may not represent the population with low back pain in Brazil; there was insufficient data extracted from the evaluation to quantify the categories of the Body Structures component; and there were range of categories and little specificity of them mainly in the components Activities and participation and Environmental factors. These last components cited contain a range of examples in each category. Some subjects reported that in some situations there is some difficulty in choosing a qualifier that is represented for the entire category. Therefore, it is necessary to note which is the example that the subject has difficulty for the intervention to be as directed as possible. It is suggested that other studies apply classification as a way of monitoring the outcomes of this treatment modality and that accompany the medium and long term the functionality of these people with low back pain. It is hoped that this study will help other researchers better understand the multifactorial aspects of low back pain using ICF as well as the replication of the study in other Back Schools in different regions or contexts.
The International Classification of Functioning, Disability, and Health (ICF) is an international classification developed by the World Health Organization (WHO) [9, 10]. In con- trast to other international classifications, the ICF highlights the structure and measurement of “health components”, and emphasizes on “functioning” rather than “impairment” to provide information on abnormal health status [11, 12]. In order to ensure the wide application of ICF in clinical practice and studies measuring the health status of diseases, the WHO has developed the corresponding ICF core sets for evaluating the health status of some diseases, which refers to the selection of the fewest ICF categor- ies relevant to the patient’s function, disability, and health based on specific diseases and environments [13–15]. These core sets are a secure, fast, and accurate instrument for the application of ICF in clinical practice . The ICF aims at providing a unified language for the description of health conditions in rehabilitation [17, 18]. Based on the ICF as a common language, it is possible to analyze functioning beyond the study of the incidence and prevalence of health conditions and beyond the limited as- pects of functioning such as activities of daily living [19, 20]. With the ICF, it is possible to analyze the relationship of elements of functioning on the level of single categor- ies. A promising approach to describe the complex rela- tionships in human functioning is graphical modeling. The least absolute shrinkage and selection operator (LASSO) graphical model is a comprehensive probabilis- tic tool to analyze and visualize dependencies between random variables. The LASSO graphical model con- stricts a regression coefficient and thus, directly turns a portion of the coefficients with small absolute value to 0 [21, 22]. The LASSO graphical model has the algorith- mic computational complexity equal to that of the least square regression and is effective for selecting variables that have intense effects on dependent variables [23–25]. The correlations among these variables can be directly shown by functional topographic maps. Some authors have used graphical modeling to investigate ICF core sets. For example, Becker et al.  used graphical model- ing to investigate the associations among functional cat- egories of head and neck cancer in ICF. Kalisch et al.  used graphical models to investigate functional data in ICF and they believe that this method can become a tool for functional analysis. Similar to the above studies, Strobl et al.  used graphical modeling to study ICF and dem- onstrated “paths” related to “structures”, which was a good illustration for the associations among ICF categories. Ehrmann et al.  used graphical modeling to describe and understand the functioning of people living with a health condition.
The contents of the five selected PRO measures were examined by extracting the meaningful concepts con- tained in the items of each measure and linking them to the ICF or ICF-CY . The meaningful concept repre- sents the first step in the linking process and it is repre- sented by the extraction of the key meaning included in one item. For example, the item No.18 in the Medtap questionnaire: “I am afraid of internal bleeding” contains two different meaningful concepts “to be afraid” and “ bleeding ” . In order to link items, established linking rules were adopted [43,47], which contain the following aspects: a) each item of a health-status measure should be linked to the most precise ICF category, b) if a single item encompasses different constructs, the information in each construct should be linked, c) the response options of an item are linked if they refer to additional constructs, d) if the information provided by the item is not sufficient for making a decision about which ICF category the item should be linked to, this item is assigned nd (not definable), e) if an item is not con- tained in the ICF classification, then this item is assigned nc (not covered by ICF).
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Background: In 2010, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) was developed, based on the concept of the International Classification of Functioning, Disability and Health (ICF). The ICF provides a common language and framework for health and health-related status and attempts to integrate the biopsychosocial model as a multidimensional perspective in understanding functioning. Activities and participation (AP) is one salient component of the ICF refers to the execution of a task by an individual, and how such tasks are involved in their daily life. It is essential to examine the gap between the general adult population and adults with disabilities. This gap may be attributed to health status, personal factors, and natural and social environments, which include social and health services and policies. The purposes: (1) To develop a normative activity and participation (AP) value for the adult population and people with disabilities; and (2) to compare the gap in AP normative values between the two groups in Taiwan.
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The Comprehensive ICF Core Set for CWP is now undergo- ing worldwide testing and validation using a number of approaches, including an international multicentre validation study and a validation from the perspective of health profes- sionals. Since patients were not directly included in the devel- opment of the ICF Core Sets, they are now explicitly involved in the validation of ICF Core Sets to establish the patient per- spective in this process. As standards of functioning and health in research and clinical practice, the ICF Core Sets have to show that they address the perspective of those who experience the disease. Since FM is a very common CWP ill- ness with clearly defined classification criteria, we decided to focus on FM patients to validate the ICF Core Sets for CWP. Qualitative methodology provides the possibility of exploring the perspective of those who experience a health problem; that is, the patient perspective [13,14]. Qualitative methods, especially focus groups, are now widely used and increasingly accepted in health research and health-related sciences [15- 17]. The idea behind the focus group methodology is that group processes can help people explore and clarify their views . The nondirective nature of focus groups allows participants to comment, explain, disagree and share experi- ences and attitudes . The Comprehensive ICF Core Set for rheumatoid arthritis was validated recently from the patient perspective using qualitative methodology. Seventy-one out of the 76 ICF categories in this ICF Core Set were confirmed, and an additional 57 categories not covered in the ICF Core Set for rheumatoid arthritis were found . Further studies for validation of ICF Core Sets from the patient perspective are currently in progress, including those for stroke, low-back pain and diabetes.
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Unfortunately, and despite many strengths of the ICF, in its current form some key conceptual shortcomings exist; specifically, it is limited in its ability to address the heterogeneity of concerns related to cancer. To demonstrate this belief, a brief discussion of the primary areas of concern for oncology in which the ICF exhibits conceptual limitations will follow. Specifically, the discussion to follow will center on the proposed revision of the following three areas of the ICF framework: (1) the replacement of the term “health condition” with the more inclusive and dynamic term “health state;” (2) the continuing development and refinement of the personal factors component to ensure issues such as comorbidities can be accounted for appropriately; and (3) the inclusion of a mechanism to account for the subjective dimension of health and functioning (eg, QOL). It is through the expansion of these conceptual parameters that the ICF may become more relevant and applicable to the field of oncology. With these important revisions, the ICF has the potential to provide a broader biopsychosocial perspective of care that captures the diverse range of concerns that arise throughout the continuum of care in oncology.
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The diagram favors ICF application but a more comprehensive use of components needs to be done to standardize and systematize the language. It is believed that the suggested adjustments will favor the application of the ICF benefiting students and teachers in the operationalization of all components of the classification. In addition, the proposed diagrams would allow the same patient, evaluated and accompanied by different students throughout a treatment period, to have his or her information collected in a systematized manner. This model can act as a pilot application to further improve the context of the study. The analysis resulted in considerations for the improvement of learning in the context of the present study, emphasizing the importance of using the ICF in a way that is complementary to the evaluation already made and that generates a systematized and standardized language.
Using the ICF as a reference, a total of 40 second-level categories was used to classify the content of condition- specific and generic measures of shoulder pain. The most frequently addressed concepts were pain, movement- related body functions and structures, sleep, hand and arm use; self-care, household tasks, work and employment, and leisure activities. Concepts of psycho-social functioning and environmental factors were less frequently addressed. Commonly used condition-specific measures showed a large variation in content; the DASH and the ASES were linked to more than twice as many ICF categories as the Constant, SST and SPADI. These large differences demon- strate the importance of clarifying the content to select the most appropriate measure both in research and in clinical work. For clinical situations, we propose use of a wide- ranging condition specific measure that conceptualizes assessments of shoulder pain from a bio-psycho-social perspective. Further research is needed to investigate whether patient-reported problems in functioning are captured in the commonly used condition-specific and generic measures.
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The first step consisted of assessing the needs for training in Italy, in consideration of the different professional skills because, for example, the labour sector’s needs are quite different from those coming from the statistical, health, education or research ones. Different groups, moreover, may require a different teaching methodology, and a complete training course cannot ignore this necessi- ty. Last, in preparing and planning the training methodol- ogy, the DIN had to take into account what other researchers are developing in other countries: liaison with WHO-Collaborating Centres and with WHO was an essential component of our work on training, as well as agreeing with WHO to get the consultancy of their experts on the training development. All available material on the ICF was reviewed. Published and unpublished papers, comments and experiences were taken into account. The contribution provided by WHO’s experts (Dr. Ustun, Dr. Chatterji and Dr. Kostanjsek) helped to take into account the development of ICF implementation strategies in dif- ferent countries all over the world. The methodology developed by the American Psychological Association for their training was studied in detail, as well as the training developed by the Canadian group as an introduction to ICF. Material available on the web was used to evaluate the different applications in different fields. The bibliog- raphy of consulted documents for the ICF development is listed below.
Statistical analysis was conducted in four steps: In step 1 a first selection of potential predictor variables was performed by the use of descriptive statistics. Each ICF category had to fulfil two criteria to be included in further analyses. First, the variables had to be important for at least 5% of the patients, i.e. at least 5% of the patients reported any kind of impairment or support (Environmental Factors) concerning the respective category. Secondly, there had to be a substantial relationship to functional health status. The relationship was analyzed by Spearman correlation coefficient. The correlation had to show a probability value lower than .15. The maximum number of variables selected of each ICF component was 10 for reasons of sample size (n=200). The variables selected in step 1 were included in analyses of regression in step 2.
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Purpose: to construct and validate a questionnaire that assess the knowledge acquired in ICF e-learning course and the use of the ICF in clinical practice. Method: methodological research of the construction and validation of questionnaires. Questions about the ICF content knowledge and use de ICF in clinical practices were elaborated and adapted. The consistency of this questions was reviewed by experienced researchers and the content and clarity was validated by 11 judges (5 with and 6 without ICF knowledge), who attributed note from 0 to 10 to each question. The percentage of concordance between judges was stipulated as ≥ 80% for content validity and clarity. Results: All questions validated already in the first round of assessment and formed 2 questionnaires: the Pre with1 question about previous contact with CIF, 10 about knowledge and 3 about use of the CIF, to be answered by the participants before the course of CIF; and the Post to be answered after, containing with 10 questions about knowledge and 2 about use. Conclusion: The 2 self-administered questionnaires contain the minimum number of questions necessary to assess the knowledge acquired in a basic CIF courses and the use of this ICF knowledge in clinical practice.
Methods: A geographical cohort of patients about to undergo lower limb joint replacement was invited to participate. Five hundred and twenty four patients completed ICF items that had been previously identified as measuring only a single ICF construct in patients with osteoarthritis. There were 13 I, 26 A and 20 P items. The SF-36 was used to explore the construct validity of the resultant I, A and P measures. The CTT and IRT analyses were run separately to identify items for inclusion or exclusion in the measurement of each construct. The results from both analyses were compared and contrasted.
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First, baseline characteristics of the sample will be pre- sented using descriptive statistics. All analysis of primary and secondary available outcomes will be realised on an intention-to-treat basis thus respecting group allocation irrespective of whether participants received the inter- vention or not. The primary endpoint for analysis is the end of the intervention: six months period. A between group comparison on the difference in scores between six months measurement and baseline, between “ we call ” and “ you call ” will be made using an independent sample t-test for both primary and secondary outcomes. Effect size of the differences with their 95% confidence interval will be reported. As we anticipate unplanned-use of health services to not be normally distributed (we might end up with many ‘zero’ negative event), we plan to con- firm parametric statistics with non-parametric testing. Also, repeated measures analysis will be realised using the four times of measurements (baseline, three months, six months and one year) where the between-subject fac- tor is the intervention type, the within-group factor is time and their interaction provides the intervention effec- tiveness, including the one-year follow up phase. Also, multiple linear regression analyses will be used to explore the contribution of the potential explanatory variables (including group assignment, age, gender, living alone versus with a significant other, comorbidity level, etc.) on change in primary and secondary outcomes.
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Outcomes research has been defined as the assessment of what does and does not work in the delivery of healthcare . While a large volume of research has focussed on examining the effect of different treatment regimes on patient outcomes, it has been widely acknowl- edged that the clinician delivering treatment is an integral component of the intervention and that the interpersonal interactions between clinician and patient may have strong influences on outcomes [2-6]. This has led for calls to research the nature, type and extent of these interpersonal factors and to assess the degree to which changes in these factors can achieve better patient outcomes [2,4]. It is also argued by researchers from within medical education that the education and development of clinicians should be evaluated in order to ascertain whether they achieve better health outcomes [1,7-11]. Such evaluation would enable researchers to delineate how healthcare education contrib- utes directly to the health of individuals and the public, improves the relevance and impact of medical education research, and enables patients and practitioners to make better-informed, cost-effective healthcare decisions [1,10]. However, this type of research presents challenges, particularly in view of the multiple factors - physical, psychosocial, economic, environmental and cultural - that can influence patient outcomes [7,12,13]. Disap- pointingly, the call for research to investigate the effectiveness of educational interventions has been largely unheeded to date as there is a dearth of litera- ture examining the impact of professional education on patient outcome [1,7,10,14-17].
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A pool of 104 mobility items was selected from the lit- erature and a panel of experts (two physicians, four nurses and three psychologists) assessed their relevance and suitability for older people, and also classified them into four domains based on three ICF categories of mo- bility: changing and maintaining body position (BP), car- rying, lifting and pushing (CLP), walking (Walking) and going up and down stairs (UDS). Walking and UDS were considered separately and items relating to moving around using transportation were not included. The relevance of the activities included was also evaluated by three focus groups of older people. As a result of the above, 48 items were selected and their ease of under- standing was assessed in 17 cognitive interviews. No items were eliminated, but modifications were made to various item statements. The item stem posed the ques- tion in terms of ability, in the present tense and made no reference to health, with a rating scale of four re- sponse categories: no difficulty, some difficulty, much difficulty and unable to do. Scores were scaled measur- ing mobility limitation: the higher the score, the worse the function.
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