a ICF-CATEGORIES EXPLORED FOR ASSESSING PARTICIPATION IN SWEDISH ADOLESCENTS AND ADULTS WITH A MILD INTELLECTUAL DISABILITY Arvidsson P, Granlund M, PhD, Thyberg I, OT, PhD Thyberg M, MD, PhD. INTRODUCTION Participation is an important issue in rehabilitation services according to the perspectives of both professionals and people with different disabilities (WHO, 2001; Stucki et al, 2007; Johnsen, 2009). For persons with an intellectual disability, interventions that enhance participation may be especially important but it is not clear how this aspect of functioning should be assessed (Granlund, 2002; Arvidsson, 2008). Although participation and participation restrictions are specific aspects of functioning and disability, the concepts are broad and extensively debated (Badley, 2008). Therefore it is difficult to know what aspects should be covered by the items of an assessment instrument, in a context of rehabilitation services and applied rehabilitation research (Coster; MeConachie; Stucki & Grimby, 2007; Stucki et al, 2007). A strategy of linking existing instruments to the Internationational Classification of Functioning, Disability and Health (ICF) is possible, but established instruments may contain a mix of ICF components and may not be related to the concept of participation or even an explicit interational model of functioning and disability (Cieza, 2002; Granlund, 2002; Arvidsson, 2008). In order to use the conceptual model and the distinctions of the ICF, an alternative strategy is to start with the ICF categories of participation, and proceed by exploring and developing adequate measurement properties, According to the ICF, and also according to some old medical definitions (Thyberg, 2010), the concept of disability recognizes the interaction between individual and environmental aspects (Bickenbach, 1999; WHO, 2001). Among the components of functioning and disability, the ICF makes a general distinction between body structure/function and activity/participation. In addition, the ICF provides lists with specific categories of the components. These lists provide an interdisciplinary terminology in neutral terms, i.e. aspects of functioning, which may also be used to describe corresponding aspects 1) Leaming and applying knowledge, 2) General tasks and demands, 3) Communication, 4) of disability. The ICF categories of activity/participation are organized into 9 domain: Mobility, 5) Self care, 6) Domestic life, 7) Interpersonal interactions and relationships, 8) Major life areas, and 9) Community, social and civic life. Although the term activity denotes an individual perspective while participation denotes a social perspective, the ICF categories of such human actions and life areas are specified in a common list. The structure of this list isbased on conceptual distinctions, and exhibits an approximate order of increasing complexity with respect to expected sequences of actions and interactions with the social environment, both in chapter order and within chapters (Badley, 2008). Thus, the whole list of possible categories of participation is quite complex and heterogeneous (Coster et al, 2007). On the one hand, it would probably be an advantage to reduce this complexity with respect to the construction of instruments for measurement. On the other hand, it may be an advantage not to make a priori reductions, but to explore empirical relationships between different aspects in different disability groups and environments. In order to capture the perspectives of persons with different disabilities, it is reasonable to focus on self-reported participation when this is possible (Arvidsson, 2008). In adolescents and adults with a mild intellectual disability it is possible to collect relevant self-reported data if the collection methods are adapted to their cognitive abilities and literacy skills (Hartley & MacLean, 2006; Arvidsson, 2008) In order to obtain a clinically useful instrument, it is necessary to make a selection of items from the extensive lists of ICF categories, and maybe also a selection among the 9 domains of participation (WHO, 2001). In this study, we did not make any a priori assumptions that certain “basic? domains of activity/participation should not be regarded as possible aspects of participation, i involvement in life situations. This approach is compatible with option 4 according to Annex 3 of the ICF (WHO, 2001). In any of the possible options regarding the 9 ICF domains, an important question is whether a measure based on a selection of items will reflect a common construct, i.e. participation. For example, it is not quite clear what kind of conceptual distinetions there are between the different domains and categories. If the domains reflect commonalities with respect to what people would be expected to be able to do, this would probably be favourable to the intemal consistency of measures focusing on capacity but not necessarily to the consistency of measures focusing on the actual performance, which may also be influenced by e.g. what activities are perceived to be important in the perspective of an individual. In addition to questions concerning the appropriate selection of items from the activity/participation list, one may question how participation should be rated in terms of e.g. performed activity, frequency of performance, or subjective engagement, operationalized as perceived importance. It is quite clear that participation does not mean just the capacity to perform certain activities, not an enabling environment as such, and not just a general sense of belonging or well-being, but rather the actual involvement and performance of activities in life situations (WHO, 2001). Involvement might be distinguished from performance in that it also contains, at least implicitly, perceptions of involvement or the perceived importance ofthe activity. Thus, two relations are important {0 investigate when trying to distinguish between the perspectives of activity and participation: the relation between capacity and Performance and the relation Between performangs and ance. Preiae te i There is a ESE, Searels ie ais jechi capacity and performance, i.e. an individual’s ability to perform an activity provided a “standard” environment or situation, versus the actual frequency or duration of performance in interaction with the actual situations of that person (WHO, 2001; Nordenfelt, 2008). in @ rhabiifation context, professions! assessments of capacity may be based on observed performance of an activity/or estimated om the basis of conceptions about related functions. Another option self-reported capacity. In analogy, thB ‘ay be based on actual experience or estimated on the basis of related experience. In any of these options, it is not easy to know, for example, how persons conceive what is a “standard” situation and what is not, and it is not clear if there are certain domains that are less dependent on the interaction with the environment (Coster, 2007; Badley, 2008). ‘Thus, one research question is whether there are different patterns of correlations between capacity and performance regarding different domains of participation. Although quite complex, the questions presented above do not consider whether certain domains or items ate perceived to be more or less important aspects of participation in the perspective of the person (McConachie, 2006; Coster, 2007; Badley, 2008; Nordenfelt, 2008222). Thus, a second research question is to explore the domains of participation considering correlations between the capacity ang performpnce aspects and the perceived importance of different items. Aa, Gorrelations 1 A how a group of respondents make distinctions between the discussed aspects. The aim of this study was to explore the following questions in Swedish adolescents and adults with a mild intellectual disability: To what extent is there intemal consistency in ratings of capacity, performance and importance in a preliminary selection of self-reported items representing different domains in the activity/ participation component of ICF? To what extent do self-reported capacity, performance and importance correlate? (ShMETHODS Inclusion process Within the Swedish municipal of eee Kommun) persons aged 16-40 who had any kind of societal service because of intellectual disability, and were estimated to understand and answer the questions of the structured interview, were offered to participate in the study. To be included in societal services because of intellectual disability the person must have had an IQ below 70 and before the age of 18 have documented deficits with adaptive behavior. At&ubsequent information sessions, the content, procedure and the conditions for taking part in the study were presented to groups of 106 potential participants, orally as well as in written text. They were suggested to read the writ text carefully, amtif necessary together with a relative or professional of their chojce, 52% P, f ae cey ect participate . Those who ere not asked about the reasony Bat about fe & reason spontaneously. The most common reason was that the study procedure was too time consuming, while some felt anxious that they would not be able to complete the whole study. Fede, Study group IG~Bz 55 informants were included, 58% men and 42% women. The mean age was 24 (SD: 8), median 20, At the time of this study, the IQ ranged from 53 to 78 with a mean of 69.9 and a melon ‘The IQ was assessed with the Wechsler Adult Intelligence Scale-III. # Of the informants lived with parents and 35% yntinuous access to professional support, 5% lived with a partner. No one lived alone without professional support. Interview guide ‘The interview guide which was developed for this study included 68 items representing a selection of categories of the 9 ICF domains of activity/participation (table 2). The intention was that the selected items should be clinically relevant and cover the 9 domains. The selection was based on the authors’ conceptions concerning clinical relevance and discussions during implementations of the ICF model (Tbragimova, 2007; Arvidsson, 2008; Pless, 2009; Tbragimova, 2009; Adolfsson et al, 2010). For clinical purposes, some items, such as eating (350) and drinking (pS60), were ‘li 8 Cer specific items were used to explorejez the IGF oe recreation and leisure (p9208). In fG, theICF codes mgr, ? blk 3indicate the categories on which the issues were based. According to Annex 2 of the ICF (WHO, 2001), the prefix p is used in the codes to indicate possible aspects of participation. Data collection The informants were interviewed by the first author (PA), a clinical psychologist with experience from testing and rehabilitation with respect to intellectual disability. The interview was conducted according to the order of 68 items given in table 2. Regarding cach item, they were asked about capacity, performance, and importance, ‘on the basis of a 3- inforthants answeredwit and the grade Likert-scale, corresponding #8 Thoted by the interviewer, according to the following: Capacity’ I ean do this fully without any help or support (2), can do it to some extent (1), can not (0). Performance, I do this often (2), sometimes or seldom (1), never (0). Importance, this is very important to me (2), somewhat important (1), not important at all (0). Regarding each item, pyretes F F the order of ut capacity, performance, and importance respectively was allowed to vary depending on the order of spontaneous answers given by the informants, Statistics Distributions were described with actual numbers and percentages with respect to each domain. Cronbach-alpha was used to explore the internal consistency among the issues of the questionnaire representing 9 ICF domains of activity/participation. Cronbach-alpha values were calculated with respec domain. In addition to the numerical data reported in the tables, the Cronbach-alpha values were denoted in bold (+0.7), ordinary figures (05.0.7), and underlined figures (<0.5), to indicate our a priori assumptions concerning values which might be regarded as high, clinical perspective, cf low. reasonably high nical perspective, Spearman rank Correlation was used to describe correlations between the different aspects (capacity, performance, and importance) with respect to each item. Correlation coefficients 0.5 or higher were denoted in bold in the tables and p values <0.05 were regarded as significant. ‘The statistical analyses were performed by Statistica 8. EthicsThe studly was approved by the Regional Ethics Committee of Linképing,RESULTS Distributions Actual ratings with respect to each domain are described in table 1 Internal consistency he Cronbach-alpha values are shown in table 2. Regarding capacity, the Cronbach-alpha value for the whole scale of 68 activities was 0.95 while the value for each domain of activities varied between 0.57 and 0.85. Regarding performance, the Cronbach-alpha value for the whole scale was 0.86 while the value for each domain varied between 0.27 and 0.66. The low values (<0.5) represented the domains of learning and applying knowledge, communication, mobility, and major life areas. Regarding importance, the Cronbach-alpha value for the whole scale was 0.84 while the value for each domain varied between 0.27 and 0.68. The low values represented the domains of learning and applying knowledge, communication, mobility, and sel Correlations In table 3, the correlations between capacity and performance, capacity and importance, and performance and importance are shown with respect to each of the 68 items. In table 4, the corresponding percentages of items with high correlations (0.5 or higher) are shown with respect to each domain of activities, and also with respect to all 9 domains together. Performance versus importance: 72% of the items showed high correlations between performance and importance, with a mean correlation coefficient among all 68 items of 0.59 (median 0.64): E.g, within the domain of learning and applying knowledge each item showed high correlations between these aspects. Within the domain of mobility each item showed, high correlations except driving a car (p4751). Within the domain of domestic life each item showed high correlations except residing as preferred (p6108). In contrast, there were no high correlations between these aspects within the domain of general tasks and demand: Capacity versus performance: 41% of the items showed high correlations (0.5 or higher) between capacity and performance, with a mean correlation coefficient among all 68 items of 0.47 (median 0.45): E.g. within the domain of domestic life each item showed high correlations except residing as preferred (p6108). In contrast, there were no high correlations between these aspects within the domain of community, social and civic life, Capacity versus importance: Only 12% of the items showed high correlations between capacity and importance, with a mean correlation coefficient among all 68 items of 0.28(median 0.25): there were no high correlations within any of the first 4 domains, and within each of the domains 5-9 there were only 1 or 2 items with high correlations between these aspects.DISCUSSION In this study, we used a preliminary selection of items in order to explore how the development of self-reported assessments of participation could be based on the conceptual model of the ICF. The internal consistency reported in table 2 may be used to judge to what degree it makes sense tose the whole listofitems included in our questionnaire, and the Cc specific domains of activities, as measures of self-reported capacity, performance, and importance respectively. Regarding the list of items as a whole, the Cronbach alpha values were high with respect to each of the three self-reported aspecls, ie. capacity, performance, and importance high value reflects that the included items may be regarded as one dimension of measurement, in a sense that although the items differ from each other they reflect a common construet. The value is dependent on both the homogeneity and the number of items. Regarding each specific domain, the Cronbach alpha values were high or reasonably high with respect to the capacity aspect, while the values were below 0.5 regarding some domains with respect to the performance aspect and the importance aspect. Low values | p indicate that the selection of items do not give a reliable measure of a common construct Regarding performance, the majority ofthe low values were found among the first 4 domains. The discrepancy between alpha values for capacity and performance for these chapters may illustrate a quite fundamental problem related to how the domains within the activity/participation were constructed. Probably, the latent constructs for the eka ffthe activity/patticipation component, and especially for these four ebiapeasy ave based on commonalities regarding the capacity an individual has for performing the acts listed, ie capacity for leaming and applying knowledge, capacity for general tasks and demands ete. The acts described in these domains are not contextualized and thus applicable for being involved in almost all the life situations listed in chapters 5 to 9. The individual will perform them when they are important for participating in the life tasks represented by chapters 5-9. Thus, there will be a high alpha value for those ratings of the latent construct that represent the theoretical underpinnings of the construct (capacity) but not for ratings of other aspects of the construct. Another illustration of the same phenomenon is the low value (0.3) regarding performance in the domain of major life areas, which could reasonably not be excluded from a construct of participation. Three of the 5 items included in this domain represented studying, apprenticeship, and working for payment respectively. In the Swedish context that was studied, few persons with a mild intellectual disability would be expected to perform morethan 1 of these 3 activities during the same period of time. Even if they are strongly related in terms of the capacity they require from the individual for being performed they might not be statistically related in whether they will actually be performed by the individual or considered as important by the individual. This discussion highlights a general problem concerning. assessments of participation: how can “full” participation be defined, and would such a measurement be reasonable without including the importance aspect. In this study, we explored the importance aspect in the perspective of the person, but regarding e.g. work and employment it may also be necessary to pay attention to the perspective of society. In consideration of the interactional model of disability and the heterogeneity of the activity/participation lists, the basic assumption that the list of items in the different activity/participation domains represents the same underlying domain specific constructs can be questioned with respect to performance, and also with respect to the importance aspect. However, in order to study questions concerning participation, a necessary step is to explore how different items in the current domains and the aspects capacity, performance and importance of these items may become measurable in a way that is clinically relevant. For the development of an overall measure of participation paying attention to both the frequency of performance and the perceived importance, improvements of Cronbach-alpha values might be relevant. However, an alternative would be to question the relevance of using a psychometric approach, e.g using Cronbach alpha, to evaluate the appropriateness of the domains for measuring participation. Using a clinimetric approach AWhieieekeEa BOLO) would suggest that items designed to measure different aspects of a phenomenon, (e.g capacity, performance, and importance) might represent the same latent construct because the three aspects in reality occurs simultaneously in specified life situations even if the aspects of the construct only have low to moderate inter-correlations. This approach would make it possible to define items in chapter 5-9 as participation independent of alpha values. For the first 4 chapters the lack of common denominators for life situations and the focus on acts rather than complex sequences of tasks a ae activity. In this study, self-reported measuréments with respect to each single item were also used to calculate correlations in order to explore how people with a mild intellectual disability may distinguish between the different aspects, i.e. capacity, performance, and importance for the same act or life situation. When all domains of activities are considered together, 72% of the items show high correlations between performance and importance, 41% of the items show high correlations between capacity and performance, and only 12% of the items show high correlations between capacity and importance. A possible interpretation of the ratherhigh correlations between performance and importance is that the respondents conceive performance and importance as closely related but somewhat different aspects of Participation. Some activities may be performed almost automatically without considerations j yl about the importance in relation to e.g. a larger project (MeConachie, 2006; Nordenfelt, 2008) yh) and might thus be considered as activity. Other activities may imply a more conscious choice in elation o what is considered to be important the perspective ofthe person. For example, 7 fs the domain of general tasks and demands may represent the former, with no high correlations, while the domain of domestic life may represent the latter, with 88% high correlations Re between importance and performance. Although the actual performance is reasonably an essential measure in the assessment of participation (WHO, 2001), it is possible that such measures should be weighted by including the importance aspect, as discussed above. If reflected upon by a person as important parts ofa larger project, even quite basic activities, such as learning and applying knowledge, communication, and mobility, should maybe be allowed to affect the total assessment of participation. ‘The finding that 41% of the items show high correlations between capacity and performance may be interpreted in different ways depending on assumptions about the perceived importance, environmental factors, and conceptual distinctions. Ifit is assumed that informants conceive capacity and performance as quite distinct aspects, one may discuss differences between the domains in terms the interaction with environmental factors, or regarding more or less automatic behaviour versus intentional action (Badely, 2008). In a rehabilitation context, the way that distinctions between capacity and performance are handled may be very important. For example, it may influence the financial living conditions for persons with disabilities because estimations of the capacity as such are crucial for decisions about disability pensions for those not participating in remunerative work (Nordenfelt, 2008). For the studied group with intellectual disabilities, discussions concerning special arrangements, with respect to e.g. work and a place to live will also depend on inction, estimations involving this dis ‘The highest proportion of items with high correlations between capacity and performance was found in the domain of domestic life. All items of domestic life with such high correlations consisted of household tasks while the only item with low correlations was related to the ICF concepts of acquiring and furnishing a place to live (with our approximate wording reside according to your preferences). Assuming that respondents wanted to perform most activities of domestic life, the results may reflect differences between household tasks and the project of acquiring a residence. The latter would reasonably be more dependent oncomplex interactions with a variety of social environments. In a clinical perspective, acquiring a place to live may be an important aspect of participation (Arvidsson et al, 2008). In terms of the distinctions discussed by Badley (2008), a project such as acquiring a place to live may encompass interactions with environmental attitudes and socio-economic factors, in addition to the basic tasks included. In the further development of measurements of domestic life, our results support this reasoning as an argument for treating household tasks and acquiring a place to live as separate issues. Regarding the domains with a rather high proportion of correlations between capacity and performance, the two domains general tasks and demands, and communication include items which could be conceived as basic “acts”, or even mental body functions. As discussed by e.g. Coster et al (2007), such items may be embedded in more complex participation in life situations. According to the reasoning by Badley (2008), such basic activities would not be expected to vary very much by culture and would only be influenced by the environment to some extent. Furthermore, one may expect that some of these basic acts will be performed automatically if one has the capacity. For example, within the domain of general tasks and demands the highest correlation between capacity and performance was found regarding the item of handling stress, ie. to manage the psychological demands required to carry out different tasks. Within the domain of communication, the highest correlation between capacity and performance was found regarding the item of understanding the news on television, Within the same domain, the capacity to write a letter did not correlate with the actual performance, Compared with understanding the news, writing a letter is an item which seems easier to define in terms of frequency and duration. With respect to items defined in that way, the relation between capacity and performance may depend on personal preferences as well as environmental demands and opportunities. There have been quite extensive discussions concerning distinctions between e.g. basic actions and generated actions, such as “activities”, “tasks”, and “life projects” (Badley, 2008; Nordenfelt, 2008). In clinical assessments of the performance aspect of participation, it seems reasonable that an item should be possible to talk about in terms of frequency and duration. If so, it could be registered in the form of a diary. However, this may be difficult regarding items such as handling stress or understanding the news. With respect to major life areas, our questions represented education, work, and the most basic aspects of economic life. Among these items, the highest correlations between capacity and performance were found regarding basic aspects of economic life, such as handling money. Our questions about education and work may reflect items that are ratherdependent on the social environment. Among these, education showed the highest correlation between capacity and performance. This may reflect that some kind of education is the most consistent opportunity provided to this group by the social environment, and the methodological factor that many informants were recruited in this context, Of course, some capacity of the individual is a condition for performance and such limitations will also contribute to correlations between capacity and performance. Within the domain community, social and civic life, we did not find any items with high correlations between capacity and performance. This may reflect that the performance of such activities is highly dependent on interactions with the social environment, as discussed by Badley (2008). For example, a person may have the capacity to visit restaurants and cafés but social attitudes may constitute an environmental barrier. The low correlations between capacity and importance may indicate that the informants conceive capacity and importance as quite distinet aspects. One way to conceptualize the difference is to see capacity , performance and importance as three point on a continuum from activity to participation with capacity primarily representing activity and importance primarily representing participation and performance representing the area where the concepts activity and participation meet. Further studies of relationships between these aspects are relevant to the development of intervention strategies. Interve ns should of course pay attention to domains that are scaled as very important in the present perspective of the person, At the same time, however, a professional aim in rehabilitation services may be to increase the general repertoire of a person in order to support e.g. the discovery of new and interesting domains, or to manage different environments. Thus, it would be relevant to study changes over time regarding the relationship between these aspects in order to clarify the role of capacity in participation, SRA TIEASPAG In conclusion, a preliminary selection of items was used in order to explore how the development of self-reported assessments of participation could be based on ICF categories. Regarding the list of items as a whole, the Cronbach alpha values were with respect to each of the three self-reported aspects, i.e. capacity, performance, and importance, reflecting that the included items may be regarded as one dimension of measurement. Within each specific domain, the Cronbach alpha values were high or reasonably high with respect to the capacity aspect, while the values were below 0.5 regarding some domains with respect to the performance aspect and the importance aspect, indicating that some selections of items do not give a reliable measure of a common construct. Regarding performance, one possible strategy could be to exclude the first 4 domains fromassessments of participation. Another strategy could be to revise the selection or grouping of items, e.g. with respect to the domain of major life areas. High correlations between importance and performance may indicate that respondents conceive performance and importance as closely related but somewhat different aspects of participation. In addition to perceived importance, a possible interpretation of the varied correlations between capacity and performance is that different items are influenced by environmental factors to a varying extent. With respect to the measurement properties of a scale, one should consider ifthe type or degree of interaction between individual and social dimensions differ within the same domain, and if this is relevant for the proper grouping of items.REFERENCES Adolfsson M, Granlund M, Bjérck-Akesson E, Ibragimova N, Pless M. Exploring changes over time in habilitation professional's perceptions and applications of the international DY). J classification of functioning, disability and health, version for children and youth (ICI Rehabil Med 2010; 42:pages?. Arvidsson P, Granlund M, Thyberg M. Factors related to self-rated participation in adolescents and adults with mild intellectual disability: a systematic literature review. J Appl Res Intellectual Dis 2008; 21: 277-291. Badley EM. Enhancing the conceptual clarity of the activity and participation components of the International Classification of Functioning, Disability, and Health. Social Sciences Medicine 2008. Bickenbach J, Chatterji S, Badley EM, Ustun TB. Models of disablement, universalism and the Intemational Classification of Impairments, Disabilities and Handicaps. Soc Sci Med 1999; 48: 1173-1187. Cieza A, Brockow T, Ewert T, Amman £, Kollerits B, Chatter S, et al. Linking health status measurements to the Intemational Classification of Functioning, Disability and Health. J Rehabil Med 2002; 34: 205-210. Coster W, Khetani MA. Measuring participation of children with disabilities: Issues and challenges. Disabil Rehabil 2007 volym och sidor Granlund M, Eriksson L, YIvén R. The utility of ICF’s participation dimension in assigning ICE codes to items from existent rating instruments. J Rehabil Med 2002; 35: 1-9. Hartley S, MacLean W Jr. A review of the reliability and validity of Likert-type scales for people with intellectual disability. Jounal of Intellectual Disability Research 2006; 50: 813- 827. Toragimova N, Lillvist A, Pless M, Granlund. The utility of ICF for describing interaction in non-speaking children with disabilities: caregiver ratings and perceptions. Disabil Rehabil 2007; 29: 1689-1700. Toragimova N, Granlund M, Bjérck-Akesson E. Field trial of ICF version for children and youth (ICF-CY) in Sweden: logical coherence, developmental issues and clinical use. Johnsen V. Skattebu E, Aamot-Andersen A, Thyberg M. Problematic aspects of faecel incontinence according to the experience of adults with spina bifida. J Rehabil Med 2009; 41: 506-511. McConachie H, Colver AF, Forsyth RJ, Jarvis SN, Parkinson KN. Participation of disabled children: how should it be characterised and measured? Disabil Rehabil 2006; 28: 1157-1164.Nordenfelt L. The concept of work ability. Brussels: PIE Peter Lang; 2008. Pless M, Tbragimova N, Adolfsson M, Bjérck-Akesson E, Granlund M. Evaluation of in- service training in using the ICF and ICF version for children and youth. J Rehabil Med 2009; 41: 451-458, Stucki G, Cieza A, Melvin J. The International Classification of Functioning, Disability, and Heali unifying model for the conceptual description of the rehabilitation strategy. J Rehabil Med 2007; 39: 279-285. Stucki G, Grimby G. Organizing human functioning and rehabilitation research into distinct scientific fields. Part I: developing a comprehensive structure from cell to society. J Rehabil Med 2007; 39: 293-298. WHO ‘Thyberg M, Nelson MC, Thyberg I. A definition of disability emphasizing the interaction between individual and social aspects that existed among Scandinavian precursors of rehabilitation medicine as early as 1912. J Rehabil Med 2010; 42: 182-183,Table 1: Actual numbers of ratings and percentages with respect to each domain eS SS | a | 1 2%) | 59@21%) | 210%) 270%) | 116 42%) 132 48%) 31 (11%) | 93.34%) | 151 (55%) 2 | nem [aaa | acim | ise | Woon | 256% | 109 | sam | mem Ip asc eae |r [onto | oo | [ees Fg (cco) sro) ree | mee || eo eer ees = [129 [eeasm | s5ee00 | 1% | war | sacm | eam | oom | sem «| za [was | socom | osaa9 | msarm | anew | sax | orca | 2690 Sp er areca loc [fre | =e eco) eg oe eee + [saan [com | recom [som | 2059 [ure | sae [scm | a6 9 | wom [rsa] ce [as0% | maa | ream | wrae0 [mone] aran0 Tau | axe9 [reano| zoe | za aem [roma] ra cen | seen [sare | msnTable 2. Cronbach-alpha coefficients for each domain and for the total (I-9) for the 3 aspects. Cronbach-alpha values >0.7 are denoted in bold, 0.5-0.7 in ordinary figures, and values <0.5 are underlined to indicate our a priori assumptions conceming high values, reasonably high in a clinical perspective, and low respectively. ICF Aspects Domain Tiems | Capacity Performance | Importance @) 1 Learning and applying knowledge 6 6 7 2 General tasks and demands 5 37 e 3 Communication 8 74_t 4 Mobility 6 QT 3 Seif-care 8 787 Domestic life 3 Si] ‘7 Taterpersonal interactions and relationships [857 8 Major life areas 5 8} | 9 Community, social and civie life 31 i) eo [9s 4Table 3. Correlation coefficients regarding capacity versus performance, capacity versus importance, and performance versus importance for each item in the questionnaire. P-values <.05 is regarded as significant (*). Significant and high p-values (20.5) are given in bold. ICE Aspects Domain Item (ICF-code) Capacity | Capacity | Performance versus versus versus Performance | Importance | Importance 7. Leaming and ‘Washing TV ora im GIT) ~04 =08) 73 applying knowledge a Tistonng To mast TTS) =05 968 Reading anwar aper O15) 3 <7 Reading a beak 1G) ae 69% ‘Wing wir posi @170) a2 30° ‘Wing wiv computer 70) 18 6a 7 General tasks and] Waking pin he morning GE303) 10 SIF demands Galingin ine tojebrao GH ZO at ae ‘Gating a ne, oer GORY ST 06 a Going to bedin te vena GEO | _S7® 08 Be Tindling sess G240D) oa 06 07 3. Communication | Comiehending newspaper @525) 80" ae 58" Conprcending TW news GSI) Si 25 ase ee ae oa ‘Taking patina dcusion @3555) | BaF 26 82 Weting ieartoce eno 5) [20 02 30% ‘Wig ordinary telephone 3600) =02 =16 90" ‘Using (pein) mobile prone A —| 59 24 16 Using enallor SMS OHA Te 28° 64 Mobility Fickng up sal cbjee 00) 65" 28" 16" Promenading 1508) a 2h oF Bg 75) 30F aa 74 ‘Dig eras passe IT 08 =05 65% Ueing sor ain or Fain GTO) 38% 30° 86" Daving car ATE B® 2 4i* 3 Selfeare ‘Shaveng or washing body GSI | 1 21 35 Braking wah GST ag =06 53* Caring Tor aad wails GSI) 85" 10" TF Toleng 550) 26 =03 =.03 Dresing nd undresing (S405) 39% =03 =02 ating and ang (550,50) ay 398 ol aang dit STO) 50" Ae SOF ining heath DSTO) 65" 58" SF &Domestic life Residing as prefered (TOBY 3a 26 27Shopping GBOOY a 2h St Frpaing your es GI) a5" 25 56 ‘Wasing your Ta GAD) a 3a iad Creag GA} a 21 8 Repaing your cts (HS) se 3a oF ‘Gacig Tp bub reas GARI) — | gy aid 90% “sing oe, og. akg GAY | 9B oa ot 7 Anerpersonal ‘elatng wih ends 7500) 20" 03 oF interactions and relationships ‘elang wih anaes GAD) a 66 Esaihng endtips G00) aa 6 essing appropiay wo body Ianguags BB oF (on08) ‘Relaing wih olaabians or senate | GW TF or works (7508) ‘Reltng with staFor echo GTO | AGF a a elatng wi paras @TEDT) 2 08 si ‘lang wih roewten G76) ——] 19 37 Ase alg wil nelahboars G7SOI) 2" 38" 30" ERDTag conc GTADN) a 25 OF ‘aang intimate elanonhip @T70) | 35 “19 aa Major life areas | Atenaing cel, sndying GRID) a 40" 7 Engaging apprenticeship GAO) 26 18 Ae ‘Woakng or parmerk GSO) AF ar Ase Paying yours GD) ou ae oa nding yourmoney G83) a 60" oT 9. Community, Engaging in aseiations GOTO) 33" 38" OF social and civie life ngaaig in panes (69200) 2 20 ee [ Baznaing in pons G50) 42" 49" 53* Engaging in eakare GID) ra SF oF Engaing Rabies DA) 2 Ar 56" Visi retains or ens @P308) | “97 oF AT ising bay GoD08) 00 21 Bi Ving ners GBIOR) 8 5 3 Vig church 2300) aL “19 18 ‘iin oantideweas @P2B) a8" 22 oF ang aia ep 5208) Ae ~05 08Table 4. Frequencies (%) of items with correlations > 0.5 between the aspects capacity versus performance, capacity versus importance, and performance versus importance respectively given for each domain, and for the total of 68 items representing the ICF domains 1-9. ICF Correlated aspects Domain Items | Capacity Capacity Performance @) | versus versus versus Performance | Importance | Importance (%) (%) (%) 1 Teaming and applying knowledge 6 7 0 100 2 General tasks and demands 5 60, 0 0 3 Communication: 8 75 oO 63 4 Mobility 6 33 o 83 5 Self-care 8 37 25 715 6 Domestic life 8 388 25 88 7 Interpersonal interactions and relationships i 36 18 82 8 Major life areas 5 0 20 0 ‘9 Community, social and civie life Lipa lo 9 B 19 ~ [ee 43 12 2