Presentation at the 2nd International Symposium: ICF Education. 30 June 2017 (Cape Town). http://www.icfeducation.org

1. ICF Environmental Factors:
Catalyst for person-centred healthcare
Janice Miller
Canadian Institute for Health Information
Ottawa, Canada
FDRG Mid-Year Meeting
28-29 June 2017
Stellenbosch, South Africa

3. Schneider M, Hurst R, Miller J, Bedirhan U. The role of Environment in the International Classification of Functioning, Disability and Health.
Disability and Rehabilitation, 2003; Vol.25, No. 11-12, 588-595
“The ICIDH was criticized both for its limited conceptualization of the
role of the environment in disability and its remaining focus on the
individual as the locus of intervention rather than the environment as
reflected in society and social organisation. The main sources of
criticism came from the disability movement and the development of
the associated social model of disability”
“..it did not sufficiently recognize the integral role played by the
environment in disability, and the associated need for interventions
focusing on changing the physical, social and policy environments in
which people live, rather than the individual”

4. 1995 -Revision process in included commitment to establishing
Environmental Factors through establishment of a task force
• Task force included majority of people with disabilities and co-
chaired by Rachel Hurst (DPI, UK)
• 3 face to face meetings to reach agreement on content
1999 – resources in place at WHO headquarters dedicated to the EF on
the ICF revision team (supported by CIHI and CDC)
2001 – ICF endorsed at the 54th session of the World Health Assembly
WHO timeline included dedicated resources for
development of Environmental Factors in the new
ICF

5. Health condition
(ICD codes)
Body function & structure
(Impairment)
• Sensation
• Pain
• Tone
Activities
(Limitation)
• Picking up
• Rolling
• Standing
Participation
(Restriction)
• Household tasks
• Employment
• Socialising
Environmental factors
• Support & relationships
• Physical environment
Personal factors
• Age
• Gender

6. ICF Environmental Factors (e)
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
• Products and technology
• Natural environment and human-
made changes to the environment
• Support and relationships
• Attitudes
• Services, systems and policies

7. 1 Products and technology
• e1201 devices for personal
indoor mobility
• e140 devices for culture
recreation and sport

8. 2 Natural environment and human-made
changes to the environment
• e2601 outdoor air quality
• e210 physical geography

9. 3 Support and relationships
• e 350 dog for
personal mobility
• e 330 substitute decision
maker

10. 4 Attitudes
• e465 social norms,
practices, ideologies

11. 5 Services, systems and policies
• e5900 labour and
employment services
• e5400 transportation systems

12. Qualifiers for EF – Barriers and Facilitators
The environment may have a
significant effect on a person‘s
functioning and it is essential to
record the degree to which it
enables or disables the person.
There are three options for coding
Environmental factors (in Annex 2
of ICF): relating to the person
overall, to each ICF component, or
to capacity and performance– the
qualifiers of A & P.
When an environmental factor
improves performance, it is coded
as a facilitator; when it lowers the
level of performance, it is coded as
a barrier.

13. Environmental Factors – evolution and use
• ICF-CY – ICF for Children and Youth, 2007
• Measuring and operationalizing the environment in ICF
• Integration and impact of EF on new and existing
classifications, surveys and datasets
• WHO Update Platform for ICF – improving and/or
reconceptualising environmental factors going forward

14. ICF - CY
• 2 new codes in e 155
• Design, construction, building product and technology for physical safety in
buildings for private use
• Design, construction, building product and technology for physical safety in
buildings for public use
• Enhanced descriptions and inclusions in Chapters 1 & 5
• Many proposals with valuable enhancements could be revisited and
re-submitted

15. Enhancing EF through the ICF Update Platform
Current proposals on:
- Water and water quality
- Land and soil quality
- Characteristics of work – health services, systems & policies
- Vibration

16. Measuring and Operationalizing EF

17. Measurement approaches
Approach Example
1 Subjective / self-report of PWD on
how EF impact participation:
a. Barriers
b. Barriers & facilitators
a. CHIEF - Whiteneck et al
b. MQE - Fougeyrollas et al
2 Self- report on specific features of
environment (PWD or other),
irrespective of their functional abilities /
participation level
HACE (Keysor et al)
3 Characterisation of community
(including household)
Environment, scientific observation
a. Global
b. Targeted, eg. mobility
a. BEAT (Araya et al)
b. CHEC (Gray et al)
Keysor JJ, How Does the Environment Influence Disability?, Disability in America, A
New Look, Institute of Medicine. Appendix D, 89-100, 2006

18. Self-reported Reported by others
Interaction of
EF with
functioning
 Questionnaires on
environmental barriers
 Questionnaires on barriers
and facilitators, eg CHIEF,
FABS/M*, MQE
 Content analysis of
historical documents of
PwD
 (Video taped) Observation of
interaction of PwD with EF
e.g. observation of older adults
during trips into community
Questionnaires
e.g. completion of CHIEF by
proxies
Independent
assessment
of EF
 Questionnaires to assess
the presence/absence of
EF
 Cognitive representations
of EF
 Observation of
community/home environment
 Content analysis of media,
laws etc.
 Questionnaires to directly
assess EF - e.g. attitudes of
health professionals
Source: Reinhardt JD, Miller J, Stucki G, Sykes C, & Gray DB (2011)
Measuring impact of environmental factors on human functioning and
disability: a review of various scientific approaches. Disability & Rehabilitation 1-15

19. EF in WHO-DAS2 36 – 3 questions
How much of a problem did you have because of barriers or hindrances in the
world around you?
ICF -EF Chapter 5
How much of a problem did you have living with dignity because of attitudes and
actions of others?
ICF -EF Chapter 4
How much has your health been a drain on the financial resources you and your
family?
ICF -EF Chapter 1
Scale:
None Mild Moderate Severe Extreme
http://www.who.int/classifications/icf/WHODAS2.0_36itemsSELF.pdf

20. EF in Model Disability Survey - Example
Should you need help, how easy is it to get help from:
- A close family member (including partner)
- Friends and co-workers ICF -EF Chapter 3
- Neighbours
Scale:
Very Easy (1) Very Difficult (5)
http://www.who.int/disabilities/data/model-disability-survey3.pdf?ua=1
http://www.who.int/disabilities/data/mds.pdf

21. ICHI Alpha 2016 – Integration of ICF
International Classification of Health Interventions
1. Interventions on Body Structure and Function
2. Interventions on Activities and Participation domains
3. Interventions to improve Environment & Health related behaviours
1. Interventions on the Environment
UA Environment: products and technology (ICF EF Ch1)
UB Natural environment including human changes (ICF EF Ch2)
UC Environment: Support and relationships (ICF EF Ch3)
UD Environment: Attitudes (ICF EF Ch4)
UE Environment: Services, systems and policies (ICF EF Ch5)

22. ICHI Alpha 2016 – Integration of ICF
3. Interventions to improve Environment & Health related behaviours
1. Interventions on the Environment
UA Environment: products and technology (ICF EF Ch1)
UA1 AAZZ Assessment of products and technology
UA1 AIZZ Monitoring of products and technology
UA1 DMZZ Installation of products and technology
UA1 KBZZ Change in external device
UA1 DHZZ Training in use of products and technology

23. Going Forward…..

24. Thank you!
Thank you!