ICF: A GUIDE TO ASSISTIVE TECHNOLOGY
DECISION-MAKING
Petra Karlsson
University of Western Sydney
Sydney, NSW
Abstract
The World Health Organization (WHO) International Classification of Function,
Health and Disability (ICF) offer a model to guide and integrate the complex
aspects of assessment for assistive technology. Assessments based on the
ICF will assist professionals to understand the intended individual’s need,
facilitate collaboration across agencies and prioritise goals for intervention.
Research tells us that not one instrument alone is able to provide an
evidence-based assistive technology specific assessment. However, the ICF
components are integrated in some well-established assessment instruments.
In the assessment process, professionals assessing assistive technology
needs must rely on their knowledge, experience and clinical reasoning. This in
combination with using well-established assessment and outcome
instruments ensures evidence-based decision-making, when recommending
assistive technology.
This paper outlines the ICF model and its application to guide the use of
existing evidence-based assessment and outcome instruments that are
applicable for most disabilities, settings and types of assistive technology.
Key words
assistive device, assistive technology, International Classification of
Functioning, Disability and Health (ICF) model, service delivery process
1. Introduction
Assistive technology is designed to provide functional benefits and to facilitate
participation for a person with a disability (World Health Organization, 2002).
However, research shows that there is a high level of device abandonment,
even with what appears to be a well matched device (M. J. Scherer &
Craddock, 2002).
Studies on device abandonment, often explained by inefficient assessments
and intervention processes (Judge, 2002; M. J. Scherer & Craddock, 2002),
have led to the development of assistive technology specific outcome
measures to evaluate the satisfaction and effectiveness of a device. There is
a lack of evidence- based procedures that are specific to assistive technology
provision.
Although the International Classification of Functioning (ICF) was not
specifically developed to guide assistive technology assessment, the literature
shows that it lends itself as a descriptive model for the assistive technology
assessment process. ICF captures the complex aspects of the impact of
assistive technology and its service delivery process and can assist the
professional in decision-making (Bernd, Van Der Pijl, & De Witte, 2009).
This paper outlines the ICF model and its application to guide the use of
evidence-based assessment and outcome instruments that are applicable to
most disabilities, environments and types of assistive technology.
2. Assistive technology
The World Health Organization defines assistive technology as any device or
system that enables a person to perform a task that would otherwise be too
difficult to execute and which facilitates a task being performed (World Health
Organization, 2004). Assistive technology includes both devices and services.
Assistive technology services are defined as a service that support assistive
technology assessment, acquisition and device use (Bausch & Jones Ault,
2008).
3. The International Classification of Functioning
The International Classification of Functioning, known as ICF, is widely used
to describe and measure health and health-related state outcomes. It provides
a common language and framework to describe health and disability. ICF is a
classification of health and health-related domains. The domains describe
changes in body function and structure, what a person is able to do, their level
of capacity, what they actually do, and their level of performance. Functioning
in ICF refers to all body functions, activity and participation, while disability is
used to describe impairments, activity limitations and participation restrictions.
In ICF, disability and functioning are seen as outcomes from interactions
between health conditions and contextual factors (World Health Organization,
2002).
Initially the ICF looks like a simple health classification, but it can be used for
a wide range of purposes. In service provision, practical issues on the
individual, institutional and social level can be addressed. On the individual
level, ICF can assist in assessments to determine the person’s level of
functioning and facilitate communication among health professionals, social
work and community agencies. At the institutional level, ICF can be used for a
number of purposes; educational and training purposes; resource planning
and development; to answer questions such as; what services will be needed
and how useful are the service provided. At the social level, ICF helps to
identify the needs of persons with various levels of disability, impairments,
activity limitations and participation restrictions. Environmental assessments
can be used to identify facilitators and barriers to support a more accessible
environment for the person (World Health Organization, 2002).
In light of the above, the ICF allows for an analysis of the effectiveness of
assistive technology through the domain of user functioning (ICF functioning)
along with factors in the environment and in the person (ICF contextual
factors).
4. Using the ICF to structure assistive technology assessment
The ICF disability and functioning are seen as outcomes between health
conditions and contextual factors. In the first part; disability and functioning
includes components of body function, body structures and activities and
participation. In the second part; contextual factors include environmental
factors and personal factors (World Health Organization, 2002).
The ICF checklist, an instrument developed to be used along with the ICF,
captures disability and functioning and contextual factors. The checklist
assists the service provider to assess the presence of an impairment, using a
five point scale, to grade the impairment of function and structure (no
impairment, mild, moderate, severe and complete)(World Health
Organization, 2003). The checklist can be used across disabilities, age groups
and settings.
The only evidence based assistive technology specific model, developed to
match the ICF and its checklist found in the literature, is the Matching Person
and Technology (MPT) model (Bernd, et al., 2009; M. J. Scherer & Craddock,
2002). The MPT is the most published model that is specific to assistive
technology assessment (Bernd, et al., 2009). It was developed to address the
environment, the person and the technology, factors that need to be
considered when evaluating a person’s need for assistive technology (M. J.
Scherer & Craddock, 2002). The MPT supports a collaborative partnership
between the service providers and the user (M. Scherer, Sax, Vanbiervliet,
Cushman, & Sherer, 2005). The Assistive Technology Device Predisposition
Assessment consumer form (ATD PA), a part of the MPT assessment battery,
is compatible with ICF and measures the impact of technology using the ICF
domains. The ATD PA items ask the user to rate their predisposition to using
the assistive technology that is being considered, to better match technology
with the person and therefore minimize device abandonment. ATD PA is
developed for adults (M. Scherer, et al., 2005). For families with children aged
0-5, an assessment form called Matching Assistive Technology and Child
(MATCH) is developed (Sherer, 1997).
The literature tells us that there is a lack of evidence-based procedures for
assistive technology provision (Bernd, et al., 2009). Where the MPT is not
applicable or available, the ICF framework can guide the service provider in
assistive technology decision-making and to the use of evidence-based
outcome measures. Through evidence-based practice, improvements in the
outcomes of interventions and services in assistive technology as well as in
other health areas, can be achieved (Adams, 2003). The outcomes guide us
as to whether an assessment and implementation were successful.
4.1 Disability and functioning
Body functions and Body structures are the physiological, psychological and
anatomical functions of the body. The ICF checklist has a list of mental
functions; sensory function and pain; voice and speech functions; respiratory
systems; neuromusculoskeletal and movement related functions, to mention a
few. The checklist will assist the service provider to assess if more specific
assessment related to cognition; speech and communication; hand function;
and mobility will be required.
When assistive technology is successful, it reduces or removes barriers, to
allow the person to take part in activities (Jutai, Fuhrer, Demers, Sherer, &
DeRuyter, 2005). The ICF checklist assists the service provider to elicits what
capabilities and limitations the user’s experience in activities and participation
related domains. Examples of relevant domains are: learning and applying
knowledge; speaking; getting around inside and outside the home; self-care;
interpersonal relationships; and social life etc.
The Canadian Occupational Performance Measure (COPM) was developed to
capture the client’s individual occupational performance as an outcome
measure. It is a published copyright semi-structured interview instrument
(Law, et al., 1999). COPM is not assistive technology specific, but looks at the
needs of the assistive technology user from a client-centred perspective.
Applied with other instruments it has been found to be a useful tool for
assistive technology assessments (Bernd, et al., 2009). COPM looks at three
important sections of daily living; self-care, productivity and leisure. When
identifying problem areas with the help of COPM, the nature of the domains of
productivity, leisure and self-care, may prompt service providers to activity
oriented goals rather than goals of participation, although the instrument
support both goals (Sakzewski, Boyd, & Ziviani, 2007).
The Goal attainment scaling (GAS) was first introduced in 1968 to evaluate
mental health services (Kiresuk & Sherman, 1968). Today it is widely used in
pediatrics, rehabilitation and mental health (Steenbeek, Ketelaar, Lindeman,
Galama, & Gorter, 2010). GAS measures the change in response to individual
goal-setting. For each goal, five pre-determined levels of outcomes are
described. GAS requires no additional qualification to administer, but training
is recommended along with problem-solving skills. GAS is flexible and
suitable to use for unique goals. GAS can be developed with or without client
involvement. However, client or family involvement when developing goals
has shown to result in a higher number of successfully implemented goals
(Østensjø, Øien, & Fallang, 2008).
The Individually Prioritised Problem Assessment (IPPA) is a generic
instrument to measure the effectiveness of any assistive technology provision.
The aim with this instrument is to measure the degree of change. The service
provider facilitates, through an interview, the user to identify problem areas.
This is similar to how COPM is administered. The user rates the importance
and level of difficulty. IPPA has been found to be a sensitive measure of
change (Wessels, et al., 2000; Wessels, et al., 2002).
In sum, the COPM, GAS and IPPA are examples of the few instruments, that
after intervention are evidence-based and unique in that they are sensitive to
measure change (Cusick, McIntyre, Novak, Lannin, & Lowe, 2006;
Sakzewski, et al., 2007). COPM and GAS have the advantage that they can
be used with clients of any age, with any disability, using any form of assistive
technology. A combination of these instruments offer service providers
additional evidence-based solutions for assessment and outcome measure in
assistive technology, as an alternative or complement to the MPT.
4.2 Contextual factors
An assessment is defined by Law, Baum & Dunn (2005) as the instruments
used to collect relevant information during the assistive technology evaluation.
In the assessment process there are many factors to consider; what the
person wants and needs to, do as well as the environment in which the
activity will take place. Examples of contextual factors are the external
environmental factors such as support and relationships; service, systems
and policies; climate; terrain; and technology. Examples of internal personal
factors are; the gender, age, social background, education, profession past
and present experience (World Health Organization, 2002). The ICF checklist
provides the service provider with a template to also collect demographical
data, and information regarding diagnosis and heath conditions (World Health
Organization, 2003). Investigating personal, environmental and health related
factors may identify the factors that influence the user’s functional ability (Jutai
& Day, 2002). Environmental and personal factors can change over time (M.
Scherer, Jutai, Fuhrer, Demers, & Deruyter, 2007). They may be the reason
for assistive technology use or abandonment (Jutai & Day, 2002).
The Psycho-social Impact of Assistive Devices Scale (PIADS) measures the
psycho-social impact of an assistive technology device on a user. PIADS aims
to describe the impact of a device on the person’s functional independence,
well-being and quality of life. By investigating the psycho-social impact the
authors hoped that it will help to explain the reason for device use or
abandonment. The 26-item scale looks at competence, adaptability and selfesteem that can be administered by a self-report questionnaire or through
interviews (Jutai & Day, 2002).
The Quebec User Evaluation of Satisfaction with Assistive Technology
(QUEST 2.0) was designed as an outcome measure. The QUEST 2.0
evaluates the users satisfaction with the assistive technology’s attributes,
such as its weight, ease of use, comfort and effectiveness. The QUEST 2.0 is
aligned with the environmental domain of ICF. The first version of the QUEST
was adapted from the MPT model (Demers, Weiss-Lambrou, & Ska, 1996).
The QUEST 2.0 can be used with adolescents, adults and the elderly
(Demers, Weiss-Lambrou, & Ska, 2002). A child version of the QUEST 2.1
has recently been developed (Murchland & Dawkins, 2010). The QUEST 2.0
has three scores; device, services and total QUEST. The QUEST 2.0 can be
self-administered using a pen and paper or administered through an interview.
It is a generic outcome measure that can be applied to a wide range of
assistive technology devices. The user can add additional items, such as
speed. These scores are reported separately to the overall QUEST score.
The psychometric properties of the instrument have mainly been tested by the
developers, but show promising results for reliability and validity (Demers, et
al., 2002).
5. Conclusion
The ICF, when used with the ICF checklist, is a useful tool to assess the
user’s abilities and assistive technology needs. It is freely available from the
World Health Organization website. The MPT is reported to be an evidencebased specific assistive technology assessment that is compatible with the
ICF. The MPT is filling a gap of instruments that consider the interactions
among device characteristics, its user and the environment. Furthermore, the
COPM, GAS and IPPA are evidence-based instruments that are useful in
assistive technology assessments and outcome measures, which identify
efficient strategies for achieving activity and participation goals. These
instruments are sensitive to measure change, a feature valuable for
evaluating any intervention for clinical or research purposes. The literature
suggests the use of the QUEST 2.0 and the PIADS when evaluating
contextual factors such as device features and the enhancement of user’s
well-being.
With improved assessments, guided by evidence-based practice and the ICF.
The service providers, in collaboration with the clients, are supported in the
assistive technology decision-making.
Correspondence
Email: p.karlsson@uws.edu.au
Petra Karlsson
University of Western Sydney
Locked Bag 1797
South Penrith DC, NSW, 1797
Phone: +61 (0)2 4736 0879
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