Work 50 (2015) 585–593 DOI 10.3233/WOR-141965 IOS Press

Using the International Classification of Functioning, Disability and Health (ICF) to address facilitators and barriers to participation at work Anabela Correia Martins Polytechnic Institute of Coimbra, ESTeSC Coimbra Health School, Physiotherapy Department, Rua 5 de Outubro, S. Martinho do Bispo, Apartado 7006 3046-854 Coimbra, Portugal Tel.: +351 239 802 430; Fax: +351 239 813 395; E-mail: [email protected]

Received 2 June 2012 Accepted 7 August 2014

Abstract. BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) was approved by the World Health Assembly in 2001. Ten years later, strong arguments have arisen regarding the added value of ICF to the policies on employment and the outcomes at the workplace. As a conceptual framework, ICF has universality because of its inclusive and comprehensive view of human functioning. At a practical level ICF can be used to quantify the impact of impairment on an individual’s ability to act in his/her environment and to assess interventions to minimize the impact of disability and maximize functioning. OBJECTIVE: To explore key indicators of social participation (life habits) of persons with disabilities, particularly related to work, among environmental and personal factors. METHODOLOGY/PARTICIPANTS: Data were collected by self-administered questionnaires from a convenience sample of 149 working-age persons with disabilities. RESULTS: Social participation is a construct composed by multiple components and employment domain is the strongest indicator of participation. Correlations between social participation and personal factors, such as self-efficacy and attitudes towards disability were moderate. Those who are employed scored higher quality of life in terms of satisfaction with life, more positive attitudes toward disabilities and higher self-efficacy than the ones who are retired or unemployed. Persons using adapted wheelchair and those who were involved in wheelchair selection scored higher in social participation in general, performance at work, and quality of life. Age and disability duration were not associated with participants’ employment status. DISCUSSION AND CONCLUSIONS: These findings suggest that rehabilitation and vocational agents, like physiotherapists and other professionals, should have knowledge and understanding of the multiple factors that influence persons with disabilities’ participation at work. Programs should provide appropriate wheelchairs, skills training, empowerment and problem-solving strategies in labour activities and occupational environment to promote employment of working-age persons with disabilities. Keywords: Assistive technologies, social participation, persons with disabilities, employment, personal factors

1. Introduction Health promotion supports the notion that being healthy is not just about “not being sick” or physically

unwell, it includes a biopsychosocial approach towards health, acknowledging that good health involves supportive environments, and social and emotional factors that affect health and wellbeing. Having the opportu-

c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00 


A.C. Martins / Using the ICF to address facilitators and barriers to participation at work

nity to work increases and maintains an individual’s participation in activities to enhance his/her quality of life. In a recent study, Martins concluded that quality of life is a construct composed by multiple components, moderately associated with regular activities and social roles [1]. Social participation is a person’s involvement in a real-life situation, representing the societal perspective of functioning [2]. Social participation in communities is one way to exercise a sense of competence and control over one’s life [3] and a sense of coherence, independence, a mechanism which reduces the reactivity to stress and enhances self-perceived quality of life [4–7]. 1.1. Conceptual framework Variables determining the development and structure of social participation and functioning are multiple and need to be analysed at different levels [8–11]. Several researches have addressed the advantages, opportunities, challenges, and limitations of the Classification of Functioning, Disability and Health (ICF) biopsychosocial approach to develop potential solutions to promote social participation [12–14]; recognizing the potential impact of personal and environmental factors should be the beginning. The ICF captures human functioning as the result of the interaction between body/person and environment, measured through activity and participation [2] (Fig. 1). Figure 1 demonstrates the role that contextual factors (i.e., environmental and personal factors) play in the process [15,16]. These factors interact with the individual’s health condition and determine the level and extent of his or her functioning. Environmental factors, a component of ICF, are extrinsic to the individual, such as the physical world and its features, the humanmade physical world, other people in different relationships and roles, attitudes and values, social systems and services, and policies, rules and laws (e.g., the attitudes of the society, architectural characteristics, the legal system) and are classified in five chapters: Chapter 1 Products and technology; Chapter 2 Natural environment and human-environment; Chapter 3 Support and relationships; Chapter 4 Attitudes, and Chapter 5 Services, systems and policies. Personal factors, on the other hand, are not classified in the current version of ICF. However, they are included in Fig. 1 to show their contribution, which may have an impact on the outcome of vari-

ous interventions. They are contextual factors that relate to the individual such as gender, race, age, other health conditions, fitness, lifestyle, habits, mood, coping styles, social background, education, profession, past and current experience (past life events and concurrent events), overall behavior pattern and character style, individual psychological assets and other characteristics, all or any of which may play a role in disability at any level [2]. The ICF gives a broad perspective and structured way to identify underlying facilitators and barriers to participation of human beings; facilitators are factors in a person and barriers to participation of human be[ings; facilitators are factors in a person’s environment that, through their absence] or presence, improve functioning and reduce disability. However, some factors act as a barrier, with negative impact in functioning [2]. For example, a person who experienced a spinal cord injury can demonstrate impairments in body functions and structures, like lack of strength, increased tonus or postural and balance impairments that lead to difficulty in walking (activity limitation), which may restrict his or her involvement in life situations, such as working (participation restriction). However, this person may continue to be active and productive if he/she works in an accessible workplace or uses specific devices designed to facilitate moving around, like a wheelchair, or a stand-up seat, to assist standing up associated with labor activities. Persons who adjust well to unexpected events, generally, lead healthy, active and happy lives after injury, but those with negative acceptance and disabilities, have a harder time accepting their changes in appearance and have difficulty in coping [17]. Studies showed that a person’s self-efficacy is a good predictor of social participation, representing a target in vocational and rehabilitative contexts [17–22]. According to social cognitive theory, self-efficacy influences the types of new challenges the person will go through, how much effort will be spent, and how long the effort will persist in the light of obstacles [17]. Intervention programs over few weeks are probably insufficient to achieve significant changes in impairments, activity limitations and restrictions on participation with well-established chronic conditions, but those who are successful continue to show desired behaviours learned during treatment sessions after they are discharged [23,24]. This work contributes to investigate the contextual barriers experienced by persons with disabilities, once some studies indicated that

A.C. Martins / Using the ICF to address facilitators and barriers to participation at work


Fig. 1. Multi-dimensions of human functioning.

employers held negative perceptions related to productivity, social maturity, interpersonal skills and psychological adjustment of them. Employment, one of the domains of activities and participation component described on ICF, is a good indicator of rehabilitation success. Persons with mobility limitations, wheelchair users in particular, face numerous barriers to achieve and maintain a job, including assistive technology (AT), transportation, physical work environment and personal assistance services [25]. Thus, a better understanding of wheelchair users’ self-efficacy beliefs could help vocational and rehabilitative professionals, like physiotherapists, to develop interventions that are effective in altering their clients’ confidence. The assumption that personal factors like self-efficacy might be an important clue, we establish self-efficacy as a primary focus. In summary, it is important that professionals have knowledge and an understanding of self-efficacy perception of wheelchair users, providing skills for physical training, self-management in activities and social participation, problem-solving strategies. 1.2. Facilitators and barriers to social participation The ICF gives a broad perspective in a structured form to identify underlying facilitators and barriers to participation of persons with disabilities; facilitators are factors, in a person’s environment, which whether absent or present, improve functioning and reduce disability [26]. Besides personal factors, there are several environmental factors, like workplace characteristics and ac-

cess to work facilities, among others that have been studied [27–33]. Our attention went to assistive technology for employment and transportation (e.g. adaptations to vehicles, wheelchairs, scooters and transfer devices); attitudes of people towards disability (e.g. individual peer’s attitudes, colleagues or people in positions of authority, particularly, opinions and beliefs about the person or about other matters, like his or her capacity to work, that influence individual behavior and participation); as well as services, systems and policies related to finding suitable work for persons who are unemployed or looking for different work. An absent factor can also be a facilitator; for example, the absence of stigma or negative attitudes. Facilitators can prevent impairments or activity limitation from becoming a participation restriction, since the actual performance of an action is enhanced, despite the person’s problem with capacity. Barriers are factors in a person’s environment which, either absent or present, limit functioning and create disability [2]. These include non-ergonomic workplaces, lack of human resources and personnel management services or lack of adapted-to-user assistive technology (e.g. preference for standard wheelchair, instead of adapted wheelchairs); negative attitudes about themselves and peers, colleagues and community members can prevent someone from participating at work. Recognizing that assistive technologies services – customizing, adapting, maintaining, and repairing devices, assistive technologies evaluations, funding, and technical assistance and training on device use – play an important role in participation, the appropriate se-


A.C. Martins / Using the ICF to address facilitators and barriers to participation at work

lection and training will impact on the psychosocial domains of quality of life as well as on social participation [34–36]. 1.3. Objectives Assuming the ICF as a theoretical model the aim of this study was to link personal and environmental factors to social participation profiles, generating new knowledge on associated factors, particularly those related to the employment domain, contributing to develop potential rehabilitative and vocational solutions to evaluate and promote workplace access for working age persons with disabilities, considered to be able and likely to work. In Portugal, we have evidenced an increase on unemployment rate (2), conducting to a great risk of unemployment and social exclusion among persons with disabilities.

2. Methods 2.1. Study population This explorative study recruited, via convenience sampling, persons with disabilities registered in rehabilitation centres in Coimbra area over a 12 months period (October 2006 to September 2007) living in community dwelling settings. The inclusion criteria were the following: women or men, aged 18–64 years, with severe limitations in mobility due to a chronic disease or injury, using a wheelchair for more than 1 year, had undergone physiotherapy at any time since the onset. Exclusion criteria included: clinical evidence of mental global or specific functions impairments and students. Written informed consent was obtained from all participants, who personally received the questionnaires. All research procedures were conducted in accordance with the Declaration of Helsinki. 2.2. Measures Data were collected by self-administered questionnaires (transversal) covering demographics, clinical, workplace and wheelchair characteristics. Another questionnaire was used to assess life habits, the Assessment of Life Habits (LIFE-H 3.1) General Short Form [37,38]; it is based on the Disability Creation Process Model and defines participation as resulting from the interaction between personal and environmental factors. The LIFE-H operationalizes par-

ticipation as life habits, defined as habits that ensure the survival and development of a person in society throughout life. Habits are daily activities and social roles that are culturally defined according to age, gender, and sociocultural identity. The LIFE-H includes both habits related to survival as those engaged in by choice. It consists of 77 items across 12 primary domains, including nutrition, fitness, personal care, communication, housing, mobility, responsibility, interpersonal relations, community, education, employment, and recreation. Employment domain contains items such as choosing a career or profession, seeking employment, having a holding paid job, getting to the principal place of occupation, entering and moving around in the place of occupation as well as using its services, including cafeteria, as well as carrying out family or home-making tasks as your main occupation [37]. The quality of life in terms of satisfaction with life was measured by the Quality of Life Index (QLI), developed by Ferrans and Powers in 1984 to measure quality of life in terms of satisfaction with life. The QLI measures both satisfaction and importance regarding various aspects of life. Importance ratings are used to weight satisfaction responses, so that scores reflect satisfaction with the aspects of life that are valued by the individual. The QLI produces five scores: quality of life overall and in four domains: health and functioning, psychological/spiritual domain, social and economic domain, and family domain [39,40]. Attitudes toward persons with disability were measured with the Attitudes Towards Disabled Persons questionnaire (ATDP-0) [41,42]. Widely used and empirically validated, it presents statements that, the more the respondent agrees with, the more positive the respondent’s attitudes are considered to. Self-efficacy was measured by the Wheelchair Users Self-efficacy Scale [43], a 13-item questionnaire designed to measure wheelchair users’ perception of selfefficacy. Its domains reflect three aspects of wheelchair-related self-efficacy: symptoms management, finding strategies and confidence in one’s own abilities. Cronbach’s alpha of the entire instrument was 0.81, and for the three individual scales scores were 0.80, 0.70 and 0.77, respectively. 2.3. Statistical analysis The statistical design included a descriptive (measures of central tendency and dispersion) and an inferential analysis (bivariate: t-test for independent sam-

A.C. Martins / Using the ICF to address facilitators and barriers to participation at work Table 1 Sample characteristics according to age, education and clinical data (N = 149) Age (years) Formal education (years) Employed Unemployed/Retired Disability onset (years) First wheelchair (years)

Min 19 1 − − 1 1

Max 64 23 − − 56 38

Mean 40.61 8.59 11.43 6.39 20.79 14.51

SD 11.13 4.55 4.48 3.21 12.36 9.91

Table 2 Sample characteristics according to sex, living and working status, diagnoses and wheelchair selection (N = 149) Women Men Living situation Living alone Living with family Occupational situation Employed Unemployed ou retired due to disability Health condition Spinal cord injury Degenerative diseases Cerebral Palsy Other health conditions Wheelchair type Standard model Adapted wheelchair User collaboration in wheelchair selection Yes No

n 40 109

% 26.80 73.20

26 123

17.40 82.60

65 84

43.60 56.40

70 31 14 34

47 20.80 9.4 22.80

113 36

75.80 24.20

86 63

57.70 42.30

ples and Pearson’s correlation coefficient). The level of significance was set at p < 0.05 with a 95% confidence interval. The statistical computer program software SPSS (version 18.0) was used to all tests.

3. Results Table 1 shows the distribution of demographic data, such as age and education, and clinical information. The study participants were, in average, wheelchair users for more than 14 years, with a long history of disability (more than 20 years). The youngest participant was 19 years old and the oldest 64 years old, a working-age sample. Compulsory education in Portugal lasts nine years; formal education of this sample was lower than 9 years; employed individuals scored higher (11.43) than unemployed or retired (6.39). Table 2 resumes the description of the participants according to sex, living and working status, diagnoses, wheelchair type and participation on the selection process.


Table 3 Description of life habits and correlations between life habits and its domains Life habits (LIFE-H) (N = 107) Nutrition (N = 139) Fitness (N = 139) Personal Care (N = 139) Communication (N = 139) Housing (N = 139) Mobility (N = 139) Responsibilities (N = 139) Interpersonal Relationships (N = 139) Community Life (N = 139) Education (N = 109) Employment (N = 132) Recreation (N = 133)

M 6.59 6.06 6.49 6.34 8.75 5.04 4.36 7.69 8.80 4.69 5.29 4.98 4.07

SD 1.87 2.97 2.59 2.94 1.89 2.31 2.28 2.68 1.84 2.73 3.64 3.29 2.72

r 1 0.78∗ 0.69∗ 0.80∗ 0.69∗ 0.80∗ 0.75∗ 0.80∗ 0.57∗ 0.73∗ 0.71∗ 0.83∗ 0.73∗

Pearson’s correlations: ∗ p < 0.001.

Women represented 26.8% of the sample. More than 82% of the participants live with immediate or extended family. Regarding occupational situation, 65 (43.6%) were employed and paid for their work. However, 84 (56.4%) were unemployed or retired due to disability. Spinal cord injury was the most prevalent diagnosis (47%), followed by degenerative diseases (20.8%) and cerebral palsy (9.4%), and a wide range of other (22.8%). More than one third of the participants used standard models of wheelchairs. Adapted wheelchairs are more expensive and were only selected by 24.2% of participants. The majority of wheelchair users (57.7%) participated in the selection process to get their wheelchair. This exploratory study indicates that social participation is a construct composed of multiple components and employment has the strongest correlation with life habits in general (r = 0.83, p < 0.001) (Table 3). Correlations between social participation, employment and personal factors such as self-efficacy and attitudes towards disability were moderate (r = 0.38, p < 0.001; r = 0.39, p < 0.001), respectively. Perceptions of quality of life in terms of satisfaction with life were moderately related to participation (r = 0.44, p < 0.01), as well as formal education (r = 0.31, p < 0.001) (Table 4). Age and time living with disability were not associated with participation. Participants, who are employed, scored higher quality of life in terms of satisfaction with life (21.95), higher social participation in general (7.30), more positive attitude toward disability (71.69) and more confidence or self-efficacy (40.95) than retired or unemployed, who scored 18.39 [t(9.78) = 6.30, p < 0.001], 5.74 [t(7.16) = 4.59, p < 0.001], 60.08 [t(0.08) = 4.20,


A.C. Martins / Using the ICF to address facilitators and barriers to participation at work Table 4 Correlations between social participation, employment and personal factors 1. Social Participation (life habits) (LIFE-H) 2. Employment (LIFE-H) 3. Quality of Life (QLI) 4. Self-efficacy 5. Attitudes toward disability 6. Formal Education (completed years)

1 − 0.83∗ 0.44∗ 0.38∗ 0.39∗ 0.31∗






− 0.37∗ 0.36∗ 0.35∗ 0.41∗

− 0.43∗ 0.48∗ 0.32∗

− 0.33∗ 0.37∗

− 0.39∗

Pearson’s correlations: ∗ p < 0.001. Table 5 Differences between employed and unemployed or retired due to disability Quality of life in terms of satisfaction with life Employed Unemployed/retired due to disability Attitude towards disability Employed Unemployed ou retired due to disability Self-efficacy Employed Unemployed ou retired due to disability Social participation (life habits) Employed Unemployed ou retired due to disability






64 82

21.95 18.39

2.69 4.11



65 84

71.69 60.08

16.36 17.00



65 84

40.95 33.31

5.83 8.98



58 49

7.30 5.74

1.42 1.99



Table 6 Differences between standard and adapted wheelchair users Quality of life in terms of satisfaction with life Standard wheelchair Adapted wheelchair Social participation (life habits) Standard wheelchair Adapted wheelchair Employment Standard wheelchair Adapted wheelchair






110 36

19.42 21.56

3.96 3.58



77 30

6.36 7.18

1.88 1.71



99 33

4.49 6.47

3.33 2.70



Table 7 Differences between users involved (Yes) and not involved (No) in wheelchair selection Quality of life in terms of satisfaction with life No Yes Social participation (life habits) No Yes Employment No Yes

p < 0.001] and 33.31 [t(10.29) = 6.27, p < 0.001], respectively (Table 5). Standard wheelchair users scored lower performance at work (4.49) than adapted wheelchair users (6,47) [t(4,02) = −3.42, p < 0.001], as well as in social






61 85

19.32 20.40

4.42 3.56



39 68

6.18 6.82

2.04 1.73



52 80

3.71 5.81

3.20 3.09



participation in general (6.36 versus 7.17) [t(0.62) = −2.07, p < 0.05], plus lower perception of quality of life in terms of satisfaction with life (19.42), compared to 21.56 perceived by adapted wheelchairs’ users [t(1.27) = −2.87, p < 0.001] (Table 6).

A.C. Martins / Using the ICF to address facilitators and barriers to participation at work

Table 7 shows a significant difference in employment performance based on that empowerment of wheelchair users, in terms of selection of his/her own device; those involved in the wheelchair selection process achieved higher scores at employment (5.81 versus 3.71) [t(0.08) = −3.75, p < 0.01]. However, this fact is not correlated with participation in general, neither with quality of life in terms of satisfaction with life.

4. Discussion/evaluation Our study has shown that social participation is positively related with self-efficacy and personal attitudes, as other have already done [17,22], According to Bandura, the higher the self-confident and the higher the self-efficacy beliefs one has, the easier a desired goal is achieved [44]. To develop health promotion plans and strategies, including strategies to involve working age persons in labour activities, it is wise to be aware of their different characteristics and the self-efficacy seems to be a personal key factor in improving it. Interventions based on such behavioral principles might emphasize the influence of the context in controlling desired and expected participation at work. This model suggest that acting on self-efficacy and attitudes towards disability may contribute to improve participation, an emergent outcome measure to a wide range of social and health professionals involved in assistive technologies selection and training, particularly physiotherapists and occupational therapists in rehabilitation settings and at the workplace and vocational training. Another important prerequisite, inspected in our investigation, was education. For anyone to have opportunities and quality in life, a good education and vocational training are essential to provide specific skills for jobs in the labour market, therefore increasing success in finding and maintaining a job [45]. Helping wheelchair users being successful in activities they consider meaningful, controlling their degree of difficulty/reducing the negative feedback, helping them to recognise their capabilities, giving them time to find solutions, promoting positive attitudes may enhance social participation; promoting social support from significant persons are other strategies [46,47]. Access to education, work and independent living accommodation offers another important pathway to success. Despite persons with disabilities everywhere have far less opportunities for education, training and employment


much has been changed over the last years. However, much more is needed [48]. In Portugal, disability policies and assistive technologies services were detected as ineffective concerning evaluation, recommendation, advocacy, training and outcome measuring. There is a need to develop strategies to enhance effectiveness, and empower wheelchair users on the selection process, what seemed to be relevant to achieve this goal. However, it is an opportunity to rethink assistive technologies services, policies and politics to sustain community-dwelling adults with disabilities. Chronic diseases will be a world-scale problem in the future, and assistive technologies will play a key role in supporting people’s independence and in helping society save economic and human resources, preventing or delaying assisted living and economic dependency. Rehabilitation and vocational agents should be aware of the newest high technology devices introduced on the market, payment sources and state assistive technologies programs at the same time they should destigmatize dependence associated to assistive technologies. Our findings confirmed that participating in wheelchair selection and having a device adapted to their specific needs lead to better quality of life in terms of life satisfaction, life habits and employment. Pursuant to having a job gives the person with disability the opportunity to break out of poverty, dependency, and social isolation, enhancing his or her social participation and quality of life [49,50]. Assistive technologies services have promising solutions to improve functioning and give opportunities to all who need assistance to be active and participative.

5. Conclusion ICF has been pointed out as a tool that professionals should use to encourage people-centered practice and increase their participation in decision-making to increase efficacy and especially lower costs. In summary, our findings support recommendations of the World Health Organization, recognising personal factors, such as self-efficacy and attitudes, as potentially important determinants of social participation. Environmental factors, like assistive technologies should be studied in more detail for a better understanding of their role in social participation. Social and health professionals and agencies should acknowledge the multiple factors that influence participation at work (addressed by ICF) and programs


A.C. Martins / Using the ICF to address facilitators and barriers to participation at work

should provide appropriated resources, like assistive technologies, physical training, self-management in activities of daily living and social rules, problemsolving strategies, self-confidence in order to enhance quality of life and wellbeing. Besides, policies on persons with disabilities employment, professional bottom-up approaches, promoting empowerment and security, as well as family, friends and community in general can play an important emotional role, facilitating the inclusion of working age persons with disabilities in an active and productive life.

Acknowledgement This work was unfunded.

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The International Classification of Functioning, Disability and Health (ICF) was approved by the World Health Assembly in 2001. Ten years later, stron...
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