Training on the International Classification of Functioning, Disability and Health (ICF): the ICF-DIN Basic and the ICF-DIN Advanced Course developed by the Disability Italian Network

Abstract

The objective is to present training on the International Classification of Functioning, Disability and Health (ICF) prepared by the Disability Italian Network (DIN) and to present strategies of ICF dissemination in Italy. A description of DIN's training methodology, prepared in collaboration with World Health Organization (WHO) experts, is provided within its practical applications in health, labour, rehabilitation and statistical sectors. The ICF-DIN Basic Course is eight hours long and focuses on ICF basic principles, structure and application in different settings. The ICF-DIN Advanced Course, three days long followed by three months of distance learning, assumes Basic Course completion, and focuses also on ICF-checklist's coding and WHO-DAS II administration. The first training courses' outcomes, held in Italy and addressed to health, social and labour professionals, are provided. The feedback received by participants at the end of the courses showed that the main mistake they made was to consider ICF as an assessment instrument. The ICF-DIN training course was crucial in explaining the correct use of the ICF as a classification and to show its impact and usefulness on daily practice, particularly in multidisciplinary teams. The ICF-DIN courses already carried out in Italy show that this teaching methodology teaches how to avoid incomplete applications, simplification and misunderstanding of ICF's complexity. [PUBLICATION ABSTRACT]

J Headache Pain (2005) 6:159164

DOI 10.1007/s10194-005-0173-2PUBLIC HEALTH SECTIONMatilde Leonardi*

Jerome Bickenbach

Alberto Raggi

Marina Sala

Paolo Guzzon

Maria Rosa Valsecchi

Guido Fusaro

Emanuela Russo

Carlo Francescutti

Ugo Nocentini

Andrea MartinuzziTraining on the International Classification

of Functioning, Disability and Health (ICF):

the ICF-DIN Basic and the ICF-DIN Advanced

Course developed by the Disability Italian

NetworkAbstract The objective is to present training on the International

Classification of Functioning,

Disability and Health (ICF) prepared by the Disability Italian

Network (DIN) and to present

strategies of ICF dissemination in

Italy. A description of DINs training methodology, prepared in collaboration with World Health

Organization (WHO) experts, is

provided within its practical applications in health, labour, rehabilitation and statistical sectors. The

ICF-DIN Basic Course is eight

hours long and focuses on ICF

basic principles, structure and

application in different settings.

The ICF-DIN Advanced Course,

three days long followed by three

months of distance learning,

assumes Basic Course completion,

and focuses also on ICF-checklists

coding and WHO-DAS II administration. The first training courses

outcomes, held in Italy and

addressed to health, social and

labour professionals, are provided.

The feedback received by participants at the end of the courses

showed that the main mistake they

made was to consider ICF as an

assessment instrument. The ICFDIN training course was crucial in

explaining the correct use of the

ICF as a classification and to show

its impact and usefulness on daily

practice, particularly in multidisciplinary teams. The ICF-DIN courses already carried out in Italy show

that this teaching methodology

teaches how to avoid incomplete

applications, simplification and

misunderstanding of ICFs complexity.Key words Disability Public

health ICF dissemination

Training methodologyPublished online: 13 May 2005

*Section EditorM. Leonardi () A. RaggiC. Besta National Neurological Institute,

Via Celoria 11, I-20133 Milan, Italy

e-mail: [email protected]

Tel.: [phone]/2498

Fax: [phone]J. BickenbachQueens University,

Kingston, Ontario, CanadaM. Sala P. Guzzon M.R. Valsecchi

Istituto Sacra Famiglia,

Cesano Boscone, ItalyG. FusaroLocal Health Agency n. 12,

2nd District, Biella, ItalyE. Russo A. MartinuzziE. Medea, Scientific Institute,

Conegliano Research Centre, Conegliano, ItalyC. FrancescuttiAgenzia Regionale Sanit Friuli Venezia-

Giulia, Udine, ItalyU. NocentiniUniversit di Roma Tor Vergata,

c/o I.R.C.C.S. Fondazione S. Lucia,

Rome, Italy160Needs for training on ICF and ICF related instruments:

general considerationsInappropriate use of the International Classification of

Functioning, Disability and Health (ICF) brings about

incomplete applications, simplification and misunderstanding of the ICFs complexity, especially regarding

consideration of the ICF as an assessment and not as a

classification. The ICF should be considered for its operational aspects, but not only for them. The ICF encourages

a deep cultural change in the consideration and overview

of health and disability: overcoming the medical perspective and stressing the importance of the biopsychosocial

model of disability; overcoming handicap-related terminology and stressing the importance of neutrality of terminology; the relevance of environmental factors as barriers or facilitators; the universal approach of the classifications model opposed to the minority model as well as the

parity between body and mind. All these aspects require a

rigorous teaching methodology that incorporates technical

aspects as well as ethical implications. These considerations have been the basis for the development of an ICF

training that became essential after the ICF approval by

the World Health Assembly in 2001 and has been developed by the experts on ICF classification in Italy, members of the Disability Italian Network (DIN).The Disability Italian NetworkThe Disability Italian Network (DIN) is a registered nonprofit organisation totally devoted to the dissemination of

the ICF in Italy and to maintaining close contact with the

World Health Organization (WHO) and with international experts working on the ICF and its related measurement tools development. As a non-profit association, the

DIN is working for the largest possible diffusion of the

WHOs ICF. At the same time DIN is trying to avoid

incomplete applications, simplifications and misunderstandings of the ICFs complexity. The scope of DIN is

also to provide the WHO with all the necessary feedback

about ICF implementation and strategies in Italy, and to

have a continuous exchange on questions and issues with

the relevant WHO staff.Experts of DIN come from leading Italian national

research institutes, universities and hospitals: they are

neurologists, psychiatrists, child neuropsychiatrists,

physiatrists, psychologists, sociologists, physiotherapists,

teachers, representatives of disabled organisations and

statisticians. Moreover, since 2004 some national research

institutes have become partners of DIN, in order to have

access to DINs experience in the use of ICF

Classification and to provide their clinical and scientific

experience to DIN. The advisory board of DIN, its core, is

composed of experts who have followed the developmental work on the ICF since 1998. DIN members have presented ICF and its related instruments in several meetings

organised by Italian Regional Administrations, research,

social and health institutions. The agenda of meetings,

seminars and presentations of 2003 and 2004 has been

incredibly rich. DIN is a growing organisation, both in

terms of associates and of activated projects, and hopes to

continue to exchange its experience with groups interested in the ICF all over the world.The procedural assessment of teaching needs carried

out by DIN and the development of training coursesThe first step consisted of assessing the needs for training

in Italy, in consideration of the different professional

skills because, for example, the labour sectors 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 necessity. Last, in preparing and planning the training methodology, 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 WHOs experts (Dr. Ustun, Dr.

Chatterji and Dr. Kostanjsek) helped to take into account

the development of ICF implementation strategies in different 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 bibliography of consulted documents for the ICF development is

listed below.DIN experts have developed the ICF-DIN Basic and

Advanced Courses, primarily as a response to the

increasing needs for training coming from the labour,

rehabilitation, statistics and education sectors. The

development of ICF training tools has been discussed in

depth with the WHO and has been, and will continue to

be, presented to other groups and Collaborating Centres

working on the ICF all over the world. After more than a161year of discussion and preparation, the WHO-DIN

course should provide the required training for those

who wish to use the ICF, ICF checklist and WHO-DAS

II, allowing them to acquire a common application

methodology. Professor Jerome Bickenbach was designated by WHO to be DINs consultant for the preparation

of training materials, and participated in the first ICF

Training Course. The course has been delivered, with a

specific adaptation, to Italia Lavoro for the ICF in Italy

Project: pilot project ICF and labour sector and is available in two languages, Italian and English.DIN organised the first national training course in

Rome on May 2004. As mentioned, the WHO-DIN ICF

training is divided into two courses (ICF Basic and ICF

Advanced Course), followed by a distance learning

component.The ICF-DIN Basic and Advanced Training CoursesThe ICF-DIN Basic CourseThe basic course is an eight-hour presentation and discussion course that covers the following topics: a brief history of disability and disability classifications; differences

between classifying, measuring and assessing; a history of

the ICFs development; the ICFs basic principles; ICF

codings structures; application of the ICF in different settings; impact of disability classification on national legislation; the ICF revolution in health and disability sector;

the ICF tool box; disability core sets and the ICF; the

WHO ICF-based assessment tool, WHO-DAS II; ICF and

children; ethical implications of the ICFs use; the ICF in

Italy project; ICF use around the world.For optimal learning impact, DIN recommends that

the basic course should be opened up to as many as 60

participants. Some simple case-vignettes have been prepared to explain, in practice, what using ICF as a coding

system entails (which is useful even for participants who

themselves will not be engaged in the exercise of coding). The main goal of the basic course is to provide participants with a key for reading the ICF classification,

enabling them to communicate using a common language that captures information on human functioning,

much in the same way as the International Statistical

Classification of Diseases (ICD) captures diagnostic or

medical information. The basic course has been structured to be useful for a broad audience: medical doctors,

psychologists, therapists, educators, social workers,

engineers, architects, politicians, administrators, members of NGOs, students and people with disabilities

themselves, as well as families.The ICF-DIN Advanced CourseThe advanced course if a three-day course followed by

three months of distance learning (DL) and a final day for

evaluation and an exam. The advanced course is available

only for those who have already attended the basic course.

The three-day course is structured as follows:- First day. ICF structure, chapters, domains; how to

code, how to use the different qualifiers, when to use

them, difficulties and FAQs. Basic principles on health

and disability, already faced during basic course, are

discussed again in depth and participants are asked to

work in small groups (45 participants) on simple clinical cases. The focus is on qualifiers and on problems

related to ICF components codification.- Second day. ICF checklist: how to use it, coding case

vignettes. Use of checklist in different settings (rehabilitation, administration, statistics). Checklist structure and rationale are presented, by means of a clinical

case. Coding and back-coding on clinical cases provided by teachers are required to participants, divided

in small groups (45 participants).- Third day. WHO-DAS II: description and use of WHODAS II, how to assess, video cases of interviews with

actors, coding. Working in couples, participants are

asked to administer the WHO-DAS II to each other.

For DL, each pupil is assigned a user ID and a password

after completing the three days of the advanced course. DIN

has specific access for training on its website. DIN teachers

have a section with question and answer made by participants about homework, problems and issues. A discussion

forum is hosted on the DIN website, reserved for those

attending DL: each case has its discussion thread, where

participants can post questions and read teachers answers.

The most common questions are set in an FAQ section.Each pupil has to code 10 pre-assigned cases, prepared

and tested by DIN, write three cases with coding, complete

five real cases from their professional practice, coded with

ICF checklists, the WHO-DAS II and, eventually, with other

specific assessment tools. At the end of the DL period, 15

days before the final exam, tutors prepare the evaluation of

homework done by participants. There is a final day to have

forum discussion related to the application of ICF in each

participants setting, difficulties and for a final group discussion and then there is the final exam on the whole course.

Finally participants are awarded with a DIN-ICF certificate.Training-related issuesAll clinical cases and vignettes used as exercises for coding with the ICF checklist are collected in DINs databank.162All participants of the ICF-DIN training become members

of the ICF interest group, which is also growing in Italy

and is coordinated by DIN. The DIN reports Italian activities and experiences to the WHO and liaises with members

of the scientific international community. A special course

has now been prepared by the DIN for trainers, because

there is a growing need to have more teachers.The first ICF training experience with the ICF-DIN

training (Rome, May 2004) was directed mainly to medical

doctors, psychologists, rehabilitation therapists, and some

educators and social workers, who had already experimented with the use of ICF in the Region of Lazio. They had a

general knowledge of ICF and its potential and were very

interested to learn more about the classification. Eighty

participants attended the basic course and 40 the advanced

course. Participants were divided into two classes which

were assigned to eight teachers, four for each class.The basic course took place in a mood of interested and

careful participation. Many participants already knew what

the ICF was, but they did not know the ICFs practical

applications and its potential utilisation in daily practice.The advanced courses participants were even more

interested and attentive, and their interventions and doubts

were very challenging and interesting for the teachers.

The presence of several ICF experts increased and

enriched the technical and cultural debate, and this was an

added value for teacher-participant interaction.The DIN prepared a feedback questionnaire for the students. The majority of comments were positive, indicating

that the learning mood was very encouraging. Sometimes

during the course the discussion was very heated, but participants different professional skills showed the ICFs

potential and usefulness in multidisciplinary teams. Most

of the participants in the final course test commented that

all of them had been using ICF, before the training, as an

assessment tool and that the training had been crucial to

understand the difference existing between ICF classification and the assessment tools. In fact, at the end of the four

days all the students understood that ICF is for classification and not assessment.These training experiences demonstrated some issues

to the DINs scientific board related to the training process

and some difficulties that arose especially during distance

learning: the main difficulties were the quality of the communication between tutors and participants, and the administration of the forum. The DINs teachers noticed that the

students had few problems in the selection of ICFs codes,

but qualifiers selection turned out to be a relevant point.

Students had different questions regarding qualifiers

selection, in particular with regard to the application of the

qualifier 9 not applicable. In providing the answers, the

DINs advisory board is noticing that different tutors, with

different backgrounds and professional skills, may propose

different qualifiers. In order to limit this difference in

answering, but not to lose the intrinsic richness of the discussion and of the diversity, DIN has decided to organise

DL and tutoring as follows. Each DIN teacher prepares one

or more case-vignettes from his or her professional setting,

and codes it with the ICF checklist. Each DIN member discusses the case with their multidisciplinary ICF team

(mainly doctors, psychologists and physiotherapists) in the

centre where he/she works. After internal agreement the

case is mailed to all other DIN teachers for forum discussion and agreement on case description and qualifiers

selection: all the comments are then summarised in a final

and agreed ICF checklist. At that point the case-vignette is

considered complete and official and the DIN secretary

posts it on the website for the students.The DINs website hosts the forum, to enable participants to contact their teachers. Every teacher is responsible for his classs forum for a week (two or three times per

course), and answers participants questions. To avoid different answers between different forums and teachers,

every time a question is posted, the DIN secretary circulates it to all teachers: when agreement is reached, the

answer is posted.ICF implementation strategies in ItalySince its translation into Italian (2002), ICF users and ICF

community have expanded in many sectors and in many

areas of Italy. DIN has developed its training course to

help ICF users to better implement ICF and its instruments in all fields.Many sectors are showing interest, however one of the

leading projects that has been crucial for ICF implementation has been the adoption of the ICF by the Italian

Ministry of Welfare, which launched the pilot project ICF

and Labour Policies.The pilot project ICF and labour sectorThe ICF and Labour Policies project, launched at the

closing conference of the Year of People with Disability

on 2003 in Rome by the Italian Ministry of Welfare, is

now entering its active phase. The focus of this project is

to introduce the conceptual framework and terminology

of the ICF into the labour sector. This is a very relevant

project because it is the first experience that uses ICF,

both as a cultural background and as a classification tool,

in practice. The main objective of this pilot programme is

to provide to the Medical Commissions, Invalidity163Commissions, and Disability and Labour Commissions a

standard methodology to define peoples functioning levels. These uniform definitions will be used to manage and

handle job requests and offers in a large data-bank,

designed to match people seeking a job with the labour

needs of companies and factories.The primary expected impacts of using the ICF in the

labour sector are: the creation of a common language

across the sector; the increased reliance on the ICF to

expand the use of the notion of functioning in the labour

sector in addition to the notions of disability and impairment; and the increased likelihood that a person with disability can fully live out the social aspects of his or her life

and in particular obtain a job that is responsive to his or

her own expectations, professional skills and functional

capacities, while at the same time being able to satisfy all

working requirements. In order to pursue these goals, the

Italian Ministry of Welfare has assigned to its special

agency, Italia-Lavoro, the realisation of the full pilot project ICF and Labour Policies. One main objective of this

project is to get better outcomes from work placement

problems, by adopting the more precise and appropriate

definition of disability and functioning found in the ICF

and ICF checklist. The project will add the ICF to the

already existing disability measurement methods, in order

to target personal capabilities in relation to social and

environmental conditions. This project will also test the

classifications use in this field, providing practice and

suggestions for its future applications in further areas,

both in Italy and internationally.The preparation of the training for an ICF pilot project

in the labour sector was assigned to DIN. Taking into

account the method developed for the ICF-DIN training

course, the DINs scientific board decided to make a special adaptation for the ICFs use in the labour sector.

Discussion with several experts (persons from Italia

Lavoro that were already involved in the work and disability field, representatives of NGOs, representatives of

unions, and medical commission for certification of invalidity rights for labour) facilitated the development of the

ICF-DIN training for the labour sector.The differences with standard ICF-DIN training mainly involve some methodological issues and contentwise

some areas more relevant for work were explained more

in detail: for example, chapter d2 (from d210 to d299) was

revealed to be crucial, and environmental factors can be

viewed and expanded beyond the present ICF checklist.On June 2004 the pilot training project started. It involved

participants from three Italian provinces attending the basic

course and the advanced course. Once this pilot project

reaches completion, a larger ICF training project will start.

This will involve 25 Italian provinces from every Italian

region and is expected to be completed by October 2005.ConclusionsThis paper presents DINs experiences with ICF training

courses. These are only preliminary comments because

only a few courses have been conducted in Italy. The DIN

also conducted a course in Macedonia, with a live translation from English to Macedonian, exporting this methodology in different settings. The comments we received from

that experience enable the DIN to say that training methodology helps to teach how to avoid incomplete applications,

simplification and misunderstanding of ICFs complexity.Overall, the trainings objectives were reached: at the

end of advanced course participants had improved their

knowledge of the ICF and ICF related tools. ICF Distance

Learning was completed in October 2004 and the final

exam was taken successfully by almost all participants.The DIN-ICF training is now improving thanks to the

contribution of several experts and all the participants.

The training developed for Italia-Lavoro for the ICF and

labour sector project, although it uses a slightly modified

and more focused content, is helping to spread correct

knowledge of the ICF and disseminate the DINs methodology across Italy.DIN is sharing the results of its efforts with the World

Health Organization as well as with ICF interested centres

around the world.ContactsDisability Italian Network website: www.icfinitaly.it

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