Development of simple descriptions of the ICF Generic-30 Set in different languages: laying the foundation for an ICF-based clinical tool for Europe

Abstract

BACKGROUND

Functioning is considered a third indicator of health and a key outcome in rehabilitation. A universal practical tool for collecting functioning information is essential. This tool would be ideally based on the International Classification of Functioning, Disability and Health.

AIM

To report the results of the development of country/language-specific versions of an ICF-based clinical tool in six European countries.

DESIGN

Consensus process.

SETTING

Expert conferences.

POPULATION

Multi-professional group of rehabilitation professionals in six European countries.

METHODS

1) Developed an initial proposal by translating the published English-language version of the simple descriptions into the targeted language; 2) conducted a multi-stage consensus conference to finalize the descriptions; 3) employed a three-stage multi-professional expert panel translation back to English. The consensus conference model was modified for geographically large countries.

RESULTS

Croatian, Flemish/Dutch, Greek, Polish, and Turkish versions were produced.

CONCLUSIONS

The creation of the country/language-specific simple descriptions is a significant part of the “system-wide implementation of the ICF” initiative that will pave the way for the implementation of the ICF in national health systems.

CLINICAL REHABILITATION IMPACT

The practical ICF-based clinical tool with country/language specific versions for standardized reporting of functioning will serve as a means of integrating functioning information in national health systems and additionally for monitoring the effects of rehabilitation interventions.

For the clinical assessment and reporting of patient functioning, rehabilitation professionals rely on a wide range of suitable data collection tools. However, a universal and simple-to-use clinical data collection tool that can be tailored to the needs of clinicians all over the world, across a range of settings and patient groups is needed. Ideally, this tool is based on the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF),¹ as the ICF is the internationally accepted standard for describing and measuring functioning and disability of persons with a health condition. Although a main driver of developing such an ICF-based clinical tool is the need to have a practical instrument to assess and report functioning in routine rehabilitation practice, initiating development activities were inspired by the World Report on Disability,² WHO’s Global Disability Action Plan 2014-2021³ and Rehabilitation 2030: A Call for Action.⁴ Major national and international Physical and Rehabilitation Medicine (PRM) bodies have taken action to meet this need.^{5, 6} Globally, the International Society of Physical and Rehabilitation Medicine (ISPRM) has led the initiative to develop, refine and maintain “ClinFIT,” an ICF-based clinical information tool that can be tailored for use along the continuum of care from acute, post-acute to long-term care, across the lifespan and for different patient populations all over the world.⁷ In line with its vision to implement the ICF in PRM and in healthcare systems at large throughout Europe,⁸ the European Union of Medical Specialists PRM Section and Board (UEMS-PRM) has been an invaluable partner in the ClinFIT initiative from the very beginning, namely to establish simple descriptions of the Generic-30 Set categories in different language/country-specific versions. The 30 ICF categories of the ICF Generic-30 Set, previously called the ICF Rehabilitation Set,⁹ is the foundation of ClinFIT. The ICF Generic-30 Set was developed as the minimum standard for the assessment and standardized reporting of patient functioning irrespective of health condition along the continuum of care. These simple descriptions are not intended to replace the ICF but rather to ensure that clinicians understand the categories in a consistent manner. Clinicians often have limited time to complete clinical assessments; thus, they need simple and concise descriptions of the ICF categories to quickly understand what they are assessing with individual categories. In Europe, first efforts were made by the Italian Society of PRM¹⁰ based on the model developed in China.¹¹ These efforts inspired other European countries to follow suit. The development activities in Europe is being coordinated by the UEMS-PRM Section (www.uems-prm.eu).

The objective of this paper is to report on the results of initiatives to develop language-specific simple descriptions of the ICF Generic-30 Set (ClinFIT categories) in six European countries (Flanders region of Belgium together with the Netherlands, Croatia, Greece, Poland and Türkiye) as a first step toward system-wide implementation of the ICF in health systems.

Materials and methods

The six countries employed the model for developing language/country-specific versions of the simple descriptions for the ICF Generic-30 Set developed in a collaboration between the Chinese Association of PRM and the ICF Research Branch¹¹ and validated in Italy.¹⁰ These six countries developed five language-specific versions, since Flanders (the Dutch speaking part of Belgium) and the Netherlands collaborated on a Dutch version that can be used in both countries. Given this, this paper refers to the developed version as “language-specific” rather than “country-specific.”

The development process has been outlined in detail in previous publications,^{10, 11} thus only summarized here. The first step in the process is to develop an initial proposal of the simple descriptions by translating the published English-language version of the Italian descriptions into the targeted language. The coordination team at the UEMS-PRM Section recommended using the Italian version instead of the Chinese simple descriptions, reasoning that Europeans would likely view the descriptions as more reflective of the European perspective, even though the descriptions are very similar. Nevertheless, Greece considered both the Italian and Chinese versions for developing their initial proposal. Since the simple descriptions should reflect the core concept of the original ICF category in a user-friendly language, the developers of the initial proposal and later the consensus process participants are asked to also consider the original ICF category description in developing the simple descriptions.

To ensure the quality of this initial proposal, two persons who are familiar with the ICF are responsible for finalizing it. The second step involves a multi-stage consensus conference in which a decision is reached on the final descriptions by a multi-professional group of preferably 19-24 rehabilitation experts, such as physicians, nurses, physical, occupational and speech and language therapists, orthotists/prosthetists, psychologists, social workers, from different regions of the country or from different countries using the same language. Following a brief ICF training and presentation of the initial proposal of the simple descriptions developed in the first step, the proposal is reviewed individually by each participant. In alternating working groups and plenary sessions, the participants discuss and vote category per category whether the proposed description for each category should be accepted as is or otherwise propose alternative wording. For their discussions and voting, participants are asked to 1) imagine real-life clinical scenarios when patient functioning has to be assessed, and 2) consider any cultural and language aspects that may impact on the consistent and accurate understanding of the description. A modification of this development process was made available for geographically large countries, as recruiting participants from far distances to physically attend a centralized consensus conference may be cost-intensive and not feasible.¹² This modified development process could have also been applied for consensus conferences held during the COVID-19 pandemic; however, all the consensus conferences were conducted before the pandemic. This modification involves holding face-to-face regional consensus conferences using the same methodology as described above, followed by a centralized consensus teleconference to decide on the final simple descriptions of the ICF Generic-30 Set. A regional leader is designated to provide a regional report comprising the results of the regional conferences, i.e. regional proposal of the simple descriptions and arguments for each proposed description, and to participate in the centralized conference on behalf of the respective region.

To acquire an English-language version of the language-specific simple descriptions for this paper, the UEMS-PRM Section coordination team recommended a three-stage multi-professional expert panel translation back to English, ideally with representation from four different disciplines.¹⁰ The recommended procedure involves that each panel member proposes his/her individual English translation of the language-specific descriptions. Afterwards, the panel discusses the proposals and finds consensus on the final English-language version. This version is then checked by a native English speaker.

Results

Table I shows the English back-translation of the language-specific simple descriptions resulting from the language group consensus conferences. The original language-specific versions of the simple descriptions are available as Supplementary Digital Material 1 (Supplementary Table I).

Table I. —Back translations of the Flemish/Dutch, Croatian, Greek, Polish and Turkish simple descriptions into English. Also shown is the English-language back translation of the Italian version used as the basis for the consensus process to produce the individual language versions.

ICF Code	Title	Base version for the consensus process	FLEMISH/DUTCH simple descriptions	CROATIAN simple descriptions
b130	Energy and drive functions	Psychological energy and motivational drive to move towards goals, satisfy needs and control impulses	Mental functions, such as psychological energy and motivation to achieve goals, meet needs, and control impulses	Psychological energy and motivation to accomplish goals, to fulfil needs and control instincts
b134	Sleep functions	Cycle, quality and amount of sleep	Cycle, quality and amount of sleep	Cycle, quality and quantity of sleep
b152	Emotional functions	Mental functions for the modulation of the expression of feelings and emotions	Mental functions for the regulation of feelings, emotions and mood	Mental functions to adjust expressions of feelings and emotions
b280	Sensation of pain	Unpleasant sensation indicating potential or actual damage of some body structures	Unpleasant feeling of possible or real damage to the body structures	Unpleasant sensation indicating potential or real damage of some body part
b455	Exercise tolerance functions	Capacity of enduring physical exertion related to respiratory and cardiovascular functions	The ability to sustain physical exertion related to respiratory and cardiovascular functions	Capacity to tolerate physical exertion associated with respiratory and cardiovascular functions
b620	Urination functions	Voluntary control and discharge from the urinary bladder	Control and discharge of the bladder	Voluntary control and urinary bladder discharge
b640	Sexual functions	Mental and physical functions related to the sexual act	Mental and physical functions related to sexuality	Mental and physical functions related to sexual acts
b710	Mobility of joint functions	Range and ease of movement of a joint	Range of motion and mobility of one or more joints	Range and ease of joint motion
b730	Muscle power functions	Capacity to generate force through the contraction of a muscle or muscle groups	The ability to generate force through the contraction of one or more muscles	Capacity to produce force by the contraction of a muscle or muscle groups
d230	Carrying out daily routine	Plan, manage and complete routine daily life activities	Plan, arrange, perform and complete daily activities	Planning, carrying out and completing daily routine activities
d240	Handling stress and other psychological demands	Manage and control the psychological demands to carry out daily tasks demanding responsibilities involving stress and/or distractions and/or critical issues	Dealing with the mental demands of performing daily tasks involving significant responsibility and stress and/or distractions and/or crisis situations	The management and control of psychological demands necessary to carry out responsible tasks that include stress and/or distraction and/or critical situations
d410	Changing basic body position	Changing the body position (for example getting up from a chair, lying down on a bed, kneeling, bending down to pick up an object)	Changing body position (e.g., getting up from a chair, lying down on a bed, kneeling, bending to pick something up off the floor)	Changing body position (e.g. getting up from a chair, lying down on a bed, kneeling, bending over to pick an object etc.)
d415	Maintaining a body position	Maintaining a body position in the way and for the time required by the situation	Maintain a body position as long as the situation requires	Maintaining body position in a certain way and for a certain period of time as required by the situation
d420	Transferring oneself	Moving from one surface to another while maintaining the same body position	Moving while maintaining a basic body position (e.g., from sitting to sitting, from lying to lying)	Transferring from one surface to another maintaining the same body position
d450	Walking	Moving in an upright position, step by step, always maintaining a support on the ground	Moving in an upright position, step by step, always keeping one foot on the ground	Moving in an upright position, step by step, always maintaining support on the ground
d455	Moving around	Moving around differently from walking (for example running, going up and down the stairs, jumping, climbing, swimming, etc.)	Moving around other than walking (e.g., running, going up and down stairs, jumping, climbing, swimming)	Movement that is different from walking (e.g. running, walking up and down stairs, jumping, climbing, swimming)
d465	Moving around using equipment	Moving around from one place to another, on any surface or space, by using specific tools (skates, skis or scuba-equipment) or assistive devices (wheelchairs etc.)	Moving from one place to another, regardless of surface or space, using specific equipment (e.g., skates, skis, or diving equipment) or aids (e.g., wheelchair)	Moving around any surface or space using certain equipment (e.g. skates, skis or diving equipment) or devices (e.g. wheelchairs etc.)
d470	Using transportation	Using different means of transportation to move around as a passenger	Using a means of transportation as a passenger	Using various modes of passenger transportation

ICF Code	Title	Base version for the consensus process	FLEMISH/DUTCH simple descriptions	CROATIAN simple descriptions
d510	Washing oneself	Cleaning, washing and drying one’s whole body, or body parts	Washing and drying oneself (e.g., whole body, body parts, or hair)	Cleaning, washing and drying of whole body or body parts
d520	Caring for body parts	Caring for skin, teeth, hair, finger and toe nails, genitals, etc. that requires more than washing and drying	Care of skin, mouth, hair, nails, genitals, etc. requiring more than washing and drying	Caring for skin, teeth, hair, nails on hands and feet, genitals etc. that requires more than washing and drying
d530	Toileting	Management of urination, defecation, and menstruation, including cleaning oneself afterwards	Dealing with micturition, defecation and menstruation, including cleaning up afterwards	Self-care of urination, defecation and menstruation including self-hygiene afterwards
d540	Dressing	Choosing, putting on and taking off clothes and footwear in accordance with climatic and social conditions	Choosing, putting on and removing clothing and footwear in accordance with weather conditions and social context	Choosing, dressing and undressing clothes and shoes according to weather and social conditions
d550	Eating	Eating food already served, in a coordinated sequence, and adapted to the context	Perform coordinated actions to eat served food in accordance with context	Eating served food in a coordinated order and according to the social surrounding
d570	Looking after one’s health	Ensuring health and physical and mental wellbeing, by adopting a healthy lifestyle	Taking care of your own health and well-being	Ensuring health and both physical and mental well-being, by adopting a healthy life-style
d640	Doing housework	Managing a household by cleaning and clearing up, washing clothes, using household appliances, disposing of garbage, etc.	Organize and perform household tasks	Housekeeping that includes cleaning and clearing up, washing clothes, using household appliances, garbage disposal etc.
d660	Assisting others	Assisting others with learning, communicating, self-care, movements and being concerned about their well-being	Support and help others (e.g., with learning, communication, self-care, and mobility)	Assisting others in learning, communication, self-care, moving around and taking care of their well-being
d710	Basic interpersonal interactions	Interacting with people in a contextually and socially appropriate manner	Engage or maintain contacts with others in accordance with context and culture	Interacting with others in a contextual and socially acceptable way
d770	Intimate relationships	Creating and maintaining close or romantic relationships between individuals such as husband and wife, lovers or sexual partners	Establish and maintain intimate relationships	Creating and maintaining intimate and romantic relationships between individuals, such as husband and wife, lovers and sexual partners
d850	Remunerative employment	Properly performing remunerative employment (full- or part-time or self-employed) in all its aspects	Performing paid work in all its aspects	Properly performing remunerative employment (full or half-time or self-employed) in all its aspects
d920	Recreation and leisure	Engaging in recreational or leisure activities (play, cultural and sports activities etc.) during spare time	Perform and/or be involved in recreational activities and leisure activities during spare time	Practicing recreational activities (games, cultural and sport activities etc.) during leisure time

ICF Code	Title	GREEK simple descriptions	POLISH simple descriptions	TURKISH simple descriptions
b130	Energy and drive functions	Psychological energy and motivation to achieve goals, meet needs and control impulses	Motivation to achieve goals, meet needs and control one’s behavior	The psychological and motivational drive required to achieve goals, meet needs and control impulses
b134	Sleep functions	Cycle, quality and quantity of sleep	Circadian rhythm, quality and quantity of sleep	The pattern, quality and duration of sleep
b152	Emotional functions	Mental function for modulating of the expression of feelings and emotions	Mental functions required to experience and express feelings and emotions	Mental functions which regulate the expression of feelings and emotions
b280	Sensation of pain	Unpleasant sensation that indicates probable or actual damage of a body structure	Sensation indicating actual or potential damage to body structures	An unpleasant sensation in any part of the body which indicates the presence of probable or actual damage

ICF Code	Title	GREEK simple descriptions	POLISH simple descriptions	TURKISH simple descriptions
b455	Exercise tolerance functions	Endurance capacity for physical exertion related to respiratory and cardiac functions	Ability to tolerate physical exertion associated with the functions of the respiratory and cardiovascular systems	Capacity regarding respiratory and cardiovascular system functions required to endure physical exertion
b620	Urination functions	Voluntary control and voiding of bladder	Emptying and controlling the bladder	Voluntary control and emptying of the urinary bladder
b640	Sexual functions	Mental and physical functions related to sexual act	Mental and physical functions associated with sexual activities	Mental and physical functions related to the sexual act
b710	Mobility of joint functions	Range and ease of movement of a joint	Range, quality and freedom of movement in joints	Range and ease of movement of a joint
b730	Muscle power functions	Ability to generate force through the contraction of a muscle or a group of muscles	Functions related to the force generated by the contraction of a single muscle or groups of muscles	The capacity of a muscle or muscle groups to generate power by contracting
d230	Carrying out daily routine	Planning, management and completion of usual activities of daily living	Planning, undertaking and carrying out activities resulting from a daily routine	Planning, performing and completing activities of daily living
d240	Handling stress and other psychological demands	Management and control of psychological requirements to complete tasks that implicate responsibilities with stress and/or distractions and/ or critical matters	Handling and controlling mentally difficult situations in order to fulfil tasks requiring taking responsibility, related to stressful and/or distracting factors and/or critical situations	Managing and controlling psychological requirements to perform responsibility demanding tasks in stressful situations and/or in situations which occupy the mind, and/or in moments of crisis
d410	Changing basic body position	Change of body position (for example, sitting up from a chair, lying in a bed, kneeling, bending down to pick up an object)	Changing body position (e.g. getting up from a chair, lying down on a bed, moving into a kneeling position, bending down to pick up an object)	Changing body position (for example rising from a chair, lying down on a bed, kneeling, bending over to pick something from the floor)
d415	Maintaining a body position	Maintaining body position in the way and the time required by the condition	Maintaining body position in a manner and time appropriate to the situation	Maintaining a body position in the way and within the time required by the situation
d420	Transferring oneself	Moving from one surface to another while keeping the same body position	Moving while sitting or lying down without changing body position	Moving from one location to another whilst maintaining the body position
d450	Walking	Moving to the upright position, step by step, always maintaining support on the ground	Moving around on foot while keeping constant contact with the ground	Moving forward step by step in an upright position, always maintaining support on the ground by one foot.
d455	Moving around	Moving in different ways apart from walking (for example running, going up/ downstairs, jumping, climbing, swimming etc.)	Moving around in any other way than walking (e.g. running, managing stairs, jumping, climbing, swimming, etc.)	Moving in ways other than walking (for example running, climbing up and down stairs, jumping, climbing, swimming etc.)
d465	Moving around using equipment	Moving from one place to another, on every surface or place, by using specific tools (rollers, ski, diving equipment) or assisting devices (wheelchair etc.)	Moving between various locations, crossing different surfaces or spaces with the use of dedicated equipment (skating, skiing or diving accessories) or assistive devices (wheelchair, etc.)	Moving from one place to another using specialized equipment such as skates, skis or diving equipment or using mobility aids such as a wheelchair
d470	Using transportation	Using different means of transportation as a passenger	Using different means of transport to move around as a passenger	Using a variety of modes of transport when travelling from one place to another as a passenger
d510	Washing oneself	Cleaning, washing and drying the whole body or parts of it	Washing and drying one’s whole body, or body parts, e.g. taking a bath or a shower, washing hands and feet, face and hair	Cleaning, washing and drying one’s entire body or parts of one’s body
d520	Caring for body parts	Caring for skin, teeth, hair, nails, genital area, etc. that demand more than washing and drying	Taking care of the body or its parts, other than washing	Caring for body parts which require more than washing and drying, such as the skin, teeth, hair, finger and toenails and genitalia

ICF Code	Title	GREEK simple descriptions	POLISH simple descriptions	TURKISH simple descriptions
d530	Toileting	Management of urination, defecation and menstruation, including personal hygiene afterwards	Undertaking activities related to urination, defecation and menstruation, including the subsequent body cleaning	Performing the toileting duties involved in urination, defecation, menstruation and being able to clean oneself afterwards
d540	Dressing	Choosing, putting on and taking off clothes and shoes, according to the climate conditions and social occasions	Selecting, putting on and taking off clothes and footwear adequately to the situation	Choosing, putting on and taking off clothes and footwear (shoes, boots, slippers etc.) in accordance with the climatic and social conditions
d550	Eating	Eating already served food with coordinated movements, adapted to the place/ context	Undertaking coordinated actions and activities associated with prepared food consumption (excluding drinking)	Eating the served food in an appropriate order and manner which is suitable for the setting
d570	Looking after one’s health	Ensuring health, physical and mental well-being, adopting a healthy lifestyle	Maintaining health by adopting a healthy lifestyle	Maintaining physical and mental well-being by adopting a healthy lifestyle
d640	Doing housework	Household management, like cleaning and tidying up, washing clothes, using household appliances, taking out garbage etc.	Performing housekeeping activities, like tidying up, cleaning, doing laundry, using household tools and appliances, disposing of garbage, etc.	Managing the household by performing housework such as cleaning and tidying the house, washing laundry, using household appliances, disposing of garbage, and the like
d660	Assisting others	Helping other people with their learning, communication, self-care, movements, with an interest in their quality of life	Helping others in learning, communicating, self-service, mobility activities and caring for their well-being	Helping others with learning, communication, self-care and movement and paying attention to their wellbeing
d710	Basic interpersonal interactions	Interacting with other people in the social context by an acceptable way	Communicating with other people in a socially acceptable and appropriate manner	Interacting with people in a culturally and socially appropriate manner
d770	Intimate relationships	Creating and maintaining close or romantic relationship with other individuals as husbands, lovers or sexual partners	Making and maintaining close contacts based on feelings, physical contact and emotional bonds between individuals, such as husband and wife, lovers, sexual partners	Forming and maintaining intimate or romantic relationships with individuals, for example becoming husband and wife, lovers or sexual partners
d850	Remunerative employment	Appropriate performing of employment with salary (full or part- time or self- employed) in all of its aspects	Performing paid work (full-time, part-time or self-employed) properly and in all its aspects	Conducting all aspects of paid work appropriately (full or part time or self-employment, such as free-lance work)
d920	Recreation and leisure	Taking part in creative or leisure activities (play, cultural or athletic activities, etc.) during free time	Undertaking initiatives and participating in various types of activities related to recreation, entertainment and leisure (e.g. games, sports, cultural life)	Participating in a variety of recreational and leisure activities (such as games, cultural and sporting activities)

The countries that developed language-specific versions were able to recruit rehabilitation professionals from different disciplines. The composition of participants is shown in Table II.

Table II. —Description of the participants.

Profession	Languages
	Croatian	Flemish/Dutch	Greek	Polish*	Turkish**
					Istanbul	Ankara	Mersin
PRM physician	13	4	14	11	4	3	3
Occupational therapist	1	6	4		1	1
Physiotherapist	2	5	4	4	2	2	3
Speech and language therapist	1	2	2	1
(Rehabilitation) nurse		1	3	4		2	2
Psychologist	1	4	2	1	1	1	1
Movement scientist		1
Gerontologist		1
Education and rehabilitation science specialist	1			2
Social worker			2		1	1
Other				4
Sub-total					9	10	9
Total	19	24	31	27	28

PRM: Physical and Rehabilitation Medicine. *The participants in Poland also included members of the ICF Board established by the Director of the Center for Health Information Systems as well as the main specialist of the National Health Program Department at the Ministry of Health (at the time). The “Other” profession comprises three representatives of Disabled Persons Organizations and one statistician; **Consensus Conferences in the Istanbul, Ankara and Mersin regions.

The consensus conferences to develop the Croatian,¹³ Flemish/Dutch and Polish versions were carried out as face-to-face conferences, while Greece exchanged comments on the proposals and conducted the voting via email rather than face-to-face. Furthermore, the regional option as described above was implemented in Türkiye. Table II shows the Turkish cities that represented the regions in Türkiye that participated in the consensus process.

Another distinguishing element between the country/regional initiatives is that Croatia already decided to implement the scoring system from 0 (indicating no problem) to 10 (indicating complete problem) that had been used and validated in China for the ICF Generic-6 Set.¹⁴ The scoring was added to the Croatian version to make it ready for implementation and this has been uploaded on their National Society’s webpage.¹³

In terms of the simple descriptions themselves, there were predominately minor differences in sentence structure, use of terms and methods for simplifying the descriptions. Simplification techniques included the consolidation of words, e.g. “passenger transportation“ instead of “means of transportation as a passenger” (Croatian), foregoing prepositions like “of” and “for,” e.g. “eating served food” instead of “eating food already served” (Croatian) and deleting examples, e.g. “cleaning and clearing up, washing clothes, etc.” of doing housework (Flemish/Dutch). Some language versions replaced words with other terms that generally have the same meaning, e.g. tidying up” (Greek and Polish) for “clearing up” in d640 Doing housework or “handling” stress (Polish) instead of “managing” stress. Furthermore, some language versions used colloquial terms like “on foot” for walking (Polish) or more everyday language, e.g. “weather” for “climactic conditions” and “paid work” for “remunerative employment” (both Flemish/Dutch), while some employed more technical terms, e.g. “circadian rhythm” (Polish) rather than the more specific type of circadian rhythm “cycle” or “micturition” (Flemish/Dutch) instead of “urination.”

An overview of the similarities and differences between the language versions is found in Table III. Table III also highlights noteworthy aspects of specific language versions, such as potential translation issues or changes to the content of the description compared to the original ICF description. Selected noteworthy aspects are detailed in the discussion section.

Table III. —Overview of the similarities and differences between the language versions. The table also highlights noteworthy aspects of specific language versions.

ICF-code	Title	Similarities	Differences	Noteworthy
b130	Energy and drive functions*	Flemish/Dutch, Greek and Turkish version are more achievement-oriented in terms of goals rather than the stage before goal-achievement Croatian and Polish versions replaced “impulses” with other words
b134	Sleep functions	Mostly consistent		Polish version used the overarching term “circadian rhythm”
b152	Emotional functions*		While the Flemish/Dutch version emphasized the regulation of feelings, emotions and mood, the Polish version deemphasized it
b280	Sensation of pain*	Greek and Turkish versions transformed “potential” damage to a more definite status of “probable” damage		Polish version neutralized the sensation by deleting the unpleasant characteristic of the sensation
b455	Exercise tolerance functions	Mostly consistent		Flemish/Dutch version interpreted exercise tolerance as sustaining or maintaining a level of exertion rather than focus on the experience of exertion (as enduring exertion)
b620	Urination functions	Flemish/Dutch and Polish versions no longer emphasize the voluntary nature of the bladder control. The ICF itself does not emphasize this it; was first introduced in the Chinese simple descriptions and was taken over in the Italian version
b640	Sexual functions	All consistent
b710	Mobility of joint functions			Polish version added “quality” as a more detailed characteristic of the joint movement. For example, a joint could have an overall good range of motion with ease, but the first part of the joint movement could be still and then become more pliant afterwards
b730	Muscle power functions	All consistent
d230	Carrying out daily routine*	All language version except the Greek version either added or even focused on the execution of the activities rather than instead of on the management of daily activities		Polish version used wording “carrying out” from the title
d240	Handling stress and other psychological demands			Possible issue in the translation: The Croatian version replaced “involving stress…” with “that include stress…” This basically means that stress, etc. is one of the “responsible tasks”. However, the category does not say this, but rather stress etc. are characteristics of the tasks. Input independent native speaker: The verb used “ uključiti” can be translated into both “involve” or “include”
d410	Changing basic body position	All consistent
d415	Maintaining a body position	Only the Flemish/Dutch version deemphasized the approach for maintaining a body position
d420	Transferring oneself			Croatian version used wording “transferring” from the category title Content change: Polish version does not clearly reflect the transferring aspect (Moving from one surface to another) but only indicated moving while sitting and lying down without change of body position. However, this can refer to any type of movement in these positions without transferring, e.g. shifting from lying on the right side of the body to the left side
d450	Walking*	Both the Flemish/Dutch and Turkish versions took text from the original ICF description that highlights keeping one foot on the ground
d455	Moving around*
d465	Moving around using equipment			Greek version took text from the original ICF description by using “rollers” as the example for “skates”
d470	Using transportation	All consistent
d510	Washing oneself	Both the Flemish/Dutch and Polish versions added specific examples of body parts, e.g. hair, to what is washed and dried. Although hair is specified in d520 Caring for body parts, d520 excludes washing and drying, thus legitimate to give as an example
d520	Caring for body parts	Mostly consistent
d530	Toileting			Flemish/Dutch version used the medical term “micturition” instead of the lay term “urination”
d540	Dressing			Turkish version gave examples of footwear
d550	Eating			Turkish version focused on the setting (physical, specific location) rather than the global context, which may encompass the cultural context
d570	Looking after one’s health			Flemish/Dutch version deleted the descriptors “physical and mental” of well-being as well as the means “healthy lifestyle” for ensuring health and well-being. Polish version focused on the maintenance of health and deleted the references to well-being
d640	Doing housework	Both the Greek and Polish versions used “tidying up” instead of “clearing up”
d660	Assisting others			Greek version changed the focus of “being concerned about their well-being” to “with an interest in their quality of life”. These are slightly different constructs. In simple terms, well-being refers to the physical and mental health status, quality of life focuses on how well one lives or the impact of health on life
d710	Basic interpersonal interactions			Content change: Polish version replaced “interacting” with others with “communicating” with others. Since communication is another domain and the present category falls under the domain interpersonal interactions, this represents a total content change. Flemish/Dutch version interpreted “socially appropriate manner” as “context and culture”
d770	Intimate relationships			Croatian version replaced “close relationships” with the term “intimate relationships” in line with the category title
d850	Remunerative employment*			Flemish/Dutch version deleted “properly” to describe the performance of work. Turkish version specified free-lance work
d920	Recreation and leisure			Possible translation issue: Greek version used “creative activities” instead of “recreational activities”, which are two different concepts

*Generic-7 Set.

Discussion

This paper summarizes the results of the development of the simple descriptions of the ICF Generic-30 Set (ClinFIT) categories^{7, 9} in Croatian, Flemish/Dutch, Greek, Polish and Turkish. These language-specific versions are an addition to the Italian version¹⁰ that served as the basis for these language versions (with the exception of Greece, who also considered the English translation of the Chinese version¹¹). These language-specific versions are not the only ones produced so far for Europe; simple descriptions in German and French have also been developed. However, since they employed a different methodology than the language versions presented in this paper, the German and French versions will be reported in a separate paper. Irrespective of the methodology used, all of these language-specific simple descriptions of the ICF Generic-30 Set will facilitate the integration of functioning information (operationalized in ClinFIT) in health systems all over Europe.

Noteworthy aspects

As shown in Table III, there are aspects of specific descriptions that are noteworthy to present in more detail.

Some language versions added content to the description that is not reflected in the base version nor in the original ICF description. For example, the Turkish version added examples for footwear in d540 Dressing and specified free-lance work as a type of self-employment in d850 Remunerative employment. Such added content does not distract from the overall meaning of the category.

Some language versions, however, interpreted terms differently from the base version and the original ICF category description, that the simple description detoured from the core concept of the original ICF category (consequently also of the base version). An example of a minor detour is the Croatian description for d455 Moving around, that is, “Moving around” was replaced by a similar term: “Movement.” “Moving around,” however, is more than “movement” as “moving around” infers going to a different location, place or position. Another example is reflected in the Greek version of d660 Assisting others, in which the focus of “being concerned about their well-being” was changed to “with an interest in their quality of life.” Well-being and quality of life are different constructs. While subjective well-being is often operationalized as happiness and satisfaction and objective well-being as the good things in life, housing, food, relationships, etc.), the construct of “quality of life” is more ambiguous as it is rather an artifact of quality of life instruments.¹⁵ In any case, the ICF and functioning are more closely linked to well-being than quality of life as indicated throughout the ICF.^{1, 15} An example of a major content change is the Polish version of d710 Basic interpersonal interactions, in which “interacting with other people” was replaced with “communicating with other people.” Since the present category falls under the domain of interpersonal interactions and communication is another domain in the ICF, this word replacement represents a total content change. The rest of the Polish simple description is consistent with the base version and the original ICF category description.

Although at a glance, the core concept inconsistencies exemplified above may seem minimal, there is a risk that users of the simple descriptions, primarily as part of ClinFIT, may misunderstand what the corresponding ClinFIT item is asking and rate a patient’s functioning differently than another rater using a different language version. This has a consequence for data comparability across language and country borders, for example in international studies using ClinFIT, but there should not be a comparability issue if the raters are using the same language version. Validation studies of the current language versions, that may include an additional comparative analysis with other language versions, may help harmonize the language versions. Furthermore, cross-cultural validation studies that include a differential item functioning (DIF) analysis using the Rasch method would help to determine whether items work the same way in diverse language versions.¹⁶

Potential use

Are these simple descriptions really user-friendly for clinicians? Based on the results of a study conducted by Gimigliano et al.,¹⁷ the answer is yes. In this 2016 study, 93 PRM residents across Italy used ClinFIT (ICF Generic-30 Set with the Italian simple descriptions) to assess the functioning of 864 persons with different health conditions receiving outpatient rehabilitation services. They found that the simple descriptions made the ICF and ClinFIT easier to use in clinical practice, and concluded that ClinFIT was useful in assessing patient functioning in outpatient rehabilitation.¹⁷ Similar studies using the different language versions, and also with rehabilitation professionals of different disciplines, would be helpful to validate the usefulness of the simple descriptions. The Gimigliano et al.¹⁷ study was a cross-sectional study and conducted in outpatient rehabilitation.

Are the simple descriptions and ClinFIT useful across time and in other rehabilitation contexts? Based on the results of a study conducted by Amatya et al.,¹⁸ the answer is yes. Amatya et al. did not specifically test the simple descriptions but rather examined the responsiveness of ClinFIT in routine inpatient rehabilitation practice in Australia, and their findings suggest that ClinFIT has potential utility in interdisciplinary inpatient rehabilitation practice, specifically in comprehensively assessing patient functioning across time, goal-setting and in providing interventions that directly meet patient needs. ClinFIT was found to be sensitive to change in functioning over time.¹⁸ Both studies are in line with the UEMS-PRM Section efforts to promote the ICF as a standard in rehabilitation practice and in clinical quality management. In its initiative to develop the ICF-based Individual Rehabilitation Project (IRP), the UEMS-PRM Section identified ClinFIT as an ICF-based clinical tool that can be employed in the assessment phase of the Rehab-Cycle element of the IRP. An IRP is a multi-element, person-centered and interdisciplinary rehabilitation management approach that can be employed across the care continuum (acute, post-acute, long-term).¹⁹ Although the IRP was developed primarily for individualizing rehabilitation services to patient functioning needs, its developers envision its use in supporting clinical quality management and national policy decisions regarding rehabilitation. Demonstration projects across Europe, that will likely use the different language versions presented in this paper as ClinFIT, are planned to evaluate its utility in these application areas.

Next steps

The immediate next step in these demonstration projects would be to validate these language versions. The validation of the individual simple descriptions could be integrated in an overall psychometric testing of ClinFIT. Reliability and validity testing has already been done for six of the Chinese version of the ICF Generic-30 Set (called ICF Generic-6 Set)²⁰ and for all 30 categories of the Japanese version^{21, 22} resulting in good to excellent inter-rater reliability. The Chinese version²⁰ additionally found that the ICF Generic-6 Set was a good predictor of length of stay and cost of inpatient treatment. While the Chinese version testing did not examine the simple descriptions, a multi-professional panel of eight ICF experts performed a critical review of the tool, including the items operationalized with the simple descriptions, and the corresponding rating guide to confirm consistency with the original ICF descriptions. A similar review could be done for the five European language versions presented in this paper. Face or content validity could also be examined with the same multi-professional panel asking the participants whether the items operationalized with the simple descriptions were understandable, along with questions about the suitability of the response options, difficulty in using the scale, and whether ClinFIT comprehensively assesses patient functioning (as part of a more extensive testing of the tool). Furthermore, the quality of the simple descriptions could be examined indirectly with inter-rater reliability testing. If two different rehabilitation professionals similarly rate the same patient, they most likely understood the items the same way. Cognitive interviews with the raters, as done in the Japanese project,^{21, 22} could additionally inform about what the raters considered when rating individual items and reason for the specific rating. Lastly, cross-cultural validity testing with DIF analysis would clarify whether items work in the same way in different language versions. Country DIF will be present when a response to a particular item differs across countries, given the same level of functioning.¹⁶

Conclusions

Following the footsteps of the Italian-language simple descriptions of the ICF Generic-30 Set,¹⁰ the Flemish/Dutch, Croatian, Greek, Polish and Turkish versions are among the first of hopefully many more European language simple descriptions that will be developed. PRM physicians and other rehabilitation professionals throughout Europe are encouraged to get involved in development as well as validation activities. These activities are the steppingstones toward ensuring person-centered and interdisciplinary rehabilitation management and the system-wide implementation of the ICF in Europe.

Supplementary Digital Material 1

Supplementary Table I

Simple descriptions in the original Flemish/Dutch, Croatian, Greek, Polish and Turkish languages.