Occupational Therapists’ Perspective on the International Classification of Functioning,Disability and Health Core Sets ( ICF –CS) for Schizophrenia

Method

Delphi Process

A web-based survey was conducted using Qualtrics (Provo, UT) from April 2017 to January 2018. All potential participants received an email with instructions and a link to the survey. Three reminders were sent: 1 week before the deadline, 2 days before the deadline, and on the deadline day itself.

In the first Delphi round, the experts received a questionnaire with six open-ended questions that covered all the ICF components (i.e., Body Functions, Body Structures, Activities and Participation, Environmental Factors, and Personal Factors). They were asked to list all the aspects they considered to be relevant when assessing or treating people with schizophrenia (see Figure 1). Answers were linked to the ICF categories (see the “Linking” section), and the categories reported by at least 5% of participants were included in the survey for the second Delphi round.

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Figure 1.

Delphi process for the study of occupational therapists’ perspective on the ICF Core Sets for schizophrenia.

In the second round, all participants received a survey with a list of the codes and definitions of (1) the 97 ICF categories from the Comprehensive ICF–CS for schizophrenia and (2) ICF categories that were not included in the Comprehensive ICF–CS but that corresponded to relevant aspects reported by at least 5% of participants. Participants did not know which categories belonged to the Comprehensive ICF–CS for schizophrenia and which did not. They had to decide whether the listed ICF categories did or did not (yes–no response) represent problems, resources, or environmental factors treated by occupational therapists in work with people with schizophrenia, and they were asked to take into account that the final list should be as short as possible to be practical but as comprehensive as needed to capture the most relevant needs of people with schizophrenia.

In the third round, participants received the same list of ICF categories with codes and definitions, this time with feedback on the responses of the expert panel as a whole and their own previous responses. They were asked again to judge the relevance of each ICF category (yes–no response).

Results

A total of 92 occupational therapists from 29 countries representing all six WHO regions completed the first-round questionnaire (72.4% of the 127 who were invited to participate). Seventy-three (79.3%) completed the third round. On average, they had 9.9 yr experience treating people with schizophrenia (range = 1–44 yr). Their professional roles primarily involved clinical practice (mean of 52.5% of their time), followed by teaching and training (18.8%), research (14.7%), management (12.4%), and other tasks (1.6%). Table 1 shows participants’ demographic and professional characteristics.

In the first Delphi round, the experts named 2,527 meaningful concepts, which were linked to 209 ICF categories. Of these, 88 categories were excluded because they were reported by fewer than 5% of participants. Regarding Personal Factors, the experts named 38, of which 7 were excluded because they were reported by fewer than 5%. Thus, 121 ICF categories and 31 Personal Factors were presented to the experts in the second round. The κ coefficient and its bootstrapped CI for the linking process were 0.73 [0.71, 0.75].

Of the 121 ICF categories presented in the second Delphi round, agreement of at least 75% was reached for 97 (80%). Consensus was reached for all categories included in the Brief ICF–CS for schizophrenia with agreements of 95% or more. The comparative analysis that follows therefore focuses on the Comprehensive ICF–CS. As shown in Table 2, of the 97 ICF categories for which consensus was reached, 89 are included in the Comprehensive ICF–CS. At the same time, of those categories represented in the Comprehensive ICF–CS, participants reached consensus on 89 (92%). Table 3 gives details on the 16 categories that did not overlap both sets of categories. Further information about the study results can be found in Supplemental Tables 1–5 (available online at https://ajot.aota.org; navigate to this article, and click on “Supplemental”). In addition,

Discussion

The results of this study show that the content validity of the ICF–CSs for schizophrenia has support from the perspective of occupational therapists worldwide. These results are in agreement with those of previous studies from the perspectives of psychiatrists (Nuño et al., 2018), psychologists (Nuño, Guilera, et al., 2019), and nurses (Nuño, Barrios, et al., 2019), further supporting the international validity of the ICF–CSs for schizophrenia. For all categories included in the Brief ICF–CS, consensus was reached with a high level of agreement. Of the 97 categories represented in the Comprehensive ICF–CS, consensus was achieved for 92%.

Regarding the Body Functions component of the ICF, most categories belong to the b1 Mental functions chapter and only one to the b6 Genitourinary and reproductive functions chapter (i.e., b640 Sexual functions). All the categories that achieved a high level of agreement within the b1 Mental functions chapter correspond to typical symptomatic manifestations of schizophrenia. Indeed, schizophrenia is associated with the presence of alterations in perception (e.g., b156 Perceptual functions), negative symptoms such as decreased expression and motivational deficits (e.g., b130 Energy and drive functions), alterations in thinking (e.g., b160 Thought functions), and cognitive deficits (e.g., b164 Higher-level cognitive functions; Bailliard & Whigham, 2017). This finding accounts for the relevance of this component and the categories in the b1 Mental functions chapter to defining functioning in people with schizophrenia from the perspective of occupational therapists. These results coincide with the findings obtained from other professional perspectives (Nuño, Barrios, et al., 2019; Nuño et al., 2018; Nuño, Guilera, et al., 2019). They also show that occupational therapists play a key role because they can guide clients, caregivers, and the treatment team with respect to multiple factors that influence the recovery or development of functional capacities (Tanaka et al., 2014). In fact, cognitive functioning has been related to occupational engagement and thus to the ability to perform daily occupations in a balanced rhythm (Lexén & Bejerholm, 2018).

As in the previous studies, one category of the b1 Mental functions chapter for which consensus was achieved (in fact, with 95% agreement) is not included in the ICF–CSs for schizophrenia: the category b126 Temperament and personality functions. Our expert participants agreed on the relevance of addressing aspects of personality in people with schizophrenia, which can expand the understanding of these clients and their symptoms. Therefore, the inclusion of this category in the ICF–CSs for schizophrenia should be considered. Likewise, although more than 60% of participants considered four categories that are part of the ICF–CSs (i.e., b117 Intellectual functions, b330 Fluency and rhythm of speech functions, b530 Weight maintenance functions, and b765 Involuntary movement functions) to be relevant, they did not reach consensus. The level of agreement may be low because this set of functions is not usually treated by occupational therapists, who focus mainly on helping people recover and participate in significant life roles.

In relation to the Body Structures component, the ICF–CSs for schizophrenia do not include any related categories. However, the category s110 Structure of brain obtained a broad consensus among the participants. This finding coincides with the results of our previous studies from other professional perspectives. Indeed, schizophrenia is associated with changes in the structure and functioning of several brain systems that are considered to underlie the cognitive disorders described in people with schizophrenia (Chang et al., 2018). Intervention by occupational therapists has been related to improvements in neurocognitive functioning (Shimada et al., 2016) and may therefore influence these brain structures. Further study of anomalies in these systems is needed to improve the understanding of their causes, their progression, and the effects of treatment to address them. Thus, from the perspective of occupational therapists, the inclusion of this category in the ICF–CSs for schizophrenia should be considered.

The Activities and Participation component had the largest number of categories for which consensus was reached. This result is not surprising because promoting participation in daily activities (e.g., productive activities, daily life skills, self-care tasks) is a priority work area for occupational therapy practitioners (Foruzandeh & Parvin, 2013). Improvements in clients’ functioning, participation in meaningful activities, self-determination, confidence, and satisfaction with community life are treatment objectives in occupational therapy (Morris et al., 2018; Tapfumaneyi et al., 2015). In accordance with our previous studies, the categories associated with work participation obtained a high level of consensus, showing that from the perspective of occupational therapists, addressing employment and involvement in meaningful activities for people living with schizophrenia is a necessary aspect of intervention (Eklund et al., 2012).

Three categories from the ICF–CSs were not confirmed in the current study: d166 Reading, d330 Speaking, and d335 Producing nonverbal messages. These categories are usually treated by other health professionals such as psychologists or neuropsychologists, which may be why they were not selected. It is also worth noting that a high level of agreement was reached for d810 Informal education, a category that is not included in the ICF–CSs, which may reflect the importance given by occupational therapy practitioners to continuous training and learning through informal education (Andersen, 2001).

The current study also shows the importance of the Environmental Factors component of the ICF for occupational therapists; consensus was reached on 31 of the 32 categories present in the ICF–CSs for schizophrenia. Consensus was also reached on other categories not represented in the ICF–CSs, such as various categories from the e1 Products and technology chapter and the e5 Services, systems and policies chapter, although the ICF–CSs already include four categories of the e1 chapter and 10 of the e5 chapter. Given that the ICF–CSs should be as short as possible, participants may have considered that the areas not included were sufficiently covered by the categories already there. The emphasis on categories in these two chapters is consistent with the importance occupational therapy practitioners place in their clinical practice on the social resources, products, and technologies people can use to facilitate activities required for daily life (e115 Products and technology for personal use in daily living), leisure and recreation activities (e140 Products and technology for culture, recreation and sport), and participation in the labor market (e135 Products and technology for employment). In addition, the categories e310 Immediate family and e355 Health professionals had high levels of agreement, showing the relevance of these agents as possible facilitators or obstacles in the recovery process of people with schizophrenia (Marwaha et al., 2009).

The Personal Factors component of the ICF has not yet been developed. In our study, the occupational therapists achieved consensus on 27 Personal Factors, 24 of them with agreement of 90% or higher. Many of the Personal Factors with a high level of agreement coincide with those identified from the perspective of psychiatrists, nurses, and psychologists. For example, 100% agreement was reached on the categories of Resilience, Personal history and biography, and Lifestyle, reflecting the important role these factors play in the recovery and well-being of people with schizophrenia (Mizuno et al., 2016), as well as in the presentation and evolution of the disease (Rajkumar, 2015). These results indicate that a classification of Personal Factors in the ICF is necessary so that professionals such as occupational therapists can describe in a detailed and exhaustive manner the relevant personal aspects that influence the health and daily functioning of people with schizophrenia to aid clients in strengthening their participation in meaningful and satisfactory occupations (Doroud et al., 2015).

Strengths and Limitations

This study has several methodological strengths. First, the Delphi method is a widely recognized and appropriate method for the purpose of this study, and its usefulness was maximized by including a large number of participants from around the world. The response rate in the study was high, and broad worldwide representation was achieved. In addition, the sample consisted of highly qualified occupational therapists with extensive experience in the treatment of people with schizophrenia in both acute and chronic stages and rural and urban settings.

However, some limitations should be considered. Despite the worldwide participation, some WHO regions, particularly Southeast Asia and the Eastern Mediterranean, are underrepresented. This imbalance may be attributable to a lower presence of the occupational therapy profession or less frequent intervention with people with schizophrenia in these regions, as well as to greater difficulties in accessing these professionals (e.g., as a result of limitations on the use of the Internet).

Implications for Occupational Therapy Practice

The findings of this study have the following implications for occupational therapy practice:

Conclusion

The results of this study support the use of the ICF–CSs for schizophrenia by occupational therapy practitioners in clinical practice with people with schizophrenia. The ICF–CSs for schizophrenia appear to be clear and useful guides to describing and classifying clients’ functioning, health, and rehabilitation using a language and frame of reference shared by other health professionals (Hemmingsson & Jonsson, 2005). Occupational therapy practitioners are essential in the rehabilitation of people with schizophrenia, and their perspective has contributed to the development and enrichment of the ICF–CSs for schizophrenia.

Supplemental Material