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Conceptual Foundations for Health Measurements

This text explores the conceptual foundations related to the measurement of disability and handicap in health. It discusses the perspectives of disease, illness, and sickness, as well as the WHO classifications and the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). The issues in defining disability and the changes in the ICIDH-2 are also discussed, along with the concept of health-related quality of life. The text concludes with a discussion on mapping physical measures onto quality of life.

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Conceptual Foundations for Health Measurements

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  1. Conceptual Foundations for Health Measurements

  2. Disability and Handicap Examples of Conceptual Foundationsfor Measurement Scales

  3. Three Perspectives:Disease, Sickness & Illness Disease (Underlying pathology; biologically defined: the practitioner’s perspective. The illness seen in terms of a biological theory of disorder) Illness (Theperson’s subjective experience of their symptoms. What the patient brings to the doctor) Sickness (Social & cultural conceptions of the condition: cultural beliefs and reactions such as fear or stigma. These affect how the patient reacts, and also what is considered a disorder suitable for medical treatment)

  4. WHO Classifications • International Classification of Diseases (ICD) • Etiological framework • Diagnosis of health condition • Disease process, signs & symptoms • International Classification of Impairments, Disabilities & Handicaps (ICIDH) • How people live; body functions • Framework to describe activities & participation • Covers non fatal outcomes

  5. Conceptions of Disability “a disability is any restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being” (WHO International Classification of Impairments, Disabilities, and Handicaps, 1980.)

  6. ICIDH* - 1 Disability Handicap Impairment Internal,body Applied Societal (N.b. dotted arrows indicate that one stage may, but need not, influence the next) * International Classification of Impairment, Disability & Handicap

  7. Issues in the Definition • Defining disability in terms of activity limitations is neat, but what activities? • What level of limitation should be used? • Same expectations for everyone, or relative to age, sex, etc.? • Threshold: does not perform an activity, versus cannot perform it? Maybe doesn’t, but could?

  8. ICIDH - 2 • Appeared March, 2001 • Conceptual changes: • From consequences of disease (1980) to components of health (2000) • Uses more positive language (‘activity’ & ‘participation’ instead of ‘disability’ & ‘handicap’) • Broadens concept of disability • More on environmental factors in which the person lives

  9. ICIDH - 2 Health Condition (disorder / disease) Body Functions & structures Activities Participation PERSON Activities SOCIETY Participation BODY Structure & Function impairment limitation restriction

  10. Body Functions • Mental functions • Sensory • Voice & speech • CVD, hematological, etc. • Digestive, metabolic & endocrine • Genitourinary • Neuro-musculoskeletal • Skin

  11. Learning Communication Movement Self-care Domestic activities Interpersonal Major life activities Community Exchanging information Communicating Mobility Personal maintenance Home life Social relationships Work & employment Social & civic life Activities & Participation

  12. A ‘Circumplex’ Model High positive affect active,elated,excited Strong engagement Pleasantness content,happy,satisfied aroused,astonished,concerned High negative affect Low negative affect relaxed,calm, placid distressed, fearful, hostile sad, lonely, withdrawn inactive,still,quiet sluggish,dull,drowsy Disengagement Unpleasantness Low positive affect

  13. Health-Related Quality of Life • QoL is deliberately subjective & value-specific • Invented in the USA • How universally applicable is it? • Definition will surely vary across cultures (naïve early enthusiasm for QoL as final outcome) • Handicap reflects impairment + environment, so measures may perform differently in different environments

  14. Quality of life is… “Having the important people in your life see your strengths and talents” “A good night’s sleep” “Validation of worth and affirmation of experience” “Having control of your own life” “Taking control of your health condition” “Life free from stigma” “Having a ‘real’ job” “Having a purpose” “Being free to come and go” Quality of Life (from a consumer’s perspective) Carne, B. A consumer perspective. Can J Community Mental Health 1998, Suppl 3: 21.

  15. The Deceptive Simplicity of HRQOL… Health-Related Quality of Life Or Quantity? (How would we we measure quality?) Definition? What model? (Caused by Associated with? or ?) Of life or Living?

  16. Mapping Physical Measures onto Quality of Life Clinical / Physical Markers (the clinician’s concern) cover part of Disease-Specific Dysfunction cover part of Health-Related Quality of Life cover part of Overall Quality of Life (the patient’s concern) Source: SH Kaplan et al. Medical Care, 2000

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