M. Cardol

The development of a handicap assessment questionnaire: the Impact on Participation and Autonomy (IPA)

Objective: To report on the feasibility and psychometric properties in terms of homogeneity and construct validity of a newly developed handicap questionnaire focusing on person-perceived handicaps: the Impact on Participation and Autonomy (IPA). Design: Cross-sectional. Setting, subjects and outcome measure: One hundred consecutive individuals from the outpatient clinic of the department of rehabilitation of an academic hospital administered the new questionnaire IPA. Results: The results show good homogeneity and construct validity of the IPA. Factor analysis showed that the scale consists of four factors, explaining 68% of the total variance: social relationships, autonomy in self-care, mobility and leisure, and family role. Homogeneity of the four subscales was considered good, Cronbachs α ranged from 0.84 (family role) to 0.87 (social relationships). Feasibility in terms of the number of missing values and administration time needed was satisfactory. Conclusion: The first results suggest that the IPA promises to be a useful handicap questionnaire. Further research is needed to establish test–retest reliability, convergent validity and responsiveness to change.

On autonomy and participation in rehabilitation

Purpose : To explore the concept of autonomy as a basis for social participation, with particular reference to rehabilitation. Method : A study of relevant literature from the field of rehabilitation, building on theory developed in other fields (ethics, social sciences), and deriving important concepts and strategies for rehabilitation practice. Results : The focus of rehabilitation for people with a chronic disabling condition is shifting from a biomedical to a client-centred perspective. Conceptions of autonomy vary among individuals and cultures, but a crucial distinction can be made between decisional autonomy (the ability to make decisions without external restraint) and executional autonomy (the ability to act as one wishes). The liberal-individualist account of autonomy over-emphasizes physical independence and does not sufficiently recognize the inter-dependency of all people, including those with disabilities. An ethic of care, complementary to the principle of respect for autonomy, should guide the development of rehabilitation strategies to enhance individual autonomy and participation in daily living. For rehabilitation, this entails an attentive attitude, maximizing opportunities for informed choices, taking full account of each persons preferences, needs and social contexts. Conclusions : Autonomy is central to client-centred rehabilitation since it is a pre-requisite for effective participation. It is suggested that autonomy, conceived as a basis for participation, is the ultimate aim of rehabilitation.

Validity of the Canadian Occupational Performance Measure: a client-centred outcome measurement

Objective: To study the convergent and divergent validity of the Canadian Occupational Performance Measure (COPM). Design: Cross-sectional study. Setting: The occupational therapy departments of two university hospitals in Amsterdam. Subjects: One hundred and five consecutive outpatients. Outcome measures: The COPM is a measure of a clients self-perception of occupational performance in the areas of self-care, productivity and leisure. Outcome measures of the COPM are: the clients most important problems in occupational performance and a total score for performance and a total score for satisfaction for these problems. Problems reported in the COPM were compared with the Sickness Impact Profile (SIP68), the Disability and Impact Profile (DIP) and an open-ended question. Results: Complete data were obtained for 99 clients. The identification of occupational performance problems with the COPM surpassed the items reported in the SIP68, the DIP and the open-ended question, which confirms the surplus value of the COPM. Divergent validity was further demonstrated by the low correlation coefficients between the total SIP68 scores and the COPM. Seventy-four per cent of the occupational performance problems reported in the COPM had a corresponding item in the DIP and 49% had a corresponding item in the SIP68. Convergent validity was supported by the fact that 63% of the corresponding problems in the DIP were reported to be a disruption of quality of life and 74% of the corresponding problems in the SIP68 were identified as a disability. Conclusion: The results of this study provide supportive evidence for the convergent and divergent validity of the COPM. The data support the assumption that the COPM provides information that cannot be obtained with current standardized instruments to measure health.

The reproducibility of the Canadian Occupational Performance Measure

Objective: To assess the reproducibility (reliability and inter-rater agreement) of the client-centred Canadian Occupational Performance Measure (COPM). Design: The COPM was administered twice, with a mean interval of seven days (SD 1.6, range 4-14), by two different occupational therapists. Data analysis was based on intraclass correlation coefficients, the Bland and Altman method and Cohens weighted kappas. Setting: Occupational therapy departments of two university medical centres. Subjects: Consecutive clients, with various diagnoses, newly referred to the outpatient clinic of two occupational therapy departments, were included. They were all over 18 years of age and perceived limitations in more than one activity of daily life. Complete data on 95 clients were obtained: 31 men and 64 women. Results: Sixty-six per cent of the activities prioritized at the first assessment were also prioritized at the second assessment. The intraclass correlation coefficients were 0.67 (95% confidence interval (CI) 0.54-0.78) for the mean performance score and 0.69 (95% CI 0.56-0.79) for the mean satisfaction score. The limits of agreement were-2.5 to 2.4 for the mean performance score and-2.3 to 2.7 for the mean satisfaction score. For the separate prioritized problems, the weighted kappas ranged from 0.37 to 0.49. Conclusions: Inter-rater agreement of the prioritized problems was moderate. The reproducibility of the mean performance and satisfaction scores was moderate, but it was poor for the scores of the separate problems. Therefore, the mean scores should be used for individual assessment.

Handicap questionnaires: what do they assess ?

BACKGROUND AND PURPOSE There is an increasing need to get insight into the social and societal impact of chronic conditions on a persons life, i.e. person-perceived handicap. The purpose of this study is to report how current handicap questionnaires assess handicap. METHOD A literature search using both Medline and the database of the Dutch Institute of Allied Health Professions (NPi) was conducted for handicap questionnaires. Questionnaires were included if addressing handicaps or life roles, environmental influences and social consequences of a disease. Excluded were questionnaires focusing on only impairments, disabilities or quality of life. RESULTS AND CONCLUSION 20 questionnaires were identified. Handicap is not uniformly defined in these questionnaires. Based on different concepts, the various questionnaires encompass different domains and different aspects are emphasized in similar domains. Fourteen questionnaires assess society-perceived handicaps, and do not address the life roles, care needs or individual problem-experience. Six questionnaires are to some extent person-perceived, but a generic person-perceived handicap questionnaire could not be identified. It is concluded that development of a generic person-perceived handicap questionnaire is essential for adequate assessment of needs, outcome, and relevance of rehabilitation interventions from the individuals point of view.

Validity of the impact on participation and autonomy questionnaire: A comparison between two countries

Purpose. To evaluate the cross-cultural validity of the five subscales of the Impact on Participation and Autonomy (IPA) measure and the full 31-item scale. Method. Data from two validation studies (Dutch and English) were pooled (n = 106). Participants (aged 18 – 75), known to rehabilitation services or GP practices, had conditions ranging from minor ailments to significant disability. Validity of the five subscales and the total scale was examined using Rasch analysis (Partial Credit Model). P values smaller than 0.01 were employed to allow for multiple testing. Results. A number of items in all the subscales except ‘Outdoor Autonomy’ needed rescoring. One ‘Indoor Autonomy’ item showed uniform DIF by country and was split by country. One ‘Work and Education’ item displayed uniform and non-uniform DIF by gender. All the subscales fitted the Rasch model and were invariant across country. A 30-item IPA also fitted the Rasch model. Conclusion. The IPA subscales and a 30-item scale are invariant across the two cultures and gender. The IPA can be used validly to assess participation and autonomy in these populations. Further analyses are required to examine whether the IPA is invariant across differing levels of disability and other disease groups not included in this study.

On autonomy and participation in rehabilitation: a response.

We are glad that our paper has stimulated what we believe is a necessary debate. Concepts and practices have been evolving rapidly, as Smith1 demonstrates. We accept that little of what we have said is entirely new. The concept of autonomy has an ancient pedigree but, as the commentaries suggest, its application in rehabilitation medicine raises theoretical and practical issues which future work must explore. (aut. ref.)