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Original Research
DOI: 10.1016/j.bjpt.2020.12.003
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Available online 30 December 2020
Functioning of women in the postpartum period: an International Classification of Functioning, Disability and Health-based consensus of physical therapists
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Élida Raquel Freitas Neri Bulhõesa, Thaissa Hamana De Macedo Dantasa, Jardelina Hermecina Dantasa, Íris Nascimento De Souzab, Luciana Castanedab, Diego De Sousa Dantasa,c,
Corresponding author
diego.sdantas@ufpe.br

Corresponding author at: Cidade Universitária, Avenida Jorn, Aníbal Fernandes, 173, CEP: 50740-560 Recife, PE, Brazil.
a Programa de Pós-graduação em Ciências da Reabilitação, Universidade Federal do Rio Grande do Norte (UFRN), Santa Cruz, RN, Brazil
b Federal Institute of Education, Sciences and Technology of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
c Programa de pós-graduação em Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brazil
Highlights

  • We identified the ICF categories relevant to describe the problems and resources of women in the postpartum period.

  • The list of ICF categories comprises all components of the ICF framework.

  • Physical therapists had a higher agreement about the relevant aspects for the assessment of the postpartum women.

  • ICF can be used for professionals in this category to improve their evaluations and clinical practice.

Received 26 July 2019. Accepted 01 December 2020
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Tables (7)
Table 1. Delphi technique — assignments and steps.
Table 2. Sociodemographic profile and professional experience of the panel of expert physical therapists in women’s health (n=45).
Table 3. Comparison between the initial and final lists.
Table 4. ICF categories included in the first and final list of the Delphi process.
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Abstract
Background

Physical therapists provide treatment for pain and other common complaints for women in the postpartum period, thereby contributing to the improvement of their functioning. However, before applying any interventions, physical therapists should assess their patients to identify the desired therapeutic goals. In this context, the International Classification of Functioning, Disability and Health (ICF) may be a useful tool for documenting functioning data and operationalizing collaborative goal setting.

Objective

To identify ICF categories and the respective domains that should be considered in the evaluation of women postpartum.

Methods

A consensus-building, three-round e-mail survey was conducted using the Delphi method. The sample included Brazilian physical therapists with expertise in women’s health. Meaningful content was analyzed in accordance to the ICF linking rules. The kappa coefficient and content validity index (CVI) were calculated.

Results

The panel consisted of 45 participants with a median age of 33 years and more than 10 years of experience in women’s health. A total of 1261 meaningful contents were identified from the responses in the first round. After consensus was achieved, a final list of 62 items was prepared, including 53 categories (11 were on structures; 15 on body functions; 12 on activities and participation; 15 on environmental factors) and nine personal factors (CVI=0.89).

Conclusion

From the perception of physical therapists, an ICF-based postpartum assessment to describe functioning and disability must comprise 53 ICF categories and nine personal factors.

Keywords:
Disability
Health status indicators
Puerperium
Rehabilitation
Full Text
Introduction

According to the biomedical model, the postpartum period corresponds to the expulsion of the placenta until the return to the pre-gestational physiological condition, which can last up to 6 months.1 In the biopsychosocial context, the postpartum period comprises a particularly delicate and variable stage of life in women.2 Women in the postpartum period face several biological, psychological, and social modifications as a consequence of motherhood. The new routine, new family context, and social role may provoke physical exhaustion, mood disorders, stress, and depressive symptoms.2–4 Thus, in addition to the intrinsic biological aspects, environmental and personal factors are determinants for maintaining or recovering health, functioning, and quality of life of puerperal women.5,6

The International Classification of Functioning, Disability, and Health (ICF) provides a useful framework for classifying patients’ problems and describing them in a standardized language for professionals worldwide.7 According to the ICF, functioning is a positive construct determined by the interaction between body functions and structures, activities, and participation components. Disability is a multidimensional issue resulting from the negative interaction between people or individuals and their physical and social environments.7 The second part of the ICF covers contextual factors, including environmental, and personal issues. In the ICF, having a problem may mean an impairment, limitation, restriction, or barrier, depending on the component.7

The ICF use in physical therapy is promising, driven by development of ICF-based measurement and by efforts for using the ICF in clinical, research, and teaching.8,9 In addition, the ICF can be useful as a clinical tool for: health needs assessment and matching treatments with specific conditions; as a statistical tool for comparing services; and as a research tool for measuring outcomes, environmental factors, or quality of life.10–13 Despite its potential, the length and time required to use the ICF in the clinical context represent important obstacles, and the development of ICF-based instruments is encouraged.14 To develop this instrument, one of the mandatory steps is to know health professionals’ perspectives about problems faced by women postpartum and to link this information with ICF categories.14–18

Physical therapists play a relevant role in the treatment of frequent complaints such as pain, musculoskeletal changes, breastfeeding complications, urinary incontinence, and other impairments.19–24 Previous evidence demonstrates the efficacy of kinesiotherapy, manual therapies, electrotherapy, and home guidance for the management of these complaints.20–24

Although the physical therapist is one of the professionals who are more familiarized with ICF,25 a knowledge gap exists about disabilities and the use of the ICF for classifying the health status of puerperal women. The ICF could be useful in goal setting and recording functioning data, contributing to the management of postpartum complaints in a biopsychosocial model.8,10,11,13

Considering that functioning is a third health indicator and the international efforts to improve the global model in rehabilitation,26,27 studies are needed to better understand the problems of puerperal women based on the ICF. Therefore, this study was aimed at identifying ICF categories and their respective components that are relevant to describing the functioning of women in the postpartum period from the perspective of physical therapists.

Methods

A consensus-building, three-round study was conducted using the Delphi technique and an e-mail survey among Brazilian physical therapists with expertise in the area of women’s health.10,14–18 This study was submitted and approved by the Research Ethics Committee of Federal University of Rio Grande do Norte, Santa Cruz, RN (CAAE: 61951816.6.0000.5568).

Recruitment of participants

The search to select the panel of experts was performed using four strategies: (1) contact through the Brazilian Association of Physical Therapy in Women’s Health (ABRAFISM); (2) active search for professors of women’s health in the public pages of public and private undergraduate courses in physical therapy in the five regions of the country; (3) search for Brazilian professionals with publications in the area of physical therapy and postpartum through the Jane Biosemantics tool (Journal/Author Name Estimator, http://jane.biosemantics.org/index.php); and (4) personal contacts of researchers.

An invitation letter was sent by e-mail to the physical therapists identified in the search. The letter contained necessary information about the purposes, Delphi process, and timeline expected for this study. In the letter, it was explained that only Brazilian physical therapists with at least 1 year of professional experience in the area of women’s health would be included in the study. Physical therapists who met these criteria needed to sign an electronic consent form to be included in the study. Professionals who self-rated their expertise as low were excluded.

The Delphi process

The Delphi process was implemented, consisting of a structured communication process with anonymity, interaction with controlled feedback, the synthesis of group response, and informed input.10,16,17Table 1 shows the process and verbatim questions.

Table 1.

Delphi technique — assignments and steps.

Delphi technique  Researchers activities  Experts activities 
First roundSending e-mail with general information, instructions, a sociodemographic questionnaire and with the following open question:  Respond to the questionnaire with indication of concepts that would serve to create a list of patient problems, patient resources, and environmental aspects treated by physical therapists in women in the immediate and late postpartum
“What are patient’s problems, patient’s resources and environmental aspects treated by physical therapists in patients in the puerperal period?” 
Linking responses to ICF categories 
Second roundThe experts receive an email with instructions and the questionnaire for the second round with the following question:  Judgment (yes / no) whether the categories listed in the ICF reflect the treatment given by physical therapists to women in the puerperium period.
“Do you agree that these ICF categories represent patient problems, patient resources or environmental aspects treated by physical therapists in women in the puerperal period?” 
Frequency calculation (% of answers “yes”) 
  Individual judgment feedback and group responses   
Third roundThe experts receive an email with instructions and the questionnaire for the third round with the following question:  Trial (yes/no) if the categories listed in the ICF reflect the treatment given by physical therapists to puerperal women.
“Given the group’s responses and your individual response in the second round, do you agree that these categories of ICF represent patient problems, patient resources or environmental aspects treated by physical therapists in postpartum patients?” 
Frequency calculation (% of answers “yes”) 
  Final analysis for linking to the ICF   

In the first round, the participants received a link to a specific form supported by Google Forms and were asked to answer questions on social and demographic characteristics (sex, age, and region of the country where they worked); and professional experience (specialization in women’s health, professional experience, self-perception of expertise). Furthermore, the participants were asked to list all the problems and environmental aspects treated by physical therapists in the puerperal period and the resources and relevant environmental issues in the treatment of each component of the ICF model, namely body functions (b), body structures (s), activities and participation (d), environmental factors (e), and personal factors (pf).10,16 Responses were linked with the ICF categories by two researchers with expertise in ICF linking, following the pre-specified standardized linking rules.28–30

In the second round, the specialists received a list of the ICF categories linked with the previous answers.15–17 The list provided the ICF categories and defined each category according to the ICF. Next, the expert was asked item by item if they agreed that those categories were essential to classify the functioning of women in the postpartum period.

In the third round, the participants received the list of the ICF categories sent in the second round, plus value of the content validity index (CVI) for each category.31 The participants had to decide to keep the category on the list or delete it. After this, the final list with the relevant ICF categories and respective components relevant to the evaluation of women in the postpartum period was defined.16

Linking process

The collected responses were analyzed to identify the meaningful content and subsequent linking with the ICF by the ICF linking rules.28–30 According to this methodology, 10 main rules and five additional rules guide the researchers step-by-step to link health information with the ICF categories. Although personal factors are relevant for understanding a health state, they are not covered in the ICF.10 Moreover, we used a list of 76 categories developed to avoid a lack of information and to enable linking the meaningful content and personal factors from the perspective of the ICF.32

Two independent raters with experience in this methodology identified the ICF categories. The researchers initially independently analyzed all the participant responses in the first round and extracted meaningful content units. A meaningful content unit or meaningful concept is a specific description that involves a common theme.16,30 Next, this main content was linked with a specific ICF category one by one. In cases of disagreement between the researchers, a third researcher acted as a judge, deciding on the most appropriate category for the content in question. Content with no ICF representation was defined as “not covered”.28–30

Data analysis

Statistical analysis was performed using the Bioestat 5.0 software program. The sociodemographic and professional experience variables of the participants were presented in the results by absolute (n) and relative (%) frequencies. The Kolmogorov–Smirnov test was used to assess the distribution of continuous variables, with those not normally distributed, presented as median and interquartile range.

The kappa coefficient tested the agreement between raters for the identification of ICF categories in the linking process.33 Kappa coefficient values were interpreted as none to slight (0.01–0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80), and almost perfect (0.81–1.00) agreement.33

The CVI assesses the extent to which each element of a measurement instrument is relevant and representative of a construct with a specific purpose for evaluation.31 CVI values ≥80% are considered acceptable.31 The CVI was calculated for each category and the overall list after the second and third rounds. The CVI for the category was determined based on the number of respondents who chose to include the category on the list divided by number of respondents. ICF categories with a CVI80% were included in the final list.15 The CVI for all the categories by round was determined as the number of categories with CVI values ≥80% divided by number of categories included in the list.15

ResultsPanel of expert physical therapists

Data collection was performed between August and December 2018. In the first month, we identified the contact information of physical therapists with experience in women’s health. The invitation letter was sent to 91 physical therapists. The process of identifying the ICF categories to classify puerperal functioning through the Delphi consensus method started in September 2018. A total of 47 professionals from the five regions of Brazil accepted the invitation to collaborate with the study through an electronic signature of consent, initially responding to the sociodemographic and professional experience questionnaire, followed by a response to the first step of the Delphi method. Two participants were excluded because they self-rated their expertise as low.

The social, demographic, and academic data of the 45 physical therapists are presented in Table 2. Most of the participants were women with specific training in the field of women’s health and a doctoral degree, working in educational institutions, and with more than 10 years of experience in this field.

Table 2.

Sociodemographic profile and professional experience of the panel of expert physical therapists in women’s health (n=45).

Variables     
Age (years)  33  27−39 
Sex
Female  42  93.3 % 
Male  6.7% 
Specialization in Women’s Health
  35  77.8% 
Highest academic qualification
University graduate  6.7% 
Specialization  17.8% 
Master  13  28.9% 
Doctorate degree  21  46.6% 
Clinical experience
1–5 years  16  25.5% 
6–10 years  11  24.4% 
More than 10 years  18  40.0% 
Self-perception of expertise
Moderate  13.3% 
High  39  86.7% 
Region of Brazil
Northeast  34  75.6% 
North  2.2% 
Midwest  4.4% 
Southeast  6.7% 
South  11.1% 
Workplace
Educational institution  21  46.7% 
Hospital  8.9% 
Clinic  6.7% 
Other  2.2% 
More than one option  16  35.6% 

Data are n (%) except for age which is median and (25%, 75%) interquartile range.

Delphi process and ICF category identification

A total of 1261 significant concepts were identified in the first round, which were linked to 258 categories of the ICF and personal factors. The agreement between the raters in the linking process was κ=0.88.

The categories identified by at least 50% of the physical therapists were included in the first list, resulting in 74 items. This list was submitted to consensus in the second and third rounds. All physical therapists included in the first round received the electronic form for the 2 subsequent rounds, but only 30 and 28 participants answered the questions in the second and third rounds, respectively. Table 3 shows a quantitative perspective of the first and final lists, while Table 4 provides all details about the consensus process in the second and third rounds. The list of categories had a CVI value of 0.94 after the second round and 0.89 after the third round.

Table 3.

Comparison between the initial and final lists.

  Initial list  Final list 
  Frequency of categories
Levels of ICF categories  (n=65)  (n=53) 
First  4 (6%) 
Second  50 (77%)  43 (81%) 
Third  11 (17%)  10 (19%) 
Fourth 
Categories by domains  (n=65)  (n=53) 
Body functions  17 (26%)  15 (28%) 
Structures  11 (17%)  11 (21%) 
Activities and participation  19 (29%)  12 (23%) 
Environmental factors component  18 (28%)  15 (28%) 
Personal factors 
Number of items  74 (65 ICF categories+9 personal factors)  62 (53 ICF categories+9 personal factors) 
Table 4.

ICF categories included in the first and final list of the Delphi process.

ICF categoryConsensus-buildingIncluded in the final list? 
Second round (n=30)  Third round (n=28)   
CVI %  CVI %   
Body functions component
b134  Sleep functions  96.7%  100%  Yes 
b152  Emotional functions  93.3%  96.4%  Yes 
b280  Sensation of pain  100%  100%  Yes 
b415  Blood vessel functions  93.3%  92.9%  Yes 
b440  Respiration functions  93.3%  96.4%  Yes 
b515  Digestive functions  80%  82.1%  Yes 
b525  Defecation functions  100%  100%  Yes 
b620  Urinary functions  93.3%  96.4%  Yes 
b6202  Urinary continence  100%  100%  Yes 
b640  Sexual functions  100%  96.4%  Yes 
b6603  Lactation  100%  100%  Yes 
b730  Muscle power functions  96.7%  96.4%  Yes 
b7305  Power of muscles of the trunk  90%  92.9%  Yes 
b755  Involuntary movement reaction functions  66.7%  53.6%  No 
b760  Control of voluntary movement functions  80%  85.7%  Yes 
b810  Protective functions of the skin  73.3%  73.3%  No 
b820  Repair functions of the skin  100%  100%  Yes 
Body structures component
s410  Structure of cardiovascular system  93.3%  100%  Yes 
s430  Structure of respiratory system  100%  100%  Yes 
s610  Structure of urinary system  100%  100%  Yes 
s620  Structure of pelvic floor  93.3%  89.3%  Yes 
s630  Structure of reproductive system  96.7%  92.9%  Yes 
s6302  Breast and nipple  93.3%  96.4%  Yes 
s730  Structure of upper extremity  93.3%  92.9%  Yes 
s740  Structure of pelvic region  100%  100%  Yes 
s750  Structure of lower extremity  96.7%  96.4%  Yes 
s760  Structure of trunk  100%  96.4%  Yes 
s7601  Muscles of trunk  93.3%  92.9%  Yes 
Activities and participation component
d230  Carrying out daily routine  96.7%  100%  Yes 
d4  Mobility  96.7%  100%  No 
d450  Walking  96.7%  100%  Yes 
d570  Looking after one’s health  100%  100%  Yes 
d5700  Ensuring one’s physical comfort  96.7%  96.4%  Yes 
d640  Doing housework  100%  100%  Yes 
d660  Assisting others  86.7%  78.6%  No 
d6600  Assisting others with self-care  90%  96.4%  Yes 
d730  Relating with strangers  63.3%  57.1%  No 
d740  Formal relationships  66.7%  64.3%  No 
d750  Informal social relationships  70%  75%  No 
d760  Family relationships  83.3%  96.4%  Yes 
d770  Intimate relationships  90%  89.3%  Yes 
d7702  Sexual relationships  93.3%  100%  Yes 
d850  Remunerative employment  86.7%  100%  Yes 
d910  Community life  86.7%  78.6%  No 
d9100  Informal associations  66.7%  57.1%  No 
d920  Recreation and leisure  100%  96.4%  Yes 
d9205  Socializing  96.7%  92.9%  Yes 
Environmental factors component
e115  Products and technology for personal use in daily living  96.7%  96.4%  Yes 
e120  Products and technology for personal indoor and outdoor mobility and transportation  93.3%  96.4%  Yes 
e155  Design, construction, and building products and technology of buildings for private use  73.3%  85.7%  Yes 
e3  Support and relationships  93.3%  100%  No 
e310  Immediate family  100%  100%  Yes 
e315  Extended family  93.3%  92.5%  Yes 
e320  Friends  96.7%  96.4%  Yes 
e325  Acquaintances, peers, colleagues, neighbors and community members  93.3%  89.3%  Yes 
e355  Health professionals  100%  100%  Yes 
e360  Other professionals  93.3%  92.9%  Yes 
e4  Attitudes  96.7%  92.9%  No 
e460  Societal attitudes  93.3%  96.4%  Yes 
e5  Services, systems and policies  96.7%  92.9%  No 
e540  Transportation services, systems, and policies  90%  89.3%  Yes 
e575  General social support services, systems and policies  93.3%  96.4%  Yes 
e580  Health services, systems, and policies  96.7%  100%  Yes 
e5800  Health services  100%  96.4%  Yes 
e590  Labour and employment services, systems and polices  86.7%  89.3%  Yes 
Personal factors22
i110  Age  100%  100%  Yes 
i150  Educational background  100%  96.4%  Yes 
i160  Occupational background  100%  100%  Yes 
i170  Economical background  93.3%  92.9%  Yes 
i210  Position in the family  93.3%  96.4%  Yes 
i220  Position in partnership and marriage  96.7%  96.4%  Yes 
i530  Personal attitudes  100%  92.9%  Yes 
i74012  Habits  100%  96.4%  Yes 
i74015  Lifestyle  100%  96.4%  Yes 

CVI — content validity index. Categories included in the final list obtained a consensus of ≥80% in the third round.

The first list had 74 items, including 65 ICF categories and nine personal factors. Most of the categories were related to activities and participation. The final list comprised all the ICF categories and ICF domains that should be included in an ICF-based postpartum assessment. The final approved list (Appendix A) had 62 items, including 53 ICF codes and nine personal factors. The ICF categories are of the second and third levels, and are mostly related to body functions and environmental factors.

Discussion

This study sought to determine the categories that would be essential to classify the functioning and problems of women in the postpartum period from the perspective of physical therapists. The final list covers all four components of the ICF and 21 ICF domains, and includes issues related to personal factors that are not covered in the ICF. Thus, the final list covers the most important impairments, limitations and restrictions, and environmental aspects of this population, based on the related literature.34–37 Personal factors were included because they can dramatically influence the outcome of physical therapy interventions. In addition, it is useful for identifying the best strategy to empower the patient to actively participate in their treatment plan.10,32

Mothers often have physical complaints such as problems of functions of sleep and pain sensation, urinary or fecal incontinence, sexual dysfunction, and pelvic organ prolapse.34–36,38 These complaints varying according to biological factors, the dependence level of the baby for care, and the level of social support received.6,37,39,40 Moreover, the impairment of pelvic floor muscle function is also widespread and occurs as a result of reduced tonus, an overload of pelvic region structures, multiparity, and traumas resulting from childbirth.41,42

Women in the immediate postpartum period usually have difficulties regarding their mobility and transfers.36 Many mothers face difficulties in performing their daily routine and taking care of their health, which can generate stress, frustration, and mental illness.6,39 These problems consequently lead to negative changes in performance of activities and participation.37 According to the current perinatal health promotion model, the attitudes of family members, friends, and health professionals play an essential role as a support network for women and must be considered from a biopsychosocial perspective.43

The list of ICF categories may be useful in the clinical practice of physical therapists as a new tool to record the data about functioning. This tool should be integrated with other measurements and questionnaires commonly used to guide the therapeutic plan to the functioning of puerperal women.10,11 Furthermore, the list shows an example of how to apply the ICF framework and operationalize the documentation about patient records from a biopsychosocial perspective of women’s health.11,12,44 Our findings can contribute to developing a culture among physical therapists that seeks to uncover ICF-based indicators of women’s functioning in clinical practice.

Although the final list had the categories of all the ICF components, some aspects of self-care were not entirely covered. Women in postpartum often have difficulties related to washing themselves, caring for their own body, and eating.45 These issues can be linked with categories of the self-care domain (d5) but have not previously been mentioned as relevant to the physical therapy professionals and care. Thus, future studies should investigate the relevance of these issues for the functioning of women in the postpartum period.

Lastly, the Delphi technique was appropriate, as it made possible the identification of relevant categories to develop an ICF-based postpartum assessment from the opinion and consensus of the participants. It is important to emphasize that this study involved the consensus among Brazilian physical therapists from five Brazilian regions. Experts were primarily from the northeast region of Brazil and, therefore were not fully representative of physical therapist experts in women’s health. As a consequence, the results do not enable the assessment of differences in conceptual framework across countries. Although we used a robust method and carefully assessed the validated content of each category, the results of any consensus may differ by different groups of participants. Thus, further studies in different countries or Brazilian regions with different experts are essential to develop a more refined representative list of ICF categories relevant to classifying the functioning of women in the postpartum period.

Moreover, this study is one step toward the development and validation of an ICF-based postpartum assessment (ICF-postpartum). ICF-postpartum is an ICF-based questionnaire that will be useful to assess the functioning and disabilities of women in the postpartum period. For this reason, additional studies are necessary to learn about patients’ perspectives, to define the best validated and reliable measure for each category, and to score them properly. The validity and reliability of the ICF-postpartum will also be determined.

Conclusion

The Delphi technique provided evidence for a suitable biopsychosocial approach and allowed us to identify the ICF categories related to the functioning of women in the postpartum period. The final list includes 62 items, of which 53 are ICF categories, and nine additional items are related to personal factors. The 53 ICF codes comprised 15, 12, 11, and 15 items of body function components, structures, activities and participation, and environmental factors, respectively. The final list of ICF categories can be used as a set of topics or guide in the assessment for classifying the functioning of women in the postpartum period based on the biopsychosocial model.

Conflict of interest

The author declares no conflicts of interest.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Appendix A
Final list
ICF-based postpartum assessment (ICF-postpartum) — version after Brazilian consensus

Date:

Name:

Personal factors  Comment 
i110 Age   
i150 Educational background   
i160 Occupational background   
i170 Economical background   
i210 Position in the family   
i220 Position in partnership and marriage   
i530 Personal attitudes   
i74012 Habits   
i74015 Lifestyle   
ICF categoryNo problem  Mild problem  Moderate problem  Severe problem  Complete problem 
b134  Sleep functions           
b152  Emotional functions           
b280  Sensation of pain           
b415  Blood vessel functions           
b440  Respiration functions           
b515  Digestive functions           
b525  Defecation functions           
b620  Urinary functions           
b6202  Urinary continence           
b640  Sexual functions           
b6603  Lactation           
b730  Muscle power functions           
b7305  Power of muscles of the trunk           
b760  Control of voluntary movement functions           
b820  Repair functions of the skin           
s410  Structure of cardiovascular system           
s430  Structure of respiratory system           
s610  Structure of urinary system           
s620  Structure of pelvic floor           
s630  Structure of reproductive system           
s6302  Breast and nipple           
s730  Structure of upper extremity           
s740  Structure of pelvic region           
s750  Structure of lower extremity           
s760  Structure of trunk           
s7601  Muscles of trunk           
d230  Carrying out daily routine           
d450  Walking           
d570  Looking after one’s health           
d5700  Ensuring one’s physical comfort           
d640  Doing housework           
d6600  Assisting others with self-care           
d760  Family relationships           
d770  Intimate relationships           
d7702  Sexual relationships           
d850  Remunerative employment           
d920  Recreation and leisure           
d9205  Socializing           
Environmental factorsBarriers  No barrier/no facilitator  Facilitators 
e115  Products and technology for personal use in daily living       
e120  Products and technology for personal indoor and outdoor mobility and transportation       
e155  Design, construction, and building products and technology of buildings for private use       
e310  Immediate family       
e315  Extended family       
e320  Friends       
e325  Acquaintances, peers, colleagues, neighbors and community members       
e355  Health professionals       
e360  Other professionals       
e460  Societal attitudes       
e540  Transportation services, systems, and policies       
e575  General social support services, systems and policies       
e580  Health services, systems, and policies       
e5800  Health services       
e590  Labour and employment services, systems and polices       

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