Disability and Rehabilitation, 2011; 33(2324): 22082216

RESEARCH PAPER

Participation frequency and perceived participation restrictions at

older age: applying the International Classification of Functioning,
Disability and Health (ICF) framework

SOLVEIG A. ARNADOTTIR1,2, ELIN D. GUNNARSDOTTIR3, HANS STENLUND4 &

LILLEMOR LUNDIN-OLSSON2
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1
Faculty of Occupational Therapy, School of Health Sciences, University of Akureyri, Iceland, 2Division of Physical Therapy,
Department of Community Medicine and Rehabilitation, Umea University, Sweden, 3Faculty of Social Sciences, School of
Humanities and Social Sciences, University of Akureyri, Iceland, and 4Department of Public Health and Clinical Medicine,
Umea University, Sweden

Accepted February 2011

Abstract
For personal use only.

Purpose. To identify variables from different components of International Classification of Functioning, Disability and
Health (ICF) associated with older peoples participation frequency and perceived participation restrictions.
Method. Participants (N 186) were community-living, 6588 years old and 52% men. The dependent variables,
participation frequency (linear regression) and perceived participation restrictions (logistic regression), were measured using
The Late-Life Function and Disability Instrument. Independent variables were selected from various ICF components.
Results. Higher participation frequency was associated with living in urban rather than rural community (b 2.8,
p 5 0.001), physically active lifestyle (b 4.6, p 5 0.001) and higher cognitive function (b 0.3, p 0.009). Lower
participation frequency was associated with being older (b 70.2, p 0.002) and depressive symptoms (b 70.2,
p 0.029). Older adults living in urban areas, having more advanced lower extremities capacity, or that were employed had
higher odds of less perceived participation restrictions (adjusted odds ratio [OR] 5.5, p 0.001; OR 1.09, p 5 0.001;
OR 3.7, p 0.011; respectively). In contrast, the odds of less perceived participation restriction decreased as depressive
symptoms increased (OR 0.8, p 0.011).
Conclusions. Our results highlight the importance of capturing and understanding both frequency and restriction aspects of
older persons participation. ICF may be a helpful reference to map factors associated with participation and to study further
potentially modifiable influencing factors such as depressive symptoms and advanced lower extremity capacity.

Keywords: Participation, elderly, ICF, rural, residence, depressive symptoms, lower extremity capacity

Introduction between an individual (with a health condition)

A growing interest in the phenomenon of participa-
tion within health sciences may be traced to the year
of 2001 when the World Health Organization
(WHO) introduced its International Classification
of Functioning, Disability and Health (ICF) [1].
Participation, one of the main components of the
ICF-model, is a positive descriptor of functioning
and defined as the persons involvement in a life
situation [1]. On the other hand, participation
restriction is one of the ICF descriptors of disability
and denotes the negative aspects of the interaction
and that individuals environmental and personal
contextual factors [1]. Participation replaces the term
handicap in the ICIDH [1] and it is conceptually
quite similar to Nagis definition of disability [2,3].
Within the area of aging, participation is now
recognised as a particularly important health-related
outcome as it is related to multiple factors that can
affect older peoples well-being [4]. Recent literature
on factors associated with participation in the general
population of older community-living people in-
cludes variables such as: older age, gender, marital
status [5], basic mobility, balance confidence [6],

Correspondence: Solveig A. Arnadottir, School of Health Sciences, University of Akureyri, Solborg v/Nordurslod, Akureyri 600, Iceland. Tel: 354-4608465.
Fax: 354-4608999. E-mail: saa@unak.is
ISSN 0963-8288 print/ISSN 1464-5165 online 2011 Informa UK, Ltd.
DOI: 10.3109/09638288.2011.563818

activity level and various environmental facilitators
and barriers [7,8]. Regardless of differences in
environmental context, older people living in
metropolitan, urban and rural areas have been shown
to have comparable participation levels [9]. Accord-
ing to the ICF, participation is to be estimated by the
performance of an individual in his current environ-
ment [1]. Additionally, to date it is recommended to
assess both objective participation performance (e.g.
frequencies) and a subjective client-centred perspec-
tive of participation (e.g. choice, importance and
perceived restrictions) [10].
To our knowledge, no assessment tools to measure
participation in community-living older people have
been developed from the ICF and these recommenda-
Disabil Rehabil Downloaded from informahealthcare.com by Michigan University on 10/31/14
tions. The Late Life Function and Disability Instru-
ment (LLFDI) [11,12] is an assessment that was
designed for research with community-living older
people and has its conceptual base in the disablement
model by Nagi [13,14]. It has a Disability component
(LLFDI-D) that has been used with promising
results to distinguish ICFs participation from activ-
ities and has been shown to capture both objective
and subjective aspects of ICFs participation [8,15].
Therefore, LLFDI-D may provide much needed
For personal use only.
objective and subjective participation measures with
clinical utility and validity for the older population.
The ICF provides a conceptual framework that
fosters biopsychosocial perspectives on aging, along
with a standard language and definitions [2,3,16].
Using the ICF when studying the multifactorial
nature of objective and subjective participation in the
general community-living older population may
provide guidance for identifying older people living
at home who are at risk for restricting their own
participation and could benefit from interventions.
The purpose of this study was to explore several
commonly used geriatric assessments and demo-
graphic variables representing various ICF compo-
nents, to determine their relationship with how
frequently community-living older people participate
in various life situations (objective) and whether they
perceive any restrictions to participate (subjective).
We hypothesised that: (1) variables representing all
assessed ICF components would be significantly
associated with both objective and subjective aspects
participation and (2) objective and subjective aspects
of participation would be associated with different
sets of independent variables.
Methods
Study design and sample
This study was a part of a cross-sectional population-
based study of older community-living Icelanders
Participation at older age 2209
[17]. Data were collected in June through September
2004 and inclusion criteria for participation were:
(1) at least 65 years of age, (2) community-living and
(3) able to communicate verbally. An intended
sample of 250 was randomly selected from the
national register of one urban and two rural
geographical clusters. Potential participants were
initially contacted by letter and then by phone a
few days later. Seniors who met the inclusion criteria
were asked to participate in a structured face-to-face
interview and one performance assessment, con-
ducted by trained research assistants. Fourteen
persons did not meet the inclusion criteria and 50
declined to participate, resulting in a study sample of
186 participants (79% participation rate). The 50
people who declined to participate did not differ
significantly from the participants with regard to
age, gender or residency. The Icelandic National
Bioethics Committee approved the study (no. 04-
037-S1) and all participants gave written informed
consent for participation.
ICF and assessments
The ICF was used as a conceptual framework for
selecting variables under study [1]. All variables
were systematically linked to the most appropriate
ICF components using the updated ICF linking
rules from 2005 (Figure 1) [18]. These rules
include a process of identifying meaningful con-
cepts of each item within an assessment tool, and
detecting the overall aim of such a tool or a single
variable.
Participation, defined as the persons involvement
in a life situation [1], was assessed with LLFDI-D
which measures self-reported frequency (objective)
of involvement and perceived restriction (subjective)
in 16 life situations [11]. These 16 items focus on
how an individual performs in his or her habitual
environment to fulfil social roles (10 items) along
with personal care needs (6 items). Participation
frequency describes the individuals regularity of
participating in life tasks [11]. Participation fre-
quency questions are phrased, How often do you
do . . . ? with five response options from very often
to never. Participation restriction, describes per-
ceived restrictions in performing these life tasks, and
includes both personal (health, physical or mental
energy) and environmental (transportation, accessi-
bility or socioeconomic) factors. The participation
restriction questions are phrased To what extent do
you feel limited in doing . . . ? with five response
options from not at all to completely. Both
frequency and restriction parts have a summary
score on a 0100 scale. Higher scores reflect more
frequent participation or less perceived restriction
 2210 S. A. Arnadottir et al.
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Figure 1. The geriatric assessment tools and demographic variables in the study linked to components of the ICF model.
[19]. LLFDI-D has acceptable reliability and validity
among community-living older adults [11,1922].
Personal factors are defined as the particular
background of an individuals life and living [1].
Data for age and gender were obtained from the
National Registry of Iceland and participants self-
For personal use only.
reported on recurrent falls during the past year and
on their education. The Physical Activity Scale for
the Elderly (PASE) [23] was used as an indicator of a
physically active lifestyle. Scores can range from 0 to
over 400 and higher scores indicate more physically
active lifestyle. Participants self-reported on medical
diagnoses and we calculated the total number.
Although the ICF health condition component
often refers to medical diagnosis, it also includes
the phenomena of aging [1]. In our study, the
process of aging was defined as the health condition
in focus while medical diagnoses were categorised as
other health conditions and, therefore, linked to the
personal factors component.
Environmental factors are defined as the physical,
social and attitudinal environment in which people
live and conduct their lives [1]. Data for location of
residency were obtained from the National Registry
of Iceland. The rural residence variable included
mainly farmers populations. Participants self-
reported if they lived alone, if they perceived their
income as sufficient and if they were employed.
Body functions are defined as physiological func-
tions (including cognitive and psychological func-
tions) of body systems [1]. Aspects of cognitive and
psychological function were tested with Mini-Mental
State Examination (MMSE) [24], Geriatric Depres-
sion Scale (GDS) [25] and Activities-specific Bal-
ance Confidence (ABC) scale [26]. Maximum range
for both MMSE and GDS is 030. Higher MMSE
scores indicate better cognitive function while higher
GDS scores indicate more depressive symptoms.
The ABC scale was used to measure balance
confidence while performing specific activities. The
summary score on the ABC is on a 0100 scale with
higher scores indicating more balance confidence.
Participants self-reported on height and weight
and body mass index (BMI) was calculated (kg/m2).
Presence of pain was reported on the bodily pain
subscale of the Short Form 36-item Health Survey
(SF-36) [27]. The SF-36 bodily pain scores can
range from 0 to 100 and higher scores indicate less
pain.
Activities, defined as execution of tasks or actions
by an individual [1], were assessed through several
indicators. The Function component of the LLFDI
(LLFDI-F) provides self-report on capacity in
various upper extremities activities and advanced
lower extremity activities [12]. The scales for upper
and lower extremities do both have a summary
score on a 0100 scale with higher scores indicating
more capacity [19]. The Timed Up and Go (TUG)
test [28] was used as a performance measure of basic
mobility. Higher TUG scores indicate worse mobi-
lity. The capacity to drive a car was self-reported.
Statistical analysis
Descriptive statistics included mean (M) and stan-
dard deviations (SD) for continuous variables and
counts and proportions for categorical variables. We
applied sampling weights in all inferential statistics to
adjust for uneven proportion of participants selected
from the urban (8.6%) and rural (51.7%) population
clusters. Missing data on individual LLFDI items
were replaced with the mean score of the partici-
pants valid responses to other items of the scale.
To meet normality assumptions in regression
analyses, we dichotomised participation restriction,
 Participation at older age 2211

log transformed the PASE and used a modified Table I. Participants characteristics.
interval scale version of the ABC [29]. Participation Characteristics N 186
restriction was dichotomised on the weighted med-
ian score of 83. The new variable had scores of Personal factors
0 more participation restriction (score of 0782) Age, years, M + SD 73.9 + 6.3
Gender
and 1 less participation restriction (score of
Man, n (%) 97 (52.2)
837100). Woman, n (%) 89 (47.8)
Regression models were used to attain the study Education, years, M + SD 7.5 + 3.3
objectives, with participation frequency (multiple Recurrent fall history, n (%) 21 (11.3)
linear regression) and perceived participation restric- Physical Activity Scale 127 (92.1)
for the Elderly (0400), M + SD
tion (binary logistic regression) as the dependent
Medical diagnoses, M + SD 3 (1.8)
variables. The independent variables represented Environmental factors
activities, body functions, environmental factors Residency
and personal factors components of the ICF frame- Urban, n (%) 118 (63.4)
work. The first step in multivariate analyses was to Rural, n (%) 68 (36.6)
Living alone, n (%) 45 (24.2)
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develop separate models based on each of the ICF Sufficient income, n (%) 123 (66.1)
components. The second step was to develop a Employed, n (%) 33 (17.7)
common model explaining participation potentially Body functions
including variables from all ICF components. At Activities-specific Balance 83 + 18.3
each step, p 0.10 was used as a criterion for Confidence Scale
(0100), M + SD
selecting independent variables for the next step in
Mini Mental State 27.2 + 2.5
modelling. Age and gender were retained in the final Examination (030), M + SD
models to adjust for their potentially modifying effect Geriatric Depression 6.5 + 4.3
of other variables. Significance level was set at Scale (030), M + SD
p 5 0.05. Body mass index, kg/m2, M + SD 26.8 + 3.8
For personal use only.

Bodily pain (0100), M + SD 65 + 40.6

Multicollinearity was examined calculating var-
Activities
iance inflation factors (VIF) for each independent Upper extremities capacity 86 + 14.8
variable and displayed no problems with all values of (0100), M + SD
VIF 52.0. SPSS 17.0 was used in data screening, Advanced lower extremities capacity 56 + 17.3
testing assumptions for regression analyses and (0100), M + SD
Timed Up and Go, sec, M + SD 10.7 + 3.6
calculating VIF. STATA 10.1 was used in analysing
Drives a car, n (%) 111 (59.7)
weighted data. Participation
Participation frequency 48 + 5.5
(0100), M + SD
Results Perceived participation 79 + 15.8
restriction (0100), M + SD

Characteristics of the 186 participants are presented
in Table I. Their age ranged from 65 to 88 years and
all of them were white. One-third of the sample was
drawn from rural communities and therefore the
proportion of men was unusually high for this age
group (52%). Five percent reported no medical
diagnosis, 30% reported one or two diagnoses and
65% reported three or more diagnoses. The partici-
pation frequency scores had a mean of 47.7
(SD 5.5) and ranged from 33 to 67. The perceived
participation restriction scores had a mean of 78.7
(SD 15.8) and ranged from 42 to 100.
Participation frequency
Univariate analyses revealed that participation fre-
quency was significantly associated with variables
from all ICF components (Table II (a)). Gender,
living alone, sufficient income and employment,
however, did not pass the inclusion criterion for
M mean; SD standard deviation; Proportions (%) are based on
valid data for each variable. Missing responses ranged from 0 to 3.
multivariate analyses that followed. For separate ICF
components (Table II (b)) the personal factors
model explained most of the variance (34%)
followed by the body functions model (19%), the
activities model (16%) and finally the environmental
factors model (3%). The common multivariate
model (Table II (c)) explained 41% of the variance
in participation frequency. In this model, participa-
tion frequency was significantly associated with age,
PASE, residency, MMSE and GDS. Higher partici-
pation frequency was associated with living in urban
rather than rural community (b 2.8, p 5 0.001),
higher score on PASE (b 4.6, p 5 0.001) and
higher MMSE scores (b 0.3, p 0.009). Lower
participation frequency was associated with being
older (b 70.2, p 0.003) and higher score on
GDS (b 70.19, p 0.029).
 2212 S. A. Arnadottir et al.

Perceived participation restriction Discussion

Univariate analyses revealed that perceived participa-
tion restriction was significantly associated with
variables from all ICF components (Table III (a)).
The variables not passing the inclusion criterion for
multivariate analyses were: education, living alone,
sufficient income and BMI. The multivariate models
for separate ICF components (Table III (b)) revealed
that the activities model explained perceived partici-
pation restriction best (27%) followed by the body
functions model (20%), personal factors model (17%)
and finally the environmental factors model (4%).
The common multivariate model (Table III (c))
explained 32% of the perceived participation restric-
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The study results confirmed our hypotheses that:
(1) variables from all analysed ICF components were
significantly related to both objective and subjective
aspects of participation in the community-living
older population and (2) several variables were only
associated with objective or with subjective participa-
tion which emphasises the importance of assessing
different aspects of participation. In the multivariate
analyses, none of the activities variables made it into
the common participation frequency (objective)
model and none of the personal factors contributed
significantly to the common participation restriction
(subjective) model.

tion. In this model, perceived participation restriction
was significantly associated with residency, employ-
ment, GDS and advanced lower extremities capacity.
The model revealed increased odds of less participa-
tion restriction if participants reported more advanced
lower extremities capacity (adjusted OR 1.09,
p 5 0.001), lived in urban area (adjusted OR 5.5,
p 0.001) and were employed (adjusted OR
3.7, p 0.011), while higher GDS score decreased
the odds of less participation restriction (adjusted
For personal use only.
Our participants reported less participation
restrictions than was seen in a sample of community
living older adults with activity limitations [8].
However, participation frequency of our participants
was substantially lower than among these older
people with activity limitations. This relatively low
participation frequency despite low perceived parti-
cipation restrictions may indicate that the older
community-living population has a reserve ability to
participate more frequently if and when needed or

OR 0.8, p 0.011). desired. The gap between these two dimensions of

Table II. Participation frequency: (a) univariate models with variables from ICF components, (b) separate multivariate models including
variables from each ICF component, (c) common multivariate model open for variables from all ICF components.

(b) Separate (c) Common

(a) Univariate models ICF-components models ICF-components model

Independent variables b p b p b p

Personal factors
Age 70.31 50.001 70.21 0.001 70.18 0.002
Gender (woman 0, man 1) 0.16 0.856 71.22 0.075
Education 0.22 0.035
Recurrent fall history 73.88 0.005 73.24 0.003 71.87 0.067
Physical Activities Scale for the Elderly 6.93 50.001 5.42 50.001 4.57 50.001
Medical diagnoses 70.70 0.009
R2 0.338
Environmental factors
Residency (rural 0, urban 1) 3.51 50.001 3.51 50.001 2.82 50.001
Living alone 70.27 0.795
Sufficient income 71.06 0.260
Employed 0.43 0.675
R2 0.034
Body functions
Activities-specific Balance Confidence Scale 0.67 50.001 0.32 0.083
Mini-Mental State Examination 0.80 50.001 0.56 50.001 0.32 0.009
Geriatric Depression Scale 70.51 50.001 70.20 0.053 70.19 0.029
Body mass index 0.23 0.083
Bodily pain 0.02 0.042
R2 0.192 R2 0.413
Activities
Upper extremities capacity 0.05 0.088
Advanced lower extremities capacity 0.10 50.001
Timed Up and Go 70.48 50.001 70.37 50.001
Drives a car 3.65 50.001 2.35 0.009
R2 0.156
 Participation at older age 2213

Table III. Perceived participation restriction (0 more restriction, 1 less restriction): (a) univariate models with variables from ICF
components, (b) separate multivariate models including variables from each ICF component, (c) common multivariate model open for
variables from all ICF components.

(b) Separate (c) Common

(a) Univariate models ICF-components models ICF-components model

Independent variables Crude OR p Adjusted OR p Adjusted OR p

Personal factors
Age 0.95 0.040 1.05 0.228
Gender (woman 0, man 1) 1.98 0.047 0.65 0.385
Education 1.00 0.936
Recurrent falls 0.10 0.007 0.19 0.085
Physical Activities Scale for the Elderly 6.77 50.001 4.21 0.018
Medical diagnoses 0.58 50.001 0.67 0.001
Pseudo R2 0.168
Environmental factors
Residency (rural 0, urban 1) 4.83 50.001 3.59 50.001 5.47 0.001
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Living alone 1.46 0.323

Sufficient income 0.79 0.540
Employed 2.22 0.077 2.70 0.088 3.66 0.011
Pseudo R2 0.044
Body functions
Activities-specific Balance Confidence Scale 1.57 50.001 1.34 0.003
Mini-Mental State Examination 1.12 0.176
Geriatric Depression Scale 0.75 50.001 0.84 0.012 0.83 0.011
Body mass index 0.99 0.813
Bodily pain 1.02 50.001 1.01 0.017
Pseudo R2 0.247
Activities
For personal use only.

Upper extremities capacity 1.07 50.001 1.04 0.016

Advanced lower extremities capacity 1.08 50.001 1.04 0.045 1.09 50.001
Timed Up and Go 0.64 50.001 0.80 0.027
Drives a car 2.33 0.017
Pseudo R2 0.265 Pseudo R2 0.318

participation may be related to the importance,
opportunity and the will to perform the life tasks
included in the LLFDI-D. This gap also highlights
the different meaning of each dimension and thereby
the importance of capturing aspects of objective and
subjective participation separately to understand the
prevalence of participation and detect meaningful
changes in older persons participation [8,10,11,30].
This difference in objective and subjective partici-
pation also emerged through unique patterns of ICF
components associated with participation frequency
and perceived participation restriction in the multi-
variate models. Of the separate ICF-components
models, the personal factors were clearly the
strongest ones in explaining the objective participa-
tion frequency. These personal factors (age, fall
history and PASE) describe a particular background
or context of an older individuals life that may be
associated with his or her choice to participate. Age
and PASE scores made it to the final common ICF-
components model for participation frequency sup-
porting other studies that have found an association
between aspects of participation and age [31,32]
and participation and reported activity level [9,33].
None of the activities variables had enough unique
association with participation frequency to be inclu-
ded in this final model. These findings are in
harmony with the results from a factor analysis of
the LLFDI-D where responses to the participation
frequency questions appeared to be independent of
mobility and physical skills [11].
Of the separate ICF-components models explain-
ing the subjective participation restrictions, however,
the activities variables (upper extremities capacity,
advanced lower extremities capacity and TUG) were
the strongest ones. These three activities variables
represent different aspects of the physical capacity of
an older adult and advanced lower extremity capacity
was the only one to make it to the final common
ICF-components model for participation restriction.
This measure of advanced lower extremity capacity
was derived from LLFDI-F, and includes 11
physically challenging items varying from walking
several blocks to running half a mile [19]. Notably,
items of this difficulty level are usually not a part of
participation studies involving older people. How-
ever, based on our study, such items are appropriate
for the general community-living older adult. None
of the personal factors contributed significantly to
the final common ICF-components model while the
 2214 S. A. Arnadottir et al.
inclusion of activities and environmental factors in
the model is concurrent with results from a factor
analysis of the subjective part of LLFDI-D which
stressed the importance of physical skills and the ability
to move around the home and community [11].
Residency and GDS were the two variables
significantly associated with both participation fre-
quency and perceived participation restriction at all
steps of the analysis. The robustness of the residency
variable in our study is in contrast with another
research were older people living in metropolitan,
urban and rural areas had comparable participation
levels despite differences in the environmental
context [9]. Our results are, however, indirectly
supported by multiple studies highlighting the
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importance of the environment in participation
[8,10,3436]. Residency has been described as a
value-loaded variable which results in multiple ways
to link this variable to the ICF environmental
component through categories such as population
density, physical geography, transportation services
and social norms [1,37]. Our study highlights the
need to explore why older rural people participate less
frequently and perceive more restrictions to partici-
pate than urban seniors. Additionally, the association
For personal use only.
we found between depressive symptoms and partici-
pation confirms results from studies on older people
with visual impairments [38] and community-living
people aged 50 years and older [31].
Our study has several limitations. First, the sample
was drawn in Northern Iceland which affects the
generalisability of the results. However, the prob-
ability sampling and the high participation rate
increases the generalisability of the results and one
may expect to find similarities between Iceland and
other Western societies. Second, the power in the
study was optimised by using continuous data where
possible and unequal sample size to ensure enough
rural representatives in the sample, yet the small
sample size limited the extent of analyses that could
be done to the data. Our results will, therefore, need
to be replicated in larger studies on this and other
populations. Larger sample would, for example,
allow for using structural equation modelling for
the examination of indirect as well as direct associa-
tions between the dependent participation variables
and the independent variables. Third, misclassifica-
tion is possible due to lack of instruments designed
explicitly for the ICF conceptual framework. We
used the LLFDI subscales to measure participation
and activities domain in this study, based on the
assumption that ICF and Nagis conceptual frame-
works are comparable despite differences in termi-
nology [2,3]. Finally, dichotomising a continuous
variable, as we do in the case of participation
restriction, decreases the power of the study and
limits the possibilities to make comparisons across
studies as there are no validated cut-offs available for
the LLFDI-D scores.
Although our cross-sectional study design does
not allow us to claim causality the results give us
relevant information which deserves further attention
in future research. It is worth noting that depressive
symptoms played a large role in less participation
frequency and more perceived participation restric-
tions. Depression is a treatable condition but if left
untreated there is evidence of an increased risk of
morbidity and mortality and associated economic
and societal burden [39]. Physical activity has been
presented as one of the most important modalities
presented to prevent and treat depression in the
older population [3941]. Higher scores on advan-
ced lower extremity capacity were related to less
perceived participation restrictions. Lower extremity
capacity indicates the individuals physical capacity
that may, e.g. be improved through proper physical
activity interventions [41]. Older community-living
people today and in the future may base their
preferred participation levels on activities that require
more advanced physical capacity than usually
assessed in todays geriatric practice and research.
In conclusion, our results highlight the common-
alities and differences between participation fre-
quency and perceived participation restriction and
thereby the importance of capturing both aspects of
participation to better understand its prevalence and
to detect meaningful changes in older persons
participation. Participation is an appealing concept
for those working with the older population where
disability is quite prominent. However, providers
would need a structured way to assess and map the
underlying strengths and weaknesses for each in-
dividual or populations, such as depressive symp-
toms, advanced lower extremity capacity and type of
residence. Such an approach would be possible if
providers could use available geriatric assessments
and commonly used demographic variables for that
mapping, as we did in this study. Further research on
objective and subjective aspects of participation in
old age is needed, exploring causal pathways and
how influencing factors may be open to interventions
at a varying degree. Our study supports the potential
of the ICF as a conceptual framework for such
research.
Acknowledgements
The authors are grateful to thank participants of the
study and Franzi Rokoske for her valuable contribu-
tion to the preparation of this manuscript. This
research was supported by grants from the Icelandic
Research Fund (050410031); the University of
Akureyri Research Fund; the KEA University Fund;

the Erik and Anne-Marie Detlofs Fundation, Umea
University; the JC Kempe Memorial Foundation; the
Faculty of Medicine, Umea University; the Icelandic
Physical Therapy Association; the Icelandic Geron-
tological Society; and the Icelandic Gerontological
Council.
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