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.
ObjectiveTo identify ICF categories and the respective domains that should be considered in the evaluation of women postpartum.
MethodsA 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.
ResultsThe 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).
ConclusionFrom the perception of physical therapists, an ICF-based postpartum assessment to describe functioning and disability must comprise 53 ICF categories and nine personal factors.
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.
MethodsA 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 participantsThe 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 processThe 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.
Delphi technique — assignments and steps.
Delphi technique | Researchers activities | Experts activities |
---|---|---|
First round | Sending 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 round | The 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 round | The 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 processThe 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 analysisStatistical 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 CVI≥80% 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 therapistsData 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.
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 | 3 | 6.7% |
Specialization in Women’s Health | ||
35 | 77.8% | |
Highest academic qualification | ||
University graduate | 3 | 6.7% |
Specialization | 8 | 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 | 6 | 13.3% |
High | 39 | 86.7% |
Region of Brazil | ||
Northeast | 34 | 75.6% |
North | 1 | 2.2% |
Midwest | 2 | 4.4% |
Southeast | 3 | 6.7% |
South | 5 | 11.1% |
Workplace | ||
Educational institution | 21 | 46.7% |
Hospital | 4 | 8.9% |
Clinic | 3 | 6.7% |
Other | 1 | 2.2% |
More than one option | 16 | 35.6% |
Data are n (%) except for age which is median and (25%, 75%) interquartile range.
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.
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%) | 0 |
Second | 50 (77%) | 43 (81%) |
Third | 11 (17%) | 10 (19%) |
Fourth | 0 | 0 |
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 | 9 | 9 |
Number of items | 74 (65 ICF categories+9 personal factors) | 62 (53 ICF categories+9 personal factors) |
ICF categories included in the first and final list of the Delphi process.
ICF category | Consensus-building | Included 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.
DiscussionThis 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.
ConclusionThe 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 interestThe author declares no conflicts of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Date:
Name:
ICF category | No 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 factors | Barriers | 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 |