Developmental Neurorehabilitation, February 2012; 15(1): 63–78

SUBJECT REVIEW

Participation and environmental aspects in education and the ICF

and the ICF-CY: Findings from a systematic literature review

GREGOR MAXWELL1, INES ALVES2,3, & MATS GRANLUND4

1
CHILD, Swedish Institute for Disability Research, School of Education and Communication, Jönköping University,
Dev Neurorehabil Downloaded from informahealthcare.com by Lakehead University on 03/12/13

Sweden, 2School of Education, University of Manchester, UK, 3Italian National Council on Disability, Italy, and
4
CHILD, Swedish Institute for Disability Research, School of Health Sciences, Jönköping University, Sweden

(Received 16 September 2011; accepted 14 October 2011)

Abstract
Background: This paper presents findings from a systematic review of the literature related to participation and the ICF/
ICF-CY in educational research.
Objectives: To analyse how and investigate the application of participation in educational research. Specifically, how
participation is related to the environmental dimensions availability, accessibility, affordability, accommodability and
acceptability.
For personal use only.

Methods: A systematic literature review using database keyword searches and refinement protocols using inclusion and
exclusion criteria at abstract, full-text and extraction.
Results: Four hundred and twenty-one initial works were found. Twenty-three met the inclusion criteria. Availability and
accommodations are the most investigated dimensions. Operationalization of participation is not always consistent with
definitions used.
Conclusion: Research is developing a holistic approach to investigating participation as, although all papers reference at least
one environmental dimension, only four of the 11 empirical works reviewed present a fully balanced approach when
theorizing and operationalizing participation; hopefully this balanced approach will continue and influence educational
policy and school practice.

Keywords: Participation, environment, ICF, ICF-CY, disability, education

Introduction the most frequently applied component [6].

The World Health Organization’s International
Classification of Functioning, Disability and Health
[1] (ICF) or its Children and Youth version, the
ICF-CY [2], is recognized as a cross-cultural frame-
work for classifying the functioning of children with
disabilities [3]. It has been proposed as providing a
suitable common language for special education [4]
and as a tool for analysing education processes and
systems [5]. In a previous article [6], based on the
same review data as this article, findings indicate that
the ICF/ICF-CY theoretical model and classification
is infrequently used but has the potential to be
applied in education systems. In this context the
activity/participation component of the ICF-CY is
However, the manner in which the participation
and environmental concepts of the ICF/ICF-CY
were applied in educational research was not
analysed in-depth; thus, this is the focus of this
article.
By education, in this paper we mean the ‘devel-
opment of human potential (. . .) personality, talents
and creativity as well as (. . .) mental and physical
abilities’ [7, p. 16] made in a formal context, usually
a school or other setting in which the main aim is not
the medical or clinical rehabilitation. All education
levels are taken into account, from early years,
compulsory schooling, further education and lifelong
learning in a formal educational setting.

Correspondence: Mr Gregor Maxwell, Jönköping University, CHILD, Swedish Institute for Disability Research, School of Education and Communication,
Högskoleområdet, Gjuterigatan 5, Jönköping, 55318 Sweden. Tel: 46(0)36101947. Fax: 46 (0)3616 25 85. E-mail: gregor.maxwell@hlk.hj.se
ISSN 1751–8423 print/ISSN 1751–8431 online/11/010063–16 ß 2011 Informa UK Ltd.
DOI: 10.3109/17518423.2011.633108
 64 G. Maxwell et al.
According to the theoretical background in the
ICF/ICF-CY manual, the component Activities and
Participation consists of two concepts, activity and
participation, that are presented as separate; yet they
are combined as one domain in the classification
(i.e. activity and participation can only be coded
together, not as distinct entities). This has led to
some confusion and criticism [8], with some aca-
demics considering them together [9] and others
separate [10]. Following the same reasoning as the
previous article [6], in this article activity and
participation are used separately because the partic-
ipation experience was considered more appropriate
for the educational context. Activity is described by
the WHO as the ‘execution of a task or action by an
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individual’, Participation is defined as involvement in a
life situation and does not occur in a ‘vacuum’ [11].
Thus, it is intrinsically linked to the environment
[12], as will be discussed later in the paper. Within
the scope of the ICF/ICF-CY, Environmental factors
are defined as ‘the physical, social, and attitudinal
environment in which people live and conduct their
lives’ [2].
Participation can be regarded as a multi-
dimensional phenomenon that has been given sev-
For personal use only.
eral meanings in the literature [13, 14]. Common to
several of these definitions is that participation can
be conceptualized as the frequency of the child’s
involvement in a life situation [15] and/or the
intensity of engagement or being involved in a life
situation. Participation, in terms of the frequency of
being active in the same situation as others and being
able to participate in the same activities as others can
be closely linked to inclusion and to a Human Rights
approach to disability (based on equal opportunities
and non-discrimination) as presented in the UN
Convention on the Rights of Persons with
Disabilities [7] (UN CRPD). Equal opportunities
imply having the same contexts and activities avail-
able and accessible as others and non-discrimination
implies not being directly or indirectly excluded from
contexts and activities. The degree of goal attain-
ment for both these implicit statements can be
operationalized as frequency of participation in the
same contexts and activities as others. Participation
also reflects choice and the extent to which the child
actively engages in the purposeful activities people
do in daily life in a specific context, for example
writing an e-mail to grandmother, playing in the
school yard with friends, eating with family. This
active engagement does not require the child to be
active in the same situation as others. It is important
to keep in mind that participation, and especially
involvement, reflect volition and can include activ-
ities children do on their own or in other situations
than most children. While it is proposed here that
participation can be an expression of inclusion
(when inclusive practices such as those outlined in
influential international steering documents [16, 17]
are followed), participation can also occur when a
child is in a segregated setting but to a lesser degree.
Merely placing children with disabilities in main-
stream settings is often referred to as integration.
Inclusion is a more complex phenomenon that
involves going one, if not many, steps further and
changing the whole system from the macro levels of
policy and law to the micro levels of the classroom.
The Salamanca statement [16] required that ‘those
with special educational needs must have access to
regular schools which should accommodate them
within a child-centred pedagogy capable of meeting
these needs’ [16, p. viii], this followed from ‘the
necessity and urgency of providing education for
children, youth and adults with special educational
needs within the regular education system’ [16,
p. viii]. This was quite innovative at the time;
however, it does not necessarily mean that inclusion
is happening, as the guidelines would appear to
describe more the opportunities for inclusion rather
than the inclusive experience itself. ‘Inclusive
Education’ has been introduced to mark the distance
from ideas, policies and practices that exclusively
focus on serving individual needs of ‘special chil-
dren’ in mainstream education settings [18]; and this
has resulted in a number of policy changes interna-
tionally in the last 30 years, culminating in the
Article 24 UN’s CRPD [7] and previously the Dakar
framework for action [17].
Participating in an activity can be seen from two
perspectives: the individual and the society (this
distinction is not made in the ICF/ICF-CY frame-
work). For this reason, participation and participa-
tion-related concepts have two conceptual roots,
both of which relate to functioning within a context:
sociology and developmental psychology [19].
Participation based on the sociological root focuses
on the availability of and access to everyday activities
such as going to school and describes participation as
equal to frequency of attending the same activities as
others. Participation based on the psychological root
focuses on the child’s intensity of involvement or
engagement within an activity and whether the
environment is accommodated to and accepted by
the child; although the authors refer to it within a
psychology context, it is not related to a medical
perspective, it consists of a subjective experience of
participation, with a focus on the child’s perception
of the situation.
The ICF/ICF-CY is derived from both a tradi-
tional ‘medical model’ of disability, where bodily
impairment is the focus, and a ‘social model’, where
society’s construction of difficulties create participa-
tion restrictions. It is argued that the two constructs
are bridged by activity as a unifier, activity is a

requirement both for judging body function and
participation. The participation component within
the ICF/ICF-CY represents the social model’s con-
tribution which focuses on the availability and access
to everyday activities, with participation being
described as equal to frequency of attending the same
situations as others or given opportunities to perform
the same activities as others. The intensity of a child’s
involvement or engagement is not in focus and in a
footnote (ICF-CY, p. 13) it is explicitly expressed
that participation should not be equated with the
experience or sense of involvement. It is stated that
participation can only be measured with the qualifier
performance in ICF-CY, defined as what the child
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does in his or her current environment.
Historically, the sociological discussions about
civil rights movements and specifically disability
rights are related to availability, accessibility and
affordability of opportunities and support for per-
sons with disabilities [9] and ‘enforceable anti-
discrimination legislation, constitutional guarantees
of equality, specific entitlement programmes and
voluntary human rights manifestos’ [20, p. 565] are
all ways of regulating this component of participa-
tion. The focus is on providing equal opportunities
For personal use only.
to participation rather than focusing on the subjec-
tive experience of participation. This is also reflected
in policy with a recent review by Maxwell and
Granlund [21] demonstrating that there is still a
tendency for inclusive education policies to refer to
the availability, accessibility and affordability of
opportunities to participate and so take a social
approach when representing participation.
Building on a conceptual re-working of participa-
tion is the recent model developed by Maxwell and
Granlund [21], Granlund [22] and Simeonsson
et al. [23] (see Figure 1) in which the two aspects
of participation (frequency of attending and intensity
of involvement or engagement) exist as a spectrum of
participation related to five environmental dimen-
sions of conditions for participation. The dimensions
were originally proposed by Simeonsson et al. [24] as
dimensions of access based on a model of access to
health [25].
The above model contains five central dimensions
concerning the environment: Availability describes
Figure 1. Frequency and intensity spectrum of participation [21].
Findings from a systematic literature review 65
the objective possibility to engage in a situation. In
terms of services it refers to the objective provision of
facilities or resources. Accessibility describes
whether you can (or perceive that you can) access
the context for the situation. Affordability covers not
only financial constraints but also whether the
amount of effort in both time and energy expendi-
ture is worth the return to engage in the situation.
Accommodability describes whether a situation can
be/is adapted and is synonymous with adaptability.
In addition, the concept of ‘Reasonable accommo-
dation’ is defined on the Article 2 of the UN CRPD
as ‘necessary and appropriate modification and adjust-
ments not imposing a disproportionate or undue
burden, where needed in a particular case, to ensure
to persons with disabilities the enjoyment or exercise
on an equal basis with other of all human rights and
fundamental freedoms’ [p. 4, emphasis added].
Acceptability covers the person’s acceptance of the
situation and other people’s acceptance of a person’s
presence in a situation. If there is an expression of
values or common beliefs, which are of a subjective
nature, then this is also acceptability. Similarly, the
concepts of Availability, Accessibility, Acceptability
and Adaptability have previously been used by the
UN in article 13 (1), the right to education of the
International Covenant on Economic, Social and
Cultural rights [26], and in associated human rights
publications from national and international devel-
opment agencies [27, 28]; this shows an interna-
tional applicability of the concepts being developed
here. The model using the five environmental
dimensions outlined has been previously used
when investigating inclusive schools by looking at
how conditions for participation are expressed for
pupils with additional support needs in education
policy documents in Sweden and Scotland [21].
Results from this study show that the model is valid
in placing availability, accessibility, accommodability
and acceptability on a spectrum, with affordability
sitting separately (see Figure 1); this spectrum can
also represent the relationship between the social
and psychological approaches to participation so the
five environmental dimensions were integrated into
the extraction review protocol used in this paper.
In an article which aims to enhance the conceptual
clarity of the activity and participation components
of the ICF, Badley [12] suggests a reciprocal
relationship between environmental factors acting
as ‘scene-setters’ (as well as facilitators/barriers,
societal involvement, tasks and acts) and participa-
tion. When using this suggestion, the environment is
intrinsically linked to the participation experience as
it acts as a prompt or cue to what activities are
adequate to perform [12, 29]. The environment can
also be seen as a necessary but not sufficient causal
factor for participation. In the ICF/ICF-CY, the
 66 G. Maxwell et al.
environmental component can be used to categorize
barriers and facilitators for participation. The use of
the participation component in the ICF/ICF-CY is
necessary for describing the scene setting aspect of
the environment, e.g. school is an important area for
learning described as an important life area in
chapter 8 in the activity/participation component; if
one takes accessible school buildings and specifically
categorize with ICF-CY codes, having an accessible
school building can be coded as e515.3 as an
environmental facilitator and for the child’s partic-
ipation in a pre-school education d815 (with what-
ever appropriate qualifier) is appropriate.
The educational environment or setting is of
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importance both in terms of setting the scene in
which the activity occurs and as a factor that can
facilitate or hinder participation in a setting. The
environment can be represented as dimensions that
relate to the availability, accessibility, affordability,
accommodability and acceptability of the participa-
tion situation or experience. It is proposed in this
paper that one potential representation of the rela-
tionships between the scene setting and barrier/
facilitator aspects of the environment and the two
For personal use only.
dimensions of participation is through the five
environmental dimensions discussed previously.
This article aimed to analyse how the concepts
participation and environment, from an ICF/ICF-
CY perspective, were applied in educational
research. Specifically, the paper focused on the
following questions:
. How is participation related to the environmental
dimensions of availability, accessibility, affordabil-
ity, accommodability and acceptability?
. Is the concept of participation, from an ICF/ICF-
CY perspective, defined and applied consistently
in educational research?
Methods
Study design
This study presents a systematic review of the
literature carried out using database keyword
searches. The selection of studies was then refined
using inclusion and exclusion protocols on both
abstract and full text level. Studies exploring the
relationship between education, the ICF/ICF-CY
and its related concepts of participation, environ-
ment and personal factors were reviewed for both
their relevance and quality. Information about how
the concept participation was applied was extracted
using an extraction protocol based on the five
environmental dimensions of conditions for
participation.
Materials
Data were collected using keyword searches in the
following databases: ERIC (Educational Resources
Information Centre), PsycINFO, PsycINDEX,
Social Sciences Citation Index (SSCI),
SocINDEX, FRANCIS. The search terms were
chosen based on the focus of the study and current
debate and were refined to include widely used
variations and abbreviations. The relevance of the
chosen search terms was explored using the search
sources and the theoretical and practical relevance
was confirmed after discussions among the authors,
experts in the field and research librarians. Search
terms had to be related to the ICF/ICF-CY (e.g.
ICF, International Classification of functioning,
environment*, personal factors, participation) and
to education (school, education*, inclusion/inclu-
sive, eligibility, goals, identification) and various
abbreviations/combinations of the phrase Special
Education Needs (SNE, SEN, ‘special needs’,
Special Ed, SpecEd, SPED). For practical reasons
in this study the authors used Participation and not
Activity and Participation as a search term, as after
different search trials the Participation experience
was considered more appropriate for the educational
context.
Initially 10 combinations were trialled and from
these four were deemed to return a viable number of
studies and so were used for the final search. The
search included academic publications in the form of
journal articles, books and book chapters and
reports, all in English. Given that the ICF was
published in 2001 this was taken as the earliest cut-
off point and the results had to be available on the
22nd June 2009.
The final search strings were:
(1) (‘ICF’ OR ‘International Classification of func-
tioning’) AND environment* AND (school OR
inclus* OR SNE OR SEN OR ‘special needs’
OR Special Ed OR SpecEd OR SPED OR
eligibility OR goal OR identification);
(2) (‘ICF’ OR ‘International Classification of func-
tioning’) AND ‘personal factors’ AND (school
OR inclus* OR SNE OR SEN OR ‘special
needs’ OR Special Ed OR SpecEd OR SPED
OR eligibility OR goal OR identification);
(3) (‘ICF’ OR ‘International Classification of func-
tioning’) AND participation AND (school OR
inclus* OR SNE OR SEN OR ‘special needs’
OR Special Ed OR SpecEd OR SPED OR
eligibility OR goal OR identification); and
(4) (‘ICF’ OR ‘International Classification of
Functioning’) AND education* AND (school
OR inclus* OR SNE OR SEN OR ‘special
needs’ OR Special Ed OR SpecEd OR SPED
OR eligibility OR goal OR identification).

Data analysis
The search results were exported and sorted using
inclusion and exclusion criteria on two levels:
Abstract and full-text level. The protocols aimed to
ensure a standardized qualitative and semi-quanti-
tative content analysis of the documents. An exclu-
sion/inclusion protocol for each level was developed
with the theoretical and practical aspects of each
being discussed with experts in the field and tested
amongst the authors. In addition to the abstract and
full-text level protocols, another protocol was
designed and applied to review and extract the
content of the selected works; this protocol focused
on the research aims of this paper and also recorded
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quality aspects such as relevance, appropriateness
and trustworthiness based on critical review methods
[30, 31]. All steps were systematically documented
using Excel and SPSS.
The first protocol was used when reviewing the
abstracts. It was used to exclude documents that did
not meet the inclusion criteria (n ¼ 29); these
included document language, date range and con-
tents (ICF and/or education-related). The second
protocol was used to review full-text documents that
For personal use only.
were included during the first screening. Besides the
inclusion/exclusion of works, the protocol was used
for detailed mapping of content. The coding scheme
constituted of 82 items such as reference type,
country of origin, publication year, type of study,
research aims and questions, study population and
contents related to education, ICF concepts and
disability. Only papers that contained both educa-
tion and ICF/ICF-CY components were included;
publications that did not meet the inclusion criteria
were excluded. The papers that met the inclusion
criteria laid down by the second protocol were
further analysed with an extraction protocol, this was
a more flexible and open-ended coding scheme
developed to extract relevant information that would
then be used to link the papers’ contents to the
research questions.
To address how the concept of participation is
used the extraction protocol used the specific
participation-related environmental dimensions
availability, accessibility, affordability, accommod-
ability and acceptability. Whether the paper con-
siders participation as an involvement experience
and if it is defined using ICF-based language or
theory (whether explicitly or not) was also recorded.
Concerning participation, a final part of the protocol
considered how participation was operationalized in
empirical studies and whether there was consistency
between the theory and practical application in these
studies. A note was also made of how the environ-
ment was defined and whether it acts as the ‘scene-
setter’ [12]. Quality-related results will not be
Findings from a systematic literature review 67
reported in this paper. In all steps, researcher
triangulation has been used to increase the validity
and reliability of the results.
Results
Mapping results reviewing and critiquing how the
ICF/ICF-CY is applied at various levels and pro-
cesses in education systems in different countries
have already been reported in Moretti et al. [6]. Only
a brief description of the initial results is provided
here followed by the results relating to the specific
focus of this paper.
Abstract analysis
The database searches returned 421 abstracts. The
first search of the retrieved abstracts, which stipu-
lated that abstracts should contain one ICF/ICF-
CY-related aspect and one education-related aspect
found a total of 71 documents which met the
inclusion criteria. Inter-rater agreement for this
stage was 80%. The main reasons for exclusion
at abstract level were no relationship to ICF/ICF-CY
(n ¼ 229) and to education (n ¼ 84). The analysis of
ICF/ICF-CY-related concepts showed that at the
abstract level activities, participation and environ-
ment feature prominently.
Full-text analysis
Four of the selected documents were not available so
a total of 67 full-text documents were reviewed with
the second mapping protocol. A check on the second
protocol’s inclusion and exclusion criteria was made
by comparing reviewers’ results after the first 20
papers had been read. For this second stage all the
authors independently examined all of the included
67 publications and made joint decisions about
which to include and exclude; 23 documents met the
inclusion criteria. The second protocol ensured that
factors relating to the ICF/ICF-CY and education
were included.
. Full-Text screened: n ¼ 67 [3, 4, 10, 12, 32–94].
. Included: n ¼ 23 [3, 4, 10, 34, 36, 39–41, 48, 50,
57, 60–64, 66–68, 77, 81, 82, 92].
Papers included
At the final stage, 23 works met the inclusion
criteria. The results about the participation-related
environmental dimensions are recorded in Table I
and, once weighted for number of references to the
participation-related environmental dimensions,
placed on the grid shown in Figure 2. To address
how the concept of participation is defined and
applied in empirical works the introduction/
 68 G. Maxwell et al.

Table I. General expressions of the five environmental dimensions of participation within all the reviewed works (empirical and
theoretical).

Paper Description of environment Avail Access Afford Accom Accept

Asbjørnslett and Hemmingsson [92] Contextual factors, school envi- X X X X

Bedell [66]
Berg and LaVesser [67]
Besio et al. [68]
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ronment, current environment,
all within a societal context.
The physical, social and attitudi- X X X X
nal environment in which
people live their everyday lives.
Interdependence of person and X X X X
environment factors to achieve
participation.
Environmental components have X X
been a useful repertoire to plan
artefacts and media (toys,

assistive technology devices) to

Campbell and Skarakis-Doyle [77]
D’Alessio [81]
Daley et al. [82]
For personal use only.
be introduced in the play
setting.
The surrounding physical, social X X X X X
and attitudinal environment
and the academic environment.
No explicit description given. X X X
Discusses pro’s and con’s of the
use of the ICF to the education
of disabled students.
Environmental factors operatio- X X X
nalize the concept of disability

Florian et al. [3]
Goldstein et al. [48]
Granlund et al. [10]
Hollenweger [47]
Maia and Lopes-dos-Santos [54]
McLeod and Bleile [57]
MHADIE Consortium [58]
Mihaylow et al. [59]
Möller and Danermark [61]
Msall [60]
Olusanya [31]
Reindal [33]
as a dynamic product of
person–environment
interactions.
The importance of understand X X X
disabilities in the context in
which they occur.
Uses the ICF and the guide to X X X X X
physical therapist practice.
Uses the ICF definition. X X X
Teaching should focus on the X X X
relationship between content,
learner and informer (the
triangle).
Takes ICF-CY and Whiteneck X X X
(2006) definitions (latter is that
it is integrally linked to partic-
ipation and vice versa).
ICF-based: products and technol- X X
ogy, support and relationship,
attitudes, services systems and
policies.
ICF-based. X X X
ICF-CY-based: Physical, social X X X X X
and attitudinal environment
may restrict participation of
children with cerebral palsy.
ICF-based. Paper is focused on X X X X X
participation and personal
factors.
Uses one of the reviewed func- X
tional measures the Pediatric
Evaluation of Disabiltiy
Inventory (PEDI).
ICF-based. X X X X
Uses the capability approach and X X
social-relational model of dis-
ability with reference to the

(continued )
 Findings from a systematic literature review 69

Table I. Continued.

Paper Description of environment Avail Access Afford Accom Accept

social, cultural, environmental

Schenker et al. [36]
Simeonsson et al. [37]
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and religious barriers.
Uses the ICF. Environment set- X X X
tings: Classroom, Playground/
recess, Transportation,
Bathroom/toileting,
Transitions, Mealtime/snack
time, Criterion.
Uses the ICF. The ICF provides a X X X
functional approach whereas
the categorical identification of
children becomes a barrier to
intervention.

Simeonsson et al. [38] Uses the ICF. Provision of inter- X X X

vention services.
Simeonsson et al. [4] Uses the ICF-CY. X X X
Count of score 23 11 6 20 16
For personal use only.

Figure 2. Summary flow of the literature review’s results.

background and discussion/conclusion sections were
analysed separately from the method and results
sections and presented and compared in Figures 2
and 3, respectively.
Full-text analysis: How is participation related to the
environmental dimensions of availability, accessibility,
affordability, accommodability and acceptability?
Table I reveals that most published studies have a
focus on participation in relation to availability and
accommodability and that few studies focus on
accessibility and affordability.
To provide structure to the review of the partic-
ipation components of the works presented here,
they are reviewed from the opposing perspectives of
Social participation (available and accessible) and
Psychological/individual participation (accommod-
able and acceptable) by using the proposed spectrum
of the environmental dimensions of participation to
structure and present results (see Figures 1 and 4 in
background). The 23 works reviewed are placed on a
 70 G. Maxwell et al.
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Figure 3. All reviewed papers placed on a participation spectrum relative to their environmental dimensions of participation.
grid in Figure 2, which is based on the social-
psychological spectrum presented earlier and also
represents the number of environmental dimensions
referenced within each work (see Table I).
For personal use only.
Figure 5 (along with Figures 2 and 3) provides a
figurative representation of the rating of the reviewed
works not only in terms of whether they can be
considered social or individual, but their degree of
‘scene-setting’ (as a rating of participation opportu-
nity/approach to participation) based on the number
of references to environmental dimensions found.
Works located towards the top left are highly/
strongly social (and not at all psychological/individ-
ual), whereas works located towards the bottom left
are only slightly/weakly social (and still not psycho-
logical/individual), similarly, works located towards
the top right can be considered highly psychological/
individual (and not at all social), whereas those
located towards the bottom right are only slightly
psychological/individual (and not social).
A balanced approach would use both a social and
psychological/individual approach equally and this
can be done to varying degrees; all but one of the
works contained two or more uses of the environ-
mental dimensions. The single work [63], which can
be considered to be exclusively using a social
approach to participation, therefore does not cluster.
The remaining works cluster around the middle and
top of the matrix (Figure 5). Three central clusters
which display a balanced approach are present: the
first indicates a strong (i.e. a high number of the
environmental dimensions are represented) balanced
approach [17, 48, 62], the second a fairly strong
balanced approach [64, 67, 92] (with one slightly
social work [18]) and the third a fairly low balanced
approach [12, 34, 36] (with one slightly social work
[13]). Around these there exist two other clusters: a
moderately balanced and slightly social cluster [39,
50, 57, 60, 61, 68, 77, 82] and a moderately
balanced and slightly psychological/individual clus-
ter [3, 4, 40, 41, 66, 81]. Additionally, nine papers
use participation as an involvement concept [10, 48,
61, 62, 64, 66, 67, 77, 92] and 18 papers use the
ICF’s definition of participation when describing the
construct [3, 4, 10, 36, 40, 41, 48, 50, 57, 60–62,
64, 67, 68, 77, 82, 92].
In addition to the inferred approaches to partic-
ipation, there are explicit references to how partic-
ipation is conceived and presented found in the
texts. From a social perspective, Asbjørnslett [92]
states that social aspects of participation are cen-
tral and that it should be developed as a highly
political-ideological notion [92]. Similarly,
Hollenweger [50] equates participation as citizen-
ship/participation as a citizen. This can all be linked
to Coster’s [95] social participation and participa-
tion as a social construct [48] and the extent to
which participation is associated with the quality of
life [66]. Reindal [36], who critiques the ICF/ICF-
CY from a social point of view, uses the capability
approach and the ICF and so talks about capability
provision and starvation and with the ICF talks
about its participation construction and its critique
(cf Nordenfelt [65], etc.). From a psychological
perspective, Berg [67] suggests that participation
implies varying levels of engagement, from observer-
participant to active-participant and Granlund et al.
[10] state that participation is related to health in
terms of active involvement. Campbell and Skarakis-
Doyle [77] always refer to activities and participation
together and Mihaylow et al. [62] is the only
reviewed paper here to explicitly link participation

with environmental factors and so follow Badley’s
[12] reasoning that the environment acts as the
‘scene-setter’ for the participation experience to
occur. In terms of presenting a more balanced
approach with both social and psychological aspects,
Möller and Danermark [64] use Eriksson and
Granlund’s [96] three-dimensional definition of
participation—the perception of participation, the
activity/behaviour itself and prerequisites for partic-
ipation—in their work.
Is the concept of participation, from an ICF/ICF-CY
perspective, defined and applied consistently in
educational research?
Dev Neurorehabil Downloaded from informahealthcare.com by Lakehead University on 03/12/13
A study has high construct validity if the measures
are good representations of the constructs used. In
this review, for studies which were empirical and so
had theoretical and results sections, the conceptual
links between the definitions of participation used
and the measures used for measuring the concept
were analysed. Thus, an investigation into the
commonality and consistency found between the
theoretical representation of participation and
the practical application in the method and results
For personal use only.
sections given in each empirical work were imple-
mented. Eleven of the 23 included works were
empirical and so were analysed for this comparison,
with the results being presented in Figures 2 and 3.
Works are consistent when they present the same
approach both theoretically (in their introduction/
background and discussion/conclusions) and practi-
cally (in the methods and results); inconsistencies
arise when an approach is more (or less) balanced in
either of these two components.
Discussion
This systematic review has revealed that most
empirical studies applying the participation concept
in educational research use a balanced approach in
which both sociological and psychological aspects of
the concept are used in measuring participation. The
definitions of the concept seem partly to be inde-
pendent of the manner in which the concept is
operationalized. The following discussion is based
on the two research questions and how they address
the results found followed by presenting limitations
and conclusions.
How is participation related to the environmental
dimensions of availability, accessibility, affordability,
accommodability and acceptability?
The clusters on the grid (Figure 5) represent
whether researchers take a social or psychological/
individual approach to participation and the degree
Findings from a systematic literature review 71
to which this is the case in terms of the environ-
mental dimensions measured. Most studies focus on
availability and accommodability, taking a balanced
approach in which both frequency of attending
(availability) and intensity of involvement (accom-
modability) are studied empirically. The results
indicate that many researchers have chosen to
include both sociological and psychological aspects
in their investigations of participation.
Parallels can be drawn between the social/
psychological distinction being made here and the
social/medical (or individual) models of disability
prominent in the field of disability studies/research.
It is proposed in this paper that an accurate and
balanced approach to participation would encom-
pass both the social and psychological/individual
representations of participation. Maybe the ICF-CY
manual, stating that participation at present can only
be measured with the qualifier performance and thus
a sociological approach to participation needs to be
supplemented with a new qualifier focusing on the
subjective experience of involvement; similar sug-
gestions have also been made based on policy
analysis [21] and empirical evidence from correla-
tional data and differences between self-ratings and
ratings by others [19].
The environmental dimensions of affordability
and/or accessibility are seldom focuses of the studies
found in this review; this may have several explana-
tions. One is that accessibility and affordability are
relatively diffuse constructs involving several possible
operationalizations and thus they are difficult to
operationalize in a consistent manner. Accessibility
may be related both to the perceived accessibility of a
situation, e.g. I think the ramps of the building are
too steep and to the more ‘objective’ possibilities a
person has to access the situation, e.g. lack of
transportation. Affordability contains several aspects
of affordability, e.g. financial costs, time costs and
energy costs. Another explanation might be that
accessibility is included in the availability construct
(the situation exists) and the accommodability con-
struct, adaptations are done within the situation
without considering whether the individual actually
attends the situation or not. Affordability may be
seen as an aspect of perceived accessibility and thus
not measured separately.
Is the concept of participation, from an ICF/ICF-CY
perspective defined and applied consistently in
educational research?
The results from the review reveal that most studies
measure more than one environmental dimension
related to participation. The most common dimen-
sions measured are availability, representing fre-
quency of attending an activity and
 72 G. Maxwell et al.
accommodability, which in an educational context
often linked to additional support being put in place
or curriculum adaptations made; this can result in
various degrees of intensity of involvement being
achieved. However, the results also reveal that the
definitions of the participation concept used in the
studies do not always match the set of measures
used. Several studies [10, 67, 82, 92] have a more
narrow definition of participation than what the
measures indicate. The majority of the studies use
the ICF-CY definition of participation ‘involvement
in a life situation’, that in the manual is explained as
only possible to measure using the performance
qualifier and is thus a sociological definition and,
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additionally, several studies [10, 41, 48, 61, 62, 64,
66, 67, 77, 92] focused specifically on the involve-
ment concept. If studies are consistent in their
conceptualization and application of the construct of
participation most of the reviewed studies ought to
present an accurate and balanced approach both in
their definitions of participation and the measures
used. Where studies present a more balanced
approach conceptually than practically then it can,
in the opinion of the authors, be considered an
For personal use only.
inconsistency of the research. The opposite case can
also be considered as inconsistent in studies that are
more balanced practically than conceptually. The
result reveals relatively weak links between the
definitions of participation provided and the mea-
sures used with only four [39, 41, 62, 66] of the
11 empirical studies being considered as consistent;
this indicates that future studies need to anchor
the conceptualizations of participation used more
explicitly both theoretically and in terms of the
measures used.
A previous review of inclusive education policies in
Scotland and Sweden [21] demonstrates that there is
a tendency for educational policy to still refer to
participation in terms of frequency of attendance as a
higher incidence of references found related to
availability, accessibility and affordability.
Culturally some differences are also seen, however,
with Scotland having a higher incidence of references
to availability at national and regional levels, whereas
Sweden referenced accommodations and acceptabil-
ity aspects. This dual trend is also seen in the works
Table II. Consistency of empirical works in the theoretical presentation and practical application of participation.
Balanced in both method/results
and theory/discussion More balanced in methods/results
Mihaylow et al. [59] Asbjørnslett and Hemmingsson [89]
Bedell [63] Berg and LaVesser [64]
Schenker et al. [36] Daley et al. [79]
Simeonsson et al. [38] Granlund et al. [10]
reviewed in this paper, where there is a high incidence
of reference to availability (all works/100%) and
accommodability (20 works/87%), a medium level of
works referencing accessibility (11 works/48%) and
acceptability (16 works/69%) and a low level of works
referencing affordability (6 works/26%) (see Table I).
This last point brings into question the usefulness of
including affordability on the social-psychological
spectrum of participation.
Relating back to the ‘societal’ vs ‘individual’
approach to conceptualizing participation, evidence
from policy [21] suggests that the operationalization
of participation within the education field is still
rather ‘social’. This is actually in keeping with the
current operationalization of participation within the
ICF/ICF-CY, which uses the performance quali-
fier to measure participation, with no opportuni-
ties for classifying the intensity of the
involvement experience. However, getting the child
to the same situations as others may no longer be the
main problem in some contexts in Global North/
developed countries, but rather the degree of
involvement while being there [97]. This has led to
recent calls to consider using a third qualifier for
intensity for the ICF-CY [19].
It is also proposed in this paper that participation
can be seen as an expression of inclusion when a
child with additional support needs is able to
participate and engage/be involved on an equal
basis to others in a mainstream school setting.
The results presented here show that four out of
the 11 empirical studies reviewed [39, 41, 62, 66]
are consistent in their theoretical description and
practical applications of participation (See Table 2).
From this it can be interpreted that these studies use
an ‘inclusive’ approach and so will be beneficial
towards promoting inclusion positively. The remain-
ing seven empirical works reviewed, which can be
described as not taking a fully inclusive approach,
can be grouped into two groups. The first group are
more balanced in their methods/results sections:
Asbjørnslett and Hemmingsson [92] and Berg and
LaVesser [67] both present balanced approaches
(neither social nor individual/psychological), but to a
lesser extent (by one environmental dimension) in
their theoretical sections. Daley et al. [82] present a
More balanced in theory/discussion
Möller and Danermark [61]
Olusanya [31]
Maia and Lopes-dos-Santos [54]

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Figure 4. Participation within the empirical works’ theoretical background and discussion sections.
For personal use only.
Figure 5. Participation within the empirical works’ data collection sections.
moderately social approach using two environmental
dimensions in their theory/discussion but present a
balanced approach using three environmental
dimensions in their method/results. Granlund et al.
[10] use a highly individual/psychological approach
in the theory using only one dimension—acceptabil-
ity in the discussion—but go on to present a
balanced approach in the method/results where
three dimensions are employed. The second group
are more balanced in their theory/discussion sec-
tions: Möller and Danermark [64] present both a
balanced theoretical outline and discussion, and
methods and results, but use one fewer environmen-
tal dimension for the latter. Olusanya [34] uses four
environmental dimensions to present a slightly social
Findings from a systematic literature review 73
theoretical outline, but this becomes more social
(moderately so) in the methods and results sections
and uses only two environmental dimensions. Maia
and Lopes-dos-Santos [57] present a balanced
approach with three environmental dimensions, but
in their methods and results the focus moves to only
one dimension—availability—and so takes a very
social approach. The approach to inclusion that
research takes when investigating participation will
have bearing on international and national policies
and practices; this ultimately has an impact on the
education and development of children themselves
and is of utmost importance for the development of
an inclusive society which truly provides education
for all.
 74 G. Maxwell et al.
Whether there is agreement on the importance of
education for the development of any child when it
comes to ‘Inclusive Education systems’, as required
in Article 24 of the UN CRPD [7], is still being
debated internationally. In fact, while different
States have diverse ways of facing the issue of
participation and inclusive education is a concept
with a definition far from being consensually
accepted between and even within country, it raises
the delicate issue of the relationship between ‘special
education’ and general education either as separate
or linked entities, which is an important philosoph-
ical distinction that will greatly influence the outlook
on policy and practice [98]. Examination of these
international documents, along with review of
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national laws and policies [21] shows that regulating
for the availability, affordability and accessibility of
support can be provided for with policy change.
When placing a person with a disability in the
mainstream classroom it appears to be more difficult
to control the subjective adjustments concerning the
accommodations made and acceptance. These pro-
visions may be provided for with local-level school
documents which, by their nature, refer to explicit
practices and so can make reference to acceptable
For personal use only.
and accommodable situations [21]. Similarly, at the
local level some efforts have been done to express
accommodable and acceptable practices with coun-
tries like Sweden demanding that schools have anti-
discrimination policy document [99] and, in the UK,
Scotland requires that schools have a policy docu-
ment outlining the practices resulting from the
nation law for additional support for learning [100].
Limitations
The overall rigour of this study itself was ensured by
reflecting on works which critically review systematic
literature reviews. From a quality perspective,
coming from the health-sciences field where a large
number of systematic literature reviews are found,
Schlosser et al. [101] provide a useful reflection on
quality guidelines and a critical appraisal for system-
atic literature reviews. Their quality-indicators
include the use of a protocol, its validity and rigour,
the presence and relevance research questions and
the sources used. Also any biases in the source-
selection, geographical and cultural constraints.
Other restrictions include the language included,
study-design constraints, and the populations being
considered. A reliable selection of studies and a log of
rejected studies is also a quality indicator along with
clear descriptions of how data was extracted and
coded from the original studies in conjunction with
a quality assessment of these studies. They also
highlight that the quality of many reviews varies and
by reviewing the reviews they hope to provide a set of
quality-indicators to guide the researcher. The
authors of the review presented here believe that
they have taken into account Schlosser et al.’s [101]
comments in presenting this study. It was also found
that the results gathered using the extraction protocol
referenced all of the categories we had defined; this is
a good indication of their appropriateness.
Results relating to the personal factors component
of the ICF/ICF-CY—obtained from the second
search string—will not be reported in this paper.
Lack of standardization and conceptual clarity [102]
make combining them with participation and the
environment difficult.
Conclusions
Every paper reviewed references at least one of the
five environmental dimensions of participation. This
further strengthens the evidence that the environ-
ment is a pre-requisite for the participation experi-
ence (the activity) to occur [103] and that it acts as
the ‘scene-setter’ [12].
A balanced approach [48, 62] uses all five of the
environmental dimensions of participation in an
equal or proportionate manner; this gives both a
social and psychological/individual approach to par-
ticipation. A parallel can be drawn here with the
social and medical/individual approaches to/models
of disability. A point of interest is that only four
[39, 41, 62, 66] of the 11 empirical works reviewed
present a fully balanced approach when theorizing
and operationalizing participation. This implies that
even the field of research is still developing an
inclusive approach to investigating participation of
children with disabilities.
Taking the two roots of participation as point of
departure (social vs psychological) it is interesting to
note how the papers divide this distinction with the
environmental dimensions of participation which
they report on. Fitting affordability into this spec-
trum has proven difficult as it does not align to either
the social or psychological interpretation of partici-
pation. This was also previously reported by
Maxwell and Granlund [21]. Affordability, while
definitely an environmental dimension of participa-
tion, appears to still be an outlier in this model.
The authors would like to propose that, given the
current direction that national and international
inclusion policies are taking in making situations
more available, accessible and affordable, there is
more focus placed on the accommodations made
and acceptability. This review highlights that the
research field is starting this trend and it is hoped
that this will soon filter down to educational policy
and school practice also.

Acknowledgement
We would like to acknowledge Marta Moretti’s
contribution during the initial development of this
paper and her ongoing support and comments. The
preparation of this paper was supported by the
MURINET (Multidisciplinary Research Network
on Health and Disability in Europe) research train-
ing network, a Marie Curie Actions Sixth framework
programme. Contract Number MRTN-CT-2006-
035794 (MURINET).
Declaration of interest: The authors report no
conflicts of interests. The authors alone are respon-
sible for the content and writing of the paper.
Dev Neurorehabil Downloaded from informahealthcare.com by Lakehead University on 03/12/13
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