Specification of measured construct and context of use
The literature review conducted in Phase 1 (Fig. 1) found eight different theoretical models for work ability [50] and two models for functioning. In the bio-medical model of work ability, an existing illness, impediment or disability determines a person’s attributes and qualities as a worker [13, 51, 52]. In the balance model, work ability is the equilibrium between the individual and work-related factors [51, 53]. The psychosocial model emphasises the psychological and psychosocial factors connected to work participation and return to work [54,55,56,57]. In the multi-dimensional models and the bio-psycho-social models, work ability is a holistic, comprehensive entity in which individual resources and work-related factors are combined by the operational environment and social support [13, 14, 27, 58]. In the employability model, work ability combines all the individual and societal actions that help a person become employed, stay employed and advance their career [59, 60]. According to the model emphasising the integration of the individual at the workplace, the concept of work ability is based on continuous change in work and work organisation [61, 62]. Work ability can also be considered a social construct that is constituted by and differs between different societies and systems [63].
As with the concept of work ability, biomedical and biopsychosocial models have been used to describe functioning and health [58]. An internationally accepted way of structuring the concept of functioning is ICF [15], the framework of which provides a standard language and multi-purpose classification of disability and health [64]. Functioning is a collective umbrella term of the ICF that describes a person’s body structures and functions and their capacity to perform daily activities in the environment in which they live. The ICF is a biopsychosocial model that combines the biomedical, social and environmental aspects of human functioning, health and disability [14, 65]. It can be used as an instrument to collect comparable data to support evidence-based decision-making in health and health-related sectors. WHO and the ICF Research Branch have created Core Sets of ICF which the essential relevant categories for specific health conditions and health care contexts [46].
The ICF framework reflects six different aspects of health and disability: health condition, body structure and body function, activity, participation, environmental factors, and personal factors [66]. Diseases or disorders, i.e. health conditions, are included in the conceptual model of health, but are classified in the International Classification of Diseases and Related Health Problems (ICD) [67]. Functioning should be understood as a continuum ranging from completely able (non-problematic) to completely disabled (problematic) and is the result of complex multifactorial interaction between the six components [68].
Concepts of work ability and functioning in the Abilitator
The Abilitator is based on the multidimensional model of work ability [13] as this model describes both individual resources and the operational environment. We chose the ICF biopsychosocial model [14] for functioning because it is widely accepted in situations of multiple and long-term impairments of health [55].
The selected multi-dimensional work ability model is called the House of Work Ability [13, 69]. It has four levels that depict the relationship between individual resources, work-related demands, and the social and operational environments that affect both individual resources and working life. The three lower levels of the model describe individual resources such as health and functioning, competence and work experience, values, attitudes, and motivation. The top level is the level of work and includes factors related to work, working conditions, work community and leadership. Individual work ability is created by the balance between all the levels of the house, which are also significantly affected by social networks, communities and environments outside the workplace [13, 70, 71]. The Abilitator does not cover the top level, because those in a weak labour market position are to a large extent without employment.
The ICF biopsychosocial model of functioning [15, 58] sees operational constraints as a mismatch between the health of a person and the requirements of their life situation. To minimise this disparity, the impact of environmental and individual factors must also be considered in addition to the person’s health-related factors. These include available support and services, work situation, family, hobbies, motivation, and religion [72, 73].
The construct of the Abilitator can be further described using a framework of four central and partly overlapping concepts that can be linked to the population in a weak labour market position. These concepts are: 1) work ability [12, 13, 69], 2) health and functioning [15], 3) inclusion [18] and 4) employability [27, 60]. They include a variety of factors, some of which are defined in the Abilitator and some not, as shown in Fig. 2.
Specification of the Abilitator’s context of use
The Abilitator was developed to be suitable for individual and multidimensional self-assessment of the work ability and functioning of the population in a weak labour market position. The use contexts in the ESF projects included: to assess the service clients’ situations individually, to set goals, to design the best service plans to reach the set goals, and to make changes in work ability and functioning apparent to both clients and professional. This information was further used to analyse the effect of the different actions on larger groups of service clients taking part in ESF Priority 5 projects.
Utilisation of expert panels in co-development and assessment of content
An example of the expert panels’ influence on the Abilitator content are questions D8 and D9 [Additional file 1]. Abilitator 0.1 contained two items for screening depression in primary care [74]. During Phase 3, systematic negative feedback from the target group, the professionals and the academic experts led to the removal of these items. The questions were considered too diagnostic to be used by professionals, too invasive to be answered by the respondents, and too difficult to evaluate in the context of their use. However, issues such as taking the initiative in everyday activities were still considered important. Therefore, the group of experts formulated two completely new items, D8 and D9. These questions were added to Abilitator 0.2 [Additional file 1] and the practical group of experts assessed their feasibility during Phases 5 and 6. Due to the systematically positive feedback received, Questions D8 and D9 of the Abilitator remained unchanged.
Abilitator 0.2 contained 76 questions and the online version also offered personal feedback. The content and format of this feedback was developed with the external expert panels along with the content of Abilitator 0.2. The internal expert group decided not to include all the questions in the feedback the Abilitator 0.2 gives the respondent because one single answer is not always enough to make meaningful assumptions about the respondent’s situation. However, the interpretations of all the questions were analysed for the professionals in the Abilitator user manual.
Based on the literature review on instruments in Phase 1 the internal group of experts created the structure and content of Abilitator 0.1 from pre-existing questionnaires and some newly formed questions into one self-report questionnaire. The literature review identified 55 self-report instruments of work ability and functioning, of which 14 were used based on face validity or partially by combining the most relevant questions. The consultations of academic specialists (n = 20) improved the 0.1 pilot version’s content. It was also decided that the Abilitator would retain the questions on overall functioning and work ability i.e. Questions B3 and B4 [Additional file 2] throughout the development process. This was to ensure that ESF Priority 5 projects could assess the overall change in work ability and functioning of their clients even if other parts of the Abilitator changed during its development.
We chose the following topics as the main elements of Abilitator 0.1: 1) Work ability and perceived health, 2) Everyday skills, 3) Social functioning and social involvement, 4) Psychological functioning, 5) Cognitive functioning, 6) Physical functioning, and 7) Background information. These topics covered the first three levels of the House of Work Ability and its dimensions of family, close community and society. Abilitator 0.1 contained 57 questions, of which 30 (54%) were taken directly from pre-existing questionnaires [Additional file 1]. The rest were newly-formed questions covering target group-specific topics that had either not been evaluated by a self-assessment method before or for which the formulation of the pre-existing questions did not directly meet the Abilitator criteria; for example, positive question format, equality, generality, and comprehensiveness.
During the development process, the content of the Abilitator was modified twice [Additional file 1]. All the feedback on Abilitator 0.1 and 0.2 was systematically gathered in written format and reviewed in detail by the internal group of experts (Phase 3, 5 and 6, Fig. 1). The suggestions were grouped into similar feedback units and the decisions regarding changes to the questionnaire were made in the internal expert group’s consensus meetings. As a result, 25% of the questions in Abilitator 0.1 remained unchanged, 50% were modified and 25% were removed. The unchanged questions were perceived as feasible for and by the target group and for evaluative purposes. The content or formulation of the questions was changed if: 1) the questions were not perceived as equal, 2) the questions’ original design was not perceived as suitable for the target group, 3) the questions’ original design did not reveal the desired issue precisely enough, 4) the questions required more text to support their comprehension, 5) the questions’ themes were perceived as too narrow or extensive, 6) the questions lacked important areas or response options and 7) the questions had too many or too few response options. The questions removed from Abilitator 0.1 were: 1) not answered as regularly as the others, 2) perceived as repetition, 3) not perceived as appropriate for or by the target population, 4) not perceived as covering the desired aspect, 5) not perceived as equal and 6) too difficult to answer. Nineteen completely new questions were added to Abilitator 0.2. If important issues or sub-issues were completely missing, or if new questions were needed to better suit the target groups’ situation, the removed question was replaced by a new one.
In Abilitator 0.1, the recall period varied from the present to 2 weeks or a month. According to the feedback, this was confusing to both the respondents and the professionals. Therefore, in Abilitator 0.2, the recall period was harmonised to the current situation, except for Section D (Mind) in which the recall period was set as one month. In addition, the scales were harmonised and presented either horizontally or vertically, and the best option was always at the furthest right or at the top, respectively.
When the final Abilitator was created, 60% of the questions in Abilitator 0.2 remained unchanged, 38% were modified and 2% were removed. The unchanged questions were perceived as feasible for and by the target group and for evaluation purposes. The content or formulation of the questions was changed if: 1) the questions required more text to support their comprehension, 2) the order of the questions was not logical within the sections of the questionnaire, 3) the question’s topic was too extensive to answer and needed splitting into two separate questions. Based on the feedback received, we added three new questions to the questionnaire to obtain a broader view of the respondent’s situation. At the end of the development process, the Abilitator contained 84 questions of which 17 were items from existing questionnaires, and 67 were either modifications or completely new items. The content of the personal feedback did not change significantly.
Information on the Abilitator's content and its use in practice
The Abilitator contains nine sections: A. Personal information, B. Well-being, C. Inclusion, D. Mind, E. Everyday life, F. Skills, G. Body, H. Background information, and I. Work and the Future (Fig. 3). Each section contains 4–14 questions. In Fig. 3, the Abilitator’s sections are further linked to general concepts and the Abilitator’s concept framework presented in Fig. 2. The whole questionnaire is presented in Additional file 2 and can also be accessed online [75].
The interpretation of the results as given in a respondent’s written feedback can be seen in Additional file 3. The feedback is built directly on the response options and has no external benchmark figures. The measure of each section is a summary scale of the selected item. The points received are converted into percentages: the minimum score is 0% and the maximum 100%. The feedback is grouped on the basis of the respondent’s situation per sections B–G: 1) the situation is good, 2) the situation is fairly good, but has some possible challenges and 3) the situation is fairly poor or poor. If the respondent evaluates some items as very poor and others as good, the feedback indicates possible challenges. The Abilitator’s content and its development versions 0.1 and 0.2, the scales, and the ICF codes by question are illustrated in Additional file 1. Another way in which to interpret the results is to do so question by question. The instructions for this are presented in the Abilitator’s user manual, currently only available in Finnish [75].
In practice, the Abilitator can be used in different ways. A service actor working in, for example, employment services can send the client a personal link to the Abilitator via email well before a scheduled appointment. On average the questionnaire takes 15–20 min to complete. The client can complete the questionnaire online independently or with a close person. Another option is that the service actor interviews the client and enters the responses directly into the online version of the Abilitator. A third option is that the service actor either gives or sends the Abilitator questionnaire in paper format to the client. The client then completes the questionnaire and returns it to the service actor, who enters the information into the online version.
The advantage of the online version of the Abilitator is that both the client and the service actor can see the results and personal feedback and prepare for their appointment accordingly. During the appointment, the client and the service actor can discuss the results, and plan targets and actions to improve or sustain the client’s work ability or functioning if necessary. In an ideal situation, they arrange a follow-up appointment during which they evaluate whether these targets have been met.
Correspondence between the Abilitator’s content and its construct
The Abilitator covered 79 ICF codes, of which 14 (18%) described body functions and structures (b), 40 (50%) activities and participation (d), 10 (13%) environmental factors (e) and 15 (19%) personal factors (pf). The ICF codes describing body structures and functions were related to global and specific mental and respiratory system functions. The codes related to activities and participation covered learning and applying knowledge, carrying out general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, and major life areas. The codes covering environmental factors described products and technology, support, relationships, and attitudes. The correspondence of all the Abilitator’s items to the ICF categories is illustrated in Fig. 4 and Additional file 1.
Assessment framework for the correspondence between the Abilitator and its construct
The direct equivalence of the Abilitator to the generic set was 4/7 codes (57%); to the brief vocational rehabilitation set, 10/13 codes (77%); and to the minimal environmental set, 1/12 codes (8%). In addition, two d4-category codes of the generic set, one e4-category code of the brief vocational rehabilitation set, and the e3-category codes of the minimal environmental set were indirectly represented in the Abilitator at another category level [Additional file 4].
The direct equivalence of the Abilitator was 5/14 (36%) WAI codes. In addition, similar aspects of four codes were indirectly covered in the e3- and e4-categories. The direct equivalence of the Abilitator was 12/27 (44%) codes of WHODAS 2.0, and there were only minor differences in the codes concerning categories d4 and d5 [Additional file 4].