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Faculteit Geneeskunde en Gezondheidswetenschappen
The lived experience of the Ghent Participation Scale of people with spinal cord injury and their treating physical therapists at the To Walk Again vzw REVAlution Center:
a phenomenological-hermeneutical method
Eva PIETERS
Masterproef ingediend tot het verkrijgen van de graad van
Master of science in de ergotherapeutische wetenschap
Promotor: Prof. Dr. Dominique Van de Velde Co-promotor: Mevr. Tessa Delien
Academiejaar 2018-2019
MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP
Interuniversitaire master in samenwerking met:
UGent, KU Leuven, UHasselt, UAntwerpen, Vives, HoGent, Arteveldehogeschool, AP Hogeschool Antwerpen,
HoWest, Odisee, PXL, Thomas More
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Faculteit Geneeskunde en Gezondheidswetenschappen
The lived experience of the Ghent Participation Scale of people with spinal cord injury and their treating physical therapists at the To Walk Again vzw REVAlution Center:
a phenomenological-hermeneutical method
Eva PIETERS
Masterproef ingediend tot het verkrijgen van de graad van
Master of science in de ergotherapeutische wetenschap
Promotor: Prof. Dr. Dominique Van de Velde Co-promotor: Mevr. Tessa Delien
Academiejaar 2018-2019
MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP
Interuniversitaire master in samenwerking met:
UGent, KU Leuven, UHasselt, UAntwerpen, Vives, HoGent, Arteveldehogeschool, AP Hogeschool Antwerpen,
HoWest, Odisee, PXL, Thomas More
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ENGLISH ABSTRACT
The lived experience of the Ghent Participation Scale of people with spinal cord injury and their treating physical therapists at the To Walk Again vzw REVAlution Center: a phenomenological-hermeneutical method
Promotion year: 2019
Student: Eva Pieters
Promotor: Prof. Dr. Dominique Van de Velde
Co-promotor: Mevr. Tessa Delien
Keywords: Ghent Participation Scale, participation, spinal cord injury
Introduction: Spinal cord injury (SCI) is a disease with significant impact on
the entire human life. The person with SCI is confronted with a changed
participation in the environment. Participation is an important aspect for well-
being and can be measured by the Ghent Participation Scale (GPS).
Aim: Collecting experiences of the GPS of people with SCI and their treating
physical therapist.
Method: a phenomenological-hermeneutical method
Results: Different themes were generated out of the collected data. The GPS
can be seen as an instrument which holds up a mirror for people with SCI to
reflect on their own functioning, the choices they make and what the achieved
scores mean to them. Besides that, the administration of the GPS is a
snapshot and depends on a few factor, but it enables measuring evolution over
time. To be able to work with the results and therefore to give effect to the
GPS, the physical therapists need to invest a lot of time in the people with SCI.
Conclusion: The GPS is a valid instrument and seems auspicious to apply in
practice. The instrument needs some additions. Besides that, time is required
to maximize the ease of use and the added value of the scale. The GPS
appears to facilitate client-centred therapy, goal-oriented care and shared
decision making, but this requires further research.
Number of words master thesis: 12147 (excluding appendix and bibliography)
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NEDERLANDS ABSTRACT
De ervaring van mensen met een dwarslaesie en hun behandelende kinesitherapeuten met de Gentse Participatieschaal in het To Walk Again vzw REVAlution Center: een fenomenologische hermeneutische studie
Promotiejaar: 2019
Student: Eva Pieters
Promotor: Prof. Dr. Dominique Van de Velde
Co-promotor: Mevr. Tessa Delien
Trefwoorden: Dwarslaesie, Gentse Participatieschaal, participatie
Introductie: Een dwarslaesie heeft een niet te onderschatten impact op het
volledig menselijk leven. De persoon met een dwarslaesie wordt
geconfronteerd met een gewijzigde participatie in zijn omgeving. Participatie is
belangrijk voor het menselijk welzijn en kan gemeten worden door onder
andere de Gentse Participatieschaal (GPS).
Doel: In dit onderzoek worden de ervaringen nagegaan van personen met een
dwarslaesie en hun behandelende kinesitherapeuten met de GPS.
Methode: een fenomenologische hermeneutische studie
Resultaten: Vanuit de verzamelde data konden verschillende thema’s
gegenereerd worden. De GPS wordt gezien als een instrument dat de
personen met een dwarslaesie enerzijds een spiegel voorhoudt om te
reflecteren over hun eigen functioneren, de keuzes die ze maken en wat de
behaalde score over hen zegt. Daarnaast is de afname van de GPS een
momentopname dat afhankelijk is van enkele factoren, maar het meten van
evoluties doorheen de tijd mogelijk maakt. Om actief aan de slag te gaan met
de resultaten en zo gevolg te geven aan de GPS moet door de
kinesitherapeuten veel tijd geïnvesteerd worden in de persoon met een
dwarslaesie.
Conclusie: De GPS is een valide instrument dat veelbelovend lijkt om in
praktijk toe te passen. De GPS moet voorzien worden van enkele
toevoegingen en in de praktijk moet vooral tijd gecreëerd worden om het
gebruiksgemak en de meerwaarde van de schaal zo groot mogelijk te maken.
Deze schaal lijkt cliëntgerichte therapie, shared decision making en
doelgerichte zorg te faciliteren, maar dit is iets wat verder onderzoek vereist.
Aantal woorden masterproef: 12147 (exclusief bijlagen en bibliografie)
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Deze pagina is niet beschikbaar omdat ze persoonsgegevens bevat.Universiteitsbibliotheek Gent, 2021.
This page is not available because it contains personal information.Ghent University, Library, 2021.
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INDEX
LIST OF FIGURES AND TABLES ................................................................... 11
ACKNOWLEDGEMENTS ................................................................................ 13
LIST OF ABBREVIATIONS ............................................................................. 15
1 INTRODUCTION ....................................................................................... 17
1.1 Background ........................................................................................... 17
1.1.1 Spinal cord injury ............................................................................ 17
1.1.2 Participation .................................................................................... 20
1.1.3 The Ghent Participation Scale ........................................................ 24
1.2 Research objective ................................................................................ 26
2 METHODS ................................................................................................ 27
2.1 Study design and theoretical basis ........................................................ 27
2.2 Sampling ................................................................................................ 28
2.2.1 Sampling method ............................................................................ 28
2.2.2 Sample size .................................................................................... 29
2.2.3 Participants ..................................................................................... 29
2.2.4 Ethics .............................................................................................. 29
2.3 Data collection ....................................................................................... 29
2.3.1 The administration of the Ghent Participation Scale ....................... 29
2.3.2 Interviews with people with SCI ...................................................... 30
2.3.3 Interviews with the physical therapists ............................................ 31
2.4 Data analysis ......................................................................................... 31
3 RESULTS ................................................................................................. 33
3.1 Elaboration of research .......................................................................... 33
3.1.1 Participants ..................................................................................... 33
3.2 Processing of data ................................................................................. 35
3.2.1 Phase 1: Naïve understanding ....................................................... 35
3.2.2 Phase 2: Structural analysis ........................................................... 35
3.2.3 Phase 3: Comprehensive understanding ........................................ 46
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4 DISCUSSION ............................................................................................ 51
4.1 Findings ................................................................................................. 51
4.1.1 The GPS as a snapshot ................................................................. 52
4.1.2 The GPS as a mirror ....................................................................... 52
4.1.3 The GPS as an added value in practice ......................................... 53
4.2 Recommendations for practice .............................................................. 54
4.3 Limitations and strengths of the study ................................................... 55
4.4 Implications for further research ............................................................ 57
5 CONCLUSION .......................................................................................... 59
6 REFERENCES .......................................................................................... 61
7 APPENDICES ........................................................................................... 71
7.1 Appendix 1: Approval Ethics Committee ................................................ 71
7.2 Appendix 2: Output of the Ghent Participation Scale ............................. 75
7.2.1 Participant 1 ................................................................................... 75
7.2.2 Participant 2 ................................................................................... 79
7.2.3 Participant 3 ................................................................................... 83
7.2.4 Participant 4 ................................................................................... 87
7.2.5 Participant 5 ................................................................................... 91
7.2.6 Participant 6 ................................................................................... 95
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LIST OF FIGURES AND TABLES
Figure 1: The staged organization of rehabilitation (Nolis et al., 2016)........... 22
Figure 2: The embedding of the Ghent Participation Scale in practice..……. 47
Table 1: An overview of instruments for assessing participation................... 23
Table 2: Characteristics of the people with SCI............................................. 33
Table 3: An overview of the interviews with the physical therapists.............. 35
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ACKNOWLEDGEMENTS
It always seems impossible until it’s done. - Nelson Mandela
Een volledig academiejaar werd gespendeerd aan de uitwerking en realisatie van deze
masterproef. Ondanks dat het onderwerp mij enorm boeit, was het een periode van
hard werken en vereiste het doorzetting en volharding. Gelukkig kon ik rekenen op de
nodige ondersteuning en bijstand van mensen die steeds in mij bleven geloven. Ik wil
dan ook mijn oprechte erkentelijkheid uiten ten opzichte van deze personen.
Mijn eerste woord van dank gaat uit naar mijn promotor prof. dr. Dominique Van de
Velde en co-promotor Tessa Delien. Hun begeleiding en ondersteuning gedurende de
hele periode zorgden ervoor dat wanneer ik stilstond, ik opnieuw het nodige perspectief
kreeg om verder te kunnen gaan. Ik apprecieer erg de vrijheid en het vertrouwen die ik
kreeg om er mijn eigen werk van te maken, alsook het krediet dat ze me gaven.
Vervolgens wil ik het To Walk Again vzw REVAlution Center Herentals, zijn
kinesitherapeuten, maar bovenal de participanten welgemeend bedanken om te willen
deelnemen en zichzelf open te stellen. Die openheid en eerlijkheid hebben me niet
alleen geholpen om perspectieven te creëren voor mijn onderzoek, maar hebben me
ook als mens rijker gemaakt. Ze doen me stilstaan bij de vergankelijkheid van het
leven. Ik heb van hen geleerd dat ik meer moet relativeren en ook klein geluk van groot
belang is. Ik bewonder hen ten volste voor hun doorzettingsvermogen en positivisme.
Ook wil ik mijn ouders bedanken. Zij gaven mij de kans om nog verder te studeren en
het behalen van dat extra diploma Master in de Ergotherapeutische Wetenschap
mogelijk te maken. Door de onvoorwaardelijke steun van mijn ouders en mijn zus Ine in
het bijzonder, naar wie ik bovendien ontzettend opkijk en die me ook taalkundig
ondersteunde, had ik het doorzettingsvermogen, het geloof en vertrouwen om dit alles
tot een goed einde te brengen. Zij bleven in mij geloven en waren er om mij af en toe
dat nodige duwtje in de rug te geven.
Tot slot wil ik mijn vrienden bedanken om er gewoon te zijn voor mij. Als ik nood had
aan een babbel, gezelschap, afleiding of ontspanning… Ik kon altijd op hen rekenen.
Griet en mijn nicht Flore in het bijzonder, voor het nalezen van mijn werk, maar ook
Floris, voor de vele momenten samen in de bibliotheek. Met plezier blik ik hierop terug.
Zonder de steun van alle bovengenoemde mensen stond ik niet waar ik nu sta.
Eva Pieters
Oostduinkerke, mei 2019
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LIST OF ABBREVIATIONS
ABBREVIATION MEANING
AIS The ASIA Impairment Scale
GPS Ghent Participation Scale
ICF The International Classification of Functioning, Disability and Health
IMPACT-S The ICF measure of Participation and Activities Screener
IPA The Impact on Participation and Autonomy Questionnaire
ISCSCI The International Standards of Neurological Classification of Spinal Cord Injury
KAP The Keel Assessment of Participation
PAR-PRO The Measure of Home and Community Participation
PARTS/M The Participation Survey/Mobility
PM-PAC The Participation Measure for Post-Acute Care
POPS The Participation Objective–Participation Subjective
P-Scale The Participation Scale
SCI Spinal cord injury
USER-participation
The Utrecht Scale for Evaluation of Rehabilitation – Participation
WHO World Health Organization
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1 INTRODUCTION
1.1 Background
1.1.1 Spinal cord injury
1.1.1.1 A description
A spinal cord injury (SCI) is, as it suggests, a damage to the spinal cord, which
extends from the foramen magnum to the cauda equina. A bruise or
interruption, often as result of a fall, a car or sports accident, knife stab or
gunshot wound, is regularly the cause of this lesion. In addition to these most
common traumatic causes, a non-traumatic occasions such as a vascular
disorder, inflammation, tumor or congenital anomaly can also be the cause of
the injury. As a result of that contusion or interruption, all functions connected
from that level and all underlying functions fall away (Nas, Yazmalar, Sah,
Aydin, & Önes, 2015; Spek, 2013)
1.1.1.2 Health outcomes
A SCI is a lesion which results in a primary disturbance of normal sensory,
motor and/or autonomous functioning (Singh, Tetreault, Kalsi-Ryan, Nouri, &
Fehlings, 2014). An interruption of descending, efferent nerve tracts in the
spinal cord that lead from the central nervous system to the periphery, results in
motor failure below the affected level. This means that random and active motor
skills are no longer possible. Depending on whether the reflex arc is damaged
or not, the disorder will be characterized by spastic or weak paralysis (Beckers,
Buck, & Pons, 1997; Nas et al., 2015; Spek, 2013). In addition to this motor
failure, there can also be sensory failure. This happens when the ascending,
afferent nerve tracts that bring impulses to the central nervous system are also
disturbed. Below this level, all sensory stimuli, including touches, pain stimuli
(phantom pain disregarded) and temperature will not be perceptible (Beckers et
al., 1997; Spek, 2013). A disruption of hand function and upper limbs, pressure
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sores and formation of contractures, increased risk of pneumonia, spasticity and
pain, urological, gastrointestinal and genital disorders are the best known
outcomes associated with the incurring of a SCI (Middleton, Lim, Taylor, Soden,
& Rutkowski, 2004; Van Asbeck & Van Nes, 2016).
1.1.1.3 The classification
The impact and extent of the SCI are determined on the basis of the level at
which the damage and/or the lesion takes place, and whether or not it is a
complete spinal cord injury (Van Asbeck & Van Nes, 2016). The neurological
level of the lesion is named after the most caudal segment where both motor
and sensory functions are still presented. This level can be determined on the
basis of The International Standards of Neurological Classification of Spinal
Cord Injury (ISCSCI) (Kalsi-Ryan & Verrier, 2011). The sensory level is
recorded on the most caudal intact dermatome. The motor level is that at which
the most caudal innervated myotome has a key muscle with a minimum muscle
value of three and the key muscle above achieves a score of five (Van Asbeck
& Van Nes, 2016).
A tetraplegia is characterized as being a damage to the cervical nerve tracts
(C1 to C8). With tetraplegia there is paralysis of all limbs. The loss of motor and
sensory functions is situated in the arms, the trunk, the organs and the legs. A
paraplegia is defined as when there is damage from the thoracic segments (T1
to T12), from the lumbar spine (L1 to L5) or from the sacral segments (S1 to
S5). There is loss of functions in the trunk, lower limbs and organs in the pelvis
(Nas et al., 2015). .
The ASIA Impairment Scale (AIS) is used to measure the completeness of the
lesion (Spek, 2013). A complete lesion is defined when neither motor, nor
sensory functions has remained intact below the level of the lesion. Functional
recovery, in sense of the possibility of acquiring skills or applying adaptation of
method change, is possible. In case of an incomplete lesion, motor and sensory
functions may still have been preserved if the score of the key muscles is at
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least three. A functional and neurological recovery is possible in this situation. A
neurological recovery means that the functions can still change and optimize
(Kalsi-Ryan & Verrier, 2011).
1.1.1.4 The impact Worldwide around 239 to 1009 people per million suffer from spinal cord injuries
(Singh et al., 2014). As what can be deduced from all the data above, a spinal
cord injury is a trauma with a significant impact on the person’s entire life. A
large part of the person’s current life undergoes a significant change when
faced with a SCI. Not just physically, but also on socio-economical and
psychological level, among others. It entails a lot of adjustments which have a
major impact on the person’s subjective well-being (Adriaansen et al., 2013;
Aman & Aslam, 2013; Derret et al., 2012; Dudley-Javoroski & Shields, 2006;
Singh et al., 2014; Teo et al., 2011; Ullrich et al., 2013). People with SCI have a
high risk of medical complications (like pneumonia, urinary tract infections,
pressure ulcers, pain and spasticity, gastrointestinal problems) for the rest of
their live. This can impede the social, mental and physical well-being.
Unfortunately, all this implications control the functioning and participation of the
patient. In addition, it can regularly lead to multiple use of the health care
services and re-hospitalizations (Middleton et al., 2004).
Research describes that the quality of life of adults with SCI can rise again
when one regains a positive, yet realistic view of life when one rehabilitates.
Despite the care needs, still being able to maintain a certain independence, is
an important condition when it comes to the well-being of people with SCI.
Among other things, this is based on rehabilitation and the form of therapy
(Chappel & Wirz, 2003). As everyone else, people with an impairment as a
spinal cord injury have the same needs as, for example, social interaction,
housing, employment and healthcare. Nevertheless, that is not always possible
without support or assistance. Still, they want social independence consisting of
control and autonomy of their own life (Shakespeare, 2000). When people are
not able to select preferred activities they are prohibited from experiencing
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feelings of participation (Milner & Kelly, 2009; Van de Velde, Bracke, Van Hove,
Josephsson, & Vanderstraeten, 2010). An increasing quality of life is
inextricably linked with the facilitation of social participation and participation in
their environment in general (Brandt, Samuelsson, Töytäri, & Salminen, 2011;
Petterson, 2006). To have a better view of what participation exactly means and
what it consists of, it is further separately discussed.
1.1.2 Participation
1.1.2.1 A description Participation is a term delimited and defined in a number of ways (Brandt et al.,
2011). In function of this study, the definition of participation used by the
International Classification of Functioning, Disability and Health (ICF) is adopted
(World Health Organization, 2001). This choice is made because of its broad
understanding and the gradual paradigm shift it brought with it in current
healthcare (Brandt et al., 2011; Van de Velde, Eijkelkamp, Peersman, & De
Vriendt, 2016b). Healthcare and rehabilitation medicine essentially used a
biomedical framework before the ICF (Le Granse, van Hartingsveldt, &
Kinébanian, 2012), but the excessively narrow focus of illness used until then
had been criticized by different authors. The prevailing social and biomedical
models were replaced by a more holistic alternative (Nirje, 1985; Engel, 1977,
1980). Psychological, social and biological as incidental dimensions of illness
were emphasized and this created a new model: the ICF with a bio-psycho-
social approach (Borrell-Carrio, Suchman, & Epstein, 2004; Wade, 2016).
In the ICF, participation is defined as “involvement in a life situation”. The World
Health Organization (WHO) also describes that participation may be executed
(in)dependently, with or without assistance or personal support. The ICF
describes even more, it gives also a definition for restriction in participation. It
defines it as “problems an individual may experience in involvement in life
situations” (World Health Organization, 2001). This description applies with the
life of people with SCI and the impact it has on their functioning, as expounded
above.
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During the past decade, professionals in outpatient clinics showed an
increasing interest in and emphasis on the measurement of participation (Post
et al., 2012). This because participation gains importance as an international
ultimate health outcome, since the focus of the bio-psycho-social ICF is client-
centred and goal-oriented healthcare concerning meaningful activities and
participation. Before, the biomedical approach focused on working with
dysfunction and disability (Imms et al., 2016; Van de Velde et al., 2017).
Notwithstanding the emerging unanimity about the importance of participation, it
remains a vague concept and issues with its appliance persist (Silva et al.,
2016; Van de Velde, 2017). However in literature participation has been
described as the goal of rehabilitation (Gandek, Sinclair, Jette, & Ware, 2007).
Meantime, the concept of participation is broadly used and various instruments
have been developed for assessing participation, but they vary greatly based on
the purpose for which they were developed and what they genuinely measure in
rating the level of participation (Van de Velde et al., 2016a, 2017).
1.1.2.2 Long-term rehabilitation and participation Because of the advances in medical technology, there is a strong increase of
people suffering from chronic diseases, like SCI. This also means that the
number of people with complex care needs is rising (Anderson, 2010). Besides
that, people want to invest in their quality of live. They constantly strive to
participate in meaningful activities and they are more aware of their own role
they want to play (Glass, de Leon, Marottoli, & Berkman, 1999).
Participation is often a lifelong process. Current rehabilitation responds strongly
to this (Barnett et al., 2012). Nowadays, rehabilitation medicine strains not only
to enable its patient, after being affected by an injury, to perform daily activities,
but also to make it possible resuming participation in life-roles. Participation is
nowadays often the ultimate goal in a program of rehabilitation (Stucki, Ewert, &
Cieza, 2002). Also for people with SCI there is a shifted focus to the importance
of the long-term consequences of their injury, such as restriction in participation
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(Spreyerman et al., 2011), just because of the achieved progress in medical
treatment with large impact on the survival rate and continued increasing life
expectancy of people with SCI (Strauss, Devivo, Paculdo, & Shavelle, 2006).
Long-term rehabilitation is for certain people, depending on their health situation
and needs the best option. There is need of an organizational model with a
graduated system, like proposed below, in figure 1 (Nolis, Vanhaute, & De
Nutte, 2016).
Figure 1: The staged organization of rehabilitation (Nolis et al., 2016)
The staged organization of rehabilitation consisting of a acute, post-acute and
chronic phase, can better respond to the care needs. This way of organization
can ensure that healthcare and more specifically rehabilitation medicine is
available in such a way that every patient with his or her current health and
rehabilitation needs can go to the most efficient health care provider (Nolis et
al., 2016). The more complex the need of rehabilitation, the more specialized
the rehabilitation (Nolis, 2015).
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1.1.2.3 Assessing participation There are several instruments which rate the level of participation that already
exist. They differ in the way the instruments have been operationalized. An
overview of the best known instruments can be found in table 1. They are
divided into four different types, based on what they exactly measure. Some of
them operationalized participation in terms of objective variables like duration
and/or frequency (1), others apply next to this also a normative variable which
consists of the limitations of activities (2). Other instruments operationalized
participation as a combination of objective and subjective variables and include
asset of variables to capture perceived satisfaction with each performed activity
and the restrictions affecting those activities (3). The last type of instrument
measuring participation include variables of choice and control (4) (Van de
Velde et al., 2016a, 2017).
Table 1: An overview of instruments for assessing participation
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Despite the existence of various instruments and the broadly concept of
participation in rehabilitation, several authors believe it to be insufficiently
operationalized (Hammel et al., 2008; Hemmingsson & Jonsson, 2005; Ueda &
Okawa, 2003). Demonstrated by qualitative research, there are still other
subjective components, than captured in the existing instruments, in addition
which are also decisive to experiencing participation (Van de Velde et al.,
2016a, 2017). These are meaningful engagement, being part of, having
responsibilities, having an impact on others (Hammel et al., 2008), exerting
influence, doing things for others, belonging (Haggstrom & Lund, 2008), making
challenges, asking for and accepting help, dealing with others (Van de Ven,
Post, de Witte, & van den Heuvel, 2008) and being in hands of others (Haak,
Ivanoff, Fange, Sixsmith, & Iwarsson, 2007). Scientific research states these
‘missing’ components as an important mark to query the content validity of the
extant instruments. As reply on these deficits, the Ghent Participation Scale
(GPS) was elaborated as a new measurement of participation (Van de Velde et
al., 2016a, 2017).
1.1.3 The Ghent Participation Scale
1.1.3.1 The content The Ghent Participation Scale is a unique instrument measuring participation
and covering all domains of the ICF. The scale operationalizes the concept of
participation by the application of fifteen subjective and two objective variables
(Van de Velde et al., 2016a). There are three subscales used to organize these
variables of the GPS. Subscale 1 is ‘self-performed activities in accordance with
personal choices and wishes’ and can be closely linked to the concept of
‘autonomy’. The second subscale includes ‘self-performed activities leading to
appreciation and social acceptance’ and can be strongly related to the concept
of ‘satisfaction’. The third subscale consists of ‘delegated activities’ and can be
strongly connected to ‘restrictions in performing activities’. These three
subscales can be linked with the underlying constructs of the previous existing
instruments which are mentioned before (Van de Velde et al., 2017).
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1.1.3.2 Psychometric characteristics Van de Velde et al. (2017) did research to confirm the structure of the GPS and
to investigate the psychometric characteristics of the scale. The GPS was
tested on factorial validity and internal consistency (Cronbach’s = 0,75-0,83;
item-total correlation = 0,67-0,86), test-retest reliability (weighted kappa (Kw) =
0,57-0,88 with no change in activity set on retest; Kw = 0,47-0,72 with separately
chosen activity sets for test and retest), construct validity and discriminant
validity and responsiveness (standardized response mean = 0.68). The study
declared that the Ghent Participation Scale can be considered as a valid
method to measure perceived participation and it is irrespective of the pathology
and health status of the person. The GPS is a reliable and valid instrument with
a good internal consistency and a good to excellent test-retest reliability (Van de
Velde et al., 2017).
1.1.3.3 In practice Research states the GPS is able to detect potential changes or improvements
in the perceived participation over time and it can be used in outpatient
rehabilitation (Van de Velde et al., 2017). The purpose of many rehabilitation
centres is not only to focus on the restorative approach of individuals from a
medical point of view, but also on the long-term consequences and the level of
participation perceived by the patient. This is only possible when a reliable and
valid measure of participation is available, like the GPS is. Besides the fact it
includes both objective and subjective factors in the area of the individuals
environmental and social context, it also creates the possibility to enhance the
ability to providers of healthcare, regarding the patient’s participation, to
evaluate the effectiveness of their therapy and interventions (Van de Velde,
2016a).
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1.2 Research objective
This study will investigate the experiences of the GPS of people with SCI and
their treating physical therapists in the phase of continuing long-term
rehabilitation. This, in function of the usability and the potential influence of the
scale in practice.
It will be gauged what they think about the test, its administration and their
concerns about the instrument. Besides that, there will be investigated if the
outputs of the GPS are recognizable for both people with SCI and therapists or
even enriching in the way of learning about their own functioning for people with
SCI and about their therapy approach for the psychical therapists.
Furthermore it will be checked what is needed for the Ghent Participation Scale
to be an added value in practice as well for the people with SCI as for the
therapists, in terms of participation and functioning in the environment.
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2 METHODS
2.1 Study design and theoretical basis The present study uses a qualitative research design with a phenomenological-
hermeneutical method, inspired on Lindseth and Norberg (2004).
Phenomenological-hermeneutical research is a frequently used design in
qualitative research. As researcher you want to get insight into the ‘lived
experience’ of the human being and his personal involvement. This is possible
through first-hand interviews (Creswell, 2013; Holloway, 1997; Kielhofner, 2006;
Robinson & Reed, 1998).
Furthermore the hermeneutic aspect starts from the idea that people are living
narrative lives. They are all ‘expressive agents’ (Taylor, Carnevale, &
Weinstock, 2011). By the use of this design the researcher tries to make a deep
underlying interpretation of the experiences, framed in a context of the human
experience and personal meaning (Gadamer, 1975; Widdershoven, 2001). The
phenomenon is described as accurate as possible, how it actually happened
and to stay true to the facts (Groenewald, 2004; Kielhofner, 2006; Stones,
1988).
The phenomenological-hermeneutical method is an interpretative approach
which contains three phases. It starts with a naïve interpretation. The second
phase consists of a structural analysis and this is followed by the final phase,
the formulation of a comprehensive understanding (Lindseth & Norberg, 2004).
This will be further clarified in the elaboration of the results, which can be found
in part 3.
28
2.2 Sampling When the phenomenological-hermeneutical method is used, the sampling
contains of selecting informants. This method only selects people, it does not
make use of literature or written or written texts (Cohen, Kahn, & Steeves, 2000;
Gentles, Charles, Ploeg, & McKibbon, 2015).
2.2.1 Sampling method In this study the purposive sampling method is used to select the participating
cases. Multiple sources confirm that purposeful or purposive sampling is an
ideal method to relate with the chosen study design (Gentles et al., 2015;
Kielhofner, 2006; van Manen, 2014). The participants are selected, with the
condition that they meet the proposed inclusion criteria. Based on their
knowledge and empowerment, they share their story in an interview.
Participants, who describe their experiences, are seen as representatives for
the group where they belong to (Gentles et al., 2015; Koerber & McMichael,
2008).
Different authors describe this as the power of purposive sampling. Within this
kind of sampling, the information is extracted from ‘rich cases’. Those who can
and will talk a lot about their experiences with the subject, their story will be an
added value to answer the purpose of the study and the research question
(Cohen et al., 2000; Patton, 2015; van Manen, 2014; Yin, 2011).
Patton (2015) makes the consideration that there must be paid attention to the
diversity of the purposive sample. To come to a representation of a
phenomenon, the sample must contain sufficient heterogeneity. Koerber and
McMichael (2008) appointed this as a pursuit of ‘maximum variation’.
29
2.2.2 Sample size The number of participants is not fixed in advance. The process of recruitment
continues until saturation of information is achieved. In phenomenological
research no large samples are needed to obtain rich data. Typical for this type
of research is that a number between one and ten participants is indicated to
achieve saturation (Starks & Brown Trinidad, 2007).
2.2.3 Participants All participants will be recruited at the REVAlution Center of To Walk Again vzw
in Herentals (Belgium), a centre where continuing long-term rehabilitation is
offered. A sample as heterogeneous as possible will be selected by
approaching the treating physical therapists. Besides the inclusion criteria of
suffering from spinal cord injury and continuing long-term rehabilitation at the
REVAlution Center, the only exclusion criteria is not being able to express
themselves in an interview.
2.2.4 Ethics This study is approved by The Ethical Committee of the Ghent University
Hospital. Every participant has to give a written informed consent before starting
the data collection. The approval can be found in appendix 1.
2.3 Data collection Different methods of data collection will be used in this study. They are further
explained just below.
2.3.1 The administration of the Ghent Participation Scale First of all, the GPS will be administered with all participating people with SCI.
The GPS is an assessment that focuses on participation in its two aspects,
namely the objective and the subjective determinants, including all domains of
ICF (Van de Velde, 2016a, 2017)
30
After the whole administration, which deliberately focuses in its questions on the
positive aspects of functioning, the GPS will calculate a general score for
experienced rate of participation and different scores for each category. The two
general categories are ‘experienced rate of participation for self-conducted
activities’ (with a subscore for ‘activities according to predefined choices and
wishes’ and a subscore for ‘activities that lead to appreciation and social
acceptance’) and ‘experienced participation rate for delegated activities’. Each
item in the scale is scored using a five-point Likert scale (from 1 ‘I totally
disagree’ to 5 ‘I totally agree’). Based on the mean scores from the three
subscales, a global score is calculated and represented in a percentage. A
higher percentage indicates a higher perceived participation level (Van de
Velde, 2016a, 2017).
Next to the general output of the GPS, the researcher will make a written
interpretation of these results. This interpretation will be based on the results in
combination with the answers that will be acquired during administration. This in
order to provide a more clear result of the test. The advantage is that by dint of
this interpretation of the results, the therapists get a handle and the ability to
work with the results and therefore to give effect to the GPS.
2.3.2 Interviews with people with SCI Interviews will be held with the people with SCI after the administration of the
GPS. At that moment the people will see their results and interpretation on the
GPS. During the interview they have the chance to give feedback on these
results and interpretation. They also will be queried about their experience with
the GPS and if it made some differences in their therapy or if the psychical
therapists did something with the information.
The persons with SCI will be asked to narrate their opinion about their results
through open-ended initial questions: ‘What do you think about this score?’,
‘How can you match this serious participation problem with your busy social
life?’, ‘What do you think about the way the GPS was administered?’, ‘In which
31
way do you think the therapists did something with these results?’, and so forth.
The probes will be altered based on the persons’ responses. It will be a semi
structured interview, so the researcher can supervise the subject and the
consecution of questions, but not every question has to be asked exactly the
same way within every interview (Lysack, Luborsky, & Dillaway, 2006).
2.3.3 Interviews with the physical therapists After the administration of the GPS the results and interpretations will be
delivered to the two physical therapists working at the To Walk Again vzw
REVAlution Center. After the interviews with the people with SCI, the therapists
will be interrogated about their opinion. By using open-ended initial questions,
the researcher want to learn more about which information is new to them, what
did they already know, if and how they already obtained this information, if they
did something with these data, what they think about the reaction of the persons
with SCI on the results, if they saw some added value in the obtained data from
the GPS, and so forth. Further questions will be based on their answers. It will
be a semi structured interview, so the researcher can supervise the subject and
the consecution of questions, but not every question has to be asked exactly
the same way during each interview (Lysack et al., 2006).
2.4 Data analysis In phenomenological research the analytical procedure starts with the first
interview and ends when all interviews of all the participants has been
conducted. Typical for phenomenological research is that the meaning of the
data is hidden after the data. It is, as it were, processed in the obtained data.
For this reason each interview has to be transcribed and must be read
thoroughly several times to capture the first understanding of this specific
interview of one participant. The purpose of this analysis technique is to provide
a theoretical story that gives an answer on the research question. The story is
validated by including examples about the subject out of the collected data
(Kielhofner, 2006; Lindseth & Norberg, 2004).
32
For the reliability of the data analysis, a well described and consistent structure
must be established in advance (Nowell, Norris, White, & Moules, 2017). The
researchers act as an instrument for analysing the obtained data. They will
make decisions in terms of coding, making themes, removing data from the
context and putting it back into the context (Braun & Clarke, 2006; Starks &
Brown Trinidad, 2007).
The collected data will be processed using the NVivo Software. In order to
maintain the reliability of the data analysis, the following steps must be followed
sequentially for thematic analysis (Lindseth & Norberg, 2004).
After the interview with the first participant is done, the administration, results
and interpretation of the GPS and following interview will be clustered one after
the other and read as a whole. This cluster of one participant was termed as ‘a
narrative’ (Nowell et al., 2017).
The data material has to be first read through several times to grasp its
meaning as a whole, achieving a naïve understanding. This to be made familiar
as researcher with the obtained data. The naïve understanding of the data is a
very precursory interpretation of the meaning of the whole data collected during
the research. It is more a circular than a static process. Next to that, initial
codes will be developed and then themes will be searched under which the data
can be divided. The themes will be revised and reconsidered. Afterwards, a
name and definition will be given to the different themes. All this to finally come
to a comprehensive understanding, an interpreted whole, which will describe
the entire phenomenon (Lindseth & Norberg, 2004).
A technique to ensure trustworthiness of the analytical procedure includes a
debriefing of the analysis and the preliminary results and discussing this within
the research team. Subsequently, a member check could be performed to
triangulate the findings and to verify the authenticity of the ongoing analysis
process . Furthermore, the inter-rater reliability and intra-rater reliability can map
the trustworthiness of the analysis of the data (Lincoln & Guba, 1985).
33
3 RESULTS
3.1 Elaboration of research
3.1.1 Participants Eight people participated in this study: Six persons with SCI and two physical
therapists who treat this people at the REVAlution Center of To Walk Again vzw
in Herentals (Belgium), a centre for continuing long-term rehabilitation.
3.1.1.1 People with SCI Six persons with SCI of the REVAlution Center, more specifically two women
and four men, volunteered to participate in this study. An attempt was made to
compile such a heterogeneous sample as possible. This in terms of age, sex
and level of nerve damage. The people with SCI were aged between 22 and 66
years old. They all suffer from a complete or incomplete spinal cord injury with
different levels of nerve damage and are able to express themselves in an
interview. The table below (table 2) shows an overview of the characteristics of
the six persons with SCI who participated in this study.
Table 2: Characteristics of the people with SCI
34
In a first phase, the Ghent Participation Scale was administered with all people
with SCI. The GPS calculated some scores and an interpretation based on this
scores in combination with the information out of the interviews was made. An
overview of the results and interpretations of the GPS for every person with SCI
can be found in appendix 2.
A second phase took place at the REVAlution Center, after the administration of
the GPS and consisted of an interview with each person with a SCI. They were
shown their results and interpretations of the GPS and were asked about their
results in an interview with open-ended initial questions. The interviews were
recorded and transcribed verbatim, by using NVivo Software. Six interviews
were performed and resulted in 128 minutes of recorded data.
3.1.1.2 Physical therapists In addition to the people with SCI, two physical therapists working at the
REVAlution Center and treating these six persons, volunteered in this study too.
Short after the administration of the GPS, the results and interpretations were
delivered to the two physical therapists working at the REVAlution Center. After
the interviews with the people with SCI, the therapists were asked some open-
ended initial questions. Because of time shortage of the physical therapists,
they both were interviewed at the same time and the results of the six persons
with a SCI were discussed in two interviews.
The table below (table 3) shows an overview of the two treating physical
therapists who participated in this study and in which interview they discussed
about which person with SCI.
35
Table 3: An overview of the interviews with the physical therapists
The interviews took place at the To Walk Again vzw REVAlution Center in
Herentals. The interviews were recorded and transcribed verbatim, by using
NVivo Software. Two interviews were performed and resulted in 25 minutes of
recorded data.
3.2 Processing of data
3.2.1 Phase 1: Naïve understanding The narratives showed that participants see possibilities in the use of the GPS,
but only if the administration of it is followed by a consequence from which they
can benefit. There are often a lot of questionnaires and tests that persons with
SCI have to administer, but people with SCI see this as overflowing and
unnecessary if nothing is done with it by the professionals. Besides that, the
administration as well as the results raise some confusion by the participants.
The GPS needs more embedding in practice to be seen as added value, both
by people with SCI and professionals.
3.2.2 Phase 2: Structural analysis The structural analysis resulted in four themes about the experiences with the
GPS of people with spinal cord injury and their treating physical therapists. The
different themes are described separately below and are supported with
quotations from the interview. The abbreviation ‘P’ after each quote stands for a
person with a SCI, the abbreviation ‘T’ refers to a physical therapist. The
following number indicates from which precise participant the quote had been
derived. For the readability of the manuscript, only ‘he and his’ and not ‘she and
her’ were used when referring to a general description of the participant. This
does not mean that the voice of women is not represented in this study.
36
3.2.2.1 Theme 1: The administration is a snapshot A first returning remark on the experience with the GPS is that the
administration of the GPS and consequently the subsequent results depend on
a few factors. Some variables can influence the given answers and scores,
which ensures that administration is a snapshot and relative to certain facts.
The experienced variables are listed below, followed by an extensive
explanation and accompanying quote.
a) The sex of the person with SCI In this study it emerged that the sex of the person with SCI can be an indicator
for the answers and the results of the GPS. As a woman with spinal cord injury,
you have to deal with other participation problems than men with spinal cord
injury. First of all, women handle differently than men do, when they have to
deal with some restrictions of their friends. According to some people with SCI,
it sometimes happens that friends take decisions in their place. One of the
people with SCI expressed this as followed: “At one point they will make the
choice for you: ‘Oh well, let’s not ask P4 along, because it’s difficult for her too.
She won’t get there anyway.’… I really don’t like that kind of reasoning and I
notice it with a lot of my female friends. Men are more easy going in that kind of
situations. They bring along someone in a wheelchair without any thought and
‘hop’ they’ll carry that person.” (P4).
Another participation issue which is different between men and women has to
do with the toilet visit. If you go out, you need a wheelchair-accessible toilet
anyway, but this is a little easier for men than women. A male person with SCI
described this as followed: “I also go to the toilet already in the morning. Then I
don’t have to think about that for the rest of the day, except for the probing. I
have to probe a couple of times a day. But at least I’m released of the “number
two”, so to say, if I take care of it in the morning.” (P5).
37
Due to the anatomical differences of the female and male urinary system, it is
slightly more complex for women to go to the toilet in public. As a man you can
pee as soon as a normal toilet is wheelchair-accessible or fairly discreet in
public, like men without spinal cord injury do. As a woman, your participation
such as spontaneous outings is much more restricted. You are really dependent
on an adapted toilet if you want to urinate discreetly without having a bladder
infection. A female person with SCI expressed this as followed: “ ’Will you go
out with us, drink something?’ It used to be like: ‘Oh yes, that’s a wonderful
idea!’. Now it’s like ‘Uh no, because there is nowhere I can use the restroom’. In
that area you miss out a little on the spontaneous things. … For me it is,
because I’m a women, even more difficult. Therefore my participation in society
sometimes is less than it used to be. … A man can pull out his member in a
men toilet, but as female… You really are seated with your legs wide open.
Women have to do everything very sterile not to get a bladder infection. So yes,
it’s not like ‘Oh, let’s do it real quick behind the car’, as a man can do.” (P4)
The examples above show that the difference in sex has an influence on the
participation and therefore also on the results of the GPS and the opinion on
this.
b) The moment of administration The moment at which the GPS is administered plays a significant role in the
given answers and the results of the test. The moment as such can therefore be
interpreted in different ways.
This can refer to the season in which the scale is queried, because the weather
and time of the year can have an impact on the mind and soul of the person
with SCI. In consequence he will have a diverse view on his activities and he
will evaluate his activities differently in the test. Not only the view on his
activities can be different, but also the activities that are performed can be
influenced by the season: “If, in that moment, I was a bit down, I would say the
results will definitely tend that way. Maybe because it was winter at the time, but
38
now the sun is shining. … Definitely when you go outside and see the sunrays.
It gives me a boost. ... When the weather is nice I go to the physiotherapist by
bike and sometimes I’ll go have a chat with my brother or go to the store by
bike.” (P6)
Another interpretation of the importance of the moment at which the GPS is
administrated is the specified week in which this falls. The GPS is based on the
question of what the five most important activities were you performed last
week. Not every week is the same, and like people without spinal cord injury,
people with spinal cord injury also have boring weeks in which hardly anything
special or fun has happened. If the administration of the GPS takes place after
such a week, the results of experienced participation rate will not be particularly
high. Despite the fact that you generally do a lot and you are active and happy
with how most things work. This can also be reversed. That you generally do
not much and that you are not that satisfied with your participation, but that the
administration took place just after a nice and active week.
The influence of the moment at which the administration falls was frequently
stressed by the people with SCI:
“That winter barbecue and diner accidently took place exactly in that week.”
(P1)
“… it changes from week to week anyway. I also have weeks where I stay at
home the whole week so to say. That’s a bit exaggerated, but I mean there are
weeks with hardly anything on my agenda, I hardly did anything, just because in
that moment, well… there are not many opportunities. For example if the
weather is really bad, well, I’ll barely go outside.” (P2)
39
c) The character of the person with SCI The answers the people with SCI give during the administration of the GPS and
the resulting percentages and interpretations depends on the character and
attitude of the person with SCI. The GPS checks your experienced participation
rate on the basis of the acceptance of the way you perform activities these days
and how you deal with delegated activities. If you are a more independent
person who believes autonomy is important, you will not get a high score on the
experienced participation rate of delegated activities and maybe you are not
even satisfied with the activities that you carry out yourself or the way you have
to implement them due to your disability.
Those two quotes below prove the different attitudes between people with SCI:
“Sometimes not doing something is easier than doing them, right?” (P5)
“Ooh, but it is accepted [the obligation of outsourcing some activities because of
his limitation]. I rather do the things myself. If there is something I can’t handle
myself I’ll ask or have it done by someone else, but if you don’t have to… I
rather try it myself than have it done by somebody else. … In contrary to when
you say things like ‘okay, go ahead, do this with me’, ‘do that’, ‘I want you to do
this’ … Yes, it’s very easy that way and okay, it is accepted. They’re allowed to
do anything from me. But on the other hand you’ll never learn something that
way. So I can let someone else open the door for me every time. That’s …
Well…A change … with me anyway.” (P2)
The Ghent Participation Scale queries three activities you definitely want to do
in the future. Also in this area you can experience a big difference between the
dissimilar characters. You have the cautious people who take realistic and
achievable goals, which also should be reachable in short term. This refers to
examples like wheelchair racing, horse riding, sit-skiing, start studying again...
40
In opposite there are people who have despite their disability wild, unfeasible,
challenging and maybe even unrealistic dreams which can probably never
become reality. The therapists confirmed this: “What struck me was that the
goals for the future differed enormously, especially among walkers [referring to
the people who walk with an exoskeleton (walking by full support of external
robotics) during therapy]. Like with this person, horse riding and a wheelchair…
But some they already do. And other goaled activities will never be possible and
will last as a dream.” (T1)
d) The life situation of the participant When determining the answers and results, it is clear that the general life
situation of the person with SCI plays an important role too. This does not only
mean age, but also living and work situation. If you are young, still being student
and living at home, a reaction like this is conceivably :”When I did the intake
interview, I still went to school fulltime etc., I did a lot more then. So yes… the
scores probably were a lot higher at the time … I think everyone my age would
rather not prepare food themselves etc. It all adds up on top of everything else,
right? The more you can hand over to someone else the better of course. … In
ten years everything would be different. If I still live with my parents by then and
they always have to cook for me… Well, I won’t feel comfortable in that situation
and my parents wouldn’t like it either. But with my age I guess it’s normal to feel
okay about it.” (P1)
This compared to someone who is already older, works fulltime, has her own
house and wants to manage her own household. This experience is completely
different, because she wants to be responsible for her household herself as her
peers do it too : “Well of course it’s not as I desired, I wish I could do it by
myself. … For example if you ask me if I would like some help cleaning, I’d
rather say no. I have the idea, you’re still young, you have to be able to maintain
your house yourself, I guess.” (P4)
These two examples show that the results also depend on the life situation and
that it can evolve over time.
41
e) The phase of the rehabilitation trajectory The next evolving variable that affects the results after the administration of the
GPS, is the phase of the rehabilitation trajectory. At the REVAlution Center,
people follow continuing rehabilitation (long-term rehabilitation). This means that
they are supported to regain their lives as good as possible. Not only the
physical aspect can be refined, but also the appropriate help and suitable tools
can be fine-tuned. This all is of considerable importance in terms of perceived
degree of participation. One of the people with SCI, expressed this as followed:
“This to see how far I will get in my rehabilitation first. Should I not rather wait to
buy another type of car? Maybe I’ll still get some progress rehabilitating, for
example maybe a little function in my legs? But in the meantime I am getting
there more or less, as what kind of car I am looking for. … I think I still have
capacity to grow, yes I do think so. For example speaking of a car, it is going to
happen, so uuhm … In anyway, I estimate that within the next year it should be
in order.” (P5)
3.2.2.2 Theme 2: The confrontation with the results is like holding up a
mirror The results of the GPS force the people with SCI and the treating physical
therapists to look into the mirror, to reflect what they know about their
participation and to be conscious of their current capabilities and possibilities.
From the reactions of the people with SCI to the results, there are three different
subthemes highlighted, which they experienced as confronting.
a) About the scores When the people with SCI saw their results and read their interpretation on the
GPS, only a few of them immediately agreed with these scores. It was not that
simple for everyone to recognize themselves in the marks, like: “In my opinion
all scores look quite low? I have a big social life and a program pretty filled with
42
activities. So, to me, these scores don’t seem very representative of my life
situation. Therefore I am actually surprised by the grades.” (P2)
The treating therapists could not always explain the resulting scores of the
people with SCI based on how they experience the participation of the people
with SCI either: “I don’t know. I could not tell you whether these results are true
or false. I have no idea how he is at home, how he’s assisted... or even how he
feels he can be helped, simply because I can’t check this.” (T1)
b) About the functioning For some of them seeing the results and reading the interpretation was
confronting or just clarifying for their awareness on their own functioning. One of
the persons with SCI described this accurately : “If I have to include what I
would like to do, the low scores definitely accord. There’s just a difference
between wishes and things you would like to do and you’re not able to do and
the things you can do by yourself eventually. Because…now, if I go to a
concert, well, in itself going to a concert just is standing up. But I can tag along
to a concert, so I can fully participate therein, but well… if I could. You know,
what I actually want to do is exercising with friends. But, that I can’t. So if that
get’s included, yes, you will become a totally different score.” (P3)
c) About making choices
In the interview, it was remarkable that reading the results and the interpretation
made most of the persons with SCI reflect on several aspects . They were
thinking about the own choices they make and what other people decide for
them and in which way their limitation makes a difference here, like: “…I have
peace with it, though. That’s what’s so difficult about the survey. I do have
peace with it, it’s not like it is keeping me awake at night, but if I have to
choose… I just feel it’s… annoying. Yes, annoying, because I rather do it
myself. But it just is that way now. It’s a fact, so I’ll have to live with it. Not that it
makes me unhappy. But if they leave me the choice I’d rather do it myself, if I
could. But the problem is I just can’t.” (P4)
43
In another perception, the people with SCI make their own choices in which
information they share in therapy at the REVAlution Center, with the physical
therapists. They chose to tell these things they want their physical therapist to
know and how strong and independent they seem in their own private life. The
people with a SCI and the therapists talk during therapy, but you can always
send the conversation in such a way, that your biggest problems will not be
illuminated. A more introvert person expressed this as followed: “Perhaps there
was some new information therein for T1 and T2, because they don’t work here
that long. I don’t talk a lot during therapy or during the walking itself, because
I’m not such a chatterbox.” (P6)
The therapists confirmed that they were not aware of much aspects of
information. Another participant mentioned this just as an advantage of the GPS
that it enables therapists to learn more about the persons, like: “Yes, in my
opinion it’s an advantage. The therapist’s awareness about the real functioning
increases and he get a better insight in what I, as a patient, really want. Now he
can challenge or encourage me in an appropriate way.” (P4)
3.2.2.3 Theme 3: In practice The results are also enriching for the physical therapists. It makes them think
about what they know about the general functioning in terms of participation of
the persons with a SCI.
a) Known information Some of the results were not surprising to the therapists, because they already
knew it. The two physical therapists working at the REVAlution Center are
working there since only a few months. They cannot have a very close bond or
a strong trust relationship with the persons with SCI yet. Nevertheless it should
not be underestimated how much information is shared informally in therapy or
during the full hour walking in the exoskeleton. The therapists confirmed this:
“Mainly, like with P2, during walks [referring to the exoskeleton: walking by full
support of external robotics]. This means one hour with almost nothing else to
do, than to concentrate on the walking and to talk a little bit.” (T1)
44
b) Unknown information To continue on what is discussed above it also shows that therapy is still in a
kind of artificial environment where people with SCI sometimes show their best
sides and less positive elements can be concealed if they want. In this way, the
person with a SCI can make the choice to show and tell the aspects they want
to in therapy. In fact, they can hide the information the professional needs in a
certain extent. This can be proved with the next citation: “In that case we didn’t
really know, since we mainly have the positive things here, like walking.
Sometimes, well, we talk about the private stuff anyway, but yes, we have less
an idea about how their daily activities look like and what role the partner plays
therein.” (T1)
c) Time Like in several organizations, time is a precious commodity. Because of the
workload and extensive range of tasks, the therapists confess they do not have
much time to invest in non physically related aspects of rehabilitation or issues
which are not part of the therapy. Not the administration of the GPS is the
biggest time intensive problem, but to be able to work with the results and
spending time to give effect to the GPS
“…honestly I just think we don’t have time for that. I guess that’s the biggest
problem. If we would include it in the intake. … Yes, you just have to spend
more time to it … I suppose that is our biggest problem ‘time’. … I think it also
particularly is a problem, not to have it filled in, but spending enough time with
it.” (T1)
Unfortunately, to create support to use the Ghent Participation Scale in practice,
time is needed. It is not only the administration which will take time, but also
succession and effectively working with it will be required to manage in
implementing the GPS. If time would be disposable, the test could be an added
value in practice. Also the persons with a SCI affirm that they see it as
unnecessary and a waste of time and energy if it is simply put aside after the
45
administration, but that however it can be an added value when working with it.
One person expressed this as followed: “I suppose it could be an added value,
if you actively work with it. But if you just say ‘well, okay, so be it’, then it won’t
be an added value. … There are so many things that are done but afterwards
nothing happens with them. In that case it’s just lost time, but… If something
gets actually done with it, that’s a good thing. But it works that way with
everything in life of course.” (P1)
3.2.2.4 Theme 4: There is room for interpretation The interviews showed that the Ghent Participation Scale contains several
elements that are open for interpretation. Not every person found everything
unambiguous, both in the administration and in the perception on the results.
a) The administration In the administration several people with SCI had trouble with the questions.
Multiple questions were not clear about how and what to answer. For example:
The questionnaire starts with the question to give the five most important
activities you did last week, performed by yourself or in which you have
participated. Some people with SCI were already doubting when hearing this
first question, because a self-executed activity can be very relative in terms of
magnitude and importance. In that way, people with SCI hesitate about what to
answer and even in the following questions they often repeated that these
activities are relative and some even are ridiculous to discuss. With regard to
this ambiguity, one person said: “I thought it was difficult. Especially because it’s
really vague. For example a performed activity, well, what is an activity? Is it
getting up in the morning, dressing yourself? Is that an activity? Because those
are very small things, something ridiculously small you do daily. But okay, some
people do need some help doing these things… It’s a bit vague how big the
activity has to be.” (P1)
46
b) The results In the interviews afterwards, it became clear that likewise the results can be
interpreted freely too. To understand what the results mean, explanation is
needed. For example: it’s not transparent that a low score on ‘experienced
participation rate for delegated activities’ is not that positive. A
misunderstanding about the score system can be found in next citation: “But
isn’t it just positive the scores are that low? Because in principle, it is since I
don’t allow it...I preferably do everything myself.” (P2)
3.2.3 Phase 3: Comprehensive understanding A lot of information can be taken out of this study consisting of the use of the
GPS and subsequent interviews. Experiences about the test, the administration,
the results and what has to be done with it were obtained by the participants
who were both people with SCI and therapists. A number of important points of
attention can be derived from this interviews.
On the one hand the remarks deal about the GPS and its administration. What
is important to keep in mind while the test is queried, which factors plays a role
or influence the answers and results? Furthermore, what the results and the
interpretation of the test do entail and how participants reflect on this. On the
other hand information on how the test can be embedded in practice can be
derived from of this study. What is required and which points need attention to
create an environment in which the Ghent Participation Scale can have an
added value in practice?
In the figure below (figure 2) the results derived from this research are
represented in a visual overview. This figure, which is two-fold, shows on the
one hand the administration of the Ghent Participation Scale and associated
determining factors, according to the people with SCI. On the other hand it
shows how it can be embedded in practice and what is needed therefore.
47
Figure 2: The embedding of the GPS in practice
The Ghent Participation Scale is proposed as a cloud, because of the
ambiguous elements in the administration and in the perception of the results.
There is room for interpretation both on the administration and on the results.
In the cloud, you can see a camera and a mirror. The camera represents the
dependence of the GPS on a few factors. Previously it was described as the
administration of the GPS is like taking a snapshot. Variables as the sex of the
person with SCI, his character, his life situation, the phase of his rehabilitation
trajectory and the moment when the administration took place have an influence
on the administration of the GPS. In addition, The mirror in the figure above
depicts the confrontation with the results of the GPS that the people may
experience. Hence the picture of a mirror, to reflect on your scores, on your own
functioning and about the choices you make in your life, in rehabilitation and
during the administration of the GPS.
48
In figure 2, you also can see the cloud floating above a table. The table
represents the situation in practice. To embed the GPS in practice, the cloud
must symbolical be sustained by the table. The biggest element of the table, of
practice, on which the GPS is based, is time. Time is needed to create an
added value with the GPS in therapy. Time means having the occasion to
collect information and to work with the results of the GPS and to collaborate
with the people with SCI to bring their results to a higher level. The table, based
on time and supported on information is balanced by two pillars: known and
unknown information. Between these two pillars there is a gap and therapists
working with the GPS have to pay attention to have an open mind in collecting
information. You have to look further than the known information. There must be
searched for the unknown information which might be hided, but which is at
least equally important as the information which is already known.
Despite the GPS is a representation of objective numeral data, without a proper
interpretation of the scores by the therapist, the scores remain superficial and
static. Moreover the opinion of the person with a SCI on the scores has a big
influence, while he can interpret best and frame the scores. This explanation is
insurmountable if they want to find out more about the person with a SCI and
his actual participation and functioning in his environment. Otherwise, the output
of the GPS, still remain hard to interpreting numbers.
3.2.3.1 Conclusion: comprehensive understanding Participants, both people with SCI and their treating physical therapists, confirm
that the Ghent Participation Scale is an interesting tool for the persons with SCI
as well as the therapists to open their eyes about participation and general
functioning in their environment and society. The test shows percentages and
scores about this, however these results remain static data.
An interpretation of the scores in form of a verbal description, as now was made
by the researcher and given to the physical therapists, is needed to handle the
scores and to get the chance to tackle them in therapy or to work with it.
49
Furthermore, a conversation with the people with SCI about the scores after the
administration is recommended, to get better insights in the scores and to be
able to frame them. Instructions or a kind of guidelines with an appropriate
interview technique to question the persons would be useful to make the GPS a
useful instrument with an added value.
Nevertheless they have to keep in mind that the administration and the results
of the test depend on several various factors who can influence the score or
even how people with SCI will deal with the results and interpretations of the
GPS. Furthermore, to embed the GPS in practice and to increase the usability,
participants agree that some aspects are needed if the GPS wants to be used
as an added value for therapy. As most importantly time has not to be
underestimated to be able as therapists to really do something with the test and
a little extension of the instrument would be appropriate.
50
51
4 DISCUSSION As described in the introduction, the administration of the GPS, the results and
the linked interview proved that people suffering from SCI experience an impact
on all possible surfaces of their whole life because of their trauma (Adriaansen
et al., 2013; Aman & Aslam, 2013; Derret et al., 2012; Dudley-Javoroski &
Shields, 2006; Singh et al., 2014; Teo et al., 2011; Ullrich et al., 2013). Still,
people with SCI have the same needs and the same dreams like all the other
people and they need and want social independence to rule their own live and
choices (Shakespeare, 2000). During administration of the GPS, they became
aware that their identity did not change over time and they did not become
someone else despite their accident. In terms of acceptance, all of the people
with SCI said that they have accepted their limitation, but most of them add to
this that in their fantasy, in their ideal dream, they still can do everything by
themselves.
As already presented in the introduction the Ghent Participation scale can
detect changes over time in terms of participation and it can be used in
outpatient rehabilitation. The aim of the study was to investigate this issue by
the experiences of people with SCI and their therapists and to understand what
is needed to add value to this test so it is useful in a rehabilitation centre.
4.1 Findings
Based on the comprehensive understanding and its formulated conclusion, it
can be stated there can be a lot of relevant and interesting information extracted
from this research. The results reveals first and foremost that the administration
of the GPS is a snapshot. Secondly it shows that a confrontation with the results
is like holding up a mirror. As third, there is time needed in practice to collect
relevant information and to give effect to the results of the GPS. The last finding
is that both administration and the results leave room for interpretation, which
creates opportunities. All these results will be discussed separately, except the
last finding about room for interpretation. This one is contained in ‘4.4
Implications for further research’, because of its substantive character.
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4.1.1 The GPS as a snapshot The results of this research show that some factors can influence the
administration of the GPS and the subsequent results. This factors are besides
the sex, the character, life situation and rehabilitation of the person with SCI,
also the moment when the scale is administrated.
The experience the administration of the GPS is like taking a snapshot affirms a
benefit of the GPS, namely this instrument has the ability to detect
improvements in terms of participation over time (Van de Velde et al., 2017).
Changes of scores are possible or rather natural because literature proves this
is influenced by the kind of pathology and the condition of the impairment. Also
the age and situation of work or education has an influence on the score (Van
de Velde et al., 2017).
Another research states that the choices people make about activities,
performing and delegating them, is determined by who they are, by the self. It is
also triggered by the influences of the sudden SCI event where the person can
search for a new identity to disclaim his own self or experiences the impact on
the identity and having the anxiety it cannot be restored (Van de Velde et al.,
2012). A large part of all the subthemes of theme 1 can be connected to this
information.
4.1.2 The GPS as a mirror This study showed that the results and scores of the GPS incite to reflect both
for people with SCI and therapist. It creates a moment to look in the mirror and
evaluate the own functioning. Most of the persons with a SCI did not instantly
agree with their achieved scores of the GPS. They said that they thought the
overall score of perceived participation was too low in comparison to how they
perceived to participate in their environment, what they do and which activities
they delegated to others because of their impairment.
53
This contrast between idea and reality is something that can be confirmed by
literature. Lawrence (2002) states that it is a common misunderstanding to see
autonomy as a synonym to self-sufficiency or independency. It is not because of
one independent person seems autonomous, he or she also experience this
autonomy or the other way around. Equating autonomy and independency
seems to be something typically Western. This goes back to Immanuel Kant
and the Enlightenment who pointed to step out from not thinking for ourselves.
So perhaps it can be stated that the people with SCI reflect to their own
functioning in another way than they actually function.
4.1.3 The GPS as an added value in practice Scientific research states an increasing quality of life must automatically be
linked with the facilitation of social participation and more general participation
in the environment (Brandt et al., 2011; Petterson, 2006). Österaker and Levi
(2005) confirm this idea by stating that performing a psychological assessment
of people suffering from SCI is an important care component for successful
rehabilitation and making maximum use of participation. Van de Velde et al.
(2018) states when the reasoning in clinical rehabilitation incorporate
participation as a concept, this offers possibilities to consider patient’s needs,
preferences and goals in therapy.
This research proves that the GPS examine deeper facts of the own
participation, functioning and handling with the situation. Therefore it can be an
added value to expose these gaps. In this way it also responds to the
recommendation of Noreau, Noonan, Cobb, Leblond and Dumont (2014) that
there is a requirement of better assessment which investigates the expressed
and unexpressed, met or unmet needs of people with SCI. The administration of
the GPS, including associated interview, seems to be an ideal instrument to
make this negotiable because of the made confrontation.
54
4.2 Recommendations for practice Only physical therapists were working at the moment of this study in the To
Walk Again vzw REVAlution Center. There are no occupational therapists,
psychologist, social workers or other caregivers at the centre to create a
multidisciplinary team. This can be a reason why the aspects of the GPS are
not fully addresses in this centre and it can be seen as a missed opportunity.
Specifically, because behaviour changes or taking hold of old activities as go
back to work or school needs also an occupational, social and psychological
input for people with SCI (Bergmark, Westgren, & Asaba, 2011). Another study
emphasizes that even after twenty years post injury and longer, there still is a
common psychological distress and consequently the need of still using follow-
up services by people with SCI (Jakimovska, Kostovski, Biering-Sorensen, &
Lidal, 2017).
The GPS is a valuable and valid instrument, but it must be used correctly to be
able to use in practice. The physical aspect in all it different ways is very
important for people with SCI and their self-reliance in long-term rehabilitation,
but it is not the only factor which deserves attention for the well-being of this
individuals (Nas et al., 2015).
The GPS is based on the ICF and covers the nine domains of participation.
Consequently, this ensures the GPS follows the bio-psycho-social approach
(Turpin & Iwama, 2011; Van de Velde, 2017). This research states that to get
the benefits out of this instrument, the approach whereupon it is based must be
used in practice. Nowadays the REVAlution Center responds to the biological
factor because of its physical focus. Nevertheless, also the psychological and
social aspects must be supported by the long-term rehabilitation centre if it
wants to reply on the effective needs of their people with SCI. Flemish research
confirmed this advice to invest in a multidisciplinary healthcare team, because
injuries with such a big impact as SCI deserve and need a multidisciplinary
approach, even after the acute phase of rehabilitation (Nolis et al., 2016).
55
Multidimensional instruments enables not only client-centred care, because it
offers more detailed information about the person, but it gives also the
opportunity to use shared-decision making (Van de Velde et al., 2018).
The first recommendation is to invest in a multidisciplinary team to make a bio-
psycho-social approach possible to respond to all needs of the people with SCI.
The second recommendation is about time. Caregivers have to create more
time in long-term rehabilitation to take care of the persons with SCI in all their
facets. Extracted from this study, time is needed to create an added value of the
GPS. There must be created time for the administration of the GPS, to query
the person with a SCI about the results of the scale, to work with this results
and to administrated it several times. This repeated measurement is
recommended if they want to utilize two advantages of the GPS. A first
advantage is that the GPS can detect improvements on participation over time,
which immediately indicate the second advantage, namely that this suggests
the possibility of evaluating the effectiveness of the offered interventions
regarding participation (Van de Velde et al., 2016a, 2017). Unfortunately, time
or even better a lack of time is one of the greatest challenges in healthcare,
more specifically in care for chronic care patients (Pennic, 2015; Quest
Diagnostics, 2018).
4.3 Limitations and strengths of the study As for limitations, there must be paid attention on a few aspects. A first point
deals about the eight included participants, consisting of six people with SCI.
One person (P4) has an incomplete SCI. Maybe the exclusion of received data
from P4 could have influenced the results. It appears subjectively P4 has a
more active life and a distinct point of vision about functioning. A heterogeneous
sample was strived, but equality in terms of complete or incomplete SCI could
bring more clarity about the influence of the fact whether a complete or
incomplete SCI affords other results.
56
The second pointed note is the data analysis was conducted with peer
debriefings with a second researcher. It can be questioned if other themes
would be reached when analysing with two researchers.
Furthermore, the physical therapists working at the REVAlution Center work
only there since a few months. The question can be made if longer seniority of
the therapists would influence their reactions about, for instance, known and
unknown information of the people with SCI. But above all, perhaps there is a
difference in added value of the GPS depending on the time that therapists
have already spent with the people with SCI.
A strength of this study is that the collection of data started from scratch. While
using the phenomenological-hermeneutical method, does not use any literature,
so the participants in this study and the information they supplied were
unprejudiced heard. This without being influenced by any theoretical concept.
A next positive topic is that the data collection kept on until saturation was
achieved, which was the case after a relatively small number of participants for
this one centre. This fast saturation shows that most of the participants had the
same thoughts and experienced the same things about the GPS. Perhaps a
study in different settings, with more participants with various background could
be an added value for research about the GPS.
As a third strength, To guarantee a certain level of quality, different methods are
adopted in this study. First of all, to keep the credibility in this study high,
different methods of data collection were used. In this way, triangulation of data
wanted to be assured (Lysack et al., 2006; Nowell et al., 2017). There was the
administration of the Ghent Participation Scale to start with. After that, there
were interviews with the participants, both with the people with SCI and with the
treating physical therapists of the REVAlution Center. In these interviews
references were made to the given answers on the GPS, so their vision on this
answers and results were checked again. A second quality characteristic is that
57
the Ghent Participation Scale and all interviews were questioned by one
research student (EP) of the second Master in Occupational Therapy from the
Ghent University. During the entire process the student has got different peer
debriefings with the promoter (Prof. Dr. DV). This happened to ensure that the
student kept a clear view on the information and to affirm that the right
interpretations on the collected data were made. Moreover, any biases are
avoided in this way. As a third guarantee of quality in this study, a member
check was held after the drafting the naïve understanding and the whole
structural analysis with the four themes. All this was sent by mail to each of the
eight participants. They were asked about what they thought about the results
and whether they could find themselves and their own vision in it. Despite all the
efforts, only four out of eight participants reacted. They could agree with what
was described and no additional comments were made.
4.4 Implications for further research Considering the results of this study, the construction of the GPS can be
improved. To increase the usability of the scale for caregivers, a guideline must
be developed with advice for questions to make the results negotiable and to
dig deeper in what actually matters to the person with a SCI in his participation
and functioning. Furthermore, the test should generate, next to an overview of
the results, a standardized list to fill in the interpretations of it.
If this two elements are added to the GPS, the scale should be implemented in
practice to link (therapy) goals based on shared decision making and
interventions. The added value of the GPS in practice, in terms of realizing
goals to increase the perceived participation and the impact of the influence of
the test to client-centred and goal-oriented therapy must be investigated.
58
59
5 CONCLUSION The Ghent Participation Scale is a reliable, valid and promising instrument to be
used in the context of participation in practice. Experiences of the participants in
this study shows that a few things must be added to increase the ease of use of
this instrument. Above all, time must be created to get started with the GPS.
The results show there are to interesting topics in this instrument connected to
measuring participation. Namely the results of GPS acts as a mirror to reflect on
the own functioning and the administration of the GPS is a snapshot, which
ensures it can be administrated several times through time. These unique
feature can expose unknown elements between the person with spinal cord
injury and his therapist and make them negotiable. Further research must prove
if the implementation of the GPS in practice support client-centred and goal-
oriented care or even shared decision making.
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61
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71
7 APPENDICES
7.1 Appendix 1: Approval Ethics Committee
72
73
74
75
7.2 Appendix 2: Output of the Ghent Participation Scale
7.2.1 Participant 1
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d6
1,0
7%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
54,6
7%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
52,8
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g57
,00
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
62,0
0%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: d
920
2
d71
02
D57
02
D57
02
d64
04
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d23
01
d64
02
d64
02
d45
53
d64
02
Sco
re v
olg
en
s IC
F:
ne
gm
atig
par
tici
pat
iep
rob
lee
m2
po
sp
arti
cip
ee
rt m
atig
2
Do
me
ine
n v
an p
arti
cip
atie
: x x x x x x
P1
°199
6
18/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
naa
r d
e w
inke
l gaa
n (
apo
the
ker
+ b
oo
dsc
hap
pe
n)
Ke
rsti
nko
pe
n d
oe
n
Bad
kam
er
kuis
en
+ d
roge
n
REV
Alu
tio
n (
the
rap
ie: s
tap
pe
n, f
itn
ess
,,,)
Kin
esi
st
Naa
r h
et
gro
otw
are
nh
uis
gaa
n
ete
n k
laar
mak
en
hu
ish
ou
de
n (
was
en
de
pla
s)
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
Win
terb
arb
ecu
e
Ete
ntj
e v
oo
r fe
est
dag
en
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
76
77
Inte
rpre
tati
e G
PS:
Toek
omst
doel
en:
Vo
lge
nd
e d
oe
len
zo
ud
en
in d
e t
oe
kom
st b
ere
ikt
wil
len
wo
rde
n:
Gaa
n z
itsk
iën
(re
ed
s e
erd
er
uit
gevo
erd
e a
ctiv
ite
it)
Ein
dd
oe
l: Vo
lge
nd
ein
dd
oe
l wo
rdt
voo
r o
gen
ge
ho
ud
en
bin
ne
n d
e t
he
rap
ie:
Fysi
ek
ste
rke
r w
ord
en
en
go
ed
eve
nw
ich
t h
eb
be
n.
Ru
gsp
iere
n o
nd
erh
ou
de
n e
n ie
ts v
ers
terk
en
vo
or
o.a
. eve
nw
ich
t e
n b
alan
s.
Arm
en
ve
rste
rke
n o
m f
ysie
k st
erk
ge
no
eg
te z
ijn
om
op
nie
uw
act
ivit
eit
en
uit
te
vo
ere
n.
On
de
rho
ud
van
o.a
. bo
tde
nsi
teit
om
nie
t m
ete
en
iets
te
bre
ken
.
Ro
bo
t ge
bru
ike
n a
ls m
anie
r o
m s
pij
sve
rte
rin
g b
ete
r te
do
en
we
rke
n e
.d.
Par
tici
pat
ie:
P1
sco
ort
61%
op
vla
k va
n p
arti
cip
atie
.
Par
tici
pat
ie in
he
t m
aats
chap
pe
lijk
e le
ven
wo
rdt
hie
r ge
me
ten
aan
de
han
d v
an t
we
e f
acto
ren
: act
ivit
eit
en
die
je z
elf
do
et
en
act
ivit
eit
en
die
do
or
and
ere
n u
itge
voe
rd w
ord
en
.
Dit
wo
rdt
be
reik
t o
p b
asis
van
62%
erv
are
n p
arti
cip
atie
graa
d m
et
be
tre
kkin
g to
t ge
de
lige
erd
e a
ctiv
ite
ite
n (
zie
gro
en
e g
ed
ee
lte
in d
e r
oo
s)
en
ee
n e
rvar
en
par
tici
pat
iegr
aad
van
54,
7% m
et
be
tre
kkin
g to
t ze
lf u
itge
voe
rde
act
ivit
eit
en
, wat
ee
n e
erd
er
zwak
ke s
core
is.
Vo
or
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g va
n z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n s
coo
rt P
1 57
% (
zie
bla
uw
e g
ed
ee
lte
in d
e r
oo
s),
maa
r d
eze
act
ivit
eit
en
ve
rlo
pe
n s
lech
ts v
oo
r 52
,8%
vo
lge
ns
zijn
vo
oro
pge
ste
lde
ke
uze
s e
n w
en
sen
(zi
e r
oze
ge
de
elt
e in
de
ro
os)
.
On
dan
ks z
ijn
aan
do
en
ing
he
eft
P1
volg
en
s h
et
ICF
ove
r h
et
alge
me
en
sle
chts
ee
n m
atig
par
tici
pat
iep
rob
lee
m.
Dit
vo
rmt
ee
n d
iscr
ep
anti
e m
et
de
sco
re '4
' of
voll
ed
ig p
arti
cip
atie
pro
ble
em
tij
de
ns
de
ze
lf u
itge
voe
rde
act
ivit
eit
'naa
r h
et
gro
otw
are
nh
uis
gaa
n'.
Bij
de
ge
de
lege
erd
e a
ctiv
ite
it 'k
ers
tin
kop
en
do
en
' ko
mt
ee
n s
core
'3' o
fwe
l ern
stig
par
tici
pat
iep
rob
lee
m n
aar
voo
r.
Op
vall
en
d b
ij z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n (
54,7
% t
evr
ed
en
he
id)
is d
at P
1 o
nd
er
2,5/
5 sc
oo
rt o
p v
lak
van
ze
lfo
ntp
loo
iin
g e
n c
on
tro
le a
ctiv
ite
ite
n.
Hij
vo
elt
zic
h h
ele
maa
l nie
t b
ela
ngr
ijk
tijd
en
s h
et
uit
voe
ren
van
act
ivit
eit
en
.
He
t is
op
vall
en
d d
at P
1 m
ind
er
pro
ble
me
n h
ee
ft e
n z
ich
be
ter
voe
lt b
ij h
et
de
lege
ren
van
act
ivit
eit
en
dan
bij
he
t ze
lf u
itvo
ere
n e
rvan
.
Do
or
zijn
glo
baa
l lag
e s
core
s o
p z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n is
dit
iets
waa
rin
hij
zo
u m
oe
ten
ku
nn
en
gro
eie
n.
Toch
is h
et
oo
k p
osi
tie
f te
no
em
en
dat
hij
ho
ger
sco
ort
(62
%)
op
ge
de
lege
erd
e a
ctiv
ite
ite
n, w
at w
ee
rge
eft
dat
hij
he
t vr
ij g
oe
d a
anva
ard
wan
ne
er
and
ere
n v
oo
r h
em
iets
(m
oe
ten
) d
oe
n.
Dit
zij
n b
ela
ngr
ijke
be
vin
din
gen
in f
un
ctie
van
he
t ve
rwe
zen
lijk
en
van
zij
n t
oe
kom
std
oe
len
.
Ge
zie
n z
ijn
lee
ftij
d e
n t
oe
kom
stp
ers
pe
ctie
f, z
ijn
he
t h
ee
l waa
rde
voll
e e
n p
asse
nd
e d
oe
len
die
hij
vo
or
zich
zelf
op
ste
lde
.
Zijn
ein
dd
oe
len
, die
ze
er
fysi
sch
ge
rich
t zi
jn, w
ee
rsp
iege
len
dat
hij
zic
h h
ier
lich
ame
lijk
wil
vo
or
inze
tte
n.
Toch
zal
ee
n s
tijg
ing
van
he
t p
sych
isch
e, m
ee
rbe
paa
ld d
e z
elf
waa
rde
en
ze
lfo
ntp
loo
iin
g, n
od
ig z
ijn
om
he
t b
ere
ike
n v
an z
ijn
do
ele
n m
oge
lijk
te
mak
en
.
De
par
tici
pat
iegr
aad
(61
%)
van
P1
vert
oo
nt
no
g ve
el g
roe
imo
geli
jkh
ed
en
.
Op
nie
uw
gaa
n s
tud
ere
n
Op
nie
uw
fys
iek
ste
rke
r w
ord
en
(h
ou
din
g, f
itn
ess
, sta
pp
en
.. -
> li
chaa
m in
he
t al
gem
ee
n)
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
78
79
7.2.2 Participant 2
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d4
8,0
0%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
56,6
7%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
58,5
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g54
,38
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
29,3
3%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: d
850
2
d92
04
d15
53
d77
01
d77
00
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d55
03
d64
03
d15
53
d45
53
d15
53
Sco
re v
olg
en
s IC
F:
ne
ge
rnst
ig p
arti
cip
atie
pro
ble
em
3
po
sp
arti
cip
ee
rt w
ein
ig3
Do
me
ine
n v
an p
arti
cip
atie
: x x x x x x x
P2
°199
2
19/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
Iets
uit
de
kas
t h
ale
n (
te h
oo
g)
tan
ken
Ban
de
n o
pp
om
pe
n
Co
nta
ct m
et
Vig
o
Ke
rsti
nko
pe
n g
ed
aan
Re
is g
eb
oe
kt
ete
n m
ake
n
hu
ish
ou
de
n (
stri
jke
n, p
oe
tse
n,,
,)
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
Po
liti
eke
ve
rgad
eri
ng
Fitn
ess
en
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
80
81
Inte
rpre
tati
e G
PS:
Toek
omst
doel
en:
Vo
lge
nd
e d
oe
len
zo
ud
en
in d
e t
oe
kom
st b
ere
ikt
wil
len
wo
rde
n:
Een
ve
rre
re
is m
ake
n
Ein
dd
oe
l: Vo
lge
nd
ein
dd
oe
l wo
rdt
voo
r o
gen
ge
ho
ud
en
bin
ne
n d
e t
he
rap
ie:
Nie
t re
leva
nt.
He
eft
nie
t h
et
ide
e d
at w
at h
ij d
oe
t o
f zo
u k
un
ne
n d
oe
n in
he
t ce
ntr
um
ech
t va
n t
oe
pas
sin
g is
op
wat
hij
in d
e t
oe
kom
st w
en
st t
e b
ere
ike
n.
Par
tici
pat
ie:
P2
sco
ort
48%
op
vla
k va
n p
arti
cip
atie
.
Par
tici
pat
ie in
he
t m
aats
chap
pe
lijk
e le
ven
wo
rdt
hie
r ge
me
ten
aan
de
han
d v
an t
we
e f
acto
ren
: act
ivit
eit
en
die
je z
elf
do
et
en
act
ivit
eit
en
die
do
or
and
ere
n u
itge
voe
rd w
ord
en
.
Dit
wo
rdt
be
reik
t o
p b
asis
van
56,
7% e
rvar
en
par
tici
pat
ie m
et
be
tre
kkin
g to
t ze
lf u
itge
voe
rde
act
ivit
eit
en
en
ee
n z
ee
r zw
akke
erv
are
n p
arti
cip
atie
graa
d v
an 2
9,3%
me
t b
etr
ekk
ing
tot
ged
eli
gee
rde
act
ivit
eit
en
(zi
e g
roe
ne
ge
de
elt
e in
de
ro
os)
.
Vo
or
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g va
n z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n s
coo
rt P
2 54
,4%
(zi
e b
lau
we
ge
de
elt
e in
de
ro
os)
en
de
ze a
ctiv
ite
ite
n v
erl
op
en
vo
or
58,5
% v
olg
en
s zi
jn v
oo
rop
gest
eld
e k
eu
zes
en
we
nse
n (
zie
ro
ze g
ed
ee
lte
in d
e r
oo
s).
Do
or
zijn
aan
do
en
ing
he
eft
P2
volg
en
s h
et
ICF
ove
r h
et
alge
me
en
ee
n e
rnst
ig p
arti
cip
atie
pro
ble
em
.
Dit
vo
rmt
ee
n d
iscr
ep
anti
e m
et
de
sle
chts
mat
ige
par
tcip
atie
pro
ble
me
n d
ie h
ij s
coo
rt a
ls h
et
gaat
ove
r h
et
zelf
uit
voe
ren
van
act
ivit
eit
en
(ke
uze
&w
en
s -
waa
rde
rin
g&aa
nva
ard
ing)
.
We
l wo
rdt
dit
we
ers
pie
geld
in d
e e
rnst
ige
par
tici
pat
iep
rob
lem
en
bij
ge
de
lige
erd
e a
ctiv
ite
ite
n, h
oe
we
l he
t w
egv
alle
n v
an z
org
en
hie
rdo
or
en
he
t ve
rtro
uw
en
sle
chts
ee
n m
atig
pro
ble
em
vo
rme
n.
De
ro
os
is v
rij g
eva
rie
erd
bij
P2
en
hij
sco
ort
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n o
p g
ee
n e
nke
l on
de
rde
el o
nd
er
de
he
lft.
Dit
zo
we
l in
he
t ge
de
elt
e v
an k
eu
ze&
we
ns
(ro
ze)
als
in h
et
ged
ee
lte
van
waa
rde
rin
g&aa
nva
ard
ing
(bla
uw
e).
Bij
he
t d
eli
gere
n v
an a
ctiv
ite
ite
n li
gt d
it a
nd
ers
, wan
t d
aar
sco
or
P2
op
ge
en
en
kel o
nd
erd
ee
l ho
ger
dan
de
he
lft.
Ee
n b
eve
stig
ing
dat
de
gro
ots
te p
rob
lem
en
zic
h h
ieri
n s
itu
ere
n.
Uit
he
t ge
spre
k ko
mt
naa
r vo
or
dat
P2
ee
n z
elf
stan
dig
en
au
ton
oo
m p
ers
oo
n is
, die
oo
k o
p d
ie m
anie
r w
il h
and
ele
n.
Hij
he
eft
inzi
cht
in z
ijn
eig
en
sit
uat
ie e
n h
ee
ft e
en
ge
vuld
so
ciaa
l en
maa
tsch
app
eli
jk le
ven
, wat
de
ind
ruk
he
eft
zij
n s
itu
atie
min
of
me
er
te a
anva
ard
en
.
Dit
wo
rdt
oo
k ge
refl
ect
ee
rd in
de
to
eko
mst
do
ele
n d
ie h
ij v
oo
rop
ste
lt. H
et
zijn
act
ivit
eit
en
die
, eve
ntu
ee
l mit
s e
nke
le a
anp
assi
nge
n, r
ols
toe
lge
bo
nd
en
haa
lbaa
r zo
ud
en
mo
ete
n z
ijn
.
Toch
is h
et
erg
en
s ja
mm
er
dat
hij
zij
n t
he
rap
ie b
inn
en
he
t R
EVA
luti
on
Ce
nte
r u
it z
ijn
eig
en
vis
ie n
iet
aan
de
ze d
oe
len
kan
ko
pp
ele
n.
Vo
ora
l ee
n g
roe
i in
aan
vaar
din
g va
n a
ctiv
ite
ite
n d
ie h
ij m
oe
t d
eli
gere
n z
al z
ijn
alg
em
en
e p
arti
cip
atie
graa
d (
48%
) d
oe
n s
tijg
en
,
maa
r e
r zi
jn z
eke
r o
ok
no
g gr
oe
imo
geli
jkh
ed
en
bij
P2
op
vla
k va
n z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n.
Een
ge
ïnd
ivid
ual
ise
erd
me
eti
nst
rum
en
t o
ntw
ikke
ld o
m d
e z
elf
erv
are
n p
arti
cip
atie
in k
aart
te
bre
nge
n.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
paa
rdri
jde
n
wh
ee
lch
air
race
n (
wh
ee
len
)
GPS
- D
e G
ents
e Pa
rtic
ipat
iesc
haal
82
83
7.2.3 Participant 3
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d5
5,8
0%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
68,3
3%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
72,0
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g63
,75
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
33,0
0%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: d
450
2
d85
01
d71
02
d92
02
d71
02
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d46
53
d55
03
d64
03
d64
03
d15
53
Sco
re v
olg
en
s IC
F:
ne
gm
atig
par
tici
pat
iep
rob
lee
m2
po
sp
arti
cip
ee
rt m
atig
2
Do
me
ine
n v
an p
arti
cip
atie
: x x x x x x x
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
stap
rob
ot
sch
oo
l
mam
a ga
at m
ee
nr
naa
iste
r
tro
uw
fee
st
kaas
en
wij
n a
von
d
ete
ntj
e m
et
vrie
nd
inn
en
hu
lp b
ij h
et
stap
pe
n
ete
n m
ake
n
P3
°198
8
19/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
was
do
en
vuil
nis
bu
ite
nze
tte
n
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
84
85
Inte
rpre
tati
e G
PS:
To
eko
mst
do
ele
n:
Vo
lge
nd
e d
oe
len
zo
ud
en
in d
e t
oe
kom
st b
ere
ikt
wil
len
wo
rde
n:
skyd
ive
n in
du
o
Ein
dd
oe
l: Vo
lge
nd
ein
dd
oe
l wo
rdt
voo
r o
gen
ge
ho
ud
en
bin
ne
n d
e t
he
rap
ie:
Go
ed
e a
rmtr
ain
ing.
Par
tici
pat
ie:
P3
sco
ort
55,
8% o
p v
lak
van
par
tici
pat
ie.
Par
tici
pat
ie in
he
t m
aats
chap
pe
lijk
e le
ven
wo
rdt
hie
r ge
me
ten
aan
de
han
d v
an t
we
e f
acto
ren
: act
ivit
eit
en
die
je z
elf
do
et
en
act
ivit
eit
en
die
do
or
and
ere
n u
itge
voe
rd w
ord
en
.
Dit
wo
rdt
be
reik
t o
p b
asis
van
ee
n v
rij h
oge
sco
re v
an 6
8,33
% e
rvar
en
par
tici
pat
ie m
et
be
tre
kkin
g to
t ze
lf u
itge
voe
rde
act
ivit
eit
en
en
ee
n z
ee
r zw
akke
erv
are
n p
arti
cip
atie
graa
d v
an 3
3% m
et
be
tre
kkin
g to
t ge
de
lige
erd
e a
ctiv
ite
ite
n (
zie
gro
en
e g
ed
ee
lte
in d
e r
oo
s).
Vo
or
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g va
n z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n s
coo
rt P
3 e
en
par
tici
pat
iegr
aad
van
63,
75%
(zi
e b
lau
we
ge
de
elt
e in
de
ro
os)
.
De
ze a
ctiv
ite
ite
n v
erl
op
en
vo
or
72%
vo
lge
ns
haa
r vo
oro
pge
ste
lde
ke
uze
s e
n w
en
sen
(zi
e r
oze
ge
de
elt
e in
de
ro
os)
.
On
dan
ks h
aar
aan
do
en
ing
he
eft
P3
volg
en
s h
et
ICF
ove
r h
et
alge
me
en
sle
chts
ee
n m
atig
par
tici
pat
iep
rob
lee
m.
Dit
ste
mt
ove
ree
n m
et
de
sco
res
van
lich
te t
ot
mat
ige
par
tici
pat
iep
rob
lem
en
die
hij
zic
hze
lf g
ee
ft v
oo
r ze
lfu
itge
voe
rde
act
ivit
eit
en
.
Dit
zo
we
l als
he
t ga
at o
ver
he
t u
itvo
ere
n v
an a
ctiv
ite
ite
n v
olg
en
s vo
oro
pge
ste
lde
ke
uze
s e
n w
en
sen
, of
als
he
t ga
at o
ver
de
so
cial
e w
aard
eri
ng
waa
rto
e d
eze
act
ivit
eit
en
leid
en
.
Er v
orm
t zi
ch e
nke
l ee
n e
rnst
ig p
arti
cip
atie
pro
ble
em
bij
he
t zi
ch b
ela
ngr
ijk
voe
len
tij
de
ns
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n.
Dit
wo
rdt
oo
k w
ee
rsp
iege
ld in
de
ro
os,
waa
rbij
hij
zo
we
l in
he
t ro
ze a
ls b
lau
we
ge
de
elt
e b
ijn
a n
erg
en
s o
nd
er
de
3,2
5/5
haa
lt, w
at e
en
ho
ge s
core
is,
uit
gezo
nd
erd
de
te
rm 'b
ela
ngr
ijk'
waa
rbij
P3
de
he
lft
nie
t h
aalt
.
Dit
sta
at in
ste
rk c
on
tras
t m
et
de
erv
arin
g va
n p
arti
cip
atie
graa
d (
33%
) b
ij g
ed
ele
gee
rde
act
ivit
eit
en
, me
t p
rakt
isch
ove
r d
e g
anse
lijn
hie
rbij
ern
stig
e e
rvar
en
par
tici
pat
iep
rob
lem
en
.
Enke
l he
t ve
rtro
uw
en
in d
e a
nd
ere
aan
wie
ze
de
act
ivit
eit
de
lige
ert
vo
rmt
sle
chts
ee
n m
atig
par
tici
pat
iep
rob
lee
m.
Oo
k in
de
ro
os
we
ers
pie
gelt
zic
h d
it, w
ant
op
ge
en
en
kele
fac
tor
in h
et
gro
en
e g
ed
ee
lte
be
haa
lt P
3 e
en
sco
re h
oge
r d
an 2
,5/5
.
P3
is e
en
ze
lfst
and
ig p
ers
oo
n d
ie g
raag
au
ton
oo
m h
and
elt
en
die
we
et
wat
ze
wil
.
He
t fe
it d
at z
e d
an o
ok
nie
t al
les
zelf
kan
do
en
en
din
gen
uit
han
de
n m
oe
t ge
ven
die
dan
vaa
k an
de
rs v
erl
op
en
dan
ze
ze
lf z
ou
do
en
, vo
rmt
he
t p
rob
lee
m.
Haa
r to
eko
mst
do
ele
n z
ijn
uit
dag
en
d, w
at w
il z
egg
en
dat
P3
no
g d
rom
en
he
eft
, lo
s va
n d
e b
ep
erk
inge
n d
ie z
e h
ee
ft o
mw
ille
van
haa
r aa
nd
oe
nin
g.
Een
lich
te s
tijg
ing
van
haa
r p
arti
cip
atie
graa
d v
an z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g in
co
mb
inat
ie m
et
ee
n g
rote
re s
tijg
ing
die
no
dig
is o
p v
lak
van
erv
are
n p
arti
cip
atie
graa
d o
p v
lak
van
ge
de
lege
erd
e a
ctiv
ite
ite
n
zou
erv
oo
r zo
rge
n d
at h
aar
alge
me
ne
par
ticp
atie
graa
d (
55,8
0%)
no
g st
erk
zo
u k
un
ne
n g
roe
ien
.
Een
ge
ïnd
ivid
ual
ise
erd
me
eti
nst
rum
en
t o
ntw
ikke
ld o
m d
e z
elf
erv
are
n p
arti
cip
atie
in k
aart
te
bre
nge
n.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
du
ike
n
skië
n
GP
S -
De
Ge
nts
e P
arti
cip
atie
sch
aal
86
87
7.2.4 Participant 4
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d5
5,6
0%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
64,6
7%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
62,4
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g67
,50
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
33,6
7%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: d
920
2
d71
01
d77
01
d92
02
D57
01
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d15
53
d64
03
d64
03
d15
51
d47
03
Sco
re v
olg
en
s IC
F:
ne
gm
atig
par
tici
pat
iep
rob
lee
m2
po
sp
arti
cip
ee
rt m
atig
2
Do
me
ine
n v
an p
arti
cip
atie
: x x x x x x
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
Bas
ketb
al t
rain
ing
Tro
uw
fee
st
Gaa
n t
anke
n
Uit
ete
n m
et
vrie
nd
Naa
r R
EVA
Nij
me
gen
gaa
n k
ijke
n (
ho
e r
eva
daa
r lo
op
t)
Stap
pe
n
Ke
rstb
oo
m b
inn
en
ge
zet
Vu
iln
is o
p s
traa
t ze
tte
n
P4
°198
0
19/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
Naa
r d
e w
inke
l gaa
n
Naa
r d
e a
uto
keu
rin
g ga
an
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
88
89
Inte
rpre
tati
e G
PS:
Toek
omst
doel
en:
Vol
gend
e do
elen
zou
den
in d
e to
ekom
st b
erei
kt w
illen
wor
den:
Dan
sen
Eind
doel
: Vol
gend
ein
ddoe
l wor
dt v
oor o
gen
geho
uden
bin
nen
de th
erap
ie:
Keih
ard
blijv
en tr
aine
n: s
tapt
hera
pie,
spi
er v
erst
erke
n…
Zou
graa
g ee
n ev
olut
ie in
de
wet
ensc
hap
zien
, waa
rdoo
r haa
r eig
en to
ekom
st ro
lsto
elon
afha
nkel
ijk z
ou k
unne
n zi
jn.
Wan
dele
n m
et e
en e
igen
sta
prob
ot is
haa
r wen
s.
Part
icip
atie
:
P4 s
coor
t 55
,6%
op
vlak
van
par
tici
pati
e.
Part
icip
atie
in h
et m
aats
chap
pelij
ke le
ven
wor
dt h
ier g
emet
en a
an d
e ha
nd v
an tw
ee fa
ctor
en: a
ctiv
itei
ten
die
je z
elf d
oet e
n ac
tivi
teit
en d
ie d
oor a
nder
en u
itge
voer
d w
orde
n.
Dit
wor
dt b
erei
kt o
p ba
sis
van
64,7
% e
rvar
en p
arti
cipa
tie
met
bet
rekk
ing
tot z
elf u
itge
voer
de a
ctiv
itei
ten
en e
en z
eer z
wak
ke e
rvar
en p
arti
cipa
tieg
raad
van
33,
7% m
et b
etre
kkin
g to
t ged
elig
eerd
e ac
tivi
teit
en (z
ie g
roen
e ge
deel
te in
de
roos
).
Voo
r waa
rder
ing
en s
ocia
le a
anva
ardi
ng v
an z
elfu
itge
voer
de a
ctiv
itei
ten
scoo
rt P
4 67
,5%
(zie
bla
uwe
gede
elte
in d
e ro
os),
maa
r dez
e ac
tivi
teit
en v
erlo
pen
slec
hts
voor
62,
4% v
olge
ns z
ijn v
ooro
pges
teld
e ke
uzes
en
wen
sen
(zie
roze
ged
eelt
e in
de
roos
).
Ond
anks
haa
r aan
doen
ing
heef
t P4
volg
ens
het I
CF o
ver h
et a
lgem
een
slec
hts
een
mat
ig p
arti
cipa
tiep
robl
eem
.
Dit
ste
mt o
vere
en m
et d
e sc
ores
van
lich
te to
t mat
ige
part
icip
atie
prob
lem
en d
ie z
e zi
chze
lf g
eeft
voo
r zel
fuit
gevo
erde
act
ivit
eite
n.
Dit
zow
el a
ls h
et g
aat o
ver h
et u
itvo
eren
van
act
ivit
eite
n vo
lgen
s vo
orop
gest
elde
keu
zes
en w
ense
n, o
f als
het
gaa
t ove
r de
soci
ale
waa
rder
ing
waa
rtoe
dez
e ac
tivi
teit
en le
iden
.
Dit
wor
dt o
ok w
eers
pieg
eld
in d
e ro
os, w
aarb
ij ze
zow
el in
het
roze
als
bla
uwe
gede
elte
ner
gens
ond
er d
e 2,
75/5
sco
ort.
Dit
sta
at in
ste
rk c
ontr
ast m
et d
e sc
ores
die
ze
beha
alt b
ij de
ged
eleg
eerd
e ac
tivi
teit
en.
P4 v
erto
ont o
p al
le v
lakk
en e
rnst
ige
part
icip
atie
prob
lem
en h
ierb
ij, e
nkel
zel
f de
keuz
e m
aken
om
de
acti
vite
it te
del
iger
en v
orm
t sle
chts
een
mat
ig p
robl
eem
.
Dit
wee
rspi
egel
t zic
h in
het
gro
ene
gede
elte
in d
e ro
os, w
aarb
ij 'k
euze
' 2,5
/5 h
aalt
, maa
r alle
and
ere
onde
rver
delin
gen
lage
r sco
ren.
De
grot
e w
ens
naar
aut
onom
ie e
n zo
veel
mog
elijk
zel
f will
en d
oen
kom
t hie
rin
naar
vor
en, m
aar o
ok h
et z
elfi
nzic
ht v
an w
at z
e ka
n en
wat
ze
effe
ctie
f die
nt u
it te
bes
tede
n aa
n ac
tivi
teit
en.
Haa
r toe
kom
stdo
elen
zijn
act
ivit
eite
n di
e ze
ook
voo
r de
aand
oeni
ng u
itvo
erde
en
haar
ein
ddoe
len
voor
de
ther
apie
zijn
alle
maa
l ger
icht
op
het a
uton
oom
han
dele
n.
De
part
icip
atie
graa
d (5
5,6%
) van
P4
zou
nog
veel
kun
nen
stijg
en in
dien
er m
eer a
anva
ardi
ng is
bij
het d
eleg
eren
van
act
ivit
eite
n,
wan
t met
een
sco
re v
an 6
4,7%
erv
aren
par
tici
pati
e op
zel
fuit
gevo
erde
act
ivit
eite
n sc
oort
ze
niet
sle
cht.
Een
geïn
divi
dual
isee
rd m
eeti
nstr
umen
t ont
wik
keld
om
de
zelf
erv
aren
par
tici
pati
e in
kaa
rt te
bre
ngen
.
Aut
eurs
: Dom
iniq
ue V
an d
e V
elde
, Pie
t Bra
cke,
Gee
rt V
an H
ove,
Sta
ffan
Jose
phss
on, P
asca
l Coo
revi
ts, G
uy V
ande
rstr
aete
n ©
Wan
dele
n
Vol
leyb
alle
n
GPS
- D
e G
ents
e Pa
rtic
ipat
iesc
haal
90
91
7.2.5 Participant 5
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d6
2,3
0%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
75,8
3%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
74,9
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g77
,00
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
34,0
0%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: D
570
1
d71
00
d71
02
d55
02
d71
00
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d47
03
D51
03
d85
03
d85
03
d85
03
Sco
re v
olg
en
s IC
F:
ne
gm
atig
par
tici
pat
iep
rob
lee
m2
po
sp
arti
cip
ee
rt m
atig
2
Do
me
ine
n v
an p
arti
cip
atie
: x x x x
P5
°196
3
19/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
On
de
rho
ud
en
van
de
tu
in
Klu
sje
s aa
n e
n r
on
d h
et
hu
is
Hu
is b
ou
we
n
Du
ath
lon
gaa
n k
ijke
n
He
lpe
n b
ij h
et
koke
n (
voo
rbe
reid
ing)
Ve
rjaa
rdag
do
chte
r vi
ere
n
Pe
rso
on
lijk
ve
rvo
er
do
or
vad
er
Ve
rple
gin
g (w
asse
n, a
ankl
ed
en
…)
GP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
Re
vali
dat
ie (
4x/w
ee
k)
Uit
ete
n b
ij v
rie
nd
en
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
92
93
Inte
rpre
tati
e G
PS:
Toek
omst
doel
en:
Vol
gend
e do
elen
zou
den
in d
e to
ekom
st b
erei
kt w
illen
wor
den:
Ver
re re
is m
aken
Eind
doel
: Vol
gend
ein
ddoe
l wor
dt v
oor o
gen
geho
uden
bin
nen
de th
erap
ie:
Ver
der o
efen
en o
p ze
lfst
andi
g op
staa
n en
sta
ppen
, zod
anig
dat
hij
dit o
ok th
uis
kan.
Oef
enen
op
het m
aken
van
tran
sfer
s.
Zelf
stan
dig
kunn
en s
taan
.
Part
icip
atie
:
P5 s
coor
t 62
,3%
op
vlak
van
par
tici
pati
e.
Part
icip
atie
in h
et m
aats
chap
pelij
ke le
ven
wor
dt h
ier g
emet
en a
an d
e ha
nd v
an tw
ee fa
ctor
en: a
ctiv
itei
ten
die
je z
elf d
oet e
n ac
tivi
teit
en d
ie d
oor a
nder
en u
itge
voer
d w
orde
n.
Dit
wor
dt b
erei
kt o
p ba
sis
van
een
hoge
sco
re v
an 7
5,83
% e
rvar
en p
arti
cipa
tie
met
bet
rekk
ing
tot z
elf u
itge
voer
de a
ctiv
itei
ten
en e
en z
eer z
wak
ke e
rvar
en p
arti
cipa
tieg
raad
van
34%
met
bet
rekk
ing
tot g
edel
igee
rde
acti
vite
iten
(zie
gro
ene
gede
elte
in d
e ro
os).
Voo
r waa
rder
ing
en s
ocia
le a
anva
ardi
ng v
an z
elfu
itge
voer
de a
ctiv
itei
ten
scoo
rt P
5 ho
og m
et e
en 7
7% (z
ie b
lauw
e ge
deel
te in
de
roos
).
Bove
ndie
n ve
rlop
en d
eze
acti
vite
iten
voo
r 74
,9%
vol
gens
zijn
voo
ropg
este
lde
keuz
es e
n w
ense
n (z
ie ro
ze g
edee
lte
in d
e ro
os).
Ond
anks
zijn
aan
doen
ing
heef
t P5
volg
ens
het I
CF o
ver h
et a
lgem
een
slec
hts
een
mat
ig p
arti
cipa
tiep
robl
eem
.
Dit
ste
mt o
vere
en m
et d
e sc
ores
van
lich
te to
t mat
ige
part
icip
atie
prob
lem
en d
ie h
ij zi
chze
lf g
eeft
voo
r zel
fuit
gevo
erde
act
ivit
eite
n.
Dit
zow
el a
ls h
et g
aat o
ver h
et u
itvo
eren
van
act
ivit
eite
n vo
lgen
s vo
orop
gest
elde
keu
zes
en w
ense
n, o
f als
het
gaa
t ove
r de
soci
ale
waa
rder
ing
waa
rtoe
dez
e ac
tivi
teit
en le
iden
.
Afg
elop
en w
eek
voer
de P
5 ze
lfs
twee
act
ivit
eite
n ze
lf u
it w
aarb
ij hi
j gee
n pr
oble
men
op
vlak
van
par
tici
pati
e on
derv
ond.
Dit
wor
dt o
ok w
eers
pieg
eld
in d
e ro
os, w
aarb
ij hi
j zow
el in
het
roze
als
bla
uwe
gede
elte
ner
gens
ond
er d
e 3,
5/5
haal
t, w
at e
en h
oge
scor
e is
.
Dit
sta
at in
ste
rk c
ontr
ast m
et d
e er
vari
ng v
an p
arti
cipa
tieg
raad
(34%
) bij
gede
lege
erde
act
ivit
eite
n, m
et o
ver d
e ga
nse
lijn
hier
bij e
rnst
ige
erva
ren
part
icip
atie
prob
lem
en.
Ook
in d
e ro
os w
eers
pieg
elt z
ich
dit,
wan
t op
zelf
s ge
en e
nkel
e fa
ctor
in h
et g
roen
e ge
deel
te b
ehaa
lt P
5 de
sco
re v
an 2
,5/5
.
P5 is
een
zel
fsta
ndig
per
soon
die
gra
ag a
uton
oom
han
delt
, maa
r aan
vaar
ding
lijk
t te
hebb
en b
ij de
act
ivit
eite
n di
e hi
j zel
fsta
ndig
uit
voer
t, m
its
aang
epas
sing
en.
Zijn
doe
len
vert
onen
ook
die
wen
s va
n ze
lfst
andi
ghei
d en
aut
onom
ie, w
ant d
eze
doel
en b
ehal
en z
ou b
etek
enen
dat
een
gro
ot s
tuk
gede
lege
erde
act
ivit
eite
n ku
nnen
weg
valle
n.
Voo
ral e
en g
roei
in a
anva
ardi
ng v
an w
at a
nder
en v
oor h
em d
oen
zulle
n zi
jn a
lgem
ene
part
icip
atie
graa
d (6
2,3%
) doe
n st
ijgen
,
wan
t P5
scoo
rt m
et e
en 7
5,8%
erv
aren
par
tici
pati
egra
ad w
el z
eer h
oog
op v
lak
van
zelf
uit
gevo
erde
act
ivit
eite
n.
Een
geïn
divi
dual
isee
rd m
eeti
nstr
umen
t ont
wik
keld
om
de
zelf
erv
aren
par
tici
pati
e in
kaa
rt te
bre
ngen
.
Aut
eurs
: Dom
iniq
ue V
an d
e V
elde
, Pie
t Bra
cke,
Gee
rt V
an H
ove,
Sta
ffan
Jose
phss
on, P
asca
l Coo
revi
ts, G
uy V
ande
rstr
aete
n ©
Aut
orijd
en
Zelf
stan
dig
rech
tops
taan
d ve
rpla
atse
n
GPS
- D
e G
ents
e Pa
rtic
ipat
iesc
haal
94
95
7.2.6 Participant 6
Alg
em
en
e g
ege
ven
s:R
esu
ltat
en
: par
tici
pat
ie f
oto
Naa
mEr
vare
n p
arti
cip
atie
graa
d4
3,7
0%
geb
oo
rte
dat
um
:
Erva
ren
par
tici
pat
iegr
aad
vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n:
49,7
2%
Dat
um
afn
ame
:-
Act
ivit
eit
en
vo
lge
ns
voo
rop
gest
eld
e k
eu
zes
en
we
nse
n
50,0
0%
-A
ctiv
ite
ite
n d
ie le
ide
n t
ot
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g49
,38
%
Naa
m a
anvr
age
r:Er
vare
n p
arti
cip
atie
graa
d v
oo
r ge
de
lege
erd
e a
ctiv
ite
ite
n:
30,3
3%
ICF-
cod
e Q
ual
ifie
r
Fift
h d
igit
De
ze
lf u
itge
voe
rde
act
ivit
eit
en
: d
640
3
d92
03
d64
04
d52
01
D57
02
Ge
de
lege
erd
e a
ctiv
ite
ite
n:
d64
01
d64
03
d64
03
d55
03
d55
02
Sco
re v
olg
en
s IC
F:
ne
ge
rnst
ig p
arti
cip
atie
pro
ble
em
3
po
sp
arti
cip
ee
rt w
ein
ig3
Do
me
ine
n v
an p
arti
cip
atie
: x x x
P6
°195
2
19/1
2/20
18
E.P
.
Hu
ish
ou
de
n
Inte
rpe
rso
on
lijk
e in
tera
ctie
s e
n r
ela
tie
s
Be
lan
grij
ke le
ven
sge
bie
de
n
Maa
tsch
app
eli
jk, s
oci
aal e
n b
urg
erl
ijk
leve
n
Lere
n e
n t
oe
pas
sen
van
ke
nn
is
Alg
em
en
e t
ake
n e
n e
ise
n
Co
mm
un
icat
ie
Mo
bil
ite
it
Zelf
verz
org
ing
vuin
lis
bu
ite
nze
tte
n
naa
r d
e w
inke
l gaa
n
ete
n m
ake
n
Gro
en
ten
ku
ise
n +
sch
ille
n
MO
TOm
ed
(e
lekt
risc
h v
oe
ten
be
we
gen
) e
n s
taan
tafe
l
stap
rob
ot
Was
sen
en
str
ijke
n
Afw
as d
oe
nGP
S -
De
Gen
tse
Par
tici
pat
iesc
haa
lEe
n g
eïn
div
idu
alis
ee
rd m
ee
tin
stru
me
nt
on
twik
keld
om
de
ze
lf e
rvar
en
par
tici
pat
ie in
kaa
rt t
e b
ren
gen
.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
sto
fzu
ige
n
Do
chte
r as
sist
ere
n v
oo
r le
sge
ven
Keuz
e
Wil
Zich
zelf
zijn
Zelf
ontp
looi
ing
Cont
role
Vei
lighe
id
Waa
rder
ing
Bel
angr
ijk
Er b
ij ho
ren
Keuz
e
Cont
role
Vei
lighe
id
Gra
ag
Zorg
en
Ver
trou
wen
0
0,51
1,52
2,53
3,54
4,55
96
97
Inte
rpre
tati
e G
PS:
To
eko
mst
do
ele
n:
Vo
lge
nd
e d
oe
len
zo
ud
en
in d
e t
oe
kom
st b
ere
ikt
wil
len
wo
rde
n:
Vo
lle
dig
au
ton
oo
m k
lusj
es
uit
voe
ren
Ein
dd
oe
l: Vo
lge
nd
ein
dd
oe
l wo
rdt
voo
r o
gen
ge
ho
ud
en
bin
ne
n d
e t
he
rap
ie:
Me
er
on
afh
anke
lijk
he
id b
eh
ale
n in
all
erh
and
e a
ctiv
ite
ite
n
Me
er
fun
ctio
nal
ite
it b
ere
ike
n (
bij
voo
rbe
eld
din
gen
ku
nn
en
op
rap
en
)
Ho
gere
gra
ad v
an a
uto
no
mie
be
reik
en
Par
tici
pat
ie:
P6
sco
ort
43,
70%
op
vla
k va
n p
arti
cip
atie
.
Par
tici
pat
ie in
he
t m
aats
chap
pe
lijk
e le
ven
wo
rdt
hie
r ge
me
ten
aan
de
han
d v
an t
we
e f
acto
ren
: act
ivit
eit
en
die
je z
elf
do
et
en
act
ivit
eit
en
die
do
or
and
ere
n u
itge
voe
rd w
ord
en
.
Dit
wo
rdt
be
reik
t o
p b
asis
van
ee
n z
ee
r zw
akke
erv
are
n p
arti
cip
atie
graa
d v
an 3
0,3%
me
t b
etr
ekk
ing
tot
ged
eli
gee
rde
act
ivit
eit
en
(zi
e g
roe
ne
ge
de
elt
e in
de
ro
os)
en
ee
n e
rvar
en
par
tici
pat
iegr
aad
van
43,
7% m
et
be
tre
kkin
g to
t ze
lf u
itge
voe
rde
act
ivit
eit
en
, wat
ee
n e
erd
er
zwak
ke s
core
is.
Vo
or
waa
rde
rin
g e
n s
oci
ale
aan
vaar
din
g va
n z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n s
coo
rt P
6 49
,4%
(zi
e b
lau
we
ge
de
elt
e in
de
ro
os)
,
maa
r d
eze
act
ivit
eit
en
ve
rlo
pe
n s
lech
ts v
oo
r 50
% v
olg
en
s zi
jn v
oo
rop
gest
eld
e k
eu
zes
en
we
nse
n (
zie
ro
ze g
ed
ee
lte
in d
e r
oo
s).
Do
or
zijn
aan
do
en
ing
he
eft
P6
volg
en
s h
et
ICF
ove
r h
et
alge
me
en
ee
n e
rnst
ig p
arti
cip
atie
pro
ble
em
.
Dit
wo
rdt
we
ers
pie
geld
do
or
de
vij
f ac
tivi
teit
en
die
hij
aan
gaf
afge
lop
en
we
ek
zelf
uit
gevo
erd
te
he
bb
en
.
Enke
l in
act
ivit
eit
en
me
t b
etr
ekk
ing
tot
zijn
re
vali
dat
ie v
ert
oo
nt
hij
vo
lge
ns
zich
zelf
lich
te t
ot
mat
ige
par
tici
pat
iep
rob
lem
en
.
De
lage
gra
ad v
an p
arti
cip
atie
wo
rdt
du
ide
lijk
we
ers
pie
geld
in d
e r
oo
s.
Op
ge
en
en
kel v
lak,
no
ch b
ij z
elf
uit
gevo
erd
e a
ctiv
ite
ite
n (
keu
ze e
n w
en
s -
waa
rde
rin
g) n
och
bij
ge
de
lige
erd
e a
ctiv
ite
ite
n s
coo
rt h
ij o
p e
en
par
amte
r h
oge
r d
an 2
,75/
5.
Dit
ve
rdie
nt
de
no
dig
e a
and
ach
t, a
ange
zie
n h
et
du
ide
lijk
is d
at d
e a
and
oe
nin
g P
6 st
erk
be
lem
me
rt b
ij h
et
par
tici
pe
ren
in h
et
dag
eli
jks
leve
n.
He
t is
op
vall
en
d d
at P
6 m
ind
er
pro
ble
me
n h
ee
ft e
n z
ich
be
ter
voe
lt b
ij h
et
zelf
uit
voe
ren
van
act
ivit
eit
en
(49
,7%
) d
an b
ij h
et
de
lige
ren
erv
an (
30,3
%).
Vo
or
zelf
uit
gevo
erd
e a
ctiv
ite
ite
n v
orm
t zi
ch e
en
ern
stig
par
tici
pat
iep
rob
lee
m o
p v
lak
van
ke
uze
vrij
he
id b
ij d
ee
lnam
e o
f u
itvo
eri
ng
van
act
ivit
eit
en
.
Oo
k is
er
ee
n e
rnst
ig g
eb
rek
aan
ve
ilig
he
idsg
evo
el e
n g
evo
el v
an b
ela
ngr
ijkh
eid
bij
de
ze a
ctiv
ite
ite
n.
He
t is
du
ide
lijk
dat
P6
sle
chts
ze
er
be
pe
rkte
aan
vaar
din
g h
ee
ft b
ij h
et
de
lege
ren
van
act
ivit
eit
en
.
He
t e
nig
e d
at s
lech
ts m
atig
ve
rsto
ord
is b
ij g
ed
ele
gee
rde
act
ivit
eit
en
is d
at h
ij w
el v
ert
rou
we
n h
ee
ft in
de
pe
rso
ne
n d
ie d
e a
ctiv
ite
ite
n v
oo
r h
em
uit
voe
ren
.
Dit
zij
n b
ela
ngr
ijke
be
vin
din
gen
me
t b
etr
ekk
ing
tot
de
mat
e w
aari
n P
6 zi
chze
lf is
in h
et
par
tici
pe
ren
aan
he
t d
age
lijk
s le
ven
.
Zijn
do
ele
n z
ijn
dan
oo
k ze
er
fysi
sch
op
gest
eld
en
me
er
auto
no
mie
be
reik
en
ko
mt
hie
r d
uid
eli
jk in
naa
r vo
ren
.
De
par
tici
pat
iegr
aad
(43
,7%
) va
n P
6 zo
u o
p a
lle
vla
kke
n n
og
ste
rk o
pge
tro
kke
n k
un
ne
n w
ord
en
.
Een
ge
ïnd
ivid
ual
ise
erd
me
eti
nst
rum
en
t o
ntw
ikke
ld o
m d
e z
elf
erv
are
n p
arti
cip
atie
in k
aart
te
bre
nge
n.
Au
teu
rs: D
om
iniq
ue
Van
de
Ve
lde
, Pie
t B
rack
e, G
ee
rt V
an H
ove
, Sta
ffan
Jo
sep
hss
on
, Pas
cal C
oo
revi
ts, G
uy
Van
de
rstr
aete
n ©
Zelf
stan
dig
sta
pp
en
(zo
nd
er
rob
ot)
Spe
len
me
t d
e k
lein
kin
de
ren
(vo
ete
n g
eb
ruik
en
)
GP
S -
De
Ge
nts
e P
arti
cip
atie
sch
aal
