Introduction
Disability is one of the phenomena that has been of interest to mankind for a long time and at every point of time, according to the prevailing economic and social conditions, different positions have been adopted towards it. A long time ago, people thought that a person with a disability is not able to work and be active due to the weakness of his physical powers, therefore, he will not have a place in the cycle of social activities. It is obvious that the result of this way of looking at people with disabilities has been removing them from the field of interpersonal interactions and depriving them of the most basic human rights; but the tremendous scientific and cultural developments of today's world have changed the way of human thinking regarding the affected groups, especially people with disabilities. Today, the issue of disability is defined based on the function of individual and social capabilities, and more importantly, the emphasis is on empowering society to adapt to the needs of people with disabilities [1].
In this regard, the need for a classification tool for health and disability was felt in the World Health Organization (WHO), which is a theoretical basis for defining measurements and setting policies for health and disability. The International classification of functioning-disability and health (ICF) is a global classification of disability and health for use in health and health-related sectors. This classification was introduced to the world community under the title of participating, disability and health classification and it is a comprehensive, global and international accepted model and has provided a classification for participation description [2, 3].
Allahyari (2021) introduce the ICF as a suitable tool for assessing disability by social workers. Also, they pay a lot of attention to the components of activities and participation and environmental factors, and it shows a systematic approach in evaluating the social dimension of disability; therefore, “ICF” can pay attention to the systematic review in rehabilitation teams especially social workers [4]. Javanmard et al. (2018) showed that the main data set of ICF in the field of cancer can provide a comprehensive picture of the patient’s participation, the results and rehabilitation processes after treatment, the patient’s needs and the environmental factors affecting the disease [5].
Sarbaz et al. (2017) showed that the use of ICF in the design of registration programs and the development of software related to speech disorders, due to the acceptance of these systems at the international level and the use of standard words, will be increase the quality of data and the ability of these systems to interact with other countries [6]. Kazemi et al. (2014) showed that by using ICF as a framework to evaluate the performance and determine the health status of diabetic patients, the hand function and the ability to do work in patients with diabetes were not at an optimal level. Their performance and ability to do work decreases with increasing blood sugar level [7]. Maleki and Kazemi (2014) showed that the framework of this classification, with the help of its components and the interaction between them, avoids the focus of therapists on the structure and function of body organs only, and an all-round focus on function, activity, participation and environmental and individual factors of the child [8].
The findings of the study by Leonardi et al. (2022) [10]in the countries under the supervision of the “WHO” family of international classifications” (WHO-FIC) group showed that the ICF is mainly used for clinical practices, policy development and social policy, and in educational contexts. Despite this, the use of ICF in different sectors is not mandatory in most countries; it is mandatory where used but provides a bio psychosocial framework for policy development in health, functioning and disability. This study provides information about the needs of ICF applications that can be useful for organizing targeted intervention programs [9]. In a research, Mukaino et al. (2020) implemented this classification in Japan. Their findings showed that the categories of this classification are clinically applicable and cooperation between researchers increases its performance in Japan [10].
Sagahutu et al. (2020) showed that behavior change based on a comprehensive patient file can result from a well-structured educational program. This classification seems to provide a common language and facilitate the interaction of healthcare professionals and patient management programs. The examples of the mentioned classification have provided an effective conceptual framework for the structure of the content of education and auditing tools [11]. Biz and Chun (2020) have described the process of implementing the ICF in a specialized rehabilitation center based on the biological psychosocial approach to health. For each department of this center, a checklist was created and the database included user information and the results of this classification during evaluation and re-evaluation. The results indicate a higher problem-solving capacity in all departments during the study period, and this training was very important to operationalize the aforementioned classification. Also, it was necessary to prepare tools based on the reality of the health center to meet the local needs and issues related to each department. In general, it was concluded that the ICF made the bio-psychosocial approach possible based on the involvement of professionals in its implementation, with evidence of the capacity to solve health care problems and the visibility and organization of the work process [12].
Providing services to different groups of people with disabilities, which according to the United Nations (UN) and WHO, include 15% of the society and up to 2% in Iran, and developing rehabilitation and empowerment programs in accordance with the daily needs of the society. One of the most important priorities of the organization is welfare, which is followed in the path of realizing justice, health and social welfare. Understanding the needs, limitations and capabilities of people with disabilities is only possible when appropriate scientific tools are available to diagnose types of disabilities and classify disabled people. Previously, the degree of disability of people was done with the doctor’s opinion and diagnosis, but for scientific and accurate diagnosis, it was necessary to use international standards to determine the type and severity of disability of people based on the definition of global factors. The defects in the guidelines and the lack of unanimity in the assessments made clear the need to review and modify the current frameworks. Emphasizing the capabilities of people with disabilities and relying on current scientific findings required the use of performance-based classifications instead of restrictive criteria. Based on the importance of the application of this classification in the treatment, rehabilitation and management system in the country, the Welfare Organization has put its use on its agenda since June 2013 [1].
But after a few years, opposing opinions emerged regarding its use, and despite the considerable efforts made to teach it to the experts of the welfare organization across the country, it seems that this classification has not been able to find the place that the organization intended. It is global health and internal managers who want to implement it in the country. On the other hand, people with disabilities and their families are worried that with this assessment, they will be excluded from the support cycle of the Welfare Organization [13].
Despite the fact that more than twenty years have passed since the publication of the ICF by the WHO and more than ten years since its acceptance and implementation by the Welfare Organization, researchers in this field and related fields have done less research on it. ; Therefore, the examination of this classification needs more research in order to increase the knowledge of this field and provide the basis for further research. Therefore, conducting this research is considered new, because so far no research has been conducted in Iran, especially with a qualitative method, to investigate the understanding of the experience and perspective of people with disabilities who are evaluated in the medical commission, in other words, the existing research does not answer the questions of this research. Therefore, the current study was conducted with the aim of knowing the views and experiences of people with disabilities with the Medical Commission of the State Welfare Organization. 

Materials and Methods
This research considered the qualitative method with interpretive paradigm [14-16]. Due to the choice of qualitative content analysis method with conventional approach, this research used inductive reasoning strategy, which means that inductively; Creates patterns, topics, and classes of data to increase abstraction levels. These reasoning strategies lead to a detailed description of the studied phenomenon [14-18].
The field of the present research was the city of Tehran and the medical commissions of the Welfare Organization departments in Tehran. This research in this field is looking for the opinions of people with disabilities or their companions on the assessment of disability based on the ICF. According to the method and analysis used in this research, the data of the research was obtained in compliance with the ethical considerations in accordance with the “consent in the research plan” form provided by the university.
A combination of snowball sampling and theoretical purposeful sampling was used. In this way, people with disabilities were either introduced by the employment officer at the commission site, or the interviewer (the first author) after obtaining permission and explaining the research to the clients in person. Either he entered the interview in absentia, or people were introduced through the mediators of the country’s disabled society, Zakiye Charity and two speech therapists and audiologists. These people could also introduce other similar people. In total, with nineteen people, ten of whom had disabilities (three women and four men with physical disabilities, one man with cerebral palsy (CP) and low vision disability and two women with RP low vision disabilities) and seven parents. (Father of a hearing-impaired child, mother of two teenagers; a hearing-impaired son and a mentally retarded daughter, twin mother of a hearing-impaired teenage boy, mother of a twenty-two-year-old hearing-impaired girl, mother of a twenty-year-old mentally retarded boy, mother of a visually impaired teenage son, RP and the mother of a teenage boy with multiple physical, motor, hearing and mental disabilities), the wife of a person with a physical disability, and the sister of a person with a MS disability were interviewed. In cases where people were not able to have a face-to-face interview, an in-person (telephone) interview was held with them if they wished.
Guiding questions for interviewing people with disabilities or their families were as follows: 
1) Explain the reason for your visit to the medical commission; 2) What steps and process did you go through to enter the medical commission? 3) Describe fully what happened on the day of the formation of the medical commission (explain your experience of attending the medical commission); 4) What are the benefits of holding these commissions for people with disabilities? 5) What are its disadvantages and negative features? 6) What suggestions do you have to improve the implementation process of the medical commission?
Qualitative content analysis technique was also used for the data analysis method [17]. The contents of the interviews were the raw materials or information of this research. In the first round of analysis, titled “initial analysis” with a general view of the text, it was analyzed according to the objectives of the research topic by giving codes or categories. In the next step, under the title of “separation”, similar codes were brought under a sub-theme, and in this way, the information was converted into data. In the following, by re-reading the codes and the contents behind them, he created the sub-themes that make up several title codes in relation to common meanings (from the sub-themes) and then defined and defined this title based on his thinking and understanding that the meaning of this word or What is the title? These words and titles were called “topics” [26].
In this research, an attempt was made to provide different forms of reliability (trustworthiness), which is specific to qualitative research, through the four pillars of credibility, dependability, conformability and transferability. Credibility in this research was achieved on the one hand by asking questions with a similar background for all participants and the evolution of the interview and observation process, during which the interviewers and observers gained new opinions and views about the phenomenon under study, which influenced the direction of the questions. Or that it made the focus on observation more specialized and limited. Through open discussion between the research team, various judgments about the similarities and differences of the interview content became more consistent over time.
In this research, the dependability of the methods of selecting participants with different experiences, interviewees with different genders and ages, and observers with different personalities, choosing the best method for collecting data and the amount and number of data, choosing the appropriate and accurate meaning unit, showing that expressions They represent the transcription of the text, the agreement between the collaborating researchers about the internal similarities and differences between the categorizations, the angle or multi-dimensionality in the tool of gathering findings and in the coding stage and finally the control by the members was counted.
With a clear description of the context, the method of selection and characteristics of the participants, the data collection and the analysis process, and with the presentation of rich and detailed findings with appropriate quotations, the transferability of the research increased.
A complete description of the research stages, including data collection, analysis and formation of themes in order to provide the possibility of research audit by the audience and readers, putting the work process at the disposal of the research group in order to confirm the correctness of the way the research was conducted, provided the ability to confirm the research [19-21].

Results: 
86 codes extracted under 13 subcategories were used for analysis in this research. Among the participants' statements, two sub-themes appeared: "Executive problems of the clients with the medical commission" and "communication problems of the clients with the members of the medical commission", which finally led to the creation of the theme "challenges of people with disabilities". Below is a detailed description of these sub-themes, which includes the codes of each sub-theme and the quotes below them.

Executive problems of clients with the medical commission
Five sub-categories make up the above sub-theme, which is further described and related quotes:
"Difficulty of the commission process from taking a turn and being accepted to the end" was the first sub-category of the above sub-theme:
"The first time you come in, unfortunately, in terms of time, they are incredibly rude people, far from John, Adam's father comes to take a moment for a commission to be formed. First, they told me that we would make an appointment over the phone. I called, Masha Allah, their phones are either busy or they don't pick up at all. I called for several days in a row, but it was useless. One day, I got up in the morning and went. They said that we are open from eight. I was there at nine o'clock, they said that the time was over, let it be for another day. Think again one more day, I became grass again, I went this way at 7:30 in the morning" (Participant (P) No. 3).
"Prolonging the commission process from the filing of the case to the end" was the second sub-category of the above sub-theme:
"The commission process takes at least three to four months, because unfortunately, the process is very time-consuming" (P 20)
“This referral to other centers for additional tests is time-consuming. The commission, which should be one month, takes a long time to go there and take this. This process is too much for someone who has urgent work” (P No. 6).
"Long time waiting for the commission day and delay on the same day" was the third subcategory of the above subtopic:
"From the time I visited, I was waiting for almost two months. He gave me an appointment for September 23. We talked to the hospital staff, we begged and begged them to keep my sister in the hospital until September 22nd, so that the 42 days will be completely filled, and we will not keep her at home because we cannot take care of her. We went today, the time we were there was a total of five hours, maybe more. We were there from 8 AM to 1 AM." (P No. 15).
"Not getting things done in one day when visiting in person" was the fourth sub-category of the above sub-theme:
"One day, I got up in the morning and went. They said that we are open from eight o'clock." I was there at nine o'clock, they said it was over, let it be for another day. Another day, I think I'll be back again, I left at 7:30 this time and I was almost the fourth person. Of course, I should also say that when they give time, I was the fourth person, it was not for the same day. For example, they would give a date that you would be here on a certain day and a certain date. Their time is like this, not that, for example, on the same day, they say that you are the fourth person, go in as the fourth person. After they took these mental, hearing and speaking tests from the children there, they did not do anything else. They said go and we will inform you the day the medical commission is formed. After some time, almost a month passed, on the day the commission was formed, they told us to come with the children that day" (P No. 3).
"The length of time waiting to receive a disability card" was the fifth code from the above sub-theme:
"My problem is that now it's almost eight months, ten months maybe more, it won't be a year, but I've been waiting for my card for ten months" (P No. 13).

Communication problems between clients and medical commission members
The following eight sub-categories form the above theme, which are discussed below:
"Not explaining about the expertise of the members and the way of doing the work of the commission" was the first sub-category of the above sub-theme:
"Doctors don't introduce themselves at all, let's see if they are a general practitioner, a specialist, an orthopedist, he is the one doing the examination. We do not have any information about these doctors who are examining. They just say that he is Mr. Doctor, he is Mr. Doctor, that's all" (P No. 8 and 9).
“As for the way they work, they don’t say or do at all. It just says get up, walk, sit, walk, goodbye, that’s it in three words. Sit, walk, walk, goodbye. It is not specialized” (P No. 22).
"Unavailability of commission members" was the second subcategory of the above subtheme:
"We did not meet the members of the commission when we went to pursue our case a month ago. We only saw our welfare manager" (P No. 2).
"Commission not paying attention to the documents provided and not having confidence in it" is the third sub-category of the above sub-theme:
"Unfortunately, welfare does not accept the specialist doctor's letter and this is very bad; That is, now my doctor is a retina specialist and not just one doctor. If I take two or three doctors, they still won't accept the doctor's letter and this is very bad. I don't know, maybe they think that people can collude with doctors. Finally, when I persisted and said that my vision problem is more severe, they introduced me to that hospital. I brought the letter that I brought from that hospital that actually showed my vision condition, those photos and those images that were taken with the machine, I brought and delivered it, and finally the special doctor of the commission accepted this letter and took it to the commission. They saw that my vision condition is more severe and finally they gave me a card" (P No. 26).
"Not paying attention to the explanations and needs of the referring person" was the fourth subcategory of the above subtheme:
"They told me to stand up and walk. Since I was a child and a teenager, when I had a prosthesis, I had learned to stand up straight and walk as a result of rehabilitation exercises. They did not consider my general condition. The first committee that did not have a doctor; But I think this commission had a doctor. I told them my situation, which I am my own guardian, I separated from my wife. I have a house but my medical expenses are high. I have osteoporosis. My leg keeps getting thinner, I need a new prosthesis, otherwise my leg will be damaged and I will have to use a wheelchair" (P No. 21).
“Not paying attention to the problems of disabled people for going back and forth between welfare centers” was the fifth sub-category of the above sub-theme:
"Anyway, they send people to hospitals, despite the hardships they have, because disabled people have problems in all aspects, in terms of transportation, after all, their conditions are very different from a healthy person, and it is very difficult to go through the steps they say. Go through it, maybe ordinary people go through it much easier" (P No. 26).
"Failure to answer the questions of references" was the sixth sub-category of the above sub-theme:
"I don't know if it is severe or not. They didn't answer us there either" (P No. 4).
 “Feeling of personal bias and involvement of personal judgment in the assessment of the commission” was the seventh sub-category of the above sub-theme:
"In the commission meeting with my friends, I will say something bad; But I really felt that they would be jealous if I was exempted from being a soldier; I mean, I understood this beautifully. I say very stylish and elegant, the word is ugly, it is not nice to be judged, let me say that I saw that complex and resentment when I went to the army, you are not, my child is gone, my brother is gone. Well, the conditions must be seen" (P No. 1).
"Absence of parents in the commission" was the eighth code from the above sub-theme:
"We sent the child inside, but we didn't go inside at all. Only at the end, when we went back, he asked about their family and mental condition; but they didn't let us in, they only called the child inside the commission" (P No. 1).

Discussion
The present study was conducted with the aim of understanding the challenges of people with disabilities with the medical commission of the State Welfare Organization. The discussions that were raised in this context by those referring to the medical commission, most of whom were people with disabilities and a smaller number of their companions or parents, are about the problems and challenges that people with disabilities had with the medical commission. Based on the repetition of the problems expressed by the participants, most of these problems related to the executive department of the medical commission included the difficulty of the commission process and taking turns and being accepted to the long time waiting for the commission day and the waiting time on the commission day and the long time to receive the card. Since people with disabilities used to refer to medical commissions to determine the severity of their disability and receive a card and services according to their disability, the hardships they faced and the long time they spent for it were not expected and were unpleasant for them, and dissatisfaction and complaints and it arouses their complaints. 
The findings of this research are in line with the results of Mohammadi et al.’s research (2013) regarding the satisfaction of the employer and government organizations (in Kermanshah Province). This research examined the satisfaction index of the performance of the studied organizations with the index of the clients’ expectations from these organizations and came to the conclusion that there is a gap between these two indicators; This means that the level of expectations of the clients from the executive bodies is much higher than the level of performance of these collections and it is an expression of the fact that the studied government sector has not been able to provide an answer to the expectations of the citizens [22]. Another research conducted by Rezaian et al. (2014) also deals with the waiting distance of clients from government organizations and their performance. This research shows that the difference between the performance indexes of the executive bodies (such as the welfare organization) compared to the level of expectation that the clients have from them, has 20 negative points. This difference in executive bodies is more than insurances, banks and state companies and slightly more than municipalities. Also, based on this research, the speed of doing things in government agencies is very important for clients. This is despite the fact that the performance of executive bodies in this field is less than that of state companies, banks and insurance companies and more than that of municipalities [23]. 
The next topic under the theme of “challenges of people with disabilities” was the problems and challenges that those referring to medical commissions had in order to communicate with the members of the commission. The findings of this research showed that the referents in cases such as providing explanations and information by the members of the commission in cases where they were unclear, communicating with people with disabilities or their companions, paying attention to the documents provided and the explanations given by the referents and trusting them, paying attention to The problems of disabled people to attend the commission and observe fairness and judgment without the interference of personal opinions complained and complained and their trust in them decreased and they expressed dissatisfaction. Mazinani et al. (2013) found in their research that the communication skills of employees, especially their verbal communication skills, are very important in solving such challenges and problems and ultimately increasing the satisfaction of clients [24]. Mohammadifar et al.’s research (2013) [22] showed that there is a significant relationship between informing in all ways, including through employees, and the satisfaction of those who refer to organizations, and in this context, there is a negative gap between the performance of organizations and the expectations of the employer, which means that the expectations of the employer In this context, it is not fully fulfilled [22]. Also, Salehi Kordabadi et al., (2009) in their research on the quality of services and the satisfaction of clients in government organizations in Gilan Province reached this conclusion, If the level of trustworthiness of government organizations in providing services and the ability of organizations to respond increases from the point of view of the clients, their level of satisfaction also increases [25].
Finally, it is recommended to use up-to-date non-attendance appointment systems such as IVR or Internet appointment and other similar methods and use them to provide information about the documents required to form a medical commission and use the SMS system to follow up to solve problems related to queuing and unnecessary commuting between welfare centers can be very helpful. Despite the fact that it is not possible to use expert doctors in all fields in the medical commissions, the use of a single electronic health record and connected to the national code with uploaded documents of the health status and finally recording the type and severity and the disability code obtained from the welfare medical commissions on This case reduces the problems caused by unnecessary trips to hospitals and other medical centers to complete the case and also increases the easy access to specialists in different fields.
In order to make this research and its findings more complete and to clarify more aspects of the performance of the Welfare Organization in measuring disability through ICF, in another qualitative research, the experience and perspective of rehabilitation assistants who have a higher management level than the secretary of the commission should be discussed. Also, in the continuation of qualitative research, it is not without benefit to conduct quantitative research. Also, using the viewpoint of the officials of associations related to people with disabilities, such as the society of the disabled, the association for the defense of the rights of the disabled, and other informants in this field also adds to the richness of the findings of this research.

Conclusion
The findings of the research showed that those referring to the medical commissions of the Welfare Organization in relation to the implementation of the ICF face many problems in the two fields of executive and communication affairs, which need to be taken into consideration by the authorities.

Limitations of the research
1) Simultaneously conducting interviews with the country's special political and security conditions in September 2022. 2) The non-cooperation of the security of one of the general welfare departments and the inappropriate and unprofessional treatment of the expert of this general department with the researcher and the research and obstruction to limit the researcher's scope of action, including not recording interviews, not interviewing people with disabilities, and not using Virtual space for interviews in the second half of the interviews. 3) The non-cooperation of the deputy of rehabilitation of one of the welfare departments and the inappropriate and unprofessional treatment of the researcher and research to introduce this person to the medical commissions to complete the desired sample. 4) The non-cooperation and obstruction of the rehabilitation deputy of one of the general welfare departments, despite being introduced to one of the medical commissions, which led to the non-cooperation of the rehabilitation commission members of the center in question. 5) The unwillingness of some members of the commissions who were given permission to interview them. 6) Lack of time for commission members to conduct interviews due to consecutive meetings of the commission in one day. 7) Lack of time for people with disabilities to conduct interviews on the day of the commission. 8) The impossibility of interviewing people with mental and neurological disabilities and the inability of their companions to interview them due to the presence of the person with disabilities on the day of the commission. 9) Unwillingness to conduct non-personal interviews by some people despite the fact that they gave their phone number or took the researcher's phone number.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR. IUMS.REC.1400.1045).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank people with disabilities and members of medical commission who helped in conducting this research.




References