On January 20 (Sat.), 2018, the 7th Ministry of Health, Labour and Welfare ICF Symposium
On January 20 (Sat.), 2018, the 7th Ministry of Health, Labour and Welfare ICF Symposium -Preparing for the Future Society through the Use of the International Classification of Functioning, Disability and Health (ICF): For a Future Society Where Everyone Can Shine- was held in Iino Hall in Kasumigaseki, Tokyo. This year’s symposium was innovative in two ways. First, the symposium invited the key person on ICF implementation from WHO, which presented a valuable opportunity to directly ask the WHO officer about “Why WHO’s focus on ICF,” the concept of ICF, and the vision for its use. Second, the symposium hosted poster presentation and exhibition on examples of ICF use to help share information and identify uses of ICF for further implementation of ICF. With close to 400 persons participating, the symposium provided a major impetus for fully fledged implementation and use of ICF.
Dr. Alarcos Cieza is the leading expert on ICF who built the foundation for use of ICF as an effective tool to monitor well-being as defined by WHO. At WHO, Dr. Cieza oversees work on rehabilitation policies and care, community-based rehabilitation, ICF-based data collection, and rehabilitation and disability research. In her keynote speech titled, “Why WHO’s Focus on ICF?” she proclaimed that WHO seeks to achieve well-being for people of all ages, that 15% of the world’s population have some forms of disability and ICF is extremely useful for achieving well-being for persons with disability, that Japan has exercised leadership in the world as a champion of the 11th Revision of ICD, that ICF is included in ICD-11 and the joint use of ICD-11 (International Classification of Diseases), ICF (International Classification of Functioning, Disability and Health), and ICHI (International Classification of Health Interventions) is expected to enable collection of health data that will serve as the base for realizing well-being, and that Japan will also be a champion in such use of the classifications.
Kanagawa Prefecture Vice Governor Kenji Shuto gave a lecture highlighting the prefecture’s efforts to promote the Healthcare New Frontier Policy in the National Strategic Special Zone based on the concept of ME-BYO, which has a high level of affinity with ICF. Lectures were also given by other leading experts working on the implementation of ICF in Japan. Through direct dialogue with WHO, the panel discussion helped to clarify the future direction of ICF implementation within the context of a global vision.
The global promotion of the Universal Health Coverage is accelerating the use of ICF. The symposium helped to set a new trend in the coming era with the cooperation of WHO.
On January 18 (Thu.) and 19 (Fri.), 2018 Dr. Alarcos Cieza of WHO Visits Japan for Courtesy Visits and Tours
Over two days on January 18 (Thu.) and 19 (Fri.), 2018, Dr. Alarcos Cieza, Coordinator for the Blindness and Deafness Prevention, Disability and Rehabilitation (BDD) Unit of the Management of NCDs, Disability, Violence and Injury Prevention Department of WHO, paid courtesy visits and made tours of various organizations that were hosting, supporting, and cooperating in the 7th Ministry of Health, Labour and Welfare ICF Symposium. Dr. Cieza was visiting Japan to attend the symposium.
Soon after arriving in Japan, Dr. Cieza went to the National Rehabilitation Center for Persons with Disabilities in Tokorozawa in the afternoon of January 18 (Thu.) to pay a courtesy visit to Dr. Yoshiko Tobimatsu, President of the center, make tours of the center, and meet and have discussions with the staff members of the center’s respective departments.
In the morning of January 19 (Fri.), Dr. Cieza made a courtesy call on Director-General Kazuaki Sakamitsu for Statistics and Information Policy of the Ministry of Health, Labour and Welfare (MHLW) to discuss ways to make the ICF Symposium of the following day a success. In consideration of Dr. Cieza’s role within WHO, officers from the Health and Welfare Bureau for the Elderly and the Department of Health and Welfare for Persons with Disabilities of the Social Welfare and War Victims’ Relief Bureau also attended the meeting from the MHLW, using the valuable opportunity to exchange views and ideas. Dr. Cieza conveyed WHO’s sincere appreciation to Japan for championing the 11th Revision of ICD and the country’s contribution to the revision. She noted that ICD-11 breaks new ground by including ICF and expressed appreciation to Japan and hopes for further collaboration.
In the afternoon, Dr. Cieza visited Kanagawa Prefectural Government, which is giving support to the 7th ICF Symposium.
As the National Strategic Special Zone, Kanagawa Prefecture is promoting the Healthcare New Frontier Policy, with the cooperation of WHO, to address the challenges of the super ageing society. There is a high level of affinity between ICF and the Healthcare New Frontier Policy.
After making a tour of Shonan Robocare Center, Dr. Cieza paid courtesy visits to Kanagawa Prefecture Vice Governor Kenji Shuto and the “Healthcare New Frontier” Promotion Headquarters Office at the Kanagawa Prefectural Government Office, confirming that the prefecture and WHO will seek to work towards further development of the collaborative relations.
On December 15 (Fri.), 2017 Dr. John Grove of WHO Pays Courtesy Visit to the Ministry of Health, Labour and Welfare
On December 15 (Fri.), 2017, Dr. John Grove, Director of the Information, Evidence and Research (IER) Department at WHO, who oversees the 11th Revision of ICD as an officer responsible for the WHO Family of International Classifications (WHO-FIC), paid a courtesy visit to Director-General Kazuaki Sakamitsu for Statistics and Information Policy of the Ministry of Health , Labour and Welfare (MHLW).
Dr. Grove succeeded Dr. Ties Boerma as Director of the IER Department. During the visit, Dr. Grove expressed appreciation for cooperation extended by Japan over many years in the work of ICD-10 updates and the 11th Revision of ICD. Director-General Sakamitsu replied by expressing profound respect for WHO’s contribution to the work of international health. They confirmed cooperation towards the release of ICD-11 in 2018 as the courtesy visit drew to a close in an amiable atmosphere. Dr. Grove was visiting Japan to attend the Universal Health Coverage Forum (UHC Forum). His visit confirmed further collaboration between Japan and WHO.
On October 16 (Mon.) to 21 (Sat.), 2017 Report on Participation in the WHO Family of International Classifications (WHO-FIC) Network Annual Meeting
The WHO Family of International Classifications (WHO-FIC) Network Annual Meetings are held every autumn in locations around the world. In 2017, the meeting was held over six days from October 16 to 21 in Mexico City, Mexico.
Each year, representatives from countries involved in the WHO-FIC gather at this meeting. From Japan, a delegation from the Centre (19 delegates with Kei Mori, Centre Head, Ministry of Health, Labour and Welfare, as the head of the delegation) participated.
|Theme for 2017:
||Sharing Data for Health
||October 16 (Mon.) -21 (Sat.), 2017
||World Trade Center
||WHO, Mexico Ministry of Health
||WHO, Collaborating Centres for the WHO-FIC, health- and statistics-related government departments, NGOs, observers, etc.
At this year’s meeting, it was announced that ICD-11, for which Japan has consistently contributed throughout the revision process, is expected to be released in June 2018. In preparation for the release, there were discussions on transitioning from ICD-10 to ICD-11 and on supporting countries in the transition.
Amid these moves, the Medical and Scientific Advisory Committee (MSAC), which was established during this financial year, had its first official face-to-face meeting during the annual meeting to enrich, and make more effective, the WHO-FIC.
From Japan, Dr. Naoko Tajima, the former Chair of the Internal Medicine Topic Advisory Group (TAG), assumed the position of the Co-Chair of MSAC, alongside Dr. Chris Chute, the former Chair of the ICD Revision Steering Group (RSG). Dr. Sumiko Nagoshi, the former Chair of the Hepatology and Pancreatobiliary WG of the Internal Medicine TAG, Dr. Satoshi Kashii, the former Chair of the Ophthalmology TAG, and Dr. Kenji Watanabe, the former Chair of the Traditional Medicine TAG, were also chosen as members of MSAC, raising hopes for their further contribution to the WHO-FIC.
Japan and other countries reported on the results of the ICD-11 field trials. In Japan, with the cooperation of Japan Society of Health Information Management and the National Institute of Public Health, some 400 people participated in coding diagnostic terms and cases that had been prepared in advance by WHO. The validity of the test results and coding-related issues were examined and presented during the annual meeting.
During the Poster Session, posters by Dr. Hiroshi Mizushima (National Institute of Public Health) and Mr. Satoshi Tamai (National Center for Child Health and Development), two members of the delegation from Japan, were selected for oral presentation during the session.
The Japanese delegation also got together during the annual meeting to exchange information and views and to report on the meeting. It was an excellent opportunity to deepen the bond among the delegates.
It was announced that the next WHO-FIC Network Annual Meeting is scheduled to be held from October 22 to 28, 2018 in South Korea. The Mexico meeting came to a close with expectations for further work and accomplishments from the member countries for the next year.
On September 1 (Fri.) and 2 (Sat.), 2017 Report of the Interactive Review Meeting for WHO ICD-11 Implementation in Japan
On September 1 (Fri.) and 2 (Sat.), 2017, the Interactive Review Meeting for WHO ICD-11 Implementation in Japan was held at the Ministry of Health, Labour and Welfare (MHLW). The meeting was jointly organized by the MHLW and the Japanese Society of Internal Medicine. Attending the meeting from abroad were the expert from WHO and two other ICD experts. From Japan, members of the ICD Expert Committee, experts from the Japanese Society of Medical Sciences, the Japanese Association for Dental Science, and other organizations, and members of related departments within the MHLW attended.
The 11th Revision of ICD was launched in Japan in 2007. For 10 years after the launch, Japan has made significant contribution to supporting the revision in terms of scientific, personnel, and financial input through comprehensive national stakeholder involvement.
The development of ICD-11 has entered the final phase towards its official release in 2018. WHO has reorganized the existing revision structure and established new organizations, including the Medical and Scientific Advisory Committee (MSAC) and other expert groups. Four members of the MSAC are from Japan, including Dr. Naoko Tajima, Professor Emerita of The Jikei University School of Medicine and the Chair of the Internal Medicine TAG of the WHO ICD-11 Revision Steering Committee.
As the development of ICD-11 progresses into a new stage with WHO’s reorganization of the revision structure, Member States are also preparing to implement ICD-11 in their countries.
In Japan, the review meeting with the WHO officer paves the way for this new stage and follows on the 1st National Conference on ICD-11 in FY 2017 held earlier in the year.
The review meeting was held on September 1 (Fri.) and 2 (Sat.), 2017, at the MHLW and was jointly organized by the MHLW and the Japanese Society of Internal Medicine. The expert from WHO and two other ICD experts were invited from abroad. Members of the ICD Expert Committee, experts from the Japanese Society of Medical Sciences, the Japanese Association for Dental Science, and other organizations, and members of related departments within the MHLW participated from Japan.
On the first day of the meeting, Director-General Sakamitsu for Statistics and Information Policy of the MHLW, Dr. Takashi Kadowaki, Chair of the ICD Expert Committee of the Statistic Subcommittee of the Social Security Council of the MHLW, and Dr. Robert Jakob, the WHO Team Leader for the 11th Revision of ICD, gave addresses. In the morning session, Dr. Hiroyuki Suenaga, President of Japan Society of Health Information Management, and Dr. Kei Mori, Director of Japan ICD Office of the MHLW, provided an overview of the history of Japan’s involvement in ICD, under the title, “International and national developments of ICD.”
This was followed by a presentation, titled, “Overview of ICD-11,” by Dr. Jakob on the general progress of the revision process, including the history of ICD-11 development and future timelines, features of ICD-11, major changes from ICD-10, and ICD-11 coding trials (examples of coding done using ICD-11 and introduction to the Coding Tool).
In the afternoon session, Ms. Lori Moskal and Ms. Megan Cumerlato gave a presentation, titled, “National Modification-From experiences in Canada & Australia-,” on the experience of Canada and Australia, which have the national modifications of ICD-10. Dr. Satoshi Kashii, Professor at Aichi Shukutoku University, gave a presentation on his experience in the field of ophthalmology.
Chief Kaori Nakayama of the International Statistics Section of Japan ICD Office of the MHLW gave a briefing on the “Points of ICD-11 national implementation,” systematically identifying key considerations when introducing ICD-11 into Japan.
At the end of the first day, a social event was held at Hibiya Matsumotoro restaurant. At the opening, Dr. Morito Monden, President of the Japanese Association of Medical Sciences, expressed, in his address, his hopes for the success of the review meeting and the future development of ICD-11. The participants were served a delicious meal and Shamisen performance by members ofMHLW. The guests promoted friendship against this backdrop of Japanese culture and warm hospitality that is the tradition of Japan ICD Office.
On the second day of the meeting, Dr. Mori gave a summary report from the first day of the meeting, which was followed by a presentation by Dean Soichiro Miura of the International University of Health and Welfare Graduate School, as he represented The Japanese Society of Gastroenterology in discussing the technical aspects of developing a specialty linearization in the field of gastroenterology.
Dr. Jakob then gave responses to questions and comments that had been received in advance from the Japanese Society of Neurology, Japanese Society of Psychiatry and Neurology, Japanese Society of Allergology, Japanese Society of Sleep Research, Japan Pediatric Society, and Japanese Orthopaedic Association. There were also active discussions during the Q&A session.
The two-day meeting was truly meaningful in terms of providing better understanding of ICD-11 among the participants and identifying concrete issues that will need to be addressed in the future by WHO.
As the participants were widely notified about how to submit proposals on ICD-11, it is hoped that experts will continue to submit concrete proposals and promote validation for implementation of ICD-11 in Japan.
August 31 (Thu.), 2017 Courtesy Call by Dr. Robert Jakob, the WHO Team Leader for the 11th Revision of ICD
On August 31 (Thu.), 2017, Dr. Robert Jakob, the WHO Team Leader for the 11th Revision of ICD, paid a courtesy visit to Director-General Kazuaki Sakamitsu for Statistics and Information Policy of the Ministry of Health, Labour and Welfare (MHLW).
Dr. Jakob’s courtesy call preceded his attendance at the Interactive Review Meeting for WHO ICD-11 Implementation in Japan, which was jointly organized by MHLW and the Japanese Society of Internal Medicine, on September 1 (Fri.) and 2 (Sat.), 2017, at MHLW.
Dr. Jakob conveyed WHO’s sincere appreciation for the cooperation, support, and contribution extended by Japan over many years for the 11th Revision of ICD, and expressed hopes for Japan’s contribution of its wisdom and expertise at the forthcoming review meeting. He said that he hoped that cooperation with Japan will further develop in the future.
Director-General Sakamitsu noted that Japan had been actively involved in the 11th Revision of ICD from the early stages and that the participants at the two-day review meeting have a keen interest in the revision and are looking forward to the opportunity to talk directly with the WHO officer responsible for the revision. Director-General Sakamitsu handed Japan’s “Response to WHO’s Request for Member State Comments on ICD-11 Development.” After a group photoshoot, the visit ended in a cordial atmosphere.
June 14 (Wed.), 2017
Report on the 1st Management Council Meeting of the WHO-FIC Collaborating Centre in Japan in FY 2017
On June 14, 2017, the WHO-FIC Collaborating Centre in Japan organized the first Management Council meeting in FY 2017 at the Ministry of Health, Labour and Welfare.
The WHO-FIC Collaborating Centre in Japan is entrusted by WHO to contribute to the development, revision, and implementation of the WHO Family ofInternational Classifications (WHO-FIC), particularly the International Classification of Diseases (ICD), the International Classification of Functioning, Disability and Health (ICF), and the International Classification of Health Interventions, which help to promote global health. The Centre carries out its activities though the involvement of all stakeholders in Japan (Ministry of Health, Labour and Welfare, National Institute of Public Health, National Rehabilitation Center for Persons with Disabilities, National Cancer Center, National Center for Global Health and Medicine, National Center for Child Health and Development, Japan Hospital Association/Japan Society of Health Information Management, and Japan Liaison of Oriental Medicine).
At the Management Council meeting, which gathers all members of the Centre, lively discussions were held on the state of development of ICD-11, the Centre’s current activities, and plans for the current fiscal year to further strengthen partnership towards promoting Japan’s contribution to the world.
Active discussions on further contributing Japan’s expertise to the world
A show of unity in front of the WHO Flag, the Centre’s symbol
May 30 (Tue.), 2017 at Fukuracia Tokyo Station Report on the 1st National Conference on ICD-11 in FY 2017
In 2007, Japan hosted the launch of the 11th Revision of ICD. For 10 years after that, Japan has made significant contributions to supporting the revision in terms of scientific, personnel, and financial input through comprehensive national stakeholder engagement.
The development of ICD-11 has now entered the final phase towards its official release in 2018. WHO has reorganized the existing revision structure and established new organizations, including the Medical and Scientific Advisory Committee (MSAC) and other expert groups.
Dr. Naoko Tajima, Professor Emerita of The Jikei University School of Medicine, who served as Chair of the Internal Medicine TAG of the WHO ICD-11 Revision Steering Group, has been appointed as the Co-Chair of the MSAC.
In response to these new developments at WHO, the national conference on ICD-11 was established with leading experts in related fields in Japan. The conference will form a part of the research group on “Development of international statistical classifications that effectively contribute to policy planning in the fields of healthcare and nursing care while taking into account changes in the social structure.” The research is funded by the FY 2017 Health and Labour Sciences Research Grant.
List of Members of the National Conference on ICD-11 (link)
At the conference, information was provided on developments at WHO regarding ICD-11 and on the system for reviewing ICD-11 in Japan. There was a meaningful discussion towards submission of Japan’s proposals on ICD-11. For the review of ICD-11 in this new era of health, there are significant expectations on the role of Japan to provide its expertise. The participants reached an agreement on further enhancing the activities of the conference.
Professor Iimura of Nara Medical University, the research principal investigator, acting as the moderator
Many participants attended, including President Kadowaki of The Japanese Society of Internal Medicine and Dr. Tajima (MSAC Co-Chair)
March 18 (Sat.), 2017 The 6th Ministry of Health, Labour and Welfare ICF Symposium
On March 18 (Sat.), 2017, the 6th Ministry of Health, Labour and Welfare ICF Symposium was held in Square Kojimachi. The theme of the symposium was “Towards the Use of the Classification of Functioning, Disability and Health,” and the subtitle was “Case Studies on the Specific Uses of the Classification.”
The symposium attracted over 230 participants.
The International Classification of Functioning, Disability and Health (ICF) is a classification developed by World Health Organization (WHO). It is a classification of “functioning,” which describes various functions that people need in order to live their lives.
WHO recommends that ICF should be used as an assessment tool in various fields of health, healthcare, and welfare.
In the previous ICF symposiums, we introduced the concept of ICF, its use as a common language across a variety of fields, and explored the use of assistive devices as one of the environmental factors. In this symposium, we listened to the voices of practitioners involved in ongoing research and actual use of ICF in the field, in the hope further expanding the use of ICF.
The speakers gave a lucid account of their experience of using ICF in a variety of specializations. In particular, Mr. Nakamura and Professor Tsutsui, who gave keynote lectures in the first session, articulated the potential of ICF use as well as challenges. There was also a very active exchange of opinions during the panel discussion. It was a very stimulating symposium for the participants. We will prepare a report on the symposium and distribute materials on the website to provide information to those who were unable to attend the symposium.
||Yoshiko Ando (Director-General for Statistics and Information Policy, Ministry of Health, Labour and Welfare)
Kozo Nakamura (Chair, Expert Committee on Classification of Functioning, Disability and Health, Statistics Committee, Social Security Council)
||・Daily Life Management
Haruki Nakamura (President, Japanese Association of Occupational Therapies)
・Japan’s Healthcare and Long-Term Nursing Care Policies from the International Perspective and Possibility of ICF Use
Takako Tsutsui (Professor, University of Hyogo Graduate School of Business)
|Panel Discussion (report of specific cases of ICF use)
||・ICF Use through Kinder Infant Development Scale (KIDS)
Keiji Hashimoto (National Center for Child Health and Development)
・ Development and Clinical Use of ICF-Based General Evaluation System in the Field of Rehabilitation
Shigeru Sonoda (Professor, Rehabilitation II, School of Medicine, Fujita Health University)
・Dementia Rehabilitation and International Classification of Functioning, Disability and Health (ICF)
Chiga Murai (Chief Occupational Therapist, Ishikawa Prefectural Takamatsu Hospital; formerly Deputy Director, Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare)
・Establishment of Comprehensive Regional Care System and Information Linkage
Hiromi Ishikawa (Executive Board Member, Japan Medical Association)
Atmosphere at the venue
October 15 (Sat.), 2017
WHO Family of International Classifications (WHO-FIC) Network Annual Meeting and ICD Revision Conference
In October 2016, WHO Family of International Classifications (WHO-FIC) Network Annual Meeting and ICD-11 Revision Conference were held in Tokyo.
The WHO-FIC Network Meeting, held at around October each year with the hosting country rotating among member countries, gathers persons responsible for the International Classification of Diseases (ICD)*1 and other Family of International Classifications for discussion, coordination, and reporting. Before this year’s meeting, Japan hosted the meeting in 2005. On the other hand, ICD-11 Revision Conference is held in anticipation of the large-scale revision of ICD. Ministries of health and other bodies representing the Member States of World Health Organization (WHO) were invited and shown the draft revised version of ICD. The participants exchanged opinions on the revision and discussed challenges related to ICD implementation and other issues.
At the joint opening ceremony, State Minister Noriko Furuya of Health, Labour and Welfare, in her address, touched on the Kobe Communiqué adopted at the G7 Health Ministers’ Meeting in 2016 and spoke about the importance of ICD as a foundation of people’s health. Dr. Margaret Chang, Director-General of WHO, delivered a speech in which she expressed hope that ICD-11 would pave the way for a new era of health information. The International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11-MMS) 2016 Edition was released for comment from WHO Member States. A wide range of sessions was organized to discuss the use of ICD-11, the environment surrounding healthcare information, maternal health and mental health, and trends in traditional medicine.
Taken together, the two conferences had more than 300 participants from around 50 countries. Many Member States invited by WHO expressed high expectations for ICD-11.
＜WHO-FIC Network Annual Meeting＞
||October 8 (Sat.) - 12 (Wed.), 2016
||Jikei University School of Medicine and Tokyo International Forum
||WHO and Collaborating Centre for the WHO-FIC in Japan*2
||Collaborating Centres for the WHO-FIC, health and statistics departments of WHO Member States, WHO Headquarters, WHO Regional Office for the Western Pacific
＜ICD-11 Revision Conference＞
||October 12 (Wed.) - 14 (Fri.), 2016
||Tokyo International Forum
||Representatives of WHO Member States, WHO Headquarters, etc.
||ICD-11 Revision Conference：Health Information in the New Era
Opening address by State Minister Noriko Furuya of Health, Labour and Welfare
Opening address by Director-General Margaret Chang of WHO
- International Classification of Diseases (ICD)
The full title of ICD is the “International Statistical Classification of Diseases and Related Health Problems.”
ICD is a statistical classification endorsed by WHO for international comparison of statistics on diseases, injuries, and causes of death. In Japan, it is used in vital statistics surveys and the Diagnosis Procedure Combination (DPC) system for medical service fee reimbursement.
WHO is working on a major revision of ICD for development of ICD-11.
- The Collaborating Centre for the WHO-FIC in Japan consists of the following organizations:
December 13, 2012
The 3rd Ministry of Health, Labour and Welfare ICF Symposium “Towards Utilization of International Classification of Functioning, Disability and Health – Challenges and Solutions”
The International Classification of Functioning, Disability and Health (ICF), adopted by WHO in 2001, is quickly becoming a “common language” among different sectors, encouraging research and development for its introduction. In Japan, two symposia have been held in the past few years (2010-2012), focusing on education and implementation of ICF as a common language for functioning, disability and health. The 3rd symposium dug deeper into the topic, as it focused on challenges faced by medical professionals in using ICF and their possible solutions.
Symposium report is available for downloading from the following link.
(Japanese text Only)
＜ Event Overview ＞
||Thursday 13, December,2012 Open 12:00 Start 13:00 Close 17:00
||The National Museum of Emerging Science and Innovation (Miraikan)
||Ministry of Health, Labour and Welfare / Japan Society of Health Information Management
||Health, Labour and Welfare Statistics Association
- Japan Medical Association
- Japan Hospital Association
- Japanese Nursing Association
- Japanese Association of Social Care Service Worker
- Japanese Association of Social Workers in Health Services
- Japan Care Manager Association
- The Japan Association of Certified Care Workers
- Japanese Association of Speech-Language-Hearing Therapist
- Japanese Association of Occupational Therapists
- Japanese Association of Schools of Social Work
- Japanese Association of Certified Social Workers
- Japanese Association of Schools of Certified Social Worker
- Japanese Society for Rehabilitation of Persons with Disabilities
- Japanese Association of Psychiatric Social Workers
- Japanese Association of Social Workers
- Japan Association for Interprofessional Education
- Japanese Physical Therapy Association