International Classification of Functioning, Disability and Health

 INTRODUCING THE ICF 

The International Classification of Functioning, Disability and Health (ICF) is a framework for describing and organising information on functioning and disability. It provides a standard language and a conceptual basis for the definition and measurement of health and disability. 

The ICF was approved for use by the World Health Assembly in 2001, after extensive testing across the world involving people with disabilities and people from a range of relevant disciplines. A companion classification for children and youth (ICF-CY) was published in 2007. 

The ICF integrates the major models of disability. It recognises the role of environmental factors in the creation of disability, as well as the relevance of associated health conditions and their effects. 

This overview provides a brief introduction to the ICF — its structure, contents, purposes and applications. 

Aims 

The ICF is a multipurpose classification system designed to serve various disciplines and sectors — for example in education and transportation as well as in health and community services — and across different countries and cultures.  The aims of the ICF (WHO 2001:5) are to: 

    • provide a scientific basis for understanding and studying health and health-related states, outcomes, determinants, and changes in health status and functioning; 
    • establish a common language for describing health and health-related states in order to improve communication between different users, such as health care workers, researchers, policy-makers and the public, including people with disabilities; 
    • permit comparison of data across countries, health care disciplines, services and time; and 
    • provide a systematic coding scheme for health information systems. 

The ICF ‘has been accepted as one of the United Nations social classifications … and… provides an appropriate instrument for the implementation of stated international human rights mandates as well as national legislation’ (WHO 2001:5-6). Hence, the ICF provides a valuable framework for monitoring aspects of the UN Convention on the Rights of Persons with Disabilities (UN 2006), as well as for national and international policy formulation. 

Underlying principles 

Four general principles guided the development of the ICF and are essential to its application. 

Universality. A classification of functioning and disability should be applicable to all people irrespective of health condition and in all physical, social and cultural contexts. The ICF achieves this and acknowledges that anyone can experience some disability. It concerns everyone’s functioning and disability, and was not designed, nor should be used, to label persons with disabilities as a separate social group. 

Parity and aetiological neutrality. In classifying functioning and disability, there is not an explicit or implicit distinction between different health conditions, whether ‘mental’ or ‘physical’. In other words, disability is not differentiated by aetiology. By shifting the focus from health condition to functioning, it places all health conditions on an equal footing, allowing them to be compared using a common metric. Further, it clarifies that we cannot infer participation in everyday life from diagnosis alone. 

Neutrality. Domain definitions are worded in neutral language, wherever possible, so that the classification can be used to record both the positive and negative aspects of functioning and disability.

Environmental Influence. The ICF includes environmental factors in recognition of the important role of environment in people’s functioning. These factors range from physical factors (such as climate, terrain or building design) to social factors (such as attitudes, institutions, and laws). Interaction with environmental factors is an essential aspect of the scientific understanding of ‘functioning and disability’. 

THE ICF MODEL 

In the ICF, functioning and disability are multi-dimensional concepts, relating to: 

    • the body functions and structures of people, and impairments thereof (functioning at the level of the body); 
    • the activities of people (functioning at the level of the individual) and the activity limitations they experience; 
    • the participation or involvement of people in all areas of life, and the participation restrictions they experience (functioning of a person as a member of society); and 
    • the environmental factors which affect these experiences (and whether these factors are facilitators or barriers). 

The ICF conceptualises a person’s level of functioning as a dynamic interaction between her or his health conditions, environmental factors, and personal factors. It is a biopsychosocial model of disability, based on an integration of the social and medical models of disability. 

As illustrated in figure 1 , disability is multidimensional and interactive. All components of disability are important and any one may interact with another. Environmental factors must be taken into consideration as they affect everything and may need to be changed. 

Figure 1: Interactions between the components of ICF (WHO 2001:18)

Although personal factors are recognised in the interactive model shown in Figure 1, they are not classified in the ICF at this time. Such factors influence how disability is experienced by the individual and some, such as age and gender, are commonly included in data collections. 

ICF components

The ICF can provide or underpin a descriptive profile of an individual’s pattern of functioning, not a ‘yes’ or ‘no’ answer about whether he or she is disabled.
A decision about where to draw a line between ‘no disability’ and ‘disability’ depends on the purposes for doing so. Individual measures, surveys and other applications must be based on this understanding as well as the knowledge that there are multiple dimensions of disability, and potentially multiple perspectives to consider.
Different measurement or policy purposes may result in different decisions about which aspects of disability to focus on and which thresholds are relevant – and hence in different measures and estimates at individual or population level.


Body functions – The physiological functions of body systems (including psychological functions). Body structures – Anatomical parts of the body such as organs, limbs and their components. Impairments – Problems in body function and structure such as significant deviation or loss.

Activity – The execution of a task or action by an individual.

Participation – Involvement in a life situation.

Activity limitations – Difficulties an individual may have in executing activities.

Participation restrictions – Problems an individual may experience in involvement in life situations.

Environmental factors – The physical, social and attitudinal environment in which people live and conduct their lives. These are either barriers to or facilitators of the person’s functioning.

Functioning is an umbrella term for body function, body structures, activities and participation. It denotes the positive or neutral aspects of the interaction between a person’s health condition(s) and that individual’s contextual factors (environmental and personal factors).

Disability is an umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between a person’s health condition(s) and that individual’s contextual factors (environmental and personal factors).

Table 2: Definitions: Functioning, disability and the components of the ICF

Each component is articulated in different levels that proceed in a branched way to each of which is associated an acronym.
In the context of the ICF, five main components are identified. Four of them are classified using codes to represent a different aspect of the person or environment. The classification of the various components is characterized by the assignment of a code: Body Functions (b); Body Structures (s); Activity and Participation (d) and Environment (e). The fifth component Personal Factors (pf), is not expanded with a code within the classification.

Thanks to the levels of classification, it is therefore possible to identify all aspects of health and those related to them, for example the abbreviation b167.3, reads as follows: (b) stands for body functions; (b1) mental structures; (b16) thought functions; (b167) mental and language functions;(3) qualifier: serious problem.


Area of Functioning ICF code ICF Rating Description of Need
Intellectual b117 0 Intelligence assessed whithin average range
Regulation of behavior b127.4 3 Has great difficulty adapting behaviour appropiately to classrom context
Impulse control b12304.3 2 Has difficulty resisting sudded urges to do things
Short term memory b1440 2 Moderste impairment in test of STM
Attention b1460 2 Both parents and teachers report moderate difficulties in maintaining attention
Orientation b1141/b1148 2 Has difficulty rwith temporal and spatola orientaton
Emotional b152 2 Emotional responsed are inappropriate and he has difficulty regulation them
Visual Perception b1561 2 Had difficulty whit all tests involving visual perception
Motor coordination b760/b7601&2 2 Fine motor coordination and finger dexterity difficulties have been identified

A further class of definition is the qualifiers, numerical codes that describe the extent and severity of the functioning of disability in that category, or the degree to which an environmental factor constitutes a facilitator or barrier. The qualifiers of body functions are the following:

xxx.0

no problem

0-4%

(absent, negligible…)

xxx.1

slight problem

5-24%

(light, small…)

xxx.2

slight problem

25-49%

(moderate, discreet…)

xxx.3

serious problem

50-95%

(remarkable, extreme…)

xxx.4

complete problem

96-100%

(total…)

xxx.8

not specified

\

\

xxx.9

not specified

\

\

In this perspective, therefore, disability is defined as the consequence or result of a complex relationship between an individual’s health condition and personal factors, and environmental factors that represent the circumstances in which the individual lives (ICF).

Figure 3: Exemple ICF: Andy ‘s Profile.

Summarizing the ICF classification, it describes individual health conditions according to three different dimensions: Body Functions and Structures, Activity and Participation, and Contextual Factors. These three dimensions, in addition to defining the functional levels, take into account the related contextual factors, divided into environmental and personal.

Operationally, the classification allows to define the level of disability in relation to the context of actual and potential use, thus providing the cognitive elements necessary for the identification of user ranks and for the planning of the intervention strategy to be adopted.
This classification can be followed, on the basis of the objectives of the assessment, by the selection of regulatory tools in the ergonomic sector, and in particular those aimed at user-centered design.

The range of other applications

The ICF provides a framework for the description of human functioning, on a continuum. It is important to remember that it classifies functioning, not people. Because the development and testing of the ICF involved people from a broad range of backgrounds and disciplines, including people with disability, the ICF has a wide range of potential applications.

People use the ICF across broad sectors including health, disability, rehabilitation, community care, insurance, social security, employment, education, economics, social policy, legislation and environmental design and modification.

The ICF offers an international, scientific tool to study disability, in all its dimensions. It may be used by persons with disabilities and professionals alike, across different sectors and care settings, (e.g., community services and support, primary care, hospitals, rehabilitation centres, nursing homes) and populations.

Examples of application

Some of the applications of the ICF that demonstrate its versatility and utility as a model of functioning and disability, and as a common language, are as follows:

    • The ICF and its model have been introduced into legislation and social policy in some countries. For example it is used in social security and registration systems in Latin America. As more countries ratify the UN Convention on the Rights of Persons with Disabilities, it is hoped that the ICF will become the world standard for disability data and social policy modeling for all countries. It provides a valuable information framework for monitoring mechanisms in order for countries to report to the UN on progress against the Convention’s targets.
    • In clinical settings the ICF can be used in its full range as a framework for rehabilitation programming (Martinuzzi et al 2010). For specific disease conditions, instead of using the entire ICF (with its approximately 1400 categories) it can be useful to have a short list of ICF categories that are essential to describe the disability experience of the person. To achieve this, ICF ‘core sets’ have been developed with practitioners and people who experience the disease, in a systematic consensus approach (see www.icf-research-branch.org/publications/publications ).
    • The ICF can be used to underpin reforms in education, employment or social welfare and ensure coherent implementation across different levels and sectors. For example in Switzerland, the ICF is used in education as a model and classification to establish eligibility (see www.sav-pes.ch) and to organise school-based support (Hollenweger, Lienhard 2007). In Italy a nationwide experience in the employment sector and local experiences in education have shown great potential (see www.reteclassificazioni.it/).
      NGOs delivering disability services see the value in using the ICF (see example of a children’s services organization at www.novita.org.au/Content.aspx?p=573).
    • The definition of disability can influence advocacy cases and the ICF can be used to support the rights based approach to disability. This broader potential value of the ICF was recognised by advocates involved in its development (Hurst 2003).
    • The ICF is suitable for use in community based life and care, and across multi-disciplinary care. The model can be used to underpin case planning, monitoring of progress, and outcomes evaluation. It is consistent with an approach to care and treatment that is person-centred, a partnership, and holistic. Accordingly, its use in primary care has been advocated (e.g. Veitch et al 2009).
    • The ICF is valuable as a unifying model in rehabilitation medicine practice, research and education (Stucki et al 2007). It assists professionals to look beyond their own areas of practice, communicate across disciplines, and think from a functioning perspective rather than the perspective of a health condition.
    • There is a growing body of research focused on the use of the ICF, not only for identifying people’s health care, rehabilitative and support needs, but also for identifying and measuring the effect of the physical, social and policy environments in their lives.

Ethical use

Every scientific tool can be misused, and the ICF is no exception. For all uses of ICF—clinical, research, epidemiological, health and social policy—it is essential that information gathered and analysed must respect the inherent value and autonomy of the individuals from whom the information is gathered. Standard rules about informed consent apply, but more importantly people with disabilities must participate in all aspects of the use of ICF and the application of the data produced.

Full participation and transparency of use are most important in the social applications of ICF and, in particular, with the anticipated use of ICF for the development of indicators for monitoring the implementation of the UN Convention on the Rights of Persons with Disabilities. This important human rights document—which embodies precisely the same conceptual refinement of functioning and disability as the ICF—is our moral compass towards the development of social policy and political change needed to achieve the full participation of persons with disabilities. The ethical application of ICF seeks to support and further this mandate for the future.

 


References

International Classification of Functioning, Disability and Health (ICF): WHO-FIC, < http://www.who.int/classifications/en/> 

 

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