SPECIAL REPORT

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND

HEALTH: AN INTRODUCTION AND DISCUSSION OF ITS POTENTIAL
IMPACT ON REHABILITATION SERVICES AND RESEARCH
To ra H. Dahl
From the WHO Collaborating Centre for the Classication of Diseases in the Nordic countries, Uppsala, Sweden
This paper provides an introduction to the content and
concepts of the World Health Organizations new Interna-
tional Classication of Functioning, Disability and Health
(2001) and discusses its potential applications in rehabilita-
tion services and research. Great interest has been expressed
in the International Classication of Functioning, Disability
and Health by its potential users and there is growing
evidence that its conceptual framework is consistent with the
understanding of functioning both for professionals and for
people with disabilities.
Key words: ICF, International Classification of Functioning,
Disability and Health, rehabilitation research, rehabilitation
concepts, disability studies.
J Rehabil Med 2002; 34: 201204
Correspondence address: Tora H. Dahl, OTD,
Roennehavew 9, DK-8520 Lystrup, Denmark.
E-mail: trdahl@postb.tele.dk
Submitted June 7, 2002; Accepted June 17, 2002
INTRODUCTION
This paper provides an introduction to the central concepts of the
World Health Organizations (WHOs) new classication
International Classication of Functioning, Disability and
Health (ICF) (1) and discusses the prospects and dilemmas
that the ICF presents in practical rehabilitation work, based on
initial experiences in Denmark and the other Nordic countries.
The potential of the ICF theoretical framework seems
promising and a large number of countries have expressed
interest in the need for such a framework and its relevance to the
professional areas of rehabilitation and public health. There is
emerging interest in the different aspects of functioning and it
seems that the ICF may also support the documentation and
evaluation of quality services in rehabilitation. During the past
two years a number of papers have been published in which the
authors express their interest in the ICF as a common framework
for clinical work and for research in rehabilitation (26). The
framework was developed over a period of time, commencing
with the work of Nagi in the 1960s, further conceptualized in the
Disablement model by Verbrugge & Jette (7), and, also of
great importance, the work by Fougeyrollas, addressing the
importance of the environment as a major determinant to what
Fougeyrollas terms the Handicap Creation Process (8).
To my mind, the WHOs approval of the ICF will not only
have an impact in the theoretical uniformity of the concepts, but
also, and more importantly, may guide member states in their
future work in the health sector of population needs in
functioning and disability.
The ICF is the result of a revision process based on the ICIDH
(9), and has been ongoing during the last decade. Revision
may not be the right word, as it is actually a new classication,
which stands on a different theoretical framework than that of
the ICIDH from 1980. The WHOs new classication was
approved by the World Health Assembly, as an ofcial member
of the WHO Family of Classications, in May 2001. The
Family of Classications launched contains both the ICD and
the ICF as the main international classications of health. From
a recent international meeting, held by the WHO in Trieste, Italy
in April 2002, the WHOs director general, Dr Gro Harlem
Brundtland, likened the ICF to the Swiss army knife, with many
tools and possible uses
1
.
Since the release of the ICIDH by WHOin 1980, to be used in
eld trials, there has been continuous discussion between
researchers, professional clinicians and the disability movement
on both the theoretical conceptualization and the use of the
ICIDH. Although the ICIDH was not recognized as an ofcial
classication, it has had an impact on development in research
and education. The literature on this topic amounts more than
1500 references which can be classied into two main
categories: On the one hand, references which are using ICIDH
as theoretical framework in different studies, and on the other
hand, references of papers, criticizing the idea and concepts of
ICIDH, and pointing out the shortcomings of adopting a
medical-biological view on disability. Recently, Pfeiffer has
debated the need for a classication as such (10, 11). Pfeiffers
view seems to capture the major criticism from people with
disabilities, as similar views have been expressed by e.g.
European Disability Forum. Pfeiffer emphasize that as long as
the conceptual basis of ICF is a medical model, disability issues
are getting medicalized. According to Pfeiffer this may be the
1
Dr Brundtlands speech is available from www.who.int.
2002 Taylor & Francis. ISSN 16501977 J Rehabil Med 34
J Rehabil Med 2002; 34: 201204
rst step towards eugencics and a class-based evaluation where
normal is the standard for measure. He attacks WHO for
maintaining stigmatization of people with disabilities. Even in
the revised form Pfeiffer express ICIDH-2 (the draft version) as
a threat to the disability community (11).
2
Classifying people with disabilities, in the same way as
diseases, does not make sense, but using the classication to
obtain systematic information about a persons functioning can
provide professionals with relevant information and can guide
the selection of interventions. Researchers and planners have an
obvious need for operationalization of those conditions we call
disability, and for different purposes. The disability movement,
however, address the criticism that a classication in this matter
may stimulate increased stigmatization, and there is a concern
that the classication may be abused in priority setting. The
various interests in the same eld: researchers, who want
scientically based knowledge, and people with disabilities,
who do not want to be classied, may have negatively
impacted on some of the necessary conceptual development and
debate.
The distinction between disability and functioning is not
easily made, since there is no xed limit or a gold standard to
determine whether a person is disabled. Instead, the concept of
disability or malfunctioning, should be seen as relativistic,
bound to the current culture and the social context, where people
live their lives, and in this context, as it relates to health.
Disability must also be seen in the societal context, and can
sometimes be described according to existing laws and regula-
tions within the given society.
This issue is far more complicated than a straightforward
dichotomous distinction between having a disability or not. This
must also be taken into account when scientists try to
conceptualize and quantify the malfunctioning, disability or
impairment in populations (12, 13).
FROM ICIDH TO ICF
Even if the ICIDHhas described the components of disability on
a linear, progressive scale, the understanding of disability is
relativistic and multifactoral in its nature. This was not captured
by the rst version of the ICIDH from 1980, and this issue was a
central aspect in the discussions during the 1980s.
The WHO did take this into account during the revision, and
has conceptualized the framework of the ICF in line with
modern understanding of disability, containing both a medical
perspective and a social perspective. As presented in Fig. 1, the
framework of functioning is related to aspects of health. The
framework is introduced as a bio-psycho-social approach to
disability, including contextual factors: environmental factors
and personal factors.
Since the rst release of the ICIDH, it has been emphasized
that disability has to be understood within a social and
environmental contextual framework. Studies have been per-
formed in Quebec, Canada, based on the Quebec Classication
and the framework Handicap Creation Process (8, 14). This
work has contributed to the current conceptualization of the
environmental impact on actual functioning at the individual
level. This conceptualization puts the ICF in line with modern
understanding of disability and functioning; disability not
only is a consequence of a health condition, but is also
determined by the physical environment, the services available
in the society, attitudes and legislation, which are environmental
factors in this respect.
The overall term in the framework is functioning, which
covers the components body functions, body structures, activity
and participation. Functioning is used as the positive or neutral
wording and the negative aspect is called disability. Disability
Fig. 1. Current understandin g of the framework of the ICF.
Reproduced by permission of the World Health Organization
(WHO) (1).
Table I. Concepts and terminology of the ICF related to components
Body functions
Component Body structure Activity Participation Environmental factors
Denition Body functions are the
physiologica l functions of
body systems (including
psychologica l functions) .
Activity is the execution
of a task or action by an
individual.
Participation is involvement in
a life situation.
Environmental factors make up
the physical , social and
attitudinal environment in which
people live and conduct their
lives. Body Structures are
anatomical parts of the
body, such as organs,
limbs and their
components.
Negative aspect Impairment Activity limitation Participation restriction Barriers/Hindrances
2
The Dutch WHO Collaborating Center has an extensive
database on ICIDH literature.
J Rehabil Med 34
202 T. H. Dahl
has changed meaning from ICIDH to ICF, from being an
individuals attribute of limited activities to currently being the
negative aspect of functioning. It is not only one dimension of
functioning, but is part of the overall concept.
Table I provides a basic overview of the denitions of the
components of ICF as a framework. It should be observed that
this is not the structure of the classication. Body functions, body
structures, activity and participation constitute one part of the
classication and the other part is made up by contextual factors,
both environmental factors and personal factors, although the
personal factors are not classied, but are part of the conceptual
framework.
The components of ICF are structured in domains and
categories. Table II gives an overview of the domains within
the components. Additionally it is possible to detail the
categories, and all are included to the second level, as from
the domains, and for body functions especially, there are
categories on third level, as from component level.
As the conceptual framework is meant to be understood in a
dynamic and not a linear way, the concept has changed as from a
causal linear relation between the components to a dynamic,
interactive framework, wherein all components are related and
inuence one another (15) (see Fig. 1).
In the introduction of the ICF, the use and meaning of
qualiers are introduced. The central message is that one
generic, ordinal scale with ve steps is suggested as being
applicable to all categories in the classication. In addition to the
ve steps, it is possible to register information as unspecied
and not applicable. Through eld trials in Denmark, practi-
tioners have identied problems with use of the qualiers
suggested in the ICF, as the generic scale cannot be applied in all
categories (Dahl, unpublished observations). This may originate
in the obvious statement that the categories are of different
character and nature and, as a consequence, may need different
types of rating scales for measures. This issue needs further
study and development in the coming years, as well as studies
mapping existing instruments into ICF categories.
ADVANCES, LIMITATIONS AND
SHORTCOMINGS
The title International Classication of Functioning, Dis-
ability and Health is confusing. One may think that we have to
classify Functioning and Disability and thereafter classify
health. Health is one of the terms added recently by the WHO,
and it has caused much confusion and a lot of reactions from
those involved in the process. Preferably, the title should state
the scope of the classication and thereby avoid misunder-
standings, as to the content. In most theories of health and ill
health, functioning and disability are central ingredients of
health and should not be disentangled.
3
This statement by Dr Nordenfelt, seems, to my mind, to
Table II. Overview on domains in the ICF Classication, 2001
Body functions and body structures Activities and participation Environmental factors
Body functions
1. Mental functions 1. Learning and applying knowledge 1. Products and technology
2. Sensory functions and pain 2. General tasks and demands 2. Natural environment and human-made
changes to the environment 3. Voice and speech functions 3. Communication
3. Support and relationships 4. Functions of the cardiovascular ,
haematological , immunological and
respirator y systems
4. Mobility
4. Attitudes
5. Functions of the digestive, metabolic
and endocrine systems
5. Self-care
5. Services, systems and policies
6. Genitourinar y and reproductive
functions
6. Domestic life
7. Neuromusculoskeleta l and movement
related functions
7. Interpersona l interactions and relationships
8. Functions of the skin and related
structures
8. Major life areas
9. Community, social and civic life
Body structures
1. Structures of the nervous system
2. The eye, ear and related structures
3. Structures involved in voice and speech
4. Structures of the cardiovascular ,
immunological and respirator y system
5. Structures related to the digestive,
metabolic and endocrine systems
6. Structures related to the genitourinar y
and reproductive systems
7. Structures related to movement
8. Skin and related structures
3
Oral presentation at the 2nd Nordic Baltic conference by Dr
Lennart Nordenfelt, University of Linko ping. The presentation
can be obtained from www.nordclass.uu.se.
J Rehabil Med 34
Introduction to the WHO International Classification of Functioning, Disability and Health 203
capture the central problem with the title of the published
classication.
Late in the revision process Activity (A) and Participation (P)
were put into a joint list, as they are the same component, and in
the annexes to the classication, several suggestions are made
for use of A and P. Several coding guidelines are also suggested
in the annexes. If different coding strategies are used in national
data sets, there is no possibility for comparing data across
countries. Uniform coding conventions are an important
prerequisite for maintaining high data quality, This is seen as
a major problem, which should be addressed in further studies,
in addition to the question as to whether the use of different
coding guidelines gives the same output in statistics and records.
There is no agreement among users whether the domains in
the component Activity and Participation, are either activity or
participation or activity and participation. As a result of this,
some countries are developing their own distinctions of Activity
and Participation (16).
The conceptual framework of the ICF identies that a
majority of outcome measures, used in clinical rehabilitation
and research reect body functions, body structures, and
activity, as these components often are major areas in medical
rehabilitation. The Quebec User Evaluation of Environmental
Factors measures the impact of the environment. Measuring
participation may be a challenging task, and the WHO have
developed WHO-DAS II, which will be released in 2002. WHO-
DAS II is a measure of aspects of functioning, and the
conceptual background is the ICF.
4
From my own experiences with the Danish eld studies and
discussions with Nordic colleagues there seems to be a strong
consensus on the suggested conceptual framework among
professionals working in the eld of rehabilitation, in the health
sector as well as in the social sector. To my mind still more
studies need to be done in order to make the ICF operational for
practical use.
POTENTIAL IMPACT FOR FUTURE
REHABILITATION SERVICES AND RESEARCH
From personal experience in discussions, teaching and ongoing
studies, it seems that the theoretical framework makes sense for
both professionals and disabled people. The discrepancies in
views between professionals and people from the disability
movement are similar to those expressed by Pfeiffer (11). In the
Nordic countries there are several studies underway, either
implementing the framework in rehabilitation settings, or doing
research with the ICF as the theoretical framework. Wade may
be right when he states that the major advances in rehabilitation
are on the conceptual level, rather than in improving quality of
interventions (6). The conceptualization can be seen as the rst
step in improving the quality of rehabilitation. The use of
common terms within the team allows the formulation of goals
for rehabilitation, which are identiable and meaningful to all
involved, and enables professionals to record interventions and
outcomes in a standardized professional language within a
uniform framework.
Different areas of rehabilitation will certainly have different
needs for documentation and assessment, and it is likely that
special versions of the ICF will be developed for use in specic
areas.
CONCLUSION
The WHO has provided a classication on functioning, which is
strongly needed for many purposes within the health area. For
the rst time, a classication has been ofcially launched and
recommended for ofcial use in the UN member states. The
framework of functioning is seen to be a great leap forward,
compared with the original ICIDH classication. However,
some central aspects of the classication still need further
development and research, especially those qualiers suggested
here. The ICF is seen as a promising input for the future
development of rehabilitation services and research.
REFERENCES
1. ICF International Classication of Functioning, Disability and
Health. Geneva: World Health Organization; 2001.
2. Dahl TH, Vik K. Is ICIDH-2 important and useful for occupational
therapy and occupational therapists? Irish J Occupat Ther 2000; 30:
4048.
3. Grimby G, Smedby B. ICF approved as the successor of ICIDH. J
Rehabil Med 2001; 33: 193194.
4. ICIDH-2 International Classication of Functioning and Disability,
Beta-2 Draft. U

stun TB, editor. [Beta 2 draft]. Geneva: World Health

Organization, 1999.
5. Gray DB, Hendershot GE. Applying outcomes research to disability
and health. The ICIDH-2: development s for a new era of outcomes
research. Arch Phys Med Rehabil 2000; 81 (suppl 2): S10S14.
6. Wade D. Recent advances in rehabilitation. BMJ 2000; 320: 1385
1388.
7. Verbrugge LM, Jette AM. The disablement process. Soc Med Sci
1994; 38:114.
8. Fougeyrollas P. Documenting environmental factors for preventing
the handicap creation process: Quebec contributions relating to
ICIDH and social participation of people with functional differences.
Disabil Rehabil 1995; 17: 145153.
9. International Classication of Impairments, Disabilities and Handi-
caps. A manual of Classication relating to the consequences of
disease. Geneva: World Health Organization, 1980.
10. Bickenbach JE, Badley EM, Chatterji S. A reply to David Pfeiffer,
The ICIDH and the need for its revision. Disability & Society
1998; 13: 829831.
11. Pfeiffer D. The devils are in the details; ICIDH-2 and the disability
movement . Disability & Society 2000; 15:10791082.
12. Murray C, Lopez A. Global burden of disease. Boston: World Health
Organization, 2000.
13. Helander E. Prejudice and dignity. An introduction to community-
based rehabilitation. New York: United Nations Development
Programme, Division for Global and Interregional Programmes,
1992.
14. Fougeyrollas P. The Handicap Creation Process how to use the
conceptual model. ICIDH International Network 1991; 4.
15. Bickenbach JE, Chatterji S, Badley EM, U

stun TB. Models of

disablement , universalism and the international classication of
impairments, disabilities and handicaps. Soc Sci Med 1999; 48:
11731187.
16. Development of mutually exclusive lists for activities and
participation: WHO International Classication of Functioning,
Disability and Health. Ottawa: Canadian Institute of Health
Information, 2001.
4
Information on WHO-DAS II can be obtained at www.
who.int/classification/icf.
J Rehabil Med 34
204 T. H. Dahl