The ICF: A Classification System and an Ideal Conceptual Framework for Audiologic Rehabilitation
This article summarizes the main features of the classification system adopted by the World Health Organization (WHO), namely the International Classification of Functioning, Disability, and Health (commonly referred to as the ICF; WHO, 2001). In addition, it illustrates how this classification system constitutes an appropriate conceptual framework for audiologic rehabilitation (AR).
The International Classification of Functioning, Disability, and Health
Presently, there is no "cure" for sensorineural hearing loss. Regardless of the treatment program undertaken, a person who consults a health professional because of difficulties attributable to hearing impairment will always have this loss. Thus, providing health services for a permanent sensorineural hearing loss strictly from the perspective of a medical model of health is not likely to yield a successful outcome (Gagné, Jennings, & Southall, 2014). Notwithstanding this prognosis, rehabilitation professionals know that many persons with a permanent hearing loss benefit from appropriate AR services. Although the hearing loss itself may not be amenable to change, efficacious AR treatment services may help a person with a permanent hearing impairment successfully overcome many of the difficulties experienced while performing activities of daily living.
The ICF (WHO, 2001) provides a biopsychosocial model of health. Within this framework, a person's health is not defined solely by the status of one's body parts and structures (i.e., one's anatomical and physiological features). Rather, it is recognized that one's health condition is also influenced by other factors at the level of (a) the person (i.e., the individual as a whole, including one's personality as well as his/her social and cultural makeup), and (b) by environmental factors (including the physical and social context).
A detailed description of the ICF and its components is beyond the scope of the present article. Gagné et al. (2014) provide a detailed account of the application of the ICF to AR. Generally, the ICF has two domains, each with two components. One domain incorporates aspects of functioning and disability. This part includes two components: (a) body functions and body structures and (b) activities and participation. Within the ICF, activity is defined as "the execution of a task or action by an individual." An activity limitation occurs when the person has difficulty executing an activity (e.g., using the telephone to communicate). Participation refers to the involvement of an individual in a real life situation. A participation restriction is experienced when the person has difficulty participating in a real life situation (e.g., conversing with others at the dining table during a family gathering or communicating with clients by telephone). To eliminate difficulties that can arise in trying to distinguish between "activities" and "participation" in many descriptions of the ICF, those two components are merged into a single component that is labelled "participation in activities". Within this perspective, a person may participate in the activity of attending a staff meeting at work or an individual may participate in the activity of watching television with family members at home.
The second domain includes contextual factors, specifically environmental factors and personal factors. Environmental factors include the physical, social, and attitudinal environment. The physical environmental factors that most often interfere with hearing and communication are the acoustical (e.g., background noise and reverberation) and the optical environment (e.g., poor illumination and poor visual contrast). Personal factors refer to all aspects (past and present) of one's life and living experiences (e.g., age, gender, educational level, level of extroversion/introversion, etc.).
Within the ICF (WHO, 2001), functioning is an umbrella term covering all body functions, activities, and participation. Disability, on the other hand, serves as an umbrella term for impairments, activity limitations, and participation restrictions. In a nutshell, according to the ICF (WHO, 2001), an individual's state of health is determined by a complex interaction that may arise among one's body structure and functions (e.g., a disorder or an impairment), one's disabilities (activity limitations or participation restrictions), and contextual factors which consist of personal factors (e.g., personality traits and other attributes of a person) and environmental factors (including both the physical and the social environment). For example, depending on the environmental factors, a person with hearing loss (impaired body function and structures) may or may not experience any disability (activity limitation or participation restrictions) while taking part in a given activity. For instance, a person with hearing loss may have difficulty conversing with a grandchild while he is driving his car in noisy traffic. However, the same person may be able to successfully converse with the grandchild when they are both sitting in close proximity and facing each other on the living room couch. Similarly, it is possible, that in a given environment, two individuals with a similar hearing loss may not experience the same level of restriction. Example: one person may experience difficulty communicating with a friend when attending a sporting activity in a noisy stadium, while another person with a similar hearing impairment may not experience the same activity limitation in that environment because he or she is a good speechreader (a personal factor), and because the communication partner uses effective communication strategies (personal factors), including clear speech to communicate.
Given its structure and the nomenclature used, the ICF (WHO, 2001) can serve as a conceptual model of health as well as a classification system. The conceptual framework applies equally well to all rehabilitation sciences. Furthermore, the ICF is accepted and recognized internationally. Thus, an important advantage of the ICF is that the same concepts and terminology can be used to compare aspects of clinical services and the results of rehabilitation research across disciplines and across countries.
Applications of the ICF to AR
Using the ICF (WHO, 2001) as a conceptual framework for rehabilitation sciences, it has been proposed that "the goal of AR is to restore or optimize participation in activities considered limitative by persons who have hearing impairment or by other individuals who partake in activities that include persons with a hearing impairment" (Gagné & Jennings, 2008, p. 390). Specifically, the goal of AR is not to improve hearing; impaired structures of the hearing system will not be modified. The impaired hearing mechanism will remain impaired even if the rehabilitation program is successful. According to the above definition, the goal of AR is to allow the client the opportunity to participate in activities that are required and/or considered important even though the person has a hearing loss that interferes with taking part in these activities. Moreover, it implies that all behaviors can be considered within the domain of activities and participation. Accepting the ICF as a conceptual framework (and agreeing with this definition of AR) has many ramifications for the way rehabilitation services are conceived, designed, organized, provided, and evaluated.
Three important implications of using the ICF as a conceptual framework for AR are outlined below. First, the model clearly illustrates that even if the body functioning component of the model (e.g., a permanent hearing loss) cannot be improved, the other components of the ICF can be called upon to reduce or eliminate activity limitations and participation restrictions. Using the ICF nomenclature, it becomes obvious that many successful AR intervention programs focus on modifying the personal characteristics of the individuals involved in the a given activity (e.g., learning to use appropriate communication strategies, speechreading, modifying expectations concerning hearing aids, and adapting an affirmative communication style) or manipulating the environment (e.g., modifying acoustic and optical properties of the environment in which communication takes place). Interestingly, according to the ICF, hearing aids and other hearing assistive technology that amplify sound do not do not address the classification system domain of structure and function (i.e., the anatomy or physiology of the hearing mechanism remains the same). Rather, hearing assistive devices serve to modify the acoustic environment (e.g., make acoustic signals louder or reduce the level of unwanted sounds at the level of the ear canal).
Second, applying the ICF leads to a very functional description of the difficulties encountered by individuals with hearing loss or by individuals with normal hearing who interact with a person who has hearing impairment (Gagné et al., 2014). All difficulties that a person might experience due to hearing loss can be described as an activity limitation or participation restriction. The focus of an AR intervention program is to reduce, eliminate, or alleviate activity limitations and participation restrictions experienced by the client. Consequently, clients who seek rehabilitation services should be asked (or shown how) to describe the effects of the hearing loss on their ability to participate in everyday activities that are important to them. For example: Mr. Smith may report having difficulty understanding his partner's speech when he plays billiard at the local bar; Mrs. White may have difficulty hearing other group members at the monthly reading club; Mr. O'Brien may report not being able to hear his family doctor during regular appointments because the doctor often talks while writing in the patient's file; and Mrs. Novak may be concerned because her father, who lives alone, does not always hear the doorbell when someone comes to visit. Within the ICF, all of the above examples may be considered activity limitations or participation restrictions due to hearing impairment. This aspect of the ICF makes it possible to clearly identify the goal of an intervention program—to overcome specific activity limitations/participation restrictions that are considered important and that are caused by the fact that someone participating in the identified activity has hearing impairment. Also, specifying the goal of the intervention program makes it easier to ascertain if it was reached by the end of the program: Has the activity limitation or participation restriction identified by the AR program been eliminated or reduced? Successful AR programs will help solve concrete problems that are important for the client and that are attributable to hearing loss.
Third, using the ICF (WHO, 2001) as a conceptual framework for AR requires that the person with hearing loss participates actively in selecting, applying, and evaluating his or her rehabilitation program. Who else can identify the activity limitations and participation restrictions that are experienced and considered important for the client? Who else can ascertain whether they are able and willing to implement specific intervention strategies? And, who else can determine the extent to which the identified limitations/restrictions have successfully been overcome as a consequence of taking part in an AR program? Within an ICF perspective, the client, the other people involved in the activity limitation/participation restrictions, and the hearing health care (rehabilitation) professional actively work in a collaborative partnership to attain the specific goal of the AR program. Viewed within this perspective, AR intervention programs based on the principles of the ICF are completely compatible with approaches to AR that are deemed to be client-centered or based on the principles of shared decision-making (see Gagné & Jennings, 2008; Erdman, 2009; Laplante-Levesque, Hickson, & Worrall, 2010a, 2010b).
Beyond serving as a classification system to describe health conditions in all domains of hearing health, the ICF (WHO, 2001) and its nomenclature can serve as a conceptual model for rehabilitation. Moreover, the conceptual framework applies equally well to all rehabilitation sciences. The ICF is widely adopted by many rehabilitation professionals (e.g., occupational therapists, physical therapists, rehabilitation psychologists, etc.). The classification system is accepted and recognized internationally by more than 190 states or countries. Thus, an important advantage of the ICF is that the same concepts and terminology can be used to compare aspects of clinical services and the results of rehabilitation research across disciplines and across countries.
About the Author
Jean-Pierre Gagné obtained a PhD from the Central Institute for the Deaf, Washington University (St. Louis, MO, USA). Dr, Gagné holds a MSc degree in audiology and aural rehabilitation from McGill University (1978) and a PhD in communication sciences and Audiology from Washington University (1983). Presently, he is a Professor at the École d'orthophonie et d'audiologie, faculté de medicine, at the Université de Montréal where he teaches undergraduate and graduate level courses in audiological rehabilitation. Contact him at
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World Health Organization. (2001). International classification of functioning, disability, and health. Geneva: World Health Organization.
Sections from this article were taken from Gagné, Jennings, and Southall (2009), and Gagnéand Jennings (2011). Do not cite this manuscript without the written consent of the authors.
Table 1. Definitions of Terms Used in the International Classification of Functioning, Disability, and Health (ICF)
Body Functions are physiological functions of body systems (including psychological functions).
Body Structures are anatomical parts of the body such as organs, limbs and their components.
Impairments are problems in body function or structure such as a significant deviation or loss.
Activity is the execution of a task or action by an individual.
Participation is involvement in a life situation.
Activity Limitations are difficulties an individual may have in executing activities.
Participation Restrictions are problems an individual may experience in involvement in life situations.
Environmental Factors make up the physical, social, and attitudinal environment in which people live and conduct their lives.
Source: World Health Organization. (2001). International classification of functioning, disability, and health. Geneva, Switzerland: Author: World Health Organization. Reprinted with permission.
Figure 1. The Integrative Model of Functioning and Disability Illustrating the Interactions of the Concepts Incorporated Into the International Classification of Functioning, Disability and Health (ICF)
Source: World Health Organization. (2002). International classification of functioning, disability, and health. Geneva, Switzerland: Author: World Health Organization. Reprinted with permission.