THE ICF: AN OVERVIEW

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.

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.
ICF components and their contents
The major components of functioning and disability are set out and defined in Box 1; these are understood
‘in the context of health’ which clarifies that participation restrictions related to other factors, for example
racial prejudice, are not within the scope of the ICF.
Box 1: Definitions: Functioning, disability and the components of the ICF

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).
Source: WHO 2001:8,10
Each component contains hierarchically arranged domains. These are sets of related physiological
functions, anatomical structures, actions, tasks, areas of life, and external influences. The ICF has a
separate chapter for each of the domains as listed in Table 1.

Table 1: ICF components and domains/chapters

Body Function: Activities and Participation:

Mental functions Learning and applying knowledge
Sensory functions and pain General tasks and demands
Voice and speech functions Communication
Functions of the cardiovascular, haematological, Mobility
immunological and respiratory systems
Self care
Functions of the digestive, metabolic, endocrine systems
Domestic life
Genitourinary and reproductive functions
Interpersonal interactions and relationships
Neuromusculoskeletal and movement-related functions
Major life areas
Functions of the skin and related structures
Community, social and civic life
Body Structure: Environmental Factors:
Structure of the nervous system Products and technology
The eye, ear and related structures Natural environment and human-made changes to
environment
Structures involved in voice and speech
Support and relationships
Structure of the cardiovascular, immunological and
respiratory Systems Attitudes
Structures related to the digestive, metabolic and Services, systems and policies
endocrine systems
Structure related to genitourinary and reproductive systems
Structures related to movement
Skin and related structures

Source: WHO 2001: 29-30

Measurement
The ICF is a framework and classification system on which tools for measuring or ‘assessing’ individual
functioning may be based, and to which they can be mapped. The broad framework puts assessment in
context and provides the focus for selecting relevant aspects of functioning and disability for assessment.
Qualifiers are codes used to record the extent of functioning or disability in a domain or category, or the
extent to which an environmental factor is a facilitator or barrier. A uniform or 'generic' qualifier scale is
provided to record the extent of the 'problem' in relation to impairment, activity limitation and participation
restriction as shown in Box 2. The environmental factors qualifier uses both a positive and negative scale,
to indicate the extent to which an environmental factor acts as either a facilitator or barrier to functioning.
Measurement is an area for further development and it is recognised that the generic qualifier requires
calibration to relate its scale to existing measurement tools.
Box 2: ICF Qualifier scales
Generic qualifier:
0 No problem
1 Mild problem
2 Moderate problem
3 Severe problem
4 Complete problem
8 Not specified
9 Not applicable
Qualifier for Environmental factors:
.0 No barrier +0 No facilitator
.1 Mild barrier +1 Mild facilitator
.2 Moderate barrier +2 Moderate facilitator
.3 Severe barrier +3 Substantial facilitator
.4 Complete barrier +4 Complete facilitator
.8 Barrier, not specified +8 Facilitator, not specified
.9 Not applicable +9 Not applicable

Two constructs, 'performance' and 'capacity', can be used in operationalising the qualifier scale for the
activities and participation domains. These constructs provide a way of indicating how the environment (in
which measurement has taken place) impacts on a person’s activities and participation, and how
environmental change may improve a person’s functioning.
‘Capacity’ relates to what an individual can do in a ‘standardised’ environment (this often involves some
kind of clinical assessment). ‘Performance’ relates to what the person actually does in his or her ‘current’
(usual) environment.
‘The gap between capacity and performance reflects the difference between the impacts of current and
uniform environments, and thus provides a useful guide as to what can be done to the environment of the
individual to improve performance’
(WHO 2001:15)
There are a variety of optional and additional qualifiers that can be useful, including qualifiers for
performance without assistance and capacity with assistance, which are particularly useful in
institutionalised settings. A ‘qualifier for involvement or subjective satisfaction’ for the activities and
participation component is a future possibility (WHO 2001:230-231).
APPLYING THE ICF

In statistics and information systems

In developing collections of information on functioning and disability it is important to consider all
components of the ICF. A common definition of disability is crucial to understanding and improving
outcomes for people with disabilities as well as for increasing the power of information through the ability to
relate data from different sources, such as in service settings and at the population level. When consistent
language and concepts are used, they facilitate comparisons, complementary information and knowledge
building. Synergy is enabled between different information systems such as surveys, research and health
records.
Classification systems have been described as the building blocks of statistical information.
‘The WHO family of international classifications provides a framework to code a wide range of information
about health … so that people can communicate about health and health care in common terms, across
various disciplines and between countries.’
(WHO 2001:3).
The ICF is recognised as a reference member of the WHO family of international classifications (WHO-
FIC), and complementary to the International Statistical Classification of Diseases and Related Health
Problems (ICD). Health conditions are classified using the ICD (most current version is ICD-10), which
provides codes for diseases, disorders, injuries or other health problems.
As functioning and disability associated with health conditions are classified using the ICF, the use of the
ICD-10 and the ICF together provides a more meaningful and complete picture of the health needs of
people and populations (WHO 2001:4). The examples in Figure 2 illustrate disabilities that may be
associated with some health conditions and environmental factors.
When population data use the same concepts and frameworks as administrative and service data, a strong,
integrated national information array can be developed. For example, Australian national data standards
(based on the ICF) are designed to promote some uniformity and standardisation of definition and data
collection, without dictating the precise content of collections. The Washington Group on Disability Statistics
has worked to create, test and adopt a short set of six questions for use in censuses and surveys, following
the Fundamental Principles of Official Statistics and consistent with the ICF.
Figure 2: Examples of ICF use with individuals

Spinal Cord Injury Spinal Cord Injury

Problems of muscle Restricted participation Problems of muscle Participation in

Difficulty moving Difficulty moving
power functions & in employment & in power functions & employment, sport and
& walking & walking
structure of spinal cord using public transport structure of spinal cord leisure: no problems

Public transport, Male, 30 yrs Education system, products and Male, 35 yrs,
building design: technology, building design, married with one
barriers immediate family: facilitators child

Notes:

1. The examples above are not intended to represent a complete picture of activity limitations, participation restrictions or
impairments, but rather represent a few domains of each component which could be related to a particular health condition and
some environmental factors. Each example is based on the assumption that Activities and Participation can be distinguished
by domains (just one option for their use – see WHO 2001: 234-237).

2. For specific situations and/or individuals the direction or magnitude of the arrows may differ, however the two-directional arrows
are retained in Figure 2 to illustrate the usual multi-directional influence.
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 organisation 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 AND LINKS
American Psychological Association Procedural Manual and Guide for the Standardized Application of the ICF:
http://www.apa.org/monitor/jan06/changing.aspx
Australian ICF-related data standards: http://meteor.aihw.gov.au/content/index.phtml/itemId/320319
Hollenweger, J., Lienhard, P. (2007). Schulische Standortgespräche. EinVerfahren zur Förderplanung und Zuweisung
von sonderpädagogischen Massnahmen. Bildungsdirektion des Kantons Zürich. Zürich: Lehrmittelverlag des Kantons
Zürich.
Hurst R 2003. The international disability rights movement and the ICF. Disability and Rehabilitation Vol 25, No, 11-
12, 572-576
ICF checklist: http://www.who.int/classifications/icf/training/icfchecklist.pdf
Martinuzzi, A, Salghetti, A, Betto, S, et al. (2010). The international classification of functioning disability and health,
version for children and youth as a road-map for projecting and programming rehabilitation in a neuropaediatric
hospital unit. J Rehabil Med 42: 49-55
Stucki G, Reinhardt JD, Grimby G, Melvin J 2007. Developing ‘human functioning and rehabilitation research’ from the
comprehensive perspective. J Rehabil Med 2007; 39: 665-671
United Nations 2006. Convention on the Rights of Persons with Disabilities.
http://www.un.org/disabilities/default.asp?navid=12&pid=150
Veitch C, Madden R, Britt H, Kuipers P, Brentnall J, Madden R, Georgiou A, Llewellyn G 2009. Using ICF and ICPC in
primary health care provision and evaluation:
http://www.who.int/classifications/network/WHOFIC2009_D009p_Veitch.pdf
Washington Group on Disability Statistics http://unstats.un.org/unsd/methods/citygroup/washington.htm
WHODAS2 http://www.who.int/classifications/icf/whodasii/en/index.html
WHO Family of International Classifications http://www.who.int/classifications/en/
WHO Family of International Classifications Network (including a list of Collaborating Centres):
http://www.who.int/classifications/network/en/
World Health Organization 2001. ICF browser: http://apps.who.int/classifications/icfbrowser/
World Health Organization 2001. The International Classification of Functioning, Disability and Health (ICF). Geneva:
WHO. http://www.who.int/classifications/icf/en/
World Health Organization (2007) The International Classification of Functioning, Disability and Health, Children and
Youth version Geneva: WHO. http://www.who.int/classifications/icf/en/

FURTHER INFORMATION AND RESOURCES

For further information contact:
Dr. T.B. Üstün
World Health Organization
Coordinator, Classification, Terminology and Standards
20 Avenue Appia
CH-1211 Geneva 27
Switzerland
Tel: 41 22 791.36.09
Fax: 41 22 791.48.85
E-mail: [email protected]
The Functioning and Disability Reference Group
In 2006 the WHO Family of International Classifications (WHO-FIC) Network established the Functioning and
Disability Reference Group (FDRG) to advise on functioning, disability and health classification and coding issues.
The FDRG has developed a work program to enable it to provide well researched advice. Topics include coding
guidelines, ICF updates, ICF-ICD joint use, education, ethical use of ICF, measurement and environmental factors.
The FDRG works collaboratively with other committees and reference groups in the WHO-FIC Network to address
these issues.
The FDRG now has over 30 members worldwide, including people from various disciplines and organisations.
Disabled people’s organisations (DPO) and an even broader collaborative network are involved in its work.
The motivations for this work program include:
• The need to educate people and potential users about the ICF
• The need to reflect on ICF implementation – useful applications, new ideas and commentary, challenges,
gathering new knowledge gained from experience with its use
• The need to develop useful tools to make ICF use easy and relevant
• The need to update the ICF in the light of experience