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Studies of people with disabilities show the social and psychological disadvantages associated with disability (Chamie and Mufarrij, 1986). Such conditions and states, known as handicaps, may vary in degree. The course from disability to handicap may take different pathways in different societies, and may present differently between individuals (Shaar and McCarthy, 1994). Researchers have noted, for example, that attitudes towards disabilities are inversely related to the economic status of a country (Jordan and Friesen, 1969). In addition, lack of access to education and high unemployment rates are found among the people with disabilities in some developing countries (Chamie and Mufarrij, 1986).

2.3.1 Definitions of handicap prior to 1980

Until recently, the terms “disability” and “handicap” were used interchangeably. This lack of differentiation and lack of a unifying conceptual basis for determining handicap had vast implications with regard to planning activities, policy formulation, and provision of services. Some of these definitions are: “Having difficulty meeting the requirements of current and previous jobs, and needing help with self-care and other daily activities” (Nagi, 1976), “The circumstances of the person with a disability include employment, occupational level, income and assets, housing conditions, and subjective feelings of deprivation” (Townsend, 1979).

2.3.2 Conceptual frameworks

Two major conceptual frameworks for defining handicap are explained in: the Nagi framework (Nagi, 1976) and the International Classification of Impairments, Disabilities and Handicaps (ICIDH) (WHO, 1980).

2.3.2.1 The Nagi framework

Nagi (1976) proposed four distinct but interrelated concepts: active pathology, impairment, function limitation and disability. Active pathology may result from infection, trauma, metabolic imbalance, etc. Impairment, on the other hand, indicates a loss or abnormality of an anatomical physiological, mental or emotional nature which results in functional limitations. Disability refers to social rather than physical functioning: it is an inability or limitation in performing or filling the socially defined roles and tasks expected of an individual within his or her sociocultural and physical environment. This framework does not have a classification system, but it is consistent with the concepts used in major US national surveys and with definitions of work-related disability used by the US Bureau of the Census.

2.3.2.2 The International Classification of Impairments, Disabilities and Handicaps (ICIDH)

Based on the work of Wood and his colleagues, the WHO proposed a classification system in 1980 to be used in conjunction with the Ninth Revision of the International Classification of Disease (WHO, 1977). This concept of disease is based on a continuum expressed as:

Disease^ Impairment^ Disability-)* Handicap

According to this model, a pathological state is manifested as a clinical disease when the individual recognises an impairment or abnormality of body structure.

appearance and/or organ system dysfunction. Consequently, the performance or functional ability of the individual may be altered; these activity restrictions represent disabilities. Social situations may place the individual at a disadvantage. This is termed handicap: the disadvantage resulting from impairment and/or disability that limits or prevents the fulfilment of a role that would be considered normal for an individual (Patrick, 1989). A review of the Nagi framework and ICIDH shows that they propose similar concepts but give them different names. Thus, both agree on the concepts of impairment and functional limitation, but social disability in Nagi’s framework is referred to as “handicap” in the ICIDH.

2.3.2.3 Revisions of International Classification of Impairments, Disabilities and Handicaps (ICIDH-2)

ICIDH aimed at unifying opinion on concepts of impairment, disability and handicap. The use of the ICIDH as an instrument tool for classification has been criticised and overviewed firstly in 1988, 1990, 1994 and finally in 2000. The ICIDH-2 reflects changes in both definitions and relationships from the 1980 version as the basis for the preparation for the final version expected in 2001.

The goals to be achieved by the revision are:

• Adaptation of the ICIDH to application not foreseen in the 1980 version; • Adaptation of the ICIDH to new developments in health care;

• Changes based on criticisms of the 1980 version.

Therefore, the WHO collaborating centre for the ICIDH in the Netherlands has formulated specific goals towards revising the ICIDH since 1990 (Halbertsma et al, 2000). The ICIDH-2 draft differs from the 1980 version in that the three dimensions of Impairments, Disabilities and Handicaps are re-framed as:

• Classification of impairments of function; • Classification of impairments of structure;

• Classification of participation;

• Contextual factors, list of environmental factors.

The current understanding of interactions within the ICIDH-2 dimensions are presented in Fig 2.1.

Fig 2.1 Interaction between ICIDH-2 dimensions

Health condition (disorder/disease) ▼ Impairment

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The coverage of the ICIDH emphasised conditions based on physical and motor problems with applications primarily involving adult populations. There are growing concerns in health, education and related services regarding the need for consistent classification of childhood disability (Stein et al., 1997). The prevalence of disability among children varies such in Britain, it has been reported to be 3% whereas 12.2% of the US school population have been identified as students with disabilities (Hutchinson, 1995). These students have been assigned to various categories, including mental retardation and deaf-blindness as well as to categories combining the prefixes orthopaedic, visual, hearing, learning and emotional with terms impairments, conditions, disorders and disabilities. This variability and the lack of a common classification system have created persistent

problems in documenting the epidemiology of disability in children and in the provision of appropriate services.

The above issues have contributed to growing interest in the revision of the ICIDH as a classification tool.

All classifications are now formulated in neutral wordings, overlap between the three classifications has been reduced and the introduction has been changed rather drastically. In this thesis, the term disability will be used to describe the impairment of an individuals’ physical abilities.