The conceptual framework for disability analysis used by this study is the International Classification of Functioning, Disability and Health (ICF) (WHO 2001), which is a refinement o f the WHO’s (1980) and WHO’s (1998) models of International Classification of Impairments, Activities and Participation (ICIDH-2). ICIDH-2 (WHO 1998) model associates issues o f disability with activities and the participation o f a person with impairment in her/his community. However, in the ICIDH (1980) model o f International Classification o f Disability and Handicap it emphasise the removal of barriers which hinder people with impairments to participate in every aspect o f their life. The ICIDH (WHO 1980) model of disablement has three interactive elements: impairment, disability and handicap. According to ICDH (WHO 1980) disability is defined as a limitation or lack of ability to perform an activity in a way perceived within a range seen normal (WHO 1980). This model assumes that there is a direct causation linked with disability (such as difficulties in verbal communication) and impairment, such as deafness. WHO (1980) defines impairment as an absence or dysfunction o f psychological or physiological of an anatomical structure. ICIDH model further assumes that the interaction between an impairment e.g. deafness and disability such as difficulties in communication is perceived causally associated with the term handicap, which is defined as a disadvantage that restricts the fulfilment o f a role considered within a range of normality. These roles depend on age, social and cultural constructs. WHO (1998) in constructing the ICIDH-2 model was responding to the criticism over the term handicap and drew positive experience over the use of the ICIDH (WHO 1980). Bickennbach et al’s (1999) proposed some models of Disablement and Universalism based on ICIDH-2 (WHO 1998) consisting of four components which interact with each other between functioning and disability. These are Bickennbach et al’s (1999) models of “Disablement and Universalism” components:
• Disablement is a concept based on any restrictions or lack of ability o f the body structure and function, personal activities and participation in the community. • Impairment is defined as the loss or dysfunction of the body structure or
physiological function, which limit the activity or participation of the individual in the mainstream community activities.
• Activity is defined as the nature and extent o f functioning at the level o f an individual.
• Participation is defined as the nature and extent of a person’s involvement in mainstream activities in relation to impairments, activity, health conditions and contextual factors.
However, the ICF model differs from the ICIDH, ICDIH-2 and Disablement and Universalism” models due to the fact that the ICF model has two parts each with two components (WHO 1980; WHO 2001; Bickennbach et al’s 1999), which are:
Part 1. Functioning and disability • Body functions and structures • Activity and participation
Part 2. Contextual factors • Environmental factors • Personal factors
The ICF model (WHO 2001) has components, which could be expressed either in positive or negative terms. These components are further sub-divided and classified into various domains. According to WHO (2001) the ICF model has these main domains expressed in health context:
• Body functions: these are physiological and psychological functions o f the body, which promote a person's well being and how s/he fits into the society. • Body structures: these also referring to anatomical parts o f the body such as
organs, limbs and their components which have a bearing on what activities an individual can do efficiently.
• Impairments: these are problems associated with the body function or the structure and are individual person’s limitations in relation to how s/he uses her/his body structures e.g. deafness posses a limitation on an individual in perceiving sound for communication and localisation.
Activity: this is the execution o f a task or action by an individual and is qualified and quantified in relation to age, sex and in context for livelihood or socialisation.
Participation: this involves the activities a person does in every day life in her/his community.
Activity limitations: these are problems an individual might have in performing certain activities e.g. some difficulties a profound deaf child using a sign language as her/his first language could have in engaging in an exclusively verbal conversation.
Participation restriction: this also refers to difficulties an individual such as a deaf child might have in performing every day life activities.
Environmental factors: these are components which constitute the physical, social and attitudinal environment in which people normally carryout their livelihood survival skills and these components and their interactions are illustrated in Fig 2.1 (WHO 2001).
F ig.2.1: ICF M od el o f “Functioning” and “D isab ility” : the Interactions b etw een the C om ponents o f ICF, adapted from W H O (2001).
B ody F unctions & S tru c tu re s
e.g. Ear problems such as otitis media, hearing loss such as
conductive and sensorineural losses
Poor services e.g. at school, high prevalence of infected otitis media, negative attitudes
Health Condition (diseases/disorder)
e.g. Deafness
Activities
e.g. Going to school, reading, writing, engaging a conversation E n v iro n m en tal F acto rs P a rtic ip a tio n 1. e.g. In school: - Education development 2. e.g. Socially: - Social development P erso n al F acto rs Preference of family to seek helps with hearing aids or sign language
Fig 2.1 illustrates the interactions of the components of ICF model (WHO 2001) of disablement. The hypothesis of this model states that a child with a hearing- impairment has a medical problem of body function and structure, which could be a hearing pathway, affected due to a disease or malformation or absence o f the conductive or sensorineural hearing structures. There are several pathological ear diseases or conditions that might affect a child’s hearing threshold levels. The degree o f the impairment depends on the extent o f the physiological and anatomical damages or malfunction o f the ear. For example the child could have mild or moderate or severe to profound hearing loss depending on the part o f the pathway and the extent o f the dysfunction of the affected ear structure. The ear structure as a function of a hearing limitation in relationship to the activity performed depends on factors such as sex, age, culture and traditional norms prescribed by the society (social constructs).
Environmental factors also come into play, if a deaf child can not attend the local school because there are no facilities appropriate for her/his condition (barriers), he can not read, write, develop sufficient communication skills to enable her/him to socialise with her/his hearing peers or family members and community members in general. Because of the verbal limitations and the discrimination imposed by the hearing world the child would later have reduced opportunities for employment or marriage because s/he has no means o f supporting a family. These barriers can be physical or social creation depending on each community setting (Thomas and Thomas 2001).
These predominant domains: environmental, social and personal factors that result in activity and participation limitations. Therefore, tackling issues o f hearing loss in children in developing countries needs a re-examination of all factors of impairment both (e.g. screening, diagnostic levels, counselling and teaching deaf children), such as what the individual can do at a personal level, which includes the degree of confidence possessed. What does the environment offer as opportunities/barriers to an individual to perform an activity with minimal restrictions? Disabled people themselves are adding value in understanding ICF (WHO 2001) domains their analysis of these components are constantly challenging the barriers and rehabilitation service delivery systems in developing countries.
There is a realisation that professional specific services are so expensive that they are unachievable and non-sustainahle, led WHO to promote a low-cost approach called the “Community Based Rehabilitation” (GBR) in the late 1970s. This is a strategy that has been adopted and implemented in many low-income countries (Boyce et al 2001; Thomas and Thomas 2001; Price 2001). The CBR approach attempts to provide rehabilitation services involving the whole community and using local resources and low technology (ILO, UNESCO, WHO, 1994). CBR approach was adopted by this study in attempting to provide valid low cost screen that can be reliably used by non specific audiological trained community workers to identify hearing loss in children for the purpose of initiating early interventions that can improve the quality o f life of deaf children in rural communities (Kandyomunda et al 2002; Schneider et al 2002). This entails a change of attitudes of the community to accept children with disabilities and promote their social integration, provision of equal opportunities and protection o f their rights (Thomas and Thomas 2001).
The conceptual framework highlighted and described the important elements of the ICDH-2 (1998) and ICF (2001). This analysis model of disability has provided the underpinning background information of the interface o f issues concerning hearing loss in children such as prevalence, consequences of hearing loss in children, causes, management of conductive and sensorineural hearing loss in children these are reviewed in the next section.