Journal of Rehabilitation Medicine 51-4inkOmslag | Page 11

Academic debate on ICF and a theory of social productivity
gave in Riga on 16 September 2015 (2). He described
rehabilitation as a health strategy aiming at optimal
functioning and setting active health goals. The Inter-
national Classification of Functioning, Disability and
Health (ICF) is a classification of health and health-
related domains (5). As the functioning and disability
of an individual occurs in a context, ICF also includes
a list of environmental factors. ICF is the World Health
Organization (WHO) framework for describing health
and disability at both individual and population levels.
ICF was officially endorsed by all 191 WHO Member
States in the Fifty-fourth World Health Assembly on
22 May 2001 (resolution WHA 54.21) and is now the
international standard for describing and monitoring
functioning. The ICF is closely linked to the emergence
of rehabilitation as a key health strategy of the 21 st
century, as it is a conceptual framework describing
function and the lived experience of health; however,
it cannot explain functioning. It is also questioned
whether theory-based approaches may relate to the ICF.
Johannes Siegrist was invited to explore how the
theory of social productivity could explain the links
between participation and well-being (3). He hypo-
thesized that full participation in social life, including
being socially productive by means of paid or volun-
tary work significantly contributes to well-being. In
his view being socially productive may offer a dual
utility, being personal needs satisfaction increasing
well-being, as well as providing societal benefits.
According to Siegrist & Fekete (3), supplementing
the ICF by theory-based approaches may advance
explanations with regard to the notion of participation.
Siegrist stated that the ICF lacks accuracy to describe
core notions/terms, such as activity and participation,
and expressed the need to disentangle these concepts,
extending participation beyond the current simple
description as it assumes involvement of other people.
He added 4 key aspects related to participation:
1. subjective meaning;
2. autonomy;
3. belongingness; and
4. opportunity of engagement through participation.
Siegrist concluded by highlighting the restriction of
the ICF as a descriptive taxonomy and the lack to ex-
plain observed variations. He stressed that the benefit
of social productivity could explain links between
participation and health and well-being.
Jerome Bickenbach, one of the developers of the
ICF, refuted this idea in his commentary. He recalled
that 1 of the important strengths of the ICF is exactly
being “theory neutral”. The ICF is primarily a clas-
sification and an international standard language for
collating comparable data about disability. Whereas the
245
ICIDH was a normative setting out of a theory of what
a good life should be, the ICF provides a framework to
collect neutral data on the lived experience of people.
Adding explanatory theories specifying the contours
of the relationship between biomedical and environ-
mental determinants of disability may, according to
Bickenbach, undermine the classification function.
However, an explanation of the relationship between
environmental factors and levels of social productivity
may enrich the ICF. He pointed out that well-being, the
outcome referred to by Siegrist & Fekete, is clearly not
an ICF component, although it is a plausible long-term
outcome, and may be linked to a person’s functio-
ning. When developing the ICF, the WHO insisted
on remaining within objective aspects of biomedical
phenomena. The term well-being can be characterized
in many ways and agreement on how to do so or assess
and measure is lacking.
Furthermore, Bickenbach did not agree with Siegrist’s
proposal to make a distinction between activity and
participation, as, for him, there is no robust way of dis-
tinguishing these constructs. The ultimate outcome is
well-being, but this cannot be normative without being
paternalistic. Normativity is in conflict with current
models of patient-centred care where a rather eudai-
monistic model is advanced, emphasizing self-efficacy,
autonomy, sense of purpose and meaning in life.
THREE COMMENTS AND DISCUSSION
Jean-Pierre Didier commented on the ICF and men-
tioned that the acceptability of the ICF is sometimes
critically discussed by people with disabilities and
their associates. Moreover, he underlines that the ICF
is still not widely used and gave 4 possible explana-
tions for this:
1. The tool is constructed within a complex (probably
too complex) structure.
2. The tool appears as a classification, too far from
clinical practice.
3. The tension between the medical and social model
of disability persists despite the ICF.
4. ICF tries to satisfy people who are too different and
needs of too different fields.
Christoph Gutenbrunner focussed on the point that the
ICF has been described as “theory-neutral”, “appro-
priate to describe” the lived situation of persons with
disability and “not normative”, and raised a number
of questions:
• Has the ICF really been developed without an (im-
plicit) theory behind it? In sociology theories about
the interaction of persons with the environment have
been existent previously.
J Rehabil Med 51, 2019