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disability in CBR community based rehabilitation WHO ICF model detailed explanation
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https://www.ncbi.nlm.nih.gov/books/NBK310968
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Disability in CBR (Community-Based Rehabilitation)
1. What is CBR?
Community-Based Rehabilitation (CBR) is defined by WHO and major NGOs as:
"A strategy within general community development for the rehabilitation, equalization of opportunities and social inclusion of all people with disabilities. CBR is implemented through the combined efforts of the people with disabilities themselves, their families, organizations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services."
CBR was first initiated by WHO following the Declaration of Alma-Ata (1978) and has since expanded from a purely medical model into a broad, multisectoral approach covering health, education, livelihood, social participation, and empowerment. It is now implemented in over 100 countries. (- Park's Textbook of Preventive and Social Medicine, p. 376; WHO CBR Guidelines, NCBI Bookshelf)
2. Understanding "Disability" - The Conceptual Framework
CBR's concept of disability is built on two interrelated classification systems:
A. ICIDH (1980) - The Original WHO Model
The International Classification of Impairments, Disabilities and Handicaps (ICIDH), first published by WHO in 1980, introduced a systematic taxonomy of the consequences of disease and injury. It defined three distinct levels:
| Term | Definition | Level |
|---|---|---|
| Impairment | "Any loss or abnormality of psychological, physiological, or anatomical structure or function." Disturbances at the level of the organ - defects/loss of limb, organ, body structure, or mental function. | Organ level |
| Disability | "Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being." Reflects consequences in terms of functional performance and activity by the individual. | Person level |
| Handicap | "A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural practice) for that individual." Reflects interaction with and adaptation to the individual's surroundings. | Social level |
(- Park's Textbook of Preventive and Social Medicine, p. 674)
Handicap may be:
- Intrinsic - arising from within the person (e.g., blindness)
- Extrinsic - arising from the social environment (e.g., loss of parents)
- Primary - the direct handicap (e.g., blindness)
- Secondary - arising from the primary handicap (e.g., poverty resulting from blindness)
B. ICF (2001) - The Current Biopsychosocial Model Used in CBR
The ICIDH was replaced by the International Classification of Functioning, Disability and Health (ICF, WHO 2001). This is the primary framework underpinning CBR today. The key shift: ICIDH focused on the consequences of disease, while ICF focuses on components of health. ICF is a classification of health and health-related domains describing body function and structure, activities and participation - recognizing that disability occurs in a social and environmental context.
ICF Model Diagram:
(Source: Park's Textbook of Preventive and Social Medicine, p. 675)
Two Parts of the ICF Framework
Part 1: Functioning and Disability
- Body Function and Structure - Describes actual anatomy, physiology, and psychology of the human body. Problems here are called impairments.
- Activity and Participation - Describes the person's functional status: communication, mobility, interpersonal interactions, self-care, learning, applying knowledge, etc. Problems here are called activity limitations and participation restrictions.
Part 2: Contextual Factors
- Environmental Factors - Factors NOT within the person's control: family, workplace, government agencies, laws, cultural beliefs. These can be facilitators (help the person function) or barriers (restrict functioning).
- Personal Factors - Race, gender, age, educational level, coping styles, etc.
The ICF model is bidirectional - all components interact with each other and with the underlying health condition. This is why CBR takes a multisectoral approach.
3. Two Models of Disability Underlying CBR Philosophy
CBR recognizes two competing views that are synthesized in the ICF:
| Model | View of Disability | Intervention |
|---|---|---|
| Medical Model | A feature of the person, directly caused by disease, trauma, or other health conditions | Medical care by individual professionals |
| Social Model | A socially-created problem, NOT an attribute of the individual; caused by an unaccommodating physical and social environment | Political response, environmental modification, attitude change |
CBR adopts a biopsychosocial synthesis - disability arises from the interaction of health conditions WITH environmental and personal factors. This explains why CBR addresses not just medical rehabilitation but also education, livelihood, social inclusion, and empowerment.
(- Park's Textbook of Preventive and Social Medicine, p. 675; Linking CBR, Disability and Rehabilitation - Afri-CAN)
4. Classification of Disability in CBR
CBR classifies disability into three main groups, each requiring different rehabilitation approaches:
A. Physical Disability (Physically Handicapped)
Includes children and adults who are:
- Blind or visually impaired
- Deaf and/or mute
- Those with congenital deformities (hare-lip, cleft palate, talipes)
- "Crippled" due to: poliomyelitis, cerebral palsy, congenital heart disease, road accidents, burns, injuries
Three broad causative groups:
- Birth defects - preventable through adequate prenatal/natal/postnatal services and genetic counselling
- Infections - e.g., polio (preventable by immunization), rubella
- Accidents - preventable through safety education
B. Mental Disability (Mentally Handicapped)
Mental handicap is a condition of sub-average intellectual function combined with deficits in adaptive behaviour.
Causes:
- Genetic: Down's syndrome, Klinefelter syndrome, PKU, Tay-Sachs disease, galactosaemia, microcephaly, congenital hypothyroidism
- Antenatal: neural tube defects, Rh incompatibility, rubella, CMV, toxoplasmosis, syphilis, drugs, irradiation
- Perinatal: birth injuries, hypoxia, cerebral palsy
- Postnatal: head injuries, encephalitis, lead/mercury poisoning
- Miscellaneous: maternal malnutrition, iodine deficiency, consanguineous marriages, late-age pregnancy
WHO Classification by IQ:
| Category | IQ Range |
|---|---|
| Mild mental retardation | 50-70 |
| Moderate mental retardation | 35-49 |
| Severe mental retardation | 20-34 |
| Profound mental retardation | Under 20 |
Among 100 mentally handicapped persons: approximately 70 mild, 20 moderate, and 5 severe cases.
C. Social Disability (Socially Handicapped)
A child or person whose opportunities for healthy personality development are hampered by:
- Parental inadequacy
- Environmental deprivation (lack of stimulation/learning)
- Emotional disturbances
- Orphaned, neglected, or destitute status
- Exploitation or delinquency
Children with physical or mental disabilities also face social handicaps due to social rejection or misunderstanding.
(- Park's Textbook of Preventive and Social Medicine, pp. 674-675)
5. Magnitude of Disability - Global and Indian Context
- At least 10% of the world's population lives with a disability, the majority in developing countries in conditions of poverty
- Nearly 83 million people globally are estimated to be mentally retarded
- 42 million people have hearing loss (41 dB and above) - 3rd leading cause of disability
- Disability from poliomyelitis has affected about 10 million globally
- In India: approximately 16.15 million persons (1.9% of population) have physical disability; about 3% of 1-14 year age group has developmental delays
6. Prevention of Disability in CBR - Three Levels
CBR operates at all three levels of prevention:
Primary Prevention (Prevent the handicap from occurring)
- Genetic counselling (optimal maternal age 20-30 years; avoid consanguineous marriages)
- At-risk approach (identify those at risk of transmitting inherited diseases)
- Immunization - polio is the main cause of disability in India; prevent with OPV
- Proper maternal nutrition to reduce prematurity
- Prenatal care, avoiding teratogenic drugs/X-rays/smoking
- Medical Termination of Pregnancy Act (1971) allows abortion of severely handicapped foetuses
Secondary Prevention (Early diagnosis + treatment)
- Early diagnosis through MCH and School Health Services
- Treatment: physiotherapy, occupational therapy, speech therapy, prosthetics
- "Physical Medicine and Rehabilitation" - the modern term
- Vocational guidance: train the handicapped to "work with what is left"
Tertiary Prevention (Rehabilitation)
- CBR aims to restore the person to the highest possible level of functioning
- Measures are medical, surgical, social, educational, and vocational
- Requires coordinated efforts by Health, Education, Social Welfare departments, and voluntary organizations
7. The CBR Matrix - Five Key Domains Addressing Disability
The CBR Guidelines present a matrix of five interconnected components, each essential for addressing disability comprehensively:
| Domain | Key Activities |
|---|---|
| Health | Promotion, prevention, medical care, rehabilitation, assistive devices |
| Education | Inclusive education, non-formal education, lifelong learning |
| Livelihood | Skills development, self-employment, financial services, social protection |
| Social | Personal assistance, marriage/family support, cultural/religious participation, sports/recreation |
| Empowerment | Advocacy, self-help groups, disabled people's organizations, political participation |
8. ICF as a Tool in CBR Planning
The ICF is used in CBR in four key ways (Schneider & Hartley, 2006):
- Planning individual intervention programmes - identifying each component of a person's disability to tailor a rehabilitation plan
- Looking at whole community issues - not just individual impairments but environmental and participation barriers
- Monitoring and evaluation of CBR generally - standardized language for measuring outcomes
- Motivating policies that promote inclusion of disabled people
The ICF, UNCRPD (UN Convention on the Rights of Persons with Disabilities), and CBR Guidelines all share a common view of disability as a human rights issue requiring equalization of opportunities and full community participation.
9. Rehabilitation in CBR - A Practical Summary
Rehabilitation measures include planned and systematic actions - medical, surgical, social, educational, and vocational - consistently over years with sustained counselling and health education to restore individuals to the highest possible level of functional ability.
The guiding principle stated in Park's: "The cheapest and surest rehabilitation is to prevent physical deformities and social and vocational disruption by early diagnosis and adequate treatment. We should never allow dehabilitation to take place and afterwards take up the uphill task of rehabilitation." (p. 375)
In India, key national institutes supporting CBR for persons with disability include:
- National Institute for Mentally Handicapped (NIMH), Secunderabad (1984)
- Ali Yavar Jung National Institute for the Hearing Handicapped, Mumbai
- National Institute for the Visually Handicapped, Dehradun
- National Institute for the Orthopaedically Handicapped, Kolkata
Key References:
- Park's Textbook of Preventive and Social Medicine - WHO definition of CBR (p. 376), disability classification and ICF (pp. 674-675)
- WHO CBR Guidelines - NCBI Bookshelf
- Linking CBR, Disability and Rehabilitation (ICF Framework)
Properly explain only disability handicap and imapirment
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I have all the authoritative content needed. Here is a clean, detailed explanation of all three terms:
Impairment, Disability, and Handicap in CBR
These three terms were formally defined by WHO in the International Classification of Impairments, Disabilities and Handicaps (ICIDH, 1980) - the foundational framework for CBR. They represent three distinct but linked levels of the consequences of disease or injury.
The ICIDH Sequence
The ICIDH describes a progression:
Disease/Injury → IMPAIRMENT → DISABILITY → HANDICAP
(Organ) (Person) (Society)
Each term operates at a different level and has a precise meaning. They are not interchangeable.
1. IMPAIRMENT
Definition (WHO - ICIDH)
"Any loss or abnormality of psychological, physiological, or anatomical structure or function."
Level: ORGAN level
Impairment is the most basic level - it is a problem at the level of a body part, organ, or organ system. It is the direct result of a disease, injury, or congenital defect.
Key Points:
- Includes defects or loss of a limb, organ, or other body structure
- Includes defects or loss of mental function
- It is a deviation from a biomedical standard - something is structurally or functionally wrong with the body
- Impairment can be permanent or temporary
Additional Impairment Categories:
| Type | Meaning |
|---|---|
| Temporary impairment | Exists only for a limited period after injury or illness |
| Permanent impairment | Assessed once Maximum Medical Improvement (MMI) is reached - no further treatment can improve it |
| Whole-person impairment | Alteration in functioning of the body as a whole; ranges from 0% (none) to 100% (cessation of all body functions) |
| Permanent partial impairment | Numeric percentage of loss of body functioning due to an affected organ system |
Examples:
- Loss of a limb (arm, leg)
- Damage to the visual cortex or the eye itself → blindness
- Loss of cochlear function → deafness
- Paralysis of leg muscles after polio
- Loss of mental function after brain injury
2. DISABILITY
Definition (WHO - ICIDH)
"Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being."
Level: PERSON level
Disability is a step beyond impairment - it is what the impairment does to the person's ability to function. It reflects the consequences of impairment in terms of functional performance and activity by the individual.
Key Points:
- Disability arises from an impairment (it is its functional consequence)
- It is assessed by comparing the person's performance to what is considered normal for a human being
- The same impairment does NOT always cause the same degree of disability - context matters
- Disability represents disturbances at the level of the person
Critical Distinction - Impairment ≠ Disability:
The degree of impairment frequently correlates with the degree of disability, but this is not always the case. A classic example from Murray & Nadel's Respiratory Medicine:
Loss of the fifth finger of the non-dominant hand:
- For an average person - small impairment = small disability
- For a concert pianist - same small impairment = significant disability in work activities
This shows that disability is contextual and person-specific, not purely biological.
| Type | Meaning |
|---|---|
| Permanent total disability | A medicolegal determination that a person's impairment precludes future gainful employment entirely |
Examples:
- Paralysis of the legs → inability to walk (disability in mobility)
- Deafness → inability to communicate through speech in normal settings
- Blindness → inability to read standard print or navigate independently
- Cognitive impairment → inability to perform activities of daily living
3. HANDICAP
Definition (WHO - ICIDH)
"A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural practice) for that individual."
Level: SOCIETY/SOCIAL ROLE level
Handicap is the broadest level. It reflects the social consequences - how disability affects the person's ability to fulfil their expected roles in society. The term handicap reflects interaction with and adaptation to the individual's surroundings.
Key Points:
- Handicap is defined by social norms - what is "normal" varies by age, sex, and cultural context
- The same disability can cause different handicaps in different societies
- It is not inherent to the person - it arises from the gap between the person's capacity and society's expectations/accommodations
- Handicap connects CBR to the social model of disability
Types of Handicap:
| Type | Definition | Example |
|---|---|---|
| Intrinsic handicap | Arises from within the person | Blindness itself |
| Extrinsic handicap | Arises from the social environment | Loss of parents, lack of accessible infrastructure |
| Primary handicap | The direct/original handicap | Blindness |
| Secondary handicap | One that arises as a consequence of the primary handicap | Poverty resulting from blindness |
Examples:
- A person who is deaf (impairment) and cannot hear speech (disability) cannot get a job requiring telephone communication → handicap in the role of "worker"
- A person with paraplegia who cannot walk (disability) but lives in a city with no ramps or accessible transport → handicap in the role of "community member"
- A mentally retarded child who cannot study at a normal school → handicap in the role of "student"
Summary Comparison Table
| Feature | Impairment | Disability | Handicap |
|---|---|---|---|
| Level | Organ/body | Person | Society/social role |
| What it is | Structural/functional loss | Restricted activity performance | Social role disadvantage |
| Caused by | Disease, injury, defect | Impairment | Impairment or disability |
| Measured against | Normal anatomical/physiological standard | Normal human activity range | Normal social roles for that individual |
| Example | Paralysed leg muscles | Cannot walk | Cannot fulfil role of independent worker/community member |
| CBR focus | Medical/therapeutic intervention | Functional rehabilitation | Social inclusion, equalization of opportunity |
Why the Distinction Matters in CBR
CBR must address all three levels simultaneously:
- Treating impairment alone (purely medical approach) is insufficient
- A person may have significant impairment but little disability if given the right training
- A person may have disability but face minimal handicap if society is inclusive and accessible
- Reducing handicap often requires changing the environment and social attitudes - not just treating the person
This is why the 2001 ICF replaced the ICIDH - it moved the focus from "what is wrong with the person" to "what factors in the person and environment together produce the disability experience," which aligns perfectly with CBR's holistic, community-based approach.
Sources:
- Park's Textbook of Preventive and Social Medicine, p. 674 - ICIDH definitions and handicap types
- Murray & Nadel's Textbook of Respiratory Medicine, p. 832 - impairment vs. disability distinction and clinical examples
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