The document discusses the disablement model and public health approach to aging. It begins by outlining Nagi's concept of disability, which views disability as a gap between an individual's abilities and the demands of their social and physical environment. It then discusses the International Classification of Impairments, Disabilities and Handicaps (ICIDH) model and its evolution into the International Classification of Functioning, Disability and Health (ICF) model. The document notes that disability results from the interaction between an individual and their environment, and that similar impairments can lead to different levels of disability depending on environmental and personal factors. It concludes by discussing how modifying tasks and environments can help reduce disability.

1. The Disablement model and
Public health approach to Aging
재활의학과
물리치료실
박관수

2. 순서
 1. Concept of disablement Model
 Nagi’s concept
 ICIDH concept
 2. Public health approach to Aging
 우리나라 노인문제 현황
 공중보건 접근방법
 * 예상 소요 시간 38 분 40 초 졸지 마세요
!

3. Understanding of the source of
contemporary conceptual confusion
 Disablement Model
 Nagi(1965)
 International Classification of Impairments, Disabilities,
and Handicaps(ICIDH-1)(WHO,1980)
 International Classification of functioning, Disability
and Health ICF (WHO,2000)
 용어의 중복
 각기 다른 협력 집단에서 각기 다른 model 의 개념을
사용

4. Nagi’s Concept of Disability
Sociologist Saad Nagi (1965)—Disability is the
expression of a physical or a mental limitation
in a social context.
Social Security Act( 연방사회보장법 )- Disability
as an inability to work due to a physical or
mental impairment
Nagi 는 disability 를 사람의 능력과 social and
physical environment 의 요구 사이의 gap 이
라고 생각했다 (Nagi,1965,1976,1991).

5. PATHOLOGY IMPAIRMENT
FUNCTIONAL
LIMITATION DISABILITY
Definition
Measures
Interruption or
interference of
normal bodily
processes or
structures
Loss and/or
abnormality of
mental,
emotional,
physiological, or
anatomical
structure or
function
Restriction or lack
of ability to
perform an action
or activity in the
manner or within
the range
considered normal
for the person as a
whole
Inability or
limitation in
performing socially
defined activities
and roles expected
of individuals
within a social and
physical
environment
Disease
Clinical
pathology
Symptoms and
signs
Pain
Balance, strength,
range of motion
(physical
performance)
Locomotor
activity
(physical
performance)
Mobility
(survey)
Instrumental
and activities
of daily living
(survey)
Level Cells and
tissues
Organs and
organ systems
Organism Society

6. Nagi’s Concept of Disability
 Disability is a limitation in performing socially
defined roles and tasks expected of an individual
within a sociocultural and physical environment.
 These roles and tasks are organized in spheres
of life activities such as those of the family or
other interpersonal relations
 Ex. work, employment, and other economic pursuits;
and education, recreation, and self-care

7. The concept of social roles
 사회적 역할은 부모 , 노동자 , 대학교수 등과 같이
사회시스템에 어떻게 참여하는지에 따라 기본적으
로 조직된다
 Role is the organized system of participation
of an individual in a social system
 Tasks are specific activities through which
the individual carries out his or her social
roles.
 Nagi : Role 은 disability concept 의 한 부분으로 목적 있
는 행동 , 조직적인 , 특별한 task 등으로 구성된다 .

8. Nagi’s Concept of Disability
 Not all impairments or functional limitations
precipitate disability, and similar patterns of
disability may result from different types of
impairments and limitations in function
 Identical types of impairments and similar
functional limitations may result in different
patterns of disability

9. Nagi’s Concept of Disability
 Disability 의 severity 와 dimension 에 영
향을 주는 요소
 1. Limitation 에 처한 개인의 반응과 상황
 2. 가족 , 친구 , 친지 , 고용주 , 동료 , 서비스
와
 benefits 을 제공하는 조직과 전문가 등 타
 인의 반응과 기대
 3. 물리적 사회적 barrier 로부터 자유로운
 정도와 환경적 특성 . (Nagi, 1991,)

10. Work Disability
 Two patient with Parkinson’s disease
 두명 모두 rigidity, bradykinesia 가 있고 slow, shuffling gait,
slow deliberate movement pattern 을 가지고 있다 .
 One patient- restricted outside activities completely, 아침에
옷입는데 도움이 필요하고 대부분 TV 시청을 하면서 보내며 ,
depressed 되어 있으며 , 지속적으로 실업상태이다 .
 The other patient- 대부분의 social life 에 참여하고 있으며
daily activity 는 배우자에 도움을 받고 있으며 , workplace
modification 을 통해 종일 근무를 하고 있다 .
 두 환자는 유사한 pathology, Impairment, functional
limitation 을 가지고 있으나 매우 다른 work disability 를 가지
고 있다 .
 Disability 는 개인의 고유한 특성이라기 보다 개인과 환경의
상호작용에 의한 결과물이다

11. Nagi’s Disablement Model 의 발전
 Verbrugge and Jette
 Nagi 의 disability 개념에 social role 을 첨가시킨다 .
 Activities of daily living (ADL)-basic mobility 와 personal care
와 같은 behavior 을 포함한다 .
 Instrumental activities of daily living (IADL)
 Preparing meals, doing housework, managing finances, using the
telephone, and shopping
 Paid and unpaid role activities
 performing one’s occupation, parenting, grandparenting, and being
s student.
 Social activities
 attending church and other group activities and socializing with
friends and relatives
 Leisure activities participating in sport and physical recreation,
reading, or taking distant trips

12. Disability 에 영향을 미치는 외부 요인
 Verbrugge & jette 은 social
epidemiological 관점에서 3 가지 변수를
고려 해야 한다고 했다 .
 Predisposing risk factor
 Intraindividual factors
 Extraindividual factors

14.  1997 –add two important concepts to the
Disablement model – concepts of secondary
conditions and quality of life
 Secondary condition
 최초 disabling condition 의 이차적 결과로 나타나는 형
태라고 정의했다 (1991, IOM report).
 Ex. pressure sores, contractures, depression, and
urinary tract infections 등이 포함된다 (Marge, 1988).
 Secondary condition 은 pathology, impairment,
functional limitation 혹은 additional disability 라고 할
수 있다고 했다 .

15. Enabling- Disabling process
 Disabling conditions not only develop and
progress but can be reversed through the
application of rehabilitation and other forms
of explicit intervention

17. Internal classification of Impairments,
Disabilities, and Handicaps
 1970’s Europe --> WHO, ICIDH(1980)

 ICF(2000)
 Health conditions
 Impairments
 Disability (Activity limitation)
 Handicaps (Participation Restriction)

18. Impairment
 Impairment is any loss or abnormality of psychological,
physiological, or anatomical structure or function (WHO, 1980).
 Impairment 는 ( 신체 일부의 심각한 변형이나 손실과 같은 ) 신
체 기능 혹은 구조상의 이상을 의미한다 . (WHO, 2000)
 ICF(ICIDH) 의 impairment 개념은 Nagi 의 impairment &
pathology concept 을 포함
 Nagi 의 impairment concept focus organs or organ system
 ICF(ICIDH) impairment concept focus function and structure of
the body and its component

19. Disability (Activity limitation)
 Disability is 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 (WHO, 1980)
 Focus– activities carried out by the person
 ICIDH disability 는 Nagi 의 functional limitation 과 disability 의 가교 역
할
 ICF 에서 disability 는 positive term 인 activity 로 바뀜
 활동 (Activity) 은 개인에 의한 임무 또는 행동을 의미한다 .
 활동제한 (Activitiy limitation) 은 개인이 활동을 할때 가질 수 있는 어려움
을 의미한다 .
 Activities may be limited in nature, duration and quality (WHO, 2000).

20. Handicap(Participation restriction)
 Handicap is a disadvantage for a given individual, resulting from
an impairment or a disability, that limits or prevents the fulfillment
of a role that is normal (depending on age, sex, and social and
cultural factors) for that individual (WHO, 1980).
 Nagi’s disability 의 role 개념을 포함하며 role 의 실재적인 수행
보다는 Disadvantage 에 초점을 맞춘 것으로 문화적 규범을 반
영한 사회 속의 사람에 초점을 맞추었다 .
 참여 (Participation) 는 실질적인 생활 상황에의 연루를 의미한다 .
 참여제약 (Participation restriction) 은 개인이 실질적인 생활 상황
에 연루될 때 겪을 수 있는 문제를 의미한다 .
 Participation may be restricted in nature, duration and quality
(WHO, 2000).

21. Handicap(Participation restriction)
 Nagi’s disability 는 ICIDH 의 handicap & participation 은 본
질적으로 같은 개념이다 .
 Participation 은 사람의 건강상태 특히 impairments or
disabilities 들과 사람이 살아가는 환경 사이의 복잡한 관계의
결과들이다
 다른 환경은 같은 impairment 혹은 disability 를 가지고 있는
사람들에게 각기 다른 영향을 준다 .
 Participation is therefore based on an
ecological/environmental interaction model (WHO, 2000).

23. Directionality and the Dynamic nature
of disability
 Static entities (Unidirectionl)
 초기의 disablement model 은 ‘ disablement
process 는 질병의 진행에 따라 단순이 한방향
성을 가지는 진행이다’ 라는 전통적 생각을 가
지고 있었다 (marge, 1988).
 Dynamic Entities(Bidirection)
 Disablement 는 생애를 통해서 fluctuate 할 수
있다 .
 최근에는 disablement process 는 downward-
spiraling 한다고 보고 있다 .

24. Disablement concepts 과 quality of life 개념의 차이점
 Quality of life 개념은 개인의 내적 상태 , 건
강상태 뿐만 아니라 사회적 , 물리적 환경
까지 고려하는 복잡한 개념이다 .
 Quality of life 측정방법
 삶의 질을 인지하는 개인 인식에 기초하는 주관
적 방법
 삶의 질의 외적 판단에 기초하는 객관적 방법
(Birren and Dieckermann, 1991)

25. Disablement concepts 과 quality of life 개념의 차이점
 Quality of life 의 구성요소 (Lawton, 1983)
 Physiological Well-being
 Perceived quality of life
 Behavioral competence in multiple area( health, functional health,
cognition, time use, and social behavior)
 Objective environment
 Most quality of life measures focus little attention on organ and
body system functioning and focus more on the consequences
of impairments at the personal activity or social role level.
 Quality of life > Disability concept

26. Disablement concepts 과 quality of life 개념의 차이점

27. Modified Disablement Model

28. Modified Disablement Model
Patient Management

29. Disablement Model
Pathology Impairment
Functional
Limitation
Self-
Reported
Disability
Diabetes
Loss of
lower-
extremity
sensibility
Altered performance
in daily tasks

30. Disablement: Examples
Pathology Impairment Functional
Limitation
Disability
Sarcopenia Loss of
strength
Slow gait
speed
Difficulty
crossing
street
Parkinson’s
disease
Loss of
balance
Tandem
stand <10 sec
Difficulty
with stairs
Alzheimer’s
disease
Memory
< age/educ
norm
Inefficient,
unsafe
cooking,
Difficulty
with meals

31. Functional Limitation 상태에서
Disability 를 예방
 Change task demands (“demand”)
 Simplify tasks (“change way you do the
task”)
 Reduce frequency of task (“do less often”)
 Recruit spared areas of ability to
compensate for deficit (“supply”)
 Use alternative muscle groups
 Organize activity efficiently to overcome
weakness or other motor or sensory deficits

32. Reduce Disability: Change Task
Demands
Pathology Impairment
Functional
Limitation
Self-Reported
Disability
Sarcopenia
Loss of
lower-
extremity
strength
Altered performance
in daily tasks
Do less frequently, change
environment