Chapter 29: Promoting Health and Wellness

Despite being among the wealthiest countries in the world,¹ and spending more than $2.3 trillion a year in health care,² the United States is ranked only 31st in healthy life expectancy by the World Health Organization (WHO).³ Some researchers have predicted that after years of increasing life expectancy, life expectancy in the United States will level off or even decline.⁴ Researchers and health professionals are struggling to understand this apparent discrepancy between health care expenditures and healthy life expectancy by examining and addressing the determinants of health in the U.S. population. An individual's health is determined by the interaction of numerous factors, including biology and genetics, social and physical environments, health services, and individual behaviors.⁵ The relative contribution of individual behaviors to levels of mortality and morbidity in the United States was first demonstrated in a landmark study published in 1993 by McGinnis and Foege.⁶ Tobacco use was estimated to be implicated in 19% of deaths, and poor diet and physical inactivity levels contributed to 14% of deaths in the United States in 1990. Mokdad et al⁷ later conducted a similar study to determine the behavioral contributors to premature death in the United States in 2000. Tobacco use was responsible for 18.1% of deaths, and poor diet and physical inactivity were estimated to be responsible for 16.6% of deaths.

Recent studies of the U.S. population have shown that these key behaviors of smoking, poor diet, and insufficient physical activity continue at high levels in the population. The Behavioral Risk Factor Surveillance System (BRFSS), the largest telephone survey in the world, tracks the health behaviors and health status of over 200,000 adults in the United States annually.⁸ The results of the BRFSS show that obesity levels in the country are climbing at an alarming rate (Fig. 29.1).⁹

According to the 2009 BRFSS, 36.2% of the adult population in the United States is overweight, and an additional 27.2% is obese.¹⁰ A majority of the U.S. adult population does not consume the currently recommended five or more servings per day of fruits and vegetables¹¹ (Fig. 29.2). Almost half of adults in the United States report that they do not engage in recommended levels of physical activity¹² (Fig. 29.3) Given the strong relationship between these key health behaviors and health status, it is clear that the current health-related behaviors of adults in the United States are adversely affecting healthy life expectancy, and efforts to support healthier behaviors are essential.

The nation's current health promotion and disease prevention agenda is articulated in Healthy People 2020, a set of national health objectives developed through a wide-reaching collaborative consensus process and published by the U.S. Department of Health and Human Services.⁵ Public health experts, government agencies, professional organizations such as the American Physical Therapy Association (APTA), and members of the public all provided input into this important document. The overall framework for Healthy People 2020 is outlined in Table 29.1.

Given the broad range of factors that contribute to the health of the population, an ecological approach will be required to meet the Healthy People 2020 goals and objectives. Interventions must be delivered not only at the level of the individual, but also at community, organizational, environmental, and policy levels (Fig. 29.4).

A number of topic areas requiring particular attention have been identified in Healthy People 2020, and for each of these 42 topic areas there is a set of specific objectives. For example, within the topic area of physical activity, there are 15 objectives (Table 29.2) accompanied by specific targets to be achieved within the next 10 years. The ecological approach to addressing the topic areas is clear from the breadth of the objectives established for each of these 42 topic areas. For example, in the topic area of physical activity, one objective is to increase individuals' levels of leisure-time physical activity (Physical Activity Objective–1), whereas Physical Activity Objective–15 identifies the need for legislative policies to address environmental factors to support increased levels of physical activity in a community. Progress toward the objectives and specific targets established for Healthy People 2020 will be tracked by measuring general health status, health behaviors, health-related quality of life and well-being, determinants of health, and measures of health disparities.

Interventions at individual, community, state, and national levels by a broad coalition of public health organizations, health professionals, educators, and government agencies will be required to achieve the objectives outlined in Healthy People 2020. All health professionals, regardless of their site or area of practice, have a key role to play in health promotion, either as individual practitioners or as members of an interprofessional health care team.¹³ Physical therapists are participating in health promotion initiatives in a variety of ways, from examining what their role should be to providing individual and community-level interventions and programs.^14,15,16,17 A number of professional publications describe the important role for physical therapists in the area of health promotion and wellness.^18,19,20,21

The Guide to Physical Therapist Practice clearly identifies health promotion and prevention as being within the scope of physical therapist practice.¹⁸ It states, "Physical therapists provide prevention services that forestall or prevent functional decline and the need for more intense care. Through timely and appropriate screening, examination, evaluation, diagnosis, prognosis, and intervention, physical therapists frequently reduce or eliminate the need for costlier forms of care and also may shorten or even eliminate institutional stays. Physical therapists also are involved in promoting health, wellness, and fitness initiatives, including education and service provision that stimulate the public to engage in healthy behaviors."^{18, p. S32} The patientc history portion of the examination should include information about the client's health status and health habits, a systems review, and tests and measures as indicated to screen for potential problems that could affect current or future health status, such as hypertension, obesity, impaired balance, or poor fitness levels. Interventions that physical therapists can utilize to promote health and prevent or minimize impairments, activity limitations, and disabilities are extensive and can include such diverse activities as education in healthy lifestyle choices and healthy behaviors, physical activity and aerobic conditioning programs, fall prevention programs, or consultation in workplace redesign. Referrals to other professionals or special programs (e.g., smoking cessation or nutritional counseling) may also be indicated. The principles of evidence-based practice should be considered as physical therapists expand their practices to include not only rehabilitation, but also health promotion. Decisions regarding appropriate programs to institute should be based on evidence of effectiveness of the intervention, the knowledge and skill level of the physical therapist, and the appropriateness of that particular intervention for the individual client given his or her unique needs, preferences, and circumstances.

In the document titled Professionalism in Physical Therapy: Core Values, physical therapist behaviors believed to represent the behaviors of a doctoring profession include the following:^{21, pp. 1-3}

• Participating in the achievement of health goals of patients/clients and society

• Focusing on achieving the greatest well-being and the highest potential for a patient/client

• Facilitating each individual's achievement of goals for function, health, and wellness

• Participating in achievement of societal health goals

These behaviors indicate a broad role and responsibility for physical therapists in health promotion and suggest the need for physical therapists to participate not only at the individual client level, but also at a societal level. Physical therapists are participating in discussions at a national level regarding public policy, health care reform, and major health initiatives, and are also involved in advocacy efforts to support the objectives articulated in Healthy People 2020.²²

At the Physical Therapy and Society Summit (PASS) meeting, future roles for physical therapists were discussed relative to the evolving health care needs of society.²³ At this conference, the opportunity for physical therapists to take a leadership role in the area of prevention, health, and wellness was emphasized. There has also been a suggestion that physical therapists should be "birth to death" health practitioners, providing regular consultations on exercise and physical activity using a practice model that is similar to the dental model and geared toward prevention and health promotion.²⁴

Given the tremendous need for health promotion, and the unique knowledge base and skill set of physical therapists, it is the professional responsibility of all physical therapists to engage in health promotion practice regardless of their practice setting. As physical therapists begin to integrate health promotion interventions into their clinical practice, they should become familiar with the various terms and definitions used in the field of health promotion.

Health and Disease

Different terms are used in the field of health promotion to define health. Although health may be seen as pertaining to the physical domain only, most currently used definitions of health conceptualize and describe health as a multidimensional construct involving more than the physical domain. In 1948, the WHO defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease," the definition of health still used by the WHO today.²⁵ Health has also been described as "a dynamic balance of physical, emotional, social, spiritual, and intellectual health."^{26, p. iv} Disease, often considered the opposite of health, is defined as a pathological condition affecting the body.¹⁸

Wellness and Illness

The term wellness is also used in the field of health promotion. In 1959, Dunn discussed the relationship between body, mind, and spirit, and defined wellness as "a complex state made up of overlapping levels of wellness."^{27, p. 786} Adams et al²⁸ defined wellness as an individual's sense of growth and balance across the physical, spiritual, emotional, intellectual, social, and psychological domains (Fig. 29.5). These two wellness definitions are worded in such a way that individuals with chronic disease could still be considered "well."

Corbin and Pangrazi describe wellness as "a multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being."^{29, p. 1} Some current definitions of health appear similar to definitions of wellness, particularly those definitions of health that include more than the physical domain. Some in the health promotion field conceptualize wellness as a process versus a state.³⁰ Taken together, these various definitions of wellness indicate that wellness is multidimensional, that salutogenic or "health-causing" variables play a key role in well-being, and that the concept of wellness is specific to each individual. Illness is the opposite of wellness, is multidimensional, and has been defined as a social construct where individuals are not achieving balance in their lives and are unable to create a higher quality of life.³¹

Quality of Life

There are a number of different definitions for quality of life. The Centers for Disease Control and Prevention (CDC) describes health-related quality of life as an individual's or group's perceived physical and mental health over time.³² Green and Kreuter describe quality of life as "the perception of individuals or groups that their needs are being satisfied and that they are not being denied opportunities to achieve happiness or fulfillment."^{33, p. 508}

Health Promotion Models

Primary, Secondary, and Tertiary Prevention

Various health promotion models are used to identify needs and plan health promotion interventions. One such model is the health protection/disease prevention model. Within this model, health is conceptualized as the absence of disease/pathology, and health promotion is therefore aimed at preventing disease. Interventions in this model are categorized as primary, secondary, or tertiary prevention³⁴ (Fig. 29.6).

Primary prevention includes activities designed to prevent injury or the onset of illness or disease. The use of bicycle helmets and seat belts, water fluoridation, and immunizations are all examples of primary prevention. Physical therapists practice primary prevention when they conduct preseason evaluation and conditioning programs for high school athletes or teach back injury prevention programs at orientation programs for workers in a factory.

Secondary prevention interventions take place following the development of pathology and are intended to identify and provide treatment for individuals in the early stages of disease in order to minimize the severity of the disease. Screening programs for breast cancer, high blood pressure, and osteoporosis are designed to identify and treat pathology in its earliest stages. Physical therapists engage in secondary prevention when they treat a patient/client with a recent injury or who has been recently diagnosed in the early stages of a chronic condition or disease.

Tertiary prevention activities are designed to slow progression of the disease and improve quality of life. Physical therapists engage in tertiary prevention when they work with patients/clients who have chronic disease or have sustained an irreversible injury—for example, with patients/clients who have long-standing rheumatoid arthritis. Physical therapists have traditionally participated primarily in secondary or tertiary prevention, but as they begin to join their fellow health professionals in health promotion practice, they will increasingly add interventions that fall under the category of primary prevention.

Population Health Management Model

A similar model to the health protection/disease prevention model is the population health management model, which is used to describe health promotion and prevention interventions for a population across a continuum of health risk³⁵ (Fig. 29.7). The population health management approach categorizes individuals based on risk for developing a disease, and then provides the appropriate intervention for the identified risk factor. Individuals at low or very minimal risk for disease receive interventions to keep them from moving across the continuum to a high-risk category or to actual development of disease or pathology.

Green and Kreuter describe health promotion as "any planned combination of educational, political, regulatory, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities."^{33, p. 506} The WHO defines health promotion as "the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions."³⁶ Gorin and Arnold³⁷ describe health promotion as activities undertaken to encourage well-being that are directed toward actualizing an individual's potential. According to Gorin and Arnold, a health promotion model has a more positive orientation and connotation than the prevention models described above that focus on simply preventing disease. Health education is one component of health promotion. Green and Kreuter define health education as "any planned combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities."^{33, p. 506} Health education interventions aim to provide information to individuals and groups about health-causing actions and the impact of negative health behaviors in order to make a connection between voluntary behaviors and health. The first step toward positive health behavior change is awareness about the relationship between behavior and disease and injury.

The definitions for physical activity and exercise are not synonymous. Physical activity is defined as any body movement produced by skeletal muscle contraction that increases energy expenditure above resting level.³⁸ It includes body movement carried out not only within formal exercise programs, but also in occupational activities, leisure activities, and transportation activities such as walking and bicycling. Exercise is defined as a subcategory of physical activity, and is planned, structured activity that is intended to improve or maintain one or more components of physical fitness.³⁹ This differentiation is important for physical therapists to consider when they work with patients/clients to help them increase their overall levels of physical activity.

Consistent with the newer multidimensional definitions of health and wellness, there has been a change in the overall framework used to guide evaluation, planning, and interventions to support and promote health. The prevailing model used in 20th century medicine was the biomedical model.⁴⁰ This model was based on the biological sciences, and health was conceptualized as the absence of disease. The locus of control in the biomedical model was with the health care providers and the patient was provided with the medical care deemed necessary by health professionals. It was an effective model for managing acute and infectious diseases and illnesses, but proved less effective for managing chronic disease⁴⁰ or in addressing the psychological, social, or behavioral dimensions of illness.⁴¹ With its primarily biological focus and external locus of control, it was also less useful in the field of health promotion where patients' decisions, behaviors, and environments are considered important elements in understanding and addressing the multiple determinants of health.⁴² As the limitations of using a purely biomedical framework to understand the concept of health became apparent, the biopsychosocial model evolved. The various biopsychosocial models used today to explain health and illness incorporate those domains missing from the biomedical model, namely the psychological and social domains. The Nagi disablement model⁴³ is an example of a biopsychosocial model and was the model used to describe physical therapist practice in the Guide to Physical Therapist Practice.¹⁸

In 2001, the WHO endorsed the International Classification of Functioning, Disability, and Health (ICF) biopsychosocial model.⁴⁴ The ICF is intended to provide a common language to describe health, function, and disability to facilitate scientific communication within and across health professions. The APTA has endorsed the use of this model as a framework for physical therapists to use in classifying and describing health, function, and disability.⁴⁵ In this model, the complex interrelationships of biological, environmental, and personal factors and the impact of these variables on health, activity, and function are recognized. See discussion of the ICF model in Chapter 1, Clinical Decision Making.

Physical therapists have already begun the process of applying the ICF model to physical therapist practice in rehabilitation.^46,47,48 A number of health professionals have also started to demonstrate how the ICF can be used in the field of health promotion research and practice.^49,50,51,52 Howard et al⁵⁰ argue that the ICF, with its acknowledgment of the important contribution of the social and physical environment to an individual's health, supports the ecological approach used in the field of health promotion. The ICF provides both the rationale for physical therapists to look beyond purely biological and physiological factors when examining and evaluating their clients and a framework to guide their plans of care and interventions. Furthermore, the ICF model is consistent with many of the behavior change theories described later in this chapter that are used to plan and implement behavior change interventions.

There is no one standard tool for measuring health, wellness, health behaviors, or quality of life. Some tools have been specifically designed to measure the health or health behaviors of a population, whereas other tools are used to measure health and personal health behaviors at the level of the individual patient. A variety of measures of perceived health and quality of life have been developed and can be used at the level of a population, as well as at the level of the individual patient.

Clinical Measures of Health

Clinical measures of health include biometric and physiological measures such as body mass index (BMI), aerobic capacity, or blood pressure. Health risk appraisals (HRAs) are increasingly being used in workforce wellness programs to help assess the level and nature of an individual's current health risks based on history, personal behaviors, and clinical variables. The goal of a health risk appraisal is to provide information about the individual in order to plan and deliver specific interventions targeted to address his or her unique risk factors.⁵³

The Guide to Physical Therapist Practice recommends that an evaluation of a patient/client's current health status and potential health risks be included in the initial examination through a thorough history and a systems review.¹⁸ Numerous tests and measures can be used by physical therapists during initial examinations to measure patients'/clients' general health status and risk factors.¹⁸

Self-perceived Health, Wellness, and Quality-of-Life Measures

The importance of adding a measure of an individual's perception of his or her general health to the patient/client examination was demonstrated in a landmark study by Mossey and Shapiro in 1982.⁵⁴ In this study of 3,128 noninstitutionalized adults over age 64, self-rated health was the strongest predictor of mortality after age, and was found to be a better predictor of mortality than a number of morbidity and health care utilization measures such as medical diagnosis, number of physician visits, number of hospital admissions, and surgical history. The CDC includes a 14-item perceptual measure of health, the Healthy Days Measure, in the annual national BRFSS survey and in the National Health and Nutrition Examination Survey.⁵⁵ The National Institutes of Health is developing a Patient-Reported Outcomes Measurement Information System (PROMIS) that will be able to capture important health-related quality-of-life information about patients who have chronic diseases and conditions.⁵⁶ The goal of the PROMIS initiative is to be able to develop profiles of PROMIS scores across health domains for various chronic conditions that can then be used in clinical research studies. The WHO has developed the World Health Organization Quality of Life Questionnaire (WHOQOL-100)⁵⁷ and a shorter version, the WHOQOL-Bref.⁵⁸ Both versions measure self-perceived physical health, psychological health, social relationships, and the individual's perceptions about his or her environment. The WHO tools can be used for the measurement of health at either the population level or the level of the individual patient/client.

Some self-report measures of perceived health, wellness, and quality of life are generic and can be completed by clients with a variety of conditions. One of the most commonly used measures of self-perceived health and quality of life is the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).⁵⁹ The SF-36 measures self-perceived health and function across eight scales that include physical, psychological, social, and emotional domains. It has been used in general populations and in specific populations, and normative scores for various groups and populations have been documented. Additional measures of self-perceived health used in clinical practice include the Nottingham Health Profile,⁶⁰ the Sickness Impact Profile (SIP),⁶¹ the Dartmouth Cooperative Functional Assessment Charts (Dartmouth CO-OP charts),⁶² and the Duke Health Profile.⁶³ The Perceived Wellness Survey (PWS) measures self-perceived wellness across psychological, physical, emotional, spiritual, social, and intellectual domains.²⁸ The survey consists of 36 statements with six items for each of the six domains. A composite score, a magnitude score, and a balance score can be computed (see Appendix 29.A). This tool has been tested and found to be valid and reliable for use with different populations.^28,64

Disease-specific Measures of Self-perceived Health, Wellness, and Quality of Life

A number of disease-specific health and wellness measures have been developed for use with specific clinical populations. The items included in these measures may more specifically address issues related to the health and well-being of a particular population than the general measures described above. The Arthritis Impact Measurement Scale (AIMS)⁶⁵ and AIMS2⁶⁶ were developed to measure the physical, mental, and social domains of health in persons with rheumatic diseases. The Child Health Questionnaire (CHQ) measures the physical and psychosocial well-being of children, and has been found to be a valid and reliable measure of health status across a variety of conditions and disorders.⁶⁷ The Cystic Fibrosis Questionnaire⁶⁸ is a health-related quality-of-life questionnaire that has both parent and child versions to measure the physical, emotional, and social impact of cystic fibrosis on children and their families. Additional disease or condition-specific quality-of-life measures that have been developed include a health and quality-of-life measure for individuals who have had a stroke,^69,70 suffer from acute and chronic facial disorders,⁷¹ and have chronic respiratory disease.⁷² The European Organisation for Research and Treatment of Cancer (EORTC) has developed a series of questionnaires designed to assess the quality of life of individuals with cancer. The 30-item EORTC quality-of-life measure has been translated and validated into 81 languages, and has disease-specific modules that can be added to it.⁷³

Assessing Health Behaviors

Reeves and Rafferty⁷⁴ identified four key behaviors as most indicative of a healthy lifestyle: engaging in regular physical activity, eating sufficient daily servings of fruits and vegetables, maintaining a healthy weight, and abstaining from smoking. It is currently recommended that health professionals routinely include an evaluation of these behaviors in their initial assessments of patients/clients.^75,76 The Guide to Physical Therapist Practice also recommends that physical therapists include questions regarding health-related behaviors in initial examinations.¹⁸ The health behaviors of engaging in regular physical activity, eating sufficient fruits and vegetables, and abstaining from smoking can be determined through patient interview or through a questionnaire. If the anthropometric measures of height and weight are taken, the client's BMI can be calculated, and the physical therapist can determine whether the patient/client is overweight or obese (Box 29.1).

The International Physical Activity Questionnaire,⁷⁷ originally developed to track levels of physical activity in populations, has also been used in clinical practice to assess individual patient/client's levels of physical activity.⁷⁸ Research is underway to develop a general health behaviors questionnaire that can be used to collect key health behavior information in an efficient manner in the primary care setting.⁷⁹

The CDC's Healthy Living website provides information about numerous behaviors that contribute to a healthy lifestyle.⁸⁰ Some of the health behaviors have the support of organizations, agencies, and schools, for example healthy menus in school cafeterias, while others are enforced by local, state, or federal laws, such as seat belt use or nonsmoking environments. Others, though significantly influenced by social, environmental, and economic factors, are primarily the personal responsibility of the individual, such as maintaining a healthy weight, eating a healthy diet, and engaging in physical activity. Some personal health behaviors are considered to be more changeable than others based on clinical research. Behaviors that are more challenging to change are those with an addictive component, those with compulsive elements, and those strongly associated with cultural or family routines, such as diet.³³ The key behaviors of increasing physical activity, increasing fruit and vegetable consumption, and quitting smoking, all included in the objectives of Healthy People 2020, have been shown to be modifiable behaviors if the behavior change interventions are appropriately designed and delivered.

The U.S. Preventive Services Task Force (USPSTF) publishes recommendations for various preventative screening measures and health behavior change interventions based on the most current evidence of the effectiveness of interventions in changing or modifying behavior.⁸¹ Clinicians can order a manual with these guidelines from the Agency for Healthcare Research and Quality⁸² or can use a website-accessed electronic tool to quickly obtain this information within the clinical setting.⁸³ Although more research is needed to support the best counseling interventions to increase physical activity, the current evidence-based USPSTF recommendations for physical activity counseling are shown in Box 29.2.

A recent systematic review of the effectiveness of counseling to improve diet and increase physical activity found that behavioral counseling can change these behaviors if the counseling is provided at a sufficient intensity.⁸⁴ Given the empirical evidence to support the efficacy of smoking cessation programs, the USPSTF currently recommends that all health care practitioners ask their patients about tobacco use and make appropriate referrals when indicated.⁸⁵ There is also evidence to support the relationship between intensive physical activity interventions and decreased risk of falls in older adults.⁸⁶ There are, therefore, clinical research studies that support the value of clinicians addressing the modifiable behaviors of tobacco use, unhealthy eating, and inadequate physical activity with their patients/clients. Research in the profession of physical therapy has shown that some physical therapists have already started to address health behaviors with their clients,^14,15,17 but more therapists should be encouraged to engage in these discussions with their patients/clients. It may be necessary to ensure that physical therapists receive additional training in how to counsel patients/clients in behavior change.⁸⁷

The decision to engage in or change a health-related behavior is the result of a complex interaction of numerous factors. Just as physical therapists must understand theories of motor control when planning interventions to improve motor function, an understanding of key theories of health behavior change is necessary if physical therapists are going to be effective in helping clients change their behaviors. Various theoretical models of human behavior have been developed and can be categorized as individual models, interpersonal models, and community and group models.⁸⁸ Behavior change interventions based on these different theories have been carried out in clinical research trials and have been found to be effective in different situations with different populations.⁸⁸

Health Belief Model

One of the earliest theoretical models developed to explain health behaviors was the Health Belief Model (HBM).⁸⁹ This individual model of health behavior was initially developed and articulated in the 1950s, when social psychologists in the U.S. Public Health Service found that despite public education about the merits of various screening programs, for example, tuberculosis screening, large numbers of adults did not participate in the programs. Over the years, the HBM has been developed and extended to incorporate additional concepts and to explain a variety of health-related behaviors beyond screening. In the HBM, it is hypothesized that an individual's perceptions about his or her susceptibility to and the severity of the disease, along with beliefs about the benefits and barriers of taking the recommended action, will influence the decision to act (Fig. 29.8). Demographic variables, sociopsychological variables, cues to action (internal and/or external factors promoting the behavior change), and self-efficacy, defined as the confidence one has that one can successfully execute the action, will also influence the individual's decision to engage in the behavior. Results from numerous research studies conducted with different populations have provided support for this theoretical model,⁸⁸ and interventions based on this model have been found to be effective in supporting behavior change.^90,91,92 If using this model in the clinical setting to promote healthy behaviors, the clinician would first assess the individual's beliefs and perceptions relative to his or her health condition and the recommended health actions. Based on this assessment, the clinician would then provide appropriate interventions, for example, educating the individual about his or her susceptibility to the disease or the effectiveness of a recommended health behavior.

Theory of Reasoned Action and Theory of Planned Behavior

The Theory of Planned Behavior, along with its predecessor, the Theory of Reasoned Action, is an individual model of health behavior that emphasizes the importance of and relationship between cognitions (thought processes) and behavioral intention. In 1967 Fishbein proposed the Theory of Reasoned Action, in which he hypothesized that an individual's attitudes and beliefs about a particular behavior directly influence the intention to engage in that behavior, which then leads to the actual behavior.⁹³ The theory was later expanded to include the construct of perceived behavioral control and renamed the Theory of Planned Behavior⁹⁴ (Fig. 29.9).

The key constructs in this theoretical model are attitude toward the behavior, subjective norm, perceived behavioral control, and behavioral intention (Table 29.3). Clinical studies that have examined a variety of health-related behaviors have provided empirical support for the constructs and the relationships articulated in this theory.^88,95,96,97 A clinician using this theoretical model to design a clinical intervention to change a behavior should begin by assessing the individual's attitude toward the behavior and the individual's perceptions regarding what significant others think about the behavior. The individual's perceived behavioral control can be ascertained by inquiring about any personal, social, or environmental barriers that might limit the ability to successfully engage in the behavior. The clinician can then tailor the intervention to the individual by addressing any areas that were identified. For example, the clinician may need to help the individual problem solve to address a perceived barrier to engaging in the recommended behavior.

Transtheoretical Model (Stages of Change)

The Transtheoretical Model (TTM), first articulated by Prochaska in 1979, is categorized as an individual model of health behavior.⁹⁸ Key constructs within the TTM includes stages of change, decisional balance, self-efficacy, and processes of change (Table 29.4).

Prochaska⁹⁸ hypothesized that there are five stages of change: precontemplation, contemplation, preparation, action, and maintenance (Box 29.3). A sixth stage called termination is occasionally included as the final stage of change, and is defined as the stage when an individual has engaged in the behavior for more than 6 months, is no longer susceptible to temptation, and has high levels of self-efficacy for maintaining the behavior. An individual cycles through the first five stages as he or she makes changes in a particular behavior. Decisional balance and self-efficacy influence an individual's decision to move from one stage to another.

Different strategies (processes of change) are employed at different stages to support the behavior change (Table 29.5). Consciousness raising, dramatic relief, and environmental reevaluation are most useful in the earlier stages of change, whereas counterconditioning, helping relationships, reinforcement management, and stimulus control are most useful in the later stages of change.

Clinical interventions based on this theoretical model have been successful in changing behaviors, particularly in the areas of smoking, diet, and physical activity.⁸⁸ The TTM has also been examined in a study looking specifically at the exercise behaviors of adults with physical disabilities, and the key constructs and relationships hypothesized in this theo retical model of behavior were supported by the researchers' findings.⁹⁹ A clinician using this theoretical model to support behavior change in a client should first start with an evaluation of the individual's stage of change for the behavior, as well as an evaluation of the individual's level of self-efficacy for the behavior. See Box 29.4 for a sample stage of change questionnaire and Table 29.6 for a sample self-efficacy questionnaire. Appropriate processes of change can then be selected and implemented by the clinician to match the individual's stage of change and self-efficacy for the behavior (refer to Table 29.5). Low self-efficacy for the behavior can be addressed by discussing how to maintain the behavior even under challenging conditions.

Social Cognitive Theory

The previous models, with the emphasis on the cognitions and behaviors of the individual, can be categorized as individual models of health behavior.⁸⁸ Social Cognitive Theory, with its additional emphasis on the individual's physical and social environment, is an example of a model of interpersonal health behavior. In a 1962 article on social learning through observation, Bandura¹⁰⁰ hypothesized that individuals could learn through watching others' behaviors and rewards. In succeeding years, Bandura¹⁰¹ further developed the theory, added additional constructs, and changed the name of the theory from Social Learning Theory to Social Cognitive Theory. According to Bandura, an individual's behavior is the result of the constant interaction among the individual's environment, personal factors (including cognitions), and behavior through a process called reciprocal determinism (Fig. 29.10).

Key constructs within the theory include environment, situation, behavioral capability, expectations, expectancies, self-control, observational learning, reinforcement, self-efficacy, and emotional coping responses (Table 29.7). According to Bandura, self-efficacy, the confidence that one can successfully engage in the behavior across different challenging situations, is the single most important prerequisite for behavior change: it affects the individual's level of effort and persistence in engaging in the behavior in the face of difficulty.¹⁰²

A number of clinical trials support the constructs and relationships proposed by this theory.^{88,103,103,103,104,105,106,107,108,109} In terventions incorporating Social Cognitive Theory constructs have been effective in changing health behaviors (see Box 29.5 Evidence Summary). Clinical application of this theoretical model requires attention to the key constructs as they apply for a given behavior and client. For example, the clinician may want to evaluate the individual's physical and social environment to determine what elements in the individual's environment must be changed in order to support the particular health behavior being promoted. If the individual does not have the behavioral capability to carry out a particular behavior, education and training in the skills needed to perform the behavior may be required. The clinician should also use a tool to measure the client's self-efficacy for the behavior and if low levels of self-efficacy are found, specific strategies can be incorporated to build confidence (Box 29.6). The role-modeling construct can be incorporated into a behavioral change program by using peer mentors or group leaders.

Physical Activity Model for People with a Disability

The preceding conceptual models can be applied to a variety of health behaviors with diverse populations. The recently proposed Physical Activity for People with a Disability (PAD) model has been developed to explain the behavior of physical activity in a population of people with a disability.¹¹⁰ This model is based on the Attitude, Social Influence, and Self-Efficacy (ASE) model.¹¹¹ It integrates behavioral theoretical models with disability models, and uses the ICF framework and terminology. In this model, environmental factors and personal factors interact to influence an individual's intention to engage in physical activity. Environmental factors include such variables as transportation, availability and accessibility of facilities, and assistance from others. Environmental factors also encompass social influence variables such as the opinion of family, friends, or health professionals. Personal factors include attitude, self-efficacy, health condition, and facilitators or barriers such as energy level, time, motivation, and skills. The authors of this model suggest that clinical application can include use of the TTM's stages of change. This new model is promising and could provide a helpful framework for physical therapists to use to address the physical activity levels of patients/clients with disabilities. Ongoing research on this model should be focused on identifying the important personal and environmental facilitators and barriers of physical activity for individuals with chronic disease or disability.

Community Models

A number of behavior change theoretical models have been developed to explain behavior change at a community level. Although a thorough discussion of community models is beyond the scope of this chapter, physical therapists who are interested in changing the health behaviors of a group or community may want to familiarize themselves with community and group models of health behavior change, ecological models of health behavior, and intervention planning models such as the PRECEDE-PROCEED planning model.⁸⁸

Motivational interviewing is a client-centered counseling method designed to facilitate a client's internal motivation to change by identifying dissonance between behaviors and values and resolving ambivalence.¹¹² This counseling technique, initially developed to support behavior change in the treatment of addiction, is now used with a variety of populations where clients' existing behaviors have adversely affected their health or quality of life. It has been effectively used to encourage adherence to medical recommendations in general practice populations, to resolve behavioral issues with criminal justice populations, and to assist couples undergoing marital counseling.¹¹² Physical therapists have used motivational interviewing to improve adherence with rehabilitation programs.¹¹³

The hallmark of this technique is the emphasis on exploring the client's values and having the client recognize discordance between current behaviors and life goals. The clinician begins by asking probing questions to encourage the client to discuss his or her priorities in life and how current behaviors support or do not support those priorities. Encouraging the client to consider the pros and cons of continuing with current unhealthy behaviors versus changing to healthier behaviors may help resolve ambivalence by tipping the balance in favor of behavior change. Reflective listening by the clinician will allow a better understanding of the client's point of view and key contextual information related to potential challenges with behavior change. A clinician who is skilled in the motivational interviewing technique is respectful of personal choice and autonomy, is empathetic, avoids arguments, and provides encouragement to support self-efficacy for behavior change (Box 29.7).

Motivational interviewing has been used in the field of health promotion to encourage change in lifestyle behaviors. Regardless of the underlying theoretical behavior change model being used to structure a health behavior change intervention, motivational interviewing can be incorporated as a technique to engage the client in important collaborative discussions about his or her behaviors. There is some empirical evidence of the effectiveness of this technique in supporting behavior change across a number of health-related behaviors, although more research is needed.¹¹⁴ It has been shown to be effective in encouraging weight loss,¹¹⁵ physical activity,^{116,117,118,119} smoking cessation,^120,121 and fruit and vegetable consumption.¹¹⁹

There is evidence that physical therapists in the United States are moving beyond their traditional roles in secondary and tertiary prevention, and engaging in primary prevention and health promotion practice in the general population.^14,15,17,87 Physical therapists are engaging in screening programs,^122,123 ergonomic consultations,¹²⁴ and sports injury prevention and conditioning programs.¹²⁵

There is, however, a great need for physical therapists to engage in more health promotion activities with individuals with disabilities and chronic diseases. One of the specific goals stated in Healthy People 2020 is to increase the number of health promotion programs for people with disabilities.⁵ Research has shown that this population has lower levels of physical activity,^{126,127,128129} higher rates of smoking,¹³⁰ and higher levels of overweight and obesity than the age-matched general population.^131,132 Physical therapists have a unique knowledge and skill set that positions them well to be leaders in health promotion and wellness initiatives for individuals with disabilities. Unlike other health professionals, therapists also interact with patients over extended periods of time. This extended period of interaction and level of accessibility allows time to develop a rapport with patients and provides the therapist an opportunity to be influential in advocating for healthy behaviors.¹³³

Examination and Evaluation

The patient management model in the Guide to Physical Therapist Practice provides a framework for therapists to carry out an examination and evaluation that will identify potential opportunities for prevention and health promotion interventions.¹⁸ During the history, the therapist should look beyond questions related to a specific impairment and ask about perceived health or use a self-perceived health, wellness, or quality-of-life questionnaire as described earlier. The therapist should also inquire about health-related behaviors such as physical activity and current smoking status. A systems review should be carried out to screen for risk factors for disease or injury, and appropriate follow-up by the physical therapist or referral to other health professionals as indicated should occur. For example, physical therapists should routinely take blood pressure before having the patient/client engage in physical activity not only as a component of safe practice, but also to be able to identify and report hypertension. Therapists who notice a mole should ask the client if he or she has discussed this predisposing factor for skin cancer with a physician. Fall risk assessments should be conducted with at-risk populations. Based on their examination and evaluation, physical therapists may identify the need to engage patients in discussions about healthy behaviors and discuss the impact unhealthy behaviors may have on recovery. For example, discussion can focus on the impact of nicotine on tissue healing, or high BMI on joint health and overall health and wellness. Referrals should be made to appropriate programs and health professionals when health issues that fall outside of the scope of practice and qualifications of the physical therapist are identified during the examination.

Interventions

Physical Activity/Exercise

The APTA encourages physical therapists and physical therapist assistants to be promoters and advocates for physical activity/exercise.¹³⁴ Individuals with chronic disease and disability report lower levels of physical activity and exercise than the general population.^{126,127,128,129} The lower levels of physical activity/exercise reported by this population may be due to a host of factors, including limited mobility, chronic pain, fatigue, fear of aggravating their condition, or limited access to fitness facilities that have the necessary equipment and personnel to enable safe and effective physical activity.^{135,136,137,138} Physical therapists are uniquely qualified to evaluate fitness levels and prescribe fitness programs for individuals with medical conditions. The APTA has identified two priority populations requiring the knowledge and skills of physical therapists in physical fitness prescription.¹³⁹ The primary priority population consists of individuals with acute and chronic impairments, activity limitations, and disabilities related to movement, function, and health, and the secondary priority population consists of individuals with identified risk for impairments, activity limitations, and disabilities related to movement, function, and health.

A physical therapy exercise program developed for a patient/client to prevent or remediate impairments falls under the category of secondary or tertiary prevention, but if therapists are truly engaging in primary prevention and health promotion, a physical activity and exercise program to improve overall fitness to the maximal level possible for that patient should also be considered. Participation in physical activity may reduce secondary health problems, improve levels of function, and improve subjective well-being in individuals with chronic medical conditions.¹⁴⁰ There is evidence that exercise can improve quality of life in individuals who are stroke survivors.¹⁴¹ The CDC recommends that adults participate in 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity every week and muscle-strengthening activities on 2 or more days a week.⁸⁰ Children should engage in 60 minutes or more of physical activity every day⁸⁰ (Table 29.8).

However, these physical activity recommendations were developed for the general population and may not be appropriate for patients/clients with disabilities and medical conditions. Physical activity recommendations should be tailored to ensure safety and effectiveness for the patient's unique medical condition. Physical therapists must consider not only the patient's condition, but also any co-morbidities and potential side effects or limitations associated with medical treatments when prescribing a physical activity program. There are excellent research-based resources to help physical therapists safely test fitness and prescribe exercise for patients with medical conditions.^16,142,143 Beyond appropriate content of a physical activity program, physical therapists should consider the previously mentioned theories of behavior change and motivational interviewing to support patients/clients and optimize their chance for successful behavior change as they begin to increase their level of physical activity. Patients/clients can also be informed about physical activity programs in the community that are geared to specific populations. Physical therapists and patients/clients should refer to the consumer website of the National Center on Physical Activity and Disability (see Appendix 29.B) for education and specific information about exercise, as well as sports and recreational activities recommended for those with disabilities.¹⁴⁴ The benefits of engaging in sports should be discussed with patients/clients; people with disabilities who engage in sports have reported enhanced function, social benefits, and an increased sense of optimism.⁵²

Smoking Cessation Counseling

There is strong evidence that even brief counseling of patients can be effective to support smoking cessation.^145,146 Given the strong evidence of the health risks associated with smoking and clinical evidence of the effectiveness of even brief counseling sessions, Bodner and Dean¹⁴⁶ effectively argue that counseling patients about smoking behaviors falls within the role of physical therapists and that physical therapists, given their prolonged contact with patients over the course of treatment, have the opportunity and the rapport necessary to be effective in smoking cessation counseling. In their systematic review, they found that intervention models based on the motivational interviewing technique are effective. The Agency for Healthcare Research and Quality recommends that clinicians include a question about smoking as part of their examination and evaluation and has designed a specific evidence-based program to assist clinicians in helping their clients address smoking behaviors.¹⁴⁷ The 5-A's tobacco cessation approach recommends that clinicians Ask their patients about tobacco use, Advise tobacco users to quit, Assess the client's readiness to quit, Assist the client with a quit plan, and Arrange follow-up to review progress toward quitting (Box 29.8). Physical therapists should also be familiar with smoking cessation programs in the local area and refer patients/clients as appropriate to these specialized programs.

Healthy Weight and Healthy Eating Counseling

Overweight and obesity are associated with the development of numerous conditions and diseases¹⁴⁸ (Box 29.9). The Guide to Physical Therapist Practice recommends that anthropometric measurements be included in initial examinations. The measurement of height and weight will allow physical therapists to calculate the patient's BMI. Calculators and charts are available on the CDC website (see Appendix 29.B) to assist therapists in calculating the patient/client's BMI.¹⁴⁹

Physical therapists should take the opportunity to educate the patient about the impact excessive weight has on the patient's current condition and future health. As specific nutritional counseling is outside the scope of practice of the physical therapist, therapists should refer patients to qualified health professionals as appropriate. Most weight management programs include physical activity and physical therapists have the knowledge and skills to create and implement physical activity programs for high-risk patients/clients.

Patients who are discharged from physical therapy to continue their exercise programs independently often find it challenging to find a facility with the necessary equipment or personnel who are sufficiently trained to address their unique medical challenges. Physical therapists have begun to recognize and address this need for physical activity programming that is specifically tailored to address the needs of patients with chronic conditions or disabilities. Fitness and health promotion programs geared to this population and offered in rehabilitation settings are growing in popularity. For example, physical therapists are providing fitness classes and health promotion programs to individuals with osteoporosis, arthritis, and cancer.^150,151,152 It is important to remember that these programs should comply with licensing requirements for physical therapists in the state, and that the same standards for physical therapist practice must be maintained whether the physical therapist is providing rehabilitation or health promotion interventions. An excellent resource for physical therapists is the APTA website Physical Fitness for Special Populations (see Appendix 29.B).¹³⁹ The website provides recommendations for the design of fitness programs tailored to the specific needs of individuals with various medical conditions, such as stroke, type 2 diabetes, and pulmonary pathology. The site also provides valuable information about malpractice and professional liability, Medicare coverage for fitness services, and other helpful resources for physical therapists.

One of the goals stated in Healthy People 2020 is the need for increased health promotion programming for individuals with disabilities.⁵ Physical therapists can make a meaningful contribution to the health of the nation by providing health and wellness to this population within their own practices as described above. In addition, physical therapists should recognize their broader social responsibility, as articulated in the Core Values document of the professional association, to advocate for the health and wellness needs of all.²¹ Physical therapists, with their unique knowledge base and clinical experience, are extremely cognizant of the needs and challenges faced by individuals with chronic disease and disability, and should participate at both the community and national levels to ensure that this population is provided the same access to health promotion and wellness programming as the rest of the population.

Physical therapists have the knowledge, the skill set, and the opportunity to engage in health promotion practice across the continuum of care. A population in special need of the guidance and support of physical therapists is the population with medical conditions and disabilities who face unique challenges when trying to incorporate healthy behaviors into their lives. At the Physical Therapy and Society Summit (PASS) meeting, the need for more research to be undertaken to better define physical therapists' role in prevention, health, and wellness, especially with respect to consumers with impairments, was identified.²³ The "Revised Research Agenda for Physical Therapy" identifies specific areas in health promotion requiring more investigation and discussion.¹⁵³ These areas include the need to examine the effectiveness of specific health promotion interventions related to the physical activity of clients/patients with movement disorders. As the profession continues to define and develop its role in health promotion and wellness, physical therapists should identify opportunities within their current practice environments to promote optimal levels of health and wellness of their patients/clients.

Questions for Review

1. What factors contribute to the health of an individual?

2. What is Healthy People 2020?

3. How does the World Health Organization define health?

4. Identify the different domains of wellness.

5. Define primary, secondary, and tertiary prevention.

6. Where in the continuum of primary, secondary, and tertiary prevention have physical therapists traditionally practiced?

7. Differentiate between the terms health promotion and health education.

8. What is the difference between the terms exercise and physical activity?

9. What tools could a physical therapist use to measure a patient/client's self-perceived health, wellness, or quality of life?

10. What health-related behaviors should physical therapists inquire about during initial examinations of patients/clients?

11. Describe the following four theories of behavior change: Health Belief Model, Transtheoretical Model and Stages of Change, Theory of Planned Behavior, and Social Cognitive Theory.

12. What is the purpose of motivational interviewing?

13. What are the five steps of the 5-A's tobacco cessation approach?

14. What professional documents support the role of physical therapists in health promotion?

Elise Henry is a 72-year-old widow who recently moved into the assisted living center where physical therapy consultation services are provided. The client was referred by a member of the center staff who reports that she is unable to participate in the recreational programs offered by the center due to her physical condition.

PATIENT HISTORY

Mrs. Henry tells the therapist on her initial visit that she is unable to participate in many of the center activities owing to her increasing problems with leg pain. She relates that she was diagnosed with peripheral artery disease 10 years ago. She was not prescribed any medication, but found that if she limited her walking, she could prevent the pain from occurring.

SOCIAL HISTORY

Her former friends live too far away to visit her at the assisted living center. She misses her weekly bridge games with them. Her only son and his family live in another city about an hour's drive away. Her son, daughter-in-law, and two granddaughters visit her about once a month. Her son also phones her every Sunday evening.

SYSTEMS REVIEW

• Height: 5 ft 2 in

• Weight: 145 lb

• Resting heart rate: 72

• Resting blood pressure: 135/85

• No skin breakdown

Rubor of dependency test and pedal pulses are consistent with diagnosis of arterial insufficiency.

HEALTH-RELATED BEHAVIORS

• Smoking: Smokes 2 to 3 cigarettes/day; the client has smoked for 50 years.

• Diet and Nutrition: Does not eat breakfast, but has coffee and muffins delivered to her room mid-morning. Goes to the center dining room for lunch and dinner. Keeps cookies in her room for snacking during the day.

• Physical Activity: She currently spends most of her days watching TV in her room. Her only regular physical activity is walking to and from the dining room for lunch and dinner. The distance from her room to the dining room is approximately 50 feet. She has mild pain in both legs and is slightly short of breath at the end of the walk.

1. Identify additional tests and/or measures that could be used to assess her level of health.

2. Identify additional tests and/or measures that could be used to assess her level of wellness.

3. What domains of wellness may be at lower levels?

4. Which health-related behaviors might be adversely affecting her health and wellness?

5. How should a conversation about her health and wellness be started?

6. If Mrs. Henry asked for help in changing her behaviors, select a theory of behavior change to guide the intervention. Which behaviors should be targeted?

7. What level of physical activity should Mrs. Henry strive to achieve for health-related benefits?

The following statements are designed to provide information about your wellness perceptions. Please carefully and thoughtfully consider each statement, then select the one response option with which you most agree.

PWS Scoring Sheet for Use with Individual Clients

Instructions: Record your score from the PWS instrument for each numbered item below. Note the^∗ items indicating reverse scoring. Add the numbers in each column and divide by 6 to determine each subscale score.

^∗Reverse Score (e.g., 1 = 6, 2 = 5, 3 = 4, 4 = 3, 5 = 2, and 6 = 1)