Craig Ravesloot, PhD
Casey Ruggiero, MA
Catherine Ipsen, PhD
Meg Traci, PhD
Tracy Boehm, MPH
Desirae Ware-Backs, MPH
Bethany Rigles, MA
conducted a review of four psychosocial health behavior change theories (HBC;
Health Belief, Theory of Planned Behavior, Social Cognitive and
Transtheoretical) to consider how these theories conceptually apply to people
with disabilities (PWD). We identified common
constructs across HBC theories that can be summarized by two over-arching
constructs, behavioral intention and perceived control. Next, we examined these HBC theories using the
International Classification of Function (ICF).(1) From
the ICF perspective, the purpose of health behavior change is to improve
physical health (i.e. Body Functions and Structures). Behavioral intention and perceived control may
be derived from the interaction of Personal Factors (e.g., outcome expectations
and self-efficacy) and Environmental Factors (e.g. environmental barriers and
social norms) in the ICF. Absent from
these HBC theories is the effect of Participation on behavioral intention and
perceived control. We propose that broadening
HBC theories to take into account the participation dimension of the ICF will
lead to more effective interventions for PWD.
Specifically, we propose the Sense of Coherence theory(2) is a framework that includes meaningful
participation in health behavior change.
Throughout most of
history, disability has been equated with illness; only recently have these concepts
4). It is the conceptual separation of disability
and health status that suggests the potential value of health behavior change
for people with disabilities. Unfortunately,
the vast majority of health behavior change research has focused on keeping
“healthy” people healthy. In recent
times, as public health and medicine have extended life expectancy, the need to
address health status following morbidity has emerged(5). The purpose of this paper is to review
commonly cited theories of health behavior change and conceptual linkages and
limitations of these theories when applied to the experience of people with disabilities.
health behavior change (HBC) theories were developed to explain observed
differences in health behavior and to guide development of HBC interventions(6). They are used both to predict adoption of
health protective behavior (e.g. exercise) as well as reduction of health risk
behavior (e.g. smoking). Over time, they
have become increasingly complex as researchers have tried to more accurately
predict behavioral and health outcomes. Recent
advances in these theories include environmental and dynamic
person/environmental interaction variables(7). Despite these disability consistent
constructs, the need for theoretical and empirical work to guide intervention
development for people with disabilities remains.
the absence of specific HBC theories, disability and health researchers have
responded to the need for intervention and developed interventions based on
existing theories of health and behavior.
Most commonly, researchers have used the social cognitive model to guide
intervention development (8-10). In our own work, we developed the Living Well
with a Disability program based on a theory of stress and illness known as
Sense of Coherence(2). We
selected this theory based on data that suggested a sense of coherence
predicted functional limitation due to secondary conditions.(11)
Behavior Change and Disability
examine role of disability in health behavior change, we selected four health
behavior change theories that are widely cited in the literature. These include Health Belief(12), Theory of Planned
Behavior(13), Social Cognitive(7) and
Transtheoretical theories(14). We reviewed these HBC theories to identify commonalities. The commonalities we identified included
outcome expectations, self-efficacy, social norms, reinforcement management and
stimulus control, and environmental facilitators/barriers.
expectations are the beliefs about the consequences of behavioral choices and
include perceived risks and benefits. Disability
experience may affect outcome expectations by increasing sensitivity to the
possibility of future disabling conditions and to the risks of behavior change
(e.g. risks associated with exercise adoption).
However, expectations about the impact of a future health condition on
quality of life may be reduced given activity and participation limitations
associated with the experienced disabling condition.
consists of a person’s beliefs about the ability to change behavior and events
in one’s life. Overall, disability can
limit the individual’s problem-solving and coping options reducing
self-efficacy. If the individual
believes the disability came from a failure of behavioral self-regulation (e.g.
blindness due to diabetes), then self-efficacy to affect future behavior and
events may be reduced.
norms include the person’s beliefs about the approval/disapproval of performing
a behavior. For someone with a disability, these norms
will vary depending on who is being referenced.
Expectations to independently engage in health promoting behavior may be
discouraged by people unfamiliar with a disabling condition, but encouraged by
peers. Alternatively, the individual may
perceive that medical providers encourage healthful behavior (e.g. exercise for
pain management) that is not approved by community providers (e.g. fitness
professionals unfamiliar with a disabling condition).
management and stimulus control include the occasion for performing a behavior
along with rewards of doing so. The cues
to action for behavior change for the general population may not have the same
impact on PWD (e.g. social marketing for stroke prevention). Similarly, naturally occurring rewards for
behavior change (e.g. buying smaller sized clothes following weight loss) may
not be as effective for people with disabilities.
environmental facilitators/barriers are features of the physical environment
that encourage or discourage performing a behavior (e.g. walking paths,
distance to preventive services). The
affect of inaccessible buildings and absence of trained personnel are clearly
influential in the HBC of PWD.
these five commonalties, we concur with other researchers who have suggested
that many psychosocial HBC theories can be summarized by two over-arching
constructs, behavioral intention and perceived control(6). Figure 1 is a proposed path diagram showing
how the five commonalties we identified may be related to two over-arching
1: Hypothesized Path Diagram
Behavior Change in the ICF Framework
identifying commonalities across the HBC theories, we examined where they might
fit into the International Classification of Function ICF framework (Figure 2).(1) Other researchers have recognized the value
of examining health promotion in the context of the International
Classification of Function.(15-17) However, they have not examined how
psychosocial HBC theories may fit into the ICF framework.
interventions are designed to change health risk and protective behaviors which
are Self-Care activities in the ICF (d570).
HBC theories are based on research that suggests changes in self-care
activities (e.g. d5701, Managing Diet and Fitness) influence the course of physical
health (i.e. Body Functions and Structures).
The two common factors of the HBC theories, behavioral intention and
perceived control, may reflect the dynamic interaction of Environmental and
Personal Factors in the ICF. Finally, included
in the ICF framework, but missing from the HBC theories is Participation.
2: The ICF Framework
The effect of
participation limitation on behavioral intention and perceived control may be
dramatic. For example, consider a
manual wheelchair user who would benefit from more physical activity. While outcome expectations for both a
disabled and non-disabled person might come from perceived severity of not
becoming more active, a wheelchair user’s expectation might also include
perception of environmental barriers and reduced perceived control. This perception may be quite different for
someone with a great deal of experience participating in community versus
someone with limited experience. As
another example, consider an individual with a traumatic brain injury who has
diabetes and is instructed to make significant dietary changes. This individual’s self-efficacy could be
limited by a memory impairment. However,
with appropriate environmental supports (e.g. support person, appropriate
written materials) self-efficacy may be increased. Again, the individual’s participation
experience that includes using either a support person or written materials may
further influence self-efficacy for making dietary changes.
Meaningfulness and Health Behavior
perceived control factor is a recent addition to many HBC theories because behavioral
intention is only modestly related to behavioral outcome. In fact, many researchers now suggest
ecological theories of HBC to highlight the role of the environment in
HBC. These dynamic theories suggest that
both behavioral intention and open and accessible environments are necessary
for behavior change. Perceived control
is clearly enhanced by accessible environments, but behavioral intention to
adopt a behavior is also necessary. The Sense
of Coherence theory takes a slightly different approach to describing how
behavioral intention and perceived control are related and provides a useful
alternative perspective on HBC for PWD.
of Coherence theory is a health and stress theory developed to explain how
positive health outcomes can occur despite stressful environments.(2) The theory includes three components; sense
of comprehensibility, sense of manageability and sense of meaningfulness. Comprehensibility is an individual’s expectation
that she will be able to understand how and why events happen in her life. Manageability is the expectation that she
will be able to deal with problems as they arise either through her own
resources or the resources of others.
Finally, meaningfulness is the belief that managing problems is
important for some greater purpose.
According to the theory, people develop a sense of comprehensibility and
manageability when they have meaningful reasons to do so.(2)
a sense of meaningfulness is probably related to participation.(18) Hence, we can imagine reciprocal effects of
participation not only on perceived control as outlined above, but also on
behavioral intention. If an individual
with a disability links his ability to participate in meaningful activities
with health behavior, he is more likely to develop intention to engage in
data has indicated that nearly a quarter of the variance in functional
limitation due to secondary conditions is predicted by Sense of Coherence. (11) On that basis, we developed the LWD program to
increase participation through development of meaningful life goals. Living Well program participants use problem
solving to develop goal-focused objectives, including health objectives. It may be the health outcomes achieved by the
LWD program are mediated by the affect of increasing a sense meaningfulness,
behavioral intention, and perceived control over outcomes.
review of four common health behavior change theories suggested commonalities
within the theories that fit nicely within the ICF framework. Absent from the HBC theories, however, is the
Participation dimension of the ICF.
Based on our implementation and evaluation of the Living Well with a
Disability program, we suggest that participation is related to a sense of
meaningfulness and health outcome for people with disabilities.
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