“Health Behavior Change Within the Disability Context”

We 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 been disentangled(3, 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.

          Psychosocial 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.

          In 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)

Health Behavior Change and Disability

          To 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. 

          Outcome 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.

          Self-efficacy 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.

          Social 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). 

          Reinforcement 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.

          Finally, 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.

          Examining 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 factors.

Figure 1:  Hypothesized Path Diagram

Health Behavior Change in the ICF Framework

          After 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. 

          HBC 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. 

                   Figure 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.

Participation, Meaningfulness and Health Behavior

          The 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.

          Sense 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)

          Developing 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 health behavior.

          Our 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. 

Conclusion

          Our 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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