Abstract:
In learning to cope with the often chronic nature of their conditions, individuals with neurological disease, not unlike individuals with health conditions of other systems, learn to rely on their abilities to adapt and compensate for their activity limitations and participation restrictions to regain the ability to participate in life. Although not an uncommon approach to life for any human being, the achievement of health or wellness takes on an increased focus for individuals with chronic health conditions, and it is strongly correlated with the quality of life they achieve. A casual consideration of the terms health and wellness indicates that they are similar, if not the same, in meaning, a commonly held belief among those without health conditions. This interpretation of the terms becomes problematic, however, in the presence of health conditions. Can an individual with a health condition be well? Can a person without a health condition be ill? The concepts of health and wellness and their associated meanings and measures will be explored in this chapter to provide a perspective for movement specialists that will enhance their ability to promote health and well-being in patients with neurological conditions. The evidence examining wellness approaches in patients with neurological conditions will be presented along with common barriers and enablers to implementation. A synthesis of concepts will be promoted through case study.
Keywords:
perceptions, well-being, wellness, whole person, health promotion, salutogenic, self-efficacy
Objectives
After reading this chapter the student or therapist will be able to:
- 1.
Define and differentiate the terms health and wellness.
- 2.
Describe the characteristics of wellness.
- 3.
Compare illness, prevention, and wellness paradigms.
- 4.
Discuss theories of behavior change and their application to wellness and neurorehabilitation.
- 5.
Determine the appropriateness of screening and standardized measures of health and wellness within the role of physical and occupational therapy.
- 6.
Apply an evidence-based, person-centered holistic wellness approach to an individual or a population living with a chronic neurological condition.
- 7.
Identify barriers and potential strategies to overcoming barriers to wellness for individuals living with neurological injury or disease.
- 8.
Synthesize a wellness approach to neurorehabilitation through case examples.
In learning to cope with the often chronic nature of their conditions, individuals with neurological disease, not unlike individuals with health conditions of other systems, learn to rely on their abilities to adapt and compensate for their activity limitations and participation restrictions to regain the ability to participate in life. Although not an uncommon approach to life for any human being, the achievement of health or wellness takes on an increased focus for individuals with chronic health conditions, and it is strongly correlated with the quality of life they achieve. A casual consideration of the terms health and wellness indicates that they are similar, if not the same, in meaning, a commonly held belief among those without health conditions. This interpretation of the terms becomes problematic, however, in the presence of health conditions. Can an individual with a health condition be well? Can a person without a health condition be ill? The concepts of health and wellness and their associated meanings and measures will be explored in this chapter to provide a perspective for movement specialists that will enhance their ability to promote health and well-being in patients with neurological conditions. The evidence examining wellness approaches in patients with neurological conditions will be presented, along with common barriers and enablers to implementation. A synthesis of concepts will be promoted through case study.
Definitions and relationships among terms
The classic understanding of the term health from a biomedical perspective is “absence of disease.” The antonym of health, therefore, is disease. The World Health Organization (WHO) contributed to the confusion between the terms health and wellness when in 1948 it defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” Indeed, there are numerous illustrations of the influence of the mind and spirit on the body and thus the importance, from a public health perspective, of considering more than the physical state of the body when formulating solutions to health problems. However, there is also value in differentiating health from more global concepts such as wellness and quality of life, if for no other reason than to explain the phenomenon that an individual can be diseased and well or can experience a high quality of life while simultaneously living with a chronic disease. Considering the catastrophic nature of many neurological diseases that compromise physical health, it is even more important to distinguish between health and wellness to recognize and pursue avenues to enhance overall quality of life and well-being.
H.L. Dunn first conceptualized the term wellness in 1961 and offered the first definition of the term: “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable.” Since Dunn’s introduction of the term, numerous researchers and educators have attempted to explain wellness by proposing various models and approaches. Although the literature is full of references to and information about wellness, including numerous definitions of the term, a universally accepted definition has failed to emerge. However, a leading wellness organization, Wellness Council of America (WELCOA), defined wellness in 2018: “Wellness is the active pursuit to understand and fulfill your individual human needs—which allows you to reach a state where you are flourishing and able to realize your full potential in all aspects of life. Every person has wellness aspirations.” Several conclusions can be drawn from the abundance of literature regarding wellness.
For many people, including the public, health and wellness are synonymous with physical health or physical well-being, which commonly consists of health-promoting behaviors such as physical activity, efforts to eat nutritiously, and adequate sleep. Health behaviors have been defined as “those personal attributes such as beliefs, expectations, motives, values, and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behavior patterns, actions, and habits that relate to health maintenance and wellness, to health restoration, and to health improvement.” Research in the 1990s indicated that when the public was asked to rate their general health, they narrowly focused on their physical health status, choosing not to consider their emotional, social, or spiritual health. This recognition has influenced researchers to ask specific questions about dimensions of health and wellness, such as physical and mental dimensions. Referring to the definitions of wellness from Dunn and WELCOA, and consistent with numerous other theorists, it is clear that wellness, as it is defined, includes more than just physical behaviors or beliefs about the physical self.
The common themes that emerge from the various models and definitions of wellness suggest that wellness is multidimensional, , , salutogenic or health causing, , and consistent with a systems view of persons and their environments. , , Each of these characteristics will be explored.
First, as a multidimensional construct, wellness is more than simply physical health, as the more common understanding of the term might suggest. Among the dimensions included in various wellness models are physical, spiritual, intellectual, psychological, social, emotional, occupational or vocational, financial, and community or environmental. Adams and colleagues in 1997, toward the aim of devising a wellness measurement tool, proposed six dimensions of wellness on the basis of the strength and quality of the theoretical support in the literature. The six dimensions and their corresponding definitions are shown in Table 33.1 .
| Emotional | The possession of a secure sense of self-identity and a positive sense of self-regard |
| Intellectual | The perception that one is internally energized by the appropriate amount of intellectually stimulating activity |
| Physical | Positive perceptions and expectancies of physical health |
| Psychological | A general perception that one will experience positive outcomes to the events and circumstances of life |
| Social | The perception that family or friends are available in times of need, and the perception that one is a valued support provider |
| Spiritual | A positive sense of meaning and purpose in life |
The second characteristic of wellness is that it has a salutogenic or health-causing focus, in contrast to a pathogenic focus in an illness model. Emphasizing the factors that promote health (e.g., salutogenic) supports Dunn’s original definition, which implied that wellness involves “maximizing the potential of which the individual is capable.” In other words, wellness is not just preventing illness or injury or maintaining the status quo; rather, it involves choices and behaviors that emphasize optimal health and well-being beyond the status quo. Thus an individual who may or may not be well even though there is no physical pathology, may similarly be well during an acute episode, or chronic pathology or health condition whether that chronic problem results in static activity limitations or even progressive participation restrictions.
Third, wellness is consistent with a systems perspective. In systems theory, each element of a system is independent and contains its own subelements, in addition to being a subelement of a larger system. , Furthermore, the elements in a system are reciprocally interrelated, indicating that a disruption of homeostasis at any level of the system affects the entire system and all its subelements. , Therefore overall wellness is a reflection of the state of being within each dimension and a result of the interaction among and between the dimensions of wellness. Fig. 33.1 illustrates a model of wellness reflecting this concept. Vertical movement in the model occurs between the wellness and illness poles as the magnitude of wellness in each dimension changes. The top of the model represents wellness because it is expanded maximally, whereas the bottom of the model represents illness. Bidirectional horizontal movement occurs within each dimension along the lines extending from the inner circle. As per systems theory, movement in every dimension influences and is influenced by movement in the other dimensions. As an example, an individual who has a complete T6 spinal cord injury will experience at least a short-term decrease and likely long-term challenges in physical wellness. Applying systems theory and according to the model, this individual may also have a decrease in other dimensions such as emotional or social wellness. The overall effect of these changes in these dimensions will be a decrease in overall wellness initially following the injury, and increased risk of reduced wellness through the individual’s life-span.
Systems theory has been used recently to define the identity of the physical therapist. The American Physical Therapy Association (APTA) has identified the movement system, the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts, to describe succinctly what physical therapists do and address with patients/patients. Physical therapists address movement system issues with patients/patients along the spectrum of wellness to illness. Indeed, the majority of interventions for those with neurological disease focus on restoring or enhancing movement. The movement system typifies a systems approach as described previously, and physical therapists “maximize an individual’s ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.” When rehabilitation is conducted with a biopsychosocial approach, movement, health, and well-being are optimized.
A term related to wellness, quality of life, is also used to indicate the subjective experience of an individual in a larger context beyond just physical health. Quality of life has been defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment.” Parallel to the issues related to the concept of wellness, there is lack of agreement on the definition of quality of life and its theoretical components, as well as variation in the use of subjective or objective quality-of-life indicators. Implied by the WHO definition, and supported by several other authors, quality of life is best conceptualized as a subjective construct that is measured through an examination of a patient’s perceptions. In other words, quality of life, like wellness, is the subjective experience of health, illness, activity and participation, the environment, social support, and so forth, and it is best measured through an assessment of patient perceptions.
A final concept important to define is the social determinants of health (SDoH)—conditions in the environments in which people are born, live, learn, work, play, worship, and age. A number of social determinants have been found to relate to health and health outcomes, including access to health services, features of the built environment, economic stability, education, and the social environment. Within the International Classification of Functioning, Disability and Health (ICF) framework, disability and functioning are the result of interactions between health conditions and contextual factors, including factors relative to the environment and those relative to the person. SDoH can be found within both the environmental (built environment, social environment) and personal (education, income) contextual factors of the ICF model.
Numerous efforts are ongoing to address SDoH across the country, for example, addressing food deserts through the establishment of farmer’s markets and community gardens, public mandates to ensure all children have access to early intervention programs and preschool, and consideration for human transportation in the design and build of cities and towns. , To the extent that physical and occupational therapists recognize the contributions of SDoH to the health and wellness of the patients they treat, and they consider SDoH in the development of plans of care, more targeted and effective plans of care will be developed and there will be a higher likelihood of adherence and better outcomes.
A paradigm shift to wellness
The importance of gaining an understanding of health and wellness is to be able to apply it and use this lens when interacting with patients/patients. The ultimate goal is thus to improve the health and well-being of the patient, as the therapist helps the patient improve movement and participation. This is critical to further the paradigm shift from a reactive illness-focused sick care system to a proactive wellness-focused health care system. , Numerous facilitators and markers of this paradigm shift exist, ranging from the Healthy People 10-year national health objectives to health care reform with Triple Aim, focus on value-based care and the US Department of Health and Human Services’ National Prevention Strategy released in 2011. To learn more about these initiatives see Table 33.2 for a listing of health and wellness resources. In 2017, the National Study of Excellence and Innovation in Physical Therapist Education stated “Individual therapists and the profession must fully commit to eliminate health disparities, address the SDoH, and improve the health care, health, and well-being of our communities and promote the health of populations.” To help conceptualize the implications of this paradigm shift, a comparison of the traditional “illness” paradigm with both “prevention” and “wellness” paradigms will identify ways in which a physical or occupational therapist can incorporate a wellness paradigm into the treatment of a patient with a neurological condition in the context of rehabilitation. The three approaches, or paradigms, are contrasted in Table 33.3 on six parameters, including the view of human systems, program orientation, dependent variables, patient status, intervention focus, and intervention method.
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| Illness | Prevention | Wellness | |
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| View of human systems | Independent | Interactive | Integrative |
| Program orientation | Pathogenic | Normogenic | Salutogenic |
| Dependent variables | Clinical | Behavioral | Perceptual |
| Patient status | Patient | Person at risk | Whole person |
| Intervention focus | Symptoms | Risk factors | Dispositions |
| Intervention method | Prescription | Lifestyle modification | Values clarification |
As stated previously, in a wellness paradigm each dimension or part of the system affects and is affected by every other part, resulting in an integrative view of the human body and the human movement system. In contrast, in a traditional illness or medical model, the systems are independent. There are specialties in medicine by body system (e.g., neurology, orthopedics, gynecology), and in many physical and occupational therapy education programs courses are arranged by body system (e.g., neurology, orthopedics, cardiopulmonary, physical dysfunction, psychosocial) as indicators of the independence of the systems. In a prevention approach, there is recognition that the systems interact, or influence one another, but not in the reciprocal fashion characteristic of wellness.
The program orientation of an illness paradigm is the pathology or disease-causing issue, whereas the orientation of a prevention paradigm is normogenic, meaning efforts are aimed at maintaining a normal state or condition (e.g., normal muscle length, tone). Shifting to a wellness paradigm requires a salutogenic or health-causing approach, with a focus on how to achieve greater well-being, health, or quality of life. This shift emphasizes the capabilities and abilities of the individual rather than the limitations and deficits.
The variables of interest in an illness paradigm are clinical variables, such as blood tests, VO 2 max (maximum volume of oxygen use), and tests of muscle strength. Changes in these variables result in labeling the patient more or less ill. In a prevention paradigm, the variables measured are behavioral, for example whether the individual smokes, exercises, or wears a helmet. Positive improvement in a prevention approach typically results in a change in an individual’s behavior. In contrast, the variables measured in a wellness paradigm are perceptual, indicating what the patient/client thinks and feels about herself or himself. Although clinical, physiological, and behavioral variables are useful and important indicators of bodily wellness and are commonly used to plan individual and community interventions, their utility as wellness measures falls short. Clinical and physiological measures assess the status of a single system, most commonly the systems within the physical domain of wellness. It can be argued that behavioral measures are a better reflection of multiple systems because of the importance and influence of motivation and self-efficacy on the adoption of behaviors, but they do not describe the wellness of the mind. On the other hand, perceptual measures, capable of assessing all systems and having been shown to predict effectively a variety of health outcomes, , , can complement the information provided by body-centered measures insofar as they are valid, congruent with wellness conceptualizations, and empirically supportable.
The influence of perceptions on health and wellness has been demonstrated repeatedly in the literature with a multiplicity of patient/client populations and in a variety of settings. Mossey and Shapiro demonstrated more than 35 years ago that self-rated health was the second strongest predictor of mortality in the elderly, after age. Numerous other researchers have replicated these findings in other populations, lending support to the value of perceptions in understanding health and wellness and indicating that how well you think you are may be more important than how well you are as measured by clinical tests and measures or the judgment of a health professional.
Shifting to patient status in each of the three paradigms, the subject receiving treatment in an illness paradigm is called the patient, whereas in a prevention paradigm the subject is a person-at-risk because of the focus on risk factors and the maintenance of a state of normalcy. In a wellness paradigm, the patient is considered a whole person, to emphasize the multiple systems interacting to produce a state of well-being, and, more importantly, that a high-functioning or intact physical dimension, although important, is not necessary to achieve a state of well-being or a high quality of life. This concept of whole person is reflected in the ICF framework built on a biopsychosocial approach.
Consistent with the patient status elements, the focus of intervention in an illness paradigm is on symptoms, and in a prevention approach on risk factors. Consistent with a whole-person focus in a wellness approach, the intervention focuses on dispositions. Defined as a prevailing tendency, mood, or inclination or the tendency to act in a certain manner under given circumstances, dispositions produce perceptions, which can be measured to indicate a global or psychosocial assessment of the whole person, given input from all of the systems. Combined with symptom and risk factor assessment, perceptions of the individual provide valuable additional information about a patient that can enhance the therapists’ ability to intervene and the success of the interventions selected. Table 33.4 lists a few measurement tools that assess patient perceptions.
The intervention method used in an illness paradigm is prescriptive. The prescriptive meaning is based on the system affected and symptoms reported. An intervention in an illness paradigm is prescribed to correct or improve the illness. Given that risk factors are the focus in a prevention paradigm and the aim is to maintain or return the person-at-risk to a normal state, the intervention method that is most appropriate is lifestyle modification in an attempt to change the behavior that is producing the identified risk. The intervention method in a wellness approach is called values clarification, and it is consistent with the focus on dispositions and measurement of perceptions. The aim of values clarification is to enhance self-understanding by surfacing the person’s perceptions of the situation and its impact on his or her life. When values clarification can precede intervention prescription and lifestyle modification, wellness will be enhanced because the intervention will be more targeted and truly person-first or whole-person–based, rather than focused on the health condition.
Theories of behavior change
A shift to a wellness paradigm from an illness paradigm will not yield positive outcomes without consideration given to factors beyond the individual (behaviors, cognitive and physical state, experience, etc.), including the physical and social environments. , A social-ecological approach describes the multiple levels of influence on health and wellness, including individual factors, family and friends, communities and employers, policies, and social norms. Factors beyond the individual include the SDoH and other features of the environment that impact access to and use of health and wellness enhancing resources. This approach recognizes that behavior is affected by and affects multiple levels of influence, and it is necessary to do more than educate and motivate people to engage in health-promoting behaviors. Social and physical environments must support the healthy choice as the easy choice for positive health behaviors to become consistent and sustainable. There are numerous examples of the impact of health-promoting programs designed to address multiple levels of influence, but perhaps the success that has been achieved in reducing rates of cigarette smoking provides the best example, in which environmental changes occurred at multiple levels simultaneously to curb the incidence of smoking (e.g., social norms [while it was once cool to smoke, nonsmoking became cooler]), policy (cigarette taxes were increased), organizations (nonsmoking sections of restaurants, airplanes, and places of employment were created). Fig. 33.2 illustrates the social-ecological model.
As illustrated by the social-ecological model, frameworks are useful to guide intervention programs. Theories of behavior change are frameworks that have been used for decades to explain, interpret, guide, and predict behavior in a specified context. Theories, or systematic explanations for naturally occurring phenomena, explain behavior and provide insight into ways to modify it. Consistent with a wellness paradigm, the use of theories creates a more holistic approach in the provision of physical or occupational therapy because they address the cognitive and emotional factors related to readiness and motivation to behave that so frequently derail intervention programs (attitude, motivation, negative emotions, etc.). Understanding and applying theories of behavior change will enable the therapist to create more targeted intervention programs, enhance patient participation in and adherence to intervention programs, and improve outcomes. Several key health behavior change theories will be discussed in the following section, starting with interpersonal theories (social cognitive theory [SCT], resilience theory) that include environmental influences on individual behavior, and moving to individual theories (the transtheoretical model [TTM], self-determination theory [SDT]) in which variables within the person are the focus.
Social cognitive theory
One of the most widely used and robust health behavior change theories, SCT emerged from social learning theory, which identified that people learn from their own experiences and by observing the experiences of others. There are three major constructs in SCT that interact to influence behavior: personal factors (age, cognitions, previous experience with the behavior, etc.), environmental factors (access to resources, safety, support from family/friends, etc.), and aspects of the behavior itself (vigor of the behavior, outcomes achieved as a result of practicing the behavior, competence with the behavior, etc.). Successful efforts to change behavior depend on identification of the positive supports and the detractors in each of the three constructs. For example, if a therapist is managing the physical or occupational therapy services of a patient who has multiple sclerosis and this patient is motivated to be physically active yet does not have a safe place to walk or be physically active near home, the patient will likely not be able to consistently perform physical activity. If the same patient works for an employer who provides an onsite gym, the patient could negotiate with her supervisor to utilize the gym to be physically active a few days a week.
Of the multiple additional constructs in SCT, several are worth mentioning. Albert Bandura, the author of SCT, identified self-efficacy, the confidence a person has in his or her ability to perform a behavior, as having a significant influence on behavior change. Self-efficacy has been shown to predict the amount of effort an individual will expend to learn and practice a behavior, the persistence demonstrated in the process, and the effort expended to overcome barriers. , Self-efficacy is behavior specific. Therapists are familiar with the importance of self-efficacy in neurological rehabilitation as patients learn and relearn movement strategies after neurological insults and the way in which repetition, small steps, verbal persuasion, and observational learning build confidence and thus competence in the movement. These same strategies enhance self-efficacy for behavior change related to enhancing wellness, and self-efficacy is key to the development of sustainable health habits.
Goal setting and social support are two additional useful constructs in SCT that fall into the broad category of self-regulation, an important skill to develop when adopting new health behaviors. The setting and achievement of goals can have a profound positive impact on learning new health behaviors, like the positive role goals play in physical and occupational therapy plans of care, with the additive effect of enhancing self-efficacy when goals are both challenging and achievable. When goals are not adequately challenging, they can decrease self-efficacy. Social support involves identifying others who will provide encouragement in the form of moral support, participation in the behavior, and accountability. For certain populations, social support has been shown to be significantly related to physical and mental health, pain, coping, adjustment, and life satisfaction.
In summary, the application of the SCT can identify both barriers and facilitators to behavior change that can become the target of interventions that support the development of health and wellness enhancing behaviors. Attending to the self-efficacy of the patient as he or she develops a new behavior and intentionally implementing an approach that enhances self-efficacy will lead to more positive results. The use of goal setting and social support within the plan of care have been shown to support positive behavior change.
Resilience theory
The concept of resilience arose from the science related to both the physiological aspects of stress and neuroplasticity and psychological aspects of coping. Resilience, as defined by the American Psychological Association, is “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress.” Resilience is thus a complex construct representing a process of adaptation to a life disturbance based on the interaction of the individual and the environment. Resilience has also been viewed as a trait or outcome. As a trait, resilience is considered a protective factor. On an intrapersonal and cognitive level, resilience traits include optimism, intelligence, humor, locus of control, and a belief in purpose in life. , On an environmental level, perceived social support has been associated with higher levels of resilience. Resilience is demonstrated behaviorally through successful coping strategies, social skills, and educational abilities.
Resiliency as a model or theory may be first credited to Richardson and colleagues in 1990, although the concept of resilience can be found in prior work. In the Resiliency Model, Richardson and colleagues describe the characteristics of a resilient individual as protective against distress and disease. The authors describe resilience as a process of psychological reintegration with four possible levels where adversity can promote growth. In the highest level of true psychological reintegration, the individual learns new skills and strengthens characteristics of resilience from a disruptive experience ultimately reframing his or her perspective in a way that is enabling and not disabling. In 1998, Carver and colleagues depicted an individual’s level of functioning after an adverse event as having four possible courses similar to Richardson’s levels of psychological integration: (1) succumbing, (2) survival with impairment, (3) resilience (or recovery), and (4) thriving, seen as bouncing back and above the stressful life event, true psychological reintegration.
Resilience has been studied across a wide range of conditions including environmental stressors such as war, developmental life stressors such as adolescence, and also health stressors such as chronic and neurological illness. Based on this work, resilience may be best conceptualized within individual domains as resiliency in one area does not necessarily equate to resilience in another, similar to the concept of self-efficacy. Given the disruption of a life-changing event such as a traumatic brain injury or a spinal cord injury, or the uncertainty and stressors associated with neurodegenerative diseases such as multiple sclerosis or Huntington disease, the study of resilience and of resilience promotion programs has grown in recent years. , In a small randomized control pilot study of the program “Everyday Matters” developed by the National Multiple Sclerosis Society, Alschuler and colleagues found persons with multiple sclerosis improved their resilience and satisfaction with social roles. Trends were seen towards improvement in positive affect and well-being, and reduction in depressive symptoms. The 6-week program was delivered by teleconference and included readings, videos, and online group participation focused on improving resilience through development of optimism and happiness, and building upon opportunities for forward movement and positive outcomes.
Physical and occupational therapists can use the concept of resilience to empower choice and opportunity for patients to grow (thrive or psychological reintegration), versus simply recover or perhaps succumb when faced with living with a neurological condition. By incorporating components of optimism and humor, as well as positive appraisals and reframing into therapeutic encounters, therapists can build resilience as a powerful tool to promote health and wellness. Therapists can also connect patients with existing community-based programs that build resilience for the life-long pursuit of wellness.
Transtheoretical model
An individual theory, the TTM has four main constructs—stages of change, decisional balance, self-efficacy, and processes of change. James Prochaska, who with colleagues first described the TTM, hypothesized that individuals cycle through the stages as they adopt a specific behavior, from precontemplation (not thinking about changing the behavior), to maintenance (having performed the behavior consistently for at least 6 months). , Together with the other three stages (contemplation—feeling ambivalent about the behavior; preparation—committed to changing the behavior but hasn’t started yet; action—engaged in performing the behavior), the five stages describe varying degrees of readiness to engage in a specific behavior. The processes of change can be used as interventions to move an individual from one stage to another and include cognitive (thinking about the influence of the behavior on self and others) and behavioral (cues and rewards) activities. Decisional balance, weighing the pros and cons of the behavior, influences movement from one stage to another, as does self-efficacy. The higher the list of pros for performing the behavior, the closer to the action stage the individual will move, and the higher an individual’s self-efficacy, the more likely the person is to be performing the behavior. It is important to note that the stages are not meant to be linear, but cyclical, in that individuals don’t progress from one stage to the next necessarily. For example, individuals who stop smoking “cold turkey” can move from contemplation to action without spending time in the preparation stage.
Identifying the stage of change an individual is in allows targeted interventions to be developed that both respect the individual’s readiness to change and resonate with the person’s thoughts and feelings about the change. For example, if a patient is in the contemplation stage for performing his home exercise program daily, it would be appropriate to discuss the pros and cons of the behavior and identify strategies to overcome the cons or barriers and ways to increase the pros or benefits. This approach will ideally move the individual to the preparation or action stage where performing the home program can be achieved. Geertz and colleagues used TTM constructs in a study with 40 subjects with multiple sclerosis aged 35 to 65 with moderate disability. Subjects in the experimental group participated in 16 to 24 standardized exercise sessions in 8 to 12 weeks individually tailored to each participant based on baseline stage of change, self-efficacy, barriers to exercising, and social support. Following the intervention, subjects in the experimental group reported a higher stage of change compared to the control group; self-efficacy stayed the same compared to the control group in which it decreased over time, and perception of barriers changed to a less restricting view in experimental group subjects.
The TTM can be useful to identify a patient’s readiness to change a behavior, to identify cognitive and behavioral interventions that will create greater readiness, and, like the SCT, to note when self-efficacy is low and to intentionally apply strategies to improve it.
Self-determination theory
Recognizing that human behavior is the largest single source of variance in health outcomes, that the effectiveness of most interventions is highly dependent on the patient’s ability to adhere to recommendations, and that adherence is generally poor, Edward Deci and Richard Ryan created the SDT to explain how humans can successfully change their behavior. , Constructs in the SDT include three innate psychological needs of humans: autonomy, competence, and relatedness to others. Autonomy refers to the process by which behaviors become regulated over time. The authors describe motivation or regulation on a continuum, including amotivated/nonregulated, extrinsically motivated/regulated, and intrinsically motivated/regulated. When people behave to gain a reward (fit into a size 8 dress for a wedding) or avoid a negative consequence (spouse nagging, feeling guilty), they are motivated by extrinsic factors, which generally do not sustain behavior long term. Intrinsic motivation includes behaving a certain way because it is consistent with a person’s deeply held values or goals, for example, to be a better parent or student or employee. Intrinsic motivation is consistent with being self-determined and can sustain behavior and health habits as lifestyle choices. Competence is the degree to which individuals feel able to change and achieve goals and outcomes and is supported by the provision of skills and tools for change and effective feedback from health care providers. The theory authors state that autonomy facilitates competence because when individuals choose to engage in a behavior they are more likely to take risks, learn, and apply new strategies. The third construct, relatedness, refers to the degree to which individuals feel connected to others in a warm, supportive way. When individuals feel respected and supported, especially by health care providers in a patient-provider relationship, they are more likely to achieve intrinsic motivation and experience success sustaining health behaviors over time.
Physical and occupational therapists can apply the SDT by providing meaningful rationale for why a behavior is recommended, acknowledging feelings and perspectives so patients feel understood, and integrating choice wherever possible in plans of care to minimize external control and pressure from the provider. Numerous studies have been published illustrating the value of guiding patients toward autonomous motivation so that they can adhere to health behaviors and improve their quality of life and health outcomes.
Measurement of wellness
As a result of the varied ways that wellness has been defined and understood, a variety of wellness measures exist. Consistent with the characteristics of wellness described, a wellness measure should reflect the multidimensionality and systems orientation of the concept and have a salutogenic focus. In the literature, as well as in daily practice, clinical, physiological, behavioral, and perceptual indicators are all touted as wellness measures. Clinical measures include serum cholesterol level and blood pressure, physiological indicators include skinfold measurements and maximum oxygen uptake, behavioral measures include smoking status and physical activity frequency, and perceptual measures include patient/client self-assessment tools such as global indicators of health status (“Compared with other people your age, would you say your health is excellent, good, fair, or poor?”) and the Short Form 36 (SF-36) Health Status Questionnaire (see Table 33.4 ).
Although some perceptual measures assess only single system status (e.g., psychological well-being, mental well-being), numerous multidimensional perceptual measures exist that can serve as wellness measures. Perceptual constructs that have been used as wellness measures include general health status, subjective well-being, , general well-being, morale, happiness, , life satisfaction, hardiness, , resilience, and perceived wellness , (see Table 33.4 ). Refer to Fig. 33.3 for the “Perceived Wellness Survey” used by professionals to help conceptualize the patient’s perception of her or his wellness. This survey was first published in the American Journal of Health Promotion in 1997. Physical therapists assess perceptions as a part of the patient/client history, as recommended in the “Guide to Physical Therapist Practice.” Occupational therapists assess perceptions as part of their focus on human performance and occupation. Some of the kinds of perceptions that can be assessed include perceptions of general health status, social support systems, role and social functioning, self-efficacy, and functional status in self-care and home management activities and work, community, and leisure activities. Although a few of these categories are included in overall wellness, such as general health status and social and role functioning, measuring wellness perceptions specifically can provide additional and more complete information about the patient that both the physical and occupational therapist can use to formulate a plan that can be insightful to the patient/client. Therefore perceptual tools should be used when measuring wellness.
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