Healey, William E. PT, EdD, GCS1; Broers, K. Blaire PT, DPT2; Nelson, Julie PT, DPT3; Huber, Gail PT, PhD1
In the past 60 years, the health care system has undergone a paradigm shift toward the inclusion of preventive services. This paradigm shift includes a changing definition of health from one that is disease focused to one that is focused on the ability of an individual to optimally reduce the risk for disease.1 Since the 1980s the US Preventive Services Task Force has provided professionals with scientific evidence for specific health promotion services.2 In addition, national goals for improving health have been disseminated via the Healthy People 2010 documents.3 The increased focus on health promotion has resulted in the incorporation of health promotion into the practice guidelines for many health care professions. Recently published literature has commented on the health promotion behaviors of health care providers such as nurses4,5 and medical doctors.6 In a survey of older adult health promotion by 72 nurses in a medium-sized general hospital in the United Kingdom, most nurses felt that health promotion was part of their role and were confident in their ability to deliver it.5 Nurse respondents also believed that health promotion was harder to implement as people get older and they did not have enough time to routinely implement a health promotion intervention.
The older adult (65 years and older) US population is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030.7 Health promotion is particularly critical for older adults as the risk of becoming disabled increases with age. Helping older adults maintain their health and function will reduce the risk for disability.8 Rehabilitation professionals, such as physical therapists, are in a position to promote health in older adult populations because of their expertise in restoration of independent function and extended individual patient contact.9 The physical therapy profession has included health promotion activities as part of its practice guidelines10 and educational requirements.11 However, there is limited research describing what physical therapists do to promote health and wellness in older adults. To develop optimal practice in the area of health promotion, it is necessary to understand how therapists currently encourage healthy behaviors.
Promoting health and preventing disease in older adults help to reduce premature mortality caused by chronic and acuteillnesses and allow older adults to maintain independence, extend their life expectancy, and maintain and enhance their quality of life.4 The Guide to Physical Therapist Practice, 2nd edition, states that physical therapists should be involved in prevention and screening activities and promote health, wellness, and fitness.10 For almost 20 years, accreditation criteria for physical therapist education has required that graduates be able to effectively address the issues of health promotion, disease prevention, wellness, and fitness when providing physical therapy services.11 Special interest groups in the American Physical Therapy Association, for example, Section on Geriatrics Health Promotion and Wellness special interest group, as well as continuing education offerings also support the inclusion of health promotion in physical therapy practice. Recently, the Section on Geriatrics sponsored the Exercise and Physical Activity in Aging Conference (2010), which invited recognized leaders in the area of physical activity and exercise health promotion to translate research into clinical practice.
Although health promotion is valued by the public12 as well as the profession, few studies have delineated the types or effectiveness of services that physical therapists provide. Behavioral change theories provide a framework to approach health promotion, including the stages of change theory, social cognitive theory, and the health belief model.13–15 Rea et al16 used components of social cognitive theory to examine health promotion behaviors of physical therapists in New York, California, and Tennessee. The study found that physical therapists who reported higher self-efficacy (confidence in ability to perform behavior) and outcome expectations (what will happen if behavior is performed) also reported spending more time on health promotion topics. Therapists working primarily with older adults were not identified as a subgroup in the study sample.
Health promotion and disease prevention have been included as part of patient education in physical therapist practice. Gahimer and Domholdt17 studied patient education in the outpatient physical therapist setting. They focused on 5 types of patient education: information about illness, home exercises, advice and information, health education, and stress counseling. Information about illness and home exercises were the most frequently discussed topics. Conversely, in the same study, specific health education and stress counseling were some of the least frequently performed patient education activities with less than 0.4 statements per treatment session. In contrast to Gahimer and Domholdt's findings, Fruth et al18 showed that physical therapists do specifically educate patients on health promotion and disease prevention as part of the treatment interaction. Fruth's group observed physical therapists in 4 different types of practice settings and recorded health promotion statements made by the physical therapist during a single patient care interaction. Physical therapists made on average 2.44 health promotion/disease prevention statements per session with their adult patients.18 Only 4.3% of the 46 physical therapists observed failed to provide health promotion/disease prevention education. However, in another study of 257 pediatric therapists, physical therapist who responded to a survey about wellness promotion practice, 45.5% failed to incorporate health promotion into their patient care.19 These studies suggest that frequency of health promotion may vary because of setting and age groups, with little specifically reported relative to older adults.
The content of health promotion activities provided by physical therapists has also been examined. Studies often provide a framework for identification of the health promotion activities. Fruth and colleagues18 used a multidimensional model of health to examine health promotion statements made to patients. The model identifies 6 dimensions: physical, emotional, mental, social, spiritual, and vocational. Physical therapists in the study addressed all of the dimensions, but the vast majority of health promotion statements were in the physical dimension (79%). A second study limited therapist responses to 4 focus areas based on Healthy People 2010 objectives.16 The amount of time therapists addressed the focus areas was physical activity 54%, psychological well-being 41%, nutrition/overweight 19%, and smoking cessation 17%. Although frameworks provide structure to studies, they also limit the types of activities documented and can lead to underestimating the types of health promotion physical therapists provide to patients. Focusing on an older adult patient population with more open-ended questions will provide an opportunity to see the breadth of activities physical therapists provide.
The literature in geriatrics does show that physical therapists have been involved with community-dwelling older adults most often in the areas of osteoporosis, fall prevention, function, and disability. In a survey of 47 physical therapists working in home health, Peel and colleagues20 reported that the majority of therapists “almost always” or “always” ask about patient fall history, identify and document fall risk factors, and provide interventions targeted at fall risk factors. Falls screening at Senior Health Fairs or Senior Centers is one way that physical therapists reach out to the community.21,22 Community interventions to reduce risk factors for falls have also been developed in collaboration with physical therapists with some success.23 Physical therapists are also involved in community prevention programs for community-dwelling older adults with resulting improvement in instrumental activities of daily living and functional performance measures.24,25 Physical therapists are contributing to the body of knowledge used in designing community programs, but there is no information on how regularly physical therapists are involved in community-based endeavors.
Despite physical therapists' involvement in individual and community health promotion, there is some evidence that physical therapists are not optimally engaged in health promotion and disease prevention. Using data from the Behavioral Risk Factor Surveillance System, a large sample of older adults with osteoarthritis reported that less than 50% were advised by a doctor or other health care professional to increase their physical activity.26
Given the frequency with which physical therapists see patients with osteoarthritis, physical therapists may not be sufficiently promoting physical activity. Screening for prevention may also be lacking. Only 7% of patients who had sustained a Colles' fracture, and therefore determined to be at risk for further osteoporotic fractures, were screened by a physical therapist for fall risk and only 20% received appropriate exercise training.27 Understanding the barriers that prevent therapists from efficiently and effectively delivering health promotion may help practitioners develop strategies to overcome hurdles and increase health promotion in their practice.
The purposes of this study were to (1) determine the scope of health promotion activities among a small sample of experienced physical therapists, (2) examine how and in what settings these physical therapists addressed health promotion topics with older adults, and (3) identify the facilitators and barriers to providing health promotion in this specific population of patients. For this study, health promotion was defined as “the combination of educational and environmental supports for actions and conditions of living conducive to health.”28(p4) The specific research questions were as follows:
1. What health promotion behaviors did this sample of physical therapists practice with older adult patients/clients?
2. What are the reasons these physical therapists do these specific health promotion activities with older adults?
3. How effective do these physical therapists feel their efforts are?
4. What helps or hinders this sample of physical therapists from counseling their older patients on health and wellness behavior?
A list of 65 physical therapists in the Chicago area was generated by one of the study investigators and by 2 directors of clinical education who identified physical therapists who worked with older adults in a variety of local practice settings. All 65 physical therapists were sent a demographic questionnaire, a signed consent form (approved by the university institutional review board), and availability information. Twenty-nine respondents returned these 3 documents. Therapists were asked to participate in focus groups if they reported an average weekly caseload of older adults of 60% or more. Older adults were defined as age 65 or older. Twenty-four of the 29 respondents met the inclusion criteria and 14 were able to attend 1 of the 3 focus groups. Figure 1 provides an overview of the recruitment process and a brief description of the separate focus groups.
This study used a qualitative research design. Focus group methodology was used to allow for open exploration of health promotion behaviors physical therapists addressed with older adults. Focus groups have been used as an “initial exploratory step in questionnaire development to learn what to ask and how best to ask it.”29(p295)
Participants were assigned to a focus group on the basis of their availability, for example, a weekday evening or Saturday morning time, and practice setting (to ensure diversity within the group). No attempt was made to manipulate the participants in any focus group. The focus groups were scheduled during a 1-month period, intended to be 1 to 2 hours in length with 6 to 8 therapists in each group. The same questions were asked of each group. The groups were tape recorded (with written consent) and facilitated by 1 of 2 physical therapist students who were study investigators (K.B.B. and J.N.); one investigator led the discussion and the other investigator monitored the time and took field notes. Follow-up or probing questions were asked on the basis of the direction of the discussion.
The interview guide used during the focus groups was generated by the authors and reviewed by a group of 5 physical therapist faculty volunteers who have clinical experience working with older adults; 2 of the faculty members have expertise in qualitative research. Several of these faculty members provided written feedback and agreed to pilot the interview questions in a simulated focus group format prior to the start of the study led by the 2 student investigators as part of their training. Further modification of the interview guide was made on the basis of the suggestions received in writing or verbally following the pilot focus group meeting (see the Appendix).
A constant comparative systematic process was used to reduce and analyze the focus group transcripts.29 Respondents were assigned a numeric identification code once enrolled in the study and the transcripts were deidentified. The 3 focus groups' data were transcribed by the same 2 study investigators (K.B.B. and J.N.) who facilitated the 3 groups. These investigators individually coded the transcripts by placing a word or phrase adjacent to the text, capturing the meaning of each passage. Health promotion factors identified in the literature were considered in the development of coded words, phrases, and categories, for example barriers, facilitators, and areas of health promotion addressed by physical therapists. Following their individual coding of each of the focus groups' transcripts, K.B.B. and J.N. met and discussed the transcribed data until agreement was reached on a final set of 56 codes. The final codes guided a second review of all transcripts. Coded words and phrases with similar or related meanings were grouped together and designated as 9 categories. Similar categories were grouped together and 3 themes emerged, which were confirmed by W.E.H.'s review of the transcripts.30 Figure 2 shows the timeline for data reduction, analysis, and progression of themes. Six months later, W.E.H. and G.H. reviewed separately the 3 group transcripts, utilizing the previous coding system, and revised the categories and themes.
Several strategies recommended by qualitative researchers were used to ensure the accuracy and credibility of this study's findings. Techniques used included triangulation of data, clarification of bias, member-checking, and peer debriefing and review.31
Triangulation. Results from 3 independent focus groups identified similar areas, which were compared and combined in developing this study's findings. In addition, multi-ple researchers reviewed the data and separately confirmed coding categories and supported the themes.
Clarification of bias. At the time this study was conducted, K.B.B. and J.N. were physical therapist students who completed this investigation as part of their fulfillment of research requirements for their physical therapist degree and were mentored by coinvestigators, W.E.H. and G.H. W.E.H. and G.H. are faculty members of a physical therapist entry-level program with 28 to 32 years of clinical experience and who are responsible for teaching health promotion content in the entry-level doctoral physical therapist curriculum. W.E.H. is a physical therapist, board certified in geriatrics, and has experience with qualitative data-collection techniques. G.H.'s doctoral work focused on older adult health promotion and she is involved with disseminating evidence-based, community exercise programs for older adults with osteoarthritis. Faculty mentors W.E.H. and G.H. worked closely with the student investigators in reviewing the literature, designing the methodology. Students did a preliminary coding and analysis of data and presented their findings in partial fulfillment of their “doctor of physical therapy” degree. Approximately 6 months later, W.E.H. and G.H. took a fresh look at the data and corroborated their results with the preliminary findings of the 2 students.
Member-checking of focus group transcription and coding was performed by selecting 3 of the 14 participants. Although we did not seek a response from all participants, each therapist was selected from a different focus group and practice setting. Participants were given the transcripts from their session and the codes and asked to comment on the accuracy of the coding. Two of the 3 participants responded and were in agreement with what they had read. The third participant did not respond.
Peer debriefing and review. K.B.B. and J.N. invited peer students involved in a similar study examining pediatric therapists' health promotion practices to review their coding and ask questions of their findings at 2 meetings facilitated by W.E.H. and G.H. during the initial study analysis. Comments made at each meeting regarding interpretation of the data were considered and incorporated into the analysis.
Thick description. Quotes from the focus group transcripts are provided that exemplify the findings in each of the themes. Participant quotes are identified by the clinical setting in which the therapist is employed followed by physical therapist, for example, hospital physical therapist.
The 14 focus group participants were all women, mostly in their middle 30s, who reported treating older adults at least part of every day in a variety of local practice settings. One of the participants was an orthopedic certified specialist; none were certified in geriatrics. Demographic characteristics of focus group participants are summarized in Table 1.
The focus groups averaged 98 minutes in length (range, 75–120 minutes).
Three main themes were identified to answer the study's questions: (1) health promotion is a part of physical therapist practice, (2) the benefits of more one-on-one time with patients, and (3) the factors that impact physical therapist provision of health promotion. A conceptual framework that summarizes the therapists' perspectives of the physical therapist role in older adult health promotion is described in the following sections and graphically displayed as Figures 3 to 5.
Health Promotion Is a Part of Geriatric Physical Therapist Practice
All 14 focus group participants identified health promotion as important to geriatric physical therapist practice. Geriatric health promotion was defined as holistic by almost all (10/14) of the therapist participants. Therapists reported that they needed to incorporate the patients' physical, social, psychological, and mental characteristics when planning and implementing health promotion activities. The participants addressed a variety of health promotion areas with their patients including physical activity and exercise (the most frequent lifestyle behavior area addressed); chronic disease management; making referrals to outside physical therapists; diet/nutrition/weight control; fall prevention/screening; ensuring safe patient function; and psychological concerns (Table 2). For example, a therapist working in the inpatient setting addressed several topics related to lifestyle behaviors and chronic disease management:
I think for me, just because I work with wound care and cardiac patients the most, I would say I counsel on activity and heart health, nutrition, foot care, good follow-up with their overall health care providers, and smoking cessation. (Hospital physical therapist)
A therapist who worked in both inpatient and outpatient settings focused more on physical activity:
I would say just overall exercise, just increasing their activity level from what they do especially if they usually do nothing. (Hospital/outpatient physical therapist)
The participants recognized community prevention for older patients as a need but were not necessarily involved:
I think it's important to distinguish between health promotion for individuals and health promotion for groups or communities. You're hoping every physical therapist is doing health promotion with their client. But what are we doing for the community (sic older adults) as a whole? (Home care physical therapist)
Although this therapist felt that community health promotion is important, the participant went on to say that health promotion activities had a marketing side benefit:
...I feel if we go out there, and we go to a senior building and we do a screening for fall prevention, I think in some ways we are doing health promotion. We're not getting paid for it, but again it sounds really crassbut it's the way it has to be, it's a good referral source to get more business, it's marketing and isn't that what it's about? So basically, yes, we're getting more clients, which we need to stay in business, but we're also proving a service in the community too. That's my attitude. (Home care physical therapist)
Regardless of the setting, participants typically engaged in health promotion during the patient's physical therapist visit. These physical therapists during the course of the visit saw an opportunity to discuss health promotion activities that could enhance the patient's function and quality of life. For example, a home care physical therapist said,
Well one of the things I like to do is, besides just seeing them for the given diagnosis, I also like to think it's not enough just to rehab someone. Say they fell and fractured their hip. It would be a great idea to address why this happened in the first place since I've been given the opportunity to work with them to try to address some of the issues. The other thing that I do is I try to talk to them about exercising for the rest of their life. Because it's a quality of life issue. (Home care physical therapist)
The acute care environment also afforded opportunities for health promotion with a focus on prevention for older adults:
I think health promotion can also be looked at as prevention as well. A lot of us are seeing a patient after the fall, after the diagnosis, after a long hospital stay, but when it comes to health promotion you're promoting wellness for the rest of their life and hopefully preventing further incidents, further falls, preventing more progression of chronic disease. (Hospital physical therapist)
In summary, all therapist participants reported that health promotion was part of their older adult clinical practice during the course of a patient visit rather than involved in community-directed approaches. Although a diverse range of health promotion topics was identified, not surprisingly physical activity and exercise was the most frequently reported topic addressed (Figure 3).
Benefits of More One-on-One Time With the Patient
The amount of time a therapist typically has with a patient is a key reason for a physical therapist's multiple health promotion opportunities, as reported by 6 focus-group participants. Generally, these participants felt that the amount of time spent with their patients facilitated the building of meaningful and trusting relationships that allowed these therapists to approach patients in a holistic way:
I think in the hospital we're in a unique position because these patients come in and they have all these services, all these doctors and nurses but nobody spends more than 5 minutes with them interacting with them. We go in there and you spend 30–60 minutes with them and it gives them a chance to think and move and maybe they have questions about their condition, what's going to happen, so that's a unique position we're in to have that interaction. (Hospital physical therapist)
We are in the right position to do that [patient education]. The doctor sees them once every 6 weeks and we see them two times a week and we have our hand on them.. you are developing a relationship with them so we are able to do that [education]. (Outpatient physical therapist)
But that's where I get lucky because I'm with them in the home for an hour and you try to encourage them to talk and things come out and you'd be surprised.that's what it takes.just spending the time with them and letting them get comfortable with you. (Home care physical therapist)
One outpatient therapist reported that having more time with her patients enabled her to address the topic of alcohol abuse with a patient, “Maybe their physician is sending them to you because they are not sure what to do and since we spend more time with them we build that rapport that is necessary for those harder discussions.”
Half of the therapist participants reported that their health promotion efforts were better received when they were focused on the individual patient needs. This patient-centeredness involved active listening skills and including the patient's goals and context when making health promotion recommendations.
My therapy interactions right now, especially with geriatric patients, are much more of a conversation than it ever was before. When I was a new grad I had my script in my head and I went through it and their answers were always good. Now I tend to speak, but I ask more questions and wait for their answers and I am much better, I hope, at processing what their answers are before I ask the next question.... They understood my goal and respect what I can do. I respect where they are at and somehow we can set them up to go home or where they desire. It's more of a conversation and before it was a one-act play. (Skilled nursing facility physical therapist)
In addition to defining geriatric health promotion as holistic, this approach facilitated therapist confidence in making referrals to other health care providers:
I would say that I think of that [health promotion] as very holistic. Yes, I treat a very specific part of their health but I agree it's our job to also be informed about other specialties, other ways they can get into the system and also to recognize some part of a person's life that may not be healthy. And to promote, oh, you might want to go see a dietitian or you might want to go see your physician about blood work or whatever just to be knowledgeable about the whole person in order to promote health as a whole. (Hospital physical therapist)
According to study participants in different practice settings, having blocks of one-on-one time with patients helped develop trusting relationships that enabled them to focus on individual patient needs in a holistic manner and encouraged them to address difficult topics (Figure 4).
Factors That Impact Physical Therapist Provision of Health Promotion
Two general areas were identified as impacting the provision of health promotion. One area was related to the physical therapists' provision of health promotion; the second area described factors related to the individual patient's adoption of the recommended health promotion (Table 3).
Physical Therapist Facilitators and Barriers
Several key resources were identified as enabling effective health promotion efforts. Clinical experience enabled the identification of facility and community resources, thus improving the physical therapists' confidence in making appropriate recommendations (Table 3).
I do have a lot of resources based on my experience, based on my leadership [at my facility]. I get calls, I call people. I think it is what you make of it. Could I use more? Always. But I do use my peers a lot. [I use the] Illinois Physical Therapy Association, American Physical Therapy Association, all those memberships, all those different things to try and figure out different answers and different resources for patients or even for my own therapists. (Hospital physical therapist)
I think the resources that I have available are better and my knowledge of the resources are better. When I first graduated and moved to Chicago it was a new city to me so I didn't know who offered classes, where to find group programs, patient education materials that were available on line. I eventually found common questions and I said, well, this is a common question, and we'll just make a handout to give out. So I think that's really expanded as I've become more experienced. (Subacute rehab hospital physical therapist)
Facilities that had health promotion resources readily available, for example, a wellness center, exercise groups, facility-generated handouts, promoted health promotion delivery.
I am in the middle of everything so I am really spoiled. But I feel all the resources are at my fingertips except for the patients that have transportation issues or no one to help them. But for a majority of the patients as long as they have transportation, all they have to do is show up and the rest is taken care of for them. (Subacute rehab hospital physical therapist)
Therapist participants identified that lack of reimbursement, time constraints, and lack of time away from direct patient care interfered with their ability to provide health promotion.
... It is a question of time... because there are patients to be seen so as far as dedicating time to program development either to promote health with certain patient populations and/or to in-service my staff so they're more knowledgeable about health promotion, time is short and you have to be creative about how you get the information out to them. (Hospital physical therapist)
On another note, one therapist reported that continuity of care was part of the issue when thinking about recommending health promotion activities at an early point in the continuum of care.
I'm constantly discharging patients to OP therapy or home health therapy so they're not quite ready to be independent in the community setting so I feel like [the facility] has tons of community classes going on— arthritis, warm water exercise, chi gong, all these classes, but if I give them a paper and say in 3 months I think this would be a good idea, it's not going [to] happen, so it's just the timeliness of it to get the education. (Subacute Rehab physical therapist)
Recognition of Patient Barriers
The focus group participants described several patient-related factors that were viewed predominately as barriers to the patient's adoption of therapists' health promotion efforts (Table 4). Almost all participants talked about the importance of patient buy-in or patient ownership of the patient's health in making changes. These therapists reported that if patients did not own the problem, they were less apt to manage their health.
My personal philosophy is that I want to be able to help a patient manage their particular problem and have them take ownership and then manage it on their own. (Skilled nursing facility physical therapist)
A therapist who worked in both an acute care hospital and a skilled nursing facility added:
I think just really stressing the importance of compliance and the ownership part of it. I think that is something that can make or break our success with patients.
Almost all of the participants discussed importance of the patient's social factors facilitating or inhibiting health promotion efforts. Factors described as positive or negative were supportive families, financial resources that paid for health-promoting behaviors, and transportation access to recommended activities.
One of the challenges in health care, you know, we talk about this all the time about the health care crisis and accessibility to affordable health care and insurances. This huge middle class that not everybody's affluent but they're not poor enough for public aid but there are huge gaps and for a lot of older adults they ask themselves, “Do I buy a pair of shoes or do I get my heart medicine this week?” And so we have to be sensitive to that and listen to the patient and be able to get some kind of social services in to help those folks. (Skilled nursing facility physical therapist)
In addition to patient resources, therapists also felt limited by their own community resources.
I just had a conversation with a patient a couple days ago talking about doing an exercise program. She was an elderly woman and I just want her to continue on, and I asked her, “is there a senior group where you can exercise,” and she said, “No, no there's nothing.” Sometimes I get frustrated because she needs something where she's supervised. She's asked me, “How do I get there?” It is somewhat limiting at times with their decreased mobility, transportation, and there's just not a lot of groups out there. No one is making money doing groups, so there's not a lot out there for exercise with geriatrics. (Hospital physical therapist)
Table 4 and Figure 5 depict what these therapists thought were physical therapist and patient factors that influenced their provision of health promotion. Availability of resources—in the facility, from knowledgeable colleagues, and in the community—facilitated health promotion delivery. On the contrary, lack of resources negatively impacted health promotion implementation and adoption. Lack of time, reimbursement, transportation, community programming, and family support were perceived as health promotion barriers. Therapists also believed that lack of patient ownership and responsibility of health limited their health promotion recommendations.
This study sought to understand what physical therapists do when promoting health with their older adult patients. Study participants reported addressing a wide variety of health promotion topics. Health promotion efforts varied and reflected the practice setting. Participants practicing in acute care settings tended to focus on fall prevention, wound prevention, and factors contributing to patient hospitalization, whereas participants in outpatient settings generally focused on healthy, successful aging.
This study's findings agree with those of prior investigations of physical therapist health promotion practice in that physical activity and exercise are the primary focus of health promotion.16,17 Similar to the results of the survey by Rea et al,16 this sample of physical therapists made statements about physical activity most often and unlike her findings, nearly 30% of participants reported addressing smoking cessation. Almost half of the physical therapist participants in our study addressed psychological issues with their patients, similar to Rea and colleagues, who reported psychological well-being as an area addressed frequently. Our study results identified chronic disease management as the second most highly reported health promotion statement, a finding in agreement with Gahimer and Domholdt,17 who reported that information about illness was the most frequently provided patient education given to patients by their physical therapist. Content areas participants addressed but felt uncomfortable discussing with their patients included obesity, depression, alcohol abuse, elder abuse, and domestic violence.
Home exercise was the second most frequently reported patient education topic found by Gahimer and Domholdt,17 and in our study the physical activity and exercise recommendations frequently revolved around a patient's home exercise program. Although Lorig defined patient education as “any set of planned, educational activities designed to improve patients' health behaviors and/or health status,”32(pxiii) these recommendations embedded in the patient's home exercise program may have been focused on the rehabilitation goals and not on exercise goals related to health promotion. Physical therapists may be instructing patients in exercise that returns them to their prior level of function but not addressing the long-term benefits of physical activity.
The therapist participants in this study appeared to address the 3 areas identified by Dean33 as important for physical therapists in their role as health promoters—physical activity and exercise, nutrition and weight management, and smoking cessation. What is not known is the effectiveness of physical therapist health promotion counseling or the methods used by physical therapists to influence the adoption of healthy behaviors. Identification of what helps or hinders health promotion is also an important next step.
Facilitators and Barriers to Health Promotion
Physical therapists may have more time to spend with patients than other health care providers, which provides opportunities to address healthy behaviors with their patients. The physical therapist participants perceived that physical therapist can do health promotion because they see patients longer in a concentrated episode of care and therefore are more apt to build relationships as compared with other health professions such as physicians. Rea et al16 believed that more time allotted per patient was one area that had potential to promote health promotion practices among physical therapists. More time with patients was perceived as promoting holistic and patient-centered care, and to assess a patient's readiness to adopt healthy behaviors. Holistic, patient- centered care is reflective of adult learning strategies that may lead to greater success at health promotion.9
However, similar to other professions such as medicine34 and nursing,35,36 physical therapists may be overwhelmed with other job tasks and patient care needs and relegate health promotion to “a nice to do but not always done” category. Physical therapists in this study reported similar time constraints. However, Fruth et al18 reported that the amount of health promotion education delivered by outpatient physical therapists did not differ by the phase of treatment (ie, early, middle, or late stages of rehabilitation) or the length of individual treatment sessions.
In addition to time constraints, the lack of reimbursement was another barrier to delivering health promotion. The physical therapist participants in our study felt that lack of reimbursement or concerns about reimbursement were limiting factors when providing individual services as well as community health promotion services if labeled as health promotion. These findings are similar to nursing35 and physician34 studies that reported a lack of reimbursement and time constraints limited health promotion delivery. This concern with reimbursement is aligned with today's health care environment where health promotion and prevention of disability receive little funding.
Facility, community, and peer resources were identified as influencing health promotion activities with older adults, similar to resources physical therapist described by Rea and colleagues16 that also included available supportive material for patients, support from the patient's significant other or family, and access to high-quality referral sources. Physical therapist participants were aware of available community resources and frequently recommended community services to promote health with their older patients. However, recognition of patient barriers to services is important as it promotes therapist-patient problem solving in order for the patient to act on health promotion recommendations.37 Patient transportation has been frequently reported as a significant barrier in following through on physical therapist counseling in using community resources.37 In addition, older adults have reported that safety (eg, crime, traffic, uneven sidewalks) is an environmental barrier to physical activity and exercise, one area that was not identified by therapist participants.38
Participants largely described their provision of health promotion activities as being influenced by job experience and not from traditional physical therapist educational experiences. Few participants reported formal education (professional or continuing education) in health promotion. Although health promotion has been emphasized in several physical therapist professional documents,10,11 formal educational activities may be less effective or not memorable to the physical therapists in this study. Rather, clinical experience may be the more powerful tool in building skills that enable physical therapists to confidently and effectively promote health.
Limitations in this study include the small number of participants representing the scope of geriatric practice. Since some settings were represented by only 1 therapist, an accurate representation of health promotion activities was not achieved. However, study participants had a variety of entry-level physical therapist degrees and represented the traditional geriatric practice settings, thus offering readers a starting point when thinking about their own health promotion behaviors. Using focus group methodology may have unduly influenced or inhibited responses.31 In addition, the questions may have been too narrowly focused or not probing enough to fully capture participants' experiences. Data analysis was conducted by relatively inexperienced qualitative researchers, rendering an overly superficial analysis.
This study was the first step in development of a survey that will be administered nationally to physical therapists working with older adults. Our findings suggest that health promotion is done by physical therapists but specific information about content, delivery methods, perceived effectiveness, and therapist characteristics warrants further exploration.
Fourteen physical therapists from a variety of practice settings reported consistently practicing health promotion while treating older adults. A common belief among the participants was that health promotion was important to the physical therapy profession. Health promotion efforts and barriers varied on the basis of the practice setting. The main facilitator of participants promoting health was therapists' ability to build relationships with their older patients due to adequate one-on-one time with them. Although participants did not have data to demonstrate the effectiveness of their health-promoting efforts, all were confident in their ability to promote health with their older patients.
With the increasing numbers of older adults, health promotion is of vital importance to reduce health expenditures and disability. Physical therapists are at a critical juncture to identify their role to meet the growing health promotion needs of older adults. Today's therapists may be looking beyond the immediate rehabilitation of their patients and recognizing health promotion strategies to return these older individuals to active participation in society.
We thank Kathy Hall, PT, EdD, the physical therapists who participated in the focus groups, and the Northwestern University PT faculty, all of whom made this research study possible.
1. World Health Organization. Official records of the World Health Organization. www.who/int/en/
. Accessed August 28, 2009.
2. Woolf S, Atkins D. The evolving role of prevention in health care: contributions of the U.S Preventive Services Task Force. Am J Prev Med. 2001;20(3)(suppl):13–20.
3. US Department of Health and Human Services. Healthy People 2010. Vol 2009. Washington, DC: US Department of Health and Human Services; 2009.
4. Resnick B. Health promotion practices of older adults: testing an individualized approach. J Clin Nurs. 2003;12:46–55; discussion 56.
5. Kelley K, Abraham C. Health promotion for people aged over 65 years in hospitals: nurses' perception about their role. J Clin Nurs. 2005;16:569–579.
6. Struck B, Ross K. Health promotion in older adults. Prescribing exercise for the frail and homebound. Geriatrics. 2006;61:22–27.
7. Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and Worldwide. Washington, DC: US Department of Health and Human Services; 2003.
8. Minkler M, Schauffler H, Clements-Nolle K. Health promotion for older Americans in the 21st century. Am J Health Promot. 2000;14:371–379.
9. Davis L, Chesbro S. Integrating health promotion, patient education and adult education principles with the older adult. J Allied Health. 2003;32:106–109.
10. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001.
11. American Physical Therapy Association. Commission on accreditation in physical therapy education. www.apta.org
. Accessed September 21, 2009.
12. Etter J. Perceived priorities for prevention: change between 1996 and 2006 in a general population survey. J Public Health (Oxf). 2009;31:113–118.
13. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
14. Martin P, Fell D. Beyond treatment: patient education for health promotion and disease prevention. J Phys Ther Ed. 1999;13:49–56.
15. Reicherter A, Greene R. Wellness and health promotion educational applications for older adults in the community. Top Geriatr Rehabil. 2005;21:295–303.
16. Rea B, Marshak H, Neish C, Davis N. The role of health promotion in physical therapy in California, New York, and Tennessee. Phys Ther. 2004;84:510–523.
17. Gahimer J, Domholdt E. Amount of patient education in physical therapy and perceived effects. Phys Ther. 1996;76:1089–1096.
18. Fruth S, Ryan J, Gahimer J. The prevalence of health promotion and disease prevention education within physical therapy treatment sessions. J Phys Ther Ed. 1998;12:10–16.
19. Goodgold S. Wellness promotion beliefs and practices of pediatric physical therapist. Ped Phys Ther. 2005;17:148–157.
20. Peel C, Brown C, Lane A, Milliken E, Patel K. A survey of fall prevention knowledge and practice patterns in home health physical therapists. J Ger Phys Ther. 2008;31(2):64–70.
21. Ness K, Gurney J, Ice G. Screening, education, and associated behavioral responses to reduce risk for falls among people over age 65 years attending a community health fair. Phys Ther. 2003;83:631–637.
22. Hakim R, Roginski A, Walker J. Comparison of fall risk education methods for primary prevention with community-dwelling older adults in a senior center setting. J Ger Phys Ther. 2007;30:60–68.
23. Shumway-Cook A, Silver I, LeMier M, York S, Cummings P, Koepsell T. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized controlled trial. J Gerontol A. 2007;62:M1420-M1427.
24. Gill T, Baker D, Gottschalk M, Peduzzi P, Allore H, Ness PV. A prehabilitation program for the prevention of functional decline: effect on higher-level physical function. Arch Phys Med Rehabil. 2004;85:1043–1049.
25. Chandler J, Duncan P, Kochersberger G, Studeski S. Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders. Arch Phys Med Rehabil. 1998;79:24–30.
26. Fontaine K, Bartlett S, Heo M. Are health care professionals advising adults with arthritis to become more physically active? Arthritis Care Res. 2005;53:279–283.
27. Myers T, Briffa N. Secondary and tertiary prevention in the management of low- trauma fracture. Aust J Physlother. 2003;49:25–29.
28. Green L, Kreuter M. Health Promotion Planning: An Educational and Environmental Approach. 2nd ed. Mountain View, CA: Mayfield Publishing Co; 1991.
29. Krathwohl D. Methods of Educational & Social Science Research: An Integrated Approach. 2nd ed. New York: Longman; 1998.
30. Bodgan R, Biklen S. Qualitative Research for Education: An Introduction to Theories and Methods. 5th ed. Boston, MA: Pearson Education Inc; 2007.
31. Cresswell J. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications Inc; 2003.
32. Lorig K. Patient Education: A Practical Approach. 2nd ed. Thousand Oaks, CA: Sage Publications Inc; 1996.
33. Dean E. Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5/6):330–353.
34. Brotons C, Bjorkelund C, Bulc M, et al. Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Eur Prev Med. 2005;40:595–601.
35. Williams R, Rapport F, Elwyn G, Lloyd B, Rance J, Belcher S. The prevention of type 2 diabetes: general practitioner and practice nurse options. Br J Gen Pract. 2004;54:531–535.
36. Jensen G, Gwyer J, Hack L, Shepard K. Expertise in Physical Therapy Practice. Boston, MA: Butterworth-Heinemann; 1999.
37. Petursdottir U, Arnadottir S, Halldorsdottir S. Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study. Phys Ther. 2010;90:1014–1025.
38. Griffin S, Wilson D, Wilcox S, Buck J, Ainsworth B. Physical activity influences in a disadvantaged African-American community and the community's proposed solutions. Health Promot Pract. 2008;9:180–190.
Focus Group Interview Guide
1. How do you define health promotion?
2. Is health promotion important to you?
a. Why or why not?
b. Does it affect what you do with your patients?
c. What behaviors are most important to you to discuss with your patients? Why?
3. Do you promote healthy behaviors with your patients?
b. Estimated frequency?
c. With whom do you promote healthy behaviors?
d. How do you make that decision?
e. Reasoning behind actions?
f. How do you think you could promote health more? Would anything have to change?
4. Do you encounter any barriers to health promotion?
a. For example, lack of education, facilities, or not enough time in session
5. What areas of health promotion are most important to you?
a. Do you feel like you promote those areas more than ones that might be more relatable to the patients' condition?
6. Where did you learn about ways/strategies for health promotion with your patients?
a. Has it influenced your actions?
7. How confident are you in practicing health promotion?
8. Do you have any resources that help you promote health to your patients?
9. How do your patients usually respond to you recommendations?
a. Do you think that they have an impact?
focus groups; health promotion; older adults
Copyright © 2012 the Section on Geriatrics of the American Physical Therapy Association