Wellness Promotion Beliefs and Practices of Pediatric Physical Therapists

Abstract

Purpose: 

The purpose of this study was to elucidate wellness promotion beliefs and practices of pediatric physical therapists.

Methods: 

From a random sample of 500 American Physical Therapy Association Pediatric Section active members, 257 physical therapists (51%) returned usable questionnaires designed to gather information on professional and personal wellness beliefs and practices.

Results: 

Descriptive statistics and chi-square analyses were performed to describe current wellness promotion practices. Most participants considered wellness multidimensional, valued wellness, and incorporated wellness practices into their personal life. Only 54.5% of respondents, however, reported incorporating wellness into pediatric physical therapy practice. A third of the respondents identified themselves as either thinking or preparing to incorporate wellness promotion into practice. Factors associated with wellness promotion were older age group, knowledge, belief that wellness promotion was a physical therapy responsibility, and participation in personal wellness lifestyle activities. The most frequent barriers cited were external factors related to resources, time, and the child/family.

Conclusions: 

Current pediatric physical therapy practice reflects a more traditional model of care rather than a wellness promotion approach. With a paradigm shift in healthcare toward wellness promotion, pediatric physical therapists need to align practice with current societal needs and national healthcare campaigns. Continuing education programs that are participatory and well matched to the characteristics and needs of the attendees combined with collegial support may prove fruitful in providing pediatric physical therapists with the knowledge, motivation, and strategies needed to accomplish this goal.

In Brief

As a result of a paradigm shift in health care towards wellness promotion, the author suggests that pediatric physical therapists need to align practice with current societal needs and national health care campaigns.

INTRODUCTION

Healthcare in the United States is shifting from a pathogenesis model of diagnosis and treatment of illness to a preventive and salutogenic approach of producing health.^1–4 Public health initiatives like Healthy People 2010⁵ aim to prevent disease and promote health nationwide. At present, however, U.S. children's physical inactivity, obesity, and diabetes rates are epidemic.^6,7 This places our youths at risk of serious chronic diseases. Additionally, children and adolescents with physical disabilities are often sedentary, under- or overuse particular muscles, and commonly have fewer fitness, social, and recreational options.⁸

Definitions and terminology related to “health,” such as health promotion, health education, quality of life, disease prevention, and wellness, can be confusing because these terms are used interchangeably in the literature.⁹ The World Health Organization¹⁰ (WHO) promotes a broad, holistic definition of health as a “state of complete physical, mental, and social well-being.” This definition goes well beyond the U.S. traditional view of health as the absence of disease, and from this all-inclusive perspective, the now popular concept of wellness has emerged.⁹

Wellness encompasses both a state of mind¹¹ and a manner of functioning.¹² Dunn¹² defines high-level wellness as a method of functioning to maximize the individual's potential. Individuals with chronic conditions and disabilities, therefore, are capable of wellness because it is the individual's potential that is the ultimate goal. In addition, wellness comprises multiple dimensions, and a person's sense of wellness emerges from the interaction and balance of these dimensions.

Adams et al¹³ identified seven evidence-based dimensions, including physical, spiritual (what is deeply sacred to the individual, a life-force energy, and one's connectedness with nature and others), psychological (optimism), emotional (self-image, self-regard, and coping skills), social (being part of an available support network and harmony in relationships), intellectual (energy and capacity for cognitive activities), and occupational (satisfying participation in work, school, and play). An individual's notion of wellness influences the range of wellness promotion activities in which the individual participates. Additionally, how health professionals define wellness can influence what they incorporate into their professional practice.

For this project, the term wellness was chosen to convey to health professionals not familiar with the literature the broad concept of well-being. Likewise, wellness promotion was chosen to convey the intentional process of facilitating change in an individual's health-related behaviors to improve well-being. Wellness promotion encompasses educational, motivational, environmental, and policy measures that empower individuals, organizations, and communities; fosters healthy behaviors; and improves potential health and well-being.¹⁴ Promoting healthy lifestyle behaviors is particularly important in pediatrics.^6,11,15 Health behaviors that develop early in life often continue into adulthood, and wellness practices can enhance quality of life for the whole family. For adolescents with disabilities, outcomes are influenced by the interaction of the severity and progression of the health condition, the adaptive responses of the youth and his or her family, and the environment.¹⁶

The American Physical Therapy Association's (APTA) Guide to Physical Therapist Practice¹⁷ specifies that physical therapists, in addition to diagnosing, managing movement dysfunction, enhancing physical and functional abilities, and providing preventive services, promote wellness, fitness, and quality of life. Preferred practice patterns for physical therapists working with children and adolescents, as outlined in the Guide, delineate the breadth of physical therapy practice and current options for care. These practice patterns extend beyond the traditional pathogenesis model and are compatible with the WHO's¹⁰ perspective. Additionally, accreditation standards for academic programs require that graduating physical therapist students possess health promotion and disease prevention skills.¹⁸ Graduates are expected to be able to assess health needs and promote optimal health.

To enhance well-being in our society, there is an increasing need for physical therapists to assume a more active role in promoting wellness. Are pediatric physical therapy practitioners equipped to embrace, model, and integrate wellness promotion into routine clinical practice? Few studies have examined wellness promotion practices of physical therapists, and most were published in the late 1990s.^1,19–23 Further, an extensive search of the literature revealed only one study that provided data specifically on the wellness promotion beliefs and practices of pediatric physical therapists.²⁴ For the purposes of this report, each author's preferred terminology, ie, “health promotion,” “health education,” “wellness practices,” etc., will be used.

In 1989, Glazer-Waldman et al¹⁹ reported that physical therapists had positive health beliefs and engaged in healthy lifestyles. The authors suggested that, based on the participants' positive personal beliefs and behaviors, physical therapists were well suited to model healthy lifestyles. While physical therapists may serve as good role models, reports from research on patient education practices reveal that physical therapists provide a rather narrow scope of wellness promotion.^1,19–21

To examine the prevalence of health promotion and disease prevention education during physical therapy treatment, Fruth et al¹ developed a checklist to elucidate six dimensions of wellness. Forty-six physical therapists from 19 clinics participated in the study. They found that physical therapists were providing health promotion and disease prevention statements at a relatively low frequency, only 2.44 statements per session, and that the overwhelming majority of statements were in the physical dimension.

Their findings matched those of two earlier studies. Sluijs,²¹ whose study was implemented in the Netherlands, reported that most of the physical therapists' educational statements addressed the patients' chief complaints and therapists rarely provided global health information or stress counseling. Gahimer and Domholdt,¹⁹ using a similar methodology with participants in the United States, audiotaped 37 physical therapy practitioners during 137 patient treatments. These researchers counted the frequency of patient education statements in five categories, including information about illness, home exercises, advice and information, health education, and stress counseling. Gahimer and Domholdt also found a low level of health promotion. The mean numbers of statements per session were only 2.54 on general advice, 0.38 on health education, and 0.21 on stress counseling.

To guide future decisions regarding curricula, Holmes²² examined the attitudes and perspectives of physical therapy students regarding patient education. Survey responses of 93 first-year and 61 second-year physical therapy students were compared with questionnaire responses of 200 physical therapists from a 1993 nationwide study of APTA members by Chase et al.²³ Holmes reported that barriers to patient education, particularly characteristics of the patient, were more often reported by students. These results may reflect limitations in student communication skills, self-efficacy (an individual's confidence in his or her ability or capability), and or a misperception that information was beyond the patient's understanding.

Findings from a recent study by Rea et al²⁴ support the importance of self-efficacy as a predictor of practice. The researchers operationally defined self-efficacy as the physical therapist's confidence in assisting patients under a given scenario. Rea et al reported that, based on multiple regression analyses, self-efficacy predicted the four Healthy People 2010⁵ health promotion behaviors under investigation, including promotion of physical activity, psychological well-being, nutrition and overweight, and smoking cessation. Assisting patients with increasing physical activity was the most frequent area of health promotion, with approximately 50% of the participants reporting that they addressed this issue. Self-efficacy scores were based on the sum of survey items including adequate education, time allotted to patient care, available supportive materials, and patient's support network. Frequency data on these potential barriers to health promotion, however, were not provided.

Physician's barriers to practice guidelines including health promotion have been examined extensively. Cabana et al²⁵ performed a systematic review of the barriers related to adherence to clinical guidelines. Three databases, MEDLINE, ERIC, AND HealthSTAR, were searched and 5658 studies were found. Of those, 76 published articles encompassing 293 potential barriers met their inclusion criteria. Cabana et al identified seven major barrier categories including cognitive related to knowledge (awareness, familiarity), affective related to attitude (agreement, self-efficacy, outcome expectance, inertia of previous practice pattern), and behavior related to external barriers (patient preferences, available resources, reimbursement, time, contradictions in guideline). They cautioned readers that, rather than one barrier, a variety of barriers may affect adherence to physician guidelines and that strategies successful in improving adherence in one setting may be less useful in other settings where the barriers may be different.

One of the most widely used models to explain health behavior and to facilitate changes in individuals is the Transtheoretical Model of Behavior Change (TTM).^26–33 A key construct within this framework, identified in Table 1, is the stage of readiness to change. At each stage, different interventions are proposed to support behavior change. While the model was originally developed to assess and promote change in an individual's health behavior, it has also been used in research to promote changes in health professional practice patterns. Main et al²⁹ examined the validity of using the TTM to measure physician readiness to change cancer screening and counseling. They reported high internal consistency and concluded that this construct may be useful in predicting physician behavior and in facilitating physician behavior change. Park et al³⁰ proposed similar support for the TTM as a construct to understand physician's counseling of smokers. TTM has also been recommended as a strategy to promote the use of evidence-based practice by Australian occupational therapy managers.³¹ McCluskey and Cusick³¹ recommended practical strategies matched to the therapist's stage of readiness to change. For example, during the preparation stage, the authors proposed that therapists may need to acquire literature search and critical appraisal skills and that overall managers needed to anticipate, encourage, and support behavior changes. To promote evidence-based practice by physical therapists, O'Brien³² also suggested the use of the TTM, among several other behavior change theories.

TABLE 1: Stages of the Transtheoretical Model of Behavior Change

To examine physical activity promotion of general practitioners (GPs) and their practice nurses in the United Kingdom, the TTM was employed to identify readiness to change of the health professionals.³³ Barriers to health promotion were also documented, and lack of time, lack of protocol, and lack of incentive were significantly associated with stage of change. That is, professionals at higher stages of change reported these barriers less frequently. The researchers, however, were most impressed by the finding that GPs, whose own stage of physical activity was high, were three times more likely to promote physical activity with their patients, and nurses with the same profile were four times more likely to promote physical activity. Incorporating participation in physical activity within self-care, Weiner et al³⁴ identified five wellness promotion categories that physician's personally engage in, including approaches to life, relationships, spirituality, self-care, and work. The authors proposed that personal health beliefs and practices may translate into interactions with patients. At present, however, this requires further empirical testing.

Given the paucity of published studies on wellness promotion practices of physical therapists, particularly in pediatrics, the purpose of this study was to survey wellness promotion beliefs and practices of pediatric physical therapists. I was particularly interested in answering the following questions: To what extent are physical therapists incorporating wellness promotion into their pediatric practice? Which therapist characteristics are associated with incorporation of wellness promotion into professional practice? Which barriers most severely hamper incorporation of wellness promotion into pediatric practice? Based on these findings, strategies that enhance the ability of pediatric physical therapists to implement wellness promotion initiatives could be proposed and tested empirically.

METHODS

Participants

Participants were required to be active members of the APTA Pediatric Section whose current physical therapy practice included the treatment of children. A random sample of 500 Pediatric Section member physical therapists' names and addresses was purchased. The response rate for usable questionnaires was 51% (n = 257). Twenty-five returned questionnaires were not used because the respondents did not treat pediatric clients and one questionnaire was returned “address unknown.” To maintain response anonymity, there was no identifying information on the questionnaire. Prior to implementation, this study was approved by the Simmons College Institutional Review Board.

Questionnaire

A questionnaire consisting for four sections was developed to gather information on wellness beliefs and practices of pediatric physical therapists. Completion of the questionnaire took about 15 minutes. In section 1, demographic data were collected, including the respondent's gender, age group, year of graduation from an entry-level physical therapy program, current employment setting(s), and current state(s) of practice. At the end of this section, confirmation that the respondent was a physical therapist who treated children was requested. Otherwise, the respondent was instructed to stop completion of the survey and return it.

Section 2 focused on professional practice, including the examination, evaluation, and intervention methods employed by the therapist. It included items to determine the information that therapists gather during a physical therapy examination and evaluation process, wellness promotion goals, and wellness promotion interventions. Participants were asked to identify whether each item was included “routinely, often, occasionally, or never.” Questionnaire examination/evaluation and goal items reflected the scope of physical therapy practice outlined in the Guide to Physical Therapist Practice¹⁷ related to wellness promotion. In addition, the intervention items reflected common complementary pediatric interventions cited in medical literature^35,36 or listed in the PubMed³⁷ MeSH headings for complementary medicine. Some of the interventions are also conventional forms of therapeutic exercise used by pediatric physical therapists (eg, massage, aquatherapy, and hippotherapy). However, all the interventions met the criteria of producing global benefits related to increased feelings of well-being and/or psychological benefits related to stress reduction. In addition, feelings of well-being are promoted by many of the interventions when they are implemented within the community as well as in group social settings.

In section 3, participants were asked to check all dimensions that they would include in a definition of pediatric wellness. Wellness dimension items were chosen based on definitions summarized by Adams et al.¹³ To identify factors that affected the participant's decision to incorporate wellness promotion into pediatric physical therapy practice, respondents indicated “yes” or “no” to a list of items identified in the literature as common barriers to practice in other medical and allied health fields.^2,22,26,27 To elucidate frameworks that guide practice, participants were asked to indicate whether they “agreed, disagreed, or were undecided” in response to statements reflecting valuing of wellness promotion, family-centered care, support for Healthy People 2010,⁵ and scope of pediatric physical therapy practice. A statement reflecting components of the health belief model,^26,38 that to change a behavior individuals need both the perception that their health is threatened and the belief that change will improve their health, was also included.

The last question in this section requested that the participant identify the statement that best reflected how the participant felt at that time. Each statement represented a stage in the TTM as identified in Table 1.^26–33

Section 4 addressed personal wellness practices. Previous literature has indicated that an individual's health status and healthcare needs can affect how one perceives the health status and needs of others.^34,38 Therefore, participants were asked to indicate whether their own health was “excellent, very good, good fair or poor,” and indicate by a “yes” or “no” answer whether they had a health concern that required them to frequently see a healthcare professional. Based on the personal wellness practices of physicians described by Weiner et al,³⁴ respondents were asked to indicate whether they ‘routinely, often, occasionally or never” participated in each listed activity.

To establish content validity, language consistent with that of the Guide to Physical Therapist Practice,¹⁷ clarity of wording, and ease in completion of the questionnaire, a panel of experts critically examined each item in the first version of the questionnaire and provided feedback to the researcher to refine the questionnaire. The panelists were chosen based on a variety of attributes including their knowledge of research and writing of survey questions, expertise in the area of wellness, expertise in the field of pediatric physical therapy, and use of the Guide to Physical Therapist Practice.¹⁷ Five panelists were physical therapy members of the APTA, and the sixth member was a licensed nurse practitioner in maternal and child healthcare and educator who taught wellness promotion to graduate physical therapy students. Critical comments and revisions were made in writing, and all suggestions were incorporated into the final version of the questionnaire.

Procedures

A cover letter outlined the scope of the study indicated that participation was voluntary and that return of the questionnaire signified consent to participate. The questionnaires with cover letters and self-addressed stamped return envelopes were mailed to a random sample of 500 APTA Pediatric Section members. To improve return rate, envelopes were coded to permit a second mailing to those who did not respond. To ensure anonymity of the responses, questionnaires were separated from the coded envelopes by the researcher, and data were entered without any identifying information. Additionally, findings were reported in the aggregate.

Data Reduction and Statistical Analysis

Responses were coded and analyzed using the statistical software package SPSS 10.0 for Windows applications. For each participant, cumulative scores were calculated for examination/evaluation, goals, and intervention, based on participant responses for items within each respective section of the questionnaire. Four points were allotted to “routinely,” 3 to “often,” 2 to “occasionally,” and 1 for “never.” Cumulative wellness definition scores represented the sum of the dimensions identified by each participant. Descriptive statistics including frequencies and percentages were generated for all questionnaire items. In addition, confidence intervals were calculated for cumulative scores. Confidence intervals were chosen since this statistic is particularly useful, providing information about the magnitude of the effect, the precision of the measure, and how well the mean estimates the population.³⁹ Confidence intervals can also provide a measure of statistical significance. The null hypothesis may be rejected if 0 is not contained within the interval or if the intervals of two samples do not overlap.

To examine construct validity of the questionnaire, cumulative examination/evaluation, goals, intervention, and dimensions of wellness scores were compared among participants classified as either incorporating or not incorporating wellness into their pediatric physical therapy practice. Cumulative scores were also analyzed by setting. In addition, chi-square analyses were performed to examine the associations between stage of change and participant characteristics, beliefs, barriers, and participation in personal wellness lifestyle activities.

RESULTS

Construct Validity

Physical therapist mean cumulative scores for examination/evaluation, goals, intervention, and dimensions of wellness, shown in Table 2, were lower for participants who reported that they did not incorporate wellness promotion into practice. Confidence intervals at the 95% level did not overlap between those who incorporated wellness into practice and those who did not, indicating that all the mean scores were significantly different.³⁹

TABLE 2: Means, standard deviations, ranges, and 95% confidence intervals for cumulative scores

Section 1: Demographics

Demographic Information.

Table 3 presents demographic information for physical therapists participating in the study. Most of the respondents were female (95%), and 54% were older than 40 years of age. More than half of the respondents were experienced clinicians, reporting 11 or more years since graduation from an entry-level program. The three most frequently reported practice settings were early intervention (30%), school system (40%) and outpatient (30%). Since many respondents practiced in more than one setting, total frequencies for this item do not equal 100%. For items related to personal health, most participants identified their personal health as very good (54%) or excellent (30%). Only 15% reported having a health concern that required frequent visits to a healthcare professional. p Values in Table 4 show that older age group was significantly associated with incorporation of wellness promotion into physical therapy practice (χ² = 85,694, df 20, p ≤ 0.000); however, work setting was not associated with a particular practice pattern.

TABLE 3: Demographic characteristics of physical therapy respondents

TABLE 4: Chi-square analyses for incorporation of wellness promotion into practice

Section 2: Professional Wellness Promotion Practices

Wellness Information Incorporated During Pediatric Physical Therapy Examination/Evaluation.

Table 5 lists the items that participants considered during a physical therapy examination or evaluation of children. The three most frequent responses, indicated as being considered either “routinely” or “often,” were caregiver's expectations and concerns about the future (91%), the child's self-care and autonomy (90%), and factors that influence the child's motivation (89%). The three least frequent responses were child's behavioral health risks (54%), family cultural beliefs and behaviors (53%), and caregiver's behavioral health risks (37%).

TABLE 5: Wellness information incorporated during pediatric physical therapy examination/evaluation

Wellness Promotion Goals Incorporated into Pediatric PT Intervention Plan.

As seen in Table 6, most participants responded that they routinely or frequently included goals to improve participation in play or leisure activities (95%), improve safety (95%), and improve ability of caregivers to assist the child (81%). The least frequent goals were acquire healthy habits that foster wellness (49%), improve sense of well-being (53%), and improve understanding of factors that promote optimal health (53%).

TABLE 6: Wellness promotion goals incorporated into pediatric physical therapy intervention plan

Wellness Interventions Incorporated into Pediatric PT Practice.

Few participants incorporated the wellness intervention items listed in this survey, and none of the participants added an item to the “other” category. The three most frequent choices identified as routinely or often used were massage for relaxation (44%), aquatherapy (36%), and deep breathing for relaxation (35%). A quarter of the participants indicated that they routinely or often used music therapy, and 18% reported to routinely or often use hippotherapy. About 10% or less of the participants reported incorporating healing or other body work, yoga, mediation, imagery, prayer, or tai chi into practice.

Section 3: Professional Wellness Promotion Beliefs

Wellness Definition Dimensions.

Over 85% of participants identified at least six wellness dimensions in their definition. Table 7 identifies the six most frequently reported dimensions included in the definition of wellness. These were the presence of a support system (88%), pleasure in daily activities (88%), physical fitness (86%), healthy diet (86%), positive feelings about self and life (88%), and effective coping with stress (80%). About half of the participants included the dimensions of absence of disease, low risk of becoming ill, and creative use of resources. The least frequently identified wellness dimension was connection to what is sacred or deeply important (36%).

TABLE 7: Wellness definition dimensions

Barriers: Most Frequent Reasons.

Table 8 illustrates that the most frequently identified barrier affecting incorporation of wellness promotion into pediatric physical therapy practice was lack of interest by the child/family (68%). About half of the participants identified lack of the physical therapist's materials/resources to implement wellness programs, economic limitations of the child's family, lack of community programs in their area, and lack of physical therapy time during treatment due to competing priorities. About one third of the participants identified that their work environment was not suitable, that they did not have sufficient education on how to incorporate wellness into practice, and that they lacked reimbursement for these services. Only 10% of respondents indicated that wellness was not a core responsibility of physical therapy, and few participants identified their own lack of interest (9%) as a barrier or the beliefs that wellness promotion activities are not effective (0.8%) or are not worth the effort or cost (3%).

TABLE 8: Barriers to incorporation of wellness promotion into pediatric physical therapy practice

Neither work environment not suitable nor lack of reimbursement were associated with incorporation of wellness promotion into practice (Table 4). In contrast, lack of time was significantly associated with practice (χ² = 13.343, df = 2, p ≤ 0.001). That is, those that reported lack of time as a barrier less frequently incorporated wellness into professional practice. In addition, belief that wellness promotion is not a physical therapist's responsibility (χ² = 13.343, df = 2, p ≤ 0.001), lack of interest (χ² = 6.143, df = 2, p ≤ 0.046), lack of experience (χ² = 34.44, df = 2, p ≤ 0.000), and lack of knowledge (χ² = 51.016, df = 2, p ≤ 0.000) were significantly associated with not incorporating wellness into professional practice.

Guiding Frameworks.

Most participants agreed with components of the health belief model that to change a behavior individuals need both the perception that their health is threatened and the belief that change will improve their health (80%).^26,38 A similar percentage showed that they valued wellness by agreeing that the quality of a child's life will be improved if the child participates in wellness promotion behaviors (78%). Almost all the respondents supported a family-centered approach and agree that the family is central to physical therapy intervention with children (96%). More participants agreed that physical therapists should incorporate injury prevention initiatives (91%) into clinical practice compared to wellness promotion (82%), and about three fourths of the participants (76%) agreed that pediatric physical therapists have an important role in promoting the objectives of Healthy People 2010.⁵

Significant associations between practice and the role of the physical therapist in promoting Healthy People 2010 and in incorporating wellness initiatives into clinical practice were found (Table 4). Associations between practice and the belief that wellness promotion enhances quality of life and the role of physical therapy in promoting injury prevention, however, were not significant.

Stage of Change in TTM.

Table 1 shows that slightly more than half (55%) of the participants reported incorporating wellness promotion into their professional practice. Most participants who were not as yet incorporating wellness into professional practice (30%) identified that they were thinking about it.

Section 4: Personal Wellness Practices

Personal Wellness Practices.

Most participants reported that they incorporated a variety of personal wellness practices into their own life. Almost all participants said they spend time with friends and family (97%) and keep a positive attitude (97%). Many balance the many aspects of their life (87%); engage in enjoyable activities like reading, hobbies, or vacations (85%); and work particular hours or in a setting that enhances their satisfaction with work (85%). Many participants reported that they engage in fitness or sports activities (81%). About three fourths of participants reported that they engage in wellness lifestyle activities like healthy eating, meditation, or yoga, and two thirds engage in religious or spiritual activities. About half of the respondents reported engaging in volunteer activities, but only 15% said they engage in bodywork activities like massage, Reiki, healing touch, or acupuncture.

Stage of change was significantly associated with participation in personal wellness lifestyle activities (χ²= 62.806, df = 12, p < 0.000), but was not associated with personal health (χ² = 15.144, df = 15, p = 0.441). That is, participants who incorporated wellness into their professional practice with greater frequency also participated in personal wellness activities. The respondents' own health, however, was not associated with any particular practice pattern. Participation in wellness lifestyle activities, however, was significantly associated with the individual's health status (χ² = 35.3, df = 20, p = 0.019), and respondents who reported to have better health also reported with greater frequency participation in personal wellness activities.

Preferred Mode of Education.

Participants were asked to identify their preferred method of continuing education if opportunities were available to gain knowledge on pediatric wellness. The top three methods of increasing knowledge of wellness were through seminar (72%), publication (67%), and video (47%). Few pediatric physical therapists were interested in home study (4%), graduate course work (5%), or attending a national conference (15%), and only one third of respondents (35%) were interested in attending a state conference.

DISCUSSION

To what extent are physical therapists incorporating wellness promotion into their pediatric practice? Merely half of the participating pediatric physical therapy section members identified that they were incorporating wellness promotion into pediatric practice, and these self-reports were supported by differences in cumulative examination, evaluation, goal, intervention, and wellness definition dimensions scores. Participants, for the most part, considered the caregiver's expectations and concerns, and the child's home environment, activities, and abilities during the evaluation process. Fewer participants, only one half to one third, gathered information related to culture or health risks. Intervention goals, overall, focused more on performance behaviors than a holistic, wellness promotion approach. Most respondents included goals related to improved participation in activities, safety, and ease of care giving, but barely half identified goals to foster wellness, sense of well-being, or knowledge of factors that promote optimal health. Few participants incorporated interventions that focused on wellness into their practice. Traditional physical therapy interventions like massage and deep breathing were reported more often than complementary interventions like yoga, meditation, or tai chi. These findings reflect a more traditional approach to care and are consistent with previously reported studies on patient education.^1,20–22 In sum, they reveal that physical therapists have been slow to assume responsibility for promoting wellness.

Which Therapist Characteristics Are Associated with Incorporation of Wellness Promotion into Professional Practice?

Personal beliefs and behaviors of the majority of physical therapists were supportive of wellness promotion and participation in healthy lifestyles. However, for half of the participants, these beliefs and personal practices did not transfer into professional practices. Pediatric physical therapists who were in the 40 and over age groups and who personally participated in wellness lifestyle activities more frequently incorporated wellness promotion into their professional practice. Self-reported health status was also associated with incorporation of wellness promotion into practice. Proportionally, more therapists who reported very good and excellent health participated in wellness lifestyle activities than those reporting fair or good health. In addition, pediatric physical therapists who identified themselves as incorporating wellness promotion into practice more often agreed with the statements that wellness promotion enhances quality of life and that physical therapists have a role in promoting Healthy People 2010,⁵ wellness promotion, and injury prevention. These therapists also included more dimensions in their definition of wellness. Although many therapists participated in a variety of personal wellness practices, most of the practices were more traditional, like spending time with friends, keeping a positive attitude, and participating in hobbies and fitness activities. Few participants engaged in complementary wellness activities.

Which barriers most severely hamper incorporation of wellness promotion into practice? The barriers most frequently cited as affecting participants' ability to incorporate wellness promotion into practice were the client and or the client's family, lack of time, and resources. All three of these factors are referred to as external barriers because they are outside the beliefs or characteristics of the individual. However, the factors more frequently associated with a practice pattern that did not incorporate wellness were internal barriers including the therapist's lack of interest, lack of personal experience, lack of knowledge, and the belief that wellness promotion is not a responsibility of pediatric physical therapists. Work setting, which in previous research has been correlated with adherence to professional guidelines,²⁵ was not associated with incorporation of wellness in this study, nor was reimbursement.

Strategies to Promote Adoption of Wellness Promotion by Pediatric Physical Therapists

To successfully promote change, desired behavioral outcomes need to be consistent with the norms and values of the societal and professional community.³² In the United States, we are bombarded by news media messages to adopt healthy lifestyles, and there are numerous national health promotion policies and initiatives. Examples of national programs specifically developed for youngsters include Bam! Body and Mind,⁴⁰ Verb: Its What You Do,⁴¹ Powerful Girls/Powerful Bones,⁴² Kids Walk-to-School,⁴³ and from the American Hearth Association,⁴⁴ Jump Rope for Heart, Hoops for Heart, and HeartPower! The APTA has also provided leadership, coordinating community health promotion campaigns, offering courses and certification in health promotion and fitness, and publishing preferred practice patterns. With a supportive environment in place, pediatric physical therapists now need help in developing self-efficacy and in translating personal beliefs and wellness promotion behaviors into professional practice. Passive forms of dissemination, such as didactic lectures or published guidelines, are often not successful.³⁰ Rather, interventions need to be targeted to the specific needs of the individual physical therapist. Since individuals are at different levels of readiness and have different barriers to change, multiple solutions are required.

From a social cognitive framework, to facilitate change, pediatric physical therapists need credible role models who engage in wellness promotion and with whom they can identify.³ To enhance self-efficacy, therapists need educational opportunities; they need to be actively engaged and receive personalized instruction and encouragement. Opportunities for collegial support are also critical. Rappolt and Tassone⁴⁵ reported that while continuing education was highly valued by participants in their study of how rehabilitation therapists gather, evaluate, and implement new knowledge, participants relied heavily on informal consultation with peers. Mentor relationships or a “buddy system” can provide ongoing support. Additionally, misperceptions of barriers need to be corrected, and pediatric physical therapists, when deciding to incorporate wellness promotion into practice, need to believe that the “cons” do not outweigh the benefits. Therefore, outcomes need to be perceived as truly worthwhile.

Many of the pediatric physical therapists who participated in this study were at the “Contemplation” stage in the Transtheoretical Model of Change.^2,26–31 They are thinking about taking action and personally recognize the benefits, but barriers to change may seem insurmountable. To progress to the next stage, “Preparation”, consciousness needs to be raised, and barriers need to be examined and overcome. Asking “What would it take for you to integrate wellness promotion into your pediatric physical therapy practice?” identifies the individual's barriers as well as the incentives for change. Emphasizing the reasons to change, particularly the short-term benefits, describing how other pediatric physical therapists have made changes in their practice, and brainstorming solutions to barriers one at a time are helpful at this stage. Another strategy to promote change is linking the new practices to the therapist's perception of being viewed positively by individuals whom the therapist values. Additionally, resources to enhance knowledge and skills should be provided.

As therapists transition to the “Preparation” stage, they are ready for action but need help in developing goals and a plan that is explicit, realistic, and convenient. Zimmerman et al²⁸ described this as a period of experimentation in which strategies to promote change shift from motivational to behavioral skills. Establishing a time schedule for change commits the therapist to decisive action and facilitates transition to the next stage.

At the “Action” stage, pediatric physical therapists are incorporating wellness promotion into practice, but they need positive, constructive feedback for reinforcement and to develop further self-efficacy. Asking “What would help you better integrate wellness promotion into practice?” identifies unresolved barriers that need to be addressed as well as potential incentives. Assistance in developing long-term goals is also helpful. Since return to old practice patterns, referred to as “relapse,” is anticipated in this model, therapists need help identifying factors that may cause relapse as well as solutions to combat it.

Martin and Fell² provided an excellent overview of society's current need for health promotion and described guidelines for physical therapists to promote good nutrition, physical activity, smoking cessation, and fall prevention. Since it is beyond the scope of this paper to provide specific health promotion strategies for clients, the reader is directed to this reference as well as other instructive articles and texts.^{3,9,14,25–27,46–49}

CONCLUSION

To effectively address the healthcare needs of today's society, pediatric physical therapists require a clear understanding of the factors influencing integration of wellness promotion into practice. The pediatric physical therapists who participated in this study valued wellness promotion, defined it broadly, and engaged in a variety of personal wellness practices. For many therapists, however, current pediatric physical therapy practice reflected a pathology model more than a wellness promotion approach. The most frequently reported barriers tended to be external factors, but many therapists indicated that a lack of education on how to incorporate wellness into practice and a lack of personal experience with wellness lifestyle activities also affected practice. With a paradigm shift in healthcare toward wellness promotion, pediatric physical therapists need to align professional practice with current national wellness promotion campaigns and societal needs. Continuing education seminars that are participatory and well matched to the characteristics and needs of the attendees combined with ongoing collegial support may prove fruitful in providing pediatric physical therapists with the knowledge, motivation, and strategies to accomplish this goal.

ACKNOWLEDGMENTS

Special thanks to the experts who served on my survey advisory panel: Donna Bainbridge, Diane Jette, Patricia Rissmiller, Lana Svien, Joanne Valvano, and Linda Wobaskiya.