Introduction to Health Promotion for People With Chronic Illness and Disability

Being healthy is an important condition for functioning optimally and integrating fully into all aspects of the American society, including work and independent living (Lynch & Chiu, 2009; Ravesloot, Seekins, & White, 2005). Research has indicated that people with disabilities are equally, if not more, susceptible to other chronic medical conditions when compared with the general population and are at higher risk for health complications resulting from their primary disability (Bishop et al., 2000). In addition, people with disabilities have been found to be at substantially elevated risk for obesity (Rimmer, 1999), psychological distress (Turner & McLean, 1989), alcohol and other drug abuse (Bombardier, Rimmele, & Zintel, 2002; Janikowski, Cardoso, & Lee, 2005), and smoking (Brawarsky, Brooks, Wilber, Gertz, & Walker, 2002). Health promotion interventions for people with disabilities have the potential to improve secondary health and mental health conditions, employment status, and quality of life (Max, Rice, & Trupin, 1996; Ravesloot et al., 2005). Although people with disabilities represent approximately 21% of the U.S. population, they account for 47% of all medical expenditures (Max et al., 1996). Minimizing the impact and scope of secondary conditions through health promotion intervention can significantly improve health outcomes and curtail health care costs for people with chronic illness and disability (Lynch & Chiu, 2009; Ravesloot, Seekins, & Young, 1998; Zemper et al., 2003).

With more than 49 million individuals in the United States with a chronic condition or disability, it is clear that health promotion for people with disabilities is a crucial goal of the rehabilitation process (Waldrop & Stern, 2003). In addition, a major objective addressed in the “Disability and Health” section of Healthy People 2020 (U.S. Department of Health and Human Services [U.S. DHHS], 2010) is to reduce the disparity in employment rates between people with disabilities and the general population. Health promotion efforts for people with disabilities are a key to achieving this goal. As a result, rehabilitation researchers are beginning to recognize the need to include health promotion interventions in vocational rehabilitation services (Ipsen, Seekins, & Ravesloot, 2010). Ipsen (2006) examined the relationship between employment and health behaviors using data from the Behavioral Risk Factor Surveillance System. She found that exercise/physical activity increased the probability of employment for people with physical disabilities. Based on the findings of their programmatic research in health and disability, Ipsen et al. (2010) indicated that many secondary conditions, including physical deconditioning, fatigue, sleep problems, weight problems, pain, depression, and social isolation, respond well to health promotion behavioral interventions. These results provide a strong rationale for the inclusion of health promotion services within the state–federal vocational rehabilitation system.

To develop effective health promotion behavioral interventions for people with disabilities, it is necessary to understand barriers and facilitators of health promoting behaviors for people with disabilities. This understanding is facilitated by examining the application of health behavior change theories to explain health promoting behaviors of people without disabilities. Some of the more popular theories include social cognitive theory, the transtheoretical (stages of change) model, theory of planned behavior, self-determination theory, and protection motivation theory (Tulloch et al., 2009). In addition, there are attempts to integrate several theories into a comprehensive health promotion model (e.g., Pender’s Health Promotion Model [HPM] and Schwarzer’s Health Action and Process Approach [HAPA]). These health promotion theories and models are useful in identifying potentially important and modifiable health promotion determinants for people without disabilities. However, there is a lack of research using these theories individually or collectively to study health promoting behavior of people with disabilities.

There is no doubt that health promotion should be included in vocational rehabilitation services to improve employment outcomes and job retention of people with disabilities. However, before developing effective health promotion interventions designed specifically for people with disabilities, research into motivational and volitional factors influencing the propensity of people with disabilities to engage in health promoting behaviors is needed to complement current health promotion intervention research. To promote interest in health promotion research in rehabilitation counseling, we have invited six health promotion research groups to contribute to this special issue of the Rehabilitation Counseling Bulletin on health promotion for people with chronic illness and disability.

Specifically, in this special issue, Karpur and Bruyere (2012) analyzed the Medical Expenditure Panel Survey (MEPS) data to estimate health care expenditures related to secondary conditions, obesity, and health behaviors among working-aged people with disabilities. They found that the annual average health care expenditure among employed people with disabilities was US$4,524 (95% confidence interval [CI] = [US$4,248, US$4,800]) compared with US$1,325 (95% CI = [US$1,299, US$1,351) for employed people without disabilities. Secondary conditions were found to account for about 20% to 25% of higher health care expenditures among working people with various disability classifications compared with their peers with disabilities who do not have secondary conditions. Specifically, lack of exercise was found to be a major risk factor for secondary health conditions. The researchers suggested that rehabilitation counselors should be familiar with health factors that might affect employers’ willingness to hire people with disabilities and be willing to help consumers develop awareness of the importance of health factors in long-term well-being.

Chiu, Fitzgerald, et al. (2012) conducted an empirical study to evaluate the extent motivational and volitional variables in the HAPA model can be used to differentiate people with multiple sclerosis (MS) who are in different stages of readiness to engage in exercise and physical activity behavior. They found that individuals in the precontemplation, contemplation, and action groups can be maximally separated by two significant canonical discriminant functions: the volition function (Function 1) comprising exercise self-efficacy and planned behaviors, and the motivation function (Function 2) comprising risk awareness and outcome expectancies. The results were consistent with the relationships between motivational and volitional variables and the intervention needs of people in different stages of change hypothesized in the HAPA intervention matrix (Schwarzer, Lippke, & Luszczynska, 2011).

Keegan, Chan, Ditchman, and Chiu (2012) evaluated the predictive ability of Pender’s Health Promotion Model (HPM) for physical activity and exercise in people with spinal cord injuries (SCI) using hierarchical regression analysis. They found that preinjury physical activity/exercise level, severity of SCI, and commitment to plan for exercise and physical activity were predictive of postinjury exercise and physical activity level (R² = .41). In addition, friend/family support, perceived self-efficacy, and perceived benefits were the strongest predictors of commitment to a plan of action for exercise and physical activity (R² = .42). The research findings support the applicability of Pender’s HPM as a motivational model for exercise/physical activity for people with SCI. The authors also suggest that the information obtained from testing Pender’s HPM can be used to design health promotion behavioral interventions for people with SCI living in the community.

Chiu, Lynch, Chan, and Lindsey (2012) also tested the HAPA framework as a motivational model of dietary self-management using path analysis. The results indicated that the HAPA dietary self-management model fit the data relatively well (normed fit index [NFI] = .90, comparative fit index [CFI] = .95, and root mean square error of approximation [RMSEA] = 0.07). However, the model only explained 15% of the variance in dietary self-management behavior. Specifically, the results indicate that recovery self-efficacy and action and coping planning directly contributed to the prediction of dietary health behaviors. Action self-efficacy, outcome expectancy, risk perception, and social support influenced intention, and the relationship between intention and dietary health behaviors is mediated by action and coping planning. In addition, action self-efficacy, maintenance self-efficacy, and recovery self-efficacy directly or indirectly affected dietary health behaviors. These findings provide additional empirical support for HAPA as a health promotion model for people with chronic illness and disability.

Bezyak, Chan, Lee, Catalano, and Chiu (2012) examined the challenging issue of assessing physical activity level using a self-report instrument. In their study of people with psychiatric disabilities, Bezyak et al. adapted the Physical Activity Scale for Individuals With Physical Disabilities as a physical activity measure for people with severe mental illness. Results indicate that case manager ratings were more closely related to body mass index than clients’ ratings. Importantly, Bezyak et al. directed our attention to the challenges of using self-reported instruments to assess physical activity of people with psychiatric disabilities and the importance of validating psychometrically sound measures of physical activity for model testing, epidemiologic research, and health promotion interventions.

Finally, instead of predicting health promoting behaviors, Sung et al. (in press) chose to examine how health promoting behaviors (i.e., exercise, diet, and stress reduction) can mediate between functional disability and health-related quality of life. They found that functional disability and health promoting behaviors, including exercise, diet, and stress management, were associated with health-related quality of life. Exercise and stress management were partial mediators between functional disability and health-related quality of life. Exercise was found to be a moderator between functional disability and health-related quality of life. Exercise had a stronger effect on health-related quality of life for individuals with lower functional disability than people with higher functional disability. Their study provided support for the need to help people with chronic illness and disability increase physical activity and exercise levels. (Editor’s note: Because of page limitations, this article will be published in the subsequent issue of the Rehabilitation Counseling Bulletin.)

In summary, we are pleased to introduce this special issue of the Rehabilitation Counseling Bulletin devoted to health promotion and disability research. The articles submitted for this special issue have been prepared to provide readers with theoretical concepts, analytic strategies, and empirical findings on social cognitive and behavioral predictors of health promoting behaviors in people with chronic illness and disability. The findings of these studies also provide recommendations for developing better health promotion theories and models for people with chronic illness and disability, health promotion behavioral interventions that will improve health outcomes of people with disabilities, and future research directions. It is anticipated that these studies will stimulate thinking and facilitate discussions about the potential integration of health promotion interventions in vocational rehabilitation. We hope that Rehabilitation Counseling Bulletin readers find this special issue to be an important and useful resource stimulating the next generation of health promotion research in vocational rehabilitation.