Health behavior change models and theories: contributions to rehabilitation Health behavior

change models and theories: Contributions to rehabilitation Abstract Purpose. This article
highlights the importance of health behavior change (HBC) theory, and its relevance to
rehabilitation research and practice. Method. An extensive review of HBC-related literature
pertinent to rehabilitation was conducted, focusing on the potential impact of these theories
and models in enhancing long-term results of rehabilitation with regard to lifestyle change
and health promotion, and outlining the benefits of incorporating HBC themes into
rehabilitation practice. For our purposes, the HBC concept is based on initiation and
maintenance of health behaviors, functioning, wellness, and self-management of chronic
conditions or disabilities within an environmental context. While comparing and contrasting
three widely known theories of HBC, the contributions of these theories to rehabilitation
research and practice are discussed. Results. Three propositions are put forward: (1) HBC
variables should regularly be used as outcome measures in evidencebased rehabilitation
research; (2) there should be a better understanding of the role of the rehabilitation provider
as a facilitator in eliciting healthy behaviors; and (3) there is a need to expand the HBC
concept into a more comprehensive view encompassing a person’s functioning within the
environmental context. Conclusions. A conceptual merger between HBC theories and
rehabilitation practice can have major implications for individuals with disabilities, their
functioning, health, and well-being Keywords: Functioning, self-efficacy, readiness for
change, environment, rehabilitation outcome, ICF Introduction Changing health behaviors
represents one of the key challenges and opportunities health providers face today in our
society [1,2]. One would expect with the current awareness of health indicators (such as
physical inactivity, obesity, tobacco use, substance abuse, mental health issues, injury and
violence [1]) that there would be demonstrated knowledge and a clear understanding of how
to prevent risky behaviors and promote healthy behaviors. However, evidencebased
research on successful health behavior change (HBC) interventions is inconclusive [3,4].
While there is a lack of a clear definition in the literature, health behavior change can be
defined as the shift from risky behaviors to the initiation and maintenance of healthy
behaviors and functional activities, and the self-management of chronic health conditions.
Health behavior change includes planning, initiating, acting upon, and maintaining primary
and secondary prevention of health conditions, as well as the promotion of health and
wellness, within one’s own environment [5 – 7]. We suggest that a person’s functioning
within the contextual environment is a critical element often not adequately considered with
regard to HBC. applications in rehabilitation and elsewhere. Environmental factors manifest
in myriad ways. Consider the following scenario. Upon the recommendation of her
rehabilitation care provider, a student using an electric wheelchair after a cervical spinal cord
injury initiates and maintains behaviors in order to prevent secondary health conditions, such
as skin ulcers or urinary tract infections. As part of her program, she is advised to engage in
regular physical activity. If the student is attending a university that offers accessible sport
and recreation for wheelchair users, with personal assistants and/or supportive faculty
members, her chances of successfully engaging in regular physical activity will be much
better than if she is attending a university with no wheelchair-accessible sport and recreation
facilities; her chances grow even fewer with no accessible transportation or support from
staff or faculty. The type of environment this student finds herself in will have a major impact
on her ability to adopt recommended HBCs, so must be considered by the rehabilitation care
provider when making recommendations and designing HBC approaches. In this paper we
focus on better understanding the HBC process for people with cognitive and physical
disabilities, although the message applies as well for those without such disabilities. Our
emphasis on functioning within the contextual environment and the understanding of how
change takes place is timely, since conceptualization of enabling and disabling environments
received major attention at the American Public Health Association annual meeting in 2004.
While much progress has been made, however, there remains a lack of integration among
environmental factors, HBC theories, and personal health indicators. Clearly, more research
is needed to clarify the overall concept and to understand the HBC phenomenon better with
respect to environment for persons with physical or cognitive disabilities. Toward this end,
there are three propositions that can be derived from the literature, which we wish to present
in order to stimulate further discussion. The first proposition advances the use of HBC
variables as outcome measures in evidence-based rehabilitation research. The second
proposition addresses the role of the rehabilitation provider in promoting functional activities,
health and well-being; specifically how providers should more consistently incorporate
principles of HBC theories into essential rehabilitation steps in order to achieve successful
outcomes of recovery and/or adaptation. The third proposition concerns the expansion of the
HBC concept to include functioning within the contextual environment. Such an expanded
concept can be more comprehensively applied to rehabilitation practice. In turn,
rehabilitation research can contribute to existing HBC theories. Definitions of health,
functioning, disability and the environment in rehabilitation The terms health, functioning, and
disability reflect standard definitions by the World Health Organization. Health is a state of
complete physical, mental and social well-being, not merely the absence of disease or
infirmity. The term functioning – derived from the WHO International Classification of
Functioning, Disability, and Health (ICF) [8] – encompasses body functions, activities, and
participation. Disability is the overarching term to connote impairments, activity limitations, or
restrictions in participation. Changes in health and functioning can take place at any time of
life because of disease, disorder or injury, and take place inevitably as we get older. These
changes can be seen in various forms as identified in the ICF: body functions and structures
(e.g., mental or sensory functions), activities (as simple as walking down the street or eating
a sandwich) and participation (e.g., voting, work, or recreation). Finally, environment
describes the physical, social, and attitudinal contexts in which people live and conduct their
lives [8] ranging from physical environment, (e.g., sidewalk curb cuts), support systems (e.g.,
the health professional), cultural perspectives about disability (e.g., presence or lack of
stigma), law and policy (e.g., equal opportunity for employment), to technology (e.g.,
adaptive technology). Methods An extensive review of the literature was conducted.
Keyword search terms included: disability, rehabilitation, health behavior change, Health
Belief Model, Social Cognitive Theory, Transtheoretical Model of Behavior Change, health
promotion, adherence, compliance, motivation, prevention, self-efficacy, and
self-management (also known as self-regulation). Six major medical databases (Cumulative
Index to Nurses and Allied Health Library (CINAHL), EBSCO, MEDLINE, Michigan Research
Library Network (MIRLYN), PROQUEST, and Web of Science) were searched for English
language articles published in peer-reviewed journals with focus on recent literature since
1994. Criteria for selection of articles for review included: empirical research investigating
HBC from the perspective of health education research and preventive medicine, nursing,
and rehabilitation services. HBC applications were searched by different rehabilitation
disciplines, including occupational and physical therapy, social work, nursing, medicine,
psychology, and recreation. More than 900 citations were found and screened by the primary
author, who determined that about 80 citations met the stated criteria and were selected for
review. Additional resources were included provided by one of the co-authors, a key expert
in the field of health behavior change and public health. Literature review Health behavior
change is generally felt to be a critical component in health and well-being [1]. There are two
major reasons for bringing theories of HBC explicitly to the forefront for rehabilitation
practitioners. First, the number of rehabilitation researchers investigating or recommending
investigation of HBC factors is growing, and there is emerging evidence that HBC factors
play an important role in rehabilitation outcomes [9 – 12]. HBC factors are prerequisites to
successful changes in lifestyle as advocated by most wellness and health promotion
programs, and evidently provide benefits to consumers. Although not yet directly linked with
HBC theories, research in assistive technology also supports the inclusion of health behavior
change variables such as self-efficacy [13]. Thus, using HBC theories, models, and
interventions as a common denominator in rehabilitation research and practice is critical to
understanding their long-term effectiveness in promoting lifestyle change, functioning,
health, and wellness. The second reason for addressing HBC theory among rehabilitation
researchers and practitioners can be extrapolated from five major themes relevant to
rehabilitation that emerged from this literature review. The first and most well known of these
themes concerns the preventive aspects of health behaviors that lead to health promotion,
well-being, and the primary prevention of a disease, disorder or injury. These preventive
behaviors carry the optimum benefit for consumers’ health and well-being, and minimizing
utilization of health services. Regular exercise, healthy diet, smoking cessation, safe sex, or
the use of automobile seat belts, and prevention of secondary conditions (e.g., skin sores for
a person with a spinal cord injury), exemplify the theme of preventive health behaviors [14 –
18]. As a form of secondary prevention, the second theme concerns early detection
behaviors that lead to early identification of a health condition. This is different from primary
preventive behaviors in that early detection precipitates behaviors addressing health issues
possibly already present, such as breast self-examination, disease screening, and stress
testing among caregivers [17,19]. The third theme found in the HBC literature,
self-management, describes self-regulation or selfmonitoring behaviors. Such tertiary
prevention involves monitoring behaviors associated with a chronic health condition or
disability, for example, asthma or chronic pain, and is closely related to rehabilitation in that
‘tertiary prevention consists of measures aimed at softening the impact of long-term disease
and disability by eliminating or reducing impairments, disability, and handicap, minimizing
suffering and maximizing potential years of useful life’ (p 142) [20]. Self-managed health
behavior change involves selfdetermination and the belief in what works and what does not
work [21 – 24]. In the context of primary, secondary and tertiary prevention, these first three
themes pertain in particular to people with disabilities who may be more vulnerable to other
health problems, who may experience an earlier onset of geriatric conditions, or who may
experience barriers to accessing health care [25,26]. A person with developmental
disabilities living in a group home where physical activities and good nutrition are not
promoted, for example, will be at greater risk of becoming overweight, having cardiovascular
problems, and having other related health problems. Treatment adherence, defined by some
scholars as the ‘necessary interface between efficacious therapies and treatment
effectiveness’ (p 114) [27], is an important fourth theme in the literature. Adherence has
recently replaced the term ‘compliance’, which was used to assess the client as ‘compliant’
or ‘non-compliant’ with provider recommendations. One major textbook on HBC theory and
empirical research addressed the issue of adherence in great detail with various populations
[22]. HBC theories are strongly linked with adherence and health promotion [9]. Since clinical
trials need outcomes based on evidence of effectiveness, treatment adherence is also key to
the completion of rehabilitation research. A fifth theme overarching recent literature focuses
on the behavior of the health care provider as critical informant [6,7,28 – 30]. The emphasis
of HBC has shifted away from the expert who provides the client with authoritative
knowledge about a condition or disability, instructing the client what to do and what not to do,
toward a facilitator of HBC. Only providing information to increase the client’s knowledge
does not often lead to HBC [4]. However, modified and extended provider actions – actively
facilitating a client’s confidence in self-management skills, promoting empowerment,
enhancing self-efficacy, increasing awareness and avoidance of potential risk factors,
improving health promotion skills, and identifying barriers to health promotion and wellness –
all offer strategies to optimize HBC [9,12,17,31]. Lack of training in this extended HBC
approach, as well as the underutilization of the provider as a facilitator of behavior change,
has been a major obstacle in certain health care delivery systems, particularly those serving
people with chronic conditions [6,7,25]. Note that these five themes are closely related to the
ecological approach to health promotion; i.e., the integration of HBC factors at various levels:
interpersonal, intra-personal, community and policy. Considered together, these themes
indicate that the role of the rehabilitation specialist in aiding HBCs deserves greater attention
[6,11,12,32]. Health behavior change models and theories In the last two decades the
number of studies examining HBC models and theories has increased considerably. A
wealth of empirical studies is being published, testing different types of behaviors with their
underlying theories and models [5,7,28,33,34]. Most research has been conducted in the
field of primary health care, nursing, and preventive medicine, with the main purpose of
clarifying treatment adherence, identifying factors influencing HBC, and designing effective
interventions. The US-based Behavior Change Consortium, consisting of 15 universities and
institutes, has investigated the efficacy of HBC interventions in improving key health
behaviors (exercise, diet and addiction) through theory-based research. Eighteen HBC
theories were tested in various studies [33], with the results suggesting that evidence-based
research does not support one single, exclusive theory of HBC [5,28]. There is clearly no
single quick-fix solution leading to HBC. Yet, comparing and contrasting existing theories and
learning from different views has been fruitful in identifying factors influencing the HBC
process and in targeting these factors for intervention. A brief review of three contemporary
HBC theoretical models will help illustrate the potential efficacy of HBC practices in
rehabilitation. Since most rehabilitation interventions take place at the interand intra-personal
level (clients, family members, care givers, co-workers), these theories have been selected
for the influence they already exert in promoting successful rehabilitation outcomes at this
level [4]: the Health Belief Model, Social-Cognitive Theory, and the Transtheoretical Model.
The Health Belief Model is widely applied in health promotion and treatment adherence.
Social-Cognitive Theory stresses the important role of self-efficacy, a variable identified by
many field experts as critical in influencing health behavior. The Transtheoretical Model
offers a significant pragmatic approach for rehabilitation practitioners. Not only are these
three concepts representative of HBC literature, but also these theories shape a
comprehensive health behavioral process for individualized rehabilitation. The Health Belief
Model (HBM) The HBM is one of the earliest theoretical models investigating health
behaviors. The theory was developed in the 1950s by Hochbaum, Rosenstock, Leventhal,
and Kegels, with the focus on enhancing people’s compliance with preventive services, such
as chest X-rays for tuberculosis screening [4]. If people perceive (believe) a threat from a
health condition, they may be motivated to engage in preventive behaviors, as long as
obstacles can be overcome to take action. HBM is founded on the concept that health
behaviors can be explained by four key constructs, plus two additional concepts of
self-efficacy and cues for action, to stimulate ‘overt’ health behavior. The four constructs are
(1) perceived susceptibility or vulnerability; (2) perceived severity of a condition; (3)
perceived benefits of treatment; and (4) perceived barriers [35]. Applying HBM in
rehabilitation, imagine an older woman who notices decreasing function in her hands, which
concerns her (perceived susceptibility or vulnerability). She sees her physician and is
diagnosed with arthritis. She begins to feel pain severe enough that daily living, household
tasks, driving, and recreation become too hard for her (perceived severity of condition). She
considers rehabilitation because her primary physician has convinced her that pain
management and a tailored exercise program will benefit her ability to perform her regular
activities (perceived benefits of treatment). Yet she hesitates to go through with the
interventions because she and her family live in the next county and she has limited finances
for transportation or assistive technology (perceived barriers). The HBM also calls attention
to cues for action – activities or situations – that stimulate or encourage a person to behave
healthfully, or to engage in functional activities safely. Cues can be internal (e.g., increased
pain) or external (e.g., information from a therapist) [35]. In the example above, her spouse
or partner could be included in her rehabilitation program, e.g., to remind her at home of the
need to pace activities or use a reacher for picking up small objects. Recently the variable
self-efficacy has been added to the HBM to reflect a shift from early detection and treatment
to primary prevention. Healthy behaviors like exercise, safe sex, good nutrition, and smoking
cessation can be difficult to adopt. A person must have a belief in his or her own ability to
overcome the particular perceived barriers in order to address the problem [36]. Back to our
example, after entering a pain management group, the woman develops a strong sense that
she could control the pain tolerance necessary to maintain modified activities, and so adopts
several changes that balance her arthritis problem with its lifestyle solution. The HBM
constructs make several contributions to rehabilitation, in particular providing a better
understanding of the reasons why a person seeks services, and adheres to or does not
adhere to a treatment plan [28,37]. Other contributions include a focus on exploring a
person’s perceptions of the benefits of a treatment regimen, and examination of perceived
barriers. Table I presents questions and strategies relevant for rehabilitation based on the
HBM. The provider can explore the client’s level of susceptibility to developing secondary
health conditions, inquire about perceived barriers for exercise, and develop a plan for
overcoming barriers. Positive reinforcements can be used as a method of cueing for action
in the implementation of HBC strategies. Social Cognitive Theory (SCT) One of the pioneers
in the development of SCT, also known as Social Learning Theory, is Albert Bandura who, in
the 1970s, argued that health behavior is influenced by a complex, interactive, reciprocal
relationship among the person, the social environment, and behaviors [38,39]. The focus
here is on a three-way reciprocal interaction of personal experience, observing others, and
believing in and knowing how to change. The environment influences, shapes, and may
constrain behavior. SCT is based on several complex concepts including reciprocal
determinism, behavioral capability, self-efficacy, expectations, and observations. Reciprocal
determinism is the influence of the environment on behavior and vice versa. The
environment shapes (e.g., supportive work environment) but also can constrain behavior
(e.g., non-accessible buildings). Behavioral capability concerns behaviors as a result of
information, knowing what to do and how to do it. Self-efficacy is the belief that one can take
control of certain aspects of one’s health actions. A person’s expectations are important in
terms of behavior outcomes. Observation of others, ‘modeling of positive behaviors’, as well
as positive reinforcement increases the chances that behaviors will be repeated [4,39].
Self-efficacy is a significant variable crucial in changing one’s behavior, and has been found
to be instrumental, for instance, in smoking cessation, adopting healthy diets and engaging
in regular physical activity [7,33,40]. In fact, SCT posits that health-related self-efficacy is a
fundamental requirement that is grounded on four interrelated experiences: (1) performance
accomplishments; (2) vicarious experiences; (3) social persuasion; and (4) emotional
arousal [39]. For instance, a person with chronic fatigue syndrome enhances self-efficacy by
exchanging experiences regarding living with a ‘hidden disability’ when joining a support
group. Sharing accomplishments with people who have similar problems can result in a
vicarious support experience, evoking positive emotional arousal. SCT contributes to
rehabilitation in the area of empowerment, self-management and self-regulation of one’s
health condition or disability, in better understanding the interrelationship among personal
functional abilities, social and physical environments. The literature shows diverse
applications of SCT in fields such as rehabilitation education, psychiatric rehabilitation,
rehabilitation nursing, and therapeutic recreation [38,41 – 44]. Researchers have found,
specifically, that individuals with strong self-efficacy likely perceive their disabilities as less
severe and report them less often, versus individuals with low self-efficacy, who are likely to
report more severe levels of disability [45]. Empirical research in the area of health
promotion for individuals with multiple sclerosis also provides evidence of the impact of
self-efficacy on self-reported wellness and quality of life [10]. Three things regarding
self-efficacy should be noted. First, the impact of self-efficacy on selfmanagement of chronic
conditions and sustaining functional ability should be considered as a critical outcome [6,11].
Enhanced self-efficacy, however, is not necessarily equivalent to functional gain. Second,
self-efficacy relates to a specific behavior and not to a personality trait. Third, a person may
have strong self-efficacy in one behavior, such as engaging in physical exercise, but not
necessarily in another behavior, such as maintaining a healthy diet. In other words,
self-efficacy as used in HBC theory is not a global ‘feel good about oneself’ construct, as
often seen in the popular media. See Table I for examples of specific SCT-related questions
applicable for rehabilitation providers. Transtheoretical Model of Behavior Change (TMBC)
The TMBC was proposed by Prochaska in the late 1970s. After examination of more than
300 theories related to behavior change and psychotherapy, Prochaska identified common
processes of change and combined these in a new theoretical model. The focus of the
model is on readiness to change toward healthy behaviors. The TMBC is grounded on the
theory that we go through stages of change before we are ready to engage in a
health-related action. In fact, HBC is a progression of different stages of behavior change
that unfolds over time and takes place in a sequential spiral, with possible relapse to a
previous stage [46 – 48]. The five main conceptual stages of change in the TMBC are: (1)
precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. A man
with depression and obesity may be ‘not ready’ yet for any action when his physician
suggests an exercise program. He may be neither motivated, informed, nor inspired, having
undergone previous unsuccessful attempts to engage in regular exercise
(precontemplation). After discussion and reflection (contemplation), he identifies a bicycling
club he wants to join (preparation). When he feels he is ready for the time commitment to
join the group, he implements his plan (action). Three years later, having lost weight and
reduced his medications, he enjoys the camaraderie of the club and wants to continue his
more active lifestyle (maintenance). The TMBC has been tested empirically across many
populations, and many different types of preventive behaviors, including smoking, weight
control, exercise, safe sex, sunscreen use, drinking alcohol, and AIDS. Studies have taken
place in various settings such as home, church, and schools [48 – 50]. The literature reveals
a wide range of TMBC contributions to rehabilitation, including the understanding of client
readiness for change to manage chronic conditions (e.g., chronic pain), for return to work,
and to promote health and well-being [12,17,18,21,49,51,52]. The TMBC model helps
identify and understand readiness for change in rehabilitation, so the provider can tailor
education, training, and intervention to the appropriate stage [37]. At the (pre)contemplation
stage, for instance, the computer worker with symptoms of repetitive strain injury receives
information to enhance general awareness of risk factors that may lead to the understanding
of the benefits of changing the work station environment and the use of safe postures.
During the planning stage the client can be guided in self-efficacy, to gain self-confidence
and the belief that he or she can make a difference in his or her own health. When targeting
the action level of change, messages can be outlined step by step and goal-oriented in
terms of using adjustable equipment, taking short postures breaks, alternating activities, and
mini-stretching. Again, see Table I for TMBC strategies and questions relevant for
rehabilitation. Comparing and contrasting HBC theories and models Comparative research
in theories of behavior change is crucial for the advancement of the existing knowledge base
and can lead to new challenges, new interventions and better ways to facilitate the HBC
process [5]. In particular in the field of rehabilitation, a comparative analysis of HBC theories
can facilitate the systematic analysis of HBC variables instrumental for individual, community
and social change in terms of health, functioning, and disability experience. Several
observations can be made when comparing and contrasting these three theoretical models
(Table I). First, each theory has a different focus within the HBC process: the person’s belief
system (HBM), the person’s interrelated experiences (SCT), and the person’s readiness for
change (TMB). While these theories in HBC have contributed to the field, some scholars
have expressed caution in terms of measurement constructs, questionable predictability of
certain aspects of the theory or lack of convincing evidence [16,53]. With these caveats in
mind, these theories combined do enhance a deepened understanding of a complex
process. A second observation regards the similarities of these three theories in terms of the
process of change that takes place at the interand intra-personal level, within the contextual
environment. The theories have two important issues in common: the influence of the
environment on HBC and the role of selfefficacy. For instance, perceived barriers to seeking
health services (HBM), the reciprocal influence between the social environment and the
individual (SCT), and the impact of positive reinforcement on readiness for change (TMBC).
A third important observation is that the variable ‘Knowledge’ is not the basis of any of these
three theories. Enhancing knowledge, teaching the medical aspects of a condition, or
educating people about the risks of developing secondary conditions, in themselves do not
lead to HBC. The overarching empirical question remains: what factors most strongly
influence HBC? Several scholars have investigated this question, targeting different
populations, such as women who received instructions about breast cancer detection,
people with multiple sclerosis in a wellness program, and office workers at risk of developing
repetitive strain injury. The findings of these studies suggest that factors including intention
to engage in healthy behaviors and self-efficacy are statistically significantly related to the
HBC itself [6,10,19,54]. Before one engages in the health action, one needs to have the
intention to perform the activity. Self-efficacy, not just ‘know how’, proves to be the essential
factor leading to the monitoring and regulation of one’s health actions within the contextual
environment. From this review of the literature, we are persuaded that HBC theories can and
should be integral to rehabilitation practice. At the moment it appears that a combination of
theories, including others not discussed here, rather than one theory, is most useful for the
needs of researchers and practitioners [7,33,37]. In addition, researchers agree that the
impact of these theories is most successful when HBC intervention strategies take place
within the ecological approach. Social and policy environments are critical in gaining success
in HBC, and this can be a problem for rehabilitation, since most health insurance providers
reimburse individualized services rather than policy-level interventions Limitations in the
literature Two shortcomings have been found in our review of the literature on HBC and its
relevance to rehabilitation. The first concerns the lack of disability issues and concerns in
general health promotion education literature. Researchers testing the HBC models in
primary and secondary health prevention, in general, have not recognized the importance of
health and wellness interventions for people with physical or cognitive disabilities. While
individuals of different socio-economic background, age, or specific conditions (AIDS,
diabetes, asthma) receive growing attention, people with physical and cognitive disabilities
are seldom mentioned [3,7,16]. Hence, disability-related matters such as accessible and
affordable interventions need to be addressed from a public health perspective to eliminate
health care disparities. This oversight is intensified since people with disabilities have a
‘thinner margin of health’ that must be addressed at all levels of health care [25]. Most
importantly, people with disabilities want and need to be informed about health and wellness,
as well as risks for secondary conditions [55]. Furthermore, the role of the rehabilitation
professional as a central care provider has not been recognized enough in primary health
care literature [16,56]. A second, crucial gap in the literature concerns the lack of
identification of key HBC variables that may explain change in functioning and in social
participation. The International Classification of Functioning, Disability, and Health (ICF) has
given us a useful, uniform roadmap of functional-related items. In our opinion, however,
using the ICF to organize and classify HBC factors being tested would help unify our
understanding of how changes in body function, activity, and participation take place. This
knowledge is essential to move evidence-based rehabilitation research forward. Three
propositions regarding HBC and rehabilitation Based on review of HBC theories and models,
the following three propositions may be useful in developing future efforts to incorporate
HBC theory into rehabilitation research and practice. Proposition 1. We suggest that use of
HBC variables as additional outcome measures should become a regular practice in
evidence-based rehabilitation research. Most current evidence-based research focuses on
changes in functional status [57 – 59]. With the inclusion of HBC variables, we can better
understand the process by which the changes in functional status take place. Health
behavior factors that induce functional outcomes, such as intention, self-efficacy, and
readiness for change, need to be identified so rehabilitation providers can more
appropriately design interventions to maximize a person’s functional capacity in the
environmental context. As one example, empirical research should be conducted to provide
insight into the distinction between a person’s execution of a task or action in a ‘standardized
environment’ (capacity) versus the actual level of execution of a task or action in his or her
own environment (performance) [8]. To assist in doing this, operational examples regarding
performance and capacity, including qualifiers to convey the extent of functioning
experienced by the person, are presented in the forthcoming Procedural Manual and Guide
for a Standardized Application of the ICF: A Manual for Health Professionals [60]. The HBC
focus can have major implications for the individual, in particular when HBC principles also
are applied to remove environmental barriers. Thus, the issue here is not only identifying
how the environment facilitates or impedes a person’s performance and capacity, it also is a
matter of understanding how the process of HBC takes place within the contextual
environment. Identifying barriers to accessing a fitness center, such as lack of transportation
or lack of a social support group may be critical elements in the self-management of regular
physical activities (e.g., intention and action). Having a friend join in an exercise regimen and
sharing the functional benefits of exercising may be more effective than promoting the idea
of exercising. Hence, HBC may well be indispensable for investigations of long-term
performance and functional outcomes. Proposition 2. The incorporation of HBC theories into
rehabilitation practice implies a shift in the role of the rehabilitation provider. More knowledge
is needed about the influence and role of the provider. We suggest that more research
should investigate the role of rehabilitation providers in terms of HBC interventions. This
information will provide insight into the most successful HBC approaches linked to
rehabilitation outcomes [6,7]. According to the traditional medical intervention model, the
medical professional is the expert from whom the patient gains knowledge about the
condition and learns what to do and what not to do. Compliance is considered a personal
choice, and most problems are identified by the medical (rehabilitation) professional. It has
been thought that the more knowledge the client has, the stronger the likelihood this will lead
to the client’s health behavior change. In recent years this assumption has been called into
question (see Table II). According to the HBC intervention approach, in contrast, the health
care provider is a facilitator, enabler and partner, asking key questions, providing cues for
action, and guiding the client in changing adopting, and maintaining healthy and
functionalbased behaviors. Information sharing is tailored to the individual’s readiness for
change, with an understanding of the contextual environment. This shift in perspective
means that health care providers who have been educated according to the traditional
medical intervention approach (see Table II) may have to adopt certain behavior changes of
their own. We suggest there is an analogous application of behavior change theories one
step removed from the level of the consumer, where we normally think of applying these
theories. Health care providers may need to go trough their own stages of ‘readiness for
change’: contemplation, planning and action in terms of adopting new ways of providing
information and promoting health and wellness. The approach used by the doctor, therapist,
and social worker can have major implications for the patient’s adherence to treatment
recommendations. The provider and the client need to identify barriers and develop a
strategy for overcoming these barriers. Thus, as was earlier identified in the fifth theme that
emerged from the literature review, the overall concept is that the role of the rehabilitation
provider is instrumental in facilitating functional change to promote primary, secondary and
tertiary health behaviors. Proposition 3. There is a need to broaden the concept of HBC in
order to develop a more comprehensive HBC model. In our opinion it is imperative that
various levels of functioning within the contextual environment be included in the concept of
HBC. We suggest studies in HBC would be more useful and relevant if they were based on a
comprehensive standardized framework. For that reason, the inclusion of ICF terms and
codes is essential for uniform communication and consistent data collection [8]. The ICF,
however, is more than codes. It provides a systematized, diverse inventory that offers
uniformity without oversimplification of the individual’s situation. To demonstrate this
approach, consider the impact of incorporating ICF functional terminology in a study of
increasing exercise to reduce risk of cardiovascular disease. HBCs that initiate and maintain
regular physical exercise, one of the leading health indicators, may lead to enhanced
functioning beyond the most commonly reported functional gains in the cardiovascular
system (ICF codes b410 – b429). This narrow approach of assessing only gains in
cardiovascular function is as far as most studies look. However, familiarity with the ICF can
remind the researcher that regular physical exercise also will impact the respiratory system
(ICF codes b440 – b449), exercise tolerance functions (ICF code b455), and selected mental
functions (ICF codes b110 – 139). Furthermore, increased physical activity could lead to
enhanced functional activities such as handling stress and other psychological demands
(ICF code d240), walking and moving (ICF codes d450 – d469) and, for some people,
enhanced self-care (ICF codes d510 – d599) and domestic life activities (ICF codes d610 –
d629). In addition, regular physical activity may result in enhanced participation in
community and civic life (ICF codes d910 – d999). Furthermore, use of ICF classifications for
environmental factors could lead to a better understanding of the impact of the environment
on HBC as a facilitator (e.g., accessible and affordable health services, ICF code e5800) or
as a barrier (e.g., lack of accessible transportation services, ICF code e540). Besides
acknowledging the dynamic personal, physiological and environmental factors, the link
between HBC theories and models and the ICF can bring into clearer view behavioral
change in its breadth, explaining functional status throughout human life span. While the ICF
provides snapshots of a person’s functional abilities within the environmental context at
different points in time, HBC theories are essential in understanding how change takes
place. Social change, community change and individual change are components of the
complex challenges rehabilitation providers face. This broadened concept of HBC is relevant
for the growing number of people with disabilities and chronic health conditions, and older
people who will face a decline in functional abilities. If the social and policy environment
recognizes disability-related concerns in terms of functioning and eliminating barriers, health
promotion and wellness can become more inclusive. For example, fitness centers should
offer equipment for people with mobility issues; parks should be accessible for users of
wheelchairs, scooters, and walkers; health promotion videotapes should be available with
captions for people who have hearing loss; and audible street crossing signals should be
available for people who have low vision or are blind. Merging HBC variables with the ICF
can ultimately result in the refinement of the classification by incorporating specific personal
health indicatorrelated codes, for instance a code for self-efficacy. A discussion about the
need to address personal factors in the ICF has been initiated by the Japan ICF
Collaborating Center, which proposes a classification of subjective dimensions of functioning
and disability [61]. In our opinion, HBC variables can fill some of the ‘missing elements’
identified by the Japan ICF Center. More specific terms such as ‘regular physical activity’
deserve an ICF code, instead of the current global term ‘recreation and physical fitness’ (ICF
code d920). With these propositions in mind, ethical issues faced by rehabilitation providers
should also come under review. While providers have the obligation to enhance ‘the best
balance of good over harm for their patients’, providers also have the obligation to respect
the client’s values and choice of lifestyle [62]. The essential ethical issue is to inform the
patient adequately about risk factors and regimens, while still respecting the patient’s
choices, decisions, and personal circumstances, even those that may impede healthy
behavior. In HBC outcomes research, the ethical concern may be found in the interpretation
of findings that stigmatize, discriminate against, or burden the client. The client’s readiness
for change, in particular, has to be interpreted cautiously and with regard to circumstances.
In other words, intervention without judgment or evaluation can be the most persuasive way
to help clients to make informed and reflective choices [62]. Summary and conclusions
Health behavior change is a critical component in health and well-being for all people and in
particular for individuals with disabilities. Scholars who compared and contrasted HBC
models agree that current models have contributed to better understanding of why and how
people change their health behaviors. This review of the literature revealed five different
HBC themes focused on primary, secondary, and tertiary prevention, the issue of adherence,
and the role of the health care provider. Three HBC theories are reviewed and their
relevance and contributions to rehabilitation discussed. The Health Belief Model contributes
to the understanding of a person’s belief system and the identification of barriers and cues
for action; Social Cognitive Theory provides insight into self-efficacy and the underpinning
experiences that lead to enhanced self-efficacy; and the Transtheoretical Model of Behavior
Change contributes to the understanding of a person’s readiness for change. Supported by
an in-depth review of the literature, several propositions regarding HBC are presented in the
hope they will promote further discussion and action. More research linking the ICF and HBC
theories and models is needed to fully understand functional change, health and wellness of
people with disabilities. In conclusion, there is an important opportunity and challenge to
develop a comprehensive, uniform model to address the impact of HBC on health and
functioning embedded in the environment. Enhanced knowledge of HBC and disability
experience can contribute to a better understanding of the promotion of health, well-being,
functioning, and self-management of a disability or other adjustments in health and illness.
This broadened view can have major implications for the treatment and quality of life of all
rehabilitation consumers, and it is essential to the empowerment of people with disabilities.
Acknowledgments Preparation of this manuscript was supported in part by the National
Institute on Disability and Rehabilitation Research (NIDRR), Grants H133P990014 and
H133P030004. The authors express their gratitude for the constructive input and supportive
feed-back they received from Denise Tate, Jaqueline Eckert, Claire Kalpakjian (University of
Michigan), Michele Heisler (Ann Arbor Veterans Hospital), and Don Lollar (National Center
on Birth Defects and Developmental Disabilities, Centers for Disease Control). We also want
to thank Barbara Hammond for her considerable contributions in typing many revisions of
this manuscript. The original version of this manuscript was written in 2001 by the first author
as a ‘Knowledge Area Module’, toward the fulfillment of doctoral requirements at Walden
University.