Health beliefs and health behaviors of physical therapists.

Health Beliefs and Health Behaviors of Physical Therapists The attitudes of health educators toward health and health care are important to the delivery of a high quality of medical care. In the area of health promotion and disease prevention, physical therapists' primary goal is a change in patients' behaviors. [1] The acquisition and dissemination of knowledge is important. The ability to disseminate knowledge and influence patients' attitude and behavior change depends on both the physical therapist's beliefs and behaviors. As pointed out by Sobush and Fehring, if patients are to achieve optimal levels of function, physical therapists should examine the suitability of their attitudes, appearances, and behaviors in eliciting desirable outcomes. Physical therapists must present attitudes and behaviors that demonstrate positive health habits if they are to serve as good role models for their patients. [2]

Beliefs and Behaviors of

Health Care Professionals

Holcomb et al surveyed the health promotion and disease prevention behaviors of certified nurse midwives, certified physician assistants, registered dietitians, and registered dental hygienists. [3] They found that most of the respondents appeared to be good role models. The authors suggested, however, that many health care professionals should consider changing their behaviors toward more positive health practices. Also many of the respondents were not well informed as to the importance of specific behaviors that they might exemplify for their patients. [3]

A study by Rothman and Badyrka illustrates the potential for positive change in health behaviors. The change in behaviors of physical therapy students from early in their program to the completion of their curriculum was investigated using health and wellness scales. Based on responses to the assessment scales, the students' health behaviors were positively changed in the areas of stress management, physical fitness, and nutritional habits. [4]

Development of

Appraisal Methods

Research has shown the utility of using the health belief model (HBM) to explain and predict various health behaviors. The relationship between health beliefs and health-promoting behaviors has been examined for a general population sample [5]; a group of randomly selected adults [6]; law students [7]; and licensed practical nurses, teachers, and college students. [8] The HBM was developed in the 1950s by a group of social psychologists at the US Public Health Service to explain why people did or did not engage in a variety of health-related actions and has become a framework for explaining and predicting acceptance of health and medical care recommendations. [9]

Health Behaviors

The study of health behaviors has been advanced in recent years by the development of health risk appraisal (HRA) methodology. Health risk appraisal has been widely used in health promotion and disease prevention programs to develop life-style change programs for individuals and groups. Health risk appraisal is a method for obtaining data about an individual's health behaviors and health status. [1] It can also be used to obtain an estimate of the probability of dying from potentially preventable causes within a specific period of time and to determine the amount of risk that can be eliminated by making appropriate behavioral changes. [1] The HRA questionnaire developed by the US Public Health Service's Centers for Disease Control (CDC) [10] is typically used to assess health behaviors. The CDC's HRA questionnaire obtains data on health behaviors, personal and family history of disease, physical measurements such as height and weight, and use of screening methods such as the Pap smear.

Numerous studies, which have been summarized by Wagner and associates, [11] have been directed at the development of methodology for HRA and its effectiveness as an adjunct to education. More recently, Katz et al reported on the use of HRA in medical education and as an adjunct to introducing wellness behaviors among medical students. [12]

Health Beliefs

A commonly used instrument for the study of health beliefs is the health belief questionnaire developed by Jette et al. [13] This questionnaire measures the perception of eight health belief dimensions: general health threat, perceived severity of specific illnesses, barriers to taking medication, concern about health, trust in physicians, perceived health status, perceived susceptibility to specific illnesses, and locus of control.

The purpose of this study was to use the HRA instrument and the HBM questionnaire to investigate the health beliefs and behaviors of physical therapists and to determine the relationship between their health beliefs and behaviors.

Method

Subjects

We selected a 10% random sample (N = 340) from the 1984 licensure list of currently employed physical therapists in Texas.

Instrumentation 

The questionnaire developed by Jette et al [13] was used with the addition of 5 items to the original 31 items. The revised questionnaire was pilot tested on a group of allied health professions students. The results of the initial factor analysis yielded results generally identical to those of Jette et al. [13] One added item pertained to the ability of individuals to contribute to their own health status. Two items pertaining to cancer--one for general health threat and one for perceived severity of illness--were added. Also added were two items pertaining to health locus of control. To increase comparability of items, a five-choice Likert-type scale was used for all items rather than the variable scales used by Jette et al. [13]

A factor analysis was performed on the structure of health belief indexes to more easily interpret the findings with respect to previous work conducted by Jette et al. [13] The factor analysis produced the same factor structure as that of Jette et al [13] with a nearly identical distribution of questions among the factors. Only one item from the set of questions included in the factor structure identified by Jette et al [13] differed from ours with regard to its location in the structure. The item "In general, my health is excellent" was factored with perceived health status in our study, whereas it was factored with both perceived health status and general health threat in the study by Jette et al. [13] Two questions that remained as single items in the factor analysis in the study by Jette et al [13] (ie, "interference of illness with usual activities" and "prevention is more trouble than it is worth") were single items in our study. The factor analysis produced 10 factors rather than the 8 in the original work by Jette et al. [13] A description of the 10 factors and an example item from each factor are as follows:

1. General health threat: A high score indicates that the individual thinks that he or she generally is not vulnerable to becoming sick. This factor comprised six items. The highest possible score is 30. An example of the items in this category was, "Compared to other people my age, I get sick more easily."

2. Perceived severity: A high score indicates the individual's belief that effects of a specific illness would be very severe. This factor consists of six items, with 30 representing the highest possible score. A sample item in this category was, "It would be very serious if I got the flu in the next 12 months."

3. Barriers: A high score indicates that if compliance with a prescribed regimen would be an inconvenience, the individual would not comply. This factor consists of four items, with 20 representing the highest possible score. One item was, "Suppose my doctor were to tell me to take a certain medicine to protect my health. It is very likely that I would stop taking the medicine if I felt worse when I took the medicine."

4. Concerns about health: A high score represents the individual's high degree of concern for his or her health. This factor contains four items, with a score of 20 as the highest possible score. One item was, "I am very concerned about my health."

5. Trust in physicians: A high score indicates the individual's considerable faith in his or her physician. This factor consists of three items, with 15 as the highest possible score. A sample item was, "If I follow a doctor's advice, I will have less illness in my lifetime."

6. Perceived susceptibility: A high score indicates the individual thinks that if protective measures are not taken, he or she is likely to become ill. This factor contains three items, with 15 as the highest possible score. One item in this category was, "If I were to do nothng in particular to protect myself, it is very likely that I will be sick enough to spend three days in bed during the next 12 months."

7. Health status: A high score indicates that the individual perceives himself or herself as healthy. There are four items in this factor, with 20 as the highest possible score. One item in this category was, "In general, my health is excellent."

8. Health locus of control: A high score indicates the individual's belief that he or she has control over his or her health. This factor contains four items, with 20 as the highest possible score. One item from this category was, "If I take care of myself, I can avoid getting sick."

9. Worth of prevention: One of the two items that did not fit the factor structure in either the study by Jette et al [13] or our study was, "Sometimes it seems that when I try to prevent illness, it is more trouble than it is worth." This item was hypothesized by Jette et al [13] as pertaining to a general rather than a situation-specific barrier, and it did not factor with items pertaining specifically to following a prescribed regimen of medication. In our study, a high score on this item meant that efforts to prevent illness are considered to be worthwhile.

10. Interference with activity: The second item that did not fit the factor structure was, "In general, when I get sick, it interferes a great deal with my usual activities." In our study, this was considered a single item in which a high score meant that illness did not interfere with usual activity.

The health behavior assessment tool used was the HRA questionnaire developed by the CDC's Center for Health Promotion and Education. The Appendix contains the health behavior items that were analyzed in our study with the associated levels of risk. Participants responded to each item by selecting the level of risk that most closely matched their current behavior.

Procedure

The survey for the project consisted of two major components: the 31-item health belief index developed by Jette et al [13] and the HRA questionnaire developed by the CDC. [10] Selected demographic information was obtained as well to aid in the description of the respondents. A typical mail survey procedure was used in the study in which the initial mailing was followed by a reminder postcard and a second mailing. Mailings were conducted at approximately three-week intervals. Confidentiality of individual responses was maintained through the use of code numbers and the deletion of any personally identifying data. Only aggregate data were reported. The study was approved by the Institutional Review Board of the Southwestern Allied Health Sciences School of The University of Texas Southwestern Medical Center at Dallas.

Data Analysis

Descriptive statistics were calculated for demographic variables and health behaviors of interest. We excluded those variables pertaining to only one sex and those variables for which there were large numbers of missing data. The health behavior questions are presented in the Appendix. The relationship between the health beliefs and health behaviors of physical therapists was examined using the Pearson product-moment correlation. Different sample sizes were used in different calculations to reflect the numbers of respondents who answered the specific questions; that is, not all questions were answered by all respondents.

Results

Demographic Data

Of the 340 surveys sent, 234 surveys (69%) were returned. The mean age of the respondents was 35 years, with an age range of 21 to 76 years (Tab. 1). Eighty percent of the respondents were women. Eighty-six percent of the respondents reported that they were currently employed; 11% reported that they were unemployed or a homemaker, volunteer, or student; and 3% reported that they were retired.

Health Belief Scores

Table 2 presents the means and standard deviations for the health belief factors. In interpreting the results presented in Table 2, note that each individual defined the "importance scale" in light of his or her own feelings and experiences. Table 2 indicates that the physical therapists did not perceive themselves as being vulnerable to sickness in general (general health threat). They also believed that if they did become ill, it would be a moderately serious matter for them (perceived severity) and that they would be somewhat likely to follow a prescribed regimen of medication even if following the regimen seemed costly, inconvenient, unpleasant, or possibly dangerous (barriers). As a group, the physical therapists were somewhat concerned about their health and the importance of taking care of themselves (concern about health). They expressed a moderate degree of faith in the ability of physicians to forestall or treat illness (trust in physicians) and were moderate in their belief regarding the role of protective measures in reducing susceptibility to common illnesses (perceived susceptibility). The respondents perceived themselves as having good health (health status) and as having some degree of control over their health (health locus of control). They also indicated that efforts to prevent illness interfered only slightly with their usual activity (interference with activity) and were worthwhile (worth of prevention).

Health Behaviors

The Appendix presents the questions for each of the health behaviors examined in the study. Each alternative represents a different level or degree of associated risk. Table 3 presents the frequency of distribution among the three levels of each behavior. Physical therapists who participated in the study tended to be nonsmokers, with the majority (65.2%) never having smoked. The distribution of the respondents' behavior with regard to alcohol was more balanced than that of the other behaviors examined. A total of 56.8% reported that they were either ex-drinkers or nondrinkers, and 43.2% reported that they were drinkers. The majority of the physical therapists surveyed reported that they rarely or never relied on drugs to affect mood or relax. The majority of respondents reported either occasional physical activity (32.5%) or regular physical activity (ie, at least three times a week) (64.5%).

Relationship Between Beliefs

and Behaviors

The correlation matrices of health beliefs and health behaviors are presented in Tables 4 and 5. Table 4 shows a significant correlation between barriers and alcohol use (p [is less than] .05). Those who believed that they would follow a presribed regimen of medication tended to be ex-drinkers or nondrinkers. A significant positive correlation (p [is less than] .01) also existed between concern for health and the physical activity level questions on the HRA questionnaire. Therapists who expressed concern about their health tended to participate in regular physical activity.

The health belief part of the HRA questionnaire contained four questions pertaining to health status, and the health behavior part of the questionnaire contained one question pertaining to health status. Table 5 shows a significant negative correlation (p [is less than] .001) between the health status factor and the health status question on the HRA questionnaire. This correlation would be expected because the content of the questions is similar while the response scales are reversed. A significant negative correlation (p [is less than] .05) existed between the health status factor an the HRA question on life satisfaction. The more healthy the respondents perceived themselves to be, the less satisfied they were with their life. As previously noted, however, a significant positive correlation (p [is less than] .01) existed between health status and physical activity (Tab. 4). The more healthy the respondents perceived themselves to be, the higher their level of physical activity. a significant positive correlation (p [is less than] .01) also existed between health status and the general health threat indication that those who saw themselves as being vulnerable to becoming ill tended to perceive themselves as healthier (Tab. 5). A significant positive correlation (p [is less than] .05) also existed between concern for health and the health status variable (Tab. 5). Therapists who expressed concern about their health and the importance of taking care of themselves also tended to consider themselves to be in good physical health.

Table 5 shows a significant positive correlation (p [is less than] .05) between locus of control and life satisfaction. The stronger the respondents' belief in their control over health, the more satisfied they are with life.

We found a significant negative correlation (p [is less than] .01) between the perceived worth of prevention and the HRA question on health status (Tab. 5) and a significant positive correlation (p [is less than] .05) between worth of prevention and use of drugs or medication and physical activity (Tab. 4). Therapists who believed that steps to prevent illness were worth the efforth tended to describe their overall physical health as being fair or poor and tended to be either partially satisfied or disappointed with their life. Those who believed that prevention was worth the effort also tended to report that they rarely used drugs an that they engaged in regular physical activity.

Discussion

Measures of health beliefs and health behaviors offer a vantage point from which to learn more about how health practices of physical therapists affect the therapist-patient interation and may influence life-style changes by patients. This study was a first step toward understanding the potential impact of the physical therapist's health beliefs and behaviors on the process of encouraging patients to adopt a prevention-oriented life style. Thus, expanding on the implications for practice from the study by Sobush and Fehring, [2] we believe that therapists should present positive health behaviors if they are to serve as good role models for their patients. Additionally, the results of this study supported the finding of Holcomb et al [3] that personal health habits influence the effectiveness of patient counseling concerning health-promoting behaviors.

Measures

The similarity of the factor struture from the original work by Jette et al [13] and the factors identified in our research suggests that the health belief index is indeed applicable to the study of the beliefs of physical therapists. The use of a five-choice Likert-type response scale to simplify the questionnaire did not appear to negatively affect the ability to obtain a factor structure consistent with the original work of Jette et al. [13] The CDC's HRA instrument was used to provide comparisons with the factors on the health belief scale.

Health Belief Scores

The scores of the physical therapists on the 10 health belief factors suggest that their belief structure was oriented more strongly toward general health matters and illness prevention than toward illness or sick role-related beliefs. Six of the 10 health belief factors (general health threat, concern about health, perceived susceptibility, health status, health locus of control, and worth of prevention) pertain to individual's perceptions of their health, its value, and their ability to prevent illness. The remaining four factors (perceived severity, barriers, trust in physicians, and interference with activity) reflect beliefs related to how individuals would react to or cope with illness. Thus, a stronger health and illness-prevention orientation held by therapist was indicated by the finding that the size of the mean score in relation to total possible score tended to be greater for the general health and illness-prevention factors than for illness and sick-role factors.

Health Behaviors

The physical therapists who participated in the study, on the average, have good health habits. To understand the results on the various health behaviors, we can look at them in view of other available research. These data were taken from surveys published elsewhere that differed somewhat in the wording of questions and the age range of the respondents. Although direct comparisons are not available, the results of the 1985 Health Promotion and Disease Prevention Survey of the National Health Interview Survey [14] indicated that 38.7% of the men and 59.7% of the women (18 years of age or older) surveyed reported that they did not drink during the two weeks prior to completing the survey. Of the physical therapists in this study, 54.6% reported that they did not drink and 2.2% reported that they were ex-drinkers, for a total of 56.8%. National statistics on smoking indicated that 32.6% of the men and 27.8% of the women (18 years of age or older) are current smokers, [14] as compared with 15.0% of the physical therapists in this study.

The national statistics on activity level are divided into three levels, as are the HRA questionnaire responses. Forty-nine percent of the men and 61.8% of the women (18 years of age or older) reported that their activity level was sedentary, [13] or level 1, as compared with 3.0% of the physical therapists in this study. Nationally, 16.5% of the men and 16.3% of the women reported their activity level as moderately active, [13] or level 2, as compared with 32.5% of physical therapists in this study. Finally, 34.1% of the men and 21.9% of the women nationally reported that they were very active, [13] or level 3, as compared with 64.5% of physical therapists in this study.

Statistics on drug use are available from 1982. [15 For those 18 to 25 years of age, use of marijuana on five or more days per month was 15.7% and 2.3% for other drugs. [15] These data can be compared with 2.6% of the physical therapists in this study who reported they use drugs that affect mood or help them to relax nearly every day and 3.0% who reported occasional use.

The health habits of the physical therapists in this study paralleled those previously reported for medical students [7,12] and for practicing physicians [7] in terms of being more health oriented than the general population. In addition, a greater proportion of physical therapists reported being nondrinkers than was reported for medical students. [7,12]

Relationship Between Health

Beliefs and Health Behaviors

A somewhat surprising finding was that only two of the health behaviors examined in this study had a statistically significant relationship to health beliefs. Tobacco use and alcohol use were not related to health beliefs in this study. Previous research summarized by Janz and Becker [9] did find statistically significant relationships between smoking (or a preventive behavior index that included smoking) and beliefs that pertained to severity of and susceptibility to disease.

The remaining two health behaviors that were included in this study (use of drugs or medications to affect mood or relax and physical activity) did show significant positive correlations with one or more health beliefs. The patters of relationships indicated, as was the case with health belief scores, that beliefs pertaining to general health matters and illness prevention play a salient role for physical therapists. The use of drugs or medications and physical activity were significantly correlated with the six health beliefs that reflected either self-perceptions of health and its importance or preventive considerations such as belief in control over health and worth of preventive actions.

The relatively central role of health beliefs for physical therapists is perhaps explained in part by the type of individual who selects physical therapy as a profession in addition to the nature of their educational preparation, the environment in which they work, and the recent national attention given to health promotion and disease prevention. The curricula of programs that prepare physical therapists for professional practice traditionally have not only included educational methodology and behavior-change techniques but also have emphasized defining health and its importance to health care delivery. [4] Although the focus of the curriculum is on concepts of illness and sick-role behavior, these concepts are frequently considered undesirable end points of inadequate life style or the result of unfortunate traumatic events. In the hospital environment, the physical therapist is repeatedly exposed to the untoward outcomes of poor health practices. The importance of illness prevention and the value of health are emphasized daily through patient care. Finally, there has been a shift in recent years among health care providers and institutions toward a greater appreciation of and greater efforts in promoting health and preventing disease. [1] The increased attention to prevention has provided a climate in which the illness-prevention orientation of physical therapists is acknowledged and appreciated. [4]

Recommendations for

Further Study

Additional research is needed to determine whether similarities and differences between physical therapists and patients indeed influence efforts to affect change in patients' life styles. Research areas include the physical therapist as a role model for patients and the change in health beliefs and behaviors of physical therapy students over time. Additionally, physical therapy curricula might be studied to determine the emphasis on health promotion and disease prevention. The methodology used in this study together with the findings are offered as a first step in such research.

Conclusion

The findings of this study indicated that the physical therapists who responded to the survey, on the average, have exemplary health habits and that beliefs pertaining to general health matters were quite salient. Both characteristics are often regarded as appropriate for persons who would serve as role models for encouraging a healthy life style among others.

Acknowledgment 

We thank Alan M Jette, PhD, PT, Massachusetts General Hospital Institute of Health Professions, for permission to use the health belief questionnaire items.

References

[1] Glazer-Waldman HR, Hart JP, Ellis A: What health care educators should know about the relationship between health beliefs and health behaviors. Journal of Healthcare Education Training 1(1):11-13, 1986

[2] Sobush DC, Fehring RJ: Physical fitness of physical therapy students. Phys Ther 63:1266-1273, 1983

[3' Holcomb JD, Mullen PD, Fasser CE, et al: Health behaviors and beliefs of four allied health professions regarding health promotion and disease prevention. J Allied Health 14:373-385, 1985

[4] Rothman J, Badyrka RD: Integration of concepts of health promotion in a physical therapy curriculum. Abstract. Arch Phys Med Rehabil 66:566, 1985

[5] Langlie JK: Social networks, health beliefs and preventive health behavior. J Health Soc Behav 18:244-260, 1977

[6] Harris DM, Guten S: Health protective behavior: An exploratory study. J Health Social Behav 20:17-29, 1979

[7] Coe RM, Miller DK, Woeff M, et al: Attitudes and health promoting behavior of medical and law students. Am J Public Health 72:725-727, 1982

[8] Turk DC, Rudy TE, Salovey P: Health protection: Attitudes and behaviors of LPNs, teachers and college students. Health Psychol 3:189-210, 1984

[9] Janz NK, Becker MH: The health belief model: A decade later. Health Educ Q 11(1):1-47, 1984

[10] Proceedings of the Centers for Disease Control Health Risk Appraisal Users Conference. Atlanta, GA, March 15-17, 1983

[11] Wagner EH, Beery WL, Schoenbach VJ, et al: An assessment of health hazard/health risk appraisal. Am J Public Health 72:347-352, 1982

[12] Katz LA, Byers P, Newman L: Health appraisal in medical education: Impact on behavior change. In Miller LA (ed): Proceedings of the Twentieth Annual Meeting of the Society of Prospective Medicine. Indianapolis, IN, Society of Prospective Medicine, 1985, pp 80-81

[13] Jette AM, Cunnings KM, Brock BM, et al: The structure and reliability of health belief indices. Health Serv Res 16(1):81-98, 1981

[14] Schoenborn CA: Health habits of U.S. adults 1985: The "Alameda 7" revisited. Public Health Rep 101:571-580, 1986

[15] The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, DC, US Dept of Health and Human Services, Public Health Service, 1986k

H Glazer-Waldman, EdD, is Assistant Professor, Department of Allied Health Education, Southwestern Allied Health Sciences School, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75235-9089.

J Hart, PhD, is Associate Professor and Director, Office of Rural Health Services, University of North Dakota Center for Rural Health, Grand Forks, ND 58201.

B LeVeau, PhD, is Professor and Chairman, Department of Physical Theraphy, Southwestern Allied Health Sciences School, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75235-9082 (USA).

This research was supported by an institutional research grant to the first author from the Southwestern Allied Health Sciences School, The University of Texas Southwestern Medical Center at Dallas.

This article was submitted August 11, 1987; was with the authors for revision for 24 weeks; and was accepted October 19, 1988.