Health promotion as a rehabilitation service for people with disabilities.

The aim of rehabilitation, "to restore an individual to his/her I former functional and environmental status, or alternatively, to maintain or maximize remaining function" (Williams, 1984, p. xiii), continues to be at the heart of all care provided to people with disabilities. Rehabilitation services based on this aim have experienced remarkable advances in the past decade; e.g., more effective intervention strategies, better coordination and planning of services, attention to career planning and development (Marge, 1988). However, comprehensive health promotion programs have generally not been a part of rehabilitation advances (Brandon, 1985). The exclusion of comprehensive health promotion programs for people with disabilities may largely be due to the lack of a focused definition and framework for applying the health terms "prevention" and "promotion" to rehabilitation objectives and strategies.

Drawing primarily from the work of Goodstadt, Simpson and Lorranger (1987) and Marge (1988), the following discussion shows how the health promotion philosophy may be incorporated within the rehabilitation process. Goodstadt, et al. (1987) provided an excellent discussion on health maintenance and health enhancement objectives that serve as the foundation for comprehensive health promotion programs. Marge (1988) distinguished between primary and secondary disabilities and emphasized the importance of health promotion programs for preventing increased health risks associated with secondary disabilities.

Health Promotion: A Conceptual

Framework

A popular definition for health promotion is "the science and art of helping people alter their lifestyles to move toward optimal health" (O Donnell, 1986, p. 1). Unfortunately, this popular definition may be too vague. Goodstadt, et al. (1987) argued that the purpose of defining the term health promotion was to establish both conceptual boundaries and relationships that govern not only what a concept should include but what it excludes. Moreover, the definition should clearly separate contextual uses of works from their broader, common meanings" (p. 61). For example, the term "health screening" has a specific meaning which differs from its everyday application in the health field. To present a more focused definition that meets this criteria, it is helpful to differentiate between the terms health and disease.

The Health Continuum 

Edelman and Milio (1986) suggested that health and wellness may be simplistically defined as the lack of disease and that illness and disease may be assumed to be interchangeable terms. The author added, however, that health and disease are not antonyms, and disease and illness are not synonyms. Although disease is generally viewed as a biomedical term, illness is a "state of being." In other words, illness includes social, psychological, and spiritual dimensions as well as biological dimensions.

O'Donnell (1987) viewed the nature of illness as a progressive continuum ranging from mild to serious. The left end of the Figure I continuum represents a state of extreme illness or premature death. Wellness exists somewhat independent of disease and disability and is represented on the right end of Figure 1. For example, individuals with rheumatoid arthritis may be considered healthy within the limitations imposed by their disease. Despite this independent view between illness/disability and wellness, Goodstadt, et al. (1987) argued that they are interrelated, "there is always some degree of wellness even among the ill, and that there is usually some unsatisfactory aspect of health, since optimal health is by definition an ideal never attained" (p. 60).

Brandon (1985) suggested that the traditional medical model view of health as the "absence of disease or infirmity" (p. 54) excludes people with disabilities from being viewed as healthy. However, the broader view of health provided by Goodstadt, et al, clearly establishes an interrelationship between initial disability and wellness. Based on this interrelationship, Goodstadt et al. (1987) defined health promotion as follows: "Health promotion is the maintenance and enhancement of existing levels of health, through the implementation of effective programs, services, and policies" (p. 61).

Health Maintenance

The reality of both policy and program interventions forces a conceptual separation between the wellness and illness dimensions illustrated in Figure 1. Goodstadt, et al. 1987) illustrated this conceptual separation as two complementary overlapping health maintenance networks: (a) Health Promotion and (b) Health Recovery (Figure 2).

The health promotion network is directed toward both primary and secondary prevention objectives. Health recovery includes secondary and tertiary prevention objectives. Primary prevention refers to preventing the occurrence of disease or illness. Secondary prevention concerns early detection and intervention to curb or retard illness/disease progression. Tertiary prevention is medical surveillance, maintenance, and rehabilitation designed to minimize illness/disease impact and, potentially, return the individual to the community (Edelman & Milio, 1986). A more thorough discussion of these two networks follows.

Health Promotion Network

The health promotion network in the Goodstadt, et al. (1987) conceptual model is directed toward "non-ill" populations by including policies and program services that increase or maintain health levels. Increasing or maintaining health levels utilize risk avoidance and risk reduction strategies. Risk avoidance strategies primarily focus on low-risk populations and maintain existing levels of health by inhibiting transition to higher health risks. The implementation of substance dependency programs in the public schools that attempt to prevent the onset of substance abuse in the adult years is an example of a primary health prevention strategy.

Risk reduction is directed toward populations that are already "at risk." The program objective is to foster a transition to a lower health risk or status. Goodstadt, et al. 1987) viewed risk reduction as a conceptual integration with primary prevention to create what is usually referred to as secondary prevention; i.e., early detection and intervention to curb progression of an illness condition. Smoking-cessation clinics are an example of risk reduction strategies. It is important to note that both risk avoidance and risk reduction strategies assume the presence of modifiable or controllable health risks.

Health Recovery Network

The health recovery network is directed toward people with disabilities. Goodstadt, et al. (1987) identified two principal health objectives within this network: (a) treatment to stabilize a condition, and (b) rehabilitation programs designed to attain a minimally acceptable level of health. Early identification and intervention strategies which are a part of the traditional concept of secondary prevention are used to attain the stabilization health objective. Commencing with a permanent or irreversible disability, the intent of tertiary prevention is to "minimize the effects of disease and disability by surveillance and maintenance aimed at preventing complications and deterioration" (Edelman & Milio, 1986, p. 11). Thus the tertiary prevention objectives are to return the client to a useful place in society and to maximize remaining functional capacities.

Health Enhancement Network

The Goodstadt, et al. (1987) definition for health promotion included a viable concern for the enhancement of health. The health enhancement component provides a key perspective as to how health promotion moves beyond the traditional prevention and treatment strategies of health maintenance. To accomplish this objective, Goodstadt, et al. viewed health enhancement as composed of two complementary strategies: (a) optimization and (b) integration. These two strategies are defined as follows:

* Optimization: this refers to the narrowing of the gap between actual and potential levels of wellness in one domain or more. This ideal state, which may never be realized, is defined by the individual's personal goals, potentials, and limitations in the different domains of health (p. 61).

* Integration: this refers to the establishment of a balance of equilibrium among the various domains of health, resulting in an overall or holistic level of wellness in one's life (p. 61).

The four health enhancement domains addressed by optimization and integration strategies are physical health, psychological health, social health, and spiritual health. Goodstadt, et al. (1987) argued, however, that most programs which label themselves as "wellness" programs are actually empty marketing ploys since they tend to focus only on physical (e.g., fitness) and psychological (e.g., stress management) dimensions of health enhancement. Social health and spiritual health which concern the quality of life and higher level functioning have virtually been ignored. This point is of critical importance when considering health promotion initiatives designed to meet the needs of people with disabilities.

Health Promotion Applied to Disability

Federal efforts in health promotion and disease prevention, as described in the 1990 Health Objectives for the Nation Report (Public Health Service, 1986), focus on primary prevention for the general, nondisabled population and strategies that promote and maintain health among people already healthy. These strategies are based on 15 health areas that are comprised of 226 discrete health objectives designed to prevent the four leading causes of death in America: cardio-vascular disease, cancer, accidents (trauma), and stroke. Unfortunately, specific attention to prevention strategies for people with disabilities has not received sufficient attention. Health maintenance objectives for people with disabilities have largely been ignored since many health providers fail to distinguish between primary and secondary disabilities. Health enhancement objectives, as previously discussed, are a missing component in health promotion programs for both "well" people and people with disabilities.

Health Maintenance and Disability

The health recovery network has been applied as a tertiary prevention strategy to meet the health needs of people with disabilities. However, the health promotion network has been virtually ignored. This exclusion may be due to a general belief by health providers that a client's disability is a static entity. Marge (1988) stated, "They behave as if the person acquires only one disability and it is their quota for a lifetime" (p. 30). Yet, health is a dynamic process whereby disability "should be perceived as a condition undergoing change at all times, from the moment of its acquisition" (p. 30). For this reason, it is important to differentiate between primary and secondary disabilities.

Marge (1988) emphasized that a "disability should be perceived on a continuum from slight to severe, fluctuating by degree of severity throughout life" (p. 30). A view of disabilities as static rather than dynamic entities also fails to distinguish between primary disabilities (condition first acquired) and secondary disabilities (conditions directly or indirectly resulting from a primary disability or developing independently). Marge further emphasized that the actual magnitude and severity of debilitation of the acquired disability is not a factor in the determination of primary and secondary" (p. 30) disability. For example, a person with cerebral palsy (primary disability) may learn to function effectively but may also become severely debilitated by a secondary disability; i.e., stroke leaves the person hemiplegic and aphasic. In this example, Marge noted that the secondary disability is more devastating than the primary disability. Thus it is imperative that allied health providers assess the extent to which a primary disability increases the client's risk for secondary disabilities.

Substantive epidemiological data on secondary disabilities associated with people with disabilities is not well-developed. Despite sparse empirical evidence, Marge (1988) and Brandon (1985) argued that people with disabilities are at greater risk than the people who do not have disabilities. Disabilities are continuously affected by a myriad of factors that progressively deteriorate a client's health; e.g., the aging process, traumatic injury, catastrophic illness, deleterious lifestyle behavior. Marge (1988) provided examples of the most common types of secondary disabilities in Table 1.

Rehabilitation professionals should determine whether or not the causes of secondary disabilities are preventable or nonpreventable. Almost all of the causes for the secondary disabilities identified in Table I are preventable. It is important to note that a disability is considered "preventable" if the probability of acquisition is substantially reduced. The Committee on Trauma Research adds:

The failure to anticipate and prevent a variety of metabolic, circulatory, respiratory, genitourinary, and musculoskeletal consequences of inactivity and immobility prolongs expensive care, delays active rehabilitation, and leads to failure to regain a state of health and preservation of residual functional capacity for purposeful activities (Marge, 1988, p. 31).

Thus, the goals of health maintenance for people with disabilities include health objectives under both the health promotion network and the health recovery network. Although the health recovery network is principally concerned with tertiary prevention, the health promotion network employs both risk avoidance and risk reduction strategies for secondary disabilities. Marge (1988) added that the major objectives underlying health maintenance strategies are twofold: (a) teach the patient with a disability to become personally responsible for one's health and (b) to co-manage a large part of one's own rehabilitation program.

Health Enhancement and Disability

The illness/wellness continuum (Figure 1) and the health promotion framework (Figure 2) present health as a relative concept whereby individuals have different and unique health needs. Brandon (1985) noted:

The definitions suggest that health is a dynamic, everchanging condition that should be measured in terms of how well individuals live with full use of their available skills or abilities at any point in time. Indeed, the greatest need of all individuals is to function to their fullest in their own unique environment regardless of physical, emotional, or cognitive disabilities. Rehabilitation personnel must recognize that perfect health is a utopian ideal that can never be reached since man will never be so perfectly adapted to this environment (p. 54).

Since optimal wellness is an unrealized ideal state, logic follows that rehabilitation is always possible. Goodstadt, et al. (1987), however, emphasized that the implementation of rehabilitation is usually limited to only part of the wellness/illness continuum; i.e., ceasing somewhere within the region of secondary prevention. Health enhancement strategies, optimization and integration, are the important means for reaching optimal wellness at the point rehabilitation ends on the wellness/illness continuum.

The integration of health enhancement strategies for people with disabilities under the health recovery network may be disturbing to some health providers since it potentially permits the inclusion of all providers under the rubric of health promotion. For example, Goodstadt, et al. (1987) suggested that some health providers will argue that treatment and rehabilitation frequently involve health promotion, including health enhancement that facilitates movement toward optimal health. However, others may argue that the principal purpose of rehabilitation programs is to stabilize an unwanted health condition and then to restore health to a minimally acceptable level. Attention to health enhancement is not of concern until the stabilization and restoration objectives are attained.

Despite these opposing views, Goodstadt, et al. (1987) saw no conceptual reason for excluding a commitment to health enhancement as a primary objective in the health recovery network. Actual treatment goals would entail a long-term movement toward optimal health (i.e., wellness) rather than a mere movement to a symptom-free state. Movement toward optimal health as a long-term goal obviously represents a radical departure from the tertiary prevention objectives presently emphasized in rehabilitation services today. This inclusion of health enhancement as part of the rehabilitation process implies an explicit attempt to provide people with disabilities with "links to the health promotion network thereby ensuring that their health continues to be enhanced after they have departed the treatment facility" (Goodstadt, et al., 1987, p. 62).

Implications for Rehabilitation

Rehabilitation professionals often work with clients on a one-to-one basis. However, health is a dynamic condition whereby the "greatest need of all individuals is to function to their fullest in their own unique environment regardless of physical, emotional, or cognitive disabilities" (Brandon, 1985, p. 54). Thus, a dynamic view of health applied to the concepts of health promotion as part of the rehabilitation process implies that rehabilitation professionals seldom work in isolation. In structuring health promotion services for people with disabilities, rehabilitation professionals are challenged to assume the roles of collaborator, educator, researcher and program provider.

Collaborator

Rehabilitation professionals are part of a network of services that require both facilitation and coordination responsibilities. Health behavior change requires a diversity of coordinated services to be optimally effective (Rehab Brief, 1985). Health promotion strategies must focus not only on initial behavior change but on the maintenance of change which is particularly difficult. Health service networks built on social support systems, such as the family and client peer groups, are likely to be more successful in sustaining long-term health behavior change.

Educator

The role of educator applies directly to the major goals of health promotion whereby rehabilitation professionals teach people with disabilities to become personally responsible for health and to co-manage a large part of their rehabilitation program. Brandon (1985) emphasized that the teaching of self-responsibility for one's own health behavior must extend beyond the basics of self-treatment by including self-control. For example, people with disabilities may not be completely free of pain or symptoms but they can "control their condition and prevent additional complications" (p. 55). Rehabilitation professionals under an educator's role can enhance self-responsibility and self-control by educating clients about their health condition, the relationship between lifestyle behaviors and health, the importance of complying with medical regimens, and the proper use of rehabilitation specialists and facilities.

Researcher

The role of researcher for studying the effects of health promotion programs as they apply to disabilities is an important challenge for rehabilitation professionals. There has been a rapidly spreading response for designing and delivering more and better health promotion programs for people with disabilities. Unfortunately, this burgeoning service has not been matched by an appropriate research response. Research demonstrations are needed to identify the effectiveness of health promotion programs for risk reduction in the acquisition of secondary disabilities over a specified period of time.

Program Provider

The role of program provider suggests that health promotion programs should commence early in the primary treatment phase and continue throughout life. Marge (1988) emphasized that once an individual acquired a primary disability and entered a rehabilitation program, that person should be exposed to programs that prevent secondary disabilities. Six general program units should be included: physical fitness, stress management, environmental sensitivity, self-responsibility for health, nutritional awareness, and substance dependency. For a general discussion of program design and content for people with disabilities, the reader is encouraged to consult Brandon (1985), Marge (1988) and Rehab Brief (1985).

Summary

The conceptual framework and foundation for health promotion and rehabilitation services discussed in this article was based on a dynamic view of health. Comprehensive health promotion programs for people with disabilities require a clear distinction between primary and secondary disabilities. Moreover, health promotion programs as part of rehabilitation services need to work in concert with traditional medical practices rather than being viewed as a completely separate system. Health maintenance strategies are directed toward secondary disabilities and health enhancement strategies are included as a viable component in tertiary care. Thus health promotion programs for people with disabilities can be viewed as an "integral part of the rehabilitation process, beginning early in the primary treatment phase and continuing throughout life" (Marge, 1988, p. 34).

References

Brandon, J. (1985). Health promotion and wellness in rehabilitation service s. Journal of Rehabilitation. 51, 4, 54-58.

Edelman, C., & Milio N. (1986). Health defined: Promotion and specific protection. In C. Edelman & N. Milio (Eds.), Health promotion throughout the lifespan. St. Louis: C. V. Mosby Company.

Goodstadt, M. S., Simpson, R. I., & Loranger, P. L. (1987). Health promotion: A conceptual integration. American Journal of Health Promotion. 1, 3, 58-63.

Marge, M. (1988). Health promotion for persons with disabilities: Moving beyond rehabilitation. American Journal of Health Promotion. 12, 4, 29-35.

O'Donnell, M. P. (1986). Definition of health promotion: Part 1. American Journal of Health Promotion. 1, 2,69.

Public Health Service. (1986). The 1990 health objectives for the nation: A Mid-course review. Washington, D.C.: U.S. Department of Health and Human Services.

Rehab Brief. (1985). Fitness and wellness among people with disabilities. December, VIII, 12. National Institute of Handicapped Research, Office of Special Education and Rehabilitation Services. Washington, D.C.: Department of Education.

Williams, T. F. (Ed.). (1984). Rehabilitation in the aging. NY: Raven Press.

  Figure 1
                       Health Continuum
Illness                                              Wellness
                       Neutral Point
              No Discernible Illness or Wellness
             disability       signs        attitudes
         symptoms           knowledge      health behavior
premature                                              optimal
death                                                   health
                             ..... health promotion
     traditional     medicine ........
From Michael P. O'Donnell,  Definition of Health Promotion,"
American Journal of Health Promotion, Vol. 1, No. 1 (used by
permission of American Journal of Health Promotion).
  Figure 2
                     Health Maintenance
Health Promotion Network             Health Recovery Network
Risk          Risk
Avoidance     Reduction
Primary                    Second                     Tertiary
Prevention                 Prevention               Prevention
Health maintenance: Health promotion and health recovery networks.
Based on the work of M.S. Goodstadt, R.I. Simpson, and
P.O. Laranger,  Health Promotion: A Conceptual Integration,"
American Journal of Health Promotion,  Winter, 1987, p. 60.
  Table 1
               Types of Secondary Disabilities
1. Decubitus ulcers
2. Genitourinary tract disorders
3. Cardiovascular disorders
4. Stroke
5. Musculoskeletal problems
6. Arthritis
7. Closed and open head injuries
8. Spinal cord injuries
9. Respiratory problems
10.Speech and language problems
11.Hearing loss
12.Vision problems
13.Emotional disorders
14.Skin disorders
From M. Marge. " Health Promotion for Persons with Disabilities:
Moving Beyond Rehabilitation." American Journal of Health
Promotion, 2, 4, Spring 1988, p. 30. Used by permission.