People with chronic illness and disability (CID) are constrained in their lifestyle choices due to the functional limitations associated with their health conditions (Leventhal, Rabin, Leventhal, & Burns, Reference Leventhal, Rabin, Leventhal and Burns2001; U.S. Department of Health and Human Services, 2011). As a result, they are at an elevated risk for developing secondary health conditions, such as obesity, cardiovascular disease, type 2 diabetes mellitus, stroke, osteoarthritis, and cancer (Chan, Chiu, Bezyak, & Keegan, Reference Chan, Chiu, Bezyak and Keegan2012; Liou, Pi-Sunyer, & Laferere, Reference Liou, Pi-Sunyer and Laferere2005; Must et al., Reference Must, Spadano, Coakley, Field, Colditz and Dietz1999). Secondary conditions are linked to functional impairment and workplace difficulties (Ipsen, Reference Ipsen2006, Ipsen, Seekins, & Arnold, Reference Ipsen, Seekins and Arnold2011; Ipsen, Seekins, & Ravesloot, Reference Ipsen, Seekins and Ravesloot2010; Pope & Tarlov, Reference Pope and Tarlov1991), including unwanted work absence and restriction in employment opportunities (Di Masso, Avi-Itzhak, & Obler, Reference Di Masso, Avi-Itzhak and Obler2001; Laxman, Lovibond, & Hassan, Reference Laxman, Lovibond and Hassan2008). Although the benefits of health promotion are clearly demonstrated and good health is known to be a necessary precursor to community integration and participation (Chan et al., 2012; Ravesloot, Seekins, & White, Reference Ravesloot, Seekins and White2005; World Health Organization, 2000), the motivation to engage in health promoting behaviour remains relatively low among people with CID. Therefore, it is important to understand psychosocial factors that influence persons with CID's motivation to engage in health promoting behaviour.
This exploratory review considers theories and models of motivation applicable to health promotion of people with CID. It seeks to address the gap in health promotion knowledge for rehabilitation counsellors by conducting a topical review of health promotion theory and model research (Hall & Walton, Reference Hall and Walton2004) that will provide a strong, foundational source of information on the topic. To achieve this goal, we included a broad range of studies on health promotion with people with CID that were published between 1990 and 2015. We reviewed research literature on motivational theories applicable to health promotion of people with CID (e.g., self-determination and self-efficacy theory), as well as models that integrate multiple theories, such as Pender's health promotion model (HPM; Pender, Murdaugh, & Parsons, Reference Pender, Murdaugh and Parsons2006), the health action and process approach model (HAPA; Schwarzer, Lippke, & Luszczynska, Reference Schwarzer, Lippke and Luszczynska2011), and the extended parallel process model (EPPM; Witte, Reference Witte1992), and noted implications for their use with people with CID in rehabilitation counselling settings.
Social Cognitive Theory/Self-Efficacy Theory
Social cognitive/self-efficacy theory (SCT/SET) provides a strong foundation for health promotion efforts (Bandura, Reference Bandura2004). In SET, self-efficacy influences goals, outcome expectations, and the perception of facilitators and obstacles to engage in a task or behaviour, such as physical activity (Bandura, Reference Bandura2004). Self-efficacy describes an individual's beliefs regarding his or her ability to change behaviour. The stronger the perception of self-efficacy, the higher the likelihood behaviour change will occur (Bandura, Reference Bandura1977; Sweet, Fortier, Strachan, & Blanchard, 2012). Outcome expectations are defined as an individual's perceptions of the benefits or costs associated with a task or behaviour (e.g., physical activity). SET postulates that self-efficacy increases outcome expectations, and both self-efficacy and outcome expectancy predict the performance of a targeted behaviour.
In health promotion research, self-efficacy and self-regulation (i.e., personal goal setting) are important aspects of SET in explaining an individual's ability to successfully change unhealthy behaviours. Plotnikoff et al. (Reference Plotnikoff, Lipke, Courneya, Birkett and Sigal2008) found that personal goal setting is a direct predictor of physical activity, outcome expectations, and social support. An investigation of adults with multiple sclerosis found SET explained 19% and 14% of the variance in self-reported physical activity and accelerometer ratings, respectively (Motl, Snook, McAuley, Scott, & Douglas, Reference Motl, Snook, McAuley, Scott and Douglas2006). Self-efficacy was predictive of women with physical disabilities’ behaviours towards their nutrition, physical activity, and stress management (Hughes, Nosek, Howland, Groff, & Mullen, Reference Hughes, Nosek, Howland, Groff and Mullen2003). An examination of messages intended to enhance self-efficacy and outcome expectancy among cardiac rehabilitation patients provides additional support to the importance of self-efficacy in health promotion (Woodgate & Brawley, Reference Woodgate and Brawley2008). Results indicated patients receiving efficacy-enhancing messages reported increased self-regulatory efficacy and greater intentions to exercise frequently compared to patients in the control group (Woodgate & Brawley, 2008).
Self-Determination Theory
Self-determination theory (SDT) focuses on the degree to which an individual's behaviour is self-motivated and self-determined (Deci & Ryan, Reference Deci and Ryan2002; Ryan & Deci, Reference Ryan and Deci2000). It postulates that three underlying innate needs (autonomy, competency, and relatedness), if satisfied, will allow for optimal function and growth (Baumeister & Leary, Reference Baumeister and Leary1995; Reeve, Nix, & Hamm, Reference Reeve, Nix and Hamm2003; Ryan & Deci, 2000). Autonomy refers to the need to experience one's behaviour as integrated within and endorsed by the self. Competency is the need to be effective in one's interactions with the environment. Relatedness is the need to establish close and secure attachments with others (Baumeister & Leary, 1995; Reeve et al., 2003; Ryan & Deci, 2000). Autonomy in particular drives behavioural regulation from an internalised motivation orientation and is considered a continuous process. SDT theorists propose that behavioural regulation can be broadly categorised as amotivation, controlled motivation, and autonomous motivation (Ryan, Patrick, Deci, & Williams, Reference Ryan, Patrick, Deci and Williams2008). Autonomous motivation refers to three different types of behaviour regulation: (a) intrinsic motivation, which is the most autonomous motivation and is described as engaging in an activity for the inherent pleasure, fun, or challenge; (b) integrated regulation, which involves participation in activities that are in line with one's personal goals and values; and (c) identified regulation, which occurs when one personally endorses or identifies with the value or importance of a behaviour or health practice. Controlled motivation refers to two different types of behaviour regulation: (a) introjected regulation, which involves behavioural performance motivated by self-esteem related contingencies and occurs when an individual is motivated by guilt or shame; and (b) external regulation, which is the least autonomous type of motivation and can occur when external pressures (e.g., rewards or punishment) encourage an individual's health behaviour (Ryan et al., Reference Ryan, Patrick, Deci and Williams2008). The final category of behavioural regulation is amotivation, which occurs when an individual has a relative absence of motivation for a certain behaviour (Ryan et al., 2008).
In addition, social contexts play an important role in facilitating an individual's self-determined motivation, healthy development, and optimal functioning. In SDT, autonomy support is used to characterise the quality of social environments. For a rehabilitation counsellor to support client autonomy, it is necessary for them to elicit and acknowledge their clients’ perspective by supporting their initiatives, offering choices about treatment options, providing relevant information, and minimising pressure and control (Williams et al., Reference Williams, McGregor, Sharp, Levesque, Kouides, Ryan and Deci2006).
A meta-analysis by Ng et al. (Reference Ng, Ntoumanis, Thogersen-Ntoumani, Deci, Ryan, Duda and Williams2012) supported the positive associations among SDT constructs, as well as significant relationships between SDT constructs and positive mental health and physical health outcomes. In the same study, Ng et al. combined techniques of meta-analysis and path analysis to test the overall SDT model for health behaviour. The authors reported that the model showed a good fit, χ 2(3) = 76.25, p < .01, CFI = .98, RMSEA = 0.07, which reinforces the usefulness of SDT to improve health behaviour.
Theory of Planned Behaviour
Theory of planned behaviour (TPB) assumes an individual's behaviours are governed by rational considerations (Ajzen, Reference Ajzen, Kuhl and Beckmann1985; Ajzen & Fishbein, Reference Ajzen, Fishbein, Albarracin, Johnson and Zanna2005). Plan behaviour includes attitudes towards a behaviour, subjective norms, perceived behavioural control, intention, and behaviour (Brooks et al., Reference Brooks, Iwanaga, Chiu, Cotton, Deiches, Morrison and Chan2017). Beliefs regarding the performance of a behaviour and the probable outcomes of a behaviour influence attitudes toward the behaviour. Subjective norms refer to an individual's perceptions of social standards (e.g., all members in the clients’ social network believe in wellness and health promotion) and they influence an individual's plans for his or her behaviours through his or her internalised desires to comply with the standards (Ajzen & Fishbein, Reference Ajzen, Fishbein, Albarracin, Johnson and Zanna2005). They influence health outcomes through their effect on perceived behavioural control. Perceived behavioural control is an individual's belief regarding whether he or she can perform a behaviour and obtain a desired outcome. It is similar to the self-efficacy construct.
TPB has been applied to health promotion for people with stroke, cardiovascular disease, spinal cord injury, arthritis, and intellectual disability (Armitage & Connor, Reference Armitage and Conner2001). For instance, Arbour-Nicitopoulos, Ginis, Wilson, and SHAPE-SCI Research Group (Reference Arbour-Nicitopoulos, Ginis and Wilson2010) reported that perceived control with planning accounts for 57% of the variance in intentions and 12% of the variance in the performance of physical activity. Similarly, Godin and Kok (Reference Godin and Kok1996) reported that planned behaviour control explains 16% of variance in clinical screening behaviours and 41% in addictive behaviours.
Transtheoretical/Stages of Change Model
The transtheoretical/stages of change model (TTM or SOC) comprises five stages of change representing different levels of motivation to change behaviour: (1) precontemplation is characterised by no intention to change behaviour at present or in the foreseeable future; (2) contemplation is described as awareness that a problem exists with thoughts about overcoming it, but with no commitment to action; (3) preparation combines intention and action with some attempts to change, with or without success; (4) action is where major change occurs; and (5) maintenance follows action and is characterised by efforts to prevent relapse, secure gains achieved in the action stage, and continue behaviour change. Relapse is an important concept to TTM, but it is not considered a specific stage. Relapse is characterised by recycling through various stages as an individual attempts to modify behaviours throughout his or her lifetime (Prochaska & DiClemente, Reference Prochaska and DiClemente1983; Prochaska, DiClemente, & Norcross, Reference Prochaska, DiClemente and Norcross1992; Prochaska, Redding, & Evers, Reference Prochaska, Redding, Evers, Glanz and Rimer2002).
The transtheoretical/stages of change model aims to explain the decisional balance in evaluations of perceived benefits and barriers to engage in a behaviour (Prochaska et al., Reference Prochaska, Redding, Evers, Glanz and Rimer2002). For instance, Kosma, Cardinal, and McCubbin (Reference Kosma, Cardinal and McCubbin2004) investigated the ability of processes of change, self-efficacy, and decisional balance capabilities to differentiate stages of change for physical activity among a sample of individuals with physical disabilities. Cognitive processes (e.g., consciousness raising), behavioural processes (e.g., stimulus-control), self-efficacy, and decisional balance provided discrimination between precontemplation and the four other stages. Cognitive processes were found to distinguish those in the contemplation stage from those in preparation, action, and maintenance stages. Bezyak, Berven, and Chan (Reference Bezyak, Berven and Chan2011) also found the TTM useful in predicting physical activity and stages of change among individuals with severe mental illness. Participants in their study with higher behavioural processes of change scores were nearly four times as likely to be in the action/maintenance stages compared to the preparation stage and nearly five times as likely to be in the action/maintenance stages compared to precontemplation/contemplation.
Pender's Health Promotion Model
Pender's HPM is an explanatory model of health behaviour emphasising the role of expectations and self-efficacy in health promoting behaviours. Pender (Reference Pender1996) incorporates several aspects of motivational theories discussed above, including SET, TTM, and TPB (Pender et al., Reference Pender, Murdaugh and Parsons2006). Three concepts are central to HPM: (a) individual characteristics and experiences, (b) behaviour-specific cognition and affect, and (c) behaviour outcomes. Individual characteristics and experiences are characterised as biological, psychological, and socio-cultural. The HPM views these variables as predictive of future behaviour and influenced by the nature of the target behaviour. Behaviour-specific cognition is the individual's personal judgment regarding potential outcomes occurring from changing or maintaining a certain health behaviour. Behaviour-specific affect is the individual's subjective feeling (positive or negative) resulting from the stimulus properties of the behaviour itself. Behaviour outcomes include a commitment to a plan of action and its implementation. Interventions focus on assisting individuals to create a realistic action plan by highlighting the benefits of a behaviour, teaching them how to overcome barriers to carrying out the behaviour, and inspiring self-efficacy and positive affect (Pender et al., 2006). It is an effective framework for health promotion interventions resulting in positive health outcomes in diabetes prevention (May & Rew, Reference May and Rew2010), management of chronic cardiovascular disease (Han, Lee, Park, Park, & Cheol, Reference Han, Lee, Park, Park and Cheol2005), self-care in outpatients with HIV/AIDS (Mendias & Parr, Reference Mendias and Parr2007), and increasing physical activity in individuals with spinal cord injury (Keegan, Chan, Ditchman, & Chiu, Reference Keegan, Chan, Ditchman and Chiu2012).
Health Action and Process Approach Model
The HAPA model also draws on aspects of SET, TPB, and TTM (Schwarzer et al., Reference Schwarzer, Lippke and Luszczynska2011). The premise of HAPA is that adopting, initiating, and maintaining health behaviours is a two-stage process consisting of the (a) motivational phase and (b) volitional phase (Schwarzer, Reference Schwarzer and Schwarzer1992). Major factors in the motivational phase include action self-efficacy, outcome expectancies, and risk assessment. These factors serve to influence the intention of individuals to change their behaviour. However, intention alone is not sufficient to affect changes and must be accompanied by planning. Without a foundational planning construct, a potential gap between intentions and actions exists (Orbell & Sheeran, Reference Orbell and Sheeran1998). To bridge the gap between the motivation and volition phases, action planning and coping planning were included as important variables in the volition phase. Action planning consists of constructing deliberate steps detailing when, where, and how to act in order to make appropriate behavioural changes in health promotion (Sniehotta, Schwarzer, Scholz, & Schuz, Reference Sniehotta, Schwarzer, Scholz and Schuz2005). In coping planning, risks to sustained behaviour change are identified, and the means to cope with those risks are developed (Sniehotta et al.). Coping strategies may take the form of pre-rehearsals for potential risk situations or the creation of deliberate coping plans to prevent relapses.
Schwarzer (Reference Schwarzer2008) found HAPA constructs to accurately predict diet, alcohol consumption, and exercise behaviours. Action planning, self-efficacy, and self-regulation strategies were associated with the adoption and maintenance of physical activities in a study with cardiac rehabilitation patients (Sniehotta et al., Reference Sniehotta, Schwarzer, Scholz and Schuz2005). Chiu, Lynch, Chan, and Berven (Reference Chiu, Lynch, Chan and Berven2011) found recovery self-efficacy, action and coping planning, and perceived barriers directly associated with physical activity in people with multiple sclerosis.
Extended Parallel Process Model
The EPPM was developed by Witte (Reference Witte1992) in the field of health communication. The focus of EPPM is on the effects of perceived threat and self-efficacy on behaviour change. Perceived threat refers to an individual's perceptions of his or her susceptibility to and the severity of a health threat (Roberto & Goodall, Reference Roberto and Goodall2009; Witte, Reference Witte1992). Perceived efficacy is composed of perceptions of both response-efficacy and self-efficacy (Witte, Reference Witte1992). Response-efficacy relates to the perception of the safety and effectiveness of a behaviour recommended to reduce a threat. Self-efficacy relates to whether an individual perceives he or she has the necessary skills and resources to engage in a specific behaviour.
There are three possible outcomes of perceived threat and efficacy. The first outcome is that no response will occur because perceived threat risk is low (Roberto & Goodall, Reference Roberto and Goodall2009). If threat risk is appraised to be high, two possible outcomes will occur: activation of either fear control or danger control (Witte, Reference Witte1994). A fear control response occurs when the perceived threat is high and perceived efficacy is low. In this situation, an individual perceives a threat risk, but is unable to identify a viable option to reduce the threat and will therefore act to reduce his or her fear through emotional or cognitive responses, such as defensive avoidance or denial. This response does not decrease the danger of the situation because the recommended action is not performed (Roberto & Goodall, Reference Roberto and Goodall2009). Conversely, if the perceived threat is high and perceived efficacy is also high, the outcome will be a danger control response (Roberto & Goodall, 2009). This response occurs when an individual believes that a serious and personally relevant threat exists, but there are also effective and manageable ways to reduce the threat. Danger control processes dominate as long as perceptions of efficacy are greater than perceptions of threat (Witte, Reference Witte1994). When both perceived threat and efficacy are high, individuals can focus on potential solutions to the problem and are more likely to have an attitude or behaviour change consistent with the health risk.
Rehabilitation counsellors may consider including accurate health information related to threats that health conditions pose along with strategies to increase health management self-efficacy in an effort to address health promotion needs using EPPM concepts. The EPPM model has been applied to various health messages and campaigns and studied in the context of sexually transmitted disease and HIV/AIDS prevention (Cho & Witte, Reference Cho and Witte2005), rape prevention (Morrison, Reference Morrison2005), physicians’ decision-making related to testing kidney function (Roberto & Goodall, Reference Roberto and Goodall2009), smoking cessation (Wong & Cappella, Reference Wong and Cappella2009), meningitis prevention (Gore & Bracken, Reference Gore and Bracken2005), and use of hearing protection (Smith et al., Reference Smith, Rosenman, Kotowski, Glazer, McFeters and Keesecker2008). A meta-analysis of fear appeals provides support for using strong fear appeals with high-efficacy messages as an effective strategy for behaviour change (Witte & Allen, Reference Witte and Allen2000).
Commonalities among Constructs of Theories and Models of Motivation
Motivational theories identifying the underlying change mechanisms for health-related behaviour provide useful frameworks to motivate and engage people with CID in health promotion (Hagger & Chatzisarantis, Reference Hagger and Chatzisarantis2009). Integrating components of theories of motivation to create motivational models of health promotion is becoming increasingly common (Hagger & Chatzisarantis, Reference Hagger and Chatzisarantis2016; Schwarzer et al., Reference Schwarzer, Lippke and Luszczynska2011). In this exploratory review, we found that SET (self-efficacy and outcome expectancy) is foundational to all theories and models of motivation applicable to health promotion. We also identified unique contributions of motivational variables in each theory and model of motivation related to health promotion. For example, autonomy is unique to SDT and risk assessment is unique to EPPM and HAPA. Figure 1 depicts a model including all the theories and models covered in this exploratory review and identifies commonalities among their constructs. The purpose of this diagram is for rehabilitation counsellors to apply theories and models of motivation in case conceptualisation, formulating clinical hypotheses, developing treatment plans, and selecting and implementing evidence-based health promotion interventions for their clients.
Commonalities among constructs of theories and models of motivation related to health promotion.
Exemplary Health Promotion Interventions
Two of the most recognised health promotion programmes are the Chronic Disease Self-Management Programs (CDSMP) developed by Dr. Kate Lorig and her research team at Stanford University and the Living Well with a Disability (LWWD) programme developed by researchers at the University of Montana. Both programmes are endorsed by the Centers for Disease Control and Prevention (Brady et al., Reference Brady, Murphy, Beauchesne, Bhalakia, Chervin, Daniels and O'Colmain2011).
Chronic Disease Self-Management Programmes
CDSMPs have been used to promote the health behaviour of people with arthritis, diabetes, chronic pain, HIV, and cancer, and can be adopted for people with disabilities and other chronic diseases. It is a 6-week programme covering eight topics: (a) techniques to deal with health problems (e.g., pain, fatigue, frustration and isolation); (b) exercise and physical activity for maintaining and improving strength, flexibility, and endurance; (c) use of medications; (d) communicating effectively with family, friends, and health professionals; (e) healthy eating; (f) making informed treatment decisions; (g) disease-related problem-solving; and (h) getting a good night's sleep (Lorig, Ritter, Laurent, & Plant, Reference Lorig, Ritter, Laurent and Plant2008). There is emerging evidence to support the effectiveness of the CDSMP. ResearchersBrady et al. (Reference Brady, Murphy, Beauchesne, Bhalakia, Chervin, Daniels and O'Colmain2011) conducted a meta-analysis (24 studies with 6,812 participants) to examine the effect of self-management programmes for people with arthritis on multiple outcomes including physical and psychological health status, health behaviours, and healthcare utilisation. They found a small to moderate effect size for increased self-efficacy for managing pain and other symptoms, increased communication with physicians, decreased fatigue, decreased anxiety, and decreased depression. In terms of overall effects, self-efficacy increased moderately in the shorter term (4–6 months) and persisted longer term (9–12 months). Psychological health status (health distress, depression, and anxiety) also showed consistent small to moderate improvements. Health behaviours (exercise, cognitive symptom management, and communication with physicians) all showed statistically significant moderate improvements at 4–6 months and persisted at 9–12 months for all variables except exercise behaviours. Although the effects of self-management education are modest, these findings have public health significance when considering the cumulative impact of small changes across a large population.
Living Well with a Disability (LWWD) Programme
LWWD is a self-management intervention developed by researchers at the University of Montana in partnership with the national network of Centers for Independent Living (CILs) and with support from the CDC's Disability and Health Branch (Ipsen, Ravesloot, Arnold, & Seekins, Reference Ipsen, Ravesloot, Arnold and Seekins2012; Ravesloot et al., Reference Ravesloot, Ruggiero, Ipsen, Traci, Seekins, Boehm and Rigles2011; Ravesloot et al., Reference Ravesloot, Seekins and White2005; Seekins, Clay, & Ravesloot, Reference Seekins, Clay and Ravesloot1994; Seekins et al., Reference Seekins, White, Ravesloot, Norris, Szalda-Petree, Lopez, Young, Simeonsson and McDevitt1999). The curriculum helps participants achieve success in self-management of quality-of-life goals to build confidence for making health behaviour changes. The LWWD programme includes an orientation session and 10 weekly, 2-hour sessions. In the orientation session, participants explore potential obstacles to attendance and examine the benefits of participation. The next four sessions encourage peer support using a solution-focused group process that focuses on achieving a meaningful and healthy life while addressing the early challenges of pursuing new goals. These sessions build analytical and problem-solving skills (e.g., frustration management and self-monitoring for depression that may need outside clinical attention). The final six sessions focus on specific self-management skills for improving health status, including effective strategies for communicating with healthcare providers; information acquisition and use; increasing physical activity; improving diet; advocating for both personal and healthcare systems improvements; and maintaining health behaviour changes over time.
Ravesloot et al. (Reference Ravesloot, Seekins and White2005) conducted a national study implemented by staff recruited from community-based agencies located in geographically diverse areas around the United States with 188 persons with disabilities. They found that the LWWD intervention was successful in reducing the average degree of limitation people report due to secondary health problems, the number of symptom days they experience, and their healthcare costs ($807 per person due to reductions in healthcare utilisation), while increasing their overall life satisfaction and the behaviours they used to improve health status. Importantly, they found that increases in physical activity are significantly related to improved health conditions.
Case Illustration
Mercedes has multiple sclerosis, is overweight, and has been told by her physician that she is at high risk for type 2 diabetes. She has asked her rehabilitation counsellor for help in identifying supports or services that might reduce her risk for diabetes (autonomy/self-determined motivation). Together, they explore health websites to learn about the risk factors of diabetes, complications associated with the disease, and the benefits of healthy diet and exercise to reduce risk (health information, risk assessment, and perceived benefits). Mercedes voiced concerns regarding exercising, as she does not have the money to join a gym and feels uncomfortable working out in a commercial gym (perceived barrier). The rehabilitation counsellor shared with her the concept of lifestyle physical activity (i.e., self-selected physical activities from one's daily routine). This gave Mercedes the idea of joining the neighbourhood's safe passage programme, which walks children to the local elementary school (self-efficacy, outcome expectancy, danger control). To encourage a healthy diet, the counsellor finds a dietetics student willing to provide free consultation for Mercedes to teach her how to shop and cook healthy meals within her budget (self-efficacy, outcome expectancy, and danger control). With her counsellor, she also develops a plan to engage in lifestyle physical activity and to cook healthy meals every day, including alternative strategies to reengage in her health routine when she is not in the mood to be active and healthy (action planning and coping planning).
Implications for Rehabilitation Counselling Research and Practice
While no single theory can address all the potential variables affecting people with CID's health behaviours, three important factors emerge across the theories that are appropriate for rehabilitation counsellors to consider. These factors include ‘information,’ ‘self-efficacy,’ and the ‘tipping point’ where health behaviours are changed. Information access is important for developing the expectancy that performing health promoting behaviours (e.g., exercise, diet, smoking cessation, and stress reduction) will result in a desired outcome. Similarly, health information is a necessary resource for people with CID to build the skills needed to act on their beliefs. A rehabilitation client's perception of threat and his or her efficacy to perform a behaviour change are based upon both the amount and quality of information he or she receives and accurately processes. Bandura's (Reference Bandura1977) concept of self-efficacy is the most common factor in the HPMs discussed, with several models identifying it as a central tenet of the theory (e.g., SCT, HPM, and HAPA). Self-efficacy influences an individual's appraisal of his or her competency to perform the tasks needed to adopt healthy behaviours. Importantly, each rehabilitation client has a personal ‘tipping point,’ or a pivotal time when an his or her behaviours change and intentions transition to health and wellbeing actions. Establishment of realistic rehabilitation goals is primary to positive change in behaviour (Ajzen & Madden, Reference Ajzen and Madden1986). Goal-setting combines with an individual's commitment to change and realigns the person-environment context to support behaviour change and subsequent maintenance. Rehabilitation counsellors should counsel for increased self-efficacy with information and motivational interventions targeted at improving or changing health behaviours. For instance, motivational interviewing techniques work well to help clients to reach a ‘tipping point,’ leading to reduced ambivalence and increased motivation to change health.
Conclusion
In summary, being healthy is critical to community integration and participation, including employment and independent living (Chiu et al., Reference Chiu, Lynch, Chan and Berven2011; Ravesloot et al., Reference Ravesloot, Seekins and White2005). Health promotion interventions have the potential to improve secondary physical health and mental health conditions, work performance, and health-related quality of life of people with CID (Chan et al., Reference Chan, Chiu, Bezyak and Keegan2012). Gaining a better understanding of evidence-based health promotion theories and relevant rehabilitation research can help rehabilitation counsellors to address overlooked secondary conditions in people with CID and improve the overall quality of rehabilitation services.
