Health Constructs and Measurement Project
Principal Investigator: Margaret Nosek, Ph.D., Baylor College of Medicine
Co-Investigators: Rosemary B. Hughes, PhD.
Heather B. Taylor, PhD.
Margarette Shelton, PhD.
Carol Howland
One of the driving questions that underlies much of our research is why some people with very severe functional limitations are able to lead healthy and productive lives while others appear to be so burdened by relatively minor limitations that they are unable to participate effectively in their families or in society. The results of several of our studies over the past ten years have offered insights into some possible reasons for this difference in health outcomes. In order to formalize these apparent relations, we are proposing a model of health promotion that incorporates the powerful psychological, social, and environmental factors that affect the health of people with physical functional limitations, with particular attention to women.
The theoretical model we have developed uses a structure comprised of contextual factors, mediators/moderators, and health outcomes. Most models of health and wellness have as their endpoint specific behaviors and not health outcomes. Many of the constructs are too vaguely worded or complex to operationalize effectively, such as Witmer and Sweeney’s (1992) concept of “self-regulation,” which includes everything from sense of control to physical fitness. Some authors introduce the concept of quality of life without identifying how it differs from wellness or health outcomes. Others do not distinguish mediators/moderators from outcomes. There is general agreement, however, that health outcomes include measures of physiological, psychological, sociocultural, and spiritual factors. Our model is intended to include these constructs and posit relations among them as observed in the population of people with physical disabilities.
RESEARCH OBJECTIVE/RESEARCH QUESTION
Objective 1: Develop a Model of Health and Wellness for People with Disabilities
Objective 2: Identify Instruments and Techniques Used to Assess Components of the Health and Wellness Model and Determine their Efficacy for Use in Various Populations of People with Disabilities.
Objective 3: Document and Disseminate the Results of this Project
This is primarily a conceptual project that required review of pertinent literature and consultation with experts in various aspects of health and wellness for people with disabilities.
Following are descriptions of the constructs included in the Mediated Model of Health and Wellness for People with Disabilities.
Contextual factors are either internal to the individual or external in the environment and cannot be easily changed, but can be enhanced through management strategies. These contextual factors include variables related to 1) disability status (disability type or etiology, age at onset of disability, duration of disability), 2) demographics (age, race, urban/rural residence), 3) relationships (family structure, friendships, intimate partner); 4) values and beliefs (attitudes, cultural context, religious or spiritual affiliation), 5) life experiences (growing up in poverty, experiencing abuse or other forms of trauma, going through a divorce), and 6) environmental resources. The category of environmental resources encompasses many aspects of the micro-, meso-, exo-, and macro-systems in which women live, including access to financial resources (such as earned income, income from other household or family members, health insurance, public and private benefit programs); education level; the built and natural environment (geographical landscape, climate, pollution, accessibility of buildings); technology (general and assistive); information from the print and broadcast media and the Internet; social support and services (including assistance received from family, friends, and others, as well as transportation, personal assistance services, and the offerings of service organizations), and access to health-care services.
The unique contribution of this model is its treatment of two critical mediators/moderators, psychosocial factors and health promoting behaviors, in close association with contextual factors. Psychosocial factors include self-efficacy, self-esteem, self-cognition (the perception of how others see you), perceived control, attribution style, coping orientation, purpose in life, and social connectedness. Our research has shown that self-efficacy, self-esteem, and social connectedness play a major mediating role in accounting for variance in health outcomes among women with disabilities. Health-promoting behaviors have been defined as “activities directed toward increasing the level of well-being and actualizing the health potential of individuals, families, communities, and societies” (Pender, 1987, p.4).
Our taxonomy of health outcomes includes 1) physical or biological health, including body mass index, general health status, vitality, pain, functional limitations, chronic conditions, secondary conditions, and use of health-care services; 2) psychological health, including general mental health, life satisfaction, perceived well-being, sense of coherence, and emotional role functioning; 3) social health, including intimacy, perceived connectedness, social functioning, and social integration; and 4) spiritual health, including transcendence and self-understanding.
As a tool for researchers in selecting methods for assessing these various constructs, we are compiling an annotated list of instruments that have been tested, validated, and published in the refereed literature. Within five general categories, status, resources, psychosocial factors, health promoting behaviors, and health outcomes, we are examining the assessment literature pertaining to 16 subcategories of constructs.
| Category | Subcategory |
|---|---|
| Status | Demographic Disability |
| Resources | Financial Human Supports Medical Resources Mobility and Technology |
| Psychosocial factors | Sense of Self Problem Solving Social Factors |
| Health Promoting Behaviors | Active Preventive Executive |
| Health Outcomes | Biological Psychosocial Social Spiritual |
The descriptions of instruments within these categories are being formatted in html for use on the OHSU Health and Wellness website.
By presenting these various factors in this theoretical configuration, we hope to encourage research that will test relations among them. Toward that end, we propose the following postulates.
Postulate #1: High health status ratings are possible at various levels of physical functioning.
Postulate #2: Psychological, social, and environmental factors can have a direct and indirect effect on an individual’s ability to maintain good health.
Postulate #3: Deficiencies in the health care system for people with disabilities, including the lack of information or clinical training on wellness in the context of disability, can interfere with an individual’s ability to maintain good health.
Postulate #4: Psychological and social factors serve as mediators of the effect of disability on health-promoting behaviors and health status.
Postulate #5: Life events can have a direct and indirect influence on health outcomes.
Postulate #6: Observed health-promoting behaviors may not always be associated with positive health outcomes in individuals with physical disabilities.
Postulate #7: The Mediated Health Promotion Model is a system, with outcomes influencing contextual and mediating factors, and vise versa.
Postulate #8: Spiritual health is an important health outcome.
Research
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The model we have proposed puts proportionately more emphasis on factors that are salient in the lives of people with disabilities than is seen in other models of health and wellness. It allows greater consideration for the contextual factors that affect the functioning of persons with physical limitations, including environmental and economic barriers, social support, and cultural values. We hope this model will be a stimulus for comparison with traditional approaches to assessing health promoting behaviors and health outcomes.
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By positing a mediating role for psychosocial factors, constructs that have been shown to be particularly relevant to women, we are inviting closer examination of the effect of gender on the delivery of rehabilitation services and the assessment of rehabilitation outcomes.
- The presentation of this model and the review of instruments that purport to operationalize its components have exposed several constructs, such as social connectedness and access to health care, that demand further investigation and development of measures that will be sensitive to the distinctive context within which people with disabilities function.
Policy
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Testing of this model will reveal gender inequities in the delivery of rehabilitation services and the assessment of rehabilitation outcomes.
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Testing of this model will enable more critical examination of the cost/benefit calculations and distribution of resources for primary and specialized health care needed by people with disabilities.
- Testing of this model will demonstrate the importance of psychosocial factors in the lives of people with disabilities and encourage the expansion of efforts to incorporate more effective interventions for psychological and social problems encountered in health care settings.
Training
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There is a critical need to train health care practitioners in the complex interconnected web of factors that affect the health of people with disabilities, with an emphasis on the effect of psychosocial factors on health behaviors and outcomes.
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There is a serious lack of psychosocial interventions throughout the spectrum of health services available to people with disabilities. Interventions to improve such critical factors as self-esteem, social connectedness, and disability self-management, for example, need to be developed, tested, and incorporated into reimbursable health care service systems.
- Training programs for providers of social and vocational services should include instruction on the importance of identifying signs of depression, social isolation, neglect, and abuse in their clients with disabilities and referring them to appropriate community and health care services.
