Feature Community Health Promotion: Reaching Beyond The Clinic There's a growing role for PTs and PTAs in addressing preventable illness. By Eric Ries | May 2018 When it came to choosing a dissertation subject for her doctorate in health promotion and wellness, Rupal Patel, PT, PhD, targeted a field about which she's passionate—diabetes prevention—and an understudied population—Asian Indians in the United States. Type 2 diabetes is the fifth-leading cause of death among Asian Americans, and Asian Indians have the highest prevalence of it within that population. According to the American Community Survey, from 2000 to 2010 the Asian Indian population in the United States grew by 67.6% (3.2 million people). Asian Indians who immigrate to Western countries are at risk of developing type 2 diabetes for reasons linked to the metabolic impact of a westernized diet and tissue resistance to insulin.1-4 So, Patel, herself of Asian Indian descent, set out to effect change in her own backyard—reaching out to 1 of the largest Hindu temples in the Houston, Texas, area. She developed a 12-week group-based lifestyle-modification program to reduce diabetes risk factors. It included sessions on physical activity and diet behaviors, while also seeking to debunk cultural myths with which she was all too familiar—such as the belief among many Asian Indians that "physical activity that makes you breathe hard is harmful to your heart." As participants gained knowledge and confidence, they began walking fast or jogging—and feeling energized rather than scared. "I plan to submit a grant later this year to sustain the program by training students from our physical therapy, occupational therapy, nursing, and nutrition programs to deliver it," says Patel, an associate professor of physical therapy at Texas Woman's University (TWU). "Ideally, we would recruit students who also are of Indian descent, because that makes a real difference in the comfort level of the people targeted by the program. There's a built-in trust factor there." Patel also is passionate about teaching students about community health. For several years, TWU students have been meeting the needs of people with early-stage dementia at a day facility in Houston named Amazing Place. It's part of Patel's effort to provide doctor of physical therapy students with experiential opportunities as part of a course on community health promotion. Among other activities, students have helped redesign group exercise classes to better meet participants' needs, trained nurses to perform balance screens, and even encouraged attendees to drink more water by working with the facility's chef to infuse it with fruit and herbal flavors. "To me, community health promotion is about focusing your lens on a population with a specific risk factor or condition rather than on a single patient with that condition, and determining how you, as a physical therapist [PT] or physical therapist assistant [PTA], can positively impact that population's health," Patel says. "I had never worked on hydration issues before, and my students hadn't, either. But we did our due diligence by identifying this need in our targeted population. We looked at the literature and developed a solution that could be implemented and sustained." Janet Bezner, PT, DPT, PhD, FAPTA, is a longtime proponent of community health promotion by PTs and PTAs. Accordingly, she was among a small group—a mix of veteran and early-career PTs—who shepherded the APTA Council on Prevention, Health Promotion, and Wellness to creation this January. (More on that later.) Bezner describes community health promotion as an inexact term that can mean different things to different people. "It includes what I would call ‘population health' approaches—where you create a program for a population with a common condition, such as people with diabetes or those with osteoporosis," says Bezner, an associate professor of physical therapy at Texas State University in San Marcos. "But it also includes efforts to enhance the overall health of an entire community or community group," she says, "such as getting involved in efforts to increase the number and availability of sidewalks in neighborhoods. It's a bucket term for activities that can address a range of social and environmental factors. The goal is to give people more control over their health and greater ability to improve it." Bezner has secured more than $30,000 in grants from the Osteoarthritis Action Alliance in the past few years to create walking programs for people with that disease. With the money, she's trained students to lead activities at 4 different locations. "Participants love it," she reports. "It makes them feel better and gives them energy. They can't believe that such a simple thing as walking can really improve their quality of life." In Michigan, meanwhile, Beth Black, PT, DSc, co-teaches a 6-week National Multiple Sclerosis Society program called Gateway to Wellness for people who have the condition. "We talk with these folks about how they can safely incorporate physical activity in their lives," says Black, an associate professor of physical therapy at Oakland University in Rochester. "We discuss ways to cope with fatigue, adapt their home and work environments, and tap community support groups. We talk about the importance of adopting healthy behaviors such as eating properly and managing stress." Black's co-instructor has MS, which Black believes is important to the success of the program. "When she says, ‘This is what I do' or ‘This is how I handle that,' it's coming from someone who understands their challenges, because she has experienced many of them." Black also has brought PT students into the homes of individuals with MS to design exercise programs specific to their lifestyles, preferences, and challenges. They helped 1 person, for example, achieve her goal of walking down the aisle at her daughter's wedding with only her husband's arm as support, rather than a walker. They addressed another individual's boredom with exercise by creating a program that alternates treadmill sessions with yoga. At the Alabama Institute for the Deaf and Blind (AIDB) in Talladega, PT students from the University of Alabama at Birmingham (UAB) work alongside peers from the occupational therapy and kinesiology programs to help individuals with disabilities engage in regular physical activity and healthful eating through a federal program called I Can Do It, You Can Do It. Tara Pearce, the school's associate director of clinical education in physical therapy, explained in UAB Magazine that maintaining a healthy lifestyle "can be a bigger challenge with students with disabilities because they sometimes need 1-on-1 support to participate" in physical activities.5 PT students from UAB "work with people [at AIDB] in small groups to get individualized attention to participate at a greater level," she noted in the article. UAB's participation at AIDB—and also at United Abilities of Birmingham, The ARC of Jefferson County, and the Horizons School in Birmingham—is a manifestation of UAB's desire to expand its students' reach beyond traditional clinical experiences, says David Morris, PT, PhD, FAPTA, who chairs the school's Department of Physical Therapy. "We want our future physical therapists to get out there and have hands-on skills related to health promotion in the community." Community health promotion has played a big role in the early career of Jessica Berglund, PT, DPT, who completed school and was licensed as a PT in 2013. Already, she's taught community education classes in falls prevention, strength training, balance and walking to older adults; has been active in the formation and development of the Council on Prevention, Health Promotion, and Wellness; and was installed as the council's chair at APTA's Combined Sections Meeting in February. Berglund also chairs the Minnesota Physical Therapy Association's Health & Wellness Committee—a panel that helps the state's PTs and PTAs better meet people's overall health needs, both 1-on-1 in the clinic and in the community. Last fall, Berglund signed on with Lifesprk, a home health company serving older adults that promotes what it calls "7 elements of well-being"—including aspects of health and wellness. Berglund says she is looking forward to helping Lifesprk develop a robust community health promotion and injury-prevention program. Her enthusiasm is palpable. "I have a big vision and big plans," she says. "I believe the physical therapy profession has an obligation to address not only the physical therapy needs of individual patients and clients, but also to engage more broadly in community health. And we must do everything that we can toward—as APTA's vision statement says—"transforming society by optimizing movement to improve the human experience." An Ideal Match "We've got to turn things upside-down, and not get stuck in what we've traditionally done as PTs and PTAs," Black says. "We must continually evolve in response to the health needs of our communities. We must consider new delivery models. We need to step up and become leaders in health promotion." It's a role that's been a long time coming, Bezner says, and its time is now. "The impetus is epidemiology showing that most of the disease that causes morbidity and mortality is preventable. With conditions such as cancer, heart disease, and diabetes, risks are greatly lessened by behaviors such as engaging in physical activity, eating healthfully, getting sufficient sleep, and managing stress," Bezner notes. "We've known this for a couple of decades, but it's just in the past 10 years or so that the need to promote these behaviors has become imperative. So, we need not only to address these issues in the clinic during the course of physical therapy but also to figure out ways to do that with groups in our communities. "We can't ignore the fact that these issues are harming society and fueling skyrocketing health care costs," Bezner continues. "If we don't address them, we're complicit—frankly, we're contributing to the problem." Many roads lead to the change that Bezner and others want to see—volunteer efforts, grant-funded initiatives, and cash-pay businesses such as those described in past PT in Motion articles—including the multidisciplinary Body Mechanics clinic in Falls Church, Virginia, and the PT-designed exercise offerings of GroupHab in Simpsonville, South Carolina. Community health promotion extends, too, to citywide mobility programs, direct-to-employer health services, and pro bono health clinics. (To read more about these efforts, see "Resources" at left.) But while there's no single way to do it, there is a specific health care provider who's uniquely qualified to provide it: the PT, say those interviewed for this article. "Our background is ideal, because we're trained in physiology and pathology," Berglund says. "We know what goes on in the body and why things happen—which means that we also know how to prevent many of those things from happening." PTs spend more time with patients than do most other health care providers, she adds, which fosters trust. That trust facilitates discussion of behavior change—so, Berglund notes, many PTs already are comfortable asking health questions, discussing options, and referring out when individuals need help with exercise and physical activities. PTs also are well-positioned to discuss with patients such lifestyle matters as healthful eating, getting sufficient sleep, managing stress, and smoking cessation—although, Berglund says, too few PTs tend to feel comfortable discussing those issues. PTAs, too, are well-suited to roles in community health promotion, Bezner adds. "If PTs are really smart, they'll set up community programs and deploy PTAs to help implement them," she states. "All of these services realistically can be delivered by PTAs. They certainly have the needed abilities—although they may in some instances need some additional instruction in areas such as motivational interviewing and health coaching." Donald Lein, PT, PhD, agrees. "Community health potentially opens up the playing field for PTAs," he ventures, "because it's a less-restrictive environment in terms of payment." Lein, director of clinical education in the physical therapy department at UAB, is among a group of faculty members there who have developed a physical therapy model that has implications for community health promotion efforts. (See "A Relevant Model" on page 19.) Addressing Barriers Ask PTs why they don't engage in community health promotion efforts, and they'll most likely cite 3 factors, say the PTs contacted for this article: time, money, and comfort level. Berglund suggests a possible strategy to address the first 2. "If you're passionate about addressing health behaviors, prevention, health promotion, and population health, but your job doesn't allow you to do that, 1 option is to reconsider where you're working," Berglund says flatly, noting that some businesses and practices—like her employer—provide such opportunities. "Or," she advises, "if your employer doesn't offer or encourage injury prevention and health promotion activities, consider being the person to spark that change by starting a new program or class." Patel is sympathetic to the reluctance of PTs and PTAs to commit to obligations after work hours, recognizing that nearly everyone feels stretched thin by life's varied demands. Still, she says, it's important that PTs and PTAs seek opportunities to get involved in their local communities—whether or not they're getting paid for it. "Reimbursement isn't always going to be there right now for community health programs led by PTs," she concedes, "but we need to get beyond that—and, in the process, build the case for why we should be paid for the community health services we provide. We don't necessarily have to look very far, or venture into unfamiliar settings," she adds. "Where do you live? Where do you work? Where do you pray? To which clubs or activity groups do you belong? Think about the ways in which you can have an impact in those places and settings by helping people change their behaviors to improve their health." APTA deems altruism to be essential to professionalism in PTs and to value-based behavior in PTAs,6 Patel notes. "Being altruistic in these situations should be foremost," she says, "because community health is a huge issue with broad societal implications. As more of us speak up and take actions that show that we can make a dent in lifestyle behaviors, policy changes related to reimbursement will come." Berglund concedes that there aren't yet nearly as many paying models in community health as she'd like to see. She adds, however, "No one is going to create innovative models for us. We need to step outside our traditional box, as PTs rooted to our clinical space, and say, ‘We are members of a doctoring profession who have a great deal to offer our communities. Are you willing to invest in some of the valuable services we can provide?'" That's 1 reason APTA's Council on Prevention, Health Promotion, and Wellness (see "Resources" on the facing page for the link) came into being in January—to serve as an actionable networking and information-gathering venue to share ideas about, and experience with, innovative practice models. The council's mission statement, Berglund notes, is "to facilitate the profession's role in transforming society and physical therapist practice by connecting people and knowledge to develop and disseminate best practices in prevention, health promotion, and wellness for all individuals and populations." What that means in practical terms, Berglund says, is sharing ideas, experiences, information, and evidence on everything from creating consistent language to pooling evidence, developing best-practice guidelines, offering practical resources and tools, and devising advocacy strategies. The council also aims ultimately to bring PTs and PTAs together with members of other health professions for collaboration. The idea is to address prevention, health promotion, and wellness "from the individual level up," as Berglund puts it—from conversations with physical therapy patients in the clinic about their health behaviors to efforts directed at social determinants of health (the physical environment, socioeconomic status, social supports, and other factors) in the community. As for the third reason PTs and PTAs may avoid community health opportunities—insufficient comfort level—the council aims to help there, too. "As we work together to develop best practices in prevention, health promotion, and wellness for PTs and PTAs in individuals and populations, more and more of us are going to feel comfortable, knowledgeable, and proficient offering these services," Berglund says. Black acknowledges that many PTs question the propriety of asking people about their health habits—and fear blowback if they do. She counters those concerns with study results that she helped garner. A few years ago, she and 2 other PTs surveyed 230 physical therapy patients at outpatient clinics in the Minneapolis and Detroit areas. "The results of this study," the research report concluded, "suggest that the majority of patients believe it is appropriate for physical therapists to incorporate health promotion into their clinical practice through discussions of patients' personal health behaviors in the areas of physical activity, healthy weight management, and abstaining from smoking."7 The survey results confirmed that "our patients have a lot of faith in us and trust us. They know we're looking out for their best interests in terms of health in the broadest sense. We have a lot of credibility with them. They will listen to us," Black says. Thinking Differently MarySue Ingman, PT, DSc, says it's no coincidence that Berglund, a recent graduate and her former student, is among APTA's movers and shakers in encouraging greater PT and PTA involvement in health promotion within the clinic and beyond. "This new generation of graduates thinks differently," says Ingman, an associate professor of physical therapy and assistant director of clinical education at St Catherine University in Minneapolis. "They get it. They understand that just fixing people after they've had a pathology is not enough—PTs need to be health promoters, as well." (Ingman was 1 of Black's coauthors on the patient survey.) At St Catherine—as in many PT education programs across the country, Ingman notes—students are taught motivational interviewing techniques and health coaching principles. "They know we need to ask people about a variety of health behaviors that impact well-being—sleep, stress, diet, smoking—and help to facilitate improvement in those areas." "Students are coming out of school with these skills," Berglund says. "My peers among early-career PTs tend to feel very strongly that we can't operate in a reactionary mode anymore, because too many people succumb to preventable conditions and diseases. Our health care system will continue to fail if we are not actively and aggressively engaged in health promotion on both the individual and community level." At Oakland University, Black says, "our students not only are learning the theory behind health promotion in their coursework, but they're also going out into the community and modeling it. They're running balance and falls clinics. They're educating dancers in injury prevention. We've incorporated health promotion service projects for our students so that when they graduate, they've already had experience with various community populations and can take things from there when they embark on their careers." That has been Patel's experience. "We've been teaching community health promotion at TWU for almost 10 years. Many of our alumni are involved in health promotion activities in their communities—most of it pro bono," she reports. "It's so gratifying to have my former students working alongside my current students and me on projects the former students started. Engaging in community health promotion is an important way in which we can help transform society." Because recent graduates aren't caught up in a traditional way of practice, they're likelier to "see opportunities that those of us who've been in practice for years don't see," Black says. "They're likelier to question our way of doing things and come up with new ideas." That excites Bezner, who urges veteran PTs who own practices and lead departments to jumpstart the process. "Today's students are prepared for these roles at graduation," she says, "So, hire them. Put them to work. Take advantage of their skills, mindset, and enthusiasm to expand our profession's footprint and improve community health." Eric Ries is the associate editor of PT in Motion. A Relevant ModelAmong the factors that may hold PTs back from engaging in community health promotion efforts are unease when it comes to asking people about their unhealthy habits and uncertainty about how best to do it. Researchers at the University of Alabama at Birmingham (UAB) have developed a clinical model that they think can help.The Health-Focused Physical Therapy Model (HFPTM), described in the December 2017 issue of Physical Therapy,1 offers a series of steps to integrate a health promotion and wellness focus into physical therapist practice. Although it pertains solely to 1-on-1 care and specifically addresses only PTs encouraging smoking cessation and regular physical activity, the model has implications for broader health-promotion efforts, according to 1 of its authors."If PTs become more comfortable addressing modifiable risk factors and unhealthy behaviors with patients on an individual basis—and I believe our model is useful in that regard—they'll be better-equipped and more motivated to address these issues in the community," says David Morris, PT, PhD, FAPTA, who chairs UAB's physical therapy department."The patient-client management model in the Guide to Physical Therapist Practice is a sequential process, but it's not linear—there's movement back and forth between different stages," Morris notes. "Recognizing its benefits, we thought, why not try to come up with a health promotion model that could be embedded into the patient-client management model?"In the resulting HFPTM, PTs screen patients and clients for health promotion needs, then develop a management plan. It might include "health-focused interventions" by the PT, referral to other providers, or both. The model also features an outcomes-analysis element—creating a feedback loop to further refine PTs' understanding of health promotion needs in the clinic and potentially at the community level.To gather additional insight and further refine the model, the UAB researchers convened a summit consisting of 21 researchers, educators, and practitioners from other health care fields. UAB researchers set up a "world café" format in which various questions were addressed in a series of roundtable discussions. The goal was for the summit participants to provide feedback on PTs' appropriate role in health promotion and on the draft HFPTM."We sought out a broad group of people who understood lifestyle medicine but didn't necessarily know that much about what physical therapists do," Morris says. He and his PT colleagues described the patient-client model and the enhancements proposed in the HFPTM. The response from the summit attendees was gratifying."Overall, the group was quite positive about our role in providing health education and promotion services," Morris reports. "Once they understood how much time we spend with our patients and the extent of our education, training, and preparation, there was a feeling among them of, ‘You guys are well-suited to this.'"ReferencesLein DH, Clark D, Graham C, et al. A model to integrate health promotion and wellness in physical therapist practice: development and validation. Phys Ther. 2017;97(12):1169-1181.ResourcesAPTA Council on Prevention, Health Promotion, and Wellness Webpage www.apta.org/PHPW/Describes objectives, offers signup opportunities via the APTA Hub community, and lists related information and materials available from the association.Twitter: @PHPWCouncilFacebook public: www.facebook.com/APTAPreventionHealthPromotionWellnessCouncil/Facebook group: www.facebook.com/groups/199939420551282APTA Prevention, Wellness, and Disease Management Webpagewww.apta.org/PreventionWellness/Links to APTA positions on the roles of the association and of PTs in prevention, wellness, fitness, health promotion, and management of disease and disability; language in state practice acts; information on annual checkup by a PT; balance and falls resources; information on nutrition and physical therapy and physical fitness for special populations; and PT in Motion's "Well To Do" wellness column. APTA Racial and Ethnic Health Disparities Homepagewww.apta.org/HealthCareDisparities/Links to research and resources on an important factor affecting community health provision.PT in Motion Articles and Columnswww.apta.org/PTinMotion/"Opportunity of a Lifetime" (November 2014). Looks at specific community health efforts and programs serving individuals across the lifespan—ranging from a family-fitness program in underserved areas of Los Angeles to a PT-owned multidisciplinary, cash-pay health promotion and wellness practice in the Washington, DC, suburbs. "PTs and Population Health" (March 2018). Examines why the association envisions a greatly expanded role for PTs and PTAs in direct-to-employer health services, and the implications of that for addressing societal health needs."Getting Around: Community Mobility" (November 2017). Describes how PTs are helping to transform society by reducing literal and figurative barriers to movement in cities and towns. "A Different Kind of Group Therapy" (February 2016). A PT recounts why she created a business that offers PT-designed and -supervised group-exercise classes to older adults and people with conditions such as cerebral palsy and Parkinson disease."Free To Lead" (March 2010). A look at student-run pro bono clinics—how they operate and the community goals they address.