Perspective

E. Dean, PT, PhD, Department of

Physical Therapy, University of British Health Competency Standards in
Columbia, T325-2211 Wesbrook Mall,
Vancouver, British Columbia V6T 2B5,
Canada, North America/Caribbean.
Physical Therapist Practice
Address all correspondence to Dr Dean
at: Elizabeth.dean@ubc.ca.
Elizabeth Dean, Margot Skinner, Hellen Myezwa, Vyvienne Mkumbuzi,
M. Skinner, PT, PhD, School of Physio-
therapy, University of Otago, Dunedin,
Karien Mostert, Diana C. Parra, Debra Shirley, Anne Söderlund, Armele
New Zealand, Asia Western Pacific. Dornelas de Andrade, Ukachukwu Okoroafor Abaraogu, Selma Bruno,
H. Myezwa, PT, PhD, Department of Diane Clark, Sif Gylfadóttir, Alice Jones, Sundar Kumar Veluswamy,
Physiotherapy, University of Witwater- Constantina Lomi, Marilyn Moffat, David Morris, Ann-Katrin Stensdotter,
srand, Johannesburg, South Africa. Wai Pong Wong, Global Health Working Group

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

V. Mkumbuzi, PT, PhD, Physiotherapy
Program, College of Medicine, Univer-
sity of Malawi, Blantyre, Malawi, Africa. Although the physical therapist profession is the leading established, largely
nonpharmacological health profession in the world and is committed to health
K. Mostert, PT, PhD, Department of
Physiotherapy, University of Pretoria,
promotion and noncommunicable disease (NCD) prevention, these have yet to be
Hatfield, South Africa. designated as core physical therapist competencies. Based on findings of 3 Physical
D.C. Parra, PT, PhD, Department of
Therapy Summits on Global Health, addressing NCDs (heart disease, cancer,
Physical Therapy, Washington Univer- hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an
sity in St Louis School of Medicine, urgent professional priority. The Third Summit established the status of health
St Louis, Missouri; and Rosario Univer- competencies in physical therapist practice across the 5 World Confederation for Physical
sity, Bogota, Colombia, North Amer- Therapy (WCPT) regions with a view to establish health competency standards, this
ica/Caribbean, South America. article’s focus. Three general principles related to health-focused practice emerged, along
D. Shirley, PT, PhD, Discipline of Phys- with 3 recommendations for its inclusion. Participants acknowledged that specific
iotherapy, Faculty of Health Sciences, competencies are needed to ensure that health promotion and NCD prevention are
Sydney, The University of Sydney, Lid- practiced consistently by physical therapists within and across WCPT regions (ie,
combe, Australia, Asia Western Pacific. effective counseling for smoking cessation, basic nutrition, weight control, and reduced
A. Söderlund, PT, PhD, School of sitting and increased activity/exercise in patients and clients, irrespective of their
Health, Care and Social Welfare, presenting complaints/diagnoses). Minimum accreditable health competency standards
Mälardalen University, Västerås, within the profession, including use of the WCPT-supported Health Improvement Card,
Sweden, Europe.
were recommended for inclusion into practice, entry-to-practice education, and research.
A. Dornelas de Andrade, PT, PhD, De- Such standards are highly consistent with the mission of the WCPT and the World Health
partamento de Fisioterapia, Universi- Organization. The physical therapist profession needs to assume a leadership role
dade Federal de Pernambuco, Recife,
vis-à-vis eliminating the gap between what we know unequivocally about the causes of
Brazil, South America.
and contributors to NCDs and the long-term benefits of effective, sustained,
U.O. Abaraogu, PT, Department of
nonpharmacological lifestyle behavior change, which no drug nor many surgical
Medical Rehabilitation, University of
procedures have been reported to match.
Nigeria Enugu Campus, Enugu, Nige-
ria, Africa; and School of Life Sciences,
Glasgow Caledonia University, Glas-
gow, United Kingdom, Europe.
S. Bruno, PT, PhD, Departmento de Fi-
sioterapia, Universidade Federal do Rio
Grande do Norte, Natal, Brazil, South
America.
D. Clark, PT, PhD, Department of Phys-
ical Therapy, University of Alabama,
Birmingham, Alabama, North Amer-
ica/Caribbean.

1242  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

T
he First and Second Physical Therapy Summits on Global Health (2007 and 2011) S. Gylfadóttir, PT, MSc, Physical Ther-
paved the way for the Third Summit (2015), the focus of this Perspective article, apy, Reykjalundur Rehabilitation Cen-
and its findings related to establishing minimal accreditable health competency ter, Mosfellsbaer, Iceland, Europe.
standards in the profession. These standards relate to health promotion and disease A. Jones, PT, PhD, Discipline of Phys-
prevention with special reference to noncommunicable diseases (NCDs). NCDs were a iotherapy, Faculty of Health Sciences,
priority given they are leading causes of morbidity, disability, and premature death The University of Sydney; and De-
partment of Rehabilitation Sciences,
worldwide and increasingly so in low- and middle-income countries.
The Hong Kong Polytechnic University,
Hong Kong, Asia Western Pacific.
The prime focus of the 3 summits was on the role of physical therapists in reducing the
S.K. Veluswamy, PT, PhD, Department
knowledge translation gap between evidence supporting healthy lifestyle choices and
of Physiotherapy, Ramaiah Medical Col-
the practices of health professionals, including physical therapists, to promote healthy lege and Hospitals, Bangalore, India,
lifestyles with targeted examination/assessment of every patient’s and client’s health and Asia Western Pacific.
lifestyle behaviors and targeted interventions, including health education and exercise

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

C. Lomi, PT, MSc, Department of
prescription. In terms of effectiveness in promoting lifelong health and preventing NCDs, Occupational and Physical Therapy,
few, if any, drugs compare with the benefits of healthy lifestyles. Thus, Karolinska University Hospital, Stock-
nonpharmacological approaches such as effective health education and physical holm, Sweden, Europe.
activity/exercise prescription, both consistent with physical therapist practice, are a M. Moffat, PT, PhD, Department of
priority in addressing contemporary global health priorities as declared by the World Physical Therapy, New York University,
Health Organization (WHO) and the United Nations as well as the World Confederation New York, New York, North Amer-
for Physical Therapy (WCPT). ica/Caribbean.
D. Morris, PT, PhD, Department of
In this article, the frame of reference for establishing health competency standards in Physical Therapy, University of Alabama
physical therapist entry-level (professional) education and practice is detailed first. Then, (NA).
the outcomes of the Third Summit are described: (1) the overarching principles that A-K. Stensdotter, PT, PhD, Department
emerged regarding the integration of health competencies into physical therapist of Neuromedicine and Movement Sci-
practice; and (2) specific recommendations regarding examination/assessment of health ence, Norwegian University of Science
status and NCD risk factors, including lifestyle behaviors, and interventions that can be and Technology, NTNU, Trondheim,
readily integrated into practice to maximize health and minimize NCD risk in every Norway, Europe.
patient and client. W.P. Wong, PT, PhD, Academic Pro-
grammes Division, Singapore Institute
of Technology, Singapore, Asia Western
Frame of Reference Pacific.
Health protection can be viewed as an element of the construct of health promotion and
[Dean E, Skinner M, Myezwa H, et
disease prevention for which physical therapists have a major role as consultants to al. Health competency standards in
policy-makers and government. Health protection focuses on social and environmental physical therapist practice. Phys Ther.
determinants of health involving communities and workplaces that align with the 2019;99:1242–1254.]
planetary health movement (Tab. 1). This perspective is consistent with the 
C 2019 American Physical Therapy As-
WCPT-supported International Classification of Functioning, Disability, and Health and sociation
the role of contextual factors, including the environment and personal attributes, in Published Ahead of Print:
determining a person’s health status.1 That patients and clients have access to the June 12, 2019
integration of “best” evidence-based practices, including health education and health Accepted: February 23, 2019
promotion and NCD prevention services, is stipulated in the first principle of ethical Submitted: July 11, 2018
practice by the WCPT.2

The gap between the unequivocal evidence regarding the relationship between lifestyle
and NCDs and lack of systematic intervention to address this gap in health services has
been referred to as the “ultimate knowledge translation gap.”3 An international
benchmarking study of physical therapist curriculum content related to health promotion
and NCD prevention supports this contention,4 first documented by Rea and colleagues.5
Given that education is a primary focus of standard practice, physical therapists are
uniquely positioned to assume a leadership role in knowledge translation related to
NCDs and their risk factors, and the minimization of these.

One knowledge translation model is the coordinated implementation model, which

depicts a multisectorial process for health protection, health promotion, and NCD
prevention.6,7 Although physical therapists have the potential to protect and promote
health and prevent NCDs at a significant level clinically, they also have a social
responsibility to share their knowledge to effect change at the organizational and societal

2019 Volume 99 Number 9 Physical Therapy  1243

Health Competencies

health policy levels and pave the way for other health continuously and seamlessly support sustained healthy
professional groups.8 The study reported by Ketkar and lifestyles in patients and clients.
colleagues9 is an example of physical therapists assuming
a leadership role and spearheading a health promotion The social and economic costs of lifestyle behaviors are
and NCD prevention initiative in the workplace, a health well recognized by governments. One seminal study
service setting for employees, as a basis for informing examined lifestyle behaviors of registrants with the
institutional health policy. Using established screening and National Health Service in the United Kingdom over 1
evaluation methods for NCDs, the investigators year. Based on a sophisticated economic analysis, the
documented poor dietary practices, suboptimal blood investigators reported that the greatest contributors to
pressures, and physical inactivity as leading modifiable health care costs in descending order of economic impact
risk factors in the cohort, a cohort that might be inclined were diet, smoking, being overweight, alcohol
to be more mindful of their lifestyle practices and status. consumption, and physical inactivity.13 Further, recent
The data provided a basis for targeted health education evidence supports that these costs can be mitigated with

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

programs for health services employees. With particular lifestyle intervention including modest nutritional
reference to 2 injurious lifestyle behaviors, namely, changes.14 Thus, compelling evidence was provided for
inactivity and smoking, Lein and colleagues10 described a systematically addressing these as a priority in every
model to integrate health promotion and wellness into patient and client.
standard physical therapist practice. This model paves the
way for establishing a database of examination/assessment Further evidence for physical therapists embracing health
tools and interventions for effecting positive and sustained promotion and NCD prevention in their patients and
lifestyle behavior change. clients. regardless of presenting problems and diagnoses,
comes from the Behavioral Risk Factor Surveillance
Two seminal studies have added particular weight to the reports on the health of people with disabilities.15 Not
argument supporting dedicated health promotion and only are people with disabilities more likely to report
NCD prevention in every patient or client interaction. First, poorer health status than those without disabilities, but
Ford and colleagues11 reported that in a cohort of over also they are several times more likely to smoke, be
23,000 adults, those with healthier lifestyle behaviors and overweight, and be inactive. These findings suggest that
related attributes (ie, not smoking, healthy eating healthy lifestyle practices are as vitally important for
practices, optimal body mass, and regular physical individuals with physical disabilities as for those without
activity), reduced the risk of several NCDs over several such disabilities. Furthermore, optimal nutrition has been
years. Specifically, the risk for type 2 diabetes was reduced reported to be of singular importance in relation to the
by 93%, myocardial infarction by 81%, stroke by 50%, and incidence of physical impairment. Hagan and colleagues16
various cancers by 36%. Even if not all 4 lifestyle behaviors reported in a cohort of 54,782 from the Nurses’ Health
or related attributes were present, the risk of developing 1 Study that greater adherence to healthy eating practices
or more chronic lifestyle-related NCDs decreased was associated with lower risk of functional impairment.
commensurate with the number of positive lifestyle factors This is a provocative notion in that by addressing eating
to which individuals adhered. Second, Blanchard and practices of patients and clients, physical therapists can
colleagues12 reported that even with a diagnosis of cancer, reduce such risk and, should impairments occur, their
the proverbial wake-up call, survivors’ lifestyle behaviors severity could be mitigated and response to interventions
were alarmingly poor, that is, in over 9000 survivors, only enhanced. Lastly, the negative consequences of the
14.8% to 19.1% adhered to the recommendations of 5 daily standard Western diet have been well documented in favor
servings of fruit and vegetables, and 29.6% to 47.3% of more healthful evidence-based nutritional regimens. For
adhered to physical activity recommendations. However, example, greater adherence to a Mediterranean-type
82.6% to 91.6% were not smoking. Only 5% met all 3 plant-based diet has been associated with reduced
general health recommendations (not smoke, consume at vascular disease and less frailty in the aged17 and superior
least 5 servings of fruit and vegetables daily, and engage health outcomes overall.
in at least 150 minutes weekly of moderately intense
physical activity/exercise). Thus, lifestyle behavior change Over the past decade, the WCPT has made strides in
warrants targeting with inbuilt mechanisms for lifelong increasing the profile of NCDs in global physical therapist
sustainability, given that having a potentially terminal practice, with the publication of several noteworthy
diagnosis does not appear to constitute sufficient reports. The WCPT, a member of the World Health
motivation to change lifestyle behavior. On an Professions Alliance, was actively involved in the
encouraging note, however, the investigators reported that development of the Health Improvement Card (HIC) with
health-related quality of life improved with each additional 4 other established leading health professions, namely,
positive lifestyle behavior reported. Thus, the need for dentistry, nursing, medicine, and pharmacy.18 The HIC
lifestyle behavior change warrants being systematically provides a strategic starting point for examining/assessing
evaluated and a targeted intervention planned in order to health and NCD risk and implementing lifestyle behavior
change interventions. There is little evidence, however,

1244  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

Table 1.
Health Competency Definitions

Term Definition Source

Health Although health promotion is subsumed in some definitions of health protection, Association of Faculties of Medicine of Canada,
protection health protection is often broader to include minimizing exposure to hazards from 2017.72
the environment, occupation, and hazardous waste. In addition, health protection
can be viewed as distinct from health promotion given that for individuals whose
health status and lifestyle practices are exemplary, protecting their health vs
necessarily promoting further health improvement is the goal

Health Health promotion aims to enhance health through public policy, healthy social and The Ottawa Charter for Health Promotion. First
promotion physical environments, healthy lifestyle practices, and personal resilience. “Making International Conference on Health Promotion,
the healthy choice the easy choice” is part of the health promotion movement. Ottawa, November 21, 198626
(http://www.who.int/healthpromotion/conferen

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

ces/previous/ottawa/en/)
“Health promotion is the process of enabling people to increase control over, and
to improve, their health. To reach a state of complete physical, mental and social
well-being, an individual or group must be able to identify and realize aspirations,
to satisfy needs, and to change or cope with the environment. Health is therefore
seen as a resource for everyday life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as well as physical capacities.
Therefore, health promotion is not just the responsibility of the health sector, but
goes beyond healthy life-styles to well-being.”

that the HIC has been systematically adopted by any of Therapy Summit on Global Health reflected on
WCPT’s member organizations. We based this observation evidence-based health examination/assessment tools and
on direct questions to the Summit participants about their health behavior change
familiarity with the tool and their knowledge of their or strategies/interventions/approaches across the WCPT
others’ use of it clinically. regions and establishing health competency standards
across regions.21
Based on these lines of reasoning and evidence, the
Summit team initiated a global forum to review the status Health Competency Standards: Principles
of health promotion and NCD prevention within the
profession and tools related to health competencies, and Recommendations
including use of the HIC, and how these could be more Three overarching principles underlying health
effectively profiled and operationalized to facilitate their competencies in physical therapist practice emerged: (1)
uptake into practice. This would be a singular their theoretical and practice foundations; (2) the construct
achievement not only for the physical therapist profession of health-focused practice; and (3) that health promotion
but as an example to other health professions. and NCD prevention need to be shared competencies
across health professionals. Recommendations for health
competencies include minimum standards for
The Physical Therapy Summits on Global examination/assessment tools to inform health promotion
Health and NCD prevention interventions, and for behavior
An outcome of the First Physical Therapy Summit on change interventions. Interventions broadly focused on
Global Health was that physical therapists are the leading, counseling for smoking cessation, healthy nutrition,
established, largely nonpharmacological health maintaining a healthy weight, reduced sitting and being
professionals, and they have a primary role in addressing physically active, optimal sleep, and manageable stress.
global health priorities, specifically, the lifestyle-related Part of the intervention competencies was knowing, based
NCDs.19 No doubt exists that for prevention and on the examination/assessment, when to refer the patient
management of the chronic stages of the NCDs, or client to another established health
nonpharmacological interventions (health education and professional.
physical activity and structured exercise) are the
interventions of choice as noted in clinical practice Principle: Incorporate Into Physical Therapist
guidelines related to the prevention and management of Education and Practice the Theoretical and
NCDs. Outcomes of the Second Physical Therapy Summit Practical Foundations of Health Competencies
on Global Health were global regional action plans that A theoretical and practice foundation reflected in the
focused on health and NCD prevention in every patient established specialty of behavioral medicine served as a
and client.20 These were developed by regional working foundation to guide and inform lifestyle-related behavior
groups in a World Café dialogue format and published. change competency standards within established physical
Based on the 2 previous summits, the Third Physical therapist practice. Behavioral medicine is defined by the

2019 Volume 99 Number 9 Physical Therapy  1245

Health Competencies

International Society for Behavioral Medicine as “an would occur throughout the entire episode of physical
interdisciplinary field dealing with the integration of therapist services. To effectively adopt this framework, the
psychosocial, behavioral, and biomedical knowledge of process depends on the health professional’s self-efficacy
relevance for health in health protection and health to effect lifestyle-related behavior change in patients and
promotion, diagnosis, treatment, and rehabilitation.”22 An clients, that is, to enhance their self-efficacy to effect such
offshoot of behavioral medicine is lifestyle medicine, change and know when to refer to other professionals.
which singularly focuses on the knowledge, skills, and Previous work supports the fact that physical therapists
competencies needed to protect and promote health.23 value health protection and health promotion practice, yet
The American College of Preventive Medicine and key they report a lack of confidence in their capacity to effect
stakeholders propose having an important role in ensuring such change.31–34 Evidence of barriers toward health
lifestyle medicine practices and programs are based on behavior change have been supported by Abaraogu and
proven and effective methods of preventing and colleagues.35–37 Dean and colleagues29 recently published
controlling disease.24 Clinical practice guidelines for an example of how 1 entry-to-practice physical therapist

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

management of chronic NCDs typically have lifestyle education program has attempted to address this in the
behavior change as the priority. absence of accreditation standards for such practice.

Principle: Incorporate Into Physical Therapist Lifestyle behavior changes most importantly need to
include smoking cessation; a healthy anti-inflammatory
Education and Practice Health-Focused Practice
diet (ie, plant-based diets such as the Mediterranean
Health-focused physical therapist practice can be defined
diet38,39 rather than the standard Western diet40 [also
as health promotion and NCD prevention practices that
referred to as the American diet]); reduced or non-harmful
target a patient’s or client’s overall health and well-being
alcohol consumption; healthy body weight; less sedentary
consistent with the WHO’s definition of health.19,25 Such
behavior; regular physical activity and exercise; better
practice is underpinned by the WCPT-supported
quality sleep; and less unmanageable stress, anxiety, and
International Classification of Functioning, Disability, and
depressive symptoms. The standard Western diet has been
Health1 and the definitions of health protection and health
reported to underlie the NCD pandemic in Western
promotion by The Ottawa Charter26 (Tab. 1). Health is
societies and other societies that are increasingly adopting
defined by the WHO as a complete state of physical,
this eating pattern.40 Lifestyle behaviors, like taking
social, and emotional well-being, not simply the absence
medications, can interact not only positively or negatively
of disease; and, health promotion is defined as “the
by possibly altering the pharmacodynamics of
process of enabling people to increase control over, and to
medications, but they may also augment the beneficial
improve, their health. To reach a state of complete
effects of each other, additively or multiplicatively.
physical, mental and social well-being, an individual or
group must be able to identify and realize aspirations, to
A component of teamwork to which physical therapists
satisfy needs, and to change or cope with the
aspire is the notion of cross-referral. For coordinated
environment.” The WHO has long advocated for lifestyle
seamless health care, physical therapists, like other health
behavior change given the evidence supporting its
professionals, need to identify what is within their scope
long-term health benefit.27 Further, in its Global Strategy
of practice-given health competencies and what is not.
on Diet, Physical Activity, and Health,28 the WHO
They need competencies to judge when to refer patients
promoted and provided support for educating health
to other health professionals, both for physical and mental
professionals about healthy nutrition and physical activity,
health issues.
either within existing programs or in dedicated
workshops, as an essential component of the curricula for
Health-based studies are needed to elucidate these
entry-level health professions’ education and postgraduate
relationships so that the invasive practices of physicians
professional development.29
and surgeons can be better integrated with noninvasive
practices, such as those of physical therapists (the largest
Principle: Incorporate Into Physical Therapist established noninvasive health professional group). Over
Education and Practice That Health Competencies time, as the benefits of a healthy lifestyle take effect for
Need to Be Shared Across Health Professionals the patient and client, health professionals can better
An example of an algorithm for interprofessional titrate invasive and noninvasive interventions and
collaborative practice in health protection and promotion procedures to the patient’s or client’s needs. By so doing,
practice appears in an article by Dean and colleagues,30 drug usage can be reduced and surgery avoided or
and it is designed to ensure that such practice is replaced with less invasive or noninvasive interventions.
expedient, seamless, and cost-effective. The process is
reflexive, that is, the examination/assessment, initiation, Recommendations for Standards for Health
intervention, and reinforcement are done by the physical Competencies
therapist or initiated by the therapist and with referral to We recommend that the minimum standards for health
another health professional. Then, ongoing evaluation competencies that emerged from the Third Physical

1246  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

Therapy Summit on Global Health be adopted into Integral to health protection and health promotion
globally endorsed accreditation standards for physical practices are interprofessional practices and cross-referral
therapist practice. Further, these competencies should be to appropriate health practitioners. In summary, a
recommended for adoption by all established health psychosocial perspective to physical therapist practice was
professions to ensure that seamless attention to the viewed as a foundation requirement based on the
patient’s or client’s needs is consistent across health principles encompassed in the established specialty of
service providers, and that due priority is given by health behavioral medicine.22
professionals to reduce the risk of patients and clients
falling through the cracks in terms of overall health and
NCD risk factors. Broad categories of lifestyle behavior Recommendation: Health and Lifestyle Behavior
change appear in Table 2, and more specific details are on Examination/Assessment Tools Be Core Physical
a dedicated website.41 Therapist Competencies
Core competencies related to health and lifestyle behavior

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

Extension of these proposed minimum standards and examination/assessment tools are broadly categorized in
adoption by other established health professions in Table 2. The tools are organized as follows: those related
addition to physical therapy has been described to general health measures; those related to
elsewhere.42,43 Health protection and health promotion lifestyle-related behaviors and attributes; and those related
practices need to be interprofessional collaborative efforts to NCD risk factors, including tools listed to
because they will only be The Ottawa Charter for Health examine/assess self-efficacy for behavior change and
Promotion. First International Conference on Health readiness to change a lifestyle behavior. More detailed
Promotion, Ottawa, November 21, 198626 examples of tools for examination/assessment and
(http://www.who.int/healthpromotion/conferences/previo intervention and related resources appear in the
us/ottawa/en/)recognized as important by patients and eAppendix.
clients through a unified effort in knowledge
translation/uptake across professions.42,43 The WHO has developed a comprehensive instrument for
risk factor surveillance.44 The STEPs instrument includes
Multiple health-based tools exist with respect to behavioral measures such as tobacco use, alcohol
examination/assessment of health and wellness, lifestyle consumption, diet, physical activity, and sedentary
behaviors, and NCD risk factors. We have compiled those behavior as well as other risk factors related to blood
deemed most readily integrated into physical therapist pressure, blood sugar, and blood lipids. Sections can be
practices with due consideration of their usefulness and used selectively, for example, diet and physical activity
psychometric soundness. In addition, we have compiled a and sedentary behavior, to provide a patient’s or
list of behavioral change theories and models that client’s baseline and outcome measures following
underpin effective lifestyle-related behavior interventions intervention.
in the context of a physical therapist episode of care
(Fig. 1). Special mention needs to be made of the HIC (Fig. 2),
which was developed and endorsed by the members of the
To be effective, lifestyle behavior change needs to be World Health Professions Alliance,18,45,46 with the WCPT
practiced consistently across health professions. Against having a prominent role. The HIC provides an easy entry
this background, the Centre of Excellence of Health into assessment of a patient’s or client’s biometrics and key
Competencies for Health Professionals, which profiles the lifestyle-related behaviors by the physical therapist, and
requisite tools for health-focused practices, was officially then provides recommendations based on a color-coded
opened during the third Summit. This database is system of green (meeting the criteria for healthy living for
accessible through the Centre’s website41 and is relevant to each behavior and low NCD risk), amber (cautionary NCD
health professional educators, researchers, program disease risk), and red (high NCD disease risk).
accreditors, administrators, consultants, and practitioners.
The purpose of the Centre’s website is to provide updated Various other tools are available to the physical therapist
evidence-informed tools for examination/assessment for assessing health attributes/lifestyle practices that
outcome for several leading lifestyle behaviors and related commonly underlie NCD risk. Clinical
intervention/strategies to support positive health examination/assessment tools that can be readily used
behaviors and address negative health behaviors. These clinically include the cardiovascular
tools have also been selected to be used in the contexts of examination/assessment tool by Grundy and colleagues,47
busy, time-constrained health professionals’ practices. CanRisk published by the Canadian Diabetes Association,48
Although tools consistent with minimum standards of and several risk assessment tools published by Harvard
health competencies are provided, additional tools are University Medical School.49 These are examples of tools
available for health professionals who wish to maximize that have been well studied and evaluated, and are short
the outcomes of their health competencies in patient and and easy to administer clinically. The fact that NCDs share
client lifestyle behavior change within their practices. common risk factors makes these options compelling to

2019 Volume 99 Number 9 Physical Therapy  1247

Health Competencies

Table 2.
Categories of Health Behavior Change Tools in the Tool Kit of the Centre of Excellence in Health Competencies for Health
Professionals: Examination/Assessment and Interventions/Strategies41,a

Health Status Parameter Related Assessment Tool or Outcome Measure

General health status Quality of life

Life satisfaction

Participation in life

Smoking practices Assessment/evaluation/outcome measures

Smoking cessation interventions and strategies

Nutrition practices Assessment/evaluation/outcome measures

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

Interventions and strategies to improve healthy nutrition

Weight loss Assessment/evaluation/outcome measures

Interventions and strategies to reduce body weight

Alcohol consumption Assessment/evaluation/outcome measures

Intervention and strategies to reduce unhealthy alcohol consumption

Sedentary behavior Assessment/evaluation/outcome measures

Interventions and strategies to reduce prolonged sitting

Physical activity Assessment, evaluation/outcome measures

Interventions and strategies to increase physical activity to healthy levels

Structured exercise programs Assessment/evaluation/outcome measures

Self-report measures

Objective measures

Interventions and strategies to increase structured exercise

Sleep health: quality and quantity Assessment/evaluation/outcome measures

Interventions and strategies to promote and support healthy sleep patterns

Mental health: well-being (states of anxiety, stress, and depressive symptoms) Assessment/evaluation/strategies

Interventions and strategies to promote and support optimal mental health

a
Physical therapists need to assess the mental health of patients and clients and promote positive mental health and well-being. For patients and clients with
mental health challenges, physical therapists should support, and reinforce the services they are receiving from others. With respect to scope of practice, physical
therapists can address depressive symptoms but not primary clinical depression or pathological mental illness for which a qualified mental health professional is
indicated. Source: https://www.mdh.se/polopoly_fs/1.82085!/Menu/general/column-content/attachment/References.pdf.

use clinically. The Ottawa Charter for Health Promotion. is at least at the contemplative stage of readiness to change
First International Conference on Health Promotion, a behavior, then the 5 “A”s, endorsed by the WHO, can be
Ottawa, November 21, 198626 (http://www.who.int/health initiated, namely, ask, advise, assess, assist, arrange.51
promotion/conferences/previous/ottawa/en/) However, if the patient or client is not expressing
readiness to change a targeted behavior, that is, the
precontemplative stage, then the 5 “R”s can be initiated,
Recommendation: Health Protection, Health namely, relevance, risks, rewards, roadblocks, repetition.52
Promotion, and NCD Prevention Interventions Be
Core Physical Therapist Competencies
Core competencies related to lifestyle behavior change Recommendation: Behavior Change Theories and
interventions appear in Table 2 and more specifically in Models Underpin Core Health Promotion and
the eAppendix. After the examination/assessment of the NCD Prevention Competencies in Physical
various lifestyle-related characteristics and personal Therapist Practice
attributes, the patient’s or client’s readiness to change each Multiple behavior change theories and models have been
lifestyle-related behavior is established based on the advanced and underpin behavioral medicine, the elements
transtheoretical model.50 Stages of change include of which can be used by physical therapists to effectively
precontemplative, contemplative, preparation, action, promote health behavior change in their patients and
maintenance, and potential relapse. If the patient or client clients. These include social learning theory,53 the

1248  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

Health belief model

model
scale

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

Figure 1.
Theories and models of behavior change that underpin health promotion and noncommunicable disease prevention examination/assessment
and interventions.

transtheoretical model,50 the health promotion model,54 individual to effect health behavior change through
the health belief model,55 theory of planned behavior,56 knowledge and skill set.53 Comparable to other accredited
and goal-setting principles. Practical behavioral physical therapist competencies deemed best practice by
approaches useful as a component of professional bodies, these competencies need to be taught
examination/assessment and intervention include progressively and integrated across semesters and years in
cognitive behavior therapy,57 behavior modification or the academic program. This is assured through various
operant conditioning,58 mindfulness and meditation,59 and multimodal formats, for example, the theoretical
motivational interviewing.60 foundations followed by clinical practice of the
competencies, initially in the classroom and then clinically
Practitioner as well as patient and client self-efficacy under supervision.
warrants special attention given it has been a
long-standing construct in health service delivery and Clinical reasoning related to lifestyle behavior change has
forms the basis of many patient and client been documented as a unique competency by Elvén and
self-management approaches. Self-efficacy has become a colleagues.62 These investigators published a clinical
central construct in health promotion and NCD prevention reasoning model for health behavior change with special
education. For patients and clients to develop self-efficacy, reference to physical therapists increasing physical activity
health professionals need self-efficacy in assessing the in their patients and clients. The model, informed both by
need for health promotion/NCD prevention education in established theory and evidence, elucidates a process
their patients and clients, in selecting and providing the algorithm for examining/assessing patients and clients,
appropriate intervention(s) with targeted and tailored and potential tools for effecting person-centered
health promotion recommendations and advice, and in management. The model is reflexive, that is, response
evaluation of their effects. This process is comparable to driven, to maximize health behavior change outcomes and
examination/assessment and prescription of interventions their sustainability.
that constitute established physical therapist practices. In a
special report to the American Heart Association with Based on the extant literature, health professionals need
respect to the need to examine translational applications to serve as health role models as well as advocates. With
of dietary recommendations to maximize long-term respect to health service delivery, physicians who practice
adherence, Van Horn and colleagues61 described several healthy lifestyles have been reported to be not only more
methods, yet they acknowledged this was an area of likely to address health promotion with their patients and
knowledge deficit for practitioners. clients63,64 but also viewed as more credible by patients.65
Consistent with this body of knowledge, we support the
Originally, Bandura conceptualized self-efficacy largely as principle of The Patient Promise66 initiative that provides a
the function of 2 factors: (1) the importance to the person public forum for health professions to pledge to both live
of the behavior to change and (2) the confidence of that a healthy lifestyle and support this in their patients. The

2019 Volume 99 Number 9 Physical Therapy  1249

Health Competencies

pledge has 3 components: (1) “what I understand about Future Directions

healthy living as a health care professional”; (2) “what This article provides a basis for including health
healthy living practices I endeavor to adhere to”; and (3) a promotion and NCD prevention competencies into
signed on-line public declaration of commitment and physical therapist professional education. as well as
endorsement to the initiative’s values and practices. To practice, as a means of reducing the knowledge
serve as credible and effective health professionals, translation gap between what is known about healthy
physical therapists should be viewed foremost as role living and NCD risk and people’s lifestyle practices. We
models in their roles as health professionals, who practice acknowledge that establishing standards of health
healthy living consistent with their commitment to health. promotion and NCD prevention competencies constitutes

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

Figure 2.
Health Improvement Card (Source: World Health Professions Alliance, 2017, with permission).18

1250  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

Figure 2.
Continued.

a work in progress, which like other scholarly endeavors, primarily nonpharmacological profession, needs to
warrants ongoing scrutiny and refinement. assume a leadership role in establishing minimum
accreditable health promotion and NCD prevention
Physical therapists could well be the first health competencies that could also be integrated into the
profession in the world to be truly committed to the practices of medicine and nursing and potentially
overall health and NCD prevention in every patient and dentistry and pharmacy. Such a position is highly
client, and to serve as leaders to other health professions. consistent with the profession’s commitment to best
They are uniquely and strategically well positioned to practice and the ethical standards of the WCPT.
assume a leadership role vis-à-vis health professionals’ Incorporating health competencies into standard practice
integrating lifestyle examination/assessment and would be a bold initiative, in that it would constitute a
interventions into their practices. We argue that the “first” within and across the leading established health
physical therapist profession, as the largest established, professions. Finally, this position is highly consistent and

2019 Volume 99 Number 9 Physical Therapy  1251

Health Competencies

aligned with the tenets of Hippocrates to which all health Data analysis: V. Mkumbuzi, K. Mostert, A. Söderlund, U.O. Abaraogu
professionals need to aspire: “first do no harm” and “the Project management: E. Dean, M. Skinner
function of protecting and developing health must rank Providing institutional liaisons: D. Shirley
even above that of restoring it when it is impaired.”67 Clerical/secretarial support: E. Dean
Consultation (including review of manuscript before submitting): E. Dean,
M. Skinner, H. Myezwa, V. Mkumbuzi, K. Mostert, D.C. Parra, D. Shirley,
With respect to the United States, Healthy People 2020 has
A. Söderlund, A. Dornelas de Andrade, U.O. Abaraogu, S. Bruno, D. Clark,
been a primary initiative to improve the health of the S. Gylfadóttir, A. Jones, S.K. Veluswamy, C. Lomi, M. Moffat, D. Morris,
population.68 It aspires to many of the same tenets as A-K. Stensdotter, W.P. Wong
those of the WHO’s documents over the years.69,70 Healthy
People 2020 constitutes a nationwide database. This Funding
database has provided an evidence base for public health
There are no funders to report.
planning in the country and development of health
behavior change initiatives across stakeholders. In Disclosures

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

addition, the database has captured income inequity data,
thereby enabling stakeholders to better address the social The authors completed the ICMJE Form for Disclosure of Potential Conflicts
of Interest and reported no conflicts of interest.
determinants of health in the United States. Planning is
now underway for Healthy People 2030.71 There is DOI: 10.1093/ptj/pzz087
opportunity for the profession of physical therapy to have
input to Healthy People 2030 and direct its agenda. References
1 World Health Organization. International Classification of
Functioning, Disability and Health. http:
Conclusion //www.sustainable-design.ie/arch/ICIDH-2PFDec-2000.pdf.
The existing health knowledge base appears not only Published December 2000. Accessed March 28, 2019.
sufficient but unequivocal and warrants translation into 2 World Confederation for Physical Therapy. Policy statement:
ethical responsibilities of physical therapists and WCPT
minimum accreditable standards of health promotion and members.
NCD prevention competencies in physical therapist http://www.wcpt.org/policy/ps-ethical-responsibilities.
practice. Comparable to the teaching of conventional Published 2017. Accessed March 28, 2019.
physical therapist competencies in professional education 3 Dean E, Lomi C, Bruno S, Awad H, O’Donoghue G.
Addressing the common pathway underlying hypertension
programs, health protection and health promotion and and diabetes in people who are obese by maximizing health:
disease prevention competencies need to be taught and the ultimate knowledge translation gap. Int J Hypertens.
evaluated in terms of their theoretical foundations, 2011;2011:835805.
examination/assessment, and interventions supported by 4 Bodner ME, Rhodes RE, Miller WC, Dean E. Benchmarking
curriculum content in entry-level professional education with
informed theories and models. These competencies that special reference to health promotion practice in physical
physical therapists must initiate and implement, or initiate therapy: a multi-institutional international study. Adv Health
and refer to other health professionals, primarily include Sci Educ Theory Pract. 2013;18:645–657.
counseling for smoking cessation; basic nutrition for 5 Rea BL, Hopp Marshak H, Neish C, Davis N. The role of
health promotion in physical therapy in California, New York,
maximal health, healing, recovery, and weight and Tennessee. Phys Ther. 2004;84:510–523.
management; sleep hygiene; and stress management; as 6 Lomas J. Retailing research: increasing the role of evidence in
well as systematic evaluation/assessment of physical clinical services for childbirth. Milbank Q. 1993;71:439–475.
activity/exercise and prescription. In addition to initiating 7 Newson RS, Lion R, Crawford RJ et al. Behaviour change for
health education programs with patients, physical better health: nutrition, hygiene and sustainability. BMC Pub
Health. 2013;13(suppl 1):S1.
therapists need to follow criteria for initiating and
referring patients to other health professionals as 8 Dean E, Bruno S, Olsen MF, Umerah G, Moffat M. ‘Best’
inter-professional practice in healthcare: bridging the
indicated by an examination/assessment of need. The knowledge translation gap in relation to non-communicable
profession of physical therapy has a responsibility to diseases. Int J Health Wellness Soc. 2015;5:121–131.
support global health initiatives of the WHO and the 9 Ketkar AR, Veluswamy SK, Prabhu N, Maiya AG. Screening for
WCPT, in turn supporting national initiatives, such as noncommunicable disease risk factors at a workplace in
India: a physiotherapy initiative in a healthcare setting. Hong
Healthy People 2020 and its successor, Healthy People Kong Physiother J. 2015;33:3–9.
2030, in the United States. 10 Lein DH, Jr, D Clark, Graham C, Perez P, Morris D. A model
to integrate health promotion and wellness in physical
therapist practice: development and validation. Phys Ther.
2017;97:1169–1181.
Author Contributions
11 Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C,
Concept/idea/research design: E. Dean, M. Skinner, H. Myezwa, K. Mostert, Boeing H. Healthy living is the best revenge: findings from
D. Shirley, A. Söderlund, A. Dornelas de Andrade, U.O. Abaraogu, the European Prospective Investigation into Cancer and
A. Jones, S.K. Veluswamy, M. Moffat, A-K. Stensdotter, W.P. Wong
Nutrition—Potsdam study. Arch Int Med. 2009;169:1355–1362.
Writing: E. Dean, M. Skinner, V. Mkumbuzi, D.C. Parra, D. Shirley, 12 Blanchard CM, Courneya KS, Stein K. American Cancer
A. Söderlund, A. Dornelas de Andrade, U.O. Abaraogu, D. Clark, A. Jones,
Society’s SCS-II. Cancer survivors’ adherence to lifestyle
behavior recommendations and associations with
S.K. Veluswamy, M. Moffat, D. Morris, A-K. Stensdotter health-related quality of life: results from the American
Data collection: V. Mkumbuzi, K. Mostert, A. Söderlund, U.O. Abaraogu Cancer Society’s SCS-II. J Clin Oncol. 2008;26:2198–2204.

1252  Physical Therapy Volume 99 Number 9 2019

 Health Competencies

13 Scarborough P, Bhatnagar P, Wickramasinghe KK, Allender S, Disease. InTech Publishing; 2012:301–318.

Foster C, Rayner M. The economic burden of ill health due to https://www.intechopen.com/books/novel-strategies-in-ische
diet, physical inactivity, smoking, alcohol and obesity in the mic-heart-disease/cardiology-best-practice-effective-health-
UK: an update to 2006–07 NHS costs. J Public Health (Oxf). education-meets-biomedical-advances-reducing-the-ultimate.
2011;33:527–535. Accessed June 8, 2019.
14 Zhang D, Cogswell ME, Wang G, Bowman BA. Evidence of 31 Bodner ME, Miller WC, Rhodes RE, Dean E. Smoking
dietary improvement and preventable costs of cardiovascular cessation and counseling: knowledge and views of Canadian
disease. Am J Cardiol. 2017;120:1681–1688. physical therapists. Phys Ther. 2011;91:1051–1062.
15 McGuire LC, Strine TW, Okoro CA, Ahluwalia IB, Ford ES. 32 Bodner ME, Rhodes RE, Miller WC, Dean E. Smoking
Healthy lifestyle behaviors among older U.S. adults with and cessation and counseling: practices of Canadian physical
without disabilities, Behavioral Risk Factor Surveillance therapists. Am J Prev Med. 2012;43:67–71.
System, 2003. Prev Chronic Dis. 2007;4:A09.
33 O’Donoghue G, Cunningham C, Murphy F, Woods C,
16 Hagan KA, Chiuve SE, Stampfer MJ, Katz JN, Grodstein F. Aagaard-Hansen J. Assessment and management of risk
Greater adherence to the alternative healthy eating index is factors for the prevention of lifestyle-related disease: a
associated with lower incidence of physical function cross-sectional survey of current activities, barriers and
impairment in the Nurses’ Health Study. J Nutr. perceived training needs of primary care physiotherapists in

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

2016;146:1341–1347. the Republic of Ireland. Physiotherapy. 2014;100:116–122.
17 Veronese N, Stubbs B, Noale M et al. Adherence to a 34 Shirley D, van der Ploeg HP, Bauman AE. Physical activity
Mediterranean diet is associated with lower incidence of promotion in the physical therapy setting: perspectives from
frailty: a longitudinal cohort study. Clin Nutr. practitioners and students. Phys Ther. 2010;90:1311–1322.
2018;37:1492–1497. 35 Abaraogu UO, Edeonuh JC, Frantz J. Promoting physical
18 World Health Professions Alliance. Health Improvement Card. activity and exercise in daily practice: current practices,
http://www.whpa.org/sites/default/files/2018-12/ncd_Healt barriers, and training needs of physiotherapists in eastern
h-Improvement-Card_web.pdf. Published 2014. Accessed Nigeria. Physiother Can. 2016;68:37–45.
June 8, 2019. 36 Abaraogu UO, Ogaga MO, Odidika E, Frantz J. Promotion of
19 Dean E, Al-ObaidI S, Dornelas de Andrade A et al. The first healthy nutrition in clinical practice: a cross-sectional survey
physical therapy summit on global health: implications and of practices and barriers among physiotherapists in southeast
recommendations for the 21st century. Physiother Theory Nigeria. Hong Kong Physiother J. 2016;35:21–29.
Pract. 2011;27:531–547.
37 Abaraogu UO, Ogaga MO, Dean E. Practices of Nigerian
20 Dean E, Dornelas de Andrade A, O’Donoghue G et al. The physiotherapists with respect to lifestyle risk factor
second physical therapy summit on global health: developing assessment and intervention: a national cross-sectional
an action plan to promote health in daily practice and reduce survey. Physiother Theory Pract. 2017;33:497–507.
the burden of non-communicable diseases. Physiother Theory
38 Amor AJ, Serra-Mir M, Martínez-González MA et al. Prediction
Pract. 2014;30:261–275.
of cardiovascular disease by the Framingham-REGICOR
21 Dean E, Umerah G, Dornelas de Andrade A, Söderlund A, equation in the high-risk PREDIMED cohort: impact of the
Skinner M. The third physical therapy summit on global Mediterranean diet across different risk strata. JAMA.
health: health-based competencies. Physiotherapy. 2017;6:e004803.
2015;101(suppl 1):e13–e14.
39 Anderson JJB, Nieman DC. Diet quality—the Greeks had it
22 International Society for Behavioral Medicine. About ICBM. right! Nutrients. 2016;8:E636.
http://www.isbm.info/about-isbm/. Published 2017. Accessed
March 28, 2019. 40 Cordain L, Eaton SB, Sebastian A et al. Origins and evolution
of the Western diet: health implications for the 21st century.
23 American College of Preventive Medicine. Lifestyle Medicine Am J Clin Nutr. 2005;81:341–354.
Core Competencies Program.
41 Mälardalen University Sweden. Centre of excellence in
http://www.acpm.org/page/lmprogram. Published 2017.
Accessed March 28, 2019. health-based competencies for health professionals.
https://www.mdh.se/amnen/2.3979. Published 2015.
24 Lianov L, Johnson M. Physician competencies for prescribing Accessed March 28, 2019.
lifestyle medicine. JAMA. 2010;304:202–203.
42 Chan WV, Pearson TA, Bennett GC et al. ACC/AHA special
25 World Health Organization. Constitution. report: clinical practice guideline implementation strategies: a
https://www.who.int/about/who-we-are/constitution. summary of systematic reviews by the NHLBI implementation
Accessed June 8, 2019. science work group: a report of the American College of
Cardiology/American Heart Association task force on clinical
26 World Health Organization. The Ottawa charter for health
practice guidelines. J Am Coll Cardiol. 2017;69:1076–1092.
promotion. First International Conference on Health
Promotion, Ottawa, 21 November 1986. http://www.who.int/ 43 Dean E, Moffat M, Skinner M, Dornelas de Andrade A,
healthpromotion/conferences/previous/ottawa/en/. Accessed Myezwa H, Söderlund A. Toward core inter-professional
March 28, 2019. health promotion competencies to address the
non-communicable diseases and their risk factors: curriculum
27 World Health Organization. Do lifestyle changes improve
health? http://www.who.int/mediacentre/multimedia/podcast content assessment. BMC Public Health. 2014;14:717.
s/2009/lifestyle-interventions-20090109/en/. Published 44 World Health Organization. WHO STEPS Instrument for
January 9, 2009. Accessed March 28, 2019. Noncommunicable Disease Risk Factor Surveillance.
http://www.who.int/chp/steps/instrument/STEPS_Instrumen
28 World Health Organization. Global Strategy on Diet, Physical
Activity, and Health. http://www.who.int/dietphysicalactivity t_V3.1.pdf?ua=1. Published 2017. Accessed March 28, 2019.
/strategy/eb11344/strategy_english_web.pdf. Published 2004. 45 World Health Professions Alliance. Non communicable
Accessed March 28, 2019. diseases: an action toolkit for health professionals, patients
and public. https://www.ifpma.org. Published 2017. Accessed
29 Dean E, Greig A, Murphy S et al. Raising the priority of
lifestyle-related noncommunicable diseases in physical March 28, 2019.
therapy curricula. Phys Ther. 2016;96:940–948. 46 World Health Professions Alliance. WHPA Health
30 Dean E, Li Z, Wong WP et al. Cardiology best Improvement Card. User Guide for Health Professionals.
https://www.ifpma.org/resource-centre/whpa-health-improv
practice—effective health education meets biomedical
advances: reducing the ultimate knowledge translation gap. ement-card/. Published 2017. Accessed March 28, 2019.
In: Lakshmanadoss U., ed. Novel Strategies in Ischemic Heart

2019 Volume 99 Number 9 Physical Therapy  1253

Health Competencies

47 Grundy SM, Pasternak R, Greenland P, Smith S, Jr, Fuster V. 59 Harvard Medical School. Positive Psychology. Boston, MA:
Assessment of cardiovascular risk by use of Harvard Medical School Press; 2011. Harvard Medical School
multiple-risk-factor assessment equations: a statement for Special Health Report.
healthcare professionals from the American Heart Association
and the American College of Cardiology. Circulation. 60 Rollnick S, Miller WL, Butler C. Motivational interviewing in
1999;100:1481–1492. health care: helping patients change behavior. New York, NY:
The Guilford Press; 2008.
48 Canadian Task Force on Preventive Health Care (CTFPHC),
Public Health Agency of Canada. CanRisk: are you at risk for 61 Van Horn L, Carson JA, Appel LJ et al. Recommended dietary
diabetes? https://canadiantaskforce.ca/wp-content/uploads/ pattern to achieve adherence to the American Heart
2016/05/2012-type-2-diabetes-canrisk-en.pdf. Published Association/American College of Cardiology (AHA/ACC)
2013. Accessed March 28, 2019. guidelines: a scientific statement from the American Heart
Association. Circulation. 2016;134:e505–e529.
49 Harvard School of Public Health. Healthy Heart Score.
62 Elvén M, Hochwälder J, Dean E, Söderlund A. A clinical
https://healthyheartscore.sph.harvard.edu/. Accessed June 8,
2019. reasoning model focused on clients’ behaviour change with
reference to physiotherapists: its multiphase development
50 DiClemente CC, Prochaska JO. Toward a comprehensive, and validation. Physiother Theory Pract. 2015;31:231–243.
transtheoretical model of change: stages of change and

Downloaded from https://academic.oup.com/ptj/article/99/9/1242/5514363 by guest on 08 July 2023

63 Lobelo F, Duperly J, Frank E. Physical activity habits of
addictive behaviors. In: Miller WR, Heather N, eds. Treating
doctors and medical students influence their counselling
Addictive Behaviors. 2nd ed. New York, NY: Plenum Press; practices. Brit J Sports Med. 2009;43:89–92.
1998: 3–24.
51 The 5 A’s behavior change model adapted for 64 Rao CR, Darshan B, Das N, Rajan V, Bhogun M, Gupta A.
Practice of physical activity among future doctors: a cross
self-management support improvement.
sectional analysis. Int J Prev Med. 2012;3:365–369.
http://www.improvingchroniccare.org/downloads/3.5_5_as_b
ehaviior_change_model.pdf. Published 2002. Accessed March 65 Frank E, Breyan J, Elon L. Physician disclosure of healthy
28, 2019. personal behaviors improves credibility and ability to
motivate. Arch Fam Med. 2000;9:287–290.
52 The Step Ahead Wellness Center. The 5 R’s of behavior change.
http://www.stepaheadwellnesscenter.com/blog/bid/87773/T 66 The Patient Promise. Facebook page.
he-five-R-s-of-Motivation. Published 2017. Accessed March https://www.facebook.com/ThePatientPromise/. Accessed
28, 2019. June 8, 2019.
53 Bandura A. Self-efficacy: toward a unifying theory of 67 The Hippocratic Oath. Wikipedia.
behavioral change. Psych Rev. 1997;84:191–215. https://en.m.wikipedia.org/wiki/Hippocratic_Oath. Accessed
March 28, 2019.
54 Pender NJ, Murdaugh CL, Parsons MA. Health Promotion in
Nursing Practice. 6th ed. Stamford, CT: Appleton & Lange; 68 Office of Disease Prevention and Health Promotion. Healthy
2010. People 2020. https://www.healthypeople.gov/. Accessed
March 28, 2019.
55 Stretcher VJ, Rosenstock IM. The health belief model. In:
Baum A, Newman S, Weinman J, West R, McManus C, eds. 69 World Health Organization. The World Health Report 1998.
Cambridge Handbook of Psychology, Health and Medicine. Life in the 21st Century: A Vision for all.
New York, NY: Cambridge University Press; 1977: https://www.who.int/whr/1998/en/. Accessed March 28,
113–121. 2019.
56 Ajzen I. The theory of planned behavior. Org Beh Hum Dec 70 Leading Health Indicators/Goals/Obj. https:
Proc. 1991;50:179–211. //www.healthypeople.gov/2020/Leading-Health-Indicators.
Accessed March 28, 2019.
57 National Association of Cognitive-Behavioral Therapists. What
is cognitive-behavioral therapy? 71 Development of the national health promotion and disease
http://www.nacbt.org/whatiscbt.htm. Published 2017. prevention objectives for 2030. Healthy People.gov website.
Accessed March 28, 2019. https://www.healthypeople.gov/2020/About-Healthy-People/
Development-Healthy-People-2030. Accessed March 28, 2019.
58 McLeod SA, Skinner BF. Operant Conditioning. Simply
Psychology Website. 72 Association of Faculties of Medicine of Canada. AFMC primer
http://www.simplypsychology.org/operant-conditioning.html. on population health. A virtual textbook on public health
Published 2017. Updated 2018. Accessed March 28, 2019. concepts for clinicians.
https://ubccpd.ca/sites/ubccpd.ca/files/AFMC%20Primer%20o
n%20Population%20Health%202014-12-23%20(2).pdf.
Accessed June 8, 2019.

1254  Physical Therapy Volume 99 Number 9 2019