Key Issues and Considerations in Health Promotion for People with Disabilities
1. Physical Activity
The vast majority of people with disabilities are not obtaining the recommended amount of physical activity needed to confer health benefits and prevent secondary conditions (e.g., heart disease, deconditioning, obesity, osteoporosis). In a study by Rimmer et al., it was found that less than 10 percent of adults with physical disabilities engaged in structured physical activity programs. A possible reason for this high level of inactivity may be linked to the number of actual and perceived barriers to exercise reported by people with disabilities. Transportation, cost of the exercise program, and not knowing where to exercise were listed as the three most common barriers. In a related study, Messent et al. reported that the barriers to physical activity participation in adults with developmental disabilities were unclear policy guidelines in residential and day service programs; transportation and staffing constraints; limited financial resources; and limited availability of physical activity programs in the person's community. While these external barriers may impose major limitations on exercise participation, internal barriers may also create obstacles to participation. Kinne et al. reported that exercise self-efficacy and motivational factors were significant predictors of exercise maintenance in a group of adults with disabilities.
Lack of Knowledge and Information
The voluminous amount of research that has been published in the field of exercise science has included very little information on how to accommodate persons with disabilities in fitness and recreation settings. In one study it was reported that over half the subjects with disabilities felt that a fitness center would not be able to meet their needs. The two primary concerns were that fitness instructors would not know enough about their disability to develop a safe program, and that fitness centers would not have the type of equipment available that they would be able to successfully use. Kinne et al. noted that at the policy level, it is important for fitness centers to present a more inclusive image since many people with disabilities doubt that they can use fitness machines or keep up in various types of fitness classes. Unfortunately, most professional training programs in fitness and exercise science do not include coursework related to training people with disabilities, and most professionals are unfamiliar with ways to adapt fitness classes or instruct clients in using equipment properly.
A New Resource for Obtaining Information on Physical Activity and Disability
There are many excellent ways to integrate people with disabilities into various types of physical activity programs. The National Center on Health, Physical Activity, and Disability (NCHPAD) was established in 1999 to increase the amount of information available to health and fitness professionals interested in learning more about physical activity and disability. This web-based information center www.ncpad.org contains information on resources, programs, medical issues, etc. related to physical activity and disability, including fact sheets, monographs, bibliographies, a national directory of accessible programs and adaptive equipment, and an annotated database of articles on physical activity and disability. The toll-free number (800-900-8086) allows end users to call in with their questions and receive timely responses to their inquiries. Users can also subscribe to a free quarterly electronic newsletter and obtain information on upcoming conferences related to physical activity and disability.
While better nutritional habits are a major concern for most people with and without disabilities, there may be some specific differences in diet and nutrition guidelines pertaining to people with specific types of disabilities. Issues related to accessing healthy foods, determining food interactions with commonly used medications to control various secondary conditions (e.g., spasticity, pain, seizures, depression), and establishing specific requirements for food supplements (e.g., vitamins, minerals, fluid intake) are all major concerns among people with certain disabilities. For example, people with spinal cord injury (SCI) have a higher rate of bone loss after their injury, which increases their risk of osteoporosis. A few studies on persons with cerebral palsy and Down syndrome have also reported a higher incidence of osteoporosis. While it is plausible that the recommended daily allowance (RDA) for calcium intake and vitamin D may need to be increased for certain types of disabilities to offset the rate of bone loss, recommended guidelines are not available. There are little data available to support this theory. There is a pressing need to conduct more research on various types of disabilities that have a reportedly higher incidence of bone loss, to determine the effects of exercise and nutritional supplements (i.e., calcium, vitamin D) in reducing or slowing the progression of this condition.
Dehydration in persons with neurological conditions (i.e., SCI, multiple sclerosis) is another area of concern. Individuals who catheterize themselves are often reluctant to drink large amounts of fluids because of the higher possibility of an accident (reflex bladder voiding), or because it will require them to perform more frequent catheterizations. Dehydration can lead to other medical problems (e.g., syncope, orthostatic hypotension, hyper/hypothermia) and increase risk of injury (e.g., falls).
Additional concerns related to nutrition may involve recommended dietary allowances (RDA) for certain nutrients. Changes in diet may be necessary because of altered metabolism or the influences of prescribed medications. Certain medications can suppress or increase appetite, alter nutritional balance, and increase fatigue.
3. Health Education
Health education can have a measurable impact on empowering people with disabilities to improve their own health. For example, people with SCI or lower extremity paralysis are often at risk for developing pressure sores and urinary tract infections. A health promotion program can teach participants how to prevent pressure sores by checking for early warning signs (i.e., redness), performing wheelchair push-ups (lifting lower body off the seat of wheelchair for a several seconds every 15 to 20 minutes), and using appropriate seat cushions to displace pressure more evenly across the lower body. Education to reduce urinary tract infections would include proper washing of hands before and after catheterization, maintaining good hydration by drinking several glasses of water daily, cleaning seat cushions frequently, and voiding the bladder several times a day to prevent bacterial growth.
A health education program for persons with Down syndrome would include an altered set of objectives. Secondary conditions often observed in this population include obesity, low physical fitness, and poor dental hygiene. The health education program should emphasize a greater volume of daily physical activity and improved nutrition to reduce body weight and good dental hygiene that includes brushing and flossing properly. Table 1 provides a few examples of various health promotion strategies for people with disabilities.
Sample Health Promotion Strategies for People with Disabilities
1. Determine various adaptations for exercise equipment and physical activity programs to assure successful inclusion (i.e., special gloves to keep hands attached to equipment, arm ergometer to develop cardiovascular endurance in persons with paraplegia, slower tempo for various group exercise classes).
2. Know which secondary conditions are associated with each disability and monitor accordingly. For example, persons with multiple sclerosis and spinal cord injury have thermoregulatory issues that require a stable and appropriate temperature in the exercise setting.
1. Know what medications the person is taking and adjust diet, vitamin and mineral regimen accordingly. For example, the blood-thinning medication, Coumadin, is often taken by stroke survivors and can have an adverse interaction with high consumption of vitamin K.
2. Maintain adequate hydration in persons with incontinence. Many individuals avoid drinking fluids so that they will not need to use the bathroom as often. This increases their risk of dehydration.
1. Determine the client's reading comprehensive level before preparing written materials. Written materials will be of limited value to persons who do not read or have difficulty reading.
2. Use empowerment and self-determination models to build or restore self-efficacy. Many individuals with disabilities have been exposed to attitudinal stereotypes through the media that imply that people with disabilities can not attain good health and will, therefore, need strong encouragement and reinforcement that they can attain good health in the same manner as anyone else.