Theory
The Health Belief Model
Given that primary care services focus so much on health and wellness, a theory that supports changing health behaviors would also support occupational therapy assessment and intervention in primary care. The Health Belief Model (HBM) is a public health theory that is used to help identify why someone would or would not engage in a health behavior. It also provides change strategies for clinicians to help individuals be more successful in managing their own health behaviors. According the HBM, there are six main constructs that are related to the individual’s desire and/or ability to improve their health: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (The National Cancer Institute: US DHHS, 2015)
The occupational therapist can address all six of these areas. They have the education and training to address many health-related concerns and treatment options. They are particularly skilled at promoting self-efficacy through the use of individualized goal-setting. They are also skilled at creating cues to action that are patient-centered and thus more likely to yield effective change.
To give an example of using the HBM to support practice, the occupational therapist may receive a referral for “noncompliance” of health management for a patient with congestive heart failure (CHF). When completing the assessment, the occupational therapist may find out that the patient does not take daily weights and does not take diuretics as prescribed. When understanding why this may be, it turns out the patient does not understand the risk and susceptibility of not taking diuretics and monitoring weights and the patient does not understand the disease process. Further, the patient finds the diuretics too much of a burden as it increases the frequency of urination, impacting the patient’s ability to go out and about in the community.
The occupational therapist can now provide targeted interventions to improve health literacy and understanding of congestive heart failure in a manner that is understandable for the patient. The patient had not been in the hospital previously for CHF, so he did not understand his susceptibility for an exacerbation. Nor did he understand the benefits of following his medical plan of care. After providing the needed education, the occupational therapist can work with the patient to create achievable cues to action. This may include giving the patient a journal to note daily weights and helping the patient identify when he will most likely remember to check his weight. The occupational therapist can call the patient weekly for check-ins and provide support and motivation to increase self-efficacy. The occupational therapist can also support the patient by advocating for his needs and desires to go out in the community. Perhaps this means changing the dosing or timing of the diuretics, which would happen in collaboration with the primary care provider. The result of using the HBM to support practice is that the occupational therapist was able to facilitate a change in health behaviors by looking at the six concepts and helping the patient implement change strategies.
The Ecology of Human Performance
While several occupational therapy frames of reference, theories, and models can be applicable to occupational therapy in primary care, the Ecology of Human Performance (EHP) was chosen because of its emphasis on context. An occupational therapist in primary care is likely going to see a more diverse group of patients compared to other settings. Further, given that this is a community setting, contextual factors should be at the forefront of any assessment and intervention. According to Dunn (1994) “The primary theoretical postulate fundamental to the EHP framework is that ecology, or the interaction between person and the environment, affects human behavior and performance, and that performance cannot be understood outside of context” (p.598).
Using EHP to guide the occupational therapist is useful when looking at the example of developing healthier habits and routines for different individuals. The recommendation may be to add more fresh fruits and vegetables and decrease fatty fried foods. There also might be a recommendation to walk 30 minutes per day. However, if these recommendations are given without appreciation for contextual factors, then the likelihood for success goes down. If a patient lives in a “food dessert” and does not have access to a grocery store, but does have access to fast food restaurants and corner stores, then healthy eating becomes much more difficult. If a person lives in an environment that is not safe for walking, then walking 30 minutes per day is not a realistic or achievable goal. If the patient lives in a household where healthy choices are not valued or supported, this also matters and can impact the success of adopting healthy behaviors. Another contextual area to consider according to EHP is that of age and stages of life. Care for someone who is nearing end of life is quite different than someone who is much younger and healthier. This is quite relevant in primary care as it is anticipated clinicians will see patients across the age span and at all levels of health and disability.
EHP also focuses on the person’s unique abilities, experiences, and skills. Occupational therapists are skilled at assessing an individual’s cognitive, physical, and psychosocial skills to determine what supports participation in desired tasks and what is a barrier. Interestingly, EHP also includes the relevance of experiences in the framework. When looking at how individuals view the healthcare system and how they view their role in their own health, experiences and culture are important. For example, racial issues in our society may contribute to unequal distribution of healthcare services. This may be caused in part by an implicit bias on the providers’ side or it could be because of a mistrust of the healthcare system on the patients’ side (FitzGerald & Hurst, 2017). An individual’s perception of the healthcare system as viewed through their past experiences and cultural lens will have an impact on their access to care and their health outcomes (ACP, 2010). Using EHP to provide more informed patient-centered approaches to care can support the occupational therapist in making better connections with the patient and thereby better outcomes.
With the EHP model, the occupational therapist, in collaboration with the patient and family, provides interventions to meet the following goals: to establish or restore, alter, adapt, prevent, and create (Dunn, 1994). Traditional occupational therapy roles often restore lost function, alter the environment to promote independence, or adapt the environment or task to better meet the individual’s needs. Primary care can utilize these approaches, but in this setting, there can also be a focus on preventing disease and disability and creating healthy habits, roles, and routines.