The Place and Promise of Theory in Rehabilitation Psychology

The International Classification of Functioning, Disability, and Health (ICF) as a community participation model for people with multiple sclerosis: A hierarchical regression analysis

Multiple sclerosis (MS) is a central nervous system disorder that impacts more than 400,000 people in the U.S. The disease results in multiple functional impairments that are diverse and varied across individuals. Additonally, MS has a profound impact on community participation which, like other rehabilitation outcomes, cannot be explained on the basis of functional limitations alone. The purpose of this study was to develop and evaluate a model of community participation for people living with MS using the World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) framework. The model focused on the roles that personal factors have as predictors of community participation, while also serving as mediators and moderators for the relationship between activity limitation and participation. Results from the hierarchical regression analysis indicated that demographic characteristics (i.e. MS type), personal factors (i.e. core self-evaluations (CSE), MS self-management, resilience, and social skills), and activity limitations accounted for 64% of the variance in participation. Further, mediation analysis indicated that CSE mediated the relationship between activity limitation and community participation. Finally, moderation analysis indicated an interaction effect between educational attainment and MS self-management. Implications for future research in rehabilitation and clinical application are discussed.

Determinants of medication adherence among Iranian patients with type 2 diabetes: An application of health action process approach

To identify determinants of medication adherence among patients with type 2 diabetes based on the health action process approach. This cross-sectional study was conducted among 734 patients with type 2 diabetes attending to south Tehran health centers during June to December 2018. Data were gathered using the Morisky Medication Adherence Scale (MMAS-8-Item) and the health action process approach questionnaire. We used Mann-Whitney, Pearson Chi-Squared, Fisher's Exact and Independent Samples Tests for comparison of adherence medication by demographic characteristics; and linear regression analysis to predict factors related to medication adherence based on HAPA. P-value less than 0.05 considered statistically significant. A total of 232 men and 502 women participated in the study, Mean age was 61.61 ± 9.74. Most participants (82.3%) reported low medication adherence (females: 68.4%). Medication adherence was significantly associated with gender (p = 0.03). Medication adherence was significantly predicted by intention (β = 0.172, p = 0.0001), task self-efficacy (β = 0.172, p = 0.01), copping planning (β = 0.6, p = 0.0001) and copping self-efficacy (β = -0.244, p = 0.001). The level of adherence to medications among type 2 diabetes patients was low. The behavior intention, task self-efficacy, copping planning and copping self-efficacy were significant determinants contributed to the medication adherence. HAPA inventory includes various factors, especially types of self-efficacy. Thus, utilization of this comprehensive model in interventional studies is suggested. These determinants should be considered in developing interventional programs to improve adherence.

An Empirically Derived Taxonomy of Biopsychosocial Factors of Adjustment to Fibromyalgia: Results of a Multivariate Analysis

Fibromyalgia (FM) is a lifelong central nervous system disorder that is precipitated by a range of biological, psycho-cognitive, and social factors. The aims of this exploratory study were to (a) identify biopsychosocial and cognitive factors that may affect an individual’s response to FM, (b) determine whether individuals with FM can be grouped into homogeneous subgroups based on biopsychosocial factors associated with response to FM, and (c) compare subgroup differences in health outcomes and life satisfaction. This study included 302 participants with FM. Principal components analysis yielded three sets of biopsychosocial factors that may affect response to FM (i.e., protective, cognitive-affective, and physical factors). Based on these three factors, a cluster analysis was performed, which produced three homogeneous subgroups: (a) the moderate amount of problems group, (b) the least amount of problems group, and (c) the many problems group. Analysis of variance (ANOVA) results indicated that these three subgroups differed significantly in terms of health outcomes and life satisfaction. The findings of this study broaden the existing literature related to understanding FM from a multidimensional symptom response perspective and contribute to the development and validation of biopsychosocial interventions for people with FM.

Antonyms: A Computer Game to Improve Inhibitory Control of Impulsivity in Children with Attention Deficit/Hyperactivity Disorder (ADHD)

The design of a computer-supported serious game concerning inhibition skills in children with Attention Deficit/Hyperactivity Disorder (ADHD) is reported. The game consists of a series of activities, each eliciting the tendency to respond in an immediate, inadequate way. The game is based on the Dual Pathway Model of ADHD proposed by Sonuga-Barke. In the game, children must block impulsive tendencies, reflect upon the situation, inhibit irrelevant thoughts, and find the non-intuitive solution. In the game, the player personifies a superhero, who is asked to save a realm on the opposite side of the Earth (Antonyms) where things happen according to the opposite of the usual rules. The hero faces a series of challenges, in the form of mini-games, to free the planet from enemies crossing different scenarios. To succeed in the game, the player should change his/her attitude by thinking before performing any action rather than acting on impulse. The player is induced to be reflective and thoughtful as well. Results from the evaluation of a preliminary version of the serious game are reported. They support the notion that Antonyms is an adequate tool to lead children to inhibit their tendency to behave impulsively.

Examining the Impact of Psychological Factors on Hospital Length of Stay for Burn Survivors: A Systematic Review

Recovery of burn patients may be impeded by mental health problems. By gaining a better understanding of the impact that psychological factors may have on hospital length of stay, providers may be better informed to address the complex needs of burn survivors through effective and efficient practices. This systematic review summarizes existing data on the adverse psychological factors for the length of burn patients' hospitalization, and assesses the methodological quality of the extant literature on mental health conditions of burn survivors. A literature search was conducted in four electronic databases: PubMed, PsychINFO, Science Direct, and the Cumulative Index to Nursing and Allied Health Literature. Results yielded reports published between 1980 and 2016. Methodological quality was assessed by using an 11-item methodological quality score system. Seventy-four studies were identified by search; 19 articles were eligible for analysis. Findings demonstrate paucity of evidence in the area. Reports indicate longer hospital stay among burn patients with mental health problems. Substance use was the most consistent mental-health predictor of longer hospital stay. Heterogeneity in data on mental health conditions rendered impossible estimation of effect sizes of individual psychological factors on length of hospitalization. Many studies over-relied on retrospective designs, and crude indicators of psychological factors. Findings indicate that mental health problems do have an impact on the trajectory of burn recovery by increasing the length of hospital stay for burn survivors. Inpatient mental health services for burn patients are critically needed. Prospective designs, and more sensitive psychological indicators are needed for future studies.

Guideline Development for Technological Interventions for Children and Young People to Self-Manage Attention Deficit Hyperactivity Disorder: Realist Evaluation

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a complex neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. ADHD can affect the individual, the individual's family, and the community. ADHD is managed using pharmacological and nonpharmacological treatments, which principally involves others helping children and young people (CAYP) manage their ADHD rather than learning self-management strategies themselves. Over recent years, technological developments have meant that technology has been harnessed to create interventions to facilitate the self-management of ADHD in CAYP. Despite a clear potential to improve the effectiveness and personalization of interventions, there are currently no guidelines based on existing evidence or theories to underpin the development of technologies that aim to help CAYP self-manage their ADHD.

OBJECTIVE

The aim of this study was to create evidence-based guidelines with key stakeholders who will provide recommendations for the future development of technological interventions, which aim to specifically facilitate the self-management of ADHD.

METHODS

A realist evaluation (RE) approach was adopted over 5 phases. Phase 1 involved identifying propositions (or hypotheses) outlining what could work for such an intervention. Phase 2 involved the identification of existing middle-range theories of behavior change to underpin the propositions. Phase 3 involved the identification and development of context mechanism outcome configurations (CMOCs), which essentially state which elements of the intervention could be affected by which contexts and what the outcome of these could be. Phase 4 involved the validation and refinement of the propositions from phase 1 via interviews with key stakeholders (CAYP with ADHD, their parents and specialist clinicians). Phase 5 involved using information gathered during phases 1 to 4 to develop the guidelines.

RESULTS

A total of 6 specialist clinicians, 8 parents, and 7 CAYP were recruited to this study. Overall, 7 key themes were identified: (1) positive rewarding feedback, (2) downloadable gaming resources, (3) personalizable and adaptable components, (4) psychoeducation component, (5) integration of self-management strategies, (6) goal setting, and (7) context (environmental and personal). The identified mechanisms interacted with the variable contexts in which a complex technological intervention of this nature could be delivered.

CONCLUSIONS

Complex intervention development for complex populations such as CAYP with ADHD should adopt methods such as RE, to account for the context it is delivered in, and co-design, which involves developing the intervention in partnership with key stakeholders to increase the likelihood that the intervention will succeed. The development of the guidelines outlined in this paper could be used for the future development of technologies that aim to facilitate self-management in CAYP with ADHD.

Self-management interventions for skin care in people with a spinal cord injury: part 2-a systematic review of use of theory and quality of intervention reporting

STUDY DESIGN

Systematic review.

OBJECTIVES

To examine use of theory and quality of reporting in skin care self-management interventions for people with SCI.

SETTING

International.

METHODS

The Theory Coding Scheme (TCS) and the Template for Intervention Description and Replication (TIDieR) checklist were applied by two independent researchers to 17 interventions identified in a systematic review of self-management interventions for skin care in people with SCI.

RESULTS

Six (35%) of the 17 interventions reviewed were reported to have a theoretical basis. Theories used included three of the most commonly featured in health behavior research (the Health Belief Model, Social Cognitive Theory, and the Transtheoretical Model). In these six interventions, theory was used to design content but not to select participants or tailor strategies. None of the interventions were used to test theories in the SCI population, or to propose theoretical refinements. Reporting quality was found to vary by TIDieR item, with 6-100% of interventions including recommended information. Information on two intervention fidelity items was missing in 53 and 82% of descriptions.

CONCLUSIONS

Use of theory and reporting quality in SCI self-management research remains suboptimal, potentially slowing down advancements in this area of research. Rehabilitation researchers should direct their efforts toward improving these practices to help build a science of SCI self-management that is cumulative and reproducible by clinicians, scientists, and policy makers.

SPONSORSHIP

This work was funded through a postdoctoral fellowship awarded to the first author by the Rick Hansen Institute.

Misconceptions about Stroke: Causal Attributions for Stroke-Related Symptoms Reflect the Age of the Survivor

With visible disabilities, observers tend to overgeneralise from the disability. In contrast, with invisible disabilities such as traumatic brain injury and stroke, observers often fail to allow for challenges resulting from the disability. Persons who have suffered a stroke claim that people misunderstand their symptoms and stigmatise them as a result of these symptoms. This misunderstanding, which happens particularly with young survivors of stroke, may reflect people's causal attributions for symptoms that follow a stroke. Using a scenario design, this cross-sectional study examined whether people attribute ambiguous symptoms that may result from stroke to other causes (the stroke survivor's personality and age) and whether these attributions reflect the age of the stroke survivor. Participants (N = 120) read scenarios describing a male who was aged either 22, 72, or whose age was unstated and who showed four symptom changes: fatigue, depression, irritability and reduced friendships. For each symptom change, participants rated three causal attributions: the person's age, his personality and stroke. The age of the person in the scenario affected attributions; when the person in the scenario was 22, participants attributed his symptoms significantly more to his personality than to his age or stroke, whereas when he was 72, participants attributed his symptoms more to his age than to his personality or stroke and when his age was unstated, they attributed his symptoms equally to age, stroke and personality. Because misattributions for stroke symptoms hinder rehabilitation, therapy can target people's misattributions to enhance rehabilitation for survivors of stroke.

Being "just normal": a grounded theory of prosthesis use

PURPOSE

Whilst research tells us about the benefits and challenges of using prostheses, little attempt has been made to account for and provide explanations for the differing experiences of prosthesis users. In this study, a core concern shared by prosthesis users and an account of how this concern is managed are explored.

METHOD

Data were collected and analysed according to Grounded Theory procedures, involving interviews with 24 participants, 17 weblogs, 17 autobiographical texts, and posts from 4 online forums.

RESULTS

Prosthesis users are primarily concerned with being "just normal": the condition of being and living in ways that persons variously perceive are "about right"; that are sufficient, fair, and generally how things "ought to be" for them. This concern is acted upon through: (i) "preserving", where persons foresee and manage threats to being "just normal", (ii) "redressing", involving rectifying things judged not to be "just normal", and (iii) "persevering", where persons keep living "just normally" despite accompanying difficulties.

CONCLUSIONS

"Just normal" is a new means for rehabilitation practitioners to better understand a key concern of prosthesis users and the motivations underlying behaviours in their prosthesis use. It is also relevant and transferable to broader fields of assistive technology use and disability. Implications for Rehabilitation The grounded theory of "just normal" invites practitioners to discover a key concern in prosthesis use, enabling a richer understanding of the needs and desires of service users. Being "just normal" is presented as an important motivator underlying a range of diverse actions within prosthesis use. The theory is relevant and transferable to broader areas of assistive technology use and disability.

Sense of Community and Its Impact on the Life Satisfaction of Adults With Brain Injury

Sense of community (SOC) refers to feelings of belonging and attachment one has for a community. Despite a growing focus on adjustment and community outcomes following disability, this construct has received little attention in the rehabilitation literature. The primary aim of this study was to examine the extent to which SOC and social identification with one’s town contribute to life satisfaction outcomes among adults with brain injury, controlling for demographic, disability, and other related social constructs (e.g., social support and social integration). Members from brain injury associations across the United States ( N = 177) participated in a survey-based study. Results from hierarchical regression analysis indicated that the final model accounted for 45% of the variance in life satisfaction, with SOC variables contributing 11%. Symptom severity, perceived emotional support, and the SOC dimension reinforcement of needs were significant independent predictors of life satisfaction. Findings from this study highlight the importance of examining SOC variables among clients with brain injury to enhance subjective well-being.

A Bioecological framework to evaluate communicative participation outcomes for preschoolers receiving speech-language therapy interventions in Ontario, Canada

BACKGROUND

The Preschool Speech and Language Program (PSLP) in Ontario, Canada, is a publically funded intervention service for children from birth to 5 years with communication disorders. It has begun a population-level programme evaluation of children's communicative participation outcomes following therapy. Data are currently being collected for all children who access this service--over 50,000 children each year.

AIMS

To understand and evaluate how therapeutic interventions in speech-language therapy impact the everyday lives of children and families by applying a theoretical framework.

MAIN CONTRIBUTION

This discussion paper critically examines how the Bioecological Model of Development can be applied to the study of communicative participation outcomes following speech and language therapy. This model will be used in future analyses of communicative participation outcomes data in Ontario's PSLP. The strengths and challenges of this approach are reviewed.

Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach

OBJECTIVES

To (1) test the effect of a health action process approach (HAPA) theory-based education program in cardiac rehabilitation (CR) compared to traditional education on patient knowledge and HAPA constructs; and, (2) investigate the theoretical correlates of exercise behavior among CR patients receiving theory-based education.

METHODS

CR patients were exposed to an existing or HAPA-based 6 month education curriculum in this quasi-experimental study. Participants completed a survey assessing exercise behavior, HAPA constructs, and knowledge pre and post-program.

RESULTS

306 patients consented to participate, of which 146 (47.7%) were exposed to the theory-based educational curriculum. There was a significant improvement in patients' overall knowledge pre- to post-CR, as well as in some HAPA constructs and exercise behavior, regardless of curriculum (p < 0.05). Path analysis revealed that knowledge was significantly related to intention formation, and intentions to engage in exercise were not directly related to behavior, which required action planning.

CONCLUSIONS

The theoretically-informed education curriculum was not associated with greater knowledge or exercise behavior as expected. Education in CR improves knowledge, and theoretical constructs related to exercise behavior.

PRACTICE IMPLICATIONS

Educational curricula should be designed to not only increase patients' knowledge, but also enhance intentions, self-efficacy, and action planning.

Integrating Health Behavior Theory and Design Elements in Serious Games

BACKGROUND

Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games.

OBJECTIVE

To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective.

METHODS

We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework.

RESULTS

A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model.

CONCLUSIONS

This study's method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user's sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose.

Baltes' SOC model of successful ageing as a potential framework for stroke rehabilitation

AIM

The aim of this paper is to explore approaches used to address some stroke rehabilitation interventions and to examine the potential use of one of the life-span theories called the Baltes' model of selective optimisation with compensation (SOC) as a potential framework.

KEY FINDINGS AND IMPLICATIONS

Some of the key considerations for a stroke rehabilitation intervention framework are highlighted including accommodating for the life management changes post stroke, alterations in self-regulation, acknowledge losses and focusing on a person-centred approach for transition from acute rehabilitation to the home or community setting. The Baltes' SOC model is then described in terms of these considerations for a stroke rehabilitation intervention framework.

CONCLUSIONS AND RECOMMENDATIONS

The Baltes' SOC model may offer further insights, including ageing considerations, for stroke rehabilitation approaches and interventions. It has potential to facilitate some of the necessary complexities of adjustment required in stroke rehabilitation. However, further development in terms of empirical support is required for using the model as a framework to structure stroke rehabilitation intervention. Implications for Rehabilitation There is a scarcity of theoretical frameworks that can facilitate and be inclusive for all the necessary complexities of adjustment, required in stroke rehabilitation. In addition to motor recovery post stroke, rehabilitation intervention frameworks should be goal orientated; address self-regulatory processes; be person-centred and use a common language for goal planning, setting and attainment. The Baltes' SOC model is one such framework that may address some of the considerations for stroke rehabilitation, including motor recovery and other life management aspects.

Cultivating Our Roots and Extending Our Branches

As a behavioral science and helping profession, rehabilitation must promote theory building and knowledge utilization through comprehensive and conscientious approaches. This article addresses notable failures to incorporate earlier and significant conceptual developments from rehabilitation into contemporary research. The identified gaps in scholarship acknowledgment concerned omissions of the groundbreaking work of several scholars who were shaped by Kurt Lewin’s mentorship and field theory. These authors advanced two fundamental principles: (a) the ecological perspective that behavior (including that associated with disability) can only be understood as the interaction of the person within an environmental context and (b) a strengths-based approach that rehabilitation assessments and interventions must tap into the assets of the person and the resources in the environment. The nexus and usefulness of these authors’ contributions have gone unrecognized in explanations of two relevant and popular psychosocial research agendas: (a) the new paradigm of disability and (b) the positive psychology movement. This article delineates these gaps in rehabilitation knowledge utilization, offers some interpretations for their occurrence, and recommends strategies to reduce the gaps. It also suggests how developments in theory or practice from rehabilitation research and philosophy could be better marketed to and utilized by our partners in other counseling/psychology specialties, disability studies, and the broader community interested in disability issues.

Helping people with HIV/AIDS return to work: a randomized clinical trial

OBJECTIVE

New treatments introduced in the mid-1990s led many people with HIV/AIDS who previously had been disabled by their disease to contemplate workforce reentry; many remain unemployed, and little is known concerning interventions that might help them return to work. We report the results of a randomized clinical trial of an intervention designed to help people with HIV/AIDS reenter the workforce.

DESIGN

We tested a mixed (group-individual) modality intervention that incorporated elements of Motivational Interviewing (Miller & Rollnick, 2002), skills building from Dialectical Behavior Therapy (Linehan, 1993), and job-related skills (Price & Vinokur, 1995). A total of 174 individuals participated in either the intervention or in standard of care and were followed for 24 months.

RESULTS

Compared with individuals referred for standard of care, participants in the intervention engaged in more workforce-reentry activities over time and, once employed, were more likely to remain employed. Dose-response analyses revealed that among intervention participants, participants who attended more than 1 individual session engaged in more workforce-reentry activities than individuals who attended 1 or fewer individual sessions, whereas frequency of group session participation did not effect a difference between participants who attended more than 6 group sessions and participants who attended 6 or fewer group sessions.

CONCLUSION

Theoretically based workforce-reentry assistance programs can assist disabled people with HIV/AIDS in their return-to-work efforts.

Unifying and Elevating Rehabilitation Counseling Through Model-Driven, Diversity-Sensitive Evidence-Based Practice

Rehabilitation counseling must embrace an evidence-based practice paradigm to remain a vital and respected member of the future community of professions in rehabilitation and mental health care and to fully discharge its responsibility to assist consumers in accessing effective rehabilitation interventions and exercising truly informed choice. The goals of this article are to (a) discuss the importance of using model-driven and culturally sensitive evidence-based rehabilitation counseling practices to enhance rehabilitation outcomes for people with disabilities, (b) highlight the needs for an integrative conceptual framework of disability that can be used to conduct systematic rehabilitation counseling research and to examine mediators and moderators affecting vocational rehabilitation outcomes, and (c) recommend changes in rehabilitation counseling practice, education, and research.