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Health promotion and disease prevention for people with disabilities:

An annotated bibliography

Alice Wong and Robert Newcomer

July 2007

Description

The following annotated bibliography consists of 26 of reports and journal articles on the subject of health promotion and disease prevention for people with disabilities. Except for four reports (Thomson 2002, North Carolina Office on Disability 2003, Hammond 2004, U.S. Department of Health and Human Services 2005), the articles and their abstracts came from a search on the academic database, PubMed. Using the terms “health promotion and disabilities” and “disease prevention and disabilities,” a number of articles were selected from the search results looking for innovative and promising practices and relevant literature within the last 6 years. A Google search was also conducted using the same search terms that yielded thousands of hits with four reports selected from those results (Thomson 2002, North Carolina Office on Disability 2003, Hammond 2004, U.S. Department of Health and Human Services 2005).

Annotated Bibliography

Almomani F, Brown C, Williams KB. (2006). The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29 (4): 274-81.

Oral health programs for people with psychiatric disabilities are rare. This study examined the feasibility efficacy of an oral health intervention for people with psychiatric disabilities. Fifty individuals were recruited and randomly assigned to receive education, reminder system and mechanical toothbrush or just the mechanical toothbrush. 42 completed the study. Plaque index scores recorded at baseline and after 4 weeks indicate a statistically significant improvement for both groups but those in the enhanced intervention improved significantly more. The results suggest the mechanical toothbrush improves the oral hygiene of people with psychiatric disabilities. The combination of mechanical toothbrush, dental instructions and reminders result in additional improvements.

Becker H. (2006). Measuring health among people with disabilities. Family & Community Health, 29 (1 Suppl): 70S-77S.

The evolution in our understanding of health has profound implications for people with disabilities. The purpose of this article is to explore how health has been defined and measured for people with disabilities. This article concludes with recommendations to improve measurement of health among people with disabilities. These recommendations include clarifying conceptual and operational definitions of health with input from people with disabilities, exploring whether existing health measures might be modified to encompass environmental supports for staying healthy and avoiding secondary conditions, and conducting population-based studies of health status of people with disabilities.

Block P, Skeels SE, Keys CB, Rimmer JH. (2005). Shake-It-Up: health promotion and capacity building for people with spinal cord injuries and related neurological disabilities. Disability and Rehabilitation, 27 (4):185-90.

PURPOSE: This is a description of a model demonstration project called Project Shake-It-Up. This project promotes the health and empowerment of people with spinal cord injuries and related neurological disabilities. It also builds the capacity of community organizations that provide services to this population. METHODS: Participants are involved in interactive seminars concerning health and advocacy on topics like nutrition and being assertive with healthcare providers. They take part in physical and recreational activities such as seat kayaking, kite-flying and hand cycling. Case coordinators support their project participation and personal goal attainment. RESULTS: Community organizations and university researchers developed a successful partnership. Individual members of the first cohort supported one another and benefited physically and psychologically. CONCLUSIONS: Project-Shake-It-Up provides positive initial signs of the value of combining the resources of universities and community agencies. Working together, these organizations can develop distinctive, multi-faceted programmes to support the health and empowerment of people with spinal cord injuries and other related neurological disabilities.

Capriotti T. (2006). Inadequate cardiovascular disease prevention in women with physical disabilities. Rehabilitation Nursing, 31 (3): 94-101.

Health promotion and screening tests are important in persons with disability to avert secondary conditions that can lead to suboptimal functioning or premature death. Conversely, the existence of a primary disability can increase a person's susceptibility to secondary conditions. Cardiovascular disease (CVD) is the major cause of death in the United States, and its prevalence has been underinvestigated in persons with disability. This descriptive study used survey research to compare the risk of CVD in samples of 100 physically disabled women with 50 non disabled women in the community. Participants, recruited from health fairs, completed questionnaires that explored the participants' knowledge of CVD risk factors, possession of specific CVD risk factors, and experience with CVD preventive screening procedures. Data revealed that compared with women without disability, women with disability were less knowledgeable about CVD risk factors and experienced marked deficiencies in CVD preventive screening. Body weigh tmeasurement, baseline electrocardiograms, family history, and smoking querieswere performed less often in women with disabilities than in women without disabilities of similar age. Physical inactivity and postmenopausal status were specific CVD risk factors found to be more prevalent in the sample of women with disability. These findings suggest that risk of CVD is underrecognized and underassessed in women with a physical disability.

Carmona RH, Cabe J, McCabe J. (2005). Improving the health and wellness of persons with disabilities: a call to action. Psychiatric Rehabilitation Journal, 29 (2): 122-7.

The purpose of this study was to determine the effects a health education and exercise program would have in limiting weight gain and in improving fitness and psychological parameters in adults with mood or psychotic disorders. Thirty volunteers were randomly assigned to the healthy lifestyle group (HL) or a control group. The HL group engaged in exercise for 12 weeks. Pre- and post-exercise testing was conducted to assess body fat, lipid profile, and cardiovascular fitness. Educational seminars were held weekly. The intervention group evidenced greater weight loss than the control group, although not statistically significant. Significant differences were observed in ratings of general health (p < .05) and empowerment (p < .01). Trends suggest that exercise interventions may encourage weight loss, particularly if barriers to full participation can be addressed. Additionally, such interventions may contribute to "perceived" well-being even among those with subclinical participation.

Centers for Disease Control and Prevention (CDC). (2006). Environmental barriers to health care among persons with disabilities—Los Angeles County, California, 2002-2003. Morbidity and Mortality Weekly Report, 55 (48): 1300-3.

In 2002, an estimated 51.2 million persons in the United States (approximately 18.1% of the population) had a disability. Recent data suggest that substantial disparities in health behaviors and overall health status exist between persons with and without disabilities. Nonetheless, when they have access to adequate health care, persons with disabilities can lead healthy lives. The World Health Organization's International Classification of Functioning, Disability, and Health stresses the importance of environment (e.g., physical environment, attitudes of others, or policies) as either a barrier or facilitator in the daily activities of persons with disabilities. In addition, increasing access to health and wellness treatment programs for persons with disabilities and reducing the proportion of persons with disabilities who report environmental barriers to participation in daily activities are goals of Healthy People 2010 (objectives 6-10 and 6-12). However, few population-based studies have explored how environment affects the lives of those with disabilities. To determine the prevalence of disability among persons in Los Angeles County, California, and assess the effects of environmental barriers on these persons, residents were surveyed during 2002-2003. The results of that survey suggested that persons with physical or sensory disabilities experienced several environmental barriers and that the prevalence of barriers varied by demographic characteristics, household income, and severity of disability. To improve quality of life among persons with disabilities, public and private health agencies should implement measures to remove environmental barriers to health care and other services.

Chess D, Krentzman M, Charde J. (2007). Creating a wellness program/safety net for the medically complex and frail patient. The Journal of Ambulatory Care Management, 30 (1): 30-8.

There is a small subgroup of Medicare and Medicaid patients (2%-4%) who have complex illnesses, frailties, and often disabilities. The medical problems of these patients are characterized by multiple diagnoses, complex medication routines, frequent hospitalizations, many physicians and physician visits, impairment of activities of daily life (including cognitive disabilities), and reliance on a caregiver for support and keeping them in the community. The cost of their care increases year after year averaging $40,000 per year. Strongly associated with these multiple problems is isolation and often depression, which compounds their medical problems resulting in nonadherence to their prescribed medical regimes which might otherwise keep them out of the hospital. This article describes a new approach to providing both a wellness program and medical safety net for this unstable population.

Cooper SA, Morrison J, Melville C, Finlayson J, Allan L, Martin G, Robinson N. (2006). Improving the health of people with intellectual disabilities: Outcomes of a health screening programme after 1 year. Journal of Intellectual Disability Research, 50 (Pt 9): 667-77.

BACKGROUND: People with intellectual disabilities (IDs) have a higher level of health needs, a higher level of which is unmet, compared with the general population. Health screening can detect unmet health needs, but it is unknown whether it effects beneficial health outcomes in the longer term. People with IDs are reliant on health management by proxy and there are many potential access barriers that may prevent health needs identified at screening from subsequently being met. This study aims to determine whether health gains can be detected 1 year after a health screening programme specific to the needs of adults with IDs. METHODS: A total of 50 participants offered the health screen intervention were individually matched for gender, age and level of IDs with 50 control participants who received standard treatment only. Outcome measures after 1 year were semi-structured review of medical case notes, and semi-structured assessment with the people with IDs and their carer. RESULTS: During the 1-year period, the incidence of health need detection was more than twice as great for intervention, compared with control participants (mean number of new needs was 4.80 compared with 2.26; P < 0.001), and the level of met new health needs was greater (mean of 3.56 compared with 2.26; P = 0.001). The level of met health promotion needs was also greater (P < 0.001), and more health monitoring needs were met for intervention compared with control participants (P = 0.039). CONCLUSIONS: This is the first study to demonstrate sustained benefits in health outcomes from a clinical intervention for adults with IDs compared with standard treatment alone. Its routine implementation is feasible, and would reduce health inequalities.

Fragala-Pinkham MA, Haley SM, Goodgold S. (2006). Evaluation of a community-based group fitness program for children with disabilities. Pediatric Physical Therapy, 18 (2): 159-67.

PURPOSE: This study examined the feasibility, safety, and effectiveness of a community-based group fitness program for children with disabilities. METHODS: Twenty-eight children with neuromuscular and developmental disabilities, 6 to 14 years of age, participated. The 16-week community-based program, held twice weekly, consisted of strengthening, aerobic conditioning, and flexibility exercises. A pretest-posttest design was used, and the following outcomes were measured: isometric muscle strength of the knee extensors, hip abductors, and ankle plantarflexors, walking energy expenditure, functional mobility, and fitness. Falls and injury data also were collected. RESULTS: Mean program attendance was 75.3%, and no injuries were reported. Improvements in all clinical outcomes were observed. The most clinically meaningful improvement was in functional mobility with a large effect size (0.87). CONCLUSIONS: Physical therapists partnering with community centers may feasibly and safely shift group fitness programs for school-aged children with disabilities from the medical setting to the community.

Hammond, L. (2004). Module 8: Concepts of health and health promotion for people living with disabilities. In C.E. Drum, G.L. Krahn, B.A. Ritacco & A.E. Drake (Eds.), Disability and Public Health Curriculum. Oregon Office on Disability and Health. Retrieved from: http://cdrc.ohsu.edu/oodh/publications/documents/DisabilityandPublicHealthCurriculumOutline.pdf

The curriculum outline is intended to provide an instructor with an organized guide to teaching a course introducing issues of disability to students of public health and other related fields. The outline is organized by topic in nine modules and each module contains key points to be discussed in class, a bibliography, and supplemental readings. The appendices include a generic class syllabus and sample exam questions.

The course is intended to provide an introduction to the field of disabilities and demonstrate how disability issues can be incorporated into academic public health. Topics to be discussed include the following: 1) models and approaches to disability; 2) a brief history of public health; 3) disability epidemiology; 4) United States governmental programs and services for people with disabilities; 5) a personal perspective on the history of disability; 6) multicultural views of disability; 7) the contemporary experience of disability in America; 8) health promotion and disability; and 9) the role of public health professionals (abstract from p. 3 of document).

Harrison T. (2006). Health promotion for persons with disabilities: What does the literature reveal? Family & Community Health, 29 (1 Suppl): 12S-19S.

A search of MEDLINE and CINAHL databases for research on disability and health promotion was done. Twenty-three articles were categorized into 1 of 3 areas: the meaning of health and health promotion, factors that contribute to health and health promotion, and health promotion interventions. Overall, health and health promotion were inductively defined concepts that emphasized function, relationships, and a positive mental attitude. Barriers to health promotion were frequently reported, fatigue being most common. Moreover, better health outcomes were reported when people with disabilities engaged in health-promoting behaviors. There were few interventions found, with only 1 being a randomized clinical trial.

Hughes RB. (2006). Achieving effective health promotion for women with disabilities. Family & Community Health, 29 (1 Suppl): 44S-51S.

The field of health promotion has yet to acknowledge the unique needs of women with disabilities, a population representing approximately 1 of 5 women in the United States. Compared with women without disabilities, women with disabilities have critical needs for evidence-based health promotion services. Women with disabilities face a lack of access to multitudinous opportunities for maintaining and improving their overall health. Inaccessible exercise equipment and other disability-related barriers discourage women with physical disabilities from engaging in health-promoting behaviors. This article identifies 10 essential elements for achieving effective health promotion research and interventions for women in this population.

Hutchinson DS, Gagne C, Bowers A, Russinova Z, Skrinar GS, Anthony WA. (2006). A framework for health promotion services for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29 (4): 241-50.

The concepts of wellness and its complement, health promotion, have popularized the notion that health itself is more than simply the absence of disease. Furthermore, the wellness concept has advanced the idea of the importance of engaging in certain health promoting behaviors within healthy environments, not simply for the purpose of preventing or better managing a disease, but also to enhance one's well-being and quality of life (Green & Kreuter, 1991; Mullen, 1986). Encouraging this emphasis on wellness is Healthy People 2010 (U.S. Department of Health and Human Services, 2000), a national ten-year plan intended to increase quality and years of life and eliminate disparities which for the now features a new area that recognizes the importance of health promotion and disease prevention in the lives of people with disabilities. Increasingly, the value of promoting wellness--including for people with disabilities--is being recognized (Rimmer & Braddock, 2002).

Kosma M, Ellis R, Cardinal BJ, Bauer JJ, McCubbin JA. (2007). The mediating role of intention and stages of change in physical activity among adults with physical disabilities: An integrative framework. Journal of Sport & Exercise Psychology, 29 (1): 21-38.

The study's purpose was to identify the mediating role of intention and the stages of change (SOC) in physical activity (PA) over a 6-month period using two models (theory of planned behavior [TPB] and TPB/SOC). Participants were 143 adults with physical disabilities (70.68% response rate; M age = 46.03). The TPB constructs, SOC (time 1), and PA (time 2) were assessed using standardized self-report questionnaires. Based on path analyses, attitude had the highest effect on intention and SOC followed by perceived behavioral control within both well-fit models. The variance in PA explained by the first (TPB) and second (TPB/SOC) models was 16% and 28% respectively. In the just identified model of TPB/SOC, the direct effect of SOC on physical activity remained strong (gamma(soc.pa) = .45) and SOC approached full mediation through attitude. Health promotion interventions need to include both intention and behavior elements (SOC) reinforcing increased PA value and barrier elimination.

Nieuwenhuijsen ER, Zemper E, Miner KR, Epstein M. (2006). Health behavior change models and theories: Contributions to rehabilitation. Disability and Rehabilitation, 28 (5): 245-56.

PURPOSE: This article highlights the importance of health behavior change (HBC) theory, and its relevance to rehabilitation research and practice. METHOD: An extensive review of HBC-related literature pertinent to rehabilitation was conducted, focusing on the potential impact of these theories and models in enhancing long-term results of rehabilitation with regard to lifestyle change and health promotion, and outlining the benefits of incorporating HBC themes into rehabilitation practice. For our purposes, the HBC concept is based on initiation and maintenance of health behaviors, functioning, wellness, and self-management of chronic conditions or disabilities within an environmental context. While comparing and contrasting three widely known theories of HBC, the contributions of these theories to rehabilitation research and practice are discussed. RESULTS: Three propositions are put forward: (1) HBC variables should regularly be used as outcome measures in evidence-based rehabilitation research; (2) there should be a better understanding of the role of the rehabilitation provider as a facilitator in eliciting healthy behaviors; and (3) there is a need to expand the HBC concept into a more comprehensive view encompassing a person's functioning within the environmental context. CONCLUSIONS: A conceptual merger between HBC theories and rehabilitation practice can have major implications for individuals with disabilities, their functioning, health, and well-being.

North Carolina Office on Disability and Health & Massachusetts Office on Health and Disability. (2003). Health promotion resource guide: Promoting the health and wellness of people with disabilities. Retrieved from: http://www.fpg.unc.edu/%7Encodh/pdfs/healthpromotionguide.pdf

This guide provides health educators, service providers, and program planners a carefully selected collection of resources that address accessibility, communication, and topic specific health promotion (abstract from: http://www.fpg.unc.edu/~ncodh/Publications.cfm).

Nosek MA, Hughes RB, Robinson-Whelen S, Taylor HB, Howland CA. (2006). Physical activity and nutritional behaviors of women with physical disabilities: Physical, psychological, social, and environmental influences. Women’s Health Issues, 16 (6): 323-33.

INTRODUCTION: We examined predictors of 2 important health behaviors, namely, physical activity and nutritional behaviors, in a sample of community-living women with physical disabilities (N = 386). METHOD: We conducted a cross-sectional survey with regression analysis. RESULTS: Our regression model accounted for 33.5% of the variance in physical activity. Women with joint problems or multiple sclerosis tended to engage in less physical activity than those with stroke-related disabilities. Those who had lived with their disability longer and those experiencing greater pain tended to report less physical activity. Consistent with the literature, women with greater self-efficacy for physical activity tended to engage in more physical activity. The regression model for nutritional behaviors accounted for 37.9% of the variance. Women with better mobility, greater self-efficacy for nutrition, and more vitality had better nutritional behaviors while those who needed assistance with activities of daily living, had lower social functioning scores, and were engaged in more productive activities reported poorer nutritional behaviors. CONCLUSIONS: Our findings highlight the importance of self-efficacy for improving health behaviors. Further research is needed to develop a new paradigm for the measurement of health behaviors, one that focuses on individual improvement rather than comparison to a norm, and health promoting interventions that are responsive to the needs and life circumstances of women with physical disabilities.

Palsbo SE, Mastal MF, O'Donnell LT. (2006). Disability care coordination organizations: Improving health and function in people with disabilities. Lippincott's Case Management, 11 (5): 255-64.

Disability care coordination organizations (DCCOs) combine attributes of the medical home model and community nursing. Teams of nurses and social workers collaborate with the client to arrange disability-competent medical and social services. This article synthesizes observational findings from site visits to approximately half of the DCCOs operating in 2004. DCCOs have 6 core clinical activities: comprehensive assessment; self-directed, person-centered planning; health visit support; centralized medical-social record; community resource engagement; and constant communication. We also identified 3 core business competencies: service coordination, patient education/behavioral modification, and continuous enhancement of disability competency. Each DCCO started as a new company rather than as a product line of an existing business, and each included the target population in the design stage. Most DCCOs contract with state Medicaid agencies under a prepaid capitation arrangement, and some also enroll Medicare beneficiaries. Capitated DCCOs retain cost savings and may be financially stronger than fee-for-service DCCOs. Although studies suggest that DCCOs improve coordination and clinical outcomes while reducing costs, the current evidence has not been peer reviewed.

Ravesloot CH, Seekins T, Cahill T, Lindgren S, Nary DE, White G. (2006). Health promotion for people with disabilities: Development and evaluation of the Living Well with a Disability program. Health Education Research Advance Access, October 10, [Epub ahead of print].

People with disabilities can benefit from health promotion opportunities to reduce the incidence and severity of secondary conditions that further limit their participation in society. This paper describes participatory action research (PAR) methods we used to develop, implement and evaluate the Living Well with a Disability program. Community-based agencies that provide information and referral services to people with disabilities (independent living centers funded under Title VII, Rehabilitation Act) recruited a convenience sample of 246 people with mobility impairments to participate in a randomly assigned, wait-list control health promotion intervention study. Paper-and-pencil outcome measures included the secondary conditions surveillance instrument, unhealthy days and health care utilization. Logistic regression on outcomes controlling for demographic variables and pre-test measures indicated reductions in all three outcome variables. People with mobility impairments who participated in the Living Well with a Disability program reported less limitation from secondary conditions, fewer unhealthy days and less health care utilization. PAR methods are particularly important to design useful interventions for this population

Rimmer JH, Braddock D. (2002). Health promotion for people with physical, cognitive and sensory disabilities: An emerging national priority. American Journal of Health Promotion, 16 (4): 220-4, ii.

Despite the growth in health promotion programs for able-bodied people, very little effort has been devoted to developing programs for people with physical and cognitive disabilities. Programs for people with disabilities must be developed with full recognition of limitations caused by both the primary and secondary disability.

Robinson-Whelen S, Hughes RB, Taylor HB, Colvard M, Mastel-Smith B, Nosek MA. (2006). Improving the health and health behaviors of women aging with physical disabilities: A peer-led health promotion program. Women’s Health Issues, 16 (6): 334-45.

OBJECTIVE: To examine the efficacy of a health promotion program for women aging with physical disabilities. METHOD: A sample of 137 middle-aged and older women with physical disabilities was randomly assigned to either an 8-week health promotion program or to a wait-list control group. Both groups completed questionnaires before, immediately after, and 3 months after the intervention. RESULTS: Relative to women in the control group, women in the health-promotion program demonstrated improvements in health behaviors, most of which were maintained at follow-up. The intervention group showed some improvements on measures of physical health, but there was little evidence of improvement in psychological health outcomes. Testing our theoretical model, self-efficacy was supported as a mediator of the effect of the intervention on health behaviors, and health behaviors combined with self-efficacy were supported as mediators of the effect of the intervention on physical health outcomes. Contrary to our hypotheses, our measures of social support and social connectedness were not affected by the intervention. CONCLUSIONS: A brief, peer-led, group health promotion program resulted in improved scores on measures of self-efficacy, increased health behavior, and physical health. Self-efficacy, which was supported as a mediator in the effect of the intervention on behaviors and health outcomes, should remain an important focus of future interventions with this population.

Smeltzer SC. (2006). Preventive health screening for breast and cervical cancer and osteoporosis in women with physical disabilities. Family & Community Health, 29 (1 Suppl): 35S-43S.

Although the Americans With Disabilities Act was enacted 15 years ago in an effort to improve access of people with disabilities to a broad range of services, women with physical disabilities continue to receive less preventive health screening than women without disabilities and less than is recommended. Furthermore, women with more severe disabilities undergo less screening than those with mild or moderate severity of disability. This article reviews findings of studies on health screening for breast and cervical cancer and osteoporosis in women with physical disabilities and identifies practice and research implications on the basis of those findings to improve the health status of women with physical disabilities.

Stuifbergen AK. (2006). Building health promotion interventions for persons with chronic disabling conditions. Family & Community Health, 29 (1 Suppl): 28S-34S.

There is a growing number of persons with chronic disabling conditions and a concurrent interest and need for health-promotion interventions to prevent disability and promote quality of life within the context of chronic conditions. Most often researchers/clinicians build their own intervention focusing on selected dimensions of health promotion for a specific population. This article recommends an alternative process of building health-promotion interventions for specific groups through the adaptation of content and processes of well-developed intervention frameworks with sound theoretical and empirical support. This efficient approach enhances the likelihood that new interventions will prove to be effective and enhance the quality of life for persons with chronic disabling conditions.

Thomson, K. (2002). Health promotion research guide depression and disability: A practical guide. Chapel Hill, NC: North Carolina Office on Disability and Health. Retrieved from: http://www.fpg.unc.edu/~ncodh/pdfs/depression.pdf

This booklet, written by clinical psychologist Dr. Karla Thompson, addresses basic information about depression, common symptoms and treatments of depression, and why people with disabilities may be at an increased risk for depression (abstract from: http://www.fpg.unc.edu/~ncodh/Publications.cfm).

U.S. Department of Health and Human Services. (2005). The Surgeon General's call to action to improve the health and wellness of persons with disabilities. Office of the Surgeon General. Retrieved from: http://www.surgeongeneral.gov/library/disabilities/calltoaction/calltoaction.pdf

This Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities emphasizes the centrality of health to the quality of our lives. Developed by the Surgeon General in collaboration with the Department’s Office on Disability, it describes the particular challenges to health and wellbeing faced by persons of all ages with disabilities. It places their health squarely among the public health issues at the forefront of research, service delivery, financing, training and education and health care policy today. It also builds upon the Nation’s efforts to promote wellness and disease prevention in all persons, including those with disabilities, as called for in the President’s Healthier US Initiative (abstract from p. 5 of report).

van der Ploeg, H.P., van der Beek, A.J., van der Woude, L.H. & van Mechelen, W. (2004). Physical activity for people with a disability: A conceptual model. Sports Medicine, 34, 639-49.

The promotion of a physically active lifestyle has become an important issue in health policy in first-world countries. A physically active lifestyle is accompanied by several fitness and health benefits. Individuals with a disability can particularly benefit from an active lifestyle: not only does it reduce the risk for secondary health problems, but all levels of functioning can be influenced positively. The objective of this article is to propose a conceptual model that describes the relationships between physical activity behaviour, its determinants and functioning of people with a disability. The literature was systematically searched for articles considering physical activity and disability, and models relating both topics were looked for in particular. No models were found relating physical activity behaviour, its determinants and functioning in people with a disability. Consequently, a new model, the Physical Activity for people with a Disability (PAD) model, was constructed based on existing models of disability and models of determinants of physical activity behaviour. The starting point was the new WHO Model of Functioning and Disability, part of the International Classification of Functioning, Disability and Health (ICF), which describes the multidimensional aspects of functioning and disability. Physical activity behaviour and its determinants were integrated into the ICF model. The factors determining physical activity were based mainly on those used in the Attitude, Social influence and self-Efficacy (ASE) model. The proposed model can be used as a theoretical framework for future interventions and research on physical activity promotion in the population of people with a disability. The model currently forms the theoretical basis for a large physical activity promotion trial in ten Dutch rehabilitation centres.