The mission and purpose of Therapeutic Recreation (TR) has always been anchored in a commitment to facilitating the achievement and maintenance of health. Without losing this sense of purpose, the profession's scope of practice has attempted to keep pace with new information and perspective that contribute to an understanding of the meaning of health and its ultimate contribution to life quality.
In recent years, there have been several significant advances in understanding health that have important implications for TR practice and research. The first, of course, is the holistic view of health that is becoming the norm within health care and human service agencies. Increasingly, systems that provide services for people with disabilities are defining health as a dynamic process aimed at achieving a sense of balance and integration between body, mind, and spirit. This holistic conceptualization of health (often referred to as "wellness") places particular emphasis on the physical, psychological, social, and environmental determinants of health and the capacity of the individual, in concert with his/her community and culture, to define, determine and manage personal health and well-being. The growing acceptance of the wellness philosophy among health and human service providers is evident in the utilization of complementary and alternative health practices such as yoga, massage, Tai Chi, aromatherapy and humor. Many of these practices fall within the rubric of complementary and alternative medicine (CAM) and are being incorporated into TR practice.
Another recent development that has particular relevance to the health and health care of individuals with disabilities is the World Health Organization's revised International Classification of Functioning, Health and Disability (ICF). The ICF is intended to provide a unified and standard language for communicating about health and health care across the myriad healthrelated disciplines and sciences world-wide. This model is intended for use as a conceptual framework for designing health promotion and disease prevention services, measuring outcomes, and influencing health policy. Of particular importance is the ICF's emphasis on environmental factors that influence one's capacity to be an active participant in all aspects of life, including community, social and civic life. As such, the ICF is a perfect framework for the TR profession to advocate for and demonstrate the importance of play, recreation, and leisure in the health and well-being of persons with disabilities.
Finally, there is clear indication that the traditional disease oriented medical model of health care must be balanced with comprehensive health promotion and illness prevention services, including the prevention of secondary health conditions for which persons with chronic illnesses and disabilities are vulnerable. This is evident in the most recent "blueprint" for the nation's health, Healthy People 2010. This document is intended to be an invitation to all health-related professions to help achieve the two overarching health goals for the nation: an increase in the quality and years of healthy life and the elimination of health disparities.
Taken together, the three advances briefly described above are opportunities through which the TR profession can articulate its relevance to the larger vision of health and health care in America. This is, in essence, the exact intent of this special issue of the Therapeutic Recreation Journal on health and health promotion. This special issue contains a number of articles that represent the TR profession's response to a call to all health-related professions to understand health from a holistic, contextual, and preventive perspective.
The selection and alignment of the articles in this issue are consistent with the CARE framework proposed by the US Surgeon General for attacking the problem with overweight and obesity in the nation. The CARE framework utilizes four components: Communication, Action, Research and Evaluation. Communication activities focus on the provision of health-related information to motivate change on the organizational as well as the individual level. Action refers to interventions that assist individuals or agencies in achieving desirable changes. Research and evaluation activities focus on developing a better understanding of effective interventions and the development of new communication and action strategies that promote change. The articles within this special issue communicate information about the national health agenda, describe action taken by TR professionals to promote health and prevent secondary conditions in persons with disabilities, and report on research and evaluation conducted on this topic. Taken together, we believe this special issue represents the "CARE" that the profession has for promoting health and life quality among persons with chronic illness, disabilities, and other health-compromising conditions.
The special issue opens with a conceptual article written by Howard, Russoniello and Rodgers. This article discusses the development, structure, organization and purpose of the nationwide health promotion and disease prevention agenda articulated in Healthy People 2010, with particular emphasis placed on foci area in Healthy People 2010 that have relevance to TR practice. The authors also provide numerous examples of actions that have been taken or can be taken to promote TR within the national health agenda.
Next in this issue are two articles that examine complementary and alternative health practices which are sometimes incorporated into TR practice. The interventions evaluated in these articles reflect actions that TR practitioners have taken in response to initiatives begun by the Center for Medicare-Medicaid Services (CMS) and the Joint Commission of the Accreditation of Healthcare Organizations (JCAHO) to better manage pain and promote health in individuals with chronic illness and disabilities.
Aromatherapy and hand massage are the foci in an evaluation study reported by Kunstler, Greenblatt, and Moreno. Using a single-subject design, these authors explore how these CAM approaches can be incorporated into TR services within a skilled nursing facility. Their findings suggest that such modalities are useful in minimizing the chronic pain that compromises the health and well-being of many elderly individuals and as such may be a new arena for TR service provision.
Another recognized CAM practice is evaluated in Bonadies' article. Recognizing that pain and anxiety are frequently co-occurring disorders in individuals with Acquired Immune Deficiency Syndrome (AIDS), Bonadies evaluated whether an 8-week yoga intervention was useful in minimizing self-perceptions of pain and anxiety in persons with AIDS.
Findings from both of these evaluation studies suggest that TR can contribute to non-pharmaceutical pain management approaches thereby enhancing the health and well-being of clients. As importantly, both of these articles represent examples of how practicing recreation therapists can take action to support the national health promotion agenda by systematically conducting evaluation studies of their interventions and sharing their results with others.
Developing a better understanding of how to assist people with disabilities to maintain optimal health and minimize secondary complications is a major foci area in Healthy People 2010. As such, the special issue contains three descriptive research studies focused on this topic. Each study reflects the importance of an environmental or contextual perspective that is consistent with the international ICF model for understanding functioning, health, and disability.
Findings from a qualitative research study investigating how persons living with multiple sclerosis (MS) enhanced their development and optimized their health and well-being are reported by Wilhite, Keller, Hodges, and Caldwell. In this research, individuals with MS articulate the importance that relationships, involvement in everyday experiences of home life, and connections to the community had to their health and well-being. They also discuss the adaptive processes and strategies they used as they strived to maintain optimal health in the face of a chronic and unpredictable disease.
Leisure-time physical activity and its relationship to health and wellness for persons with physical disabilities is the focus of the next article in the special issue. Using one of the leading health indicators in Healthy People 2010, Santiago and Coyle describe the amount and types of leisure-time physical activity reported by women with mobility impairments and explore how their involvement relates to their self-perceptions of their physical and mental health.
Sable and Bocarro's report on clients' perceptions of the usefulness of a unique recreationbased health promotion program designed to assist individuals with spinal cord injury achieve a healthy lifestyle through health and wellness information, leisure education, and peer mentoring. Findings revealed that participants were highly supportive of the program and suggested it was successful in assisting them with becoming active community members by providing them with social and emotional support, individualized and holistic health information, information and access to adaptive equipment and programs, and addressing environmental barriers. Participants' comments suggest that the provision of recreation-based health promotion programs is a fruitful area in which the TR profession can be involved in achieving the goals of Healthy People 2010.
The last article in the special issue is a conceptual paper focused on the role of TR within the emerging paradigm of positive psychology. Carruthers and Hood provide a comprehensive review of the literature on positive psychology and relate it to the concepts of health promotion and primary prevention. They also discuss ways in which the theoretical framework of positive psychology can be utilized to support TR services, especially those services focused on building clients' strengths and resources so as to promote health and life quality.
While the manuscripts in the special issue highlight preliminary work completed related to TR and health promotion, much remains to be done. The profession must continue to communicate a health promotion message to recipients of TR services in institutions and communities. As a discipline, we have not systematically developed or tested theory-driven tailored communication strategies and interventions that promote health. Research that is sensitive to an individual's readiness to make lifestyle changes and which uses physically and socially active recreation involvement as a means to maintain and improve the health of persons with disabilities is needed.
Additionally, most of the TR research related to health promotion has focused on the efficacy of interventions. However, impact analysis research on TR health promotion interventions is also needed. Unlike efficacy research, impact analysis includes participation rates when determining the ultimate effectiveness of an intervention. Within the health promotion agenda, interventions that are moderately effective in promoting physically and socially active lifestyles and which have good participation rates (i.e., do not lose participants due to poor attendance) are as relevant as highly efficacious structured exercise or conditioning programs. Impact studies that examine TR's role in promoting physically and socially active lifestyles is a future area of research that may capture the unique contribution TR has for the nation's health promotion agenda. In addition, TR professionals also need to begin to conduct large-scale epidemiological research that examines the contribution of physically and socially active lifestyles from a community and population-based perspective.
While the role of TR as a profession and as a distinct set of services has yet to be fully understood and articulated within the larger health agenda, the articles contained in this special issue are excellent examples of positive action and promising directions for continued action in the future. As guest editors, we have appreciated the opportunity to work with the authors and reviewers, and thank them for their contribution to this issue.
Catharine Coyle, Ph.D., CTRS
John Shank, Ed.D., CTRS
Guest Co-Editors, TRJ Special Issue on Health and Health Promotion
Copyright National Recreation and Park Association Second Quarter 2004
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