Health promotion for people with disabilities attracts a diverse audience: people with disabilities themselves, policymakers, service providers and others.

This Guideline discusses our research on effective strategies for marketing and promoting RTC: Rural's two health promotion programs: Living Well with a Disability (an eight-week workshop) and the New Directions physical activity program. It also describes the barriers people with disabilities anticipate when they consider participating in a health promotion program. If marketing strategies address these barriers, more people with disabilities may participate in health promotion activities.

Secondary conditions are the medical and psycho-social conditions people with disabilities often experience following the onset of a disabling injury or disease. Chapter 6 of Healthy People 2010 focuses on increasing the proportion of people who engage in healthy behaviors that may prevent and/or manage secondary conditions. There are many approaches to changing health behavior, but health education continues to be the standard strategy to teach people how to prevent health problems, and how to maintain and even improve their health. Health promotion programs often include structured classes that target behaviors such as healthy eating and exercise. Living Well with a Disability aims to effect lifestyle changes that may reduce the incidence and severity of secondary conditions. Although our research indicated that Living Well works for people with disabilities, we knew that to reach our audience we would need to package and promote the program effectively.

Barriers to Health Promotion:

Research has identified the most common barriers to participating in disability-related health promotion activities. Almost three-quarters of Murphy-Southwick and Ravesloot's sample said chronic pain and fatigue were their greatest barriers (Readiness for Health Promotion, 2000). In 1990, Stuifbergen and others found the top barriers to be fatigue and lack of money. In Rimmer's 1999 study, women with physical disabilities said transportation, ability to pay for a health promotion program, and lack of energy were their main concerns.

Some barriers make participation in health promotion activities impossible. Others drive up the "cost" of participation and decrease the person's perception of its benefit. For example, we found pain and fatigue to be the greatest barriers to health promotion participation. People who fear that participating in a health promoting activity will leave them tired and hurting may believe this cost outweighs any benefit they might gain.

We asked new Living Well recruits to predict their greatest barriers to attending the program. Then we asked program graduates to rate the same list of barriers based on their actual experiences. Overall, workshop graduates rated the barriers as having been much less (50%) problematic than they had predicted. Table 1 compares the barriers predicted as most problematic by two samples - Living Well workshop recruits, and Medicaid beneficiaries (the "Exercise Recruitment" group) who participated in a marketing study for our New Directions physical activity program. The Disability and Health Perceived Barriers Questionnaire has 28 items scaled from 0 (not a problem) to 3 (a very big problem).

Table 1: Top-rated Barriers from the Disability and Health Perceived Barriers Questionnaire 

Description of Table 1.

Barrier	Living WellMean (n=115)	Living WellRank	Exercise Recruitment Mean (n=224)	Exercise Recruitment Rank
I get tired easily.	1.25	1	2.21	1
I have pain when I do too much.	1.21	2	1.95	2
My disability is limiting me too much these days.	.84	3	1.47	3
I will need someone to help me.	.80	4	.75	12
I don't have accessible transportation.	.78	5	.95	7
I lose control over my bowel and bladder functions.	.69	6	.57	14
The weather is often too bad to get out.	.66	7	1.21	4
Buildings are not accessible to me.	.66	8	.40	17
I have a hard time thinking and concentrating.	.60	9	1.18	5
My daily self-care needs take too much energy.	.58	10	.81	10
I'm too busy to take time away from other important activities	.24	19	1.03	6
Chemicals in the environment bother me.	.31	18	.87	8
My weight makes it hard to get around.	.40	13	.82	9

These results are important for health promotion program recruiters. First, you must acknowledge that people with disabilities face these and other barriers to community participation. Second, even if you make the "perfect" plan to accommodate participants, potential recruits may still overestimate the difficulty of attending the program. Your marketing effort must reflect that you understand your clients' anticipated barriers and it must explicitly address those barriers.

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Techniques for Promoting, Marketing and Recruiting:

In two studies conducted over several years, we tested seven recruitment methods. Here are our conclusions, recommendations, and tips for marketing health promotion services for people with disabilities:

Our first study tested the relative effectiveness of:

1. Targeted mailings to centers for independent living (CIL) consumers;
2. Oral presentations by CIL staff to consumers;
3. Mass media distribution (public service announcements, television and radio interviews);
4. Flyers posted around the community;
5. Information packets distributed to medical providers.

Our second study investigated the relative effectiveness of:

1. A newsletter series focusing on specific secondary conditions;
2. Telephone calls using Motivational Interviewing techniques.

Letters, mass media, flyers, information packets and newsletters are passive marketing methods - a person is given information and then must choose whether to act on it. The active methods involve dialog between the marketer and an individual. Table 2 shows the effectiveness of each strategy based on our research.

Note: Please consider study cohort differences when comparing strategies. Target audience for methods 1 & 2 was CIL consumers. Target audience for methods 3, 4 & 5 was the general population of people with disabilities. Target audience for methods 6 & 7 was Medicaid beneficiaries with physical disabilities.

Table 2: Relative Effectiveness of Recruitment Techniques. 

Description of Table 2.

Recruitment Method	# of Contacts	# Recruited	%
1. Letters sent to CIL consumers	639	55	8.6
2. Speaking with CIL consumers	164	38	23.2
3. Media contacts	374	25	6.7
4. Medical provider packets	268	2	0.7
5. Flyers posted in the community	250	6	2.4
6. Newsletter series	119	9	7.6
7. Motivational Interviewing	123	24	22.9

Of the seven methods examined, "Speaking with CIL consumers" and "Motivational Interviewing" are clearly the most effective means of recruiting people into health promotion services. In these active methods the marketer directly contacts and interacts with potential participants. Perhaps talking about the available services allows people to more realistically assess possible barriers to their participation. Each active method targeted a specific audience. In "Speaking with CIL consumers", the CIL staff contacted people who might be interested in the program. We used "Motivational Interviewing" with a sample of individuals who had completed a health survey but had not specifically indicated an interest in health promotion activities.

Active marketing: How to Talk with People about Health Promotion:

Helping people think about the costs and potential benefits of health promotion activities is one of the keys to active marketing. As our research shows, people with disabilities face substantial barriers and they fear the costs of participating in health promotion activities will be high. Moreover, if medical providers have said that their condition won't improve, they may expect few benefits from health promotion. Any conversation about health promotion activities must take such expectations into account. When talking with people about health promotion:

1. Introduce the topic of your conversation.
2. Ask the person to describe his or her disability experience: This helps you understand the complex interplay between the person's expectations of the costs and benefits of participation. Ask "Would you mind telling me a little bit about your condition?", followed by "How has (your condition) limited the things you like to do?" The answers can help you begin to understand that person's specific concerns and the nature of the barriers he or she faces.
3. Ask the person how he or she expects to benefit from practicing healthy behavior: For example, you might ask, "Do you think there is any connection between the way you feel and the things you eat every day?" If the person believes there is a connection, he or she may be more likely to believe improvements in diet can be beneficial. If a person's anticipation of barriers seems unrealistic, ask if you may provide additional, accurate information. For example, many people with pain believe that any exercise will increase their pain. You might say, "May I tell you a little bit about what many other people with pain have experienced when they start a supervised exercise program?" If the person consents, describe how gradually progressing from very low activity levels to greater activity levels typically has minimal impact on pain.
4. Help the person explore the barriers he or she is likely to face when attempting to change behaviors, and determine whether his or her expectations are realistic: Barriers may be personal (such as lack of motivation or depression), social (such as personal assistance needs or difficulty reading standard print materials) or environmental (such as inclement weather or environmental chemicals). If the person is pessimistic about barriers, help him or her explore these fears and ask if you may provide information that may result in more positive expectations.

Passive Marketing: Putting the Information Out There:

In our study, each passive marketing method was almost equally successful and each provided information to consumers. Whatever the format - newsletters, flyers, information packets, or letters to individual consumers - consider incorporating these useful marketing techniques. Anticipate possible barriers to participation and provide specific information about how you can help participants overcome them. As you strive to minimize the perceived "costs" of participation, also provide specific information about its potential benefits.

Although passive marketing strategies are cost-effective, they recruit a relatively small proportion of your target audience. Active marketing strategies are more expensive, but they are also more effective in recruiting people with disabilities who can benefit from your health promotion services.

A Combination of Passive and Active Marketing Methods Works Best.

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References:

Murphy-Southwick, C. & Seekins, T. (2000.) Readiness for Health Promotion: Rural Disability and Rehabilitation Research Progress Report #5. Missoula: The University of Montana Rural Institute.

Ravesloot, C. (2003). Marketing Health Promotion for People with Disabilities: Rural Disability and Rehabilitation Research Progress Report #18.  Missoula: The University of Montana Rural Institute.

Rimmer, J.H. (1999). Health promotion for people with disabilities: The emerging paradigm shift from disability prevention to prevention of secondary conditions. Physical Therapy. 79, 495-502.

Stuifbergen, A., Becker, H. & Sands, D. (1990). Barriers to health promotion for individuals with disabilities. Family & Community Health. 13,1,11-22.

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For more information, contact:

Craig Ravesloot, Ph.D., Health Projects Director
Research and Training Center on Disability in Rural Communities,
The University of Montana Rural Institute: A Center of Excellence in Disability
Education, Research and Services, 52 Corbin Hall, Missoula, MT 59812-7056;
(888)268-2743 toll-free; (303) 774-6196; (406) 243-4200 (TTY); (406) 243-2349 (fax)
email the Rural Institute
http://rtc.ruralinstitute.umt.edu

This research is supported by grant #R04/CCR818823-01 from the Centers for Disease Control and Prevention. Opinions expressed reflect those of the author and are not necessarily those of the funding agency.

This guideline was prepared by Craig Ravesloot, © RTC: Rural 2003. It is also available in large print, ASCII DOS text, and Braille formats. The Rural Practice Guidelines Series is edited by Diana Spas.

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