Social Power and the Movement System: Why and How Physical Therapists Might Influence the Upstream Currents of Health.

Social determinants of health are an emerging focus within physical therapist practice, research, education, and advocacy as a necessary condition for movement system health disparities. Fundamental cause theory suggests that the sociopolitical environment sets the context for individuals' socioeconomic positioning, which determines the availability of resources that are necessary for groups and individuals to maintain health. These resources include knowledge, money, power, prestige, and social connections. Yet, it is the hierarchical organization of society that dictates both the availability of socioeconomic resources and the ability of patients and clients to use those resources to promote and maintain movement system health. The presence of social hierarchies indicates the need for physical therapists to consider social power as a key determinant of movement system health. Consideration of social power in clinical initiatives and advocacy agendas would provide a framework for physical therapists to begin the dynamic, and often, adversarial process of breaking down social hierarchies and redistributing social power, rather than simply redistributing socioeconomic resources, in pursuit of societal transformation and community-building. This Perspective discusses social power as the fundamental driver of movement system health inequalities and explores the effects of social power on exposure, susceptibility, experience, and recovery related to movement system pathology-including the influence of social power on the ability of people to acquire socioeconomic resources and convert them to health-relevant resources. This perspective concludes with recommendations for physical therapists to identify and dismantle inequalities in social power through structural competency.

Improving shared decision-making for prosthetic care: A qualitative needs assessment of prosthetists and new lower-limb prosthesis users.

BACKGROUND: Prosthesis design is complex and multiple appropriate options exist for any individual with lower-limb amputation. However, there is insufficient evidence for guiding decision-making. Shared decision-making (SDM) offers an opportunity to incorporate patient-specific values and preferences where evidence is lacking for prosthesis design decisions. To develop resources to facilitate SDM, and consistent with the International Patient Decision Aid Standards, it is necessary to identify the decisional needs of prosthetists and prosthesis users for prosthesis design decisions. OBJECTIVES: To assess the needs of prosthetists and new prosthesis users for SDM about the first prosthesis design. STUDY DESIGN: Qualitative descriptive design. METHODS: Six focus groups were conducted with 38 prosthetists. Individual semistructured interviews were conducted with 17 new prosthesis users. Transcripts were analyzed using directed content analysis, with codes defined a priori using existing frameworks for SDM: the Three Talk Model for SDM and the Ottawa Decision Support Framework. RESULTS: Four main themes were identified among prosthetists and prosthesis users: acknowledging complexity in communication, clarifying values, recognizing the role of experience to inform preferences , and understanding the prosthetic journey . CONCLUSIONS: Resources that support SDM for the first prosthesis design should consider methods for identifying individual communication needs, support with clarifying values, and resources such as experience for achieving informed preferences, within the context of the overall course of rehabilitation and recovery following lower-limb amputation. The themes identified in this work can inform SDM to promote collaborative discussion between prosthetists and new prosthesis users when making prosthesis design decisions.

Strengthening Population Health Perspectives in Physical Therapist Practice Using Epigenetics.

Health starts where we live, learn, work, and play. Population health represents a unifying paradigm for understanding systematic variations in health and related factors, informing integrated action, and reducing health disparities. The pathways connecting social, environmental, and structural factors and various health outcomes have been illuminated by the emergence of epigenetic and epigenomic research, further bolstering the value of population health perspectives in supporting clinical practice, community-based programs, and societal policies. The purpose of this perspective is to consider the placement of epigenetic and epigenomic insights within a population health framework to strengthen the physical therapy profession's understanding of variations in health, inform integrated action, and further justify our role in reducing health-related disparities.

What Are DPT Program Practices and Attitudes Related to Population Health, Prevention, Health Promotion, and Wellness? Results of a National Survey.

OBJECTIVE: Noncommunicable diseases have increased in prevalence and are now responsible for the majority of the burden of disease. Aligning entry-level (professional) physical therapist education with these changing societal needs may position physical therapists to best address them. However, no comprehensive understanding of the practices and attitudes related to population health, prevention, health promotion, and wellness (PHPW) content among accredited US professional doctor of physical therapy (DPT) programs has been established. This study aims to identify practices and attitudes related to PHPW content among accredited US DPT programs. METHODS: A mixed-methods cross-sectional design using an electronic survey was utilized. Program directors of each accredited DPT program were identified using an official Commission on Accreditation in Physical Therapy Education list and invited to ascertain the perceived importance of PHPW, describe the delivery of PHPW content, and identify factors that influence inclusion of PHPW content in US DPT programs. RESULTS: Individuals from 49% of 208 invited programs responded. Nearly all programs reported teaching prevention (96.1%), health promotion (95.1%), and wellness content (98.0%), while fewer reported teaching population health (78.4%). However, only 15% of PHPW topics were covered in depth. Facilitators and barriers to the delivery of PHPW content were reciprocal and included faculty with PHPW expertise, logistical flexibility and support, and the perceived importance of PHPW content. CONCLUSIONS: The majority of US DPT programs are teaching PHPW content. Lack of trained faculty and lack of professional competencies hinder further integration of PHPW content into curricula. IMPACT: The findings of this study highlight avenues for additional research to determine professional PHPW competencies and additional educational needs for faculty members.

Beliefs Regarding Development and Early Intervention Among Low-Income African American and Hispanic Mothers.

OBJECTIVES: Understand the role of health beliefs in shaping maternal decisions regarding help-seeking for children with developmental delay (DD) and explore differences between African American and Hispanic mothers. METHODS: Open-ended, semistructured interviews were conducted with African American and Hispanic mothers of children aged 0 to 36 months with DD. Interviews were recorded, transcribed, and analyzed by using inductive content analysis. RESULTS: Mothers (n = 22) were African American (36%) or Hispanic (64%), 25 to 34 years old (64%), had less than a high school education (59%), and had children receiving public insurance (95%). Five major themes emerged describing the role of maternal health beliefs in shaping key stages of the help-seeking pathway for children with DD: (1) "I can see" (observing other children and making comparisons); (2) "Children are different and develop in their own time" (perceiving that their child might be different, but not necessarily delayed); (3) "It's not that I don't trust the doctor" (relying on social networks rather than pediatricians to inform the help-seeking pathway); (4) "I got so much going on" (difficulty prioritizing early intervention [EI] because of competing stressors); and (5) limited and conflicting information (delaying or forgoing EI because of limited or conflicting information). Differences between African American and Hispanic mothers are also described. CONCLUSIONS: Understanding maternal health beliefs and expectations regarding DD and EI, acknowledging the influence of social networks on help-seeking, and addressing social and financial stressors are critical to ensuring that children with DD are identified and supported at an early age.

Racial and Ethnic Disparities in Unmet Need for Pediatric Therapy Services: The Role of Family-Centered Care.

OBJECTIVE: To examine whether individual elements of family-centered care (FCC) mediate racial/ethnic disparities in parent-reported unmet therapy need. METHODS: We conducted a secondary data analysis using the 2009-2010 National Survey of Children With Special Health Care Needs. A total of 6478 black, Hispanic, and white children ages 0 to 5 years had complete data on parent-reported unmet need and FCC. Five measured indicators of FCC included whether the child's health care provider spent enough time with the child (time), listened carefully to the child's parents (listening), was sensitive to family culture and values (sensitivity), delivered information specific to the child's health (information), and helped parents feel like partners (partnership). We performed staged multivariate logistic regression to test the association between race/ethnicity and parent-reported unmet therapy need, and to explore whether this association was mediated by elements of FCC using the Baron-Kenny mediation framework. RESULTS: Eighteen percent of children with special health care needs 0 to 5 years old with reported therapy need experienced unmet need. Black and Hispanic children were more likely than white children to have parent-reported unmet therapy need (adjusted odds ratio 1.59, 95% confidence interval 1.08-2.36). This disparity was no longer significant after adjustment for the FCC elements of time, sensitivity, or partnership. CONCLUSIONS: The provision of FCC is likely an important factor in meeting the therapy needs of children with developmental delay and in reducing racial/ethnic disparities in parent-reported unmet therapy need. Interventions aimed at fostering parent-provider relationships through improved cultural sensitivity and engagement of parents as partners are necessary to ensure equitable utilization of these services.