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Toward core inter-professional health promotion competencies to address the non-communicable diseases… Dean, Elizabeth; Moffat, Marilyn; Skinner, Margot; Dornelas de Andrade, Armele; Myezwa, Hellen; Söderlund, Anne Jul 14, 2014

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DEBATE Open AccessToward core inter-professcompetencies is a compelling and potentially cost-effective initial means of preventing and reversing non-communicableDean et al. BMC Public Health 2014, 14:717http://www.biomedcentral.com/1471-2458/14/717Columbia, V6T 1Z3 Vancouver, CanadaFull list of author information is available at the end of the articlediseases. Learning evidence-based health promotion competencies within an inter-professional context would helpstudents maximize use of non-pharmacologic/non-surgical approaches and the contribution of each member of thehealth team. Such a unified approach would lead patients/clients to expect their health professionals to assess theirhealth and lifestyle practices, and empower and support them in achieving lifelong health. Benefits of such curriculumassessment include a basis for reflection and discussion within and across health professional programs that couldimpact the epidemic of non-communicable diseases globally, through inter-professional education and evidence-basedpractice related to health promotion.Keywords: Health behaviors, Health professional entry-level curricula, Health promotion interventions, Lifestyleinterventions, Lifestyle, Non-communicable diseases* Correspondence: elizabeth.dean@ubc.ca1Department of Physical Therapy, Faculty of Medicine, University of BritishSummary: Assessment of the curricula in health professionacompetencies to address the non-communicablediseases and their risk factors through knowledgetranslation: Curriculum content assessmentElizabeth Dean1*, Marilyn Moffat2, Margot Skinner3, Armele Dornelas de Andrade4, Hellen Myezwa5and Anne Söderlund6AbstractBackground: To increase the global impact of health promotion related to non-communicable diseases, healthprofessionals need evidence-based core competencies in health assessment and lifestyle behavior change. Assessmentof health promotion curricula by health professional programs is a first step. Such program assessment is a means of 1.demonstrating collective commitment across health professionals to prevent non-communicable diseases; 2. addressingthe knowledge translation gap between what is known about non-communicable diseases and their risk factorsconsistent with ‘best’ practice; and, 3. establishing core health-based competencies in the entry-level curricula ofestablished health professions.Discussion: Consistent with the World Health Organization’s definition of health (i.e., physical, emotional and socialwellbeing) and the Ottawa Charter, health promotion competencies are those that support health rather than reducesigns and symptoms primarily. A process algorithm to guide the implementation of health promotion competencies byhealth professionals is described. The algorithm outlines steps from the initial assessment of a patient’s/client’s health andthe indications for health behavior change, to the determination of whether that health professional assumes primaryresponsibility for implementing health behavior change interventions or refers the patient/client to others.An evidence-based template for assessment of the health promotion curriculum content of health professional educationprograms is outlined. It includes clinically-relevant behavior change theory; health assessment/examination tools; andhealth behavior change strategies/interventions that can be readily integrated into health professionals’ practices.l education programs with respect to health promotion© 2014 Dean et al.; licensee BioMed Central LCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.ional health promotiontd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Dean et al. BMC Public Health 2014, 14:717 Page 2 of 10http://www.biomedcentral.com/1471-2458/14/717BackgroundAlthough non-communicable diseases (NCDs) have beendescribed by the World Health Organization (WHO) asbeing largely preventable [1,2], priorities for action basedon the foundation value of health promotion from theOttawa Charter remain to be fully implemented [3]. Theseinclude strengthening structures and processes for healthpromotion, moving toward knowledge-based practice,and building a competent health promotion workforcethrough professional education that is responsive tosocietal priorities [4,5]. Scriven and Speller [3] haveargued that advocacy at all levels of health deliveryand care needs to continue to ensure that policy goalsrepresent the principles of Ottawa..’. Consistent withthis thrust, Mittelmark [6] described the need for settingan ethic agenda for health promotion based on dialogueresulting from the Ottawa Charter and more recently fromthe Bangkok Charter that established the cornerstone forhealth promotion. Others [7] have argued that healthpromotion must go beyond a narrow interpretation inthe field and requires greater participation of peoplewith respect to their health practices. We proposethat health professionals can impact societal healthmore broadly by empowering their patients/clients withthe universal practice of established core health promotioncompetencies that include the examination of healthand health behaviors and implementation of strategiesto modify these as needed.The ultimate knowledge translation gap in healthservices delivery has been described as the one thatexists between what is known unequivocally about thecausal and contributory relationships between NCDsand lifestyle behavior, and the need to implement thatknowledge into behavior change [8,9]. To address theglobal NCD epidemic, much has been documentedabout lifestyle behavior change to maximize health andreduce health risk though initiatives such as smokingcessation, and optimizing diet and physical activity.Although substantial health benefit can result from smallchanges in health behavior [10], assessing health-relatedlifestyle practices and effecting health behavior changeconstitute unique competencies. Comparable to the basisfor drug prescription, they require systematic assessmentof the patient’s/client’s needs and wants which may involvefamily and community, and implementation of one ormore lifestyle-behavior change interventions, which up tonow have not been systematically integrated withinand across the curricula of health professional programs.Depending on identified needs and wants, patients/clientsmay require referral to one or more health professionals.The work of Blanchard and colleagues is sobering. Itprovides strong evidence for core health promotioncompetencies being practiced by health professionals[11] as opposed to vague advice such as ‘stop smoking’,‘lose weight’, or ‘be more active’. These investigatorsreported that even when people receive the proverbial‘wake-up call’, e.g., those who are diagnosed withcancer, their long-term adherence to healthy livingrecommendations is alarmingly poor.The need for health promotion has been advocatedacross health professions including medicine, nursing,occupational therapy, pharmacy, and physical therapy,yet its implementation has lagged [12-17]. Examples ofattempts to benchmark lifestyle behavior change curriculacontent have been made in some health professionalprograms, notwithstanding several challenges that challengethe validity and reliability of the data [18,19]. Althoughhealth behavior change is becoming an overarching priorityconsistent with population health systems, regardless of theparticular health professional that a patient/client may beseeing, its practice remains fragmented and silo-ed [4,20].A systematic approach based on core competencies thatare shared within and across health professions would be astep toward bridging the gap between the value of healthpromotion and its systematic implementation into practice.Key elements of health promotion practice include:systematic assessment of global health and health behaviors,people’s environmental and social contexts, and targetedinterventions; accountability of the health professional andpatient/client; and systematic follow-up. We propose thatthe effect of any health behavior change intervention that isinitiated and/or supported by multiple health professionalswill be augmented given the opportunity for the healthmessage and interventions to be systematically andconsistently reinforced.Based on the WHO’s definition, health is not synonym-ous with the absence of signs and symptoms of a healthcondition or disease, but rather is a complete state ofphysical, mental and social wellbeing [21]. In the era ofchronic NCDs, people may expect to live for many yearswith these conditions, if not a full life expectancy. Thehealth backdrop of people with chronic health conditionsis often not the primary focus of health services, whichmore often focuses on signs and symptoms. Maximizinghealth through health behavior change in its own righthowever warrants being a primary goal designed to:prevent the NCDs; reduce the signs and symptoms ofthese and other chronic conditions; and improve theoutcomes of both non-pharmacologic/non-surgical inter-ventions as well as pharmacologic/surgical interventions.That ‘healthy living is simply good for you’ is a circuitousargument and one that is challenging to refute. Smith andPell [22] deduced the value of such observational databased on a systematic review that addressed the value ofparachutes to counter the negative effects of free fallgravitational force. We extend their logic regardingthe validity of observation with respect to the benefitsof parachute use, to the benefits of healthy living. WeDean et al. BMC Public Health 2014, 14:717 Page 3 of 10http://www.biomedcentral.com/1471-2458/14/717propose that assumptions can be made about healthypeople and their reduced need for health services,and their augmented response to health services whenneeded compared with unhealthy people. Assumptionsthat can be made about healthy people include: Healthy people get sick less often. When they do, they are sick for less time, recoveringfaster with fewer complications. Healthy people need fewer biomedical procedures;take fewer drugs and need less surgery. When they need these, they need less medication forless time, and benefit from less invasive surgery. Healthy people place fewer social and economicdemands on society. Healthy people stay in the workforce with lessabsenteeism, and long-term sick leave. Healthy people tend to leave their jobs for reasonsother than sickness.In a recent study [23], Wilson and colleagues showedthat lifestyle modification was mentioned in fewerthan half the studies in one major published report of anestablished Cochrane review of the effects of anti-hypertensive medication. Given that lifestyle modificationis the established first-line best practice in the managementof hypertension regardless of its severity or the presence ofmultiple co-morbidities [24], its omission in major drugtrials raises critically-important questions about the degreeto which research paradigms should reflect established bestclinical practice. Masking the effects of lifestyle practiceswith sophisticated randomization methods may leadto undermining these powerful effects and failure toappreciate important interactions of lifestyle practiceswith medications. Conversely, a study of lifestyle practiceson hypertension that did not consider the precise medica-tion prescription of its participants would be consideredmethodologically flawed.Given the powerful effects of healthy lifestyle practices,neglecting to assess lifestyle and prescribe healthy livingpractices to patients’/clients’ as systematically as evidence-supported medication by a highly qualified practitioner orprescribed surgery without the requirement for an equallyevidence-based systematic assessment of health and healthrisks and evidence-based health behavior change strategiesor interventions, is no longer justified in our view. Insupport of this position, we first define health promotioncompetencies. Then we outline a process for clinicaldecision making for a health professional related topatient/client health and risk factor assessment, criteriafor referring to other health professionals, and the needfor on-going support. Some simple tools are describedthat are universally accessible for the assessment of healthand health risk and health behavior change strategies andinterventions. These tools and strategies provide the basisof a template for program assessment of the curriculumcontent of health in health professional educationprograms. Assessment of this content constitutes onestep toward establishing what health content is beingincluded and the time devoted to it, in turn providing abasis for conversation within and among health profes-sional entry-level programs about core competencies aswell as more specialized competencies related to health byeach specific established health profession.Defining health promotion competenciesHealth is multidimensional, thus no single metric existsto assess it. The WHO has put forth the InternationalClassification of Functioning, Disability and Health (ICF)that delineates three levels at which health status can beassessed and interventions targeted (level of bodyfunction and structure, activity, and participation) [25].Global indices of health have become more commonand include tools such as sickness/disability impactprofiles, life satisfaction, wellbeing, and quality of life,which assess functional independence and social participa-tion (subsumed within the contextual factors of the ICF,specifically, personal factors and environmental factors).Health promotion competencies are those that reflect theholistic construct of health in the ICF. Although reducingtroublesome signs and symptoms may be the focus ofcare, attention to the comprehensive health needs of thepatient/client requires advice about smoking reduction/cessation, basic nutrition, physical activity, sleep hygiene,and stress management; these being core health pro-motion competencies. Particularly, in chronic healthconditions such as the NCDs, the degree to whichsuch behavior change translates into improved activityand social participation is central to an individual’soverall health and wellbeing, given quality of life metricsare largely associated with the capacity to participate inone’s life’s roles. A healthy lifestyle is associated with betterhealth outcomes with or without a health condition, andreduced risk for NCDs, thus healthy lifestyles warrantbeing advocated for all by health professionals. Such anapproach may help address the social determinants ofhealth however health policy is needed to effectivelyaddress population health outcomes.Assessment of health content of education curricula ofhealth professional programsFactors that inform contemporary health professionalcurricula have not been well described. Much of thecontent of journals on education in the health professionsfocuses on pedagogical issues, e-learning, and technologyrather than examining how curriculum content shouldbe established based on epidemiological, social, andeconomic considerations, and how curricula shouldTable 1 Assessment of health promotion competencies (assessment/evaluation and health behavior change strategiesand interventions) for entry-level health professionals in their program curriculaHealthbehaviorAssessment andoutcome evaluationOverall hoursTheory: Practical:ClinicalHealth behaviorchange strategiesand interventionsOverall hoursTheory: Practical:ClinicalSmoking Goal: Non smoker Readiness-to-change stage-basedinterventionsNon smoker Pre-contemplative stage→ 5 R’s (Relevance, Risks,Ever smoked, if so, how much forhow long Number of quit attemptsRewards, Roadblocks, Repetition)Contemplative/preparation/action stages→ 5 A’s (Ask, Advise, Assess, Assist, Arrange)Smoker: how much for how long Formal established training program insmoking cessation, e.g., http://www.quit.org.nz/94/helping-others-quit/health-professionalsNumber of quit attemptsEquivalent of ‘The Why Test’ toestablish motivation for smokingAdvice, e.g., cutting back, setting a quit date,garnering social support, goal setting,developing competing interests, e.g., exerciseReadiness to quitNicotine replacement therapyCounseling strategies:Motivational interviewingCognitive behavior therapyAcceptance commitment therapyOther: e.g., quit blogsNutrition Goal: Healthy body massand body fat, and healthylean tissueReadiness-to-change stage-basedinterventionsPre-contemplative stage→ 5 R’sBody mass index Contemplative/preparation/action stagesWaist-hip ratioServings of vegetables daily → 5 A’sGoal: >5 A-Day Counseling strategies:Servings of fruit daily Motivational interviewingWhole grains servings daily Cognitive behavior therapyAcceptance commitment therapyLow red meat and processed meatconsumptionReadiness to eat more healthily Other:Activity andexerciseGoal: ↓ Sedentary activity Readiness-to-change stage-basedinterventionsPre-contemplative stage↑ Regular physical activitydaily and structuredexercise 3-5 x/wk→ 5 R’sContemplative/preparation/action stages→ 5 A’sWalks around hourly duringperiods of prolonged sittingCounseling strategies:Motivational interviewingCognitive behavior therapyAcceptance commitment therapyHours of prolonged sittingwork dayOther:Hours of regular physicalactivityDean et al. BMC Public Health 2014, 14:717 Page 4 of 10http://www.biomedcentral.com/1471-2458/14/717eseiDean et al. BMC Public Health 2014, 14:717 Page 5 of 10http://www.biomedcentral.com/1471-2458/14/717Table 1 Assessment of health promotion competencies (assand interventions) for entry-level health professionals in thModerately-intense activityRegular structured exerciseAerobicStrengthYoga/tai chiReadiness to be more activeSleep Goal: 7-9 h/nightAverage number of hoursrespond to changing epidemiological trends. The contentof health professional education curricula appears toreflect historic precedent rather than being informed by acoherent rationale based on epidemiology and societalpriority. To make the point, if these curricula were to bedesigned for the first time today, in the current healthclimate, they are likely to look very different.Evaluating health professional curricula is fraught withmethodological challenges [18]. One challenge is whoprovides the information in terms of his or her know-ledge and familiarity with the curriculum and his or hercommitment to providing this information that can betime-consuming particularly in contemporary curriculacommitted to integrated and case-based learning. Inaddition, the quality of the data about the curriculumAverage number of times up at nightQuality of sleep overall (0 =worst to10=best)Readiness to improve sleep quality andquantityMental health(anxiety and stress)Goal: Feels unhurried and canmanage stress most daysDaily irritationsLife challenges Holmes RaheStress testReadiness to reduce stressThe columns titled Overall Hours (Theory: Practical: Clinical) are where the number(assessment/outcome evaluation and each health behavior change strategy and intGeneral tools to assess Global Health: e.g., Health Improvement Card (Figure 2).Template of a tool to assess non-communicable disease risk: e.g., type 2 diabetes msment/evaluation and health behavior change strategiesr program curricula (Continued)Readiness-to-change stage-basedinterventionsPre-contemplative stagemay be questionable due to a range of words anddescriptors (general description of curriculum contentor specifics), and the quality of specific content may beimpacted by having to search horizontally and verticallyacross courses and years in the program. Such curriculaevaluations have the potential for poor reliability andvalidity. To avoid these issues and improve the credibilityof the data, program assessment may be a useful initialstep toward reflection of programs regarding healthpromotion content, and comparison of the content ofentry-level programs across health professions and arrivingat consensus regarding what constitutes basic core healthpromotion competencies.A benchmark of evidence-based health promotioncontent of entry-level curricula for health professional→ 5 R’sContemplative/preparation/action stages→ 5 A’sCounseling strategies:Motivational interviewingCognitive behavior therapyAcceptance commitment therapyOther:Readiness-to-change stage-basedinterventionsPre-contemplative stage→ 5 R’sContemplative/preparation/action stages→ 5 A’sCounseling strategies:Motivational interviewingCognitive behavior therapyAcceptance commitment therapyOther:of hours are entered by a given health professional program for each topicervention). Hours are categorized as theory, practical, and clinical.ellitus (CANRISK) (Figure 3).Dean et al. BMC Public Health 2014, 14:717 Page 6 of 10http://www.biomedcentral.com/1471-2458/14/717education programs augment program awareness andknowledge, and could facilitate development of a databaseto inform basic shared content across professions andindividual content within a profession. As well, it couldidentify gaps that need to be addressed across and withinprograms. With such data available, discourse could thenbe initiated about minimal standards for inter-professionalhealth promotion competencies including a process forinter-professional cross referral.Table 1 itemizes health promotion curricula content attwo levels (assessment/evaluation and health behaviorchange strategies and interventions) that could beconsidered core requirements for practice based on thehealth behavior change literature. The table includes acolumn for hours that a program includes in relation toeach of these broad topics for each major health behavior,with respect to hours of theory, hours of practical applica-tion, and hours of clinical practice. To be integrated intothe curricula of a health profession’s entry level education,health and health risk assessment/outcome evaluation,and evidence-based strategies and interventions to changeseveral leading health behaviors, need to be taught asclinical competencies that warrant being included themanagement of most patients/clients.Figure 1 Steps in the decision making process for health professionasupporting lifestyle-related health behavior changes. Source: adaptedDiscussionBased on recent reports in The Lancet and from theWHO, health professionals continue to practice largelyin silos [4,20]. They have focused largely on their uniquecompetencies that define them professionally and limitedcompetencies that could be performed by others.Inter-professional health service delivery including sharedgoals is being strongly advocated. Inter-professionalhealth service delivery is hallmarked by a commitment toevidence-based practice and commonalities of approachesto service delivery. No benchmarks exist for health pro-motion content in the entry-level of health professionaleducation curricula. The notion of focal areas to sup-port international co-operation of global stakeholdersin health promotion has been raised by Magnussenwho argued such collaboration would result in greaterimpact [26].Most health professions are committed to evidence-based practice including knowledge translation and inte-gration. The elements of evidence-based health promotioncompetences include a process for assessment and inter-vention that is common across health professionals, thusfacilitating the integration and implementation of suchclinically-relevant tools into their practices.ls to augment their patient/client outcomes by initiating and/orfrom Dean et al. 2012 [8].Dean et al. BMC Public Health 2014, 14:717 Page 7 of 10http://www.biomedcentral.com/1471-2458/14/717Process: Health promotion clinical decision makingInter-professional health promotion competencies require ashared process and shared context to guide their implemen-tation. An algorithm that outlines the steps in this process isshown in Figure 1. Each health professional needs to assessthe patients’/clients’ health, lifestyle practices, presence of orrisk for the NCDs and their risk factors, and readiness tochange health behaviors. Readiness to change includespersonal readiness, the reliance on social support and familyfor such change, and the physical environment to supporthealth behavior change. Based on these assessments, eachhealth professional would then determine what healthbehavior change strategies and interventions are within theircompetency and determine if they take a primary role ineffecting a given health behavior change or they refer to oneor more other health professionals. Regardless of whetherthey intervene or refer, health professionals must be respon-sible for appropriate follow up to assure a life-long positivechange. Timely, re-evaluation may indicate refinement orrevision of the program or whether re-assessment of therole of other health professionals is needed.Figure 2 Health Improvement Card. Source: Health Improvement Card. R2014. http://www.ifpma.org/fileadmin/content/Publication/2011/ncd_HealthCompetencies that could be shared inter-professionallyboth during education and in practice, fall into twocategories (Table 1): 1) health assessment and outcomeevaluation tools and 2) health behavior strategies andinterventions.Competencies: Health assessment and outcomeevaluation toolsNo single test or measure exists to assess health. Globalhealth assessment tools include those for sickness impact,life satisfaction, wellbeing, and quality of life. The use ofsuch tools cross references with a comprehensive healthprofile within the framework of the ICF. The ICF providesa framework for assessing health at levels other than onlyfunctional and structural limitations, namely, activity andsocial participation.In 2012, the World Health Professions Alliance, agroup of six leading health professional organizationsrepresenting over 26 million health professionals [27],published the Health Improvement Card [28] (Figure 2) sohealth professionals can readily assess a patient’s/client’seprinted with permission from the World Health Professionals Alliance,-Improvement-Card_web-1.pdf.Dean et al. BMC Public Health 2014, 14:717 Page 8 of 10http://www.biomedcentral.com/1471-2458/14/717health and make recommendations to improve his orher health.Health professionals need competency in the assessmentand outcome evaluation of several health behaviorsrelated to the NCDs and their risk factors. Most notably,these include the status of a patient/client with respect totobacco use; harmful use of alcohol; unhealthy diet; over-weight/obesity; prolonged periods of sitting; insuffi-cient physical activity; disturbed sleep; and unmanageablestress; in addition to objective measures including raisedblood pressure, raised blood sugar, and raised choles-terol. Table 1 lists some tools that can be used to as-sess these.Valid and reliable lifestyle behavior risk factor assessmenttools do exist. It would be neither time nor resource effect-ive for health professionals however to administer riskFigure 3 Prototype of a lifestyle-related health risk assessment tool: CCanada. Reproduced with permission from the Minister of Health, 2014.assessment questionnaires for each NCD and each risk fac-tor. Risk factors for these conditions have commonalitiestherefore selection of one may help to provide a risk factorassessment for lifestyle-related conditions in general.One comprehensive form that may serve as a template isthe short (12 questions) type 2 diabetes mellitus riskfactor assessment form entitled CANRISK [29] (Figure 3).Many of the questions reflect risk for other lifestyle-related conditions therefore if a generic risk factor assess-ment tool were to be used, a rationale could be made forCANRISK.Competencies: Health behavior change strategies andinterventionsCompetency in several health behavior change strategiesand interventions are needed by health professionals inANRISK. Source: © All rights reserved. Public Health Agency ofaddressing four questions. Lancet 2011, 378:449–456.Dean et al. BMC Public Health 2014, 14:717 Page 9 of 10http://www.biomedcentral.com/1471-2458/14/717areas that address the NCDs, including smoking cessation;healthy nutrition; weight loss; reduced sedentary behaviorand increased physical activity; optimal sleep and reductionin unmanageable stress. Table 1 itemizes evidence-basedbehavior change strategies and interventions relatedto the lifestyle health practices of patients/clients thatcan be readily integrated into the busy, time- andresource-constrained practices of health professionals.SummaryHealth assessment and effective health behavior changeare unique health promotion competencies with a strongevidence base. Such competencies need to be viewedwith the same rigor as competencies required for impair-ment examination to prescribe exercise, functional training,or medications. A template has been presented for a pro-gram of assessment of health promotion competencies inthe curricula of health professional programs. Such assess-ment is a first step toward dialogue regarding commonhealth promotion competencies within and across healthprofessions. By unifying the approach of health profes-sionals to the NCDs and their risk factors that includeshealth and lifestyle practice assessments and knowledgeof effective health behavior change strategies andinterventions, inter-professional ‘best practice’ can beachieved. A united front of health professions in the eyesof patients/clients in addressing these burdensome NCDsand their risk factors would be a major step forward inaddressing these conditions globally. It would also high-light through consistent personal messaging to the publicthat their health professionals are committed to best prac-tice and reversing the NCD epidemic through cost-effectivemeasures. Such inter-professional health promotion com-petencies emphasize to the public that non pharmacologicalinterventions are as important, if not more important inmany cases, than invasive (drug and surgical) interventionsin the management of the NCDs.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsED, HM, AD, MS have contributed to this debate based on participation inThe First and Second Physical Therapy Summits on Global Health(Vancouver, 2007 and Amsterdam 2011), and planning of the Third PhysicalTherapy Summit on Global Health (to convene in Singapore 2015). MM hascontributed through position statements of the World Confederation forPhysical Therapy in her capacity as president of the organization, andthrough her contribution to framing and editing the ideas and theirdevelopment. AS has contributed through scholarly collaboration with EDrelated to her areas of expertise in behavioral medicine and related clinicaldecision making. In addition, AS’s broad-based perspectives and insightsderive from her role as Editor-in-Chief, European Journal of Physiotherapy.All authors read and approved the final manuscript.AcknowledgementWe acknowledge the contributions of global health summit participants whohave contributed to the ideas developed in this article.14. Dean E, Al-ObaidI S, Dornelas de Andrade A, Gosselink R, Umerah G,Al-Abdelwahab S, Anthony J, Bhise A, Bruno S, Butcher S, Fagevi Olsen M,Frownfelter D, Gappmeir E, Gylfaddotir S, Habibi M, Hasson S, Jones A,LaPier T, Lomi C, Mackay L, Mathur S, O’Donoghue G, Playford K, Ravindra S,Sangroula K, Scherer S, Skinner M, Wong WP: The First Physical TherapySummit on Global Health: Implications and recommendations for the21st century. Physiother Theory Pract 2011, 27:531–547.15. Meetoo D: Chronic diseases: the silent global epidemic. Br J Nurs 2008,17(21):1320–1325.16. Sun F, Norman IJ, While AE: Physical activity in older people: a systematicreview. BMC Pub Health 2013, 13:449. doi:10.1186/1471-2458-13-449.17. Wong FY, Chan FW, You JH, Wong EL, Yeoh EK: Patient self-managementAuthor details1Department of Physical Therapy, Faculty of Medicine, University of BritishColumbia, V6T 1Z3 Vancouver, Canada. 2Department of Physical Therapy,New York University, New York, USA. 3School of Physiotherapy, University ofOtago, Dunedin, New Zealand. 4Departamento de Fisioterapia, UniversidadeFederal de Pernambuco, Recife, Brazil. 5Department of Physiotherapy,Witwatersrand University, Johannesburg, South Africa. 6School of Health, Careand Social Welfare, Physiotherapy, Mälardalen University, Västerås, Sweden.Received: 24 February 2014 Accepted: 27 June 2014Published: 14 July 2014References1. World Health Organization: Priority noncommunicable diseases andconditions. 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World Health Organization: International Classification of Functioning,Disability and Health; 2002. http://www.sustainable-design.ie/arch/ICIDH-Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionDean et al. BMC Public Health 2014, 14:717 Page 10 of 10http://www.biomedcentral.com/1471-2458/14/7172PFDec-2000.pdf.26. Magnusson RS: Rethinking global health challenges: towards a ‘globalcompact’ for reducing the burden of chronic disease. Pub Health 2009,123(3):265–274. doi:10.1016/j.puhe.2008.12.023.27. World Health Professions Alliance: Teaming Up for Better Health.http://www.whpa.org/.28. 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