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

Abstract

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.

Introduction

Society’s needs are changing as non-communicable diseases (NCDs) have overtaken infectious diseases as the leading cause of mortality worldwide, accounting for 40 million or 7 out of 10 deaths annually.^1–3 In the United States, NCDs accounted for an estimated 40% to 45% of the burden of disease in 2016, costing $47 trillion in lost gross domestic product from 2011 to 2025.^4–6 To address the shift in epidemiology, health care practitioners’ roles, including physical therapists, must also change.^7–9 Aligning physical therapist education with societal needs related to NCD prevention and mitigation may not only demonstrate leadership among other allied health professions but also address the burden of disease posed by these conditions.^10,11

The Commission on Accreditation in Physical Therapy Education (CAPTE) requires that doctor of physical therapy (DPT) curricula include content and learning experiences designed to prepare students to address population health, prevention, health promotion, and wellness (PHPW) for individuals and communities (Tab. 1).¹² However, this mandate is explicitly provided in only 1 CAPTE standard (7D34) and implicated in another (7D14). Moreover, the 7D34 standard utilizes language that is broad and does not suggest any competencies that may be required to provide PHPW services. Recent language adopted by the American Physical Therapy Association (APTA) highlights that physical therapists have a role in NCD prevention and health promotion efforts.¹³ In addition, the APTA mission statement, “Building a community that advances the profession of physical therapy to improve the health of society,” stresses the need to train DPT students so that our communities’ and nation’s health is improved. The APTA document “Professionalism in Physical Therapy: Core Values” specifically cites the responsibility physical therapists must take in addressing the health needs of society in 3 of its 7 core values.¹⁴ Renewed emphasis on the importance of population health knowledge and competencies for physical therapists to address NCDs has led some authors to advocate for revisiting existing educational standards in prevention and health promotion.^7–10,15,16

Table 1.

Key PHPW Definitions^a

Term	Definition
Population health	The health outcomes of a group of individuals, including the distribution of such outcomes within the group29
Prevention	Avoiding or minimizing the burden of diseases and associated risk factors30
Health promotion	The process of enabling people to increase control over, and to improve, their health30
Wellness	A sense that one is living in a manner that permits the experience of consistent, balanced growth in the physical, spiritual, emotional, intellectual, social, and psychological dimensions of human existence31

^a PHPW = population health, prevention, health promotion, and wellness.

Little is known about andragogical practices intended to help DPT students pursuing a first professional degree to develop prevention and health promotion competencies. Two international surveys of the first professional degree physical therapist education curricula found important gaps in health promotion content, including the integration of theoretical concepts into practical and clinical competencies.^17,18 However, 1 of these projects confined the content under study to exposure to general health behaviors such as smoking, weight control, and alcohol consumption,¹⁷ and the other focused on prescribing exercise to address lifestyle behaviors.¹⁸ To date, no comprehensive survey of US entry-level (professional) DPT education programs regarding health promotion and NCD prevention content has been undertaken, to our knowledge. In light of this important gap in knowledge, the objectives of this study were to (1) ascertain the perceived importance of PHPW in DPT education; (2) describe the delivery of PHPW content, including the placement, breadth, and depth in professional curricula; and (3) identify factors that facilitate or impede inclusion of PHPW content in professional programs.

Methods

Study Design and Survey Population

A national mixed-methods cross-sectional study of accredited US DPT programs was undertaken using an electronic survey. Chairs or program directors of each DPT program in the United States were identified and asked to complete the questionnaire if appropriate or to forward it to a faculty member with robust knowledge of PHPW content within the program’s curriculum.

Survey Instrument

This online survey consisted of 22 items organized into 4 blocks by content area (Suppl. Appendix 1). The first block addressed provision of content within the curriculum, including breadth, depth, placement, and learning activities. Question types in the first block included “select all that apply,” open response, and 4-point Likert scales. The second block assessed attitudes toward PHPW content in entry-level education as well as associated facilitators and barriers. Question types in this block were open response and designed to elicit rich descriptions from participants. The third block included questions pertaining to knowledge of guiding documents, including relevant APTA guidelines and position statements, rated on a 4-point Likert scale. The fourth block incorporated program and respondent demographic information, including CAPTE accreditation status, provision of pro bono services, geographic region of the program, respondents position within program, highest educational degree, additional education (eg, in health promotion, public health, etc.), years teaching PHPW content, years licensed as a physical therapist, and primary area of clinical practice/ expertise.

Items for the survey were drawn from PHPW-related items in APTA position statements,^13,19 proposed interprofessional health promotion competencies,²⁰ APTA’s Minimum Required Skills of Physical Therapist Graduates at Entry-Level,²¹ APTA’s core values,¹⁴ and the Clinical Prevention and Population Health Curriculum Framework for Health Professionals.²² The survey went through 7 rounds of development with input from authors on the study team to establish face validity. Five academic physical therapists piloted the survey. Feedback resulted in minor revisions to enhance readability, clarity, and comprehensiveness.

Distribution Procedure

Program directors or chairs from each of the 208 accredited DPT programs based in the United States were identified using the official CAPTE electronic directory.²³ Program directors were contacted via e-mail, provided a unique survey link, and encouraged to complete the survey themselves or forward it to someone on their faculty who was best positioned to provide the most accurate information on PHPW across the program’s curricula. The survey was administered using Qualtrics (Provo, UT, USA). Data collection was anonymous and occurred over a 6-week period from May to July 2018 with reminders sent at 3 and 6 weeks. The Colorado Multiple Institutional Review Board approved this study (18–0604).

Data Analysis

Only fully completed surveys were analyzed.²⁴ Descriptive statistics were performed on participant demographics and responses to each survey question. Statistical analyses were performed using IBM SPSS Statistics Version 25 (IBM, Chicago, IL, USA). Qualitative survey data from the second block of survey questions were analyzed using a stepwise process. Initially, each author was responsible for coding 1 question, which was then followed by all authors discussing the coding, determining categories from the codes, and adjudicating any disagreements. After the authors met to discuss the categories, the primary author (Z.D.R.) inputted the responses into NVivo version 12 (QSR International Pty. Ltd., Burlington, MA, USA) and used a thematic content analysis approach to identify key facilitators, barriers, and resources consistent with study aims.²⁵ This process included reduction of the data through the use of codes followed by thematic analysis and visual representation to verify findings. Reduction of the data involved repeatedly reviewing the data to determine the most meaningful sections. Semantic meaning units were coded with labels that indicated common themes (eg, lack of time). Concept maps were used to display overlaps among themes and allowed for the condensation of codes into themes and subthemes. For example, text may have been coded initially as “lack of priority” or as “lack of relevance.” During visual display of the data, the coded text may have been collapsed under the major theme “lack of importance.” Following this process, the second author (J.L.M.) independently repeated the analyses for consistency. The 2 additional analyses did not lead to any disagreements that required further adjudication. Thick descriptions, or full quotations, were also used to represent the key findings.

Results

Responses

A total of 208 surveys were distributed. After 3 and 6 weeks, a reminder was provided. Total responses yielded 102 initiated (49.0%) and 88 completed surveys (42.3%).

Demographic Data

Demographic data of survey respondents are provided in Table 2. The majority of respondents were faculty involved directly in teaching PHPW content (n = 79; 89.8%), though only 60.2% (n = 53) reported any formal training in PHPW areas. The respondents most commonly had been teaching PHPW content for 0 to 5 years (n = 26; 29.5%). Completed surveys were received from individuals representing DPT programs from each geographic region of the United States. The Mid-Atlantic (n = 15; 17.0%), Northeast Central (n = 14; 15.9%), and South Atlantic (n = 14; 15.9%) had the largest number of participants. A plurality of participants had practiced for more than 26 years (n = 43; 48.9%), reported being the chair or program director (n = 39; 44.3%) and were tenured (n = 36; 40.9%). The vast majority of respondents had a terminal academic degree (n = 72; 81.8%). The most common areas of expertise reported were biomechanics (n = 30; 34.1%), home health (n = 28; 31.8%), and exercise physiology (n = 27; 34.1%).

Table 2.

Demographics of Survey Participants (n = 88)^a

Characteristic	No. of Participants	% of Participants
Faculty of record for PHPW	79	89.8
Formal training in PHPW (n = 86)
Yes	53	60.2
No	22	37.5
Years teaching PHPW content in professional PT education
Not applicable	9	10.2
0–5	26	29.5
6–10	22	25.0
11–15	12	13.6
16–20	11	12.5
21–25	6	6.8
>25	2	2.3
Location
New England	9	10.2
Mid-Atlantic	15	17.0
Northeast Central	14	15.9
Northwest Central	7	8.0
South Atlantic	14	15.9
Southeast Central	6	6.8
Southwest Central	7	8.0
Mountain	7	8.0
Pacific	8	9.1
Years practicing
Not applicable	1	1.1
0–5	1	1.1
6–10	1	1.1
11–15	8	9.1
16–20	14	15.9
21–25	20	22.7
> 26	43	48.9
Highest level of education
Bachelor’s degree (BSPT)	13	14.8
Master’s degree (MSPT)	12	13.6
Clinical doctorate (DPT or tDPT)	19	21.6
MPH or other master’s-level degree	10	11.4
Academic doctorate (PhD, ScD, etc)	72	81.8
Position in program
Chair or program director	39	44.3
Tenured	36	40.9
Program provides pro bono physical therapist services
Yes	73	83.0
No	14	15.9
I do not know	1	1.1
Primary area of expertise
Acute care	18	20.5
Anatomy	3	3.4
Aquatics	20	22.7
Biomechanics	30	34.1
Cardiovascular and pulmonary	10	11.4
Exercise physiology	27	30.7
Geriatrics	5	5.7
Home health	28	31.8
Neurology	10	11.4
Oncology	7	8.0
Orthopedics	6	6.8
Pediatrics	4	4.5
Sports medicine	15	17.0

^a PHPW = population health, prevention, health promotion, and wellness.

Perceived Importance of PHPW Content

Data describing the perceived importance of including specific PHPW content in DPT education are available in Table 3. More than 50% responded that all PHPW topics should be included in DPT education with the exception of relationships between service sectors (eg, health, employment, justice, transportation) (n = 36; 40.9%), strategies for community health program funding and resource management (n = 22; 25%), community design and the built environment (eg, zoning, active transportation) (n = 29; 33.0%), and public health preparedness (n = 26; 29.5%). Respondents could indicate if they felt each topic should be included in post-professional or co-curricular education. There were a few topics, primarily in the realm of population health, that respondents felt were better suited to these educational formats (Suppl. Table).

Table 3.

Attitudes Toward PHPW Topics in Professional Physical Therapist Education (n = 88)^a

	Should Be Included in Professional PT Education
PHPW Topic	No.	%
Use of quantitative methods to describe a population’s health (eg, epidemiology and biostatistics)	60	68.2
Use of qualitative methods to describe a population’s health (eg, focus groups and in-depth interviews)	49	55.7
Evaluation of health services research (eg, study design, measurement, power)	53	60.2
Outcomes measurement (eg, mortality, morbidity, cost effectiveness, health care quality)	66	75.0
Quality improvement	70	79.5
Health surveillance (eg, vital statistics, disease surveillance)	46	52.2
Population health (eg, the distribution of health outcomes within and between populations)	60	68.2
Influence of genetics and biological factors on health	75	85.2
Influence of behavioral and psychological factors on health	86	97.7
Influence of economic, social, and political factors on health	76	86.4
Influence of environmental factors on health	81	92.0
Socioecological theories and models	59	67.0
Health informatics (management and use of patient/client health information)	66	75.0
Screening and counseling for healthy behaviors (eg, active living, healthy eating, smoking cessation, stress management, alcohol moderation, and substance-free living, sleep health)	84	95.5
Screening and counseling in the area of injury prevention (eg, falls prevention, workplace injury prevention, community injury prevention)	83	94.3
Behavior change strategies	85	96.6
Approaches to providing culturally appropriate care	85	96.6
Organization of clinical and public health systems	56	63.6
Relationships between service sectors (eg, health, employment, justice, transportation)	36	40.9
Health services financing (eg, fee-for-service vs value-based)	72	81.8
Process of health policy-making	57	64.8
Methods for participating in the policy process (eg, advocacy, council advisory)	67	76.1
Understanding the influence of health and health care policies on populations	69	78.4
Developing leadership, management, and governance skills	67	76.1
Community engagement strategies (eg, building partnerships and coalitions)	59	67.0
Designing community health needs assessments and improvement plans	55	62.5
Strategies for community health program design, implementation, and evaluation (eg, PRECEDE-PROCEED, RE-AIM)	46	52.3
Strategies for community health program funding and resource management	22	25.0
Community design and the built environment (eg, zoning, active transportation)	29	33.0
Promoting health equity	72	81.8
Understanding the influence of culture and social networks on health	81	92.0
Globalization and disease burden	44	50.0
Public health preparedness (eg, terrorism, natural disasters)	26	29.5

^a PHPW = population health, prevention, health promotion, and wellness; RE-AIM = reach, effectiveness, adoption, implementation.

Characteristics of PHPW Content Within Curriculum

Nearly all programs reported teaching prevention (n = 85; 96.6%), health promotion (n = 85; 95.6%), and wellness content (n = 87; 98.9%) while only 77.3% (n = 68) reported teaching population health (Tab. 4). However, the amount of time spent on each topic, placement of the content within curricula, and learning activities varied widely. The mean number of contact hours devoted to PHPW domains was low with considerable variability (mean, range [hours] included population health, 9.7, 0–60; prevention/health promotion 24, 2–175; wellness 18.7, 1–1000).

Table 4.

Characteristics of PHPW Teaching and Learning (n = 88)^a

Characteristic	No. of Participants	% of Participants
Program provides content in:
Population health	68	77.3
Prevention	85	96.6
Health promotion	85	96.6
Wellness	87	98.9
PHPW content is organized in curriculum
Integrated across curriculum	54	61.4
Designated PHPW course(s)	54	61.4
Other	22	25.0
Contact hours for population health (n = 72)
0	3	4.2
1–5	34	47.2
6–10	18	25.0
11–15	5	6.9
>15	12	16.7
Contact hours for prevention/health promotion (n = 85)
0	0	0
1–5	6	7.1
6–10	23	27.1
11–15	11	12.9
>15	45	52.9
Contact hours for wellness (n = 85)
0	0	0
1–5	10	11.8
6–10	28	32.9
11–15	16	18.8
>15	31	36.5
PHPW content is taught in
Anatomy	3	3.4
Clinical reasoning	19	21.6
Evidence-based practice	20	22.7
Health care delivery	32	36.4
Medical conditions	31	35.2
Motor control and motor learning	10	11.4
Musculoskeletal conditions	41	46.6
Neuromuscular conditions	38	43.2
Professional development	34	38.6
Stand-alone course (ie, health and wellness)	32	36.4
Other	26	29.5
Types of PHPW learning activities utilized
Community project	70	79.5
Lecture/discussion	30	34.1
Lab activity	28	31.8
Case study	18	20.5
Personal wellness plan	16	18.2
Presentation	11	12.5
Written paper	10	11.4
Integrated into clinical education	5	5.7
Interprofessional education	5	5.7
Knowledge of guiding documents
APTA guideline regarding “Minimum Required Skills of Physical Therapist Graduates at Entry Level”21
Very	38	43.2
Somewhat	29	33.0
Not very	20	22.7
Not at all	1	1.1
APTA position statement regarding “Core Values for the Physical Therapist and Physical Therapist Assistant”14
Very	51	58.0
Somewhat	26	29.5
Not very	11	12.5
Not at all	0	0
APTA position statement regarding “Physical Therapists’ Role in Prevention, Wellness, Fitness, Health Promotion, and Management of Disease and Disability”13
Very	45	51.1
Somewhat	35	39.8
Not very	7	8.0
Not at all	1	1.1
APTA position statement regarding “Health Priorities for Populations and Individuals”19
Very	28	31.8
Somewhat	30	34.1
Not very	21	23.9
Not at all	9	10.2
APTA position statement regarding “The Association’s Role in Advocacy for Prevention, Wellness, Fitness, Health Promotion, and Management of Disease and Disability”
Very	35	39.7
Somewhat	30	34.1
Not very	16	18.2
Not at all	7	8.0

^a APTA = American Physical Therapy Association; PHPW = population health, prevention, health promotion, and wellness.

The organization of PHPW content in the curriculum differed considerably, with 61.4% (n = 54) reporting the content was integrated across the curriculum and 61.4% (n = 54) reporting a designated PHPW course. The most common courses that included integrated PHPW content were musculoskeletal courses (n = 41; 46.6%) and neuromuscular conditions courses (n = 38; 43.2%). In contrast to the nearly 60% of programs reporting a course that was designated to house PHPW content, only 36.4% (n = 32) of respondents reported a standalone PHPW course. The majority of participants reported feeling very familiar with only 2 of the 5 APTA guiding documents related to PHPW: the APTA Position Statement regarding “Professionalism in Physical Therapy: Core Values” (n = 51; 58%) and “Physical Therapists’ Role in Prevention, Wellness, Fitness, Health Promotion, and Management of Disease and Disability” (n = 45; 51.1%).

The learning activities most commonly reported as being utilized were designing community health promotion projects (n = 70; 79.5%) and lecture (n = 30; 34.1%), while few respondents reported integrating PHPW into clinical education (n = 5; 5.7%) or interprofessional education (n = 5; 5.7%). Only 5 topics were reported as being covered in depth by more than 50% of respondents: the influence of behavioral and psychosocial factors on health (n = 49; 55.6%), screening and counseling for healthy behaviors and injury prevention (n = 56; 63.6%), behavior change strategies (n = 55; 62.5%), and approaches to providing culturally appropriate care (n = 53; 60.2%). Topics reported as not being covered in depth are shown in Table 5.

Table 5.

PHPW Topic Depth Reported by Participants (n = 88)^a

PHPW Topic	Not Covered		Covered Superficially (ie, Introduced)		Covered Somewhat (ie, Discussed)		Covered In-Depth (ie, Included as Part of Graded Activity)
	No.	%	No.	%	No.	%	No.	%
Use of quantitative methods to describe a population’s health (eg, epidemiology and biostatistics)	7	8.0	42	47.7	25	28.4	14	15.9
Use of qualitative methods to describe a population’s health (eg, focus groups and in-depth interviews)	22	25	43	48.9	12	13.6	11	12.5
Evaluation of health services research (eg, study design, measurement, power)	12	13.6	36	40.9	24	27.3	17	19.3
Outcomes measurement (eg, mortality, morbidity, cost effectiveness, health care quality)	3	3.3	22	25	42	47.7	22	25
Quality improvement	11	12.5	23	26.1	38	43.2	15	17.0
Health surveillance (eg, vital statistics, disease surveillance)	12	13.6	36	40.9	33	37.5	7	8.0
Population health (eg, distribution of health outcomes within and between populations)	7	8.0	29	33.0	37	42.0	15	17.0
Influence of genetics and biological factors on health	3	3.4	35	39.8	30	34.1	20	22.7
Influence of behavioral and psychological factors on health	0	0	10	11.4	29	33.0	49	55.6
Influence of economic, social, and political factors on health	0	0	21	23.9	34	38.6	33	37.5
Influence of environmental factors on health	0	0	21	23.9	34	38.6	33	37.5
Socioecological theories and models	9	10.2	32	36.4	25	28.4	22	25
Health informatics (management and use of patient/client health information)	8	9.1	39	44.3	30	34.1	11	12.5
Screening and counseling for healthy behaviors (eg, active living, healthy eating, smoking cessation, stress management, alcohol moderation and substance-free living, sleep health)	0	0	10	11.4	22	25	56	63.6
Screening and counseling in the area of injury prevention (eg, falls prevention, workplace injury prevention, community injury prevention)	0	0	6	6.8	27	20.7	55	62.5
Behavior change strategies	2	2.3	9	10.2	24	27.3	53	60.2
Approaches to providing culturally appropriate care	1	1.1	11	12.5	27	30.7	49	55.7
Organization of clinical and public health systems	8	9.1	27	30.7	39	44.3	14	15.9
Relationships between service sectors (eg, health, employment, justice, transportation)	20	22.7	30	34.1	30	34.1	8	9.1
Health services financing (eg, fee-for-service vs value-based)	4	4.5	18	20.5	40	45.5	26	29.5
Process of health policy-making	7	8.0	27	30.6	32	36.4	22	25
Methods for participating in the policy process (eg, advocacy, council advisory)	2	2.3	24	27.2	33	37.5	29	33.0
Understanding the influence of health and healthcare policies on populations	2	2.3	28	31.8	36	40.9	22	25
Developing leadership, management, and governance skills	5	5.7	18	20.4	29	33.0	36	40.9
Community engagement strategies (eg, building partnerships and coalitions)	4	4.5	27	30.7	29	33.0	28	31.8
Designing community health needs assessments and improvement plans	8	9.1	27	30.7	20	22.7	33	37.5
Strategies for community health program design, implementation, and evaluation (eg, PRECEDE-PROCEED, RE-AIM)	21	23.9	20	22.7	19	21.6	28	31.8
Strategies for community health program funding and resource management	31	35.2	32	36.3	18	20.5	7	8.0
Community design and the built environment (eg, zoning, active transportation)	34	38.6	32	36.4	17	19.3	5	5.7
Promoting health equity	8	9.1	23	26.1	41	46.6	16	18.2
Understanding the influence of culture and social networks on health	2	2.3	20	22.7	36	40.9	30	34.1
Globalization and disease burden	15	17.0	33	37.5	35	39.8	5	5.7
Public health preparedness (eg, terrorism, natural disasters)	38	43.2	35	39.8	15	17.0	0	0

^a PHPW = population health, prevention, health promotion, and wellness; RE-AIM = reach, effectiveness, adoption, implementation.

Themes Influencing Inclusion of PHPW Content

Thematic content analysis of narrative data from open text responses revealed 8 themes describing barriers and facilitators to delivering PHPW content in DPT education as well as 2 themes related to resources needed for successful inclusion and delivery (Tab. 6).

Table 6.

Emergent Qualitative Themes

Topic	Themes
Barriers	Lack of knowledge
	Lack of importance
	Lack of time
	Lack of support
Facilitators	Expertise
	Importance
	Logistical flexibility
	System-level factors
Resources needed	Education
	Professional competencies

Barriers to Delivering PHPW Content

Eighty-two (93%) of participants responded to the question asking for barriers to including PHPW content in DPT education. Four themes emerged, including perceived lack of time, perceived lack of importance, lack of faculty knowledge, and lack of support (Tab. 6). The most commonly cited barrier to incorporating PHPW content into curricula was lack of time. The quantity of information currently taught in DPT education was a common reason for lack of time due to other curricular needs: “The sheer quantity of information in the entry-level education impacts these more global topics.”

A lack of time was related to a perceived lack of importance of PHPW content. Within this theme, 2 subthemes emerged: a perceived competition of priorities and a perceived lack of relevance. Respondents highlighted competing priorities within DPT education and cited curriculum standards and scope of practice as challenges to incorporating PHPW content. One respondent stated: “Our scope of practice itself is extremely large. Constraints and competition within a 3-year time-frame to produce clinically excellent PTs within a doctorate degree limits the inclusion of these topics in any meaningful engagement.” Conversely, other participants reported a perceived lack of relevance for PHPW content in DPT education: “Although, health is related to the ability to move—aren’t we supposed to be focusing on the movement system and teaching the students how to return a patient/client to normal movement patterns—which is more neuromusculoskeletal and cardiopulmonary in nature.” Respondents acknowledged that though “our scope of practice itself is extremely large,” “the profession cannot serve all roles,” and questioned the relevance of PHPW content in both the didactic phase as well as “the lack of immediate relevance being clear in many clinical education sites.”

The theme of lack of faculty knowledge was supported by 2 subthemes: a lack of faculty with relevant PHPW expertise as well as a lack of understanding among physical therapy faculty generally about PHPW content and its importance. Barriers in identifying qualified faculty members with “appropriate credentials and expertise” or faculty teaching outside DPT programs such as “population health departments that can deliver data in the breadth of these topics” was expressed. Also reported to be a barrier was a “lack of support by all faculty” including “getting other faculty to integrate and build upon the baseline instruction” provided to DPT students.

Respondents identified the theme, lack of support, as a barrier to integrating PHPW content into DPT education. Three sub-themes were identified: lack of cultural support, lack of environmental support, and lack of student support. Respondents reported an academic culture that is “resistant to change” and steeped in tradition. Respondents reported that the overall culture within health care raises challenges as well: “Overall, the health care culture of the USA, public policy and insurance regulation negatively influence the environment of health education. There is a focus on treating disease and not on salutogenic health promotion policies.” Environmental challenges were also identified as a barrier; a lack of coordination and collaboration with experts across disciplines was identified. For example, respondents questioned whether smaller and more rural DPT programs would have access to potential collaborators. The final barrier identified was student interest. Respondents reported challenges engaging students in PHPW content: “Some students are so focused on the clinical hands on component of learning to become a PT, they don’t fully appreciate the broader scope of factors that will influence their profession in the long-term eg health care policy and engagement in advocacy for population health.” Further, students not viewing PHPW “as part of [the] PT scope of practice” represented a significant hurdle.

Facilitators to Delivering PHPW Content

Seventy-nine (90%) participants responded to the question asking for facilitators to include PHPW content in DPT education. Four themes emerged, including expertise in PHPW topics, logistical flexibility, the importance of PHPW content, and system-level factors (Tab. 6). The most commonly reported facilitator was faculty expertise in PHPW topics, including 2 sub-themes: faculty with relevant expertise and faculty support of PHPW topics. Respondents identified that having a faculty member with “expertise and passion” in PHPW content areas facilitates its delivery. Respondents identified those with advanced training such as a master of public health or a PhD degree in areas related to PHPW as good candidates to lead this content. In addition to qualified faculty, respondents also identified that “an understanding on the part of faculty about how critical these topics are in addressing health in a global society” was important.

Logistical flexibility was identified as a facilitator of PHPW content inclusion. Four sub-themes emerged—environmental support, integration of PHPW across the curriculum, interprofessional education, and service-learning opportunities. Environmental support was identified as having a rich institutional environment with collaborative opportunities with other programs such as “public health, epidemiology and medical anthropology.” Respondents also identified administrative support, organizational structure, and an emphasis on research in PHPW areas as facilitators. Integration of PHPW content into other coursework was seen as an important facilitator: “Conscious development of these topics needs to occur throughout the curriculum so students get the message that they are important and gain the skills necessary to use them in practice.” In addition to the learning benefits provided to students, respondents identified that weaving PHPW content through the curriculum is a feasible way to create space for it. Interprofessional education was identified as a facilitator to integrating PHPW content with respondents noting that “some of the topics lend themselves well to interprofessional education.” Service-learning emerged as another useful framework to apply PHPW content. Respondents reported that a shift from “just traditional research projects as a culminating experience and include community focused service-learning projects as an option, with the potential to influence local population health” could improve uptake of PHPW content into DPT education.

The importance of PHPW content in DPT education emerged as the third theme as a facilitator. Two sub-themes emerged: the priority of PHPW topics and their relevance to DPT education. Regarding priority, many respondents agreed that PHPW content “is critical to include” based on “the future trends on the US healthcare delivery system.” Respondents had awareness “that our profession is moving to more emphasis in prevention and health promotion” and verbalized “a desire to stay current on topics that our graduates will experience.” Social responsibility was identified as one of the reasons why PHPW topics are a priority. Respondents reported an awareness that PHPW topics are part of universities’ “mission grounded in service to others and global perspective.” Further, responsibility to society was identified as a facilitator to increasing “awareness of the multiple determinants of health and (PTs) role/responsibility in ameliorating social and environmental factors.” In addition to the priority of PHPW content, the subtheme relevance of material to the physical therapy profession emerged where respondents reported that given the broad scope of topics within the PHPW umbrella, “topics that directly impact immediate patient care fit well within the curriculum.” These topics were suggested to include: “prevention and direct patient impact of wellness and prevention including the influence of sociobiologic and environment factors all influence clinical care and practice.” Relevance was also addressed from the student perspective with respondents reporting that student characteristics including interest, enthusiasm, engagement, and expectations would facilitate inclusion of PHPW topics into curricula.

System-level factors were identified as facilitators to deliver PHPW content. Two subthemes emerged: the changing health care system and changing professional expectations. The changing health care system was identified as a facilitator as a whole and with specific initiatives including increasing “emphasis on patient-centered care,” a “shift away from fee-for-service toward population health and value-based purchasing,” and increasing stress on “systems thinking, recogniz(ing) the limitations of disease/health condition management on our economy and population health.” Changing professional expectations were also identified as facilitators with an increased emphasis on PHPW in APTA guiding documents and in CAPTE standards acknowledged as key components necessary to drive practice.

Resources Needed to Successfully Deliver PHPW Content

Eighty participants (90%) responded to the question asking for recommendations regarding needed resources. Two themes emerged regarding resources needed to successfully deliver PHPW content: further education and professional competencies (Tab. 6). Further education was identified as a need for both faculty and practicing clinicians. Suggestions included conference workshops, educational modules, clinical fellowships, the development of support networks, and shared educational PHPW content. The development of entry-level PHPW competencies was also identified as a resource need. Respondents reported that the development of such competencies would create a minimum standard across DPT programs and improve awareness of PHPW topics. Respondents also reported that competencies would benefit “faculty who are not well-prepared to teach these topics.”

Discussion

Our findings support that PHPW is incorporated in the curricula of the majority of accredited participating DPT programs in the United States and that respondents believe the content should be included in DPT education. These findings are consistent with prior research by Bodner et al¹⁷ and are encouraging as it may indicate that DPT curricula are increasingly aligning to meet the profession’s guiding documents.^13,14,19 These findings expand on Bodner et al¹⁷ by assessing the inclusion of prevention and population health topics in DPT education. Bodner et al¹⁷ focused more narrowly on the teaching of specific health promotion behaviors such as smoking cessation and weight management.

The findings of this study indicate that DPT programs and faculty are currently teaching a largely disparate amount of content related to population health, prevention, health promotion, and wellness. This finding is perhaps not surprising given that the CAPTE accreditation criteria on this topic are explicit in only 1 standard and address PHPW content broadly. The quantity of time spent teaching PHPW content in curricula varied widely, and lack of time was the most cited barrier to inclusion. It is challenging to recommend a specific minimum hour requirement to appropriately cover PHPW topics and is beyond the scope of this study, though current data suggest that medical students receive minimal levels of PHPW content as well.^26,27 Further, though the quantity may be adequate, gaps in PHPW content may persist. Despite a majority of programs including PHPW content, only 5 out of 33 PHPW topics were reported to have been covered in-depth by a majority of respondents, and a perceived lack of relevance was a barrier to inclusion.

Integrating PHPW topics into professional curricula represents a shift from the more traditional paradigm of physical therapists functioning in tertiary prevention to involvement in primary and secondary prevention. While barriers to this shift existed, so too did multiple facilitators, including perceived importance, logistical flexibility in curricula, system-level support, and faculty with expertise. Further education of physical therapy faculty, which was identified as an important resource needed, should occur along with collaborations with public health educators and practitioners, who would be a valuable source of education and teaching support. The findings of this study provide insight into current practices by DPT education programs related to PHPW topics. As few PHPW content areas were covered in-depth by a majority of respondents, determining what specific content areas are most important is indicated. Providing a set of recommended PHPW competencies, as identified in resources needed, for students to attain by the end of professional education may provide a framework for programs to deliver this content to their students.

This study has several limitations. First, the relatively low response rate of 42.3% could lead to non-response bias and decrease confidence in the accuracy of our findings. However, this response rate is similar to other surveys of academic faculty.^17,28 Second, there is a risk for selection bias, where faculty members teaching PHPW topics might have been more inclined to report positive feelings and perceptions about the topic. Third, although the survey did undergo numerous rounds of development to ensure face validity, readability, and clarity, the reliability of the survey was not quantified.

This study established that the majority of professional DPT programs in the United States are currently teaching a largely disparate amount of content related to population health, prevention, health promotion, and wellness despite their familiarity with professional documents and rating of perceived importance. Lack of trained faculty and lack of entry-level competencies related to PHPW represent barriers to further integration of this content in DPT programs. Support from faculty, logistical flexibility, and an awareness of the importance of PHPW topics were identified as facilitators and opportunities to improve the delivery of PHPW content. Professional agreement about standard PHPW content is indicated to support faculty to equip DPT program graduates with the knowledge, skills, and abilities necessary to fully engage in the prevention of disease and the promotion of health and wellness at the individual and population levels.

Author Contributions

Concept/idea/research design: J.L. Maxwell, J.R. Bezner, T.E. Davenport, E.H. Bradford, M.S. Ingman, D.M. Magnusson

Writing: Z.D. Rethorn, J.L. Maxwell, J.R. Bezner, T.E. Davenport, D.M. Magnusson

Data collection: J.R. Bezner, M.S. Ingman, D.M. Magnusson

Data analysis: Z.D. Rethorn, J.L. Maxwell, J.R. Bezner, T.E. Davenport, M.S. Ingman, D.M. Magnusson

Project management: Z.D. Rethorn, E.H. Bradford, D.M. Magnusson

Providing participants: J.R. Bezner

Providing facilities/equipment: D.M. Magnusson

Consultation (including review of manuscript before submitting): Z.D. Rethorn, J.L. Maxwell, J.R. Bezner, T.E. Davenport, E.H. Bradford

Ethics Approval

This study was approved by The Colorado Multiple Institutional Review Board (18–0604).

Funding

There are no funders to report for this study.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.