Background: This study aimed to diagnose the quality of life of people
with disabilities through social, epidemiological, behavioural, educational, and
ecological factors based on the Predisposing, Reinforcing, and Enabling Causes in
Educational Diagnosis and Evaluation (PRECEDE) diagnostic model.
Methods: Using the systematic stratified cluster sampling method, 605
people with disabilities from five districts (Seoul, Gyeonggi, Chungcheong,
Jeolla, and Gyeongsang) who were registered at the welfare centres in 2019 were
recruited. In addition, the study participants were limited to grades 1 to 4 with
disabilities, and those with physical disabilities who did not have intellectual
disabilities. The final model’s goodness of fit was found to be good
The desire to improve the quality of life (QoL), the qualitative measure of life, is commonly pursued as valuable in the human race ; further, in doing so, there will be no difference between the persons with and without disabilities. In South Korea, the former’s number increased by 1,240,000 from 1,330,000 in 2000 to 2,580,000 in 2017 due to the surge in the risk factors for various issues such as the ageing population and tragic events and diseases .
People with physical disabilities in Korea face more health problems than non-disabled people, and they suffer from complications due to disability and secondary disabilities that occur in addition to the existing disability . There is a growing interest in their economic stability and health . Further, they experience challenges with their upper or lower body or body structure. As compared to those without disabilities, they have poor physical health and a higher level of depression . Their reduced physical and mental health can directly impact their health deterioration and negatively affect their societal adjustment . All humans have the right to enjoy health, including physical, mental, and social well-being. Nonetheless, domestic and international studies about people with disabilities have reported them as being a vulnerable group within adequate health and low QoL as they encounter greater health problems and have a higher likelihood of being exposed to diverse socio-economic issues than those without disabilities [6, 7, 8, 9].
The health-related programs’ analysis intending to improve the people with disabilities’ QoL revealed the following problems [10, 11, 12, 13]. Most programs were operated in a short and fragmentary manner, leading to only one-time participation [14, 15]. In addition, most participants were passive and not self-motivated to partake in them . In particular, the programs were inefficient because they offered the same contents as those developed for persons without disabilities by failing to consider their attributes [17, 18]. This demonstrated the limitation that such health promotion programs have been unsuccessful in applying or reflecting the people with physical disabilities’ special nature or demands. This could be due to insufficient research about building a system regarding the pre-existing health promotion programs for these individuals.
Heller et al.  advocated the importance of a community-based health promotion system that reflects personal and social factors because the practice or the maintenance of self-management behaviours for health promotion is affected not only by personal aspects such as knowledge and coping skills but also by the environmental ones such as social support and access to resources. Specifically, to enhance the people with physical disabilities’ health, it deems necessary to establish a health promotion scheme that can promote health from a continuous and long-term perspective by considering both their personal and social factors. To consider diverse and complicated variables for developing such a system, pre-diagnostic research involving these individuals is required.
The Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation (PRECEDE) model is a framework that integrates multiple theories about psychological, sociological, and physical activities. It is used for developing and evaluating the programs for behavioural change related to an individual’s health . Further, it has been employed for developing health-related programs for diverse individuals ; overseas scholars are applying the model in the research regarding these people’s health attributes [21, 22, 23]. Similarly, the PRECEDE model can be utilised for people with physical disabilities. Their ecological attributes and unique needs can be considered as individual units for improving their QoL . In addition, it can provide an answer to what causes the health problems or behavioural decisions for individuals and organizations; this can direct us to the right path towards eliminating the causes or inducing a desirable behaviour .
In other countries, there is a growing need for diagnostic research on people with disabilities’ attributes . In Korea, such an investigation that applies the PRECEDE model to examine the domestic factors influencing the QoL of this group can provide the baseline data for the health promotion systems to improve the feasibility and satisfaction among the Korean people with physical disabilities, considering that they may have unique attributes on a personal or circumstantial level. The aim of this study is to perform validation procedure of PRECEDE diagnosis model to measure QoL.
The PRECEDE model can be applied to enhance the people with physical disabilities’ QoL by implementing the phase-wise access strategy as follows. Phase 1 includes performing a social diagnosis and identifying the subjects’ social problems or interests. This study aimed to diagnose the QoL perceived by individuals with physical disabilities. The QoL is a representative variable of social diagnosis and shows what one perceives to be valuable in life and what hinders the improvement in the QoL [25, 26]. Phase 2 is an epidemiological diagnosis; it determines the social or health issues or goals that have been recognised in Phase 1. This research purported to analyse the health condition perceived by people with physical disabilities. Health condition refers to the status of effective adjustment or balance with the environment regarding the physical, mental, social, and spiritual states . In particular, the spiritual state means self-judgment of the meaning and satisfaction of life. Furthermore, Phase 3 involves a behavioural diagnosis of specific health behaviours linked to the selected health issue, which was examined by this study. Health promotion behaviours entail planned and systematic activities that promote health . Phase 4 is an educational and ecological diagnosis and valuation of the factors that affect the subjects’ health-related behaviours or lifestyles, such as the predisposing, reinforcing, and enabling factors. Predisposing factors influence motivation as the driving force for behavioural change. To examine the health attributes of people with physical disabilities, we selected physical self-efficacy as perceived by them . Moreover, reinforcing factors serve to strengthen the drive for a subject’s behaviour or to stop it. This research selected social support for the health promotion behaviours of people with physical disabilities as a reinforcing factor. Social support encompasses all types of support from an interpersonal relationship; it is a positive resource that fuels the affiliation with others [30, 31]. Lastly, enabling factors facilitate action and influence the fulfilment of motivation and the condition for behavioural change. The health promotion behavioural intention of the individuals with physical disabilities was chosen as this research’s enabling factor; it entails any personal behavioural intention for all health-related preventative actions .
Phase 5 encompasses an administrative and policy diagnosis based on the analysis of the budget and human resources so that the planned program can be easily implemented in the organization’s system. This research employed Phases 1 to 4, while excluding Phase 5, which is an administrative and policy analysis.
In this cross-sectional research, we built a hypothetical model for diagnosing people with physical disabilities’ QoL by applying the PRECEDE model and performed a structural model analysis to verify the model’s suitability and hypotheses. This study’s conceptual framework is shown in Fig. 1. Although the diagnosis model of PRECEDE is the first stage of social diagnosis, this study aims to verify the impact on the quality of life of people with physical disabilities. Therefore, from the 4th stage, ecological diagnosis, the effect on quality of life, which is a social diagnosis, is to be verified.
Statistical schematic of structural models.
As this study’s subjects, we selected individuals with physical disabilities attending social welfare programs since 2019. We extracted the sample from five regions (Seoul, Gyeonggi, Chungcheong, Jeolla, and Gyeongsang) using the systematic stratified cluster sampling method. In the structural equation model, the sample size needs to be 10 to 20 times per observation variable . Therefore, overall 625 people with physical disabilities were recruited as the research subjects, thus meeting the sample size requirement for the 18 observation variables. Of the collected responses, the final analysis included 605 responses after eliminating 20 responses that were either inconsistent or incomplete.
Regarding the subjects’ age, 278 people (46.0%) were in their 40s and 50s, followed by 170 in their 30s (28.1%), and 157 in their 60s (26.0%). In terms of sex, there were more men (64.3%) than women (35.7%). Furthermore, those whose income was below 1,000,000 KRW were 380 (62.8%), followed by 153 (25.3%) with 1,010,000 KRW–1,500,000 KRW, and 72 (11.9%) with 1,510,000 KRW–2,000,000 KRW. Moreover, 407 individuals (67.3%) had acquired disabilities. Regarding the severity class, 222 individuals (36.7%) were found to have Class 2 severity, followed by 169 (27.9%), 109 (18.0%), and 105 people (17.4%) with Class 3, 1, and 4 severities, respectively (Table 1).
|Personal background variables||Gender||Male||389||64.3|
|Age||30’s or younger||170 (M106/F64)||28.1|
|40’s to 50’s||278 (M171/F107)||46.0|
|Income level||Less than 1 million won||380||62.8|
|Less than 101 to 1.5 million won||153||25.3|
|1.5–2 million won or less||72||11.9|
|Disability-related variables||Type of disability||Congenital||198||32.7|
|Degree of disability||1st grade||109||18.0|
This study used a structured questionnaire to achieve its objective. To develop a proper research scale pertaining to the PRECEDE model’s four diagnostic factors, we held a panel of nine experts: three people with physical disabilities (employed at an organization related to sports for individuals with disabilities); one Special Physical Education professor; two Special Physical Education doctors; one Health Sciences professor; and two Public Health doctors. Moreover, for social diagnosis, quality of life, meaning the individual’s perception of the position he occupies in goals, expectations, standards, and interests, in the context of the culture and value system in which he lives, was selected. For epidemiological diagnosis, health condition was selected, which means continuous and dynamic with respect to effective adaptation or opposing forces, is being adjusted for better, and is in balance with the environment. For behavioral diagnosis, health promotion behaviour, which means activities for health promotion planned and systematically, was selected. Perceived confidence related to the body for ecological diagnosis. Physical self-expression confidence and perceived physical ability, meaning physical self-efficacy, and health promotion behavioural intention, meaning individual behavioral intentions for all preventive behaviors related to health. Also, social support, which means all types of help given and received through interpersonal relationships, and a positive resource that provides relationships with others, was selected.
The QoL was measured using the Quality of Life Questionnaire developed by Song and Oh ; after modifying it, it was employed by Shin  for assessing people with physical disabilities. It consists of 16 questions pertaining to four sub-factors: physical and mental health, leisure activities, sense of self and general life, and relationship with friends and other people. All questions were measured on a five-point Likert scale; a higher score indicated a greater level of QoL. Based on the results of the exploratory factor analysis, we eliminated the following items as their factor loading was below 0.50: physical and mental health, leisure activities, sense of self and general life, and relationship with friends and other people (2, 2, 1, and 1 items, respectively).
For measuring the health condition, we utilised a Korean version of the Total Health Index; it was developed by Lim  and used among people with physical disabilities by Hwang  after modifying the health condition items for this study. After collecting the responses, we reverse-coded them because the questionnaire developed by Lim  comprised negative items. This measure consists of 16 questions included in four sub-factors: physical, mental, spiritual, and social health. All questions were assessed on a five-point Likert scale, with a higher score indicative of an increased level of health condition.
To assess the health promotion behaviour, we used the questionnaire developed by Walker et al.  that was used among people with physical disabilities by Kim et al.  after modifying the health promotion behaviour items for this study. It comprises three sub-factors with 12 items: health management, interpersonal relationship, and physical activities. All questions were measured on a five-point Likert scale, with a higher score indicating a greater engagement level of health promotion behaviour.
The questionnaire for the educational and ecological diagnosis comprised three factors, namely, the predisposing, reinforcing, and enabling factors.
220.127.116.11 Predisposing Factor: Physical Self-efficacy
For measuring the physical self-efficacy as a predisposing factor, we used the Physical Self-efficacy Scale developed by Ryckman et al. ; it was employed among people with physical disabilities by Lee and Seok  after modifying it. It consists of eight items included in two sub-factors: physical ability and physical self-expression. A higher score indicates a greater perception level of the two.
18.104.22.168 Reinforcing Factor: Social Support
Social support, as a reinforcing factor, was examined using the Social Support Scale developed by Yoo and Seol ; after modifying the items, it was utilised among people with physical disabilities by Oh . It has 16 items and the following four support sub-factors: materialistic, informational, emotional, and appraisal. A greater score indicates a higher level of social support.
22.214.171.124 Enabling Factor: Health Promotion Behavioural Intention
For examining the health promotion behavioural intention as an enabling factor, we used the Health Promotion Behavioural Intention Scale, utilized in Kim and Cha’s  study after modifying its items. It consists of four items rated on a five-point Likert scale, with a higher score indicating a greater level of health promotion behavioural intention.
Regarding the data collection, the researcher and the research assistant surveyed 625 subjects from September 2019 to November 2019. We visited the social welfare centres for individuals with disabilities in five regions and obtained prior consent from their directors after describing the research. Subsequently, the researcher and the research assistant explained the study’s purpose to the subjects, who were the members of these centres; the self-administered questionnaires were distributed and retrieved immediately after they were filled out by willing individuals.
The collected data were analysed using the SPSS 22 (IBM Corp., Armonk, NY, USA)
and AMOS 22.0 (IBM Corp., Armonk, NY, USA) programs. To identify the subjects’
attributes, we used descriptive statistics. The research scale’s validity was
tested using confirmatory factor analysis. The normality of the sample was
verified using a multivariate normality test based on the mean, standard
deviation, skewness, and kurtosis. The correlation between the measurement
variables was examined using Pearson’s correlation coefficient. The model
parameters were estimated using the maximum likelihood method. To assess the fit
of the model, the
Prior to hypothesis testing, the reliability and validity of the research tool were secured through exploratory factor analysis and reliability verification. The quality of life questionnaire’s reliability was as follows: 0.90, 0.88, 0.80, and 0.67 for physical and mental health, leisure activities, sense of self and general life, and relationship with friends and other people, respectively. The health condition questionnaire’s based on the exploratory factor analysis’s results, we eliminated those items whose factor loading was found to be below 0.50; they are as follows: physical, mental, social, and spiritual health (1, 1, 2, and 2 items, respectively); their reliabilities were 0.75, 0.73, 0.75, and 0.71, respectively. The health promotion behaviour questionnaire’s based on the exploratory factor analysis’ results, we eliminated one item in health management because the factor loading was found to be below 0.50. The questionnaire’s reliability was as follows: 0.61, 0.83, and 0.83 for health management, interpersonal relationship, and physical activities, respectively. The physical self-efficacy questionnaire’s based on the exploratory factor analysis’ results, we eliminated one item in physical expression because the factor loading was below 0.50. The questionnaire’s reliability was 0.75 for physical ability and 0.70 for physical expression. The social support behaviour questionnaire’s based on the exploratory factor analysis’ outcomes, two items from the materialistic, informational, emotional, and appraisal support each were excluded as their factor loadings were below 0.50. The questionnaire’s reliability was reported to be 0.76, 0.79, 0.75, and 0.77 for the materialistic, informational, emotional, and appraisal support, respectively. The health promotion behavioural intention questionnaire’s exploratory factor analysis’ result showed that the factor loading of each item was above 0.50 and the reliability of the questionnaire was 0.82.
The research variables’ descriptive statistics and the verification of normality
are shown in Table 2. Regarding the subjects’ QoL, the scores of each sub-factor
ranged from 3.00 to 3.48. In perceived health conditions, they ranged from 2.19
to 2.61. Furthermore, the score for health management in health promotion
behaviour, interpersonal relationship behaviour, and physical activities was
3.20, 3.48, and 3.36, respectively. The physical self-efficacy and social support
scores of each sub-factor ranged from 2.84 to 3.57 and from 3.46 to 3.57,
respectively. The score for health promotion behavioural intention was 3.65. The
condition of the normal distribution necessary for applying the structural
equation model was satisfied as the relevant absolute values of all measurement
variables satisfied the standards for skewness (
|QoL, quality of life; SS, social support; PSE, physical self-efficacy; HPBI, health promotion behavioural intention; HS, health status; HPB, health promotion behaviour.|
The convergent and discriminant validities were used to determine how appropriately the construct was measured by the observation variables (Table 2). According to this study’s result, the convergent validity was verified because each of the standard factor loading, AVE, and CCR were above 0.5, 0.5, and 0.7, respectively. The discriminant validity is verified when the AVE of the latent variable is greater than the square value of the correlation coefficient between them . This criterion was met in this study, proving the discriminant validity.
To determine whether to statistically accept or reject the hypothesis
established in this study, we designed a statistical model to be confirmed using
path analysis. Fig. 2 shows the details. To verify the structural relationship
between the factors that influence the health promotion of people with physical
disabilities, we carried out a structural model analysis (Fig. 2). First, we
examined the model fit; the result was as follows:
Conceptual framework. Note: QoL, quality of life; SS, social support; PSE, physical self-efficacy; HPBI, health promotion behavioural intention; HS, health status; HPB, health promotion behaviour. This framework and further computation are performed in the AMOS software.
|Endogenous variables||Exogenous variables||Direct effect||Indirect effect||Total effect||SMC|
|QoL, quality of life; SS, social support; PSE, physical self-efficacy; HPBI, health promotion behavioural intention; HS, health status; HPB, health promotion behaviour.|
Regarding the factors that influence the subjects’ QoL, physical self-efficacy and social support were found to exert a significant positive effect, whereas the health promotion behavioural intention was not found to have a statistical effect. This finding is partially consistent with multiple previous studies that identified the relationship between these factors [27, 44, 45, 46, 47, 48].
First, this research’s finding that physical self-efficacy (a predisposing factor) affects health promotion behaviour is supported by many previous studies [27, 45]. It is speculated that confidence in one’s own physical ability and positive physical self-efficacy to accept and overcome one’s disability can induce health promotion behaviour in the individuals with physical disabilities. Specifically, a higher level of physical self-efficacy indicates a greater likelihood of encouraging health promotion behaviour in such persons.
Second, the health promotion behavioural intention (an enabling factor) had no effect on the health promotion behaviour. It is difficult to compare this finding directly with the previous ones because there are insufficient studies examining the relationship between these variables. Nevertheless, it is contrary to Choi’s  result that behavioural intention to prevent oral diseases influences oral disease prevention behaviour, as well as to Kim and Cheon’s  finding that the intention to participate in general sports class has a positive effect on the college students’ health behaviour. Unlike these studies, which were conducted on persons without disabilities, this research’s subjects were those with physical disabilities. It is believed that the health promotion behavioural intention could not account for the health promotion behaviour because the subjects could have encountered various external obstacles such as environmental aspects that inhibited such behaviour even if the individuals had health promotion behavioural intention. Specifically, it can be inferred that the people with physical disabilities’ health promotion behaviour is constrained by external factors, despite their own intention. Thus, it should be classified as a key factor to be considered in building a health promotion system.
Third, this study’s outcome that social support (a reinforcing factor) has a positive effect on the health promotion behaviour is supported by many previous studies [46, 48, 49]. Social support refers to receiving positive feedback about health behaviours from the surrounding people ; regarding the people with physical disabilities, it indicates the other people’s acceptance and support of their health behaviour. It was found that a higher level of social support increases or reinforces this group’s health promotion behaviour level.
In summary, the ecological attributes such as the predisposing (physical self-efficacy) and reinforcing factors (social support) can induce or reinforce the people with physical disabilities’ health promotion behaviour. Thus, it deems necessary to develop programs tailored to their characteristics by considering their ecological attributes. Specifically, programs should improve their physical self-efficacy, while inducing positive feedback from the surrounding people on their behaviour. Meanwhile, it is believed that the health promotion behavioural intention did not exert a significant effect on the health promotion behaviour because of its various limitations for the people with physical disabilities. This implies the requirement for an in-depth analysis of such limitations.
Among the factors that influence the people with physical disabilities’ QoL, the result of examining the link between the behavioural (health promotion behaviour) and epidemiological factors (health condition) showed that health promotion behaviour exerted a positive effect on health conditions. This finding is consistent with that of Lee and Lee  regarding the association between the health promotion behaviour and the health condition; they found that 65-year-old people’s health management behaviour rhad a positive effect on the latter. Elderly people develop various health conditions as they age, however, their health management behaviour can maintain or improve their health condition. Similarly, it is believed that the individuals with physical disabilities—this study’s subjects—can prevent secondary diseases, despite having a higher risk of developing them; further, they can maintain or improve their health condition through health promotion behaviours. Nonetheless, insufficient research findings are available to support this outcome. Previous studies have focused on the effect of health conditions on health promotion behaviour. Although the latter was not used as a direct variable, Namgung’s  study about health conditions based on the level of partaking in daily sports indicated that more frequent participation was an indicator for a better health condition, which is consistent with this study’s result. Therefore, it can be considered that the health promotion behaviour of people with physical disabilities improves health condition. Thus, it is necessary to develop programs to induce such behaviours for enhancing their health condition. Additionally, it implies that the criteria for a health condition could be used as indicators to manifest the health promotion behaviour programs’ effect.
Among the factors that influence the QoL of people with physical disabilities, it was demonstrated that health promotion behaviour exerted a positive effect on the QoL. This finding corresponds to the results from the studies that determined the relationship between health promotion behaviour and QoL [1, 52]. Kim  reported that the health promotion behaviour of people with physical disabilities is a direct factor for improving the QoL and that they can overcome their disability and re-join the community through interpersonal relationships and participation in daily sports (health promotion behaviour). Specifically, the individuals with physical disabilities are isolating themselves from the community and viewing themselves negatively due to their incapacity; however, various health promotion behaviours can help them overcome this issue. Therefore, it is believed that such behaviours of the people with physical disabilities are an extremely important variable for improving the QoL; thus, it is necessary to build a health promotion system that applies the ecological factors (physical self-efficacy and social support) that affects their health promotion behaviours.
Among the factors that influence the people with physical disabilities’ QoL, the result of examining the relationship between the epidemiological (health condition) and social factors (QoL) showed that health conditions exerted a positive effect on the QoL. This finding is consistent with those from the previous studies that determined the link between the two variables [53, 54]. Jang  reported that all sub-factors of perceived health conditions among middle-aged adults (such as physical, social, and psychological domains) had a positive effect on their QoL. Specifically, the positively perceived health condition of individuals with physical disabilities can improve the QoL. Moreover, such people take their health conditions especially seriously and hold an extremely high expectation from the government, as reported by a national survey . This could be considered as a suggestion for the establishment of the government-initiated system for enhancing health conditions through the people with physical disabilities’ health promotion .
In summary, in establishing the strategies for improving the QoL of people with disabilities, it is necessary to consider diverse ecological factors that can reinforce their health promotion behaviour. Furthermore, when their perceived health condition improves through their health promotion behaviour, their QoL would also improve. However, a prior study involving people without disabilities reported that the health promotion behavioural intention positively affected health promotion behaviour; hence, this research’s outcome that the former did not have a significant effect on the latter indicated that regarding their health promotion behaviours, such individuals experience obstacles in their physical environment due to their disability. Therefore, it is essential to conduct follow-up research to identify the factors that have an actual influence on their health promotion behavioural intention.
Also, the male group showed the same results as the total group, but the female group showed statistically significant results only in the relationship between promotion behavior and health status, and promotion behavior and quality of life. This is because sports for the disabled have been centered on men in the past, and in particular, in Korea, the activation of sports for the disabled is lower than that of men. Therefore, women with disabilities are classified as a vulnerable group compared to men with disabilities, and there is an urgent need to develop various programs to solve this problem.
This research has the following limitations. First, the study participants were limited to people with physical disabilities and failed to reflect the attributes of the other disability types. Therefore, follow-up research should include various disability types in addition to the physical ones and identify their health attributes and promotion needs. Second, this study restricted the number of sub-factors and failed to consider the others. Therefore, follow-up research should consider more diverse aspects. Based on this study’s findings, it is necessary to design a program to promote the people with physical disabilities’ health and to evaluate its effect.
This study aimed to diagnose the individuals with physical disabilities’ QoL. It showed that improving their self-efficacy and social support from the surrounding people is the key to enhancing their QoL. Furthermore, their health promotion behaviour had a positive effect on their health condition and QoL. This finding could be used as the data for building an efficient system for improving the QoL of people with physical disabilities. In addition, in all pathways, males showed the same results as in the total group, but in females, only the relationship between promotion behavior and health status, and promotion behavior and quality of life was found to be significant. This shows that women with disabilities are more vulnerable to health promotion than men with disabilities. Therefore, it is judged that it is necessary to develop various programs to promote the health of women with disabilities.
YW designed the research study. YW performed the research. SH re-edited and revised the paper. YW and SH analyzed the data. YW and SH wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
Because the research subjects were persons with physical disabilities in an unfavourable environment, we obtained permission regarding the research ethics (DKU2019-08-002-001) from Dankook University Institutional Review Board before carrying out the field research. Before the study, the researcher obtained consent from the subjects and reassured them regarding the strict confidentiality and anonymity, ensuring the protection of their privacy and personal information in all circumstances.
We would like to thank all the disabled people who participated in this study and the researchers who provided generous advice.
This research received no external funding.
The authors declare no conflict of interest.