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Essay on theories and models of health promotion

The word ‘health’ came from the old English word for heal (hael) which means ‘whole’, indicating that health concerns the whole person and their integrity, soundness, or well-being (Crafter 1997). Health can be defined as a state of well-being, interpreted by the World Health Organisation as ‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’ (WHO 1946).

Health promotion (HP) is ‘the process of enabling people to increase control over and to improve their health. HP is a positive concept emphasizing social and personal resources as well as physical capacities’. WHO (1984)

In this assignment I will discuss health, HP principles, changing people’s behaviour and attitudes and I will also apply the application of a HP strategy (Beattie’s model). Beattie (1991) identifies three areas, health persuasion, personal counselling and community development. It also incorporates the knowledge, attitudes and beliefs (KAB model) which helps to support Beatie’s theories. His model offers a structural analysis of HP approaches. This model involves advice and information that is evidence based, insuring that the correct information is available to the client so she can make an informed choice, as the Nursing and Midwifery council (NMC 2008) stipulates. The KAB model, when applied, concentrates on what makes a person want to change.

Dahlgren and Whitehead (1991) discuss the layers of influence on health and it’s social and ecological theory. They also attempted to link the relationship between the individual, their environment and disease. Individual people are at the centre, with a set of fixed genes. Surrounding them are influences on health that can be changed or modified. The first layer is personal behaviour and ways of living that can promote or damage health. e.g. one’s choice to drink alcohol. Individuals are often affected by friendship patterns and their communities. The next layer of Dahlgren and Whitehead’s theory is social and community influences, which provide mutual support for members of the community in unfavourable conditions. But they can also provide no support or have a negative effect. The third layer includes structural factors such as housing, working conditions, access to services and provision of essential facilities.

Festinger (1957) used the term ‘cognitive dissonance’ to describe a person’s mental state when new information is given. This prompts the person either to reject the new information (as unreliable or inappropriate) or to adapt attitudes and behaviour, which could fit with it.

Bradshaw’s needs also plays a critical role in HP. The schedule of antenatal care is dominated by a medical model. When providing care, the needs of women must be heard and incorporated into their care.

Bradshaw's needs can be used by midwives and other professionals to identify women's needs in pregnancy. This can lead to the type of healthcare which is more likely to address the social determinants of health and improve health outcomes for pregnant women.

Normative Need: As defined by an expert, to be a need that all require. Such as the advised number of antenatal visits.

Felt Need: an individual or groups own personal need.

Expressed Need: A felt need which turns into an expression for help

Comparative need: Comparing the needs of different groups and finding a common occurance.

Bradshaws concept has four different types of need:

My HP strategy focuses on Bradshaw’s comparative need. To educate women of 30yrs+ to abstain from alcohol during pregnancy. This is evidence based on research showing the link between alcohol and FAS.

HP is a key part of the midwife’s role. However, the effectiveness of its practice is often not easily recognisable. The document, Saving Lives-our healthier nation, (DOH 1999), suggests that individuals are not solely responsible for their own ill health. Health professionals i.e. Midwife and the government all play an important part in working towards achieving health for all and reducing inequalities in health and health care provision. The report also states that Healthcare authorities and primary care groups have a responsibility towards public health. (DOH 1999)

The Royal College of Midwives (RCM 2000) suggests that maternity care is not just a ‘delivery service’. Midwives make a major contribution to family well-being and the wider public health and its contribution is yet to reach its full potential.

HP is often used to describe behaviour or actions, which directly or indirectly influence the health of others. This may include preventing ill health, maintaining positive health, raising public awareness of health issues, protecting the public from harm, educating people to make healthy lifestyle choices and reducing inequalities in health and provision of healthcare (Dunkley 2000).

HP within midwifery, involves enhancing positive health and reducing the risk of ill health through education. For expectant mothers it is a time of immense psychological and physiological development. During this time the woman acquires a great deal of new and sometimes confusing information from family, friends, magazines and health professionals. Midwifes have a duty of care to inform women about health damaging behaviour where this may occur. They also have a duty to encourage discussion on such topics i.e. alcohol in pregnancy, nutrition and choices of feeding.

Following articles written in the Guardian and Telegraph newspaper in February 2010 stating that the Department of Health advice is that ‘women should not drink at all when trying to conceive or when pregnant, but if women do chose to drink they should not have more than one or two units once or twice a week and not drink enough to feel drunk’ is what inspired my decision to look at Alcohol in pregnancy for this HP. The National Institute on Alcohol and alcoholism (NIAA) clearly states that NO alcohol should be consumed in pregnancy. The Telegraph newspaper in January 2009 reported that O’Leary (an Australian scientist) states ‘Women who drink five small glasses of wine during the course of a week in the first three months of pregnancy increase their risk of a premature birth by 70 per cent’, even if they stop later. Research from the Infant feeding survey 2005 shows that drinking alcohol socially when pregnant has a higher occurrence in women in the 30-35 year age range and above.

The Royal College of Obstetricians and gynaecologists (RCOG) 29th June 2010 stating there is ‘no evidence that a couple of units of alcohol once or twice a week will harm an unborn baby’.

These contradicting reports led me to research the need for a HP on alcohol consumption in pregnancy.

Professor Phillip Steer of the RCOG believes that if women ate and drank a more healthy diet this would result in healthier babies thus a healthier nation.

Another specialist, Dr Raja Mukherjee, consultant psychiatrist and expert in foetal alcohol syndrome, stated that if a wealthier woman who has previously consumed wine on a regular basis, continues into her pregnancy, she is in the high risk group. He reports that they are actually putting their babies at risk before they even know they are pregnant, in some cases.

Mukherjee (NOFAS) also reported that one of the ‘most severely affected children he has seen, was born after a wealthy woman continued to consume half a bottle of wine 2 to 3 times a week’.

In my HP plan I wanted to target women in the older age ranges. Using the media to publicise the damage caused by alcohol consumption in pregnancy. My idea constituted a run of billboard posters depicting babies being forced to consume alcohol as well as television advertising. The adverts would be hard hitting with a simple “don’t drink” slogan. The campaign would be called the “you drink, I drink” campaign. The primary aim would be to stop women drinking alcohol in pregnancy. The secondary aim would be to at least educate and inform women of the concerns related to drinking alcohol. Both aims would hope to have an effect in reducing the cases of fetal alcohol syndrome, currently 1:100, (NOFAS 2010), caused by drinking alcohol in pregnancy.

Models have been used in HP for some time, but can they be a part of midwifery? It could be claimed that the unique and individual situations of pregnancy and birth do not lend themselves to categorising women and their needs. Every woman and every pregnancy is different. Could it be possible to apply a standard package of professional care? If midwifery is viewed as a health-promoting activity, then it may be that HP models and approaches can enhance the way that midwives deliver care by developing an agreed research-based framework, which, ‘rather than labelling women, standardize good practice’ (Crafter 1997). The NHS plan, (NHS 2000), which seeks to develop an NHS that is patient-centred and fit for the 21st. Century, suggests that the ‘role of the midwife should be developed in public health and family well being’.

Whilst researching my strategy I found that the first reported association between maternal alcoholism and a characteristic pattern of cranio-facial, limb and cardiovascular defects in the offspring was published in The Lancet Saturday 9 June 1973. Since then the results of a large body of research have been published. This is clearly an indication that a new HP aimed at pregnant women is needed!

In 1996 the RCOG published a guideline on alcohol consumption in pregnancy. They wrote that there was ‘no conclusive evidence of effects in either growth or IQ at levels of consumption below 120 gms per week”. Nonetheless, they recommended that women should be careful about alcohol consumption in pregnancy and limit this to no more than one standard drink (8 gms of alcohol) per day. This disagrees with the recommendations from NICE. Who state that if a woman does decide to drink alcohol, she should drink ‘No more than one or two units, once or twice a week’.

It is clear that the consumption of alcohol during pregnancy cannot be deemed without risk, however, controversy continues as to whether there is any safe level which women should be advised not to exceed.

According to The National Organisation on Fetal Alcohol Syndrome (NOFAS), the medical and scientific literature overwhelmingly supports the hypothesis that there are risks of alcohol related brain damage from drinking low to moderate amounts of alcohol during pregnancy.  Based on these findings, NOFAS’ position is that there is ‘no safe time, no safe amount, and no safe alcohol during pregnancy’. (NOFAS 2007)

The obvious way forward is to re-educate women through HP. There are key drivers in health matters such as the National institute of clinical excellence (NICE) and the Acheson Report for the Department of Health, which was a report to contribute to the development of the Government's strategy for health and an agenda for action on inequalities in the longer term. The publication in February 1998 of the consultation paper "Our Healthier Nation; a Contract for Health" was an important landmark. It identified the need "to improve the health of the worst off in society and to narrow the health gap" as an overriding principle. (DOH 1998)

The report took into account the main features of "Our Healthier Nation" as they affect inequalities. It discussed tackling inequalities in the settings of schools, the workplace and neighbourhoods. The section on the NHS included an element on the reduction of inequalities through local partnerships taking into account plans for Health Improvement Programmes and Health Action Zones. It also takes into account the changes outlined in the White Paper "The New NHS: Modern and Dependable".

Whilst developing my HP strategy I looked for current Local and National strategies. The key strategy is that of the National Organisation on Fetal Alcohol Syndrome (NOFAS). They offer an extensive service, including conferences, support group meetings, publications and in particular the "Baby Bundle Project". The training for Midwives Project is an initiative of NOFAS-UK to provide useful and positive health information about the consumption of alcohol in pregnancy. Midwives play an important role and can help prevent FASD.

Another key strategy is Drinkaware. Drinkaware aims to change the UK’s drinking habits for the better. They ‘promote responsible drinking and find innovative ways to challenge the national drinking culture to help reduce alcohol misuse and minimise alcohol-related harm’.

They are an independent, UK-wide charity, who are supported by voluntary donations from across the drinks industry to equip people with the knowledge they need to make decisions about how much they drink.

Drinaware also helps tackle alcohol misuse. As well as working with other organisations and individuals across the UK to fulfil the ‘educational, community and awareness campaigning function envisaged in the Government's Alcohol Harm Reduction Strategy’. They also provide easily accessible, evidence-based information about alcohol and its effects, to employers, young people, teachers, parents and community workers, such as Midwives. They use a range of advertising mediums, such as film, multimedia and TV.

Another National strategy is NICE. Their current recommendations on alcohol in pregnancy is that ‘Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible, because it may be associated with an increased risk of miscarriage’.

But as previously discussed they also advise that women planning a pregnancy or in the first 3 months should not drink at all.

The negative theory of this is that the government is presuming that all women will know what 8g of alcohol is, or 1.5 units. Should the government be advising women in a more user friendly way? The HP strategy advising women what they should or should not do will fail as not all women will know how much is too much. This creates a concerning risk. The government need to re-address the strategy to be usable by midwives and pregnant women alike. They should be re-thinking ways to educate women as to what a measure of alcohol is.

Nice is also adding to the confusion in saying avoid alcohol then expressing that it can be drunk but in moderation. This sends a very confusing message to health promoters and pregnant women.

According to NICE it is the responsibility of the midwife to educate their clients in the safe levels of alcohol consumption at their first meeting.

At the expectant mothers first visit to the antenatal clinic the midwife should explain how the pregnant woman will be monitored with regular examinations and tests to ensure that the pregnancy is progressing normally. It should also be emphasised that the woman’s health inevitably influences that of the fetus and can have major impact on health in childhood and later life.

Midwives need to advise their clients on what is safe. Would it be safer and clearer to advise all women, all of the time, not to drink alcohol at all? But the midwife would then not be offering the woman informed choice. It is the role of the midwife to offer lifestyle advice and to tell women of the implications of what alcohol consumption can do to a fetus. Then as Beatties model states, it’s the clients prerogative to choose what their actions are but it is the midwives role to try to encourage a change in previous unhealthy behaviour.

During the development of my HP strategy i gained a peer review. (See appendix A). The positive feedback was tremendous. Confirming that I had correctly assessed the need for the target audience to be women aged 30-35 years+ and that a hard hitting advertising campaign was the right route to take. It highlighted the need to define which health models i would use and I decided on Beatties and KAB rather than Tannahill, which is another well know model. Although I did realise the need to decide on a primary and secondary aim for my promotion. The review also highlighted the need to be able to assess the success of this strategy. This would be easily measured by seeing a reduction in babies born with FAS.

During antenatal care Midwives impart relevant information in a teaching way, but it is of no value if that teaching is facilitated in a lecturing style. Women won’t learn if spoken ‘at’. It is not possible to provide an exhaustive coverage of pregnancy, labour, and the postnatal period during a set of 3/4 classes. A childbirth educator can boost her clients’ self esteem by valuing everyone’s comments and creating an atmosphere in which learning is a shared experience. The aim of childbirth education, therefore should be to help the women understand the importance (for their mental health) of getting the information they need, and to empower them to ask questions when and of whoever they want. ‘It has been clearly demonstrated that a woman’s mental health after delivery has been closely linked to the amount of information she received during her labour’ (Oakley 1980).

Health promoters are not always effective at providing information. Hillan (1992) suggests many women feel that ‘there are a variety of ways during an antenatal class to empower women to ask questions of their caregivers. Women can be empowered by the attitude of their teacher. In Beattie (1991) Strategies for HP, he incorporates empowerment as an important aspect of his model to empower individuals to have the skills and confidence to take more control over their health. Analyses of empowerment shows there is a need to distinguish between self-empowerment and community empowerment. Self empowerment is used to describe HP strategies which are based on counselling and which use non-directive, client centred approaches aimed at increasing people’s control over their lives. Midwives frequently engage in client-centred work, as they are concerned with facilitating client autonomy. The client sets the agenda and the health professional’s role is facilitating, guiding, supporting and empowering the client to make informed choices (Dunkley 2000). Community empowerment is used to describe a way of working which increases people’s power to change their ‘social reality’. It is also a way of working which seeks to create active participating communities who are empowered and able to challenge and change the world about them. This approach helps people identify their own concerns and gain the skills and confidence to act upon them. It is unique as a ‘bottom-up’ strategy and calls for the different skills from the health promoter (Kendall 1998). The midwife, becomes a facilitator whose role is to act as a catalyst.

Carl Rogers has also developed the theory of facilitative learning. The basic premise of this theory is that learning will occur by the educator (in this case, the Midwife) acting as a facilitator, thus establishing an atmosphere in which learners feel comfortable to consider new ideas and are not threatened by external factors.

When teaching adults we must be aware of their different learning styles. Adult learners are a very diverse group. Andragogy (the teaching and learning of adults) was first developed by Alexander Knapp in 1833. Then in 1984 Knowles used Knapps theory and expanded on it. Knowles emphasizes that adults are self-directed and expect to take responsibility for decisions. Adult learning programs must accommodate this fundamental aspect.

Knowles himself changed his position on whether andragogy really applied only to adults and came to believe that ‘pedagogy-andragogy represents a continuum ranging from teacher-directed to student-directed learning and that both approaches are appropriate with children and adults, depending on the situation.’ (Knowles 1984)

Beattie offers a structural analysis of the HP approaches. He suggests that there are four paradigms for HP. These are generated from the dimensions of mode of intervention which ranges from authoritative (top-down and expert-led) to negotiated (bottom-up and valuing individual autonomy). Most HP work involving advice and information is determined and led by practitioners, or midwives in this case.

The work and thoughts of Carl Rogers in the 1960’s have been formative in understanding the importance of self-awareness and the experiential learning in helping individuals to understand and make decision. It is therefore important before commencing adult education to examine the structure of the model and look at whom it is aimed at. It is important when working within a team that certain values are shared and made explicit so that the carers can work towards the same goals and the recipients of care can be clear about the standards and outcomes to expect. ‘Developing and working with unified models and approaches in health promotion and midwifery can therefore help midwives to communicate with each other more effectively and strengthen initiatives, which benefit everyone’ (Crafter 1997).

The transition to parenthood is an emotional time for both the pregnant woman and her partner. The shift from marriage or partnership to the first pregnancy is a major transition point in a women's life. It is also the time that HP can have its biggest effect. Women are open to learning new things and hearing from many different sources about what’s best for them during this time. A number of studies have suggested and therefore confirm this theory that ‘the most difficult transition for couples to make is the birth of the first child’ (Cowan & Cowan, 1992). All major transitions involve making changes and a period of disequilibrium.

A professional career woman may find the whole process out of her control and be left reeling. Motherhood can significantly challenge a

woman’s sense of identity, revealing a tension between ‘personhood’ and

‘parenthood’. Antenatal classes, media, books etc all play a part in acclimatising the woman to her new role.

Other outside influences are the social surroundings. Pregnant women from lower or working classes may not feel they have the same support as those from middle or upper class social areas. They may not reach out to areas of support, including what we consider basic antenatal care. Younger mothers may look at parenthood through ‘rose tinted spectacles’, imagining their baby will sleep through the night. While the more mature first time mother is more realistic in her outlook. This is where HP again plays an integral part in educating the woman through sources of media, care and through learning in the community.

Expectations and theories have changed greatly over the last 40 years. Older mothers are more common as are teenage mothers. Teenage mothers in the 1960’s were sent away to discreetly have their babies, now they are a common part of the community with different needs to that of the older mother. HP has to be aimed at all groups all of the time. It is up to the care giver to facilitate this information at the right level for each individual case.

Good quality teaching, support and HP’s received well, all contribute to the transition to parenthood, thus increasing the confidence of the new parent. After all, it is one of the most vulnerable times in their life.

With successful antenatal learning in place this would then enhance the transition to parenthood and that of attachment. Bowlby (1969) devoted extensive research to the concept of attachment, describing it as a "lasting psychological connectedness between human beings"

Proximity Maintenance - The desire to be near the people we are attached to.

Safe Haven - Returning to the attachment figure for comfort and safety in the face of a fear or threat.

Secure Base - The attachment figure acts as a base of security from which the child can explore the surrounding environment.

Separation Distress - Anxiety that occurs in the absence of the attachment figure. Bowlby (1969)Bowlby believed that there are four distinguishing characteristics of attachment:

These characteristics are learned as children and are what we use when moving from childhood to parenthood. Without a good base we cannot expect new parents to successfully proceed into parenthood without some re-education and the support of quality care givers.

In conclusion, the RCM Vision 2000 describes the midwife as a public health practitioner. Midwives have always enhanced, facilitated and supported factors, which promote physical health, psychological, social and spiritual well being for the woman and her immediate family. Some of the key points that should be considered for the future of midwifery HP practice, is that it needs to be clearly defined, ‘national and political recognition of the midwives contribution to public health should be improved and midwives should promote health within the socio-culteral and economic context of how individuals live their everyday lives’ (Dunkley 2000). Providing antenatal care to woman and fetus demonstrates a unique opportunity to enhance holistic health through advice, guidance, support and social networks where the woman can be offered further specialised care if needed. This assignment has discussed the concept of health and HP, the value of alcohol avoidance and briefly the effects on the pregnant woman. Beattie’s and KAB model was used to show the importance that a supportive environment is created in which people can challenge ideas and question beliefs. Beattie’s model is adaptable and could be applied to many scenarios, the model shows a knowledge of awareness of adult education by provoking a deep understanding of processes and problem solving, and therefore the quality of teaching and the learning process. There are a number of ethical issues involved in parent education. Participants need to be listened to carefully and their questions answered truthfully, which gives a positive effect on the woman and leads to the skills and confidence to take more control over their health.

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