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Health promotion is a new public health initiative which has been integrated into governmental strategies to improve health either within a family, a community, health institutions and work places. It refers to effort to prevent ill health and promote positive health with the aim of enabling people to take control over their own health (Wills, 2007). This essay primarily seeks to discuss how a health promotion model could be utilised by nurse practitioners to facilitate an empowerment within a family unit. Health action model (HAM) will be adapted to develop a means by which the said patients could be helped by the nurse practitioner. The essay begins with a general overview and literature about what health and health promotion is about, and then narrows the discussion down to the health promotion model - which will be used to assess a patient named Jojo (See Appendix 1 for patient profile). The essay then concludes by evaluating the model used in assessing the patient and if any other model could be used to assess the patient or not.
DEFINITION OF HEALTH
According to the World Health Organisation (WHO)(1986), health is defined as a condition of complete social, physical and mental well being of a person and not purely the absence of disease or infirmity. This when elaborated could mean that both positive and negative aspects of well being and health, which stressed on social and mental aspects of health, though not just illness related. Waxman et al., ( 1998) even emphasised that physical , social and mental aspect of health are connected. There are several factors to determine health including social factors, gender, education, environment, biological factors and lifestyle. According to some scholars like Skolnik (2008) describes social factors as an essential factors that determine the health of individuals. Based on his view, there is a great difference between people of higher status to that of those of a lower status. This is because those with a higher status are well educated, well employed and earning a lot and also taking care of their health. This when compared to those with a lower status, it is the opposite of those with a higher status. For instance, someone on a low income may find it difficult to afford some of the necessary needed in order to live a normal life like keeping the house warm or replacement of faulty stuff in the house (Anderson and Blenkinsopp, 2001). Moreover, those who are better off do not buy form local shops at expensive prices but rather do travel for miles to bigger supermarkets to shop. This is because things sold at the supermarkets are of a cheaper price and of more quality than those in local shops. The other side of the story is that, the better off do not depend on public transports to travel for miles to shop whilst those on a low income always do so. So if the bus does not turn up, they have to go to these local shops to but their foodstuff (Anderson and Blenkinsopp, 2001).
The ideas of (Skolnik, 2008, Anderson and Blenkinsopp, 2001) can be supported by (Shi et al, 2008). Shi et al., (2008) suggest that socioeconomic also plays a significant role in people's live. That is those who are well off tend to live in better houses and in locations where there is the risk of being exposed to air pollution is low, have better access to health care, avoid risk lifestyles such as smoking and drinking as well as using of drugs. Building on with their argument, it was proved that the correlation and status concerning the health of Americans who are less educated died younger than those highly educated as described by (Shi et al, 2008).
In addition to this, those who are more educated tend to have much knowledge about their health as well as practising good health. That is, they are equipped with knowledge as well being in charge over their lives knowing what is and not good for them. This also helps them to have loads of information which will help them understand how to live a healthy life. For instance (Skolnik, 2008) said that a person who is well educated will adapt a good lifestyle in order to remain healthy such as having a well balance diet, having fewer children and smoke less as weigh against those who are less educated.
The environment also acts as an important factor that influences the health of people that includes a mixture of different factors altogether (Anderson and Blenkinsopp, 2001). Shi et al., (2008) argued that physical, socioeconomic, socio-political and sociocultural are what the environmental factors are made up of. For instance, physical environmental factors are important factors which influence health. This includes food, contaminated water, waste, air pollution, and habitat alteration that can cause different health problems. For example living in a smoky environment can cause respiratory illness such as asthma.
The contribution of (Carter and Slack, 2009) described the interaction of a person's environment as having both negative and positive effects on them. That is a person living in an environment where there is access to health care, good drinking water, less risk of environmental pollution and radiation leads to good health with a positive effect as an outcome. On the other side, those living in environments where there is a poor access to healthcare, drinking contaminated water, exposure to environmental pollution and radiation lead to a bad health which is exactly the opposite of those living in good environment as said by (Carter and Slack, 2009).
Furthermore, (Kozier et al, 2008) said that some of the biological factors that influence health are genetic makeup, age, sex and developmental level. In terms of genetic makeup, it can have an effect on the person's intellectual stage or activities and innate personality. This also can have negative features on a people's health whereby they are prone to susceptible to particular diseases. Nevertheless, it was made known that people who are more susceptible to genetic diseases are mostly much greater in parents from the same ethnic genetic pool as said by (Kozier et al, 2008). For example in a family where there is a history of asthma or heart disease will by all means affect the other generations of that family.
As stated by (Naidoo and Wills, 2009), gender also accounts for the factors which influences health. That is, women are more likely to report illness that men because most of these women are unlikely to be in full time employment. Women on the on the other side of the story tend to have more access to health care because they are anxious about their health and always want to stay healthy as compared to men whereas they only take less advantage of their health. According to biological explanations, women are more prone to infections and do gain from the protective effect of oestrogen that decreases the death rate of such infection in them. More so, it was further explained by the biological explanations that the female hormones and the reproductive system causes women to be responsible for both physical and mental health illness as described by (Naidoo and Wills, 2009).
Kozier et al., (2008) argued that lifestyle also acts as a factor that influences the health of people which however does have both negative and positive result on the individual concerning their choice of living. This includes individuals having control over their lives in association to their behaviour or activities that involves living condition and sociocultural factors. For instance, eating healthily will help individual with their weight management even when they get older. Another example is how exercising is of a great benefit to the body. This is because exercise help decrease the risk of developing stroke, heart disease, prevents fractures and weak bones and also maintaining flexibility in the joints. This was further explained in terms of spiritual and religious beliefs as having impact on people's life. For instance, (Kozier et al, 2008) gave a typical example in relation to the donation of blood by members of the Jehovah witnesses. This group of people avoids the donation of blood which is also against their beliefs because it is not written in the bible.
DEFINITION OF HEALTH PROMOTION
TALK ABOUT EDUCATION, TRAINING AND COUNSELING AS THE NURSES' ROLE IN HEALTH PROMOTION
Health promotion is defined as ways of allowing individuals to enhance control over their health as well as to improve it as defined by (WHO, 1986). It encompass various approaches including bio- medical, behavioural / life style and socio- environmental. Though critics have argued that behaviour / life style approach have various limitations including expect- led which is a top- down approach. For example the nurse led approach to the patient. Regardless of the above mention, Jackson (2007) states that the role of the nurse in health promotion is very essential because it lays emphasis on how the health care and the service provided are viewed. In terms of promoting health, it involves the nurse spending time to listen and to talk to their clients or patients. This involves taking the needs of their clients or patients into consideration using high level of communication skills.
Ewles and Simnett (2003) said that through effective listening, the health promoter can help people to speak out their point of view as well indicating their needs and how they feel. This will enable them believe that they are being listened to.
Effective listening is an important aspect of communication in terms of health promotion which includes eye contact, facial expression, posture or gesture indicating the feelings of clients. This helps the nurses to listen to their clients carefully without disruption. Through listening, the nurses are able to capture majority of what the clients have said. This enables them to confidently ask lots of open ended questions in order to demonstrate to them that they are being listened to as stated by Morrison and Burnard (1997). An example is a client not wanting to speak to the nurse attending to him because of the disease he has been diagnosed of. Through sympathizing and listening, the client will gain the confidence to speak to the nurse regarding his condition.
Jackson (2007) again outlined that through health promotion, the clients are involved in making decision concerning their own health care. This is also a client centred which is based on the assessment of the needs of the clients by taking their point of view into consideration as well as valuing them.
Moreover, Rose (2006) states that knowledge is being increased through health promotion which helps people change their behaviour. This is because each individual is responsible and making choices about their health without taking factors that may have influence on them such as socioeconomic factors. Hence, through health promotion, the nurse as a health promoter will give much information to the client in the form of leaflet and using different resources such as information from trusted web sites to educate the patient or client by talking it through with them or one to one basic in the form of counselling (Neis and McEwen, 2001). The client or patient together with his or her family will gain the knowledge about what they are being told which will lead them in making the choices about their health. For example, the nurse advising clients about healthy eating such as eating five a day and its benefit or the side effect of overeating, smoking and drinking. So after giving them all these information it is in the own interest of the client to either adopt a healthy lifestyle or not.
It is the responsibility of the nurse practitioner as a health promoter or educator to form of a therapeutic or beneficial relationship between the nurse, community individuals and their families. Through this therapeutic relationship, the nurse is able to develop ideas, other nursing interventions and resources which will help facilitate empowerment (Neis and McEwen, 2001). For example, before a nurse can persuade a client to quit smoking, she must know what the effect of smoking is and explaining it to the clients in a simplify language with confidence.
Advocacy is also an essential aspect of health promotion. This is where the nurse practitioner helps people especially vulnerable people who are disempowered within the society that cannot speak for themselves because of their disability or illness makes choices for their health. This is done via taking possible measures to help them become self empowered and independent (Elwles and Simnett, 2003).
INTRODUCTION OF THE MODEL
Narayan-Parker (2002) defines empowerment as shaping of people's life through the enlargement of liberty of choice and action.
There are two types of empowerment which are self empowerment and community empowerment. The self empowerment in terms of health promotion is based on counselling which includes non-directive measures and is a client centred approach with the goal of enabling people to be the controllers of their lives at a higher level. (MOVE THIS PARAGRAPH)
There are lots of health promotion models but because of Jojo's condition, the HAM developed by Tones in the 1970s will be used to assess Jojo falls under behavioural change model will be used to assess him. The behavioural change model recognises health as a possession of the individual being in charge of it by adopting the kind of lifestyle that they want to in order to maintain it. This is because the aim of this particular model is to persuade people to change their behaviour by adapting a better lifestyle which will help maintain their health as described by (Naidoo and Wills, 2009). The HAM as stated by (Squire, 2002) gives an idea as to why some people decide to change to healthier lifestyle whilst others may not by emphasising on the self concept of the individuals. The self concept includes self esteem which is how people feel about themselves and self image which is how they perceive themselves to be. (REF). Squire (2002) made it known that people with a high level of self esteem and self image are persuaded or enthused to adopt a healthier lifestyle. On the other side of the story, those with a low level of self concept may feel that they are less likely to adopt such lifestyle with no hope of doing so because they believe that they are not in control of their life but rather controlled by fate, chance or luck as described by (Squire, 2002).
The HAM has identified different factors that influence the ability of people to change to a healthier lifestyle. These include psychological, social and environmental factor which indicates the likelihood of a person to change his or her behaviour by putting them into practice. However, there are other manipulating relating factors such as beliefs, motivation, normative and the self that works together to indicate the possibility of a person's intention of changing his or her health lifestyle (Green and Tones, 2010). The four manipulating factors which are beliefs, motivation, normative and the self factors will be elaborated on to access Jojo and his family.
INTRODUCTION OF PATIENT,
Upon using the Body Mass Index (BMI) calculation on my Jojo during a clinical practice as a student nurse, it was deduced that Jojo is overweight. Several questions were asked to ascertain the causes of his overweight. It was however noticed that, family lifestyle could play an important role in Jojo being obese. As a student nurse practitioner, it is therefore vital to promote initiatives that could help Jojo and his entire family to adapt good healthy practices. Various models do exist in health promotion to effect behaviour change (Naidoo and Wills 2000). In practical terms, any model for desired change must indicate what they are doing, why they are doing it, how they going to do it, its outcome and its side effects.
Obesity is affecting not only developed countries but that of developing countries which has been a global concern and posses a great challenge to medical practitioners (Jackson-Leach and Lobstein, 2006). It is real that human beings cannot live without food, it is therefore essential to understand the effects that food has on the body of humans and knowing how to keep the body in a good health by eating a balanced diet. It is also essential to give the body whatever it needs knowing that the body needs nutrients to grow. It should be borne in mind that the choices of food have a long term effect or impact on the body. Eating a healthy diet can reduce the risk of illness such as obesity (Bupa, 2008). This is because most problems encountered by health practitioners is that of obesity especially in children leading to a negative effect in adulthood if the necessary means are not taken to prevent it from the onset.
Childhood obesity is a condition where excess body fat negatively affects a child's health or wellbeing. (Wang, 2001). As stated earlier, obesity in childhood can lead to many other health complications that may even tend to indicate that that child will be obese later in adulthood. The techniques to determine body fats directly are difficult, though diagnosis of obesity is often based on Body Mass Index (BMI) (Hesketh, 2005). Due to the rising prevalence of obesity in children and its many adverse health effects it is being recognized as a serious public health concern. The term overweight rather than obese is often used in children as it is less stigmatizing.
Obesity increases the risk of insulin resistance and type 2 diabetes which is normally a disease seen in later life in adults. However, increasingly children in their teens are presenting with type 2 diabetes as a consequence of being obese. There are also marked psychological effects leading to low self-esteem which is how they feel about themselves. (Shahar, 2005) In the UK, around 27 per cent of children are now overweight and research suggests the main problem is a continual reduction in the amount of exercise children take. Many overweight children have overweight parents which is often a matter of family lifestyles (Shaya, 2008).
Statistics do specify that there was 5.9% increase in obesity among children between the ages of 2 and 10 years from 1995 to 2002 (Department of Health, 2004). The trend of child obesity prevalence in the UK keeps increasing yearly. To effect a change therefore requires effective intervention based on evidence. Evidence based practice in recent times has attracted the attention of medical professionals as well as other health care practitioners about how the rate of obesity is increasing especially in children(Daly et al, 2007).
Since the three system stated in HAM which are the beliefs system, motivation system and the normative are dimensionally linked together, each of these factors will first be defined before using it to access the patient and his family. The normative system described by (Green and Tones, 2000) is an influence by people's expectation that leads others to act in agreement to the perception of others so that they would be liked by them. For example,
This assignment has adapted behavioural change model to empower Jojo and his family to change their attitudes, beliefs and behaviour on their family lifestyle .Though, the theory of planned behaviour suggests that, the intention to perform a certain behaviour is influenced by the risks and rewards associated with that choice (Corcoran, 2007). This will be discussed in three sections which may be interconnected as described in HAM namely normative, cognitive and motivational system.
CON + INTER
Literature suggests that initiatives or interventions must acknowledge the needs of people and create a supportive and working environment which will aid an integration of their daily activities (Baric 1994) to influence behaviour change. Though, one way to promote health is to change behaviour by modifying individuals' knowledge, beliefs and attitudes. However an increase in the knowledge acquired may not necessarily lead to behaviour change (Bandura, 2004).In behaviour change, the choice is with the individual (Corcoran, 2007), but
Norms + INTER
it can be facilitated by positive agents of behaviour change or influential people such as parents, teachers and etc, who may act as agents for behavioural change, influencing norms or customs usually as a result of direct exchanges and discussions (Turner, 1999). According to the conceptual theory, behaviour change like modifying knowledge works better when used in combination with other approaches such as empowerment and other factors (Pajares, 2004).
Therefore positive agents when empowered might dispose high initiatives and exceptional interpersonal skills to enable them reach out to others (Turner, 1999).
In Jojo case, the family will be empowered via training on healthy eating, habits, exercises and other skills which will help them achieve the planned goals.
Management and intervention of obesity(talk abt what schools can do, change individual levels)
EVALUATION OF THE MODEL
The evaluation of the HAM will be embarked on after the management and intervention which is concerned with a long term change. Hence, evaluation of this model will be the right of measuring the outcome of the interventions. As described by (Naidoo and Wills, 2000) it is hard to point out the long term outcomes to one intervention or model that adopts the behavioural change model. On the other hand, interventions applied by single organisations often affect the long term change because these interventions need to rely on many organisations in order to achieve something at a higher standard.
Nevertheless, the nurse practitioner will work in collaboration with different organisations in order to help individuals change their lifestyle for a better outcome such as the school, dietician, social service, ...
Due to Jojo's condition and the family's situation, the nurse practitioner will have to assess Jojo using the HAM but must have to take into consideration some of the factors that may act as modifying factors. For example, peers pressure may act as an agent to undertake unhealthy diet and other perceived barriers such as lack of money or not having the time. Therefore, the nurse practitioner will be accountable for providing a program that will help overcome these factors because if the perceived barriers are not dealt with, then the participation will be less.
However, to evaluate the HAM used to assessed Jojo, three types of the evaluation methods will be used namely process evaluation (i.e formative evaluation. The way things are done, monitoring of progress during program), impact evaluation (short term outcome, the impact of the intervention on the audience. Eg. Comments from the audience, peer group) and outcomes evaluation (i.e summative evaluation, measurement of challenge at the end of the program, measure the consequences, the long term effect of the intervention)
The belief system is where the individual's belief that he or she is at risk of a particular condition and suspecting it as real. Becker (1974) a health belief model made it known that demographic variables such as susceptibility, seriousness, cost, benefits and cue to action are taken into consideration for behaviour changes. That is people are persuaded by the way they see themselves in such situation either it is a demand for them to fight or flight or an illness as well as how severe that situation is. More so, (Green and Tones, 2010) state that there is a relations between the belief and motivational system whereas beliefs are referred to as cognitive and how people make their own judgement about how an event is likely to happen which is known as the subjective probabilities.
Apparently, Jojo is aware that his dad died of high blood pressure with obesity as being the cause. Now that Jojo himself is overweight and knowing that his life too is at risk and if such measures are not taken to help him changed to a better lifestyle, something different will come up. Looking at all these episodes surrounding his life, he will be tasked by these challenging beliefs to change to a healthy lifestyle. His mum on the side will also encourage him to change his eating habit and not Jojo alone will she encourage but the rest of her children as well.
Nevertheless, the belief of an event likely to take place will cause the emotional state of the individuals or to give rise to the person's attitude of adhering to a particular action (Green and Tones, 2010). That is people with optimistic attitudes see both behavioural control and normative pressure above their behaviour will enable them to adopt a strong intention to change their behaviour. ( Fishbein and Ajzen 1975)
The belief system will have effect on the person's self concept for taking such an action will all be considered by the person. This is because self concept links to the beliefs system indicating how people develop broad analysis about themselves. This includes their temperament, attitudes, abilities and beliefs. This is related to how people say and do and the way they understand feedbacks given to them by others (Plummer, 2005). This belief system will not only affect the person's self concept only but also on the self efficacy. This is described by the social cognitive theorist (Bandura, 1997) as one's ability to carry out a task in a way that will lead to a particular goal.
Powell (2005) said that people build up self esteem as they grow older. Hence, self esteem is described as how people feel or perceive themselves which includes their way of looking, abilities to do things and relationships with others (Powell, 2005). Therefore, people with a high self esteem perceive and belief themselves to be important, worthy and feeling good about themselves with a positive self appraisal as stated by (Kasser, 2002).
On the side of the story, how people feel about themselves can lead to poor coping of such demand. This is because (Kaaser, 2002) states that people with a low self esteem feel being unwanted, unloved, worthless, neglected and belittled.
Furthermore, because Jojo is aware that he is overweight and in the position to change to a healthier lifestyle, his attitude towards that will lead to a strong emotional state that will empower him to adapt to that change as well as coming with a positive outcome.
In Jojo's case,
It is suggested that people who have a strong and a permanent objective to change to a particular behaviour are motivated to take actions based on their intentions to do so. On the other hand, it was also manifested that though some individuals are extremely serious to change their behaviour, their intention to do so are not that strong to enable them fulfil that action. This is because for any action to be fulfilled, other factors act in association with it such as beliefs and poor emotional state which always make it difficult for some people to achieve the targeted action (Ajzen, 2005).
Since Jojo is obese and is highly motivated to lose weight, the intention to do so must be in the form of meticulous information of how to put that intended action into practice. For example, the planning of this should include how to go about it like when to exercise or the quantity of food to be eaten daily and the variety. Other intended actions to be taken include walking to school instead of taking the bus. This on the other side will take time for him to get there thereby leading to a poor emotional state which will drive him to get the bus if his intentions are not strong to act on the targeted actions.
The community and societal norms also play a major role in shaping the behaviour of people as well as having influence on them especially by those around them such as families, peers and friends. This is because (Anderson, 2004) said that community norms act as persuasive principles that show the actual things to and not to be done by the individuals which influences people's health leading to a behaviour change. Social norms on the other side as stated by (Shanrma and Malhotra, 2007) helps people to know what acceptable and abnormal behaviours are. This is based an agreed behaviours established by members of that society acting as a strong influence on their social behaviour.
Further to this, the theory of planned behaviour suggest that the intention of a person to act on his or her behaviour depends on normative system or beliefs which comprises of peers, parents, societal norms and close friends. Hence, the person wanting to change his or her behaviour will have to belief that these groups of people will agree or disagree with the intended behaviour to be carried out (Ajzen, 2005). It is this group of people which are normally refer to as behaviour change agents. Nevertheless, Tone and Tilford (2001), assertion that the way people view the national norms and their motivation in order to act to these norms will be less likely to be important than the norms or practice of their community and the associate motivation to comply to it.
Unequivocally, for Jojo to take up this action, his mother acting as an agent can help persuade him to take up that action regardless of its side effect such as drive, where he will be feeling hungry and will be tempted to eat more to satisfy himself. His peers on the other hand of the story, because Jojo is being bullied by them because he is overweight, that alone will make him feel that he is overweight, which will intend motivate him to change his eating habit leading to a high self efficacy. According to ................., those with a high self efficacy are capable of performing a given task such as exercising; dog walking, going to the gym and eating healthily in order to lose weight. However, those with a low self efficacy will be persuade not to take up that action because they feel they cannot make it and do not have the confidence to go about it. This will also lead to a low self esteem which is where that fellow sees or value him or herself to be.
That is to be responsible for own feelings or emotions by own values about the self in order to carry out a particular task (Green and Tones, 2010). This could also be linked to the theory of planned behaviour developed by (Fishbein and Ajzen 1975) in association with HAM for behavioural change.
On the other side of the story, families, peers, friends and other networks also act as a strong influence on the normative system.
MANAGEMENT AND INTERVENTIONS OF OBESITY
Various methods and interventions are being used to manage obesity in children. Goldfield and Epstein (2002) said that parents can be used as agents in tackling behaviour change in children. This is because it increases the chances of changing the environment as well as providing them with the necessary supports. This can also be termed as stimulus control whereby parents will be persuaded not to bring such food stuff into the house like foods high in fat or energy dense foods. This will not only help the child that they are trying to change his or her behaviour but also the other family members (Goldfield and Epstein, 2002).
Nevertheless, adaptation of dietary intake, increasing physical activities and time spent on inactive behaviour should be reduced which will help prevent individuals from becoming overweight. More so, the amount of time spent watching television should be monitored and parents should see to it that they do not allow their children spend much time watching television as said by (McLennan, 2004).
The ideas of (McLennan, 2004) can be supported by the view of (Rippe and Hess, 1998). Rippe and Hess (1998) said that physical activity plays a major role in the maintenance of the body including achieving good energy balance that is required to stop obesity. However, during physical activities, energy is spent. Hence, several studies have indicated that a good healthy diet combined with increasing physical activity is mainly the successful interventions that can help with weight loss and maintenance (Rippe and Hess, 1998).
Plourde (2006) argued that family physicians also play a major role in the management of childhood obesity as well as the community and not the burdens of the family alone. However, in order to prevent or treat obesity in children, different interventions should be used focusing on physical activity, nutrition, behaviour change and decreasing the amount of time spent watching television. This was however concluded by saying that the only best mean of managing childhood obesity is counselling the families about changing of behaviour.
On the other hand (Serban and Brunard, 2003) state that the target of the primary prevention of obesity should not only include losing of weight and the limitation of diet but also aimed at a long term body mass index curve. The aim of the prevention should include consideration of the family and social environmental conditions, promotion of healthy eating adapted to child growth, increase in physical activity as well as management of this childhood obesity should be within the normal life circumstances.
Berry et al. (2004) based their research on articles published between 1980 and 2004 using three different databases namely MEDLINE, PSYCLIT, and CINAHL. This was used to evaluate the interventions of the family as an agent in treating childhood obesity using 13 different studies altogether. The interventions used include behavioural interventions such as behavioural therapy and modification, exercise and nutrition education. Each of these interventions was used to access the involvement of parents. Behavioural change interventions and behavioural therapy were aimed at both parents with their children separated or together, a good outcome was achieved helping with weight loss in both parent and their children. When the problem solving interventions was used, aimed at parents of these children, an outcome of weight improvement was achieved. Surprisingly, this on the other hand did not bring about any weight improvement when the same problem solving behavioural interventions was used in both parents and their children separated or together (Berry et al., 2004).
Fox et al. (2009) argued that a non medical intervention such as lifestyle and school based interventions which are primary prevention of obesity is of a great advantage to the whole community and not the child only. This will also help reduce the amount of money spent on health care in tackling obesity as well as recuperating the health of the nation in the future.
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