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Schaller and James (2005) stated that good quality dietary habit is a fundamental factor for optimum wellbeing, while nutrition is a very crucial factor in promoting good health and disease eradication (Mowe et al ., 2008). Acquiring facts about nutrition is very crucial but not adequate for dietary transformation (Hendrie et al., 2008). This was related by Bandura (1986) that behavioural change is influenced by so many factors among which is knowledge that necessitated its exploration in terms of its influence on people's dietary activities. Axelson and Brinberg (1992) also assumed that acquiring an education in nutrition which is tantamount to enhancing once nutritional knowledge can also have an influence on human behaviour.
One of the most essential approach in which the health care labour force is structured is through their learning programme (Morison et al., 2010). This establishes the proficiency, outlook and information they require to maintain their position as an expert in their field. To establish a high profile of whichever area of medical practice like nursing it is paramount that proper acknowledgment is given to their programme of instructions in schools so as to ensure that at every stage of their degree nursing student and nurses are well groomed to face the challenges of nutrition in the patient they handle (Morison et al., 2010). Age Concern (2006) also confirmed that there is an indication to recommend that pre-qualification health care training needs to be put in place to ensure influx of students into health care profession.
Definition of Health
It is very crucial to start this literature review by stating the definition of health, because it was confirmed from various literature sources that different explanation and views is given to this concept (Ewles and Simnett,2003; Naidoo and Wills, 2009). In this literature review the significance of health will be thoroughly examined to generate accurate perception of the concept. For proper insight into what health is all about pertaining to this study, its definition will be viewed from the lay people's perspective. The outlook people give to health is transferred from one generation to another, which made peoples belief about health to be embedded into the people's cultural norms (Robertson, 1989). It was related by Downie et al. (1997) that people embrace an uncomplicated opinion about their health as well as other peoples well being which does not give a straightforward definition by everybody. This was argued by Mclaren et al (2000) that a 'common sense' insight to wellbeing is never obvious, but is actually a multifaceted issue. Ewles and Simnett (2003) related that health could simply mean "not being ill", which confirms the conceptualisation of the lay peoples perspective of referring to health as not being ill, but shaped by their understanding, experiences, and opportunities in life (Cox et al ., 1997).
Health was also considered by Ewles and Simnett (2003) as the absence of disease or illness, which is improved by an encouraging analysis of health as a state of well-being, and could also be viewed by health practitioners from the objective perspective as liberty from medically defined ailment and disability. This must be able to face criticism and thorough analysis from people, and must reveal an encouraging health, that involves empowerment and full management of one's life (Downie et al., 1997).
Health practitioners and intellectuals are often more at ease with renowned definition of health such as the WHO (1946; 2006) definition of health which is stated below as:
"......a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity"(WHO, 1946; 2006).
This contested definition was viewed by a lot of people as a desire, .i.e. an interpretation of health that is unattainable because of its nature. This definition of health has broadened the scope of health further from the absence of disease to embrace positive wellbeing and strongly admitting its comprehensive holistic nature (Green and Tones, 2010). The bio psychosocial model of health that was proposed by Engel (1977) also suggested that emphasis is not only placed on the biological signs and symptoms, but also on peoples' psychological state and their social factors that is interactions with the family and the community at large. This paradigm brought about another definition of health stating that
"Health is a dynamic subjective concept which is influenced by an array of factors" (Daly et al., 2002, p.37).
It was argued by (Saracci, 1997) that the definitions of health, like that of the WHO definition basically link health with joy, which makes the restrictions to health endless, and turning various inconveniences to become a health problems. This led to an impending unrestricted claim for health care facilities (Green and Tones, 2010).
Acknowledging the boundaries of the original definition of health, the WHO modified it in 1986 to recognize the fact that:
"Health is therefore seen as a resource for everyday life, not the objective for living: it is a positive concept emphasising social and personal resources, as well as physical capabilities" (WHO, 1986).
The above definition is supported by Seedhouse (1986), where he confirmed that acknowledging personal improvement, fulfilment of indispensable requirements and the ability to acclimatize to new surroundings are essential factors for health determinant. He also argued that health is not a permanent condition that one should desire; rather health is a means to an end, which was disagreed by (Naidoo and Wills, 2009) where they stated that health might not be a permanent state but neither is it a means to an end, but to a certain extent it is a necessity brought into limelight by the social and environmental factors which is outside the power of an individual. Despite all the criticisms of the WHO definition of health, this definition is still of great importance today and health is viewed by the organisation from the holistic point of view, which means an individual physical, mental, social, sexual, spiritual, and emotional desires, is being influenced by the peoples cultural environment (Naidoo and Wills, 2009).
Therefore it was concluded that enhancing the health of people and the communities requires more effort than just avoiding and treating disease. It is more of a progression towards uninterrupted adaptation compared to realization of a static condition. Finally, for the purpose of this study, health will be viewed from the holistic perspective angle. This put into consideration the social, economic, physical, cultural and environmental factors that are meant to be beyond human control in determining their health conditions (DHSSPS, 2002).
Health Promotion and Health Promotion Model
Health promotion is an extensively challenged concept, which is used in numerous ways by diverse people and establishment (Tones, 2001). Promoting health is a complex issue just like defining health is not a simple issue pertaining to its definition and implementation (Edmondson and Kelleher, 2000). According to Fleming (2007), he agreed that health promotion originated from health models that is the medical or the social model, which is all about health conceptualisation in the context of whether it is positive or negative. That is healthy living and absence of disease respectively (Wills and Douglas, 2008). The phrase health promotion is a new development, and is usually sighted as a way of empowering and enabling the public to be in command of their individual health and safety (Green and Tones, 2010). This was supported by Ewles and Simnett (2003) where they consider health promotion as the process of "improving health by progressing, supporting, encouraging and putting it on the public schema". Health promotion was differentiated from prevention of disease by Nutbeam (1986) where he stated that they are separate entity but complement themselves in the way their activities are being performed. He later argued that there is just a minute change in re-orientating health forces from the idea of chronic and severe ailment towards initialising expertise and empowerment in health promotion (Nutbeam, 2008). The repeatedly quoted definition of health promotion is stated as
"the process of enabling people to increase control over and to improve their
health" (WHO, 1986).
This describes both the behavioural and the socio-environmental perception which utilize a broad set of approach. It encompasses the individuals' action, the community, community groups, formal settings that include schools, places of work, and government at various levels. This acknowledges the fact that human health can be manipulated easily by decisions taken by other people in our absence; by involving communities in those decisions to augment and to prevent any harm whatsoever to health (Schou and Locker, 2002).
This contemporary health promotion materialized out of the need for a basic transformation in the approach to improve health and lessen health inequalities (Ashton and Seymour, 1990). The Ottawa charter (WHO, 1986) that was promulgated for health promotion helped to identify five action areas that were peculiar for the health promotion advancement. These include Building healthy public policy, creating supportive environments, strengthen community action, developing personal skills, and reorienting health services (WHO, 1986). All these areas made provision for different scope of conducts that health promotion is engulf in. It was stated by Orme et al. (2007) that for the fact that health promotion as brought a wealth of knowledge in its multi-faceted practice to advancement in health and well being by extending their scope beyond the biomedical approach, there is still more to be realised from the foundation of the Ottawa Charter which is empowerment.
Empowerment is analysed by some authors as an element which make a distinction between health promotion and other public and community health communication (Ridde, 2007), while some other authors like (Wills et al., 2008; Wise, 2008) declared that the target of health promotion to lessen the space in health standard of minority groups makes it differ from public health. Health inequalities was said to be the outcome of societal and political organization (Ridde, 2007) and so far the health structures is part of health determinant (Danzon, 2009), it is very important that attention is given to the health system as well as the view of people that use the system. Since public infirmity cannot be alleviated by improved National health system, as stated by (Bambra et al., 2005), this must be the foundation on which health promotion must lay their plan ,so far health care is meant to be an individual right.
The task in health promotion is on individuals, society, health practitioners, health care provider and the governments at large. Health promotion currently laid much emphasis on planning, legislative controls, as identified by community members (Milio, 1986). Collaboration of these sectors can bring about fairness in health by maximizing everyone chance of being healthy, but regrettably, this can elevate the political, ethical and moral problem associated to being healthy, if resources allocated for programmes are not utilised judiciously on those activities that will make great impact on the populace (Humphris and Ling, 2000).
Politics of Health Promotion
Most writer have illustrated different ways by which health promotion have being confounded with the term public health traditions, but (Ridde, 2007) advocated for its revitalization in confronting the social inequalities in health. It was also identified by (Scott-Samuel and Springett, 2007) that the basis of health promotion principles include empowerment, involvement, enablement and social fairness, in which the introduction of social fairness brought about its being politicised. Referring to health promotion as a political or social group is an elongation of its value in the sight of the government (Raphael, 2008). On the other hand health is categorised as not being politically inclined considering its promotion in all political campaign, which was supported by Bamara et al. (2005) where he confirmed that all health organisation her controlled by the people in authority.
Health Promotion Approaches and Models
Health promotion practice can come in different forms, considering the location of the activity and the predisposition of the health promoter alongside the skills to be dissipated.
To achieve an optimum health promotion practice, a framework of approaches to health education practice was developed by Ewles and Simnett in 1985 and re-examined in 2003 to create five approaches to health promotion. These include the medical, behavioural change, educational, empowerment and the societal change. Since all these approach have their strengths and limitations, a blend of all the approaches may produce a good result during health promotion, but it was criticised that this framework does not recognize how changes occur in people's way of life (Jones and Naidoo, 1997).
Scott-Samuel and Wills (2007) also compared the contemporary health promotion approach to a 'corpse' and a kind of misplaced discipline which brought a limelight into health promotion in relation to the less privileged admitted into an health institution.
To ensure good practice a model that will provide a theoretical framework which helps one to display how things are related to one another must be employ to bring about new theoretical approaches.
It was related that Tones and Tilford (1994) model try to express the link between health education, achievement of health, and empowerment. If inability is a major risk factor for ailment and poor health (Wallerstein, 1992), this could make people in the lower socioeconomic position more prone to increased death and morbidity rates (Macintyre, 1986). Therefore, it involves a lot of dedication that include to be well informed to make correct and an empowered option, but this can only come to reality when the societal and the environmental factors are put into consideration.
Beattle (1991) also brought into limelight a model of health promotion that endeavour to connect health promotion approaches to political and social organization. This model is useful when attempting to balance social ethics, no matter whether the approach is reliable or negotiable, individual or combined (Beattle, 1993). Beattle model have been used on several occasion in addressing the setting approach to health promotion in colleges of higher education (O'Donnell and Gray, 1993) and also modified for use in the nursing contexts (Twinn, 1991).It was discovered that it can only be applied as a tool, and not as a guide to action, and also that some strategy may not fit into a definite quadrant which might result into an overlap.
The Health Belief Model (HBM) (Rosenstock et al., 1988) (Appendix) also made provision for an exact way of accepting and organizing personal beliefs that are significant to health behaviour. Gillam (1991) stated that the HBM has been used to predict protective health behaviour, when health practitioners advice patient. It is understood from the perspective of the HBM that a person can indulge in a health behaviour pertaining to how they feel about the susceptibility to the disease, if it is apparent that the ailment is severe, also if they are informed of the consequences and they believe that their deed can help to conquer the ailment.
In additional to this model is the "cues to action" which demonstrate a situation that a person is likely to take a defensive action if he is well informed about a probable health problem. This may come in form of a counsel from a health practitioner like nurses whose proficiency is valued and reliable (Rosenstock et al., 1988).
Humphris and Ling (2000) stated that one of the downside of this model is that it emphasized too much on ailment rather than on the behaviour of people involved in the action of getting the disease, which he attempt to predict. He also mentioned that behaviour is formed by external forces and individual factors such as emotional feelings and not just through the economic evaluation of the problem. It was supported by Conner and Norman (1995) that the HBM made use of an emotional construct that is reasonable and is a very good framework in health promotion.
This Health belief model is quite appropriate for this study because it tries to appreciate the problem underlying human actions, which is based on the fact that a sense of susceptibility to disease incites human behaviour (Rosenstock et al., 1988).
A different model was presented by (Ajzen and Fishbein, 1980) which is the Theory of Reasoned Action (TRA). This model is meant to predict behaviour which makes use of the beliefs held by an individual. TRA incorporate only the beliefs about an intended behaviour compared to HBM that deliberate more on beliefs about disease alone. Therefore, Baranowski (1990) concluded that to have an intention to execute a health related behaviour does not predict that the action will take place, especially if there are obstacles on its part. There was an introduction of an additional variable to the Theory of Planned behaviour that explained the gap between intention and behaviour, which is perceived behavioural control (Ajzen, 1991). This shows how determined an individual that is the nurse is motivated to be in preparation to transform her behaviour. Conner and Armitage (1998) condemned the model for failing to embrace variable like self uniqueness, self-efficacy, past deeds, affective response and decent judgement.
Definition of Nutrition
Potter (2008) stated that Nutrition is a foundation of excellent recuperation from sickness which could cause a hindrance if patient diets are not well catered for. This could result into patient being underfed, which could delay their recuperation. Amarantos et al. (2001) also stated that nutrition could be mainly defined within the medical concept by putting into consideration the patient dietary, biochemical and medical signs. This was also confirmed by Amarantos et al. (2000) that the dietary intake of patient can be associated with their sensory, emotional and societal facet of life. Blades (2000) confirmed that satisfactory nutrition is not all about healthy food but is more associated to the psychological well being of the patient in question. He also stated that since the period of serving food and feeding the patient is a very crucial part of admission into a hospital, it could also inspire happiness and contentment, which signifies a crucial stage in caring for patient.
Amarantos et al. (2001:55) declared that hospital food is quite essential that it provide protection and good organization to patient hospital stay. He also confirmed that they may instill the indispose person with thoughts of being familiar with his environment, autonomy, privilege and wisdom of making choices of different varieties food
Nutritional support is said to be categorised as one in which reduced attention is given to during healing management and assessment in a hospital setting (Morley, 1991; Mowe et al., 2006). Even though there are numerous procedures which promote the use of systematic nutritional screening but this has not yet being implemented globally (Elia et al., 2005).
Nutrition education and training among Nurses
The declarations concerning the accountability of nurses for nutritional care refer to all sick individual no matter their age (Morison, 2010). This was confirmed by the United Kingdom Central Council for Nursing, Midwifery and Health Visitors (UKCC) (1997) that it is the duty of the nurses to ensure hospitalised patients eat a well nourished diet. This obligation also encompasses nutrition screening, scrutinizing patient nutritional status, supporting patient when eating and ensuring food is completed, recognition of patient that needs diet modification, and directing other health care practitioners to patients' nutritional care (RCP, 2002). The Nursing and Midwifery council (NMC) has also created an 'Essential Skills Clusters' which are declaration laid down under several broad titles that harmonise some of the NMC outcome and expertises limited around the Standards of proficiency for pre-registration nursing education (Morison, 2010).
Poor Educational Training
An obstacle to successful dietary care to patient is deprived educational training with regard to nutritional knowledge among all nurses and other health care staff (Morison et al., 2010). It was also stated by Beck et al. (2001) that general practitioner as well as nurses education is deprived of nutrition courses and training which made the lesson they receive to have fallen below the standard of the new development in dietary research.
Beck et al.(2001:457) declared that nutritional care meant more than weight management and giving food to patient, it involves more of enlightening the patient, organizing the patient, fascinating the patient, encouraging the patient to eat and some all other ways of showing concern. He also likened the food culture among all hospital staff to the term food chain to exhibit the fact that nutrition begins from food preparation and menu variety, to clinical as well as nursing care (Beck et al., 2001).
Newton et al. (2004a) claimed that research is all about making enquiry through questioning and getting the result. The type of the question posed will establish the research method that is suitable, the kind of information and statistics that must be used, and the conclusion that need to be derived from the final outcome (Newton et al., 2004b). To make an accurate choice of methodology, the aims and objectives of the research during the first phase must be well examined (Williams et al., 2004a).
The aim of this study is to explore student nurses' general knowledge about nutrition. The objectives were defined as:
To explore student nurses level of knowledge about nutrition.
To establish the level of awareness of nutrition among student nurses and whether or not they use this knowledge when caring for patients.
A quantitative design approach will be employed by the researcher because she felt it is the most suitable method of data collection to achieve the study aims and objectives. Nutrition knowledge will be assessed using a validated common nutrition knowledge questionnaire (Parmenter and Wardle, 1999; Hendrie et al., 2008). The validity and reliability of the questionnaire was recognized by the original authors' Parmenter and Wardle (1999), where the construct and the content validity were ascertained and the reliability of the nutrition knowledge test gave an excellent result that ranges from 0.7-0.97. This was verified by the use of a standardised Cronbach's alpha coefficient.
Quantitative research methods is said to be suitable when accessing a typical populace, or when one is testing an hypothesis, but the facts gather may give minute insight into understanding the depth of the research, while qualitative research could widen the scope of what is being studied which could unfortunately not be attributed to the entire population (Parahoo, 2006; Stewart et al., 2008).
In research, two main concepts are acknowledged. Primarily the positivist concepts that recommend the accuracy of a study materializes from the observation and the measures taken during a research ,which is sometimes refer to as an experiential method (Topping, 2006.p.157), clarified that there is a fundamental statement:
"...that the world is stable and predictable, and phenomena can be measured empirically".
This opinion brought about the values of quantitative research. This was supported by Parahoo (2006) when he depicted that quantitative research originated from positivism, with the idea emerging from:
"...a philosophical paradigm which views human phenomena as being amenable to objective study, in particular, to measurement." (p.48)
Parahoo went ahead with his statement by confirming that the principle behind a quantitative research is to determine the people's perception accurately and to employ suitable statistical analysis to explore variable relationship. Parahoo (2006) and McColl and Thomas (2000) professed that a primary tool for carry out a quantitative research is the use of a suitable questionnaire to gather the information needed. It was pointed out by Denscombe (2003) that the use of questionnaires in data collection is predominantly prolific that is:
When the information sourced is simple and not contentious.
When an already validated questionnaire is used,
When the respondent is given the opportunity to answer the question using his or her own idea
When the subject is able to comprehend all the question asked
When a huge number of respondent are sourced from different areas
Also Denscombe (2003) added that questionnaires usage have the following advantages which are as follows: They are economical
They are straightforward in arranging compared to several personal interviews
Finally data collation and its pre-coding make analysis easier and faster.
For the fact that there are a lot of advantages associated to questionnaire usage the researcher decided to use a validated questionnaire for her study. Though there are a lot of advantages linked to questionnaire usage, it still have some disadvantages which were pointed out by Parahoo (2006), Denscombe (2003), and De Vaus (2002). These are as follows:
Reluctance in answering the questions willing
Partially completed answers
Very complex to detect whether the respondent is sincere in tackling the questions
Bias might come up from the researcher end which may limit the form of the answer options