Concepts of health promotion

Before we discuss how different concepts and theories can be used to promote health, nurses need to know what the term “health promotion” means. An authoritative definition of health promotion comes from the W.H.O which defines it as “the process of enabling people to increase control over, and to improve their health”. (W.H.O 1986). Health education is considered the core component of health promotion. Until the mid 1980’s the term “health education” was most widely used to describe the work of practitioners such as nurses and doctors in promoting health. Health promotion is putting education into action. With evidence based information, the patient is more likely to comply with a treatment regime if she understands the regime, the reasoning behind it and is given the tools to achieve it. (McDonald et al 1999).

Models are useful tools in Health promotion because it helps to visualize and to test theories. It helps to lend support for or against theories, explaining phenomena and plan possibilities for interventions. Beattie 1991 is a model that offers a structural analysis of the health promotion repertoire of approaches and this model will be the framework of this essay bringing in psychosocial models. His typology argues that there are 4 strategies for health promotion. Health persuasion by health care professionals, legislative action, personal counselling and community development.

The Legislative Action part of Beattie’s model are interventions led by professionals but intended to protect communities such as lobbying for a ban on tobacco advertising. The nurse is in the role of “custodian” knowing what will improve the people’s health and to protect the population by making healthier choices more available. Staying in the legislative perspective, the nurse as a health educator or promoter must also always adhere to the NMC code of conduct. This code dictates accountability and advocacy for vulnerable clients and in this essay it is emphasised that a person with health behaviour is a vulnerable. Other aspects of legislation that we are duty bound to is the European policy framework, the “Health 21 targets”. This was introduced to achieve full health potential for all people in the region and this world health document emphasises the date and time when damaging health behaviour have to be eradicated. Another legislation is the Patient Charter which involves the patient in their health education/promotion plan. It is vital for the nurse to work out where the patient is with regards to changing the behaviour and therefore work at the patients pace.

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In order to demonstrate a clear knowledge of health education and promotion, a scenario will be applied. Mrs Smith (pseudonym name) in compliance with the NMC (2008) on confidentiality, a 55 year old housewife who has been admitted in the casualty department after an episode of severe chest pain and a degree of dyspnoea which has already lasted for 2 hours. She has been otherwise well, but at 110kg and 5″4 she is clearly overweight. She has been a smoker for 30 year. Her initial assessment shows that the pain is not cardiac and a working diagnosis of acute reflux oesophagitis is made. Routine screening has shown that she has a random blood sugar of 18mmol/L.Although there are several health issues highlighted in this case, this essay will focus on Mrs Smith’s predisposition to Type 2 diabetes mellitus due to her obesity. Factors including weight loss and how much she is in control over her blood sugar levels in the long term (Stratton et al 2000) can determine the eventual outcome. Therefore, the main health promotion activity relating to her is giving her advice on weight reduction to improve her diabetic control (Terry et al 2003).

In order to work out the stage of change Mrs Smith is in, the nurse has to carry out personal counselling with the patient. This is another strategy of Beattie’s model. Here Beattie focuses on the patients’ personal development and to encourage the patient to have the skills and confidence to take more control over their health. Personal counselling focuses on the client’s specific needs and normally works on one to one basis and the nurse acts as a counsellor to discuss and negotiate client needs. Decisions are made based on the client’s wishes. The client needs to be assessed by Maslow’s hierarchy of needs. Abraham Maslow’s model indicates that basic, low-level needs such as safety must be satisfied before higher-level needs such as self-fulfilment are achieved. While a person is motivated to fulfil these basal desires, they continue to move toward growth, and eventually self-actualization. An interview is done at this stage of Beattie using a client centred approach. The patient needs to be physically and psychologically comfortable in order to assess how motivated they are and what stage of change they are at. It is the nurse’s role to persuade or encourage people to adopt healthier lifestyles here, educating the patient with evidence based information to give them full understanding of their unhealthy behaviour and the results of it. Therefore advice and information from the nurse is the main features in Beattie’s health persuasion strategy.

A relevant model to this part of Beattie is the work of Prochaska and DiClemente (1984, 1986) in developing the stage of change model. This framework can be used to describe the different phases that individuals’ progress through during health related behaviour change. It focuses on the individual’s readiness to change or attempt to change towards healthy behaviours and encourages change in addictive behaviours. Although the model can be used in addictive behaviours, it can be used to show that most people go through a number of stages when trying to change behaviours. The model is important in showing that any transition we make is not final but part of an ongoing cycle. The model shows 5 stages the patient goes through. They can start from the pre-contemplation stage where the patient has not yet considered changing their lifestyle, possibly from the lack of awareness of any risks in their health behaviour. Identifying this stage is important because it allows the nurse to realise that the patient may not be ready to undergo any change. This may mean the healthcare worker should focus on other issues. Once the patient is aware of the problems, she can then proceed to the contemplation stage. At this stage the patient is aware of the benefits of changing but is not ready to do so and needs information and support to help make that decision. It is the nurse’s role to provide the patient with evidence based information to encourage them to change. For some, this stage may last only a short period whilst some may never progress beyond this stage. A nurse must work at the patients pace and only move on when the patient is ready to proceed to the next stage. When the change seems possible and worthwhile to the patient, they may be ready to change, perhaps seeking for some extra support. At this stage, the patient should be motivated and ready for the stage of ‘making the change’. The patient should be given a clear goal along with a realistic plan and support at this stage. The early days of change needs the patient to have positive decisions to do things differently. If the patient manages to make the change of her lifestyle with the nurse’s support then the patient falls into the final stage of the model – Maintenance. At this stage the patient is to have moved into a healthier lifestyle and sustained her new behaviour. In order to analyse how effective this strategy is for the patient, the progress needs to be reviewed and assessed.

This stage’s of change model is different to other concepts in that it is about how people’s behaviour change and not why people do not change. The advantage of this model is that if any patient relapse’s back to previous stages, it is not considered to be a failure because she can go backwards and forwards through the cycles of change. The patient would still be aware of the benefits of changing and nurses only have to focus on small things to encourage them to proceed to the next stage once again. This can be rewarding to the patient as there is identifiable progress.

Most health behaviour models are related to self-efficacy where it involves how one person believes they are capable to attain certain goals by possibly having the feeling of self worth and being optimistic, resulting in motivation to change. Not only does self efficacy influence the challenges the patient chooses but it also affects how high standard they set their goals. Individuals with a strong self-efficacy select more challenging goals (DeVellis & DeVellis, 2000 xClose

DeVellis, B. M., & DeVellis, R. F. (2000). Self-efficacy and health. In: A. Baum, T. A. Revenson, & J. E. Singer (Eds.), Handbook of Health Psychology (pp. 235-247). Mahwah, NJ: Erlbaum. ) than people with a weaker self efficacy. In relation to the case study, if Mrs Smith had a strong sense of self efficacy then she may result in adherence to a particular diet whereas if she had a weaker sense of self efficacy she will become discouraged and give up. Self efficacy is therefore directly related to the future behaviour and must be taken into account when assessing the patient.

Continuing on to the next strategy of Beattie’s model, Community development is similar to personal counselling. The nurse tries to emancipate groups and communities so they recognize what they have in common and how social factors can influence their lives. Here patients should be given statutory support as well as voluntary support. In Mrs Smith’s case, her health would more than likely be improved if she lost weight. Ideally she could aim for a BMI in the region of 24-25, but this is seldom achieved in practice, but it is none the less a goal. (NICE 2000). Staff in primary care or the integrated diabetic clinic will probably be responsible for producing a full evaluation and implementation of Mrs Smith’s condition. A smoking cessation nurse could also be useful in helping Mrs Smith quit smoking improving her overall health. Offering the patient statutory support means she will further understand the whole regime and feel more comfortable, resulting in compliance. Voluntary support can also be offered to the patient. An example would be Weight Watchers for Mrs Smith to assist her with weight loss and maintenance, offering her various dieting products and services.

The four paradigms for health promotion by Beattie is useful for health promoters because it identifies a clear framework for choosing a strategy, and it reminds them that the choice of these is influenced by social and political perspectives. However, as this model deals with information, education, legislation, psychological and social factors as strategies in achieving help, it has been criticised. Some argue that health has other dimensions not considered including physical, mental, spiritual and environmental that is essential for total health and well-being. Health behaviour models are there for nurses to use to motivate patients to change and make nurses aware of the barriers present. However, the nurse must always accept the work with the patient at their stage. By building a therapeutic relationship and working in partnership with the patient, it allows nurses to give the support the patient needs whilst enabling the client to make choices for themselves. The nurse needs to be aware of their communication skills such as using open questions, listening and encouraging, clarifying and summarizing and showing reflective listening. The goals set for the patient must be realistic, desirable and the nurse must help the patient to believe that they can achieve goals, praise and reinforce positive behaviour and provide emotional support. The nurse must continue to be accountable and continue using evidence based practice.