Health Promotion for Nurses

Theory and Practice

Stewart Piper

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781135267131
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Health promotion is an increasingly high profile aspect of a nurse's role – both in line with health policy and as nursing has shifted from a disease model to a health model. This textbook explores how and why health promotion works in nursing, developing a new framework for understanding the nurse's role and promoting evidence-based practice.

Drawing on empirical research and discussing existing theories of health promotion and of nursing, Stewart Piper identifies three principal approaches:

• The Nurse as Behaviour Change Agent
• The Nurse as Strategic Practitioner
• The Nurse as Empowerment Facilitator

The book describes the aims, processes, impact and outcomes of health promotion interventions in nursing for each of these models and identifies criteria for evaluating the associated nursing interventions – enabling clinical judgements about effective practice.

Evidence-based examples demonstrate the relationship between health promotion theory and pragmatic applications for nursing throughout. Each chapter includes an introduction, learning outcomes and exercises, making this an essential book for all nursing students studying health promotion.

PART 1

THEORY

1
CONCEPT ANALYSIS AND THE LANGUAGE OF THEORY AND PRACTICE

INTRODUCTION

Consistent with the absence of consensus over a unifying framework for classifying health promotion theory and practice, there has also been considerable debate over the demarcation points and meaning given to health, health education and health promotion. Over the years attempts have been made to settle the theoretical disputes regarding the convergence and divergence between the latter two in particular and to define these concepts (for example, the UK Ministry of Health 1964; Keyes 1972; Anderson 1984; Fisher et al. 1986; Tones and Tilford 1994; Naidoo and Wills 2000; Tones and Tilford 2001; Tones 2001; Tones and Green 2004). However, it has not been a straightforward process. For example, Cribb (1993) found health promotion confusing because of the apparent lack of boundaries and Tannahill (1985) felt that because health education was used in different ways it was a meaningless concept. Thus, both the general and the nursing literature have found health promotion to be a contested and, at times, an ill-defined concept. Some of the definitions represent little more than broad generalisation and some authors fail to set conceptual boundaries and imply that health promotion is any activity that improves health.

Whereas for Cribb and Duncan (2001) this lack of clarity and convergence over the definition of health education and health promotion persists, for Bunton and Macdonald (2002) and Whitehead (2007a) there has been movement toward a consensus over the meaning of health promotion. These conceptual disputes have been compounded by the introduction of competing contemporary terminology, such as health development/improvement and a widening of the definition of public health. In addition, Piper (2004, 2008), when researching the meaning nurses gave to health education and health promotion and how these fitted with existing language, theory and practice, found the understanding and definition of the concepts by participants were inconsistent with the mainstream literature and contemporary health and social policy. They reflected a more traditional understanding of the term; thus lacking a modern feel and any socio-political role was overlooked.

Hence, it is important for the purpose of clarification to explore the meaning of these concepts in the general and nursing literature and policy documents, to give a flavour of their chronological development and consider these in relation to the concept of nursing theory and philosophies to identify their relationship. For Berg and Sarvimäki (2003), vague conceptualisation and the lack of a distinctive health promotion nursing focus means that such an exercise is required.

The identification of what constitutes a health promoting nurse and what this means for practice (Robinson and Hill 1998) for this book starts here. This chapter, taking and developing work from Piper’s (2004) unpublished study, defines health education and health promotion (including primary, secondary, tertiary and quaternary)and the related concepts of health, public health, health development and health improvement. The intention is not to provide an exhaustive critique of these concepts, as topics of this magnitude require broad academic debate to do them justice, but to outline the basic connections between them, and place in context the language of theory, policy, debate and practice for nursing.

LEARNING OUTCOMES

By reading this chapter, and completing the learning triggers at the end, the reader should have a better critical understanding of:

• health as a contested concept;
• the relationship between disease and illness;
• the concept of health education;
• the concept of health promotion;
• the relationship between health education and health promotion;
• the relationship between health education, health promotion and nursing;
• primary, secondary and tertiary health promotion;
• the relationship between health promotion and nurse education;
• the concepts of public health, health development and health improvement.

HEALTH

Health is a contested concept. In other words, as Ewles and Simnett (1999) point out, it is different for different people and may be viewed on a continuum of subjective perceptions. These range from health being perceived as an absence of illness (medical model negative conception of health (Naidoo and Wills 2000)); having a strong constitution with the ability to fight off infection and disease; to positive expressions of mental health such as having a high self-esteem and feeling empowered. Illness is also a subjective experience, i.e. how a person feels and the signs and symptoms may be scientifically validated as disease (feels ill, has disease) by objective medical diagnosis, or disease status may be denied (no disease diagnosed despite the subjective experience of feeling ill). Individuals may also feel well with or without disease (Box 1.1). Personal perceptions of health, illness and disease are influenced by such factors as social class, cultural experiences, age and gender. These factors, together with genetic predisposition, lifestyle and environment are also important determinants of mortality and morbidity with the quality of personal relationships and social networks (social capital) as possible additional contributory factors (Kawachi et al. 1997).

BOX 1.1 THE RELATIONSHIP BETWEEN DISEASE AND ILLNESS

• feels ill, disease objectively (i.e. medically by doctor, nurse, etc.) diagnosed;
• feels ill but no objective diagnosis;
• feels well but has undetected disease;
• feels well and no disease.

(Naidoo and Wills 2000)

The key elements of the WHO (1998a) definition from the 1948 constitution state that health is a holistic and multi-dimensional concept. It is more than simply the absence of disease and:

• has physical, social and mental dimensions;
• is a resource for individuals to lead a productive social and economic life, i.e. as Seedhouse (1986) puts it, health provides the foundations for achievement in life rather than being an end in itself.

The WHO Ottawa Charter (1986) highlights the relationship between socio-economic conditions, the environment and both health and health-related behaviour and contends that the following conditions (Box 1.2) need to be in place before health (and thus health education/promotion outcomes) can be attained.

HEALTH EDUCATION

In 1964, the UK Ministry of Health struggled with the meaning of health education and this set the tone for subsequent discussion. They concluded that its function was to promote mental and physical health through information and instruction and to persuade people to resist using glamorous health-damaging products. They identified four categories of health education as follows:

• specific action (for example, immunisation and vaccination);
• habit and attitude change (for example, healthy eating);
• education on the appropriate use of health services;
• support for community action (for example, clean air, fluoridation).

The latter contrasts with the WHO (1954, 1969) definitions, which more closely resemble the second and third of the Ministry of Health (1964) categories. In particular, emphasis was given to persuading individuals to take action and accept the responsibility for health improvement (WHO 1954) and later (WHO 1969) to improve their environment in line with priorities determined by health professionals.

BOX 1.2 WHO OTTAWA CHARTER (1986) PREREQUISITES FOR HEALTH

• peace;
• adequate economic resources;
• food and shelter;
• stable eco-system;
• sustainable resource use.

Despite the contested views, the general tenor of many of the definitions (for example, Griffiths 1972; Horner 1980; Baric 1982, 1985; WHO 1983; Tannahill 1985; Fisher et al. 1986; Nutbeam 1986; O’Donnell 1989; Downie at al. 1990; Tones 1990; Bunton and Macdonald 1992; WHO 1993; Naidoo and Wills 2000; Tones and Tilford 2001; Tones 2001) accord with the sub-themes of the Ministry of Health (1964). Health education aims to change beliefs, attitudes and health-related behaviour on risk factors and promote healthy lifestyles to prevent mortality and morbidity. For Baric (1982, 1985), Nutbeam (1986), Tones (1990), Bunton and Macdonald (1992) and Tones and Tilford (2001) the educational methods of health education aim to improve knowledge and understanding including on illness. Many of these interventions are based on the assumption that individuals are in a position to choose the healthy option (Minkler 1989) and reflect a top-down, expert-determined agenda where success is measured by compliance levels (Naidoo and Wills 2000). Health education is thus defined by Tones and Tilford (2001: 30) in a traditional and narrow educational way as:

any intentional activity that is designed to achieve health or illness related learning, i.e. some relatively permanent change in an individual’s capability or disposition. Effective health education may, thus, produce changes in knowledge and understanding or ways of thinking; it may influence or clarify values; it may bring about some shift in belief or attitude; it may facilitate the acquisition of skills; it may even effect changes in lifestyle or behaviour.

The limitations of this definition are acknowledged, with the literature including encouraging action on, or raising awareness about health and social policy, legislation and environmental factors and their impact on health as part of health education. It is also concerned to develop life-skills and clarify personal values (Tones 1990), equip people with the skills to manage health problems before seeking assistance from health services (Baric 1982, 1985) and to get people to use those services appropriately (Tones 1997).

For others (Griffiths 1972; WHO 1983), health education creates channels for the identification and expression of community needs or is a two-way and empowering process that embraces community development (Tannahill 1985). Greenberg (1978), Tones (1981, 1986, 1997) and Naidoo and Wills (2000) also have empowerment, and Naidoo and Wills (2000) education for informed choice, as core values of health education, but the focus is on individuals.

The WHO (1983) were critical of the top-down and paternal medical model and the almost patronising and victim-blaming tone of some of these definitions of health education. Brown and Margo (1978) also advance that although in theory health education can be a force for change, in practice ideological forces and the desire for increased professional status anchor the interventions of practitioners firmly in the established conservative health-care delivery system. A situation that still persists in nursing (Whitehead 2005a). For Brown and Margo (1978), this undermines any real contribution to progressive social development, community empowerment or an assault on the social determinants of health and disease, and contributes to maintaining the social status quo.

The above was counteracted by the WHO (1991b) who defined health education, using the type of language and terminology that has come to be associated with them, as intervention to help people be in control of their health behaviour and factors that influence health status. This clearly builds on and broadens earlier definitions and the document advances that community and societal action for equitable health, and advocacy on issues of public policy for health and empowerment are part of health education.

HEALTH PROMOTION

A starting point for defining health promotion has to be the WHO (1986) Ottawa Charter, as prior to this there had been little effort to establish a consensus. The WHO (1986) definition below builds on their earlier established concepts and principles of health promotion (WHO 1984). This contends that health promotion unifies change in the ways and conditions of living, mediates between people and their environments and combines personal choice with social responsibility. Although it does include promoting positive health behaviour and disseminating health information, the Ottawa Charter widened the debate by emphasising a population approach, a focus on social context, the cause of disease and the need to employ a range of methods (Box 1.3).

BOX 1.3 HEALTH PROMOTION METHODS

• communication;
• education;
• legislation;
• community development.

(WHO 1986)

The Ottawa Charter (WHO 1986) espoused the need for public participation and for health professionals – particularly those working in primary health care – to enable health promotion. Its ubiquitous definition of health promotion has come to be seen as somewhat idealistic with unattainable goals, such as, for example, complete wellbeing. Health promotion is defined as:

the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment … health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyle to well-being.

(WHO 1986: 1)

In outlining prerequisites for health, the Ottawa Charter calls for equity in health, and healthy alliances and partnerships between relevant organisations. Health promotion extends to building healthy public policy, creating supportive environments, strengthening community action and social networks, developing personal links and reorienting health services. The significance of this was in representing a departure from the medical model to a socio-political position advocating the shift of power from bureaucracies to people (Green and Raeburn 1988). It thus widened and redefined the concept of healthy public policy (Jones 1997).

Like the WHO (1993), Nutbeam’s (1986) definition of health promotion concurs with the WHO (1984, 1986) but both add that it should include increasing control over the determinants of health. He draws on the principle of health promotion engaging with the community and everyday life context of people and mediating between them and their environment. They should be active participants in needs assessment and interventions on the determinants of health, and this should be part of the process of partnership between the community and public services.

At one level, health promotion is about promoting healthy lifestyles and life-skills for individuals (Anderson 1983; Fisher et al. 1986; Nutbeam 1986; Green and Raeburn 1988; WHO 1993) or promoting, maintaining and improving health in individuals and communities. At another, it is concerned to influence socio-economic and environmental policy for collective health gain (Baric 1985; Rutten 1995). Noak (1987) talks of integrating these policies with economic, employment and health policy and legislation and occupational health but Fisher et al. (1986) see legislative and public policy interventions as a means to support the adoption of health-related behaviour. Green and Raeburn (1988) take a different line in advancing that health promotion needs, including those that stem from these latter factors, can be devolved to people as long as they are equipped with the information, skills and financial and organisational wherewithal.

The starting point for Tones (1990) and Tones and Tilford (2001: 9) is that health promotion is deliberate and planned ‘micro’, ‘meso’ and ‘macro’ intervention to promote health and manage disease. It can be encapsulated using the domains of the health field concept of Lalonde (see Box 1.4).

A key feature of health promotion is social policy, i.e. legal, fiscal (financial) and environmental interventions. In an earlier article Tones (1985) argued that this helps make healthier choices the easy choices. Tones and Tilford (1994) add that the goal of health promotion is the equable distribution of power and resources and this may involve challenging the impact on health of dominant ideologies such as the enterprise culture. Anderson (1983), writing for the WHO, concludes that three categories of health promotion activity emerge from these considerations. They are the action of individuals to improve health; interventions aimed at helping the preceding category be achieved; and those which act at a macro policy level and are thus independent of personal effort. For the WHO Jakarta Declaration (1997a) this means influencing the determinants of health so as to maximise health gain for people, reducing inequalities in health, furthering human rights and building social capital.

BOX 1.4 DOMAINS OF HEALTH PROMOTION

• individual behaviour and lifestyle;
• social and environmental causes;
• health services.

(Tones 1990; Tones and Tilford 2001)

THE RELATIONSHIP BETWEEN HEALTH EDUCATION AND HEALTH PROMOTION

Although it is difficult to differentiate clearly between health education, disease prevention and health promotion a number of authors (Catford and Nutbeam 1984; Tones 1985; Tones and Tilford 2001; Whitehead 2004a) have endeavoured to clarify this relationship. The WHO (1986) contend that the area of overlap between health education and health promotion, as defined in the Ottawa Charter, is advocacy and supportive health policy. Tones (1985) similarly defines health promotion as the synthesis of health education and social engineering and for Tones (1993), Tones and Tilford (2001), Tones (2001) and Tones and Green (2004) health promotion is the sum of health education and healthy public policy.

Catford and Nutbeam (1984) define health education as information provision and advice on health risks and preventive behaviour via various media and the promotion of self-esteem and empowerment. The...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• ACKNOWLEDGEMENTS
• INTRODUCTION
• PART 1 THEORY
• PART 2 PRACTICE
• CONCLUSION
• REFERENCES