needs assessment of a case, assessment might have to be carried out at different levels from the individual, to the family/group and the community in which the individual lives, depending on the purpose.
35
Promoting Health and Well-Being
Health promotion models
There are several models of health promotion, examples of which appear in Box 2.4.
Other theories that contribute towards the understanding of the effect of health promotion interventions on the client and why people seek help are the psychological theories of behaviour change which aim to explain why and how people can change their behaviour. An example is Becker’s Health Belief Model (cited in Wills and Earle, 2007).
Assets approach
Demographic changes, reductions in public sector spending and the gap between the life and health outcomes of the best and the worst off have influenced recent discussion about the need for new approaches to public service delivery.
One specific model which has attracted much attention is the use of asset-based approaches to improving health.
Taking an asset-based approach involves mobilising the skills and knowledge of individuals and the connections and resources within communities and organisations, rather than focusing on problems and deficits. The approach aims to empower individuals, enabling them to rely less on public services. However, there remains a limited evidence base linking actions to strengthen individual and community assets with improved health and well-being. An asset-based approach is, therefore, one which seeks positively to mobilise the assets, capacities or resources available
Box 2.4 Health Promotion Model Examples
MODEL
Beatie (1991) Beatie (1991, cited in Katz et al., 2000) developed an analytical model that highlighted the interplay of intervention (authoritative or negotiated which equates to professional or client led) and the focus of intervention (individual or society). Beatie (1991, cited in Katz et al., 2000) developed an analytical model that highlighted the interplay of intervention (authoritative or negotiated which equates to professional or client led) and the focus of intervention (individual or society).
Tannahill (1985) Tannahill identified prevention, health education and health protection in overlapping spheres to describe the services and activities that constituted health promotion practice.
Tonnes and
Tilford (2001) Tonnes and Tilford identified educational, preventative,
empowerment and radical approaches but viewed empowerment as central to health promotion.
Ewles and
Simnett (2003) Ewles and Simnett proposed a model that described five approaches to health promotion: medical, behaviour change, educational, client-centred and societal change. The values which underpinned the approaches were represented in a corresponding gradient from professional-led to client-led activity. (See Box 2.5.)
Box 2.5 Approaches to Behaviour Change (Ewle and Simnett, 2010)
APPROACH
Medical • Based on a medical model of health
• Aims to reduce morbidity and premature mortality (freedom from medically defined disease and disability)
• Targets whole populations or high-risk groups
• Values preventative medical procedures
• Prominent in current health promotion and healthcare, but could be considered paternalistic (i.e. one person deciding what is best for another)
• Focuses on the absence of disease rather than on promoting positive health
• Ignores the social and environmental dimensions of health
• Primary prevention – The goal is to protect healthy people from developing disease or injury in the first place
• Education – Nutrition, regular exercise, dangers of tobacco, alcohol and other drugs
• Legislation – Seatbelts, Health and Safety at Work Act 1974, food hygiene laws
• Examinations and screening tests to monitor risk factors for illness
• Immunisation against infectious disease
• Controlling potential hazards at home and work
• Secondary prevention – Interventions after an illness or serious risk factors diagnosed
• Goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury
• Tertiary prevention – Interventions after an illness or serious risk factors are diagnosed
• Goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury
Behaviour change • Encourages individuals to change their behaviour and adopt healthy lifestyles
• Views health as belonging to an individual, and it is the individual who chooses when he or she is ready and able to change his or her lifestyle and improve health which involves a change in attitude followed by a change in behaviour Educational • Provides individuals with knowledge and understanding to
make well-informed choices about their health behaviour
• Aim of health promoter/health professional to impart information with minimal personal values
• Individual decides whether to act on the health education and any decisions reached
• Can also include developing skills required for healthy living
• Does not try to persuade or motivate change in one direction
37
Promoting Health and Well-Being
to individuals and communities which could enable them to gain more control over their lives and circumstances (Foot and Hopkins, 2010).
A wide range of techniques are used to take an asset-based approach, including asset mapping, co-production and various community-led, community engagement and community development methods.
Assests can be grouped into the following:
Individual assets (e.g. resilience, commitment to learning, self-esteem, sense of purpose)
Community assets (e.g. family and friendship networks, social capital, community cohesion, religious tolerance, intergenerational solidarity) (NES, 2011).
Strengths-based approach
‘Strength-based working’ is a term that is heard more frequently in health and social care settings and can be seen as similar to assets approaches to promoting health behaviour change and public health outcomes. Strength-based working means viewing and treating people in a positive manner and can be aligned with the concepts of self-efficacy. Self-efficacy is identified by Borland (2013) as individuals’ belief that they can facilitate change in themselves within the context of their circumstances; therefore, some people who have a high level of self-efficacy may be able to affect change with some success, whereas other people who have low self-efficacy may choose to not attempt health-improving activity or give up easily when challenges are presented. Borland (2013) suggests
Empowerment/
client-centred
• ‘Bottom-up’ approach, seeks to enable people to take control over their lives, identify their concerns and gain the skills and confidence to act on them
• Agendas set by client(s) – Health professionals guide, support, facilitate and encourage; initiates the process then withdraws
• Conditions for empowerment: For people to be empowered they need to
• Recognise and understand their powerlessness; feel strongly enough about their situation to want to change it;
feel capable of changing the situation by having information, support and life skills (Naidoo and Wills, 2016)
Social change • Sometimes termed radical health promotion; recognises importance of socio-economic environment in determining health
• Focuses at policy/environmental level
• Tries to change physical, social and economic environments to have the effect of promoting health; i.e. focusing on changing society, not the behaviour of individuals
that self-belief if negative can get in the way of health-promoting changes in behaviour due to an unsuccessful concept or image of individuals in their mind, and this image can be changed by developing an adjusted sense of self. Upton (2013, cited Banduram 1977b: 51) identifies two particular areas from Bandura’s social learning theory and suggests that in order to develop this adjusted sense of self we can look to strength-based working to support self-efficacy by influencing verbal persuasion and reduce emotional arousal. This can be achieved by identifying a genuine potential for change in individuals by recognising, naming and developing abilities, skills, expertise and social networks in the individual and by reducing the emotional arousal associated with a negative self-image.
Neuroplasticity can help us consider how thinking positively about individual’s strengths can change the way the individual thinks. Davidson and Begley (2012) advocate that by encouraging individuals to think positive thoughts about their abilities they can change the chemistry of their brains to become more successful in the actions they undertake.
Nursing skills
Given the complexity of concepts of health, and the interrelationship between the multiple factors that influence it, you will appreciate that a variety of approaches and methods can be utilised to promote health.
To help you clarify your own understanding of how health promotion has developed over the twentieth century, access the Ottawa Charter for Health Promotion on the WHO site.
Many of the above theories describe or analyse health promotion practice, but the skill of health promotion practice requires a deep understanding of communication and partnership working theory to achieve the goal, which is to enable people to increase control over and to improve their health (empowerment and choice).
Rollnick et al., (1999) proposed a client-centred philosophy of partnership working (Motivational Interviewing) to complement Prochaska and DeClemente’s (1983) Trans-theoretical (stages of change) theory. The aim was to facilitate individuals to move through the stages of precontemplation – contemplation – making changes – maintaining changes. Rollnick et al., suggested that a practitioner could reduce resistance to change by relationship building using a therapeutic approach based on trust and information exchange to negotiate the agenda and to set achievable goals based on the individual’s vision of importance and their confidence to make the change. Motivational interviewing is discussed further in Chapters 8 and 13.
Gallant et al., (2002) conducted a very informative concept analysis of partnership working which identified three phases to the partnership working relationship: the initiating phase, the working phase and an evaluation phase. To work in partnership one needs to build a professional therapeutic relationship based on trust. The professional must be competent and honest and display professional integrity (to work in the best interests of the client/patient) at all times and the client must be a willing partner (Potter and Wills, 2013).
39
Cultural Awareness