Defining Health Promotion
The World Health Organization (1984) states that health promotion is a process which enables people to increase control over, and to improve their health. Health promotion is generally regarded as an umbrella term encompassing a range of activities. Naidoo and Wills (1998) identify four elements:
- Disease prevention – activities focusing on individuals or groups, e.g, screening and immunization
- Health education and information – activities aimed at preventing disease and enhancing health through education giving, e.g. nurse-client consultations and media campaigns
- Public health promotion — activities that promote health through social and environinental measures, e.g. improving access to services, housing, smoking bans.
- Community development – activities that enable individuals to develop personal skills, knowledge and social networks, e.g. women’s health groups, exercise classes for older people.
Promoting health is a major part of the nurse’s role. Nurses are increasingly influential in planning and implementing local initiatives through representation on Primary Care Trusts. Funding arrangeinents may determine which health promotion activities take a higher priority. However, these activities may be compromised bv heavy ivorkloads or time constraints.
Debate continues over the best ways to promote health. Traditional health education was designed to change the behaviour of the individual towards healthier lifestyles by making people fit the environment. However, this did not make the environment a healthier place to live in and has resulted in ‘victims’ being blamed for their own ill health. This traditional approach had a further limitation: it was based on the conviction that the expert (usually the doctor) knew best. Ewles and Simnett (1992) point out:
There is a danger of imposing alicn values on a client. Frequently this is an imposition of white, middle-class values on working-class people. For example, a doctor may perceive that the most important thing for a patient is losing weight and lowering blood pressure, but drinking beer in the pub with friends may be far more important to the overweight, middle aged, unemployed patient. Who is to say which set of values is right ? Whose life is it anyway ?
The client-centred approach involves working with clients on their own terms and helping them to make decisions and choices. Clients are valued as equals. The key is self-empowerinent evolving from increasing self-awareness and self-esteem. This is in stark contrast to the traditional paternalistic model.
Planning Health Promotion
Much health promotion is opportunistic – done during a busy clinic or over the phone. A few minutes may be all that is available, or necessary. Issues needing more tine can be followed up when it is more convenient – by an individual lppointinent or a group session. Remember that the best plan can go wrong: your colleague is ill; the video breaks down; your client is more concerned about last night’s TV programme on breast cancer than her smoking habits. Be flexible and prepared to depart from your plan.
When Constructing a programme it will help to:
- Assess your client’s needs
- Decide on your aims
- Set objectives, i.e. goals to be achieved
- Select which methods/strategies to use
- Ensure support from your manager and colleagues
- Check that everyone involved has the appropriate knowledge and skills
- Contact your local health promotion department for advice and resources
- Find Out what services your local agencies provide – can clients self-refer ?
- Compile a list of national and local organizations, helplines and support groups – ask for promotional materials
- Devise an evaluation strategy for clients, e.g. a questionnaire
- Allow time for staff debrief/feedback-clinical supervision may provide a supportive environment for developing ideas
- Audit helps future planning and to monitor quality standards.
CHANGING HEALTH BEHAVIOUR
Achieving changes in health-related behaviour forms an element of many of the National Service Frameworks.
- Helping patients make healthy choices is a challenge for all nurses.
- Individuals have freedom of choice and some patients may choose to continue with unhealthy behaviour (such as smoking) because they believe the benefits outweigh the risks.
- Changing health-related behaviour is a complex process involving psychological, social and environmental issues.
Stages of change
Research has demonstrated that a behaviour change model is effective in changing a variety of health-related behaviours such as drug abuse and weight control (Ewles and Simnett, 1999). Prochaska and DiClimente (1984) identified stages in the process of behaviour change. Using this model you can help your patients to make changes by focusing on moving them one step further around the cycle.
- Pre-contemplation stage. At this point the patient has no awareness of a need to change. Health education and advice can be used at this stage to raise awareness of the unhealthy behaviour. Questions, delivered in a nonjudgemental way such as ‘how do you feel about smoking?’ may prompt consideration of the health-related behaviour.
- Contemplation stage. This is where the change starts. Patients in this stage are sufficiently motivated to begin to think about making a change. Patient self-empowernlent is key to moving through this stage of the cycle.
- Commitment stage. Patients in this stage are making a serious decision to change an aspect of their health-related behaviour. hi this stage you can help to turn a decision into action by developing an action plan, coping strategies and identifying sources of support. A date to change behaviour and to review progress can be set.
- Action stage. Patients in this stage are changing their health-related behaviour. Support during this phase can be given through continued sessions with a health professional, as part of a support group, from friends and family, via telephone help lines or a combination of some or all of these.
- Maintenance stage. This is the stage where patients are endeavouring to maintain the behaviour change they have made. Using the coping strategies identified during the commitment stage will improve maintenance. Continuing to gain Support is also vital and satisfaction is gained from maintaining the behavioural change. Remember most patients are not successful at inaintaining their health behaviour at their first attempt.
- Relapse stage. In this stage they have relapsed back into their old behaviour. You can help patients identify this relapse as a stage on the way to making their change, and move them on to the comtemplation stage again. On average, smokers take three cycles of the change model to successfully quit smoking.
- Exit stage. This is the stage where a healthrelated change has been successfully made and can be maintained.
Remember that practical problems may limit change. A woman may see no need to alter her lifestyle. She may lack the self-esteem and confidence to cope with big changes. She may be unable to change because she lacks control over her life at home or at work, maybe due to financial problems or insufficient support. In addition, you may not have the necessary time she needs in order to help her.
All these pressures highlight the need to strike a balance between meeting government targets, respecting your client’s wishes and being realistic about what is achievable for both you and your client.
Preconception Care And Early Pregnancy
Preconception care has two aims:
- To give the baby the best possible start to life by minimizing risks associated with lifestyle, heredity, medical history and maternal age
- To promote the health of the mother.
A woman wishing to conceive can be given advice about timing intercourse during the most fertile phase of the menstrual cycle, i.e. 14 days before the expected start of the next period.
In theory, a contraception, sexual health or wellwoman consultation provides an ideal oppoi’htility to discuss plans for planning a pregnancv, to check your client’s general health and to arrange appropriate screening. In practice, however, you may not see your client until she presents for a pregnancy test. A negative result will determine if she needs either contraception or preconception counselling. A positive result will enable you to discuss other issues covered in this section or the possibility of counselling for termination of the pregnancy.
The first four weeks of a pregnancy are the most critical in a baby’s development – the time of maximum velocity in cell division, when the heart, brain, spine and other major organs begin to develop. This is why it is so important to give health promotion advice before conception, rather than after pregnancy is confirmed. Nevertheless, even if the client does not present for several weeks, you can still emphasize that it is never too late to make healthy lifestyle changes.
A report for the British Dietetic Association (Doyle, 1994) says that women with a high risk of poor pregnancy outcome should be targeted for nutrition counselling. Their needs may extend beyond diet and call for a more holistic approach.
Preconception and early pregnancy care should include:
a) A review of medical and family histories
b) Advice on smoking, alcohol and other drugs
c) Nutritional advice
d) Advice on exercise, lifestyle and occupational hazards for both partners
e) Information about stopping contraception.
A woman who becomes pregnant whilst taking hormonal contraception should be advised to stop immediately, but be reassured that studies do not show any detectable increased risk of fetal abnormality (Guillebaud, 1999).
RISK FACTORS FOR POOR PREGNANCY OUTCOME :
|1) Poor obstetric history, e.g. previous low-birth weight baby or congenital abnormality2) Smoking, heavy drinking or abuse of other drugs3) Adolescence
4) Pre-existing medical conditions, e.g. diabetes, hypertension and malabsorption states
5) Low socio-economic group and poor housing
6) Close birth spacing and large families
7) Very under- or overweight
8) An inadequate diet, e.g. some vegans with a limited nutritional intake or families with poor cooking facilities
9) Eating disorders, e.g. anorexia or bulimia.
A review of general medical history should include illness, previous Surgery and any medicltion. Gynaecological and obstetric history should cover previous pregnancies: deliveries, miscarriages, abortions, stillbirth and intrauterine death, toxaemia, fertility investigations, sexually transmitted infections, hepatitis and I-Ja V status, if known. Ask about previous cervical smears, rubella status and sickle cell and thalassaemia trait. Take a family history for both partners, if possible, and offer screening for inherited disorders. Women who have had recurrent miscarriages, and couples with a family history of inherited disorders may be referred for genetic counselling. Screening in specialist centres is available for conditions such as cystic fibrosis, muscular dystrophy and fragile X syndrome.
The importance of a healthy diet before and during pregnancy cannot be overemphasized. With the exception of folic acid, there are no proven benefits associated with taking vitamin or mineral supplements unless the diet is inadequate or very restricted, e.g. vegan. ‘Fortified’ breads and breakfast cereals are a good source of extra vitamins and minerals. Zinc deficiency reduces sperm count and is believed to be associated with poor pregnancy outcome. Zinc is lost when alcohol intake increases. Calcium is important for adequate mineralization of fetal bone, partictilarly in the third trimester. Adequate iron intake is required throughout pregnancy to prevent anaemia and for normal fetal brain development, and iodine plays a role in cognitive functioning of the baby. Maternal intake of vitamins A and D influence development Of visual and skeletal systems, and long-chain fatty acids from fish oils promote neural development (HEA, 1998a).
Women who are overweight should be advised to cut down high calorie foods; but to avoid restricting their diet if they are actively trying to become pregnant. Ideally, they should aim to lose weight well in advance of conception to let their weight and metabolism stabilize. An underweight woman or one who is over-exercisinb may have difficulty conceiving. Being underweight also increases the risk of having a small baby. Chronic long-term dieters should try to eat three good meals a day to ensure the baby is adequately nourished in those important first few weeks of pregnancy (Doyle, 1994).
Folic acid supplements can reduce the incidence of neural tube defects, such as spina bifida. The Department of Health advises women planning pregnancy to take 400 µg of folic acid daily, in addition to dietary intake, until the 12th week of pregnancy. If there is a family history of spina bifida the woman is advised to take a higher daily supplement of folic acid (5 mg). The DoH (1992a) recommended that this daily dose should be reduced to 4 mg if a licensed preparation became available. There is still no 4 mg licensed preparation available to date, so women should continue to take 5 mg.
An excessively high intake of retinol or animal . forms of vitamin A is associated with birth defects. The plant form (beta-carotene) is safe. Pregnant women are advised to avoid cod liver oil and vitamin A supplements in excess of 700 µg or foods known to be high in vitamin A, such as liver or liver products.
Immunity is reduced in pregnancy and some women may fall prey to illnesses more easily. Listeriosis is a bacterial infection common in enimals, including cattle, Pigs i1nd poultry. It may also affect humans. Maternal infection can result in miscarriage, stillbirth, brain damage or severe illness in a newborn baby. Foods to avoid in pregnancy include ripened soft cheeses, e.g. Brie, Camembert and blue-veined cheeses. Unpasteurized milk and tulpastturized milk products and pite may contain high levels of listeria. Cookedchilled meals and ready-to-eat poultry should be avoided unless they are thoroughly reheated.
Raw or partially cooked eggs or foods containing raw egg (e.g. mousses and mayonnaise) and undercooked chicken can cause salmonella poisoning and should be avoided.
Remind Your client about food hygiene. Emphasize the importance of hand washing before and after handling food, especially raw meat, eggs, etc.; and the need for separate chopping boards and knives for raw and cooked foods (DoH, 1997b).
Exercise, Lifestyle and Occupational Hazards
Adequate sleep and relaxation is also important. Both partners should avoid occupational hazards, e.g. exposure to chemicals and radiation. Ask your client to encourage her partner to eat healthily, reduce alcohol consumption and to cut down or stop smoking. The mutual support that a partner can give by adopting a healthy lifestyle is a positive factor and lays the foundations for bringing up children with a similar approach.
Ask your client if she has any pets. Toxoplasinosis is an infection caused by a parasite found in cat’s faeces, raw and partially cooked meat and unpasteurized goat’s milk and cheese. Exposure in early pregnancy can cause miscarriage and fetal damage, which may lead to mental retardation and blindness. Pregnant women should avoid changing cat litter; but if this is essential, they should wear rubber gloves. They should be especially careful to wash their hands thoroughly after handling animals, cat litter, earth or raw meat; avoid eating rare meat; wash salads thoroughly and wear gloves for gardening. On farms, pregnant women should avoid lambing.
“…….to be Continued…….WOMAN and NUTRITION…..”
Andrews G. (2005) Woman’s Sexual Health, third edition, London, Elsevier Ltd.