Health is a major focus of interest and concern in society with the notion of health as “the foundation of achievement” (Seedhouse 1986). Health promotion is generally understood as the activities that intend to prevent disease, improve health and thus enhance wellbeing (Naidoo & Wills 1998). Kendall and Latters (1997) argue that health promotion should be aimed at enhancing positive health and wellbeing and not just focussing on the prevention of ill health. This is because they believe that health promotion is often perceived negatively as it advises “giving up pleasurable habits for the sake of avoiding illness in the long term” (Kendall & Latters 1997). Just as there are different concepts of what health is there are different approaches to health promotion that can be used depending on the situation.
- The medical approach: this approach is targeted at high risk groups with the aim to reduce morbidity and premature mortality. The overall aim is freedom from medically defined disease and disability. The medical approach promotes medical intervention to prevent or reduce ill health and requires individuals to comply with preventative medical procedures.
- Behavior change: this approach aims to encourage the adoption of healthy behavior that is conducive to freedom from disease. This in turn will ensure improved health through healthy lifestyles.
- Educational approach: this approach provides the knowledge and information so that individual’s can make informed choices with regards to their health behavior. Through having information regarding the cause and effects of health, and the exploration of values and attitudes the individual will develop the skills required for healthy living
- Empowerment: this approach works with the individual on their own terms. By working with health issues, choices and actions with which the individual identifies enables the facilitation for the individual gain the skills to act on them.
Approaches to health promotion are descriptions of what happens, the analytical means of identifying types of health promotion has been the development of health promotion models (Naidoo & Wills 1994). A model can be described as a conceptual framework. It an abstraction of reality in that it is a descriptive picture of practice which adequately represents the real thing. Models are important as they are the theories and concepts of health promotion practice. Using models encourages one to think theoretically and to prioritize. There are many health promotion models available but due to word constraints three models that are relevant to occupational health nurses will be discussed.
The aim of health promotion is to focus on changing behavior towards a healthier lifestyle (Alston & Atwell 1990). The stages of change health promotion model developed by Prochaska and DiClemente (1984) has its origins in showing the process through which people travel to change addictive behavior (Kendall & Latters 1997). This model believes that individuals go through many stages in relation to undergoing change and that any changes are not an ending but one of many (Naidoo & Wills 1994). The stages of change are:
- Precontemplation: Individuals at this point are not thinking about making any changes in their lifestyle. They may not be aware that there is a problem and could be resistant to making changes.
- Contemplation: at this point the individual may be aware that there is a problem that could be improved, or the potential risks of continuing current behaviour. The individual at this stage is thinking about change in that they are weighing up the costs and benefits of change, but they are not yet ready to make the changes.
- Preparation: An individual becomes aware that the perceived the benefits of change outweigh the costs. The individual starts to believe that change is possible and worthwhile, they may make small behavioral changes, and make a commitment to act.
- Action: the individual takes action to change their behavior, At this point the individual needs a clear goal, with realistic planning, and support and rewards to ensure success.
- Maintenance: Once habits are broken the individual must settle into a new way of behaving. As the new habits become established the individual sustains the change in behavior and moves on to a healthier lifestyle.
Prochaska et al (1992) believe that whilst few individuals go through each stage in an orderly fashion they will however, go through each stage. Thus the individuals go through a cycle of change with the end result being a healthier lifestyle. The key to this model is that the individual sees it is in their best interest to change and remains motivated to do so. The Prochaska and DiClemente model focuses on the process of change and the support that individuals might need to enable them to work through the change. However, this model is mainly descriptive and has been critisised for presenting a smooth unidirectional process of change, when change is often fluctuating and unpredictable (Heather 1991). This model only demonstrates how people change but not why they change. By contrast Downie et al (1990) looked at health promotion as three overlapping circles of activity: health education, health protection, and prevention. The three areas overlap and relate to each other in the process that is known as health promotion (Naidoo & Wills 1994). Within the intersecting circles lie seven possible dimensions of health promotion:
- Preventive services such as immunisations and health screening/surveillance.
- Preventive health education, e.g. smoking advice.
- Preventive health protection, e.g. reduction in workplace exposures and provision of personal protective equipment.
- Health education for preventive health protection e.g. training and education with regards personal protection equipment
- Positive health education, e.g. healthy lifestyle promotion, healthy options in canteen.
- Positive health protection, e.g. implementation of workplace policies such as smoking and alcohol policies
- Health education aimed at positive health protection, e.g. campaigning for protective legislation
Downie’s model highlights the potential overlap between prevention and positive action, taking the view that effective health education is the building block for securing change. This model offers many combinations of approach to health promotion but it does not make explicit the political or social values that underlie each approach. This model describes what goes on in practice and allows the health promoter to link the activity with other areas. This model is relevant to an area such as occupational health and addressing health in the workplace through health surveillance, by means of protecting current levels of health, preventing ill health and educating the employers and employees. Indeed Hodges (1998) states that the role of the occupational health nurse is to promote health at work and protect the health of the worker. However as Delany (1994) argues, the process of education intends to produce learning that can be contribute to the protective and preventative activities. Health promotion can seen as an umbrella which encompasses a range of activities that contribute to a healthy lifestyle (Delany 1994, Naidoo and Wills 1994). A third approach to health promotion is that of Tones et al (1990) who see health promotion as the process of public policy and health education working together. The education and information allow individuals to make informed choices. The health education also sets the agenda to raise awareness and create pressure for public health policies. “Changes in the social environment achieved through healthy public policy will produce changes in individuals”(Naidoo & Wills 1994). This model is an empowering model, which gives the individual the autonomy to take more control of their lives. Empowerment is the process where an individual acquires power, with self-empowerment being the ability for an individual to take control of their life. Empowerment is an interpersonal process for providing the tools and environment to develop, build and effectiveness of others so that they might set and reach goals (Hawks 1992). In this context “health promotion is seen as the process of enabling people to increase control over and improve their health” (WHO 1986). Kendall and Latters (1997) believe that the aim of empowerment is fundamental with this type of health promotion as inequalities in health can only be addressed by health promotion work that is both enabling and empowering for individuals (Sturt 1998, Tones 1991). There are a number of components to empowerment (Tones 1991). Self-efficacy is the idea that an individual must believe that they are capable of change, this can be fostered through discussion with the health promoter or developed by the individual, however Sturt (1998) argues that efficacy acquired through verbal persuasion is weaker than that that rose personally. Self-esteem is also important if an individual has feelings of self worth then they are more likely to look after themselves and have a healthy lifestyle (Gillis 1993). Health promotion that is linked to self-efficacy enables the practitioner to work in a client centred way, ensuring the emphasis remains on the client’s lifestyle and culture (Sturt 1998). Changes towards a healthier lifestyle would then move at a pace that is dictated by the client as they become more empowered and are able to work towards their own agenda. The fostering of self esteem by the facilitator, through praise for recent success can therefore spur the client on to continue with the lifestyle changes that they are undertaking.
The three models of health promotion discussed above are all relevant to the occupational health nurse, who may find that they use a combination of all three models. As discussed earlier the Downie model of health promotion looks at the activities of health education, health protection and, prevention as being health promotion. These areas are all within the remit of occupational health nurses and are activities that the occupational health nurse undertakes on a daily basis. One could therefore argue that according to Downie’s model the sole objective of the role of the occupational health nurse is health promotion. However, occupational nurses are involved in other areas, but Downie’s model gives great scope for the occupational health nurse to target individualised health promotion whilst carrying out health surveillance for example, and acts as a reminder of the different dimensions that health promotion takes. The Prochaska and DiClemente model is useful in that it enables the practitioner to identify at which point within the cycle of change that the client is at. With this knowledge the occupational health nurse is able to plan an individualised approach to health promotion, that is relevant to the client at that point in the cycle of change. The occupational health nurse will also be able to identify if a client has become “stuck” at a particular point or has regressed to an earlier stage, thus requiring the need to retrace previous ground before being able to focus on moving to the next stage. By working with the client using an individualised client centred approach the occupational health nurse will strive to empower the client so that through increased awareness and knowledge they are able to take more control over their lifestyle and make health conscious changes. This model of health promotion could however, be time consuming when working with individuals in areas such as smoking cessation, and the occupational health nurse may need to justify to the employer, the cost benefits of this approach with some topics such as smoking cessation.
The government is taking the approach to health promotion that Tones et al (1990) advocated. The government are tackling the health inequalities and attempting to increase the nation’s health through policy and education. Social policy can be described as taking deliberate action to achieve change in individuals or society (Gough et al 1994). Social policy springs from observations and ideas of how society ought to be. Social policy is normative in that it contains values and beliefs about how society should be ordered and the ideal relationships between certain groups in society, advocating change when reality conflicts with such values and beliefs. Social policy is therefore seen as having a deliberate social engineering function. One such tool for social change that the Government has introduced is the white paper Saving Lives: Our Healthier Nation (1999). This white paper sets out how the government plan to save lives, promote healthier living and reduce the inequality in health that continues to exist. The Saving Lives: Our Healthier Nation (1999) is an action plan with targets to be attained by 2010. These targets are:
- To reduce the death rate of cancer in the under seventy-fives by at least a fifth
- To reduce the death rate in the under seventy-fives through coronary heart disease by two fifths
- To reduce death rate following accidents by at least a fifth and reduce serious injury by a tenth
- To reduce the death rate from suicide by a fifth
The Government recognise that “better health is central to economic performance” (DOH 1999). A healthy workforce improves productivity and performance, which is good for the economy. In 1995 there were 20 million working days lost through work related ill health. These can be broken down as follows:
Number of days lost from work related illness in 1995 (HSE 1995):
- Musculoskeletal, including back pain 11 Million
- Stress, depression, or anxiety 5 Million
- Trauma 1 Million
- Other 4 Million
Ill health is expensive not only in human terms but also in economic terms. By cutting the cost of sickness at work the burden on business will be decreased. The Government believes that as we are aware of the causes of diseases such as coronary heart disease, action can be taken to reduce the incidence of these preventable diseases. The Government believes that “this in turn will reduce welfare spending as we tackle health inequalities and improve the health of the worst off” (DOH 1999). Caraher (1994) argue that the Government’s current concerns with health promotion and healthy lifestyle is related to the crisis of funding. The Government is aware that the current emphasis on treatment and cure is placing a burden on public spending. The way to stem this cash crisis according to Caraher (1999) is to redress the balance through health promotion and encouraging healthy lifestyles. The Government recognise that the workplace provides opportunities to improve the health of the workforce and to address health inequalities (DOH 1999), after all it is where many people spend the majority of their waking hours (McFall 1999). Whilst employees are more likely to prioritise their own health and security, an employer’s requirements are for a fit workforce (Thompson 1998). The health of employees is a core management issue as a healthy workforce is required for a business to succeed. A healthy workplace brings with it increased productivity through lower rates of sickness absence due to fewer accidents and less illness. As well as improving the health of individuals at work, experience demonstrates that a strong health and safety culture contributes significantly to profitability (HSC 2000). The Government’s proposals for healthy workplaces are a key strand of the public health strategy (Thompson 1998). The government also recognises that for health policies in the workplace to be effective they must be professionally led; therefore, the government has singled out occupational health nurses as the key to promoting health at work (Thompson 1998). In light of this recognition and within the remit of promoting a “healthier nation”, the Health and Safety Commission has developed a ten year strategy for occupational health. Securing Health Together (Health and Safety Commission 2000) is a ten-year occupational health strategy for Britain. The Health and Safety Commission recognise that whilst individuals who suffer most from ill-health are those without a job, the work environment is an ideal opportunity to promote health of individuals who may not necessarily be reached by other healthcare professionals due to their state of wellness. The occupational health strategy provides the opportunity to promote health and reduce ill health. The Securing Health Together Strategy has the following goals:
- To reduce ill health on workers and the public caused, or made worse by work
- To help people who have been ill, to return to work
- To improve work opportunities for people currently not employed due to ill-health or disability
The following targets have been set for achievement by 2010
- 20% reduction in the incidence of work related ill health
- 20% reduction in ill health to the members of the public caused by work activity
- 30% reduction in the number of working days lost due to work related ill health.
These targets are linked to Saving Lives: Our Healthier Nation and are designed to focus individuals and inspire action (HSC 2000). If this strategy is to succeed then occupational health nurses must set their own targets that are appropriate to their working environment and associated ill health problems (HSC 2000). “The estimation of the gross benefits to society of reaching three of the above targets is between £8.6 –21.8 billion by 2010”. (HSC 2000). The cost benefit implications is enormous in both in terms of the general economy and the releasing up of funding that can be redirected into other areas and begin to assist in addressing the health inequalities that there are currently.
The government believes that occupational health nurses have a unique role to play within health promotion due to their role within the workplace. Prevention activities such as provision of immunisations and health surveillance are only a small part of the role of an occupational health nurse. An occupational health nurse according to Thompson (1998):
- Assists with risk assessments
- Facilitates communication on health and related matters at work
- Develops and contributes to strategies to improve the health of organisations
- Provides other services that add value to, and improve employee health and welfare
Whilst it is good that the government appears to recognise the importance of occupational health with regards to the focus on primary healthcare, the recent documents and strategies however, “offer few realistic measures on how it can contribute to the nation’s health” (McFall 1999). The strategies are non-prescriptive in that they provide targets to inspire action but not ideas as to how the subject areas can be tackled. The occupational health nurse must therefore set their own programme within the workplace with an approach that is relevant to their working environment. The programme should be one that with increased awareness and relevant incentives will improve the health of the workforce.
Above all occupational health should offer an “integrated, holistic approach to health management”, as this will improve quality of life both inside and outside of work (Suff 2000).
The occupational health nurse is therefore in an ideal position to contribute to the Saving Lives: Our Healthier Nation strategy. The strategy as discussed earlier proposes four priority targets: heart disease, accidents cancers and mental health. Gyngell (1998) argues that these are ideal topics for the occupational health nurse to become involved with. The two, most important causes of ill health at work that lend themselves to a wide approach are musculoskeletal disorders and stress (Gyngell 1998). Many occupational health nurses would argue that they have been promoting the health of workers as part of their role for some time. Not only through health surveillance and back care initiatives, but also through major campaigns such as national No Smoking Days, healthy eating initiatives and sun protection campaigns for example. Occupational health nurses have long been aware of their ability to input into the promotion of healthy lifestyles for their workers, and the facilitation for the development of workplace policies. The government are recognising at last the contribution that occupational health nurses can make towards public health and the health agenda. The realisation has been made that the occupational health nurse is ideally suited to address issues in the workplace by way of the prevention of ill health, promotion of well being and the protection and education of employees and employers. These issues can be addressed through health promotion using one or a variety of approaches. The practice of occupational health nursing today is focused on the promotion of health in the workplace (Hodges 1997). Whilst occupational health nurses have previously been undertaking health promotion either directly or indirectly it may have been a hit or miss affair with the practitioner working in a way that suits them. With the advancement of specialist practitioner status and the necessity for continuos updating occupational health nurses are applying research to their role and examining the theories and concepts behind the activities that they undertake. Occupational health nursing, as with other nursing is developing a research based practice which in the area of health promotion will enable the practitioner to apply theory to practice and utilise the appropriate theories and models of health promotion to the benefit of the client.
Occupational health nurses are part of public health provision and are an important contribution to the targets within government strategy such as Saving Lives: Our Healthier Nation (1999) and Securing Health Together (2000).
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