Transcript Health Promotion

Health Promotion and
Clinical Prevention
Overview
University of Mary, Spring Semester
Lecture Summary
Brief Course Overview
Health Promotion and Clinical Prevention
Nola Pender’s Health Promotion Model
Motivational Interviewing
Health Promotion Overview
2010 United States Leading
Causes of Death
Heart disease: 597,689
Cancer: 574,743
Chronic lower respiratory diseases: 138,080
Stroke (cerebrovascular diseases): 129,476
Accidents (unintentional injuries): 120,859
Alzheimer's disease: 83,494
Diabetes: 69,071
Nephritis, nephrotic syndrome, and nephrosis: 50,476
Influenza and Pneumonia: 50,097
Intentional self-harm (suicide): 38,364
From http://www.cdc.gov/nchs/fastats/deaths.htm
Discussion Question
What are the
commonalities in
these TOP TEN
causes of death in the
United States?
What are the commonalities?
Preventable
Involve Behaviors
Several can be prevented with the same
approach
– Nutrition
– Exercise
– Stress Management
– Preventive Health Practices and Screening
Other Issues of Growing Concern
Anxiety and Depression
– About 4 million US adults have generalized
anxiety disorder
– More women than men affected
– Usually affects people in their 20’s
– In any given year, 9.5% of the population
(18.8 million adults) suffers from depression
(CDC, NIMH)
Other Issues of Growing Concern
Fatigue
– One in 10 Americans suffers from chronic or
debilitating fatigue with psychological causes that are
completely avoidable (AMA)
Osteoporosis
– The number of Americans who have osteoporosis or
osteopenia increased from 44 million in 2000 to 52
million in 2010 and to 61 million by 2020
– Women are 4x as likely as men to be affected, but
men are not immune (National Osteoporosis
Foundation)
Making a Difference
Prevention
– Evidence well notes that the majority of
deaths occurring in Americans younger than
age 65 are preventable
– Role of primary care providers
Motivate/Empower Patients to institute healthy
lifestyle behaviors
–
–
–
–
–
Nutrition
Smoking and Alcohol Use
Exercise
Injury Prevention
Prevention of STDs
Resources to Help
Implement Change
AHRQ – US Preventive
Services Task Force
– http://www.ahrq.gov/clinic/u
spstfix.htm
www.cdc.gov
http://www.who.int/en/
www.nih.gov
AHRQ Guide to Clinical
Preventive Screening
– 1-800-358-9295
To order
– Send an email:
[email protected]
– To Download on your PDA:
http://epss.ahrq.gov
Up for discussion…
Are “health” and “wellness” the same?
Are they different? If so, how?
Is the distinction important? Why or why
not?
What is Health?
WHO definition - a state of complete physical,
mental and social well-being and not merely the
absence of disease or infirmity (1948-2003)
“a formal wholeness or completeness which
continually changes” (Jensen & Allen, 1993)
Institute for the Future – perfect or ideal health is
a state of complete physical, mental, social, and
spiritual well-being (2000-2010)
Health and Wellness Concepts
Health = A state of being, an outcome,
objective, body only
– Health-Disease continuum
Wellness = a lifestyle process, includes
mind, body and spirit, subjective
– Wellness-Illness continuum
Can an individual be diseased and well
at the same time?
Health Promotion Defined
Any large-scale attempt to enhance people’s health has
to include many aspects which do not involve the
biomedical orientation to the specific targeting of
diseases.
Health education is certainly an important component of
health promotion but it is neither the same thing nor
necessarily is it always in harmony with it. Health
education involves the transmission of information
related to health. As such, it need not involve the people
proactively.
Theodore H. MacDonald 1998. Rethinking health promotion: A global approach. Routledge: London.
Health Promotion Continued…
Health promotion involves empowerment, a process
whereby individual people are encouraged to assert their
own autonomy and self-esteem sufficiently to be able
to identify their own health agendas, rather than being
told what to do or what is ‘good for your health’.
Health promotion recognizes that health is social as
much as individual. Effective and healthy communities
are sustained by ‘neighborhood advocacy’ of various
types – people identifying their health agendas as
individuals and being sufficiently empowered to develop
the necessary social and political skills to see how to tie
it in with the neighborhood or social context.
Theodore H. MacDonald 1998. Rethinking health promotion: A global approach. Routledge: London.
Clinical Prevention
A health care service delivered in clinical
settings for the purpose of preventing the
onset or progression of a health condition
or illness
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The
McGraw-Hill Companies, Inc.
Healthcare Provider Roles
Traditional
Healthcare system or
independent practice
Insurance dependent
Reactive – patient
comes to you
Illness focus
Expanding
Wellness and fitness
facilities, schools,
worksites,
communities
Private pay
Proactive – provider
goes to client
Wellness focus
How do we View the Person?
Illness – patient
Prevention – person at risk
Wellness – whole person
– Where do health care providers focus?
– Where do most commercial wellness
programs focus?
– An expanded view of the person/community is
needed!
USPSTF Recommends the following
principles to incorporate into Primary Care
Preventive Strategies:
Promote prevention
Share decision
making
Be selective
Take every
opportunity
Participate in
community-level
interventions
RATINGS
– A: strongly recommends; evidence that service
improves health outcomes
– B: found at least “fair” evidence that services improve
health outcomes
– C: makes no recommendations for or against.
Balance of benefits and harms is too close to justify a
general recommendation
– D: recommends against providing services to
asymptomatic patients
– I: evidence insufficient to recommend for or against
routinely providing services
Guide to Clinical Preventive Services, 2007. Recommendations of
the US Preventive Services Task Force
Other Resources
Healthy People 2020
www.healthypeople.gov
Two Primary Goals
– Increase quality and
years of healthy life
– Eliminate health
disparities
Wellness Revolution
Consumer demand
– Baby boomers are interested in quality and
choice of products
– Higher than average income and education
levels
– Increasing number of females that drive the
market
Employers offering wellness/health
promotion programs
– 93% of major US employers (> 5,000
employees) in 2001 offered wellness programs
(Hewitt Associates)
– Reduce health care costs and absenteeism
– Improve productivity/presenteeism
Wellness Revolution (cont.)
Insurers offering discounted wellness
services
Growth and increasing legitimacy of
Alternative Medicine in the US
Acceptance of spiritual interventions and
influences
Mind/body research
Terms to Know
Primary Prevention
– Reducing the incidence of disease or health problems
Secondary Prevention
– Early detection of illness/health problems
Screening surveys
Education regarding recognition of sx
Tertiary Prevention
– Treatment and rehabilitation of illness/health
problems
Test Yourself!
Secondary prevention strategies
commonly used for women’s health care
include which of the following:
– A. PAP smear
– B. Contraception counseling
– C. Pre-pregnancy counseling
– D. Monitoring diabetes and compliance with
diabetic regimen
Test Yourself!
Which of the following is an example of a
primary prevention activity in a 76-year-old
woman with osteoporosis?
– A. Bisphosphonate therapy
– B. Calcium supplementation
– C. Home survey to identify fall hazards
– D. Use of a back brace
Test Yourself!
An example of a primary prevention
measure for a 78 year-old man with COPD
is:
– A. Reviewing the use of prescribed
medications
– B. Ensuring adequate illumination in the home
– C. Checking pulmonary function
– D. Performing a digital rectal examination
and fecal occult blood test (FOBT)
Test Yourself!
Secondary prevention measures for a 78
year-old man with COPD include:
– A. Checking stool for occult blood
– B. Administering influenza vaccine
– C. Obtaining a serum theophylline level
– D. Advising about appropriate use of car
passenger restraints
Test Yourself!
Tertiary prevention measures for a 69
year-old woman with congestive heart
failure include:
– A.
– B.
– C.
– D.
Administering anti-pneumococcal vaccine
Adjusting therapy to minimize dyspnea
Surveying skin for precancerous lesions
Reviewing safe handling of food
Prevention and Risk Reduction
Terms to Know
Primary
– Changeable vs. Unchangeable
– Developmental
Secondary
– Criteria for Screening
Characteristics of disease
Screening test
Population
Screening
Types of Screening
–
–
–
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Individual
Group or mass
One-test specific
Multiple- test
Selected Screening
Tests
Terms to Know
Sensitivity
Specificity
When referring to a medical
test, sensitivity refers to the
percentage of people who test
positive for a specific disease
among a group of people who
have the disease. No test has
100% sensitivity because
some people who have the
disease will test negative for it
(false negatives).
When referring to a medical
test, specificity refers to the
percentage of people who test
negative for a specific disease
among a group of people who
do not have the disease. No
test is 100% specific because
some people who do not have
the disease will test positive for
it (false positive).
Terms to Know
Positive and Negative Predictive Value
– Positive and negative predictive values are
influenced by the prevalence of disease in the
population that is being tested.
– If we test in a high prevalence setting, it is
more likely that persons who test positive truly
have disease than if the test is performed in a
population with low prevalence.
Terms to Know
Positive Predictive Value
The probability that a
patient with a positive test
result really does have
the condition for which
the test was conducted
Negative Predictive Value
The probability that a
patient with a negative
test result really is free of
the condition for which
the test was conducted
Terms to Know
Lead Time
The bias that occurs when two tests for a disease are compared,
and one test (the new, experimental one) diagnoses the disease
earlier, but there is no effect on the outcome of the disease—it may
appear that the test prolonged survival, when in fact it only resulted
in earlier diagnosis when compared to traditional methods.
It is an important factor when evaluating the effectiveness of a
specific test.
Terms To Know
Length Time Bias
Form of selection bias, a statistical distortion of results which can
lead to incorrect conclusions about the data. Length time bias can
occur when the lengths of intervals are analyzed by selecting
intervals that occupy randomly chosen points in time or space. This
process favors longer intervals, thus skewing the data.
For example, length time bias can affect data on screening tests for
cancer. Faster-growing tumors generally have a shorter
asymptomatic phase than slower-growing tumors, and so are less
likely to be detected. However, faster-growing tumors are also often
associated with a poorer prognosis. Slower-growing tumors are
hence likely to be over-represented in screening tests. This can
mean screening tests are erroneously associated with improved
survival, even if they have no actual effect on prognosis.
Test Yourself!
Blood Pressure Screening is
considered a form of :
–
–
–
–
A.
B.
C.
D.
Health counseling
Primary prevention
Secondary prevention
Tertiary Intervention
Test Yourself!
The primary objective
of screening is to:
– A. Prevent a disease
– B. Detect a disease
– C. Determine the
treatment options
– D. Promote genetic
testing to prevent
passing on the
disease
Test Yourself!
If a screening test was used on 100 individuals
known to be free of breast cancer and identified
80 individuals who did not have breast cancer
while missing 20 of the individuals, the specificity
would be:
–
–
–
–
A.
B.
C.
D.
80%
60%
40%
20%
Bottom Line
We can’t and shouldn’t be waiting until
people become “patients”
We need to find ways to promote healthy
behaviors sooner, in the clinic setting and
out in our communities
All of the data and statistics in the world
can’t produce behavior change
A different approach is necessary….
Change Theories
- Stages of Change Model
- Health Promotion Model
Stages of Change Model
/Transtheoretical Model (TTM)
Transtheoretical Model of Change, a theoretical model of
behavior change was originally explained by Prochaska &
DiClemente, 1983.
Basis for developing effective interventions to promote health
behavior change.
The model describes how people modify a problem behavior
or acquire a positive behavior.
The TTM is a model of intentional change. This model
focuses on the decision making of the individual.
The transtheoretical model may help to explain differences in
persons’ success during treatment for a range of
psychological and physical health problems.
This model has been widely applied in behavior modification
techniques.
Core Concepts of TTM
The processes of change
Decisional balance
Self-efficacy
Temptation.
TTM Concepts
Processes of Change
Processes of change are the covert and overt activities that people
use to progress through the stages.
There are ten such processes as explained by Prochaska:
– Consciousness Raising (Increasing awareness)
– Dramatic Relief (Emotional arousal)
– Environmental Reevaluation (Social reappraisal)
– Social Liberation (Environmental opportunities)
– Self Reevaluation (Self reappraisal)
– Stimulus Control (Re-engineering)
– Helping Relationship (Supporting)
– Counter Conditioning (Substituting)
– Reinforcement Management (Rewarding)
– Self Liberation (Committing)
TTM Concepts
Decisional Balance
Decisional Balance reflects the individual's
relative weighing of the pros and cons of
changing.
The Decisional Balance scale involves
weighting the importance of the Pros and
Cons.
TTM Concepts
Self-Efficacy
Self-efficacy represents the situation
specific confidence that people have that
they can cope with high-risk situations
without relapsing to their unhealthy or
high-risk habit.
This concept was adapted by the theory
author’s from Bandura's self-efficacy
theory.
TTM Concepts
Temptation
Reflects the intensity of urges to engage in
a specific behavior when in the midst of
difficult situations.
Temptation is the converse of self-efficacy.
The most common types of tempting
situations are;
– negative affect or emotional distress
– positive social situations, and
– craving.
TTM Stages of Change
People pass through a series of stages
when change occurs.
The stages discussed in their change
theory are:
– precontempation
– contemplation
– preparation
– action, and
– maintenance
TTM Stages of Change
Precontemplation
Client
No intention of changing;
Often denies a problem; may blame others or the
environment for their problem
Provider
Rushing people in this stage is usually not
effective. Try to help the person see the
consequences and offer hope for change
TTM Stages of Change Cont…
Contemplation
Client
Acknowledges the problem;
Willing to change; Anxious about change
Begins to focus on the solution rather than the
problem.
Begins to think more about the future than the
past.
Provider
Needs to provide information---acknowledge
ambivalence; help clarify goals and ways to
eliminate barriers to change
TTM Stages of Change Cont…
Preparation
Client
Explore different options; planning to make change
soon…within 1 month—ready to GO PUBLIC
Provider
Encourage client to GO PUBLIC;
Focus on the future and benefits of making the
change
TTM Stages of Change Cont…
Action
Client
Overtly making changes;
Busy, substituting healthy behaviors for old
behavior;
Support group involvement
Provider
Affirmation and support is helpful in this stage
TTM Stages of Change Cont…
Maintenance
Client
Continuing change;
Learning to devalue the old behavior
Lapse may occur
Provider
If lapse does occur - help them reframe it into a
learning opportunity without imposing guilt
TTM Stages of Change Cont…
Termination
Client
Has taken on a new self-image;
Former behavior no longer a threat;
Don’t have to think about new behavior;
Change is sustained
Provider
Continue to promote person’s self efficacy
TTM References
Prochaska JO, DiClemente CC, Norcross JC (1992). In search of
how people change. Applications to addictive behaviours. Am
Psychol 47:1102.
Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., &
Redding, C. A. (1998) Smoking cessation and stress management:
Applications of the Transtheoretical Model of behavior change.
Homeostasis, 38, 216-233.
Prochaska JO , Velicer WF , Rossi JS , et al. ( 1994 ) Stages of
change and decisional balance for 12 problem behaviors . Health
Psychology 13, 39 – 46 .
Prochaska JO and DiClemente CC ( 1984 ) The Transtheoretical
Approach: Towards a Systematic Eclectic Framework . Dow Jones
Irwin , Homewood, IL, USA .
The web page of UCLA Centre for Human Nutrition.
http://www.cellinteractive.com/ucla/physcian_ed/stages_change.htm
l
Nola Pender’s Health
Promotion Model
Nola Pender’s
Health Promotion Model
The health promotion model (HPM) proposed by Nola J
Pender (1982; revised, 1996) was designed to be a
“complementary counterpart to models of health
protection.”
It defines health as "a positive dynamic state not merely
the absence of disease".
Health promotion is directed at increasing a client’s level
of well being.
The health promotion model describes the multi
dimensional nature of persons as they interact within
their environment to pursue health.
HPM Assumptions
Individuals seek to actively regulate their own
behavior.
Individuals in all their biopsychosocial complexity
interact with the environment, progressively
transforming the environment and being transformed
over time.
Health professionals constitute a part of the
interpersonal environment, which exerts influence
on persons throughout their life span.
Self-initiated reconfiguration of person-environment
interactive patterns is essential to behavior change.
Pender Health Promotion Model
HPM Theoretical Propositions
Prior behavior and inherited and acquired
characteristics influence beliefs, affect, and enactment
of health-promoting behavior.
Persons commit to engaging in behaviors from which
they anticipate deriving personally valued benefits.
Perceived barriers can constrain commitment to
action, a mediator of behavior as well as actual
behavior.
Perceived competence or self-efficacy to execute a
given behavior increases the likelihood of commitment
to action and actual performance of the behavior.
HPM Theoretical Propositions Continued…
Greater perceived self-efficacy results in fewer
perceived barriers to a specific health behavior.
Positive affect toward a behavior results in greater
perceived self-efficacy, which can in turn, result in
increased positive affect.
When positive emotions or affect are associated with
a behavior, the probability of commitment and action is
increased.
Persons are more likely to commit to and engage in
health-promoting behaviors when significant others
model the behavior, expect the behavior to occur, and
provide assistance and support to enable the
behavior.
HPM Theoretical Propositions Continued…
Families, peers, and health care providers are
important sources of interpersonal influence that can
increase or decrease commitment to and engagement
in health-promoting behavior.
Situational influences in the external environment can
increase or decrease commitment to or participation in
health-promoting behavior.
The greater the commitments to a specific plan of
action, the more likely health-promoting behaviors are
to be maintained over time.
HPM Theoretical Propositions Continued…
Commitment to a plan of action is less likely to result
in the desired behavior when competing demands
over which persons have little control require
immediate attention.
Commitment to a plan of action is less likely to result
in the desired behavior when other actions are more
attractive and thus preferred over the target behavior.
Persons can modify cognitions, affect, and the
interpersonal and physical environment to create
incentives for health actions.
HPM Concepts/Definitions
Personal Factors to Consider
– Personal biological factors –
Include variable such as age gender body mass index
pubertal status, aerobic capacity, strength, agility, or
balance.
– Personal psychological factors
Include variables such as self esteem self motivation
personal competence perceived health status and
definition of health.
– Personal socio-cultural factors
Include variables such as race ethnicity,
accuculturation, education and socioeconomic status.
HPM Concepts/Definitions Continued
PERCEIVED BENEFITS OF ACTION
– Anticipated positive out comes that will occur from health
behavior.
PERCEIVED BARRIERS TO ACTION
– Anticipated, imagined or real blocks and personal costs of
understanding a given behavior
PERCEIVED SELF EFFICACY
– Judgment of personal capability to organise and execute a
health-promoting behavior.
– Perceived self efficacy influences perceived barriers to action so
higher efficacy result in lowered perceptions of barriers to the
performance of the behavior.
HPM Concepts/Definitions Continued
ACTIVITY RELATED AFFECT
– Subjective positive or negative feeling that
occur before, during and following behavior
based on the stimulus properties of the
behaviou itself.
– Activity-related affect influences perceived
self-efficacy, which means the more positive
the subjective feeling, the greater the feeling
of efficacy. In turn, increased feelings of
efficacy can generate further positive affect.
HPM Concepts/Definitions Continued
INTERPERSONAL INFLUENCES
– Cognition concerning behaviors, beliefs, or
attitudes of the others. Interpersonal
influences include: norms (expectations of
significant others), social support
(instrumental and emotional encouragement)
and modeling (vicarious learning through
observing others engaged in a particular
behavior).
– Primary sources of interpersonal influences
are families, peers, and healthcare providers.
HPM Concepts/Definitions Continued
SITUATIONAL INFLUENCES
– Personal perceptions and cognitions of any
given situation or context that can facilitate or
impede behavior.
– Situational influences may have direct or
indirect influences on health behavior.
HPM Behavioral Outcomes
COMMITMENT TO PLAN OF ACTION
– The concept of intention and identification of a planned strategy
leads to implementation of health behavior.
IMMEDIATE COMPETING DEMANDS AND PREFERENCES
– Competing demands are those alternative behavior over which
individuals have low control because there are environmental
contingencies such as work or family care responsibilities.
– Competing preferences are alternative behavior over which
individuals exert relatively high control, such as choice of ice
cream or apple for a snack
HEALTH PROMOTING BEHAVIOUR
– Endpoint or action outcome directed toward attaining positive
health outcome such as optimal well-being, personal fulfillment,
and productive living.
HPM References
Marriner TA, Raile AM. Nursing theorists and their work. 5th ed.
Sakraida T.Nola J. Pender. The Health Promotion Model. St Louis:
Mosby; 2005
Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed.
Philadelphia: Lippincott Williams & Wilkins; 2007
Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed.
Philadelphia: Elsevier Mosby; 2006.
Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis:
Elsevier Mosby; 2006.
Motivational Interviewing
KEY TEXT:
Miller, WR & Rollnick, S. (2013).
Motivational Interviewing: Helping
People Change, Third Edition. New
York: The Guilford Press.
Motivational Interviewing
Overall style of MI is one of guiding, which
lies between and incorporates elements of
directing and following styles.
Involves attention to natural language
about change, with implications for how to
have more effective conversations about
it, particularly in contexts where one
person is acting as a helping professional
for another.
MI Definition
A collaborative, goal-oriented style of
communication with particular attention to
the language of change.
Designed to strengthen personal
motivation for and commitment to a
specific goal by eliciting and exploring the
person’s own reasons for change within an
atmosphere of acceptance and
compassion.
Motivational Interviewing
Key Points
Ambivalence is a normal part of preparing
for change and a place where a person
can remain stuck for some time.
When a provider uses a directing style and
argues for change with a person who is
ambivalent, it naturally brings out the
person’s opposite arguments.
People are more likely to be persuaded by
what they hear themselves say.
Methods of MI
Engaging
– Process of establishing a helpful connection and working
relationship.
Focusing
– Process by which you develop and maintain a specific
direction in the conversation about change.
Evoking
– Process that involves eliciting the client’s own motivations
for change and lies at the heart of MI
Planning
– Process that encompasses both developing commitment
to change and formulating a concrete plan of action.
MI Five Key
Communication Skills
Open Questions
– Offers the client broad latitude and choice in how to respond
Affirming
– Interviewer statement valuing a positive client attribute or
behavior
Reflecting
– Interviewer statement intended to mirror meaning (explicit or
implicit) of preceding client speech
Summarizing
– Reflection that draws together content from two or more prior client statements
Providing Information and Advice – with Permission
– Information is offered when given permission with the understanding that the
patient is always free to agree or not, heed or not, implement or not, and it is
often useful to acknowledge this directly.