Health Promotion

Whilst on placement on an adult mental health acute ward, I had the chance to participate in health promoting activities. One health promoting activity I took part in was ensuring a safe and effective discharge of a 33 year old patient who had a diagnosis of disorganised schizophrenia, in order to prevent readmission. Mr. Raja (pseudonym) is divorced and lives alone, lacks in family support and is unemployed. He was admitted onto the ward after he had a relapse because he was not taking his medication. Service users who stop their prescribed medication regime are at a greater risk of experiencing a relapse of their mental illness (Carter et al 2003).In this assignment I will be discussing the health promotion aimed at encouraging concordance to medication regime. I shall discus the definition of health and health promotion and also the model of health promotion that best describes the care that was given to the service user. Mr Raja had other noticeable health issues such as overweight and smoking; however this will not be addressed in this essay.
The World Health Organisation (WHO) describes health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 2009). The constitution goes on to explain that the highest achievable standard of health is one of the basic rights of every human being without distinction of race, religion, and political belief, economic or social condition (WHO 2009).
Hubley and Copeman (2008) illustrate that this description of health is multi-dimensional, in that it is not exclusively concerned with physical health, but also takes into account mental, social, emotional and spiritual health. The W.H.O. definition of health would suggest that Mr Raja is not in good health because he is suffering from both mental and physical health problems lacking social activity as well. Physical health and mental health impact on each other and their relationship can also affect the beginning, course and outcome of each (Green and Tones 2010). Green and Tones (2010) states that controlling the outcome of both physical and mental well-being, with clients having a sense of control, optimism and meaning, protecting both mental and physical health is essential to health.
The negative aspects of W.H.O. definition of health is that it is totally unrealistic because it implies that anyone with any kind of defect cannot say they are healthy, e.g. a person wearing glasses or an amputee (Green and Tones 2010). In support of this argument Ewles and Simnett (1995) suggest that the W.H.O. definition is very exclusive in that it excludes so many people from ever achieving state of health. Ewles and Simnett (1995) also go on to ask how anyone can define health for such a large population when health means different things to different people.
Health promotion is defined as “the process of enabling people to increase control over, and to improve, their health” (Ottawa Charter for Health Promotion, 1986). Green and Tones (2010) illustrates that according to (WHO, 1984) “Health promotion represents a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health to create a healthier future”.
Green and Tones (2010) believes that health promotion should include any initiative which seeks to promote health or prevents disease, disability and premature death. Its objective is to prolong life and to improve quality of life, that is to prevent or reduce the effects of impaired physical or mental health on those individuals who are directly (e.g. patients) or indirectly (e.g. carers) affected. Naidoo and Wills (1998) illustrates that nurses, midwives and health visitors should integrate into their professional care, whether in hospital or community, activities connected to the promotion of health, prevention of disease, and an approach which encourages individuals to take responsibility for their own health. Lord Darzi (2008) recommended that the NHS should be equally active in promoting good health as it is in treating disease and therefore modern nurses require knowledge of effective health education materials to enhance health promotion.
Critics of health promotion state that programs and models aimed at improving health are too focused on individual lifestyle changes as an ultimate goal and do not address the cultural, economic and social concerns often associated with ill-health within the greater society (Green and Tones 2010).
Harris et al (2009) argues that people with schizophrenia have a chronic condition which, for many requires daily medication in order to keep up mental wellness. In this perspective, good mental health improves the person's quality of life (Harris et al 2009). Sticking to a daily medication regime entails the individual to develop behaviour which supports it. In that context, medication concordance can be seen as a health-promoting behaviour (Norman and Ryrie 2009).
The major health promotion activity that related to Mr Raja was when the staff nurse was giving him advice on the importance of taking his medication in order to avoid a relapse and to encourage concordance to medication (Norman and Ryrie 2009). Research evidence suggests that antipsychotic medication reduces the positive symptoms of psychosis, such as hallucinations and delusions, and if taken continuously may prevent these symptoms returning (Harris et al 2009). Because of Mr Raja’s condition Harris et al (2009) suggests that Mr Raja had to be educated on symptoms, effects and treatments.
They are a number different models of health promotion, for the purpose of this submission I consulted the educational approach by Ewles and Simnett (2003) and Janz and Baker Health Belief model 1984, of health promotion which I think best describes the health promotion activity conducted by the named nurse for Mr Raja who was not adhering to his medication regimes.
Concordance describes a partnership approach to medicine prescribing and taking (Marinker 1997). It is different from 'compliance', which describes the patient's medicine taking in relation to the prescriber's instructions (Harris et al 2009). Given the necessity of therapeutic agreement, the term compliance has given way to adherence and concordance (Marinker 1997). According to Carter et al (2003) concordance recognises that Mr Raja had to make his own decisions about whether or not to take a prescribed treatment and acknowledges that by well-informing Mr Raja they would be a possibility that he would adhere to treatment after learning about the relative benefits and risks. Patients who have been involved in making a decision about their treatment are more likely to be committed to taking their medicine (Carter et al 2003).
According to the Health Belief Model (HBM) Mr Raja’s readiness to take action depends on his perceived seriousness and susceptibility of illness, vulnerability to relapse and perceived benefits and barriers of taking his medication (Hubley and Copeman 2008). In general Glanz et al (2002) suggest that people will take action to prevent, or to control unhealthy conditions if individuals regard themselves as susceptible to the condition; if a person believes it will have serious consequences; if the individual believes that a course of action available to them would be beneficial in reducing either their susceptibility or to the severity of the condition; if a person believes that the anticipated barriers to taking action are outweighed by the benefits and if they are confident in their own ability to take action.
Perceived susceptibility suggests that the staff nurse convinced Mr Raja to accept that his condition was serious and made him believe that he was at risk of psychotic breakdown. Denial of the diagnosis can be a major obstacle to concordance. It was important for the staff nurse to establish how Mr Raja felt about his condition (Carter et al 2003). Anger about the diagnosis or secondary gain related to attention generated by missing doses can also impact on concordance (Carter et al 2003). The staff nurse engaged Mr Raja in a professional manner showing empathy and understanding the service user’s situation. According to Harris et al (2009) professional-patient interactions based on sharing, respect, agreement on roles, rights and responsibilities and mutually set goals are critical. Harris et al (2009) illustrates that patients should be treated as equal partners in their care. According to Carter et al (2003) many patients reported that the way they are treated by their health professional has a great impact on whether or not they follow medical advice.
Mr Raja received a pamphlet explaining his rights and responsibilities as a patient and other information about schizophrenia. He was constantly encouraged to share opinions and raise questions and was reminded that he was the ultimate decision maker in the relationship.
Self-efficacy involved instilling confidence in Mr Raja assuring him that he was capable of managing his medication regime. By making Mr Raja feel self-confident, Harris et al (2009) argues that Mr Raja was more likely to be able to cope with and continue with adhering behaviour.
Since Mr Raja was not in good books with the members of his family, the staff nurse managed to convince the family to get involved in Mr Raja’s care. The family members were present in ward rounds and were involved in decision making about Mr Raja. Including the patient and family in decision making values the patient as an individual, improves their self-esteem and increases the patient’s chances to continue medication adherence (Harris et al 2009). When counselling the patient or family it is useful to offer a number of suggestions for methods which will increase concordance and then allow them to choose which method to adopt (Harris et al 2009).
Perceived barriers to health-promoting behaviours illustrates that the presence of medication side effects in schizophrenia is consistently reported as a major cause of none concordance with medication (Harris et al 2009). On the ward Mr Raja stated that the Clozapine he was taking was making him feel drowsy all the time and that he was finding it difficult to cope. Mr Raja was also gaining weight because of the medication he was taking. He referred to this as the main reason for not sticking to his medication regime which led to his readmission. According to Healy (2005) weight gain and drowsiness are some of the side effects of taking Clozapine.
The staff nurse reassured Mr Raja that sedation in the first couple of weeks of treatment may be expected and tolerance will develop. It was explained to him that if symptoms continued the nurse would consider changing the dose to a lower dose or changing the time for medication, for instance Mr Raja will take his medication when he is going to sleep. Changing the medication to a less sedative drug or a depot which he would get once a month were another options that were presented to Mr Raja.
According to Mitchell and Selmes (2007), weight gain due to medication has been linked with non-adherence and subjective distress (Fakhoury et al 2001). Weiden et al (2004) suggested that obese individuals are more than twice as likely as those with a normal body mass index to miss their medication cited in Mitchell and Selmes (2007). Research done by Fakhoury (1999) found that more than 70% of patients described weight gain due to antipsychotics as extremely distressing, which was higher than that for any other side-effect (Mitchell and Selmes 2007).
A study by Rosenheck et al cited in Mitchell and Selmes (2007) found that 68% of patients treated with haloperidol and 43% of those treated with Clozapine had discontinued medication before the end of a one year trial. In the 18th month Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study by Lieberman et al (2005) a remarkable 74% of patients discontinued medication prematurely. The most common reasons for discontinuation were patient choice, lack of effect or intolerability of side-effects.
According to Glanz et al (2002) the educational approach supplied Mr Raja with relevant information and to gather knowledge and understanding of a health issue. As from this point Mr Raja was able to make informed decisions. Norman and Ryrie (2009) suggest that patient education can help to engage patients, improve acceptance and integration of the illness and promote appropriate use of drug therapy with the purpose of increasing understanding and promoting concordance. Glanz et al (2002) also argues that the educational approach respects the client as an individual and empowers the client to make decisions towards their own health.
Education was particularly useful for Mr Raja, not only with regard to the issue of concordance with medication, but also with the whole question of his mental health (Norman and Ryrie 2009). The education approach comes with an assumption that with the relevant information people will make the right choice, however as stated before external factors have an influence on this decision making process (Naidoo & Wills, 2009). According to Naidoo and Wills (2000) learning involves three psychological aspects, cognitive, affective and behavioural. Information is not enough to change a client’s lifestyle. It is important that information giver understands the learning process and the factors that help or hinder learning (Naidoo & Wills, 2000).
Mr Raja was supplied with information concerning his medication which facilitated positive health promotion, not just in better management of the underlying diagnosis but also allowing Mr Raja a greater understanding of side effects and how best to manage them (Norman and Ryrie 2009). Providing instructions or teaching skills that may make medication adherence easier and less demanding is also helpful (Harris et al 2009). Good communication that was between Mr Raja and the staff nurse, getting family members involved, and behaviourally focused interventions such as reinforcing and encouraging Mr Raja specific medication-taking patterns improved Mr Raja’s adherence and concordance to medication (Harris et al 2009).
In conclusion the health promotion models applied in this submission allows for a rapid assessment of behavioural factors which influence concordance. It facilitates identification of a patient's strengths and weaknesses so the plan will be tailored to the individual patient's needs and can easily be implemented by a nurse in a clinical setting. This submission has addressed concordance as a process which may affect behaviour and can be described by the models I have discussed. Concordance therefore can be understood using health promotion models that assess the process of interaction between patient and clinician. Norman and Ryrie (2009) illustrates that, it is important for clinicians to determine the specific reasons for poor adherence and then tailor treatment and other interventions accordingly.

References
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