Joumal of Advanced Nursing,

1992,17,1291-1296

Health promotion in primary care: taking account of the patient's point of view Michael F Kelly BA(Hons) MPhil PhD Senior Lechtrer, Department of Public Health, University of Glasgow, 2 Lilybank Gardens, Glasgow GlZ 8RZ, Scotland

Accepted for publicahon 9 March 1992

KE L L Y M P (1992) Joumal of Advanced Nursmg 1 7 , 1 2 9 1 - I 2 9 6

Health promotion in primary care: taking account of the patient's point of view Some of the difficulties of putting health promotion into practice are considered It IS argued that, in a health promotion mtervention aimed at lifestyle change, three questions need to be considered concemmg the image, the meanmg and the implementation of the programme INTRODUCTION Health promotion has been widely canvassed in recent years as part of a broad move towards prevenhon (Secretary of State for Health 1991) FoUowmg vanous reforms and mitiahves m the Bnhsh National Health Service, many pnmary care teams are presently orgamzmg themselves m ways which will allow the delivery of such mterventions Practice nurses m particular are deeply mvolved in the process The purpose of this paper is to draw attention to the idea that health promotion mterventions such as opportunistic screening, provision of prachce leaflets, immunization and cervical sereemng campaigns, provision of weU person clinics and coronary heart disease prevention achvities all need to take some account of the patient's perspechve Without consideration of the patient's perspective, there may be important umntended consequences of such mtervenhons which may negate and reduce their effechveness In order to clanfy this argument, three elements associated with health promotion interventions are considered, these are image, meaning and implementahon The underlying philosophy which informs this paper is denved firom the phenomenological work of Schutz (1953, 1970) The insights from phenomenology are extremely helpful m dealing with the perspective of lay people The major focus of this paper is health promohon interventions concemed with lifestyle changes relating to identified nsk factors It is acknowledged, of course, that health promohon may be defined more broadly than just

lifestyle mterventions (Dowme et al 1989) and that the factors which lmpmge on health are wider than those which fall under the umbreUa of 'lifestyles' (Kelly 1989, Strong 1990, Whitehead 1987) However, because of the important emphasis in the recent reforms on lifestyle factors it IS worth exammmg the special problems attachmg thereto

IMAGES AU health promotion activity has or creates images among its actual and potenhal reapients Images may be mtended, or unmtended The term 'image' is used here both to mean something visual as weU as somethmg less concrete such as an idea, or a concept Much health promotion matenal IS deliberately loaded with visucJ images This is most obviously true m the case of thmgs like leaflet lUustrahons, posters and television commercials Visuals are also evident in broader-based campaigns too Most selfrespectmg coronary heart disease prevenhon programmes, for example, have carefuUy designed logos Corporate imagery and assoaated pubbc relations are integral to a great deal of health promotion Indeed, market research is rouhnely used at national level to evaluate health promotion programmes, and to collect data about the general public's awareness of expliat logos and the penetration of iniagery (Leathar 1987) The queshon of imagery goes further than particular visual graphics or design, however Imagery is also concemed with the textual and/or deeper ideas people have m 1291

MP Kelly their mmds Thus a piece of campaign matenal which encourages people to 'be better hearted' or 'be good hearted' may carry a freight of umntended imagery For some people the word 'heart' may be associated with anatomy, death and dissection — perhaps highly negahve connotations These sorts of thmgs are to some extent highly personal and idiosyncratic and will reflect personality and previous soaal expenence They cire impossible to control for m the recipient population and what may appear to be a highly positive image from the health promoter's point of view may be extremely negative from the recipient's standpoint Worrying about such matters is not usually the province of the pnmary care team However, because human bemgs bve m a world of imagery, expertly produced on television and video and in the arts and saences of advertising and marketing, the importance of imagery carmot be ignored once the pnmary care team becomes involved m health promotion All health promotion activities, great or small, carry their own images (intended or umntended) Any member of the pnmary care team doing a health promotion activity IS creatmg or reinforcing particular positive, negahve or benign imagery The average practice preparmg a pnmary care practice leaflet or putting up a poster m a patient waitmg area to invite people for screening cannot employ Madison Avenue copywnters to design their matenals However, that in itself does not stop the imaging effect of local efforts Neither does it stop individuals drawmg particular and idiosyncratic umntended messages

and the North Amencan images remind me of violent gangster movies or television senes, my interpretation may be extremely negative In similar vein, a newspaper campaign by an environmental group using mtended images of bttle furry creatures to represent the endangered planet may spark off my phobia about mice A campaign by an oil company to teU me that they care for me as a motonst because they have just modemized all their filling stations m a tasteful, environmentally fnendly green baffles me, so at best I am neutral towards it The important point is that meaning is as much a quality of the perceiving subject as it is of the object which is being perceived The manner and context of its presentation may affect the image but the interpretative element on the part of the receiver is the key to meamng Consequently, the meamng which people denve from particular images cannot be predicted in any easy way Certain pattems of responses might be discemed if psychometnc questionnaires are used to assess them But in real bfe, as opposed to the world of questionnaire design, people's concepts, ideas and interpretative sblls are highly vanable Most individuals do not think logically most of the time because, for the most pairt, they do not need to Thus their mterpretative activities are highly mdividual Impacts defined m this sense cannot be easily predicted on the basis of some cause and effect model (McQuail 1972) Rather, a range of possible interpretative activities need to be anticipated

MEANING A sbghtly different although related idea is that of meaning Images may be stnbng or they may be bland What the concept of mearung is concemed with are the subjechve processes of mterpretation and understanding by the reapients of the images As was argued m the previous section, we are surrounded by a world of images some of which are deliberately mampulated in order to change us or to entertain us Meanmg is defined here as concemed with the extent to which the individual receiving the image interprets it, as good or bad, positive or negative, warm or hostile For example, I may see an advertisement on television which seUs me an airline as fnendly, welcommg and fun to fly with The adverhsement contains a bttle story to the effect that people having flown from London to Canada have enjoyed their flight so much that they do not want to disembark from the aeroplane The adverhsement m queshon IS fuU of intended warm, homely images However, if the thought of gomg on an aeroplane fills me with terror. 1292

Appraisal and interpretation Meamng is about the process of appraisal and mterpretahon The position advanced m this paper is that while appraisal processes are extremely difficult to predict, and simple models of cause and effect are mappropnate, there is nevertheless a relahvely simple way to develop an awareness of the problem This involves takmg an openly and questioning and cntical stance to what we do m any health promotion mtervention We operate as health professionals with aU manner of assumptions and unwntten rules in what we do, as do all occupational groups One of the most central such assumptions is a belief m the value of health The assumphon that health is good and ill health bad is, however, an assumption Inter alia, that preventing lU health is a worthwhile thmg to do IS also an assumption or a value which may not be shared by the population at large For some people, routme mtoxication with alcohol at levels weU beyond anythmg remotely safe may contnbute to a

Health promotion m pnmary care

posihve quabty of bfe (Hunt & Macleod 1987) Some people enjoy being drunk We may feel sorry for them or despise them for it, or note the pathological sequelae of the behaviour, but the central role of the enjoyment of intoxication in people's lives is what is significant Thinking of another example, nsk tabng may look foolish when viewedfiroma statistical point of view, but to the risk taker — whether it be on the road, in bed, or in respect of hazardous industnal substances — the activity may be exciting and glamorous In a related, if inverse vein, the idea that certam types of protective behaviour like lmmumzahon, using condoms and not smoking are healthy and worthwhile things to do assumes people believe that their, or their children's health, IS worth protecting It is, of course, also the case that individuals may lay great stress on prevention for themselves and their family, but because of their personal arcumstances, and/or because of competing pnonhes, they are unable to translate this into behaviour (Kelly 1990) This IS not to argue that we should abandon rational health preservation strategies because we have no way of predicting the meanmg that people will take from what we do Rather, it means that when a strategy is planned, whether it is screening, immunization or the production of posters about weight reduction classes, the values which underpin the campaign must be clear m the mmds of the people doing the intervention and the bnds of ideas in individual's heads which may interpret these thmgs must be considered

Specific campaigns In terms of a specific campaign or mitiahve, three simple queshons for discussion among the prachce team can help m this respect The three questions are who? what? and why? The answers to each of these help to elucidate the values of the team and also help to get a perspechve on the clients' viewpoints Who IS our intervention aimed at, l e which particular members of the practice population — individuals at high nsk, or all members of the practice population, speafic categones of people, young, old, women, dnnkers, smokers, chronically lU, or whom? What IS the purpose of this mtervenhon? Is it to effect change, if so in what — in knowledge, in athtudes, in intenhons, or m behaviour itself^ What do we know about the knowledge, athtudes, intentions and behaviours of our client group, and how much do we intend to change it? What wiU be our client group's views once we try to change them? Will they be recephve or hostile?

Why IS it important to do these thmgs? Is there a sound basis epidemiologically, statisticaUy, climcaUy or behaviourally to what is proposed? This is particularly important For example, how weU thought out is our coronary heart disease prevention programme? Is it a highnsk approach? Is it a mass approach? Are we certain our preferred strategy is appropnate? Even assuming we know why we want to effect change, and assummg we can take our patients with us, will they be m a position to go in the direction we want them to? WiU they have the resources to do so? This bst of questions is simple, but the answer to the questions raises some fundamental pomts which should be thoroughly aired

IMPLEMENTATION It IS not suffiaent to assume that the existence of a programme wiU in itself alter things A useful way to think about this IS in terms of the so-called stress-copmg paradigm (Lazarus 1976, 1980) The stress-copmg paradigm states the foUowmg Stress is not a quality in an object — say a snarling dog, a man wieldmg a knife, a diagnosis of cancer, or the loss of a job Stress denves from the interpretations put on the phenomenon by the perceiving or receiving subject Thus, if I am confronted by a snarling dog as I enter a darkened house, my reaction will be very different if I am a burglar or if I £im the dog's owner who, with the command 'Good boy. Rover', can get the dog to sit quietly by my side Likewise, whether the man wielding the kmfe is an actor on the stage in a play at the theatre where I am a member of the audience, or if he is a man I meet as I tum a comer on the way home from the theatre, wiU have very different stressful potentials Whether the diagnosis of cancer is m myself or is in one of my patients wiU likewise have very difiFerent connotations To deal with this, the stress-coping paradigm states that copmg with somethmg involves two separate cognihve processes The first is called pnmary appraisal, the second is called secondary appraisal Pnmary appraisal may be illustrated as foUows When an individual is confronted by a stimulus he or she may appraise it as positive (I see a longlost fnend), as benign or of no significance (I heeir a barbng dog m the distance), or as stressful (the dog is sneirbng outside my office door apparently barbng mad) If the situation IS stressful this means I have appraised the presence of the dog as something which represents harm, threat (anticipated harm), loss, or something I see as a challenge to which I can respond m a way that is self-developing For the metaphoncal dog subshtute a health promohon campaign designed to 'mcrease mformation and change 1293

MP Kelly behaviour' It does so by teUmg people how much danger there is to themselves and to others if they smoke, it does so by screerung them for evidence of malignancy or givmg them a cholesterol score which is high, or it informs them that misusing drugs wiU bU them In each of these arcumstances, a situation has been set up debberately to create images which have meanmgs which are stressful, fiightening or alarming In terms of the stress-copmg paradigm this is the process of pnmary appraisal A favounte nostrum of health education is that fear does not work as a means of behaviour change The reasons for this are easy to discem If a stressful or fearful image is created without explanation as to how to deal with the problem, the audience becomes defensive and they selectively perceive — 'Oh, it won't happen to me' They then find reasons to disregard the message — 'The experts all disagree anyway, what can you eat these days?' 'My granny smoked tiU she was 90, then she died because she was run over by a tram' Or they deny it altogether This IS where the secondary appraisal comes mto operahon Secondary appraisal is the process of deciding what can be done about the situation once it is defined as stressful If I deade the snarbng dog can be dealt with by some resource that I have to hand, a stick, a gun or my charm and personabty, then I cope by bnngmg these resources to bear Altemahvely, I might cope by putting a heavy object up agamst the door and shoutmg for help from my wmdow EquaUy I may cope by saymg prayers Indeed I nught try aU these strategies Copmg mvolves usmg sbUs or resources to solve the problem In the stress-copmg paradigm, pnmary appraisal deals with the question 'What is the nature of the danger to me of this stimulus?' Secondary appraisal is about the queshon 'What can I do about it?' Pnmary appraisal is about the stress part of the paradigm, secondary appraisal IS about the copmg part of the paradigm

threat Intimidatmg motonsts with greater and greater penalties for drmk-dnvmg, without offenng an infrastructure of reliable public transport, is not only pointless but only deals with half the problem TeUmg young people not to experiment with drugs without offenng skills trammg on how they might extncate themselves from situations where there is pressure from the f)eer group, is similarly unhelpful Sereemng without support, counseUing and explanations IS not just unhelpful, arguably it is a form of cruelty (Marteau 1989, 1990) Advismg parents of the benefits of immunization with the infra-structure to help mothers to get children to surgenes is again only dealmg with part of the problem Technical help In this context it is helpful to thmk of coping sbUs and copmg resources as bemg of four bnds Coping may first be purely a technical matter It may be about physical objects and thmgs, and about changing them in some way It IS about acting on the environment directly and achvely Advice on how to use and wear a condom, advice on how to do a breast self-examination, advice on funchonal altemahves to nicotme, provision of late-night bus services m the case of dnnk-dnvmg, advice on the techmcal aspects of coobng and prepanng food m ways which are nutnhous and low m cholesterol, advice on how to do basic exercises for fitness and teachmg breast feedmg are aU of this type of resource or sbU

Organization of institutions

The second type of sbU is at the institutional or orgamzahonal level Self-evidently, human bemgs do not live in self-contamed vacuums, they relate constantly to each other Interaction takes place m many arcumstances and mstitutions m factones, offices, shops, discos, school Translated into health education playgrounds, and so on lnshtutions themselves can be structured m ways which Translated into health education and health promotion and m terms of implementation, the paradigm works as foUows make them more or less conduave to health What is meant If an mtervention creates stress or threat (debberately and here is that if the places where we work, play and travel are legitimately, as in an anh-smokmg or a dnnk/dnving cam- arranged m ways which make health-damagmg behaviour paign, or madvertently m a breast screenmg programme), inevitable, what chance health promotion? We need look no further than our own professional then only half of the programme has been implemented If no means of dealmg with the threat is provided at the same worbng bves to see the problem Is the average hospital hme, the reapients wiU not necessanly have the sbUs for organized m ways which maximize or nummize stress? How much of our woriang lives are spent sorting out the secondary appraisal More preasely, messages about the numbers of deaths vaganes of mshtuhons, dealmg with apparently mefiliaent firom lung cancer create the threat Systemahc help on how admimstrahon and uncomprehending management? Are to give up smobng deals with the way to cope with the the work pattems of health service staff conduave to the 1294

Health promohon m pnmary care

health of the staff? Frequently they are not More generaUy, worbng and home environments contain things within them which create rather than mibtate against stress Interpersonal skills The third level concems mterpersonai sbUs If we are going to make a commitment to stopping children from ever starting to smoke, we need to be able to equip them with the interpersonal sbUs of what to do when they are offered a cigarette and there is peer pressure to accept Similarly, if the project is to encourage safer sexual practices, the sbUs required need to be rehearsed long before people get close to mabng love If the sbll we want to teach is self-examination, or more broadly self-screening for symptoms of all bnds, we need to be able to get at that cnhcal point at which the selfscreeners make a putative self-diagnosis but then decide to delay because they are fnghtened that their self-diagnosis wiU be confirmed If we wish to encourage parents to get their children immunized but do not deal with parental fears of side-effects (other than by dismissing them), then we are failing our subjects

Language The fourth level of sblls are conceptual and linguistic Earlier m the paper it was suggested that it was difificult, not to say impossible, to get at people's subjective interpretative processes That remains true However, that is not to argue that people's interpretative processes, and the ways m which people make thmgs meanmgful, are not amenable to influence by others Far from it The whole process of education is based on the assumption that it is possible to change the way people think and perceive thmgs, by providing them with concepts and a language to descnbe the concepts Translated mto the world of health educahon/promohon, the argument is that language, the way thmgs are descnbed, provides the basis for the ways m which people make sense of and understand thmgs It is the way the world is given meaning The basic messages about health and the things which damage it may well be at odds with many people's common-sense expenence of the world, but people's common-sense expenences can be altered by saenhfic or other evidence Only very few Westem adults entertain the belief that the world is flat and that the sun moves through the sky Physics teUs us that the world is roughly sphencal and that that sphere is spinmng in space around the sun Our everyday common-sense expenences of our environment contradict the saentific argument, yet most

people bebeve the scientific version rather than the common-sense version The fact is that because we cannot expenence the world we have to rely on others to provide us with the ways of t3^ifymg, explaining and rendenng meamngful that part of the world that we do not know for ourselves The health education/health promotion sbU is m the language, the concepts and the items which we use to descnbe the world Images Neglect of this important element bnngs us back to the question of images Words as much as visual images are part of our symbolic battery and m many ways more important because they provide us with the vocabulary with which to account for and explam things (MiUs 1940) As such, they are the basis of human mohves Motivation is not some a pnon sprmg to action, motive is a before and after the event verbal justificahon for doing things m parhcular ways and it is about findmg reasons for not doing others In the context of health education and promohon, motive IS about findmg reasons for stopping smobng, reducing alcohol consumption, for takmg children to be immunized, for restnctmg sexual partnerships and abandonmg casual sex altogether It is about bemg vigilant m respect of body signs Motive IS also about finding reasons for continuing to smoke ('I like it, it is one of my few pleasures'), about continuing to dnnk heavily ('I enjoy it, I dnnk less than my doctor, everythmg is bad for you these days'), for not practismg safer sex (That's for fames', 'people like me don't get pregnant'), for not tabng children to be immunized (They say that whooping cough vaccine bUs the wee ones'), etc, etc Health education/promotion is, m this sense, an agenda setter, or a concept provider and a reason giver Through the practice of the achvity, the concepts and words we use wiU provide people both with a set of ideas and concepts about health and its protection and also a set of reasons, rhetoncs or vocabulanes for domg or not domg those things which wiU promote or damage their health

CONCLUSION The discussion in this paper has highlighted the fact that it IS important to consider three elements involved in a health-promotion mtervention aimed at lifestyle change The first is the image or imagery associated with particular mtervenhons This applies equaUy weU whether the intervention IS a national advertising campaign (where it will 1295

MP Kelly happen routinely) or whether it is a local practice leaflet for a weU woman dime Images m people's heads may be very different from those planned by the health educators and promoters The second issue is that aU health promotion educahon uiihahves need to consider the queshon of meanmg The danger is to assume that the meaning ascnbed by the health educator/pronrater is the same as that of the target It might be, but it cannot be assumed to be so So not only must the health promoter or educator consider in detail the bnds of meanmgs and assumptions the lay pubbc gave to particular thmgs, but also their own professional and lay assumphons need to be made expbat FmaUy, if we assume that images do create the desired meamng, the issue of implementahon involves thinbng of implementation as a dual process If the mtervention IS regarded as a stimulus we need to know whether the stimulus creates a threat or is regarded as bemgn, posihve or irrelevant If it is regarded as a threat we must also provide people with the sblls — techmcal, orgamzahonal, and conceptual/linguishc — to handle that threat

Acknowledgements The author wishes to thank Jim McEwen, Andrew and Carol TannahiU and Norah Adams for help and advice

References Dowme R, Fyfe C & TannahiU A (1989) Health Promohon Oxford University Press, London Hunt S & Madeod M (1987) Health and behavioural change Community Medicine 9,68—76

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KeUy M P (1989) Some probl«ns of health promotion research. Health Promohon 4,317-330 Kelly M P (1990) Behavioural change and the stress coping paradigm some conunents on modeUmg the European Code on avoiding cancer Joumal of Public Health Mediane 12, 105-108 Lazarus R (1976) Pattems of Adjustment 3rd edn McGraw Hill, New York Lazarus R (1980) The stress and coping paradigm In Competence and Copmg Dunng Adulthood (Bond L & Rosen J eds), University Press of New England, New Hampshire Leathar D (1987) The development and assessment of mass media campaigns Joumal of the Instthite of Health Educahon 125, 65-72 McQuail D (ed) (1972) Soaology of Mass Commumcations Penguin, Harmondsworth Marteau T (1989) Psychological costs of screening Bnhsh Medical Joumal 299, 527 Marteau T (1990) Reduong the psychological costs Bntish Medical Joumal 301, 26-28 MiUs C W (1940) Situated achons and vocubulanes of motive Amencan Soaological Review 5, 904-913 Schutz A (1953) Common sense and saenhfic interpretation of human action Philosophy and Phenomenological Research 14, 1-37 Schutz A (1970) On Phenomenology and Soaal Relahons University of Chicago Press, Chicago Secretary of State for Health (1991) The Health of the Nahon A Consultahve Document for Health m England Cm 1523 HMSO, London Sh-ong P (1990) Black on dass and mortabty Joumal of Public Health Mediane 12,168-180 Whitehead M (1987) The Health Divide Inequalities in Health in the 1980s Health Educahon Counal, London

Health promotion in primary care: taking account of the patient's point of view.

Some of the difficulties of putting health promotion into practice are considered. It is argued that, in a health promotion intervention aimed at life...
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