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International Journal of Nursing Studies 41 (2004) 163–172
How effective are health education programmes—resistance, reactance, rationality and risk? Recommendations for effective practice
Dean Whiteheada,*, Graham Russellb
Institute of Health Studies (Exeter), Faculty of Health, University of Plymouth, Veysey Building, Earl Richards Road North, Exeter, Devon EX2 6AS, UK b Faculty of Health, University of Plymouth, Reynolds Building, Drakes Circus, Plymouth, Devon, UK Received 3 February 2003; accepted 9 June 2003
Abstract Behavioural-change-related health education programmes represent a mainstay of health care activity. Where adopted, however, the theoretical and practical constructs and constraints are not always considered. The failure of many health education programmes to achieve their intended life-style-related behavioural-change outcomes is often directly related to the complexity of the task itself. Changing a client’s health behaviour is notoriously difﬁcult and requires concerted and systematic activities to ensure any measure of success. This article draws upon existing literature to develop a critical theoretical and practical perspective for health education practice in nursing. It aims to explore the underpinning theoretical considerations for undertaking behavioural-change health education programmes. This article also proposes speciﬁc recommendations for nurse’s current and future health education practice, as a means for facilitating a more structured approach to health education programme planning and evaluation. r 2003 Elsevier Ltd. All rights reserved.
Keywords: Health education; Preventative health behaviour; Behaviour change; Social-cognitive theory; Health promotion
1. Introduction Effective health education programmes are highly dependent on the way that they are delivered and the nature of their intention. The vast majority of nursingrelated health interventions are centred on ‘traditional’ behavioural-change health education activities (Norton, 1998; Whitehead, 2001a). The last decade or so has witnessed calls for nurses to increase their preventative health education activity, but this has not always been the case (Sheahan, 2000; Whitehead, 2001b). This
*Corresponding author. Tel.: +44-1392-475-155; fax: +441392-475-151. E-mail addresses: email@example.com (D. Whitehead), firstname.lastname@example.org (G. Russell).
underlies the fact that socio-cognitive behaviouralchange programmes are notoriously complex, problematical and, more often than not, are unsuccessful. It appears that many nurses base their health education practice on the assumption that individuals can alter their health behaviour as a part of a relatively easy behavioural-change process. It is also sometimes believed that behavioural-change programmes can be easily accommodated within the considerable constraints of a nursing role, whilst not taking into account the scale and the complexity of the task at hand. Often the main factor that is not considered is that individual clients may not be in a position to alter their behaviour or simply do not want to. This is not to say that nurses should not attempt to incorporate behaviourally focused health education activities into their practice
0020-7489/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00117-2
How achievable are behavioural-change health education programmes? Research consistently demonstrates that the importance that clients attach to their health status plays a major role in guiding their adoption/non-adoption of a behavioural health change (Callaghan. Many practitioners are yet to move beyond the misconception that behavioural-change strategies are straightforward and uncomplicated. economic and political determinants of health care. based on disease avoidance/ reduction management frameworks. Many nurses mistakenly use the terms health education and health promotion interchangeably (Henshaw. Joffe. Many authors confuse the terms deliberately as part of a semantic tradition. 1999. Traditionally. Deﬁning the terms of health education and health promotion may seem an easy task.
3. on the other hand. this paper seeks to put forward recommendations for the concerted and realistic implementation of successful preventative health education programmes.. 2002). Nearly all the cited references refer to issues surrounding behavioural-change health education activities. Tones and Tilford (1994) use the term radical health education to denote health promotion activity. are associated with the broader empowerment-based and socio-political approaches that concern themselves with communitybased social. the chances of successful outcome are limited (Norton. ‘Fully’ informing individuals about health and health risk does not necessarily lead to a change in health behaviour. that they need to be more conversant with and realistic about the nature and process of their interventions. Added to this. 2002)—this simply cannot be expressed as a guaranteed outcome. Most nurses work within traditional health education behavioural-change frameworks of practice. This is despite the fact that there are profound and distinct differences between the two. This article aims to clarify the theoretical and practical constructs that underpin behavioural-change health education. A more realistic approach lies with the expectation that long-term and sustained behavioural change is often unlikely. given the fact that many leading health promotion academics themselves use the terms interchangeably. but this is deﬁnitely not born out in practice. What is health education? One of the main problems for nursing-related health programmes is that they are often contextually confused. yet many of them confusingly have health promotion in their title. 2000). individualistic and allopathic modes of delivery. For instance. Subsequently. This would help to avoid one of the major criticisms aimed at preventative health education programmes—that of victim-blaming. It would be ethically incorrect to suggest that giving up a healthdamaging behaviour will subsequently result in improved health (Cribb and Duncan. G.
contextual. is the dilemma of promoting the beneﬁts of the change activity. Changing a client’s health-related behaviour is a notoriously problematical and complex task (Lawrence. Equally so. A commitment to modify health behaviour usually equates to the client giving up something that is part of their life-style that they most likely enjoy or is part of their daily routine. 1998) states that health education and health promotion require a broad conceptualisation of theory that recognises that its knowledge-base is contingent and
. Similarly. Even with the most sustained and concerted efforts to implement detailed and focused health education programmes. the nurse is ultimately trying to sell a ‘health product’ that may appear unpalatable or unappealing to the client. Sedlak et al. health education activity is rooted in behavioural-focused medical/preventative health programme interventions. Victim-blaming occurs where the health professional deems that the responsibility for any failure on the part of the client to modify a chosen health behaviour lies solely with the client. (1996) use the term modern health education to describe health promotion activity. For instance. Changing a client’s health behaviour presents a multitude of dilemmas for the nurse. The change process is often perceived as being uncomfortable and involving the loss of a pleasurable/ habitual activity. Whitehead. It is not always helpful that different viewpoints and positions come down to individual perception and interpretation. 2003a). as a means to raise awareness about the nature and reality of its programmes. As such. 1998). most clients are threatened not so much by a possible looming illness. The natural reluctance of individuals to incorporate new health information into their existing cognitive processes means that new information will be at best only slowly incorporated (Dowd.ARTICLE IN PRESS
164 D. 2000). 1998. A case in point leads to the reference list in this article. Russell / International Journal of Nursing Studies 41 (2004) 163–172
environment but. determinate and invariable. It is not surprising that nurses might be contextually confused. Buchanan (1994. but by the forthcoming health change activity itself (Baird. instead. This approach fails to take into account the considerable barriers that the client usually has to overcome with any behavioural-change programme. 2001). Downie et al. Health promotion strategies. rather than broader-ranging health promotion activities (Foster. 1996. Its activities are ﬁrmly rooted within positivist biomedically orientated frameworks that advocate reductionist. 1999). engaging in potentially health-damaging behaviour
2. but useful if it does happen. rather than universal. Whitehead. environmental.
In adopting this approach. Ellis and Beck’s work was effectively compartmentalised and it was some years later before psychologists began to seriously question the assumption that behaviour is principally mediated by rational decision-making processes. 225) highlight the limitations of a ‘simplistic health education mythology’ which assumes that an increase in health knowledge will lead to a shift in attitude which. leaving the client unable to predict potential health outcomes (McCormick. Most of these pre-conceived ideas will have some psychological theoretical construct attached to them.
. These techniques employed basic behavioural principles. Theories of health behaviour As mentioned previously. Evidence suggests that nurses often do not inform clients. 1974. According to the law. Janz and Becker. Even if the behaviour did result in ill-health. this is usually a protracted and on-going process. clients will seek out information from a health professional simply as a means to reinforce their current behaviour. behaviour modiﬁcation was. Whitehead. If this is the case. The theory underpinning behavioural-change health education programmes 4. a phenomenon that could be safely ignored when considering normative behaviour. From the former premise sprang the Health Belief Model (Becker. behaviour change achieved in clinical settings often failed to translate to the wider social environment. p. is met by a barrage of preconceived ideas which mediate the way that the information is interpreted (Joffe. it is perhaps small wonder that the health education activity of nurses has been described as ‘a constrained activity logically limited in its impact’ (Dines. such as those that follow. personality and emotion played a negligible role in determining human behaviour. 2002). 1976. 2002). behaviour modiﬁcation principles remained the dominant theoretical force in the ﬁeld until the development of new ideas in the 1970s led psychologists to focus their attention on the role of cognitions in mediating behaviour. in turn. Rather. while experience in practice settings revealed consistent problems that limited effectiveness. leads to a change in health behaviour. 1980. 1984. principle led to the development of
techniques that are still widely embraced in contemporary behaviour change programmes. They may selectively ‘ﬁlter out’ the information that they do not want to hear and only accept the information that validates their current behaviour. unpredictability and unfamiliarity) is a cognitive state that is created when the client cannot adequately structure an illness event because of the lack of sufﬁcient clues. Programmes designed to facilitate change often proved complex and required a high degree of co-operation between health care staff. even when a client actively seeks out health education advice. Collectively. and is. This. 2000. The development of health belief or social-cognition models can be traced from the early 1970s to the present day (e. 1984). When health information is offered to clients it is known that this information is not simply processed but. 2001). Despite these problems. p. These factors remain common barriers in modern change interventions that utilise behavioural principles. A causal link between health beliefs and health behaviour cannot be assumed (Wilkinson. costs and beneﬁts are considered in a rational. 2002). Rather surprisingly.1. In addition. these models represented an emphatic rejection of the early behaviourists’ insistence that cognitions. In many instances. Yet. or simply do not document their activity when it comes to health education advice (Sheahan. 1974). was founded on the principle that beliefs concerning perceived risk. 1977). G. Viewed historically. instead. the ﬁrst of a series of health behaviour theories. inconsistency. Uncertainty in illness (a mixture of ambiguity. 1985). The original theory speciﬁcally excluded cognitions and emotions from its framework. The offending behaviour was generally bound to an array of variables that positively reinforced behaviour. 1999). A lack of information or misinformation can also prevent behavioural change. 1994.
4. vagueness. Russell / International Journal of Nursing Studies 41 (2004) 163–172 165
need not necessarily result in ill-health (Saraﬁno. Piper and Brown (1998a. Ellis.g. Of particular note was the advent of cognitive therapies for people with mental health problems (Beck. this perspective was not reﬂected in the thinking of mainstream social psychology. may misinform them. Thorndike’s (1989) Law of Effect represented a landmark in the ﬁeld of ‘behaviour modiﬁcation’ as it was then called. Becker. Hence. behaviour is modiﬁed by its consequences and this simple. 2000). Rogers. 225).ARTICLE IN PRESS
D. irrational thinking was characterised as symptomatic of psychiatric disorder. the offered information will usually be ignored or misapplied (Niven. whilst all too often the desired behaviour was associated with negative or aversive outcomes. Henshaw. not without its problems. 1983. Other problems were also revealed. These factors are probably why. formulaic fashion (in much the same way that a chemist might balance positive and negative ions in an equation). but demonstrated that irrational beliefs frequently play a pivotal role in the genesis and perpetuation of dysfunctional emotions and behaviour. who objectively and rationally processed facts (Nisbett and Ross. yet powerful. Rather. Ajzen and Fishbein. individuals were viewed as ‘naive scientists’. behavioural change is difﬁcult to achieve and therefore theorists have developed increasingly complex frameworks in order to understand and predict the key factors that determine change. Prochaska and DiClemente.
risk tends to be over-estimated. G. Miller. Health resistance Under certain circumstances it is known that some clients will actively resist the health messages that are aimed at them by health professionals. characterised by constructs such as denial. Investigators such as Janis and Mann (1975). Whitehead.ARTICLE IN PRESS
166 D. where the patient or client jumps at the ﬁrst available treatment option (Janis and Mann. Conversely. High threat-low success situations can lead to hypervigilance or panic. Nisbett and Ross (1985) and Taylor and Brown (1988) had already shown human decision-making and behaviour to be characterised by an impressive array of cognitive inconsistencies and biases (much as Ellis and Beck had proposed in their mental health work). The ﬁrst category is characterised by commonly occurring biases and failures of logical thinking. repression and downward social comparison (Russell. situational distance from illness lends itself to underestimation of risk. 1982. 1975). exposure to common illnesses leads to the development of schematic models that contain generalised information and beliefs concerning key dimensions. Folkman and Greer. Viewed collectively. which is mediated by schematic beliefs about illness that are linked to personal experience and abstracted knowledge about the nature of symptoms. which stem from the routine use of cognitive heuristics that have evolved to help us manage large amounts of complex information. Other conceptual developments in psychology bolstered the perceived importance of beliefs in decisionmaking processes. cause. which typically occur in response to threat. and ultimately health protective behaviour (Russell. Miller. Of particular note being the concept of schematic processing. These heuristics typically take the form of cognitive ‘rules of thumb’. consider how others might respond to a change in behaviour. such as symptoms. the earlier algorithm of the chemist’s equation is a reasonable way of seeking to understand the potential complexities of behavioural change. Risk perception. these states can have a signiﬁcant impact on the quality and objectivity of decision-making processes that feed behavioural change. That is. The second category of bias is associated with the use of psychological defence mechanisms. which are often over-extended leading to errors in decision-making (Kahneman et al. where there is little or no motivation to absorb new information or consider behaviour change (Lazarus and Folkman. for example. 1984. 1983. 1985). Cohen and Lazarus. vulnerability. Health behaviour and decision-making is inﬂuenced by personal perception of risk. such conditions may foster denial and avoidance.
5. For any given course of action these sociocognitive models predict that individuals rationally balance the potential risks. 1977. duration and treatment (Leventhal et al. bias can be caused by the use of heuristics to deal with complex information or by psychological defence mechanisms that are associated with stressful states that inhibit rational thinking. In considering these factors. when recent events or salient health information focus attentional processes on illness. whilst signiﬁcantly more emphasis was placed on the function of cognitions and beliefs in mediating the process of change. When symptoms deviate from expected patterns. 1984). Rofes (2002)
. the normative attitudes of signiﬁcant others towards the proposed change. the evidence suggests that we should not assume apriori that health decisions are necessarily rationale and objective. According to this approach. These may be regarded as automatic and unconscious attempts to deal with stressful events from which there is no apparent escape (Lazarus. 1989). 1993). Low-cost positive outcome expectancies are associated with problem-solving and change motivation (Bandura. may be disproportionately inﬂuenced by information that is recent. and make a judgement about the perceived likelihood of success or failure. concern is raised leading to increased vigilance. treatments and outcomes. 1983). 2000). is primarily determined by individual judgements relating to risk and outcome expectancies. Russell / International Journal of Nursing Studies 41 (2004) 163–172
the principles of behavioural reinforcement were implicitly accepted.. 1999). The role of these beliefs and cognitions can be summarised by stating that the motivation or intention to engage in behavioural change. 1985). their clinical utility has been questioned on the basis that they fail to take account of irrational beliefs in mediating decisions concerning health. these models did not embrace parallel developments in the ﬁelds of social and cognitive psychology during this important period.. Indeed. Alternatively. 1989. For our purposes we may dissect irrational thought and carve it into two discrete (though not mutually exclusive) categories. In addition. Although these social-cognition models are generally deemed to have good predictive validity (Janz and Becker. and personal beliefs relating to selfefﬁcacy and control. This information is employed in decisionmaking processes to determine the normality or potential seriousness of any given symptom. Nisbett and Ross. Importantly. High costs coupled with negative outcome expectancies lead to engagement in passive or avoidant forms of coping that inhibit behavioural change. available and vivid. This was important because the demonstration of common bias in normative information processing seriously
undermined the proposition that the processes underpinning behavioural change are necessarily objective and rationale. efforts to seek lay or professional help. costs and beneﬁts.
Maddux and Rogers (1983) protection motivation theory determines that the perception of a health threat (risk) is the starting point in any behavioural-change activity. can be interpreted as a violation of a client’s rights. Whitehead. coercive or manipulative. it nevertheless sets the scene for the suggestion that many individuals posses faulty risk assessment capabilities. This is precisely the group of people that health educationalists are often trying to target in terms of health risk. this offers the practitioner a framework for avoiding resistance behaviour where possible. The analogy of telling people ‘not to press the red button’ can be applied here. Russell / International Journal of Nursing Studies 41 (2004) 163–172 167
argues that repeated health education messages. 1997). Joffe (2002) concludes that clients are simultaneously orientated to both health-enhancing forces and a more destructive instinct towards healthdamaging forces. Paradoxically. this type of activity has the potential to induce the individual to
. Gott and O’Brien (1990) found that one of the characteristic dimensions of nursing health education practice was the transmission of information to individuals who were perceived to live ‘in ignorance’ of their health. especially if the message is biased. health risk represents the ‘balancing act’ that individuals have to regularly perform in relation to their health behaviour.ARTICLE IN PRESS
D. whilst Preston’s (1997) study demonstrates that the fear of risk is omnipresent with certain clients. p. Whilst such statements may be over-generalised and emotive.
6. 1997). Crossley (2001a) has developed a speciﬁc scale that is capable of measuring the degree of resistance that an individual may feel towards health education messages within different populations. leading to heightened irritation against the messenger. This is especially so where clients do not want to be perceived as conformists or traditionalists—particularly in the case of many teenagers or young adults. but this is especially so if the health educator adopts a dominant and authoritarian role (Dowd. Consequently. Essentially.ve scientists’ they are. Imposing restrictive. often serve only to irritate or alienate. 2002. Health reactance bears subtle yet distinct differences to health resistance (Dowd. The main difference with reactance is that the individual’s freedom is directly threatened or impinged upon. it may increase the motivation for the individual to actually take up or increase involvement in their unhealthy behaviour. As ‘na. It follows that clients do not always react well to paternalistic and patriarchal health programmes that reduce normal features of the life cycle to a medicalised disease deﬁciency (Henshaw. Interestingly. 154). defensive processing. If the health educator is imposing their health message on someone. Theoretically. Norton (1998) also warns of the problems of presenting health messages as examples of an ‘unmitigated good’. lay people make erroneous assessments of their risks. it appears that individuals over-estimate their potential to overcome any health risk they may encounter. Crossley (2002) asserts that when health messages are portrayed or interpreted as a moral good then clients will resist or rebel against them. This may make the messenger appear to the recipient as being on a moral crusade. In effect. Rhodewalt and Marcroft (1988) proved that Type A coronary-prone individuals are particularly sensitive and actively respond to threats made on their personal control. Health reactance Brehm (1966) originated the theory of psychological reactance. controlling and ‘expert-driven’ health messages will often have this effect. G. Jacks and Devine (2000) similarly suggest that individuals may engage in a process of ‘anticipatory counter-arguing’ even prior to health messages being given. whereas this is not necessarily the case with resistance. 2001). the issue of risk-related health behaviour has dominated health education planning over the years (Preston. In these cases the health educator can inadvertently appear as simply a peddler of healthism for health’s sake. They are repression. On the whole. They cannot do ‘the sums’. All situations have the potential for arousing a reactance response in clients. A reactance response is aimed at recapturing the threatened freedom and preventing the loss of others (Fogarty. Brown (2001) describes four speciﬁc forms of resistance theory that can be used within such a framework. often associated with nurse-led health education interventions.They are ignorant about the effects of the risks they take (Joffe. This has serious implications for the behavioural changes that nurses can realistically expect from their health education practice. 2002). ı unable to think about their probabilities accurately. that individual may feel his or her liberty or freedom has been violated. Health risk Individuals live in a risk-laden society. 2002). Both responses may induce and result in non-compliance. The expert-driven health information.
actively oppose the health intervention. This situation is what Weinstein (1987) refers to as optimistic bias and others more recently term as unrealistic optimism (Taylor and Brown. As noted earlier.
7. It is worth noting that a message that produces a health resistance response may also restrict freedom and initiate a reactance-type response too. which cosset the values of improved health and good behaviour. It is deﬁned as an unwelcome and uncomfortable motivational reaction to the threat or removal of an individual’s freedom to determine his or her own health status. downward comparison and reactance.
Most of the offered recommendations follow the general pattern of concepts and ideas introduced in the main body of the text. in turn. to lessen the likelihood of defensive reactions. Individuals behave within their own socially constructed reality. Whitehead. 1992. Try not to present health information as a ‘moral good’. These recommendations. He argues that this experimentation is not merely about biological function. G. emotionally and spiritually capable of. 2002). whether this is part of a perceived or actual assessment (Wight et al. Health rationality
Individuals cannot be held directly responsible for any health actions that are constrained by inﬂuences beyond their control. Crossley (2002) highlights the fact that clients are now increasingly sceptical about ofﬁcial health messages and are no longer willing to believe them just because they have the authority of an ofﬁcial scientiﬁc/government edit underpinning them. provide informed guidelines for facilitating effective and successful health education practice. 2000). Merely presenting information based on disease risk. Callaghan (1998) highlights the fact that nurses play a signiﬁcant role in determining a client’s health-related behaviour through the social support that they offer. whilst not exhaustive. but not in all cases. This restrictive rationality is then. Ham (1999) argues that health professionals are constrained by a bounded rationality where health decisions are limited by restrictions in information. It is only when we actively listen to a clients interpretation of why they succumb to disease. Fox. some of the above views can appear superﬂuous. Depending on the stance taken. harmfulness or lethality can result in
. leading us on to the notion of health rationality. Subsequently. This reinforces the importance of attending to the client’s health beliefs (Leventhal et al. 1999). but about testing the limits of what our bodies are socially. It suggests that clients do not like to dwell upon the intricacies of health risk. Health professionals do not all behave alike when it comes to demonstrating their our own rationality. Finucane et al. Some nurses will believe that behavioural-change activities are directly underpinned by the rationality of a scientiﬁc biomedical or health policy position. that the nurse can realistically assist the client towards better health (Schickler. Russell. This too may represent a complete misnomer. Risk has been largely co-opted into health education circles as a term reserved for negative or undesirable outcome. Russell / International Journal of Nursing Studies 41 (2004) 163–172
1998. Fox (2002) views risky behaviour as merely an ‘experiment in living’. Joffe (2002) suggests that individuals can also initiate ‘cognitive trickery’ mechanisms. They are as follows:
8. passed on to the client. 1980. alongside their understanding of their social world. what is sufﬁcient and what the timing should be in terms of the health information provided. 2002). it is considered useful to offer a series of recommendations. The recommendations essentially reﬂect the main dilemmas that nurses will face with their behavioural health education activities. This said. Ogden.
Consider ﬁrstly whether the proposed intervention comprises health education or health promotion activity—or both? Clarify what is necessary. in this context. 1999). The extent to which a client can control their risk behaviour is also related to how much control they feel they have over their situation. preferring instead to over-simplify their personal risk assessment. Crossley (2002) actively challenges the idea that risky behaviour is irrational.. Risk. It may be that manifested risk-related behaviour is not really based on inaccurate or misplaced estimations of risk. in their ability to process this information and interpret the information in an appropriate context. is seen as a socially constructed function of social and cultural organisation and a normal feature of behaviour (Plant and Plant. Be aware of health resistance and health reaction responses and the steps to prevent these by presenting information in a non-authoritarian way and by enhancing a sense of control where possible. Their health behaviour might merely reﬂect an individual’s quest to make sense of their own situations and apply logical interpretation to perceived events..
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168 D. (2000) refer to the process of an effect heuristic (mental short-cut) that clients may perform to make judgements about personal health risk. Sultan et al..
especially at a professional and organisational level. the rationality of health practitioners often sits counter to the clients that they serve. He adds that this social support is more credible to the patient if the nurses own health behaviour reﬂects the rationality of the client. 1998). For instance. Indeed. Warning a client about the topic and position of an ‘upcoming’ health education message often results in resistance behaviour (Jacks and Devine. 2000. This reality will be a reﬂection of their personal and collective rationality. Recommendations for effective behavioural-change health education practice In light of the underpinning theoretical considerations covered previously in this article. in that they might compare themselves to others who are at high risk in order to maintain a sense of low personal risk. Health risk may be a necessary and unavoidable element in motivating behavioural change. Slovic (2000) identiﬁes that an individual’s interpretation of risk is essentially intertwined with their unique ‘world-view’.
it might be best not to set up health education interventions for some clients. only a change in their socio-political-environmental situation will produce the circumstances where they are empowered to modify their behaviour (Piper and Brown. Be aware that a client’s personal assessment of personal health state and risk susceptibility may be distorted. 2002). Offering a range of possible options and scenarios through the processes of informed choice will help to avoid this. Nies and Kershaw (2002) highlight the strong link between psycho-social and environmental factors. Charlton et al. which.ARTICLE IN PRESS
D. Sometimes presenting the knowledge of health harmfulness serves as the primary motivation to engage in and reinforce the harmful behaviour. however. Reassessment. 2003b). Imposing health interventions that make the client feel indignation or apathy towards their behaviour. 2003). 1995). as predictors for successful outcomes in behavioural-change programmes. In the interest of saving valuable resources and maintaining good client/nurse relationships. Theoretical health education assessment
tools will facilitate more objective assessment and compliment the overall assessment process. 1998b. Assess past health behaviour history. felt by clients. Dramatic changes in behaviour are likely to result in failure or relapse (Nies et al. Russell / International Journal of Nursing Studies 41 (2004) 163–172 169
adverse resistance to the presented message. For some. the better the evidence-base for what constitutes appropriate nursing activity in health education practice. (2002) highlight that the most effective
. thus increasing the chances of successful outcome. c.. Perhaps one of the most important things to be aware of in a health education programme is that some people do not want to modify or alter their behaviour. (1998) reports that the better the theoretical basis is underpinning the behavioural programme. inconsistency. beneﬁts and costs. High emotional arousal impairs the performance of the client’s behavioural-change capacity and can lead to impaired decision-making. This allows the nurse to measure and monitor for the effectiveness of their health interventions. This is where wider-ranging health promotion programmes might be preferable. It is known that the effects of past behaviour can impinge on current behaviour (Norman and Smith. G. 2001). (2002) argue that nurses need to posses a ‘deep’ understanding of target behaviours and their phenomenon. A lack of information. 2003a). Use a diverse range of designs and methods to measure and evaluate the effectiveness and success of health education programmes (Whitehead et al. may uncover a more favourable opportunity. 2002). Try not to ﬁlter or censure information nor dilute the message in such a way that the client receives an unbalanced viewpoint—thus avoiding accusations of health persuasion/coercion/manipulation. Acknowledge the culture and inﬂuence of family members and signiﬁcant others (Preston. may differ from those held by the nurse. to accept simplistic health education messages related to limiting behavioural change. Health education programmes should be based on realistic goals and outcomes. Health professionals should be prepared for such eventualities. Ensure that theory-based cognitions are targeted. 2001). 1997). In this context. A full explanation of the facts is part of an enabling process. A lack of willingness/ability with a client to change their behaviour. Clients need to be in possession of accurate healthrelated information in order that they can make informed decisions about their behaviour (Norton.. stated intentions to engage in behavioural change are generally a better predictor of change than an expressed attitude. Crossley (2001b) describes the emerging sense of scepticism and reluctance. if they are to design effective health behaviour interventions. Ensure that health education programmes are systematically planned and evaluated using structured theories and models for guidance (Whitehead. (Dougherty et al. Kennedy et al. Whitehead. 2001). potentially achieving the opposite of what is intended (Crossley. ambiguity or vagueness will all lead to uncertainty in the client (McCormick. This said the health educator is advised to be mindful of ‘information overload’ or producing overly technical information that serves to exacerbate the discomfort felt by the client. at an appropriate time. Ensure that the client is not too anxious or stressed by their current predicament. Their impact on the client may be the key to determining if behavioural change is possible or not. Whitehead. Negative emotions associated with resistance reception or processing will inhibit the likelihood of behavioural change rather than enhance it (Brown. A positive health status is not the priority of all clients whereas others are not in a suitable position to be able to change their health behaviour. the higher the likelihood of effective health education activity. 1998). as well as setting up programmes that assign the client to failure.. The more that this occurs. does not have to be viewed as an intractable state. Health education initiatives are not just conﬁned to singular processes of information-giving and behavioural-change activities. 2001b. Explore and understand the client’s health beliefs and consider that schematic processes generate expectancies about treatment outcomes. Wight et al. are counter-productive. panic or denial. Assess the emotional capacity for change within the client.
Health beliefs and their inﬂuence on United Kingdom nurses’ health-related behaviours. I. P. There is no one single approach that covers all health education eventualities. Health promotion materials alone are unlikely to change individual behaviour (Bernhardt. 219–226. 193–199. Whitehead.. 1977.L.. Health education can be used as an enabling and supportive mechanism for developing a client’s active participation in determining his or her own health planning.A. A...L. M. Dines.S. Blackwell. Beyond positivism: humanistic perspectives on theory and research in health education. Health Promotion Practice 2 (4). 1980. Callaghan. 439–450. What changes in health behaviour might nurses logically expect from their health education work? Journal of Advanced Nursing 20. Academic Press. A. Dougherty. A.. 290–294. Duncan. Summary McMurray (1999) identiﬁes that health education experts are still unable to agree on what constitutes a consistent approach to changing people’s health-related attitudes and behaviour. Understanding Attitudes and Predicting Behaviour. E. Nursing Standard 12. Tannahill. 1127–1133. Change theory and health promotion.... A. 273–283. Australian Psychologist 36 (3).R. Prentice-Hall.L. M. Charlton.L.. 1–146. Alhakami. Johnson..M. Advances in Nursing Science 24. Health Promotion: Models and Values. Indeed. We would argue that might is the operative word here. R.
10.... Brehm. 2002. Health Education Journal 60 (4). 2002. Becker.ARTICLE IN PRESS
170 D.. A.. their health education programmes are far more likely to result in successful interventions (Nies et al.M. Baird. D. Coyne. Introduction to the symposium ‘health resistance’: the limits of contemporary health promotion. P. Oxford University Press. This paper is designed to help the practitioner to approach their health education practice in such a concerted. 197–204.. ‘Resistance’ and health promotion. New York. The health resistance (HR) scale: developing a measure of resistance to health promotion. Tannahill.M.. Health Education Journal 61 (2). Emotive health advertising and message resistance. A. 28–35. G. Health Education Journal 60 (3).. will help considerably. Meridian. McQueen (1996) suggest that the true challenge for implementing behavioural-change health education programmes lies in identifying when and how the change might occur. Listening to the clients needs and priorities.. Johnson-Crowley. R. A Handbook of Rationale-Emotive Therapy. Buchanan. Downie. Beck. Where the nurse is able to recognise and understand the complexity of behavioural change.
Ajzen. 2001). Slovic. A.). Fishbein... 1974. Crossley. Horsley..-M. The health belief model and personal health behaviour. Grieger.. Prentice-Hall. If nurses have a better understanding of the processes of behavioural change. 2002. 1998. 1976. whereby the nurse promotes the client to self-deﬁne their health behaviour as a protection against the threat of illness. Ellis. 1999. 329–346.. NJ. Health Promotion and Professional Ethics.. M. C. systematic and realistic fashion..A. M. P. 1994. 101–112. Journal of Behavioural Decision Making 13. Social Learning Theory. Health Education Journal 61.. Theoretical development of nursing interventions for sudden cardiac arrest survivors using social cognitive theory. Careful consideration of the theoretical and practical constructs that underpin health education programming will result in better patient outcomes. C. 1998. Crossley. Reﬂections on the relationship between theory and practice. NJ. M. Oxford.. F. A. 313–326. A.
. Health Education Research 9. Shaw (1999) advocates that different types of information packages for health education programmes could be developed to suit the different personal proﬁles of clients.. Social support and locus of control as correlates of UK nurses’ health-related behaviours. Both Sheahan (2000) and Galvin et al. Kulbok et al.. Finucane.M. The effect heuristic in judgements of risk and beneﬁts. New York. 2001a. (Eds. Buchanan. 78–86. Reducing cancer mortality: does health promotion work? A discussion paper.R. N. In: Ellis. as well as negotiating change activities alongside their expressed wishes. Health Education Research 13. A. (2000) also stress that further research is needed which examines how nurses can effectively facilitate behavioural change in their clients. S. the more realistic theirs and their client’s expectations of success will be. 2001). The nurse cannot assume that behavioural change will occur and it is unethical to blame clients when change is not seen. Bandura. 1966.L. J. The basic clinical theory of rational-emotive therapy.. J.. 34–36. M. 2nd Edition. Englewood Cliffs. A. 1–17. Thompson. 1977. New York. S. 1998. Springer. S. 1996.. 2001. Cognitive Therapy and Emotional Disorders. (1997) refers to health protection as a valid approach.. 2000.. This fact is worth bearing in mind when nurses conduct their health education activities. D. Callaghan. Health Education Monographs 2. 2001.. Cribb. the nurse compromises their professional position if they set up unrealistic and unplanned health education activities. but there are a range of options that will improve the chances of successful intervention and outcome.T. 1994. Crossley. Brown. Oxford. A Theory of Psychological Reactance. Journal of Advanced Nursing 29 (1). 2001. 2001b. Englewood Cliffs. Journal of Advanced Nursing 28. P. Lewis. Bernhardt.R. Russell / International Journal of Nursing Studies 41 (2004) 163–172
health education programmes combine the information-giving and behavioural-change activity with ‘skills-building’. Developing health promotion materials for health care settings.
. 1997. M. 637–641. DiClemente.Z.. Policy framework for health promotion. Nisbett. L. J. (Eds...L. Joffe. Rogers. 469–479. 2002. T.O. 1980. New York. S. (Ed. L. J. Health Policy in Britain: the Politics and Organisation of the National Health Service. Health Promotion International 11.. 2002. Nies. Danford. Foster. IL. 2002.). Webb. McMurray. 1988.E.. 1998b. Gott.ARTICLE IN PRESS
D. 243–249. UK. Ethnography: studying the fate of health promotion in coronary families. Adherence to health messages: a social psychological perspective. 1982. 120–126. Devine.S. Folkman. Sydney. Health promotion and health education: what role should the nurse adopt in practice.. Brown. International Dental Journal.A.. A.. H. 1995. Wiley. Simnett. 171 McCormick.R. F. Journal of Advanced Nursing 18.E. pp. Janz.. Journal of Advanced Nursing 28. 1998a. Smith. Journal of Nursing Scholarship 34. 139–159.. A concept analysis of uncertainty in illness... Decision Making: a Psychological Analysis of Conﬂict. D.). The search for theory in health behaviour and health promotion. 1997.. (Eds. Norman.).. Appels. P.. II. J. Free Press. Wright.. Protection.M. Duffy. Ross. and resistance to persuasion... 27–32. Judgement under Uncertainty. M. M. Cambridge. Baldwin. 1999. The outcome of a nurse-led health education programme for patients with peripheral vascular disease who smoke: assessment using attitudinal variables. K. forewarning of message content. A stage-based approach to behaviour change.K. C.. 349–354. 1990. New York. The Denial of Stress. 2000. Guilford Press. Whitehead. 2002.. Representations of health risks: what social psychology can offer health promotion. (Eds. The common sense representations of illness danger.. Slovic. Lazarus. Children’s perceptions of TV and health behaviour effects. E. R. Greer.). C. In: Perkins. 11–19. Plant. 12–20.A. Handbook of Behaviour Medicine.. Kulbok.T. Journal of Nursing Scholarship 34. Basic and Applied Social Psychology 22 (1). 1983. Nies. Preston.. Hillier. S. In: Rachman. J. In: Gentry. Piper. Lazarus.V. O’Brien. Cambridge University Press.W. NJ. 1277–1288. Pergamon Press. In: Cacioppo. Cox. 1–47.M..L.A. Psychosocial and environmental inﬂuences on physical activity and health outcomes in sedentary women.C. Galvin. Joffe. A.. Heuristics and Biases. Kennedy. Petty. G... 1998. Leventhal. 1984. The health belief model: a decade later. 2nd Edition. Risk Takers.. Maddux. M.. R.M.. C. Wallston. I. 1984.C. Harcourt. The theory and practice of health education applied to nursing: a bi-polar approach. Englewood Cliffs. Norton. P. H. Tversky. The theory of planned behaviour and exercise: an investigation into the role of prior behaviour. M..A. Health Psychology: a Textbook. Coping information and control in patients undergoing surgery and stressful medical procedures.. S. Psychology as a theoretical foundation for health education in nursing: empowerment or social control? Nurse Education Today 18. K. R. A. 2000. In: Steptoe. 383–389. Journal of Applied Social Psychology 18. Journal of Advanced Nursing 25.). Journal of Nursing Scholarship 33. Jacks. Psycho-oncology 9. Becker. Folkman. 19–29.. L. R. Clinical Effectiveness in Nursing 4. Kahneman. 1996. Prochaska... 2001. 1269–1275. Cognitive and psychological processes in fear appeals and attitude change: a revised theory of protection motivation theory. Churchill Livingstone.. Nursing Standard 5 (1).. Russell. 1992. J. Social Psychophysiology.. 1989. Rogers.. Health Education Quarterly 11 (1)... Ogden.S. L.. N. N. Reactance theory and patient noncompliance. Is there a future for radical health promotion? Health Care Analysis 4 (2).C. R. Plant. S. 3rd Edition. Oxford.. Ham. Miller.. 64–75.M. 241–255. C. Health Education Journal 60. J. behavioural intentions and attitude variability. Wiley. In: Brenitz. Journal of Advanced Nursing 27. J. The role of denial in clinical practice. H. Evaluation of an instrument for assessing behavioural change in sedentary women. Journal of Nursing Scholarship 34. Kershaw. A.W.T. 90–92. Promoting well-being in the face of serious illness: when theory research and practice inform each other. Strzempko. Open University Press. Rhodewalt. Evidence-Based Health Promotion. 1985. R... European Journal of Social Psychology 25. MacMillan...). Kershaw. 2000.. 1983. Nerenz. Health Education Journal 61 (2). Advances in Nursing Science 20. 403–415. Prentice-Hall. 127–131.S. McQueen. Human Inferences. R.. 1997. D. Type A behaviour and diabetic control: implications of psychological reactance for health outcomes.. 1999. T. Routledge. New York.). Advancing discourse on health promotion: beyond mainstream thinking. S.M. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy.H. L. Hepworth. 2002. London..D. 54–66.. 1983. P. Janis. Choice and Commitment.. Personal Control and Health. I.. 1996. Russell / International Journal of Nursing Studies 41 (2004) 163–172 Fogarty. P. (Ed. 554–561. C. Basingstoke. Henshaw. Lawrence. T. Piper.. G... 1999. 2000. S. Attitude importance. The costs and beneﬁts of denial... C.. M. Meyer.. Coping and adaptation. 295–303. L. K.E. Strategies and Shortcomings of Social Judgements. Buckingham. Niven. The impact of class position on women’s experience of receiving health education information whilst in hospital. R. Kools. D. Brown. W..
. Mann. motivation and self-efﬁcacy: a revised theory of fear appeals and attitude change. J. 2001. Health Psychology for Health Care Professionals. S. M. UK. P.. Dow Jones Irwin. D. 1993. 2000. Community Health and Wellness: a Socio-ecological Approach.. Desires as deﬁance: gay male sexual subjectivities and resistance to sexual health promotion. New York. M. (Eds.. International Press. V.A.. 938–940. Vol. Journal of Experimental Social Psychology 19. P. (Ed. New York. Edinburgh. Social Science and Medicine 45 (8). Marcroft. Rofes. Health Education Journal 61. 153–165. S. 2000.. 1984.G. Contributions to Medical Psychology. 1975.. D.A.. 125–137. Chichester.. Stress. S. Guilford. F. E. 289–294..
Osteoporosis in older men: knowledge and health beliefs. 61–66. C. Risk Perception. G... 245–250. Health Education Research 13. A framework for the study of coping. Documentation of health risks and health promotion counseling by emergency department nurse practitioners and physicians. Whitehead.. 38–46. Promoting people’s health: the importance of lay perceptions.P. Norton. 2003a. Action research in health promotion. D. Taylor. M. Doheny. 1998. 2000. London. 5–22. 2002. 1994. 320–322.. Whitehead. Evaluating health promotion: a model for nursing practice. P. Understanding patients’ health beliefs. D. S. Routledge. E.E. 1999. Russell. E. ed. Journal of Risk Research 5 (2). Individual psychology of risk-taking behaviours in non-adherence. 1987. Sultan. London. Health Education Journal 62. 1999. C. 1246–1255. 1984.. 2000. Wiley. Tones. Sheahan. Tilford. A. Saraﬁno.L...D. Whitehead. Thorndike. Wight. Orthopaedic Nursing 19. Psychology of Learning and Behaviour.. P. Smith.
. G. 1989 as cited in Schwartz. Slovic.. 822–832. Professional Nurse 14. 1988. Advancing Clinical Nursing 3. 2003.. A stage planning model for health education/health promotion practice. Wilkinson. 481–2495.. Journal of Nursing Scholarship 32.. 2001c. D... 4th Edition. D. A. Brown.. illness behaviour and outcomes. S... Essential Psychology for Nurses and other Health Professionals. Schickler. Andronikof. Scott. Efﬁciency & Equity. P. Health Education: Effectiveness. C.O.. 490–498.ARTICLE IN PRESS
172 D.J. Journal of Advanced Nursing 36. 1999. Unrealistic optimism about susceptibility to health problems: conclusions from a community wide sample. Whitehead. Journal of Advanced Nursing 36. D. 2001a. 2003b. Illusion and well-being: a social psychological perspective on mental health. 137–145. Sedlak. 2nd Edition. B. 2001b. Health education.. S.. 2002. Earthscan. Whitehead. Journal of Clinical Nursing 12. Whitehead. Shaw... S. Journal of Advanced Nursing 29. S.A. N. K.. 311–320... Chapman & Hall. J. J.. New York. Whitehead. Estok. 317–330. Abraham. D. A socio-cognitive model for health education/health promotion practice. behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing 34.. Journal of Behavioural Medicine 10.. D. Russell / International Journal of Nursing Studies 41 (2004) 163–172 Weinstein. Incorporating socio-political health promotion activities into clinical practice. Journal of Advanced Nursing 41.L.. Bungener. Towards a psychosocial theoretical framework for sexual health promotion.D. C. 2000. 193–210..A. 2nd Edition. London. Taket. 1999. Health Psychology: Biopsychosocial Interactions. Psychological Bulletin 103 (2). London. P. 417–425..