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Patient Education and Counseling 54 (2004) 7378

Health promotion in the acute hospital setting:


the receptivity of adult in-patients
Anita McBride
Health Promotion in Professional Practice Research and Development Unit, Oxford University, Oxford, UK
Received 20 May 2002; received in revised form 8 March 2003; accepted 9 June 2003

Abstract
There is a growing international awareness and development of health promotion in hospitals. For patients, this involves encouraging
them to take an active participatory role according to their specific health potentials. The aim of this study was to investigate their receptivity
to health promotion in an acute hospital setting. Data are drawn from a questionnaire survey of 320 adult in-patients (100% response rate),
excluding terminally ill patients for ethical reasons. In general, respondents supported the development of health promotion in the hospital
setting. Concerns were expressed over the knowledge base and the ability of professionals to deliver health education interventions that
met their specific needs. Non-smokers were more supportive than those who smoked. For effectiveness, the hospital needs to be considered
as a whole system where policies and practices are mutually supportive and integrated into the culture of the organisation. The survey
identified that this is not always in evidence.
2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: Health Promoting Hospital; Health promotion; Hospital; Patients; Receptivity

1. Introduction
There has been a growing international awareness and
development of health promotion in the hospital setting
[13]. There has been structured development through the
World Health Organisation (Europe) Health Promoting
Hospital (HPH) movement. The Health Promoting Hospital
concept has been described as an umbrella concept consisting of a number of methods that share the common focus
of better health and the empowerment of patients, staff and
the local community [4]. This approach has provided concrete strategies for project implementation that are based
on the WHO Ottawa Charter for health promotion which
defines health promotion as the process of enabling people
to increase control over and to improve their health [5].
Indeed, the concept of empowerment is a common feature
of discussions on health education and health promotion
[6]. For hospital patients, this involves encouraging them
to take an active participatory role [7]. Thus, a major issue
is the evaluation of the individual empowerment process in
terms of the extent to which the capacity to exert control
over personal determinants of health are reinforced [6].

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Studies have examined the attitudes, beliefs and practices


of health care professionals in hospital settings in the UK [8],
the US [9] and India [10]. These demonstrated that staff are
keen to develop hospital-based health promotion. However,
a review of the literature concludes that hospitals appear
to have insufficiently defined so far the type of educational
activities that are effective in addressing the challenge of
enabling people to increase control over and to improve their
health [6]. Thus, this study investigates health promotion in
the hospital setting from the patients perspective, examining
the attitudes of hospital in-patients to health promotion in
the hospital setting. From this, their degree of receptivity
to hospital health promotion and barriers to its development
can be assessed.

2. Method
The hospital can act as a change agent and is also a
physical and social setting [4]. Attitudes concerning these
factors are indicators of receptivity to health promotion in
the hospital setting. Thus, patients attitudes towards the
broad concept of health promotion in the hospital setting
and towards specific interventions were investigated. This
included attitudes towards both the principle of health promotion in the hospital and a smoking policy as an example

0738-3991/$ see front matter 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S0738-3991(03)00198-8

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A. McBride / Patient Education and Counseling 54 (2004) 7378

of a health promoting policy. Attitudes concerning key


elements of health education practice were investigated,
including information given verbally and in leaflets, and
whether patients considered that these were meeting their
needs. Many of these questions were related to nursing
practice as nurses are in frequent contact with patients and
have more opportunities for health education directly with
patients than other health care professionals.
Demographic data were also collected to enable investigation of whether groups of patients with specific demographic
characteristics were more receptive to health promotion.

completion [12,13]. Statements reflected both positive and


negative views of health promotion so that more stable attitude components could be deduced [14]. General guidance
regarding the length, language that is meaningful to respondents and appearance of the questionnaire were followed
[15,16].
Patients were also asked demographic and lifestyle questions, such as educational attainment, age, gender and smoking status. Subsequent analysis determined whether these
accounted for variations in response, thereby reducing confounding bias [17].

2.1. Research method

2.3. Improving validity

A cross-sectional survey was undertaken to generate data


concerning attitudes towards health promotion in order to
investigate the receptivity of adult in-patients to health promotion in an acute hospital setting.
A questionnaire survey was conducted of adult in-patients
in a large acute teaching hospital. As there was a potential
for bias as patients were still under hospital care whilst participating in the study, a questionnaire survey approach was
selected. Questionnaires were intended to be self-completed.
It was considered that this would increase patients belief in
confidentiality and thus encourage honesty.
All patients, both emergency and planned admissions,
aged between 16 and 64 years admitted to acute adult wards
over a 3-month period were included in the survey. Children and elders of 65 years and over were excluded from
the study. This was because they have potentially different
decision-making pathways, such as degree of independent
choice. For example, children can only exert limited influence over their diet. In-patients over 65 years raise additional aspects beyond the scope of this study. These include
the impact of multiple pathology and the ageing process.
In order to meet the selection criteria, patients had to be
admitted to an acute ward at least 48 h before administration of the questionnaire. This was to allow sufficient time
for them to become orientated to the ward. Terminally ill
patients with a limited prognosis were not included in the
survey for ethical reasons. The ward staff identified these
patients. The local Health Authority Research Ethics Committee approved the project.

It was not assumed that patients accorded distinction between the meanings of the terms health promotion and
health education. In attitudinal questions, indirect questions were used as this tends to counter respondents giving
answers perceived as being those desired by the researcher
[12]. Expert health care professionals and a convenience
sample of patients reviewed individual items and the entire questionnaire for clarity and relevance. Multiple choice
questions included a Dont know category so that respondents were not forced to select an option that did not represent their views.

2.2. Questionnaire
Questions were developed from previously validated surveys [11]. These surveys had been designed for use with
a health care professional population. Minor changes were
made to questions so that they were appropriate for a lay
sample. The questionnaire was subsequently piloted with a
convenience sample of 10 medical and 10 surgical patients.
Patients were invited to agree or disagree with statements relating to health promotion and lifestyle issues using
four-point Likert-type scales. Attitude statements were designed to be relevant to the patients in order to encourage

2.4. Data collection


All acute wards with adult in-patients were visited on
alternate days to ensure that all patients who met the criteria
could be invited to participate in the survey. Patients meeting
the criteria for inclusion in the survey were identified with
the assistance of nursing staff. They were given a blank
envelope for the completed questionnaire and confidentiality
was highlighted in the invitation letter, consent form and the
questionnaire.
2.5. Sample
Despite being given the opportunity to decline, all 320
patients approached agreed to participate, generating a response rate of 100%. One hundred thirty-two patients (41%)
were female. One hundred ninety-eight patients (62%) were
aged 4564 years. As indications of socio-economic status,
patients were asked their age on leaving school and their educational attainment in later life. The majority, 218 patients
(68%), left school at the minimum age, whilst 138 patients
(43%) had not experienced further or higher education.
As patients were recruited from all adult wards, the sample reflected a wide range of acute diseases and illnesses.
Although length of stay ranged up to over 40 days, 224 patients (70%) had been in hospital between 2 and 9 days at
the time of participating in the study. Only 47 were in excess
of 14 days.
Patients were asked about their smoking history to enable
investigation of whether smoking status affects attitudes to

A. McBride / Patient Education and Counseling 54 (2004) 7378

health promotion issues and responsiveness to interventions.


Approximately, one-third of the sample reported that they
had never smoked, one-third gave up some time ago, and
one-third currently smoke or recently gave up. Many patients
reported unhealthy lifestyles. These responses were not validated, for example, by calculating the body mass index for
each patient. One hundred and twenty (37.7%) considered
that they were overweight and 31 (9.7%) underweight. One
hundred sixty-one (50.6%) expressed the view that they did
not take enough exercise, whilst nine (2.7%) patients reported that they exercised too much. Eighteen (5.7%) patients stated that they considered that they consumed too
much alcohol.
2.6. Methods of analysis
Data were analysed using the computer software package
Epi-Info Version 5 [18]. Where P-values are calculated, a
two-tailed test of significance was used because it cannot
be assumed whether respondents would give a positive or
negative response. To test for the statistical significance of
the ordinal data, the Spearman rank correlation was used as
a measure of association strength.

3. Results
3.1. Receptivity to health promoting policies
To ascertain broad attitudes towards the principle of health
promotion in the hospital setting, respondents were asked
whether hospitals should be taking a role in promoting health
as well as being centres for the treatment of disease. Compatible with the Health Promoting Hospital concept whereby
hospitals should develop health-orientated perspectives and
objectives, 300 patients (95.2%) agreed with the principle.
To investigate whether this attitude is consistent when
applied to a specific policy, patients were asked whether

smoking should be prohibited on hospital premises for staff


and for patients. The majority, 237 patients (76.5%), would
like smoking to be prohibited for staff, whilst 250 (79.4%)
would like a ban for patients. These results do not differ
in statistical significance from each other. Defining patients
by their smoking status, attitudes towards banning smoking on hospital premises are illustrated in Fig. 1. Significantly more non-smokers than smokers agree that smoking
should be banned on hospital premises for staff (P < 0.01,
2 = 42.06, d.f. = 1, n = 310) and for patients (P < 0.01,
2 = 87.01, d.f. = 1, n = 315). However, a sizeable proportion of current smokers advocate a ban on smoking and
a small proportion of non-smokers feel that smoking should
be allowed. There was no significant difference apparent
based upon gender, age or educational attainment of the
respondents.
3.2. Receptivity to health promoting practices
Most patients expressed a wish to modify some aspect
of their lifestyle behaviour, as shown in Fig. 2. Only 65 patients (20.3%) did not express a wish to modify at least one
of these factors. Two hundred eighty-nine patients (90.9%)
agreed that the way people live affects their health. However,
there is a significant difference apparent (P < 0.05, 2 =
3.89, d.f. = 1, n = 318) between smokers and non-smokers
responses. Almost three times as many current cigarette
smokers (16.6%) disagree with the statement compared with
patients who have never smoked (5.8%). There is no significant difference apparent between respondents by sex or age.
The vast majority, 304 patients (97.7%), agreed with the
statement that detailed explanations are reassuring. Significantly more men report reassurance than women patients
(P < 0.05, 2 = 6.47, d.f. = 1, n = 311), independent of
age, smoking status or educational attainment. Patients were
asked their opinions on health education issues in a statement
using authoritative language. Ninety-four patients (29.9%)
agreed with the statement that hospital nurses should not

100
87.2

86

90
80
70
60

smokers

50

non-smokers
40
29.1

32.8

30
20
10
0
for staff

75

for patients

Fig. 1. Percentages of patients agreeing that smoking should be banned on hospital premises for staff and for patients, n = 315.

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A. McBride / Patient Education and Counseling 54 (2004) 7378

alcohol consumption

7.3

92.7

69.3

smoking*

31.7

exercise level

50.5

49.5

weight

49.1

50.9

0%

change

not change

50%

100%

Fig. 2. Patients expressing a wish to modify their lifestyle by percentage of population, n = 318; () percentage of smokers, n = 56.

interfere with peoples lives by telling them to stop smoking, lose weight or take more exercise. Although there is no
significant difference in response by age or gender of patient, there is a significant difference according to the age
of leaving school (P < 0.05, d.f. = 9, n = 287). Those
patients who left school at the minimum statutory school
leaving age were more than twice as likely to agree with
the statement (35.6%) than those who remained at school
(15.1%) beyond this age. Patients were asked if they would
have liked information or advice from their nurse about exercise, smoking, diet or alcohol. One hundred forty-one patients (44.1%) did not want advice. Those in the younger
age group, 1624 years, were significantly less likely to have
information or advice (P < 0.01, 2 = 16.17, d.f. = 2,
n = 310). However, those who left school at the statutory
minimum school leaving age were significantly more likely
to have information or advice (P < 0.01, 2 = 18.9, d.f. =
3, n = 310). Although the majority of this group expressed
the view that nurses should challenge lifestyle issues and
that they would have liked information or advice there is

a greater spread of opinion than in the remainder of the


sample.
As an indicator of attitudes to the knowledge base of
health promotion, patients were asked whether they considered that experts could not agree about which foods are
unhealthy. The majority, 259 patients (81.9%), indicated a
negative view concerning the knowledge base in relation to
diet. The most uncertain are women in the younger 1624
years age group; 92.3% agreed with the statement. Younger
women are significantly more questioning of health issues
than older women (P < 0.05, 2 = 5.12, d.f. = 1, n =
132). For men, there is no significant difference apparent
between the age groups.
Although few patients reported being given leaflets, nearly
all of these patients reported actually reading them, as shown
in Fig. 3. Most patients receiving leaflets, a cornerstone of
health education practice, reported finding them as useful in
extending their knowledge, illustrated in Fig. 4. Numbers of
respondents are small, consequently such data is indicative
rather than statistically reliable.

alcohol (n=23)

diet (n=57)

smoking (n=32)

exercise (n=46)

0%

50%
read all

mostly read

just flicked through

100%
not read

Fig. 3. Patients reported reading of leaflets on lifestyle issues given to them in the ward.

A. McBride / Patient Education and Counseling 54 (2004) 7378

alcohol (n=23)

43.5

47.8

diet (n=54)

53.7

smoking (n=29)

55.2

exercise (n=46)

0%

8.7

35.2

37.9

50

43.5
very useful

quite useful

77

not really useful

11.1

6.9

6.5

100%

Fig. 4. Patients reports of usefulness of leaflets given to them.

The majority, 235 patients (80.8%), agreed that patients


generally take notice of what nurses say to them about
lifestyle. When advice was given, patients generally considered it helpful. Of the 138 patients reporting receiving advice, 100 (72.5%) reported that it was helpful, 25 (18.1%)
responded that the advice was not helpful, whilst 13 patients (9.4%) were unsure. No significant difference was
detectable statistically by gender, smoking status or age
group.
Some patients reported taking the initiative and asking the
nurses for advice. Sixty-five patients report asking a nurse
about diet (20.5%), 51 about exercise (16.3%), 43 about
smoking cessation/reduction (13.5%) and 24 about reducing
alcohol consumption (7.7%). There is no significant correlation of response according to age, age on leaving school,
educational attainment, or gender of the respondents. The
only exception to this is patients asking about exercise (P <
0.01, 2 = 6.76, d.f. = 1, n = 315) where men are almost
four times as likely to request advice than women. This item
may not be particularly valid as asking a nurse is also dependent on other aspects such as the nursepatient relationship, the availability of nurses and how the patient views the
nurse as a source of information.

4. Discussion and conclusion


Adult in-patients are generally receptive to the introduction of the HPH approach to promoting health and support
interventions designed to promote health. The data demonstrated patients receptivity to health education and also to
hospitals taking a broader role in health promotion. From
the data, they generally view current professional practice
as compatible with the HPH approach.
A negative attitude is expressed concerning the robustness
of the knowledge base. This is particularly evident amongst
women in the younger age group but a negative attitude
is expressed across all patient groups. Concerns over the
adequacy of the knowledge base cannot be addressed fully
within the HPH approach per se. Advances in increasing

receptivity could be made through increasing awareness of


the areas within which the knowledge base is secure.
Most patients consider that the way people live affects their health suggesting that they might be responsive to initiatives that they considered to be grounded in
evidence-based knowledge. A majority of smokers expressed that they wished to either reduce their smoking
or stop completely. This was the largest response group
of those expressing a wish to modify an aspect of their
lifestyle in relation to smoking, diet, exercise level or alcohol consumption. This suggests that patients are likely to
be receptive to a HPH approach to promoting health. It also
indicates an area of challenge in that smokers, a significant
number of which have expressed a wish to change, appear
to be least receptive. In terms of introducing the HPH, some
of this group might be seen as a core of resistance who will
never come to accept policy introduction. For the HPH, the
implication would be the need to introduce policies that
were sensitive to this, otherwise fundamental principles
such as choice are compromised.
Generally, patients report a positive attitude towards
health promotion but have concerns regarding translation into practice. For the introduction of the HPH, there
are some areas that could be addressed within the hospital to increase receptivity. For example, concerns over
professionals ability could be reduced through increasing
awareness of interventions, such as training days within the
hospital, designed to increase the professionals knowledge
and their ability to promote health effectively.
Many patients reported that they were not asked about
their lifestyle. However, this may be a perception rather than
reflecting reality. Further research could be undertaken to
investigate this finding. If patients are not being asked about
their lifestyle, then professionals should be encouraged to
develop their health education role.
Patients appear to generally support the introduction of a
policy to ban smoking on hospital premises. However, it appears that the majority of smokers might resist initiatives to
reduce smoking within the hospital. It is likely that a strategy of inter-related initiatives would be the most productive

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in increasing receptivity to the HPH approach. For example, policies could be developed that allowed smoking in
some areas which, over time, moved the hospital towards
becoming smoke-free. This could be combined with health
education and the offering of alternative methods to support
individual smoking and stress reduction.
Most patients expressed the views that they would like
information and advice regarding lifestyle issues and that
they are reassured by explanations. This suggests that they
wished to make informed choices about their lifestyle, an
attitude supporting the empowerment of patients and compatible with the HPH approach to promoting health.
Although individual items have identified differences in
response according to demographic characteristics, no clear
pattern emerges. It is not possible from the data to identify
patients from demographic features who might be more receptive and thus assist the hospital culture to change. It appears that those patients who do not smoke are the group
most likely to be favourable towards the HPH approach in
that their views are most in accordance with its principles.
This is independent of age group, gender and educational
attainment.
4.1. Conclusion
The survey has demonstrated that patients are generally
receptive to health promotion in the hospital setting. Most
patients expressed a desire to modify some aspect of their
lifestyle behaviour and wanted to be able to make informed
choices about their lifestyle.
A key feature of the HPH and effective health promotion
is that a hospital needs to be considered as a whole system.
This means that policies and practice are mutually supportive
and that health promotion is integrated into the culture of
the hospital.
4.2. Practice implications
The findings of this study suggest that hospital-based practitioners should be encouraged to develop their role in health
promotion. A strategy should be developed across the hospital setting so that initiatives do not contradict each other.

Interventions should also be relevant to a patients medical


condition. Patients reported that both advice and leaflets are
helpful provided that they are consistent and relevant.
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