Chapter 4:

Chapter 4: Health promotion and disease prevention

Health promotion: core of community and public health nursing

Since its beginning, nursing has focused on helping individuals, groups, and

communities maintain and protect their health. Florence Nightingale and other

nursing pioneers recognized the importance of nutrition, rest, and hygiene in

maximizing and protecting one's state of health. Although people are responsible for

their health and medical care, they often seek advice from nurses in the community

regarding health promotion and to help them make sense of the many, often

competing recommendations that appear daily on W, online, and in newspapers and

in magazines.

Green and Kreuter (1991) define health promotion as "any combination of health

education and related organizational, economic, and environmental supports for

behavior of individuals, groups, or communities conducive to health" (p. 2). Parse

(1990) states that health promotion is that which is motivated by the desire to

increase well-being and to reach the best possible health potential.

In discussing health promotion, it is helpful to define what is meant by health. One

definition states that health is "being sound in body, mind, and spirit: freedom from

physical disease or pain" (Merriam-Webster Online Dictionary, 2009). As health

promotion has become an important strategy to improve health, the way health is

defined has shifted from a focus on the curative model to a focus on multidimensional

aspects such as the social, cultural, and environmental facets of life and health

(Benson, 1996).
The Ottawa charter on health promotion

The World Health Organization (WHO) organized the first International Conference

on Health Promotion at Ottawa, Canada on November 17-21, 1986. The Ottawa

Charter defines health promotion as the process of enabling people to increase

control over, and to enhance their health, which requires that an individual or a group

must be able to identify and realize aspirations to satisfy needs, and to change or

cope with the environment. Health is a positive concept highlighting social and

personal resources, as well as physical capacities. Therefore, health promotion is not

just the responsibility of the health sector, but goes beyond healthy lifestyles to well-

being (WHO, 1986b).

The three basic strategies for health promotion are: ( I ) advocacy for health to

provide for the conditions and resources essential for health, (2) enabling all people

to attain their full health potential, (3) mediating among the different sectors of the

society in effons to achieve health (WHO, 1986b).

Build Healthy Public Policy. Health promotion place health on the agenda of policy

makers in all sectors and at all levels, directing them to be aware of the health

outcomes of their decisions and to accept their responsibilities for health. Health

promotion policy is a coordinated action that combines multiple but complementary

approaches including legislation, fiscal measures, taxation, and organizational

change. Health promotion policy requires the identification of impediments to the

adoption of healthy public policies in non-health sectors and measures of removing

them (WHO, 1986b)

Create Supportive Environments: Health cannot be separated from other goals. The

inseparable links between people and their environment constitute the basis for a

socioecological approach to health. The overall guiding principle for the world,

nations, regions, and communities alike is the need to encourage mutual

maintenance—to take care of each other, our communities, and our natural

environment. The conservation of natural resources throughout the world should be

emphasized as a global responsibility. Health promotion generates living and working

conditions that are safe, stimulating, satisfying, and enjoyable (WHO, 1986b). Open

spaces, parks, gardens, and ramps on streets form part of an environment in the

community that supports health.

Strengthen Community Actions: Health promotion works through tangible and

effective community actions in setting priorities, making decisions, planning

strategies, and implementing them to achieve an improved health. At the core of this

process is the empowerment of communities—their ownership and control of their

own endeavors and destinies (WHO, 1986b). Engaging people to actively participate

in various health initiatives thru community organizing is a major activity under this

area. Example includes mobilizing women in the village to start a wellness program

like a daily exercise club.

Develop Personal Skills: Health promotion favors personal and social development

through providing information, education for health, and enhancing life skills. Hence,

it increases the options available to people to exercise more control over their own
health and their environments and to make choices conducive to health. Enabling

people to be life-long learners and preparing them for all of the life stages and to

cope with chronic illness that may arise are essential (WHO, 1986b).

Reorient Health Service: The individuals, community groups, health professionals,

health service institutions, and the government do all have the shared responsibility

for health promotion in health services. They must work hand in hand towards a

health care system that contributes to the pursuit of health.

Moving into the Future: Health is created and lived bv people within the settings of

their everyday life. Settings wherein they learn, work, play, and love. Health is

generated by caring for oneself and of others, by having the ability to make decisions

and having control over one's life circumstances, and by ensuring that the society

that one lives in promotes conditions that permits the realization of health by all its

members. Caring, holism, and ecology are vital points in developing strategies for

health promotion.

Theories of health promotion

Health promotion activities are broad in scope and in setting. Community health nurses

and their clients engage in health promotion activities in workplace settings, schools,

clinics, and communities. The theories that are used most in health promotion are very

diverse to accommodate the variety of settings, clients, and activities in community

health. A working knowledge of theory is important in understanding why people act as

they do and why they may or may not follow the advice.

Health Promotion Model

The HPM depicts the complex multidimensional factors with which people interact as

they work to achieve optimum health. This model contains seven variables related to

health behaviors, as well as individual characteristics that may influence a behavioral

outcome.

Pender's model does not include threat as a motivator, as threat may not be a

motivating factor for clients in all age groups

Individual Experiences Behavior- Affect Behavioral

Characteristics and specific Cognitions Outcome

The health belief model

Initially proposed in 1958, the Health Belief Model (HBM) provides the basis for much

of the practice of health education and health promotion today. The HBM was

developed by. Why do people who may have a disease reject health screening? Why

do individuals participate in screening if it may lead to the diagnosis of disease? This

research documented that information alone is rarely enough to motivate one to act.

Individuals must know what to do and how to do it before they can take action.
Information must be related in some way to the individual's needs. One of the most

widely used conceptual frameworks in health behavior; the HBM has been used to

explain behavior change and maintenance of behavior change and to guide health

promotion interventions (Champion and Skinner, 2008).

Stages of Change Model (Transtheoretical Model)

The Stages of Change Model, also called the Transtheoretical Model, explains an

individual's readiness to change their behavior. It describes the process of behavior

change as occurring in stages. These stages include:

 Pre-contemplation: There is no intention of taking action.

 Contemplation: There are intentions to take action and a plan to do so in the

near future.
  Preparation: There is intention to take action and some steps have been taken.

 Action: Behavior has been changed for a short period of time.

 Maintenance: Behavior has been changed and continues to be maintained for

the long-term.

 Termination: There is no desire to return to prior negative behaviors.

Theory of reasoned action

Developed by Fishbein and Aizen, the Theory of Reasoned Action (TRA) attempts to

predict a person's intention to perform or not to perform a certain behavior (Montano

and Kasprzyk, 2008 ). The TRA is based on the assumption that all behavior is

determined by one's behavioral intentions. These intentions are determined by one's

attitude regarding a behavior and the subjective norms associated with the behavior
(Montano and Kasprzyk, 2008). One's attitude is determined by one's beliefs about the

outcomes of performing the behavior, weighed by one's assessment of the outcomes.

Consider Rosario T. for a moment. Rosario must believe strongly that exercise will

have positive results, as she rises early and takes time from her busy schedule to work

out daily. Conversely, Rosario may believe strongly that routine immunizations or

health screenings will have negative results.

Risk and health

Oleckno (2002, p. 352) defines risk as "the probability that a specific event will occur in

a given time frame." A risk factor is an exposure that is associated with a disease (Friis

and Sellers, 2004). Rosario T, from the clinical example of the previous section, has an

increased risk of heart disease and cancer Rosario's risk factors include a family history

of both of these diseases, work stress, her age, environmental exposures, and gender.

There are known risk factors for some diseases, such as smoking and its association

with lung cancer, as well as high blood pressure and heart disease. Some risk factors

are assumed, such as repeated use of cell phones and brain tumors.
Primary prevention relates to activities directed at preventing a problem before it occurs

by altering susceptibility or reducing exposure for susceptible individuals. Primary

prevention consists of two elements: general health promotion and specific protection.

Health promotion efforts enhance resiliency and protective factors and target essentially

well populations. Examples of primary prevention include promotion of good nutrition,

provision of adequate shelter, and encouraging regular exercise. Specific protection

efforts reduce or eliminate risk factors (risk reduction) and include such measures as
immunization, seat belt use, and water purification. In terms of disaster management,

activities such as earthquake and fire drills are forms of primary prevention.

Secondary prevention refers to early detection and prompt intervention during the

period of early disease pathogenesis. Secondary prevention is implemented after a

problem has begun but before signs and symptoms appears, and targets those

populations that have risk factors. Mammography, blood pressure screening newborn

screening, and Papanicolaou tests are examples of secondary prevention. Secondary

prevention is also directed toward prompt intervention to prevent worsening conditions

of the affected population. This includes measures during the early stage of the disease

to prevent complications.

Tertiary prevention targets populations that have experienced disease or injury and

focuses on limitation of disability and rehabilitation. Aims of tertiary prevention are to

keep health problems from getting worse, to reduce the effects of disease and injury,

and to restore individuals to their optimal level of functioning. Examples include teaching

how to perform insulin injections and disease management to a patient with diabetes,

referral of a patient with spinal cord injury for occupational and physical therapy, and

leading a support group for cancer patients who have undergone cancer treatment,

such as surgery, chemotherapy, and/or radiation therapy. Palliative treatment for those

with chronic illness is likewise included.

The relationship of risk to health and health promotion activities

Health is directly related to the activities in which we participate, our lifestyle, the food

we eat, and the substances to which we are exposed dailv. Our genetic makeup,

gender, age, and the environment in which we live also impact health. In the

assessment of risk regarding health and health promotion activities, there are two types

of risks: modifiable risks and non-modifiable risks. Modifiable risk factors are those

aspects of a person's health risk over which he or she has some control. Examples of

modifiable risk factors include smoking, a sedentary or active lifestyle, type and amount

of food eaten, and the type of activities in which he or she engages (mountain climbing

is riskier than bowling). Non-modifiable risk factors are those aspects of one's health

risk which one has no or little control.

In 201 5, the number of registered deaths in the Philippines is 560,605. About 56% of

deaths were attributed to conditions related to lifestyle factors: diseases of the heart,

diseases of the vascular system, malignant neoplasms, diabetes mellitus, and chronic

lower respiratory tract problems. Diseases of the heart were stated as the cause of

24.4% of all deaths in that year. (Department of Health, Epidemiology Bureau, 2015).

The relationship of lifestyle factors to mortal ity is so strong that medical care has been

found to play a minor role in preventing premature deaths (Schroeder, 2007). A 2012

study found that people adopting healthful behaviors such as exercising, eating a

healthful diet, not using tobacco, and maintaining a normal weight had a 66% lower risk

of death than those who did not adopt these behaviors (Wef and Walach, 2012).

Unfortunately, many people experience a clustering of unhealthy lifestyle behaviors

such as poor diet, physical inactivity, obesity, and smoking.

Tobacco and health risk

Smoking cessation is an important step in achieving optimum health. In the United

States, smoking is the leading cause of preventable death, accounting for approximately

one out of every five deaths, or 438,000 deaths, per year. Smoking is a causal factor in

cancers of the esophagus, bladder, stomach, oral cavity, pharynx, larynx, cervix, and

lung, with more than 90% of lung cancers in men and 80% of lung cancers among

women attributable to smoking (Centers for Disease Control and Prevention ICDCI,

January 2, 2013). Smoking also has an economic impact, costing $97.2 billion annually

in health care and lost productivity.

Smokers who are trying to quit experience withdrawal symptoms such as anxiety,

increased appetite, irritability, and difficulty concentrating. "these symptoms make

quitting difficult, and most people relapse several times before being able to quit

successfully. Nicotine replacement, pharmaceutical alternatives, hypnosis, and

acupuncture may be helpful in the attempt to quit smoking.

• Make the decision to quit. Any change is scary, and smoking cessation is a big

change, requiring a long-term commitment.

• Set d date to quit and choose a plan.

• Mark the date on vour calendar.

• 'IAI vour familv and friends about the date, and ask for their support.

• rid of all tobacco products, ashtrays, and lighters in your environment.

• Stock up on oral substitutes such as sugarless gum, hard candy, fmit, and carrot

sticks.

• Decide on a plan and prepare to implement it; register for the stop-smoking

class, or see your doctor about nicotine replacement therapy or pharmaceutical

alternatives.

• Praaice saying "No thank you, I don't smoke."

• DIIÄink back to your previous attempts to quit and see what worked and what did

not work.

• If you are taking bupropion or varenicline, take vour medication each day of the

week leading up to your quit day.

Deal with withdrawal by:

• Avoiding temptation.

• Changing your habits. Walk when you are stressed or during breaks. use hard

candy, carrot sticks, or gum to satisfy the need to put something in your mouth. If you

feel the urge to light up, tell yourself that you are going to wait 10 minutes before giving

in. Usually, the urge will pass within that time.

• Staying off of tobacco is a lifelong process. Many former smokers state that they

experienced strong desires to smoke after weeks, months, even years of smoking

cessation. These unexpected cravings can be difficult to deal with.

• Remind yourself of the reasons why you quit. Wait out the craving. There is no

such thing as just one cigarette or just one puff.

• Avoid alcohol.

• Begin an exercise program and work on eating a healthy diet to avoid gaining

weight.

It is important to remember that smokers who are trying to quit smoking need support,

and most families and loved ones want to help.

Only 4% to 7% of smokers are able to quit smoking on any attempt without

pharmaceutical or other interventions to help them, so nurses must provide information

and referrals to help clients access resources that help them to get off and to stay off

tobacco.

Smokeless tobacco also poses a health threat. Commonly called spit tobacco,

smokeless tobacco is a significant health threat and is not a safe substitute for smoking

tobacco. Smokeless tobacco is known to be a cause of cancer and oral health

problems. Smokeless tobacco causes nicotine addiction and dependence, and

adolescents who use smokeless tobacco are more likely to take up smoking. Smoking

bans may be increasing the use of smokeless tobacco as smokers use these products

in settings where smoking is prohibited (CDC, 2014)

Alcohol consumption and health

Alcohol use is very common in our society, and serving alcoholic beverages is

considered customary in social gatherings. In 2015-2017, consumption of alcohol by

Filipinos aged 15 years and older was estimated at 6.6 liters per capita. Drinkers had a

per capita consumption of 19.9 liters, with male drinkers consuming 25.0 liters and

female drinkers, 9.1 liters.

Single occasion for men or four or more drinks in a single occasion for women. In the

Philippines, 3490/0 of adults, who are currently alcoholic beverages drinkers, engaged

in binge drinking Adults, with age range of 40.0-49.9, were found to binge drink more

frequently. Among this adult population, binge drinking is more common among males

(58.5%) than among females (41.1%) (DOST-FNRI, 2016). An alcoholic drink is any

beverage containing 0.6 ounces or 1.2 tablespoons of pure alcohol. An alcoholic drink

can also be in the following forms.

• 12 ounces of beer or wine cooler

• 8 ounces of malt liquor

• 5 ounces of wine

• 1.5 ounces of 80-proof distilled spirits or liquor (gin, rum, vodka, whiskey) (CDC,

July 25, 2016)

The short-term risks of alcohol consumption are usually due to binge drinking or excess

drinking and include risky sexual behavior, violence, unintentional injuries from motor

vehicle accidents, falls, firearms, and drowning. Miscarriage or stillbirth and alcohol
poisoning are also possible immediate effects of excessive alcohol use. The long-term

risks of alcohol use are neurological conditions such as dementia and stroke;

cardiovascular problems such as MI, hypertension, and cardiomyopathy; psychiatric

problems such as depression and anxiety; social problems such as unemployment and

family dysfunction; cancer of the mouth, throat, liver, and breast; and liver disease,

including cirrhosts and hepatitis. Pancreatitis and gastritis are other gastrointestinal

consequences of long-term alcohol consumption (CDC. July 26, 2016).

Clinical implications for health promotion related to alcohol consumption emphasize

prevention of underage drinking and identifying and assisting groups and individuals at

risk for alcohol abuse and dependence (CDC, 2013).

Preventing underage drinking is a public health priority. Enforcement of the legal

drinking age, as well as enforcement of bans on sales of alcohol to minors, is an

important aspect of prevention. Increased excise tax on alcoholic beverages has also

been found to decrease underage drinking. Education of both adults and youth

regarding alcohol and the myriad of risks posed by underage alcohol consumption must

accompany enforcement efforts (CDC, October 17, 2016).

Diet and health

Diet is one of the most modifiable of risk factors. A healthy diet contributes to the

prevention of such chronic diseases as type 2 diabetes, hypertension, heart disease,

and some cancers. The problem of being overweight and obese in the country is

alarmingly increasing in number.

What does it mean to be overweight or obese? Both of these terms are used to indicate

a condition of excess weight for height. Both terms also identify ranges of weight that

have been found to be associated with an increased risk of certain diseases or

conditions. The body mass index (BMI) is used to determine weight status in adults and

children. The BMI takes both height and weight into account and has been found to

correlate well with the amount of body fat present. An adult with a BMI of 25 to 29.9 is

considered overweight and an adult with a BMI of 30 or higher is considered obese.

In 2015, 9.2% (nine in every 100) of Filipino adolescents were found to be overweight /

obese. There were more cases of overweight / obesity among young males and mostly

are in the 100- to 129-year-old age group. In addition, the occurrence of

overweight/obesity was shown to increase with the improving socioeconomic status of

the adolescent. Adolescents living in urban areas and those in the upper socio-

economic class have the highest prevalence of overweight / obesity (DOSTFNRI, 2016).

Nutritional Guidelines for Filipinos

Eat a variety of foods every day to get the nutrients needed by the body.

- Breastfeed infants exclusively from birth up to six months and then give appropriate

complementary foods while continuing breastfeeding for two years and beyond for

optimum growth and development.

- Eat more vegetables and fruits to get the essential vitamins, minerals, and fiber for

regulation of body processes.

- Consume fish, lean meat, poultry, egg, dried beans or nuts daily for growth and repair

of body tissues.

- Consume milk, milk products, and other calcium-rich food such as small fish and

shellfish, every day for healthy bones and teeth.

- Consume safe foods and water to prevent diarrhea and other food-and water-borne

diseases.

- Use iodized salt to prevent Iodine Deficiency Disorders.

- Limit intake of salty, fried, fatty, and sugar-rich foods to prevent cardiovascular

diseases.

- Attain normal body weight through proper diet and moderate physical activity to

maintain good health and help prevent obesity.

- Be physically active, make healthy food choices, manage stress, avoid alcoholic

beverage, and do not smoke to help prevent lifestyle-related non-communicable

disease.

There is no single food that contains all the nutrients that our body needs so eating a

variety of food ensures that daily nutritional needs are met.

There was also a decrease in consumption of fruits from 77 grams in 205 to 54 grams in

2008 and also a decrease in milk consumption from 44 grams to 42 grams. These

results were the basis of message no. 3 and 5, respectively.

Vegetables and fruits are the main sources of vitamins, minerals, and fiber, while milk is

a good source of calcium.

Low urinary iodine excretion is still a prevalent problem among pregnant and lactating

mothers, indicating to low iodine intake. Iodine is important during pregnancy because it

is needed for the brain development of the infant while lactating mothers must have

adequate supply of iodine in their breastmilk. This is the message of NGF no. 7.

The total cholesterol level among Filipino adults increased from 8.5 (mg/dL) in 2003 to

10.2 (mg/dL) in 2008.

High cholesterol level may be attributed to the high consumption of sodium rich foods by

Filipinos.

Salt and soy sauce were among the top 10 widely used miscellaneous food items used

by Filipinos.

In addition, heart diseases ranked first among the causes of death based on the 2005

Department of Health survey. This is the reason behind no. 8 of NGF.

Excessive intake of salt and soy sauce can result to high blood pressure specially to

salt-sensitive individuals. Persistent high blood pressure can result to cardiovascular

diseases.

There is also a decreasing trend of physical inactivity among Filipinos and also a large

percentage of Filipino smokers at 31.0% and drinkers at 26.9%. These situations where

the basis of messages no. 9 and 10 of the NGF.

People are always encouraged to exercise at least thirty minutes a day, three to five

times a week.
Limit alcohol drinking to one drink per day for women and two drinks for men is also

advised.

One alcoholic drink is equivalent to one and half ounce distilled beverage such as gin or

12 ounces or a bottle of beer or four ounces’ wine or half glass wine or an ounce of 100

proof whiskey.

Let’s practice the ten nutritional guidelines to achieve good health and optimal

nutritional status.

For many people, eating at home all the time is impossible or impractical, and food is

central to many social interactions. In order to consume fewer calories when eating out,

one may:

 Prioritize establishments that offer a variety of fond choices and are willing to

make substitutions or changes

• Order lower-fat steamed, broiled, baked, roasted, or poached items, or ask that

an item be prepared in a lower-calorie way. such as grilled rather than fried

• Choose lower-calorie sauces or condiments, or do without them altogether

• Substitute colorful vegetables for other side dishes (such as French fries)

• Ask for half of the meal to be boxed to take home before the meal is brought to

the table Share an entrée with someone

• Order a vegetarian meal

• Select a fruit for dessert

"10 decrease reliance on away-from-home foods, plan ahead and:

• Pack healthy snacks

• Cook a healthful dinner at home and make extra to pack for lunch the next day

• Purchase healthful foods when grocery shopping to pack for lunch, such as

prepackaged salads, fresh fruits, vegetables. and low-calorie soups

• For travel or longer excursions, bring along nutritious foods that will not spoil,

such as fresh fruits and vegetables, or pack a cooler with healthy foods

Physical activity and health

Many reasons why people engage in activity and exercise: for weight management,

increased energy, or better appearance, to fit into those favorite clothes; to prevent

development or worsening of a chronic health condition; to manage stress; to improve

mood and self-esteem; or any combination of these reasons.

How much exercise do I need? What counts as exercise? Nurses in the community

hear these questions commonly as they educate the public on the need to increase

physical activity. The answers to these questions depend on the age, physical condition,

and gender of the client.

Sleep

Essential component of chronic disease prevention and health promotion, yet

74% of adult’s report having a sleeping problem one or more nights per week.
Insufficient sleep is associated with diabetes, heart disease, obesity. and

depression. Insufficient sleep contributes to 100,000 motor vehicle crashes each

year and 15,000 deaths. Sleep requirements change as people age. According to

the National Sleep Foundation, the recommended sleep per day based on their

age are as follows: newborns (1-2 mo) — 10.5-18 hr; infants (3-11 rno) = 9-12 hr

during night and 30 min to 2 hr naps, 1-4 hr a day; toddlers (1-3 yr) = 12-14 hr:

preschoolers (3-5 yr) = 11-13 hr; school-aged children (512 yr) + 10-11 hr; teens

(11-17 yr) = 8.5-925 hr; adults = 7-9 hr; and older adults - - 7-9 hr, and depending

on life circumstances, one may require more than the minimum hours mentioned.