Therapy and Health Promotion

Health Promotion Rehabilitation: an endeavour towards better health.

“Preventive measures are less expensive than the restorative measures” (Clark 1992, Friedland et al 2001, Hajnal 1997, Sheiham 1992).

Introduction
The article will define health promotion first and than will look into upstream thinking. The importance of health education in health promotion, along with different types of health promotions will be discussed. Health promotion on a wider perspective will be explored and will be related to rehabilitation. Finally the article will discuss change of health behaviour using health promotion model. The aim is to gain understanding of health promotion for the rehabilitation professional in order to incorporate them into rehabilitation practice.
An analogy of upstream thinking.
McKinlay(1979) analogy of a man standing by a fast flowing river who spent his time jumping in and pulling out people who were drowning. The task of jumping in, pulling them to the shore and applying artificial respiration was so demanding of his resources that he had no time to go upstream to prevent them falling (or being pushed in the river). The story introduced the notion of refocusing upstream and of upstream planning and action.

Defining Health Promotion
Health promotion can be described as the process of enabling people to increase control over and to improve their health (WHO, Ottawa Charter 1986).Ennis et al (2006) describe health promotion activities as behavioural, cognitive and emotional endeavour to promote health and well being of people. It is a multidisciplinary endeavour taken up in diverse setting (Scriven et al, 2004).

Education in Health Promotion: Primary Health Promotion activity
Enabling people by empowerment was emphasised as being a part of health promotion process (Gottwald, 2006). In a systematic review, McDonald et al (2004) found in nine studies involving 782 participants from a pool of 17 potentially eligible studies, the evidence that preoperative education prior to hip and knee replacements, reduces anxiety. The review included only randomised studies which could be seen as its limitation, as inclusion of other rigorously completed studies could have increased the sample size. But empowering people by education is not just health promotion (Davis, 1995 and Gottwald, 2006). In a randomised controlled trial Ennis et al (2006), found health promotion education for multiple sclerosis to be effective in increasing level of health promotion activity undertaken by patients, confidence and belief in ability to undertake health promotion activity as well as certain domains of quality of life. Although the limitation of the study can be seen in its sample size, as it was completed on sixty two adult multiple sclerosis patients. In another randomised controlled trial, Almomani et al (2006) found in a treatment group of twenty patients that dental hygiene instructions along with dental education and a mechanical toothbrush, had a positive effect. The control group was provided with mechanical toothbrushes, in a cohort of fifty mentally ill patients which included schizophrenics, bipolar disorders and other mentally ill clients. The generalisation of the result however can be argued as patients were only followed up once in four weeks and that the study was completed with fifty patients. However the two studies highlight the importance of education in health promotion. But health promotion is not just empowering people by education (Davis 1995 and Gottwald 2006). It is a much broader concept.
Scriven et al (2004) described “Primary health promotion activities” as upstream activities that target the well population. The goal is to prevent illness and disability by health education (targeting lifestyle and behavioural change) and/ legislation (Such as the smoking policies).

Health Promotion: A wider perspective
Davis (1995) in a qualitative study identified that nurses use health promotion and health education in neuro rehabilitation. The research resulted in the development of a model in which policy making, social and physical environment were all considered as health promotion activities. Empowering patients and working with them to make them independent (clients being the co manager of their conditions) was considered as health education. The study was completed rigorously although the ethical considerations and the data analysis could have been more explicit.
Health promotion includes wider perspective like consideration of social environment, preventive health service, community based work, public health policies, environmental health policies, organisation development, economic and regulatory activities (Gottwald , 2006). Scriven et al (2004) described “Secondary health promotion” is directed at individuals or groups in order to change health damaging habits and/ or to prevent ill health moving to a chronic or irreversible stage and where possible to restore people to their former state of health and/ or community development approaches that encourage structural and environmental changes. The “Tertiary health promotion” takes place with individuals who have chronic conditions and /or are disabled and is concerned with making the most of the potential for healthy living (Scriven et al 2004). These might include client centred approaches, such as those used in rehabilitation, or the management of chronic disease programmes. The therapists currently in United Kingdom (UK) work as the secondary or the tertiary health promoters and hence the emphasis is to work as the primary health promoter, yet that would need a paradigm shift altogether (Scriven et al, 2004).

Health promotion in Orthopaedic or surgical Occupational Therapy Practice
Occupational Therapists see patients in the pre-admission clinics or do pre-operative home visits, before they come in for total hip replacement surgeries. These activities can be seen as “Primary Health Promotion” as the aim is to prevent post operative complications (Most common of which is the hip dislocation). The assessment and intervention includes discussing/ assessing home situations, assessing baseline functioning, providing equipment to assist in ADLs, problem solving patient issues (addressing anxiety of the surgery), addressing sexuality issues for the post operative period and also referring to the other multidisciplinary team members. These activities can be clustered as primary health promotion activities as the aim is to prevent illness or disability.
Therapists see amputee patients immediately post operatively. The empowering process post operatively can be viewed as primary health promotion as it helps patients’ to be better compliant for the forthcoming therapy and helps them to accept their disability, although this can be argued as tertiary health promotion as interventions are following disability caused.
The Occupational Therapists see patients following hip/ knee replacements in hospital wards. They address their home situation, discuss precautions with the operation, assess home environment, check mobility and transfers following the surgery and refer patients to the community team for follow up. These activities can be clustered as “secondary health promotion”, as the aim is early detection of problems and to address them in order to prevent future disability. However therapists in hospitals/ community who work with patients with recurrent hip dislocations can be viewed as “tertiary health promotion”, in the area of practice. Hence Occupational Therapists in order to promote upstream thinking should assess patients pre-operatively. This does not necessarily rule out the need of Occupational Therapists in the wards, but Physiotherapists can contribute to secondary health promotion, in the area of practice. However the roles of Occupational Therapists and the Physiotherapists are indispensable in order to manage trauma patients (admitted following dislocations) for tertiary health promotion.
When rehabilitating the amputees, adapting the home environment and prosthetic rehabilitation can all be viewed as tertiary level health promotion (as the patient is permanently disabled following amputation). Empowering amputees from time and regularly following them up in outpatient/ community can also be seen as secondary health promotion activities. Hence for amputees the process of empowering, environmental adaptations, prosthetic rehabilitation and regular follow up, contributes to health promotion.
Understanding Health Promotion in Rehabilitation: An Overview.
Apart from education, other examples of preventive health service or community based work which can be viewed as upstream working by therapists, can be extrapolated from the rehabilitation of elderly patients in the General Practitioners’ surgery. Time up and Go test (TUG) is an outcome tool for falls assessment in rehabilitation. In a pilot study, Dinan et al (2006) found of the two hundred and forty two patients referred for exercise classes at the GPs surgery, one hundred seventy eight completed cycles of classes. The TUG scores were obtained at the baseline and at follow up. TUG values showed reduced risk of fall for these individuals in the community implicating beneficial effect of the exercises although the sample had more females than male adults. In a randomised controlled trial, Rosendahl et al (2006) found similar positive long term effect of high intensity functional exercise programme in balance, gait ability and lower limb strength for older people dependent in activities of daily living (ADL). Another example of community based work and health promotion is the motivation to volunteer. Black et al (2004) found volunteering to have beneficial effect in mental wellbeing of the elderly population. In an Adult Health Development Program (AHDP), when students from various disciplines (including nursing students) were being paired up with adults to engage in several health promotional activities, it was found to have beneficial effect (bi directional). The activities included health education hour, low impact exercise group, swimming and water aerobics, weight training, trampolining, billiards, Tai chi, walking, three wheel biking, dancing, parties, celebrations and socialising with friends. This was termed as Transgenerational Health Promotion by Watson et al (2000), as students learnt about the ageing process and the program helped to improve health and wellbeing of the adults. This can be viewed as another form of community working in order to promote health and wellbeing. Health promotion in rehabilitation can also be understood by group work called “Problem based rehabilitation”. It is an active group work where the group members discusses and facilitates by problem solving and by providing psychosocial support for each other. Medin et al (2004) in a case study with disabled people on long term sick leave from work found problem based rehabilitation to have positive effect to help people return to work and also to improve self esteem, without making any generalisation of the finding.
Thus health promotion and rehabilitation are linked very intricately. Change of models of health promotion.

Health behaviour change using health promotion model.
Health behaviour change was defined as “the shift from risky behaviors to the initiation and maintenance of healthy behaviors and functional activities and the self management of chronic health conditions” (Nieuwenhuijsen et al 2006). Health promotion can be achieved by understanding individual “locus of control”. The Locus of control affects a person’s behaviour which could be internal or external (McPherson, 2001). People with internal locus of control usually are self motivated and are capable of making independent decisions. However people with external locus of control are reliant on others to take decisions on their behalf. They are easily influenced by other people. Gottwald (2006), reports people with internal locus of control usually are motivated hence their behaviour change happens early. They are less likely to come out of the cycle when undergoing change of behaviour in the stages of change (Prochaska and DiClemente, 1982) model. The stages include PreContemplation (No intention to change)?Contemplation (Thinks about changing) ?Commitment (Determined to change behaviour) ? Action/ Maintenance (Person finds it difficult but changes behaviour)? Relapse (Person goes back to previous behaviour).This is considered healthcare professionals responsibility to help get them back in the cycle by working as a team with patients’ and their family. Gottwald (2006) reports a person may come out of the cycle few times before being able to complete the cycle. Nieuwenhuijsen et al 2006, report an understanding of a person’s environment (social environment or the work place environment), health models and personal factors are all essential to bring about health behaviour change. Five themes were being identified in relation to health promotion from the literature. The themes were: 1) Preventive aspect of health behaviour (Prevention against primary disease), 2) Early detection behaviour (includes early detection of a condition), 3) Self management of condition. Usually applies for chronic conditions, 4) Treatment adherence or being compliant to treatment, 5) Behaviour of health care providers. Nieuwenhuijsen et al 2006 and Beattie’s 1991, emphasised the need for client centred practice/ or client led practice and argues that a bottom up approach (Negotiation mode of intervention) is preferred to a top down approach (Authoritive mode of intervention), as the former is patient lead. The bottom up approach in health promotion is hence called “client led or client centred approach”.
Nieuwenhuijsen et al 2006, argues that the health promotion models however lacks adequate address of disability issues and also for its more uniform application needs to be based on comprehensive framework like the International Classification Of Functions (ICF).

Conclusion
The article has discussed the different types of health promotion used in rehabilitation. The aims of health promotion were then related to an area of practice. Health promotion and change of behaviour was discussed using the Stages of Change Model (Prochaska & DiClemente, 1982).It can be said that health promotion and rehabilitation have similar aims, as the emphasis of both is to give clients the control to decide for their own health. Healthcare professionals are the facilitators in the process and that the change of behaviour is only achieved better, if a client centred approach is used in interventions. The shift of emphasis is now recognised from professional directed to client led.

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