How a health promotion model reduces disabling complications of diabetes
The incidence of diabetes is increasing worldwide, and in England 1.3 million people - 2 to 3% - have the condition (DH, 2001a). Diabetes affects physical and psychological well-being, as well as lifestyle, relationships, income and life expectancy, and the financial implications are significant: 5% of the total NHS budget and 10% of acute-sector resources are spent on diabetes.
Gloria Daly, BA, BSc, RGN.
Local Learning Manager for First Contact Care in London, NHSU, London
These costs increase more than fivefold for treating disease-related complications (DH, 2001a), including:
- Ischaemic heart disease
- Peripheral vascular and neuropathic disease
- Cerebrovascular disease
- Diabetic eye disease
- Diabetic renal disease.
But complications are not inevitable and much can be done to prevent or greatly reduce them (Stratton, 1998). The St Vincent Joint Task Force Report (DH, 1995) challenged health-care professionals to develop models of care to reduce long-term complications.
The underlying principles of documents such as The NHS Plan (DH, 2000) and The Expert Patient (DH, 2001b) are to support patients with diabetes in managing their own lifestyles through structured support and education. The article on page 37 highlights the work of the Desmond project in this area.
Diabetes UK (2000) lists three key risk factors that can be tackled through effective health promotion: smoking, obesity and lack of physical activity.
Health promotion activities should be co-ordinated through effective partnerships across disciplines, professions and agencies, and delivered in a culturally sensitive way. The Jakarta Declaration (WHO, 1997) identified five strategies for successful health promotion:
- Build a healthy public policy
- Create a supportive environment
- Strengthen community action
- Develop personal skills
- Reorientate health services.
Partnership working has a major role in delivering the aims of the Jakarta Declaration (WHO, 1997). Broadening the base for health interventions means addressing socioeconomic and environmental issues, improving access to services, reducing inequalities and targeting education at all groups, transcending age, ethnicity, gender and status barriers.
Tackling health inequalities
Tackling health inequalities must be considered as part of developing an action plan or intervention. Acheson (DH, 1998a) highlighted 11 areas of inequality (Box 1).
Professionals across all agencies have a role in delivering effective local interventions to reduce inequalities at the same time as addressing health promotion and prevention initiatives to reduce diabetes complications.
Many of Acheson’s recommendations (DH, 1998a) can be delivered in a local setting, such as increasing the uptake of benefits within eligible groups, developing health promotion in schools, encouraging walking and ensuring that the needs of people from ethnic groups are taken into account when developing policies.
Several models exist to support health promotion. These fall into two broad types that can be simply defined as:
- Models that define health promotion as a range of interventions (Tannahill, 1985; French and Adams, 1986; Beattie, 1991)
- Models that examine health determinants and recommend responsive serivces (Laframboise, 1973; Raeburn and Rootman, 1989; Hancock, 1993).
Within these models practitioners have a role as either leaders (authority figures) or facilitators (negotiators) (Naidoo and Wills, 2000).
Beattie’s health promotion model
We have successfully used Beattie’s health promotion model in practice (Figure 1), supported by an action plan (Table 1). Beattie (1991) identifies four paradigms:
- Health persuasion
- Personal counselling
- Community development
- Legislative action.
These contribute to achieving a whole picture when developing local action plans for partnership working.
Any model for health promotion activity needs underpinning by the patient’s intention to change behaviour. The theory of planned behaviour (Ajzen, 1991) is one of many models of behaviour change cited in the Health Development Agency’s website resource (HDA, 2001). It lists three steps:
- The individual’s attitude, determined by their beliefs about consequences
- The expectations of others
- The individual’s perceived control and belief in their ability to change.
Each partner or agency involved is encouraged to use the same models to support their own initiatives while creating a multi-partnership, strategic approach.
The action plan in Table 1 is a guide to implementing a health promotion strategy to reduce complications of diabetes. The objectives are to build a healthy lifestyle support programme for people with diabetes, so they can manage their individual and community programmes.
The underlying principle is founded on partnership working with communities and users, based on a multiprofessional, multi-agency approach. Achieving the plan depends on proactive communication and consultation skills.
Any strategy must consider ‘how?’ as well as ‘why?’, and its large and complex objectives should be factored into local action plans (Hrebiniak and Joyce, 1984).
Bryson (1995) states: ‘Strategic planning is simply a set of concepts, procedures and tools designed to help leaders, managers and planners think and act.’ A strategy’s action plan should recognise the need for organic practice and realise that local actions are a combination of what is intended and what emerges along the way (Bryson, 1995).
Traditional health promotion evaluation assesses activities in terms of their impact on goals, using a biomedical model. But this technique tends to be rigid, and Tones (2000) argues against using biomedical indicators to evaluate health-promotion activities.
However, in today’s climate of government targets, it is necessary to report milestone achievements to contribute to future decision-making and programme setting. Downie et al (1996) identify two main types of evaluation:
- Measuring what has been achieved
- Measuring how the objective has been achieved.
Combining both methods enables health-care practitioners to monitor the process of change and to ensure that health promotion activity is relevant to the individual.
Judd et al (2001) advocate a three-step process, integrating evaluation of process, impact and outcome - that is, measuring the changes taking place as well as targets achieved. There is a need to balance evaluation to accommodate community realities and professionals’ need for evidence of health improvement.
The long-term view
Health promotion activities must include socially empowering and enabling activities (Tones, 2000). The strategy used as an example here is based on the The National Service Framework for Diabetes (DH, 2001a), and the standards aimed at reducing complications of diabetes through promotion of healthy lifestyles. But it has been developed with a wider remit to sustain health promotion activities through community involvement and participation, and ensure the eradication of inequality of health care for people with diabetes within ethnic-minority groups.
The Beattie strategy shown here recognises the need to move the emphasis in health promotion from ‘doing’ to building relationships for the longer term, and ensuring that public health promotion, prevention, education, and protection are the responsibility of all - not just those with a health promotion remit.
To be effective, health promotion must create healthy public policy and supportive environments, foster individual or group skills and capacities, strengthen community action and reorientate health services (WHO, 1986).
Improving diabetes services and promoting lifestyle changes
- The National Service Framework for Diabetes (DH, 2001a) sets out 12 standards aimed at prevention, improving services, helping people with diabetes manage their condition and preventing complications. Standards 3 and 4 target lifestyle changes that reduce complications
- Standard 3: People with diabetes are empowered to enhance their personal control over the day-to-day management of their diabetes in a way that enables them to experience the best possible quality of life
- Standard 4: To maximise the quality of life of all people with diabetes and to reduce their risk of developing long-term complications.
Author’s contact details
Gloria Daly, Local Learning Manager, First Contact Care in London, NSHU, 88 Wood Street, London EC2V 7RS. Email: email@example.com
Ajzen, I. (1991)The theory of planned behaviour. Organizational Behaviour and Human Decision Processes 50: 179-211.
Beattie, A. (1991)Knowledge and control in health promotion: a test case for social policy and theory. In: Gabe, J., Calnan, M., Bury, M. (eds) The Sociology of the Health Service. London: Routledge/ Taylor and Francis.
Bryson, J. (1995)A Guide to Strengthening and Sustaining Organisational Achievement. Riverside, NJ: Simon and Schuster.
Department of Health and British Diabetic Association. (1995)St Vincent Joint Task Force of Diabetes; The Report. London: DH.
Department of Health. (1998a)Independent Inquiry into Inequalities in Health: The Acheson Report. London: The Stationery Office.
Department of Health. (1998b)Smoking Kills: A white paper on tobacco. London: DH.
Department of Health. (2000)The NHS Plan: A plan for investment. A plan for reform. London: DH.
Department of Health. (2001a)National Service Framework for Diabetes. London: DH.
Department of Health. (2001b)The Expert Patient: A new approach to chronic disease management for the twenty-first century. London: DH.
Diabetes UK. (2000)Recommendations for the Management of Diabetes in Primary Care: A report (2nd edn). London: Diabetes UK.
Downie, R.S., Tannahill, C., Tannahill, A. (1996)Health Promotion: Models and values (2nd edn). Oxford: Oxford University Press.
French, J., Adams, L. (1986)From analysis to synthesis. Health Education Journal 45: 71-73.
Hancock, T. (1993)Health, human development and the community ecosystem: three ecological models. Health Promotion International 8: 41-47.
Health Development Agency. (2001)Developing the Public Health and Health Promotion Role of Nurses. Available at: www.hda.nhs.uk/ nurseeducators/index.html
Health Development Agency. (2004)Developing Healthy Communities. London: HDA.
Health Education Authority. (1996)Active for Life. London: HEA.
Hrebiniak, G., Joyce, W. (1984)Implementing Strategy. London: Collier MacMillan.
Judd, J., James, C., Moulton, G. (2001)Setting standards in the evaluation of community-based health promotion programmes: a unifying approach. Health Promotion International 16: 4, 367-380.
Laframboise, H. (1973)Health policy: breaking the problem down into manageable fragments. Canadian Medical Association Journal 108: 388-393.
Naidoo, J., Wills, J. (2000)Health Promotion Foundations for Practice. London: Ballière Tindall.
Raeburn, J., Rootman, I. (1989)Towards an expanded health field concept. Health Promotion 3: 383-392.
Stratton, I. on behalf of the United Kingdom Prospective Diabetes Study Group (1998)Association of glycaemic and macrovascular complications of Type 2 diabetes. British Medical Journal 321: 405-412.
Tannahill, A. (1985)What is health promotion? Health Promotion Journal 44: 167-168.
Tones, K. (2000)Evaluating health promotion. Patient Education and Counselling 39: 227-236.
World Health Organization. (1986)The Ottowa Charter for Health Promotion. Geneva: WHO.
World Health Organization. (1997)The Jakarta Declaration. Geneva: WHO.