Taking into consideration individuals’ differing beliefs and levels of confidence in their ability to change their behaviour can improve the impact of health promotion messages
Nurses play a vital role in providing integrated mental and physical healthcare to patients who have long-term conditions and live in the community. The absence of assessment tools to systematically respond to individual patient constructs of their illness and their perceived potential for recovery contribute to the difficulty of providing effective, personalised care. This article explores the use of an assessment instrument to develop an effective personalised health promotion strategy using an evidence-based approach.
Citation: Lau-Walker M (2014) Personalising health promotion for more impact. Nursing Times; 110: 44, 18-20.
Author: Margaret Lau-Walker is lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF including any tables and figures
The Department of Health promotes a personalised care approach to optimise self-care management in patients with long-term conditions (Department of Health, 2006). Research into a range of such conditions - coronary disease (Ekman et al, 2011), asthma (Effing et al, 2007) and diabetes mellitus (Warsi et al, 2004) - suggests that a personalised care approach might improve healthcare outcomes. However, the delivery of health promotion is complex, requiring healthcare practitioners to provide health education and strategies to help individuals manage their behaviour relating to diet, exercise, smoking and lifestyle changes.
Research in health education indicates that generic health education and advice rarely translates into health behaviour change (Mullen et al, 1992). Effective patient education requires a more tailored approach to encompass individuals’ beliefs about their health condition and to provide strategies to build their confidence to manage their health and self-care. Research in illness beliefs shows that people with a similar health condition can behave differently in their responses toward health promotion strategies, treatment and care, which is why health education needs to be personalised to be effective (Leventhal et al, 1984; Petrie and Weinman, 1997).
Two psychological theories feature prominently in research into the development of personalised care:
- Illness representation (Leventhal et al, 2001; 1984); and
- Self-efficacy (Bandura, 1997).
Research in illness beliefs has demonstrated that patients’ individual illness beliefs have a greater influence on their health behaviour changes than the severity of their illness (Petrie and Weinman, 1997). Experimental evidence also shows that individuals’ perceived self-efficacy (an individual’s confidence in their ability to manage a task) predicts their behaviour change (Bandura, 1997). The psycho-educational interventions based on these theories intend to respond to individual patient constructs of their illness and the potential for recovery, and are particularly relevant for personalised care.
I developed an interactive care model (Lau-Walker, 2006) combining the therapeutic use of these two psychological theories to describe a personalised care approach that addresses both patients’ illness perceptions (illness representation) and their confidence in self-management (self-efficacy).
Use of care models
The active model (Lau-Walker, 2006) (Fig 1) illustrates current health promoting practice, for example health promotion in healthy dieting. In this model, healthcare practitioners aim to actively engage the individual by providing up-to-date information about healthy dieting:
- Why have a healthy diet;
- What a healthy diet looks like;
- How to go about maintaining a healthy diet; and
- Understand the potential problems of not adhering to a healthy diet.
However, research shows that convincing individuals that certain behaviour leads to a desirable outcome will not lead to behavioural change unless the individual has the confidence to perform the behaviour in the required situation (Bandura, 1997). For example, a person might accept that exercise will improve his/her health, but may still dismiss this health strategy because they do not believe they will be able to maintain regular exercise (“exercise is not my thing”, “I never exercise regularly”).
The interactive care model I developed (Lau-Walker, 2006; Fig 2) captures more patient perceptions to create personalised health-promoting practice. In the interactive care model, healthcare practitioners personalise the care approach by addressing the individual’s illness beliefs (illness perceptions) and confidence in health behaviour change (self-efficacy) because these have a direct impact on the health outcome. This model illustrates that effective personalised health promotion requires the practitioner to:
- Interact with the individual to understand and respond to their interpretation of health promotion advice; and
- Recognise and support the individual’s capacity to manage the suggested health behaviour or lifestyle changes.
In addition to the focus on the why, what and how of a health behaviour change, there needs to be a focus on the individual’s interpretation of the health promotion advice, along with their ability to realise the suggested health behaviour changes.
Personalised patient education in practice
For the interactive model to be used in practice and to address the complexity of a consistent approach to personalised care, a personalised patient education protocol (PPEP) was developed for patients diagnosed with myocardial infarction (MI). This was designed to provide the necessary structure to enable healthcare practitioners and patients to engage in the personalisation of care. It is intended to be used in addition to any existing cardiac rehabilitation routine care. The PPEP aims to address cardiac patients’ illness beliefs and expectations to:
- Promote self-management;
- Aid recovery; and
- Provide effective management of their cardiac risk factors after the diagnosis of MI.
I developed the PPEP supported by cardiac patients, cardiac rehabilitation staff (cardiologists, cardiac rehabilitation nurses, health psychologists) and physiotherapists from three London hospitals. Cardiac patients and health professionals revised the timing and practicality of the PPEP’s delivery to ensure information was given in a consistent, concise, clear manner and patients did not have information overload. Although the PPEP was initially designed to be delivered to patients before their hospital discharge, it is now also recommended to be used in community practice and at GP clinics.
The PPEP training manual and PPEP patient workbook, based on the interactive care model, comprise an illness belief protocol (IBP) and a self-management protocol (SMP).
Illness belief protocol
The IBP consists of a list of illness belief questions and key feedback messages developed by cardiac rehabilitation healthcare practitioners.
The following example explores an individual’s beliefs:
Question: How long do you think your cardiac condition will continue?
Answer: Patient scores using a scale of 0-10 (0 = a very short time; 10 = forever).
Key feedback message: This is a progressive disease/This is a long-term condition.
The SMP comprises information developed by patients and health professionals to promote an individual’s confidence in managing their cardiac risk factors and cardiac symptoms, and to encourage them to adopt a problem-solving approach to the management of their symptoms. As an example, the SMP discusses step-by-step symptom management. A six-point approach is suggested to promote patients’ confidence in self-managing their symptoms:
- Describe my experience of the symptom;
- Is this symptom related to my cardiac condition?
- Interpret the severity and impact of the symptom;
- Identify appropriate responses/actions;
- Monitor and evaluate progress; and
- Any follow-up action recommended?
Details of individual cardiac symptom management are found in the PPEP training manual.
PPEP training manual
The PPEP training manual was developed as a training and reference guide for healthcare practitioners who deliver PPEPs. It contains four chapters:
- Description of PPEP;
- How to deliver PPEP;
- Details of IBP tools; and
- Details of SMP tools.
PPEP patient workbook
The PPEP patient workbook is designed to be used at home and consists of three sections, which cover the following:
- Record of an individual’s answers to the questions on illness beliefs;
- Record of an individual’s cardiac risk factors with action boxes to record actions and notes about each of the relevant risk factors; and
- A potential symptoms checklist, along with comment boxes to record the frequency of symptom experiences plus notes and potential questions to raise at the next doctor visit.
Patients are advised to use the workbook alongside appropriate learning resources, for example the British Heart Foundation’s booklet entitled Heart Attack (tinyurl.com/BHFHeartAttack) and our trust’s leaflet on discharge advice after a heart attack.
Case study feedback
Cardiac rehabilitation nurses offered feedback on the structure and use of the PPEP (Table 1). Their main points are as follows:
- The PPEP made practice more patient centred - “listen to patients more”, “the structure of the PPEP tools enable me to adopt a facilitative approach”.
- It enabled them to systematically take in patients’ views and expectations - “patients express their views and ask more questions”, “surprised to hear some patients think that they have been cured by the angioplasty (stent) and no longer have any heart condition”.
- It enabled cardiac rehabilitation nurses to provide consistent key health promotion messages - “prompts are good to provide standardised and consistent health promotion messages”, “it will be particularly good for training junior healthcare practitioners”.
- The PPEP should be integrated with existing care packages - “Initially, the implementation of the PPEP feels artificial”, “take some time to be spontaneous again and now integrate the PPEP with the existing care packages and feel very comfortable with it.”
- More time was spent on patients’ concerns - “have now introduced the IBP tool again during cardiac rehabilitation outpatient rehabilitation patient education sessions, have more time to discuss PPEP with patients”.
- PPEP should be delivered by health professionals who have a good knowledge of cardiac care so they can provide individuals with appropriate information and support.
The PPEP tools have been reviewed and tested by patient and cardiac rehabilitation professionals at three London hospitals. One of three participating hospitals is leading the implementation of the PPEP and delivering this as a new service.
- The integration of mental and physical healthcare delivers more effective and efficient healthcare
- A personalised patient education protocol (PPEP) takes into account patients’ views and ability to manage their long-term conditions
- PPEPs help nurses to address patients’ physical and mental health needs
- PPEPs provide a framework to enable patients to express their views about their illness
- They allow patients to take more responsibility of their own healthcare
Bandura A (1997) Self Efficacy: The Exercise of Control. New York, NY: WH Freeman and Co.
Department of Health (2006) Supporting People with Long Term Conditions to Self Care: A Guide to Developing Local Strategies and Good Practice.
Effing T et al (2007) Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews; 17: 4, CD002990.
Ekman I et al (2011) Effects of person-centred care in patients with chronic heart failure: the PCC-HF Study. European Heart Journal; 33: 9, 1112-1119.
Mullen PD et al (1992) A meta-analysis of controlled trial of cardiac patient education. Patient Education and Counselling; 19: 143-162.
Lau-Walker M (2006) A conceptual care model for individualised care approach in cardiac rehabilitation - combining both illness representation and self-efficacy. British Journal of Health Psychology; 11: 103-117.
Leventhal H et al (2001) Representations, procedures and affect in illness self-regulation: a perceptual-cognitive model. In: Baum A et al (eds) Handbook of Health Psychology. Mahwah, NJ: Lawrence Elrbaum Associates.
Leventhal H et al (1984) Illness representations and coping with health threats. In: Baum A et al (eds) A Handbook of Psychology and Health: Volume IV, Social Psychological Aspect of Health. Hillsdale, NJ: Lawrence Erblaum Associates.
Petrie K, Weinman J (1997) Perceptions of Health and Illness. Amsterdam: Harwood Academic Publications.
Warsi A et al (2004) Self management education programmes in chronic disease. A systematic review and methodological critique of the literature. Archives of Internal Medicine; 164: 9-23.