9 Introduction to Functional Health Patterns and Health Promotion
Health is defined in many ways. It is not merely the absence of disease, but includes aspects of physical, mental, social, and emotional well-being. In a positive model of health, the definition includes factors such as strength, resilience, resources, potentials, and capabilities rather than focusing just on pathology. Health involves a biopsychosocial perspective (Pender et al, 2011). Health care is considered by many to be a birthright, and health is highly valued by all cultures in the world. Although valued, health is often compromised by behaviors of daily living. The landmark paper by McGinnis and Foege (1993), since updated by Mokdad and associates (2004), links 50% of the mortality in the U.S. to lifestyle-related behaviors—tobacco use, poor dietary habits, inactivity, alcohol consumption, illicit drug use, and risky sexual practices.
The majority of life-threatening and debilitating conditions of children are preventable. The proposed goals of Healthy People 2020 (HP 2020) (U.S. Department of Health and Human Services [USDHHS], 2010) focus on essential lifestyle and behavioral factors related to health with benchmarks related to the above health-related behaviors. The leading health indicators that remain in place from the Healthy People 2010 guidelines include:
Children’s health depends on a multitude of factors, including appropriate nutrition, stimulation, exercise, rest, and emotional and social nurturance. Teaching and modeling healthy behaviors help children learn to promote their own health and, because many health problems of children are carried into adulthood, working with children has long-term health effects on the whole population. In addition to healthy lifestyle behaviors, prevention and management of illness and injury are essential to children’s growth and development. Health care providers work with children and their families to ensure that decisions made and actions taken regarding health management are best suited to growing children’s needs.
Family health is also important because the child cannot thrive in an unhealthy family. Family health has been defined as a dynamic changing state of well-being, including biologic, psychological, sociologic, spiritual, and cultural factors affecting the family system. Characteristics of healthy families include support for one another, shared responsibilities, shared leisure time, shared religious and core values, respect, trust, and family traditions (Pender et al, 2011).
The skilled clinician must take a broad view of practice and outcomes. Working in an interdisciplinary way at the individual, family, community and health care systems, and policy levels will make more of a difference than working with individual patients alone (Institute of Medicine [IOM], 2001; Williams et al, 2008). A broad array of professionals and citizens must be involved. Nurses, teachers, health educators, city planners, legislators, the industrial community, volunteers, and others from all levels of society need to guide development of an infrastructure that supports individual as well as overall community health. Although this text focuses on management of individual children within families, a broader perspective on community intervention and support for health also needs to be maintained. When opportunities to work with communities on their primary health care issues arise, the provider is strongly encouraged to become involved.
This chapter introduces the functional health patterns unit of the book and examines the first of those patterns: health perception and health management. Within the context of the health perception and health management pattern, models that predict health behavior, factors that influence health promotion behaviors, assessment methods, and specific management strategies for use with children and families are presented. These topics serve as foundations for discussion in the subsequent chapters of this unit, where each of the remaining functional health patterns and its relationship to health are discussed. This chapter emphasizes health promotion and wellness management, specifically looking at how providers can work with children and families to ensure that healthy choices are made. The chapter’s goal is to give the reader tools and issues to address to help families change for the better and to help families create environments in which children will thrive physically, mentally, and developmentally.
The functional health patterns construct is unique to nursing (Gordon, 1987, 2010) and serve as a framework to organize and analyze all the lifestyle factors that have an effect on children’s health. It is a model appropriate to the practice of all pediatric primary care providers. The use of functional health patterns focuses the provider’s practice directly on lifestyle and health behaviors and emphasizes the importance of health promotion. It is consistent with the vigorous attention primary care providers apply to the issues of nutrition, activity, coping and stress tolerance, tobacco and drug use, accident prevention, and other lifestyle factors. Lifestyle risk modification has the same or greater effect on health as managing minor illnesses in primary care practice.
The 11 functional health patterns that Gordon (1987, 2010) used to describe the domain of nursing practice serve as the framework for the chapters in this unit. The patterns describe the health-related behaviors in which people engage. These functional health patterns are universal, applying to all humans regardless of age, sex, culture, health status, or other factors. All people need to eat, sleep, and eliminate, for example. Each pattern is described as follows:
• Health perception–health management pattern: Describes client perceptions of personal health and health care behaviors, prevention, and compliance with prescriptions for management of health and illness problems. Health management includes the actions taken to deal with these experiences. Health management is based on health perceptions and reflects the judgments of individuals and families, the ways they solve problems, and the decisions or choices they make. Positive health management assumes that wise decisions are made and that resources are available for families to implement these decisions.
• Activity-exercise pattern: Describes patterns of activity and exercise, including type of activity, schedule of participation, vigor, effect on leisure, physical state, and meaning of activity to the client.
• Cognitive-perceptual pattern: Describes sensory-perceptual and cognitive patterns, including adaptations to hearing, vision, or other perceptual losses; includes the process of finding meaning from environmental stimuli and the effectiveness of efforts to compensate for deficits. Pain perception is a component.
• Sexuality-reproductive pattern: Describes patterns of satisfaction or dissatisfaction with sexuality and sexual relationships. Involves perception and development of sexual identity, in addition to reproductive expectations, behaviors, and outcomes.
• Coping-stress tolerance pattern: Describes patterns of coping with the range of stresses experienced. Includes strategies used, effectiveness, support systems, and perceived ability to control and manage difficult situations.
• Values-beliefs pattern: Describes patterns of values and beliefs that influence daily living activities, guide decision-making, and provide meaning to life. Involves religious and spiritual activities and personal values and beliefs.
All people in all cultures make decisions that they believe will positively affect their health and well-being. The primary care provider’s job is to assist families to choose lifestyles that will maximize their health using the best evidence available to science. By exploring a family’s health perceptions, providers can begin to see reasons behind family health decisions. Components of health perception include: (1) how individuals perceive and feel about their general state of health (past, present, and future); and (2) the belief that there is a relationship between health status and health practices. These factors influence subsequent health behaviors.
The degree to which parents and children believe that they can influence their health status varies. Individuals with an “internal locus of control” believe they can take actions that will make a difference in health outcomes. They are motivated to make change, are active problem-solvers, and are able to more effectively cope with health problems. Those who believe that health outcomes are beyond their control are more likely to be passive and dependent, and may fail to follow through with recommended treatments. The following health behavior prediction models can be used to assess clients’ health perceptions to determine the extent to which clients believe they can influence health outcomes. These models can also be used in planning intervention strategies to help families engage in more healthful behaviors.
Assessment of health perceptions and prediction of health behaviors can be accomplished using a number of different models. Only four of those models are discussed here: the health belief model, the self-efficacy model, the transtheoretical (stages of change) model of behavior change (Prochaska, 1995; Prochaska et al, 1992, 1994), and the health promotion model (Pender et al, 2011). The first three models primarily address issues of motivation, the first step toward action. They provide guidance to assess the client’s motivation and strategies to help the client take steps toward positive action. The fourth model is broader in scope.
It is not well understood how the various factors that influence health behaviors develop in children and how and at what age effects will occur. However, these same factors influence parents and health care providers (do providers feel, for example, that they have the requisite teaching and knowledge skills, limited barriers, and the like to influence their clients’ health-related behaviors, such as smoking or lack of physical activity), so adult models are important to understand.
The health belief model explains behavior used to prevent disease rather than behavior that attempts to promote health. According to this model, people engage in preventive behaviors if they have a reason or motive to do so and if they hold certain beliefs. They must meet the following criteria:
For example, this model can be illustrated by assessing the motivation for tooth brushing behavior: the client must believe that caries are possible; that tooth loss, pain, or disfigurement would be an unfortunate consequence of caries; that brushing teeth can prevent caries; and that the benefits of brushing outweigh the inconvenience, time, and costs of maintaining a supply of toothbrushes and toothpaste over time. This is a simple example. Getting a teenager to change the content in his or her diet after considering the consequences of obesity and perhaps heart disease in later life is not so easy.
Self-efficacy augments the health belief model in predicting when people will make decisions regarding their health behaviors (Bandura, 1997). Bandura explained that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Bandura thought that two kinds of expectations were important. First, a self-estimate of one’s capacity to do what is required to achieve the goal is based on past accomplishments, watching the consequences of other’s efforts, and positive verbal persuasion. Emotional arousal provides additional energy for action. Second, the individual needs to believe that if he or she performs as well as expected, the outcome will be favorable—to use the tooth-brushing example, the client believes that he or she can brush adequately to prevent caries. Based on this model, the provider’s role is to help clients understand unhealthy conditions, the effects on them if they do nothing, the improved outcomes possible if they take action, and the belief that they are capable of initiating coping behaviors that will be helpful to their health. This is then followed by the provider helping clients master the skills to take effective action or by providing resources to clients.
The transtheoretical model is in wide use. It incorporates elements from health belief and self-efficacy theories to develop a model that can be used to describe the stages of change that individuals go through as they initiate behaviors that promote health. The model describes five stages of change, 10 processes that facilitate movement from one stage to another, and two of the patterns that individuals use to progress through the various stages (Fig. 9-1) (Prochaska et al, 1992). Health providers who understand the stages of change can facilitate movement from resistance to consideration to action for many health behaviors. Motivational interviewing is discussed later as a strategy to help people move through the various stages.
FIGURE 9-1 Transtheoretical (stages of change) model.
(Adapted from Prochaska J, DiClemente C, Norcross J: In search of how people change: applications to addictive behaviors, Am Psychol 47:1102-1114, 1992.)
The five stages are precontemplation, contemplation, preparation, action, and maintenance. Shifts in attitudes and behaviors occur at each stage. The time required in each stage depends on the individual and the task to be attempted.
• Precontemplation. At this stage the individual does not acknowledge that a serious problem exists, although a wish to change may be expressed. Resistance to change is the hallmark of this stage, and the reasons not to change are most clear to the individual.
Most people are not able to proceed through all five stages in a linear way. Rather, there are relapses to the precontemplation stage. Environmental barriers, external pressures to change beyond the individual’s own desires, or problems with maintenance of steps not mastered at earlier stages can contribute to relapses. Recycling is a regression to the contemplation or preparation stages. The person spirals through small increments of change, recycling and moving forward again. Success with the change increases with effort, action, and mastery of the tasks of each stage.
Another component of the transtheoretical model is the cognitive exercise of weighing the pros and cons of change. In the precontemplation stage, the pros of no change dominate over the pros of change (e.g., “If I stop smoking, I’ll gain weight”). To sustain behavior in the action stage and move to the maintenance stage, the pros of change must outweigh the cons of returning to old ways (e.g., “Not smoking is cheaper than smoking”). Because most people at risk for health problems are in a precontemplation stage, programs need to be designed to move them to the contemplative stage. Also, programs designed to maintain changes are important. Many dieting, smoking cessation, and drug rehabilitation programs fail to initiate and sustain changes because assessment of readiness and readiness training that help individuals move through stages successively are not included in the initial plans. Motivational interviewing, discussed later in the chapter, is a strategy based on the stages of change that appears to have excellent success rates for many health-related behaviors because it helps individuals move to the next stage.
Pender and colleagues (2011) developed a broad model with a focus on health promotion rather than on disease prevention. The model consists of two main domains—cognitive-perceptual factors and modifying factors—that explain participation in health promotion behaviors (Fig. 9-2). The cognitive-perceptual factors include all the concepts in the health belief and self-efficacy models, locus of control notions, and individuals’ definitions of health and their own health status estimates. It adds modifying factors to the model including demographic, biologic, behavioral, and situational factors, in addition to interpersonal influences. Social support structures, the emotional competence of family members, past experience, education and knowledge level (health literacy), values and cultural perspectives, and economic conditions are all modifying factors of importance. Together the two groups of factors help a person decide whether and when to engage in health promotion behaviors. The model applies to any health behavior.
FIGURE 9-2 Health promotion model.
(From Pender N, Murdaugh CL, Parsons MA: Health promotion in nursing practice, ed 6, Upper Saddle River, NJ, 2011, Prentice-Hall).
Commitment to a plan of action is the first step toward behavior change. Immediate or competing demands and preferences influence behavior intentions. The outcome is behavior change to attain a positive health status.
Children’s health promotion behaviors are influenced by their own understanding of health and illness, the views and behaviors of their family, and community variables (the last include direct effects of standards and practices in childcare, school, and other community settings, and indirect effects such as cultural and community values related to health). Providers need to understand the health beliefs of their young patients as well as their goals, hopes, priorities, health interests and concerns, perceptions about seriousness of problems, feelings of vulnerability to health problems, and perceptions of benefits and barriers to taking action.
Children’s concepts of health and illness must be considered within a developmental framework. One model for understanding children’s processing of health information, used more in the 1970s and 1980s, is Piaget’s theory of cognitive development. Applying this framework, preschoolers are in Piaget’s preoperational stage of cognitive development. They have an egocentric view of health. Children at 3 to 5 years old are just learning about the differences between being sick versus being well for themselves and their family members. They have little understanding of their internal bodies. Their lack of understanding of time and transformations means that the process of healing, for example, is not clearly understood. School-age children are in the concrete operational stage of cognitive development. They list specific acts and rules used to maintain health and generally need overt signs of illness or health to recognize the health status of a person. Adolescents, who are in the formal operations stage, understand the difficulties of defining health (e.g., a person who looks well, but has a cancerous tumor inside versus a person whose mobility is limited but is actually healthy). Teenagers understand the difference between the sick role and actual pathologic conditions, are sensitive to feeling states, and differentiate mental health from physical health. Nevertheless, the provider should not consider all adolescents ready for adult explanations because they vary in their use of formal operations thinking with age and issue.
Koopman and colleagues (2004) studied 158 children in Sweden, 80 with diabetes and 58 healthy classmates. They asked about their understandings of different types of illness (cold, diabetes, infection, and the most and least serious of these). They also asked about illness-related concepts such as pain, becoming ill, and going to the doctor or hospital. They concluded that development of illness concepts is congruent with Piaget’s theory of cognitive development. However, they also discovered that the child’s perception of illness is based on development of causal thinking about illness. At first, children see causes as invisible. Next they see illness from a distance perspective, that is, illness comes from external activities, in some cases, magically. In a third phase, children add the notion of proximity—one must be close to the people, objects, and events for illness to occur. Later phases are characterized by contact and then internalization (the causes now are viewed as problems from an unhealthy organ or body part, influenced by something external that was dirty or from an unhealthy body condition such as obesity). Finally, the child describes body processes that result in illness and then the child conceptualizes the mind and body interactions of illness.
Many developmental theorists are disappointed with the Piagetian framework because they believe it underestimates children’s cognitive abilities. Further, they argue that Piaget’s theory describes children’s logic and capabilities, not their understandings of specific concepts.
Current models assume children are developing their own theories of how things work, including health and illness processes. Research in this area investigates children’s understanding of illness and health in light of their understanding of biologic processes. Findings indicate that with more experience and knowledge, children can incorporate more elaborate concepts into theories of how the body works, contagion, and differences between physical and mental well-being, for example. An excellent study by Myant and Williams (2005) explores the understanding of four different conditions—injuries (bruises and broken leg), chickenpox, colds, and asthma—by children at 4 to 5, 7 to 8, 9 to 10, and 11 to 12 years old. The children were asked to describe the condition, its cause(s), prevention, time course to onset of symptoms, recovery process, and time for recovery. Children had the best understanding at earlier ages for injuries and colds, conditions they experienced in some form. Their understanding became more sophisticated with age. They had the least understanding of asthma, which was neither visible nor commonly experienced. Similarly, adults may be cognitively sophisticated, but demonstrate very elementary understanding of specific conditions based on lack of experience and knowledge rather than inability to process information. Clinicians should provide information based on the child’s current base of knowledge and experience. If providers assume, on the basis of age alone, that the child has a certain level of knowledge, experience, or cognitive abilities, they may fail to provide the most useful information to the child.
Children’s understandings of mental illness become more refined with age (Wahl, 2002; Watson et al, 2005) (experience, in contrast to age, with mental illnesses has not been studied well as yet). At younger ages children may confuse mental illness with physical illness or learning disabilities. Older children see links between behavior and emotions and cognitive associations. The work of Roose and colleagues (2003) found that by ages 10 or 11 years, youth understood that mental illness is complex and different from physical problems. They saw that emotions, thoughts, and behaviors were all linked in mental illness. From early primary grades, children view deviant behavior negatively, with aggressive behavior causing more rejection than withdrawn behavior. Walsh (2009) suggests that helping children separate the illness from the person may be helpful, especially for those living with a parent with a mental illness. Differences in views of deviant behavior exist among children from different cultures, and the media have a role in children’s understanding of mental illness: children will use media stereotypes to structure their thinking about the behavior of people who are mentally ill.
Health management is the process of making decisions, taking action, and using resources to maintain and promote health. Health management reflects the underlying beliefs and perceptions that families, parents, and children have about health as discussed previously. The way children’s health is managed is also strongly influenced by external factors, including the family, community, environment, peers, their culture, and the degree of health literacy among caregivers. Assessment of these areas, presented here as determinants of health for children, gives the provider invaluable data about health decisions and actions, areas of concern, and appropriate interventions.
The family is the basic unit of health care management for children. The family influences lifestyles and the health status of its members. Child health care is really triadic care, including health care provider, family, and child at every point, which is more complex than adult care. Parents are the primary decision-makers regarding health care of children. Thus, providers need to understand adult and child perspectives on health, decision-making styles, and family dynamics. The psychological characteristics of the family, the belief that members can make a difference, and the role of the family as a natural support system are all important in planning effective health promotion strategies. Knowledge of the family’s composition, health, lifestyle, nutrition, economic resources, and recent changes is helpful. Exercise, diet, hygiene, and rest patterns are family routines affecting the health of individual members.
Health literacy is the ability to read, understand, and apply health information. High health literacy enables individuals to understand their health issues and how they can be treated, know when and where to go when help is needed, take medicines and use other treatments properly, and evaluate the information about health available to them (Betz et al, 2008; Nutbeam, 2000). Although health literacy is defined in broader terms, literacy (reading) and numeracy (arithmetic) are basic factors. An Institute of Medicine (IOM) report, Health Literacy: A Prescription to End Confusion (Nielsen-Bohlman et al, 2004) highlights the importance of this issue for the nation’s health. The results of low health literacy are costly both in terms of health outcomes and in use of health services (DeWalt and Hink, 2009). Poor health status, adverse health outcomes, and higher disease and disability risks are related to poor health literacy. Those with low health literacy skills use more health services, use more expensive health services such as emergency care, and have greater risks for hospitalization (Mancuso, 2009; Nielsen-Bohlman et al, 2004). Adults with low health literacy are 1.2 to 4 times more likely to exhibit negative health behaviors that affect child health. Teens with low literacy are twice as likely to exhibit aggressive or antisocial behavior. And chronically ill children who have caregivers with low literacy are twice as likely to use more health services (Sanders et al, 2009). Betz (2007) refers to health literacy as the “missing link in the provision of health care for children and their families.” Children of parents with higher literacy skills are more likely to have better health promotion outcomes.
The prevalence of limited health literacy is very high among adults (range 34% to 59%) (Eichler et al, 2009). Downey and Zun (2008) found 20% of adult patients in urban emergency departments and community health clinics had low health literacy levels. A 2009 review article determined that one third of adolescents and young adults had low health literacy, whereas most health information was written above the tenth-grade level. More than 28% of parents had below basic to basic health literacy. Sixty-eight percent were unable to enter names and birthdates correctly on a health information sheet, and 46% were unable to perform at least half of medication-related tasks. Those with low health literacy reported difficulty understanding over-the-counter medication labels and nutrition labels (Yin et al, 2009). Another study found that 75% of the American Academy of Family Physicians (AAFP) educational materials for patients were written above the average reading level (eighth to ninth grade) of the population (Wallace and Lennon, 2004). See Figure 9-3 for a model of the relationship between health literacy and health behaviors and health management.
FIGURE 9-3 Health literacy and health actions.
(From von Wagner C, Steptoe A, Wolf M, et al: Health literacy and health actions: a review and a framework from health psychology, Health Educ Behav 36:863, 2009. Used with permission.)