How effective are health education programmes—resistance, reactance, rationality and risk? Recommendations for effective practice

https://doi.org/10.1016/S0020-7489(03)00117-2Get rights and content

Abstract

Behavioural-change-related health education programmes represent a mainstay of health care activity. Where adopted, however, the theoretical and practical constructs and constraints are not always considered. The failure of many health education programmes to achieve their intended life-style-related behavioural-change outcomes is often directly related to the complexity of the task itself. Changing a client's health behaviour is notoriously difficult and requires concerted and systematic activities to ensure any measure of success.

This article draws upon existing literature to develop a critical theoretical and practical perspective for health education practice in nursing. It aims to explore the underpinning theoretical considerations for undertaking behavioural-change health education programmes. This article also proposes specific recommendations for nurse's current and future health education practice, as a means for facilitating a more structured approach to health education programme planning and evaluation.

Introduction

Effective health education programmes are highly dependent on the way that they are delivered and the nature of their intention. The vast majority of nursing-related health interventions are centred on ‘traditional’ behavioural-change health education activities (Norton, 1998; Whitehead, 2001a). The last decade or so has witnessed calls for nurses to increase their preventative health education activity, but this has not always been the case (Sheahan, 2000; Whitehead, 2001b). This underlies the fact that socio-cognitive behavioural-change programmes are notoriously complex, problematical and, more often than not, are unsuccessful. It appears that many nurses base their health education practice on the assumption that individuals can alter their health behaviour as a part of a relatively easy behavioural-change process. It is also sometimes believed that behavioural-change programmes can be easily accommodated within the considerable constraints of a nursing role, whilst not taking into account the scale and the complexity of the task at hand. Often the main factor that is not considered is that individual clients may not be in a position to alter their behaviour or simply do not want to. This is not to say that nurses should not attempt to incorporate behaviourally focused health education activities into their practice environment but, instead, that they need to be more conversant with and realistic about the nature and process of their interventions.

This article aims to clarify the theoretical and practical constructs that underpin behavioural-change health education, as a means to raise awareness about the nature and reality of its programmes. Subsequently, this paper seeks to put forward recommendations for the concerted and realistic implementation of successful preventative health education programmes.

Section snippets

What is health education?

One of the main problems for nursing-related health programmes is that they are often contextually confused. Many nurses mistakenly use the terms health education and health promotion interchangeably (Henshaw, 2001). This is despite the fact that there are profound and distinct differences between the two. Traditionally, health education activity is rooted in behavioural-focused medical/preventative health programme interventions, based on disease avoidance/reduction management frameworks. Its

How achievable are behavioural-change health education programmes?

Research consistently demonstrates that the importance that clients attach to their health status plays a major role in guiding their adoption/non-adoption of a behavioural health change (Callaghan, 1999). Changing a client's health-related behaviour is a notoriously problematical and complex task (Lawrence, 1999; Sedlak et al., 2000). Many practitioners are yet to move beyond the misconception that behavioural-change strategies are straightforward and uncomplicated. Even with the most

Theories of health behaviour

As mentioned previously, behavioural change is difficult to achieve and therefore theorists have developed increasingly complex frameworks in order to understand and predict the key factors that determine change. Viewed historically, Thorndike's (1989) Law of Effect represented a landmark in the field of ‘behaviour modification’ as it was then called. According to the law, behaviour is modified by its consequences and this simple, yet powerful, principle led to the development of techniques

Health resistance

Under certain circumstances it is known that some clients will actively resist the health messages that are aimed at them by health professionals. Rofes (2002) argues that repeated health education messages, which cosset the values of improved health and good behaviour, often serve only to irritate or alienate. Jacks and Devine (2000) similarly suggest that individuals may engage in a process of ‘anticipatory counter-arguing’ even prior to health messages being given, leading to heightened

Health reactance

Brehm (1966) originated the theory of psychological reactance. It is defined as an unwelcome and uncomfortable motivational reaction to the threat or removal of an individual's freedom to determine his or her own health status. A reactance response is aimed at recapturing the threatened freedom and preventing the loss of others (Fogarty, 1997). Health reactance bears subtle yet distinct differences to health resistance (Dowd, 2002). The main difference with reactance is that the individual's

Health risk

Individuals live in a risk-laden society. Consequently, the issue of risk-related health behaviour has dominated health education planning over the years (Preston, 1997). Maddux and Rogers (1983) protection motivation theory determines that the perception of a health threat (risk) is the starting point in any behavioural-change activity, whilst Preston's (1997) study demonstrates that the fear of risk is omnipresent with certain clients. Essentially, health risk represents the ‘balancing act’

Health rationality

Individuals cannot be held directly responsible for any health actions that are constrained by influences beyond their control. Individuals behave within their own socially constructed reality. This reality will be a reflection of their personal and collective rationality. Health professionals do not all behave alike when it comes to demonstrating their our own rationality, especially at a professional and organisational level. Indeed, the rationality of health practitioners often sits counter

Recommendations for effective behavioural-change health education practice

In light of the underpinning theoretical considerations covered previously in this article, it is considered useful to offer a series of recommendations. Most of the offered recommendations follow the general pattern of concepts and ideas introduced in the main body of the text, but not in all cases. The recommendations essentially reflect the main dilemmas that nurses will face with their behavioural health education activities. These recommendations, whilst not exhaustive, provide informed

Summary

McMurray (1999) identifies that health education experts are still unable to agree on what constitutes a consistent approach to changing people's health-related attitudes and behaviour. This fact is worth bearing in mind when nurses conduct their health education activities. There is no one single approach that covers all health education eventualities, but there are a range of options that will improve the chances of successful intervention and outcome. If nurses have a better understanding of

References (82)

  • J.A. Brehm

    A Theory of Psychological Reactance

    (1966)
  • S.L. Brown

    Emotive health advertising and message resistance

    Australian Psychologist

    (2001)
  • D.R. Buchanan

    Reflections on the relationship between theory and practice

    Health Education Research

    (1994)
  • D.R. Buchanan

    Beyond positivismhumanistic perspectives on theory and research in health education

    Health Education Research

    (1998)
  • P. Callaghan

    Social support and locus of control as correlates of UK nurses’ health-related behaviours

    Journal of Advanced Nursing

    (1998)
  • P. Callaghan

    Health beliefs and their influence on United Kingdom nurses’ health-related behaviours

    Journal of Advanced Nursing

    (1999)
  • A. Charlton et al.

    Reducing cancer mortalitydoes health promotion work? A discussion paper

    Health Education Journal

    (2002)
  • A. Cribb et al.

    Health Promotion and Professional Ethics

    (2002)
  • M.L. Crossley

    The health resistance (HR) scaledeveloping a measure of resistance to health promotion

    Health Education Journal

    (2001)
  • M.L. Crossley

    ‘Resistance’ and health promotion

    Health Education Journal

    (2001)
  • M.L. Crossley

    Introduction to the symposium ‘health resistance’the limits of contemporary health promotion

    Health Education Journal

    (2002)
  • A. Dines

    What changes in health behaviour might nurses logically expect from their health education work?

    Journal of Advanced Nursing

    (1994)
  • C.M. Dougherty et al.

    Theoretical development of nursing interventions for sudden cardiac arrest survivors using social cognitive theory

    Advances in Nursing Science

    (2001)
  • R.S. Downie et al.

    Health PromotionModels and Values

    (1996)
  • A. Ellis

    The basic clinical theory of rational-emotive therapy

  • M.L. Finucane et al.

    The effect heuristic in judgements of risk and benefits

    Journal of Behavioural Decision Making

    (2000)
  • S. Folkman et al.

    Promoting well-being in the face of serious illnesswhen theory research and practice inform each other

    Psycho-oncology

    (2000)
  • P. Foster

    Is there a future for radical health promotion?

    Health Care Analysis

    (1996)
  • M. Gott et al.

    Policy framework for health promotion

    Nursing Standard

    (1990)
  • C. Ham

    Health Policy in Britainthe Politics and Organisation of the National Health Service

    (1999)
  • L. Henshaw

    The impact of class position on women's experience of receiving health education information whilst in hospital

    Health Education Journal

    (2001)
  • J.Z. Jacks et al.

    Attitude importance, forewarning of message content, and resistance to persuasion

    Basic and Applied Social Psychology

    (2000)
  • I.L. Janis et al.

    Decision Makinga Psychological Analysis of Conflict, Choice and Commitment

    (1975)
  • N.K. Janz et al.

    The health belief modela decade later

    Health Education Quarterly

    (1984)
  • Joffe, H., 2000. Adherence to health messages: a social psychological perspective. International Dental Journal,...
  • H. Joffe

    Representations of health riskswhat social psychology can offer health promotion

    Health Education Journal

    (2002)
  • Kahneman, D., Slovic, P., Tversky, A. (Eds.), 1982. Judgement under Uncertainty; Heuristics and Biases. Cambridge...
  • C.M. Kennedy et al.

    Children's perceptions of TV and health behaviour effects

    Journal of Nursing Scholarship

    (2002)
  • P.A. Kulbok et al.

    Advancing discourse on health promotionbeyond mainstream thinking

    Advances in Nursing Science

    (1997)
  • T. Lawrence

    A stage-based approach to behaviour change

  • R.S. Lazarus

    The costs and benefits of denial

  • Cited by (64)

    • Health education: A Rogerian concept analysis

      2019, International Journal of Nursing Studies
      Citation Excerpt :

      In 1978, the international Alma Ata Conference (WHO, 1978), consolidated by the Ottawa Charter for Health Promotion in 1986 (WHO, 1986), defined health education as a state of welfare where individuals actively seek to determine and increase their personal health status and not just seek to prevent or abolish illness, disease or disability (Glanz et al., 2008). Health education is focused on enabling people to increase control over their health (Salci et al., 2013; Whitehead and Russell, 2004). Despite past, recent and ongoing theoretical work (Green et al., 1980; Tones et al., 1990; Whitehead, 2004; WHO, 2012), translating an evolving definition of health education into practice remains challenging (Whitehead, 2004, 2008).

    • “This is the way ‘I’ create my passwords”.. does the endowment effect deter people from changing the way they create their passwords?

      2019, Computers and Security
      Citation Excerpt :

      Yet these same recipients either decline to change their regular routines, or change their behavior in the short term and then revert to their original routines (Albrechtsen, 2007; Van Niekerk and von Solms, 2005). Some trainers attribute this kind of resistance to personal failings on the part of the recipients (Duggan et al., 2012; Patrick et al., 2003; Whitehead and Russell, 2004). This kind of attribution does not help to resolve the situation.

    View all citing articles on Scopus
    View full text