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