3.4 Health Education, Teaching-Learning & the Determinants of Health
Key Takeaways
The Ottawa Charter (1986) defines health promotion as enabling people to increase control over and improve their health, through five action areas.
The Health Belief Model links action to perceived susceptibility, severity, benefits, barriers, cues to action and self-efficacy.
In the Transtheoretical Model, a client who says they will start exercising next month is in the preparation stage.
Psychomotor skills such as insulin injection are taught by demonstration and evaluated by return demonstration.
Programme evaluation has three levels: process (delivery), impact (knowledge and behaviour change) and outcome (health indicators).
Health Education, Teaching-Learning and the Determinants of Health
The Health Promotion and Maintenance of Wellness (HPMW) domain asks for more than knowing the immunisation schedule. Its competencies require you to:
- help clients see the link between health promotion strategies and outcomes across the life cycle;
- use evidence to plan, implement, monitor and evaluate health education activities;
- assess health beliefs and practices;
- work with the team on the determinants of health; and
- use an ethical framework to judge how social policy affects vulnerable groups.
This section supplies the theory behind those competencies, so you can recognise it in application questions.
Health Promotion: Definitions and the Ottawa Charter
The WHO Ottawa Charter for Health Promotion (1986) defines health promotion as the process of enabling people to increase control over, and to improve, their health. It names five action areas:
| Ottawa action area | Caribbean nursing example |
|---|---|
| Build healthy public policy | Supporting school nutrition rules or taxes on sugar-sweetened drinks |
| Create supportive environments | Clearing water-storage containers and drains with a community to cut Aedes breeding |
| Strengthen community action | Working with a church or citizens' association on blood-pressure screening days |
| Develop personal skills | Teaching a client with diabetes to inspect the feet and read food labels |
| Reorient health services | Moving chronic disease care from hospital clinics into health centres |
Health education is one tool inside health promotion: planned learning experiences that help people make informed decisions. A poster alone is information. Health education has objectives, a method, and an evaluation.
Determinants of Health
The Dahlgren–Whitehead "rainbow" (1991) places the person (age, sex, genetics) at the centre. Around the person it adds layers of individual lifestyle factors, social and community networks, living and working conditions (education, work, food, water and sanitation, housing, health services), and finally general socio-economic, cultural and environmental conditions. In practice, determinants explain why two clients with the same diagnosis have very different outcomes.
| Determinant | How it shows up on an RENR item |
|---|---|
| Income and employment | A client cannot afford test strips, so glucose control fails despite teaching |
| Housing, water and sanitation | Stored drinking water, pit latrines and flooding raise risk of dengue, gastroenteritis and leptospirosis |
| Education and health literacy | Written instructions are not understood; use teach-back and pictures |
| Social support | An older adult living alone misses clinic visits; arrange a community health aide visit |
| Culture and beliefs | Bush teas, religious practices and beliefs about "pressure" and "sugar" affect adherence |
The fourth HPMW competency asks you to use available resources in care plans that address these determinants. Examples include referral to social work, the National Health Fund for drug subsidies, community groups and home visits.
Why People Change (or Don't): Behaviour Models
Health Belief Model
A person is more likely to act when they believe:
- they are susceptible;
- the problem is serious;
- the action has benefits;
- the barriers are manageable; and
- they have the self-efficacy to do it.
A cue to action (a relative's stroke, a nurse's reminder) triggers the behaviour. When a client says, "Diabetes runs in my family but it won't happen to me," the targetable belief is perceived susceptibility.
Transtheoretical Model (Stages of Change)
| Stage | Client statement | Nursing approach |
|---|---|---|
| Precontemplation | "I don't need to stop drinking." | Raise awareness and give personalised information without lecturing |
| Contemplation | "I know smoking hurts me, but…" | Explore ambivalence; weigh pros and cons |
| Preparation | "I plan to start walking next month." | Help set a specific plan and goals |
| Action | "I've cut out sweet drinks for three weeks." | Reinforce, problem-solve barriers |
| Maintenance | "It's been eight months." | Prevent relapse; plan for high-risk situations |
Relapse is common and expected. Re-enter the cycle without blaming the client. Motivational interviewing uses open questions, affirmations, reflections and summaries (OARS) to draw out the client's own reasons for change.
Orem's Self-Care Deficit Theory
Orem's theory links directly to the CDM competency of "providing information to enable patients to make informed choices and to practise self-care skills". Nursing systems are:
- wholly compensatory: the nurse does for the client, for example a client who is unconscious;
- partly compensatory: the client and nurse share care; and
- supportive-educative: the client can do the care with teaching and guidance. Most discharge and clinic teaching sits here.
The Teaching-Learning Process
| Learning domain | What is learned | Best method | How to evaluate |
|---|---|---|---|
| Cognitive | Knowledge (what insulin does) | Discussion, simple handouts, question and answer | Client explains in own words |
| Affective | Attitudes and values (accepting a colostomy) | Role-play, support groups, peer stories | Client's statements and behaviour |
| Psychomotor | Skills (drawing up insulin) | Demonstration, then return demonstration | Observe the client performing the skill correctly |
Adult learners (Knowles' andragogy) are self-directed, bring experience, want problem-centred content they can use now, and learn best when the content matters to them. Check readiness to learn first. Pain, nausea, anxiety, denial or exhaustion block learning. Treat the pain first, then teach, and keep sessions short. For children, use play and simple, concrete words. For older adults, allow more time, reduce background noise and use large print.
Planning and Evaluating a Health Education Programme
- Assess needs: use community data (clinic registers, notifiable-disease reports), surveys and focus groups to identify the problem and the audience.
- Write SMART objectives: specific, measurable, achievable, realistic and time-bound. For example: "By the end of the session, each participant will demonstrate daily foot inspection using a mirror."
- Select content and methods to suit literacy, language and culture, such as group talks, demonstrations, radio or social media messages, posters or home visits.
- Implement with the right resources and partners (community health aides, schools, churches, the media).
- Evaluate:
- process evaluation: was the programme delivered as planned;
- impact evaluation: did knowledge, attitudes or behaviours change; and
- outcome evaluation: did health indicators improve, for example fewer amputations or fewer dengue cases.
Social Policy, Equity and Vulnerable Groups
The fifth HPMW competency asks you to use an ethical framework to judge social policies. Use the principles of justice and beneficence. Equality gives everyone the same resource; equity gives more to those with greater need, such as free transport to clinic for a client with a disability. Vulnerable groups include children, older adults living alone, people with disabilities, people living with HIV, migrants, people in poverty or informal settlements, and people with severe mental illness. Look for the option that removes a barrier to access while respecting the client's autonomy and confidentiality.
A client with newly diagnosed type 2 diabetes says, "I'll start walking every evening after my exams finish next month." In the Transtheoretical Model, which stage is the client in?
Preparation
Maintenance
Contemplation
Action
The nurse is teaching a mother to give insulin to her 10-year-old child. Which evaluation best confirms that learning has occurred?
The mother scores well on a written quiz about insulin action
The mother correctly draws up and injects the dose while observed
The mother signs a form stating she understands every step of the procedure
The mother states she has read the leaflet twice and has no questions
A community nurse plans a programme to reduce diabetic foot amputations in a parish. Which result is an outcome evaluation measure?
The proportion of participants seen inspecting their feet daily at a home visit
The number of foot-care classes delivered as scheduled
The parish rate of lower-limb amputations among people with diabetes one year later
Participants' scores on a foot-care knowledge test after the class
A client with severe arthritis and limited income misses health centre appointments because of transport costs. Which intervention best reflects equity in care?
Giving the client the same appointment card all other clients receive
Discharging the client from the clinic register to free a place for others
Telling the client that missed appointments will be recorded as non-compliance
Arranging subsidised transport or a home visit so the client can receive care
Sections you finish are checked off in the contents.