health promotion intervention essay

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Health Promotion and Disease Prevention Interventions for the Elderly: A Scoping Review from 2015–2019

Ching-ju chiu.

1 Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan; wt.moc.oohay@g53406g

Jia-Chian Hu

2 School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan; moc.liamg@02202adnap

Yi-Hsuan Lo

3 Department of Statistics, College of Management, National Cheng Kung University, Tainan 70101, Taiwan; moc.liamg@9991lynaffit

En-Yu Chang

Associated data.

In this study, a scoping review method is used to review the distribution and trends in health promotion research and explore the use and contribution of eHealth technologies in health promotion in the elderly. The study includes six search databases: PubMed, CINAHL, the CochraneLibrary, EMBASE, PubPsych, and ERIC (EBSCOhost), and studies published from January 2015 to October 2019, written in English, were included and analyzed. The findings of the study reveal that the amount of literature on promoting health for the elderly has increased, and some specific types of interventions are still favored in current health promotion efforts for older adults. The most commonly used methods were found to be health promotion ( n = 322), followed by screening ( n = 264), primary prevention ( n = 114), and finally social support ( n = 72). Beyond the above interventions, eHealth technology is also used in health promotion activities to prevent the elderly from falling and to improve home safety, etc. However, although the application of eHealth technology has been applied in areas such as fall prevention, mental health promotion, and home security monitoring, it is still immature, and thus more rigorous research is needed in different areas, especially in older populations, various professions, women, and people with dementia.

1. Background

According to the World Health Organization, health promotion enables people to take more control over their health. It covers a wide range of social and environmental interventions designed to benefit and protect everyone’s health and quality of life by addressing and preventing the causes of poor health, rather than just focusing on treatment and cures [ 1 ]. It can help people to manage their physical and psychological conditions, improve personal, family, and social health, and improve quality of life. It also increases the average healthy life expectancy and reduces unnecessary medical expenses and waste [ 2 ].

However, the promotion of health in the elderly is not based on a single aspect of health. It covers a wide range of issues, including nutrition, sleep, disability, and obesity. The elderly differ from the young in many ways. For example, according to a 2018 Taiwan elderly status survey report, the rate of self-reported chronic diseases among those aged over 65 is 64.88%. Therefore, in the formulation of policy or research, the special characteristics of diseases as well as the physical and mental needs of the elderly must be taken into account [ 3 ]. According to the World Health Organization, 20% of the world’s population will be over the age of 60 by 2050. The soaring incremental increase in the elderly population has made advanced health promotion an important issue.

Due to the wide range of entry points for that study of health promotion in the elderly, Duplaga et al., published a study on the promotion of health in the elderly in 2016 [ 4 ], which systematically summarized and reviewed research published on this topic from January 2000 to April 2015 and used a scoping review to systematically collate reviews. Although both scoping reviews and literature reviews contain reviews of empirical literature, their purposes and focuses of discussion are different. A scoping review mainly involves the collection of all relevant material to provide rather extensive coverage of a topic in order to provide an integrated discussion and report the relevant research designs and methodologies. The main concepts in the topic are determined in order to provide a complete system and valid comparability. A literature review, on the other hand, focuses on only one research problem and collects the most relevant and least relevant studies to review. In terms of data analysis, a scoping review describes the literature as a whole, while a literature review evaluates a single topic and empirically extracts the relevant research results.

Mariusz Duplaga’s research covered studies conducted from 2001 to 2015, where research over a five year period was collected to further explore the current technologies used to promote heath in the elderly so that health management programs for the elderly could be constructed, and valid policy suggestions could be made based on the elderly at different ages and states of health. Based on this research, the current study further explores whether the trends in and distribution of the literature on health promotion in the elderly has changed since 2015. Different from Duplaga et al., this study focuses on the role and application of eHealth technologies in health promotion in the elderly. eHealth is the use of ICT with cost-effective, secure methods in order to support health and health-related fields, including health-care services, health surveillance, the health literature, and health education, knowledge, and research [ 5 ]. Using ICT technologies can make it possible for the elderly to acquire effective health services faster and more efficiently. In addition, the WHO also listed eHealth as a priority for project development, which infers that eHealth has a great potential in the area of elderly health promotion. Therefore, it is important to search the usage and results of eHealth technologies in existing research. The objectives for this study are as follows: (1) to investigate the distribution of and trend in the secondary literature on health promotion in the elderly over a recent five year period, (2) to explore the use and contribution of eHealth technology in the secondary literature on health promotion in the elderly, and (3) to make suggestions for the development of health policies for the elderly in the future.

The present study was based on scoping review methodologies designed in the last five years (2015–2019), with the purpose of identifying and reviewing the effectiveness of different interventions addressing elderly health promotion and related areas. This study is a continuation of the research of Duplaga et al. [ 4 ]. The concept of the scoping review in the present study follows that of previous scoping review studies, such as Arksey and O’Malley [ 6 ], and further discussion by Levac, Colquhoun, and O’Brien et al. [ 6 ]. Arksey and O’Malley stated six steps for conducting a scoping review. The first step was to identify the purpose of the research. The purpose of this study is to provide a scoping review of health promotion and a variety of interventions for elderly people in a recent five year period (2015–2019). Based on the Population-Concept-Context (PCC) mnemonic for a scoping review, the study population (P) is elderly people; the concept (C) is health promotion, and the context (C) is related systematic reviews and/or meta-analysis in a recent five year period.

2.1. Search Strategy

The search strategy for this study followed the PCC context and the concept of health promotion based on a previous study conducted by Duplaga et al. (2016) [ 7 ] using a combination of keywords shown in Table 1 . The search strategy included six search databases: PubMed, CINAHL, the CochraneLibrary, EMBASE, PubPsych, and ERIC (EBSCOhost) , and the included reviews were published in English from January 2015 to October 2019.

Keywords used in the search related to health promotion.

2.2. Searching Strategy Process

The search process included the following steps: (1) searching for keywords from all six databases, (2) screening titles, (3) screening abstracts, (3) screening full reports, and (4) adding the remaining studies into this scoping review study.

2.3. Data Extraction and Assessment

The reviews in this study were classified into different categories based on previous studies, including the year of publication, database, the age, sex, and country of the targeted audience, intervention types, and the target of the interventions. Beyond the categories shown in Table 1 , this scoping review included another category, “eHealth technology applications”, for the purpose of further discussion of the trend in eHealth technology applications in an effort to determine what types of technologies are more useful and how they work in the area of health promotion in the elderly.

The classification process was conducted by two authors independently, with each of them overseeing three databases. Divergent opinions were resolved on a consensus basis. If a consensus was not reached, a third author was referred to for the final decision.

The data collection tools used in this study were EndNote X9 and Excel. After downloading and duplicating all the reviews in EndNote, we imported the final data into Excel and began the screening process. The final results after the screening process include 2 reviews in CINAHL, 8 reviews in Cochrane, 143 reviews in Embase, 19 reviews in Eric host, 207 in reviews PubMed, and 107 reviews in PubPsych, with a total of 486 reviews.

The screening and classifying processes were completed by 23 March 2020, and the figures were plotted with Excel using the list of data.

We provided definitions and the related provenance of different items in order to give a clearer understanding ( Supplementary 1 ), and we used the PRISMA-SCR checklist containing 20 essential reporting items to provide more information. ( Supplementary 2 )

We reviewed 2843 studies after searching the six databases, retaining 1091 studies after screening the titles, 730 after screening the abstracts, and ultimately retaining 486 studies for the scoping review study. The process diagram is shown in Figure 1 . We provide a list of the 486 reviews included in the study and the title, year of publication, population, gender, general area of intervention, targeted area, and references. The list is ordered by title. ( Supplementary 3 )

Scoping review search strategy.

3.1. Numbers of Reviews Sorted by Years

Figure 2 shows that from 2015 to October 2019, the number of studies related to elderly health promotion increased annually, from 61 studies in 2015 to 121 studies in 2019, where there were more reviews in the first ten months of 2019 than in the entire year of 2018. It can be inferred from this that an increasing number of scholars are paying attention to issues related to the health of the elderly and related topics, such as assisting technologies, etc.

Number of reviews from 2015 to 10 October 2019.

3.2. Gender

Most of the studies in this scoping review did not have a specific gender target. Only 10 out of the 486 studies focused specifically on elderly females, and there was no research focusing only on males.

3.3. Intervention Methods

The classification for the interventions methods followed Duplaga et al. [ 4 ] and was divided into four categories: health promotion (HP), primary prevention (PP), screening (SC), and social support (SS).

The most common method was health promotion, where 322 out of the 486 reviews (66%) were classified as health promotion (HP) interventions. Meanwhile, 264 (54%) were classified as screening (SC), 114 (23%) were classified as primary prevention (PP), and 72 (15%) were classified as social support (SS), as shown in Figure 3 . Since studies may include more than one intervention method, the total number of studies exceeded the number of reviews.

Number of reviews based on four intervention categories.

If every combination was considered to be an independent category, the most common intervention method was health promotion ( n = 118, 24.3%), and the second most common method was health promotion and screening ( n = 99, 20.4%), for which the results are shown in Figure 4 .

Number of reviews according to specific intervention categories.

3.4. Areas Targeted for Health Promotion

The areas targeted for health promotion were classified as “disease-oriented,” “physical activity,” “general health,” “quality of life,” “frailty,” “cognitive function,” “mental health,” “nutrition,” “disability,” “independence,” “sleep quality,” “psychosocial functioning,” and “addiction.”

Figure 5 shows that the most common target for the review studies was “disease-oriented” ( n = 214, 44% of all 486 reviews), followed by “physical activity” ( n = 120, 24.7%), “general health” ( n = 118, 24.2%), “quality of life”( n = 106, 21.8%), “cognitive function” ( n = 100, 20.5%), “frailty”( n = 85, 17.5%),“nutrition”( n = 72, 14.8%), “mental health”( n = 57,11.7%), “psychosocial functioning”( n = 51,10.5%), “independence”( n = 26, 5.4%), “sleep quality”( n = 13, 2.7%), and finally, “addiction”( n = 4, 0.8%) and “disability” ( n = 4, 0.8%). Since every study may consider more than one area, the total number of studies exceeded the number of reviews.

Number of reviews classified by specific intervention target area.

3.5. EHealth Technology Applications

Twelve out of the 486 reviews show the use of eHealth technology as an interventive tool for elderly health promotion. The technologies reviewed in the present work included “virtual reality” ( n = 3), “smart homes and home health monitoring technologies” ( n = 1), “socially assistive robots” ( n = 5), and “electronic assistive technology” ( n = 3). In addition, according to the statistical results, involvement in eHealth technology is also experiencing a slightly increasing trend.

4. Discussion and Future Directions

In this study, studies in the field of elderly health promotion from 2015 to October 2019 were summarized using a scoping review to investigate the research trends and distribution in the past five years in order to compare the results with studies compiled by Duplaga between 2000 and 2015. In this study, it was found that studies on health promotion in the elderly have increased annually. The topic of health promotion in the elderly is clearly receiving increasing scholarly attention.

A total of 486 articles from 2015 to 2019 were included in our study, with an average of 97 articles per year, compared with the 334 articles included by Duplaga in the 15 years from 2000 to 2014, with an average of 23 articles per year. From the above statistics, it can be seen that there has been a significant increase in the research on health promotion in the elderly. We did not find any studies specifically targeted at a single gender. Of the 486 studies, only 10 (2.1%) were found on older women, and the proportion of gender-specific studies in Duplaga was also small. Only 33 (9.9%) of the 486 studies were gender-specific. Therefore, it was found that health promotion in the elderly covers all genders at present, which means that in the future, gender effects and effects associated with different groups are worthy of study.

According to the research results for intervention methods, the most commonly used research methods for health promotion in the elderly during the period under observation included health promotion (HP), screening (SC), primary prevention (PP) and social support (SS), and many systematic reviews and meta-analyses used two or more types of intervention methods for health promotion in the elderly. When each combination was examined separately, the top five found in this study were “Health promotion,” “Health promotion and Screening,” “Screening,” “Health promotion and Primary prevention,” and “Health promotion and Social support.” Based on these results, it was found that health promotion accounts for a significant proportion of the issues related to health promotion in the elderly, indicating that the issue of health promotion for the elderly is currently under active investigation. Compared with the results of Duplaga’s research, where primary prevention accounted for the majority of the issues, it can be inferred that the current issue of health promotion is not limited to primary prevention, but is being studied in a multi-faceted manner with a more diverse range of topics and interventions. To compare the present study with that conducted by Duplaga et al. [ 4 ], we provide a table ( Supplementary 4 ) including a comparison of the aims, numbers of studies included, publication years, databases, target areas of interventions, general area of interventions, specific gender target, and classification differences.

Based on the results, purpose-oriented studies can be ranked in the following order: disease-oriented, physical activity, general health, quality of life, general health, frailty, nutrition, mental health, psychosocial functioning, independence, sleep quality, disability, and addiction. The classification results also reveal a trend in multi-purpose-oriented discussions in some of the studies, including: disease-oriented vs. physical activity, physical activity vs. general health, quality of life, cognitive function, disease-oriented vs. nutrition, general health vs. general health, etc. This phenomenon suggests that the issue of health promotion in the elderly needs to be studied from many perspectives, rather than discussed as a single topic. It is also worth noting that the results of the author’s classifications are consistent with Duplaga’s top four results, with the first issue in all studies being treating and preventing disease, followed by physical activity, general health, and quality of life. The following is a discussion of the top five categories.

Among the purpose-oriented classifications, those related to diseases predominated and covered a relatively wide range, such as knee arthritis or sarcopenia of the musculoskeletal system, Alzheimer’s disease, and Parkinson’s disease. Psychological disorders included depression, bipolar disorder, post-traumatic stress disorder, and delirium. Chronic diseases included diabetes, hypertension, and kidney disease. Other illnesses included anorexia and dry mouth. Multiple complications were also the target of some studies. The authors in the literature attempted a variety of interventions, such as medication, physical activity, diet plans, and aromatherapy, to slow or even cure age-related illnesses. Due to the high heterogeneity of health status among the elderly and the significant influence of diseases on health promotion in the elderly, it is necessary to consider the influence of disease during the health promotion of the elderly and to create a health promotion policy based on a multi-dimensional assessment. Therefore, in the future, more in-depth discussion and research on specific diseases would certainly lead to remarkable results in the promotion of health in the elderly.

The physical activity category was the second largest among the purpose-oriented categories. It mainly focuses on sports, such as aerobic exercise, dancing, Tai-Chi, yoga, water aerobics, etc. However, some studies investigated digital behavior interventions, Pilates training, resistance training, physical activity monitoring, etc. In terms of type, most of the studies were related to disease, aging, and cognitive function, so physical activity was used fairly often as an intervention. In addition, Hu et al. conducted a scoping review in 2019 on the involvement of elderly people in physical activities as interventions who did not receive adequate medical services. The results suggest that interventions that are appropriate to the characteristics of older persons with disabilities should be tailored to their race, socioeconomic status, and level of physical disability [ 8 ]. It was observed that the ethnicity, socio-economic status, cultural characteristics, and diseases of the target subjects should be considered as factors in the design of interventional physical activities for the elderly.

The general health category was the third largest among the purpose-oriented categories and covered a wide range of areas, typically including physical functioning, role functioning, social functioning, mental health, health perception, and pain [ 9 ]. Therefore, if the intervention method discussed in each study contained three or more of the above conditions, it was included in this classification. From the classification results, it was found that there were more studies focusing on multi-field comprehensive analyses, while the analysis of a single factor tended to decrease over the period under consideration. For example, in this category, some studies discussed the effect of exercise on the overall health of the elderly and further discussed the impact on cognitive function. There were also some studies on intervention and general health in specific groups (e.g., elderly people in prison, veterans, women during menopause, elderly volunteers/workers, etc.). This classification involves a variety of targets and is comprehensive, and is therefore likely to be one of the research focuses of health promotion in the elderly in the future.

The fourth largest category was quality of life, which comprises health status, social contacts, and other elements [ 10 ] and is also related to the impact of declines in function [ 11 ]. In the screening results for this project, in addition to some of the studies sharing common research themes with other interventions such as physical activity, mental health, psychosocial functioning, sleep quality, etc., there were also studies focusing on independent topics. For example, there were many papers on prevention of abuse and neglect of older adults, and some other papers on the prevention of suicidal behavior and reduction in suicidal ideation, reminiscence therapy interventions, environmental and behavioral modifications, preventive house visits, lifelong learning, etc. The research themes in the relevant studies were quite diverse and will contribute to the formulation of future health and social services policies for the elderly [ 10 ].

The fifth largest category in the purpose-oriented categories was cognitive function, which was compared to “frailty” based on Duplaga’s screening results (2016), which was the only difference among the top five indices. According to the current study, cognitive decline is one of the symptoms of dementia and is not directly related to aging, physical health status, and pre-morbid activity patterns [ 12 ]. This discourse fits the results of the present screening. There was an overwhelming majority of the studies related to dementia. The results of the screening also reveal a wide range of interventions, including non-pharmacological interventions such as physical activity, structural brain plasticity-induced training, video games, electronic-assistive devices, etc. In the face of dementia, which has a longer course of disease and high incidence rates [ 13 ], it is necessary to specify multiple interventions as a research topic to find more effective treatments intended to slow cognitive decline.

In addition to focusing on the distribution of the studies under consideration in this study, studies on the application of eHealth technology were also examined. According to the findings, eHealth technology has been used in recent years as an intervention tool for health promotion. These tools include virtual reality ( n = 3), smart homes and home health monitoring technologies ( n = 1), socially assistive robots ( n = 5), and electronic assistive technology ( n = 3).

Some studies explored whether the use of virtual reality technology can improve problems that lead to debilitation in the elderly and prevent them from falling. The results show that virtual reality games are better than traditional interventions for improving balance and preventing falls in the elderly and can strengthen the awareness of the harm caused by falls in the elderly [ 14 ]. Scoglio and Abdi et al. investigated whether socially assistive robots can help the mental health and well-being of the elderly, and their findings suggested that there is positive potential for companionship, cognition, and mental health improvements associated with their use. However, due to the limited number of people involved in the related research and some methodological problems, the helpfulness and value of socially assistive robots in the health promotion of elderly people still requires further research. [ 15 , 16 ]. Elderly people have both positive and negative views of socially assistive robots in geriatric care. A further understanding of experience with and willingness toward use is needed to consider the use of socially assistive robots in this area [ 17 ]. Brims and Oliver suggested that the effectiveness of assistive technology in reducing hospital admission rates is inconclusive. However, assistive technology has been tested to reduce the risk of falls, accidents, and other risky behavior, as well as to improve home safety for people with dementia [ 18 ]. Nevertheless, Roest’s study indicated that it is not clear whether AT can actually help resolve dementia-related memory problems [ 19 ]. Tangcharoensathien’s research pointed out that the promotion of assistive technologies requires the establishment of a policy framework and the encouragement of assistive technology product development through the training of professionals and support and promotion programs [ 20 ]. Liu et al. reviewed the impact of smart homes and health monitoring technologies on the health of the elderly, and their results show that eHealth technology could be used to monitor daily life, cognitive decline, mental health, and heart conditions in elderly individuals with complex needs. However, smart homes and home health monitoring technologies are not yet mature [ 21 ].

The authors found that most of the studies on eHealth technology interventions were focused on treatment rather than prevention. Seven out of 12 studies using eHealth technology focused more on treatment. For example, Roest et al. [ 19 ] focused on how to make use of assistive technology (AT) to help dementia patients and their caregivers manage their daily lives and enhance their safety [ 17 ]. Abdi et al. [ 15 ] suggested five roles for social assistive technology (SAR), which included affective therapy, cognitive training, social facilitation, companionship, and physiological therapy. Four of the studies focused more on prevention. Neri et al. studied improvements in balance and mobility in the elderly [ 17 ]. Liu et al. investigated the interaction between smart homes and home health monitoring technologies and life functioning, cognitive ability, mental health, and cardiac status among older adults [ 17 ]. There was also one study that focused on both treatment and prevention, Afsaneh et al. [ 22 ] found that self-care ATs can efficiently reduce care hours and also help to increase levels of independence. In this study, only 2.5% ( n = 12) of the studies were on the use of eHealth technologies among the searchable reviews. However, with the rapid development of technology (e.g., where robots may gradually replace people, and 5G technology will be mature), older people are becoming increasingly more receptive to technology. It is expected that the use of eHealth technology as an intervention tool for health promotion in the elderly will become a trend, and in the future, more in-depth research can be conducted on the use of eHealth technology as an intervention tool for health promotion in the elderly. Therefore, before using eHealth technology in this way, it is important to know how receptive older people are to eHealth technology in order to develop strategies for its use among different groups, such as women, aborigines, and people with dementia. In this study, the results of these studies also show that eHealth technology as a means of health promotion for the elderly is not yet mature and requires larger samples and more rigorous research designs.

The present study has the following limitations: First, there were different research standards for each paper. Through the comparison, it was found that in fact, there are different types of studies, such as meta-analyses and systematic reviews, different types of participants, including different health conditions and ages, different types of interventions, and various outcome measures and analysis technologies used for research statistics and analysis purposes. This may have led to errors in the literature comparison. Secondly, not all of the studies under review had specific results due to such things as time limitation, outcomes being both positive and negative, and a lack of maturity of the technologies leading to adequate experience and data to analyze, etc. Muellmann et al.’s study noted that due to a lack of research time, it was impossible to confirm whether long-term health interventions increase physical activity in 55 year-old individuals [ 17 ]. Vandemeulebroucke’s research mentioned that there were both positive and negative results found for the use of socially assistive robots in the area of elderly care. They demonstrated that technology intervention in the area of elderly care is not yet mature, and it is necessary to learn more about the past life experiences of the elderly and to use more rigorous research designs in more groups [ 17 ]. In addition, some studies mentioned that before using technology as an intervention for health promotion in the elderly, it is important to determine how receptive older people are to this technology in order to develop strategies suitable for different groups, such as women, aborigines, and people with dementia. It was also mentioned in many studies that more study is needed for corroboration due to the shortage of existing research on this topic. Therefore, there is also no definitive conclusion as to whether technology promotes behavioral change [ 23 ]. Another limitation is language restrictions. This study includes reviews written in English. Further studies are suggested to include works written in other languages.

It was found in this study that the presence of diseases and co-morbidities is an important direction of concern for health promotion in the elderly. Health promotion in the elderly typically has three purposes: maintaining and increasing function, maintaining or improving self-managed health, and creating active social networks. However, all of these aims are intended to contribute to independence and a better quality of life. Older people struggle to stay healthy, not only because of the challenges of aging, but also because they are more likely to be ostracized and socially isolated than younger people. However, subjective or psychosocial factors are often neglected in the implementation or formulation of advanced age health promotion programs. Therefore, it is important to go beyond the physical to further explore the psychosocial components of a strategy and how these factors affect overall happiness. Self-reported survey data can be used to measure psychosocial factors (e.g., loneliness, self-efficacy) so as to provide a clearer picture of the real needs of this population.

Supplementary Materials

The following are available online at https://www.mdpi.com/1660-4601/17/15/5335/s1 . Supplementary 1: Definitions used in the process of classification, Supplementary 2: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist, Supplementary 3: List of systematic reviews and meta-analyses included in this study. Supplementary 4: Comparison between the current study and Duplaga et al. [ 4 ]

Author Contributions

Writing—original draft, C.-J.C.; Writing—review & editing, J.-C.H., Y.-H.L. and E.-Y.C. All authors have read and agreed to the published version of the manuscript.

This research was supported by grants from the Health Promotion Administration of Taiwan, grant number (MOHW108-HPA-H-114-000710).

Conflicts of Interest

The authors declare no conflict of interest.

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Article Contents

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Nurses' roles in health promotion practice: an integrative review

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Virpi Kemppainen, Kerttu Tossavainen, Hannele Turunen, Nurses' roles in health promotion practice: an integrative review, Health Promotion International , Volume 28, Issue 4, December 2013, Pages 490–501, https://doi.org/10.1093/heapro/das034

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Nurses play an important role in promoting public health. Traditionally, the focus of health promotion by nurses has been on disease prevention and changing the behaviour of individuals with respect to their health. However, their role as promoters of health is more complex, since they have multi-disciplinary knowledge and experience of health promotion in their nursing practice. This paper presents an integrative review aimed at examining the findings of existing research studies (1998–2011) of health promotion practice by nurses. Systematic computer searches were conducted of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases, covering the period January 1998 to December 2011. Data were analysed and the results are presented using the concept map method of Novak and Gowin. The review found information on the theoretical basis of health promotion practice by nurses, the range of their expertise, health promotion competencies and the organizational culture associated with health promotion practice. Nurses consider health promotion important but a number of obstacles associated with organizational culture prevent effective delivery.

The role of nurses has included clinical nursing practices, consultation, follow-up treatment, patient education and illness prevention. This has improved the availability of health-care services, reduced symptoms of chronic diseases, increased cost-effectiveness and enhanced customers' experiences of health-care services ( Strömberg et al ., 2003 ; Griffiths et al ., 2007 ). In addition, health promotion by nurses can lead to many positive health outcomes including adherence, quality of life, patients' knowledge of their illness and self-management ( Bosch-Capblanc et al ., 2009 ; Keleher et al ., 2009 ). However, because of the broad field of health promotion, more research is needed to examine the role of health promotion in nursing ( Whitehead, 2011 ).

The concept of health promotion was developed to emphasize the community-based practice of health promotion, community participation and health promotion practice based on social and health policies ( Baisch, 2009 ). However, empirical studies indicate that nurses have adopted an individualistic approach and a behaviour-changing perspective, and it seems that the development of the health promotion concept has not influenced practical health promotion practices by nurses ( Casey, 2007a ; Irvine, 2007 ). On the other hand, there has been much discussion about how to include health promotion in nursing programmes and how to redirect nurse education from being disease-orientated towards a health promotion ideology ( Rush, 1997 ; Whitehead, 2003 ; Mcilfatrick, 2004 ).

The aim of this integrative review was to collate the findings of past research studies (1998–2011) of nurses' health promotion activities. The research questions addressed were: (i) What type of health promotion provides the theoretical basis for nurses' health promotion practice? (ii) What type of health promotion expertise do nurses have? (iii) What type of professional knowledge and skills do nurses undertaking health promotion exhibit? (iv) What factors contribute to nurses' ability to carry out health promotion?

An integrative review was chosen because it allowed the inclusion of studies with diverse methodologies (for example, qualitative and quantitative research) in the same review ( Cooper, 1989 ; Whittemore, 2005 ; Whittemore and Knafl, 2005 ). Integrative reviews have the potential to generate a comprehensive understanding, based on separate research findings, of problems related to health care ( Kirkevold, 1997 ; Whittemore and Knafl, 2005 ). The integrative review was split into the following phases: problem identification, literature search, data evaluation, data analysis and presentation of the results ( Whittemore and Knafl, 2005 ).

Search method

Several different databases were searched to identify relevant published material. Systematic searches of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases were undertaken using the search string ‘nurs* AND professional competence* OR clinical competence* OR professional skill* OR professional knowledg* OR clinical skill* OR clinical knowledg* AND health promotion OR preventive health care OR preventive healthcare’. The searches were limited to studies published during the period 1998–2011 because, prior to 1998, nurses' health promotion practice was mainly linked to health education.

Search result

The original search identified 1141 references: 119 in the Cochrane databases; 227 in Cinah, 345 in PubMed, 128 in the Web of Science, 100 in PsycINFO and 222 in Scopus. After duplicate papers were excluded one researcher (V.K.) read the titles and abstracts of the remaining 412 research papers. No specific evaluation criteria are employed when conducting an integrative review using diverse empirical sources; one approach is to evaluate methodological quality and informational value ( Whittemore and Knafl, 2005 ). All three researchers (V.K., K.T. and H.T.) defined the inclusion criteria together. Studies were included in the integrative review if they met the following criteria: the language had to be English, Swedish or Finnish, as translators for other languages were not available and the papers had to be published in peer-reviewed journals and describe nurses' health promotion roles, knowledge or skills and/or factors that contributed to nurses' ability to implement health promotion in nursing delivered through hospital or primary health-care services. The main exclusion criteria were: the published works were editorials, opinions, discussions or textbooks, or they described health promotion programmes, competencies other than health promotion or nursing curricula, or if the group studied included patients. The included studies were tabulated in chronological order under the following headings: citation, aim of the paper, methodology, size of the sample, measured variables, method of analysis, major results, concepts used as the basis of the study and limitations. Studies included in this review are available in Supplementary data, Table S1 .

Data analysis

Conducting an integrative review that analyses various types of research paper is a major challenge ( Whittemore and Knafl, 2005 ). In this review, the concept map method was adopted for both data analysis and presentation of the results. The use of concept mapping promotes conceptual understanding and provides a strategy for analysing and organizing information and identifying, graphically displaying and linking concepts. The concept map method was applied according to the recommendations of Novak and Gowin [( Novak and Gowin, 1984 ), p. 15–40] and Novak ( Novak, 1993 , 2002 , 2005 ). According to Novak ( Novak, 1993 , 2002 , 2005 ) the process of concept mapping involves six phases: (i) Identify a key question that focuses on a problem, issue or knowledge central to the purpose of the concept map. (ii) Identify concepts through the key question. (iii) Start to construct the concept map by placing the key concepts at the top of the hierarchy. After that, select defining concepts and arrange hierarchially below of the key concepts. (iv) Combine the concepts by cross-links or links between concepts in different segments or domains of the concept map. (v) Give the cross-links a name of a word or two. (vi) To concepts can be added specific examples of events or objectives that clarify the meaning of the concept.

All three researchers (V.K., K.T. and H.T.) were involved in the concept mapping process. The process proceeded as follows: first, one researcher (V.K.) read studies that met the inclusion criteria and the concepts were identified through the four research questions upon which the review is based. Second, one researcher (V.K.) began to construct four concept maps hierarchically. This was achieved by putting the key concepts on the top of the left side of a page then listing definitions of the concepts down the middle of each page. Other researchers (K.T. and H.T.) verified the first and the second phases of the concept mapping process. Third, one researcher (V.K.) continued the construction of each concept map by combining main concepts and definition concepts using links that were then named. Other researchers (K.T. and H.T.) critically evaluated the concept maps thus produced. Fourth, one researcher (V.K.) selected examples of the main concepts and these were listed on the right side of each page for clarification.

In the end 40 research papers, were included in our integrative review. The research papers were methodologically very diverse: 16 of them included qualitative approaches; 14 were different types of reviews; 8 were quantitative; 1 used concept analysis and 1 was a mixed-method study. Twelve empirical studies were conducted in hospitals and fourteen in primary health-care settings. Eleven studies were published in the period 1998–2004, twenty-two between 2005 and 2009 six between 2010 and 2011.

What type of health promotion provides the theoretical basis for nurses' health promotion practice?

The theoretical basis underlying nurses' health promotion activities was identified in 25 of the research papers ( Benson and Latter, 1998 ; McDonald, 1998 ; Robinson and Hill, 1998 ; Sheilds and Lindsey, 1998 ; Burge and Fair, 2003 ; Hopia et al ., 2004 ; Whitehead, 2004 , 2006a , b , c , 2009 , 2011 ; Berg et al ., 2005 ; Runciman et al ., 2006 ; Casey, 2007a , b ; Folke et al ., 2007 ; Irvine, 2007 ; Piper, 2008 ; Witt and Puntel de Almeida, 2008 ; Chambres and Thompson, 2009 ; Fagerström, 2009 ; Richard et al ., 2010 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). According to these papers the theoretical basis of health promotion reflects the type of practical actions undertaken by nurses to promote the health of patients, families and communities. The research suggests that nurses work from either a holistic and patient-oriented theoretical basis or take a chronic diseases and medical-oriented approach. These theoretical foundations were considered to represent the main concepts of health promotion orientation and public health orientation in this review (Figure  1 ).

Concepts and examples of the theoretical basis of nurses' health promotion activities.

Health promotion orientation

The most common factor influencing the concept of health promotion orientation was individual perspective ( Robinson and Hill, 1998 ; Hopia et al ., 2004 ; Runciman et al ., 2006 ; Casey, 2007a ; Chambres and Thompson, 2009 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). When nurses' health promotion activities were guided by individual perspective nurses' exhibited a holistic approach in their health promotion practice, they concentrated on activities such as helping individuals or families to make health decisions or supporting people in their engagement with health promotion activities ( Hopia et al ., 2004 ; Irvine, 2007 ; Chambres and Thompson, 2009 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). Nurses' strategies for health promotion included giving information to patients and providing health education ( Casey, 2007a ). However, patient participation was mainly limited to personal aspects of care, such as letting patients decide on a menu, when to get out of bed and what clothes they wanted to wear ( Casey, 2007a ).

The second common defining concept of health promotion orientation was empowerment, which was related to collaboration with individuals, groups and communities ( McDonald, 1998 ; Berg et al., 2005 ; Whitehead, 2006a ; Irvine, 2007 ; Piper, 2008 ; Richard et al ., 2010 ; Samarasinghe et al ., 2010 ). Such orientation was described in these studies in terms of nurse–patient communication and patient, group and community participation. Although these studies found empowerment to be one of the most important theoretical bases for health promotion activities by nurses, empowerment was not embedded in nurses' health promotion activities ( Irvine, 2007 ).

The third common defining concept of health promotion orientation was social and health policy ( Benson and Latter, 1998 ; Whitehead, 2004 , 2006a , b , 2009 , 2011 ). These studies suggested that nurses' health promotion activities should be based on the recommendations in, for example, the World Health Organization's (WHO) charters and declarations and directives and guidance from professional and governmental organizations. However, the studies examined found that nurses were not familiar with social and health policy documents and that they did not apply them to their nursing practice ( Benson and Latter, 1998 ; Whitehead, 2011 ).

The last defining concept of health promotion orientation was community orientation ( Sheilds and Lindsey, 1998 ; Whitehead, 2004 ; Witt and Puntel de Almeida, 2008 ). These papers revealed that nurses had knowledge of community-orientated health promotion: they were expected to use health surveillance strategies, work collaboratively with other professionals and groups and respect and interact with different cultures. In addition a health promotion orientation appeared to result in nurses working more closely with members of communities, for example, being involved in voluntary work and implementation of protective and preventive health measures.

Public health orientation

Public health-orientated chronic disease prevention and treatment has traditionally been the theoretical basis of nurses' health promotion activities ( Burge and Fair, 2003 ; Berg et al ., 2005 ; Whitehead, 2006c ; Folke et al ., 2007 ; Casey, 2007b ; Irvine, 2007 ; Chambres and Thompson, 2009 ; Fagerström, 2009 ; Richard et al. , 2010 ). The first defining concept of public health orientation was disease prevention ( Berg et al ., 2005 ; Whitehead, 2006c , Folke et al ., 2007 ; Irvine, 2007 ; Fagerström, 2009 ; Richard et al. , 2010 ). According to these studies, this occurred in health promotion when the focus was on diagnosis, physical health and the relief of the physical symptoms of disease. The second defining concept of public health orientation was the authoritative approach ( Burge and Fair, 2003 ; Casey, 2007b ; Irvine, 2007 ; Chambres and Thompson, 2009 ). This approach emphasizes the need for nurses to give information to patients. In addition, the authoritative approach suggests that health promotion activities should aim to change patients' behaviour ( Irvine, 2007 ; Chambres and Thompson, 2009 ).

What type of health promotion expertise do nurses have?

The expertise of nurses with respect to health promotion was described in 16 research papers ( Robinson and Hill, 1998 ; Whitehead, 2001 , 2006b , 2007 , 2009 , 2011 ; Hopia et al ., 2004 ; Cross, 2005 ; Jerden et al ., 2006 ; Runciman et al ., 2006 ; Kelley and Abraham, 2007 ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ; Parker et al ., 2009 ; Goodman et al ., 2011 ; Whitehead, 2011 ). According to these papers nurses implemented a range of types of health promotion activity and applied different health promotion expertise across a wide range of nursing contexts. Depending on the context nurses are able to make use of a variety of types of expertise in health promotion. Nurses can be classified into: general health promoters, patient-focused health promoters and project management health promoters (Figure  2 ).

Concepts and examples of the types of nurses' expertise as health promoters.

General health promoters

Health promotion by nurses is associated with common universal principles of nursing. The most common health promotion intervention used by nurses is health education ( Robinson and Hill, 1998 ; Whitehead, 2001 , 2007 , 2011 ; Runciman et al ., 2006 ; Witt and Puntel de Almeida, 2008 ; Parker et al ., 2009 ). General health promoters are expected to have knowledge of health promotion, effective health promotion actions, national health and social care policies and to have the ability to apply these to their nursing practice ( Witt and Puntel de Almeida, 2008 ; Whitehead, 2009 ).

Patient-focused health promoters

There is growing recognition that different patient groups, such as the elderly or families with chronic diseases, have different health promotion needs. In promoting the health of these different groups, nurses can be regarded as patient-focused health promoters ( Hopia et al ., 2004 ; Cross, 2005 ; Jerden et al ., 2006 ; Kelley and Abraham, 2007 ; Goodman et al ., 2011 ). These studies revealed that when health promotion for patient groups who need high levels of care and treatment is required, nurses must have the ability to include health promotion activities in their daily nursing practice.

Managers of health promotion projects

Nurses should be able to plan, implement and evaluate health promotion interventions and projects ( Runciman et al ., 2006 ; Whitehead, 2006b ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ). Projects can facilitate the development of health promotion in nursing practice ( Runciman et al ., 2006 ). Thus, managers of health promotion projects should have advanced clinical skills and take the responsibility in supervising and leading research and development actions in nursing as well as having the ability to co-ordinate educational and developmental interventions in health-care units and communities ( Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ).

What type of professional knowledge and skills do nurses undertaking health promotion exhibit?

Nurses' knowledge of health promotion and their relevant practical skills were described in 18 research papers ( McDonald, 1998 ; Nacion et al. , 2000 ; Burge and Fair, 2003 ; Whitehead, 2003 ; Hopia et al ., 2004 ; Reeve et al ., 2004 ; Spear, 2004 ; Cross, 2005 ; Irvine, 2005 , 2007 ; Rush et al ., 2005 ; Jerden et al ., 2006 ; Casey, 2007b ; Kelley and Abraham, 2007 ; Piper, 2008 ; Witt and Puntel de Almeida, 2008 ; Wilhelmsson and Lindberg, 2009 ; Goodman et al ., 2011 ). These studies suggested that nurses' health promotion activities consisted of a variety of competencies. We classified these into multidisciplinary knowledge, skill-related competence, competence with respect to attitudes and personal characteristics (Figure  3 ).

Concepts and examples of nurses' health promotion competencies.

Multidisciplinary knowledge

Nurses' health promotion activities were often based on a broad and multidisciplinary knowledge ( Nacion et al ., 2000 ; Burge and Fair, 2003 ; Spear, 2004 ; Irvine, 2005 ; Casey, 2007b ; Witt and Puntel de Almeida, 2008 ; Whitehead, 2009 ). This included a knowledge of: health in different age groups; epidemiology and disease processes and health promotion theories. In addition, nurses need to have the ability to apply this knowledge to their health promotion activities ( Burge and Fair, 2003 ; Spear, 2004 ; Irvine, 2005 ; Runciman et al ., 2006 ; Piper, 2008 ; Witt and Puntel de Almeida, 2008 ). Nurses were also expected to be aware of economic, social and cultural issues, social and health policies and their influence on lifestyle and health behaviour ( Burge and Fair, 2003 ; Irvine, 2005 ).

Skill-related competence

Nurses must possess a variety of health promotion skills; of these, communication skills were considered to be the most important ( McDonald, 1998 ; Nacion et al. , 2000 ; Burge and Fair, 2003 ; Hopia et al ., 2004 ; Irvine, 2005 ; Jerden et al ., 2006 ; Casey, 2007b ). Nurses play a particularly important role when they encourage patients and their families to participate in decision-making related to treatment or to discuss and express their feelings about situations associated with serious illness ( Hopia et al ., 2004 ). Skill-related competence also includes the ability to support behavioural changes in patients and the skill to respond to patients' attitudes and beliefs ( Burge and Fair, 2003 ). In addition, skill-related competence involves teamwork, time management, information gathering and interpretation and the ability to search for information from different data sources ( Irvine, 2005 ; Jerden et al ., 2006 ).

Competence with respect to attitudes

Competence with respect to attitudes emerged as a positive feature of health promotion ( Whitehead, 2003 ; Reeve et al ., 2004 ; Spear, 2004 ; Cross, 2005 ; Irvine, 2005 , 2007 ; Kelley and Abraham, 2007 ; Piper, 2008 ; Wilhelmsson and Lindberg, 2009 ). Effective health promotion practice requires nurses to adopt a proactive stance and act as an advocate. An affirmative and egalitarian attitude towards patients and their families, as well as the desire to promote their health and well-being, are important attitudes with respect to health promotion activities ( Irvine, 2005 , 2007 ; Wilhelmsson and Lindberg, 2009 ). In addition, nurses who have personal experience, for example, of having had a baby, have a more positive attitude towards promoting the health of patients in the same situation ( Spear, 2004 ).

Personal characteristics

Traditionally, nurses were perceived to be healthy role models, engaging in healthy activities, not smoking and maintaining an ideal weight Burge and Fair, (2003) ; Reeve et al. , 2004 ; Rush et al ., 2005 ). In addition, personal confidence and flexibility are personal characteristics that nurses working in health promotion are expected to possess ( Burge and Fair, 2003 ; Rush et al ., 2005 ).

What factors contribute to nurses' ability to carry out health promotion?

Thirteen research papers identified features which contributed to nurses' health promotion activities ( Robinson and Hill, 1998 ; Reeve et al ., 2004 ; Jerden et al. , 2006 ; Runciman et al ., 2006 ; Whitehead, 2006b , 2009 , 2011 ; Casey, 2007a , b ; Kelley and Abraham, 2007 ; Wilhelmsson and Lindberg, 2009 ; Beaudet et al ., 2011 ; Goodman et al ., 2011 ). All of the features related to cultural aspects of the organization in which nurses work. We considered that these could be classified as either supportive or discouraging (Figure  4 ).

Concepts and examples of organizational culture associated with health promotion activities.

First, organizational culture consisted of three supportive aspects: hospital managers, culture of health and education. The hospital managers were responsible for whether health promotion was a strategically planned and whether it was considered to be of great importance ( Whitehead, 2006b , 2009 ). In addition, the hospital managers were key individuals in ensuring that health promotion activities did not conflict with other work priorities ( Jerden et al ., 2006 ; Casey, 2007a ; Beaudet et al ., 2011 ). Hospital managers also have an important role in cultivating a culture of health in the work community, for instance by prohibiting smoking during working time ( Casey, 2007a ). Education enhanced nurses' health promotion skills and health promotion projects were catalysts for health promotion in nursing practice ( Goodman et al ., 2011 ). Organizational culture included three discouraging factors. The major one was a lack of resources, including a lack of time, equipment (e.g. computers) and health education material ( Robinson and Hill, 1998 ; Reeve et al ., 2004 ; Runciman et al ., 2006 ; Casey, 2007b ; Kelley and Abraham, 2007 ; Wilhelmsson and Lindberg, 2009 ; Beaudet et al ., 2011 ). In addition, nurses may lack skills to implement health promotion in their working place ( Goodman et al ., 2011 ). Recent studies have also revealed that health promotion activities are still unclear to nurses ( Beaudet et al ., 2011 ; Whitehead, 2011 ).

Several authors have identified a need to clarify the concept of health promotion in nursing ( Goodman et al ., 2011 ; Whitehead, 2011 ). We found the concept map method useful to enhance conceptual understanding of this complex nursing phenomenon. This integrative review was intended to identify the findings of nursing-specific studies of health promotion activities published in the period 1998–2011. We identified 40 relevant English research papers. Most of these studies were published between 2005 and 2009. Combining qualitative and quantitative studies is complex and can introduce bias and error ( Whittemore and Knafl, 2005 ). The data examined herein originated from methodologically diverse research. Therefore, we should be cautious of generalizing our findings. Most of the studies were qualitative, but a broad range of health promotion activities undertaken by nurses was described. The concept map method was used to analyse the data; the results of this review are reported both as text and concept maps. Concept maps are rarely used as a data analysis tool and therefore we employed researcher triangulation (V.K., K.T. and H.T.) during the research process; this enhanced our understanding and increased scientific rigour ( Jones and Bugge, 2006 ).

We found that health promotion and public health orientation have guided nurses' health promotion activities (e.g. McDonald, 1998 ; Whitehead, 2009 ; Richard et al ., 2010 ; Povlsen and Borup, 2011 ). It was surprising that, even though there has been much public debate and research has emphasized that health policies should guide nurses' health promotion activities worldwide, health policies have little impact on nursing practice (e.g. Benson and Latter, 1998 ; Irvine, 2007 ; Whitehead, 2011 ). Nurses have a variety of types of expertise, some working as general health promoters, some as patient-focused health promoters and some as managers of health promotion projects (e.g. Whitehead, 2008 ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ; Goodman et al ., 2011 ). The management of health promotion projects is particularly important, although only three studies ( Whitehead, 2006b ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ) described the type of expertise possessed by such managers. We found that there has been great interest in nurses' health promotion competencies (e.g. Irvine, 2005 , 2007 ; Witt and Puntel de Almeida, 2008 ; Wilhelmsson and Lindberg, 2009 ). A number of studies found that nurses' health promotion activities were based on multidisciplinary knowledge (e.g. Burge and Fair, 2003 ; Irvine, 2005 ; Whitehead, 2009 ). Interestingly, knowing about the trends that will influence the population's health in the future, such as multiculturalism, new technologies and ecological changes, were not identified as nurses' health promotion competencies. Unexpectedly for us the competencies associated with attitudes were not emphasized as one of the most important competencies even though nurses should be advocates of good health. We also found that nurses' individual health-related beliefs and lifestyles are important personal characteristics in health promotion and that nurses are expected to be healthy role models (e.g. Burge and Fair, 2003 ; Reeve et al. , 2004 ; Rush et al. , 2005 ). Nurses are aware of the importance of health promotion, but organizational culture with respect to health promotion can either support or discourage them from implementing it (e.g. Reeve et al ., 2004 ; Casey, 2007a , b ; Goodman et al ., 2011 ; Whitehead, 2011 ). Managers in health-care organizations should appreciate the value of health promotion activities and ensure adequate resources for their implementation (e.g. Casey, 2007b ; Beaudet et al ., 2011 ).

According to much of the health promotion research, it appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities. Instead, nurses can be considered general health promoters, with their health promotion activities based on sound knowledge and giving information to patients. Nursing is an appropriate profession in which to implement health promotion, but several barriers associated with organizational culture have a marked effect on delivery. Therefore, more research is needed to determine how to support nurses in implementing health promotion in their roles in a variety of health-care services.

V.K. was responsible for the computer-based data searches and the data analysis via the concept map method. K.T. and H.T. verified that the data searches were made properly. K.T. and H.T. verified that the concept mapping process proceeded properly and made critical appraisals in every phase of the research process. V.K. was responsible for the drafting of the manuscript. K.T. and H.T. made critical revisions to the paper for important intellectual contents, conceptualization, support in theorizing the findings and provided material support. K.T. and H.T. supervised the study.

This research received a specific grant from The Finnish Foundation for Nurse Education and The Finnish Nurses Association.

Virpi Kemppainen would like to acknowledge the support from the University of Eastern Finland, Department of Nursing Science.

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Promoting Health: Intervention Strategies from Social and Behavioral Research (2000)

Chapter: conclusions.

Recommendation 21: Greater attention should be paid to funding research on social determinants of health and on behavioral and social science intervention research addressing generic social determinants of disease.

Behavioral and social science research has provided many new advancements in the effort to improve population health, and offers promise for the development of new interventions with even greater utility and efficiency in the years to come. As summarized below, the committee finds that social and behavioral interventions can improve health outcomes across a range of developmental stages and levels of analysis (e.g., individual, interpersonal, and community levels). Further, coordination of intervention efforts across these levels may efficiently and effectively promote healthy individuals and environments.

The committee found compelling evidence that expectant mothers can deliver healthier children as we improve our understanding of the social, economic, and intrapersonal conditions that influence the mother's health status over her life course, not just in the period prior to conception and birth. The physical, cognitive, and emotional health of infants can be improved with comprehensive, high-quality services that address basic needs of children and families. These same interventions assist children to enter school ready to learn. Similarly, adolescents can enjoy healthier life-styles as researchers and public health officials pay greater attention to the social and environmental contexts in which youth operate. These interventions pay great dividends for later health, as poor health habits can be avoided and developmental risks averted.

The evidence also suggests that adolescents and adults can benefit from co-ordinated health promotion efforts that address the many sources of health influences (e.g., family, school, work settings). Opportunities for behavioral and social interventions to improve health do not end during adulthood, however; compelling data indicate that older adults can age more successfully as policies and institutions attend to their social, cognitive, and psychological needs, as well as their physical health needs.

While further research is needed, evidence is developing that elucidates the pathways through which behavioral and social interventions may mediate physiological processes and disease states. This evidence indicates that behavioral and social interventions can directly impact physiological functioning, and do not merely correlate with positive health outcomes due to improvements in health behavior or knowledge. Further refinements of this research will aid in the development of more efficient and effective interventions.

As interventions are developed, special consideration must be given to gender as well as to the needs of individuals of different socioeconomic, racial, and ethnic backgrounds. These attributes powerfully shape the contexts in which individuals gain access to health-promoting resources (e.g., education, income, social supports), the barriers that restrict more healthful life-styles (e.g., demands

of gender roles), and the ways in which individuals in these groups interpret and respond to interventions. Because socioeconomic status exerts direct effects on health, intervention efforts must attend to the broader social, economic, cultural, and political processes that determine and maintain these disparities.

Efforts to improve the health of communities can benefit from specific levers for public health intervention, such as enhancing social capital and enacting public policies that promote healthful environments. While further research is needed to better understand means of manipulating these levers, it is clear that these interventions are most effective when members of target communities participate in their planning, design, and implementation. Communities that are fully engaged as partners in this process are more likely to develop public health messages that are relevant, are more likely to fully “buy in” and commit to community change, and are more likely to sustain community change efforts after research and/or demonstration programs end.

All such interventions are likely to be more successful when applied in co-ordinated fashion across multiple levels of influence (i.e., at the individual level; within families and social support networks; within schools, work sites, churches, and other community settings; and at broader public policy levels). While more research is needed to ascertain how coordination is best achieved and the cost-effectiveness of each component of a multilevel intervention strategy, the evidence from the tobacco control effort suggests that such a multilevel strategy can reap benefits for broad segments of the public. This success can extend both to those individuals at greatest risk for poor health by virtue of their unhealthful behaviors or disadvantaged social, political, or economic status, as well as those at relatively low risk. Such efforts require, however, that funders, public health officials, and community leaders are patient and persist with intervention efforts over a longer period than the 3 to 5 years typically allotted for most demonstration or research efforts.

To best accomplish these goals, researchers must learn to work across traditional disciplinary boundaries, and adopt new methodologies to evaluate intervention efforts. A range of social, behavioral, and life scientists must collaborate to fully engage a biopsychosocial model of human health and development. Further, these researchers must be open to adopting less traditional evaluation approaches, such as qualitative methodologies, and combining these approaches with quantitative methodologies.

In summary, the committee concludes that serious effort to apply behavioral and social science research to improve health requires that we transcend perspectives that have, to this point, resulted in public health problems being defined in relatively narrow terms. Efforts to design and implement multipronged interventions will require the cooperation of public health officials, funding agencies, researchers, and community members. Evaluation efforts must transcend traditional models of randomized control trials and incorporate both quantitative and qualitative methodologies. Models of intervention must consider individual behavior in a broader social context, with greater attention to the social construction of gender, race, and ethnicity, and to ways in which social

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Peer-reviewed

Research Article

Health promotion interventions for the control of hypertension in Africa, a systematic scoping review from 2011 to 2021

Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

Affiliation Mo-im Kim Nursing Research Institute, College of Nursing, Yonsei University, Yonsei-ro, Seodaemun-gu, Seoul, Korea

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Mo-im Kim Nursing Research Institute, College of Nursing, Yonsei University, Yonsei-ro, Seodaemun-gu, Seoul, Korea, Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

Roles Data curation, Investigation, Methodology, Writing – original draft

Affiliation War Memorial Hospital, Navrongo, Upper East Region, Ghana

• Jinhee Shin, 
• Kennedy Diema Konlan, 
• Eugenia Mensah

• Published: November 29, 2021
• https://doi.org/10.1371/journal.pone.0260411
• Peer Review
• Reader Comments

A proportion of hypertension patients live in developing countries with low awareness, poor control capabilities, and limited health resources. Prevention and control of hypertension can be achieved by applying both targeted and population-based health promotion interventions. This study synthesised the health promotion interventions for the control of hypertension in Africa.

An in-depth search of PubMed, CINAHL, EMBASE, Cochrane library, web of science, google scholar yielded 646 titles and 615 after duplicates were removed. Full text (112) was screened, and ten articles were selected. The data analysis method was thematic analysis through the incorporation of convergent synthesis. The major sub-themes that were identified were reduction in the prevalence of hypertension, increase in knowledge, impact and feasibility, role in the reduction of risk factors, and the cost associated with health promotion interventions.

Health promotion interventions led to a remarkable decrease in the prevalence of hypertension, increased knowledge and awareness in the intervention compared to the control groups. Community-based interventions were noted to have a positive impact on people’s adoption of measures to reduce risk or identify early symptoms of hypertension. There was a significant relationship for the reduction in salt consumption, smoking, alcohol use, and increased physical activity after the administration of an intervention. Interventions using community health workers were cost-effective.

To sustain health promotion interventions and achieve control of hypertension especially in the long term, interventions must be culturally friendly and incorporate locally available resources in Africa.

Citation: Shin J, Konlan KD, Mensah E (2021) Health promotion interventions for the control of hypertension in Africa, a systematic scoping review from 2011 to 2021. PLoS ONE 16(11): e0260411. https://doi.org/10.1371/journal.pone.0260411

Editor: Muhammad Shahzad Aslam, Xiamen University - Malaysia Campus: Xiamen University - Malaysia, MALAYSIA

Received: September 3, 2021; Accepted: November 9, 2021; Published: November 29, 2021

Copyright: © 2021 Shin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Worldwide, hypertension causes significant morbidity and mortality, contributing to 57 million (3.7% total) disability-adjusted life years and 7.5 million (12.8%) premature deaths annually [ 1 ]. The incidence of hypertension among Africans is noted to be higher than Caucasian populations [ 2 , 3 ], and remains an emerging public health problem especially in developing countries. Most hypertension patients (639 million) live in developing countries where they are faced with low awareness, poor control capabilities, and limited health resources [ 4 , 5 ]. This high prevalence and poor control of hypertension are important factors in the increasing prevalence of cardiovascular disease especially among Africans. Poor hypertension control is noted to lead to increasing prevalence of haemorrhagic and ischaemic stroke, ischaemic heart disease, cardiovascular disease, heart failure and other peripheral heart diseases [ 6 , 7 ].

Hypertension is a complex polygenic disorder that is influenced by combinations of genetic, environmental, socio-economic and demographic factors [ 8 ]. Genetic factors are noted to be influenced by the environment as modifiable epigenetic factors are known to be inherited over several generations [ 9 , 10 ]. Although the genetic predisposition cannot be modified, the risk of hypertension can be lowered by modifying key environmental and lifestyle factors. The important factors that increase hypertension prevalence in childhood and early adulthood are weight gain leading to obesity, excessive sodium, inadequate potassium intake, insufficient physical activity, and consumption of alcohol [ 9 – 11 ]. Key improvements can be made through individual adoption of positive behaviour that minimises the risk of hypertension. These can be attained through sustained implementation of lifestyle modifications that limits the risk associated with hypertension [ 12 ] and can be achieved through the implementation of health promotion interventions that ensure sustained control.

Prevention and control of hypertension can be achieved by applying both targeted and a population-based strategies. The targeted approach is a traditional strategy used in clinical practice, which seeks to reduce high blood pressure among clinical patients. The strategy that uses population-based approach is derived from public health mass environmental control experiences that do not specifically target a particular set of the population [ 13 ]. The goal in this strategy is to have little reduction in blood pressure within the population as these may have a downward shift in the population’s overall risk and prevalence [ 2 , 8 , 10 , 13 ]. It is generally believed that the population-based approaches offer greater potential for preventing cardiovascular diseases than the targeted strategies [ 13 , 14 ]. This is based on the principle that many people exposed to small cardiovascular disease risk may result in more cases than few people exposed to various risks [ 13 ]. It is noted that reducing the diastolic blood pressure in the general population by 2mmHg would be expected to reduce the incidence of hypertension (17%), stroke (14%), and coronary artery disease by 6% [ 6 , 15 ]. However, both strategies may use the same interventions, as they are complementary and mutually reinforcing emphasizing the imperative to institute health promotion interventions that are key in the control of hypertension in the at-risk population and among patients.

Research over the decades has implemented several strategies in Africa with the goal of identifying acceptable, culturally friendly, feasible, and cost-efficient means for the control of hypertension. These tested strategies are noted to be geographically sporadic, uncoordinated, and have produced diverse outcomes or impacts. It is therefore imperative to ensure synthesis and collation of these studies in a single document to ensure easy implementation for the control of hypertension. This study synthesised health promotion interventions for the control of hypertension in Africa.

Materials and methods

Primary research articles published between 2011 to 2021 were reviewed and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework [ 16 – 18 ]. The time frame of 2011 to 2021 was chosen to critically examine the health promotion interventions that are adopted for the prevention of the risk of hypertension in Africa. This review was conducted from April to August 2021.

Search strategy

We searched six (PubMed, CINAHL, EMBASE, Cochrane library, web of science, google scholar) electronic databases for eligible studies after making scoping searches through manual search guided by the reference list of the selected studies. The key words were first searched in Pubmed, and the corresponding medical subject heading of indexed keywords were identified. The medical subject headings (MeSH) for index words and free text search for non-indexed words were searched by combining the appropriate Boolean operators in the various electronic databases using the advanced search option. In google scholar the first three pages comprising 150 titles were searched manually and appropriate manuscripts were selected. The population, intervention, comparison, and outcome (PICO) framework was integrated in PRISMA in searching, screening, and selecting eligible studies. The population were adolescents and young adults, the intervention was any health promotion intervention, comparisons were not clearly defined, and the outcome was hypertension control [ 16 – 18 ]. The MeSH terms and the free text words and phrases that were searched with the appropriate Boolean operators were (hypertension OR high blood pressure OR elevated blood pressure OR HTN or hypertensive) AND (health promotion OR health education OR patient education) AND (adolescents OR teenagers OR young adults OR teen OR youth). The articles were screened for only African, English-based articles from 2011 through to April 2021.

Search results

In searching from the six electronic databases, 646 titles were identified from using the keywords and 615 titles after duplicates removal. After filtering for only English, published in Africa and within 2011 to 2021, only 615 titles were eligible for abstract and full-text screening. The titles for all these 615 titles were read and screened independently by two of the researchers. Titles that did not focus on health promotion intervention were excluded for full-text screening. The total number of articles selected from this round of screening was 112. abstracts. The full-text of these selected abstracts was screened, and ten articles were deemed to be eligible for this study.

Inclusion and exclusions criteria

The selection of each study depended on predefined inclusion and exclusion criteria. The inclusion criteria took into consideration the following: article focused on a health promotion intervention, study conducted in Africa, published in English and between 2011 through to 2021. The exclusion criteria included articles that measured prevalence and incidence of hypertension, identified comorbidities, and focused on other variables than health promotion intervention.

Data collection and extraction

To extract data, a matrix was first developed, discussed, and agreed on by all the researchers. The matrix guided the way the data was extracted. All the researchers independently extracted data using the matrix. The extracted data were compared and where there was a discrepancy, it was resolved through discussion and consensus. The major variables that were contained in the matrix included. Authors and year of publication, study design, setting, population and sample, data analysis and measurement tool for outcome variables. Other variables extracted were the intervention provider, duration of intervention, name of health promotion intervention and the key findings.

Quality appraisal

The tool used for quality appraisal is the Mixed Methods Appraisal Tool (MMAT) version 2018. Two researchers independently appraised the quality of each study as suggested by Hong et al., 2018 [ 19 ]. The appraised data were then compared and where there were discrepancies, it was resolved by consensus. Where a consensus could not be reached, the two researchers consulted a third person, and the majority decision prevailed. The MMAT tool contains methodological criteria for the appraisal of quantitative, qualitative, and mixed methods studies as well as for interventional and experimental studies. The section that was appropriate for the appraisal of the studies was the part that pertains to randomised control trials, non-randomised control trials and mixed methods study. The MMAT tool allowed for screening of each research work by confirming a response of affirmation or disagreement. If there were clear research questions and if the data collection method allowed for the addressing of the research questions. All the studies were affirmative to these screening questions.

The appraisal questions for the section that entailed in randomised control trials section were five and include the appropriateness of randomisation, comparability of groups at baseline, completeness of outcome data, the blindness of assessors and participants adhered to assigned interventions. Only one study was evaluated in this category and had a negative response in respect of the questions that pertained to the blinding of the assessors in respect to the intervention [ 20 ]. Five questions were related to the non-randomised control section. These criteria include representativeness of the sample to the population, appropriateness of measurement of both the outcome and the intervention, completeness of outcome data, accounting for confounders in the design and analysis, and whether the interventions were administered as expected. The appraisal showed that some studies did not meet the criteria pertaining to the representativeness of study participants to the population [ 21 – 24 ], presence of complete outcome data [ 25 ], accounting for confounders in the design and analysis [ 22 , 24 , 25 ] and whether an intervention was administered [ 24 ]. One of the studies used a mixed-method study design and met all the criteria that include the adequacy of rationale for mixed-method study, appropriate integration of quantitative and qualitative data, divergence, and inconsistencies between quantitative and qualitative results, and that the different levels of the study adhered to the quality criteria of each tradition of the methods used. It did not however meet the criteria for different components of the study effectively integrated to answer the research question [ 26 ]. One of the studies was a quantitative study [ 25 ] and met all the criteria questions that are stipulated for this section.

Data analysis

The data analysis method that was adopted is convergent synthesis. The convergent synthesis method was used because of the diversity of study designs that were adopted by the primary studies [ 27 , 28 ]. Prior to the synthesis, there was identification and description of the various health promotion interventions that were used for the prevention of hypertension. To use a convergent synthesis analysis method, the study findings were translated into descriptive qualitative sentences [ 28 ]. There was then a purposeful collation and integration of the findings [ 29 ] into themes from subthemes that were developed from the codes generated. In the views of Pluye and Hong, while conducting this type of synthesis, the various items identified must be integrated into subthemes and similar or related sub-themes collated to form broad umbrella themes [ 29 ]. The integration of quantitative and qualitative findings mainly occurred in the coding and development of sub-themes stage [ 27 ]. These themes were then described to have meanings that are beyond the originally identified items and hence allow for interpretation and critical analysis. No subgroup analysis and test of the robustness of study finding was conducted as this study was mainly aimed to be a narrative synthesis.

There was an in-depth search of six (PubMed, CINAHL, EMBASE, Cochrane library, web of science, google scholar) electronic databases that yielded 646 titles and 615 after duplicates were removed, as shown in Fig 1 . The titles, abstracts, and full text (112) were then screened, and ten articles were identified as appropriate for this study.

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https://doi.org/10.1371/journal.pone.0260411.g001

Study characteristics

The study designs adopted were survey [ 21 , 25 ], quasi-experimental [ 30 – 32 ], Cohort [ 22 , 24 , 25 ], mixed methods [ 26 ], randomised control [ 20 ], and exploratory uncontrolled pre–post intervention [ 23 ] as shown in Table 1 . The studies were conducted in the Faculty of Pharmacy at Rhodes University [ 21 ], the Gugulethu township of Cape Town [ 26 ], Khayelitsha [ 24 ] all in South Africa [ 22 , 25 ], Sousse in Tunisia [ 30 ], Afon and Ajasse Ipo districts in Kwara State in Nigeria [ 31 ], three community pharmacies in the Ashanti Region of Ghana [ 23 ], and the slums of Korogocho and Viwandani in Nairobi [ 30 ]. The target participants for the health promotion interventions had a minimum age of eleven [ 21 ] and a maximum of sixty-five years [ 30 ] and included both sexes. The sampling methods adopted were the convenience [ 21 , 23 , 24 , 26 , 30 ], stratified convenience [ 25 ], random [ 30 ], stratified 2-degree random probability by geographic areas [ 31 ], and the Markov model used as a tool for sampling with the focus on age variability of cardiovascular diseases [ 22 ]. The study duration for each intervention study ranged from a minimum of a day health education programme [ 21 ] to a maximum of 36 months health promotion for behaviour change [ 30 ]. The other studies were 3months [ 25 ], 4 months [ 20 , 26 ], 5 months [ 23 ], 9 to 10 months [ 25 ], 12 months [ 22 ], 18months [ 32 ] and 24 months [ 24 , 31 ] health promotion interventions.

https://doi.org/10.1371/journal.pone.0260411.t001

Reduction in prevalence of hypertension after health promotion interventions

Health promotion interventions were noted to have a positive impact on the prevalence of hypertension [ 30 – 32 ] as shown in key findings in Table 2 . The health promotion interventions led to a remarkable decrease in the prevalence of hypertension in the intervention compared to the control groups [ 30 , 31 ]. It was reported that the prevalence of hypertension decreased in the treatment group globally from 37.3% to 33.7% [ 30 ]. After stratification for age, for participants younger than 40 years old, a significant decrease in the prevalence of hypertension from 22.8% to 16.2% in the intervention group and 14% to 15.4% in the control group was also noted [ 30 ]. A significant decrease in the prevalence of hypertension from 31.4% to 26% was observed among nonobese participants in the intervention group [ 30 ].

https://doi.org/10.1371/journal.pone.0260411.t002

It was also shown that health promotion interventions were noted to improve the intervention group’s ability to control blood pressure [ 30 – 32 ]. The number of respondents with controlled blood pressure increased from 3.0% to 38.8% in the program area, and a lower increase (4.0% to 26.1%) rate was noted in the control group [ 31 ]. In instances where there were improvements for hypertension prevalence in both the intervention and the control groups, the changes in the intervention groups were noted to be remarkable [ 30 , 32 ]. Mean blood pressure was said to reduce remarkably in intervention groups than in the control groups [ 31 , 32 ]. There was a significant reduction in mean SBP between baseline and end-line measurements in the intervention (2.75 mmHg) than the control (1.67 mmHg) groups [ 32 ]. It was statistically significant that systolic blood pressure decreased by 10.41 mmHg in the intervention, representing a 5.24 mm Hg greater reduction compared with in the control, which showed a decrease of 5.17 mmHg only. Diastolic blood pressure decreased by 4.27 mmHg in the intervention, a 2.16 mmHg greater reduction compared with the control, where blood pressure decreased by 2.11 mmHg [ 31 ].

Knowledge increase after health promotion intervention

Health promotion interventions that sought to increase community knowledge on hypertension yielded positive outcomes as knowledge levels were noted to increase [ 21 , 23 , 25 ]. In a post-intervention quiz, there was a significant increase in the scores from 78.2 to 85.6% in hypertension knowledge among those that received a health promotion intervention [ 21 ]. During a post-intervention survey, it was also noted that 40% of the participants reported having heard, read, or seen any food and/or health-related advertisement campaign in the last few months, compared to less than 20% at baseline, across all age and LSM groups [ 25 ]. Participants’ awareness of having hypertension in the intervention group was noted to be higher than in the control group [ 32 ]. In Ghana, people among the intervention group who were referred to the hospital because they had higher blood pressure (>140/90) did not need to be put on medication [ 23 ]. Most of the respondents with hypertension were unaware of their status during the baseline survey but showed significant awareness upon implementation of the intervention [ 31 ]. In another health promotion intervention, it was observed that overall knowledge about blood pressure and hypertension increased among those who received treatment [ 20 , 26 ]. It was noted that 40.0% from the intervention group and 17.9% in the control group showed improved knowledge on hypertension [ 20 ]. Health promotion on text messaging to hypertension participants on medication adherence was also noted to have a remarkable impact as the treatment arm demonstrated a significantly higher knowledge for an extended duration [ 26 ]. In instances where the intervention group was given diaries to use, 97.7% showed it benefited them to remember their medication and clinic appointment [ 20 ]. After a media campaign, participants were identified to adopt positive lifestyle modifications (weight loss and no salt or alcohol intake) that reduced their risk of hypertension [ 25 ]. After a media campaign for the reduction in salt intake, 77.8% reported that they had seen or heard the specific SaltWatch media campaign that included salt-related health information on TV and radio [ 25 ].

Feasibility of health promotion interventions and impact

Community-led health promotion interventions were noted to have a positive impact on people’s adoption of measures to reduce risk or identify early the symptoms of hypertension [ 22 , 23 , 31 , 32 ]. It was noted that the community pharmacy is a feasible setting for screening and detection of hypertension if the right structures are put in place [ 23 ]. The use of this intervention strategy is also appropriate due to easy accessibility for providing information on lifestyle practices to prevent hypertension [ 23 ]. During community intervention programs, newly identified people who have hypertension are referred to the health facility to seek and use professional care [ 31 ]. The use of these intervention strategies has led to an increase in the antihypertensive drug treatment from 4.6% to 13.1% among those that were screened- the intervention group [ 31 ].

Health promotion interventions reduced hypertension risk factors

Most of the indicators of knowledge, attitudes, and behaviour change showed a statistically significant relationship for the reduction in salt consumption, smoking, alcohol use, and increased physical activity after the administration of an intervention [ 23 , 25 ]. Significantly more participants reported that they were taking steps to control salt intake especially adding salt while cooking and at the table [ 25 ]. Given the message that was communicated during the health promotion intervention, the participants could readily remember the key messages that are likely to improve the chance of behaviour change. The most frequently recalled messages were that “too much salt is bad for your health” followed by “you should eat less salt”, these made participants who thought they had consumed the right amount of salt-reduced salt intake [ 25 ]. Among patients with hypertension in the control group, smoking and alcohol use were also reduced significantly [ 32 ]. It was also noted in Ghana that physical activity levels increase significantly among intervention than in the control groups [ 23 ]. It was also noted that there was a significant decrease in the numbers of those reporting inadequate physical activity among the intervention compared with the control group at the population level and among hypertension people at baseline [ 32 ].

Cost of health promotion interventions

Community health worker intervention was noted to be cost-effective as it led to a remarkable reduction in the cost of care for hypertension patients [ 22 ]. Once the annual cost per patient was below $6.50, the community health worker intervention became “cost-saving” because it saved costs and increased life expectancy, especially when the blood pressure reduction was above 4.98 mmHg [ 22 ]. After text messaging, the intervention group had positive increases in self-reported behaviour changes [ 26 ]. Health promotion interventions were also noted to produce an improvement in health insurance coverage as the intervention group had a 40.1% increase and the control had less than a percentage point [ 31 ]. Self-reported general use of health care resources increased in the program area and decreased in the control area [ 31 ].

This systematic review synthesis the health promotion interventions that are critical in the control of hypertension in Africa. It is important to note that the major determinants of hypertension can be categorised into genetic or epigenetic and environmental or social factors that interact in a complex iterative fashion to increase an individual’s risk and the ability to control hypertension. Hypertension health promotion interventions are mostly targeted to those factors that can be altered through individual efforts-largely referred to as modifiable risk factors [ 33 – 36 ]. These targets of health promotion intervention incorporate those environmental and social determinants of health that include lifestyle factors like heart-healthy diet [ 37 , 38 ], reduction in sodium and adequate potassium [ 35 – 38 ], increased physical activity [ 37 ], reduction in overweight and obesity [ 39 – 42 ] as well as increased knowledge on hypertension risk factors [ 11 , 35 – 38 , 43 ]. The specific target of these modifiable risk factors, especially among the entire population, has been shown in this study to be critical if significant gains are going to be made in the total control of hypertension. Specific health promotion interventions that are reviewed showed significant positive improvement in knowledge and people’s adoption of behaviours that reduce the risk associated with hypertension.

To ensure sustained hypertension control among those diagnosed and reduce the incidence, several barriers are identified to be implicated. These barriers included cultural norms, insufficient attention to education, lack of resources for interventions for hypertension control. Other barriers associated with population-based hypertension control included poor health education, lack of physical activity culture and space to engage in same, urbanisation and its attendant increased in restaurants and the consumption of fast foods rich in calorie and fat, consumption of large amounts of sodium and lower potassium, and inadequate information on how to control hypertension [ 11 , 43 , 44 ]. Health promotion interventions that specifically target mitigation or the elimination of these barriers have been shown through the various studies in Africa to be cardinal. It is important that in a resource-limited setting like Africa, health promotion interventions specifically target these barriers and identify means to mitigate the same. Other factors incorporating wealth and income levels and social determinants like employment, access to health care, social inequalities are noted to influence individual ability to adapt to measures that prevent hypertension [ 45 , 46 ]. These factors are identified to hinder the early detection, awareness creation, control, and management of hypertension in Africa. It is therefore imperative that multi-pronged approaches are adopted to target all populations (at work, school, and industries) and not only those at risk. In developed countries, there have been many health promotions programs for hypertensive patients to change modifiable factors [ 45 – 47 ].

There are several limitations in implementing health promotion programs in developing countries compared to developed countries. Health promotion interventions are mostly messages that are communicated and, in some instances, will require the extensive reading of health information material. In Africa, literacy levels remain low, coupled with the relative lack of a common language that is usually locally accepted and understood by all. The contents of most health education programs in developing countries are often difficult to read and understand by most people because of relatively low educational levels [ 48 ]. This makes the training method for health promotion interventions to be rather tedious and inefficient, and hence the implementation of health promotion interventions in these low resource settings relatively difficult. However, the use of culturally friendly, easily understandable, and the use of local resources was seen as one of the best means of health promotions interventions and has the propensity to mitigate the difficulty associated with language. It was realised that the use of community-based pharmacy, health education granted in local languages, and use of next of keen as reminders on medication adherence has been keen in early detection, increased knowledge, and appropriate medication adherence among hypertension patients, respectively. There has been increasing interest in using diverse strategies for measures that can curtail hypertension prevalence. The use of telecommunication is gaining widespread popularity in African countries and leveraging of such means promises to be one positive means of health promotion for persons at risk. The use of cell phones and short messaging services, and mobile notifications have been shown to have positive effects in several Human immunodeficiency virus infection intervention studies [ 49 , 50 ] and hypertension patients [ 26 ] in Africa. In response to the changing African environment, useful and accessible methods of disseminating health-promoting knowledge, especially for the prevention of chronic diseases like hypertension, must be developed and implemented.

Several studies have shown health promotion interventions for people with hypertension particularly yield positive outcomes. This has even been the case over two decades ago when it was reported that a sustained 5years campaign for the implementation of measures to reduce the incidence of hypertension resulted in a 2.9% and 1.5% reduction in prevalence among men and women, respectively [ 51 ]. Similarly, other health promotion interventions that target physical activity resulted in a significant decrease in the prevalence of hypertension among the intervention group after five years of implementation [ 52 ]. Various health promotion interventions have resulted in a significant decrease in the number of obese participants, increased physical activity, and decreased salt intake [ 23 , 42 ], which are particular risk factors to hypertension [ 7 , 52 , 53 ].

It is also important that significant health promotions intervention that target hypertension risk factors focus on salt intake, a significant risk factor for hypertension [ 54 ]. Since reducing salt intake reduces blood pressure [ 53 ], it is often used as an intervention strategy. Salt reduction strategies based on improving individual and group health, increasing awareness, and changing behaviour should be relatively easy to implement and have a high probability of hypertension risk reduction. A health education program (six months of education) on the harmful health of high salt intake provided by a community healthcare provider to residents has lowered the population’s prevalence of blood pressure with an average reduction of 2.5/3.9 mmHg in the intervention group [ 55 ]. For a salt reduction of less than 3g, the mean population systolic blood pressure decreased by 1.3mmHg. It must be noted that these are cost-effective and useful interventions that can produce tremendous results for poor resource settings.

Strengths and limitations

This study provides a comprehensive overview of the health promotions interventions that are used for the control of hypertension in Africa. It is important to note that all the researchers worked as a team in all the phases of this study, and where there was a disagreement, a consensus was built. This reduced the likelihood of subjectivity that is usually associated with study selection, data extraction, and analysis in systematic reviews. The study is not without limitations as only English-based articles were included in the study, creating the possibility of some salient articles in other languages left out. The protocol for this study did not receive prior registration. Also, the quality assessment of the included studies was minimal as it was largely limited to assessment for only the risk of bias.

Conclusions

This study showed the role of health promotion interventions in the control of hypertension in poor settings in Africa. It was realized that health promotion interventions that focus on increasing education, information dissemination, and promoting behaviour change were seen as useful in the control of the entire hypertension incidence and prevalence. Interventions that use local resources and are largely community-based also showed positive health outcomes. It is imperative that to sustain health promotion interventions and achieve control of hypertension, especially in the long term, interventions must be culturally friendly and incorporate locally available resources. It is also noted that health promotion interventions that are coupled with the increase in knowledge were seen to improve people’s tendency to be healthy and to screen for early detection and treatment of hypertension. These types of intervention need to be further tested in various cultures of Africa and to ensure sustained prevention of hypertension risk factors.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0260411.s001

S1 File. MMAT appraisal of individual studies.

https://doi.org/10.1371/journal.pone.0260411.s002

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Health Promotion Reflective Essay Sample

Health Promotion Reflection and Rationale for the creation of a Poster

Introduction

According to the World Health Organisation (WHO) definition of health refers to not only the absence of disease but complete social, mental, and physical well-being (WHO, 2021). "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love" (WHO, 1986, pp.3). From a medical perspective, illness refers to the feeling of and health which is personal and innate to the individual. It is often associated with the disease, but the disease may not be declared, such as cancer in its early stages (Boyd, 2000). Health promotion is a means of empowering and enabling a particular target group to use the available resources to promote action-oriented and competent-based health that is sustainable to reduced inequalities (Grabowski et al., 2017). Several tools and instruments are used to relay health promotion messages, such as the use of media, leaflets, one-on-one discussions, and focus groups; nonetheless, the current essay pays particular attention to using the poster as a health promotional tool. The following essay will provide a brief discussion on the process used to develop a health promotion poster (See Appendix 1) and later discuss the application of health promotion strategies for preventing illness and making every contact count across the lifespan.

However, the conceptualization of health by WHO described above has been criticised due to its unrealistic nature, inability to promote health, and lack of distinct parameters to measure it. Hence, Hubers et al. (2011) concept of health and well-being is favoured, which refers to the capacity to adapt and self-manage; this conceptualisation empowers individuals to be a salient force in determining their health. It also means that health is different from one person to the next depending on their situation in need (hence it considers the wider determinants of health). The principles of health promotion include: conceptualising health broadly and positively, involvement in addition to participation, a perspective on the individual setting, health equity, and development of action and its competence (Gregg and O'Hara, 2007). Health promotion strategies should be based on a life-course approach, which involves health promotion and health education measures, which are then supported by protective and preventive measures, with curative approaches being the last line of defence to quality of life and well-being (Eriksson and Lindström, 2008).

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According to an integrated review by Kemppainen et al. (2013), nurses have three roles in health promotion. One is the traditional general role of disease prevention in encouraging healthy behaviour. The second role involves patient-focused health promotion. The nurse identifies health promotion needs in different groups and gives specific advice based on their broad knowledge of various diseases and symptoms. Three, the nurses are seen as managers of health promotion projects through implementing health promotion plans, coordinating educational plans within the health facility and in the community, and being involved in health promotion activities for the person, their family, and even the community.

The poster being applied as a medium for communication transmits the message through graphical synthesis that combines images and text to draw the attention of the intended audience (Akister et al., 2000). The posters are considered a hybrid of paper and speech. This is because they offer more detail than speech but less detailed than paper and allows for more interactivity than both (Boggu and Singh, 2015). A poster should be visually appealing and have slogans and images that pull the audience's attention. A poster has a positive appeal, making it readily transcends public acceptance on an emotional, social, intellectual, sensorial, and economic level (Akister et al., 2000).

Before developing a health promotion strategy, one requires to perform a needs assessment. Information required is with regards to the size and nature of the population, identification of areas of unmet needs as well as those that are already met, the prevalence of the disease or condition one is interested in, the efficacy of available interventions, the available services in addition to their capacity, quality and effectiveness (Lawrence, 2020). The group notably used national statistics to define the UK population's problem, whereby 62% of the population is overweight while over 25% of adults are classified as obese (Public Health England [PHE], 2020). Obesity has been linked to metabolic syndrome, which triggers most chronic conditions such as diabetes heart disease and contributes to the National Health Service's significant disease burden. Complications of being overweight are estimated to cost the NHS 6.1 billion GBP every year (Scarborough et al., 2011).

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Additionally, the group drew information from the current political climate of the COVID-19 pandemic. The COVID-19 pandemic posed two obvious challenges; people were less likely to exercise because of the lockdown, which encouraged weight gain and being obese and overweight increases one's susceptibility to the Coronavirus through a decreased immune response and significantly higher inflammation levels (PHE, 2020). Nurses must recognise themselves as health promotion agents by making every contact count (MECC), which is a role that has been amplified by the Coronavirus, which minimizes community interventions due to the lockdown. Working with patients at the individual level denotes the nurse can tailor the interventions to every contact, consistent with the principles of person-centred care (NICE, 2019). Additionally, the MECC approach is a requirement of all nursing practitioners within the NHS. The team also ensured that the poster was brief per the national institute for healthcare excellence guidelines, which states that the interventions should be between 30 seconds to a couple of minutes for easy delivery during routine appointments where the nurse can take advantage of the contact to foster and promote health through behavioural change interventions. The nurse can use the poster to support the brief advice discussion, and patients can have a reference tool for audio-visual learning (NICE, 2019).

The team also considered the life-course approach in promoting health and well-being. Even though the intervention focused on adults, it recognises the intergenerational approach to health improvement (PHE, 2019). It is important to note that when adults change their diet, it creates a healthy environment for the dependents and children, who will also be exposed to healthier food choices (Caswell et al., 2013). Hence, reducing the likelihood of also developing obesity later in life. Also, the adults being more active will create a mental schema that will encourage them to be more active through the enculturation process (Caswell et al., 2013). Research by Fuemmeler et al. (2013) obesity in parents increases the likelihood of children becoming obese. When parents are obese, the children have a 10 to 12 fold chance of becoming obese.

One of the most salient stakeholders relied upon when making the health promotion poster is the government's department of health and social care (DHSC) new obesity strategy dubbed " Tackling obesity: empowering adults and children to live healthier lives" developed in 2020 which aims at getting people fit and healthy to protect themselves against covid-19. The UK government recognises obesity as a ticking time bomb due to the risk of severe illness and death from COVID-19. The NHS services will encourage health practitioners to become coaches of a healthy weight through training delivered by Public Health England. Excess weight is considered by the DHSC (2020) as one of the few factors that can be modified to reduce the impacts of the COVID-19 pandemic.

Concerning health, a strategy chosen, the Ottawa charter developed by WHO suggests three dimensions to health promotion that mediate, enable, and advocate (Saan and Wise, 2011; WHO, 2009). The mediation dimension requires coordination of all concerned stakeholders such as government sectors, voluntary organisations, local authorities, the industries, and the media to mediate the different interests in society to achieve better health outcomes (Saan and Wise, 2011; WHO, 2009). The enable dimension focuses on ensuring health equity is attained by reducing current health status differences and ensuring equal access to health resources, ensuring that one has the best health outcomes regardless of one demographic profile. The advocacy dimension aims at improving the conditions of an individual's political, economic, social, cultural, environmental, behavioural, and biological factors to ensure an improved quality of life (Saan and Wise, 2011; WHO, 2009).

The health promotion poster developed focused on their advocacy domain and specifically changed the behavioural factors to improve the individuals' quality of life by reducing their susceptibility to the Coronavirus (WHO, 2009). Health promotion aims to bolster one's personal and social skills development by providing the audience information about health and enhancing their life skills and how to ensure their choices promote their well-being (WHO, 2009).

The potential strategy that will be applied to convey the health promotion poster's information is a caring conversation developed by Dewar, which involves delivering compassionate care to human relationships (Dewar and MacBride, 2017). The 'caring conversations' aim at conversing with the patient at a deeper level and knowing who they are, what is important to them, and the experiences they have had, and their feelings towards them. In having a caring conversation, the nurse ought to have seven key attributes: courage, emotional connection, consideration of other perspectives, curiosity, collaboration, celebration, and compromise (Bullington et al., 2019). It is critical to be open to the patient's experience and point of view for them to field part of the intervention as opposed to being one-sided and providing a prescriptive approach rather than involving them and collaborating with them in developing the intervention, which is consistent with person-centred care (Dewar and MacBride, 2017). The person-centred approach allows for tailoring the nursing communication to consider the patient's disabilities to ensure that they understand the message relayed (Bullington et al., 2019). The caring conversation approach is consistent with the NMC (2018) code, which advocates that communication should be adapted and tailored to meet a person's needs.

Regarding health literacy, the poster used words that were easy to understand (Osborne, 2012). The words aimed to push the audience into understanding that obesity was a modifiable factor in helping them become more resilient to the COVID-19 pandemic. Additionally, the poster used numerous images and applied words sparingly to relay people's message to understand the language regardless of their ethnicities readily. The use of pictures is a universal language that creates visual appeal, and the fact that it transcends language barriers common in London due to the high percentage of black and ethnic minorities (BME) communities (Sany et al., 2020).

In conclusion, using the poster as a health promotional tool was effective, especially if the nurse combined it with less jargon and a caring conversation approach. The caring approach ensures avoidance of a one-size-fits-all approach to the conversational delivery but being considerate of the towards understanding them personally and adopting the approach of delivery to fit their context. It is also critical to underline the fact that the essay adopted Hubers et al. concept of health and well-being as a capacity to adapt and self-manage, which relegates the domain of health as being something that can be modified through behavioural change. The nurse focused on the advocacy role and specifically behavioural modification following the Ottawa charter's health promotion model. Evidence shows that the nurse has a role in health promotion, primarily through making every contact count. This role has been amplified by reducing communal avenues due to the lockdown brought on by the Coronavirus pandemic. Additionally, the poster applied a life-course approach by ensuring that adults in the family understood the role of behavioural change in weight and the benefits gained, extending to their children.

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• Open access
• Published: 03 June 2022

What are the barriers and facilitators to effective health promotion in urgent and emergency care? A systematic review

• B. Schofield 1 ,
• U. Rolfe 2 ,
• S. McClean 3 ,
• R. Hoskins 1 ,
• S. Voss 1 &
• J. Benger 1  

BMC Emergency Medicine volume  22 , Article number:  95 ( 2022 ) Cite this article

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There are potential health gains such as reducing early deaths, years spent in ill-health and costs to society and the health and care system by encouraging NHS staff to use encounters with patients to help individuals significantly reduce their risk of disease. Emergency department staff and paramedics are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health. The aim of this research was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff.

A systematic search of the literature was performed to review and synthesise published evidence relating to barriers and facilitators to effective health promotion by urgent and emergency care staff. Medical and social science databases were searched for articles published between January 2000 and December 2021 and the reference lists of included articles were hand searched. Two reviewers independently screened the studies and assessed risk of bias. Data was extracted using a bespoke form created for the study.

A total of 19 papers were included in the study. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) staff comfort in broaching the topic; 3) format of health education; 4) competency and training needs. Whilst urgent and emergency care staff view health promotion as part of their job, time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. Staff and patients have different priorities in terms of the health topics they feel should be addressed. Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. Staff often stated the need for more training.

Conclusions

Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings and there is a lack of evidence about the acceptability of health promotion activity. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients.

Peer Review reports

The NHS is committed to using all staff encounters with patients to help individuals significantly reduce their risk of disease [ 1 , 2 ]. This could reduce early deaths, years spent in ill-health and costs to society and the health and care system. NHS staff have the opportunity to recognise appropriate times and situations in which to engage with patients and help them on the pathway to improving their health and wellbeing. Emergency Department and Emergency Medical Services (Ambulance) staff are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health.

The World Health Organisation describes health promotion as a process of enabling people to increase control over, and to improve, their health [ 3 ]. Patient education and effective communication can support individuals to make healthy choices [ 4 ]. A range of factors may complicate communication in the Emergency Department (ED). These include variable workloads, crowding, uncertainty and time constraints [ 5 ]. Some of these factors also apply to the work environment of paramedics. Whilst the nature of urgent and emergency care may offer challenges when considering health promotion activities, it may also be the ideal environment to create opportunities for a ‘teachable moment’ that will promote subsequent health behaviour change [ 6 ]. There is also an economic evidence base for health promotion and disease prevention, as reducing the risk of chronic diseases and injury through interventions aimed at modifying lifestyle risk factors is known to be cost-effective, and could reduce health inequalities [ 7 ].

Given the potential health gains, research should be encouraged to organise and deliver effective health promotion interventions in urgent and emergency care settings. The aim of this systematic review was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff. This paper reports on an evidence synthesis relating to the barriers and facilitators to effective health promotion interventions in urgent and emergency care settings. The paper will inform the direction of future research in this field by providing a basis to further explore areas of interest and expressed needs.

Study design

The search methodology and reported findings comply with the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 8 ]. Prior to performing this review, a protocol was developed and registered with PROSPERO (registration number CRD42020205180). The research question guiding this systematic review was as follows: “What are the barriers and facilitators to effective health promotion interventions in urgent and emergency care settings?”

Consensus was reached among all reviewers on search syntax, inclusion and exclusion criteria, and the criteria for assessment of validity and relevance in the identified articles.

Eligibility criteria

Our eligibility criteria followed the Participant, Exposure, Outcome and Study design (PEOS) framework [ 9 ]. We only included papers written with publication dates limited from January 2000 to August 2020 in all our information sources. Limiting the search period to 2000 onwards sought to identify all relevant research published in a contemporary timeframe.

Search strategy

The search strategy was informed by an initial overview of literature in the field and the assistance of a subject librarian. The following bibliographic databases were searched: CINAHL, MEDLINE, Cochrane Central, Cochrane sensitive RCT search strategy, Scopus and PsycINFO on 18th August 2020. The search was repeated on 14th December 2021 to capture any relevant papers published since the original search date. The search included title, abstract, keywords and subject headings to describe the population (paramedics, doctors, nurses and support staff in emergency departments) and the setting (pre-hospital emergency medical (ambulance) services and hospital emergency departments). A detailed strategy for MEDLINE is given in (Table  1 ) and was adapted to the other databases. All articles that met the search terms were exported from the search engines to the Covidence systematic review management system [ 10 ]. Backward chaining within the final sample was reviewed for potentially relevant papers.

Selection of studies

A range of research methods was considered including randomised controlled trials, observational studies, surveys and qualitative research. Any literature (quantitative, qualitative or mixed methods) that reported on the facilitators or barriers to health promotion in urgent and emergency care settings was considered for inclusion. This included research papers of any kind but not systematic reviews, literature reviews, editorials, commentaries or letters. Unpublished data was not included.

Based on the inclusion criteria (Table  2 ), two reviewers (BS and UR) independently screened the titles and abstracts of eligible articles to eliminate articles not meeting the inclusion criteria. Articles not meeting the inclusion criteria based on the title and abstract were excluded at this point. The full text of the agreed included articles was screened independently by the same two reviewers (BS and UR). Articles were excluded at the full-text stage if they did not directly meet the eligibility criteria on closer inspection of the full article. Additionally, references in review articles were screened using the same criteria. Any conflicts during the screening process were resolved through discussion by the two reviewers with reference to the inclusion and exclusion criteria.

Due to heterogeneity between study settings, designs and screening tools used, the included studies have been described narratively [ 11 ].

Data extraction and quality assessment

A bespoke data extraction form was designed in consultation with the review team and piloted on two papers identified during the scoping search. No changes to the data extraction form were recommended following the pilot phase. The data extraction form is reproduced in Additional file  1 Appendix 1. Two authors extracted data separately from the eligible studies (BS and UR). The reviewers conferred and agreed on studies to be included.

The Mixed Methods Appraisal Tool (MMAT) was used to assess the studies for risk of bias, relevance, trustworthiness and results [ 12 ]. The authors of the MMAT encourage the provision of a detailed presentation of the ratings of the five criteria within the tool to reflect the quality of the included studies. In this review the studies were ranked as high (all criteria met), medium (four out of five criteria met) and low (three or less criteria met). Much of the MMAT assessment process focuses on the risk of bias in the study under consideration, and therefore studies judged as low quality are at the highest risk of bias when this tool is applied. Conflicts in risk of bias assessment were resolved through discussion by the two reviewers and with reference to the appraisal tool. The methodological quality of each study was independently analysed by two authors (BS and UR). No studies were excluded based on quality assessment. The quality rankings for each study are presented in Table  3 .

Study selection

Overall, research into barriers and facilitators of health promotion activity in urgent and emergency care settings was found to be limited. No relevant research was identified regarding paramedics. It was therefore necessary to increase the scope of the review to include community paramedicine programmes in rural settings in North America and Australia. Whilst these programmes are not directly transferable to the role of paramedics more generally, they are able to demonstrate the acceptability of this non-traditional role, which includes health promotion, amongst the wider paramedic profession.

154 papers were identified through database searching. Following the removal of duplicates, 108 records were reviewed by title and abstract. Of these, 63 were removed. 45 records were assessed for eligibility based on a full text review. 26 were excluded, with 19 records being included in the review. Inter-rater agreement for full text exclusion was strong (k = 0.86). A flow-chart of the search strategy and selection is presented in Additional file  1 Appendix 2.

Studies took place in the following countries: 11 in the US [ 13 , 14 , 16 , 18 , 20 , 22 , 23 , 25 , 26 , 27 , 28 ], 1 in Jordan [ 30 ], 2 in the UK [ 17 , 24 ], 4 in Australia [ 15 , 19 , 21 , 31 ] and 1 in Canada [ 29 ]. The characteristics of the included studies and participants are described in Table 3 .

Data synthesis

The 19 studies were published between 2000 and 2020 and included a range of populations and research methodologies. Ten studies were surveys, four were randomised controlled trials, two were retrospective reviews of records and three were qualitative interviews/focus groups. Sample sizes ranged from 2149 to 11 participants. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) risk of offending patients; 3) format of health education; 4) competency and training needs. These four themes capture the reported barriers and facilitators to effective health promotion interventions in urgent and emergency care settings.

Should it be part of our job?

In general staff support health promotion taking place in the ED. [ 17 , 18 , 21 , 24 , 26 , 28 ] Paramedics in rural communities and emergency services technician firefighters also see health promotion as an acceptable part of their jobs [ 20 , 27 , 29 ]. However, ED nurses in one Jordanian study felt it was not part of their role [ 30 ].

Whilst nurses felt that health promotion was part of their role, they reported providing health promoting advice less than half the time when these interactions would have been indicated. They reported lack of time and a lack of support systems for patient follow up as barriers [ 18 ]. Although ED doctors reported feeling responsible for promoting the health of their patients, only a minority reported routinely screening and counselling their patients with identified modifiable risk factors. Most reported not feeling confident in their ability to help patients change their behaviour [ 26 ]. In one study doctors reportedly offered health promotion intervention more often than nurses. Time constraints and a lack of health promotion infrastructure in the ED were cited as challenges to intervention delivery [ 17 ]. Patients and carers attended to by community paramedics accepted paramedics in a non-traditional preventative healthcare role [ 29 ].

Staff comfort in broaching the topic

The health conditions of interest to ED patients in one study were stress and depression and among the health topics, participants were most interested in exercise and nutrition [ 22 ]. Smoking is the health topic most commonly discussed according to ED doctors in one study [ 26 ]. Whilst ED staff in another study stated that drug and alcohol misuse were the most appropriate risk factors to discuss in ED and that the interventions in the ED were most appropriate when risk factors were directly related to the ED presentation [ 17 ]. Paramedics had success with injury prevention advice as part of their role in community paramedicine [ 27 ]. The recording of health risks and counselling was noted in only 22% of nonacute patients with one or more modifiable risk factors; with doctors documenting more health risks than nurses [ 28 ].

Whilst 20% of all calls for an ambulance service involve alcohol, not many ambulance officers ask the patients they attend about quantity and frequency of alcohol use [ 21 ].

Format of health education

Educational, and to a lesser extent behavioural change, approaches are the main forms of health promotion described in the urgent and emergency care setting [ 32 ]. Patients and visitors stated they preferred traditional forms of books and leaflets to support the information they were given on health-related topics [ 22 ]. An educational video used during ED waiting was shown to improve knowledge and act as an acceptable low-cost teaching tool for focused patient education that may allow clinicians to use patient waiting time for health promotion [ 16 , 25 ]. The use of learning style-tailored information led to patients perceiving improved knowledge [ 14 ]. Using a structured education tool improved nurse confidence in undertaking personalised education prior to discharge from the ED. [ 19 ] A computer kiosk to promote child safety in a randomised controlled trial in an urban paediatric emergency department demonstrated the applicability of computer technology for education in a busy ED. [ 13 ]

Inadequate patient education has been cited as a potential cause of re-attendance of asthma patients to the ED. A randomised study aimed to compare the effectiveness of patient-centred education (PCE) and standard asthma patient education on ED re-attendance. PCE patients had fewer re-attendances at 4 and 12 months. A learner-centred approach to education may be useful in reducing re-attendances to the emergency department [ 15 ]. Internet referrals may provide a potential solution to limited staff time in emergency departments for health education [ 23 ].

Competency and training needs

There was a statement of continued need for education in health promotion roles in those studies where staff views were collected [ 19 , 21 , 24 , 26 , 30 , 31 ]. Nurses felt they lacked competency [ 30 ], were less knowledgeable on some health topics than others [ 24 , 26 , 31 ], and requested a structured approach [ 16 ]. Paramedics requested specific training to deal with patients affected by excessive alcohol intake [ 21 ]. Staff were concerned that existing health promotion interventions were not systematic and had not been evaluated and risked becoming a marginalised part of their work [ 31 ]. Lack of health promotion knowledge, lack of time and not wanting to extend a patient’s stay in the ED were reported as barriers.

Nineteen studies with varying designs were identified as relevant for our exploration of barriers and facilitators to effective health promotion in urgent and emergency care. The evidence base is not well developed. There is limited evidence describing the barriers to health promotion activities in EDs, and facilitators are particularly poorly captured. Two literature reviews suggest that educational interventions in the ED are both possible and feasible, while indicating that additional research is needed to provide a more substantial evidence base from which to identify effective approaches designed specifically for this healthcare setting [ 33 , 34 ]. This review supports these statements and highlights a need for further research in this area, in particular to understand the views of staff and patients on the potential for an expansion of the role of ED nurses and paramedics.

Almost all relevant research has suggested that urgent and emergency care staff view health promotion as a part of their job, however time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. If emergency nurses feel more confident in their educating practices, and are supported by a structured format, patients may benefit from better quality patient education provided in the ED. The provision of a health promotion infrastructure in the ED will be a positive step towards providing a standard approach and is likely to include training and support pathways for ED staff to ensure that health promotion is an integral part of their role.

Whilst patients have reported that the health promotion topics they are most interested in are exercise and nutrition, ED staff shy away from health promotion interventions relating to weight management, diet and exercise [ 18 , 22 , 26 ] There may be worries around seeming insensitive to patients and further stigmatising patients that prevent staff from engaging in these interactions. Staff in general report providing health promotion interventions on blood pressure management, smoking and alcohol use. ED staff agree that health promotion interventions are most effective if related to an acute ED presentation. This may be one reason why diet and weight management are not seen as appropriate interventions in this setting. A study of General Practitioners and practice nurses in the UK on talking to primary care patients about weight found that staff had concerns about raising the issue of overweight; the most common being that patients would react emotionally to the message [ 35 ].

Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. A systematic review of the effectiveness of traditional media (leaflet and poster) to promote health in a community setting, demonstrated that traditional health promotion media such as leaflets and posters are still useful in the current digital era, especially for adult respondents [ 36 ].

A number of studies have demonstrated the feasibility of video and internet use in the ED waiting areas as acceptable methods of patient education. A disease-specific educational video may be a relatively low-cost tool for focused patient education in the ED waiting room. These combined approaches may have the potential to offer improved outcomes for patients visiting the ED but adopting them will require structural and cultural changes. A systematic review of the effectiveness of video-based education in modifying health behaviours demonstrated that for certain health messages and conditions video interventions appear to be effective [ 37 ].

Patient discharge from the ED appears to be an effective time to maximise engagement with ED recommendations and improve self-care according to the literature reviewed. A variety of potential teaching methods and teaching materials have been used in the ED; however, it is still unclear which of these are most effective, and for which subgroup of the population [ 38 ]. Given the potential for health gains, research should examine how to organise and deliver the most effective patient education in the ED.

The role of the paramedic in health promotion is beginning to receive some attention [ 39 , 40 ]. Health promotion and healthy lifestyle interventions are outlined in the Paramedic Specialist in Primary and Urgent Care Core Capabilities Framework produced by the College of Paramedics [ 41 ]. The included literature demonstrates support from community paramedics and emergency medical technicians in Canada, US and Australia for the expanded role of health promotion as part of their activities when treating patients in the community [ 20 , 21 , 27 , 29 ]. This literature highlights how paramedics in the ambulance service may be able to adapt to health promotion activities when treating and discharging patients at home.

The themes identified in this review can be both facilitators and barriers to undertaking effective health promotion interventions in urgent and emergency care settings. If staff view health promotion as part of their role it will be a facilitator to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, if staff feel there is a tension between their role as urgent and emergency care practitioners and health promotion, it is likely to act as a barrier with restraints on time and lack of confidence having an impact on the likelihood of staff engagement with health promotion interventions in these settings. On the theme of staff comfort of broaching the topic, if staff view the health promotion discussion as sensitive, it will act as a barrier, and they are less likely to engage in the conversation. Conversely, if staff feel comfortable with the health promotion topic it will act as a facilitator, and they are likely to engage with the patient more readily. Additionally, if the format of the health education approach is patient-centred, and appropriate for their learning needs, it is likely to act as a facilitator to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, inappropriate health education approaches could act as a barrier in these settings. Finally, if staff feel they lack competency and training in health promotion it is likely to act as a barrier to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, staff who feel they have adequate competency and training will be more likely to undertake effective health promotion interventions.

Heterogeneity in study settings, designs and the screening tools used in the included studies affects the conclusions and recommendations of this systematic review as it decreases the generalisability of the findings to the management of health promotion interventions in the urgent and emergency care settings [ 42 , 43 ]. This variability in participants and methodological diversity is the reason we decided to describe the included studies narratively, rather than attempting any form of statistical analysis.

The lack of evidence on the acceptability of health promotion for patients and service providers in urgent and emergency care settings, coupled with an imperative to ensure staff talk to the public they are treating about their health and wellbeing across all health and social care organisations, requires further exploration. There is a need to efficiently integrate existing information and determine the extent to which findings are generalisable across health care settings. This will guide future research on health promotion in urgent and emergency care to generate evidence on patient benefit. This review draws together a disparate literature to identify themes and create an overview with pointers towards future research that has the potential to change practice.

Limitations

This review was limited to research papers published since January 2000. There is a risk of missing grey literature and relevant literature published prior to 2000. The wide range of methods, countries and interventions described in the included studies makes generalisation difficult.

Future directions

Future research is necessary to define and understand the barriers and facilitators to health promotion interventions in urgent and emergency care settings. Current evidence does not support changes to clinical practice, and further research is required to build an evidence base that will justify the introduction of new interventions and staff behaviours when caring for patients in emergency care. We anticipate existing clinical practice will be modified if high quality research demonstrating the clinical and cost effectiveness of one or more defined interventions relevant to a particular health system is published.

Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings. The papers reviewed in this article demonstrate a willingness amongst staff in urgent and emergency care to undertake health promotion activities. The studies included highlight what emergency department nurses may need to undertake the role of health promotion in their clinical setting. The included papers are mainly from the US, Canada and Australia and there are cultural considerations that need to be considered in future research. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients, and to generate an emerging evidence base that will direct future research and practice.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Schofield, B., Rolfe, U., McClean, S. et al. What are the barriers and facilitators to effective health promotion in urgent and emergency care? A systematic review. BMC Emerg Med 22 , 95 (2022). https://doi.org/10.1186/s12873-022-00651-3

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DOI : https://doi.org/10.1186/s12873-022-00651-3

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