Health-promotion practice and planned interventions can be directed through different health promotion models, including Tannahill’s 1984 Venn diagram model, which provides a framework for health-promotion definition and implementation (Naidoo & Wills, 2005). This specific model utilises three interconnecting spheres of health development, i.e. health education, prevention and heath protection, in order to present health-related activities in a comprehensible manner. The model is considered to be linguistically straightforward and to offer a clear outline of the concept of health promotion, although it has been criticized for being overly simplistic and, as a consequence, not offering adequate theories for indelible factors in health-promotion practice (Downie et al., 1996). In addition, the model was criticised for not taking into account factors that are community based, hence Tannahill revised his explanation in order to take into account the consequences for health for individuals, groups and populations (Tannahill, 2008). Subsequently, community-based activities were prioritised in a modified definition, which emphasises equity and diversity, as it promotes “sustainable enhancement of positive health and reduction in ill-health in populations through policies, strategies and activities in the overlapping action areas of: social, economic, physical environmental and cultural factors” (Tannahill, 2008, p. 1390). Tannahill’s model has been utilized in healthcare for diabetes, with the objective of enhancing the individual’s lifestyle through diabetic support clinics, on both individual and community levels (Daly, 2004). It has been found to reduce the incidence of complications, although it is emphasized that a nurse must provide advice to the patient that is of sufficient quality.
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Theoretically, this model influences the present study, as it offers guidance when identifying health education competencies for PHC nurses from an educational perspective. This is because, according to Koutoukidis, Stainton, and Hughson (2012), Tannahill’s model is considered a beneficial framework and curriculum model for both under- and post-graduate nursing education. According to Tannahill, (2008), it is a theory that focuses on modern-day public health policies, which hinge on reducing health inequalities and improving life circumstances, which is consistent with health protection and an essential part of a PHC nurse’s role. Hence, the ideal that can be observed in this model is that health education for nurses can be part of the desired framework to fulfil the study aims. However, it has to be borne in mind that such a theoretical model fails to consider community-based factors that are key to all health-promotion practices (Raingruber, 2013), especially in a country like S.A, which is replete with cultural factors that need to be considered in any nursing educational programmes.
Tones’ empowerment model
The model put forward by Tones and Tilford (2001) focuses on how health education and public policies interact, which is a key component of health promotion. It is further explained that policy is vital to understanding the environmental and cultural factors, as well as socio- economic ones, that affect and impact on service quality when delivering improved health (Whitehead & Irvine, 2010). Therefore, health promotion is linked to improvements in social status and policies that influence the health of the community (Whitehead, 2004). Moreover, it is explained by Lavis and Sullivan (2000) that political advocacy influences the reform of public policies for health. Tones and Tilford (2001) define health-promoting political advocacy as a particular type of role that helps underprivileged people in the community. Also, they explore health status vis-à-vis the agenda of policymakers who develop policies focusing on social improvement via guiding the health of individuals.
Pender’s health-promotion model
Pender et al. (2006, p.23) define health as “the actualization of inherent and acquired human potential through goal-directed behaviours, competent self-care, and satisfying relations with others, while adjustments are needed to maintain a structural integrity and harmony with the
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relevant environment''. This definition includes the means used to promote health by considering the individual’s view of themselves and their lifestyle. The health model which has been promoted and developed by Pender since 1982 combines behavioural science and nursing with an expanded view of health which is not limited to the absence of disease, functional limitations or lack of adaptation (Pender et al., 2006). This is known as the ‘Health Promotion Model’ (HPM), and it concentrates more on achieving high levels of well-being and self-actualization, although the base requirements need to be attained prior to a patient’s self-actualization development (Pender, 1987).
HPM has been shown to assist nurses in gaining an understanding of the major factors, including social factors that determine health behaviours which creates the foundation for future counselling and promoting health (Pender, 2011). Moreover, an individual is believed to be more self-motivated through using HPM. The bio-psychosocial structure of people will adapt and transform to suit a given environment. Therefore, the way in which healthcare workers interact with the patient is vital to the interpersonal environment, although a patient’s behaviour development needs to be self-motivated in order to be truly beneficial (Pender, 1996).
Health-belief model (HBM)
In the early 1950s, various health-screening services, such as vaccines, were administered publically (Pender, 1987), although a small percentage of people did not partake in these new initiatives. Subsequently, a framework was identified to understand the reasons behind opting into new health services or not, and this created a foundation for HBM to examine the health and behaviour of patients (Janz & Becker, 1984).
Health behaviour is initially predicted and described through a psychological model, which is structured by documenting how a person thinks or their personal attitude. The model is broken down into four distinct sections relating to an individual’s beliefs. First, perceived susceptibility helps people to understand their risk. Secondly, the perceived severity of a problem and its consequences need to be explained. Thirdly, the perceived benefits relate to how a person can minimise their risk or level of illness by taking action. Lastly, there are perceived barriers when the negative aspects of health become obstacles to following recommended behaviour (Janz & Becker, 1984).
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Pope (2011) identifies that the benefit of HBM is that people’s health choices are based on emotions, habits, social conditions and personal preferences. This facilitates the selection of effective social teaching methods concerning healthy habits. However, HBM does not consider the economic and environmental factors that may influence health conditions. Rather, it is limited to risky health behaviours, such as ‘smoking’. This represents a limitation, however, as it is clear that beliefs can influence a person’s decision to smoke but do not influence whether that person will develop lung cancer. Consequently, this model helps health professionals, including PHC nurses, to develop education programmes aimed at changing behaviour, but it does not increase the knowledge of how to treat/ deal with health problems after they have occurred.
Having outlined several key models of health promotion, along with some examples of their adoption, the next section will illustrate the relationship between these models and the current study.
Relationship between the models and the present study
As the above discussion highlights, there is no single model that is exactly suited to the aims of the present study. With Pender’s model (1987), for example, it is not entirely clear how it is to be used in different cultural environments. According to Peterson and Bredow (2009) the model requires an explanation of how it works for nurses in multicultural countries, such as in S.A. where there are many people with different cultures and behaviours, and important gender differences. However, Pender’s model (1987) helps nurses to understand the surrounding variables, and this is an essential aspect in health education.
A strength of Tones’ model (2000) is that it offers an understanding of how policy impacts on health promotion, including cultural and socioeconomic factors. This is important, as competencies have to be approved by policy makers in order to be implemented effectively. Also, Tannahill’s model (1984) may be helpful due to the way in which Tannahill emphasizes the role of health education in the process of health development. The three models of Pender (1987), Tannahill (1984) and Tones (2000) support the current study as health education is the main subject. Conversely, HBM does not suggest a way of changing health behaviours as it focuses more on confirming the ways in which beliefs and attitudes influence health behaviour. Based upon the above review, the models of Pender (1987); Tannahill (1984) and Tones (2000) can help to identify health education competencies for PHC nurses, especially
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in the specific context of S.A. where the religion of Islam significantly shapes everyday experiences. Following this discussion of health promotion models, the next section will explore the processes involved in health promotion/health education.