The Role Of Empowerment In Health Promotion

Empowerment, a concept that is so diverse and can be applied in numerous ways within literature, is a fundamental aim of health promotion and thus a key element within nursing practice. The Ottawa Charter (1986) from which health promotion principles are derived, resulted in the concept gaining momentum in the later twentieth century. Health promotion is defined by the World Health Organisation (1986) as “a process of enabling people to increase control over, and to improve, their health”, whilst the term empowerment is generally explained in terms of a process of gaining mastery and “helping people to feel in control of their own lives”. As nurses, we can empower targeted groups or individuals by enabling them to ‘gain’ such control through processes such as education, and by allowing them to accumulate confidence, and self-determination for their own health in turn leading to and promoting improved health outcomes. When reflecting upon my previous practice experience, it is apparent that empowerment is not only key to promoting and/or sustaining physical health outcomes but is too essential for individuals to be in a position to improve their poor mental health - with poor physical and mental health often coinciding.

Throughout my nursing placements, I identified that individuals whom were suffering with the mental illness depression, participated in no, or a very limited amount of physical activity; A common theme that was present in both an acute inpatient ward, and within the community setting. Thus, the health topic I have chosen to explore is depression, and the impact that physical activity has on the mental illness as well as physical health. The exploration of this health topic has then informed my artefact, an application software (app) designed to empower my target audience to engage in physical activity, i. e. exercise, in order to better manage/improve their health outcomes. I made the decision to create an app as the majority of society use smartphones and tablets; In their latest communications report in 2018, Ofcom published that 78% of individuals aged sixteen and above use mobile phones, and 58% use tablets. I therefore felt it would be the most effective way to connect with my target audience, and that it would be an engaging way to present the information. The target audience of my artefact is individuals between the ages of eighteen and twenty-five years old, whom are suffering and/or recovering from depression. I have chosen this age group as I believe that if behaviours are adopted before the brain is fully developed (at around twenty-five years old), these behaviours are more likely to be sustained throughout adulthood.

Depression, “a mental state characterized by excessive sadness” (Oxford Dictionary of Nursing, 2017), is a common mental disorder that can affect the way individuals feel and behave. The disorder is “the leading cause of disability world-wide” contributing to the “overall global burden of disease”. The severity of the illness ranges from mild to severe depending on the number of symptoms the individual presents with and the impact these symptoms have on their day to day functioning. With focus on my health topic, the symptoms of the disorder that may contribute to a lack of physical activity include low mood, reduced energy and activity, loss of self-confidence and self-esteem, and anxiety. These symptoms alone are likely to leave an individual feeling disempowered to take action, whilst each symptom may serve as a reason to explain why those depressed are physically inactive. The prevalence of Depression is vast globally, with the World Health Organisation reporting that there are 322 million cases of depression worldwide, with 40. 27 million cases in the European Region alone. Whilst this source is a good indication of the scope of depression amongst the population, the figures will presumably be much higher as many people may not report their depressive symptoms. This is often as a result of specific barriers such as the perception that treatment is unnecessary, lack of time, the stigma associated to the disorder, and the preference of self-managing. Therefore, my artefact will be a useful tool to many, as my target audience will cover a large population, and will be available to allow those experiencing depression to self-manage, regardless of whether they are seeking treatment. Exercise as a treatment for mental health problems is becoming an increasingly favourable option amongst practitioners with the engagement in physical activity known to have desirable impact on an individual’s mood. Physical activity, which can cover anything from small physical tasks to vigorous exercise, increases metabolism, oxygenation, and blood flow; All of which promotes changes in the brain which lead to reduction in the levels of the body’s stress hormones and the release of neurochemical factors such as endocannabinoids, trophic factors and opioids.

The release of such neurochemicals can lead to enhanced mood as it “promotes a sense of euphoria and well-being”, and may also alleviate other symptoms of the disorder. With focus on physical health, numerous research suggests that engagement in regular physical activities can reduce the risk of many chronic illnesses as well as obesity (the most common physical health problem in mental health). UK guidelines recommend that adults should participate in 150 minutes of exercise per week, or 75 minutes of vigorous activities such as running. By incorporating regular physical activity into their routine, an individual can reduce the risk of coronary heart disease by up to 50%, the risk of developing type two diabetes by 35-50%, and can reduce the risk of numerous cancers. As my artefact has been produced for those whom are suffering with depression and are physically inactive, individuals whom use my artefact are presumably more likely to be more susceptible to such physical illnesses and health complaints mentioned; and therefore by empowering them to engage with exercise at their age, I will be enabling them to improve their physical health outcomes for their future. If they were to develop such illnesses, they may then feel further disempowered, with further detrimental effects on their mental health. I have included information of the benefits of exercise on physical health within my artefact, however I am aware that an individual who is depressed may not feel motivated to make changes to their behaviour based on the positive effects of physical activity on their physical health alone. By including this information, I can indirectly increase their awareness of the physical implications of inactivity, which may motivate the individual further. I have also included information on the effects of physical activity on their mental health, including factors such as their feelings of self-worth and their mood. This will be more empowering as the individual can feel that the information that I have included is directly applicable to themselves, making my app more engaging, and ensuring that it is as person-centred as possible.

By including a range of exercises, I am ensuring that the user has options to choose from. “In a mental health context, empowerment refers to the level of choice, influence and control that users of mental health services can exercise over events in their lives. ” I have included exercises that focus on strength training, flexibility, balance, and aerobic exercise. For example, within my app I have exercises such as sit-ups, crunches, leg balances, different types of stretches, and activities e. g. walking and jogging. By providing the individual with choices, they can tailor their own exercise routine enabling them to have the control in their health behaviour change process. The different exercises are displayed as medium sized icons on the page, so that the user can see the vast choice of exercises they have to choose from. When the user clicks on the icon, a short animation of the exercise followed by the word or phrase that describes it will be shown. This will make it easy for the user to understand what the exercise is, and therefore they will be able to replicate it without difficulty. Furthermore, the exercises on the app will be divided into two categories: Exercises that can be done at home/indoor setting, and Outdoor exercises. With low self-worth and self-esteem being a symptom of the mental disorder, it would be unrealistic to expect that every depressed individual will feel initially comfortable with the idea of exercising in public settings, so by providing them with the category such as the ‘home/indoor setting’ I hope that this would reinforce that exercise does not have to be completed somewhere official, and may encourage them to make a start on their journey to being physically active in the environment in which they feel most comfortable i. e. their home. In addition, the categories can be empowering as they will disregard the idea that to be physically active you have to be in a fitness environment such as a gym, which may be daunting, but also can be costly. There are strong links between inequalities in society and mental health, with “lower-income groups having higher rates of mental health conditions”. This may mean that people with depression may not be in the financial situation to spend money to attend such environments to exercise. By not focusing on fitness environments, i wanted to eliminate the chance of such settings being an exclusion criteria for those in lower-income groups, which otherwise would be a limitation of my artefact. My artefact is primarily based on Prochaska and DiClemente’s Transtheoretical Model of Change (1983) and can be applied to numerous stages of this health promotion model. The Transtheoretical Model comprises of six stages to show that of a cyclical process for health changing behaviours, although the stages do not have to occur in a particular order.

The stages of the model include Pre-contemplation, Contemplation, Preparation, Action, Maintenance, and Relapse. In the contemplation stage, the individual is considering making the change. This can be influenced by what others may say or, when applied to my artefact, influenced by the information provided on how exercise can benefit physical and mental health. The benefits are visually listed and will be desirable to the individual i. e. improvement of their mood, directly linking to the principle of expectancy in Bandura’s Social Cognitive Theory (1977): “the belief that certain action will result in desired outcomes”, and thus will further empower the depressed individual to take action. For the preparation stage, my artefact will be a beneficial tool as it will provide the individual with the required information needed to make the behaviour change, i. e. different types of exercises that they can perform. When they begin to participate in these exercises this reflect the action stage of the model, as they are directly implementing behaviour changes. If the individual sustains this change and engages regularly with the app over a longer period of time they will be referring to the stage of maintenance, which sees the process of behaviour change as an ongoing process. Sustaining change is often difficult, and may require social support and self-efficacy. A future development of my artefact could consider a forum where the users could interact with one another through the app, offering social support, and leading to further empowerment by peers. My rationale for using this model is that its primary focus is on the individual’s readiness to change, and therefore allows for an individualistic approach. It “illustrates the importance of tailoring programmes to the individual, rather than assuming the intervention will be equally applicable to all”. I favoured the model over others, e. g. the Health Belief Model, as I felt that it was the most appropriate. Becker’s Health Belief Model (1974) focuses on the idea that an individual will have to believe that not changing their behaviour will be detrimental to their health. This would be ineffective for my target audience as a person who is depressed has often lived with the mental illness for a period of time already and therefore are not likely to be concerned with the detrimental effects of their behaviour. I feel that by using the transtheoretical model as the basis for my artefact, the information focuses on empowering the individual through positive education and desired outcomes, rather than focusing on the consequence of not altering ‘bad’ health behaviour. The model is limited by the fact that there is no set time limit of when the individual should progress to the next stage, which means that the individual could begin to lack the motivation to make this progression. However, the following elements of design shall act to counteract this. When designing my artefact i wanted to ensure that the colours I use had positive connotations, to ensure that it is empowering, as there are numerous studies to suggest that colours can impact the way we feel. In a study on ninety-eight college students where different principal hues were shown and their responses of emotions were collected, the colours of which received positive responses were those of primary principal hues (red, blue, green yellow, and purple). Whilst the study is limited due to the age group and small number of its participants (which means it may not be generalisable to a wider population) I found it a useful indication of what colours could be empowering to my target audience. Therefore, I have used such colours (red, blue and green) in my artefact, due to the positive connotations and emotions associated with the colours. This is also with the assumption that they will result in my target audience being more likely to adopt a positive attitude towards the exercise displayed, and thus participate resulting in augmented health outcomes.

For example, red has “an exciting and stimulating hue effect”, so I have used a red background on the pages where vigorous exercises, e. g. running and strength exercises are present. The rationale behind this decision is to subconsciously encourage the user to complete such exercises, by this stimulating hue. I chose to use three colours to ensure my app is not visually overwhelming, and delegated each colour to different areas of my app. Furthermore, the app will act as an empowering tool to my target audience as it will send out daily alerts to the user, for instance “I hope you’re having a good day!” and “Fancy checking in for some exercise?”. These alerts are empowering as they are supportive and encouraging, and by questioning whether the user wants to ‘check in’ my artefact is enabing them to make that decision. These alerts also act as prompts for the individual to use the app regularly, which they may otherwise forget to engage with overtime. By motivating the individual to engage with the app and thus the exercises included, they may start to recognise improvements in their health which could lead them to feel further empowered. I have selectively included language such as ‘You’ within my artefact, to further ensure that it is empowering to my target audience.

By using the pronoun ‘You’, any information included in my artefact allow the individual to feel that it is directly aimed at themselves, ensuring they feel involved in the personal process by which they can work at their own pace to achieve goals in, and contribute to “participatory behavior, motivations and feelings of efficacy and control”, all examples of individual empowerment. For their to be a high degree of empowerment in any circumstance, an individual should be in the participation stage of the empowerment gradient. In this stage they have already been provided with the information needed to make changes, and now feel as they have the delegated authority and the control to make all decisions. I feel that the rationale behind every decision that has formed the basis of my artefact, whether this is design or the information included, allows for my target audience to be at this stage of empowerment, with empowerment a prerequisite of health promotion.

10 December 2020
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