I N T EG R A T I V E L I T E R A T U R E R E V IE W S A N D M E T A - A N A L Y S E S

Health education, behavioural change and social psychology:

nursing's contribution to health promotion?
Dean Whitehead MSc PGDipHE RGN ONC RNT
Senior Lecturer, University of Plymouth, Institute of Health Studies, Exeter, UK

Submitted for publication 22 August 2000

Accepted for publication 23 February 2001

Correspondence: WHITEHEAD D. (2001) Journal of Advanced Nursing 34(6), 822832

Dean Whitehead, Health education, behavioural change and social psychology: nursing's contribution
University of Plymouth, to health promotion?
Institute of Health Studies (Exeter),
Aims. To critically review the complex processes that underpin the modication of
Veysey Building,
a client's health-related behaviour. This paper also seeks to contextualize the
Earl Richards Road North,
Exeter EX2 6AS, operational differences between health-educating and health-promoting activities
UK. as a means of rationalizing current practice.
E-mail: dwhitehead@plymouth.ac.uk Background. In `health promotional' encounters, there is a plethora of evidence
that suggests that nurses work predominantly within a `traditional' preventative
framework of practice. The prevalence of a culturally inherent biomedical frame-
work, governing most nursing practice, tends to reduce health-related client
interventions to little more than one-off, reductionist information-giving exercises.
The expectation on clients to respond to and subsequently modify their health
behaviour, when presented with such information, is unrealistic in most cases.
Nurses are often unaware of the extremely complex human phenomena associated
with modifying health-related behaviours and the resultant change processes. In
nursing-related health encounters, the planned or unplanned intervention and the
subsequent outcomes are mostly viewed within a too simplistic and supercial
context.
Design. A selective review of the relevant literature.
Conclusion. Where many nurses believe themselves to be health promotionalists,
the likelihood is that they are instead more likely to be traditional health
educationalists. Not that this is the main problem, in itself but if nursing is to
progress on this issue, it must rst become more effective in delivering its current
health education initiatives. Armed with further knowledge and understanding of
their practices, health educators are far more likely to achieve a degree of success in
their behavioural-change encounters as well as approach the intervention with a far
more realistic expectation of outcome. Without this further understanding, it is
argued that the integration of health educational initiatives into nursing practice will
generally do little or nothing to change the health status of clients.

Keywords: health education, health promotion, behavioural change, social

psychology

822 2001 Blackwell Science Ltd

Integrative literature reviews and meta-analyses
Introduction
Facilitating the modication of harmful health-related beha-
viours in clients at risk of illness or disease, may seem a
relatively straightforward exercise for many nurses. In most
instances the health-related encounter is based on an altered
health status and the perception of contributing events by
both the nurse and the client (Shaw 1999). Such an encounter
ensures that there is often an expectation on the part of both
parties, that the client's altered health status will be modied
to varying degrees and extents. It is likely, however, that the
higher expectation will lie with the nurse. The subsequent
assumption from these encounters, on the part of the nurse, is
the expectation that the client is probably only too willing to
modify and adapt their behaviour readily in exchange for a
positive health gain. Merely providing the necessary health
education information is often seen as the most effective and
possibly the only intervention required (Delaney 1994). The
consequence of this type of activity is that, any failure on the
part of the client to comply with the information given, is
usually seen as a fault of the client and attributable to their
irrational and ckle ways (Whitehead 1999a). This paper
argues on the other hand, that any resultant failure usually
lies predominantly with the nurse both in not recognizing
their unrealistic expectations and also in failing to understand
the complexities and nature of the task demanded of their
clients.
Cowley (1997) conrms that the results of the extensive
3-year `OXCHECK Study Group' (1995) health survey
concluded that, where health educational advice was given
by nurses to `at risk' clients, this had a disappointingly
small and limited impact on the health behaviour of the
clients involved. There is a fast growing realization that
health education encounters do not necessarily result in any
modication of a client's health-related behaviour. Where
clients simply understand a health issue, this does not
provide a guaranteed precipitation of a health action on
their part (Mackintosh 1995, Norton 1998). Stuifbergen
and Rogers (1997) indicate that, even when clients possess
the appropriate health knowledge, their life circumstances
and experienced symptoms make it extremely difcult for
them to implement any particular health action. Health
professionals, instead, are seen to be better served if they
seek to understand why clients adopt a particular lifestyle,
rather than merely attempting to provide them with
information on that lifestyle (Hogg 1991). Whitehead
(1999a) asserts that any move to recognizing and under-
standing the reasons behind clients' health-related beha-
viour, marks an integral step towards being able actively to
promote health.
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
Nursing and health promotion
Bennett and Murphy (1997) state that the health-related
behaviours of our clients occur within a complex system of
various interacting inuences. McQueen (2000) endorses this
viewpoint by highlighting the real challenges that face any
potential health educator suggesting that there are no easy
answers to such complex phenomena. Other authors
acknowledge the highly complex and potentially confusing
nature of facilitating behavioural change strategies with
clients (Galvin 1992, Tones 1995, McQueen 1996). Accord-
ingly, Haggman-Laitila (1997) identies that in order to
support our clients' health-related experiences, we need to
understand how clients understand health, how health is
realized in their existence, and how health is actually
experienced by them in everyday life.
This paper sets out to review the literature surrounding the
area of health-related behavioural change and, subsequently,
identies the current constraints associated with such activ-
ities. If behavioural change is seen to be the ultimate goal of
health education (Stubbleeld 1997), it also seeks to identify
the limitations of these approaches. Through this, and
through exploring the nature and intention of social
psychology cognitive theories and models, it is hoped that
the nurse who supports the use of health education initiatives
may be equipped better to acknowledge and proactively
incorporate these ndings into their future practices. This is
especially in light of the fact that, if wellbeing and social
adaptation are a priority of the nurse and their clients, then it
is imperative that the nurse has a clear understanding of
social psychology (Davies 1999). The need to explore the
context of social psychology and highlight its importance in
health educational activities is further stressed by Cole (1995)
who claims that all health care practitioners, knowingly or
not, base their work on its theories and models.
The nature of the health educational
encounter in nursing
One of the main problems that nurses face in dening their
health role is that of contextualization. Confusion reigns in
deciphering the context and meaning of health promotion
and health education (McBride 1995). This is compounded
by the fact that many authors utilize the terminology
interchangeably rather than establishing the differences
between the two approaches. As such, health education
refers to those activities, which raise an individual's awareness, giving
the individual the health [ill-health] knowledge required to enable
him to decide on a particular health action (Mackintosh 1996, p. 14).
Health education is viewed as being based on an `authority'
model that is derived from medical science and whereby its
823
D. Whitehead
focus is on disease prevention which has, in turn, meant
that it is seen by some to have a negative focus (Naidoo &
Wills 2000). Health promotion, on the other hand
involves social, economic and political change in order to ensure that
the environment is conducive to health. Health promotion not only
encompasses a nurse educating an individual about his health needs,
but also demands that the nurse plays her part in attempting to
address the wider environmental and social issues that adversely
affect people's health. (Mackintosh 1996, p. 14)
The confusion that lies within the terms being used inter-
changeably, stems from the fact that sometimes health
promotion is referred to as `radical' health education (Tones
& Tilford 1994) or `modern' health education (Downie et al.
1996). Alternatively, health education in its more reduc-
tionist and biomedical form is sometimes differentiated from
the other forms of health education as being `traditional'.
Other authors, however, may not distinguish between health
education and health promotion and just use one of the terms
to describe any health-related activity that they refer to.
Those that subscribe to older schools of thought are more
likely to refer to all health-related activities as being health
educational having failed to adopt the terminology of
health promotion when it became more widely established in
the early 1980s. In viewing health promotion as an `umbrella'
concept, traditional health education is recognized only as a
part-component of health promotional activity that may be
used on its own or as part of a more encompassing health
promotion initiative (Ewles & Simnett 1999). Naidoo and
Wills (1998) state that the adoption of this perspective is a
useful and practical way forward whilst accepting, at the
same time, that there is no clear or widely accepted consensus
on what is meant by health promotion itself. This is helpful in
one sense but may also be problematic in that it adds to the
confusion surrounding the context of health promotion.
The most predominant health-related activity used in
nursing practice, is the provision of health information.
Downie et al. (1996) conrm that this activity, serving as the
foundation of most health education action, is also the most
commonly adopted component of health promotion meth-
odology. Using health education on its own, as many nurses
do, limits the overall effectiveness and impact of any health
promotion strategy.
Behaviourist approaches to health promotion [health education]
implicitly, if not explicitly, separate individuals from the social,
physical and economic environments in which they live. Many health
information programmes operate as though personal behaviour is a
simple matter of informed choice rather than of complex processes
(Dean 1989, p. 151).
824
Thomson (1998) also identies that nurses over the years
have practised health education in a `patchy and uneven'
manner and on a basis of chance, rather than on a basis of
proven need. Stemming from this situation, is the further
realization that the predominance of such limited and
reductionist frameworks actually serve as a barrier to nursing
fullling its potential health promotional role (Robinson &
Hill 1998). It is argued here that if nurses continue to work
within reductionist and biomedical frameworks, they will
also fail to be motivated politically and consequently, will
tend not to collaborate with other agencies to facilitate
societal and environmental `engineering' strategies. Piper and
Brown (1998a, p. 388) identify that `for many patients the
inequalities and social injustices they face require legislative
restitution to enhance health'. It is these types of activities
that currently constitute health-promoting rather than health-
educating practice. This being the case, it is argued that most
nurses are not in a position truly to call themselves `health-
promotionalists' (Whitehead 2000a, 2000b).
Nurses may call themselves health promoters but in reality
are nothing more than `traditional' health educators (Norton
1998, Whitehead 1999b, 2000c). Stubbleeld (1997) comple-
ments this notion in suggesting that the primary role of a
so-called health-promoting nurse is usually merely that of a
`persuader'. In essence, nurses as health educators, tend
`paternally' to preselect the specic behavioural outcomes
that they deem are appropriate for the client and seek to
coerce the client towards an expected response, for example,
smoking cessation (Brown & Piper 1995). Health education
outcomes themselves tend to be based on predetermined and
dened epidemiologically driven and resourced government
targets, such as those providing the basis of the Health of the
Nation (DoH 1992) and Our Healthier Nation (DoH 1998)
documentation.
McBride (1995) identies that nurses tend to feel that their
health educational activities are a good idea, despite the fact
that their objectives are often unclear and that they lack any
objective evaluation of the outcomes. The limitations of
outcome-based health education interventions are further
highlighted by Galvin et al. (2000) who state that these
activities are mostly constrained unless they also adopt a
theoretical basis that acknowledges the contextual nature of
the processes involved, alongside the health behaviour in
question. Hogg (1991) takes the debate even further and
suggests that traditional health education strategies are not
only ineffective but may actually represent a danger to the
client's health. This viewpoint is likely to sit uncomfortably
with many nurses and might initiate some sort of defensive
stance. Any defensive position could be based on the
assumption that health education `might' represent an
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
 Integrative literature reviews and meta-analyses
activity of some value (Dines 1994b). For instance, Ewles and
Simnett (1999) believe that health education represents an
important facet of health-related activities for nurses. Never-
theless reductionist `sick-nursing', as opposed to humanisti-
cally inspired `health-nursing', is seen to be the predominant
health-related framework within which most nurses nd
themselves working (Caraher 1994, Cowley 1997, Benson &
Latter 1998).
How successful are health educational encounters?
Health education's seeming lack of success is based upon the
fact that its limitations are highlighted by the huge discrep-
ancies that exist between clients' beliefs and behaviours, as
well as the notion that most clients fail to adhere to the
`oughts' of health behaviour (Dines 1994a). Such a process
appears awed when presented with the evidence that the
causal relationship between health beliefs and health beha-
viour cannot be assumed (Wilkinson 1999). Added to this is
the fact that clients are, more often than not, unwilling to
discuss issues related to their health beliefs and current/past
behaviours. They are usually already aware of their limita-
tions in this area (the fact that they are accessing health
services will usually conrm this) and do not necessarily want
this situation reinforced. Failure to acknowledge this on the
part of the nurse, can often result in the noncompliance or
withdrawal of a client from any intended health-modifying
programme. Norton (1998) asserts that in order to avoid
such a pitfall, clients should be free to choose whatever
priorities they feel are pertinent to them and not be pressured
into choosing health as one of these priorities.
The opinions of lay groups and health professionals present
a very wide variance in their interpretation of health and
ill-health. For instance, Preston's (1997) ndings suggest that
coronary families' perception of heart disease causation are in
complete contrast to the prevailing orthodoxy of health
education. Dines (1994a) suggests that `oversimplied
dogmatic messages' about healthy lifestyles when presented
by the nurse, are unlikely to relate to the conceptual
frameworks of many clients. Also, the context in which
messages are delivered to clients are likely to be alien. People
tend not to see illness and disease within a biomedical
framework, nor as a discrete entity, but are more likely to
view it in a socio-cultural, temporal and historic context
1 (Mackintosh 1995, Schickler 1999). A related problem lies in
the fact that clients are usually unable to bring these contexts
into any bio-medically orientated health service arena.
Naidoo and Wills (2000) argue that the health beliefs of
medical science and the lay public could perceivably overlap
and coexist, but do not and never have done.
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
Nursing and health promotion
It is argued here, that simply basing the clientnurse
relationship on an illness/disease outcome is fundamentally
awed as a health-related activity. If we acknowledge
Antonovsky's (1987) notion of `health as a sense of coher-
ence', he believes that the prevention or treatment of disease
does not necessarily lead to a promotion of health status in
the client. In reverse, any engagement in health-maintaining
behaviour may reduce the threat of illness, but does not
entirely eliminate the risk of developing disease in the rst
place (Bennett & Murphy 1997). It is on this basis that
MacDonald (2000) reminds us that there is a growing
consensus, that the traditional approaches to health educa-
tion which subscribe to the illness/disease outcomes of
biomedical paradigms, are now considered to be more and
more inappropriate when applied to health care settings. This
is despite the limited evidence that suggests that some
social psychology cognitive-based nursing health education
programmes may demonstrate varying degrees of success
under certain conditions (Dusseldorp et al. 1999, Baranowski
et al. 2000, Galvin et al. 2000).
Brown and Piper (1995) argue that the type of health
education activity that is aimed at the health determinants of
clients which are deemed to be modiable, are likely to be
ineffective unless the outcomes are based upon empowering,
egalitarian, collaborative and client-led strategies. Bolstering
self-esteem, self-worth and value through offering encourage-
ment, acknowledgement and positive regard, are seen to
be essential attributes of the health education encounter
(Mackintosh 1995, Salisbury 1996, Schickler 1999).
Stuifbergen et al. (2000) indicate that interventions which
enhance social support (societal, environmental, political and
economic), decrease barriers and increase self-efcacy are
most likely to result in a positive health promotion outcome.
Figure 1 demonstrates some of the wider-reaching and
encompassing activities, outlined above, that would be
more likely to constitute a nursing-based health promotion
initiative.
It is Piper and Brown (1998a) who indicate that human-
istically inspired patient-empowerment approaches to health
education should always be adopted as the most valid
approach (that is radical or modern health education tech-
niques). There is substantial anecdotal evidence to support
the claim that such activities are unlikely to be part of the
nurses' health education practices (Caraher 1994, Benson &
Latter 1998, Latter 1998, Whitehead 2000c). Where health
educational activity is incorporated into nursing practice,
Dines (1994b, p. 225) states that it is likely to present as
`a constrained activity logically limited in its impact'. This is
partly the case because most traditional health educational
encounters are reliant on the co-operation of a passive and
825
D. Whitehead

The nurse as a health promoter

(radical or modern health educator)

Nurse identifies client/s in hospital or Collaborate with other disciplines/

community setting who wish for health
promotional support. Proactive discharge
planning and community liaison for
hospitalized clients.
agencies in order to identify the best
possible options and resources for client.
Nurse may withdraw at this stage if other
parties are deemed to be more
appropriate.

Establish clients/familys personal health

Establish priorities for resourcing
needs and requirements based on clients
programme and make necessary
perception of their own needs and
provision available. Match provision
conversant with their societal position.
against community needs and
Establish realistic objectives and arrange
established Health Needs Assessment.
regular follow-up to monitor progress.

Educate, improve self-esteem and empower
clients within their own settings in line with
client s own wishes. Integrate into
surrounding community if required. Facilitate
any necessary social, environmental or
political changes required to fulfil assessed
needs.
Where clients are unable, until they are
suitably empowered to represent
themselves, the nurse/health
professional acts as an advocate and
lobbyist for the client politically,
economically and environmentally.

The nurse, other significant parties and

client evaluate agreed programme. Nurse is
accepting of any unmet needs or withdrawal
of initial needs, at any stage in the process
as rationale course and choice of client.
Possible re-defining or re-setting of new
objectives if the client requests these then
the process begins again. If the client is
suitably empowered they may no longer
require the nurses support and can
establish their own mechanisms for further
progress.

Client exits programme.

Possibly becomes an
empowered resource /
facilitator for others within
their community.

Figure 1 The nurse as a health promoter (radical or modern health educator).

compliant client who is willing to be moulded in any way that any behavioural change is witnessed (Molloy & Cribb 1999).
they are directed (Kuokkanen & Leino-Kilpi 2000). This is Figure 2 demonstrates the type of activity that is most likely
arguably a recipe for undesirable and unethical outcomes to occur within the course of a typical traditional health
which pay `lip service' to the health needs of clients', even if education encounter.

826 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
Integrative literature reviews and meta-analyses
The nurse as a traditional
health educator
Nurse targets passive,
mouldable and
compliant client/s.
Nurse adopts a
medically-defined
preventative approach.
Nurse, as an expert, determines and
prioritizes the clients health needs. Health
needs are usually based on predetermined
epidemiologically driven biomedical targets
and resourced accordingly, e.g. reduction of
CHD (smoking cessation programme).
Nurse offers a health education programme or
one-off information-giving initiative, based on
disease/illness management and risk-
reduction/prevention intervention. Patients are
deemed to be responsible for their own health
and expected to comply with advice/treatment
offered. Client is encouraged to rationalize their
health behaviour. Noncompliance enforces
victim-blaming attitudes by nurses. Clients
health status is viewed within a biomedical
context. Societal, economic or environmental
factors are not usually considered or addressed.
Nurse may be referred to follow-up or liaison
personnel or part of OPD follow-up although
this is not usually the case. Unlikely that the
intervention/treatment will be evaluated or
reviewed. Success is often measured in terms
of short-term behavioural change and
subsequent modification of disease/illness
status.
Figure 2 The nurse as a `traditional' health educator.
In presenting a further dilemma for the biomedical frame-
working of certain health education activity, Seedhouse
(1986) describes that health services are most often based
on a `health as a commodity' concept. This is whereby the
medical profession cynically creates the health need of its
clients in the rst place. Within this framework, health
appears as a nebulous activity that seems to exist apart from
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
Nursing and health promotion
the client but, which can be re-captured when lost, if
pharmacological or surgical interventions are adhered to
or indeed if traditional health education interventions are
subscribed to. This notion implies that our clients might
remain healthy if they were not inuenced by some external
stimuli creating the initial biomedical problem. These view-
points remain inherently awed in the respect that they
ignore the individual attributes of clients and reduce unique
and complex entities to that of a biomedical entity or a mere
disease. Illich (1977) argues that this situation arises because
clients are unable and hindered in their ability to act as
autonomous beings. Fitzpatrick (2001, p. 7) states that
medicine, as a self-selected `guardian of public morality', is
adopting a `quasi-religious crusade' against disease as its
contribution to health promotion although it is generally
incapable of determining or combating the major contem-
porary diseases. The position of health education sits uncom-
fortably within this framework. That is more likely to be the
case if one takes into account that preventative health
educational initiatives are viewed as a peripheral activity of
biomedical health services where its priorities and outcome
measurement are based purely upon discharge and treatment
gures (Mckie 1994).
Changing health-related behaviours
When implementing behavioural-change strategies, there is
usually a call for a signicant departure from a clients'
normal pattern of behaviour and therefore the challenge lies
in identifying when and how these changes might occur
(McQueen 1996). Clients need a strong incentive to change a
behaviour that threatens or already affects their health status.
Most clients feel threatened, not so much by their ill-health
status, but by the health change itself and seek to maintain a
healthy ambivalence towards this (Baird 1998). Many clients
will have chosen already the health messages that they can
comfortably comply with and subsequently discarded any
others (Preston 1997). It is suggested that, in most cases,
clients are usually aware of when they are ill or when they are
worried about their health without this having to be
conrmed by nurses. On this basis, nurses need to be mindful
that they may already be `preaching to the converted' or
simply supplying health-related information that has already
been rejected by their clients. Clients usually respond to
certain health messages at the expense of others and so their
actions are often based on a rational choice of valuing some
aspects of their life above that of their health (Dines 1994b).
The expectations of health educationalists, in relation to
client outcomes, do not tend to lend themselves well to the
prediction of behavioural performance (Bandura 1997).
827
 D. Whitehead
Further complications arise when one considers the issue
of how the nurse presents himself or herself within the
health educational encounter. Several authors raise the issue
that the nurse's own health beliefs may well conict with
the messages that are being delivered to the client (Dines
1994a, Callaghan 1998). Effectively, the health-educating
nurse needs to draw a line between being, on the one hand a
poor role model and on the other being too healthist. An
added complication, but further beyond the control of the
nurse, relates to the way that we are generally perceived by
the public at large. Clark (1999) conrms that media
portrayals of nurses may lessen their credibility as health
educators in the eyes of their clients.
Health education work suffers from the assumption that all
clients are able to be educated and fails to acknowledge that
they might be actively constrained in their endeavours to
change their behaviours. Niven (2000) highlights that, even
when clients may actively seek out health interventions, the
odds are that the advice offered by health professionals will
usually be ignored or misapplied. There are many `rational'
reasons why clients are unable or unwilling to amend harmful
health-related behaviours. For instance, the satisfying of a
short-term craving may be far more powerful an urge than
the consequences of a long-term health gain. Exaggerated
role models may provide the impetus for continuing a client's
health behaviour. For example, the known elderly relatives/
acquaintances who are long-lived despite their over-indul-
gence in smoking/drinking activities. The inuence of various
media in determining what activities are socially acceptable
or even socially desirable, are a powerful determinant of
health behaviour in individuals (Fazio 1990, Whitehead
2000e). Vicarious Learning Theory suggests that role-mod-
elling is a powerful motivator for behaviour. That is, the
health-damaging behaviour of signicant others may provide
the impetus to begin or continue harmful behaviour. Inter-
mittent Reinforcement suggests that, even where clients do
not enjoy the consequences of their behaviour (for example
hang-overs or violence associated with heavy drinking), they
are generally happier when alcohol reduces their inhibitions
and they then become witty and gregarious (Bennett &
2 Hodgson 1992). Even where clients feel social discomfort
from those other than themselves, they may feel that this is
easier to tolerate than the discomfort caused by modifying
their behaviour. Some clients may adopt a fatalistic perspec-
tive and consider that luck, misfortune, other forces, fate, etc.
determine their health status and therefore, their health is
beyond theirs or anyone else's control (Wilkinson 1999).
Nurses need to be aware that despite their own health
beliefs (which may be faulty in themselves), the clients' beliefs
may not always be based on the weight of objective evidence;
828 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
they can also be based on inaccurate personal estimations
(Downie et al. 1996). For instance, the greater the perceived
threat (such as the fear of cancer), the less likely the client is
to seek or accept help a sort of `health paralysis' (Nursing
Times Learning Curve 1997). McBride (1995) also argues
that health-promotional initiatives, because of the intimid-
ating and alien nature of health care settings in which they are
implemented, are just too stressful for the client to consider
or adopt. This is even if the nurse and client have stated a
clear willingness to change. Intention to change health-
related behaviour does not necessarily represent a desire,
ability or appropriateness to change especially in unfamiliar
or stressful settings.
Social psychology theories and models of health behaviour
Social psychology involves a variety of approaches which, in
themselves, reect its multidisciplinary location. Models of
health-related behavioural change are usually derived from
the eld of social psychology and have their origins based in
consumer research (Cole 1995). Social psychology research
studies have been seen to lead to effective health interventions
based on social inuence processes (Mittelmark 1999). There
is evidence that specic social psychology theory has been
employed by some nursing studies within the context of
health education (Davies 1999, Kuokkanen & Leino-Kilpi
2000). This contribution appears to have been somewhat
limited despite the fact that health psychology is dominated
by biomedical models of health, and based upon a dualist and
monist philosophy (Curtis 2000).
Social Cognition (Social Learning) Theory, as a branch of
social psychological theory, is used extensively as a means
to explain health behaviours and to focus on the social
context of behavioural change and its underpinning cogni-
3 tive processes (Curtis 2000, Dilorio et al. 2000, MacDonald
2000). Its underlying tenet is that behaviour is guided by
expected consequences. The cognitive component is related
to the client's belief about an object or attitude (Downie
et al. 1996). Social learning theory implies that health-
related behaviour is the result of an interaction between
cognitive processes and environmental events (Bennett &
Murphy 1997). It adopts the processes of behaviour therapy
and behaviour modication in line with their antecedent
theories: classical and operant conditioning. These represent
a move away from a previous focus on disease/illness
associated risk-factors towards the motivation of positive
health, through considering the factors associated with
clients' attitudes, beliefs and behaviour change (Thomson
1998).
A closely related component of the social psychology
theories touched on, so far, is that of cognitive dissonance.
Integrative literature reviews and meta-analyses
This is loosely based on Heider's Theory of Cognitive
Consistency (Heider 1944) and Heider's (1958) balance
theory. It is based on the concept that, when clients' face a
situation where the delivered health educational message is
in conict with their current belief, attitude and value
system, they react in such a manner so as to create
dissonance. Festinger (1957), as the originator of this
psychological theory, suggested that cognitive dissonance
occurs when an individual's beliefs are in conict with their
actual behaviour. This theory contradicts the Rational-
Empirical theory that assumes that clients will make rational
decisions based on the information presented to them (Baird
1998). With health-related information, the rationality of
the client is often called into question and highlights the
complexity of the change process. For many health educa-
tors, cognitive dissonance may not address the issue of why
it is that clients do not accept the advice offered, even when
presented with overwhelming evidence that their behaviour
is harmful to their health (Niven 2000). Cognitive disson-
ance, however, should be viewed as a motivational state
because the client is most likely to be seeking out ways to
minimalize or eliminate the tensions and discomfort they
feel within their existing behaviour (Stubbleeld 1997,
Clark 1999). This activity will often be conducted without,
or in spite of, any guidance from a health care professional.
The ip side of cognitive dissonance is manifest in the form
of Attribution Theory. Devised by Abramson et al. (1978),
this involves a demotivational state on the part of the client.
The client believes that they have no control over unplea-
sant experiences (for example, ill-health) leading to
passivity, cognitive decit and learned helplessness.
The most commonly utilized social psychology models in
health behavioural terms, are widely dened within this
eld of activity. They include The Health Belief Model
(Becker 1974) which has been expanded to incorporate the
Concept of Self-Efcacy (Bandura 1977), The Stages of
Change Model (Prochaska & DiClemente 1984), The
Health Action Model (Tones 1977, 1987) and The Theory
of Reasoned Action Model (Ajzen & Fishbein 1980). A
plethora of literature exists that seeks to dene, describe
and critique the above mentioned models (Conner &
Norman 1995, Ogden 1996, Pitts & Phillips 1998, Niven
2000). These behavioural models share many similarities,
although subtle differences between them do make some
more suitable in certain contexts or settings than others.
Most models look to establish the relationships between
clients' knowledge, attitudes, beliefs and values and include
theories around self-efcacy, self-attribution, self-evaluation,
locus of control and motivation, in order to explain these
relationships (Tones & Tilford 1994, Pender 1996, Bennett
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
Nursing and health promotion
& Murphy 1997). They also tend to acknowledge that
factors such as social norms, cost-benet analysis, percep-
tion of effectiveness/value of interventions and perception of
risk and severity of disease, are also important contributory
predictors of the behavioural change capacity of clients
(Pitts & Phillips 1998). It is worth noting, however, that
such models are no more than descriptions of how a
process might work, rather than how something does work
(Curtis 2000) and therefore they do not present as
solutions in themselves. As a word of caution, Cole (1995)
conrms that there are many criticisms associated with
models of behavioural change. They need to be approached
cautiously and not viewed as a panacea for poor health
education techniques.
Various schools of thought on the validity of various social
psychology theories of health behaviours serve to offer
contrasting debate. Authors, such as Piper and Brown
(1998b), argue that the existence of such theories are the
result of a failure on the part of traditional and simplistic
health education, to move beyond the primitive notion that
increased knowledge leads to a shift in attitude which, in
turn, results in supposed behavioural change. This desire to
see a move away from such simplistic viewpoints is seen to
have necessitated a theoretical sophistication of the medical
paradigm of health educational activities. On the other hand,
some believe that these theories represent time-consuming,
esoteric and out of touch modes of health care provision
(Cole 1995).
Nevertheless, such theories also offer valuable insight into
the motivational forces and constraints that underpin our
clients' health action and behaviour, as well as assist nurses in
planning timely and appropriate interventions (Piper &
Brown 1998b, Thomson 1998). They also reect a far more
exclusive prediction of a precise and scientic approach to
health-related practices (Cole 1995). Tones (1995) feels that
properly constructed, behavioural models can facilitate eval-
uation, illuminate practice and help health practitioners make
better decisions. He subsequently sees them as a slimmed
down version of reality.
Conclusion
Where does this leave nursing in relation to health
promotion?
Drawing on appropriate social psychology theories is
believed to result in an increase in the client's knowledge
base and leads to an increased adherence, motivation and
satisfaction when co-opted into a therapeutic health-related
regime of care (Salisbury 1996). Such theories can have a
829
 D. Whitehead
productive role within more encompassing health education
programmes but only if they are seen to facilitate client
power and choice (Brown & Piper 1995). Adoption of such
theories and models, in isolation from appropriate setting and
context could result in an inadvertent reinforcement of
traditional health education paradigms and the advocation
of biomedical control and authoritarianism (Piper & Brown
1998b). According to Preston (1997), anthropological
perspectives have reinforced the disillusionment felt by many
health educationalists, that underpin those restrictive medi-
calized approaches which focus purely on client lifestyle and
behavioural change. The call for less medical intervention in
health education appears to be well served, although
achieving this will require a different philosophy than that
which currently prevails in nursing (Cowley 1997). Cambell
(1990) strongly asserts that health education, in order to
move away from its current roots, must begin to free itself
from political (professional) control and the vested interests
4 of individual practitioners. Mittelmark (1999) states that this
type of move will require a comprehensive `social inuences'
approach to health promotion because health-related educa-
tion, on its own, is unlikely to change current predicaments.
He adds that positive change can only be facilitated through
instilling health promotion values in policy arenas beyond the
health care sector, and alongside a better understanding of
the dynamics of policy-making behaviours related to social
inuence processes. On a client-interaction level, Conner and
Norman (1995) suggest that health strategies that employ
multiple level interventions, such as the utilization of process
models (social cognition models) of persuasive communica-
tion, are of the utmost importance.
As nurses seek to move away from a rigidly biomedical
paradigm towards a more encompassing and humanistic
paradigm (Whitehead 2000a, 2000d), they might be well
served in realizing their potential and also their limitations to
do so. The Royal College of Nursing (RCN 1998, p. 12)
states that:
The nursing workforce remains very much a sleeping giant. Its huge
size means that nurses have enormous potential as agents of social
control in promoting health and well-being. It does not take too much
to imagine what the impact might be if over half a million people [plus
many more millions of nurses throughout the World] became
empowered, assertive and articulate agents of change for better health.
This paper, however, does not subscribe to notions of nurses
acting as mere agents of social control. To do so might
further endorse the current limited practices of using health
promotion as an exercise in social control (Brown & Piper
5 1995, Fitzpatrick 2001). This paper also does not necessarily
subscribe to the notion of nursing as a `sleeping giant' in this
830 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 822832
matter. The fact is that a great deal of evidence demonstrates
that `traditional' health education techniques have long been
an established part of nursing practice. On this basis, it is
argued that the giant is already awake but is in need of a
concerted shift away from established norms, towards more
encompassing and wide-ranging health promotion strategies.
Failing this, the least that nurses could do would be to further
understand the complexities of their `more limited' health
education encounters and try, at the same time, to ensure that
their outcomes are more successful. Understanding the
contextual nature of our health-related practices and
the complexities of our clients' health behaviour should be
the rst major hurdle to overcome before nurses begin to
tread the path of initiating constructive social change. A
recognition and acknowledgement that, as things currently
stand, a valid overall health promotion contribution by the
nursing profession still remains questionable (Antrobus
1997), might also provide a useful platform for further
discussion and reform.
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