This assignment will look at the health promotion of a patient who is required to lose weight before surgery can take place using the Transtheoretical Health Promotion Model (Prochaska and Diclemente 1983) to follow the patient through the journey of weight loss. It will discuss the healthcare professional’s role in helping a patient to change their behavior and the steps the patient will need to take to achieve weight loss. It will then analyse if the Transtheoretical Model is a suitable for this kind of health promotion and identify any shortcomings.
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Mrs Smith is a 52 year old female, is 5’4″, weighs 20 stone, and has a Body Mass (BMI) in excess of 40. Her name has changed to protect patient confidentiality (Nursing and Midwifery Council (NMC) 2008. Mrs Smith needs to lose 3 stone before she can undergo surgery. She is married, works shifts in a call centre and generally leads a sedentary life.
McArdle (2002) describes obesity as”A biological response to an individual’s environment that can have a profound impact on patients Health”. Obesity is identified by an increase in body weight and a BMI of >30 which leads to excess adipose tissue (Rollo 2004, World Health Organisation (WHO) 2003). In England obesity levels have dramatically increased over the last 30 years and are a growing concern. In 2008 61.4% of adults were obese and if the trend continues 60% of men and 50% of women will be classed obese by 2050 (Department of Health (DOH) 2009). Public Health is a key issue for the Government who are committed to reversing the increasing trend of obesity (Scriven and Orme 2001). Strategies have been such as healthy weight; healthy lives (DOH 2008) to provide practical support and improve care for adults with obesity focusing on health not illness.
Obesity increases risks during and after surgery. All surgery carries a risk of stroke and even death which will increase with obesity (reference).The thick adipose tissue around Mrs Smith’s abdomen will mean the incision will be longer and access to her womb will be restricted causing difficulties during surgery and increases the risk of infections post operatively (Baxter 2003). She may also experience more unpleasant side effects of anesthetic than a patient with a healthy BMI. Generally being obese will increase the risk of many other illnesses such as Diabetes Type 2, heart disease, cancer, high blood pressure, osteoarthritis and respiratory problems (Jebb 2005)
Mrs Smith needs to be as healthy as possible for surgery. WHO (2003) define health as:
“A state of complete physical, mental and social well being and not merely the absence of disease or infirmity”.
It is clear that Mrs Smith is not in the best physical health and it could be argued the consequences of which may have an effect on her mental and social well being (reference).
Health promotion will help her achieve optimum health and is defined as:
“Enabling people to exert control over the determinant of health and thereby improve their health.” (The Public Health Agency (PHA) 2010)
Healthcare professionals are required to promote health and wellbeing (NMC 2008). Combing health education with healthy public policy the National Institute for Clinical Excellence (NICE) (2006) recommend the implementation of structured programmes to promote individual tailored health advice to patients in collaboration with others agencies such as, local authorities, social services, voluntary sectors and workplaces.
The Transtheoretical/Stages of Change Model (Prochoska et al 1992) is based on people changing their behavior, it is used in a variety of settings including well known campaigns associated with addictive behaviors such as smoking and alcohol. (WW website). It works on the basis that most people have tried to give up an addictive habit at some point but have given up due to a number of factors including support, no motivation, time and knowledge. (Naidoo and Wills YEAR). Changing the health related behavior of patients is challenging for nurses due to the complex mix of psychological, social and environmental factors and this model helps nurses to help patients focus and move forward to the next stage. It is an ongoing cycle, of stages in which people move forwards as well as backwards. (Naidoo and Wills YEAR).
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The first stage of Pre-Contemplation assumes Mrs Smith is unaware of any potential risks to her health (Naidoo and Wills YEAR). However it is hard to imagine that she is not aware of the detriment to her health considering national media campaigns such as the NHS Change 4 Life progamme (2010) aimed at improving the nation’s health. It is more likely that she is in denial and does not want to change. Her views on health may differ to the healthcare professional’s view, which might be related to age, experiences or cultural beliefs (Helman 2007). It is therefore important to try to understand her believes. She may have tried to diet before and failed. Education and advice will raise awareness the effects of her lifestyle before she progresses to the next stage of the model (Benbow and Jordan 2007).
At the Contemplation stage Mrs Smith will not be ready to make changes but seeking advice and information to help her weigh up whether making changes are worth the effort. The healthcare professional will have an opportunity to tailor information specifically to help her understand that weight loss means eating less and increasing physical activity (NMC 2008). The advice and information communicated to her should be clear, precise, evidence based and at the right level to help her make an informed choice regarding weight loss (Naidoo and Wills YEAR). Time should be spent to build Mrs Smiths confidence and motivation by explaining the many benefits she can expect to see from weight loss, such as in addition to undergoing surgery, improvements to her health will include amongst others reduced breathlessness, increased mobility (Jebb 2005). Regular exercise will reduce her medical problems including improving gylcaemic control, cholesterol level, cardiac fitness, and physical well being. The healthcare professional’s priority will be to focus on empowering Mrs Smith to want to make the behavioral changes and move towards the next stage in the cycle which they could do by identifying what prevented Mrs Smith from losing weight before or asking her to visualize a forthcoming event and how she might look and what she might wear if she lost some weight (Rollo 2004).
At the third stage of the model, Preparing to Change, Mrs Smith will be serious about her decision to change and will be ready to take action (Rollo 2004). Healthcare professionals will need work together with her to assess her current lifestyle and help her understand what she needs to do to achieve weight loss (Naidoo and Wills). Clinical assessments will be taken for baseline purposes and will include past weigh loss/gain history, medical and psychiatric history, weight, BMI, waist measurement, blood glucose levels, thyroid function and lipid profile (Cook 2009). With support she will need to be prepared to make a change for life and any myths she may have will need to be dispelled if she is to be successful (Jebb 2005). A plan should be formulated to help Mrs Smith succeed, outlining what activities are required for her achieve weight loss. This list is exhaustive but might include keeping a food and exercise diary, controlling portion sizes, introducing regular mealtimes, changing to healthier food types and aiming to use healthy cooking methods (Jebb 2005). As Mrs Smith does very little physical activity at the moment recommendations might include introducing a something new like a low impact exercise such as swimming or walking more often. Her expectations should be discussed, and any difficulties identified and coping strategies implemented. For example, Mrs Smith is works shifts so she will need to plan healthy meals in advance (Jebb 2005). It is proven that people who spend more time in the planning stage achieve a higher weight loss than those who don’t (reference). The plan should also include, the rewards she will get for losing weight and what support will be available, and when monitoring and review will take place (Cook 2009).
The fourth stage is Making the Change. During this stage healthcare professionals can help Mrs Smith to make positive decisions to modify her diet and physical activity by agreeing clear realistic goals and how they are going to be achieved, taking into account cultural and individual preferences. These can be broken down into small steps to give her greater sense of achievement (McArdle 2002). For example, to achieve weight loss she will need to reduce food intake byaround 600 kcal/day, concentrating on losing 1-2lbs per week will seem more achievable than focusing on losing several stone and maintaining a food and exercise diary will enable her see the positive changes she has made (Jebb 2005). As she leads a sedentary life it would be totally unrealistic to suggest high impact aerobic exercise, instead she could perhaps walk for ten minutes each day increasing the time as she increases her physical fitness. To maintain momentum ongoing practical support, information and advice should be available at continuous sessions and support groups (Rollo 2004).
The fifth stage of the model is Maintenance. Mrs Smith should be encouraged to make changes she can sustain indefinitely. Managing obesity is a long-term commitment and she will need to be educated with new skills to enable her to maintain her new habits. She will need to identify when she is likely to fail and have a coping strategy in place, such as choosing a healthy option when eating out. Mrs Smith may require additional support at particular stressful times in her life to prevent her gaining weight again (Jebb 2005).
The last stage is Relapse. Maintaining new habits can be difficult and Mrs Smith is likely to regain weight at some point. She may relax once her target weight has been achieved and slip back into bad habits or she may be disappointed if she doesn’t achieve the weight loss as quickly as she anticipated. She will then revert to previous stages of the model. Additional support and encouragement will be needed to help her understand that she is not a failure, that it is human nature to relapse and to help her get back on track. It is likely that she will go back and forth many times through the different stages (Naidoo and Wills).
In conclusion obesity is a major concern today and it would appear this model is successful in helping people to achieve weight loss. Both commercial and government organisations use the model for major health campaigns (NHS 2010, ww 2010). This model aims to help people make lifestyle changes that are permanent. However it is very much dependent on people changing their behavior and as people are individuals it cannot be applied in a set manner, what works for one person will not necessarily work for another (Benbow and Jordan 2007). The model involves therapeutic intervention and the outcomes can be significantly affected by the healthcare professional. The patient/healthcare professional relationship is based on trust and understanding and will only work if the patient is ready to change. Success of this model cannot be measured short term as managing obesity is a life-long commitment (REFERENCE)
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