Learning Outcomes
By the end of this section, you should be able to:
- 15.4.1 Describe barriers that negatively impact health outcomes.
- 15.4.2 Examine factors that influence participation in health promotion activities.
- 15.4.3 Recognize opportunities for health promotion and disease prevention across health care settings.
- 15.4.4 Explain how systems can serve as barriers to effective disease prevention and health promotion.
Many factors influence the health of individuals and communities. A barrier is a circumstance or obstacle that keeps people from progressing toward achieving a positive health outcome. Barriers to health promotion and disease prevention exist at various levels, including the individual level, family level, system level, and community or population level. The health care setting may even present barriers. On the other hand, communities provide many opportunities for health promotion and disease prevention, particularly within health care. Nurses who understand barriers can capitalize on available opportunities.
Barriers to Health Promotion and Disease Prevention
Nurses should be aware of barriers, including barriers to economic stability and those that block access to high-quality education and health care, so they can plan to overcome them for clients or populations. Other barriers relate to neighborhood and built environment and to social and community contexts. These barriers can also contribute to health disparities, as described in Health Disparities. As discussed, the SDOH are barriers that can prevent an individual from obtaining the resources they need to achieve better health outcomes and improved quality of life (Healthcare Information and Management Systems Society, 2020; see Social Determinants Affecting Health Outcomes.) Table 15.9 provides individual and system-level examples of barriers to health promotion and disease prevention that may occur within each area of the SDOH.
| Social Determinants of Health (SDOH) | Example of an Individual-Level Barrier | Example of a System-Level Barrier |
|---|---|---|
| Economic Stability | A client’s primary provider instructs them to follow a low-sodium diet. The client will not receive a paycheck until Friday and only has $30 for the next 2 days. Rather than choose a salad from the grocery, the client chooses a fast-food meal to make the money they have last longer. | A client who has recently experienced respiratory difficulties lives in a rental apartment in a community with little stable housing. A neighbor reported mold in the building due to frequent water leaks. The client’s primary provider is concerned that the apartment may be contributing to the client’s respiratory condition. The client can barely afford the apartment and cannot afford to move. |
| Education Access and Quality | An individual with limited English proficiency has chest pain. Because they are not sure they can describe their symptoms, they choose to rest at home rather than seek health care. | A child is enrolled in a low-quality school with limited health resources, multiple safety concerns, and low teacher support. The child is diagnosed with type 1 diabetes and requires insulin injections twice during the school day. There is no school nurse. |
| Health Care Access and Quality | A client who does not drive lives in a rural area. She has arranged for her grandchild to drive her to an appointment for a mammogram 2 hours away, but the grandchild’s vehicle is unreliable and is not drivable on the day of the appointment. | An urban clinic has experienced a shortage of providers following the COVID-19 pandemic. This has resulted in clients experiencing longer wait times and delayed care. |
| Neighborhood and Built Environment | A client is diagnosed with obesity and instructed by their primary provider to walk 30 minutes daily. The client lives in an urban area with a high crime rate. The only available walking locations are the city streets and a dimly lit park known for drug dealing and use. The client works 12-hour daytime shifts, so the only time they can walk is after dark. | An older adult client relies on a neighbor to perform weekly grocery shopping. The neighbor does not have a car and walks to the closest nearby store, approximately 1 mile away. The store has no fresh produce and is not a chain supermarket. A convenience store within a gas station is the only other store within walking distance. The client would like fresh fruits and vegetables, but these are unavailable. |
| Social and Community Context | A transgender teenager is bullied and experiences depression. They experience social rejection and isolation, decreased social support, and verbal abuse daily. | A family of color lives in a neighborhood that has historically been ignored for social improvements. The family’s children were all considered small-for-gestational-age births. |
The experience of structural racism results in chronic discrimination, stress, and depression, which has a further negative impact on the ability of those within historically marginalized populations and can create a further barrier to health promotion and disease prevention (Churchwell et al., 2020). One particular form of a barrier to health outcomes has already been discussed in Structural Racism and Systemic Inequities. The COVID-19 pandemic illustrated this point:
- Black, Hispanic, and Latino people; American Indians/Alaska Natives; and Pacific Islanders had a higher COVID-19 morbidity and mortality rate than White people.
- Counties that had over 45 percent of residents belonging to a historically oppressed group recorded higher rates of COVID-19 infection and mortality compared to counties with mostly White residents regardless of the county’s poverty level.
- During the pandemic, there was a rise in anxiety and depression. Studies show that Hispanic and Latino adults (22 percent) and Black adults (18 percent) experienced a higher rate of substance use initiation or increase than White adults (11 percent) during this time (Churchwell et al., 2020).
As individuals and populations encounter these many barriers to health promotion and disease prevention, health outcomes begin to decline. Overcoming these barriers is the only way to successfully achieve positive health outcomes, as an individual or a population.
Barriers to Health Promotion and Disease Prevention Within a Health Care Delivery System
The structure of health care delivery systems is made up of internal and external factors that can influence health promotion and disease prevention, therefore impacting health outcomes. Internal factors include everything within the environment in which health care services are provided as well as the resources required for providing those services. These include, but are not limited to, leadership styles, organizational culture, policies and procedures, and information sharing. External factors include government’s role in health care, community expectations and influences, ownership of the health care system, and the extent of services the system provides.
A nurse serving in a role related to health promotion and disease prevention may encounter internal or external barriers from the health care system. The system may lack financial or political support for health promotion implementation. There may be a lack of time for effective health promotion and disease prevention activities, particularly in competition with the day-to-day demands. Poor communication may exist between the various entities within and outside the health care system. Finally, others within the system may lack interest in health promotion and disease prevention (Rogers et al., 2021).
Unfolding Case Study
Part B: Health Screening Follow-Up
Read the scenario, and then answer the questions that follow based on all the case information provided in the chapter thus far. This case study is a follow-up to Case Study Part A.
During Deanna’s appointment, a nurse working in the primary care provider’s office is teaching Deanna about lifestyle modifications to lower her high blood pressure level, such as a low-sodium diet and regular exercise. As the nurse is discussing lifestyle changes with Deanna and answering her questions, the office manager calls the nurse out of the room and asks why they are spending longer than the allotted 15 minutes with the client. The nurse explains that Deanna has many questions about the recommended dietary changes. The manager indicates that the client should be dismissed and instruction can be continued at her follow-up appointment in 2 months.
Factors That Influence Participation in Health Promotion Activities
How individuals and populations define health and health problems, and their perception of health’s importance, influence any attempts to improve their health through health promotion activities. Three factors either support or form barriers to participation in health promotion activities:
- A predisposing factor includes any characteristics of the individual or population that affect personal motivation to bring a change in behavior, including their knowledge, beliefs, values, attitudes, and norms. An example of a predisposing factor leading to a positive health outcome would be the belief that smoking is harmful to health.
- Reinforcing factors occur in the form of positive or negative feedback, such as rewards or punishments, and the influence of a peer, teacher, family, or other person or group perceived as important (Figure 15.2). Continued receipt of feedback can motivate repetition of behavior. Using the smoking example, a reinforcing factor leading to a negative health outcome would be peer pressure to smoke.
- Enabling factors are social and environmental factors that facilitate or motivate attainment of specific behaviors, such as ease of access, availability, health-related laws, resources, and skills. An example of an enabling factor that leads to a negative health outcome would be the easy availability of cigarettes when other members of the family smoke. Table 15.10 provides additional descriptions and examples of these factors.
| Factors | Description | Examples | |
|---|---|---|---|
| Predisposing factors | Intellectual and emotional “givens” that tend to make individuals or populations more or less likely to adopt a healthy or risky behavior or lifestyle or to approve of or accept particular environmental conditions | Knowledge | A person is more likely to avoid using smokeless tobacco if they know it can lead to cancer. |
| Attitudes | People who have participated in athletics as youths tend to see regular exercise as a normal part of life. | ||
| Beliefs | A client may believe that if a food’s label says “low fat,” it is healthy to eat or that premarital sex is a sin, so teenagers should not be provided with condoms. |
||
| Values | A person who values cleanliness is more likely to follow hand hygiene guidelines. | ||
| Confidence | A client may not attempt to follow a weight loss regimen simply because they do not feel they are capable of doing so. | ||
| Enabling factors | Internal and external conditions directly related to the issue that help individuals or populations adopt and maintain healthy or unhealthy behaviors or lifestyles, or to embrace or reject particular environmental conditions | Availability of Resources | A person who abuses drugs is more likely to get help if recovery assistance is readily available to them. |
| Accessibility of Services | If a specialist has a waiting list over a year long and is located 10 hours away, a client is less likely to agree to their care. | ||
| Community and/or Government Laws/Policies | A person is less likely to drink alcohol if they live in a community that does not sell or serve alcoholic beverages. | ||
| Issue-Related Skills | A person who is very organized and manages their time well will be more likely to stick to a prescribed health regimen. | ||
| Reinforcing factors | The people and community attitudes that support or make difficult adopting healthy behaviors or fostering healthy environmental conditions | Largely the attitudes of influential people or groups | A child from a family who supported the use of masks during the COVID-19 pandemic was more likely to wear a mask in public. |
Educational interventions can influence some of these factors, while some are not as easily influenced. In the case of reinforcing factors, it may be useful to aim interventions at these influential people and groups to effectively impact an actual target individual or group (The University of Kansas, 2023).
When providing educational interventions, the nurse must also consider the health literacy of individuals. Health literacy involves each person’s ability to find, understand, and use health information and services (HHS, 2021). Health literacy will be discussed in more detail in Assessment, Analysis, and Diagnosis.
Opportunities for Health Promotion and Disease Prevention Across Health Care Settings
The Ottawa Charter first introduced the term health promotion setting, a place or social context where daily activities and various factors interact to influence health and well-being. Health promotion settings are actively used and shaped to address health-related issues rather than used solely for delivering specific services or programs. Typically, settings have physical boundaries, defined roles for people, and an organizational structure (WHO, 2021b, p. 30). Health promotion settings exist in cities, hospitals, schools, universities and colleges, and workplaces (Kokko & Baybutt, 2022). These are described more in Table 15.11.
| Setting | Description | Examples |
|---|---|---|
| Health Promotion Cities | Global networks of cities that have come together to engage in health promotion and disease prevention | South-East Asia Healthy Cities Network The Partnership for Healthy Cities |
| Health Promotion Hospitals | First identified in the 1990s as a way to support hospitals that were beginning to put the Ottawa Charter into practice; now range from implementing one health promotion project, to assigning a specific role or department to health promotion, to playing a large part in promoting the health of the community | The Wellness Institute at Seven Oaks General Hospital in Canada |
| Health Promotion Schools | Established to enhance health through education and promotion for students, school staff, families, and the community | CDC’s Virtual Healthy School that uses the Whole School, Whole Community, Whole Child (WSCC) model |
| Health Promotion Universities and Colleges | Guided by the 2015 Okanagan Charter, An International Charter for Health Promoting Universities and Colleges, which calls on institutes of higher education to embed health into all aspects of campus culture and to lead health promotion actions and collaboration locally and globally | The University of Alabama at Birmingham Health Promoting University |
| Health Promotion Workplaces | Provide programs and policies to reduce health risks and improve the quality of life for workers | CDC’s Workplace Health Promotion focused on hospital employees’ health |
The Roots of Health Inequities
Urban Health Inequities
Data on urban health inequities, or disparities in health outcomes among and within cities, has been extensively documented worldwide, spanning countries and regions, irrespective of their economic development and health care infrastructure. These disparities reflect the overarching disparities in the SDOH including economic conditions, education, the physical and built environment, and the quality and accessibility of health care. To promote health equity, nurses must tailor their health promotion and disease prevention efforts to the specific location and the population being served.
(See Freitas et al., 2020.)
Prisons, the digital environment (including social media), and more recently airports, places of worship, and specific coastal communities in the United Kingdom are other identified health promoting settings (Kokko & Baybutt, 2022). Global initiatives to address the health of those who work and live in prisons, particularly in the United Kingdom, have provided benefits from the development of a “whole-prison approach” to health promotion. This approach involves peer support for both workers and incarcerated people, behavior modification initiatives, disease prevention and screening, easily accessible information about health services and current health campaigns, and a focus on continuity of care (Woodall & Freeman, 2019). This approach has not been adopted in the United States. However, the CDC (2022) does offer recommendations and guidance for correctional settings, including information on infectious disease, COVID-19 management, traumatic brain injury, and other medical problems and conditions.
The WHO (2021a) issued its Global Strategy on Digital Health 2020–2025, which provided guiding principles, strategic objectives, a framework for action, and implementation principles for the strategy and action plan related to using digital technologies to shape the future of global health. This strategy incorporates the use of a variety of technologies to create a continuum of care (WHO, 2021a, p. 8). The WHO (2023b) has also convened a panel of experts to address infodemic management and social listening. An infodemic is an overabundance of information, including misinformation, that surges during a health emergency. The WHO recognizes that during a health emergency, people seek, receive, process, and act on information differently than in other times, making it even more important to use evidence-based strategies to address health issues. Social listening is the process of gathering information about people’s questions and concerns and the circulating narratives and misinformation about health from online and offline data sources. This includes data from social media platforms. The WHO (2023b) hopes to provide an ethical framework and tools that can be used for social listening and infodemic management.
How to Protect Yourself in the Infodemic
Watch this video to learn more about the misinformation that spread during the COVID-19 pandemic, and then respond to the following questions.
- What are some negative consequences of an infodemic?
- Do you see any positive aspects of an infodemic? Explain your answer.
- Name three ways you can protect yourself from an infodemic during a pandemic.
Over 400 airports of various sizes prioritized health and safety during the peak of the COVID-19 pandemic by becoming accredited or participating in the Airports Council International (ACI, 2023) Airport Health Accreditation (AHA) program. These airports, including several in the United States, implemented airport industry best practices to ensure an airport-centric approach to health requirements. Moving forward, the program has moved to the Public Health and Safety Readiness (PHSR) accreditation, which considers a wider range of health emergencies that may lead to air travel concerns (ACI, 2023). A variety of research has also been performed investigating the benefits of health promotion in places of worship (Kwon et al., 2017; Tomalin et al., 2019; Woodard et al., 2020) and determined that faith-based organizations and places of worship can play a vital role in health promotion, particularly for Black, Asian, and minority ethnic communities.
Finally, a setting for health promotion can be even larger than a city. The United Kingdom House of Commons (2022) identified, through a 2021 Chief Medical Officer’s report, that English coastal communities have a higher disease burden across physical and mental health conditions as well as lower health outcomes including life expectancy, healthy life expectancy, and disability-free life expectancy. In particular, there are worrying trends in public-health-related outcomes for children and young people. As a result, the Royal College of Physicians and others are encouraging a national strategy to improve the health of these coastal communities.
No consensus exists on a single setting that is best for health promotion. Instead, there are a variety of settings around which individuals and groups live, grow, work, and age that are appropriate for health promotion and disease prevention activities. Settings can be as small as an office and as large as a country, but collaboration and coordination of all entities involved can lead to improvement of health outcomes.