This assignment will look at the development of a health promotion tool to assist in the delivery of healthy eating goals to tackle health problems related to poor nutrition and food choices taken by people with mild to moderate learning disabilities who live in supported accommodation. During a placement which was based in an NHS Continual Health bungalow, it became apparent to the author that over 50 percent of the service users were obese. The author checked the weight charts of service users and confirmed that 12 of 20 service users were clinically obese and their weight was slowly increasing over time. Only 3 of the service users undertook regular weekly exercise.
The menu planning was the responsibility of staff which resulted in the service users having no participation into the food which they consumed. The menu choices chosen by the members of staff were often nutritionally poor, mainly consisting of high calorie cheap foods, and lacked an alternative option. There were very few meals per week which included fresh vegetables, and the staff admitted on questioning that often the service users would not eat any vegetables accompanying meals, so such choices had been cut from menus. Similarly, a number of service users said that they did not feel encouraged to eat healthy foods and would just eat what was given to them.
Although consideration was given for each menu planned, a healthy balanced diet was not finalised and staff tended to be reactive to service users’ preferences rather than proactive to service users’ health needs. The author believes this was one of the factor’s resulting in the service users being overweight and underactive.
Service users are at risk of weight problems or poor nutrition as they do not make their own food choices, it is vitally important that their immune system is bolstered by a balanced diet, not only to maintain their weight, but also to fight disease and other medical problems.
Service users have the same health needs as the general population, however their conditions which often leave them less socially aware bring extra health needs. A lack of regular exercise in gyms or leisure centres, or other social settings, can be owing as much to poor socialisation skills as to weight problems. If service users are inactive and therefore not burning calories at the same rate as the more active general population then it is all the more important that their calorie intake is from nutritionally balanced foods.
Throughout this essay the author will discuss health and health promotion, and explain the importance of health promotion plus the barriers faced by a person who has a learning disability when accessing health promotion. The rationale of choosing 5 a day and healthy eating will be provided along with the strategy for developing the tool. The development and evaluation of the tool will be discussed alongside recommendations for practice.
Learning Disability Defined
The Department of Health (DOH 2001) defined learning disability as a person having a considerably decreased ability to grasp new or complex information and to learn new skills. This also coincides with the ability to function independently; it is diagnosed before adulthood and has an effect on the person’s development. Whilst it is not the sole defining feature of a learning disability, an IQ test will often be done to identify whether someone has a learning disability: if the person scores less than 70 then they are defined as having a learning disability; If the score is between 50-69 this would show that the person has a mild learning disability; 35-49 a severe learning disability; and 20-34 profound learning disabilities (Gates 2007).
The success of the tool depends on service user interaction and understanding, and a willingness to actively make food choices. It is therefore aimed at service users with a mild to moderate learning disability, although the concurrent education of staff to deliver this tool is hoped to have benefits for service users with more severe learning disabilities too.
What is health?
Everyone has a different view to what Health means, the World Health Organisation (WHO 1946) defined health as:
“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief economic or social condition” p 29.
This definition is not new but continues to be used regularly amongst healthcare professionals and academics. It hints at the subjective nature of health. This may be unrealistic as every person with a learning disability may have social interaction problems which make them “unhealthy”. However, it is the best measure to adopt when tackling health problems, as mental and social wellbeing feed directly into the choices made by service users and tackle the cause of health problems at their root.
Seedhouse (1986) has stated his definition of health as “an optimum state of health is equivalent to the state of the set of conditions which fulfil or enable a person to work to fulfil his or her realistic chosen and biological potentials”. He further argues that some aspects of health are reasonably objective (such as physical health and to remain free from physical limitations), where most are dependant upon the individual (such as degree of social interaction). This definition recognises that there should be some objective standards, rules to apply to all people, but is rather unwieldy to apply to a service user as being overweight does not prohibit a service user working towards his or her potentials, and what is realistic depends on who is assessing the service user and when the service user is assessed.
Hart (2003) recognises that standards are not the same for all people, and that individuals with a learning disability are particularly prone to poor health, and recognises the subjectivity of the WHO definition.
Whatever the definition, it is clear that health is linked to quality of life. Society is not equal, and service users find great difficulty in accessing the same services as the general population (Saunders 2006). Saunders has criticised overly objective delivery of health goals, when health itself is subjective.
Medical/behavioural/social models
The approach to mental health and the views on health promotion have changed dramatically throughout the 20th Century. The medical model pre 1950 which focussed on treating people with learning disability as people with a condition to be managed has given way to focus on development and control of behaviour and in recent years on social awareness.
Not all people with a learning disability exhibit poor health choices owing to challenging behaviour. However most people with a learning disability have a distinct lack of social awareness and social skills (Kay 2003).
Staff have a fundamental role to advise and assist with making healthy food choices. However, the goal of the health promotion tool is to enable service users to understand which food choices they should try to make every day, which is the first step to encouraging development of such social concepts as body image and the importance of exercising and long term health. These goals are secondary to the tool, but are no less important to its long term success and changing the behaviour of service users permanently.
Health Promotion At all times a learning disability nurse must remember that their key role is to enable a person to live their life to the fullest and as independently as possible. The NMC (2008) further states that a patient should always receive support regarding their health needs.
Health promotion has emerged in the last decade as an important force to improve both quality and quantity of people’s lives. Sometimes termed ‘the new public health’ it seeks to support and encourage a participative social movement that enables individuals and communities to take control over their own health. (Bunton, R & Macdonald,G 1992).
The World Health Organisation describes health promotion as being about helping a person improve and take control of their own Health. Health promotion concerns the knowledge and sill of helping people alter their way of life in order to move towards a state of best health (Acheson 1998). The aim of health promotion according to Melling et al (2004), is to achieve a better health for individuals and lower equalities in health between groups. This would include reducing and preventing disease, increasing life expectancy and improving someone’s quality of life (Melling et al 2004).
The Department of Health (1995) states that people who have a learning disability lack access to health promotion, they believe that this needs to be addressed, in ways such as the production of good practice documents. The Government White Paper “Valuing People” (Department of Health 2001), states that “good health is an essential prerequisite for achieving independence, choice and inclusion” (DoH 2001 p23).
Barriers to Health Promotion
The main barrier to health promotion for people who have a learning disability is communication and understanding. This encompasses both the difficulty experienced by service users in communicating with the world around them and engaging with ideas; and also the delivery of important social skills by healthcare professionals to service users. This affects the accessibility of health promotion material as service users are often illiterate or uninterested in their own health.
It is key to the success of any health promotion that strong reinforcement is given to service users. As an educative tool, its delivery is severely weakened if the people communicating it are not educated themselves. Therefore the first stage in the delivery of a health promotion is to ensure that staff understand exactly what message they are giving.
Fitzsimmons & Barr 1997, Langan et al 1993, Thornton 1996, believes that a significant barrier is staff lacking in communication skills and not able to communicate efficiently with service user. This would results in lack of important health advice for the person with the learning disability, compared to the overall population (Langan et al 1993), causing a major barrier. To try and overcome this problem all multidisciplinary teams should be educated in effective communication skills (Mental Health Foundation 1996).
Bollard (2002) states that inappropriate attitudes may be due to staff not having much specific learning disability experience when working with learning disability service users. If staff in the healthcare setting have negative attitudes, they may feel that it is not essential to promote a healthier lifestyle. The effect of this for the service user could be that they go on to expect a poorer type of support treatment and service (Mansell and Northway 2003).
Rationale
People with learning disabilities face the same nutritional health related problems as the general population. Large amounts of promotion regarding healthy eating has become available in the past few years, often very public schemes such as Jamie Oliver’s School Dinners. But the problem that people who have a learning disability may face is that they are unable to understand this information. This would then make the information available irrelevant. People in supported accommodation often rely on staff to prepare meals, and often have little positive input into items of shopping or menu choices.
When the author was on a learning disability placement within a continual health bungalow, it came to her attention that 12 of the 20 service users were clinically obese (4 being morbidly obese) and not regularly eating a well balanced diet, plus regular input of fresh fruit and vegetables were not incorporated into the daily menus. This causes many health risks, the most prevalent of which is obesity. Obesity has been cited as a risk factor for cardiovascular and renal disease, some forms of cancer, hypertension, diabetes, respiratory problems and other conditions, within the general population (Royal College of Physicians 1983).
Obesity can be defined as a body mass index (BMI) above thirty (Perry 1996). The incidence of morbid obesity (BMI above 40) is higher in people with learning disabilities than the general public (DoH 2002).
Obesity is a major concern due to its increasing prevalence, this would include the general population but particularly among people who have a learning disability where its prevalence is higher than the general population). Yamaki (2005) reported a prevalence of 35% in 1997-2000 in a sample of 3,499 people with learning disabilities living in the community in the US, while Emerson (2005) reported 27% in 1,304 residential service users with learning disabilities in England. People with learning disabilities present particular challenges for primary care professionals, both in terms of prevention and clinical management of obesity. The learning disability group comprises of 2.5% of the UK population (Whitaker 2004).
The aim of the health promotion tool is to ensure that a well balanced healthy diet is promoted whilst ensuring that five items of fruit and vegetables are incorporated into each day’s menu. The nutritional status of people is seen as of particular importance in the field of nursing, not only in the physical sense of health, but as LeMay (1996) stresses also the influence it has on the person’s psychological and social wellbeing. Sarah Mullally, England’s Chief Nursing Officer stated ‘Every nurse is responsible for ensuring that people receive dietary care appropriate to their needs’ (Dinsdale 2000). Staff need to be educated and ready to provide such a service and be prepared to change menus to provide the “5 a Day”. This can also be supplemented by provision of fruit bowls to allow service users to snack healthily.
There are many ways to promote healthy living, but the government recommendation of five portions of fruit and vegetables a day is the most readily accessible and applicable to all service users. Whilst healthy eating can tackle weight problems, it also will tackle service users with other nutritional problems, and can be monitored by service users very easily without needing to absorb or retain complex information.
Development of the tool
When using and making a health promotion tool it is essential to put all information in a logical order, and ensure that it is easy to read and understand without reading thoroughly. Service users often have poor reading skills, and poor concentration. Large print at 14 point or above will work best. The use of symbols or pictures is essential to communicate the most important aspect of the message immediately with very little analysis required. Abstract thought must be avoided, the message must be consistent and key words should be repeated. Healh staff should read instructions aloud so that the person with the learning disability can hear and understand (Townsley & Gyde 1997).
It is for this reason that the tool is contracted on a large laminated poster of A2 size so that it can forma focal point of the kitchen. The poster contains the most popular fruit and vegetables which the author gathered using a service user questionnaire, to ensure that all the items are easily recognisable. They are bold and colourful to enable service user to grasp their meaning immediately with very little cognitive effort. The fonts are clear and easily readable and the “5 a day” message is clear on the poster.
A service user can see throughout the day at a glance if they have had the recommended daily intake of fruit and vegetables. However, the tool is not supposed to be used in isolation. Before implementing, it is vital that staff are educated as to how the “5 a Day” scheme works. For instance, no one fruit or vegetable can count twice in one day, and there should be a range of colours eaten for the best nutritional benefit. It is vital that carers instil enthusiasm into service users by helping them prepare meals, and to educate service users in the “5 a Day” logos which appear on packaged supermarket products when shopping, and have service users interact with their food choices from shop to plate.
The plan is laminated to be reusable, but large enough to be a focal point of the kitchen. It is brightly coloured, but its sturdy nature means that it is a low cost tool. It conveys the message primarily by pictures and simple words. The “5 a Day” scheme is simple which will enable the rules to be conveyed to care staff quickly and easily, and at very low cost without further training material, and can be incorporated into current training regimes.
It is not submitted that the health promotion tool is suitable for service users with a more intrusive learning disability which necessitates primary carers making all choices for the service user, but hopefully the education of primary carers will assist these also.
There may be a risk with the tool being applied too rigidly by service users who are high on the autistic spectrum who may become unnecessarily concerned if they do not manage to eat 5 a day, or may become concerned with limiting themselves to only 5 a day or to the exact quantities shown on the poster. The tool is not designed to be this rigidly applied, only to provide guidance towards good health. For this reason, service users with autism should be monitored closely when using the tool, and the tool be withdrawn if it is used incorrectly.
Evaluation of the tool
Evaluation of a health promotion tool is vital to ensure it is valid and reliable as a method of increasing health, or awareness of health. It can be adapted to be used in other areas, such as portion control, or being used by staff to help them plan their menus, with only minor adaptations.
The tool has been discussed with the multi-disciplinary team at the unit at which the author had her placement. This included a dietician who agreed that the tool would have a positive impact on health if it worked correctly.
In the short term during a work experience placement where the tool has been trialled, it was noted that service users in general adapted their eating plans accordingly. Information on a daily basis was collated by asking service users to record their food intake. Whilst it was noted that many service users continued to eat unhealthy extra foods, such as chocolate and sugary or high fat snacks, 18 out of 20 service users were eating at least 5 fruit and vegetables a day in their main meals.
The tool can be evaluated in the long term on a number of scores:
Medically: The most immediate measure will be to monitor changes in weight, body shape or activity. Those service users who are lethargic through weight to health problems should find themselves with more energy to do more social activities. This can be evaluated by simply asking the service users and the staff how their lives have changed. The drawback to assessing the impact on only this ground is that a lack of physical or social change does not mean that the tool has not improved general health, or that the change in lifestyle will stop future health problems. Whilst the future long term effects can be monitored, a more reliable indicator may be changes in blood pressure, cholesterol and other routine observations taken by medics in the unit or GPs. The results of an annual health check may also provide reliable data.
Socially: The service users could be assessed objectively on whether they have socialised more, felt more confident, or have taken greater participation in everyday social tasks such as shopping. This could be via a questionnaire to assess the subjective impact and review of the care records to assess objective changes.
As an effective tool: On another level, the service users and carers can be asked to assess how easy the tool was to persist with, and whether service users have found it a chore or have engaged readily. This will give more direct feedback on whether the tool is easily accessible and suitable to be used in a wider health context, perhaps with children.
As an important contributor to changes in healthcare delivery: Another evaluation can be an assessment of how health care content has changed. For instance, how shopping trips have changed, whether more time is spent on preparing meals, or whether the service user has increased their independence. This can have important consequences for determining the future changing role of carers and other professionals.
Conclusion
Whilst completing the health promotion tool, the author has come to the conclusion that obesity, plus lack of healthy eating is a major problem within society and this has resulted in extreme health related problems. Despite well publicised health promotions for the general population, such as Jamie Oliver’s attempt to improve health choices for schoolchildren, the evidence is that health choices remain poor. What concerns the author is that if people without a learning disability are unable to change their attitudes about food and take pride in their actual intake of healthy fruit and vegetables, people with learning disabilities are going to face even more barriers.
For service users such as the ones who resided in the continual health bungalow, it is the responsibility of the staff to prepare the meals. Therefore the author believes that education must be reinforced through staff as well as the service users. Often other healthy eating promotions such as the “eat well plate” are placed on a fridge or behind the door and easily forgotten the difference with the 5 a day tick away chart is that you have to use it to get the full benefits out of it.
The experience has shown the author that it is possible to develop health promotion tools which have a direct impact on service users’ health, and also on their outlook. By promoting service users to make the right subjective decisions and pressing the importance of health, it is realistic to see health as defined by the WHO as encompassing social wellbeing. In the end, the proof will be in the long term evaluation, which is one of the inevitable weaknesses of the tool.