A response to D. Von Ah, S. Ebert, A. Ngamvitroj, N. Park & D.-H. Kang Predictors of health behaviours in college students. Journal of Advanced Nursing48(5), 463–474.
Article first published online: 14 MAR 2005
Journal of Advanced Nursing
Volume 50, Issue 1, pages 111–112, April 2005
How to Cite
Whitehead, D. (2005), A response to D. Von Ah, S. Ebert, A. Ngamvitroj, N. Park & D.-H. Kang Predictors of health behaviours in college students. Journal of Advanced Nursing48(5), 463–474. Journal of Advanced Nursing, 50: 111–112. doi: 10.1111/j.1365-2648.2004.03342.x
- Issue published online: 14 MAR 2005
- Article first published online: 14 MAR 2005
While I am always interested to read any health promotion-related paper, the one by Von Ah et al. raised a number of concerns for me.
The study on which the paper was based was grounded in the psychosocio-cognitive, behaviourally-orientated, lifestyle-related framework that focuses on issues of individual self-efficacy, social learning, stress and threat/risk. Von Ah et al. then suggest that their study outcomes can be applied to current and future health promotion programmes. However, individualistic, behavioural and preventative-focused indicators do not fit with wide-reaching health promotion programmes. Health education has several functions that include imparting health-related information to influence values, beliefs, attitudes and motivations in order to achieve health- or illness-related learning through knowledge acquisition, assimilation and dissemination, skills development and lifestyle/behaviour modification. These activities are generally targeted at the level of individuals and range from information-giving through to enabling processes. On the contrary, health promotion seeks to directly influence the broader aspects of ecological, cultural, economic and environmental health that determine the health of individuals in their communities, and have political underpinnings within an ‘environmental engineering’ process. Current health promotion strategies are drawn from policy-driven initiatives that work through the processes of social examination and modification, particularly at the level of collective social action.
According to the above and my recent concept analysis, Von Ah et al.'s study has little to do with health promotion, but is firmly located instead in a health education context (Whitehead 2004a). Interchangeably categorizing behaviourally-focused health education outcomes with those of broader health promotion strategies sets a dangerous precedence for health-related researchers in today's climate. All nurses need to define and delineate exactly what constitutes both health education and health promotion practice. Rawson (2002, p. 267) argues that ‘the asking will help better define the subject matter and create the discipline to discover the true potential of health promotion’. Similarly, Whitelaw et al. (1997) argue that health promotion is judged not only on its actions but also on its capacity to develop an appropriate theoretical agenda. Therefore, effective health promotion and health education practice need to be based on clear conceptual theory in order to validate current practice and serve as a springboard for innovation and advancement. Health researchers need to understand the context of their health education and health promotion research so that their findings can be compared with those of other studies in terms of location and conceptualization.
Von Ah et al. (p. 465) state that their study was ‘designed to delineate factors, which significantly contribute to health behaviours in college students’, implying that their research is original and suggesting that similar studies are lacking. However, many studies have been reported in the generic (and sometimes nursing) health promotion and health education literature on the same and similar subjects (see, for example, Carter & Kahnweiler 2000, Kear 2002, Barth et al. 2002, Prokhorov et al. 2003, Britton 2004). Much of the literature used by Von Ah et al. has become dated in comparison with many of the studies I have cited. Also, the theoretical link between cognitive health behaviour, threat, social mechanisms and self-efficacy has long been established in social learning theory (Dijkstra & de Vries 2000, Keeling 2000, Leganger et al. 2000). Thus, this study only seems to ‘prove what is already well proven’.
Socio-cognitive behavioural-change programmes are notoriously complex, problematical and, more often than not, unsuccessful without very careful consideration and attention to their context, aims, rationale and considered outcomes (Whitehead 2001a,b, Whitehead & Russell 2004). In this case, I would have to argue that the apparent lack of any health-related programme to pin the findings on, or to match them against, presents a precarious state of affairs for this research. Using terms, as the authors do, like ‘must use interventions to maximise self-efficacy’, ‘should incorporate methods for enhancing self-efficacy’, or ‘further research…may be needed’ come across as polemical, especially in the absence of programme-related findings or outcomes.
Another issue is that of the validity of the findings. Von Ah et al. acknowledge the small sample size, need for further psychometric testing of the questionnaires, limited generalizability of the findings, and need to interpret the findings with caution.
Finally, there is barely a mention of nursing or the implications of this study for nurses. Four of the five authors are attached to schools of nursing, yet the first mention of nursing comes in the final line of the conclusion. Also, the study is heavily biased in favour of the US context and the discussion is not balanced to reflect the wider international context. This means that related important international texts are not acknowledged (e.g. Petkeviciene et al. 2002, Xiangyang et al. 2003). There is also no mention of the World Health Organisation's (WHO) Health Promoting University (HPU) movement which has been in place since 1997 (Dooris 2001). Nor do Von Ah et al. mention the 72-member college and university institutions of the American Network of Health Promoting Universities (ANHPU) movement – through its association with the Association of Academic Health Centres (AHC) (Whitehead 2004b).
I do not want to seem overly negative about this paper but, on the contrary, criticism of any published research may help to ensure that future studies are more robust. Nursing has long had a poor reputation in the field of health education and health promotion research. This is slowly changing, with more examples emerging of sound evaluation studies of health-related programmes. However, studies such as that reported by Von Ah et al., are merely replicating what is well-established and not adding to the development of health-related research. This needs to change so that appropriately located, constructed and valid recommendations can emerge from future nursing-related health research.
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