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J Edu Health Promot 2019,  8:144

Health promotion perception among health-care providers working in educational hospitals of Isfahan, Iran: A Qualitative study

1 Department of Community Health Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Isfahan Health Care Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Social Development & Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
4 Department of Child Growth and Development, Research Institute for Primary Prevention of Non-Communicable Disease, Isfahan University of Medical science, Isfahan, Iran

Date of Submission11-Oct-2018
Date of Acceptance07-Apr-2019
Date of Web Publication29-Jul-2019

Correspondence Address:
Dr. Atefeh Afshari
Department of Community Health Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_336_18

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BACKGROUND: Although the World Health Organization has emphasized the need for reorientation of hospitals toward health promotion (HP), HP in hospitals of Iran is a new concept. This study investigated the concept of HP among health-care professionals working in educational hospitals of Isfahan, Iran, 2015.
METHODS: A descriptive exploratory qualitative approach was employed in this study, with semi-structured interviews to investigate HP concept. The study settings included four selected educational hospitals affiliated to the Isfahan University of Medical Sciences. A purposive sample consisted of 15 health-care professionals who were participated in the study.
RESULTS: Most of the participants perceived HP as a concept synonymous to health education and disease prevention. Other meaning attributes to HP were improved quality of life and well-being, clinical practice, individual and group approach to increase health, and holistic view to health. Some empowerment strategies were described by participants, but most of the participants rarely went beyond traditional health education strategy aimed at an individual target. A sizeable number of participants used interchangeably the terms “health promotion” with “prevention,” “health education,” and “hygiene”.
CONCLUSIONS: It seems that participants of this study had limited knowledge about HP. Health-care staff have a decisive role for reorienting hospitals toward HP; thus, there is a need for ongoing in-service training for health-care professionals of hospitals to focus on HP.

Keywords: Health promotion, health-care professionals, hospital, qualitative study

How to cite this article:
Afshari A, Ghahnaviyeh LA, Khezeli M, Daniali SS. Health promotion perception among health-care providers working in educational hospitals of Isfahan, Iran: A Qualitative study. J Edu Health Promot 2019;8:144

How to cite this URL:
Afshari A, Ghahnaviyeh LA, Khezeli M, Daniali SS. Health promotion perception among health-care providers working in educational hospitals of Isfahan, Iran: A Qualitative study. J Edu Health Promot [serial online] 2019 [cited 2021 Sep 24];8:144. Available from: https://www.jehp.net/text.asp?2019/8/1/144/263444

  Introduction Top

The World Health Organization (WHO) has emphasized the need for reorientation of hospitals toward health promotion (HP) in response to health system challenges, such as the need for a reduction in health-care costs and for the effective prevention and management of noncommunicable diseases. Hence, the project of health promoting hospitals (HPHs) was launched in Europe in 1988, and the hospitals were encouraged to move toward HP.[1],[2],[3] The responsibility for HP in health services is shared among individuals, community groups, health professionals, health service institutions, and governments.[1] Since the project of HPHs was launched in Europe in 1988, the hospitals were encouraged to move toward HP.[2],[3] HP firstly defined as a process of enabling people to increase control over and to improve their health.[1],[4] Afterward, HP is considered as a broad term, which encompasses community and population-based health, public health, primary health care, advocacy, health policy, and social equity and especially contains the elements of health education.[5] It also is considered to be the core concept of medicine in general and hospitals in particular.[6] However, studies showed that general physician, nurses, and allied health professionals devote most of their time to clinical duties, and HP activities may not even provide basic health education services.[7] Recent studies have identified many barriers to carryout HP in hospitals. One common barrier relates to limited understanding toward the concept of HP and HPHs.[8],[9],[10] Studies showed that managers and health-care professionals had limited understanding toward the concept of HP and some never heard about HPHs.[7],[10],[11] Other studies show that HP is a misunderstood concept in nursing, and many nurses still do not understand the extent to which they apply HP or health education in their practice.[12] One study showed that midwives had a limited knowledge about HP, and this concept often used interchangeably with health education.[5] This lack of understanding in health-care professionals hinders hospitals' ability to effectively reorient health services.[9],[10] The implementation of the HP program is new in hospitals of Iran, and this concept has been taken into account just in line with the Accreditation and Quality Improvement Program. Hospitals move toward HP require the commitment of all health-care professional groups,[7],[9],[13] and the effective use of the potential of hospitals for implementing these programs is affected by the HP perceptions of these groups. The studies have also focused on identifying the perceptions of health-care providers about this concept and its clarity.[14] Since HP is a new concept in hospitals of Iran and professional's perception regarding this concept has not been studied, the necessity of conducting qualitative studies is felt to gain a deeper understanding to components of HP and the strength and weakness points of perception toward HP in context of the Iran's hospitals. A clear understanding of the perception of health-care professionals can be helpful in planning to hospitals reorienting to HPHs. Therefore, this study aimed to investigate conceptualizations of HP among health-care professionals working in educational hospitals of Isfahan, Iran.

  Methods Top

Design and sample

The present study was conducted using qualitative exploratory method to discover the perception of health professionals about HP in 2016. Participants were a group of hospital care professionals who have been involved in leading the Accreditation and Quality Improvement Program in hospitals (including HP program). The participants were selected from four selected educational hospitals affiliated to the Isfahan University of Medical Sciences, in the central part of Iran. Proposed sampling method was used to achieve maximum diversity of participants. The inclusion criteria for the participants were occupational relationship with HP, participation in HP activities in the hospital, having at least 1 year of work experience in the hospital, and having the opportunity and interest to speak about HP. Regarding the multidimensional nature of HP in the hospital, and to assess the general perceptions of health-care professionals, participants from different specialties were invited to study. Data were collected using semi-structured interview with 15 participants. The interviews were conducted at the time appointed by the participants at their workplace and during the official hours and lasted an average of 30 min. Data collection continued until information saturation. Hence, after 15 interviews, there was no new information in the data collection and analysis. Initially, interviews began with short questions to examine the characteristics of the participants (such as education, employment status, and work experience) and then continued with open questions such as “May you explain what health promotion means to you?”

All participants provided verbal consent for participation. Moreover, we obtained their verbal consent for recording the interviews and ensured them of the anonymous handling and reporting of their information.

Analysis strategy

Data analysis was performed simultaneously with data collection. Conventional content analysis was used to analyze the data. Initially, researchers listened to audio files several times to get an overview of the interviews. The interviews were later verbatim transcribed, and the coding was done using the MAXQDA software developed and distributed by VERBI Software based in Berlin, Germany. First, the data were read by line to line, and the primary codes were extracted. Subsequently, the codes that were conceptually similar to each other were in one class, and eventually, the classes that were similar in terms of meaning and content were placed within the themes. To meet the credibility of data, researchers have read manuscripts several times to arrive at a single correct diagnosis. Furthermore, after each step of collecting information and obtaining new findings, member check was used to examine the acceptability of the views of the participants. For this purpose, the interviews were randomly assigned to a number of samples in order to determine that the interpretation of the results reflects their perceptions. To ensure the dependability of the data, the research team determined a specific and agreed logic structure from the beginning of the data analysis for recording and coding, and the stepwise replication method was used. As a result, during some stages of the analysis, the researchers divided into two groups and independently analyzed the data and shared the results with each other. The researchers, with the arrogance of their HP interests in hospitals, committed themselves to limiting their interests and the ineffectiveness of these interests and experiences and focused on research based on contributions from contributors to avoid bias.

  Results Top

Participant characteristics

Fifteen multidisciplinary health-care professionals participated in the study. The mean age of participants was 38.8 years. Seven (46.6%) participants were female and 8 (53.3%) were male. The mean years of experience in their careers and current positions were 15.4 and 4.6, respectively. Most of the participants were nurse. [Table 1] shows the characteristics of these participants.
Table 1: Characteristics of the participants (n=15)

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The health-care professional perceptions were categorized into two categories – (1) meaning attributed to HP and (2) HP strategies. The meaning attributed to HP, as shown in [Table 2], included the following subcategories: HP means prevention, health education, clinical performance, quality of life and well-being, holistic approach to health, and individual and group approach to maintaining and improving health. The category of HP strategies also included the following subcategories: individual empowerment and community empowerment [Table 3].
Table 2: Subcategories and frequency of related statement of meaning attributed to health promotion in participants

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Table 3: Subcategories and frequency of related statement of health promotion strategies in participants

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Meaning attributed to health promotion

The most frequent meaning of HP was prevention. In some cases, the terms of prevention and health were used instead of HP by the participants. Most contributors called HP synonyms for early prevention, aimed at preventing illness and hospitalization. Furthermore, the issue of prevention is better than treatment and has been emphasized by some participants. Some contributors said that the treatment of the disease is not a HP process:

What we do for the treatment of disease does not seem to me to be a health promotion process; we have to do these efforts and they are part of the process of treating a disease, while, in my opinion, the health promotion is a distinct and different issue. Health promotion is matter before getting illness; means that people not getting sickness at all” (participant 4).

Health promotion means prevention

Some contributors consider the HP as a community-based approach to prevention, and patient treatment is in the next priority.

“Health promotion is equivalent to prevention and is not just specific to the patient. I think that up to 90 percent, the prevention is important, and just 10 percent the treatment and attention to the patient is important” (participant 9).

Health education

Another main extracted theme was the health education. Contributors understood the health education and HP as synonymous, and they understood that these two concepts are closely connected. In this sense, HP means increasing the knowledge and awareness of patients and the community to change behavior and prevent health issues. Although some contributors perceived HP as a concept beyond health education, patient education as one of the main HP activities that were conducted in hospitals was expressed by all contributors.

Health promotion as clinical performance

In this subtheme, HP was identified as a leading role of physicians and nurses in the hospital. One nurse believes that what physicians and nurses are doing to improve the health of patients is a HP, and furthermore, all the diagnostic and therapeutic processes in the hospital are HP. One of the nurses introduced the nursing diagnosis process as one of their HP functions.

“Nurse's work is a health promotion, I said, in a shift work we can also promote the health. For example, my patient now has a fever, and my plan to the end the shift, is to reduce the fever. So, I help him/her to improve by reducing the degree of the fever. Well this means the same health promotion.” (participant 8).

Health promotion as quality of life and well-being

Another meaning of HP was the increase in the quality of life and well-being of the healthy person and the patient. Some nurses pointed out that increasing life expectancy, healthy old age, having the ability to done everyday life activities, increasing the quality of remaining life, enjoying the living in all persons, and the availability of facilities for the disabled are samples of this subtheme.

“Health Promotion means both reducing illness and promoting quality of life. For example, if you assume I'm going to be 60 years old to live, be able to rely on myself during these years, be able to do my own work and travel, rather than from one age to the next not to be able to do a lot of things” (participant 14).

Holistic approach to health

A limited number of contributors perceived HP as a broad concept, which has a comprehensive look to the health. One of the physicians introduced HP as a health-care approach rather than a therapeutic process. In this category, attention to the mental, psychological, social, and spiritual health of patients beyond the physical dimension in the hospital was defined.

“Health Promotion means that when patients come to treat disease, both their illnesses be medicated and their underlying issues be taken into consideration. In fact, in addition to providing quality care and providing patient's physical health, the patient's social and mental health should also be considered” (participant 9).

Individual and group approach to maintaining and improving health

Some contributors paid attention to improving the health of the community, and some, along with the healthy community, also referred to the health of the patients. HP was introduced in this sense as a forward movement in the health and disease spectrum, which focuses on maintaining a healthy community, improving the health of the patients, and rehabilitation of disabled people for daily activities.

“Health Promotion is both for the person and community, which means raising the level of health in general. The person may be a disabled and you try to improve his health by returning him to daily activities, or be a healthy person and you may teach him how to maintain his health and this is my perspective to the Health Promotion” (participant 5).

Health promotion strategies

Participants' perceptions in the form of individual and social strategies for promoting health were ranked in this category. Most participants were focused on the individual strategies of HP to extensive environmental strategies.

Individual empowerment

In this subtheme, participants emphasized on improvement of individual lifestyle and health accountability using increase awareness, knowledge, and skills. Education was referred as the most important and most repetitive HP strategy. Participants believed that increasing knowledge and awareness about health problems in society and patients will lead to the empowerment in self-care and prevention of future health problems. Patient and fellows' participation was another strategy that was referred to limitedly. One of the nurses believed that patient and fellows' participation in decisions related to their health is the most important HP strategy that has been neglected in the hospital.

“Health promotion is the empowerment of patients in the field of self-care; a proper and planned self-care. By providing knowledge and information to the patient, we can prevent wrong self-care, disability, and complications of the illness and also empower people” (participant 11).

Community empowerment

Participants' perceptions about the environmental and social factors contributing to the health were limited. One of the contributors believed that HP is a broad area, and the health of the patient and society is achieved through the provision of essential health infrastructures. The strategies mentioned included community participation in health issues, creating supportive health policies, attention to health by legislators and control institutions, and provision of environmental facilities.

“I think health promotion does not occur unless proper infrastructure and essential perspective to it to be institutionalized. When we use the food, if the factory that produces food is not controlled, my health and other people are at risk. Even if we try to work as a nurse, doctor, or healthcare provider, it will not be beneficial and the community will not move toward health promotion” (participant 7).

  Discussion Top

This study was designed to identify the perceptions of hospital health-care professionals about the concept of HP. The meanings attributed to HP included HP means prevention, health education, clinical performance, quality of life and well-being, holistic approach to health, individual, and group approach to maintaining and improving health. HP strategies also were identified at individual and community levels.

Hospitals have a high capacity for HP, given their widespread access to health-care professionals.[6] However, based on the frequency of codes has mentioned in [Table 2] and [Table 3], the results of the study showed that most experts in this area had limited views on HP, and most of them understood the concept of HP as prevention and education. Furthermore, the use of terms of education, prevention, and hygiene in several cases rather than HP showed that participants do not have a clear perception of the difference between the mentioned concepts. Other studies have pointed to similar results consistent with the present study.[5],[15],[16],[17] Another study found that health professionals have a better understanding to these concepts than other health-care professionals.[16] While some contributors did not consider the hospital's role as a HP function, some clinicians (nurse and physician) understood everything that they are doing for the patient's healing as HP. It should be noted that HP in the hospitals of Iran has started with the launch of new hospital accreditation programs. The novelty of this concept and its nonspecificity in the hospital can be a source of ambiguity and misunderstanding of experts in the field.

While some contributors perceived HP in terms of risk avoidance, others understood HP in terms of positive quality of life and positive conditions such as well-being and healthy lifestyles. A similar result was obtained from the study of Richard et al., among nurses about the public health,[17] and in Casey's study, nurses introduced HP as a factor in increasing the quality of life of patients.[18] HP is an abroad approach that, in addition to the health of the patient, contributes to the health of the community and, in addition to the physical aspect of health, also affects other aspects of health.[19] However, these principles were not addressed in most individuals except in a limited number of contributors. Although some contributors pointed to physical, social, mental, and spiritual aspects of health, the economic, political, and environmental dimensions of health were not considered. In the study of Richard et al., the lack of attention to the dimensions and determinants of health, especially the social environment, was demonstrated in nurses' perceptions.[17] Conventionally, hospitals have been based on a medical approach, and attention has been paid to the treatment of physical illness. This limited perception of the health dimension may be due to limiting the health-care professionals to the treatment of the underlying cause of the patient's referral.

Some contributors acknowledged that HP is limited to the health of the community, which is more the task of health system than a hospital. Understanding the implementation of HP as a role of the health system may be a factor in lowering the attention of the participants to the patients.

Contributors highlighted some of the HP strategies in explaining their perception, but the results showed that the participants did not go beyond the traditional individual strategies that focused on education and lifestyle changes. In this study, social strategies for promoting health including organizational, political, economic, and social strategies were not considered in most of the participants. Furthermore, participation and engagement of people in the process of health-related decisions is one of the ways of empowerment that is emphasized by the WHO,[19] and this strategy was only mentioned by one of the participants. In other studies, similar results were obtained.[5],[17],[20] In similar studies, traditional health education approaches that emphasize on lifestyle, early detection, and disease prevention have been reported by most nurses and a small percentage of nurses referred to environmental and sociopolitical approaches.[17],[20] Studies have shown that inadequate awareness and understanding of health professionals about the concept of HP is an obstacle to the effective implementation of HP in hospitals.[9],[21],[22] Therefore, the reform of the perception of health professionals is recommended to go beyond the health education strategy and more effectively implement of HP in the hospital.

Job engagement and lack of time for study participants, especially in managers, were the limitation of the study.

  Conclusions Top

The results of the study provided valuable information about the perceptions of health-care providers of hospital related to the concept of HP. This study confirmed the insufficient insight and understanding about the concept of HP in health-care providers in the hospital and indicated that their insights were more limited to health education and disease prevention. Participants in this study were purposefully individuals who had the role of managing and directing of quality improvement programs at the hospital (including the HP program) and were agent of change and role models in the organization. Creating sound HP insights in role models of hospital is the first step in facilitating the implementation of HP in hospitals. Therefore, the implementation of educational programs focusing on HP concepts is recommended.

Studies showed that there were limited studies in Iran regarding HP in the hospital. This study also was limited to examining the perceptions of specialists who had the role of conducting and implementing the programs of accreditation and improving the quality of the hospital (including HP). Hence, we suggest conducting further studies to identify the perception of specialists and staff in other areas of the hospital.


The authors would like to thank the health-care providers and specialist of Isfahan hospitals because of their active participation

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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