Attitudes Toward Health Promotion Among Nurses in Primary Care Settings: A Cross-Sectional Study

Positive attitudes were found with a mean score of 25.26 out of 32 (SD = 2.96). While 87.6% of participants agreed that nurses should assume more responsibility for health promotion, 60.7% agreed that patients found health promotion dull and boring. While 71% claimed to have the necessary skills to conduct health promotion, only 43.4% agreed that they had enough time to conduct health promotion. Furthermore, nurses with a bachelor’s degree had significantly higher attitude scores compared to nurses with an associate degree (t [143] = -2.053, p = .042).


INTRODUCTION
Health promotion is a process of enabling people to increase control over and improve their health [1]. It is considered one of the effective strategies to manage the needs of community health, besides decreasing health disparities among people. It is also considered one of the most effective ways to control health care costs [2]. The first international conference on health promotion was held in Ottawa in 1986 as a response to ongoing expectations for a new public health movement internationally. The World Health Organization (WHO) global health conferences have established and developed global principles and action areas for health promotion. Recently, the 9 th global conference highlighted the promotion of health as a sustainable development goal as well [3].
The leading cause of death globally is non-communicable diseases (NCD) such as diabetes, heart disease, hypertension, and respiratory disease. Each year, 15 million people die from NCD between 30-69 years of age, and 85% of premature deaths occur in low-middle income countries [4]. Thus, some of the modifiable risk factors such as tobacco use, diet, inadequate physical activity, obesity, and overweight could be improved by health promotion [5]. In Jordan, public health appears to be regressing in terms of lifestyle as 32.3% of the population reported being tobacco smokers [6], and only 27% reported being physically active [7].
Vital NCD interventions through a primary health care approach can strengthen early detection and treatment [4]. The induction of health promotion in primary care settings could help build an effective health care system leading to improved health equity, effectiveness, and efficiency [8]. Jordanian primary health care centers are considered the first point of contact in the national health system [9].
Nowadays, health care providers are becoming more involved in disease prevention and improving the well-being of people. It is very important for them to understand the concept of health promotion and to use it in practice [10]. Limited studies were conducted in the Middle East regarding the attitudes of primary health care practitioners toward health promotion. For example, a cross-sectional study among 322 Jordanian primary health care practitioners revealed that 61.7%, 41%, and 38% of them felt that patients did not need education about the association between smoking, diet, physical activity and cancer, respectively while 36.5% reported that counseling made them feel uncomfortable [11]. On the other hand, a cross-sectional study among 120 Iraqi nurses revealed that 88.3% of nurses concurred that they should take more responsibility for the promotion of health, while 59.1% and 53.3% agreed that they had enough time and skills to conduct health promotion effectively [12].
Health care providers face many barriers that could influence and affect the success of practicing health promotion [13]. For example, a descriptive study was conducted among 144 health Turkish care providers in 33 different family health centers. Insufficient time and lack of personnel were the most reported barriers by 65.3% and 39.6% of participants, respectively [14]. Another cross-sectional study was conducted among 803 primary health care providers in 75 primary centers in Saudi Arabia. More than half of the nurses and physicians reported lack of time as the main barrier in addition to lack of educational materials, appropriate training and guidelines, patient cooperation, and financial incentives [15].
Nurses comprise the largest occupational group of frontline healthcare providers in the healthcare sector. Thus, they must be aware of this responsibility to promote behavioral change through health education. This study will measure the attitudes of nurses in primary care settings and the barriers preventing them from conducting health promotion in primary care settings in the new century. This will give us an idea on whether to implement more training programs for nurses to improve their role in health promotion in primary care settings.

Study Design and Setting
A cross-sectional design study was used between November 2020 and February 2021 to describe the attitudes toward health promotion among Jordanian nurses in primary care settings, in addition to describing the possible relationships between its variables.
This study was conducted in 47 primary health care centers directed by the Ministry of Health in northern Jordan. Each health care center has at least two general practitioners, two nurses, one midwife, one dentist, one internal medicine doctor, two pharmacists, and one gynecologist and one pediatric doctor who visit only twice a week. Health care services are available six days per week from 8 am till 2 pm.

Population and Samples
The target population of this study is all nurses working in primary care settings in Jordan. The accessible population is all nurses in the selected primary care settings. The inclusion criteria were all Jordanian nurses working in primary care settings, dealing directly with patients, having either a bachelor's degree or an associate degree (a college degree after two years of study), and a minimum of one year of experience.
Non-probability convenience sampling was used to recruit the participants. All those who met the eligibility criteria and agreed to participate were recruited until the desired sample size was achieved. The sample size was estimated using G*Power software (2014). Using a conventional power estimate of 0.80, alpha of 0.05, and a medium effect size, it was estimated that for the t-test (two groups), 142 healthcare providers were needed. A total of 145 nurses were approached to cover for missing data.

Instrument
A self-administered questionnaire was used in this study to collect the data. One part of the "nurses' knowledge and attitudes toward health promotion questionnaire" by Faris (2015) was used. The used instrument was adopted from a previous study in Baghdad after taking approval from the researcher [12]. Since Arabic is the official language in Jordan, the questionnaire was translated into an Arabic version with back-translation from Arabic to English by a professional expert.
The questionnaire focuses on nurse's attitudes toward health promotion. The questionnaire comprised two parts focusing on demographic data and attitudes of nurses toward health promotion. The first part of the demographic data includes nurses' age, gender, educational level, number of experience years, and the receiving of training courses on health promotion or lack of it. The second part about nurses' attitudes includes 16 items (three related to constraints, five to responsibilities, and eight to client's reception responses). Items were measured using a two-level scale of agree and disagree. The reliability of the instrument was checked. The Cronbach's alpha of the whole instrument was 0.72.

Ethical Consideration
Ethical approval for conducting this study was obtained from the Institutional Research Committee (IRB) in Jordan University of Science and Technology (Ref # 211/132/2020). The IRB was also obtained from the Ministry of Health to conduct the study in the primary health care centers. The purpose of the study was explained to the participants and the consent form was obtained. Confidentiality, voluntary participation, and anonymity were maintained. Finally, Helsinki Declaration has been followed for involving human subjects in this study.

Data Collection Procedure
The data collection began after obtaining approval from the Institutional Review Board (IRB), the primary investigator's university and the Ministry of Health (MOH). Each health center director was approached by the researcher or assistant researcher to discuss the purpose, significance, and nature of the study, and to approve the needed help in recruiting the participants. After that, all participants who satisfied the eligibility criteria were included until the sample size was achieved. Each participant was asked to fill the questionnaire within an average time of 10 minutes. A total of 145 participants were recruited. The data collection process continued for about three months from November 2020 to February 2021.

Data Management and Analysis
The Statistical Package for Social Science (SPSS), version 22 was used to analyze the data. The collected data was cleaned and screened for any incomplete or missing data. There were no missing data. Statistical significance was accepted at p < 0.05 for all tests. Descriptive statistics were used to describe the characteristics of the sample and the study variables. Pearson correlation and independent-sample t-test were used to answer research questions.

Socio-Demographic Characteristics of Study participants
One hundred and fifty nurses who satisfied the inclusion criteria were approached in the primary care centers of Irbid and AL-Ramtha. Of those, one hundred and forty-five nurses agreed to participate with a response rate of 96.6%. Of those, 90 were from Irbid and 55 from AL-Ramtha primary health care center.
Of the total sample, 78.6% were females. The age of participants ranged from 23 to 52 (mean = 38.6, SD = 6.16). The participants' experience ranged between 1 and 30 years (mean = 12.8, SD = 6.9). About 60% of the participants had an associate degree in nursing, and 55.9% attended training courses in health promotion as illustrated in Table 1.

Nurses' Attitudes Concerning the Health Promotion
The attitudes of nurses were measured using16 items. These items were classified into constraints (three items), responsibilities (five items), and perception of the client's responses (eight items). The answers for all items were (disagree = 1) and (agree = 2). Items 6,7, and 9-15 were reversed. The mean total attitude was 25.26 out of 32 (SD = 2.96).
Regarding the constraints that prevent nurses from implementing health promotion, only 43.4% of participants agreed that they had enough time to conduct health promotion, while 71% agreed that they had the necessary skills to conduct health promotion for their patients. Regarding health promotion responsibilities, 87.7% agreed that nurses should assume more responsibility for health promotion, while 49.7% thought that patients were totally responsible to promote their own health. Regarding the client's perception, 60.7% of participants agreed that patients found health promotion dull and boring when they provided it to them. Moreover, 51.7% agreed that in general, people do not take any notice of what nurses say on lifestyle ( Table 2).

Relationship Between Demographic Data and Attitude toward Health Promotion Among Nurses
The results revealed no significant correlation between attitude and years of experience (r [143] = .141, p = .091). Furthermore, there was no significant difference between nurses who received training on health promotion (mean = 25.26, SD = 2.52) and nurses who did not (mean = 25.25, SD = 2.55) in terms of attitude score t[143] =.022, p = .9830. However, the results revealed that nurses with a bachelor's degree (mean = 25.78, SD = 2.56) had a significantly higher attitude scores compared to nurses with an associate degree (mean = 24.91, SD = 2.45), t [143] = -2.053, p = .0420 ( Table  3).

DISCUSSION
In the current study, most of the participants showed a positive overall score of attitudes toward health promotion, which is supported by studies conducted in Saudi Arabia and Iraq in which nurses held positive attitudes towards health promotion [12,16]. Regarding the constraints preventing participants from conducting health promotion, around half of the nurses in the current study thought that nurses or even medical doctors do not have enough time to conduct health promotion. This might be explained by the workload on nurses and the shortage of staff affecting their health promotion practices. These results are supported by a study in Saudi Arabia in which half of the nurses agreed that staff nurses do not have enough time to carry out health promotion effectively [16]. Other studies in Australia and Turkey reported time as the main constraint preventing nurses from conducting health promotion [14,17].
Unsurprisingly, over 85% of the participants in this study agreed that nurses should take more responsibility for health promotion, which is consistent with previous studies in Saudi Arabia and Iraq where the majority of nurses agreed on the same [12,16], while half of the participants stated that patients are totally responsible for promoting their own health, and less than half agreed that nurses should only provide health promotion if requested by the doctor. These findings are also supported by the same studies in Saudi Arabia and Iraq where half of the nurses or even less agreed on the same [12,16]. This might be explained by the fact that nurses are confident that they are knowledgeable and qualified enough to provide health promotion.
Furthermore, two-thirds of nurses in the current study agreed that clients find health promotion dull and boring and that the client's lifestyle was conditioned by their culture and environment. However, less than half of the nurses agreed that they should not interfere with a client's life by telling him/her to stop smoking, lose weight, or exercise more. These findings approximated the ones reported in the Iraqi study where half of the nurses and more agreed that clients found health promotion dull and boring and that the client's lifestyle was conditioned by their culture and environment, while less than half agreed that they should not interfere with a client's life [12]. The findings of this study emphasize that the majority of nurses believe that health promotion is a vital component of primary care, but they still need to believe that the clients themselves are willing to learn, and that their time and efforts are supported by their administrators and work environment.
The current study reveals a significant relationship between the attitudes of nurses and their educational level. This result was supported by the findings of a study conducted in the United Kingdom, which revealed that years of education play an important role in nurses' feelings and attitudes toward health promotion [18]. An explanation of this result might be that health promotion and patient education, in general, are crucial components in the bachelor level of the nursing curriculum, affecting the positive value of health promotion among graduate nurses. However, the attitudes of nurses and their training bore no relationship to health promotion. This result may indicate that the currently provided training is not strong enough to enhance attitudes of trained nurses in comparison to the untrained, emphasizing the need for more consistent and comprehensive training.
This study has several implications. For example, nurses who work in primary care settings can play a vital role in preventing and screening for NCDs and improving the quality of life for their patients by guiding them toward a healthy lifestyle. That is why attitudes toward health promotion should be enhanced and their role supported by their supervisors. Policymakers should encourage the adoption of participatory approaches for health promotion initiatives to provide minimum financial resources, support further research that could help in the health promotion process, and support the establishment of a training and education infrastructure to develop expertise in the field. A previous study recommended updating the preservice training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement [19].
This study helped to gain a better understanding of the attitudes of nurses toward health promotion in primary care settings in Jordan, although it still has some limitations. The use of a cross-sectional design and a relatively small convenience sample from the northern part of Jordan only limited the ability to generalize the results of this study and to examine causality between variables. Moreover, the use of a self-report questionnaire may occasion the possibility of inaccurate answers and response bias. Thus, similar studies of advanced designs, larger samples, and more comprehensive measurements are highly needed. The results can be used to guide further research in the health promotion area. Future qualitative studies are recommended to examine nurses' perceptions toward health promotion. Future quantitative studies are also recommended to study the attitudes toward health promotion and to investigate the relationship with other variables using large random samples of health care providers with different specialties from different settings all over the country.

CONCLUSION
This study indicated generally positive attitudes toward health promotion among nurses working in primary care settings. However, the role of nurses in primary care settings as health promoters should be enhanced. The present study results supported also the relationship between nurses' attitude toward health promotion and their educational level. Thus, the value of health promotion should be emphasized early on among all nursing students. More time and resources should be allocated to facilitate health promotion in primary settings, and policymakers and administrators should establish clear guidelines and a supportive environment to enhance the nursing role in health promotion.

LIST OF ABBREVIATIONS WHO
= World Health Organization NCD = Non-communicable Disease

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical approval for conducting this study was obtained from the Institutional Research Committee (IRB) in Jordan University of Science and Technology (Ref # 211/132/2020). The IRB was also obtained from the Ministry of Health to conduct the study in the primary health care centers.

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION
The purpose of the study was explained to the participants and the consent form was obtained. Confidentiality, voluntary participation, and anonymity were maintained.