Introduction

The population's general health is increasingly affected, becoming a concern for everyone ¹. The Pan American Health Organization ² reported that non-communicable diseases (NCDs) cause more than 41 million deaths each year, with a total annual mortality rate of 71 % and more than 85 % of these deaths occur in countries with low and middle-income economies. Non-communicable diseases are chronic conditions with a long evolution and slow progression, including cardiovascular diseases, cancer, respiratory diseases and diabetes. Because of these alarming figures, health promotion and disease prevention have taken on great importance and are currently priority themes in global public health policies and management ³. Since the first International Conference on Health Promotion in Ottawa, Canada in 1986, it was established that health promotion "is the process of enabling people to increase control over their health in order to improve it" ⁴. Health promotion is considered an elemental strategy that encourages modifications in the environment that contribute to promote and protect health ⁵ so that people acquire and develop personal skills and abilities that allow them to modify health-related behaviors and the acquisition of a healthy lifestyle, contributing to improve their quality of life ⁶. A healthy lifestyle consists of adopting multidimensional behaviors that must be maintained over time by internal and external factors; the person must modify those behaviors that make them more or less prone to disease, in addition to maintaining or improving their state of health and reducing the risks to their health ⁷.

Related behaviors are behavioral patterns in diet, tobacco consumption, physical activity or lack of it, leisure hazards (consumption of alcohol, drugs, and other related activities) and occupational ones. Depending on the behavior, they are considered protective or risk factors for health, since the latter promotes the development of communicable or non-communicable diseases (diabetes, cardiovascular diseases, cancer, among others) ⁶. The increase in risky behaviors and unhealthy lifestyles adopted through voluntary or involuntary interventions performed individually or collectively by individuals promotes harmful outcomes and undermines health ^8,9.

The World Health Organization (WHO) defined health-promoting lifestyle as “a way of life that is based on identifiable patterns of behavior, determined by the interaction between individual characteristics, social interactions, and socioeconomic and environmental living conditions” ¹⁰. These factors are not uniform for all health behaviors, this can be seen in the variety of behaviors of individuals, since they can live with healthy and unhealthy lifestyles simultaneously; if the individual performs some healthy behavior, it does not guarantee that he will perform other healthy behaviors. In the same sense, Pender, a nursing theorist, established that health-promoting behavior or health-promoting style “is the result of actions aimed at positive health outcomes, such as optimal well-being, personal fulfillment and productive life” ¹¹. A healthy lifestyle or behavior involves executing positive activities that promote the probability of obtaining short- or long-term physical and physiological effects that promote physical well-being and survival; therefore, a health-promoting lifestyle permits the development of behaviors that intervene positively in people's health ¹². The identification of the most relevant perceptions by users and health service providers allows nurses to propose cost-effective interventions that encourage people to change their family, work or recreational environments to healthy or low-risk ones, by establishing strategies that transform living conditions and daily activities and keep the individual motivated, with the purpose of reducing vulnerabilities and valuing the networks that provide social support to improve their quality of life, by being a proactive agent of health ¹³.

The International Council of Nurses ¹⁴ pointed out that nursing is an essential profession in the entire health care system and has a great deal of responsibility, since it plays a fundamental role in helping to reduce lifestyle-related health risks and encourages the acquisition of a health-promoting lifestyle by incorporating nursing interventions aimed at promoting physical activity and healthy nutrition. In terms of risk prevention, nursing seeks to avoid the harmful intake of alcohol, tobacco and other substances, taking into account the socioeconomic status, gender, and cultural and religious beliefs of the persons being cared for. A primary function of nursing is to preserve health and promote the well-being of people by providing care based on a theoretical foundation that supports its actions, attending not only the individual at risk or sick, but also healthy individuals, to strengthen their health assets ^15,16.

When reviewing the scientific literature, few qualitative studies were found that addressed the experiences of adults and health professionals on health promotion and healthy lifestyles; most of the literature was quantitative and focused on improving a disease condition (obesity, diabetes, hypertension, among others). Therefore, it is considered pertinent to include the results of these primary researches through a qualitative meta-synthesis with the purpose of gathering in a single research report a series of evidences that allow directing health promotion to develop a lifestyle in the population from the perception of the people and the health team. Based on what was analyzed, the following question was posed: What was the health promotion perception of adults and health professionals in order to modify their lifestyle?

This review uses a qualitative methodology in the field of nursing, which allows us to discern complex and varied realities, in addition to exploring the representations of human experience and approaching them to capture the subjective and contextual elements of social processes ¹⁷. This research design considers some main criteria for assessing the potential relevance of the qualitative approach, including convenience, social relevance, practical implications, ethical value, methodological usefulness, as well as analyzing feasibility and reasoning possible implications ¹⁸.

At present, like quantitative research, meta-analysis or qualitative meta-synthesis is considered the highest level of complexity in qualitative secondary research ¹⁹; it is a novel methodology of great contribution and interest for the disciplines, which, through its methods and types, provides elements to establish, describe or explain theories regarding useful phenomena ²⁰. This includes qualitative meta-analysis, systematic review and critical review of a study ^17,21. The purpose of this study was to examine what qualitative evidence indicates about the perception of health promotion by adults and health professionals to contribute to lifestyle change.

Methodology

Qualitative meta-synthesis was used, which allows the integration and synthesis of findings obtained from several meta-studies with metadata analysis (analysis and interpretation of diverse qualitative research results) ²⁰ to respond to a sociocultural approach through different modern procedures used in the analysis and synthesis of these qualitative scientific results reported in several primary studies already published ¹⁹. In addition, Sandelowski and Barroso's proposal ^22,23 was used, which consists of a process of integration or comparison of results, giving relevance to the interpretations made by the primary scientists and to the scientific evidence that reports results on the phenomenon of interest.

The research question was formulated using the acrostic elements: P=Population or subject of interest, I=Intervention, C=Comparison, O=Outcome and T=Time of the study (PICOT format) (24), this research question was established as P=Adults and health professionals, I=Lifestyle, C=No comparator, O=Perception on health promotion, T= Qualitative primary studies from 2008 to 2019. The search period was from September 2019 to March 2020. The selection criteria were: primary qualitative descriptive or interpretative qualitative research that addressed the perceptions of adults and health professionals regarding health promotion and lifestyle, the articles must have been published between 2008 and 2019, in Spanish, English and Portuguese. The databases used for the search were the Virtual Health Library (VHL), Scientific Electronic Library Online (Scielo), Latin American and Caribbean Health Sciences Literature (LILACS), CUIDEN and the Google Scholar search engine. Keywords based on health science and BIREME descriptors included: health promotion, healthy behaviors, healthy lifestyle, adult, and qualitative research, in all possible combinations and using AND OR Booleans.

The exclusion criteria were studies with a quantitative approach, health promotion aimed at modifying lifestyle in the pediatric population or with a specific health problem; in addition, repeated studies were eliminated, (Table 1).

As mentioned above, 156 referenced articles were obtained, which were screened by title and abstract, resulting in 27 manuscripts. The final screening was performed by full-text analysis, resulting in only 10 articles that met the established inclusion criteria, (Figure 1).

Source: Own-developed

Figure 1: Articles included in the literature review, 2022 

The articles were classified as follows: a) people's perception of health promotion, b) vulnerable populations' perception of health promotion, c) health professionals' perception of health promotion programs. To verify the scientific rigor of the selected research articles, the criteria established by Lincoln and Guba were applied, who proposed: credibility of the criterion similar to internal validity, transferability equivalent to external validity, analogous terms reliability and relative confirmability comparable to objectivity, thus assuring quality from the naturalistic paradigm ²⁵. Finally, for the presentation of the results, the data were organized taking into account the authors, year of publication, title, country, objective, sample, methodology, and criteria of scientific rigor.

Results

With the analysis of the qualitative primary articles, it was found that the countries where the articles were developed corresponded 50 % to Brazil ^26-30, 20 % to Spain ^31,32 and 10 % to Sweden ³³, Colombia ³⁴ and England ³⁵, respectively. The population and age of the participants ranged from 21 to 80 years, with 20 % being young adults ^29,34 and 80 % adults and older adults ^{26-28,30-33,35}.

In relation to the research design, 70 % were exploratory descriptive; in addition, the following techniques were used: individual interviews ^26,28,29, focus groups ^33,34, semi-structured in-depth interviews ³², and participant observation ²⁸. For data analysis, some authors used collective subject discourse ²⁶, discursive practices and mind-mapping ²⁷, participant observation and dialectics ²⁸, reflection using an instrument with open and closed questions and convergent assistance ²⁹, participatory action and Freire's Method ³⁰, sociological discourse analysis model ³¹, Braun and Clarke's realistic thematic analysis ³², content analysis with phenomenological hermeneutic method ³³, action-participation with field diary ³⁴, and realistic thematic analysis ³⁵.

The studies did not mention in their rationale the scientific rigor that supported their research, but with the analysis it was possible to demonstrate that 70 % of the studies met the criteria of credibility, dependability and confirmability ^{27,29-31,33-35}. In 30 % of the studies the transferability of the results could not be guaranteed because the population studied was very specific ^26,28,32.

According to the classification of the articles, 30 % of the studies addressed the perception of health professionals such as nurses ²⁷, other health professionals ³³ and patients in relation to health promotion activities in interventions to improve lifestyle or healthy behaviors in various areas such as tobacco use, exercise and diet on an individual or group basis, in already established programs, and the use of health technology ^30,31,35. Twenty percent (20 %) of the authors analyzed people's perception of health promotion in indigenous populations ²⁶ and individuals with intellectual disabilities ³².

In relation to people's perception of health promotion, it was identified that the sociocultural context ²⁶, interpersonal or family relationships ²⁹, macro and micro social environment ³¹, and internal and external influences ³⁵ directly influenced people's acceptance or rejection of some interventions to modify their behaviors or their resistance to change health habits.

People recognized that doctors, nurses and other health professionals had the knowledge, role and moral authority to generate changes in aspects of their health; however, they mentioned that the time dedicated to them in each of the programs or activities was insufficient, due to the diversity of tasks and the excessive demand for health services, especially for the elderly ^30,31. There were difficulties in communication and dissatisfaction with health professionals, which was an obstacle in the efforts to achieve healthy lifestyle behavior. Another aspect was the multiple roles played by medical and nursing staff in the healthcare systems, coupled with the experiences, beliefs and values that influenced the self-perception of change and possible effects of the outcomes ^31,35. In addition, a model of hospital care focused on the disease was observed ²⁶. People acknowledged that at a certain age it was difficult to make attempts to change their lifestyle; "it becomes useless", which suggested that it was too late and "they would only change their behavior if they really wanted to" ³⁵. Likewise, they identified both barriers and facilitating factors to carry out activities that would allow them a healthy lifestyle; they recognized the importance of adopting a healthy lifestyle; however, many of them, did not practice it ³⁴ arguing that the planned activities were aimed at the disease; in addition, they sought excuses for not attending due to a lack of knowledge about the activities they were going to perform; they believed that "they were only for sick people" ³⁰. The healthy lifestyle practices recognized were an adequate diet, physical activity, maintaining a suitable weight, and being healthy, among others ^32,34. Tobacco and alcohol consumption were recognized as harmful to health, for which they had to make a personal commitment to stop consuming them ^28,32. Some people reported difficulty in carrying out health promotion activities, attributing it to a lack of time, little information on the benefits and how to carry them out, and a lack of adequate and convenient spaces or facilities ^29,34, (Table 2).

Regarding the perception of vulnerable populations on health promotion, there were difficulties in providing them with health services because they belonged to an ethnic group with its own cultural barriers, health personnel were not adequately prepared to meet their needs, there was little access to health promotion programs, and therefore, health care actions were discontinuous and lacked determination to carry them out, hindering people's education on self-care ²⁶. Individuals engaged in risky behaviors that affected their health in the short, medium and long term, due to the consumption of alcohol, tobacco and other substances. Some reasons that encouraged the abandonment of these risky habits were: personal motivation, self-reflection, family influence, thinking about the future, and learning about their own self-care ³². Inconsistencies were identified in health professionals in relation to the culture; they were unaware of the cultural environment, the lifestyle, the relationship that existed between people and their environment, they denoted ignorance and detachment of health in the indigenous reality, which was considered disrespectful and intolerant when ignoring their traditional medicine ²⁶, (Table 2).

Regarding the perception of health professionals about health promotion programs, a variety of successful and effective practices carried out in the community were found. Health promotion was recognized as a mediating strategy between people and the environment ²⁸, and some nursing students reported having good expectations about self-care activities to modify their lifestyle ^29,34. The healthcare professionals recognized that an important factor that could encourage changes in healthy lifestyles were personal circumstances such as the knowledge and education of people, and their real interest in adopting health promotion behaviors. It was identified that a barrier that could influence lifestyle change were social circumstances; the person would change their behavior only if they wanted to do it, and the lack of motivation became an obstacle to seeking support centers ³⁵.

From the perspective of health professionals (doctors and nurses), the previous experiences of people should be considered, to prevent education from becoming an act in which the educator did not have an impact on people ³⁰. Physicians had a lack of time and resources; they were forced to ignore what was best for the patient's health; they considered it positive to integrate digital tools in primary care, such as digitalization, which should be implemented as a complement, but not as a replacement of the encounter between physicians and patients ³³. In addition, they recognized that they should improve their professionalism and the quality of their professional competencies, and explore better ways to promote health, using a person-centered approach with an integrated and holistic vision ³³.

Nursing professionals recognized that health promotion was closely linked to the history and prevention of disease, where attitudes and knowledge aimed at guiding or assisting individuals or communities to remain healthy within their environment should be demonstrated ²⁷. The role played by nursing professionals within the health promotion team was relevant; they should promote interdisciplinary and intersectoral health education actions aimed at integrating the family, school and community, awakening interest and enhancing people's knowledge; however, it was recognized that some actions might not be enough, despite the efforts made. Nurses acknowledged that they felt limited in the support they could offer people during an insufficient and very restrictive time for consultation, which did not allow them to replicate the "best practices" for people's education ^27,35, and the new routines reduced the possibility of addressing lifestyle problems ³³.

Another relevant aspect identified by health professionals to promote a healthy lifestyle were: interpersonal or family relationships, a participatory environment and the positive influence of parents to promote the adoption of a healthy lifestyle among its members, from dietary practices for weight gain or conservation, to direct influence on self-care. The aforementioned could be a positive influence in the search for health promotion programs ²⁹.

Discussion

Based on the literature review and analysis of qualitative evidence on the perception of health promotion by adults and health professionals to modify their lifestyle, it was found that the qualitative scientific literature on the perception of health promotion has been more developed in Latin America, mainly in Brazil and Colombia. The foregoing coincides with the literature that reports an increase in Latin America in the use of qualitative research methodology in different investigations in the area of health sciences ³⁶; however, in Mexico it has been less used ³⁷, which coincides with the results of the searches in this review, since no study was found to have been conducted in Mexico. Nowadays, nursing science is increasingly conducting qualitative research in health areas, primarily because of the humanistic character of the discipline ³⁸.

Regarding the exploratory descriptive design that predominated in the studies, we can say that this is due to the fact that this design allows examining the problems experienced, the perceived social and cultural situations in the area of health care, and the services and illnesses of the people investigated, which is why the use of different qualitative designs is required for its approach ³⁶. This coincides with the approaches identified, since the majority used individual, focus group and semi-structured in-depth interviews as techniques, due to the simplicity and information they provide ³⁹.

The primary qualitative studies employed different theoretical approaches such as participant observation, reflection, participatory action, and the phenomenological-hermeneutic method, among others, which coincides with the literature reviewed that argues that there should not be a single approach to explore the phenomenon under the qualitative study, because there are no similar social realities or contexts. Therefore, the researcher must use flexibility with diverse methodological approaches to adapt to the social realities being explored; it is important to comply with the considerations of each theoretical approach in order to preserve the validity and transferability of the information ⁴⁰.

Regarding health promotion in the different populations explored in the studies, there is coincidence with its approach, since it requires the active participation of all the people involved in the actions and in the established process, which implies the need for motivation and commitment to empower people to preserve and improve their health through promotion and prevention actions ⁴¹.

Regarding the categories of analysis, it was found that people's perceptions were both positive and negative, with multiple internal and external factors influencing people to accept, adopt or modify their lifestyle when a health promotion program was implemented. This is confirmed by studies that mention that among the external factors is the social environment, which directly influences family dynamics and ends up being a determining factor in modifying patterns of daily behavior in the environment where the individual develops ⁴²; in addition, marital status and educational level are factors that allow more access to health care ⁴³. To facilitate health promotion, the healthcare institutions must consider both internal and external factors and establish strategies that take into account the determinants of health in order to create healthy possibilities for the population, generating adequate conditions for groups and individuals to behave, empower and make decisions in favor of their health and wellbeing ⁷.

It was recognized that nurses, physicians and other health professionals had the knowledge, function and moral authority to generate changes in the health aspects of people; in addition, factors were found that directly influenced the self-perception of change and the possible effects of the outcomes on the people they attended, such as giving more emphasis to the disease than to health promotion and prevention. In this sense, health professionals have health education tools, which are a relevant strategy for health promotion; however, it is still perceived that their application at the institutional level is insufficient, and the biomedical orientation towards disease is greater than the orientation towards the overall health of the population to promote healthy habits and prevent health risk factors ⁴⁴.

It was found that the nursing personnel are agents of change in their own health behaviors; however, in the application of health promotion, they had many activities, and the main objective of health promotion was lost, they used uncreative and uninteresting methodologies that demotivated some people and did not contribute to the modification of health behaviors. In addition, it has been shown that nursing professionals have the responsibility to care for patients and families as their reason for being, and while providing nursing care, health promotion and education can also be provided at any level of care, although it is a priority that this be done from the primary care level onwards ⁴⁵. In order to establish creative and innovative strategies, the nursing professional has the responsibility to identify the health needs of individuals and groups of people, thus becoming a human resource of liaison or link of trust between the community and the health services, which allows them to promote behaviors for the adoption of healthy lifestyles ⁴⁶.

As a limitation we can mention that the literature search did not find any articles from Mexico; a little more than half of the articles came from Brazil and Colombia (Latin America), and the rest from Spain, England and Sweden (Europe). Probably in these countries it is established that primary health care should carry out the health promotion programs.

Conclusions

Qualitative research allows the understanding and improvement of clinical nursing interventions based on the perceptions, experiences, and behaviors exhibited by the people to whom health care is provided in a given context. Health promotion continues to be an ideal strategy to encourage actions to benefit the health of individuals and communities; however, macro and microeconomics, social and cultural aspects, as well as health policies, can become barriers that can limit the implementation and access to programs for the population that requires this type of healthcare assistance.

The role of nurses as agents of change should continue to be strengthened in health systems, since they are the personnel who maintain the most contact with people; however, it is recognized that there are limitations to being able to act assertively and achieve a greater impact on the population; these limitations are the excessive demand that exists and the multiple functions they perform, probably due to the limited number of personnel academically prepared to provide timely and adequate care. In addition, the particular characteristics of each population group should be considered when implementing health promotion programs.

Conflict of interest

The authors state that there is no conflict of interest.

Funding

The authors state that no funding was received.