Health Promotion and Disease Prevention: Considerations and Interventions

Health promotion and disease prevention strategies for a healthy ophthalmic system need to be appropriate for each specific individual. Carefully consider all the data you have collected, both subjective and objective. Subjective data collection involves asking the client about risk factors, social determinants, and other considerations. This kind of inquiry should be integrated throughout the entire assessment. You will ask many probing questions during the subjective assessment, but you should also formulate additional questions based on critical reflection of the data you have collected during the subjective and objective assessment. Together, these findings will inform your clinical judgement for each specific client and the health promotion needed.

Smoking

Smoking cigarettes and consuming tobacco in any form is a risk factor that can negatively affect ocular health. Smoking is linked to vision loss, blindness, cataracts, and macular degeneration (Brûlé et al., 2018; Government of Canada, 2023). The chemicals in the smoke can damage cells in the eye (e.g., the retina) and decrease blood flow to the blood vessels. Some consider vaping to be healthier, but the American Heart Association (2024) also considers vaping to be unsafe.

Probing questions related to smoking and tobacco consumption may include:

• Do you smoke cigarettes (such as conventional tobacco cigarettes), e-cigarettes/vapes, or use any tobacco-related products? If the client’s answer is affirmative, ask probing questions (using their own language): How much do you smoke? How many packages of cigarettes do you smoke a day? How many years have you smoked? Can you tell me about the reasons that you started smoking?
• If the client does not currently smoke or consume tobacco, ask if they have ever done so. If the answer is affirmative, ask similar probing questions as above, including the reason that they quit.
• If the client currently smokes or consumes tobacco, ask if they have ever tried quitting.
  • If the client’s answer is affirmative, ask probing questions: Tell me about what made you want to quit? How long did you quit? Did you use any strategies to help you quit?
  • If the client’s answer is negative or dissentive, make a non-judgemental comment like: “If you ever want to discuss quitting, let me know, there are many resources to help you.”

The effectiveness of health promotion efforts are influenced by client interest and collaborative intervention: both factors are important in producing a successful outcome (in this case, smoking cessation). Each intervention must be tailored to the client, and could include counselling, cognitive-behavioural therapy, pharmacology treatments (e.g., nicotine replacement therapy), smart-phone applications, and short text message services. Sometimes a brief discussion about risks and a recommendation to quit smoking is sufficient. You might also choose to be involved in developing public health educational campaigns and resources about how smoking affects health as a population-based prevention strategy. Nurses and healthcare providers need to educate clients who smoke, as well as non-smokers of the risk of smoking to eye health (Brûlé et al., 2018). Health promotion interventions can include smoking cessation and prevention programs in school, smoke-free community and recreation centres, and age-specific warning labels on cigarette packages. It may be helpful to access training in smoking cessation counseling, such as programs offered by the Centre for Addiction and Mental Health.

Contextualizing health promotion related to smoking from a sociocultural perspective will help you understand who might be more vulnerable or at risk. For example, smoking is more prevalent among individuals with lower socio-economic status and lower education attainment, and those experiencing racial and ethnic discrimination (Wang & Wu, 2020). These populations are also less likely to have access to resources pertaining to smoking cessation. It is important to consider interventions as they relate to the social determinants of health, rather than using a one-size-fits all approach (Brady, 2020).

Diet

A diet rich in antioxidants (vitamins C and E) and nutrients such as lutein, zeaxanthin, zinc, and omega-3 fatty acids are beneficial to ocular health and can help protect eyes from disease (American Academy of Ophthalmology, 2023a; Grant et al., 2022). These vitamins and nutrients can be found in dark leafy vegetables, citrus fruits, nuts, fish, and red meats. Adequate consumption of vitamin B12 and omega-3 monounsaturated fatty acids, also found in fish, are also important to ocular health and vision (Cirone et al., 2023). Therefore, you might advise clients who follow a vegan diet to supplement with vitamins (Cirone et al., 2023). In addition, it is best for clients to choose water on a regular basis and try to reduce their caffeine and alcohol intake.

Probing questions related to diet may include:

• Tell me about your usual diet?
• What have you eaten in the last 24 hours? Is that your usual diet?
• Have you had any recent changes in your life that have affected your diet?
• Do you add sugar and salt to your food?
• How much fluid do you typically drink in a day? What fluids (e.g., water, caffeinated beverages, alcohol)?
• Do you take any supplements? If so, what?

You may want to assess a client’s familiarity with Health Canada’s (2019) Food Guide and discuss with them how to use it. This is the newest version of the guide, but it still has a Eurocentric bias, so you should collaborate with clients about its relevance in the context of their cultural food practices. In addition to Canada’s Food Guide, the Food Guide Snapshot is now offered in dozens of languages, and many resources related to food safety for Indigenous people are also available, such as Healthy Eating and Food Safety for Indigenous Peoples.

Some key elements of Canada’s Food Guide are:

• Be mindful of eating patterns.
• Choose water as the drink of choice.
• A dinner plate should be one-half vegetables/fruit, one-quarter protein, and one-quarter whole grains.
• Make time to enjoy eating meals with others.
• Cook when possible, as opposed to eating processed meals and purchasing fast foods.
• Reduce sodium, saturated and trans fats, sugar, processed foods, and monitor portion sizes.

Many types of diets can be healthy, and research suggests that the Mediterranean diet in particular, which emphasizes more plant-based foods and fish, can decrease the risk of age-related macular degeneration (American Academy of Ophthalmology, 2023b; Grant et al., 2022).

Healthy eating is related to behavioural actions but also relational and structural actions. A healthy diet first requires the ability to access healthy food and the financial capacity to purchase it – this is known as food security. The rising cost of food globally has made this a challenge, and in many remote regions of Canada’s North access to nutritious food is limited in terms of availability – and even when available, the costs are excessive.

Socioeconomic status is well-known to affect food purchasing. Individuals from socioeconomically disadvantaged communities – those with lower household income and lower levels of education – purchase fewer healthy foods like fruits and vegetables (Turrell et al., 2002). Therefore, health promotion efforts should focus on narrowing socioeconomic differences in food purchasing.

Nurses can work in partnership with individuals experiencing structural, social, and financial barriers, and then tailor a health promotion approach to their particular needs (Turrell et al., 2002). For example, you could direct clients to organizations that partner with vulnerable communities to support access to healthy foods, skill development, and capacity-building in terms of community-led initiatives (Turrell et al., 2002). One example of an innovative initiative to address food security in Toronto, Canada, involves use of mobile food trucks to bring fresh food into local communities. Other examples include community initiatives in the Niagara region of Canada, which are working to address access via partnerships and community gardens. As a nurse, you can also advocate on behalf of vulnerable communities for more effective social policy to address food insecurity (Turrell et al., 2002). It is important to partner with communities and co-create effective strategies to improve access.

Exercise

The eye, its vasculature, and its muscles, benefit from overall exercise and exercise of the eye muscles.

Continuous screen time, such as on the computer, television or videos, can negatively affect ocular health. Prolonged screen time can lead to symptoms including eye strain, dry eyes, heaviness in eyelids, eye redness, blurry vision, sensitivity to light, difficulty focusing, and myopia in children (Trott et al., 2022). Eye exercises can assist in strengthening eye muscles and relieve eye strain. Dr. Valeria Lam discusses eye strain in the video “Why Do Our Eyes Hurt When Looking At Screens?”

Guidelines vary based on age and health, but most recommendations suggest that individuals  participate in about 30–60 minutes of aerobic activity, five to seven times per week. Nurses should use a relational and structural health promotion approach when addressing activity. A community of support can promote activity, so you should assess the client’s access to support (e.g., friends, family, acquaintances) who may have similar activity interests or goals. A structural approach to health promotion can also help address and eliminate inequities. For example, culturally traditional forms of exercising or even walking outside may not be accessible due to maldistribution of resources. Community infrastructure may lack playgrounds or basketball courts, gym memberships and sports registration fees may be unaffordable, and neighbourhoods may be unsafe. It is important to be aware of these factors and consider them as you partner with clients on activity plans. You may also need to advocate for policies to address these inequities.

Probing questions related to activity may include:

• Tell me about your screen time (e.g., computer, phones, television, videos)?
• What screen time have you engaged in the last 24 hours? Is that your usual amount?
• Do you have any concerns about your level of screen time?
• Do you take physical breaks from screens? What type of breaks do you take?
• Do you have any concerns about your level of activity or exercise?
• Tell me about your daily pattern of activity? What activities are you involved in?
• What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? If the client plays sports, ask about their use of protective equipment, if relevant.

Nurses can educate clients about the effects of prolonged screen time and encourage them to monitor their screen time to promote ocular health. For example, you could draw from the Canadian Association of Optometrists/Canadian Ophthalmological Society Joint Position Statement: Effects of Electronic Screens on Children’s Vision and Recommendations for Safe Use to discuss screen time recommendations for children. Also encourage clients to follow the 20-20-20 rule: every 20 minutes, take a 20-second break to focus on something approximately 20 feet away – this helps relax the eye muscles and promote ocular health (Canadian Association of Optometrists, 2023).

Environment

A client’s physical environment can also affect their ocular health, so nurses can play an important role in educating clients on how to create a healthy environment. Some elements to consider include sun exposure, engagement in physical activities, and work environments.

You should educate clients about the effects of the sun’s ultraviolet (UV) rays, which can increase the risk for cancer, cataracts, pterygium, and photokeratitis (American Academy of Ophthalmology, 2020). Encourage clients to monitor their time in the sun, avoid looking directly at the sun, and be aware of the importance of wearing UV-blocking sunglasses and brimmed hats to protect their eyes from direct sunlight.

Another risk factor is eye injuries during sports, activities, or certain work situations. Advise clients to use appropriate eye equipment to decrease the risk of damaging the ocular structures and vision when engaging in activities and sports such as racquetball, hockey, cycling, and swimming. Some work environments require eye goggles due to potential contact with various elements such as chemicals, projectile objects, bloodborne pathogens, and/or microorganisms; these employees may include gardeners, construction workers, welders, and healthcare providers.

Nurses can also be involved in larger structural approaches involving education campaigns, healthy social policy, and scientific research related to the environment.

Probing questions related to the physical environment may include:

• Tell me about your sun care routine? What sun preventative strategies do you use (e.g., sun glasses, brim hats)?
• Do you wear eye protection when playing sports, activities, or at work? What type of eye protection do you use?
• Do you have access to eye protection at work?

Hygiene

Hygiene practices are another important element of promoting eye health and preventing eye conditions. Regular handwashing is important, especially in healthcare and work settings, when returning home, prior to making and eating food, and before and after using the washroom. Tell clients to wet their hands with water, lather with soap for 20 seconds, rinse and dry their hands, and then turn off the tap with their elbow or a paper towel. Consider ways to make this fun for children: you could tell them to sing a song that lasts 20 seconds, like Happy Birthday.

Advise clients to avoid touching their eyes and when necessary, to wash their hands first. Encourage them to avoid sharing towels and cosmetics including make-up, and when applicable, to take proper care of contact lenses. Keep in mind that there are many types of contact lenses: some are used to address a refractive error whereas others are used for aesthetic reasons. Some lenses are not approved by regulatory bodies such as Health Canada and may pose a risk to the eyes because of the material used; they can cause corneal abrasions and infections. Also be aware that the lens colour may be used to change the eye colour so the iris might not be reflective of the person’s true iris colour.

Probing questions related to handwashing and immunization may include:

• Tell me about when you wash your hands?
• What is involved in washing your hands? What are the steps involved? How long do you do it for?
• If the client wears contact lenses, ask: Tell me about the reasons you wear them? At one time, how long do you wear them for? Tell me about the process you use to insert and remove them? How do you store and clean them?

References

American Academy of Ophthalmology (2023a). Diet and nutrition. https://www.aao.org/eye-health/tips-prevention/diet-nutrition

American Academy of Ophthalmology (2023b). Mediterranean diet: Healthy eating for healthier eye. https://www.aao.org/eye-health/news/mediterranean-diet-healthy-eating-healthier-eyes

American Academy of Ophthalmology (2020). The sun, UV light and your eyes. https://www.aao.org/eye-health/tips-prevention/sun

American Heart Association (2024). Is vaping better than smoking? https://www.heart.org/en/healthy-living/healthy-lifestyle/quit-smoking-tobacco/is-vaping-safer-than-smoking

Brûlé, J., Tousignant, B., Marcotte, S., & Moreau, M. (2018). Smoking and the eye: what Québec teenagers know and fear. Clinical and Experimental Optometry, 101(1), 73–76. https://doi.org/10.1111/cxo.12560

CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. https://www.nicotinedependenceclinic.com/en/canadaptt/PublishingImages/Pages/CAN-ADAPTT-Guidelines/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

Canadian Association of Optometrists (2023). 20-20-20 rule. https://opto.ca/eye-health-library/20-20-20-rule#:~:text=Every%2020%20minutes%2C%20take%20a,at%20least%2020%20feet%20away.&text=Many%20of%20us%20spend%20a,eyes%20and%20cause%20eye%20fatigue.

Canadian Association of Optometrists (n.d.). Canadian association of optometrists/Canadian ophthalmological society joint position statement: Effects of electronic screens on children’s vision and recommendations for safe use. https://www.cos-sco.ca/wp-content/uploads/2020/08/CAO-COS-Joint-Position-statement-Electronic-Screens.pdf

Cirone, C., Cirone, K., & Malvankar-Mehta, M. (2023). Linkage between a plant-based diet and age-related eye diseases: a systematic review and meta-analysis. Nutrition Reviews, 81(4), 428-440. https://doi.org/10.1093/nutrit/nuac067

First Nations Health Authority (2024). Respecting tobacco. https://www.fnha.ca/wellness/wellness-for-first-nations/wellness-streams/respecting-tobacco

Government of Canada (March, 2023). The visible health consequences of smoking. https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/legislation/tobacco-product-labelling/visible-consequences-smoking.html

Grant, M. B., Bernstein, P. S., Boesze-Battaglia, K., Chew, E., Curcio, C. A., Kenney, M. C., Klaver, C., Philp, N. J., Rowan, S., Sparrow, J., Spaide, R. F., & Taylor, A. (2022). Inside out: Relations between the microbiome, nutrition, and eye health. Experimental Eye Research, 224, 109216–109216. https://doi.org/10.1016/j.exer.2022.109216

Trott, M., Driscoll, R., Iraldo, E., & Pardhan, S. (2022). Changes and correlates of screen time in adults and children during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine, 48, 101452–101452. https://doi.org/10.1016/j.eclinm.2022.101452

Turrell, G., Hewitt, B., Patterson, C., Oldenburg, B., & Gould, T. (2002). Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics, 15(5), 355-364. https://doi.org/10.1046/j.1365-277X.2002.00384.x