HEALTH PROMOTION MODELBY NOLA J. PENDER

AUGUST 16, 1941 – PRESENT

CONCEPTUAL FRAMEWORK

Major Concepts and Definitions

Prior Related Behavior- Frequency of the same or similar behavior in the past. Direct and indirect effects on the likelihood of engaging in health-promoting behaviors

Personal Factors - Categorized as biological, psychological, and sociocultural. These factors are predictive of a given behavior and shaped by the nature of the target behavior being considered.

Personal Biological Factors- included in this factors are variables such as age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance.

Personal Psychological Factors- These factors include variables such as self-esteem, self-motivation, personal competence, perceived health status, and definition of health.

Personal Sociocultural Factors- These factors include variables such as race, ethnicity, acculturation, education, and socioeconomic status.

Perceived Benefits of Action- Perceived benefits of action are anticipated positive outcomes that will occur from health behavior.

Perceived Barriers to Action- Perceived barriers to action are anticipated, imagined, or real blocks and personal costs of undertaking a given behavior.

Perceived Self- Efficacy- Perceived self- efficacy is judgment of personal capability to organize and execute a health promoting behavior. Perceived self- efficacy influences perceived barriers to action, so higher efficacy results in lowered perceptions of barriers to the performance of the behavior.

Activity- Related Affect- An activity- related affect describes subjective positive or negative feelings that occur before, during, and following behavior based on the stimulus properties of the behavior itself. Activity- related affect influences perceived self- efficacy, which means the more positive the subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive affect.

Interpersonal Influences- These influences are cognitions concerning behaviors, beliefs, or attitudes of others. Interpersonal influences includes norms (expectations of significant others),

social support (instrumental and emotional encouragement), and modeling (vicarious learning through observing others engaged in a particular behavior). Primary sources of interpersonal influences are families, peers, and health care providers.

Situational Influences- Situational influences are personal perceptions and cognitions in any given situation or context that can facilitate or impede behavior. They include perceptions of options available, demand characteristics, and aesthetic features of environment in which given health- promoting behavior is proposed to take place. Situational influences may have direct or indirect influences on health behavior.

Commitment to a Plan of Action- This commitment describes the concept of intention and identification of a planned strategy that leads to implementation of health behavior.

Immediate Competing Demands and Preferences- Competing demands are alternative behaviors over which individuals have low control, because there are environmental contingencies such as work or family care responsibilities. Competing references are alternative behaviors over which individuals exert relatively high control.

Health- Promoting Behavior- A health- promoting behavior is an end point or action outcome directed toward attaining positive health outcomes such as optimal wellbeing, personal fulfillment, and productive living.

ASSUMPTIONS AND ASSERTATION

7 Major Assumptions

1. Persons seek to create conditions of living through which they can express their unique human health potential.

2. Persons have the capacity for reflective self awareness, including assessment of their own competencies.

3. Persons value growth and directions viewed as positive and attempt to achieve a personal acceptable balance between change and stability.

4. Individuals seek to actively regulate their own behavior.5. Individuals in all their biopsychosocial complexity interact

with the environment, progressively transforming the environment and being transformed over time.

6. Health professionals constitute a part of the interpersonal environment, which exerts influences on persons throughout their life-spans.

7. Self-initiated reconfiguration of person environment interactive patters is essential to behavioral change.

14 Theoretical Assertions

1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health- promoting behavior.

2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.

3. Perceived barriers can constrain commitment to action, mediator of behavior, and actual behavior.

4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of behavior.

5. Greater perceived self- efficacy results in fewer perceived barriers to specific health behavior.

6. Positive affect toward a behavior results in greater perceived self- efficacy, which can, in turn, result in increased positive affect.

7. When positive emotions or affect are associated with a behavior, the probability of commitment and action are increased.

8. Persons are more likely to commit to and engaged in health- promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable behavior.

9. Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health- promoting behavior.

10. Situational influences in the external environment can increase or decrease commitment to or participation health-0promoting behavior.

11. The greater the commitments to a specific plan of action, the more likely health- promoting behaviors are to be maintained over time.

12. Commitment to a plan of action is less likely to result in the desired behavior when competing demand over which persons have little control require immediate attention.

13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.

14. Persons can modify cognitions, affect, and the interpersonal and physical environments to create incentives for health actions.

METAPARADIGM

1. Person

Recipient of care, including physical, spiritual, psychological, and sociocultural components.

Individual, family, or community

2.  Environment

All internal and external conditions, circumstances, and influences affecting the person

3. Health

Degree of wellness or illness experienced by the person a positive dynamic state not merely the absence of disease

4. Nursing

Actions, characteristics and attributes of person giving care

SAMPLE SCHEMATIC DIAGRAM OF THE STUDY

Health Promotion Model of Nursing Practice

Health Promotion Behavior Assessment:Health Promotion Model Approach in a Client with Chronic Heart

Failure

Individual Characteristics and Behavior-Specific Experiences Cognitions and Affect

Prior Related Behavior

Personal Factors Biological Psychological Socio-cultural

Perceived benefits of action Perceived barriers to action Perceived self-efficacy Activity-related affect Interpersonal influences Situational influences

PsychopathophysiologicalEffect

PLAN OF ACTION Immediate Competing Demands and Preferences

Health Promotion and Health Maintenance Behavior

Behavioral Outcome

Proposed Health Promotion – Home Care Management program

SAMPLE STATEMENT OF THE PROBLEM OF THE STUDY

The study utilized Nola Pender’s theory on health promotion in the care of a client diagnosed with congestive heart failure (CHF) Class III (Stage C). The study aimed to answer the following:

1) What are the significant health assessment findings of a client with CHF with regards to the following variables in the HPM:

1.1 Individual Characteristics and Experiences;1.1.1 Prior-Related Behavior1.1.2 Personal Factors

1.12.1 Biological1.1.2.1.1 Functional Health Pattern1.1.2.1.2 Physical Fitness1.1.2.1.3 Nutrition1.1.2.1.4 Health Risk Appraisal

1.1.2.2 Psychological

Immediate and Long Term Health Promotion Needs

1.1.2.2.1 Life Stress1.1.2.2.2 Spiritual Health1.1.2.2.3 Health Beliefs1.1.2.2.4 Health Promoting Lifestyle

1.1.2.3 Socio-cultural (social Support Systems)1.2 Behavior-Specific Cognitions and Affect

1.2.1 Perceived Benefits of Action1.2.2 Perceived Barriers to Action1.2.3 Perceived Self-Efficacy1.2.4 Activity-Related Affect1.2.5 Interpersonal Influences1.2.6 Situational Influences?

2) What is the psychopathophysiology of the client with Congestive Heart Failure Stage III?

3) What Health Promotion Plans are formulated based on:3.1 Immediate Competing Demands and Preferences;3.2 Commitment to a Plan of Action3.3 Nursing Interventions

3.3.1 Raising Consciousness;3.3.2 Reevaluating the self;3.3.3 Promoting Self-efficacy3.3.4 Enhancing the benefits to change;3.3.5 Controlling the environment 3.3.6 Managing Barriers to change?

4) What behavioral outcomes are observed in the client?SAMPLE NURSING CARE PLAN

Nursing Diagnosis: Fluid volume excess related to sodium and water retention secondary to decrease cardiac output and congestion of systematic capillaries

Individual Characteristics and Experiences:

Prior Related Behavior: Previous experience: Patient claims to dine regularly on “buwad” and “manggang hilaw” with salt or “ginamos” because these are easily accessible. Knowledge: She verbalizes “lain-lain man gud akong ipanga na pagkaon” and stated “kung naa, mukaon man sad ko og utan og prutas.”

Personal Factors: Biological factors: Client presents with bipedal, truncal and facial edema. She had a weight gain of around 10 lbs. in three weeks. Sociocultural factors: Educational attainment is elementary level. Her sources of income include her husband’s wages and occasional monthly allowances received from her parents.

Behavior-Specific Cognitions and Affect:

Perceived Benefits of Action: Client verbalizes “Mawagtang ang akong panghupong kung likayan nako ang mga parat.”

Perceived Barriers to Action: “Naanad man gud ko mukaon og ingon ana nila. Namaligya ra man sad and carenderia dapit sa amo og igo ra ko mu palit ngadto.”

Perceived Self-Efficacy: “Kung maninuod gyud ko, malikayan ra gyud nako baya. Basta ako lang huna-hunaon nga dapat mawagtang ang akong panghupong kay lisod na niining kondisyona.”

Activity-Related Affect: Client was doubtful at first but very determined. She is gradually attempting to carry out the goals she set for herself and verbalizes, “Dali ra ko nabusog kadtong nikaon ko og utanon.”

Interpersonal influences: Norms, support, models: Her husband, mother and sister constantly remind her of the limits and conditions and her resolve is strengthened by their support.

Situational influences: Options, demand characteristics, aesthetics: “Duol ra baya ang merkado unya daghan ang kapilian na mga sud-anon. Naa sad ang akong bana nga kamao muluto og iyang klase-klasehon ang sud-an para dili ko mapul-an.” The client prefers smaller servings that she can limit her urge to eat more.

Immediate Competing Demands and Preferences: Tempted to revert to her old nutrition pattern and eating more than prescribed amount of food and sodium.

Commitment t a Plan of Action: Was able to formulate and agree on the meal plan that has been collaborated with her family and that has been approved by the hospital dietician. Verbalizes, “Ako gyud ning tumanon para mumaayo akong panglawas. Ako gyud gi-agwanta nga i-limit akong gipangkaon og nidili gyud ko sa mga pagkaon na akong hilig niadto.”

Interventions and Rationales:

Raising Consciousness- Determined client’s knowledge of a nutritional diet and need

for supplements.R: This information is useful in developing an individual teaching plan based on client’s current state (Aukley and Ladwig, 1999).

- Helped client identify the problem, feelings associated with eating and circumstances in which the client turns to food.

R: Permanent weight loss starts with examination of factors contributing to weight gain (Sparks and Taylor, 2005)

Reevaluating the Self - determined client’s motivation to lose weight and eliminate

edema (for health benefits). R: Often a healthier body weight is only 5 t 10 percent

reduction from initial body weight (Auckley and Ladwig, 1999).

Promoting Self-Efficacy- Suggested t plan meals with her husband to suit her

preferences. R: To improve motivation and encourage compliance (Sparks

and Taylor, 2005).- Encouraged involvement in the purchase of food items. R: Food choices in today’s food markets are enhanced even

for those on a limited budget (Aukley and Ladwig, 1999).- Provided client with positive feedback about her progress

toward reaching goals. R: To improve motivation and encourage compliance (Sparks

and Taylor, 2005).

Enhancing the Benefits of Change- Initiated a client contract that involves rewarding and reinforcing progressive goal attainment. R: Patient contract provide a unique opportunity for patients

to learn to analyze their behavior in relationship to the environment and to choose behavioral strategies that will facilitate learning (Aukley and Ladwig, 1999).

Controlling the Environment- Encouraged social involvement in activities other than eating. R: Energy needs decrease an estimated 5 percent decrease

after the age of 46 (Aukley and Ladwig, 1999).

Managing Barries to Change- Instructed client regarding adequate nutritional intake. R: Permanent lifestyle changes must occur for weight loss to

be lasting. Eliminating are treats is not sustainable (Aukley and Ladwig, 1999).

- Observed for socioeconomic factors that influence food choices.

R: Food choices in today’s food markets are greatly enhanced even for those on a limited budget (Aukley and Ladwig, 1999).

Behavioral Outcome/Health Promotion Behavior: The client was found to have adhered to her meal plans without reverting to her old eating habits. Stated, “Nakuntento na gyud ko sa akong kinan-

an karon. Nigamay nasad akong panghupong. Bout ipasabot ni-epekto gyud ang akong pag-kontrolar sa akong kinaon og pag-inom

ASSESSMENT TOOL

HEALTH PROMOTION LIFESTYLE PROFILE II

DIRECTIONS: This questionnaire contains statements about your present way of life or personal habits. Please respond to each item as accurately as possible, and try not to skip any item. Indicate the frequency with which you engage in each behavior by circling:

N for never, S for sometimes, O for often, or R for routinely

1. Discuss my problems and concerns with people close to me.

N S O R

2. Choose a diet low in fat, saturated fat, and cholesterol.

N S O R

3. Report any unusual signs or symptoms to a physician or other health professional.

N S O R

4. Follow a planned exercise program. N S O R5. Get enough sleep. N S O R6. Feel I am growing and changing in positive ways. N S O R7. Praise other people easily for their achievements. N S O R8. Limit use of sugars and food containing sugar (sweets).

N S O R

9. Read or watch TV programs about improving health. N S O R10. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber).

N S O R

11. Take some time for relaxation each day. N S O R12. Believe that my life has purpose. N S O R13. Maintain meaningful and fulfilling relationships with others.

N S O R

14. Eat 6-11 servings of bread, cereal, rice and pasta each day.

N S O R

15. Question health professionals in order to understand their instructions.

N S O R

16. Take part in light to moderate physical activity (such as sustained walking 30-40 minutes 5 or more times a week).

N S O R

17. Accept those things in my life which I can not change.

N S O R

18. Look forward to the future. N S O R19. Spend time with close friends. N S O R20. Eat 2-4 servings of fruit each day. N S O R21. Get a second opinion when I question my health care provider's advice.

N S O R

22. Take part in leisure-time (recreational) physical N S O R

activities (such as swimming, dancing, bicycling).23. Concentrate on pleasant thoughts at bedtime. N S O R24. Feel content and at peace with myself. N S O R25. Find it easy to show concern, love and warmth to others.

N S O R

26. Eat 3-5 servings of vegetables each day. N S O R27. Discuss my health concerns with health professionals.

N S O R

28. Do stretching exercises at least 3 times per week. N S O R29. Use specific methods to control my stress. N S O R30. Work toward long-term goals in my life. N S O R31. Touch and am touched by people I care about. N S O R32. Eat 2-3 servings of milk, yogurt or cheese each day. N S O R33. Inspect my body at least monthly for physical changes/danger signs.

N S O R

34. Get exercise during usual daily activities (such as walking during lunch, using stairs instead of elevators, parking car away from destination and walking).

N S O R

35. Balance time between work and play. N S O R36. Find each day interesting and challenging. N S O R37. Find ways to meet my needs for intimacy. N S O R38. Eat only 2-3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day.

N S O R

39. Ask for information from health professionals about how to take good care of myself.

N S O R

40. Check my pulse rate when exercising. N S O R41. Practice relaxation or meditation for 15-20 minutes daily.

N S O R

42. Am aware of what is important to me in life. N S O R43. Get support from a network of caring people. N S O R44. Read labels to identify nutrients, fats, and sodium content in packaged food.

N S O R

45. Attend educational programs on personal health care.

N S O R

46. Reach my target heart rate when exercising. N S O R47. Pace myself to prevent tiredness. N S O R48. Feel connected with some force greater than myself.

N S O R

49. Settle conflicts with others through discussion and compromise.

N S O R

50. Eat breakfast. N S O R51. Seek guidance or counseling when necessary. N S O R52. Expose myself to new experiences and challenges. N S O R© S.N. Walker, K. Sechrist, N. Pender, 1995. Reproduction without the author's express written consent is not permitted. Permission to use this scalemay be obtained from: Susan Noble Walker, College of Nursing, University of Nebraska Medical Center, Omaha, NE 68198-53

HEALTH-PROMOTING LIFESTYLE PROFILE II

Scoring Instructions

Items are scored as Never (N) = 1Sometimes (S) = 2Often (O) = 3Routinely (R) = 4

A score for overall health-promoting lifestyle is obtained by calculating a mean of the individual's responses to all 52 items; six subscale scores are obtained similarly by calculating a mean of the responses to subscale items. The use of means rather than sums of scale items is recommended to retain the 1 to 4 metric of item responses and to allow meaningful comparisons of scores across subscales. The items included on each scale are as follows:

Health-Promoting Lifestyle 1 to 52Health Responsibility 3, 9, 15, 21, 27, 33, 39, 45, 51Physical Activity 4, 10, 16, 22, 28, 34, 40, 46Nutrition 2, 8, 14, 20, 26, 32, 38, 44, 50Spiritual Growth 6, 12, 18, 24, 30, 36, 42, 48, 52Interpersonal Relations 1, 7, 13, 19, 25, 31, 37, 43, 49Stress Management 5, 11, 17, 23, 29, 35, 41, 47

BIOLIOGRAPHY

A. Book

Pender, Nola, Murdaugh and Parsons. Health Promotion in Nursing Practice. 5th Ed. New Jersey: Prentice Hall, 2006

B. Unpublished Material

Reynes, P.M.A. (2009). Pender’s Health Promotion Model in the care of a patient with Congestive Healrt Failure. Cebu City: Cebu Normal University.

C. Internet Sources

http://currentnursing.com/nursing_theory/introduction.html

http://nursingtheories.blogspot.com/2008/07/health-promotion-model-heuristic-device.html

http://images.search.yahoo.com/images/view?