A.

NOLA PENDER

NoLa Pender
Health Promotion Model
Nola J. Pender (1941– present) is a nursing theorist who developed the Health
Promotion Model in 1982. She is also an author and a professor emeritus of nursing at
University of Michigan. She started studying health-promoting behavior in the mid-
1970s and first published the Health Promotion Model in 1982. Her Health Promotion
Model indicates preventative health measures and describes the critical function of nurses
in helping patients prevent illness by self-care and bold alternatives. Pender has been
named a Living Legend of the American Academy of Nursing.
What is Health Promotion Model?
The Health Promotion Model notes that each person has unique personal characteristics
and experiences that affect subsequent actions. The set of variables for behavioral
specific knowledge and affect have important motivational significance. These variables
can be modified through nursing actions.
Health promoting behavior is the desired behavioral outcome and is the endpoint in the
Health Promotion Model. Health promoting behaviors should result in improved health,
enhanced functional ability and better quality of life at all stages of development. The
final behavioral demand is also influenced by the immediate competing demand and
preferences, which can derail intended health-promoting actions.

Major Concepts of the Health Promotion Model

Health promotion is defined as behavior motivated by the desire to increase well-being
and actualize human health potential. It is an approach to wellness.

On the other hand, health protection or illness prevention is described as behavior

motivated desire to actively avoid illness, detect it early, or maintain functioning within
the constraints of illness.
Individual characteristics and experiences (prior related behavior and personal factors).

Behavior-specific cognitions and affect (perceived benefits of action, perceived barriers

to action, perceived self-efficacy, activity-related affect, interpersonal influences, and
situational influences).

Behavioral outcomes (commitment to a plan of action, immediate competing demands

and preferences, and health-promoting behavior).

Subconcepts of the Health Promotion Model

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

a. Personal biological factors. Include variables such as age gender body mass index
pubertal status, aerobic capacity, strength, agility, or balance.
b. Personal psychological factors. Include variables such as self-esteem, self-
motivation, personal competence, perceived health status, and definition of health.
c. Personal socio-cultural factors. Include variables such as race, ethnicity,
acculturation, education, and socioeconomic status.
2. Perceived Benefits of Action
Anticipated positive outcomes that will occur from health behavior.

3. Perceived Barriers to Action

Anticipated, imagined or real blocks and personal costs of understanding a given
behavior.

 Perceived Self-Efficacy
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
Subjective positive or negative feeling that occurs 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 a further positive affect.

 Interpersonal Influences
Cognition concerning behaviors, beliefs, or attitudes of the others. Interpersonal
influences include 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 healthcare providers.

 Situational Influences
Personal perceptions and cognitions of any given situation or context that can facilitate or
impede behavior. Include perceptions of options available, demand characteristics and

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aesthetic features of the environment in which given health promoting is proposed to take
place. Situational influences may have direct or indirect influences on health behavior.

Behavioral Outcome:
 Commitment to Plan of Action
The concept of intention and identification of a planned strategy leads to the
implementation of health behavior

 Immediate Competing Demands and Preferences

Competing demands are those alternative behaviors over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behaviors over which individuals
exert relatively high control, such as choice of ice cream or apple for a snack

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

Major Assumptions in Health Promotion Model

1. Individuals seek to actively regulate their own behavior.
2. Individuals in all their biopsychosocial complexity interact with the environment,
progressively transforming the environment and being transformed over time.
3. Health professionals constitute a part of the interpersonal environment, which exerts
influence on persons throughout their life span.
4. Self-initiated reconfiguration of person-environment interactive patterns is essential
to behavior change.
Major concepts and Definitions of the Health promotion Model
1. Individual characteristics and experiences.
2. Prior related behavior
3. Frequency of the similar behavior in the past. Direct and indirect effects on the likehood
of engaging in health promoting behavior.

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SELF-EFFICACY THEORY
Self Efficacy and Nursing
Self-efficacy theory (SET) was first developed in 1977 by Albert Bandura. He first presented
his theory in the Journal of Psychological Review. Titled “Self-Efficacy: Toward a Unifying
Theory of Behavioral Change,” he proposed SET as the determining force of behavior
change. Clearly, behavioral change plays a big part in both nursing education and nursing
care.
What is Self-Efficacy?
Persons with low SET with often blame themselves for a lack of success. Whether the
problem is minor or a major part of their lives, they will usually feel their lack of abilities
makes it impossible for them to succeed. A person with high SET will usually not blame
their own abilities if they fail. On obtaining a bad test score, someone with high SET might
decide the test was unusually hard, or they did not study the right materials. The thought
that they cannot learn the subject will never enter their mind. These people will try again
until they succeed because they expect they can succeed.

Self-efficacy differs from self-esteem. People with high self-esteem are satisfied with
themselves, regardless of their abilities. High self-esteem does not always translate to the
ability to solve a crisis. Someone who has high self-esteem may not choose to take on a
challenge because they are fine the way they are. A person with high efficacy will always
jump at the chance, and they will often see solutions that are closed to other people.

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Psychological Research
Given a choice between low efficacy and high efficacy, it is clear that high efficacy will lead
to more satisfied life. In fact, this trait is about the ability to control situations that erupt
around oneself. Parents will find that their children are happier if they help them develop a
high sense of efficacy about life. Norwegian studies with twins have shown that 75% of self
efficacy comes from family heritage and 25% from their environment. Clearly, mentors and
parents can increase this characteristic in their children. Equally important is the effect this
can have on nursing care.

Bandara lists the factors that affect SET:

• Experience
• Modeling
• Social Persuasion
• Physiological Factors
The most important to develop a high SET is mastery of tasks. The more success one has,
the higher the SET. Next important is copying someone that the person perceives very
similar to them. Social persuasion is the acceptance of other people’s opinions.
Physiological response to stress can also limit success. Responses to each of these four
components can be changed to increase one’s SET level.

Further studies by Bandura showed that there are three factors that make up one’s SET.
These factors are:

(1) behavior,
(2) environment, and
(3) cognitive factors.
Of these, the most important to look at are the cognitive factors. According to Alberta
Bandura, it turns out that SET is the main indicator of the ability to learn new behaviors.

SET in Health Care

According to Luszczynska and Schwarzer, “self-efficacy plays a role in influencing the
adoption, initiation, and maintenance of healthy behaviors, as well as curbing unhealthy
practices.” Low SAT levels can clearly prevent changes in behavior that clients often need
to make to improve their condition, especially chronic symptoms and disease. Self-efficacy
is becoming increasingly adopted as part of nursing theory due to its effect on learning,
change and retention.

A client coming into the care has experienced a loss of control. He is not feeling well and
has been unable to take care of the problem. If he or she is in the hospital, this loss of
normalcy could be permanent and require major changes in their life going forward.

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The success a patient has with a new condition, especially a chronic one, relates directly to
their level of SET. The larger the changes and the lower the SET, the less likely the patient
will be successful. Thus, it is reasonable for a nurse to access a patient’s SET. Nursing
theory directs that nurses teach any required demonstrations, explain needed medical
treatment, and how to deal with any problems or backsliding that might result once they
return home. Each patient should have a plan that shows how to handle and difficulties that
might arise. Guidelines need to be clearly established before leaving medical care that
would trigger the need to return to care.

Nurses can organize their teaching to improve SET when needed. They can arrange
demonstrations and lifestyle lessons in small increments. The more positive experiences,
the better the low SET patient will respond. It is also important to access their cognitive
level. One style of teaching will not fit all patients. As you would explain something to an
adult differently than to a small child, nursing theory is clear that the teaching must be able
to be understood by the patient.
Patients with high SET levels are also less likely to provide false information to medical
personnel. Some patients don’t want to admit problems to nursing staff for fear of having to
leave home or some other personal problem. A person with a higher SET will build trust with
their care givers easier. This makes the patient more receptive to the information given by
the nurse.
Ralf Schwarzer, et.al., describes SET in his studies on cancer control as “cognitions that
determine whether health behavior change will be initiated, how much effort will be
expended, and how long it will be sustained in the face of obstacles and failures.” Clearly,
SET is important in every nurse’s practice and patient care. Yet, how many nurses access
for learning readiness at all?

Conclusion
Besides looking at teaching patients, nurses also spend time mentoring or training other
nurses. A SET assessment is useful for student nurses, too. Time spent raising the SET
usually yields better learning retention and the ability to apply the learning to new patient
situations. Nurses have been found to have low levels of SET. Including consideration of
SET in a nursing training program means that program has a better chance for success.
Persons with high levels of SET are more satisfied with their lives. Satisfied employees
have less turnover resulting in a more seasoned staff.

Patients and staff with low SETs should not be assigned to the bottom of the heap. SET can
be improved by exposure to the proper environment and structured learning. Including SET
in nursing theory will result in more successful patient outcomes and great satisfaction by
professional nursing staff.

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The Health Belief Model
The Health Belief Model is a theoretical model that can be used to guide
health promotion and disease prevention programs. It is used to explain and
predict individual changes in health behaviors. It is one of the most widely
used models for understanding health behaviors.
Key elements of the Health Belief Model focus on individual beliefs about
health conditions, which predict individual health-related behaviors. The
model defines the key factors that influence health behaviors as an
individual's perceived threat to sickness or disease (perceived susceptibility),
belief of consequence (perceived severity), potential positive benefits of
action (perceived benefits), perceived barriers to action, exposure to factors
that prompt action (cues to action), and confidence in ability to succeed
(self-efficacy).

Health Belief Model Examples

 The Michigan Model for Health™ is a curriculum designed for implementation
in schools. It targets social and emotional health challenges including
nutrition, physical activity, alcohol and drug use, safety, and personal health,
among other topics. This model adapts components of the Health Belief
Model related to knowledge, skills, self-efficacy, and environmental support.

Considerations for Implementation

The Health Belief Model can be used to design short- and long-term
interventions. The five key action-related components that determine the

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ability of the Health Belief Model to identify key decision-making points that
influence health behaviors are:

 Gathering information by conducting a health needs assessments and other

efforts to determine who is at risk and the population(s) that should be
targeted.
 Conveying the consequences of the health issues associated with risk
behaviors in a clear and unambiguous fashion to understand perceived
severity.
 Communicating to the target population the steps that are involved in taking
the recommended action and highlighting the benefits to action.
 Providing assistance in identifying and reducing barriers to action.
 Demonstrating actions through skill development activities and providing
support that enhances self-efficacy and the likelihood of successful behavior
changes.
These actions represent key elements of the Health Belief Model and can be
used to design or adapt health promotion or disease prevention programs.
The Health Belief Model is appropriate to be used alone or in combination
with other theories or models. To ensure success with this model, it is
important to identify "cues to action" that are meaningful and appropriate
for the target population.

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PRECEDE-PROCEED
The PRECEDE-PROCEED model is a comprehensive structure for assessing
health needs for designing, implementing, and evaluating health promotion
and other public health programs to meet those needs. PRECEDE provides
the structure for planning a targeted and focused public health program.
PROCEED provides the structure for implementing and evaluating the public
health program.

 PRECEDE stands for Predisposing, Reinforcing, and Enabling

Constructs in Educational Diagnosis and Evaluation. It involves
assessing the following community factors:
o Social assessment: Determine the social problems and needs
of a given population and identify desired results.
o Epidemiological assessment: Identify the health determinants
of the identified problems and set priorities and goals.
o Ecological assessment: Analyze behavioral and environmental
determinants that predispose, reinforce, and enable the
behaviors and lifestyles are identified.
o Identify administrative and policy factors that influence
implementation and match appropriate interventions that
encourage desired and expected changes.
o Implementation of interventions.

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 PROCEED stands for Policy, Regulatory, and Organizational Constructs
in Educational and Environmental Development. It involves the
identification of desired outcomes and program implementation:
o Implementation: Design intervention, assess availability of
resources, and implement program.
o Process Evaluation: Determine if program is reaching the
targeted population and achieving desired goals.
o Impact Evaluation: Evaluate the change in behavior.
o Outcome Evaluation: Identify if there is a decrease in the
incidence or prevalence of the identified negative behavior or an
increase in identified positive behavior.

Implementation Considerations
The PRECEDE-PROCEED model provides a structure that supports the
planning and implementation of health promotion or disease prevention
programs. This model has worked well for many health promotion topics,
and can effectively support one-time interventions or long-running
programs. Like the Community Readiness Model, PRECEDE-PROCEED invites
participation from community members, and has the potential to increase
community ownership of the program. When determining whether to use
PRECEDE-PROCEED as a model for health promotion or disease prevention
programs, it is important to consider whether all parts of the model are
appropriate for the program and the resources available to support
implementation. It is also important to remember that components of the
plan may be adapted over time, as needed.

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Health education is defined as “any combination of learning experiences designed to
facilitate voluntary actions conducive to health” (Green and Kreuter 2005). Although the
history of health education dates back to the 19th century, it was not until the 1940s that
the field began evolving as a distinct discipline. Over time, health education’s theory and
practice base have broadened from focusing on one-to-one and mass media behavioral
interventions to encompass responsibility for policies, systems, and environments that
affect population health. In the early 21st century, the terms health education and health
promotion (i.e., the latter including an ecological approach) are often used
interchangeably in the United States, while internationally health promotion is used as
an overarching concept that includes health education. Health education is considered a
mature profession given that it has developed a discrete body of knowledge, defined
competencies, a certification system for individuals, a code of ethics, a federal
occupational classification, and recognized accreditation processes in higher education.
Health education is generally aligned with the behavioral and social sciences as one of
the core dimensions of public health study and practice. Additionally, the field draws
from theories and models from education, health studies, communications, and other
diverse areas. The unique combination of these knowledge areas forms the basis for
health education competencies. Health educators employ a core set of competencies,
regardless of the diverse practice settings in which they work (i.e., schools, universities,
health departments, community-based organizations, health-care settings, worksites,
and international organizations). This bibliography is organized around major areas of
health education practice, such as assessing, planning, implementing, managing, and
evaluating health education or health promotion programs, services, and interventions.
It includes historical and philosophical foundations, and development of its
professionalism and ethics. The discipline embraces both qualitative and quantitative

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methods, community-based participatory research, health communication and social
marketing principles, and policy and media advocacy to accomplish program objectives.
Health educators are stalwarts in the fight for social justice and believe that the health of
a population should be a priority in any society.

Definition and Scope of Practice

The definition and scope of health education have evolved since the 1950s, particularly
in relation to improved understanding of behavioral and socio-ecological influences on
health. The early definition of health education in Griffiths 1972 primarily emphasized
the provision of learning experiences to promote voluntary changes to individual health.
Subsequent work in Robertson and Minkler 1994, Schwartz, et al. 1995, and Downie, et
al. 1996 provides a broader context of health education in relation to policy, systems,
and environmental changes inherent in the practice of health promotion and related
philosophies. Taub, et al. 2009 provides a concise overview of how the terms health
education and health promotion are used differently in the early 21st century in the
United States versus internationally, due to historical, cultural, and political
considerations. Gold and Miner 2002 and Modeste, et al. 2004 provide good sources of
contemporary definitions for many other terms, which is especially important due to the
eclectic base from which health education draws.

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