H e a l t h P r o m o t i o n M o d e lThis page was last updated on January 31, 2012

I N T R O D U C T I O N

The health promotion model (HPM) proposed by Nola J Pender (1982;

revised, 1996) was designed to be a “complementary counterpart to

models of health protection.”

It defines health as "a positive dynamic state not merely the absence of

disease".

Health promotion is directed at increasing a client’s level of well being.

The health promotion model describes the multi dimensional nature of

persons as they interact within their environment to pursue health.

A B O U T T H E T H E O R I S T

Nola J. Pender, PhD, RN, FAAN - former professor of nursing at the

University of Michigan

Visit her page at University of Michigan

website: http://www.nursing.umich.edu/faculty-staff/nola-j-pender

The model focuses on following three areas:

o · Individual characteristics and experiences

o · Behavior-specific cognitions and affect

o · Behavioral outcomes

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

end point in the HPM.

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 an intended health

promoting actions.

A S S U M P T I O N S O F T H E H E A L T H P R O M O T I O N M O D E L

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 chang

T H E O R E T I C A L P R O P O S I T I O N S O F T H E H P M

The HPM is based on the following theoretical propositions:

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, a mediator of

behavior as well as actual behavior.

4. Perceived competence or self-efficacy to execute a given behavior

increases the likelihood of commitment to action and actual performance

of the behavior.

5. Greater perceived self-efficacy results in fewer perceived barriers to a

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 is increased.

8. Persons are more likely to commit to and engage in health-promoting

behaviors when significant others model the behavior, expect the behavior

to occur, and provide assistance and support to enable the 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 in health-promoting 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 demands 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

environment to create incentives for health actions.

M A J O R C O N C E P T S A N D D E F I N I T I O N S

Individual Characteristics and Experience

Prior related behaviour

Frequency of the similar behaviour in the past. Direct and indirect effects

on the likelihood of engaging in health promoting behaviors.

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 behaviour being considered.

Personal biological factors - include variable such as age gender body

mass index pubertal status, aerobic capacity, strength, agility, or balance.

Personal psychological factors - include variables such as self esteem

self motivation personal competence perceived health status and definition

of health.

Personal socio-cultural factors - include variables such as race

ethnicity, accuculturation, education and socioeconomic status.

PERCEIVED BENEFITS OF ACTION

Anticipated positive out comes that will occur from health behaviour.

PERCEIVED BARRIERS TO ACTION

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

given behaviour

PERCEIVED SELF EFFICACY

Judgment of personal capability to organise and execute a health-

promoting behaviour.

Perceived self efficacy influences perceived barriers to action so higher

efficacy result in lowered perceptions of barriers to the performance of the

behavior. 

ACTIVITY RELATED AFFECT

Subjective positive or negative feeling that occur before, during and

following behavior based on the stimulus properties of the behaviour 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

Cognition concerning behaviours, beliefs, or attitudes of the others.

Interpersonal influences include: norms (expectations of significant

others), social support (instrumental and emotional encouragement) and

modelling (vicarious learning through observing others engaged in a

particular behaviour).

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 behaviour.

Situational influences may have direct or indirect influences on health

behaviour.

Behavioural Outcome 

COMMITMENT TO PLAN OF ACTION

The concept of intention and identification of a planned strategy leads to

implementation of health behaviour. 

IMMEDIATE COMPETING DEMANDS AND PREFERENCES

Competing demands are those alternative behaviour over which

individuals have low control because there are environmental

contingencies such as work or family care responsibilities.

Competing preferences are alternative behaviour over which individuals

exert relatively high control, such as choice of ice cream or apple for a

snack

HEALTH PROMOTING BEHAVIOUR

Endpoint or action outcome directed toward attaining positive health

outcome such as optimal well-being, personal fulfillment, and productive

living.

R E F E R E N C E S

1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida

T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005

2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed.

Philadelphia: Lippincott Williams & Wilkins; 2007

3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed.

Philadelphia: Elsevier Mosby; 2006. 

Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier

Mosby; 2006.

   

ealth promotion theories and models

There are a number of significant theories and models that underpin the practice of health promotion. It would be useful to make a differentiation between theories and models.

The following information has been adapted from Theory at a glance. A guide for health promotion practice. (Second edition). (US Department of Health and Human Services. National Institutes of Health. 2005.) For further information go to www.nci.nih.gov/theory 

Theory An integrated set of propositions that serves as an explanation for a

phenomenon Introduced after a phenomenon has already revealed a systematic

set of uniformities A systematic arrangement of fundamental principles that provide a

basis for explaining certain happenings of life

Examples: Social Cognitive Theory, Theory of Planned BehaviourModel

A subclass of a theory. It provides a plan for investigating and or addressing a phenomenon

Does not attempt to explain the processes underlying learning, but only to represent them

Provides the vehicle for applying the theories

Examples: Health Belief Model, Transtheoretical Model The main models and theories utilised can be summarised as follows:1. Those theories that attempt to explain health behaviour and health behaviour change by focusing on the individual. Examples include:

Health Belief Model Theory of Reasoned Action Transtheoretical (stages of change ) Model Social Learning Theory

2. Theories that explain change in communities and community action for health. Examples include:

Community mobilisationo social planningo social actiono community development

Diffusion of innovation

3. Models that explain changes in organisations and the creation of health- supportive organisational practices. Examples include:Theories of organisational change

Summary of Theories: Focus and Key Concepts

Theory Focus Key conceptsIndividual Level

Stages of Change Model

Individual's readiness to change or attempt to change toward healthy behaviours

PrecontemplationContemplationDecision/determinationActionMaintenance

Health Belief Model

Person's perception of the threat of a health problem and the appraisal of recommended behaviour(s) for preventing or managing the problem

Perceived susceptibilityPerceived severityPerceived benefits of actionCues to actionSelf-efficacy

Interpersonal Level

Social Learning Theory

Behaviour is explained via a 3-way, dynamic reciprocal theory in which personal factors, environmental influences and behaviour continually interact

Behaviour capabilityReciprocal determinismExpectations Self-efficacyObservational learningReinforcement

Community Level

Community Organisation Theories

Emphasises active participation and development of communities that can better evaluate and solve health and social problems

EmpowermentCommunity competenceParticipation and relevanceIssue selectionCritical consciousness

Organisational Change Theory

Concerns processes and strategies for increasing the chances that healthy policies and programmes will be adopted and maintained in formal organisations

Problem definition (awareness stage)Initiation of action (adoption stage)Implementation of changeInstitutionalisation of change

Diffusion of Innovations Theory

Addresses how new ideas, products and social practices spread within a society or from one society to another

Relative advantageCompatibilityComplexityTrialabilityObservability

Health Promotion Model: Heuristic Device for Health Care ProfessionalsOurselves, our body, our health….. enhancing self usage towards prevention of illnesses & promoting well-being.

Nora J. Pender developed the Health Promotion Model that is proposed as a holistic predictive model of health-promoting behavior for use in research and practice. She is Professor Emeritus in the School of Nursing at the University of Michigan, and an advocate of health promotion.

“I committed myself to the proactive stance of health promotion and disease prevention with the conviction that it is much better to experience exuberant well-being and prevent disease than let disease happen when it is avoidable and then try and cope with it.”Nola J. Pender, PhD, RN, FAAN

Health Promotion Model has given health care a new direction. According to her, Health Promotion and Disease Prevention should be the primary focus in health care, and when health promotion and prevention fail to prevent problems, and then care in illness becomes the next priority. She defined 2 concepts: health promotion & health protection.

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. (Kozier, 2004)

Figure 1 – Health Promotion Model

This model (Figure 1) is moving towards understanding multi-faceted nature of persons correlating with their interpersonal nature and interacting with their interpersonal & physical environments as they trail towards health.Because of the model, nurses have already advanced their health approaches, addressing not only the curative side, but as well as prevention of diseases & promotion of well-being. Application of this theory is varied and substantive on its own.

Applications

Nursing Practice

“We are moving toward an era of science-based practice in nursing that incorporates the latest findings from the behavioral and biological sciences into practice to assist people of varying cultural backgrounds to adopt healthy lifestyles.” – Pender

As what they say, prevention is better than cure. Thus, health promotion is valued much. But how? Question seems hard…hard as if you don’t know how to solve the problems of the world…But how, again? If super heroes could save life using their super powers, we nurses could do more by using our caring touch, and therapeutic talks. Health teachings are always part of nurses’ experience in the workplace. Despite of various clinical & community health care settings, we nurses are always interacting

with our patient/client.

Community health care setting is the best avenue in promoting health & preventing illnesses. Using Pender’s Health Promotion Model, community program may be focused on activities that can improve the well-being of the people. Health promotion and disease prevention can more easily be carried out in the community, as compared to programs that aim to cure disease conditions. This is because the people in the rural area tend to veer away from modern medical methods. Most of them, due to financial reasons, choose to avail of the services offered by “herbolarios” and other folk healers. In our local setting, promoting health to our fellow Filipinos is very crucial. Though, there are campaigns provided by our government’s health agency, which is the Department of Health (DOH), there’s still a big percentage in the population who live unhealthily and many are suffering from different type of diseases.

Nurses, though are scattered in different fields, have common primary concern: to promote health to every individual. The following are just examples of methods on how to promote health to our fellows.

Insight from an Academe nurse teaching CHN… A group of students taught the families the value of eating a balanced diet. They introduced the concept of including the different food groups in all their meals. They also stressed the benefits and advantages of the various vitamins and minerals found in those food. Another group encouraged the community to practice lifestyle modification. They discussed the disadvantages of vices such as smoking and drinking alcoholic beverages. For

disease prevention and health protection, one group tried to inculcate the importance of early detection of illnesses. They taught the women the proper way and timing of self-breast examination. The mothers were also encouraged to avail of the vaccination services offered by the nearby health center. These programs proved to be very beneficial to the community. Because one can truly build a healthier tomorrow through good community health practice.

Insight from an ICU nurse… Although most patients admitted in the ICU are experiencing health problems, Health Promotion Model may still be applied in one way or another. This is projected towards improving health condition and prevention of further debilitating conditions. Diet modifications and performing passive & active range of motion exercises are examples of its application.

Nursing Education

“I believe that the future will be very bright and productive for nurses who direct their careers toward understanding disease prevention and health promotion processes.” – Pender

Nurses are expected to be adaptive. Indeed, changes are always constant. In health care settings, patients come & go. Meet & greet. Recover or expire. As this theory advocated, we should not allow our patients to experience severe conditions if we could only prevent them from encountering such. We are expected to know, if not in depth, the disease processes. Because of this know-how, we could apply health promotion and worsening prevention before the hands of the clock stop moving.

Percentage of nurses is geared towards continuing professional education. Attending seminars & conventions. Enrolling to masteral & doctoral classes. All are goaled towards becoming competent nurses. Nursing education is not a one-phase process. It does not end after passing the licensing exam. It is continuous. Unending. Ever changing. We must be abreast with new technologies, new approaches, and new techniques. Because of this theory, we nurses could address more the needs and problems of the client before it progresses to exacerbation. This model could be a basis for structuring nursing protocols and interventions.

Nursing Research

“I was committed to health promotion and encouraged other scholars to move in that direction long before health promotion and risk reduction became popular.” - Pender

Research help Health Care provider to develop a systematic problem-solving approach to improve and develop strategies to promote good health to individuals. Through research we will be able to clarify and verify the phenomenon.

Evidenced-based practice is fast emerging because of its factual and substantive results. These researches yield fruitful outcome that of great help in addressing arising problems and in setting nursing protocols. Much more research must be done to tailor interventions to individuals rather than to group stereotypes.

If we could remember, common research topics in our nursing college days are health promotion techniques and disease prevention. To name a few, some geared their research on effectiveness of Expanded Program on Immunization, others on health practices of mothers and families, some on efficiency of early detection of common illnesses. These are all but few of the model’s application to research.

Of all the theories presented in the module, Health Promotion Model is the easiest of them, yet substantive & useful. In our day-to-day experiences as nurses, we are always promoting health, preventing illnesses, and upholding well-being. We are seen by the public as health advocates. We have knowledge on health & illnesses, thus, we are expected to share this to laymen and contribute to their well-being. As what Pender said, “We cannot continue to let people become ill when we have the means to keep many people well--particularly when problems are environmentally and behaviorally induced”. Thus, the theory of Pender on Health

Promotion is indeed a great to advocate to prolong and preserve life. This theory really manifests the noble work of a NURSE. Remember, nurses we are LOVE SERVES.