Theory Evaluation of Pender’s - PowerPoint Presentation

Slide1

Theory Evaluation of Pender’s

Health

Promotion Model

(

HPM

)

Nursing 8440

November 26, 2012

Jennifer Bauman, RN, BA, PCCN

Slide2

Purpose and Topics

Critically

evaluate Nola J. Pender’s Health Promotion Model (HPM

)

High

prevalence and

cost of

conditions that are caused by poor lifestyle choices – conditions that are largely

preventable

According

to Pender (1996), “in the United States, it is estimated that unhealthy lifestyles are responsible for 54% of the years of life lost prior to age 65, environment for 22%, and heredity for 16%” ( p. 5).

Potential to decrease

the pervasiveness of lifestyle-related conditions and achieving cost savings through health promotion and illness prevention.

Topics

Background of author and overview of theory

Historical

development of the

theory

Origins

Main

structural

elements

Ongoing

development of the

theory

Critique

of the theory using Fawcett’s theory evaluation

recommendationsSlide3

Nola J.

Pender: Background

Born

1941 in Lansing, Michigan

Masters

degree in human growth and development at Michigan State University in 1965

“’The M.A. in growth and development influenced my interest in health over the human lifespan. This background contributed to the formation of a research program for children and adolescents,’ stated Pender” (

Sakraida

, 2006, p. 453).

PhD in

psychology and

education in 1969 at Northwestern University in Evanston, Illinois

Dissertation in 1970 investigated developmental changes in encoding processes of short-term memory in children

“Pender credits Dr. James Hall, a doctoral program advisor, with ‘introducing me to considerations of how people think and how a person’s thoughts motivate behavior’” (

Sakraida

, 2006, p. 453).

Shift

in her thinking toward defining the goal of nursing care as the optimal health of the individual

Influenced by Dr. Beverly

McElmurry

at Northern Illinois University and the book,

High-Level Wellness

, by

Halpert

Dunn (1961)

Also influenced by husband Albert Pender, associate professor of business and economicsSlide4

Overview

“The

HPM is an attempt to depict the multidimensional nature of persons interacting with their environment as they pursue health” (Pender, 1996, p. 53).Slide5

Overview

Behaviors motivated by

prior related health promotion

behaviors

and

personal

factors

Biological

,

psychological, sociocultural

Weighs benefits

and barriers of health promoting

actions

Perceived self-efficacy

Affect

related to the specific

activity

Interpersonal

and situational influences

Commit to a plan

of action to promote

health

Immediate

competing

demands

Adopts

the health promoting behavior.

Client plays an ACTIVE

role in initiating and maintaining health promotion behaviors, as well as altering the environment to be

successfulSlide6

HPMSlide7

Historical

Development

of

Theory

1975 first

published

in

Nursing Outlook

, « A

Conceptual

Model for

Preventative

Health

Behavior

 »

1982 HPM first in nursing

literature

1987 HPM in

Health Promotion in Nursing Practice

1996 revised HPM after six year study Slide8

Origins

Philosophical origins: “Reciprocal

Interaction World View, in which humans are viewed holistically, but parts can be studied in the context of the whole. Human beings interact with their environment and shape it to meet their needs and goals” (Pender, 2011, p. 2).

Theoretical origins: derived

inductively from many psychological

theories, especially expectancy-value

theory and social cognitive

theorySlide9

Expectancy-Value Theory

of Human Motivation

Initially

conceptualized by Norman T. Feather in

1982

States

that “individuals engage in actions to achieve goals that are perceived as possible and that result in valued outcomes” (Pender, 2011, p. 2).

Emphasizes

that human behavior is rational and economical (

Syx

, 2008). Slide10

Social Cognitive Theory

Originally

published by Albert Bandura in

1977

“…Thoughts

, behavior, and environment interact. For people to alter how they behave, they must alter how they think”

(Pender, 2011, p

. 2).

Self-efficacy

, which is “a judgment of one’s ability to carry out a particular course of action” (Pender, 1996, p. 54

)

Greater

perceived self-efficacy results in persistent engagement in behavior despite obstacles.Slide11

Main Structural Elements: Assumptions

Reflect

the behavioral science perspective and emphasize the active role of the patient for managing health behaviors through environmental modification (

Sakraida

, 2006

)

Seven Assumptions:

1. “Persons

seek to create condition 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 in directions viewed as positive and attempt to achieve a personally 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 influence on persons throughout their lifespans.”

7. “Self-initiated

reconfiguration of person-environment interactive patterns is essential to behavioral change.” Slide12

Main Structural Elements: Concepts

Three

categories:

Individual

characteristics and

experiences

Prior

related behavior and personal

factors

I

mportance

of their effects

depends on target behavior and population

Behavioral-specific cognitions and affect

Major

motivational significance and modifiable through nursing

actions

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 (the end-point or action outcome in HPM

)Slide13

Main Structural Elements: Theoretical Assertions

The assertions emphasize that the HPM contains a competence- or approach-oriented focus, unlike other health behavior theories which are avoidance-oriented models that rely upon fear or threat to health as motivation for health behavior. In Pender’s theory, health promotion is motivated by the desire to increase well-being and actualize human potential (

Sakraida

, 2006).Slide14

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

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

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

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

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

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

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

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.

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.

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

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

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.

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.

Persons can modify cognitions, affect, and the interpersonal and physical environments to create incentive for health actions.Slide15

Ongoing Development

Revision from 1987 to 1996

“The 1996 revisions intended to increase utility of the model for prediction and intervention in health behaviors” (Young, Taylor, M-R, 2001, p. 308).

King (1994) critiqued Pender’s original model, stating:

Pender viewed environment, situational and interpersonal factors as modifiers of the central cognitive—perceptual factors. Pender viewed the environment as it relates to behavior rather than how it relates to health (…) Pender gave little recognition to the impact that the sociopolitical context has on the individual. Rather, Pender focused on individuals, their perception of control, their definition of health, and their decision-making capacity. (…) Pender's model is further limited as the existence or complexity of interrelationships among the factors is not acknowledged. (…) The model also does not specifically address motivating factors. (p. 214

)Slide16

Pender and colleagues

Six-year, federally funded study (really,

studies

) by Pender and colleagues

Tested the validity of the HPM and the Health-Promoting Lifestyle Profile tool in the populations of working adults, older community-dwelling adults, ambulatory patients with cancer, and patients undergoing cardiac rehabilitation.

Proved validity and reliability of the model and tool but that revisions neededSlide17

Empirical Evidence

Studies from 1987 through 1996 investigated 5-12 of the HPM variables, or concepts, at one time

Variance in health promoting lifestyle and behaviors explained by these concepts ranged from 19% to 59% (Pender, 1996)

Empirical findings were consistent with social learning theory (Pender, 1996)

Perceived self-efficacy, benefits, and barriers were empirically supported as predictors of health behaviors (Pender, 1996) Slide18

Importance of health

Perceived control of health

Perceived self-efficacy

Definition of health

Perceived health status

Perceived benefits of health-promoting behavior

Perceived barriers to health-promoting behaviors

COGNITIVE-PERCEPTUAL FACTORS

Demographic characteristics

Biologic characteristics

Interpersonal influences

Situational factors

Behavioral factors

MODIFYING FACTORS

Likelihood of engaging in health-promoting behavior

Cues to action

PARTICIPATION IN HEALTH-PROMOTING BEHAVIORSlide19
Slide20

Changes from 1987 to 1996

Deletion of “importance of health,” “perceived control of health,” and “cues for action” as predictors

Repositioned “definition of health,” “perceived health status,” and demographic and biological characteristics in the model

Included in the category of personal factors.

Added 3 variables that serve to influence the individual to engage in health-promoting behaviors: activity-related

affect

, commitment to a plan of action, and immediate competing demands and preferences

Overall

Direct

and

indirect effects

of all concepts on health

promoting

behaviors

Each

concept’s dynamic influence on the other concepts (and vice

versa)

Application

of certain aspects of each concept to

specific

health behaviors and populations, as well as to

general

health-promoting lifestyles. Slide21

Critique:

Fawcett’s theory evaluation

Significance

Concepts, propositions, philosophical claims, and conceptual model from which the theory was derived are all explicitly stated.

Authors of antecedent knowledge – expectancy-value and social cognitive theories – are acknowledged.

Bibliographical citations are provided.Slide22

Critique, continued …

Internal consistency

Content and context of the HPM are congruent, clear, and consistent

Theory propositions reflect structural consistency

Parsimony

(met when “statements clarify rather than obscure the topic of interest”)

Stated and explained clearly and concisely

However, the theoretical assertions are lengthy Slide23

Testability

(Theoretical concepts should be observable and the propositions measurable)

Research methodology reflects the HPM

Facilitates generation of testable hypotheses

Theory concepts are observable through appropriate, empirically proven, instruments

Health Promoting Lifestyle Profile (HPLP), which was created in 1987, tested, and revised in 1996 (HPLP II)

Data analysis techniques

Analysis of variance and hierarchical multiple regression are not appropriate due to the interactive effects of the concepts

A structural equation model should be used

(Johnson et al)Slide24

Empirical Adequacy

(Are the middle range theory’s assertions harmonious with the research studies’ empirical results?)

Tested

the validity of the HPM or used the HPM as a framework, in a variety of populations and with a diverse health behaviors:

Hearing protection among farmers (

McCullagh

, Lusk,

Ronnis

, 2002)

Hearing protection among construction workers (Lusk et al., 1999, which was used to develop an interactive, video-based program to increase hearing protection use)

Hearing protection among Mexican-American workers (Kerr, Lusk, &

Ronin

, 2002)

Caregiver burden and health promotion (Sisk, 2000)

Physical activity in Taiwanese youth (Wu & Pender, 2005)

Women with multiple sclerosis (

Stuifbergen

& Roberts, 1997)

Smoking and non-smoking college students (

Martinelli

, 1999)

Health promotion activity in employed Mexican American women (Duffy,

Rossow

, Hernandez, 1996)

Long term married couples (

Padula

& Sullivan, 2006)

Pregnant women over age 35 (

Viau

,

Padula

, Eddy, 2002). Slide25

Pragmatic Adequacy

(Use in clinical practice and research)

Special education and skill training is not essential to apply the theory in clinical practice.

The

HPM applies across the lifespan and is useful in a variety of settings.

Useful in clinical practice, health policy, nursing and patient education, nursing

research

Difficult to derive clinical procedures/policies due to personalizationSlide26

Concluding Remarks

Simple to use and understand

Generalizable to many populations and many health behaviors

Empirically proven to be valid and reliable

Future endeavors

More intervention studies needed

Health policySlide27

Questions?