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ABSTRACT The objective of this study was to describe the everyday physical activity habits of students and analyze

the practice of physical activity and its determinants, based on the first component of Pender's health promotion model. This cross-sectional study was performed from 2004 to 2005 with 79 students in a public school in Fortaleza, Ceará, Brazil. Data collection was performed by interviews and physical examinations. The data were analyzed according to the referred theoretical model. Most students (n=60) were physically active. Proportionally, adolescents were the most active (80.4%). Those with a sedentary lifestyle had higher rates for overweight and obesity (21.1%). Many students practiced outdoor physical activities, which did not require any physical structure and good financial conditions. The results show that it is possible to associate the first component of Pender's health promotion model with the everyday lives of students in terms of the physical activity practice. Key words: Health promotion. Motor activity. Child. Adolescent.

INTRODUCTION
In the healthcare area, the biomedical model, based on biological knowledge, risk and individual care, is increasingly unable to explain and respond to a given population's health and disease processes. Evidence shows that health is more related to people's lifestyle than the prevalent idea about their genetic-biological determination(1). This situation shows the need to outline strategies and actions that will contemplate the positive aspects of the emerging healthcare approach, replacing the notion of health as absence of disease by another that increases the autonomy of the subjects to attain health with quality of life. Therefore, health promotion arises as a conceptual, methodological and instrumental field, seeking to overcome the idea of the natural history of diseases, demanding a broadened perspective of the health-disease process(1-2). With the publication of the Ottawa Charter for Health Promotion (1986), several conferences and international meetings were held regarding the relevance and meaning of health promotion, including healthy public policies (Adelaide, 1988), favorable environment (Sundsvall, 1991), strengthening of community actions (Jakarta, 1997) and the consolidation of health promotion as a fundamental component of public policies and programs (Mexico City, 2000)(3). It is worth noting that all charters address lifestyle as one of the central components of health promotion strategies. Lifestyle is defined as a set of individual decisions that affect health, over which a certain level of control can be exerted. Personal decisions and habits that are detrimental for health create risks originated by the individual himself. When these risks result in disease or death, it can be said that the lifestyle contributed to or caused the disease or disorder (4). After the Industrial Revolution, socioeconomic and cultural changes and the many technological advances yielded a new lifestyle for the world population. Even considering the benefits from an economic perspective, the lifestyle changes brought by modernization can be translated in a general, imminent risk for health(5).

Among lifestyle changes, one of the main characteristics was that it became more sedentary. A sedentary lifestyle is responsible for approximately two million deaths worldwide. Yearly, it is estimated to be responsible for 10% to 16% of colon and breast cancers and diabetes, and 22% of ischemic heart diseases. Promoting health, therefore, depends on giving attention to integral development, contemplating the following aspects: attention to the quality of interpersonal relationships, a balanced dietary supply, good living conditions and access to healthcare services, access to information and formal or professional education and doing sports or other types of leisure in order to have good physical, emotional, intellectual and social development (7). School is one of the spaces acknowledged for the promotion of a healthy lifestyle. The health promoting school is defined as a place with an integral view of being human, which considers people – especially children and adolescents – within their family, community and social environments. Therefore, the school is seen as one of the most important spaces in the promotion of a healthy lifestyle, with the practice of physical activities, since children and adolescents, as well as teachers and auxiliaries, spend a great deal of time there (8). However, sedentary habits like playing videogames and watching television are increasingly more common in the daily routine of children and adolescents(9). Besides, physical activity actions acquired in childhood seem to persist during adult life. They can even be vital in the prevention of several diseases, and especially in attaining a healthier life(10). As such, healthcare professionals need to become aware of the habits of children and adolescents in school, especially regarding the practice of physical activity, so that they can implement strategies to promote health and wellbeing for schoolchildren, as well as the prevention of diseases. In an effort to meet this need, Pender developed a theoretical nursing model of health promotion that may be used to know, execute and assess health promotion actions, including the practice of physical activities(11).

GOALS
The purpose of this study was to describe physical activity habits in the daily routine of a specific group of schoolchildren and analyze the practice of physical activity and its determiners, according to the first theoretical component of health promotion proposed by Pender(11).

METHOD
The Health Promotion Model (HPM) was developed by Nola J. Pender, professor emeritus of the Nursing School at University of Michigan in the United States, and is supported on the concept of health promotion, defined as those focused on the development of resources that can maintain or improve wellbeing(11-12). American, Asian and European researchers have often used this health promotion model to study behaviors that lead to health promotion. Its theoretical basis is focused on the multidimensional nature of individuals, in which there are interpersonal and environmental

according to three basic components: 1) individual characteristics and experiences (previous behaviors and personal factors). demands and preferences). allowing for planning. 2) feelings and knowledge about the desired behavior (perception of benefits. intervention and assessment of their actions(12). Both contribute substantially to achieve health (11-12).interactions. this science model attempts to evaluate the behavior of individuals that leads to health promotion. . as seen in figure 1(11-12). and 3) desirable health promotion behavior (commitment to the plan of action. enabling nurses to provide care either individually or as a group. Its structure is simple and clear. In addition. interpersonal influences). barriers. self-efficacy.

It was carried out at a public elementary and high school. Data collection occurred with individual interviews. It is important for primary care to be organized in order to reduce or eliminate barriers that make it difficult for patients to seek a healthy behavior. located in the city of Fortaleza/Ceará/Brazil. the spaces available for physical activities in the school and how physical education classes were organized in the school. practice of physical activities and time spent daily on sedentary activities. It is worth noting that. during weekly visits to the school in the morning and afternoon periods. with the consent of their parents. The results were analyzed by reading and interpreting the data. especially for the practice of physical activities(12). according to the researchers' availability. Considering the administrative and ethical aspects of scientific research. normal weight (between percentiles 5% and 85%). involving the researchers and the schoolchildren and/or their parents. In the present study. As such. according to Pender's theoretical model of health promotion(11). family income. Previous behavior is defined in the adopted theoretical model as the individual's previous habits related to the search for health. whenever the children or adolescents did not know how to answer the form questions. The BMI values were classified in percentages. when a form was filled out with data like gender.As nurses have experience with biopsychosocial factors and ongoing contact with the patients. and personal factors interfere directly in individual behavior in order to promote health. 2005. The studied group consisted of 79 children and adolescents who agreed to participate in the study. previous behavior is the standard condition for the elaboration of nursing interventions. we chose to address the lifestyle of a group of schoolchildren with children and adolescents. in an attempt to comprehend these data in relation to the first component of the theory. 2004 to March. The form also included space for observations about what occurred when the students arrived or left school. overweight (between percentiles 85% and 95%) and obesity (above the 95% percentile). according to the first component of the illustrated diagram (figure 1). children and adolescents who did physical activities less than three times a week for less than 30 minutes were considered sedentary. The study population contained children and adolescents aged 6 to 18 years. such as low weight (below the 5% percentile). In addition. they have the chance to improve the health of the community. requesting authorization to perform the study. children and adolescents were submitted to an anthropometric evaluation (weight and height measurements) to calculate the BMI. After the interview. and is linked to the idea that people have personal factors/characteristics and experiences that subsequently affect their actions (11). which includes doing physical activities (11). As for the practice of physical activities. This is a cross-sectional study. Data collection occurred from October. school management received the appropriate documents. according to the American method(13). age. the study proposal was sent to and approved by the . which was granted. their parents or legal guardians answered them.

COMEPE. if at all possible – of moderate intensity. communities and primary healthcare to complement the role of the school in physical activity(11). being enrolled for either morning or afternoon classes. age range and Body Mass Index (BMI) among physical factors. In addition. the school offered cultural activities and permitted the development of research and extension activities in several areas. projects on cardiovascular disease. Once per week. . It is worth noting that the place where the physical education classes were held was also used for other activities. The figure below shows the profile of physical activity practice in children and adolescents. guided by a physical educator. as a strategy to reduce the risk of non-transmissible chronic diseases and to improve quality of life. RESULTS AND DISCUSSION All 79 children and adolescents study in a public school in the outskirts of Fortaleza. as well as the Schoolchildren's health program. we chose to focus on gender. Researchers note the importance of the school to promote the daily involvement of children and adolescents in basic physical activities(11). Each class had a 50-minute physical education class once a week. in accordance with recommendations for research involving human beings. (Protocol No 95/04). This situation contradicts the recommendations of the National Policy of Physical Activity Promotion (14). the teachers and coordinators welcomed the children and adolescents in the main schoolyard to inform them about the general activities planned for the week. Among these. are worth noting. With the purpose of analyzing the first component of Pender's Theory. The same authors address the need for families. The physical activities promoted by the school were available only for the 5 th grade and upwards. healthcare education and eye care of the Nursing Department of Universidade Federal do Ceará.Review Board of Universidade Federal do Ceará . Most students walked to school by themselves or with friends. At the school where the study was developed. which made it difficult to have physical activities more often. the idea of a healthpromoting school focused on physical activity had not been incorporated. which emphasizes the incorporation of at least 30 minutes of physical activity. most days of the week – daily. The students' parents or legal guardians often did not accompany them. especially healthcare.

As for gender. girls were more sedentary when compared to boys. Although the school did not develop physical activity practice according to health policy recommendations. most children and adolescents practiced physical activities for over thirty minutes more than three times a week. Regarding gender. authors of the theory(11) state that physical activity declines by about 50% during adolescence. the authors state that physical activity is higher among boys than girls. higher prevalence of overweight and obesity was observed among sedentary children and adolescents (Figure 3). in accordance with our study. In contrast with our findings. it should be noted that physical activity is defined as any body movement produced by the muscle-skeletal system that consumes energy beyond baseline consumption (15).In order to analyze issues regarding the practice of physical activity. . Such behavior is justified because girls mention more setbacks to start physical activities and not enjoying physical education classes in school(11). Regarding the Body Mass Index. Regarding the age range. adolescents (12 to 18 years old) were proportionally more active.

It is known that the influence of the family during childhood has a positive effect on the development of an active lifestyle(11). Socioeconomic status is one of the sociocultural factors addressed in the theory. as a health-promoting place. more time spent on sedentary activities (television. This concept refers to strengthening the promotion of a healthy lifestyle by building on the capacity of choice(16). the tendency to a sedentary life is still a matter of discussion as to whether it is a cause or consequence of obesity. has a fundamental role in changing sedentary habits. videogames. which did not require special facilities or good financial conditions. the school. Particularly socioeconomic level directly influences participation in sports organized outside the school. to deal with the multiplicities of conditioners for physical activity practice. a large share developed unsupervised outdoor physical activities. such as gymnastics. In addition to the school. and obesity itself can make them even more sedentary(9). . bodybuilding. but also active subjects who can contribute with their own resources for the process of health production. As such. Among active schoolchildren. since there are financial expenses involved with the sport and transportation. Changes in the physical activity profile of the population. especially the practice of physical activity(16).It is known that the practice of physical activities in overweight individuals is usually lower than that of non-obese. playing soccer and riding bicycles. such as considering excess weight as a synonym of health and prosperity. Children and adolescents tend to become obese when they are sedentary. Another obstacle is that family members need to find time to take their children to the places where these activities are held. families and informal community networks should not only be considered receivers of healthcare. as well as their families. dancing. computers) and the change of sociocultural factors. such as: walking. since it can encourage and strengthen the capacity of children and adolescents. However. Other activities needing professional supervision and with financial expenses. swimming and water gymnastics were not common among these students. has a negative impact on health(11).

environmental and family supports are. as families with better financial conditions can provide better resources and access to multiple sports activities(11). the higher the social.Health behaviors may be related to family support. it was observed that the students were active and motivated to do physical activities during periods like class intervals and before or after school. in its first precept. social integration and development of skills that result in higher self-esteem and confidence for the child. It should be noted that. self-motivation and perception of their health status. the importance of primary healthcare is evidenced by the empowerment of the school and the community. the higher are the chances of complying with and keeping up physical activities in children and adolescents. The empowered individual is capable of behaving in a certain way. by making people aware of the importance and the benefits that derive from a healthy lifestyle in order to attain quality of life. . as explained before. In the present study. that genetic and acquired features influence the search and involvement in activities directed at health promotion. socioeconomic variables and socialization by means of the family. The practice of physical activities offers opportunities for leisure. the school and the media. The analysis of previous behaviors in relation to sedentary activities in children and adolescents is presented in Figure 4. The theoretical model highlights. The authors of the theoretical model of health promotion (11). described that it includes variables like self-esteem. Socioeconomic status plays a significant role in these behaviors. The previous behavior of individuals is another element in the first component of Pender's theory(11). Initiatives that use education with environmental support have the highest chances of success(12). influencing his own environment and acting according to the goals of health promotion(17). In this context. by addressing the psychological factor. although the school does not assume the role of promoting physical activities.

Some studies evidenced concerns with the time spent on electronic activities like computers and television (9).73 hours. sociocultural and psychological factors. In this study. as it should encourage children and adolescents to perform leisure and socialization activities in association with the educational process. respectively. Sedentary ones had a higher prevalence of overweight and obesity. The media plays an important role in broadcasting and building opinions. and that television takes up the free hours in which a child could be doing other activities. 27% and 35%. CONCLUSIONS The use of theoretical nursing models could help healthcare professionals to understand the health-disease complex. A large share of the schoolchildren did outdoor physical activities. There is a study showing that the obesity rate for children who watch television for more than one hour a day is 10%. five or more hours per day are associated to a prevalence of nearly 25%. it should disseminate information related to health and wellbeing. families and communities(11). which would promote the health of individuals. In addition to the media. which would favor the development of sedentary habits. although most subjects practiced some type of physical activity. . Therefore. which did not require special facilities or good financial conditions. the average daily hours spent using the computer and watching television amounted to 2.In the studied group. and also support nursing practice. The child often eats in front of the television. The main results show that most schoolchildren were active. supporting nursing interventions in order to promote the health of schoolchildren. As such. so that they have fewer moments of idleness. they spent many hours a day on sedentary activities. four. whereas habits of watching television for three. focusing on physical activities. non-nutritious foodstuffs. they can be seen as either benefits or barriers for the acquisition of healthy habits. Healthcare institutions. and a large share of the commercials offer calorie-rich. The present study showed that the first component of Pender's theoretical model of health promotion can be related with the daily routine of children and adolescents. the school where the study was held did not promote the health of its students. family and the school environment are important resources that can influence the commitment and involvement of people with behaviors that lead to health promotion either positively or negatively. In spite of these findings. the school has an important role in health promotion. Physical. emphasizing the importance of a healthy lifestyle and encouraging such habits since childhood. as well as previous behaviors proposed in the first component of the theory under study are considered to influence physical activity practice of children and adolescents.

It is worth noting that the notion of schools as health-promoting institutions is an eminent idea. so that it can benefit the health of children and adolescents. which still needs to be consolidated in Brazilian public policies. . if encouraged since childhood. and. it will contribute to reduce health risks throughout life.The importance of physical activity is well-known as a component that promotes the health of the population.

The models success is based on the following assumptions (Nursing Theory. The model is used extensively as a framework for research aimed at predicting health promoting lifestyle (McEwen & Wills. behaviors that may deter success must be addressed. Health promotion is not isolated to a person(s) but interactive with the environment. The major concepts of the Health Promotional Model are as follows (McEwen & Wills. Nola Pender sought to influence behaviors promoting health through positive motivation. Is extrapolated from situational influences and dictates the intent with effective nursing presence to guide health promotion. Due to this environmental influence. 2011). each plan is tailored. Personal factors play an important role because it identifies behaviors that need adjustment in order to obtain the desired results. Due to environmental influences. 2011): a) Individual characteristic and experience as manifested by prior related behavior. This seeks to utilize past experience and behavior to assess possibility of change.The Health Promotion Model seeks to improve the health of the global population through universal utilization. The environment is not limited to the physical space occupied. The role of nursing is integral within the community in general and its individual components. the strengths and weaknesses and is a great way to create a platform to formulate a plan of action. b) Behavior specific cognitions and affect (the perceived benefits of action). taking into consideration possible reasons for failure or causes that increase difficulty that may derail success. but cultural and social influence within the community. It identifies patterns that maybe beneficial. 2011): a) b) c) d) e) f) g) People attempt to create optimal living conditions People have the ability to complete a self-assessment and know their strengths People value growth People seek to regulate their behavior People interact and transform their environment Nurses and other health professions are an integral part of the community People have the ability to change their behavior as necessary. This plan will clearly outline the benefit of changing ones behavior and the steps necessary to attain such a .

Public attention to a positive state of health began escalating in the late 1980s (Pender. It can also be concluded that many more studies need to be done applying this model to the adolescent population. Pender‟s health promotion theory offers a holistic view of the patient. Health promoting behaviors can lead to a patient‟s overall sense of well-being as well as protection from disease and chronic illnesses. but to the general public. In this tailored plan. Health promotion can bring about a sense of . 2003). Abstract Health promotion is but one of the primary objectives in modern nursing.Health Promotion Theory 3 Introduction With healthcare costs rising. 1996) and a variety of “wellness programs” began developing as a result (Galloway. c) Behavioral outcome. The health promotion theory can ideally be applied to all populations but is especially important in the adolescent population since they are at a critical time in their life for making independent health care decisions. assessing the patient‟s background and self-perceptions to allow the nurse to intervene and construct a plan accordingly. This measures the viability of the plan of action and resources available versus resources to be attained. immediate competing demands and preferences. and health promoting behaviors. thereby highlighting the behavioral outcome of health promotion. health promotion has been of increasing interest not only to health care workers.goal. commitment to plan of action. good health and increased capacity for self-care. Health promotion describes behaviors an individual can perform to bring greater longevity and a high quality of life. A thorough critique of this theory indicates that this model can be useful in the adolescent population but may need to be adapted in various ways to be successful. nurses should seek to empower individuals with information necessary to achieve success. An important point is that health promotion is not just about disease prevention.

Adolescence can be an important time for intervention and encouragement of health promotion. Pender however. and can also decrease social problems including violence and suicide (Peterson & Bredow. 2009). Theory Description Purpose Nola Pender‟s Health Promotion Model (HPM) was created to serve as a “multivariate paradigm for explaining and predicting health promoting component of lifestyle” (Pender. The model is used to assess an individual‟s background and perceived perceptions of self among other factors to predict health behaviors. 1990. another similar model had been developed which also took into account these factors to predict health behaviors. wanted to define health as not just being free of disease. 2009). she first published the HPM in 1982. centered on the idea that fear or threatHealth Promotion Theory 4 of disease is the predictor for positive health behaviors (Peterson & Bredow. and positive environmental influences (Srof & Velsor-Friederich. 2003). Taking into account her expanded view of health. Studies support the HBM as being a disease avoidance model (Galloway. 2009). she then revised it in 1996 (Pender. Adolescents are unique in that they are not completely independent in their health choices and are much more vulnerable to both negative. 2006). can increase energy. This model. p. Peterson & Bredow. 2002). 1996. 2009). the Health Belief Model (HBM).326). Therefore it is critical that health promotion be fully explored in this population. In response to a particular study using her model. Before the HPM was published.wellbeing and harmony to the individual. Her definition of health includes measures taken to promote good health and includes the patient‟s own view of themselves and their lifestyle (Peterson & Bredow. Pender‟s model is meant to be a “guide for exploration of the complex biopsychosocial . Nola Pender‟s Health Promotion Theory is one of the most frequently used models for health promotion in adolescents (Montgomery.

1996). These two theories are the expectancy-value theory and the social cognitive theory. Each concept in the model applies to a specific area of patient assessment or action. By not including this factor as a determinant towards behavior the HPM focuses more on health promotion and less on illness prevention as the HBM aims to do (Pender. 51). The social cognitive theory describes the concept of perceived self-efficacy which is “a judgment of one‟s ability to carry out a particular course of action” (Pender. 1996. Concepts Two theories underlie Pender‟s model which are important for understanding the concepts she describes. p. make it especially useful for use in adolescents (Montgomery. Walker. The expectancy-value theory is based on the idea that the course of action will likely lead to the desired outcome. One concept that was included in the HBM that has been purposely left out of the HPM is perceived threat of disease. .processes that motivate individuals to engage in behaviors directed toward the enhancement of health” (Pender. more specific concepts. 1996. p. and that this outcome will be of positive personal value (Pender. There are three major concepts in Pender‟s model which are further subdivided into narrower. it can be applicable in many more situations across the lifespan (Pender. The major concepts are individual characteristics and experiences. Pender created this model to be “applicable to any health behavior in which „threat‟ is not proposed as a major source of motivation for the behavior” (Pender. p. Since the model does not rely on potential threat of disease as a source of motivation. This and the fact that the model addresses resources. 1990). 1996). and behavioral outcome. 1996. Sechrist & Stromborg. 53). Health Promotion Theory 5 54). 2002). behavior-specific cognitions and affect. Pender predicts that a high confidence level will lead to greater likelihood that the behavior will be performed. which adolescents may lack.

Relationships Pender‟s model identifies many relationships between concepts. aspirations and accomplishments. p. attitudes. and providers) and situational influences. Personal factors are broken down in the model to biological. and directly influenced by intermediate competing demands (Pender. It Health Promotion Theory 6 can also be inferred that Pender is breaking down the overall “environment” into what she defines as interpersonal influences (family. Pender fully defines each of the concepts mentioned above in her book. It is important to note that her definition offers a holistic view of the individual and does not just focus on their illness (Peterson & Bredow. peers. psychological. Perceptions of self and influences on the individual directly influence commitment to a plan of action which then leads to the health promoting behavior. activities. Personal factors are independent variables that directly influence behavior-specific cognitions and also directly influence the specific health promoting behavior. Health promoting behavior is identified as the ultimate outcome of the model. Health promoting behaviors are also both indirectly and directly influenced by prior related behaviors.Definitions Before the definitions of HPM can be fully understood. She states that “Health is the actualization of inherent and acquired human potential through goal-directed behavior. 1996). and sociocultural making it clear which personal factors are being considered. 22). Health Promotion in Nursing Practice. Structure . it is important to reiterate Pender‟s definition of health which serves as a basis for the entire model. competent self-care. Pender also offers a classification of behavioral expressions of health divided by affects. 2006. 2009). and satisfying relationships with others while adjustments are made as needed to maintain structural integrity and harmony with relevant environments” (Pender.

Clarity The model is easily understood and the key concepts are clear. 2009). According to Srof & Velsor-Friedrich (2006). 1996). Studies have shown that perceived self-efficacy. Another assumption is that health professionals exert an interpersonal influence on an individual throughout their life (Pender. Her . Internal Criticism AdequacyHealth Promotion Theory 7 The HPM adequately pulls together all of the factors that can motivate an individual to improve their health.The model links the three major concepts in a general linear fashion towards the overall goal of the health promoting behavior. The definitions of the concepts are in an uncomplicated language and are understood by all health professionals. It is assumed that a patient can self-reflect. This in turn supports Pender‟s model as an adequate predictor of health behavior since self-efficacy is a central theme in her model. and behavioral outcome. behavior-specific cognitions and affect. and barriers all play a role in predicting health behaviors (Pender. actively seek to regulate behavior. 1996). benefits. the model may not be adequate for adolescents because of differences between adolescents and adults in independent decision making. and initiate behaviors that modify their environment. Srof & Velsor-Friedrich‟s (2006) analysis of the model also indicates that self-efficacy and the behavior specific cognitions are supported as a predictive variable in multiple studies. Assumptions Pender (1996) outlines specific assumptions her model is based on which overall emphasize the fact that the patient has an active role in their health behavior. The diagram itself is also structured in a way that the key concepts are clearly organized under the three headings: individual characteristics and experiences. One weakness in the theory is that the model may not be completely accurate in use for communities and families as a whole since the focus is on an individual (Peterson & Bredow.

Peterson & Bredow (2009) point out that this may not always be easily distinguished in practice.Health Promotion Theory 8 Consistency The terminology and definitions are consistent throughout the model with the health promoting behavior being the end goal. and the outcomes/goals of health promotion. Certain behaviors may be seen as both health-promoting and protection from disease. 2009). Although Pender has defined the difference between health promotion and health protection by eliminating threat of disease from her model. or indirectly lead to this end point so that although there are many relationships between concepts. Pender based her model on the HBM and “successfully addressed many of its criticism” (Montgomery. Threat of disease therefore may still be one motivation in certain health-promoting behaviors and it is unclear how this affects Pender‟s model (Peterson & Bredow. 2009). Level of theory development . Each of the other concepts in the model either directly.diagram clearly represents the relationships between the many factors involved in the patient‟s behaviors and affects. It is also important to mention that Pender addressed results of studies using her model. Logical development The model is already supported by Feather‟s Expectancy Value Theory and Bandura‟s Social Cognitive Theory which are well-established and provide the foundation for the model itself (Peterson & Bredow. Pender‟s argument for removing threat from her model is also a logical step in acknowledging the modern definition of good health used by all health care providers as not being simply “disease-free”. and revised it to be more applicable to all populations (Peterson & Bredow. Although one of Pender‟s assumptions is that the health care provider can intervene in an individual‟s behaviors towards health promotion. 2002). 2006). the overall goal remains clear. it is unclear at which point(s) on the model the provider should intervene.

many of them Health Promotion Theory 9 both directly and indirectly affecting the ultimate endpoint of health promoting behavior. One study analyzed by Srof & Velsor-Friedrich (2006) used an approach combining the HPM with the TTM in adolescents. Galloway (2003) puts forth other theoretical models that describe health promotion including the Transtheoretical Model (TTM) and the Theory of Reasoned Action (TRA). The TTM however focuses mostly on the process of change and less on the factors that influence it. The study concluded that both models used together may have been more adequate at predicting dietary behaviors in adolescents than either model used alone (Srof & Velsor-Friedrich. It is . clearly defined. The TRA focuses more on behavioral intent and their attitudes towards performing a certain behavior. Discrimination ` Health promotion is a unique role of nurses but it does have similarities with other models such as the HBM discussed previously.The HPM represents a middle range theory because it describes a specific phenomenon in healthcare practice with a concrete end goal. 2006). It also has been refined to focus on 10 determinants of behavior that can be assessed for each patient (Pender. and it is easy to distinguish the progression from personal backgrounds to cognitions and affect and finally to health promoting behavior. 2006). There are many relationships between each concept. 1996). concepts which keeps it from becoming too cluttered and complex. External criticism Complexity The model is limited to 11 key. This makes the theory less abstract than a grand theory and specific enough to use for research and healthcare settings. The overall framework however is linear. One possible weakness however in this linear approach is that it does not incorporate reciprocal relationships Bandura (creator of the social cognitive theory on which the HPM is founded) describes in his work (Srof & Velsor-Friedrich.

The HPLP is a 52 point questionnaire.clear that more work needs to be done in testing the HPM in different populations. including the Health Promoting Lifestyles Profile (HPLP) that Pender recommends. reinforcing and identifying strengths in the individual. 296). Reality Convergence Not only are the concepts in the HPM well known to the health care field. This signifies a need for health promotion education for adolescents and their care providers. 1996). it does not explicitly describe how nurses can effect changes in client perceptions” (p. and identifying and setting specific goals. and premature morbidity and mortality (Brown. A particular concern in Health Promotion Theory 10 America is rising obesity in children and adolescents leaving them at risk for cardiovascular disease. The model does not outline specific ways to assess the patient to determine likelihood of action towards a behavior. Pender also discusses using contracts with the nurse or “self-contracts” so the patient can be independent in rewarding themselves when they choose certain actions. In this case the patient “serves as the source of rewards” instead of the nurse allowing the patient to be selfsufficient (Pender. reiterating benefits of change. type II diabetes. but many instruments have been developed to do this using the HPM as a basis. Most of these. Pragmatic Peterson & Bredow (2009) state: “Although the model identifies foci for nursing interventions. 2008). This can be a problem in the adolescent population because of the . 2009). health promotion has captured the attention of the general public as well. 2003). but Pender‟s book describes specific interventions to tailor plans to their patients including. are intended for adults rather than adolescents (Galloway. They are correct in that the model itself does not do this. in general the HPM is unique in that it distinguishes itself from other models by not counting threats or avoidance as a motivator for health promotion (Peterson & Bredow. Although similarities to these other models exist.

and therefore can be applied in a broad sense to many different settings. and stress management. This allows the nurse to develop a unique care plan that takes these behaviors into account. the Adolescent Life Change Scale.Health Promotion Theory 11 Scope The scope of the theory is limited to predicting and identifying health promoting behaviors without including disease avoidance as a motivator for health behavior. Utility The model is very useful in that it takes into account each individual‟s behavior and preferences. Many other studies have also proved . Pender does mention other instruments more appropriate to use for adolescents including Ryan-Wegner‟s Schoolager‟s Coping Strategies Inventory which measures stress-coping strategies. and hospitals but also in a broader scale including health promotion within families and in the community. 297). Pender (1996) recommends using the nursing process including using nursing diagnoses and model-based assessments such as the Health Promoting Lifestyles Profile II. Peterson & Bredow (2009) draw from various studies to note that “tailoring interventions has been found to increase intervention effectiveness” (p. Pender also outlines specific strategies in her book for constructing plans for individuals for health promotion. schools.comprehension needed and possibly large amounts of time needed to fill the questionnaire out accurately (Galloway. She outlines a multi-step process in developing a plan of care based on client‟s strengths and preferences. and the Adolescent Perceived Events Scale (Pender. exercise programs. Specifics include nutrition information for individuals of all ages. The model does not limit itself to a specific type of health behavior performed. 2003). 1996). Pender (1996) discusses many different settings the theory can be used in including the workplace.

2009). Pender‟s model is useful to the nurse because it helps expand their role to promote good health as opposed to just decreasing their risk for becoming ill. allowing them to be agents of change. Srof & Velsor-Friedrich (2006) state that “little work has been done to apply and explore the HPM in relation to the adolescent population” (p. The HPM has been also adapted to be more useful in adolescents. by focusing on self-efficacy.useful in explaining variances in behavior in health promotion (Peterson & Bredow. and capabilities” for each patient and providing resources and education to promote improved health and a better quality of life (Peterson & Bredow. p. 292). Brown (2009) reviews studies that have used the Physical Activity Lifestyle Model (or PALM) which is similar to the HPM but has been more useful in the needs of adolescents. 366). . 2009. This model allows the patient and the nurse to work together towards a goal of a better quality of life. potentials. Although many studies exist using Health Promotion Theory 12 the HPM in adults. it also puts the patient‟s health in their hands. Significance Peterson & Bredow (2009) accurately note that this model has changed the focus of the role of the nurse from simply disease prevention to health promotion. Not only does the model expand the role of the nurse. The nurse‟s goals are now aimed at “strengthening resources.