THE HEALTH PROMOTION MODEL

BY:

NOLA J. PENDER

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.

The Health Promotion Model, developed by nursing theorist Nola Pender, has provided healthcare
a new path. According to Nola J. Pender, Health Promotion and Disease Prevention should be the
principal focus in health care, and when health promotion and prevention fail to anticipate
predicaments and problems, then care in illness becomes the subsequent priority.

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.

Nola Pender’s Health Promotion Model theory was originally published in 1982 and later
improved in 1996 and 2002. It has been used for nursing research, education, and practice.
Applying this nursing theory and the body of knowledge that has been collected through
observation and research, nurses are in the top profession to enable people to improve their well-
being with self-care and positive health behaviors.

The Health Promotion Model was designed to be a “complementary counterpart to models of

health protection.” It develops to incorporate behaviors for improving health and applies across
the life span. Its purpose is to assist nurses in knowing and understanding the major determinants
of health behaviors as a foundation for behavioral counseling to promote well-being and healthy
lifestyles.

Pender’s health promotion model 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. It
describes the multi-dimensional nature of persons as they interact within the environment to pursue
health.

The model focuses on the following three areas: individual characteristics and experiences,
behavior-specific cognitions and affect, and behavioral outcomes.

WHAT ARE THE CONCEPTS/CONSTRUCTS, ASSUMPTIONS, AND PROPOSITIONS

OF THE THEORY?

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

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.
 • Personal biological factors. Include variables 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, acculturation,
education, and socioeconomic status.

Perceived Benefits of Action

• Anticipated positive outcomes that will occur from health behavior.

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
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.

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

• Individuals seek to actively regulate their own behavior.

• Individuals in all their biopsychosocial complexity interact with the environment,
progressively transforming the environment and being transformed over time.
• Health professionals constitute a part of the interpersonal environment, which exerts
influence on persons throughout their life span.
• Self-initiated reconfiguration of person-environment interactive patterns is essential to
behavior change.

Propositions

• 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, a mediator of behavior as well as
actual behavior.
• Perceived competence or self-efficacy to execute a given behavior increases the likelihood
of commitment to action and actual performance of the behavior.
• Greater perceived self-efficacy results in fewer perceived barriers to a 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 is 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 commitments 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 environment to
create incentives for health actions.
 EXPLAIN HOW THE THEORY WAS DEVELOPED OR MODIFIED

The HPM was formulated through induction by use of existing research to form a pattern
of knowledge about health behavior. The HPM is a conceptual model from which middle-range
theories may be developed. It was formulated with the goal of integrating what is known about
health-promoting behavior to generate questions for further testing. This model illustrates how a
framework of previous research fits together, and how concepts can be manipulated for further
study.

The HPM, served as a framework for research aimed at predicting overall health-promoting
lifestyles and specific behaviors such as exercise and use of hearing protection (Pender, 1987).
Pender and colleagues conducted a program of research funded by the National Institute of Nursing
Research to evaluate the HPM in the following populations: (1) working adults, (2) older
community-dwelling adults, (3) ambulatory patients with cancer, and (4) patients undergoing
cardiac rehabilitation. These studies tested the validity of the HPM (Pender, personal
communication, May 24, 2000). A summary of findings from earlier studies is included in the
1996 edition of Health Promotion in Nursing Practice (Pender, 1996). Studies further testing the
model are discussed in the fifth edition of Health Promotion in Nursing Practice (Pender,
Murdaugh, & Parsons, 2006). The fifth edition includes an emphasis on the HPM as applied to
diverse and vulnerable populations and addresses evidence-based practice.

The rationale for revision of the HPM stemmed from the research. The process of refining
the HPM, as published in 1987, led to several changes in the model (Pender, 1996). First,
importance of health, perceived control of health, and cues for action were deleted. Second,
definition of health, perceived health status, and demographic and biological characteristics were
repositioned as personal factors in the 1996 revision of the HPM (Pender, 1996) and the fourth
edition of Health Promotion in Nursing Practice (Pender, Murdaugh, & Parsons, 2002). Third, the
revised HPM added three new variables that influenced the individual to engage in health-
promoting behaviors (Pender, 1996):

WHAT ARE THE SOURCES FOR THEORY DEVELOPMENT

Pender’s background in nursing, human development, experimental psychology, and

education led her to use a holistic nursing perspective, social psychology, and learning theory as
foundations for the HPM. The HPM integrates several constructs. Central to the HPM is the social
learning theory of Albert Bandura (1977), which postulates the importance of cognitive processes
in the changing of behavior. Social learning theory, now titled social cognitive theory, includes
the following self-beliefs: self-attribution, self-evaluation, and self-efficacy. Self-efficacy is a
central construct of the HPM (Pender, 1996; Pender, Murdaugh, & Parsons, 2002). The expectancy
value model of human motivation described by Feather (1982) proposes that behavior is rational
and economical and was important to the model’s development. The HPM is similar in
construction to the health belief model (Becker, 1974), which explains disease prevention
behavior; but the HPM differs from the health belief model in that it does not include fear or threat
as a source of motivation for health behavior. The HPM expands to encompass behaviors for
enhancing health and applies across the life span (Pender, 1996; Pender, Murdaugh, & Parsons,
2002).
 WHAT ARE THE STRENGTHS AND WEAKNESSES OF THE THEORY

Strengths

• The Health Promotion Model is simple to understand yet it is complex in structure.

• Nola Pender’s nursing theory gave much focus on health promotion and disease prevention
making it stand out from other nursing theories.
• It is highly applicable in the community health setting.
• It promotes the independent practice of the nursing profession being the primary source of
health promoting interventions and education.

Weaknesses

• The Health Promotion Model of Pender was not able to define the nursing metaparadigm
or the concepts that a nursing theory should have, man, nursing, environment, and health.
• The conceptual framework contains multiple concepts which may invite confusion to the
reader.
• Its applicability to an individual currently experiencing a disease state was not given
emphasis.

DOES THE THEORY GENERATE TESTABLE HYPOTHESES?

Yes, the assumptions and the propositions of the theory can be converted into testable hypotheses,
and these are the assumptions and propositions of the theory:

DOES THE THEORY CONTRIBUTE TO YOUR DISCIPLINE?

The applicability of the theory is not only applied to a specific discipline. Health promotion
is a concern and a responsibility of every person. As health care professionals, we carry in our
shoulders the four-fold responsibility to promote health, to prevent illness, to restore health and to
alleviate suffering. Thus, this theory will greatly contribute to the healthcare profession in terms
of practice, education, and research/scientific knowledge.
The model continues to be improved and evaluated for its ability to clarify the relationships
among variables that are thought to affect changes in a wide variety of health behaviours. There is
also ample scientific evidence for model factors to justify planning and performing intervention
trials to assess pattern-based clinical approaches for such behaviours.

WHAT ARE THE IMPLICATIONS OF THE THEORY TO HEALTH CARE PRACTIE

AND SCIENTIFIC KNOWLEDGE

Implications to Health care practice

Wellness as a healthcare specialty has grown in prominence, and current state-of-the-art clinical
practice includes health promotion education. Healthcare professionals professionals find the
HPM relevant, as it applies across the life span and is useful in a variety of settings (Pender, 1996;
Pender, Murdaugh, & Parsons, 2002). The model applies the formation of community partnerships
with its consideration of the environmental context and extends to global health promotion
(Pender, Murdaugh, & Parsons, 2010).

Clinical interest in health behaviors represents a philosophical shift that emphasizes quality of lives
alongside the saving of lives. In addition, there are financial, human, and environmental burdens
upon society when individuals do not engage in prevention and health promotion. The HPM
contributes a healthcare solution to health policy and health care reform by providing a means for
understanding how consumers can be motivated to attain personal health.

Implications to Education and Research

The HPM is commonly used in graduate education in the United States and increasingly in
undergraduate nursing education (Pender, personal correspondence, May 24, 2000). In the past,
health promotion was put behind illness care, as professional education was predominantly
performed in acute care environments (Pender, Baraukas, Hayman, et al., 1992). As an aspect of
health assessment, community health nursing, and wellness-focused courses (N. Pender, personal
communication, May 24, 2000), the HPM is increasingly incorporated into nursing curricula.
International efforts are growing across a number of countries to integrate the HPM into the
nursing curricula (Pender, personal communication, May 6, 2004; Pender, Murdaugh, & Parsons,
2002).

The HPM is widely used in graduate education and in US undergraduate nursing education
(Pender, Personal Communication, May 24, 2000). Health promotion has been put behind illness
care in the past, when professional education was predominantly performed in intensive care
environments (Pender, Baraukas, Hayman, et al., 1992). As an component of health evaluation,
community health care and wellness-focused workshops (N. Pender, personal contact, May 24,
2000), the HPM is gradually integrated into nursing curricula. International initiatives are growing
across a range of countries to incorporate the HPM into the nursing curricula.

References

Alligood, M. R. (2013). Nursing Theory-E-Book: Utilization & Application. Elsevier Health

Sciences.

Gonzalo, A. (2019). Nola Pender: Health Promotion Model. Nurselabs. Retrieved at

https://nurseslabs.com/nola-pender-health-promotion-model/

Murdaugh, C. L., Parsons, M. A., & Pender, N. J. (2018). Health promotion in nursing practice.
Pearson Education Canada.

Sakraida, T. J. (2017). Chapter 2. Health Promotion Model. Nurse Keys. Retrieved at

https://nursekey.com/21-health-promotion-model/

Submitted by: Dr. Mila Maruya