COMMUNITY HEALTH NURSING

CONCEPTS

(INSTRUCTIONAL MODULE)
UNIT 1 (Topic 2):
THEORETICAL MODELS/ APPROACHES
I. LESSON OVERVIEW
Public health nursing is a community-oriented, population-focused nursing
specialty that is based on interpersonal relationships. The unit of care is the
community or population rather than the individual, and the goal is to promote
healthy communities. Theories and models of community/public health nursing
practice aid the nurse in understanding the rationale behind community-oriented
care.

II. LEARNING OBJECTIVES:

At the end of the session, the learners will:

 Describe different theories and their application to community/public health

nursing.
 Critique a theory in regard to its relevance to population health issues.
 Explain how theory-based practice achieves the goals of community/ public
health nursing by protecting and promoting the health of the public.
III. MODULE REQUIREMENTS:

Pre-requisite knowledge on : NuCM 101, NuCM 102, NuCM

103,NuCM 104

Refer to the lectures attach in the https://elearning.vsu.edu.ph/my/

on Community Health Nursing Module. (For those using the
elearning site and moodle virtual classroom).

Watch video presentation integrated in this module.

Answer the activity for each unit.

Answer the assessment tasks for each unit.

 IV. LESSON PROPER

HOW THEORY PROVIDES DIRECTION TO NURSING

The goal of theory is to improve nursing practice. Chinn and Kramer (2008) stated
that using theories or parts of theoretical frameworks to guide practice best achieves
this goal. Students often find theory intellectually burdensome and cannot see the
benefits to their practice of something so seemingly obscure. Theory-based practice
guides data collection and interpretation in a clear and organized manner; therefore,
it is easier for the nurse to diagnose and address health problems. Through the
process of integrating theory and practice, the student can focus on factors that are
critical to understanding the situation. The student also has an opportunity to
analyze the realities of nursing practice in relation to a specific theoretical
perspective, in a process of ruling in and ruling out the fit of particular concepts
(Schwartz-Barcott et al., 2002). Barnum (1998, p. 1) stated, "A theory is like a map
of a territory as opposed to an aerial photograph. The map does not give the full
terrain (i.e., the full picture); instead it picks out those parts that are important for its
given purpose". Using a theoretical perspective o plan nursing care guides the
student in assessing a nursing situation.

The concept of community is defined as "a group of people who share some
important feature of their lives and use some common agencies and institutions."
The concept of health is defined as "a balanced state of well-being resulting from
harmonious interactions of body, mind, and spirit." The term community health is
defined by meeting the needs of a community by identifying problems and managing
interactions within the community

Basic Elements

The six basic elements of nursing practice incorporated in community health

programs and services are:
(1) promotion of healthful living

(2) prevention of health problems

(3) treatment of disorders

(4) rehabilitation

(5) evaluation and

(6) research.

Major Roles

The focus of nursing includes not only the individual, but also the family and the
community, meeting these multiple needs requires multiple roles. The seven major
roles of a community health nurse are:

(1) care provider

(2) educator

(3) advocate

(4) manager

(5) collaborator

(6) leader, and

(7) researcher.

Major Settings

Settings for community health nursing can be grouped into six categories:

(1) homes

(2) ambulatory care settings

 (3) schools

(4) occupational health settings

(5) residential institutions, and

(6) the community at large.

Community health nursing practice is not limited to a specific area, but can be
practiced anywhere. Theories and Models for community health nursing. The
commonly used theories are:

 Nightingale’s theory of environment

 Orem’s Self care model
 Neuman’s health care system model
 Roger’s model of the science and unitary man
 Pender’s health promotion model
 Roy’s adaptation model
 Milio’s Framework of prevention
 Salmon White’s Construct for Public health nursing
 Block and Josten’s Ethical Theory of population focused nursing
 Canadian Model
The Health Belief Model

Initially proposed in 1958, the Health Belief Model (HBM) provides the basis for much of
the practice of health education and health promotion today. The HBM was developed
by a group of social psychologists to explain why the public failed to participate in
screening for tuberculosis (Hochbaum, 1958). Hochbaum and his associates had the
same questions that perplex many health professionals today: Why do people who may
have a disease reject health screening? Why do individuals participate in screening if it
may lead to the diagnosis of disease? Through their work, this group found that
information alone is rarely enough to motivate one to act. Individuals must know what to
do and how to do it before they can take action. Also, the information must be related in
some way to the individual's needs. One of the most widely used conceptual
frameworks in health behavior, the HBM, has been used to explain behavior change.

The Health Belief Model is a theoretical model that can be used to guide health
promotion and disease prevention programs. It is used to explain and predict individual
changes in health behaviors. It is one of the most widely used models for understanding
health behaviors.

Key elements of the Health Belief Model focus on individual beliefs about health
conditions, which predict individual health-related behaviors. The model defines the key
factors :

 influence health behaviors as an individual's perceived threat to sickness or

disease (perceived susceptibility)
 belief of consequence (perceived severity)
 potential positive benefits of action (perceived benefits)
 perceived barriers to action, exposure to factors that prompt action (cues to
action)
 confidence in ability to succeed (self-efficacy).
Considerations for Implementation

The Health Belief Model can be used to design short- and long-term interventions. The
five key action-related components that determine the ability of the Health Belief
Model to identify key decision-making points that influence health behaviors are:

 Gathering information by conducting a health needs assessments and other

efforts to determine who is at risk and the population(s) that should be targeted.
 Conveying the consequences of the health issues associated with risk behaviors
in a clear and unambiguous fashion to understand perceived severity.
 Communicating to the target population the steps that are involved in taking the
recommended action and highlighting the benefits to action.
 Providing assistance in identifying and reducing barriers to action.
 Demonstrating actions through skill development activities and providing support
that enhances self-efficacy and the likelihood of successful behavior changes.

These actions represent key elements of the Health Belief Model and can be used to
design or adapt health promotion or disease prevention programs. The Health Belief
Model is appropriate to be used alone or in combination with other theories or models.
To ensure success with this model, it is important to identify "cues to action" that are
meaningful and appropriate for the target population.

The Health Belief Model (HBM) is one of the first theories of health behavior.

The health belief model proposes that a person's health-related behavior depends on
the person's perception of four critical areas:

1. the severity of a potential illness,

2. the person's susceptibility to that illness,

3. the benefits of taking a preventive action, and

4. the barriers to taking that action.

HBM is a popular model applied in nursing, especially in issues focusing on patient
compliance and preventive health care practices.

The model postulates that health-seeking behavior is influenced by a person’s

perception of a threat posed by a health problem and the value associated with actions

aimed at reducing the threat. HBM addresses the relationship between a person’s

beliefs and behaviors. It provides a way to understanding and predicting how clients will

behave in relation to their health and how they will comply with health care therapies.

MILIO’S FRAMEWORK FOR PREVENTION

Nancy Milio a nurse and leader in public health policy and public health education
developed a framework for prevention that includes concepts of community-oriented,
population focused care.(1976,1981).

The basic treatise is that behavioral patterns of populations and individuals who make
up populations are a result of habitual selection from limited choices. She challenged
the common notion that a main determinant for unhealthful behavioral choice is lack of
knowledge. Governmental and institutional policies, she said set the range of options for
personal choice making. It neglected the role of community health nursing, examining
the determinants of community health and attempting to influence those determinants
through public policy.

Levels of Prevention Model

 advocated by Leavell and Clark in 1975

 This model suggests that the natural history of any disease exists on a
continuum, with health at one end and advanced disease at the other.

LEVELS OF PREVENTION
  Primordial prevention- prevention of the emergence or development of risk
factors in population or countries in which they have not yet appeared.
 efforts are directed towards discouraging children from adopting harmful
lifestyles.
 Primary prevention-An action taken prior to the onset of disease, which removes
the possibility that the disease will ever occur.
 Secondary prevention- Action which halts the progress of a disease at its
incipient stage and prevents complications.
 Tertiary prevention-All measures available to reduce or limit impairment and
disabilities, minimize suffering caused by existing departures from good health
and to promote the patient's adjustment to irremediable
conditions.
 Modes of intervention
- Health promotion
- Specific protection
- Early diagnosis and treatment
- Disability limitation
- rehabilitation

NOLA PENDER’S HEALTH PROMOTION

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.

Nola Pender’s Health Promotion Model

Have you ever noticed advertisements in malls, grocery stores, or schools that advocate
healthy-eating or regular exercise? Have you gone to your local centers or hospitals
promoting physical activities and smoking cessation programs such as “quit” activities
and “brief interventions?” These are all examples of health promotion. 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.

What is Health Promotion Model?

The Health Promotion Model notes that each person has unique personal
characteristics and experiences that affect subsequent actions. The set of variables for
behavioral specific knowledge and affect have important motivational significance.
These variables can be modified through nursing actions. Health promoting behavior is
the desired behavioral outcome and is the endpoint in the Health Promotion Model.
Health promoting behaviors should result in improved health, enhanced functional ability
and better quality of life at all stages of development. The final behavioral demand is
also influenced by the immediate competing demand and preferences, which can derail
intended health-promoting actions.

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
 behavioral outcomes.

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.

1. Individual characteristics and experiences (prior related behavior and personal

factors).
2. Behavior-specific cognitions and affect (perceived benefits of action, perceived
barriers to action, perceived self-efficacy, activity-related affect, interpersonal
influences, and situational influences).
3. 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 :

1. Biological
 2. psychological
3. 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.

Strengths and Weaknesses

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
metapradigm 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.

Conclusion

Due to its focus on health promotion and disease prevention per se, its relevance to
nursing actions given to individuals who are ill is obscure. But then again, this
characteristic of her model also gives the concepts its uniqueness.

Pender’s principles paved a new way of viewing nursing care but then one
should also be reminded that the curative aspect of nursing cannot be detached
from our practice.

Community health care setting is the best avenue in promoting health and
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.

For an individual to fully adhere to a health-promoting behavior, he or she

needs to shell out financial resources. This limits the application of Pender’s
model. An individual who economically or financially unstable might have lesser
commitment to plan of action decreasing the ideal outcome of a health-
promoting behavior even if the individual has the necessary will to complete it.

Although not stated in the model, for example, in the Intensive Care Unit,
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 and active
range of motion exercises are examples of its application.
LAWRENCE GREEN’S PRECEDE – PROCEED MODEL

 Behavior is a characteristic of animal or human that can be observed.

 Behavioral change approach is a planned activity, interventions and strategies
developed and carried out for bringing appropriate change in health behavior of

people.

PRECEDE/PROCEED model

 PRECEDE/PROCEED model is a widely used model in public health for bringing

change in behavior.
 PRECEDE stands for:

P – Predisposing,

R-   Reinforcing,

E – Enabling,

C – Construct in,

E-   Educational,

D – Diagnosis and

E – Evaluation.

PROCEED Stands for:

P – Policy,

R – Regulatory,

O – Organizational,

C – Construct in,

E – Educational and

E – Environmental,

D – Development.

 PRECEDE model was put forward by Lawrence W. Green and colleagues in year
1970s. Further in year 1991, PROCEED was added to the model encompassing
policy, regulatory and recognizing environmental factor as an important
determinant of health and behavior of individuals.

 It emphasized on improving health of people by bringing change in health related

behavior.

 This model is used for implementing programs and for carrying out behavior
change interventions.
  PRECEDE/PROCEED model is used in planning, implementing and evaluating
behavior change program in order to promote and protect health.

Purpose of PRECEDE/PROCEED model:

 It provides structural framework for developing behavior change intervention.

 This model is also used for monitoring and evaluating the intervention program.

 It is participatory model and involves community participation.

 Content, methods/media for a particular program is selected according to need.

PRECEDE/PROCEED Framework:
Phases of PRECEDE/PROCEED Framework

PHASE 1: Social diagnosis

 In this phase, social problem that can affect the quality of life of target population
are identified and evaluated.
 During this phase, programmer try to figure out the connection between social
problem and quality of life affected resources availability, needs of given
population, readiness of community people towards the change and determine
desired outcome.
 Information regarding social problem is gained by using various methods such as
interview, focus group discussion, surveys, community forums etc.

PHASE 2: EPIDEMIOLOGICAL DIAGNOSIS

 Health problems associated with quality of life is determined in epidemiological

diagnosis.
  Primary or secondary source data are used for acquiring required information.
 It seeks to identify the specific health problems and non health factors associated
with poor quality of life.
 Health problems are described on the basis of time, place and person.
 Priorities are set within health problem and with target population.
 Epidemiological data includes vital statistics, disability, incidence, prevalence etc.

PHASE 3: Behavioral and environmental assessment

 Behaviors, practices, lifestyle, environmental factors are determined affecting

health problem identified in phase 2.
 This assessment facilitate planner to prioritize behavior which will be targeted in
intervention program.
 Behavioral diagnosis analyzes behaviors that influence the problem identified
in phase 1 and 2.
 Environmental diagnosis analyzes physical and social environment that would
affect the behavior of the individual.
 Non behavioral factors include factors such as climate, workplace, availability
and adequacy of health institutions.

PHASE 4: Educational diagnosis

 In this phase, predisposing, reinforcing and enabling factor that may support or
form barrier to changing environment. 

Predisposing factor

It includes any characteristics of individual or population that affects personal motivation

to bring change in their behavior. It includes:

 Knowledge
 Beliefs
 Values
 Attitudes
 Norms etc

E.g. believe that smoking harmful for health.

Reinforcing factors
Reinforcing factors are feedbacks from others which may be positive or negative;
continued reward, incentive can motivate repetition of certain behavior. It includes:

 Reward/Punishment
 Peer influence
 Teacher
 Family etc.

E.g. peer pressure for smoking.

Enabling factors

They are social and environmental factors that enable motivation attain specific
behavior.

 Availability
 Access
 Health related laws
 Resources
 Skills

E.g. cigarette is readily available in market.

PHASE 5: Administrative and policy diagnosis

 It identifies administrative and policy factors which should be focused before

program implementation.
 Policy diagnosis: it analyzes if goals/ objective of program is compatible with that
of organization.
 Administrative diagnosis: it analyses policies, resources in organizational
situation that facilitate or hinder development of program.

PHASE 6: Implementation of program

 In this phase, planned program is put into action in targeted population.

PHASE 7: Process evaluation

  In process evaluation, implementation process is evaluated; it helps to determine
if the program is being conducted as planned and helps to bring modification if
necessary to improve the program.

PHASE 8: Impact evaluation

 This evaluation is carried out immediately after implementation of program.

 It helps to determine effectiveness and efficiency of the program as well as
change in predisposing, reinforcing and enabling factors.

PHASE 9: Outcome evaluation

 It evaluates if the program implemented produce effect favorable to outcomes

identified in phase 1.
 It measures achievement of overall objective of program and change in quality of
life.
 It determines effect of program in health and quality of life of the community.