COLLEGE OF NURSING

MODULE 7: HEALTH PROMOTION AND THE COMMUNITY

OVERVIEW OF THE MODULE:

Pender’s Health Promotion Model, Bandura’s Socio Cognitive approaches, and
Green’s PRECEDE-PROCEED Model are presented in this lesson. Application to
community health practice using these models are explained through concepts
and examples in levels of individual, family and community as clients.

LEARNING OUTCOMES:
At the end of the lesson, student is expected to:
 Relate health promotion models to CHN practice
 Apply concepts and principles of health promotion models in developing
health promotion activities

OBJECTIVES:
 Examine the similarity and differences of the three health promotion
models
 Create a health communication plan using at least one of the models
 Identify which model(s) most suitable to caring for a family in the
community
DISCUSSION:

A variety of health promotion models were developed which may help a

community health nurse in advancing community and family health in many
levels. Health promotion models are concepts which resulted from experiences of
its innovator which most likely conform to the values, context and needs of his or
her time. Given the complexity of the health promotion models of Pender,
Bandura and Green, it can help the community health nurse develop a roadmap
for a potentially effective, multi-level, client-centered and comprehensive health
programs for the community.

Pender’s Health Promotion Model

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 (Gonzalo A.
2019).

Pender’s model has been discussed in chapter 4. To further the discussion,

this model, based on social learning theory, stresses cognitive processes that
help
regulate behavior such as perceptions people have that directly influence their
motivation to begin or continue health-promoting behaviors. These include, for
example, perceptions of control of health, health status, benefits of health-
promoting behaviors, and barriers to engaging in health-promoting behaviors
(Allender J. et. al. 2014).

Five types of modifying factors which influence the people’s perceptions about
pursuing health-promoting behaviors are demographic factors, biologic
characteristics, interpersonal influences, situational factors, and behavioral
factors.

By understanding these modifying factors and defining characteristics for

health promotion, this model can be utilized for a diverse group of population.
For example, caring for an ethnic or indigenous group in a geographically
isolated area, we can use Pender’s model in understanding people’s
perception about improving health and find solutions on how we can help
increase their knowledge and develop healthy behaviors like importance of
complete prenatal care, value of preventable vaccines for children, and
dangers of teenage pregnancy and its socio-economic implications to a young
mother.

Adapted from Theoretical Basis of Community/Public Health Nursing (Allender, et.al. 2014)

(Related studies) Several researches have already tested this model:

1. One of the important factors that affects the health promoting lifestyle of
military spouses is social support. Social support is found significant to
improving perception on health and health promoting behaviors (Padden
D., Steward D., and Agazio J. 2012).
2. Individual counselling using Pender’s model was found useful in
increasing post-myocardial infarction clients in improving self-efficacy,
 prognosis, functional capacity and risk factors for post-myocardial
infarction patient (Sevinc S. and Argon G. 2018).
3. Using the model in developing training for obese women with focus on
their nutritional behavior, perceived benefits, perceived self-efficacy,
commitment to action, interpersonal and situational influences,
behavior-related affect, and perceived barriers, was found effective in
improving nutritional behavior of its participants (Khodaveisi M., Omidi
A., Foroki S., and Soltanian A. 2017).

Bandura’s Health Promotion by Social Cognitive Approaches

Albert Bandura is known for his contribution to education – specially in his
works about social learning theories. Different from most learning theories
which are focused on conditioning, positive reinforcement and punishment,
Bandura asserted in his work that most human behavior is learned through
observation, imitation and modeling. Bandura agreed with the behavioral
theorists who noted that external reinforcement shapes learning, but he also
acknowledged that learning is not always a result of external reinforcement. He
claimed that learning is a result of intrinsic reinforcement as well. For example,
a student might learn something because of their pride, for a sense of
satisfaction, or to fulfill a feeling of accomplishment (Kurt S. 2020).
🔎 For example, a student nurse might focus on learning because of
distinctive desire to be come a nurse; a professional nurse pursues
continuing learning opportunities because of pride or to satisfy yearning for
accomplishments; and, a community health nurse choses to serve the most
deprived population group for sense of satisfaction and dedicated heart to
service.

Bandura’s model argued that learning is not equated to behavioral change –

like, mastering the steps in handwashing does is not an indicator that there is a
change in behavior. According to Bandura, in addition to observation the
following steps are necessary for an observable behavior to be learned:
attention, retention, reproduction and motivation.

Attention Retention OBSERVABLE

(the learner (the learned Reproduction Motivation BEHAVIOR
needs to focus) needs to focus) (LEARNED)

Adapted from Bandura’s Social Cognitive Theory (Kurt S. 2020)

Using Bandura’s model of learning, the nurse can focus on:

Attention Retention Reproduction Motivation
 Use age-appropriate  Use appropriate  Allow the client to  Create observable
motivating activities presentation practice motivators to

 Control the learning methods  Encourage encourage the client

environment  Encourage or application of the to imitate the

promote memory knowledge behavior (or

 Adapt unique and
interesting models
 Time your pace
accordingly
 Allow breaks
The nurse should
ensure that clients  Use relatable
are not distracted
and are focused on
the activity
techniques such as punishment to
 Consider the client’s
writing, mnemonics, extinguish faulty
developmental age
repetition, etc. behavior)
in facilitating motor
reproduction
 Utilize positive and
activities negative
reinforcements
“Practice makes
examples
perfect” is the adage Allow the client to
Note: emotional
related to find reason to
events are often
reproduction imitate the healthy
stored than non-
emotional events

This model is best utilized to facilitate development of self-efficacy beliefs and

motivations to promote health and prevent diseases, by enabling the client to
focus process knowledge, induce values to the information, facilitate skills
development, and motivating behavior change through positive or negative
reinforcement.
 (Source: Health Education and Behavior by Bandura A. 2004)

Structural paths of influence wherein perceived self-efficacy affect health habits

both directly and through its impact on goals, outcome expectations, and
perception of sociostructural facilitators and impediments to health-promoting
behavior (Bandura A. 2004).

Application to Public Health Practice

Self-efficacy plays a central role in social cognitive theory. Self-efficacy is

defined broadly as the confidence in one's ability to execute a specific behavior
or set of behaviors. In other words, if an individual does not feel confident in his
or her ability to resist peer appeals to use drugs, the likelihood of employing
appropriate communication skills is diminished; similarly, low efficacy regarding
athletic performance may inhibit involvement in physical activity. Two
fundamental assumptions regarding self-efficacy are critical to understanding
its importance in social cognitive theory (Allensworth D., Lawson E., and
Nicholson L. 1997).

According to the WHO Reproductive Health Library, one study used a

customized intervention programme using social cognitive model to delay
second births among adolescents and results showed that adolescents in the
treatment group were less likely to have had a second birth within two years
compared with usual care (Warriner I. 2012).

Taking Human Immunodeficiency Virus (HIV) test is stressful for many reasons
– fear of knowing the real condition and fear of the stigma attached to HIV.
Using social cognitive approaches through health education sessions, one-on-
one counseling and strengthening peer-to-peer mechanisms of health
promotion programs enabled health advocates to reduce the fear attached to
HIV testing as evident by increase in number of clients willfully undergoing HIV
screening.

Green’s PRECEDE-PROCEED Model on Health Promotion

Lawrence Green is a known specialist in public health education. He is

researcher, educator, epidemiologist and a biostatistician among others. The
precede-proceed model developed for use in public health, however, its
principles is applicable to other community issues as well.

Assumptions and Recommendations

Assumption
Since the health-promoting behaviors
and activities that individuals engage in
are almost always voluntary, carrying
out health promotion has to involve
those whose behavior or actions you
want to change.
Health is, by its very nature, a
community issue.
Health is an integral part of a larger
Recommended action/application
PRECEDE-PROCEED should be a
participatory process, involving all
stakeholders – those affected by the
issue or condition in question – from
the beginning.
It is influenced by community attitudes,
shaped by the community environment
(physical, social, political, and
economic), and colored by community
history.
It is only one of many factors that make
 context, probably most clearly defined
as quality of life, and it’s within that
context that it must be considered.
Finally, health is more than physical
well-being, or than the absence of
disease, illness, or injury.
Source: Precede-Proceed by The Community Tool Box | University of Kansas (2020)
life better or worse for individuals and
the community as a whole. It therefore
influences, and is influenced by, much
more than seems directly connected to
it.
It is a constellation of factors –
economic, social, political, ecological,
and physical – that add up to healthy,
high-quality lives for individuals and
communities.

In adapting this model, just like most nursing interventions, it is important to

know your issue. However, it is essential to avoid picking out issues at random
and respond to the issue with whatever available program is there in the
community. The nurse must – consult with the community; assess, understand
and analyze the situation of the community using data; apply your own and
other’s observations; and consider the context of the people and the
community – in developing needs-based nursing interventions.

PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in

Educational Diagnosis and Evaluation. Community assessment involves the
following factors:
Social assessment: Determine the social problems and needs of a given
population and identify desired results.
Epidemiological assessment: Identify the health determinants of the
identified problems and set priorities and goals.
Ecological assessment: Analyze behavioral and environmental
determinants that predispose, reinforce, and enable the behaviors and
lifestyles are identified.
Identify administrative and policy factors that influence implementation and
match appropriate interventions that encourage desired and expected
 changes.
Implementation of interventions.
Source: Rural Health Information Hub (2020)

PROCEED stands for Policy, Regulatory, and Organizational Constructs in

Educational and Environmental Development. It involves the identification of
desired outcomes and program implementation:
Implementation: Design intervention, assess availability of resources, and
implement program.
Process Evaluation: Determine if program is reaching the targeted
population and achieving desired goals.
Impact Evaluation: Evaluate the change in behavior.
Outcome Evaluation: Identify if there is a decrease in the incidence or
prevalence of the identified negative behavior or an increase in identified
positive behavior.
Source: Rural Health Information Hub (2020)

The PRECEDE-PROCEDE is distinct to its characteristic that it gives the

community health nurse a roadmap to pattern his or her community health
nursing intervention – from identification of your desired result or outcome, to
evaluation of program implementation.

To define your end goal or ultimate outcome, focus on what the client finds
most important, what the client needs, and what the client wants. It could be or
not related to what you see a problem as a nurse, however, involving the
community by engaging them and drawing them in from the very start of the
process. Participation is best maximized through ‘ownership and involvement’.
PRECEDE is the diagnostic portion of the model. It starts with the idea that
the focus of change must be on its desired outcome, and works backward
from that outcome to construct an intervention that will bring it about. It has
four phases:

Phase 1: Social diagnosis – determine what the community wants and needs
to improve its quality of life.

Phase 2: Epidemiological diagnosis – determine the health problems or other

issues that affect the community’s quality of life. Include also the behavioral
and environmental factors that must change in order to address these
problems or issues. Behavioral factors include patterns of behavior that
constitute lifestyles. In considering environmental factors, you should include
the physical, social, political, and economic environments.

Phases 1 and 2 identify the goals of the intervention.

Phase 3: Educational and organizational diagnosis – determine what to do in
order to change the behavioral and environmental factors in Phase 3, taking
into account predisposing factors (knowledge, attitudes, beliefs, values, and
confidence); enabling factors (availability of resources, accessibility of
services, government laws and policies, issue-related skills), and reinforcing
factors (largely the influence of significant others in the social environment).

Phase 4: Designing programs or interventions and the support for them

through administrative and policy diagnosis – determine (and address) the
internal administrative and internal and external policy factors that can affect
the success of your intervention. The former include organizational structure,
procedures, culture, and resources; the latter encompass both internal
policies and funders’ requirements, oversight agency regulations, state or
federal laws, or local ordinances, and unstated community policies.

Phases 3 and 4 set the structure and targets for the planning and design of
the intervention.

PROCEED is, in medical terms, the treatment portion of the model, and
comprises the implementation and evaluation of the intervention. It consists
of four phases:

Phase 5: Implementation – conduct the intervention.

Phase 6: Process evaluation – determine whether the intervention is actually

taking the actions intended.

Phase 7: Impact evaluation – determine whether the intervention is having

the intended effects on behaviors and/or environment.

Phase 8: Outcome evaluation – determine whether the intervention

 ultimately brings about the improvements in quality of life identified by the
community as its desired outcome.

An unstated but important part of the model is that, at any point, your plan or
intervention can and should be revisited and revised, based on continued
analysis and the results of the various evaluations.
Source: Precede-Proceed by The Community Tool Box | University of Kansas (2020)

These models can help the nurse in assessing, planning, implementing and
evaluating health programs for the community. In the family and individual levels,
the health promotion models can be adapted in creating health communication
plan and health education strategies.

The purpose of the models at a micro level is to help the nurse find spaces and
opportunities in the community to effect change. Health education for example,
its main purpose is to change. Remember, that change does not happen
overnight and it affects the norms of most people in the community. Hence,
programs and activities should be done with utmost considerations of what the
community perceives the change you want to happen – like, reduction of
maternal mortality, prevention of cancer, increase in physical activities,
accessible services, etc.
EVALUATION:

📝 Activity 1: Among the three models presented in this chapter, in your own
point of view, which one is most suitable in developing nursing care plan at the
level of the family? Justify your argument by citing facts and providing examples.

📝 Activity 2: The local government officials in the community you are working
with often make decisions that reflect a lack of knowledge regarding the health
situation of the community and health care in general. How will you ‘educate’ the
local officials using the health promotion model(s) presented?

REFERENCES:
Allender J., Rector C., and Warner K. (2014), “Community and public health
nursing: promoting the public's health", Wolters Kluwer Health - Lippincott
Williams and Wilkins 2014, China
Gonzalo A. (2019), “Nola Pender: health promotion model” retrieved from
“https://nurseslabs.com/nola-pender-health-promotion-model/#what_is_heal
Khodaveisi M., Omidi A., Foroki S., and Soltanian A. (2017), "The Effect of
Pender’s Health Promotion Model in Improving the Nutritional Behavior of
Overweight and Obese Women" retrieved from
"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385239/"
Kurt S. (2020), “Social learning theory: Albert Bandura”, retrieved from
“https://educationaltechnology.net/social-learning-theory-albert-bandura/”
Padden D., Steward D., and Agazio J. (2012), “Application of Pender's health
promotion model in military spouses”, retrieved from
“https://www.researchgate.net/publication/266815537_Application_of_Pend
er's_health_promotion_model_in_military_spouses”
Rural Health Information Hub (2020), “Precede-proceed”, retrieved from
“https://www.ruralhealthinfo.org/toolkits/health-promotion/2/program-
models/precede-proceed”
Sevinc S. and Argon G. (2018), “Application of Pender’s health promotion model
to post-myocardial infarction patients in Turkey”, International Journal of
Caring Science Volume 11 – Issue 1,
“http://www.internationaljournalofcaringsciences.org/”
th_promotion_model”
The Community Tool Box - University of Kansas (2020), “Precede-proceed”,
retrieved from “https://ctb.ku.edu/en/table-contents/overview/other-models-
promoting-community-health-and-development/preceder-proceder/main”
Warriner I. (2012), “Theory-based interventions for contraception”, retrieved from
“https://extranet.who.int/rhl/topics/fertility-regulation/contraception/theory-
based-interventions-contraception”