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Carolyn L. Murdaugh • Mary Ann Parsons • Nola J. Pender

HEALTH EIGHTH EDITION

PROMOTION
in Nursing Practice
 CONTENTS

Foreword xvii
Preface xix
Introduction: Health Promotion in a Changing Social and Digital
Environment 1

Part 1 The Human Quest for Health 7

Chapter 1 Toward a Definition of Health 8

Health as an Evolving Concept 9
Definitions of Health that Focus on Individuals 11
Health as Stability 11
Health as Actualization 12
Health as Actualization and Stability 13
Health as an Asset 15
An Integrative View of Health 15
Definitions of Health that Focus on the Family 16
Definitions of Health that Focus on the Community 17
Social Determinants of Health 18
Social Determinants and Global Health 19
Building a Culture of Health 20
Conceptions of Health Promotion 21
Measurement of Health 24
Considerations for Practice in the Context of Health 25
Opportunities for Research On Health 25
Summary 26  •  Learning Activities 26  •  
References 26

Chapter 2 Individual Models to Promote Health Behavior 30

Individual Potential for Change 31
Use of Theories and Models for Behavior Change 31
Social Cognition Theories and Models 32
The Health Belief Model 33
Theory of Reasoned Action and Theory of Planned Behavior 35
Self-Efficacy and Social Cognitive Theory 37
The Health Promotion Model 40
Theoretical Basis for the Health Promotion Model 40
vii
viii Contents

The Health Promotion Model (Revised) 40

Individual Characteristics and Experiences 40
Behavior-Specific Cognitions and Affect 42
Commitment to a Plan of Action 44
Immediate Competing Demands and Preferences 44
Behavioral Outcome 44
Stage Models of Behavior Change 45
Transtheoretical Model 45
Theories of Health Behavior in the Digital Age 47
Theories of Persuasion and Digital Health Technologies 48
Persuasive Technology 48
Strategies for Health Behavior Change 49
Setting Goals for Change 49
Monitoring Progress Toward Goals to Promote Change 50
Promoting Self-Efficacy 51
Enhancing Benefits of Change 52
Managing Barriers to Change 52
Tailoring Communication for Behavior Change 53
Behavior Change Strategies in Persuasive Technology 55
Ethics and Health Behavior Change 56
Considerations for Practice in Health Behavior Change 57
Opportunities for Research with Health Behavior Theories and
Models 57
Summary 58  •  Learning Activities 58  •  
References 58

Chapter 3 Community Models to Promote Health 63

The Concept of Community 64
Community Interventions and Health Promotion 65
Community Social-Ecological Models and Theories 67
Social-Ecological Model 67
Social Capital Theory 70
Community Planning Models for Health Promotion 72
The PRECEDE–PROCEED Model 72
Community Dissemination Models to Promote Health 74
Diffusion of Innovations Model 74
Social Marketing Model 78
Considerations for Practice Using Community Models
of Health 80
 Contents ix

Opportunities for Research with Community-Based Models 80

Summary 81  •  Learning Activities 81  •  
References 82

Part 2 Planning for Health Promotion and Prevention 85

Chapter 4 Assessing Health and Health Behaviors 86
Emerging Technologies and Nursing Assessment 87
Nursing Frameworks for Health Assessment 93
Guidelines for Preventive Services and Screenings 95
Assessment of the Individual Client 96
Functional Health Patterns 96
Physical Fitness 96
Nutrition 98
Life Stress 100
Spiritual Health 101
Social Support Systems 103
Lifestyle 103
Assessment of the Family 105
Assessment of the Community 107
Considerations for Practice in Assessing Health
and Health Behavior 108
Opportunities for Research in Health Assessment
and Health Behavior 108
Summary 108  •  Learning Activities 109  •  
References 109

Chapter 5 Developing a Health Promotion–Prevention Plan 113

Health Planning Process 115
Review and Summarize Assessment Data 115
Emphasize Strengths and Competencies of the Client 115
Identify Health Goals and Related Behavior
Change Options 116
Identify Desired Health Behavior Outcomes 117
Develop a Behavior Change Plan 118
Develop a Behavior Change Plan for Low-Literacy, Culturally
Diverse Populations 118
Identify Stage of Change and Reinforce Benefits
of New Behavior 120
Address Environmental and Interpersonal Facilitators
and Barriers to Change 124
x Contents

Determine a Time Frame for Implementation 124

Formalize Commitment to Behavior Change Plan 125
Revised Health Promotion–Prevention Plan 126
Community-Level Health Promotion–Prevention Plan 126
Considerations for Practice in Health Planning 127
Opportunities for Research in the Planning Process 128
Summary 128  •  Learning Activities 128  •  
References 128

Part 3 Interventions for Health Promotion

and Prevention 131

Chapter 6 Physical Activity and Health Promotion 132

Health Benefits of Physical Activity 133
Potential Risks of Physical Activity 135
Genetics, Environment, and Physical Activity 135
Prescribing Physical Activity to Achieve Health Benefits 136
Promoting Physical Activity Across the Life Span 138
Promoting Physical Activity in Children and Adolescents 139
Gender and Physical Activity in Children and Adolescents 139
Implementing Guidelines for Physical Activity in Children
and Adolescents 140
Promoting Physical Activity in Families 142
Promoting Physical Activity in Schools 142
Promoting Physical Activity in Adults and Older Adults 143
Racial and Gender Differences in Physical Activity in Adults
and Older Adults 144
Implementing Physical Activity Guidelines for Adults
and Older Adults 145
Promoting Physical Activity in the Workplace 149
Promoting Physical Activity in Persons with Disabilities 149
Community Programs to Promote Physical Activity 150
The Built Environment and Physical Activity 151
Physical Activity Interventions for Diverse Populations 153
Technology and the Promotion of Physical Activity 155
Nurses as Role Models of Physical Activity Behavior 155
Considerations for Practice to Promote Physical Activity 156
Opportunities for Research in Physical Activity 157
Summary 157  •  Learning Activities 157  •  
References 158
 Contents xi

Chapter 7 Nutrition and Health Promotion 161

Promoting Healthy Diet and Nutrition 162
Nutritional Health of Americans 162
Dietary Guidelines for Americans 163
Challenges to Dietary Guidelines 165
MyPlate: A Visual Guide to Healthy Eating 165
Issues in Undernutrition 166
Factors Influencing Eating Behavior 168
Genetic–Biological Factors 168
Psychological Factors 169
Socioeconomic and Cultural Factors 170
Environmental Factors 172
Health Policy Factors 173
Nutritional Needs Across the Life Span 174
Infants and Children (0 to 8 Years) 174
Adolescents (9 to 19 Years) 174
Adults (20 to 50 Years) 176
Older Adults (51 Years and Older) 176
Strategies to Promote Dietary Change 177
Strategies for Maintaining Recommended Weight 178
Strategies to Promote Dietary Changes in Diverse Populations 179
Strategies for Initiating a Weight-Reduction Program 179
Interventions to Change Eating Patterns 181
Interventions for Children and Adults 181
Interventions for Worksites and Schools 182
Role of Technology in Designing Interventions 182
Considerations for Practice in Nutrition and Health Promotion 183
Opportunities for Research in Nutrition and Health Promotion 184
Summary 184  •  Learning Activities 185  •  
References 185

Chapter 8 Stress Management and Health Promotion 188

The Stress Response 189
Stress and Health 191
Stress Across the Life Span 192
Children 192
Adolescents 193
Young and Middle-Age Adults 193
Older Adults 194
xii Contents

Stress in the Workplace 194

Stress Generated by Technologies 195
Stress Generated by Migration 196
Approaches to Stress Management 197
Strategies to Minimize the Frequency of Stress-Inducing
Situations 197
Strategies to Increase Resistance to Stress 198
Complementary Therapies to Manage Stress 200
Mindfulness-Based Stress Reduction 201
Relaxation through Imagery 202
Yoga and Tai Chi 202
Conventional Approaches to Manage Stress 204
Role of Primary Care in Managing Stress 204
Role of E-Therapies in Stress Management 204
Considerations for Practice in Stress Management 205
Opportunities for Research on Stress Management 206
Summary 206  •  Learning Activities 206  •  
References 206

Chapter 9 Social Support and Health 210

Social Networks 211
Social Integration 213
Social Support 213
Family as the Primary Source of Support 214
Peers as a Source of Support 216
Community Organizations as Sources of Support 216
Functions of Social Support Groups 217
Self-Help Groups 217
Social Media as a Source of Support 218
Assessing Social Support Systems 220
Social Support and Health 220
Social Support and Health Behavior 221
Autonomy Support and Health Behaviors 222
Enhancing Social Network and Support Systems 222
Facilitating Social Interactions 223
Enhancing Coping 223
Preventing Social Isolation and Loneliness 223
Considerations for Practice in Social Support 225
Opportunities for Research in Social Support 225
 Contents xiii

Summary 226  •  Learning Activities 226  •  

References 226

Part 4 Evaluating the Effectiveness of Health

Promotion 229

Chapter 10 Evaluating Health Promotion Programs 230

Purpose of Evaluation 230
Approaches to Evaluation of Health Promotion Programs 231
Efficacy or Effectiveness Evaluation 231
Process or Outcome Evaluation 232
Quantitative or Qualitative Evaluation 233
Deciding Outcomes to Measure 234
Nurse-Sensitive Outcomes 234
Individual, Family, and Community Outcomes 235
Short-Term, Intermediate, and Long-Term Outcomes 236
Economic Outcomes 238
Steps in Evaluation of Health Promotion Programs 239
Evaluating Evidence for Health Promotion Practice 241
Strategies for Promoting Effective Health
Promotion Outcomes 241
Designing the Program 241
Selecting Outcomes 242
Deciding Time Frame 243
Sustaining Behavior Change 243
Using Mobile Technologies in Program Evaluations 243
Evaluating Mobile Health Applications 244
Considerations for Practice in Evaluating Health Promotion
Programs 244
Opportunities for Research in Evaluating Health Promotion 246
Summary 246  •  Learning Activities 246  •  
References 247

Part 5 Approaches for Promoting a Healthy Society 249

Chapter 11 Empowering for Self-Care to Promote Health 250

Orem’s Theory of Self-Care 251
Self-Care or Self-Management 252
Client Activation and Self-Care 252
Self-Efficacy and Self-Care 253
xiv Contents

The Process of Empowering for Self-Care 254

Education to Empower Clients 255
Self-Care Empowerment Strategies 256
Mutually Share Information to Assess Strengths and
Limitations 256
Identify Strategies to Meet Goals 257
Facilitate Self-Paced Learning 257
Use Autonomy Support to Increase Motivation for Learning 258
Create a Supportive Environment for Learning 259
Track and Evaluate Progress Toward Goals 259
Barriers to Self-Care Empowerment 260
Health Literacy as a Barrier to Self-Care 261
Self-Care to Promote Health Throughout the Life Span 262
Self-Care for Children and Adolescents 262
Self-Care for Young and Middle-Aged Adults 265
Self-Care for Older Adults 266
The Role of Healthy People 2020 in Promoting Self-Care 270
The Role of the Internet in Empowering for Self-Care 271
Considerations for Practice in Self-Care 272
Opportunities for Research in Self-Care 272
Summary 272  •  Learning Activities 273  •  
References 273

Chapter 12 Health Promotion in Diverse Populations 276

Social Determinants of Health Disparities and Health Inequities 277
Socioeconomic Determinants and Health Inequities 280
Promoting Equity in Health 281
Implement Multilevel Interventions 281
Empower Communities 282
Engage in Community-Based Participatory Research 283
Advocate for Upstream Policies 283
Health Literacy and Diverse Populations 283
Expanding Definitions of Health Literacy 284
Health Literacy Strategies for Diverse Populations 285
Use Plain Language to Communicate Oral Messages 286
Use Plain Language to Communicate Written Messages 286
Apply Teach-Back Method to Confirm Understanding 287
Incorporate Culture and Language 287
Address Internet Access and eHealth Literacy Messages 288
Health Literacy Training for Health Professionals 289
 Contents xv

Health Care Professionals and Cultural Competence 290

Continuum of Cultural Competence 290
Strategies for Culturally Competent Communication 291
Considerations in Planning Culturally Competent Programs 292
Strategies for Developing Culturally Appropriate Programs 294
Considerations for Practice in Diverse Populations 296
Opportunities for Research in Diverse Populations 296
Summary 297  •  Learning Activities 297  •  
References 297

Chapter 13 Health Promotion in Community Settings 300

Health Promotion in Families 301
Health Promotion in Schools 302
School Curricula and Healthy Environments 303
Health-Promoting Schools 304
The Whole School Collaborative Approach to Learning
and Health 305
Health-Promoting Interventions in Schools 306
Health Promotion in the Workplace 308
Changes in Work and Workplaces 308
Costs and Benefits of Workplace Health Promotion
Programs 311
Participation in Workplace Programs 312
The Community as a Setting for Health Promotion 313
Health Promotion in Low-Income, Culturally Diverse
Communities 314
Creating Health Partnerships 315
The Role of Partnerships in Educating Health Professionals 316
Health Promotion in Community Nurse-Led Clinics and Practices 317
Considerations for Practice to Promote Health
in Community Settings 318
Opportunities for Research in Community Settings 319
Summary 319  •  Learning Activities 319  •  
References 320

Chapter 14 Promoting Health through Social and Environmental

Change 323
Health as a Social Goal 324
Health in a Changing Digital Social Environment 325
Promoting Health with Public Policy 327
Addressing Obesity with Public Policy 329
Promoting Health in All Policies 330
xvi Contents

Promoting Health by Changing the Physical Environment 331

Addressing Health-Damaging Features of Environments 331
Promoting Healthy Social and Built Environments 336
Promoting Health Through Legislation 338
Personal Choice versus Paternalism 338
Health Care Access and Health Equity 340
Considerations for Practice to Promote Social
and Environmental Change 341
Opportunities for Research in Social and Environmental Change 342
Summary 342  •  Learning Activities 343  •  
References 343
Index 346
 FOREWORD

I am pleased to write the foreword for the eighth edition of Health Promotion in Nursing
Practice. The promotion of health is recognized globally as essential to the well-being of
the world population and to the achievement of health equity across diverse racial,
ethnic, and economic groups. Many organizations speak of the need to develop a “culture
of health” worldwide. Increasingly, health policies are being designed and imple-
mented to move toward the goal of high-level health and wellness for all. Widespread
adoption of this goal by health care providers would result in new models of care,
decreased monies spent on acute illness, and a lower incidence of devastating chronic
diseases. Access to innovative health promotion programs for all populations, particu-
larly those most vulnerable, is a major focus of this eighth edition.
This book helps the nurse link health promotion practices with national health
goals such as those articulated in Healthy People 2020. Nurses must lead positive change
in health promotion and prevention policies and design health promotion programs as
a multisectoral endeavor. Healthy environments, schools, and worksites with adequate
air quality, water supply, housing, vector control, and shelter from the devastating
effects of natural disasters are essential to quality living. Community-based health pro-
motion strategies are the first lines of support for the health of all people. This new edi-
tion provides strategies that nurses can use to help communities activate their power to
engage in competent individual, family, and community self-care. These strategies
address the social and physical environments critical for healthy longevity. Approaches
to evaluating the effectiveness of behavior change programs in communities and in
primary care are also described.
New communication, tracking, and linking technologies are developing at a
rapid pace, thus enabling widespread dissemination of health promotion information
and innovative support of individuals and families who want to make positive life-
style and environmental changes. Sporadic programs do not result in the continuity of
care needed for real health behavior change at the family and community levels. In
this edition, the authors speak to the importance of social media, mobile applications
(apps), and other digital technologies to support better continuity of care and follow-up
essential to effective long-term behavior change.
Cultural sensitivity to the health promotion needs of diverse populations
is important as many communities are experiencing a wider array of languages,
cultural practices, and lifestyles. Fitting health promotion services to individuals,
families, and communities from diverse backgrounds requires listening to their priorities,
respecting them as persons with dignity and worth, and adapting health promotion
strategies and technologies to differing cultural values, levels of education, and life
stages.
It is important that health promotion services be provided by nurses and other
health care workers who maintain healthy lifestyles and healthy work environments.
The American Nurses' Association declared 2017 as the year of the Healthy Nurse.
Educational programs for nurses and other health professionals must provide healthy
learning environments and preparation for healthy lifestyles to be consistent with
valuing health promotion as an important aspect of nursing practice.
xvii
xviii Foreword

Knowledge about health promotion and effective interventions continues to emerge.

This eighth edition integrates the results of the latest research and theoretical advances
into useful, evidence-based information to help nurses provide scientifically sound health
promotion and prevention services. Dr. Carolyn L. Murdaugh and Dr. Mary Ann Parsons,
nurse experts in health promotion, will inspire you to incorporate new health promotion
strategies into your organizational policies, create scientifically sound nursing protocols,
and provide leadership in the development of a culture of health.
Nola J. Pender, PhD, RN, FAAN
Distinguished Professor
Marcella Niehoff School of Nursing
Loyola University Chicago
Professor Emerita
School of Nursing
University of Michigan
 PREFACE

The overall goal of the eighth edition is to provide nurses and other health promotion
practitioners practical, evidence-based information to promote the health of racially,
ethnically, and culturally diverse individuals, families, and communities. The book
aims to (1) present a comprehensive approach to health promotion that is based on the
most recent research and federal guidelines; (2) describe the role that digital technolo-
gies are playing in health promotion in all ages and populations; (3) integrate factors in
the social and physical environments that influence health and health inequities; and
(4) offer strategies to implement and evaluate programs to promote health in indi-
viduals across the life span, and in schools, worksites, and communities. We believe
information in the book provides the foundation on which to build the practice of
health promotion.

ORGANIZATION OF THIS BOOK

• Part I, The Human Quest for Health: Multiple conceptions of health are reviewed,
and both individual and community models are described to guide the develop-
ment of health promotion programs.
• Part II, Planning for Health Promotion and Prevention: Strategies are presented
to assess health, health beliefs, and health behaviors, and develop a health
promotion plan.
• Part III, Interventions for Health Promotion and Prevention: Four core health-
promoting behaviors are addressed: physical activity, nutrition, stress manage-
ment, and social support.
• Part IV, Evaluating the Effectiveness of Health Promotion: Practical methods for evalu-
ating health promotion programs are described.
• Part V, Approaches for Promoting a Healthy Society: Four areas are included:
empowering individuals for self-care; promoting health and health literacy and
decreasing health inequities in diverse populations with culturally sensitive ap-
proaches; promoting health in schools, worksites, and communities; and building
a healthy society through social and environmental change.

NEW TO THIS EDITION

• An overview of several theories and models that currently guide the development
of digital health promotion applications.
• The role of technology in health assessment and health planning.
• The application of social media, mobile health, and other digital technologies
in promoting healthy behaviors for physical activity, healthy eating, and stress
reduction.
• The use of online communities to provide support.
• Strategies to empower individuals and communities for self-care.
• Federal plain language guidelines to promote health literacy.
xix
xx Preface

• Updated information on environmental contaminants, including herbicides, lead,

and shale gas extraction.
• Information about the Robert Wood Foundation goal to create a national move-
ment to promote a culture of health which promotes health equity.
• Incorporation of Healthy People 2020 midcourse evaluations and Healthy People
2030.
• Updated chapter content, tables, and figures based on the most recent literature.
For the learner, each chapter contains learning objectives, figures, tables, and displays
to highlight and reinforce material covered in each chapter; suggestions for applying
the information to practice; recommended avenues for research; and learning activities
to provide experiences in health promotion activities and challenge the student to criti-
cally think about the chapter content. Last, an extensive reference list is available at the
end of each chapter, and relevant websites are included throughout the book.
The book is ideally suited for undergraduate students in nursing and health pro-
motion, graduate students in advanced practice programs, including the DNP, and
nurses and other health care professionals who practice in health promotion settings.

ACKNOWLEDGMENTS
We are deeply indebted to Alice Pasvogel, PhD, Assistant Research Scientist, College of
Nursing, University of Arizona, who spent countless hours editing, formatting, and
preparing the tables and figures. Her patience, attention to detail, and expert editorial
assistance enabled us to finish the book in a timely manner.
Our sincere appreciation is also extended to many persons at Pearson who have
supported us in completing this revision. We are especially appreciative of Ashley
Dodge, who guided the revision of the eighth edition, and Neha Sharma and Cheena
Chopra at Noida, India, who worked closely with us during the final preparation and
production stages. Neha's sensitivity to the stressors of writing and deadlines, and both
Neha's and Cheena's expertise and attention to detail are sincerely appreciated. Last,
we acknowledge the reviewers who provided valuable feedback on several chapters
for this edition.

Carolyn L. Murdaugh
Mary Ann Parsons

Reviewers
Sharrica Miller, PhD, CPNP-PC, RN
Assistant Professor
College of Health & Human Development
School of Nursing
California State University
Fullerton, California
Judith Peters, Ed.D. RNC
Associate Professor
School of Nursing
Loma Linda University
Loma Linda, California
Preface xxi
Ira Scott-Sewell, PhD, RN
Associate Professor
Associate of Science in Nursing Department
Alcorn State University
Natchez, Mississippi
Jutara Srivali Teal, DNP, MTOM, RN, L.Ac.
Assistant Professor
College of Health & Human Development
School of Nursing
California State University
Fullerton, California
This page intentionally left blank
 INTRODUCTION

Health Promotion in a
Changing Social and
Digital Environment

T
he rapid expansion of digital technologies, along with rising health care costs,
increasing population diversity, and persistent health inequities, has moved the
need for health care reform and health promotion to center stage. Dramatic
advances have occurred in health and health care over the past century, mainly due to
public health efforts and new medical technologies. However, the health care system in
the United States is no longer the best in the world, and persistent health care inequities
have resulted in declining health for many Americans. The need to promote health
brings both opportunities and challenges, as culturally diverse individuals and their
social and physical environments must be addressed.

HEALTH EXPENDITURES AND HEALTH

IN THE UNITED STATES
Expenditures for health care in the United States are higher than any other high-
income country in the world, and were before the Affordable Care Act (Dieleman et
al., 2016). In spite of the amount of money spent on health care, of 35 industrialized
countries, the United States reports the highest child and maternal mortality rates,
homicides, body mass index, sexually transmitted diseases, and major chronic dis-
eases, including diabetes, ischemic heart disease, and chronic lung disease.
Although the projected life expectancy is predicted to increase in most countries by
2030, life expectancy gains for the United States are projected to be one of the low-
est. In addition, the United States is the first country to experience a reversal of
height in adulthood, which is associated with greater longevity (Kontis et al., 2017).
These findings have been described as the American “health care paradox,” as the
large number of dollars spent on health care in this country has not resulted in
better health and longevity, compared to other countries (Bradley, Sipsma, &
Taylor, 2017).

1
2 Introduction • Health Promotion in a Changing Social and Digital Environment

How health care dollars are spent matters. Countries projected to have greater
longevity have higher ratios of social service to health care spending to address the
social determinants of health. The ratio of social service to health care spending in
the United States is the lowest of all 13 high-income countries, and the United States
is the only one of the 13 countries without universal health coverage. In 2013, the
second highest health care spending in the United States was for chronic illnesses,
such as diabetes, ischemic heart disease, chronic lung disease, and cerebrovascular
disease, all conditions with modifiable lifestyle factors. Pharmaceutical costs were
highest for hyperlipidemia and hypertension, two risk factors that can frequently be
reduced with lifestyle change. Most of public health spending went to manage com-
municable diseases, with little allocation to the promotion of healthy lifestyles
(Dieleman et al., 2016).

HEALTH AND THE SOCIAL ENVIRONMENT

Where people live also determines their health. The contributions of the social, economic,
and environmental conditions of communities to health and longevity are no longer
questioned. Longevity increases with income. In research reported in 2016, a longevity
difference of 15 years for men and 10 years for women was observed in persons who were
in the top 1% income bracket compared to persons in the bottom 1%, and this inequality
has increased over the past 12 years (Chetty et al., 2016). Geographic differences in lon-
gevity in low-income persons were observed; low-income persons who live in affluent
cities have greater life expectancies that those who live in less affluent cities. Affluent cit-
ies are more likely to provide public services for all its citizens than poorer cities.
The role of social determinants in health was recognized in the Healthy People 2020
goals; two overarching goals in the proposed Healthy People 2030 framework are to
achieve health equity for all and eliminate disparities, and to create social and physical
environments that promote attainment of health and well-being for all (Office of Dis-
ease Prevention and Health Promotion, 2017).

THE SOCIAL ENVIRONMENT AND A CULTURE OF HEALTH

In 2010, the Robert Wood Johnson Foundation (RWJF) developed a long-term vision for
a culture of health in all communities (Robert Wood Johnson Foundation & RAND Cor-
poration, 2015). The major outcome of the culture of health action framework is
improved population health, well-being, and equity. Priority areas include interven-
tions to develop healthy children, increase access to affordable care, and address com-
ponents of social and built environments that promote health.
Creating a culture of health presents opportunities for nurses who incorporate
health promotion in their practice. Expanded skills, knowledge, and innovative practice
models are required to integrate the social determinants of health into health promotion
(Denham, 2017). Knowledge that promotes communication, collaboration, and leader-
ship to foster community engagement, partnerships, and empowerment will enable
nurses to improve the health of individuals in diverse communities. Becoming cultur-
ally competent and gaining skills to promote health literacy are also necessary. Interdis-
ciplinary teams are essential to building a culture of health in a community, so nurses
should also possess skills needed to work as a team member in a community and be
able to provide team leadership.
Another random document with
no related content on Scribd:
que si me la hallaban quedaria
pobre y si moria sin que supiesen
donde estaba pesábame pensar
que se habia de perder. Pues
venido á mi patria y no sin
congoja y dolor, venida la noche,
cuando todos estaban en silencio
y quietud, levantabame yo y abria
las huesas adonde tenia el tesoro
enterrado y en una mesa
comenzabalo á contar y
mirandolo me pesaba porque lo
poseia, pues en conservarlo me
daba tanta congoja y dolor, y
despues de vuelto á la tierra no
podia dormir considerando si
estaba seguro allí, si los cofres en
que estaba la plata y aparador los
podian hurtar; en viendo un raton
ó una mosca luego saltaba de la
cama pensando que ladrones me
hurtaban y robaban; voceaba con
gran priesa y espanto y levantada
mi gente decianme denuestos é
injurias, que aun agora con ser
gallo no los querria sufrir,
llamabanme abariento rixoso
miserable y que ellos mismos me
robarian con enojo de mi misera
abaricia, dezian que no querian
serbirme y tenian mucha razon
porque muchas noches los azia
lebantar cinco y seys vezes que
no los dexaba dormir: ¿Quién
contaria agora, Micillo, por orden
los sobresaltos, las malas
comidas y bebidas que yo pasé?
Hallarias de verdad que son los
ricos verdaderos infelices sin
algun descanso ni plazer porque
se les va la gloria y el descanso
por otros albañares de
asechanzas que no se paresce,
ladrillados por encima con
lisonjas. E quánto mejor duerme
el pobre que no el que tiene de
guardar con solicitud lo que con
trabajo ganó y con dolor de lo
dejar. El amigo del pobre será
berdadero y el del rico simulado y
fingido, el pobre es amado por su
persona y el rico por su azienda,
nunca el rico oye verdad, todos le
dizen lisonjas y todos les
maldizen en ausencia por la
enbidia que tienen á su posesion.
Con gran dificultad allarás en el
mundo un rico que no confiese
que le será mejor estar en su
mediano estado e en esta
pobleza, porque en la berdad las
riquezas no hazen rico sino
oqupado, no hazen Señor, sino
mayordomo, y más son siervos de
sus riquezas y ellas mesmas les
acarrean la muerte, quitan el
plazer, borran las buenas
costumbres; ninguna cosa es tan
contraria del sosiego y buena bida
quel guardar y arquerir tesoros y
habellos de conservar. Gran
trabajo es sobre todo ver el
honbre veynte hyjos alredor de si
de contino pregon á Dios que yo
me aya de morir porque ellos se
entreguen y hereden mi posesion.
Pues sobre todos mis males te
quiero contar los trabajos que
pasé despues.
 CAPITULO X

Que pone como fue casado con

quatro mugeres y lo que le
sucedió con la primera; cosa
de notar.

Yo fui casado con quatro mugeres

mientras bibi, que si me oyes me
maravillaré cómo no lloras como
yo en acordarme de la mala vida
que me dieron porque sepas que
no hay dolor hasta en el casar;
con cuatro mugeres fue casado é
con todas deseando tener paz
mucha nunca me faltó guerra; la
primera con quien me casé se
llamaba Alcybia que por ser fija
de Teodosio Rey, menos preciaba
mis palabras y tenia en poco mis
obras y aun los dioses saben las
palabras que me dezia en
secreto, mis criados saben cómo
me trataba en publico y por que
bia, que procedia su desacato de
ser mejor que yo por ser hyja de
Rey.
 CAPITULO XI

Como fue casado la segunda vez

y lo que pasó con la segunda
mujer.

Ya sabras que yo me casé la

segunda vez con mujer que era
mi ygual, que se llamaba Tribuña
hyja de un Tribuno de Jerusalen y
traxo á mi poder el mayor dote
que hasta hoy se halla haver
dado en estas partidas y
pensando que por ser yguales en
personas nos acompañaría la paz
jamás con ella me faltó guerra
diziéndome que guardaba lo mio
sin lo querer comunicar y que
gastaba lo suyo en conbytes con
mujeres públicas y desonestas
haziendo desordenados gastos,
dandome afrentas en lo publico y
amenazas en lo secreto, de
donde nos benia tan cierta la
discordia quando más me era
deseada la conformidad.
Queriendome dar los dioses
entera vengança en ella,
dieronme en ella un hyjo que
despues de sus dias que fueron
brebes heredó los bienes de la
madre por quya muerte
sucedieron en mi; en biendo la
desgracia que habia tenido en las
dos vezes que me abia casado, la
vna por ser la mujer mejor que yo
é la segunda por lo mucho que
me dieron.
 CAPITULO XII

Como se casó la tercera vez y lo

que con le sucedio.

Gallo.—Proquré de casarme la
tercera vez con una que se llamó
Laureola hyja de Aureo Consul
que ni en generacion ni estado
era mi ygual, salbo que era la
más apuesta dama que en toda la
probincia se halló, la qual tomé
porque siendo pobre y no de tan
buena parte no tenia causa de
conquistarme como las pasadas.
Quiero dezir, amigo Micyllo, sy
con las pasadas habia tenido
trabajada bida, con aquella no me
faltaron tragos de muerte, porque
sintiendose tan soblimada en
hermosura y a mi con sennales
de vejez en la cara y con algunas
canas y con algun desquydo della
en la cama y sin dientes para
comer, dezia cosas abominables
contra su padre, porque siendo
ella tan hermosa la habia casado
con honbre tan feo, pudiendo
enplearla en persona de mayor
merescimiento y de menor edad
con que ella pudiera mejor gozar
su edad é hermosura; digote en
verdad, Micillo amigo, que
haziendome vna mannana de
dormido le oí dezir estando en
contemplacion: ¡oh! malandantes
sean los dioses y todo esto que
permiten y ordenan, pues
ordenaron y permitieron que mi
gentileza y hermosura se pusiese
en poder deste monstruo, el qual
piensa que con los bienes me
paga y que con el buen
tratamiento me contenta y con las
palabras me satisfaze. Sy supiera
en quanto tengo sus riquezas y el
caso que hago de su tratamiento
y lo que estimo sus buenas
palabras, no haria bida conmigo,
é maldita sea la donzella que se
casa con quien no conosce
porque no se vea engannada y
lastimada segun yo agora;
pluguiera á los dioses que me
traxeran agora no á poder de
quien tanto duerme y de quien tan
poco bela, bueno para lo que le
cumple, malo para lo que le
conbiene, diestro á las malicias,
torpe en las buenas obras. Bien
penso Areo Consul, mi padre, que
en darme este marido me hazia
gran bien y merced; bien paresce
que tubo mayor quydado de su
probecho que dolor de mi daño.
Si tubiera memoria de mi bien no
me procurara tanto mal; penso
que me casaba con él para tener
descanso, yo pienso que jamas
me faltará trabajo, porque quien
duerme despues de haber
dormido y no trabaja despues de
haber holgado como este bestiglo
haze ¿qué puedo esperar del sino
que el bibira con su desquydo y
yo morire con mi quydado? a él
se pasa en sueños la vida y a mi
se me trasporta en trabajos el
tiempo, maldita sea yo quando
dixe de sy; ¿por qué no dixe de
no? porque me matara un honbre
bibo y no me diera vida un
hombre muerto; aunque creo que
la vida que me dara será tal como
de las otras dos mugeres que ha
tenido; pluguiese á los dioses que
asi como agora está se quedase y
que nunca mas mis ojos le viesen
despierto. Y quando vi, Micillo,
que tan deshonestas cosas dezia
hize que despertaba por no oyr
otras peores en viendome
despierto; lebantóse de apar de
mí más enojada que contenta,
diziendo que me levantase en
hora mala que se me pasaba el
tiempo en dormir, sobre lo qual
benimos en tanta descordia que
no descansé hasta que puse las
manos en ella y de aquel enojo
murio, de cuya muerte y no
menos de la vida quedé con tal
escarmiento que acordandome de
aquella muger y no poniendo en
olbido las otras propuse de hacer
vida solo y no mal acompañado, y
no queriendo olbidarme la
rigorosa fortuna de contentarse
con el mal pasado me dieron a
Coridona por muger, con la qual
por...
 CAPITULO XIII

Como casó la quarta vez y lo que

con esta muger le sucedio.

Gallo.—Y ansi no quiriendo

olbidarme la rigurosa fortuna de
contentarse con el mal pasado
me dieron a Coridona por muger,
con la qual por su buena fama
casé, porque ni era hermosa ni
fea, ni tan poco baxa de estado ni
alta de generacion y antes pobre
que rica, y si con ella casé no
pienso, amigo Micillo, que lo
causó el apetito de la voluntad ni
aun el contento que me quedó de
las mujeres pasadas, salvo por el
deseo que tenia de haber hijos y
tambien por la necesidad que
tenia de la guarda de mis bienes y
por otras causas que son
legitimas para ello y tambien
porque pensaba que no teniendo
alguna cosa de las que las otras
pasadas tenian no me daría la
vida que las otras me daban, en
especial siendo en todas sus
operaciones la mejor y mas sana
donzella que creo en el mundo se
hallase; mas quiero que sepas,
Micillo, que si me guerreó la
primera por ser de mejor parte
que yo y la segunda por ser el
dote tan grande que me dio y la
tercera por la gran hermosura que
poseyó, que tambien me dio
guerra Coridona porque muy
buena se halló. La qual quando
guerrear me queria me ponia
delante el tratamiento que las
otras mujeres pasadas me
hazian, diciendome: ni vos me
meresceys ni ellas fueron mis
yguales, porque aunque en linaje
la una me hizo ventaja y la otra en
riquezas y la otra en hermosura,
yo se la hago á ellas en ser muy
mejor de mi persona y condicion
que ninguna dellas, porque si la
primera os trató con poca estima
yo os trato con mucha, y si la
segunda os pedia quenta en qué
dispendiays sus bienes yo huelgo
que dispendiays los vuestros; y si
la tercera os agrabiaba con sobra
de palabras yo os sirvo con sobra
de buenas obras; de tal manera
que apenas le hablaba con
paciencia, quando luego me
respondia con yra diciendome:
peores afrentas que las pasadas
mujeres habia menester yo que
no della; que ellas me trataban
como yo merescia; de donde
venia que ella por mucho hablar,
yo por poco sufrir le daba algunos
castigos y venia en tanta
diferencia con ella y en tanta
guerra y discordia que parescia
que era más que no las pasadas,
y aun digote, amigo, en verdad
que fueron mayores las que
tubimos despues que engendró
un hijo, que quisimos mucho, y
aun mucho, mas á menudo
reñiamos que antes que lo
hubiese; lo uno por el preñado; lo
otro porque se tenia por muy
buena no osaba hablarle lo que
me combenia por no venir con
ella en enojo; en fin ella se murio
y si más me durara yo me
enterrara vivo, porque no me
aquerdo estar dia sin pasion ni
noche sin renzilla, y yo quedé
della tan hostigado que me
paresce que hace mas el hombre
que sufre á la muy buena mujer
que la mujer que sufre al mal
varon; por que no hay ninguno
por malo que sea que una vez en
el dia no perdona la falta de su
muger, ni ninguna muger por muy
buena que sea que disimule ni
enqubra la quiebra del baron;
nunca vi cordura tan acertada
como lo que hizo Udalio Gario en
Jerusalen cuando fue
importunado por los tribunos que
se casase con Palestina, que
porque no veniese el casamiento
en efeto puso fuego a todos sus
bienes y pregutado porqué lo hizo
responde que porque queria mas
estar pobre y solo que no rico y
mal acompañado, porque sabia
que Palestina era mujer loca y
presuntuosa; y otra cosa hizo
Anteo en Grecia; que por no sufrir
las airadas palabras de Hentria su
mujer se subio á un gran monte y
hizo sacreficio de si mismo
quemandose en un gran fuego;
Fulsio Catulo en Asia que era del
linaje de los partos, viendose
descontento con Mina su mujer
por la mala vida que con ella
tenia, se subio con ella á la mas
alta torre de sus palacios y
diciendo, nunca plega á los
dioses que tú, Mina, des á otro
ningun varon mala vida, ni á mi
buena otra mujer; y acabadas
estas palabras la lanzó de la torre
abajo no quedando él encima.
Mira bien, Micillo, qué felicidad
tienen con sus riquezas los ricos y
qué descanso con las mujeres
que son casadas; mira si tien aqui
qué desear.
Micillo.—¡Oh! mi buen
Pitágoras, cuan notables cosas
has traido á mi noticia; por cierto
á mi me parescen increibles
cuando son tan admirables. Mas
dime agora, porque rescibo gran
deleite [en] te oir, ¿que fueste de
ti despues que fueste Epulon el
rico?
 CAPITULO XIV

Como de Epulon fue

transformado en asno; cosa de
notar y gran sentencia.

Gallo.—Oyeme, mi buen Micillo,

que yo te satisfare; sabras que
como complí el espacio de mi
vida en el qual había de dejar de
ser Epulon, fue llevado á los
infiernos á ser sentenciado de mis
costumbres y despues que con
gran compaña de ánimas me
pasó en su barca Aqueron, fue
presentado ante las Furias
infernales Aleto y Tesifone y los
jueces Minos y Pluton, los quales
estaban asentados en un tribunal
cercados de los acusadores y en
siendo empresentado vi ante los
ojos junto todo mi mal, que me
parescio que otra vez pasaba por
él; y como le vi rescebí muy
entrañable dolor, tan grande que
tuviera por bien dejar de ser;
despues que Minos me hubo
desanimado mandó que me
leyesen la sentencia conforme á
su ley é levantóse un viejo calvo
de gran autoridad é abriendo un
libro dijo ansí: ley teneis ¡oh
dioses! conforme á la qual el
mismo se puede condenar; pues
oíd; el viejo en alta voz leyo ansi:
porque los ricos en el mundo
mientras viven cometen
nefandísimos pecados, robos,
usuras, latrocinios, fuerzas,
teniendo á los pobres en
menosprecio, es determinado por
toda nuestra infernal
congregación que sus cuerpos
padezcan penas entre los
condenados y sus ánimas
vuelvan al mundo á informar
cuerpos de asnos, hasta que
conforme á sus obras sea nuestra
voluntad. Y como fuese leida esta
ley, mandó Minos que fuese asno
diez años y luego lo aprobo toda
la congregacion y aulló
Proserpina y ladró muy
fieramente el can Cerbero, porque
se requería esta solenidad porque
fuese alguna cosa firme y
enviolabre en el infierno, y como
no pude suplicar fue sacado de
allí y en esta oportunidad
ofreciose en Egito estar de parto
una burra de un geciano, y como
vino á parir yo me vine á ser el
asno primero que nasció, y
desque yo me vi metido en
cuerpo tan vil pense rebentar de
enojo; mas como vi que era
escusada mi pasion pues traía
poco provecho el mucho me
doler, aunque por una parte
pense dejarme morir de hambre y
no mamar pensandome escapar
de la cruel sentencia, mas desque
consideré que era inviolable ley y
ya estaba determinado en el
senado infernal y como vi que
aquel egicio era rico que me
podia bien mantener determiné de
sufrir con paciencia mi malhadada
suerte, pensando que podia venir
á manos de otro en el mundo que
no me tratase tan bien, y más que
como mi amo me veia pequeño y
bonito y el primero y que con
grandes aullidos me apartaba de
la madre y no queria mamar,
entre tres hermanos mios se
condolia de mi y me traia con
gran piedad á las tetas y puestas
á la boca me las apretaba y
aunque yo no queria me hacia
mamar por fuerza.
Micillo.—¡Oh! donosa
transformacion de rey y filósofo
en asno; ¿y no rescibias en ello
enojo? porque me huelgo en te lo
oir.
Gallo.—Ansi como acaesce
deleitarse el hombre recontando
entre sí aquello que en tiempos
pasados con prospero estado le
acaesció y se regocija en lo
contar de nuevo mill veces á sus
amigos, representándoles
qualquiera particularidad notable
que en ello se ofreciere, ansi sin
ninguna comparacion apasionan
más las adversidades traidas á la
memoria, enojan considerar de
mucho qualquiera miseria y fatiga
que cada cual pasó; mas yo tengo
por bien padescer cualquiera
dolor que de contarte mis trabajos
se me puede seguir, por te
complacer. Y ahora, Micillo,
sabrás que como fue
convalesciendo en edad con gran
regalo como el egicio me criaba,
esforceme á sufrir mi miseria
aunque conosciese mi dolor, y
mientra fue pequeño no tengo
cosa que de contarte sea, porque
con la niñez todos los animales
pasan el mal sin sufrir. Inviábame
con [mis] hermanos al prado y
despues que de mamar y pascer
las yerbas tiernas estábamos
hartos, armabamos batallas por
aquellos campos deleitosos;
corriamos con grandes relinchos y
saltos; ansi veniamos á juntar con
los pechos é boca, peleabamos
sin nos herir y despues con
mucho placer volviamos á
escaramuzar é íbamos á las viñas
y mieses; con gran sabor
hartábamos nuestros estomagos
á nuestro querer, y si los