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Health promotion increases healthy behaviors, enhances health status, and
decreases health care costs of chronically ill persons. Nola Pender developed a health
promotion model in 1982 and made revisions in 1987. The model is one of the
predominant models of health promotion in nursing. The model was proposed as an
explanation of why individuals engage in health behavior. Primary prevention involves
activities aimed at the prevention of health care problems before they occur and the
avoidance of disease. Health promotion is intended to increase the level of well being and
self-actualization of an individual or group. Due to the rising rates of cardiovascular
diseases, obesity, diabetes, and cancers in the US, Pender’s theory can be utilized to teach
patients health promotion.
Pender’s model is based on a series of theories of human behavior. There is an
increased recognition of the role of behavior in primary prevention and health promotion,
and there is an increased attention among health care providers to helping clients adopt
healthy behaviors. The model is based on the two theories of health behavior. The first,
expectancy value theory, is based on the work of Ajzen and Fisher and explains that
people are most likely to work towards goals that believe is a value to them. The second,
social-cognitive theory, based on the work of Bandura. Pender believes that when a
person has high-perceived competence or self-efficacy in a certain behavior, it results in a
greater likelihood that the person will commit to action and actually perform the behavior
(Peterson & Bredow, 2009).
Pender identifies the behavior-specific cognition and affect as the major
motivational mechanisms for health promotion behavior. These include perceived

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benefits of action, perceived barriers to action, perceived self-efficacy, activity-related
effect, interpersonal influences, and situational influences. Individual characteristics and
experiences (prior related behavior and personal factors), the importance of which are
said to vary either target behavior. Behavior specific cognitions are considered to be of
major motivational significance and amenable to nursing intervention. There is
commitment to a plan of action, which implies an underlying cognitive process and
initiation of a behavioral event unless there are immediate competing demands and
preferences (Peterson & Bredow, 2009).
Internal Criticism
Adequacy: the theory does address needs of the individual but doesn’t address
that of the family. The model identifies interpersonal influences as cognitions concerning
behaviors, beliefs, or attitudes of others, including family members. The model has the
implications for the health promotion of families and communities; however, use of
multiple models would be ideal t address these populations (Peterson & Bredow, 2009).
Clarity: the theory clearly states the main components. Theoretical propositions of
the health promotion model help to identify client characteristics such as prior behavior,
demographic characteristics, and perceived health status. They are not alterable but offer
a basis for tailoring of nursing interventions.
Consistency: The theory uses key concepts like perceived benefits of action and
perceived barriers to action. She also includes perceived self-efficacy, immediate
competing demands and immediate competing preferences. The model doesn’t provide

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assistance in selecting which concepts and relationship are appropriate for specific
behaviors
Logical development: This model is straightforward and easy to understand. The
Health Promotion Model has been used successfully in several research studies. It also
uses frameworks from 2 other theories of human behavior the expectancy value theory
and social cognitive theory.
Level of theory development: It is consistent with the conceptualization of a
middle range theory. It offers a conceptual framework for the provision of effective
nursing care directed at improving health and functional ability.
External criticism
Complexity: The model has 3 basic components with subsets that have clear
characteristics. The first is individual characteristics. The second, behavior specific
cognitions and affect, and thirdly, behavioral outcomes. The model directs nurses to
systematically assess clients for their perceived self-efficacy, perceived benefits,
interpersonal influences, and situational influences that are relevant to the selected
behavior.
Discrimination: This theory can be used to test hypothesis. It uses Banduras
theory, which is a component of the model. The self-efficacy theory could also be used to
test certain hypothesis as well. Health promotion is a unique theory to nursing since
nurses are the ones who do much of the health teaching, esp. in inpatient hospitalizations.
However the Health Belief Model (Rosenstock 1974) has also been used in similar
studies in health promotion.

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Reality convergence: The theories underlying assumptions ring true and do
represent the real world. The entire component involved in this model to encompass the
real world of nursing. However, it gives little recognition to the sociopolitical context of
the individual
Pragmatic: This theory can operationalized in real life settings however, the
existence or complexity of interrelationships among the factors is not acknowledged.
Also, it doesn’t explicitly describe how nurses can effect changes in patient’s
perspectives.
Scope: The range of phenomena is broad yet narrowed enough to be a middle
range theory. This model is more useful when applied to the individual rather than a
group. However the authors also describe the application of the model to health behavior
beyond the scope of health promotion (Peterson & Bredow, 2009).
Significance: The results of research carried out by using this theory as a
framework can affect the way nurses carry out interventions in the real world. There has
already been several studies done that have used this theory and have provided
recommendations to improve health promotion in nursing care. The issues addressed are
essential to nursing care in order to prevent an increase of major illnesses and mortality in
human beings.
Utility: This theory can be operationalized to provide interventions in real life
settings. As previously mentioned, this theory has generated hypotheses that have been
researched by nurses for over 20 years

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This theory directly relates to any advanced practice nurse that interacts with
patients in a variety of settings including schools, workplaces, homes, clinics, hospitals,
and nurse managed community health centers. Areas of intervention for health promotion
include exercise nutrition, stress management, and social support. Nurses in practice must
be ‘committed to community involvement and development’ (Doucete 1989) and are
invited to act as role models, educators, advocators, facilitators and problem solvers.
Pender’s model of health promotion for nursing is one that stresses the individuals
control over ‘complexity, variation, and meaningfulness of stimuli within theory
environment’. Advanced practice nurses are in a prime position to explore these factors
within individuals and communities.
Examples of research that has been done based on Pender’s model are:
-In the study, “Perceptions of health and self-care learning needs of outpatients
with HIV/AIDS”, reported a statistically significant difference in communication needs
of participants diagnosed with HIV versus AIDS. Findings have led to practice changes,
health promotion activities, and further research (Mendias & Paar, 2009).
-In the study, “Promoting prevention and early recognition of malignant
melanoma”, found that appropriately identifying high risk patients, performing in office
annual skin exams, offering patient education regarding self skin exams and sun-
protective behaviors, and pushing for stronger restrictions on the indoor tanning industry
can decrease melanomas morbidity and mortality (Torrens & Swan, 2009).
-In the study, “Long term married couples’ health promotion behaviors:
Identifying factors that impact decision-making”, regression analysis identified four

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predictors variables as explaining 31% of the participation in health promotion behaviors:
relationship quality, perceived barriers, perceived self-efficacy, and social support
(Padula & Sullivan, 2006).
-In the study, “Health-promoting behaviors of sheltered homeless women”, found
that homeless women were noted to practice health –promoting behaviors in all areas but
scored the lowest on physical activity and nutrition. Significant findings reflected
women’s personal strengths and resources in the areas of spiritual growth and
interpersonal relations (Wilson, 2005)
-In the study, “An explanatory model of variables influencing health promotion
behaviors in smoking and non smoking college students”, stated that health promotion
behaviors were found to be most effective when student: had an increased self-efficacy,
avoided environmental tobacco smoke, perceived themselves as healthy, were female,
and had a powerful external and internal health locus of control. College students may
benefit from health promotion interventions designed to influence the avoidance of
environmental tobacco smoke, altered perceptions of self-efficacy, control of health, and
health status. Such interventions may result in a decrease in both active and passive
smoking (Martinelli, 1999).
Clearly, Pender’s model has been used in many studies that have been useful to
nursing care. Advance practice nurses (APN) can participate in nursing research that
focuses on complex interrelationships among relevant concepts such as health, wellness,
disease prevention, health behavior, health maintenance, health protection, lifestyle, self-
care, empowerment and control will enhance the theoretical knowledge on health

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promotion as a nursing phenomenon. Health promotion should be multidisciplinary so
advanced practice nurses need to adopt a collaborative approach with other disciplines
(King, 1994).
In conclusion, APN’s should be encouraged to use Pender’s Model. The model
can be used in clients already experiencing illness or in patients whose health status is
stable and basic needs are met. Pender’s model can guide APN’s to help patients achieve
improved health, enhanced functional ability, and better quality of life.

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References
King, P. (1994). Health promotion: the emerging frontier. Journal of Advanced Nursing,
20, 209-218.
Martinelli, A. (1999). An explanatory model of variables influencing health promotion
behaviors in smoking and non-smoking college students. Public Health Nursing, 16(4),
263-269.
Mendias, E. & Paar, D. (2007). Perceptions of health and self care learning needs of
outpatients with HIV/AIDS. Journal of Community Nursing, 24(1), 49-64.
Padula, C. & Sullivan , M. (2006).Long term married couples health promotion
behaviors. Journal of Gerontological Nursing, 16(4), 37-47.
Peterson, S & Bredow, T. (2009). Middle range theories: Application to nursing
research. Lippincott, William, & Wilkins: Philadelphia, PA.
Torrens, R. & Swan, B. (2009). Promoting prevention and early recognition of malignant
melanoma. Dermatology Nursing, 21(3), 115-122.
Wilson, M. (2005). Health promoting behaviors of sheltered homeless women. Family
Community Health, 28 (1), 51-63.