Ebook Issues and trends in nursing (2/E): Part 2

(BQ) Part 2 book “Issues and trends in nursing” has contents: Cultural diversity and care, legal issues in nursing, healthcare policy and advocacy, rural and urban healthcare issues, nursing in the global health community,… and other contents.

as primary prevention

Discuss how dietary practices, lack of exercise,and tobacco use may contribute to increasedrisk of developing major chronic diseases in theUnited States

Provide examples of how health behaviors aredistributed in vulnerable populations

and motivating clients to improve their healthbehaviors

Discuss challenges for improving health

behaviors in vulnerable populations

The editors wish to acknowledge the contributions ofDiane Baer Wilson and Lisa S Anderson to the

The increased prevalence of chronic diseases in theUnited States has a widespread impact on individuals

as well as healthcare delivery systems A chronic disease is typically defined as diseases lasting morethan 3 months—they are associated with decreasedquality of life, increased financial burdens, and

decreased life expectancy Although chronic diseasesare increasing in numbers, many of these chronic

conditions are completely preventable Recent datasuggests approximately one half of all adults living in

chronic diseases (Ward, Schiller, & Goodman, 2014).Heart disease, cancer, and diabetes continue to rank

as the top three chronic diseases that are estimated toresult in 1.2 million deaths a year (Centers for

Disease Control and Prevention [CDC], 2015a).However, in learning more about the populations

represented in these statistics, one might be surprised

at the demographic trends Research reveals that poor,underserved, and minority populations have higherdeath rates across all of these diseases Furthermore,these individuals are also less likely to have healthinsurance and thus, they find it more difficult to accesshealth care or receive high-quality health care in

of 10 deaths in the United States

populations and provide a discussion on why these

frequently overlooked populations are at greater risk forpoor health outcomes compared to other populations

In addition, this chapter explores the role of diseaseprevention or risk reduction of chronic disease Threecategories of prevention are aimed at reducing healthrisk outcomes: primary prevention, secondary

prevention, and tertiary prevention Primary

prevention refers to modifying health behaviors such

as diet, sedentary behavior, or tobacco use to reduceone’s risk of developing chronic diseases such as heartdisease, stroke, cancer, and diabetes Secondary prevention focuses on early detection of disease

usually detected through early assessment findings ordiagnostic tests or procedures, such as a prostate-specific antigen (PSA) test for prostate cancer or

mammography to detect breast cancer The goal of

tertiary prevention is to implement strategies that willslow disease progression, limit disability from a

disease, and restore individuals to their optimal level offunctioning (Nies & McEwen, 2014) Examples of

disease or cancer An example is reducing

one’s dietary fat intake to help lower cholesterollevels and prevent one from exceeding the

The final part of this chapter details the nurse’s role as

an advocate for individuals within these vulnerablepopulations Through education and support, nursescan play an instrumental role in encouraging vulnerablepopulations to participate in healthy lifestyle choicesand ultimately reduce chronic conditions

Defining Vulnerable Population

Although a wide range of factors and income

categories may be used to define poverty, a broaddefinition for poverty is when an individual or group ofindividuals lacks human needs because they simplycannot afford to meet these needs (Short, 2016) Anunfortunate common consequence of poverty is

services Socioeconomic status and poverty rates havemore of an impact on health status and mortality ratesthan any specific race or culture Over time, data havedemonstrated that socioeconomic status is a strongand persistent predictor of health status For example,adults living in poverty report higher incidence of

diabetes, kidney disease, liver disease, and chronicjoint pains compared to adults who were not poor

Moreover, a higher percentage of adults living in

poverty reported more feelings of being hopeless, sad,

or worthless compared to nonpoor adults (Blackwell, Lucas, & Clarke, 2014) A landmark study, published

in 1967, examined this issue in the United States andEurope tracing back to the 17th century and reportedbetter health and lower mortality rates were

consistently associated with higher income and higherlevels of education (Antonovsky, 1967) If one looks atany of several measures, the results are consistent inthe relationship between socioeconomic status andmortality rates For example, life expectancy in 2013was 52 years in Angola, which is a very poor country,compared to 79 years in the United States, a highlydeveloped country (World Health Organization

[WHO], 2015a)

Poverty: When an individual or group of

individuals lacks human needs because they

simply cannot afford to meet these needs

Alarmingly, the highest percentage of group of

individuals living in poverty in the United States arechildren under age 18 (21.1 percent), followed by

adults ages 18 to 64 years (13.5 percent) and olderadults over the age of 64 (10 percent; DeNavas-Walt

& Proctor, 2015) Approximately 6 percent of children

in the United States under the age of 19 are withouthealth insurance (Smith & Medalia, 2015)

People with Disabilities

Vulnerable populations may include people in

additional groups, such as individuals with a disability.Although many people with disabilities are fully

functional, maintain employment, and have a high

quality of life, some disabilities can make it more

is at greater risk for developing infection, having poorcirculation, and developing heart disease Thus, peoplewith diabetes serve as another example of a potentiallyvulnerable population

physiological issues contribute to these groups beingmore at risk for poor health than individuals in otherage groups Elderly people are often on a fixed incomeand may not have health insurance to supplement

governmental health plans; thus they may not be able

to afford medical procedures or medications that arenot covered by Medicare Children are particularly atrisk if they either are uninsured or have insufficientcoverage for medical care because the lack of

resources may lead to inadequate access to medicalcare Children with health insurance coverage have a

Insured children are more likely to receive timely

diagnoses of serious or chronic health conditions andthus have fewer avoidable hospitalizations (Price,

Khubchandani, McKinney, & Braun, 2013)

Physiological differences also contribute to

vulnerabilities Older people, particularly those withless body mass, as well as very young children, do nottolerate extreme heat or cold temperatures For

example, these two age groups are targeted in extremeheat warnings in the summer because they are moreprone to dehydration and heat stroke Overall,

however, individuals in these age categories tend tohave a weaker immune response and they are oftenprioritized for public health initiatives such as influenzavaccination distribution, usually given in fall months

The Interplay of Economic, Social, and Cultural Issues on Health Status

How living in poverty actually affects health and healthstatus turns out to be a complex issue Over the lastdecade, thinking has shifted from a primary focus onpoverty as the prime factor related to health status to abroader focus In reality, there is no one reason thatexplains why those who live in poverty are more likely

to become ill, suffer from chronic conditions, and morelikely to die prematurely Many factors beyond income

environment, genetics, educational background, andour social support systems all have a considerableimpact on our overall health status (WHO, 2015b) Themechanisms by which economic, social, and culturalissues are operational and affect health are not widelyknown, which opens research opportunities for socialscientists, public health epidemiologists, as well ashealthcare providers such as nurses, physicians,

psychologists, and allied health professionals to

explore these contextual variables Social

determinants of health (see Figure 13-1) includebroad factors that can contribute to an individual’soverall health status These factors may include social-economic aspects, physical environment, and

individual behaviors or characteristics (WHO, 2015b).The schema shown in Figure 13-1 depicts a widelyadopted rainbow model of determinants of health,demonstrating the layered connectivity among

individual lifestyle factors and variables such as socialnetworks and cultural-environmental influences

Health Disparities

Once evidence was found that overall mortality ratesvaried by education and socioeconomic status, morestudy was given to examine chronic disease rates inorder to determine whether mortality rates also

reflected differences across groups of individuals

Population health refers to the aggregation of

healthcare outcomes within specified groups of

individuals and the distribution of outcomes amongthese groups The term health disparities is used todescribe groups that have a disproportionate amount ofdisease compared to the proportion of representation

in the population (see Contemporary Practice

diseases we see, for example, that African Americanmen are more likely to develop prostate cancer andhave a higher mortality rate from the disease compared

to Caucasian men Moreover, African American womenare approximately 9 percent more likely to die frombreast cancer than Caucasian women (U.S Cancer Statistics Working Group, 2015) Although overalldeaths from cancer have declined in the United Statesover the past decades, from 1999–2012, the cancerdeath rates were higher among African American menand women compared to other ethnic/racial groups(U.S Cancer Statistics Working Group, 2015; see

Figure 13-2) Hypertension is also a concern amongchronic diseases because of the detrimental

consequences of cardiovascular disease and stroke.African Americans have the highest occurrence of

hypertension and identified as a racial group most

likely to develop high blood pressure at a young age(Mozaffarian et al., 2015)

Population health: The aggregation of

healthcare outcomes within specified groups ofindividuals and the distribution of outcomes

among these groups

Health disparities: Differences in the

incidence, prevalence, mortality, and burden ofdisease and other adverse health conditions

that exist among specific population groups

CONTEMPORARY PRACTICE HIGHLIGHT 13-1

HEALTH DISPARITIES ACROSS THE CANCER CONTINUUM OF CARE

The model shown in Figure 13-1 depicts the

multifactorial aspects that may be contributory to

an individual’s health status Dahlgren &

Whitehead (1991) present the interrelatedness ofindividual factors, environmental, social, and

cultural influences that together place individuals

at greater risk for having a disproportionate burden

of poor health care across the continuum of careand potentially suboptimal health outcomes Thismodel is particularly relevant for healthcare

practitioners because it emphasizes the synergycreated by the intersection of multiple factors

Disparities in disease outcomes may begin withdifferences in each of the areas of care; thus,

healthcare practitioners must be diligent in

completing thorough history assessments of theirclients and families By obtaining a comprehensivehealth history, the healthcare practitioner can

develop a comprehensive understanding of theclient’s social determinants of health and

potentially identify future risks for chronic disease

cancer sites combined, United States, 1999–2013 A.Male B Female

Other racial and ethnic groups suffer disproportionatelyfrom chronic diseases such as diabetes In the UnitedStates, approximately 25.8 million individuals havediabetes and an estimated 7 million of these individualsare undiagnosed (Spanakis & Golden, 2013)

According to the American Diabetes Association (2016), the prevalence of diabetes is highest amongAmerican Indians/Alaskan Natives (15.9 percent) andlowest among non-Hispanic Caucasians (7.6 percent;see Figure 13-3)

Summary of Vulnerable Populations

Overall, there is evidence that a combination of severalfactors including poverty, culture, and social issuescontributes to individuals being at risk for poor healthoutcomes including chronic disease and lower life

expectancy This section discussed minorities, peoplewith disabilities, and very young and elderly persons as

susceptible to poorer health outcomes

Individual Health Behaviors: Primary Prevention

Evidence demonstrates a direct link between healthbehaviors and illness Behaviors such as dietary

practices, activity levels, use of tobacco products, orconsumption of alcohol may increase our risk of

developing the most prevalent chronic diseases in theUnited States (WHO, 2013) In fact, the top three

chronic diseases in the United States—heart disease,stroke, and cancer—are all fueled by obesity and bybeing physically inactive In other words, if peoplewould reduce their food intake and exercise in order toreach a body mass index (BMI) of 18–25 kg/m , manyheart attacks, strokes, and cancer diagnoses wouldlikely be averted Research suggests that dietary

intake, regular exercise, and stress reduction maycontribute to lower risks or improved outcomes of

chronic conditions, such as prostate cancer (Hebert et al., 2013)

Obesity: Having excess body fat Obesity is

clinically determined by body mass index (BMI),which is calculated by dividing a person’s weight

in kilograms by height in meters squared

2

2

(kg/m ) A person with a BMI of 30.0 or more isdefined as obese.

In this section of the chapter we discuss the top

preventable causes of death in the United States andhow they are distributed in vulnerable populations (see

Contemporary Practice Highlight 13-2) Preventable

causes of death have also been quantified to showhow much they contribute to the top diseases that

account for the most deaths in the United States

Obesity

Being overweight or obese is one of our most

concerning public health issues today and the rates ofobesity are increasing at alarming rates (see Box 13- 1) The majority of Americans are overweight; morethan 69 percent of the adult population has a BMI

greater than 25 kg/m (CDC, 2015b) In 2003, U.S.Surgeon General Richard Carmona, MD, MPH, said

“As we look to the future and where childhood obesitywill be in 20 years, it is every bit as threatening to us as

is the threat of terrorism Obesity is the threat fromwithin” (Ornish, 2007) Dr Carmona was responding tothe fact that an obesity epidemic is a serious and costlyissue in the United States, based on the significantincreases in the prevalence of obesity Rates of

overweight and obesity are increasing not only in the

2

2

children as well In 2011–2012, approximately 17

percent of children and teenagers were obese and 31percent were either overweight or obese Racial andethnic inequities exist related to obesity in children.According to Ogden, Carroll, Kitt, and Flegal (2014),

22 percent of Latino children and 20 percent of AfricanAmerican children are estimated to be obese

compared to only 14 percent of Caucasian, non-Latinochildren

automated and require less physical labor; with the

2

CONTEMPORARY PRACTICE HIGHLIGHT 13-2

nonpharmaceutical modifiable factors for reducingrisk of chronic disease Thus, there is greater

focus on these issues by the healthcare industry,food manufacturers and marketers, businesses,and organizations at all levels of our society tosupport individuals in disease prevention and

promoting healthy lifestyles through smoking

cessation, healthier diets, and more physical

activity

BOX 13-1 THE OBESITY EPIDEMIC

Being overweight and obesity have significantlyincreased among both adults and youth in theUnited States, and the rates continue to increase

as illustrated in Figure 13-5 Being overweight orobese is a risk factor for diabetes, heart disease,stroke, and many types of cancer including breastcancer Ethnic and racial inequities in weight

status exist among particular groups For example,being overweight or obese affects more than threeout of every four Hispanic or African American

United States These increases prompted the U.S.government to identify an obesity epidemic to raisethe public’s awareness of the health

consequences and suggest solutions across

multiple domains such as business, health care,marketing, schools, churches, and individuals’health behavior choices Health policy and federalfunding has also increased to battle the obesityepidemic The Healthy, Hunger-Free Kids Act of

percentages by race/ethnicity

Food Consumption Patterns

Changing patterns in society and the marketplace havecontributed to people consuming more calories

Consumption of fast and takeaway food continues to

be a prevalent pattern in the United States and is

particularly widespread among children and

adolescents (Jaworowska, Blackham, Davies, & Stevenson, 2013) Frequent consumption of fast-fooditems that are high in fat, sodium, and sugar can lead

to poor dietary quality, increasing a person’s risk forchronic diseases

According to a recent Gallup poll, approximately 28percent of Americans reported eating fast food at leastonce a week and 16 percent reported to consume fastfood several times a week (Dugan, 2013) Fewer

people cook at home, where it is easier to have controlover portion sizes and the ingredients used in cooking.Eating out often translates into eating larger portionsand consuming higher levels of fat and sugar Fastfood is not only convenient, it is relatively inexpensive,making it easy for working families to go to the drive-through to pick up fast food on the ride home from

work

Food Advertising

The marketing of food is a huge part of the food

industry Food advertising is so sophisticated that ittargets specific gender, age, and ethnic groups

Companies place a significant focus on conductingmarket research so they specifically learn what appeals

to various groups Cereal manufacturers are a goodexample They are very successful at marketing cerealproducts to kids through Saturday morning cartoons ontelevision, so much so that these practices came under

promote products that did not meet certain nutritionalguidelines (Martin, 2007) The guidelines were based

on the calorie, sugar, fat, and sodium content of

primarily breakfast foods Kellogg’s made its decisionbecause of the threat of a lawsuit by two advocacygroups and private citizens who wanted to eliminatethe promotion of less healthy food items to young

children (Center for Science in the Public Interest,

2007)

Cola beverage companies represent another marketsegment that competes so heavily that they are said tohave “advertising wars.” They are known for state-of-the-art ad campaigns that appeal to nearly all ages buttarget teens and young adults A few companies douse health to target certain groups, such as the leanmicrowave dinners that appeal to men and women whoare health and fitness conscious or dieters with goals

of losing weight

Beverage Consumption

There have been huge shifts in the U.S consumptionpatterns of beverages over the past several decades.Whereas milk used to be the top consumed beverage

sources of calcium and vitamin D, providing essentialnutrients for healthy bones and teeth In earlier times,carbonated sodas were an occasional treat; however,carbonated beverages now are very popular,

convenient, and inexpensive Restaurants often

provide drink refills at no charge, which add additionalcalories In addition, standard serving sizes for

beverages have increased substantially In the 1960s,

a small nondiet soft drink at a restaurant was generally

8 ounces and approximately 80 calories, whereas thestandard now is 12 or 16 ounces resulting in

consumption of 140 to 180 calories Some

convenience stores offer 24 or 36-ounce cup options; asoft drink in the latter container size contains

approximately 310 calories Consumption of soft drinks

as well as sugar-sweetened drinks, such as sports andenergy beverages, has particularly increased amongteens and youth (Babey, Wolstein, & Goldstein,

2013)

In a 24-hour period, beverage intake can significantlycontribute to higher caloric intake and more body fatcontributing to a risk factor of obesity in adolescence oradulthood Soft drink vending machines have become

a controversial topic recently, especially vending

machines in schools, because they offer “empty

observe that placing vending machines in schoolssends mixed messages to students learning abouthealth and nutrition in class during a time when obesity

of daily living has been reduced significantly in theUnited States Life in schools, places of work, andcommunities is less physically active than in past

years Many families provide an automobile for eachchild of driving age In younger children, safety may be

an issue so that walking to school occurs less often aswell Television, computer, and phone use consumesmany hours for school-age children and teens Studiesshow that the number of hours of television watchedper day is directly correlated with being overweight orobese (Twarog, Politis, Woods, Boles, & Daniel,

2015)

Policy changes in local school districts have resulted inless physical education for students in public schools;many states have used time formally designated for

research demonstrates a positive correlation betweenexercise and chronic disease Researchers found thatthe lack of moderate weekly physical activity was acontributing factor leading to death among individualswith cardiovascular disease, type 2 diabetes mellitus,and breast and colon cancer (Lee et al., 2012)

Obesity Consequences: Chronic

Disease

There are many consequences of being overweight,including both psychological and physiological issues.Bullying, anxiety, depression, and poor academic

performance are adverse outcomes associated withweight stigmatization among children (Puhl & King,

increased risk of developing cardiovascular disease,stroke, and diabetes, more recently published datahave linked obesity to an increase in all-cause mortalityrisk An analysis of the data from the Framingham

consumption patterns are deeply rooted behaviors thatare complex and are often steeped in family culture,religion, food preferences, and food availability as well

as socioeconomic status Thus, it is important to

assess and understand what factors may be related to

a client’s weight status so that healthcare providers can

chapter deals specifically with strategies that nursesand other healthcare professionals can use to assistclients in health behavior changes when clients decide

to implement healthy lifestyle choices

Smoking and Smokeless Tobacco

Control

Although cigarette smoking rates among adults havedeclined over the last 2 decades, approximately 16.8percent of U.S adults still smoke cigarettes today inspite of an increase in legislation and policies that bansmoking in restaurants, government agencies, andbusiness offices (Jamal et al., 2015) As cigarette

smoking declined, smokeless tobacco use has

increased, particularly among adult men

Approximately 4 percent of adults are reported to usesmokeless tobacco products, such as chewing tobacco

or snuff (U.S Department of Health and Human

Services, 2014)

As early as 1930, physicians began to notice that mostclients with lung cancer were smokers It wasn’t untilthe 1950s that definitive evidence from work by Dr.Ernst Wynder and others established that smoking wasrelated to significant negative health outcomes

including an increased risk of developing lung cancer

of heart disease, stroke, emphysema, chronic

obstructive pulmonary disease, and oral cancers

Tobacco control is estimated to prevent 8 million

premature dates and increase lifespan by 20 years(Holford et al., 2014) Reducing disability, illness, anddeath related to tobacco use and secondhand smokeexposure is a key Healthy People 2020 objective forprimary prevention of chronic diseases in the U.S

citizens Healthy People 2020 can be accessed

at http://www.healthypeople.gov

In the 1990s the government brought a lawsuit againstthe tobacco industry The U.S Tobacco Settlement wasreached, whereby cigarette manufacturers were shown

to be dishonest in advertising as well as in targetingchildren States received funding from the settlement tohelp farmers transition from growing tobacco to

growing other crops and support youth smoking

demonstrated that youth who smoke are significantlymore likely to have a lower intake of milk and

vegetables as well as exercise less frequently thannonsmokers These patterns were more likely in girlsthan boys and were evident even starting in middleschool Combining smoking with poor food intake mayplace youth at even higher risk of developing chronicdiseases as they mature, given lower intake of

protective nutrients that may offset damage from

tobacco use (Wilson et al., 2005) It is important toassess smoking or tobacco use in clients when theyare seen by healthcare providers for either an illnessvisit or a physical exam Smoking is a very difficulthabit to change and it can be easy for healthcare

providers to decide that it is just too challenging to

address with a client However, it has been shown thathaving a healthcare provider ask patients about theirsmoking status and remind them of how damaging thehabit is may prompt a certain percentage of clients toquit smoking, indicating that healthcare providers areperceived as powerful influencers when they articulatehealth promotion messages to clients New models of

by some state health departments and organizationssuch as the American Cancer Society

Client Education to Improve

Health Behaviors

As already noted, health behavioral change is one ofthe most challenging issues that nurses and otherhealthcare professionals face Behavior, such as

lifestyle habits that include smoking, diet, and exercise,

is learned over time, and unlike an acute conditionsuch as an infection, cannot be changed just by takingprescription medicines Medical knowledge has led tomany advances that enable us to make organ

transplants, insert heart pacemakers, and map thehuman genome Yet it has been recognized that

medical advances that have successfully treated acutedisease are not well suited for chronic disease, which

is a long-term condition that requires diligent self-management of certain health behaviors (Bandura,

2004) The complexity of health behavior has made itdifficult to understand people’s motivations and

encourage change that will benefit those with chronicdisease For example, why is it that some people

continue to smoke after a heart attack or being

diagnosed with chronic lung disease? What makes it

The third section of this chapter presents health

behavior change theories and tools for assessing andaddressing unhealthy behaviors in clients and in

various clinical and community settings

Major Theories of Health Behaviors

There are a number of universally accepted

explanations for what drives human behavior, many ofwhich are specific to health-related behaviors Theseexplanations are known as models or theories and areuseful in understanding why people choose to change

or continue certain habits and how best to motivatethem to make healthy lifestyle changes Although thereare many theories or models, some of the most

commonly used health behavior theories are SocialCognitive Theory, the Health Belief Model, and theTranstheoretical Model

Social Cognitive Theory

Social Cognitive Theory (SCT), developed by AlfredBandura and first published in the 1970s, departedfrom the prevailing thought that environment was themain influence on behavior (Bandura, 1977, 1986).SCT instead is based on the idea that people’s

cognitive processes also influence their environment

interaction that occurs among people, their

environment, and their behavior, is central to

understanding behavior The ideas of self-efficacy, thebelief in one’s ability to change a behavior successfully,along with self-control, the ability to maintain a change

in behavior, are central to SCT Thus, clients who firmlybelieve they can reduce sodium intake in their diet ismore likely to succeed in meeting this goal than clientswho have low confidence in their ability to adhere tonew dietary guidelines

Health Belief Model

The Health Belief Model (HBM) is one of the oldestmodels of health behavior and has been widely used toexplain the adoption of several different health

behaviors (Becker, 1974; Rosenstock, 1966) Based

on the impact of personal beliefs on actions related tohealth, the HBM contains four main components:

perceived susceptibility, perceived severity, perceivedthreat, and perceived benefits of action weighed

against perceived barriers to action According to theHBM (see Figure 13-6), clients will not consider a

health-related behavioral change without first

perceiving (a) that they are susceptible to a disease,(b) that the disease would have severe effects on thempersonally, and (c) that based on the perceived

susceptibility and perceived severity, the disease isbelieved to be a threat Perceiving a threat creates

however, final action is influenced by (d) perceivedbenefits of the action weighed against (e) perceivedbarriers to successfully taking that action

For example, a fair-skinned woman who believes she

is more susceptible to skin cancer and that the diseasewould affect her severely perceives sun exposure to be

a threat Her final decision to take preventive actionwould be based on whether she believes she can

overcome the barriers to taking action (e.g., the

inconvenience of wearing a hat in the sun and applyingsunscreen) to realize the benefits (reduced risk of

related aging)

sunburn and skin cancer and diminished effects of sun-Figure 13-6 Health Belief Model.

exercise routines Instead, change occurs in stages:precontemplation, contemplation, preparation, action,and maintenance

It is important to note that some stages may last formonths or years For example, it is possible for

someone to be in the precontemplation stage for years

or in the preparation stage for several months In

addition, the stages do not always progress in clearsuccession; at any stage after precontemplation, aclient may relapse and have to begin the process

again

The three health behavior theories just described

represent some of the most well known in the field, butmany more exist and refinements and new

developments arise as researchers continue their work

Box 13-2 provides information on a few other healthbehavior models, including some that are newer to thefield

Understanding and changing health behaviors are twodifferent things Simply informing clients about a need

to change an unhealthy behavior is unlikely to succeed

in eliciting positive behavioral change Clients should

be provided a comprehensive educational strategy withthe tools and resources needed to change behavior.Although it is helpful to provide clients with a tailorededucation program that involves more than one

member of the healthcare team (e.g., nurses,

physicians, dietitians, psychologists) and uses a

collaborative approach, even brief interventions byprimary care practitioners can be effective for

unhealthy behaviors such as smoking (Aveyard,

Begh, Parsons, & West, 2012) Research

demonstrates that client engagement, such as clienteducation, equips individuals with the skills and

acceptance Effective education actively involves

clients by assessing their readiness to change,

establish their own goals, and evaluate their ongoingprogress in terms of these goals Nurse educators also

motivation, encouragement, and ultimately sustainbehavioral change Although a variety of educationalapproaches exists to facilitate behavioral changes, acomprehensive model typically includes assessment,development, implementation, and evaluation

osteoporosis), from lack of awareness throughawareness and decision making to taking

action (Weinstein & Sandman, 2002)

Human Strengths Approach: A holistic

approach to health promotion based on

Leddy’s Theory of Healthiness, the HumanStrengths Approach focuses on the role ofclient strengths in maintaining health and

emphasizes the importance of the nurse andclient as partners, with the nurse acting as a

“client resource” rather than an expert who tellsthe client what to do (Leddy, 2006)

model explains the factors that influence

health-promoting behaviors Pender (1996)

based this model on two other theories, SocialCognitive Theory, described in this chapter,and Expectancy-Value Theory, which is based

on the concept that human behavior is rationaland economical and that people will not puttime and effort into working toward goals

unless they value those goals and believe them

to be achievable Pender’s original Health

Promotion Model (HPM) was proposed as away to integrate nursing and behavioral

science viewpoints into the factors that affecthealth behaviors (Pender, 1996) It differedfrom other models in that it did not incorporateperceived fear or threat as motivating factorsand thus was deemed applicable to healthbehaviors for which threat is not judged to be amajor motivator The RHPM, a refinement ofthe original HPM, is based on three major

factors that influence health-promoting

behaviors: (a) individual characteristics andexperiences, such as prior related behaviorand personal factors; (b) behavior-specific

cognitions and affect (such as interpersonalinfluences from family, peers, situations, orperceived barriers and perceived self-efficacy);and (c) behavioral outcome (e.g., committing to

a plan of action that results in behavioral