THEORETICAL MODELS/APPROACHES

Chapter 2: Theoretical Foundations of

Community Health Nursing
 INTRODUCTION:
Nurses who work on a complex community health
problem, they need to think strategically. They need to
focus their time, energy, and programmatic resources. If
nurses use organizational resources in unfocused manner,
they will not solve the problem at hand and may create
new problems along the way. If they don’t build strong
relationships with community partners (e.g., parent
groups, church leaders, community organizations), they
will fail.
Cont.
If nurses are unable to advocate for their constituencies in a
scientifically responsible, logical, and persuasive manner,
they will fail. How can nurses succeed in their goal to
improve public health in these challenges?
There are road maps for success and some of those
road maps can be found by reading a nursing history book or
an archival work that tells the story of a nurse who succeed-
ded in improving health by leveraging diplomacy skills or
improving th neighborhood power;
Lilian Wald (founder of Public Health Nursing) is one
example of such a nurse. Another example is Mary
Breckinridge, the founder of the Frontier Nursing Service in
Kentucky, who was instrumental in reducing infant mortality
rates in remote mountain settlement before World War II.
Cont.
This chapter addresses another road map for success:
the ability to think conceptually, to formulate a plan to
solve complex problems.
This chapter begins with a brief overview of nursing
theory and discussion of several theoretical approaches
that the community health nurse may apply in efforts to
improve the community health.
Historical Perspective on Nursing Theory
❑ In the years after the leadership of Florence Nightingale,
nursing practice became largely a theoretical and was
based primarily on reacting to the immediacy of patient
situations and the demands of medical staff. Thus, hos-
pital and medical personnel defined boundaries of nursing
practice. Once nursing leaders saw that the others were
defining their profession, they became proactive in
advancing the theoretical and scientific foundation of
nursing practice.
❑ From 1980 onwards, several nursing theorists, Dorothty
Johnson, Sister Callista Roy, Imogene King, Betty Neuman,
and Jean Watson among them, included community
perspectives in their definition of health.
HOW THEORY PROVIDES DIRECTION TO
NURSING
❑ The goal of theory is to improve nursing practice. Chinn
and Kramer (2008) stated that using theories or parts of
theoretical frameworks to guide practice best achieves
this goal.
❑ Theory-based practice guides data collection and interpretation in a
clear and organized manner; therefore,
it is easier for the nurse to diagnose and address health
problems.
❑ Barnum (1998) stated, “A theory is like a map of a territory as
opposed to an aerial photograph. The map does not give the full
terrain (i.e., the full picture);
instead it picks out those parts that are important for its given
purpose”. Using a theoretical perspective to plan nursing care guides
the student in assessing a nursing situation and allows the student “to
plan and get lost in the details or sidetracked in the alleys” (J. M.
Swanson personal communication to P, Butterfield, May 1992).
Some definitions of theory proposed by
nursing theorist.
❖ “A systematic vision of reality; a set of interrelated concepts that is
useful for prediction and control” (Woods
and Catanzaro, 1988).
❖ “A conceptual system or framework invented for some purpose; and
as the purpose varies, so too must the structure and complexity of the
system” (Dickoff and James,1968).
❖ “A creative and rigorous structuring of ideas that projects
a tentative, purposeful, and systematic view of phenomena”
(Chinn and Kramer,1999).
❖ “Theory organizes the relationships between the complex events that
occur in a nursing situation so that we can assist human beings. Simply
stated, theory provides a way of thinking about and looking at the
world around us” (Torres, 1986).
Theoretical Models/Approaches
1. Health Belief Model
> This was initially proposed in 1958, the Health Belief Model
provides the basis for much of the practice of health education
and health promotion today.
> The HBM was developed by a group of social psychologists to
explain why public failed to participate in screening for
tuberculosis (Hochbaum, 1958).
> Hochbaum and associates had the same questions that perplex
(puzzle) many professionals today: Why do people who may have a
disease reject health screening? Why do individuals participate in
screening if it may lead to the diagnosis of disease?
> Through their work, they found that information alone is rarely
enough to motivate one to act. Individuals must know what to do
and how to do it before they can take action. Information must be
related in some way to the individuals needs.
 > HBM is one of the most widely used conceptual frameworks in
health behavior and has been used to explain behavior change
and maintenance of behavior change and to guide health
promotion interventions (Jans et al., 2002).
> HBM has several construct:
- perceived severity,
- perceived susceptibility,
- perceived benefits of treatment,
- perceived barriers to treatment,
- cues to action, and
- self-efficacy.
❑ Perceived susceptibility – One’s belief regarding the chance of
getting a given condition.
❑ Perceived severity – One’s belief regarding the seriousness of a
condition.
❑ Perceived benefits – One’s belief in the ability of an advised
action to reduce the health risk or seriousness of a given
condition.
Cont.
❑ Perceived barriers – One’s belief regarding the tangible
and psychological costs of an advised action.
❑ Cues to action – Strategies or conditions in one’s
environment that activate readiness to take action.
❑ Self-efficacy – One’s confidence in one’s ability to take
action to reduce health risks.

❖ Kurt Lewin proposed that behavior is based on current

dynamics confronting an individual rather than prior
experiences (Maiman and Becker, 1974).

❖ Health Belief Model is based on the assumption that the major

determinant of preventive health behavior is disease
avoidance.
Disease avoidance includes:
 Perceived susceptibility to the disease “X,”
 Perceived seriousness of the disease “X,”
 Modifying factors,
 Cues to action,
 Perceived benefits minus perceived barriers to prevent
health action,
 Perceived threat of disease “X,” and
 The likelihood of taking a recommended health action.
> Disease “X” represents a particular disorder that a
health action may prevent.
> Example the cue to action in the prevention of Dengue
Fever maybe provided through an information
campaign, making people of the barangay aware of the
Cont.
occurrence of the disease in the community. One of
the campaign objectives should be to make the people
understand that everyone is susceptible to the disease
and that the disease is serious and may be fatal. In
situations such as this, HBM may be applied by the
nurse to assist clients in making necessary behavior
modifications precisely by making them conscious of
the need for such modifications.
❖ A major limitation of the HBM is that it places its burden of action exclusively
on the client. It assumes that only those clients who have distorted or
negative perceptions of the specified disease or recommended health action
will fail to act.
❖ HBM focuses the nurse’s energies on interventions designed to modify
the client’s distorted perceptions, without acknowledging the health
professional’s responsibility to reduce or alter health care barriers
other than patient’s perspectives.
Theoretical Models/Approaches
2. Milio’s Framework For Prevention
> Milio’s Framework for Prevention (1976) provides a
complement to the HBM and provides a mechanism
for directing attention upstream (an analogy mention
in Chapter 1) and examining opportunities for nursing
intervention at the population level.
> Nancy Milio outlined six propositions that relate an
individual’s ability to improve healthful behavior to a
society’s ability to provide accessible and socially
affirming options for healthy choices.
> Milio stated that policy decisions in government and
private organizations shape the range of choices
available to individuals.
Cont.
> She believed that national-level policy making was the
best way to favorably impact the health of most
people rather than concentrating efforts on imparting
information in an effort to change individual patterns
of behavior.
> Milio (1976) proposed that health deficits often result
from an imbalance between a population’s health
needs and it’s health-sustaining resources.
> She stated that the diseases associated with excess
(e.g., obesity, and alcoholism) afflict affluent
societies, and the diseases that result from
inadequate or unsafe food, shelter, and water afflict
the poor.
Application of Milio’s Framework in
public health nursing (Milio, 1976)
❖ Population health deficits’ result from deprivation and/or excess of
critical health resources. > Population health examples – Individuals
and families living in poverty have poorer health status compared with
middle- and upper-class individuals or families.

❖ Behaviors of populations result from selection from limited choices;

these arise from actual and perceived options available as well as
beliefs and expectations resulting from socialization, education,and
experience. > Population health examples – Positive and negative
lifestyle choices (e.g., smoking, alcohol use, safe sex practices,
regular exercises, diet/nutrition, seatbelt use) are strongly
dependent on culture, socioeconomic status, and educational level.
Cont. Milo’s Framework of Prevention
❑ Personal and societal resources affect the range of
health-promoting or health-promoting or health
damaging choices available to individuals.
❑ Personal resources include the individual’s awareness,
knowledge, and beliefs and the beliefs of the individual’s
family and friends.
> Money, time, and the urgency of other priorities are
also personal resources.
❑ Community and national conditions strongly influence
societal resources. These resources include the availability and
cost of health services, environmental protection, safe shelter,
and penalties or rewards for failure to select the given options.
Cont. Milo’s Framework for Prevention
❑ Health-promoting choices must be more readily available
and less costly than health-damaging options for
individuals to gain health and for society to improve
health status.
❑ Milo’s framework provides for the inclusion of economic,
political, and environmental health determinants;
therefore, the nurse is given broader range in the
diagnosis and interpretation of health problems.
❑ Lifestyles are patterns of choices made from available
available alternatives according to people’s socioeconomic
circumstances and how easily they are able to choose some over
others (Milio,1981).
❑ Milio’s framework encourages the nurse to understand health
behaviors in the context of their societal milieu.
Cont. Application of Milio’s framework in
public health
❖ Organizational decisions and policies (both governmental and
nongovernmental) dictate of the many options available to individuals
and populations and influence choices. > Population health examples
- Health insurance coverage and availability are largely determined
and financed by the government through the National Health
Insurance Corporation (Philhealth) and private insurance (out-of-
pocket expense by patients or provided by employers); the source and
funding of insurance influences health provider choices and services.

❖ Individual choices related to health promotion or health damaging

behaviors are influenced by efforts to maximize valued resources. >
Population health examples – Choices and behaviors of individuals
are strongly influenced by desires, values and beliefs. Example. The use
of illegal drugs by adolescents is often dependent on peer pressure and
the need for acceptance, love, and belonging.
Cont. Theoretical Models/Approaches
❖ 3. Nola Pender’s Health Promotion
> Pender’s Health Promotion Model was developed in
1980s and revised in 1996,
> Pender’s Health Promotion Model (PHM) explores
many biopsychosocial factors that influence indi-
viduals to pursue health promotion activities.
> The HPM depicts the complex multidimentional
factors with which people interact as they work to
achieve optimum health.
> This model contains seven variables related to
health behaviors as well as individual characteristics
that may influence a behavioral outcome.
Cont. Pender’s Health Promotion Model

> Pender’s model does not include threat as a

motivator, as threat may not be motivating factor
for clients in all age groups (Pender et al., 2006)
Cont. Theoretical Models/ Approaches
❖ 4. Lawrence Green’s PRECEDE-PROCEED Model
> PRECEDE-PROCEED Model was developed by Dr.
Lawrence W. Green and colleagues.
> PRECEDE-PROCEED Model provides a model for
community assessment, health education planning,
and evaluation.
> PRECEDE, which stands for predisposing, reinforcing,
and enabling construct in educational diagnosis and
evaluation is used for community diagnosis. PROCEED,
an acronym for policy, regulatory, and organizational
constructs in educational and environmental
development, is a model for implementing and evaluating
health programs based on PRECEDE.
Cont. PRECEDE-PROCEED MODEL

> This model, predisposing factors refer to people’s

characteristics that motivate them toward health-
behavior.
> Enabling factors refer to conditions in people and
the environment that facilitate or impede health-
related behavior.
> Reinforcing factors refer to feedback given by
support persons or groups resulting from the
performance of the health-related behavior.