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Analysis of the Explanatory Model of Health Promotion and QOL in Chronic Disabling Conditions
Until recently, persons with disabling conditions have not had adequate attention paid to their health promotion and disease prevention needs. This lack has resulted in a scarcity of relevant data on which to base effective healthcare practices. The Explanatory Model of Health Promotion and QOL in Chronic Disabling Conditions, by Stuifbergen and colleagues, is the result of years of research investigating the health-related needs and perspectives of the disabled population. This article explicates the model by reviewing its constituent origins and meanings. The model also is analyzed critically for logical adequacy, usefulness, generalizability, parsimony, and testability. Finally, the model is proposed as a sound framework to guide nursing practice and research.
Within the current milieu of delivering quality health care while limiting costs, the paradigm of evidence-based practice (EBP) has evolved (Wyatt, 2003). EBP, although derived from evidence-based medicine (EBM), has been widely accepted in nursing (Ingersoll, 2000; Jennings & Loan, 2001). EBM can be described as the practice of integrating personal clinical expertise with the best clinically relevant research in making decisions about the care of individual patients (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). EBP includes evidence hierarchies and systematic reviews aimed at critically appraising research for merit and feasibility for patient care interventions (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Wyatt, 2003). The randomized controlled trial (RCT), also known as the randomized clinical trial, tops the evidence hierarchy for healthcare research set forth by the Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality [AHRQ]). Thus, the RCT is considered to be the gold standard of healthcare research (Wyatt, 2003).
Unfortunately, for the 54 million Americans with disabling conditions, RCT use in rehabilitation research is almost nonexistent (Brandt & Pope, 1997; U.S. Department of Health and Human Services [DHHS], 2000). A 1997 Institute of Medicine report indicated that EBP was not the norm in rehabilitation and that without sufficient clinical-effectiveness research, such practices could not be developed (Brandt & Pope). One notable research imperative was to include not only measures of impairment, functional capacity, and performance, but also more global measures of health status and health-related quality of life (QOL) in outcomes research to facilitate comparison among various types of treatment programs and yield evidence upon which to base practices. Brandt and Pope suggested that reliable clinical research should provide insight into treatment modalities as well as stimulate theory-developing and theory-testing research designs.
Theory evaluation can facilitate further theory development, as well as guide the choice of a theoretical framework for nursing research. The pursuit of knowledge about phenomena relevant to nursing requires iterative theory testing and fine-tuning. The purpose of this paper is twofold. The Explanatory Model for Health Promotion and QOL in Chronic Disabling Conditions (Stuifbergen, Seraphine, & Roberts, 2000) will be analyzed critically according to the academically respected method of theory analysis set forth by Walker and Avant (1995), and the relevance of this theoretical model to evidence-based nursing practice will be discussed. The Walker and Avant method of evaluation examines a theory’s origin, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability. The first three steps of theory analysis tend to be lengthier than the last four because these steps serve to produce the necessary information on which to base the latter judgments. Within the nursing literature, the terms “conceptual frameworks,” “models,” and “theories” are used inerchangeably to describe the same types of ideas (Meleis, 1997). For purposes of this analysis, Stuifbergen’s model is treated as a theory.
Determining the origins of a theory involves examining the purpose and reason for its development as well as existing evidence for support of its claims. Stuifbergen and Becker (1994) developed a much-needed model of health promotion and QOL in persons with chronic disabling. Although QOL research for persons with chronic conditions was not new, Stuifbergen (1995) posited that the relationship between health-promoting behaviors and QOL in persons with chronic illness had not been examined in studies to date. QOL in this model refers to an individual’s sense of well-being, perception of health, and satisfaction with life.
Becker, Stuifbergen, Ingalsbe, and Sands (1989) explored the use of Pender’s Model of Health Promotion (Pender, 1987) to measure health-related attitudes and behaviors of individuals with disabilities. Pender’s framework purported that the acquisition and maintenance of health-promoting behavior depends upon three components: cognitive/perceptual factors, modifying factors, and cues to action. Cognitive/perceptual factors (e.g., perceived self-efficacy, perceived health, definition of health, perceived barriers, and benefits) are considered to be the primary mechanisms directly affecting the chance of adopting health-promoting behaviors. Modifying factors (e.g., demographic characteristics, biologic characteristics, and interpersonal influences) are mediated through the cognitive-perceptual factors, and thus indirectly influence health-promoting behaviors. Cues to action may be internal or external and serve to stimulate behavioral actions (e.g., feelings of elation after exercise, peer encouragement, and mass media).
The lack of measurement instruments addressing perceived barriers to health-promotion in persons with disabilities, such as cognitive or perceptual factors, led the researchers (Becker et. al., 1989) to develop a 16-item tool to assess these barriers. The extent and impact of barriers, especially for persons with disabilities, deserves accurate measurement in health-promotion research (Becker, Stuifbergen, & Sands 1991; Stuifbergen, Becker, & Sands, 1990). The Barriers to Health Promotion Activities for Disabled Persons Scale, an 18-item tool that is based upon the previously mentioned 16-item tool, has continued to be used in subsequent studies by Stuifbergen and colleagues (Becker, Stuifbergen, Oh, & Hall, 1993; Stuifbergen, 1995; Stuifbergen & Becker, 1994; Stuifbergen, Becker, Blozis, Timmerman, & Kullberg, 2003; Stuifbergen, Seraphine, & Roberts, 2000).
Pender’s Health Promotion Model was used again in a descriptive correlational study that examined health-promoting activities in persons with disabilities (Stuifbergen & Becker, 1994). Stuifbergen and Becker also examined the subjects’ self-efficacy for health-promoting behaviors. Self-efficacy is the perception of one’s capabilities to carry out certain behaviors required to produce a given outcome (Bandura, 1997). A situation-specific measure of self-efficacy called the Self-Rated Abilities for Health Practices Scale was developed by the researchers for this study (Becker et al., 1993). Bandura’s (1982) expertise in self-efficacy theory guided the authors’ decision to measure self-efficacy beliefs specific to the targeted behavior. Self-efficacy for health-promoting practices in this population include nutrition, physical activity/exercise, psychological well-being, and responsible health practices. Ongoing use of this scale is evident in later research by Stuifbergen and colleagues (Stuifbergen, Becker, et al., 2003; Stuifbergen et al., 2000).
Findings from the Stuifbergen and Becker study supported the power of cognitive-perceptual factors to explain differences in self-reported health behaviors (1994). Higher scores on specific and general self-efficacy, as well as a wellness orientation to health, explained 46% of the variance in total scores on the measure of health-promoting behaviors. Although Stuifbergen’s and Becker’s research findings supported the use of Pender’s Health Promotion Model in this study of persons with chronic disabling conditions, they considered the possibility that different experiences of onset and trajectory of disabling conditions may influence individuals’ baseline attitudes.
Stuifbergen (1995) examined the relationship between health-promoting behaviors and QOL in persons with chronic disabling conditions by developing and utilizing a new conceptual model designed by the integration of findings from her prior research and pertinent literature. This 1995 version of the model pictured the antecedent variables (i.e., demographic/disease factors, barriers, resources, and perceptual factors) directly influencing health-promoting behaviors, which then directly influence QOL. The factors associated with health-promoting behaviors and QOL were identified to be perceived health, financial resources, specific self-efficacy, and reciprocity (getting something back). The study also supported the positive relationship between engaging in health-promoting activities and QOL. However, because demographic and disease variables were significantly associated with QOL but not with health-promoting behaviors, Stuifbergen suggested a revision of the model that pictured these variables as coexisting with, rather than preceding, health-promoting behaviors. Now disease variables measured by functional disability and illness severity could be tested for their direct and indirect influence on QOL.
The subsequent phase of this model (Stuifbergen & Rogers, 1997) included three stages, with any of the three stages potentially influenced by the contextual factors of demographic and disease characteristics. Stage 1, the antecedent phase, included barriers, resources, and perceptual factors. These three antecedents directly influenced Stage 2, the health-promoting behaviors phase. Stage 3, the outcome phase, was measured by QOL and resulted from the direct influence of health-promoting behaviors. Qualitative strategies employed to test this model resulted in clarification of antecedent variables (e.g., acceptance and self-efficacy replaced perceptual factors) and the addition of paths from resources and severity of illness to QOL. Severity of illness became the dominant contextual factor, replacing demographic and disease characteristics. The model’s antecedents now included barriers, resources, self-efficacy, and acceptance. Severity of illness combined with the antecedents had direct or indirect influences on health-promoting behaviors, which themselves had a direct effect on QOL (see Figure 1). Stuifbergen and Rogers predicted that completion of model testing would produce a tool for designing, testing, and implementing interventions for this population. They cautioned, however, that because their population was limited to persons with multiple sclerosis (MS), further research was needed to clarify any unique characteristics peculiar to other chronic disabling conditions.
The final model testing and refinement support their hypothesis that QOL is the result of multiple factors, including contextual factors (e.g., severity of illness), antecedent variables, and health-promoting behaviors (Stuifbergen et al., 2000). This model of health promotion provided the framework for both a pilot wellness intervention for women with MS (Stuifbergen, Becker, Rogers, Timmerman, & Kullberg, 1999) and a randomized clinical trial of the same intervention for a sample size of 113 women with MS (Stuifbergen, Becker et al., 2003). The latter study demonstrated an improvement in self-efficacy, health-promoting behaviors, selected aspects of QOL, and employment rate for the treatment group.
Examining the meaning of a theory includes identifying the basic ideas or concepts of the theory, defining those concepts, and examining the relationships between the concepts, which usually are expressed as statements. The major concepts presented by Stuifbergen et al. (2000) in their model of health promotion and QOL in chronic disabling conditions are as follows: (a) severity of illness, (b) barriers (to health-promoting behaviors), (c) resources (social support), (d) self-efficacy, (e) acceptance (of illness), (f) health-promoting behaviors, and (g) QOL (see Table 1). Although abstract, the concepts are all theoretically and operationally defined.
The final model is a product of Stuifbergen’s cumulative qualitative and quantitative investigations. The compilation of interrelated theories from the health-belief model (Becker, 1974), Pender’s Health Promotion Model (Pender, 1987), and self-efficacy theory (Bandura, 1997) set the foundation for the model’s conception. Further refinement of the definitions and relationships of the concepts occurred over time as the authors collected and analyzed data, primarily from persons with MS. The concept of acceptance resulted from thematic analysis of qualitative research (Stuifbergen & Rogers, 1997), whereas the other concepts were derived directly from the aforementioned theories. A sample of 786 persons with MS was recruited for the last phase of the study and resulted in the generation of the following relational statements:
While causality is not ascribed to the relationships, the associational nature of the major concepts is apparent (see Figure 1). Data analysis showed that the model explained 66% of the variance in QOL scores, which lends empirical support to the validity of the statements.
As noted earlier, this model of health promotion and QOL served as the framework for a randomized clinical trial applying a wellness intervention to women with MS (Stuifbergen, Becker, et. al., 2003). The multiple statistical methods employed in this trial validated the observed gains in the treatment groups, and thereby supported the overall effectiveness of the wellness program. Subsequent research with former polio patients again supports the model’s suitability to data obtained from a different population of persons with chronic disabling conditions (Stuifbergen, Seraphine, Harrison, & Adachi, 2003). Stuifbergen, Becker, et al. (2003) recommended that future research explore the adaptation of their wellness program to other persons with chronic disabling conditions.
The boundaries of this model are expanding as the model is tested in other chronic conditions. This model (or theory) conceivably could be classified as middle-range based upon the following criteria by Higgins and Moore (2000). They maintain that middle-range theories should be able to explain empirical aspects of nursing, guide the generation of hypotheses about the phenomena under study, be testable across several different clinical situations, and offer research and practice direction. The model has progressed from a situation-specific nursing theory developed for persons with MS to a middle-range theory, evidenced by its suitability to multiple clinical populations. Ongoing testing of the model will help to define its scope.
Logical adequacy refers to whether the concepts involved are precise and clear enough for the relations among them to be expressed abstractly and whether the model’s logic is correct in moving from statements to predictions and conclusions. An analysis of the logical adequacy of a theory asks whether the content makes sense, whether the scientists in the discipline agree with the predictions, and whether any false assumptions exist.
A useful tool for examining the logical structure of a theory is a matrix representation of the stated relationships between the concepts (see Figure 2). The direction of influence on the variables along the horizontal axis by the variables along the vertical axis is indicated by a positive (+) or negative (-) symbol. A positive association means that both concepts vary together in the same direction (i.e., both increase or decrease), and a negative association indicates that as one increases, the other decreases. If a clear matrix diagram of the direction of the relationships between the variables is possible (in isolation from the actual meaning of the variables), then support is rendered for the logical adequacy of the model. The major concepts identified in this model are severity of illness (SI), resources (RES), barriers (BAR), self-efficacy (S-E), acceptance (ACC), health promoting behaviors (HPB), and quality of life (QOL). The matrix diagram of this model clearly shows the predicted association between the variables. However, there may be more relationships between the variables that are not yet specified by the model.
There seems to be agreement about the predictions of the theory among the researchers who have worked together to develop it. The academically respected theories of health belief, health promotion, and self-efficacy serve as the underpinnings of this model and contribute to its general soundness. The results of testing this model were published in 2000, and to date, no other scientists have published reports about its use. However, it seems reasonable that given the robust outcomes of Stuifbergen’s research, other findings would support the credibility of the premises predicted by the model.
The usefulness of a theory refers to its practicality in explaining the phenomenon under study. The model provided the framework for the initial trial of the Wellness Program for Women with MS (Stuifbergen et al., 1999) and the subsequent randomized clinical trial of 113 women with MS (Stuifbergen, Becker, et al., 2003). Additionally, this model-based wellness program is in use in at least 3 countries, and has been requested by more than 100 providers in 28 states and 4 countries (A. Stuifbergen, personal communication, October 20, 2003). Although the theory may be similar to other theories of self-efficacy and health promotion, its niche of specificity for chronic disabling conditions has proven to be valuable.
The following research findings lend more support to the usefulness of the model. Stuifbergen, Seraphine, and Roberts (2001) found that persons with MS who reported more health-promoting behaviors had higher scores on self-efficacy, social support, and acceptance of illness, and lower scores on reported barriers. These same persons reported less depressive symptoms and a more positive perception of QOL than their counterparts with a lower frequency of health-promoting behaviors. Results of another study that included only women with MS revealed that women who reported higher levels of health-promoting behaviors reported a decrease in incapacity status as compared with those women who reported lower levels of health-promoting behaviors (Stuifbergen & Becker, 2001b). Thus, the model allows researchers to reasonably predict antecedents and outcomes of health-promoting behaviors, all of which directly or indirectly influence QOL.
Defining a theory’s generalizability centers on assessing its applicability to other situations or phenomena. This model, originally tested with MS patients, has since been tested in men (n = 513) and women (n = 1217) with post-polio syndrome (Stuifbergen, Seraphine, et al., 2003). The researchers found that the contextual factor (severity of illness) and antecedent variables (barriers, resources, acceptance, and self-efficacy) accounted for 54% of the variance in health-promoting behaviors and 32% of the variance in perceived QOL. Structural equation analyses reportedly determined adequate fit of the model to this population. An upcoming study of women with fibromyalgia will utilize the wellness intervention generated from this model and test the fit of the model for this new population (Stuifbergen, 2003). Although further testing will ultimately define the boundaries of the model, current opinion (as evidenced by NIH funding) considers the model to be applicable to at least several different chronic conditions. In addition, a comparison of the effects of the MS wellness intervention between a small subset of ethnically diverse women (1 Asian, 3 Hispanic, 4 “other,” and 13 African-American women) and Caucasian women did not reveal any significant differences in measured outcomes based upon ethnic group status (Stuifbergen & Becker, 2001a).
Parsimony refers to how succinct, yet complete, the model is in describing its components and structure. The relational statements of this model are not redundant and therefore cannot be condensed. This model would sacrifice adequate explanatory power were it any simpler; therefore the level of complexity of the model is well suited to the phenomenon of QOL in chronic disabling conditions. Future testing and analysis may serve to add or eliminate antecedents of health-promoting behaviors and QOL, but at this time, clarity and completeness are evident in the model. The model diagram (see Figure 1) supports this conclusion.
The testability of a theory has to do with the capacity of the theory to generate hypotheses that can be supported or refuted via empirical investigation. Reliable statistical measurement of all seven model concepts demonstrates model testability. Additionally, the model withstood the rigor of an RCT. Empirical evidence generated by repeated testing not only serves to support the model’s usefulness and generalizability, but also demonstrates that the hypotheses examined made good sense. The asset of testability has been reliably documented for this model.
Discussion and implications
The weakest link in this model is the acceptance variable. Its single effect is on health-promoting behaviors, and it is influenced only by resources. This variable also was the last to be added to the final model. Some nurse researchers consider the concepts of acceptance and denial of a health condition or illness to be meaningless because of a person’s highly variable reaction to chronic illness at any given time (Paterson, 2001). Paterson proposed a shifting perspective of chronic illness in which illness and wellness shift from the background to the foreground, and vice versa. Some chronically ill persons may need to keep illness in the background, which does necessarily imply denial, to maintain their sense of well-being and optimism. Others may accept their illness to such an extent that the illness perspective may be overly accentuated.
Another concern about the acceptance variable involves its applicability to a condition of uncertain etiology, such as fibromyalgia syndrome. Only during the last 10 years has research about the condition focused on physiologic, rather than behavioral or psychological, causes (Lash, Jones, & McCoy, 2003). However, to date, no specific etiology has been identified nor have agreed-upon standards of care been delineated. The lack of definitive diagnostic tests for the syndrome invariably will leave some individuals to doubt its existence.
Some models of QOL include measures of depression in the outcome prediction (Patrick, Kinne, Engelberg, & Pearlman, 2000; Szalda-Petree, White, & Heath, 2000). Patrick et al. found that having fewer depressive symptoms predicted a higher QOL in adults with various chronic conditions. Szalda-Petree et al. noted a strong association between psychological health and satisfaction with life. Perhaps measures of psychological health (e.g. depression, acceptance, hope, and resilience) should be included in future testing of Stuifbergen’s model.
Among the very few models of health promotion and QOL for disabled persons, Patrick’s Model of Health Promotion for People with Disabilities deserves mention. This is a grand-scale model encompassing four planes: total environment, opportunity, the disabling process, and QOL (Jette & Keysor, 2002). All but the last contain multiple variables that affect the totality of that particular plane. The variables are not specifically operationalized, but all seem to have enough concreteness to allow measurement (e.g., impairment, independent living, health care, and so forth). The complexity of Patrick’s model is intimidating, but it does expand the idea of health promotion and QOL from the personal level to a much more sociopolitical one. Obviously, many factors contribute to QOL, and no single study can measure all possible variables, even if they could be identified. Nonetheless, researchers should continue to investigate explanations and predictors of this important dimension.
Suggestions for practice
Outcome measures, such as QOL, are now frequently included in research studies of persons with chronic health conditions or disabilities. A combined CINAHL and MEDLINE search from inception to present yielded 3,442 entries for the coupled terms of disability and QOL. From migraine headache (Tkachuk, Cottrell, Gibson, O’Donnell, & Holroyd, 2003) to psoriasis (Choi & Koo, 2003) to rheumatic disease (Currey, Rao, Winfield, & Callahan, 2003), QOL is the dependent variable under investigation. In fact, the first goal of Healthy People 2010, a national health initiative in the United States, involves improving both life expectancy and QOL (DHHS, 2000). The promotion of health, prevention of secondary conditions, and elimination of disparities between people with and without disabilities is a goal of Healthy People 2010 of great relevance to the rehabilitation community. Unfortunately, the development of health-promotion programs for individuals with physical, cognitive, or sensory disabilities has been scant (Rimmer & Braddock, 2002, Stuifbergen & Becker, 1994).
Stuifbergen and colleagues’ research findings, as reviewed in this article, serve to expand the knowledge base of nurses and other professionals involved in the care of persons with disabilities. The nurse-delivered wellness intervention for women with MS could be considered an example of a health-promotion program that succeeded in decreasing the burden of functional limitations and increasing QOL in susceptible women (Stuifbergen et al., 1999).
As far back as the time of Florence Nightingale, nursing has been concerned with optimizing the environment to promote healing and optimal health (Meleis, 1997). Nurses, because of their education, professional skills, and ongoing involvement with clients, are ideally positioned to offer leadership in the promotion of better health practices among individuals, families, and communities (Pender, 1987). Nurses and other healthcare professionals can deliver interventions aimed at affecting attitudinal variables, such as perceived self-efficacy or acceptance of illness, and thereby influencing an individual’s performance of health-promoting behaviors. Because practicing behaviors that promote health may improve QOL, persons with chronic conditions also could benefit from interventions designed specifically to decrease barriers and enhance social support. Stuifbergen’s and colleagues’ Model of Health Promotion and QOL in Chronic Disabling Conditions, the product of theory-testing research, provides guidance for nursing practice.
Good ideas pass the test of time.Theory analysis provides a systematic method for examining a theory’s potential for nursing knowledge development. In nursing clinical practice, knowledge of the soundness of any theory enables the practitioner to choose appropriate interventions with some expectation of their efficacy (Walker & Avant, 1995). For the advancement of nursing research, theory analysis can reveal gaps or inconsistencies, thereby spurring further hypothesis testing and theory refinement.
Crosscultural evaluation of the model discussed in this article is limited; therefore, future research using the model should include participants of different ethnic and cultural backgrounds. For instance, because of the increased prevalence of diabetes in Hispanic Americans and the expanding Hispanic population in the United States, application of the model in this setting would scrutinize both its cultural sensitivity and utility for another chronic disease (National Institute of Diabetes and Digestive and Kidney Diseases, 2004).Testing the model in persons with other chronic disabling conditions, such as chronic back pain, Parkinson’s disease, stroke, cardiac disease, limb loss, or lung disease, will enable researchers to identify possible gaps or condition-specific variables that need to be addressed in applying the model in clinical practice.
The author would like to thank Eun-Ok Im, PhD MPH RN CNS, Graham McDougall, PhD RN FAAN, and Lynn Rew, EdC RNC HNC FAAN for their guidance and encouragement in preparation of this article and Alexa Stuifbergen, PhD RN FAAN for her commitment to health promotion research for individuals with disabling conditions. This work was supported by the National Institutes of Health (Grant No. T32NR07107).
About the Authors
Lorraine J. Phillips is a doctoral candidate and graduate research assistant at the University of Texas at Austin. Address correspondence to Lorraine J. Phillips, 1556 Homewood Circle, Round Rock, TX 78664, or e-mail lorrainephillips@ yahoo.com.
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