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Concept Analysis: Health-Promoting Behaviors Related to Human Papilloma Virus (HPV) Infection Tonna McCutcheon, APRN-BC, CGRN Tonna McCutcheon, APRN-BC, CGRN, is DNP Student at Vanderbilt University, Nashville, TN. Keywords Concept analysis, health promotion, health-promoting behaviors, human papilloma virus Correspondence Tonna McCutcheon, APRN-BC, Vanderbilt University, Nashville, TN E-mail: tonna.mccutcheon@ vanderbilt.edu
McCutcheon
PROBLEM. The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursingbased Health Promotion Model. Despite the fact that the concept of health-promoting behaviors has a nursing influence, literature suggests nursing has inadequately developed and used this concept within nursing practice. A further review of literature regarding health promotion behaviors and the human papilloma virus suggest a distinct gap in nursing literature. METHOD. This article presents a concept analysis of health-promoting behaviors related to the human papilloma virus in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline. CONCLUSION. Attributes of health-promoting behaviors are presented and include empowerment, participation, community, and a positive concept of health. Antecedents, consequences, and empirical referents are also presented, as are model, borderline, and contrary cases to help clarify the concept. Recommendations for human papilloma virus healthpromoting behaviors within the nursing practice are also provided.
The concept of health-promoting behaviors encompasses environmental, psychological, biological, medical, and physical sciences, and is depicted in various forms of literature with the common goal of the acquisition of optimal health. This concept involves individuals as well as communities, and incorporates knowledge, education, skills, and strategies to endorse control over and development of health-related behaviors. Although health promotion and associated behaviors are integrated within nursing literature, Kemppainen, Tossavainen, and Turunen (2012) suggested that nursing has been focused on disease prevention, and therefore is in need of reorientation to a health promotion philosophy. Povlsen and Borup (2011) published a literature review regarding the relationship between holism in nursing and health promotion. They concluded the
following: (a) nursing-based literature ignored the psychosocial, political, and ethical aspects of health promotion; (b) the nursing philosophy of individualism prevented the integration of health promotion into nursing practice; (c) nursing focused on patient education rather than health-promoting behaviors; and (d) nursing maintained a traditional function rather than eliminating boundaries in order to expand health promotion roles. Therefore, the purpose of this analysis is to clarify the concept of health-promoting behaviors related to the human papilloma virus (HPV) in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline. 75
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
Concept Analysis: Health-Promoting Behaviors Literature Review Databases used to obtain information included CINAHL Plus, PsycINFO, and ProQuest Health and Medical Complete. The terms health-promoting behavior, health promotion behavior, and promotion of health behavior were inserted with further limitations of the concept by use of the phrase human papilloma virus or human papillomavirus. Exclusion criteria included articles published before 2009, articles published in any language other than English, and articles that were not published in scholarly journals. Inclusion criteria consisted of articles with the keyword “healthpromoting behavior” or some form of the concept. Overall, results were low, with CINAHL producing 19 articles using “health-promoting behavior,” but no results when using “health-promoting behavior and human papilloma virus.” The same was true for PsycINFO. ProQuest Health and Medical Complete produced 283 articles for “health-promoting behavior and human papilloma virus”; however, only five articles included the key phrase “health-promoting behavior,” and unfortunately only one of these articles defined the concept of concern. Consequently, definitions for “health-promoting behavior” were found through Google searches for “health promotion,” “health-promoting behavior,” and “health promotion in nursing,” with resultant definitions from reference Web sites, organizational Web sites, and manuals. A few scholarly articles were also found through CINAHL searches for “health promotion in nursing.” The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursing-based health promotion model (Pender, 2011). The concept of health promotion, which was an outcome of the Ottawa Charter for Health Promotion in 1986, was defined as “the process of enabling people to increase control over, and to improve, their health” (World Health Organization, 2013a, para. 1). The World Health Organization later redefined health promotion in 2005 as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health” (World Health Organization, 2013a, para. 1). Many authors have since adopted the World Health Organization’s definition of health promotion, such as Povlsen and Borup (2011), who described health promotion as “a social and political process that enables people to increase control over determinants of health in order to achieve health and quality of life” (p. 798). However, others have expanded the definition and 76 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
T. McCutcheon incorporated the ideas of community and healthcare strategies. One such example is the College of Public Health (2013), which defined health promotion as “the development of individual, group, institutional, community, and systemic strategies to improve health knowledge, attitudes, skills, and behavior” (para. 2). An additional definition of health promotion that also originated from the public health sector is “a positive conception of health that emphasizes the holistic model and focuses on the healthy population as well as on marginalized and vulnerable groups, on inequality and inequity, and on the social and economic determinants of ill health” (Tengland, 2010, p. 204). Similarly, Tremblay and Richard (2011) defined health promotion as “collective efforts to enhance and promote the health of individuals, groups, or communities through an array of methods and strategies that target individuals or environments” (p. 2). Pender’s health promotion model brought forth the element of behavior in health promotion due to the influence by Albert Bandura’s social learning theory and Fishbein’s theory of reasoned action (Masters, 2011). Collectively, these theories postulate that cognitive processes, personal attitudes, and social norms affect behavior (Masters, 2011). In the Health Promotion Model Manual (Pender, 2011), health-promoting behaviors were defined as “the desired behavioral end point or outcome of decision-making and preparation for action” (Pender, 2011, p. 4). This psychologically influenced nursing theory has been used within nursing under the premise of nursing education as well as health promotion. One such example is the definition of health-promoting behaviors developed by Liu, Ling, Feng, Guo, and Chen (2009) in their article, “Responses, Actions and Health-Promoting Behavior Among Rural Taiwanese Women With Abnormal Papanicolaou Test.” They suggested, for the purposes of their study, that health-promoting behaviors were a “women’s practice of health-related behavior, focusing particularly on three dimensions: health responsibility, stress management, and exercising behavior” (Liu et al., 2009, p. 135). Other definitions of health-promoting behaviors include “personal actions to sustain or increase wellness” (Health Promoting Behavior, 2013, para 1), and Healthline, a public health-related Web site, defined healthpromoting behaviors as “the actions of individuals, groups, and organizations, as well as the determinants, correlates, and consequences, of these actions which include social change, policy development and implementation, improved coping skills, and enhanced
T. McCutcheon quality of life” (Glanz & Maddock, 2002, p. 2). For the purposes of this concept analysis, health-promoting behaviors will be defined as the individual’s and/or community’s ability to obtain control over actions that are influenced by the provision of HPV education, and strategies for the purpose of improving health knowledge, attitudes, intentions, and behaviors related to HPV to thereby achieve optimal health. Method of Concept Analysis The method used for the concept analysis is Walker and Avant’s simplified version of Wilson’s classic concept analysis procedure (Walker & Avant, 2011). This revised method addresses the selection of the concept, the purpose of the analysis, the evaluation of all uses of the concept, the definition of concept attributes, the presentation of model cases, the identification of a borderline and contrary case, the definition of concept antecedents and consequences, and the identification of empirical referents (Walker & Avant, 2011). Defining Attributes Defining attributes, as described by Walker and Avant (2011), are a group of characteristics that are most frequently associated with the concept of concern and allow for a broader insight regarding the concept. Health-promoting behaviors are intermingled with characteristics of community, improvement of health, prevention of disease, and control of behaviors, as well as health knowledge and strategies to decrease health risks. Therefore, these notions may be summarized into defining attributes (or characteristics) of empowerment, participation, community, and positive concept of health. These attributes are thought to have developed from the public health focus on social inequities in health, which were formalized in the Ottawa charter (Tremblay & Richard, 2011). Empowerment is a process in which an individual or community gains control over behaviors and decisions regarding his/her health, and is fostered by participation, which is the involvement of the individual or community in behaviors that ultimately affect health (Povlsen & Borup, 2011; Tremblay & Richard, 2011). The community ensures the importance and application of health promotion behaviors, and forms an active commitment in the planning process for
Concept Analysis: Health-Promoting Behaviors interventions to reduce the incidence of disease (Tremblay & Richard, 2011). Finally, a positive concept of health is an optimistic impression of health, and involves personal and social resources, as well as the consideration of an individual’s physical abilities (Tremblay & Richard, 2011). College-aged males are a high-risk population for sexually transmitted infections (STIs) due to multiple sexual partners, sexual partners with STIs, and unprotected sexual intercourse (Katz, Kam, Kreiger, & Roberto, 2012). Such behaviors may suggest the lack of awareness of susceptibility to HPV and overall lack of HPV education (Katz, Krieger, & Roberto, 2011). Katz et al. (2011) did a cross-sectional survey of 165 college-aged males. Results indicated that 80% of surveyed males were sexually active, 43.9% reported having had five or more sexual partners, and 12.9% reported rarely or never using condoms. However, only 21% of the sexually active college-aged males reported a perceived risk of HPV. This study also suggested that most college-aged males had limited knowledge of HPV, reported unreliable sources of HPV information such as Internet, TV, and friends, and only 4.5% were concerned about HPV infection. Furthermore, Kim (2012) discovered decreased HPV awareness, decreased intention to change sexual behaviors, and an increase in barriers to HPV prevention in males as compared with females. Therefore, the community is in a unique position to provide adequate HPV information through development and implementation of HPV health-promoting programs. As a result, collegeaged males may develop an awareness of a conceivable risk for HPV infection, may establish a positive concept of health, and may become empowered to participate in behavior change related to condom use, the number of sexual partners, and HPV vaccination. Model Case As defined by Walker and Avant (2011), a model case is an illustration of the use of the concept that exhibits all the defining attributes of the concept. A model case, as it relates to health-promoting behaviors and HPV, is as follows: Paul is a 20-year-old university student. He attends an educational program regarding HPV for extra credit in his health and wellness class. Paul is surprised to learn that HPV affects males as well as females, and that it is easily transmitted during sexual intercourse. Since he is sexually active, Paul decides to consistently use condoms and obtain the HPV vaccine. He also decides to join an on-campus 77
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
Concept Analysis: Health-Promoting Behaviors health education initiative to decrease rates of STIs. This is an example of a model case because Paul has become empowered to change his behavior through education, and is participating in behavior change and has become involved in community health promotion. Borderline Case Walker and Avant (2011) characterize a borderline case as an example of a concept that demonstrates only portions of the defining attributes of the concept. The application of health-promoting behaviors and HPV within a borderline case is as follows: Jeff is a 24-year-old male who is waiting for a doctor’s appointment. While sitting in the waiting room, Jeff picks up an HPV pamphlet to read. He was unaware of the risks of HPV, the risk of the development of cancer and anogenital warts, and the availability of a vaccine for males and females. Jeff asks his physician for more information regarding the vaccine, which is then provided. Jeff takes the information home with the intention of reading the vaccine pamphlet, but tosses it on the desk and over time forgets about the information. He never returns for the vaccine. This is a borderline case since Jeff received education and was initially empowered to make a change but never followed through. There was no participation or community involvement. Contrary Case A contrary case, as described by Walker and Avant (2011), is a sample of the concept that does not exhibit any defining attributes of the concept. This idea may be applied to health-promoting behaviors and HPV as follows: Robert is an 18-year-old male who is watching TV when a commercial regarding HPV comes on. He quickly turns the channel to watch sports. This is a contrary case because Robert did not obtain education or any sense of a concept of health; there was no participation or community involvement. Antecedents Antecedents are events that must ensue prior to the occurrence of the concept (Walker & Avant, 2011). Antecedents related to HPV include health attitudes, existing health knowledge, health consciousness, and individual motivation. Health attitudes involve the 78 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
T. McCutcheon individual or community view of certain healthrelated behaviors and most often are directly related to existing knowledge. Health attitudes, as well as motivation to change existing behaviors to more healthpromoting behaviors, are also influenced by health consciousness, or the perceived belief of contracting a disease and the subsequent effects on the quality of life (Conner, 2002). Liddon, Hood, Wynn, and Markowitz (2010) reported that male attitudes regarding acceptance of HPV vaccination were noted to be low in a sample of males aged 18–45 years, with 33% of males stating that they would be vaccinated and 40% undecided. A 78% acceptance rate in college-aged males was noted when the vaccine was presented as a prevention of cervical cancer and anal condyloma (Mehta, Sharma, & Lee, 2013). Conversely, acceptance rates in males for vaccines that are only preventing cervical cancer were only 34% (Mehta et al., 2013). Therefore, Mehta et al. (2013) concluded that college-aged males tend to only evaluate their personal perceived risk of HVP infection rather than consider the protection of their partner. The efficacy rates for the HPV vaccine are high; however, overall vaccination rates are low. For females in the United States between the ages of 13 and 17, Flagg, Schwartz, and Weinstock (2013) reported that the single-dose HPV vaccination rate was an estimated 53%. Of those vaccinated, only 35% of females and 7% of males had obtained the entire three dose series of the vaccine (Daugherty, 2013). Studies have suggested that low vaccination rates are a direct result of inadequate HPV education. In fact, a national survey in 2000 indicated that less than one third of the U.S. population had heard of HPV and only 2% identified HPV as an STI (Sandfort & Pleasant, 2009). Additionally, Krawczyk, Stephenson, Perez, Lau, and Rosberger (2012) reported that many young adults have no knowledge of HPV, the consequences of the disease, or vaccine availability. Furthermore, barriers to HPV vaccination contribute to overall low vaccination rates, and include lack of HPV knowledge, cost, concern regarding safety of the vaccine, and no perceived HPV infection risk (Katz et al., 2011). Conversely, the motivation to obtain the HPV vaccine was noted to be higher if males perceived a greater risk for contracting HPV infection, and who believed partners, family, and healthcare providers would encourage HPV vaccination (Liddon et al., 2010). Therefore, existing HPV knowledge accompanied by attitudes regarding HPV and perceived HPV risk will influence
Concept Analysis: Health-Promoting Behaviors
T. McCutcheon the motivation to accept HPV vaccine, thus reaffirming the need for provision of HPV education and healthpromoting behaviors within the community.
Consequences Consequences are events that transpire as a result of the occurrence of the concept, and may be positive or negative in nature (Walker & Avant, 2011). Initiation of health knowledge and strategies to decrease risk behavior may lead to positive consequences, such as a decrease in morbidity and mortality. Presently, HPV is the most common STI in the world, and is an identifiable source of 99% of cervical cancers, 80–90% of anal cancers, 70% of vaginal cancers, 40% of penile and vulvar cancers, 25% of oral and oropharyngeal cancers, as well as 90% of anal condylomas (The HPV and Anal Cancer Foundation, 2013). A worldwide mortality rate for HPV-related cervical cancer is an estimated 270,000 annually, with more deaths in developing countries where cervical cancer screening programs are nonexistent (World Health Organization, 2013b). Mortality related to HPV-related oralpharyngeal cancers in males was a predicted 5,500 in 2013 (American Society of Clinical Oncology, 2013). Healthy People 2020’s stated goal is to decrease the incidence of HPV-related cervical cancer below the target of 2.2 deaths per 100,000 (Hariri, Dunne, Saraiya, Unger, & Markowitz, 2011). Unfortunately, no stated goals have been placed regarding a decrease in the incidence of other HPV-related cancers or condylomas. An additional positive outcome may be an overall decrease in contraction and transmission of HPV. Within the United States alone, approximately 20 million individuals are infected with HPV and an estimated six million newly diagnosed HPV infections occur annually (Katz et al., 2011). As indicated by Workowski and Berman (2010), STI prevention is based on five strategies: education and counseling; identification of asymptomatic and symptomatic individuals unlikely to seek diagnostic or treatment services; effective diagnosis, treatment, and counseling of infected individuals; evaluation, treatment, and counseling of sex partners of infected individuals; and preexposure vaccination of individuals at risk for contracting STIs. Healthy People 2020 also specified goals specific to STI prevention as “the promotion of healthy sexual behaviors, strengthening of community capacity, and increasing access to services to prevent
STIs and their complications (Healthy People, 2013, para. 1). Furthermore, an increase in HPV vaccination rates and decrease in health risk behaviors may also be a consequence of HPV knowledge and provision of strategies to decrease risk behavior. Since the advent of the HPV vaccine in 2006 for females and 2009 for males, overall vaccination rates have been low. Healthy People 2020 indicated a goal of 80% coverage of the HPV vaccine series in females 13–15 years of age (Hariri et al., 2011). Regrettably, no actual goal is indicated for males; however, Healthy People 2020’s Objective 1.6 is to create an HPV vaccination goal for males (National Cancer Institute, 2013). Moreover, individual and/or community knowledge assists in the continued promotion of HPV education and will result in overall decrease in healthcare costs. HPV-related healthcare costs are a reported annual expenditure of $8 billion globally for prevention and treatment of HPV-related disease (Morton, 2013; Saraiya, Dunne, Stokley, Middleman, & Markowitz, 2013). This annual expense includes $6.6 billion for cervical cancer screenings and follow-up, $1 billion for cervical and oropharyngeal cancers, $.3 billion for genital condylomas, and $.2 billion for recurrent respiratory papillomatosis (Chesson et al., 2012). The negative consequences of health-promoting behaviors regarding HPV include disrespecting autonomy, moralizing, social labeling, and stigmatization, which in turn may affect intentions and health behavior choices. Autonomy is the respect of an individual’s right to self-determination (Merriam-Webster, 2014). In reference to HPV, it has been proposed that the HPV vaccine should be a mandatory vaccination for all female adolescents to help decrease the incidence of HPV-related disease. This suggests disrespecting parental autonomy regarding the decision to obtain the HPV vaccine in an effort to decrease morbidity and mortality. Balog (2009) indicated that this is a point of contention due to suggestions that mandating adolescent females to obtain the HPV vaccine may in fact promote sexual promiscuity, create a false sense of security related to contraction of STIs, and disrespect adolescents’ autonomy when they will carry the burden of HPV infection rather than the parent who would be affected indirectly. Moralizing, or the expression of an opinion about a topic in terms of right or wrong, may lead to social labeling and stigmatization (Dictionary.com, 2014; Masse & Williams-Jones, 2012). Individuals diagnosed 79
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
Concept Analysis: Health-Promoting Behaviors
T. McCutcheon
Figure 1. Schematic of Health-Promoting Behaviors and Human Papilloma Virus (HPV) ANTECEDENTS Health attitudes/lifestyle choices regarding condom use, number of sexual partners, other risky
DEFINING ATTRIBUTES: behaviors. Influenced by past Action: individual or community experiences. response to newly acquired HPV Existing health knowledge knowledge regarding HPV infection, risk Empowerment: process in which an factors, transmission, treatment, individual gains control over behaviors prevention, and existence of and decisions regarding HPV that will vaccine ultimately affect his/her health Health /Consciousness: or the Participation of the individual in individual’s belief of his/her attainment of negative HPV status or chance of contracting HPV and negative HPV transmission how it would affect his/her daily
Community: ensures importance of HPV health interventions and is involved in the health planning process
HPV HEALTH-
life Individual motivation/self-
PROMOTING
BEHAVIOR
management to change and maintain behaviors to prevent HPV infection/transmission. Influenced by self-efficacy.
EMPIRICAL REVERENTS: Increasing health knowledge Increasing health attitudes Increasing health consciousness Increasing individual motivation
CONSEQUENCES: POSITIVE Decrease in morbidity and mortality rates of HPV disease and cancers
CONSEQUENCES: NEGATIVE
Decrease in contraction and transmission of HPV infection
Ethical issues: Disrespecting autonomy, Increase in HPV vaccination rates and condom use; moralizing, and social labeling of “dirty” behavior, decrease in number of sexual partners stigmatization Ability to educate others about HPV Decreased healthcare costs for HPV-related disease and cancers
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Concept Analysis: Health-Promoting Behaviors
T. McCutcheon with HPV or HPV-related disease, as well as individuals seeking HPV education or vaccination, may be mistakenly labeled as promiscuous, homosexual, bisexual, or having a multitude of STIs. This may lead to feelings of anxiety and shame, and affect risk behavior change, HPV cervical cancer screenings, and HPV vaccination rates (Waller, Marlow, & Wardle, 2007). Empirical Referents Empirical referents are “classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself” (Walker & Avant, 2011, p. 168). They are interconnected to the theoretical base of the concept, and therefore are beneficial for instrument development (Walker & Avant, 2011). Also, empirical referents are advantageous to nursing practice in that they provide observable and clear phenomenon in which to establish the existence of the concept in individuals regarding HPV awareness (Walker & Avant, 2011). The concept of health-promoting behaviors is an abstract concept; therefore, increasing health knowledge, health attitudes, health consciousness, and individual motivation regarding HPV is considered the empirical referents for health-promoting behaviors related to HPV. Refer to Figure 1 for a schematic of healthpromoting behaviors and HPV. Conclusion In conclusion, the concept of health-promoting behaviors has not been well defined or applied in nursing literature despite the influence of Pender’s health belief model. A literature review indicated a distinct gap in literature regarding health-promoting behaviors and HPV. Therefore, it is paramount for the nursing discipline to become engaged in the concept of HPV health-promoting behaviors with the purpose of expanding HPV education and strategies to increase vaccination rates, to promote further research regarding health-promoting behaviors, and to apply healthpromoting behaviors to other populations and situations within the nursing practice. References American Society of Clinical Oncology. (2013). Oral and oropharyngeal cancer. Retrieved from http:// www.cancer.net/cancer-types/oral-and-oropharyngealcancer/statistics
Autonomy. (2014). In Merriam-Webster. Retrieved from http://www.merriam-webster.com/dictionary/autonomy Balog, J. E. (2009). The moral justification for a compulsory human papillomavirus vaccination program. American Journal of Public Health, 99(4), 616–622. doi:10.21D5/ AJPH.2007.131656 Chesson, H. W., Ekwueme, D. U., Saraiya, M., Watson, M., Lowy, D. R., & Markowitz, L. E. (2012). Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine, 30(42). Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/22867718 College of Public Health. (2013). What is health promotion and behavior? Retrieved from http://www.publichealth .uga.edu/hpb/what-health-promotion-behavior Conner, M. (2002). Health behaviors. Retrieved from http:// userpage.fu-berlin.de/~schuez/folien/conner2002.pdf Daugherty, D. (2013). Anti-HPV vaccination rate among adolescent males improving. Retrieved from http://www .examiner.com/article/anti-hpv-vaccination-rate-among -adolescent-males-improving Flagg, E. W., Schwartz, R., & Weinstock, H. (2013). Prevalence of anogenital warts and potential impact of human papillomavirus vaccination. American Journal of Public Health, 103(8), 1428–1435. Glanz, K., & Maddock, J. (2002). Behavior, health-related. Retrieved from http://www.sanjeshp.ir/phd_91/Pages/ Refrences/health%20education%20and%20promotion/ [Karen_Glanz,_Barbara_K._Rimer,_K._Viswanath]_Heal (BookFi.or.pdf Hariri, S., Dunne, E., Saraiya, M., Unger, E., & Markowitz, L. (2011). Manual for the surveillance of vaccinepreventable diseases. In Human papilloma virus (5th ed.). Retrieved from http://www.cdc.gov/vaccines/pubs/survmanual/chpt05-hpv.html Health Promoting Behavior. (2013). In free dictionary. Retrieved from http://medical-dictionary.thefreedictionary .com/health+promoting+behavior Healthy People. (2013). Sexually transmitted diseases. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicId=37 The HPV and Anal Cancer Foundation. (2013). HPV. Retrieved from http://www.analcancerfoundation.org/ learn/hpv/ Katz, M. L., Kam, J. A., Kreiger, J. L., & Roberto, A. J. (2012). Predicting HPV vaccine intentions of college-age males: An examination of parents and sons’ perceptions. Journal of American College Health, 60(6), 449–459. Retrieved from http://dx.doi.org/10.1080/07448481 .2012.673523 Katz, M. L., Krieger, J. L., & Roberto, A. J. (2011). Human papillomavirus (HPV): College males’ knowledge, perceived risk, sources of information, vaccine barriers, and communication. Journal of Men’s Health, 8(3), 175–184. Kemppainen, V., Tossavainen, K., & Turunen, H. (2012). Nurses’ role in health promotion practice: An integrative review. Health Promotion International, 28(4), 490–501. doi:10.1093/heapro/das034 Kim, H. W. (2012). Gender differences in knowledge and health beliefs related to behavioral intentions to prevent human papillomavirus infection. Asia-Pacific Journal of 81
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Concept Analysis: Health-Promoting Behaviors Public Health, 25(3), 248–259. Retrieved from http://www .ncbi.nlm.nih.gov/pubmed/22652244 Krawczyk, A., Stephenson, E., Perez, S., Lau, E., & Rosberger, Z. (2012). Deconstructing human papillomavirus (HPV) knowledge: Objective and perceived knowledge in males’ intentions to receive the HPV vaccine. American Journal of Health Education, 44(1), 26–31. Retrieved from http://www.tandfonline.com/doi/ abs/10.1080/19325037.2012.749714#preview Liddon, N., Hood, J., Wynn, B., & Markowitz, L. E. (2010). Acceptability of human papillomavirus vaccine for males: A review of the literature. Journal of Adolescent Health, 46, 113–123. doi:10.1016/j.jadohealth.2009.11.199 Liu, H., Ling, X., Feng, M., Guo, Y., & Chen, M. (2009). Responses, actions and health-promoting behavior among rural Taiwanese women with abnormal Papanicolaou test. Public Health Nursing, 26(2), 134–143. doi:10.1111/j.1525-1446.2009.00764.x Masse, R., & Williams-Jones, B. (2012). Ethical dilemmas in health promotion practice. In I. Rootman, S. Dupere, A. Pederson, & M. O’Neill (Eds.), Health promotion in Canada (3rd ed., pp. 241–253). Toronto, ON: Canadian Scholars’ Press. Masters, K. (2011). Models and theories focused on nursing goals and functions. In J. B. Butts & K. L. Rich (Eds.), Philosophies and theories for advanced nursing practice (pp. 383–412). Sudbury, MA: Jones & Bartlett Learning, LLC. Mehta, P., Sharma, M., & Lee, R. C. (2013). Using the health belief model in qualitative focus groups to identify HPV vaccine acceptability in college men. International Quarterly of Community Health Education, 33(2), 175–187. Moralizing. (2014). In Dictionary.com. Retrieved from http:// dictionary.reference.com/browse/moralize Morton, K. (2013). Implementing evidence-based health promotion strategies. Nursing Standard, 27(33), 35–42. National Cancer Institute. (2013). Accelerating HPV vaccine uptake: Urgency for action to prevent cancer. Retrieved from deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/ Part3Goal1.htm Pender, N. (2011). The health promotion model manual (Doctoral dissertation). Ann Arbor, MI: University of
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T. McCutcheon Michigan. Retrieved from http://deepblue.lib.umich.edu/ bitstream/handle/2027.42/85350/?sequence=1 Povlsen, L., & Borup, I. K. (2011). Holism in nursing and health promotion: Distinct or related perspectives?—A literature review. Scandinavian Journal of Caring Science, 25(4), 798–805. doi:10.1111/j.1471-6712.2011.00885.x Sandfort, J. R., & Pleasant, A. (2009). Knowledge, attitudes, and informational behaviors of college students in regard to the human papillomavirus. Journal of American College Health, 58(2), 141–149. Saraiya, M., Dunne, E. F., Stokley, S., Middleman, A., & Markowitz, L. E. (2013). Reducing the burden of HPV-associated cancer and disease through vaccination in the US. Retrieved from http://www.cdc.gov/about/grandrounds/archives/2013/february2013.htm Tengland, P. (2010). Health promotion or disease prevention: A real difference for public health practice? Health Care Analysis, 18(3), 203–221. doi:10.1007/s10728-0090124-1 Tremblay, M., & Richard, L. (2011). Complexity: A potential paradigm for a health promotion discipline. Health Promotion International, 29(2), 378–388. doi:10.1093/heapro/ dar054 Walker, L. O., & Avant, K. C. (2011). Concept analysis. In M. Connor (Ed.), Strategies for theory construction in nursing (5th ed., pp. 157–179). Boston: Pearson Education. Waller, J., Marlow, L. A., & Wardle, J. (2007). The association between knowledge of HPV and feelings of stigma, shame and anxiety. Sexually Transmitted Infection, 83(2), 155–159. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2598611/ Workowski, K. A., & Berman, S. (2010). Sexually transmitted diseases treatment guidelines 2010. Morbidity and Mortality Weekly Report, 59(12), 1–110. World Health Organization. (2013a). Health promotion. Retrieved from http://www.who.int/topics/health _promotion/en/ World Health Organization. (2013b). Human papillomavirus (HPV) and cervical cancer. Retrieved from http:// www.who.int/mediacentre/factsheets/fs380/en/
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Concept Analysis: Health-Promoting Behaviors Related to Human Papilloma Virus (HPV) Infection Tonna McCutcheon, APRN-BC, CGRN Tonna McCutcheon, APRN-BC, CGRN, is DNP Student at Vanderbilt University, Nashville, TN. Keywords Concept analysis, health promotion, health-promoting behaviors, human papilloma virus Correspondence Tonna McCutcheon, APRN-BC, Vanderbilt University, Nashville, TN E-mail: tonna.mccutcheon@ vanderbilt.edu
McCutcheon
PROBLEM. The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursingbased Health Promotion Model. Despite the fact that the concept of health-promoting behaviors has a nursing influence, literature suggests nursing has inadequately developed and used this concept within nursing practice. A further review of literature regarding health promotion behaviors and the human papilloma virus suggest a distinct gap in nursing literature. METHOD. This article presents a concept analysis of health-promoting behaviors related to the human papilloma virus in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline. CONCLUSION. Attributes of health-promoting behaviors are presented and include empowerment, participation, community, and a positive concept of health. Antecedents, consequences, and empirical referents are also presented, as are model, borderline, and contrary cases to help clarify the concept. Recommendations for human papilloma virus healthpromoting behaviors within the nursing practice are also provided.
The concept of health-promoting behaviors encompasses environmental, psychological, biological, medical, and physical sciences, and is depicted in various forms of literature with the common goal of the acquisition of optimal health. This concept involves individuals as well as communities, and incorporates knowledge, education, skills, and strategies to endorse control over and development of health-related behaviors. Although health promotion and associated behaviors are integrated within nursing literature, Kemppainen, Tossavainen, and Turunen (2012) suggested that nursing has been focused on disease prevention, and therefore is in need of reorientation to a health promotion philosophy. Povlsen and Borup (2011) published a literature review regarding the relationship between holism in nursing and health promotion. They concluded the
following: (a) nursing-based literature ignored the psychosocial, political, and ethical aspects of health promotion; (b) the nursing philosophy of individualism prevented the integration of health promotion into nursing practice; (c) nursing focused on patient education rather than health-promoting behaviors; and (d) nursing maintained a traditional function rather than eliminating boundaries in order to expand health promotion roles. Therefore, the purpose of this analysis is to clarify the concept of health-promoting behaviors related to the human papilloma virus (HPV) in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline. 75
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Concept Analysis: Health-Promoting Behaviors Literature Review Databases used to obtain information included CINAHL Plus, PsycINFO, and ProQuest Health and Medical Complete. The terms health-promoting behavior, health promotion behavior, and promotion of health behavior were inserted with further limitations of the concept by use of the phrase human papilloma virus or human papillomavirus. Exclusion criteria included articles published before 2009, articles published in any language other than English, and articles that were not published in scholarly journals. Inclusion criteria consisted of articles with the keyword “healthpromoting behavior” or some form of the concept. Overall, results were low, with CINAHL producing 19 articles using “health-promoting behavior,” but no results when using “health-promoting behavior and human papilloma virus.” The same was true for PsycINFO. ProQuest Health and Medical Complete produced 283 articles for “health-promoting behavior and human papilloma virus”; however, only five articles included the key phrase “health-promoting behavior,” and unfortunately only one of these articles defined the concept of concern. Consequently, definitions for “health-promoting behavior” were found through Google searches for “health promotion,” “health-promoting behavior,” and “health promotion in nursing,” with resultant definitions from reference Web sites, organizational Web sites, and manuals. A few scholarly articles were also found through CINAHL searches for “health promotion in nursing.” The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursing-based health promotion model (Pender, 2011). The concept of health promotion, which was an outcome of the Ottawa Charter for Health Promotion in 1986, was defined as “the process of enabling people to increase control over, and to improve, their health” (World Health Organization, 2013a, para. 1). The World Health Organization later redefined health promotion in 2005 as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health” (World Health Organization, 2013a, para. 1). Many authors have since adopted the World Health Organization’s definition of health promotion, such as Povlsen and Borup (2011), who described health promotion as “a social and political process that enables people to increase control over determinants of health in order to achieve health and quality of life” (p. 798). However, others have expanded the definition and 76 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
T. McCutcheon incorporated the ideas of community and healthcare strategies. One such example is the College of Public Health (2013), which defined health promotion as “the development of individual, group, institutional, community, and systemic strategies to improve health knowledge, attitudes, skills, and behavior” (para. 2). An additional definition of health promotion that also originated from the public health sector is “a positive conception of health that emphasizes the holistic model and focuses on the healthy population as well as on marginalized and vulnerable groups, on inequality and inequity, and on the social and economic determinants of ill health” (Tengland, 2010, p. 204). Similarly, Tremblay and Richard (2011) defined health promotion as “collective efforts to enhance and promote the health of individuals, groups, or communities through an array of methods and strategies that target individuals or environments” (p. 2). Pender’s health promotion model brought forth the element of behavior in health promotion due to the influence by Albert Bandura’s social learning theory and Fishbein’s theory of reasoned action (Masters, 2011). Collectively, these theories postulate that cognitive processes, personal attitudes, and social norms affect behavior (Masters, 2011). In the Health Promotion Model Manual (Pender, 2011), health-promoting behaviors were defined as “the desired behavioral end point or outcome of decision-making and preparation for action” (Pender, 2011, p. 4). This psychologically influenced nursing theory has been used within nursing under the premise of nursing education as well as health promotion. One such example is the definition of health-promoting behaviors developed by Liu, Ling, Feng, Guo, and Chen (2009) in their article, “Responses, Actions and Health-Promoting Behavior Among Rural Taiwanese Women With Abnormal Papanicolaou Test.” They suggested, for the purposes of their study, that health-promoting behaviors were a “women’s practice of health-related behavior, focusing particularly on three dimensions: health responsibility, stress management, and exercising behavior” (Liu et al., 2009, p. 135). Other definitions of health-promoting behaviors include “personal actions to sustain or increase wellness” (Health Promoting Behavior, 2013, para 1), and Healthline, a public health-related Web site, defined healthpromoting behaviors as “the actions of individuals, groups, and organizations, as well as the determinants, correlates, and consequences, of these actions which include social change, policy development and implementation, improved coping skills, and enhanced
T. McCutcheon quality of life” (Glanz & Maddock, 2002, p. 2). For the purposes of this concept analysis, health-promoting behaviors will be defined as the individual’s and/or community’s ability to obtain control over actions that are influenced by the provision of HPV education, and strategies for the purpose of improving health knowledge, attitudes, intentions, and behaviors related to HPV to thereby achieve optimal health. Method of Concept Analysis The method used for the concept analysis is Walker and Avant’s simplified version of Wilson’s classic concept analysis procedure (Walker & Avant, 2011). This revised method addresses the selection of the concept, the purpose of the analysis, the evaluation of all uses of the concept, the definition of concept attributes, the presentation of model cases, the identification of a borderline and contrary case, the definition of concept antecedents and consequences, and the identification of empirical referents (Walker & Avant, 2011). Defining Attributes Defining attributes, as described by Walker and Avant (2011), are a group of characteristics that are most frequently associated with the concept of concern and allow for a broader insight regarding the concept. Health-promoting behaviors are intermingled with characteristics of community, improvement of health, prevention of disease, and control of behaviors, as well as health knowledge and strategies to decrease health risks. Therefore, these notions may be summarized into defining attributes (or characteristics) of empowerment, participation, community, and positive concept of health. These attributes are thought to have developed from the public health focus on social inequities in health, which were formalized in the Ottawa charter (Tremblay & Richard, 2011). Empowerment is a process in which an individual or community gains control over behaviors and decisions regarding his/her health, and is fostered by participation, which is the involvement of the individual or community in behaviors that ultimately affect health (Povlsen & Borup, 2011; Tremblay & Richard, 2011). The community ensures the importance and application of health promotion behaviors, and forms an active commitment in the planning process for
Concept Analysis: Health-Promoting Behaviors interventions to reduce the incidence of disease (Tremblay & Richard, 2011). Finally, a positive concept of health is an optimistic impression of health, and involves personal and social resources, as well as the consideration of an individual’s physical abilities (Tremblay & Richard, 2011). College-aged males are a high-risk population for sexually transmitted infections (STIs) due to multiple sexual partners, sexual partners with STIs, and unprotected sexual intercourse (Katz, Kam, Kreiger, & Roberto, 2012). Such behaviors may suggest the lack of awareness of susceptibility to HPV and overall lack of HPV education (Katz, Krieger, & Roberto, 2011). Katz et al. (2011) did a cross-sectional survey of 165 college-aged males. Results indicated that 80% of surveyed males were sexually active, 43.9% reported having had five or more sexual partners, and 12.9% reported rarely or never using condoms. However, only 21% of the sexually active college-aged males reported a perceived risk of HPV. This study also suggested that most college-aged males had limited knowledge of HPV, reported unreliable sources of HPV information such as Internet, TV, and friends, and only 4.5% were concerned about HPV infection. Furthermore, Kim (2012) discovered decreased HPV awareness, decreased intention to change sexual behaviors, and an increase in barriers to HPV prevention in males as compared with females. Therefore, the community is in a unique position to provide adequate HPV information through development and implementation of HPV health-promoting programs. As a result, collegeaged males may develop an awareness of a conceivable risk for HPV infection, may establish a positive concept of health, and may become empowered to participate in behavior change related to condom use, the number of sexual partners, and HPV vaccination. Model Case As defined by Walker and Avant (2011), a model case is an illustration of the use of the concept that exhibits all the defining attributes of the concept. A model case, as it relates to health-promoting behaviors and HPV, is as follows: Paul is a 20-year-old university student. He attends an educational program regarding HPV for extra credit in his health and wellness class. Paul is surprised to learn that HPV affects males as well as females, and that it is easily transmitted during sexual intercourse. Since he is sexually active, Paul decides to consistently use condoms and obtain the HPV vaccine. He also decides to join an on-campus 77
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Concept Analysis: Health-Promoting Behaviors health education initiative to decrease rates of STIs. This is an example of a model case because Paul has become empowered to change his behavior through education, and is participating in behavior change and has become involved in community health promotion. Borderline Case Walker and Avant (2011) characterize a borderline case as an example of a concept that demonstrates only portions of the defining attributes of the concept. The application of health-promoting behaviors and HPV within a borderline case is as follows: Jeff is a 24-year-old male who is waiting for a doctor’s appointment. While sitting in the waiting room, Jeff picks up an HPV pamphlet to read. He was unaware of the risks of HPV, the risk of the development of cancer and anogenital warts, and the availability of a vaccine for males and females. Jeff asks his physician for more information regarding the vaccine, which is then provided. Jeff takes the information home with the intention of reading the vaccine pamphlet, but tosses it on the desk and over time forgets about the information. He never returns for the vaccine. This is a borderline case since Jeff received education and was initially empowered to make a change but never followed through. There was no participation or community involvement. Contrary Case A contrary case, as described by Walker and Avant (2011), is a sample of the concept that does not exhibit any defining attributes of the concept. This idea may be applied to health-promoting behaviors and HPV as follows: Robert is an 18-year-old male who is watching TV when a commercial regarding HPV comes on. He quickly turns the channel to watch sports. This is a contrary case because Robert did not obtain education or any sense of a concept of health; there was no participation or community involvement. Antecedents Antecedents are events that must ensue prior to the occurrence of the concept (Walker & Avant, 2011). Antecedents related to HPV include health attitudes, existing health knowledge, health consciousness, and individual motivation. Health attitudes involve the 78 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
T. McCutcheon individual or community view of certain healthrelated behaviors and most often are directly related to existing knowledge. Health attitudes, as well as motivation to change existing behaviors to more healthpromoting behaviors, are also influenced by health consciousness, or the perceived belief of contracting a disease and the subsequent effects on the quality of life (Conner, 2002). Liddon, Hood, Wynn, and Markowitz (2010) reported that male attitudes regarding acceptance of HPV vaccination were noted to be low in a sample of males aged 18–45 years, with 33% of males stating that they would be vaccinated and 40% undecided. A 78% acceptance rate in college-aged males was noted when the vaccine was presented as a prevention of cervical cancer and anal condyloma (Mehta, Sharma, & Lee, 2013). Conversely, acceptance rates in males for vaccines that are only preventing cervical cancer were only 34% (Mehta et al., 2013). Therefore, Mehta et al. (2013) concluded that college-aged males tend to only evaluate their personal perceived risk of HVP infection rather than consider the protection of their partner. The efficacy rates for the HPV vaccine are high; however, overall vaccination rates are low. For females in the United States between the ages of 13 and 17, Flagg, Schwartz, and Weinstock (2013) reported that the single-dose HPV vaccination rate was an estimated 53%. Of those vaccinated, only 35% of females and 7% of males had obtained the entire three dose series of the vaccine (Daugherty, 2013). Studies have suggested that low vaccination rates are a direct result of inadequate HPV education. In fact, a national survey in 2000 indicated that less than one third of the U.S. population had heard of HPV and only 2% identified HPV as an STI (Sandfort & Pleasant, 2009). Additionally, Krawczyk, Stephenson, Perez, Lau, and Rosberger (2012) reported that many young adults have no knowledge of HPV, the consequences of the disease, or vaccine availability. Furthermore, barriers to HPV vaccination contribute to overall low vaccination rates, and include lack of HPV knowledge, cost, concern regarding safety of the vaccine, and no perceived HPV infection risk (Katz et al., 2011). Conversely, the motivation to obtain the HPV vaccine was noted to be higher if males perceived a greater risk for contracting HPV infection, and who believed partners, family, and healthcare providers would encourage HPV vaccination (Liddon et al., 2010). Therefore, existing HPV knowledge accompanied by attitudes regarding HPV and perceived HPV risk will influence
Concept Analysis: Health-Promoting Behaviors
T. McCutcheon the motivation to accept HPV vaccine, thus reaffirming the need for provision of HPV education and healthpromoting behaviors within the community.
Consequences Consequences are events that transpire as a result of the occurrence of the concept, and may be positive or negative in nature (Walker & Avant, 2011). Initiation of health knowledge and strategies to decrease risk behavior may lead to positive consequences, such as a decrease in morbidity and mortality. Presently, HPV is the most common STI in the world, and is an identifiable source of 99% of cervical cancers, 80–90% of anal cancers, 70% of vaginal cancers, 40% of penile and vulvar cancers, 25% of oral and oropharyngeal cancers, as well as 90% of anal condylomas (The HPV and Anal Cancer Foundation, 2013). A worldwide mortality rate for HPV-related cervical cancer is an estimated 270,000 annually, with more deaths in developing countries where cervical cancer screening programs are nonexistent (World Health Organization, 2013b). Mortality related to HPV-related oralpharyngeal cancers in males was a predicted 5,500 in 2013 (American Society of Clinical Oncology, 2013). Healthy People 2020’s stated goal is to decrease the incidence of HPV-related cervical cancer below the target of 2.2 deaths per 100,000 (Hariri, Dunne, Saraiya, Unger, & Markowitz, 2011). Unfortunately, no stated goals have been placed regarding a decrease in the incidence of other HPV-related cancers or condylomas. An additional positive outcome may be an overall decrease in contraction and transmission of HPV. Within the United States alone, approximately 20 million individuals are infected with HPV and an estimated six million newly diagnosed HPV infections occur annually (Katz et al., 2011). As indicated by Workowski and Berman (2010), STI prevention is based on five strategies: education and counseling; identification of asymptomatic and symptomatic individuals unlikely to seek diagnostic or treatment services; effective diagnosis, treatment, and counseling of infected individuals; evaluation, treatment, and counseling of sex partners of infected individuals; and preexposure vaccination of individuals at risk for contracting STIs. Healthy People 2020 also specified goals specific to STI prevention as “the promotion of healthy sexual behaviors, strengthening of community capacity, and increasing access to services to prevent
STIs and their complications (Healthy People, 2013, para. 1). Furthermore, an increase in HPV vaccination rates and decrease in health risk behaviors may also be a consequence of HPV knowledge and provision of strategies to decrease risk behavior. Since the advent of the HPV vaccine in 2006 for females and 2009 for males, overall vaccination rates have been low. Healthy People 2020 indicated a goal of 80% coverage of the HPV vaccine series in females 13–15 years of age (Hariri et al., 2011). Regrettably, no actual goal is indicated for males; however, Healthy People 2020’s Objective 1.6 is to create an HPV vaccination goal for males (National Cancer Institute, 2013). Moreover, individual and/or community knowledge assists in the continued promotion of HPV education and will result in overall decrease in healthcare costs. HPV-related healthcare costs are a reported annual expenditure of $8 billion globally for prevention and treatment of HPV-related disease (Morton, 2013; Saraiya, Dunne, Stokley, Middleman, & Markowitz, 2013). This annual expense includes $6.6 billion for cervical cancer screenings and follow-up, $1 billion for cervical and oropharyngeal cancers, $.3 billion for genital condylomas, and $.2 billion for recurrent respiratory papillomatosis (Chesson et al., 2012). The negative consequences of health-promoting behaviors regarding HPV include disrespecting autonomy, moralizing, social labeling, and stigmatization, which in turn may affect intentions and health behavior choices. Autonomy is the respect of an individual’s right to self-determination (Merriam-Webster, 2014). In reference to HPV, it has been proposed that the HPV vaccine should be a mandatory vaccination for all female adolescents to help decrease the incidence of HPV-related disease. This suggests disrespecting parental autonomy regarding the decision to obtain the HPV vaccine in an effort to decrease morbidity and mortality. Balog (2009) indicated that this is a point of contention due to suggestions that mandating adolescent females to obtain the HPV vaccine may in fact promote sexual promiscuity, create a false sense of security related to contraction of STIs, and disrespect adolescents’ autonomy when they will carry the burden of HPV infection rather than the parent who would be affected indirectly. Moralizing, or the expression of an opinion about a topic in terms of right or wrong, may lead to social labeling and stigmatization (Dictionary.com, 2014; Masse & Williams-Jones, 2012). Individuals diagnosed 79
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Concept Analysis: Health-Promoting Behaviors
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Figure 1. Schematic of Health-Promoting Behaviors and Human Papilloma Virus (HPV) ANTECEDENTS Health attitudes/lifestyle choices regarding condom use, number of sexual partners, other risky
DEFINING ATTRIBUTES: behaviors. Influenced by past Action: individual or community experiences. response to newly acquired HPV Existing health knowledge knowledge regarding HPV infection, risk Empowerment: process in which an factors, transmission, treatment, individual gains control over behaviors prevention, and existence of and decisions regarding HPV that will vaccine ultimately affect his/her health Health /Consciousness: or the Participation of the individual in individual’s belief of his/her attainment of negative HPV status or chance of contracting HPV and negative HPV transmission how it would affect his/her daily
Community: ensures importance of HPV health interventions and is involved in the health planning process
HPV HEALTH-
life Individual motivation/self-
PROMOTING
BEHAVIOR
management to change and maintain behaviors to prevent HPV infection/transmission. Influenced by self-efficacy.
EMPIRICAL REVERENTS: Increasing health knowledge Increasing health attitudes Increasing health consciousness Increasing individual motivation
CONSEQUENCES: POSITIVE Decrease in morbidity and mortality rates of HPV disease and cancers
CONSEQUENCES: NEGATIVE
Decrease in contraction and transmission of HPV infection
Ethical issues: Disrespecting autonomy, Increase in HPV vaccination rates and condom use; moralizing, and social labeling of “dirty” behavior, decrease in number of sexual partners stigmatization Ability to educate others about HPV Decreased healthcare costs for HPV-related disease and cancers
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Concept Analysis: Health-Promoting Behaviors
T. McCutcheon with HPV or HPV-related disease, as well as individuals seeking HPV education or vaccination, may be mistakenly labeled as promiscuous, homosexual, bisexual, or having a multitude of STIs. This may lead to feelings of anxiety and shame, and affect risk behavior change, HPV cervical cancer screenings, and HPV vaccination rates (Waller, Marlow, & Wardle, 2007). Empirical Referents Empirical referents are “classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself” (Walker & Avant, 2011, p. 168). They are interconnected to the theoretical base of the concept, and therefore are beneficial for instrument development (Walker & Avant, 2011). Also, empirical referents are advantageous to nursing practice in that they provide observable and clear phenomenon in which to establish the existence of the concept in individuals regarding HPV awareness (Walker & Avant, 2011). The concept of health-promoting behaviors is an abstract concept; therefore, increasing health knowledge, health attitudes, health consciousness, and individual motivation regarding HPV is considered the empirical referents for health-promoting behaviors related to HPV. Refer to Figure 1 for a schematic of healthpromoting behaviors and HPV. Conclusion In conclusion, the concept of health-promoting behaviors has not been well defined or applied in nursing literature despite the influence of Pender’s health belief model. A literature review indicated a distinct gap in literature regarding health-promoting behaviors and HPV. Therefore, it is paramount for the nursing discipline to become engaged in the concept of HPV health-promoting behaviors with the purpose of expanding HPV education and strategies to increase vaccination rates, to promote further research regarding health-promoting behaviors, and to apply healthpromoting behaviors to other populations and situations within the nursing practice. References American Society of Clinical Oncology. (2013). Oral and oropharyngeal cancer. Retrieved from http:// www.cancer.net/cancer-types/oral-and-oropharyngealcancer/statistics
Autonomy. (2014). In Merriam-Webster. Retrieved from http://www.merriam-webster.com/dictionary/autonomy Balog, J. E. (2009). The moral justification for a compulsory human papillomavirus vaccination program. American Journal of Public Health, 99(4), 616–622. doi:10.21D5/ AJPH.2007.131656 Chesson, H. W., Ekwueme, D. U., Saraiya, M., Watson, M., Lowy, D. R., & Markowitz, L. E. (2012). Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine, 30(42). Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/22867718 College of Public Health. (2013). What is health promotion and behavior? Retrieved from http://www.publichealth .uga.edu/hpb/what-health-promotion-behavior Conner, M. (2002). Health behaviors. Retrieved from http:// userpage.fu-berlin.de/~schuez/folien/conner2002.pdf Daugherty, D. (2013). Anti-HPV vaccination rate among adolescent males improving. Retrieved from http://www .examiner.com/article/anti-hpv-vaccination-rate-among -adolescent-males-improving Flagg, E. W., Schwartz, R., & Weinstock, H. (2013). Prevalence of anogenital warts and potential impact of human papillomavirus vaccination. American Journal of Public Health, 103(8), 1428–1435. Glanz, K., & Maddock, J. (2002). Behavior, health-related. Retrieved from http://www.sanjeshp.ir/phd_91/Pages/ Refrences/health%20education%20and%20promotion/ [Karen_Glanz,_Barbara_K._Rimer,_K._Viswanath]_Heal (BookFi.or.pdf Hariri, S., Dunne, E., Saraiya, M., Unger, E., & Markowitz, L. (2011). Manual for the surveillance of vaccinepreventable diseases. In Human papilloma virus (5th ed.). Retrieved from http://www.cdc.gov/vaccines/pubs/survmanual/chpt05-hpv.html Health Promoting Behavior. (2013). In free dictionary. Retrieved from http://medical-dictionary.thefreedictionary .com/health+promoting+behavior Healthy People. (2013). Sexually transmitted diseases. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicId=37 The HPV and Anal Cancer Foundation. (2013). HPV. Retrieved from http://www.analcancerfoundation.org/ learn/hpv/ Katz, M. L., Kam, J. A., Kreiger, J. L., & Roberto, A. J. (2012). Predicting HPV vaccine intentions of college-age males: An examination of parents and sons’ perceptions. Journal of American College Health, 60(6), 449–459. Retrieved from http://dx.doi.org/10.1080/07448481 .2012.673523 Katz, M. L., Krieger, J. L., & Roberto, A. J. (2011). Human papillomavirus (HPV): College males’ knowledge, perceived risk, sources of information, vaccine barriers, and communication. Journal of Men’s Health, 8(3), 175–184. Kemppainen, V., Tossavainen, K., & Turunen, H. (2012). Nurses’ role in health promotion practice: An integrative review. Health Promotion International, 28(4), 490–501. doi:10.1093/heapro/das034 Kim, H. W. (2012). Gender differences in knowledge and health beliefs related to behavioral intentions to prevent human papillomavirus infection. Asia-Pacific Journal of 81
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Concept Analysis: Health-Promoting Behaviors Public Health, 25(3), 248–259. Retrieved from http://www .ncbi.nlm.nih.gov/pubmed/22652244 Krawczyk, A., Stephenson, E., Perez, S., Lau, E., & Rosberger, Z. (2012). Deconstructing human papillomavirus (HPV) knowledge: Objective and perceived knowledge in males’ intentions to receive the HPV vaccine. American Journal of Health Education, 44(1), 26–31. Retrieved from http://www.tandfonline.com/doi/ abs/10.1080/19325037.2012.749714#preview Liddon, N., Hood, J., Wynn, B., & Markowitz, L. E. (2010). Acceptability of human papillomavirus vaccine for males: A review of the literature. Journal of Adolescent Health, 46, 113–123. doi:10.1016/j.jadohealth.2009.11.199 Liu, H., Ling, X., Feng, M., Guo, Y., & Chen, M. (2009). Responses, actions and health-promoting behavior among rural Taiwanese women with abnormal Papanicolaou test. Public Health Nursing, 26(2), 134–143. doi:10.1111/j.1525-1446.2009.00764.x Masse, R., & Williams-Jones, B. (2012). Ethical dilemmas in health promotion practice. In I. Rootman, S. Dupere, A. Pederson, & M. O’Neill (Eds.), Health promotion in Canada (3rd ed., pp. 241–253). Toronto, ON: Canadian Scholars’ Press. Masters, K. (2011). Models and theories focused on nursing goals and functions. In J. B. Butts & K. L. Rich (Eds.), Philosophies and theories for advanced nursing practice (pp. 383–412). Sudbury, MA: Jones & Bartlett Learning, LLC. Mehta, P., Sharma, M., & Lee, R. C. (2013). Using the health belief model in qualitative focus groups to identify HPV vaccine acceptability in college men. International Quarterly of Community Health Education, 33(2), 175–187. Moralizing. (2014). In Dictionary.com. Retrieved from http:// dictionary.reference.com/browse/moralize Morton, K. (2013). Implementing evidence-based health promotion strategies. Nursing Standard, 27(33), 35–42. National Cancer Institute. (2013). Accelerating HPV vaccine uptake: Urgency for action to prevent cancer. Retrieved from deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/ Part3Goal1.htm Pender, N. (2011). The health promotion model manual (Doctoral dissertation). Ann Arbor, MI: University of
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T. McCutcheon Michigan. Retrieved from http://deepblue.lib.umich.edu/ bitstream/handle/2027.42/85350/?sequence=1 Povlsen, L., & Borup, I. K. (2011). Holism in nursing and health promotion: Distinct or related perspectives?—A literature review. Scandinavian Journal of Caring Science, 25(4), 798–805. doi:10.1111/j.1471-6712.2011.00885.x Sandfort, J. R., & Pleasant, A. (2009). Knowledge, attitudes, and informational behaviors of college students in regard to the human papillomavirus. Journal of American College Health, 58(2), 141–149. Saraiya, M., Dunne, E. F., Stokley, S., Middleman, A., & Markowitz, L. E. (2013). Reducing the burden of HPV-associated cancer and disease through vaccination in the US. Retrieved from http://www.cdc.gov/about/grandrounds/archives/2013/february2013.htm Tengland, P. (2010). Health promotion or disease prevention: A real difference for public health practice? Health Care Analysis, 18(3), 203–221. doi:10.1007/s10728-0090124-1 Tremblay, M., & Richard, L. (2011). Complexity: A potential paradigm for a health promotion discipline. Health Promotion International, 29(2), 378–388. doi:10.1093/heapro/ dar054 Walker, L. O., & Avant, K. C. (2011). Concept analysis. In M. Connor (Ed.), Strategies for theory construction in nursing (5th ed., pp. 157–179). Boston: Pearson Education. Waller, J., Marlow, L. A., & Wardle, J. (2007). The association between knowledge of HPV and feelings of stigma, shame and anxiety. Sexually Transmitted Infection, 83(2), 155–159. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2598611/ Workowski, K. A., & Berman, S. (2010). Sexually transmitted diseases treatment guidelines 2010. Morbidity and Mortality Weekly Report, 59(12), 1–110. World Health Organization. (2013a). Health promotion. Retrieved from http://www.who.int/topics/health _promotion/en/ World Health Organization. (2013b). Human papillomavirus (HPV) and cervical cancer. Retrieved from http:// www.who.int/mediacentre/factsheets/fs380/en/
