Secondary Logo

Journal Logo


Assessment of a Health Promotion Model on Obese Turkish Children

Eren Fidanci, Berna1*; Akbayrak, Nalan2; Arslan, Filiz3

Author Information
doi: 10.1097/JNR.0000000000000238
  • Free



Obesity results from a chronic caloric imbalance in which more calories are consumed than expended. Several factors regularly contribute to obesity, including nutritional habits, hereditary factors, environmental factors, metabolism, culture, and socioeconomic status. For children, obesity has risen in prevalence worldwide, which suggests that the prevalence of this disease in adults will also rise (De Mutsert, Sun, Willett, Hu, & van Dam, 2014). Most obese adults were also obese as adolescents, and in turn, most obese adolescents were also overweight and/or obese as children (Lloyd, Langley-Evans, & McMullen, 2012). Recent estimates from the National Health and Nutrition Examination Survey (Silventoinen, Magnusson, Tynelius, Batty, & Rasmussen, 2009) indicate that approximately one third of children in the United States are overweight or obese, of whom approximately 17% meet the criteria for obesity (i.e., a body mass index [BMI] score above the 95th percentile). Results from the “Obesity Prevention and Control Program of Turkey” show that, in children between the ages of 3 and 17 years, 18.7% of boys and 14.7% of girls are obese (Ministry of Health of Turkey General Directorate of Primary Health Care, 2010). Globally, it has been estimated that childhood obesity affects nearly 43 million people, indicating an increase from 4.2% in 1990 to 6.7% in 2010 (Tirosh et al., 2011).

Studies of childhood obesity have shown that fostering healthy life behaviors is more important than losing weight (Carroll, 2013). Although no studies reporting this result have been based on a theoretical nursing model, using models of this type in practice provides a systematic approach and scientific basis to the concepts and principles of nursing practice (Pender, Murdaug, & Parsons, 2002; Tillet & Pender, 1998).

One type of nursing model, the Health Promotion Model (HPM), provides a theoretical perspective for investigating the factors and relationships that contribute to health-promoting behaviors and, in turn, to the enhancement of health and quality of life (Srof & Velsor-Friedrich, 2006). For instance, Pender’s HPM assists nurses to understand the major determinants of health behaviors to guide behavioral counseling to promote a healthy lifestyle (Pender et al., 2002). The HPM identifies factors that influence health behavior. By using this model and collaborating with the patient or client, nurses may facilitate behavioral changes in patients to achieve a healthy lifestyle. Thus, although positive health behaviors must be instilled and maintained to improve health, the appropriate knowledge, skills, and attitudes of both nurse and patient are necessary to maximize behavioral change (Johnson, 2005; Vural, 1998).

The HPM is based on Bandura’s social learning theory, which postulates the importance of cognitive processes in effecting behavioral change. Fishbein’s reasoned action theory, which asserts that behavior is a function of personal attitudes and social norms, is also important to the development of the HPM. Although the HPM is similar in construction to the health belief model, the HPM not only explains disease prevention behavior but also encompasses behaviors for promoting health (Pender et al., 2002).

The HPM has been tested for its effectiveness, especially in terms of its applicability to adolescents and their physical activity (Robbins, Pender, Ronis, Kazanis, & Pis, 2004; Robbins, Pis, Pender, & Kazanis, 2004a, 2004b; Wu & Pender, 2005). The findings of these studies suggest that the concepts of HPM such as gender, social support, modeling, self-efficacy, and perceived benefits and barriers to performing physical activity influence the physical activity behavior of Taiwanese adolescents both directly and indirectly.

Taymoori, Lubans, and Berry (2010) evaluated the HPM as a means to predict physical activity in a sample of Iranian adolescent boys. They found that self-efficacy, commitment to planning, and enjoyment were associated with physical activity in the revised HPM model. Thus, competing demands influence physical activity within the context of the HPM.

Borrowing from Pender’s HPM, Dehdari, Rahimi, Aryaeian, and Gohari (2014) used the HPM to determine the effectiveness of a nutrition education intervention in improving the frequency and nutrient intake of breakfast consumption among female Iranian students. HPM-related concepts such as perceived benefit, perceived self-efficacy, positive-activity-related affect, interpersonal influences, situational influences, commitment to a plan of action, and frequency of consumption of macronutrients and most micronutrients were significantly higher in the experimental group than the control group after the nutrition education intervention. The authors concluded that the constructs of Pender’s HPM are suitable for guiding the design of both strategies and content for nutrition education interventions.

Using a quasi-experimental, pre–post design with a four-session multimedia (Internet, video, gym, and snack lab) intervention, Frenn, Malin, and Bansal (2003) hypothesized that students in the intervention group would show significantly less dietary fat intake and greater physical activity duration than the comparison group. However, their findings identified no significant differences between the two groups in terms of percentage of dietary fat and physical activity. Although both groups showed decreased physical activity, the level of decline was significantly less in the intervention group than in the control group. Moreover, gender differences were noted, with women in the intervention group showing significant decreases in the amount of dietary fat and increased consumption of low-fat foods (Frenn et al., 2003). The importance of this study to the literature is that it showed how the HPM may be used to guide interventions.

This study implemented an intervention that was based on a theoretical nursing model. A nursing intervention that is framed around a model systemizes the provision of care and makes the intervention more effective and measurable. Furthermore, model-based care allows caretakers to practice in a planned and collaborative way. This study applied Pender’s HPM as it offers guidelines for collecting data on obese children and for evaluating and developing healthy lifestyle behaviors. Although several nursing theories related to healthy behavioral change exist, Pender’s HPM was chosen because this model explores, from a theoretical perspective, the factors and relationships that contribute to health-promoting behavior and to enhanced health and quality of life. Furthermore, this model was chosen because it had yet to be tested on obese children.

This study was conducted to determine the healthy life behaviors of obese children and their families, the difficulties of promoting healthy life behaviors, and the effect of obesity on self-confidence. Furthermore, it sought to assess the effects of an education and nursing follow-up program that was designed within the framework of a nursing model to address the healthy life behaviors and self-confidence of children.



A quasi-experimental design was used in this study. Data collection was conducted at the pediatric endocrinology department of an education and research hospital in Turkey from April 2009 to April 2010. The sample consisted of 86 obese participants who had returned for a follow-up examination in that department. Inclusion criteria included patient age of between 8 and 18 years, ability to read and write in Turkish, consent to participate, absence of all other diseases, and agreement to attend follow-up examinations. No sample selection was performed, with the aim of enrolling all of the patients who met the abovementioned criteria as participants. A simple randomization technique was applied that used a single sequence of random assignments. The participants were assigned to the study and control groups sequentially based on their time and date of clinical arrival. Forty-eight participants were in the experimental group, and 38 were in the control group. Although participants were randomized sequentially (1:1) into either the experimental group or the control group at admission, two participants from the experimental group and 12 participants from the control group left the study for various reasons. Statistical expert opinion holds that the resultant imbalance between the two groups should not affect the reliability of the data.

Qualitative Data Collection

Qualitative data were collected using a semistructured interview form with a qualitative design. This form was developed by the authors by using the framework of Pender’s HPM and included open-ended items that were designed to gather data regarding the experience of the participants. These items provided each participant with an opportunity to express his or her feelings and thoughts about obesity, health problems, healthy life behaviors, and the need for education.

A semistructured interview guide was used to obtain the data. Interviews were audio-recorded and transcribed verbatim. Content analysis was used to identify and elucidate the issues of the participating children and their parents.

Quantitative Data Collection

The following tools below were used to collect quantitative data.

Form for sociodemographic and medical characteristics of participants

The form for sociodemographic and medical characteristics of participants (SMCP form) included questions addressing the sociodemographic characteristics of participants, including age, gender, height, weight, and education, and addressing the anthropometric measurements and education of the parents.

Form for nutrition and activity

The form for nutrition and activity (NA form) was developed by the present researchers to assess the nutrition and exercise patterns of the participating child and his or her family. This form consists of 27 questions addressing the number of meals eaten per day, frequency of fast-food and snack consumption, duration of exercise, duration of sedentary activity, and the eating habits and activity patterns of the family.

Piers–Harris children’s self-concept scale

The Piers–Harris Children’s Self-Concept Scale (PHCSCS) was developed by Piers in 1964 (Alexopoulos & Foudoulaki, 2002), and the reliability and validity of the questionnaire in Turkish have been confirmed (Oner, 1996). The PHCSCS aims to assess the thoughts, feelings, and attitudes of children, with results used to determine the development of the child’s self-concept and the relationship between personality and environmental elements. The scale consists of 80 items and requires children to indicate whether each item applies to them by selecting either “yes” or “no.” Higher scores on the PHCSCS are associated with a stronger positive self-concept, whereas lower scores are associated with a stronger negative self-concept. The scale has six subdimensions, including physical appearance and attributes, intellectual and academic status, happiness and satisfaction, freedom from anxiety, behavioral adjustment, and popularity. The Cronbach’s alpha value for the internal consistency of the PHCSCS used in this study was calculated to be .901 before the intervention and .913 afterward.


Participants who met the inclusion criteria and volunteered to participate were invited to attend the educational program with their parents. The ethics of this study were approved by the hospital research ethics committee before commencement. Each participant was assured that he or she could decline to participate or withdraw from the study at any time. Interviews with the participants and their parents were conducted face-to-face in a room in the pediatric endocrinology department.

Experimental group procedures

During the first interview with the experimental group, the participants and their parents were informed about the study, including its objectives, method, forms and scales, education and follow-up program, and the required visit frequency. Written consent was obtained from all participants before the start of related procedures.

The body weights of the children, their mothers, and their fathers were measured using a SECA digital scale (0.1-kg sensitivity) after shoes and clothes had been removed. The heights of these individuals were measured using a Harpenden stadiometer (0.1-cm sensitivity). BMI was calculated as kilograms per square meter, and BMI standard deviation score (SDS) scores were calculated. The anthropometric data of the parents were collected to determine if these data were similar between the two groups. The results are shown in Table 1, with no difference identified between the two groups.

After collecting the completed SMCP and NA forms, qualitative interviews were conducted with each participant. Data were collected during individual interviews, which involved the researchers and the children and/or their parents. Interviews with participants and their parents were conducted face-to-face. These interviews aimed to determine the experience of participants with obesity along with related physical and psychosocial problems, to assess his or her self-perception with regard to weight, to clarify his or her related educational needs, and to guide the development of the education and follow-up programs. Qualitative data were collected through an in-depth interview with each participant and his or her parents using a semistructured interview form. Because of the unique nature of the experiences and needs of each participant, this type of interview format was chosen because of its capacity to provide an appropriate venue for each participant to express freely his or her experiences. Answers given by participants were audio-recorded, and the authors took notes to further enrich the content of the answers that were provided. The first interview lasted 25 minutes.

All of the data gathered during the first interview were used to plan individualized education and follow-up programs. After the first interview, participants completed the PHCSCS, during which time the researcher evaluated the forms and developed individualized educational content. The results were analyzed by reading and interpreting the data, in accordance with Pender’s theoretical model of health promotion, in an attempt to comprehend these data in relation to the components of the theory. The personal factors and the data related to prior diet experience were evaluated using the individual characteristics concept of the model. How the parents and children felt about their weight and about their relationships with friends as well as situational effects were evaluated within the framework of the behavior-specific cognitions and affect concept. Healthy lifestyle behaviors (e.g., diet regulation, regulation of physical activity, reduction of sedentary activities) were evaluated using the behavioral outcomes concept of the model.

The individual education development process considered topics such as the child’s self-perception of his or her weight, identification of strong and weak aspects of the child, need for support in participating in a weight control program, need for help in determining goals for weight management, and the properties of a healthy diet and exercise program for the child. This content was prepared within the framework of the HPM. Major concepts of the model were used in the individual interviews to explain the relationships among the factors that were believed to influence health-related behavioral change.

The second interview, which addressed group education, was scheduled 3 months after the first interview to allow for the evaluation of the forms and the development of educational content. Participants were invited to an education group addressing principles for healthy life behaviors.

The educational program addressed the following topics:

  • General information regarding obesity
  • The regulation of nutrition
  • Number of meals per day
  • Foods to be avoided
  • The rules to be followed during mealtimes
  • Nutrition education by a dietician
  • Calculation of calories
  • Nutrient exchange lists
  • The regulation of exercise activities
  • Discussion on lifestyle modifications
  • Follow-up visits
  • Encouragement of participants and their parents to call the researchers regarding any questions or problems

All of the abovementioned topics were addressed in the group education session. The researcher explained the general rules of obesity management, and a dietician explained the importance of nutritional regulation. The participants expressed their difficulties with managing their nutrition and exercise habits and modifying their lifestyle. The group education session lasted for 60 minutes and was videotaped with the permission of the participants. The telephone numbers of the researchers were given to the participants, who were invited to call the researchers as needed during the interval between the second and third interviews, and the questions of participants and their parents were answered.

The third interview was scheduled for 3 months after the second interview. The participants were invited to visit the pediatric endocrinology department, where their height and weight were measured using the same scale and stadiometer as used previously. The NA form and PHCSCS were completed again.

Control group procedures

During the first interview with the control group, participants and their parents were informed about the study, and their consent forms were obtained. Participants then completed the SMCP form, the NA form, and the PHCSCS. The control group received a delayed intervention.

The second interview for the control group was conducted 6 months after the first. In the second interview, participants were asked to again complete the NA form and PHCSCS, after which they received the same educational program as the experimental group. Participants in the control group did not receive qualitative interviews, as this study aimed to evaluate the efficiency of education and follow-up programs in the framework of the HPM so that the education requirements and the difficulties of participants could be identified. Qualitative interviews were not performed with the control group, as it was considered that interviews may affect their behavior.

The stages of the research application are shown in Figure 1.

Figure 1.
Figure 1.:
Application stages of the research.
Sociodemographic and Medical Characteristics of the Participants

Data Analysis

Qualitative data analyses

Data were analyzed using the content analysis method, in which formulated meanings were organized into categories and themes. When the researchers disagreed about the designation of categories and themes, differences were discussed collectively until consensus was reached.

Quantitative data analyses

Statistical analyses were conducted using SPSS software for Windows (Version 15.0; SPSS Inc., Chicago, IL, USA). The compatibility of the continuous data with a normal distribution was examined using the Kolmogorov–Smirnov test. Descriptive statistics were presented as mean ± standard deviation, median, frequency, and percentage. The comparisons of continuous variables that were normally distributed were performed using independent or paired samples t tests, whereas comparisons of continuous variables that did not fit the normal distribution pattern were performed using the Mann–Whitney U or Wilcoxon signed-rank test. The Spearman correlation test was used to analyze correlations between demographic data and the scale scores. Those p values < .05 were considered to be significant.


Qualitative Results

The data that were obtained through individual interviews are presented in the framework of the HPM’s major concepts, which include individual characteristics and experiences (i.e., prior related behavior and personal factors), behavior-specific cognitions and effects (i.e., perceived benefits of action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences), and behavioral outcomes (i.e., commitment to a plan of action, immediate competing demands and preferences, and health-promoting behavior).

Individual characteristics and experiences

According to Pender, the success of past health behavior affects present behavior. In this study, all of the participants reported having previously undertaken a diet that ultimately failed. It is clear that parents felt anger and frustration regarding their children because of this failure. One participant stated, “The whole family was forced to start the diet. He [G. E.] always broke the diet because of birthdays, Mother’s Day, weekends. No, it did not work.” (mother of G. E., 10 years old).

Personal factors (e.g., biological, psychological, sociocultural) are general characteristics of each individual that influence health behavior, including age, personality, race, ethnicity, and socioeconomic status. The demographic data for the participants are presented with the quantitative results.

Regarding health status and self-esteem, the degree to which obesity complicates the lives of children and their parents, as well as the barriers that they face, significantly affects the decision to practice a specific behavior. In this study, parents stated that their children had difficulty finding age-appropriate clothes, experienced health problems, received negative criticism from their friends, and had difficulty initiating age-appropriate social relationships. Furthermore, parents reported feeling sad and anxious. One parent stated, “We [M. Y. and her mother] could not find age-appropriate clothes. The clothes that were suitable for her age did not fit her body; the clothes that fit her body were not age-appropriate. So [she projected] the image of a small woman.” (mother of M. Y., 11 years old).

Behavior-specific cognitions and effects (perceived benefits of action, perceived self-efficacy, activity-related effects, interpersonal influences, and situational influences)

The parents expressed feeling anxious about the risk of obesity on their child’s health and believed that implementing health-promoting behaviors in their lives would be beneficial. One parent stated, “Obesity is really too dangerous for health. When we [the mother and father] looked at the blood values we were shocked. The cholesterol and blood fats were higher than mine and my wife’s. If so at this age, what will we do in the future? I think this program will be very useful. It has helped us realize the situation as well as talk about the measures to take.” (father of D. D., 12 years old).

Children reported having difficulty complying with previous diets and exercise treatments for reasons such as lack of enthusiasm, overwhelming preference for junk and fast food, lack of available healthy foods, and lack of athletic fields near their homes. One child stated, “I was afraid of going to the mall. In the first half hour, I would get hungry. I would eat fast food, then ice cream, popcorn, cotton candy, and so on.” (E. Ö., 12 years old).

In this study, parents expressed that their children were significantly influenced by peer relationships and very distressed by their peers’ judgments of their weight. One mother said, “He [M. C.] did not like physical education classes. Especially in team games, he was the last selected because he could not run fast. He was cumbersome and quickly tired. So, he got discouraged.” (mother of M. C., 10 years old). Another parent stated, “There were school auditions for drama. She [S. N.] was very excited and very hopeful that she would take part. When I went to school that evening, she was so sad. My child was cast as a glutton.” (mother of S. N., 8 years old).

Regarding situational effects, parents stated that their children spent too much time in front of the computer and television, could not control their eating, and did not participate in any athletic activities.

Behavioral outcomes (commitment to a plan of action, immediate competing demands and preferences, and health promoting behavior)

According to the HPM, action includes initiating a strategy based on the will of the individual or of someone else. According to the interview results with the participants and their parents, the perception of weight, the strengths and weaknesses of the child, and the need for education about the issues that relate to the child’s weight management were determined, after which education was provided. This study ultimately aimed to cultivate healthy lifestyle behaviors (e.g., diet regulation, regulation of physical activity, and a reduction in sedentary activities) among the participants and their families.

Quantitative Results

The sociodemographic and medical characteristics of participants are presented in Table 1. No significant statistical differences were found between the groups in terms of sociodemographic or medical characteristics (p > .05).

In the experimental group, healthy eating habits showed a significant increase after the education in terms of eating at least one meal together as a family (Z = 2.449, p = .014), the child’s participation in the process of food preparation (Z = 5.584, p < .001), noting food portions (Z = 5.231, p < .001), and choosing water instead of sugary drinks (Z = 4.130, p < .001).

Moreover, in the experimental group, the average daily time spent in front of the television or computer decreased significantly after education (Z = 5.085, p < .001), whereas no significant change was observed in the control group (Z = 0.707, p = .48). Furthermore, after education, the exercise periods of the experimental group increased significantly (Z = 5.536, p < .001; Table 2).

Comparison of Time Spent Daily With Television and Computer and Exercise Periods of the Experimental and Control Groups Before and After the Educationa

In the experimental group, the total BMI SDS of all the participants decreased after education (Z = 6.031, p < .001), whereas only 10 participants (26.3%) in the control group showed decreases in total BMI SDS. These results suggest that education was highly effective for gaining healthy life behaviors and the control of BMI of the participants (Table 3).

Comparison of BMI SDS and of the Experimental and Control Groups Before and After the Education

Before education, a comparison of self-confidence scores between the groups did not show any significant difference (Z = 1.358, p = .175). By contrast, after education, the mean self-confidence scores of the experimental group were significantly higher than those of the control group (Z = 5.971, p < .01, vs. Z = 3.796, p < .01; Table 4).

Comparison of Self-Confidence Scores of the Experimental and Control Groups Before and After the Education

For the experimental group, the scores for all of the dimensions (i.e., physical appearance and attributes, intellectual and school status, happiness and satisfaction, freedom from anxiety, behavioral adjustment, and popularity) increased after education (p < .001). However, there was no statistically significant difference in the control group’s scores before and after education.

Spearman’s correlation analysis was performed to assess whether changes in BMI impacted scale scores and revealed a correlation between BMI and scale scores after education in the experimental group (ρ = 0.501, p < .01).

Therefore, the results suggest that BMI SDS scores decreased significantly because of the effectiveness of education. Furthermore, a negative correlation was found between this decrease and self-confidence scores, whereas no correlation was found between BMI SDS scores and self-confidence scores (ρ = 0.145, p = .38).


The incidence of obesity, a major health problem in children, continues to increase steadily (Ng et al., 2014). Thus, the development of obesity prevention action plans that promote healthy nutrition, physical activity, and the reduction of sedentary activity is needed (Berkey et al., 2000; St-Onge, Keller, & Heymsfield, 2003).

Although model-based obesity prevention studies are more effective at reducing and preventing obesity, only a limited number of prior studies have used a nursing model (Frenn et al., 2003; Golan, Weizman, Apter, & Fainaru, 1998; James et al., 2008; Neumark-Sztainer, Story, Hannan, & Rex, 2003). Therefore, this study used an intervention targeting the reduction and prevention of obesity in children in Turkey that was based on Pender’s HPM. Evaluations were made to effectively reduce obesity by educating children about healthy lifestyle behaviors and by facilitating a follow-up program that incorporates the concepts of the developed model.

Evidence supports that childhood obesity carries over into adulthood, at which time obesity poses a greater risk of metabolic disease. Thus, focusing on childhood and adolescent prevention and treatment of obesity is wholly appropriate to cultivating healthy weight in children as these children develop into adulthood (Lloyd, Langley-Evans, & McMullen, 2010; Owen et al., 2009; Singh, Mulder, Twisk, Van Mechelen, & Chinapaw, 2008). In this sense, this study focused specifically on promoting healthy life behaviors instead of programmatic weight loss.

No statistical differences between the groups were identified in terms of age or gender. For this study, it was very important to evaluate the effectiveness of education and to eliminate any confounding factors among the participants.

Family eating preferences, types of cooking, and eating patterns are factors that relate to the development of obesity. By the same token, certain changes in family eating habits contribute to changes in the behavior of children (Golan et al., 1998). The educational program that was attended by the experimental group in this study emphasized the importance of the schedule of both the child and family’s eating habits and addressed important subjects that related to healthy eating, including close attention to portions, inactivity while eating, and avoiding sugary drinks. The results show that these recommendations were put into practice.

In addition to food consumption, energy expenditure, generally in the form of physical activity, is highly important to maintaining healthy weight. Children in contemporary societies are often restricted in the range of possible physical activities and thus spend more time at home, especially in urban areas with playground restrictions and security concerns. A general decrease in the duration of active exercise and an increase in the duration of sedentary activity are factors that have been associated with weight gain and that contribute to obesity in children (Ball & Bindler, 2006; Hockenberry, 2005).

In this study, time spent in front of a television or computer by children was used to calculate sedentary activity. The daily durations of sedentary activities and exercise were 4 hours (interquartile range = 2.0) and 20 minutes, respectively.

Using computers, playing video games, and riding school buses may contribute to a general reduction in physical activity for children. There is a positive correlation between the prevalence of obesity and the duration of sedentary activities (Leermakers, Dunn, & Blair, 2000). By contrast, an active lifestyle and healthy nutrition are factors in normal anthropometric measures (Berkey et al., 2000; Dennison, Erb, & Jenkins, 2002). For personal health, it is very important to increase exercise times, decrease sedentary activity, and adopt other healthy life behaviors. Thus, these and similar recommendations should be addressed in educational programs for childhood obesity. In this study, after receiving education, experimental group participants spent less time in front of a television or computer, whereas the time spent exercising increased significantly.

Furthermore, the total BMI SDS of children in the experimental group decreased after education, suggesting that individual or group education may influence BMI SDS. Educating children, parents, and teachers about healthy nutrition, physical activity, and sedentary activity thus promotes normal anthropometric measures in children (Müller, Asbeck, Mast, Langnäse, & Grund, 2001). Similar results indicated that these focuses also contributed to reducing obesity in children. Regardless of the method used and the duration of education, obesity parameters have been found to decrease significantly after education in all previous studies of weight reduction programs (Cakir & Pinar, 2006; Kang et al., 2008; Tucker, 2009).

Dallar, Erdeve, Çakir, and Köstü (2006) found that the PHCSCS scores for obese children (n = 40) were statistically lower than the scores for nonobese children (n = 40). The adolescent obese girls included in Phillips and Hill (1998) showed lower self-confidence, especially with regard to physical appearance and more dysfunctional social relationships with peers. In another study, French, Perry, Leon, and Fulkerson (1996) found a negative correlation between self-confidence and BMI. These and other studies show that obese children have problems with their physical appearance and with social acceptance.

In this study, the self-confidence scale scores increased significantly more in the experimental group after education than in the control group, which suggests a negative correlation between BMI scores and self-confidence scale scores.

Although there were some positive changes in the experimental group, there were no differences in some of the subdimensions of the self-confidence scale. The “intellectual and school status” and “freedom from anxiety” subdimensions were not affected by the intervention program. This program may have achieved different effects in the experimental group because it may not be able to successfully manage the effects of obesity over the long term. This program was conducted for a limited time only. Thus, there is a need for implementing longer-term follow-up programs.


The population of this study was limited in terms of age, as all participants were between 8 and 18 years old because of the appropriateness of this age group for taking the PHCSCS.

Although different age groups were included in this study, these groups were evaluated individually during the qualitative interviews and individual education. Healthy life behaviors were emphasized in the group education session.


Obesity affects children physically, psychologically, and socially and especially in terms of self-confidence. However, decreased BMI, healthy life behaviors, and increased self-confidence result from model-based, well-planned education and follow-up programs. It is thus crucial for health professionals to recognize the physical, psychological, and social risks of obesity in children and to focus on these problems in the search for solutions. It is also recommended that education and nurse follow-up programs be developed based on nursing models.

Future studies should include larger sample sizes and implement longer time intervals. In addition, follow-up programs should be maintained to avoid an obesity “honeymoon effect.”

How Might This Information Affect the Nursing Practice?

The weight management programs that are currently used to treat obese children are largely ineffective over the long term. By contrast, model-based education and follow-up programs afford a holistic approach and conceptual framework for evaluating children and their parents. This study found that patient education based on Pender’s HPM substantially increased healthy life behaviors (i.e., healthy nutrition, increased exercise time, and decreased sedentary activity) in the experimental group. Furthermore, we determined that, although Pender’s HPM had not been tested on obese children, this model offers an effective guideline for nursing activities that seek to develop healthy life behaviors in children.

The results of this study support implementing obesity management, education, and follow-up programs that are based on nursing models for obese children and their parents. These programs effectively have been shown to foster healthy life behaviors, whereas programs that focus on weight loss do not. Above all, an educational program based on Pender’s HPM should be made available to nurses in clinics that treat children with obesity.


Alexopoulos D. S., Foudoulaki E. (2002). Construct validity of the Piers–Harris Children’s Self-concept Scale. Psychological Reports, 91(3, Pt. 1), 827–838. doi:10.2466/pr0.2002.91.3.827
Ball J. W., Bindler R. C. (2006). Child health nursing: Partnering with children and families. Upper Saddle River, NJ: Pearson.
Berkey C. S., Rockett H. R., Field A. E., Gillman M. W., Frazier A. L., Camargo C. A. Jr., Colditz G. A. (2000). Activity, dietary intake, and weight changes in a longitudinal study of preadolescent and adolescent boys and girls. Pediatrics, 105(4), E56. doi:10.1542/peds.105.4.e56
Cakir H., Pinar R. (2006). Randomized controlled trial on lifestyle modification in hypertensive patients. Western Journal of Nursing Research, 28(4), 190–209. doi:10.1177/0193945905283367
Carroll A. E. (2013). Obesity interventions can improve more than just body mass index. JAMA Pediatrics, 167(11), 1002–1003. doi:10.1001/jamapediatrics.2013.2405
Dallar Y., Erdeve Ş. S., Çakir İ., Köstü M. (2006). Does obesity lead to depression and self-esteem deficiency in children? Gulhane Medical Journal, 48(1), 1–3.
Dehdari T., Rahimi T., Aryaeian N., Gohari M. R. (2014). Effect of nutrition education intervention based on Pender’s Health Promotion Model in improving the frequency and nutrient intake of breakfast consumption among female Iranian students. Public Health Nutrition, 17(3), 657–666. doi:10.1017/S1368980013000049
De Mutsert R., Sun Q., Willett W. C., Hu F. B., van Dam R. M. (2014). Overweight in early adulthood, adult weight change, and risk of type 2 diabetes, cardiovascular diseases, and certain cancers in men: A cohort study. American Journal of Epidemiology, 179(11), 1353–1365. doi:10.1093/aje/kwu052
Dennison B. A., Erb T. A., Jenkins P. L. (2002). Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics, 109(3), 1028–1035. doi:10.1542/peds.109.6.1028
French S. A., Perry C. L., Leon G. R., Fulkerson J. A. (1996). Self-esteem and change in body mass index over 3 years in a cohort of adolescents. Obesity Research, 4(1), 27–33. doi:10.1002/j.1550-8528.1996.tb00509.x
Frenn M., Malin S., Bansal N. K. (2003). Stage-based interventions for low-fat diet with middle school students. Journal of Pediatric Nursing, 18(1), 36–45. doi:10.1053/jpdn.2003.6
Golan M., Weizman A., Apter A., Fainaru M. (1998). Parents as the exclusive agents of change in the treatment of childhood obesity. The American Journal of Clinical Nutrition, 67(6), 1130–1135.
Hockenberry M. J. (2005). Wong’s essentials of pediatric nursing. St. Louis, MO: Elsevier-Mosby.
    James K. S., Connelly C. D., Rutkowski E., McPherson D., Gracia L., Mareno N., Zirkle D. (2008). Family-based weight management with Latino mothers and children. Journal for Specialists in Pediatric Nursing, 13(4), 249–262. doi:10.1111/j.1744-6155.2008.00162.x
    Johnson R. L. (2005). Gender differences in health-promoting lifestyles of African Americans. Public Health Nursing, 22(2), 130–137. doi:10.1111/j.0737-1209.2005.220206.x
    Kang R. T., Zhong Y., Luo H. Y., Jiang Y. H., Liu K. X., You C. (2008). Epidemiologic status and influencing factors of simple obesity in preschool children. Chinese Journal of Child Health Care, 16(6), 101–113.
    Leermakers E. A., Dunn A. L., Blair S. N. (2000). Exercise management of obesity. Medical Clinics of North America, 84(2), 419–440. doi:10.1016/S0025-7125(05)70229-7
    Lloyd L. J., Langley-Evans S. C., McMullen S. (2010). Childhood obesity and adult cardiovascular disease risk: A systematic review. International Journal of Obesity, 34(1), 18–28. doi:10.1038/ijo.2009.61
    Lloyd L. J., Langley-Evans S. C., McMullen S. (2012). Childhood obesity and risk of the adult metabolic syndrome: A systematic review. International Journal of Obesity, 36(1), 1–11. doi:10.1038/ijo.2011.186
    Ministry of Health of Turkey General Directorate of Primary Health Care. (2010). Turkey battling and controlling obesity program, 2010–2014. Retrieved from
    Müller M. J., Asbeck I., Mast M., Langnäse K., Grund A. (2001). Prevention of obesity—More than an intention. Concept and first results of the Kiel Obesity Prevention Study (KOPS). International Journal of Obesity, 25(1, Suppl.), S66–S74.
    Neumark-Sztainer D., Story M., Hannan P. J., Rex J. (2003). New moves: A school-based obesity prevention program for adolescent girls. Preventive Medicine, 37(1), 41–51. doi:10.1016/S0091-7435(03)00057-4
    Ng M., Fleming T., Robinson M., Thomson B., Graetz N., Margono C., Gakidou E. (2014). Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384(9945), 776–781. doi:S0140-6736(14)60460-8
    Oner N. (1996). Piers–Harris Children’s Self-Concept Scale handbook. Ankara, Turkey: Psychologists Association.
    Owen C. G., Whincup P. H., Orfei L., Chou Q. A., Rudnicka A. R., Wathern A. K., Cook D. G. (2009). Is body mass index before middle age related to coronary heart disease risk in later life? Evidence from observational studies. International Journal of Obesity, 33(8), 866–877. doi:10.1038/ijo.2009.102
    Pender N. J., Murdaug C. L., Parsons M. A. (2002). Health promotion in nursing practice. Retrieved from
    Phillips R. G., Hill A. J. (1998). Fat, plain, but not friendless: Self-esteem and peer acceptance of obese pre-adolescent girls. International Journal of Obesity Related Metabolic Disorders, 22(4), 287–293. doi:10.1038/sj.ijo.0800582
    Robbins L. B., Pender N. J., Ronis D. L., Kazanis A. S., Pis M. B. (2004). Physical activity, self-efficacy, and perceived exertion among adolescents. Research in Nursing & Health, 27(6), 435–446. doi:10.1002/nur.20042
    Robbins L. B., Pis M. B., Pender N. J., Kazanis A. S. (2004a). Exercise self-efficacy, enjoyment, and feeling states among adolescents. Western Journal of Nursing Research, 26(7), 699–715.
    Robbins L. B., Pis M. B., Pender N. J., Kazanis A. S. (2004b). Physical activity self-definition among adolescents. Research and Theory for Nursing Practice, 18(4), 317–330.
    Silventoinen K., Magnusson P. K., Tynelius P., Batty G. D., Rasmussen F. (2009). Association of body size and muscle strength with incidence of coronary heart disease and cerebrovascular diseases: A population-based cohort study of one million Swedish men. International Journal of Epidemiology, 38(1), 110–118. doi:10.1093/ije/dyn231
    Singh A. S., Mulder C., Twisk J. W., Van Mechelen W., Chinapaw M. J. (2008). Tracking of childhood overweight into adulthood: A systematic review of the literature. Obesity Reviews, 9(5), 474–488. doi:10.1111/j.1467-789X.2008.00475.x
    Srof B. J., Velsor-Friedrich B. (2006). Health promotion in adolescents: A review of Pender’s Health Promotion Model. Nursing Science Quarterly, 19(4), 366–373. doi:10.1177/0894318406292831
    St-Onge M. P., Keller K. L., Heymsfield S. B. (2003). Changes in childhood food consumption patterns: A cause for concern in light of increasing body weights. American Journal of Clinical Nutrition, 78(6), 1068–1073.
    Taymoori P., Lubans D., Berry T. R. (2010). Evaluation of the Health Promotion Model to predict physical activity in Iranian adolescent boys. Health Education & Behavior, 37(1), 84–96. doi:10.1177/1090198109356407
    Tillet L. A., Pender N. J. (1998). The health promotion: Nursing theorist and their work. St. Louis, MO: Mosby.
    Tirosh A., Shai I., Afek A., Dubnov-Raz G., Ayalon N., Gordon B., Rudich A. (2011). Adolescent BMI trajectory and risk of diabetes versus coronary disease. The New England Journal of Medicine, 364(14), 1315–1325. doi:10.1056/NEJMoa1006992
    Tucker S. J. (2009). Parents as agents of change for childhood obesity prevention: A clinical nursing research programme. Paediatrics and Child Health, 19(2, Suppl.), S189–S193. doi:10.1016/j.paed.2009.08.023
    Vural K. B. (1998). Determination of health risks and the importance for nursing. Journal of Cumhuriyet University School of Nursing, 2(2), 39.
    Wu T. Y., Pender N. (2005). A panel study of physical activity in Taiwanese youth: Testing the revised health-promotion model. Family & Community Health, 28(2), 113–124. doi:10.1097/00003727-200504000-00003

    obesity; health promotion; Nola J. Pender; pediatric nurse; self-confidence

    Copyright © 2017 Taiwan Nurses Association