Critique a theory using a standardized method, such as Walker and Avant, that could guide a study of African American women with hypertension. Denote the strengths and weaknesses of the theory/model related to research and practice emphasizing its relevance to African American women with hypertension.
Theoretical Foundation
The theoretical framework, Cox's interaction model of client health behavior (IMCHB) (1982), was analyzed according to the theory analysis described by Walker and Avant (2005). In the study of medication adherence issues in African American women with hypertension (HTN), the IMCHB could serve as a useful guide for research and clinical practice. This model is recognized as a middle-range theory because of its relevance to practice situations (Lasiuk & Ferguson, 2009). Walker and Avant's (2005) theory analysis evaluates the IMCHB origin, meaning, adequacy, usefulness, generalizability, parsimony, and testability.
Origins
Cox (2010, August 4), while employed as a nurse practitioner at the University of Tennessee, was asked to set up a practice for medical students in the Nashville and Memphis areas. She served clients, mostly sharecroppers, who lived in small, yet proud communities. Cox said it was difficult to understand their dynamics because the clients did not have many resources, so the health care providers has to figure out how to make up for their lack of resources. As her work evolved, she found that establishing rapport was vital in order to figure out what the clients knew about their health problem and what they did not know. The clients in these communities were not motivated by their lack of knowledge. Therefore she had to figure out what the health problem was and how to make it right. She determined that the client also had to have a role in what the health problem was and how to make it right, along with knowledge of the risks involved, knowledge of how they contributed to the risk, and the role they needed to play with risk reduction. In an effort to figure out the interventions that yielded the best outcomes, Cox got permission to tape record her client interactions. She discovered that her interaction was different from one client to the next. In essence, she responded to each client's cues; if the client was jolly, anxious, or shy, she had to incorporate their cues into her interaction. Oftentimes, the client's affect (fear, anxiety) had to be dealt with before getting to their knowledge base. During the interaction, she found that she influenced the client and the client also influenced her: Mutual influence occurred during the interaction. As a result of the interaction, she expected to see changes when she saw her clients again in two weeks. She later called these changes dynamic variables (intrinsic motivation, cognitive appraisal and affective response), and these changes were her cue to proceed to the next step. If there was no change, she had to reassess the background variables and start over (Cox, 2010, August 4).
Cox (2010, August 4) worked about 10 years with this population who were predominantly African Americans. She stated that these clients informed the IMCHB. She mentioned that if she had worked in suburbia with people who had sufficient resources, then the IMCHB would have been different. Cox further mentioned that if health care providers today took more time on the front end to thoroughly assess background variables, establish rapport, and evaluate the client's knowledge base, then they could clear up misperceptions, misunderstandings, and misknowlege, leading to better health outcomes (Cox, 2010, August 4).
As a result of her clinical practice, Cox did not think the nursing profession was doing a good job of defining the nurses' role in affecting client health outcomes. She felt there was lack in a number of areas such as documentation of client care, provision of nursing care, meeting client needs with nursing interventions, and effective health care outcomes after the nursing care experience (Cox, 1982). Cox identified three areas that summarized the failures of nursing theory and research: (1) conceptualization of the client as an individual, (2) the process of client-professional interaction, and (3) health care outcomes following nursing interventions (Cox, 1982).
Cox's IMCHB is a deductive synthesis influenced by the work of four nonnursing health behavior models that were derived primarily from psychological and sociological influences (Cox, 1982). The Rosenstock's health belief model, from a cognitive psychological background, addresses explanations of preventive health and illness behaviors whereby threatening health problems cause people to seek care and make health decisions (Cox, 1982; Matthews, Secrest, & Muirhead, 2008). The Suchman model, derived from a sociological focus, explains client health behaviors based on the influence of sociocultural variables and selected individual characteristics (Cox, 1982; Matthews, et al., 2008). The Andersen and Newman model, built on the Suchman and Rosenstock models, adds economic and community resources (Cox, 1982; Matthews, et al., 2008). The Self-regulation model, also based on cognitive psychology, explains the client's ability to process information from various sources and how this information influences the health care problem and actions to resolve the problem (Cox, 1982).
Cox (1982) noted several shortcomings in these health belief models. First, these models were not responsive to the multidimensionality and variability in client behaviors and therefore, they were considered to be of little benefit to the clinical practitioner. Second, these models lacked practical use because they are discipline specific, thus none of the models represented a holistic view of the client's health beliefs or behavior. Third, all of the models, except the self-regulation model, evolved from the medical model that focuses primarily on the physiological and biological aspects of diseases when diagnosing and treating illnesses. Fourth, these model offered theoretical speculation on the characteristics of noncompliant clients, rather than more guidelines for interventions. For some models, the word compliance implied that a client would relinquish their freewill and choose only behaviors consistent with the goals established by the health care provider, neglecting the individualistic nature of today's clients (Cox, 1982).
The IMCHB has several assumptions: (1) the responsibility of care remains the client's responsibility (Carter & Kulbok, 1995; Cox, 1982); (2) most client health behaviors are voluntary whereby clients choose to engage in positive or negative behaviors based on their personal goals (Cox & Wachs, 1985); (3) the client has the ability to make their own health care choices and subsequent health behaviors; (4) clients should exert control over determining optimal health for themselves and the actions necessary to attain their health status according to their environmental limitations; and (5) the client and health care provider's perceptions of reality may differ, but the client's perception dominates in their lives (Carter & Kulbok, 1995; Cox, 1982).
Cox (1982) purports that health care problems today are not just the health care provider's concerns, they are the client's concern as well. She further asserts that with the advent of information technology, much is known about causes and treatments of illnesses and health problems. Therefore, interventions should be centered on facilitating client health decisions and behaviors that promote positive health outcomes (Cox, 1982).
Meaning
The three major elements in the IMCHB (see Figure 1) are: client singularity, client-professional interaction, and health outcome. The IMCHB was formulated at an abstract level and cannot be tested directly. Therefore, a specific model for a particular health care issue must be derived from the general model (Cox & Roghmann, 1984). Concepts are operationally defined.
The client singularity concepts address assessment factors in the nursing process and these factors can be operationalized as the client's human responses to actual or potential health problems. The client professional interaction concepts address operational interaction factors relevant to nursing practice and are evident in nursing literature. The health outcomes concepts are broad and can contain multiple outcome measures that are both operational and sensitive to nursing interventions (Cox & Roghmann, 1984). According to Cox (1986), the application of one, two or all three elements of the IMCHB can be operationalized dependent on the scope of the research study. The IMCHB has a broad framework and broad conceptual variables reflective of an abstract theory that covers large content area and has been used in a number of studies with both qualitative (Brown, 1992; Matthews, et al., 2008) and quantitative research designs (Dougherty, et al., 1998; Marion & Cox, 1996; Troumbley & Lenz, 1992).
Client singularity, the first element, defines the individuality of the client and reflects holism. Singularity addresses the client's interaction with their background variables that include demographic characteristics, client social group influence, previous health care experiences, and environmental resources (Cox, 1982, 1986). These variables are highly predictive of health behaviors because of their interactive nature: They do not occur in isolation and remain virtually unchanged during the client-provider relationship (Cox, 1982). The element of client singularity includes dynamic variables. The dynamic variables are amendable to influence during the client-provider relationship and include intrinsic motivation, cognitive appraisal, and affective response (Cox, 1982). Intrinsic motivation represents free choice and the need to be self-determined and competent in health behaviors. Motivation varies among individuals and health situations (Cox, 1982; Cox & Wachs, 1985). Cognitive appraisal aids in the client's perception or interpretation of their current health state. Affective response relates to the emotions of the client that have the capacity to affect cognition and behavior (Cox, 1982).
The second element, a major influence on the client's health care behavior, is the client-professional interaction. The four components of the interaction include provision of health information, affective support, decisional control, and professional technical competencies. How the client will use health information is dependent on other factors such as singularity, relationship with the health care provider, and client perceived control. Affective support addresses the affective response to keep emotions intact so cognitive appraisal will process health information. Decisional control is dependent on adequate cognitive, motivational, informational and affective responses to obtain desirable results from decision-making. The technical skills of the health care provider, the last component, decrease as the client is able to increase their ability to process information and make decisions for themselves (Cox, 1982).
The final element, health outcome, reflects the client's health results based on behavior. The five outcome elements include utilization of health care services, client health status indicators, severity of health care problem, adherence to the recommended care regimen, and satisfaction with care (Cox, 1982).
The following relational statements (Cox, 1982) imply directional relationships from background variables to dynamic variables, from dynamic variables to elements of health outcome, and from elements of client professional interaction to elements of health outcome. A causal relationship is noted at the nonrecursive block of the model.
Background variables (demographic characteristics, social influence, previous health care experience, and environmental resources interact cumulatively, simultaneously, and often interdependently) have directional influence on dynamic variables
Background and dynamic variables (intrinsic motivation, cognitive appraisal, and affective response interact cumulatively, simultaneously, and often interdependently) have nonrecursive causal influence with elements of client professional interaction and a directional influence on elements of health outcome.
Elements of client professional interaction (affective support, health information, decisional control, and professional/technical competencies interact cumulatively, simultaneously, and often interdependently) has directional influence on elements of health outcome (utilization of health care services, clinical health status indicators, severity of health care problems, adherence to the recommended care regimen, and satisfaction with care).
The IMCHB is a middle range theory with broad boundaries. The content is abstract and covers a large content area, for example, the elements of client singularity are comprehensive and acknowledge personal, social, psychological, and environmental influences on health behavior. The model has been tested on multiple client populations such as children (Cox, 2003), older women (Cox, 1986), and military personnel (Troumbley & Lenz, 1992). In a study of with parents of children with biochemical genetic disorders, the overall model of three indepenct variables (parental satisfaction with social support, child adaptive functioning, and difficulty meeting the child's needs) accounted for 50% of the variance in parenting stress using the IMCHB. The relational nature of the major concepts were apparent in this study.
Empirical support for the model is sound. Qualitative (Brown, 1992; Matthews, et al., 2008) and quantitative (Dougherty, et al., 1998; Marion & Cox, 1996; Troumbley & Lenz, 1992) research studies support the relational statements.
Adequacy
The IMCHB is sensible and the concepts and relationships are clear. The research supports valid conclusions. Predictions can be made from the model and researchers agree with the predictions. The logical sequence is similar to the steps of the nursing process and the scientific method. Published by Cox and Roghmann (1984), the results of the empirical testing of this model demonstrates the ability of the model to guide scientific investigations. A diagram is shown in Figure 2. The relationships specified in the model are drawn with solid lines and arrows indicating the direction of relationships. The relational statements describing the figure are listed:
Background variables have directional influence on dynamic variables
Dynamic variables have nonrecursive causal influence with elements of client professional interaction and a directional influence on elements of health outcome.
Elements of client professional interaction have directional influence on elements of health outcome.
As indicated inside the individual boxes and depicted by double arrows, background variables, dynamic variables, and elements of client professional interaction interact cumulatively, simultaneously, and often interdependently.
Figure 2. Logical adequacy of Cox IMCHB.
Usefulness
The IMCHB is used as a model for nursing practice and provides the framework for numerous research studies (Dougherty, et al., 1998; Waisbren, Rones, Read, Marsden, & Levy, 2004). Research supports the model as a useful tool to explain and predict specific health behaviors. Because the IMCHB was derived from other health belief models, there are obvious similarities, however it differs in several ways: the (1) ability to view the individuality of clients; (2) influence of the client-provider relationship; and (3) health care providers ability to affect client health outcomes based on interventions (Matthews, et al., 2008). Since the model is not limited to nursing practice, it can be used as an interdisciplinary model in any type health care setting (Cox & Roghmann, 1984; Matthews, et al., 2008).
Generalizability
The IMCBM has a broad framework that has been tested in various research studies (Dougherty, et al., 1998; Troumbley & Lenz, 1992; Waisbren, et al., 2004) using selected conceptual variables from the model. Use of the model in this manner does not give consideration to the interaction of all variables in the model. Therefore, the results of these studies must be interpreted with caution and the strength of the overall framework of the model is decreased. Due to the complexity of the model, it has not been tested in its entirely, therefore generalizations are limited. Large scale funded studies to test the model in its entirety are warranted (Carter & Kulbok, 1995).
Parsimony
The IMCHB lacks simplicity and parsimony and Cox describes the model as lacking a. Instead, the model is general, comprehensive, and complex with multiple variables that could present statistical challenges, especially the presence of feedback loops/ reciprocal relationships (Cox, 1986). In addition, the model has a broad framework that could allow the simultaneous examination of multiple variables, however, it must be narrowed to the specific variables of interest (Troumbley & Lenz, 1992). Although this model could be reduced to a simplistic format to obey the statistical rules of factor analysis, structural equation modeling, and development of instrumental variables, Cox (1986) contends that this approach would overlook the interaction and polarity of variables apparent in this model. Therefore, Cox (1986) stated that she would rather sacrifice statistics than hinder the knowledge necessary to improve the future of nursing practice and research.
Testability
Cox's IMCHB is described as a middle-range theory and one of the related criteria is the ability to generate testable hypothesis: Hypothesis can be generated from the IMCHB. All three elements of the model have undergone reliable statistical measurements whereby portions of the model have been tested; however, the model has not been tested in its entirety due to its complex nature. Cox and Roghmann (1984) conducted an empirical test of the IMCHB to demonstrate the testability of the model in a secondary data analysis of the decisions of 203 women at-risk for fetal abnormalities to determine factors that predicted if they would have or not have an amniocentesis. The secondary data contained all major variables for this study. Data were analyzed using multiple regression, discriminant analysis, and structural equation modeling to describe the consistency of correlations and associations. Results revealed excellent discriminating ability, correctly predicted 87.2% of those who would or would not have an amniocentesis, and explained 58% of the variance in the client's amniocentesis decision that was explained by the elements and variables/concepts in the model.
Strengths and weaknesses of model
According to Cox (1982), theories should provide answers to the questions of "what nursing is" and "what nursing does." Theories are developed to guide practice, but become useless when they attempt to change "what is" without first addressing "what is" (Ohashi, 1985). Cox centers the IMCHB on the holistic client lifestyle and health behavior and the role of the health care provider in effecting client behavior to achieve positive health outcomes. The strength of Cox's model lies in the client-focused theoretical framework that can be used to guide both practice and nursing research (Cox, 1982).
The IMCHB was originally designed as a prescriptive theory for nursing (Cox, 1982). Three of the four factors of prescriptive theory as described by Dickoff and James (1968) are evident in the IMCHB and considered strengths of the model: (1) factor-isolating (classification or naming the presented situation) in the elements of client singularity, (2) factor relating (situation depicting or interrelationship of factors) in the singularity dynamic variables, and (3) situation relating (predictive, if A happens, then B happens) in the assessment phase of the elements of client-professional interaction (Carter & Kulbok, 1995; Dickoff & James, 1968; Dickoff, James, & Wiedenbach, 1968). This model has shown positive results in predicting and explaining health behaviors. Large percentages of the variance of health behaviors have been explained by portions of the model used in various studies (Cox, 1986; Cox & Roghmann, 1984; Marion & Cox, 1996; Waisbren, et al., 2004).
The fourth factor, situation producing (prescriptive, activities to bring about desired outcomes) is viewed as a strength of the IMCBH (Carter & Kulbok, 1995; Dickoff & James, 1968; Dickoff, et al., 1968), but a weakness in clinical practice. The nonrecursive part of the model where reciprocal relationship should exist is not well developed in nursing practice whereby consistent effective health outcomes are evident. The demands of nursing practice and the client-staff ratio does not allow nurses to practice consistently in the manner described in this model. As nursing practice continues to evolve, the prescriptive ideation of this model could become a reality.
The complexity the IMCHB is also viewed as both a strength and weakness. As a strength, the complexity of the model allows for the study of multiple variables and is ideal for working with clients who have complex health behaviors. African American clients in particular, have an array of complex physical, psychosocial, and environmental factors that impact illness such as hypertension. Since African Americans informed the initial origins of this model, the concepts fit the multifaceted nature of their health behaviors well (Cox, 2010, August 4). As a weakness, the complexity of testing the entire model may be time consuming and expensive. Because the complexity of the model, it has not been tested in its entirely, therefore generalizations are limited. In addition, when selected conceptual variables in the model are tested without considering the interaction of all variables in the model, the results of the study must be interpreted with caution and this decreases the strength of the overall framework of the model (Carter & Kulbok, 1995).
The IMCHB is a nursing practice model that closely parallels the nursing process in the areas of assessment, intervention, and evaluation (Dougherty, et al., 1998). As a result, nurses in the clinical practice setting should be able to use most elements of this model with ease. This model is applicable to nursing practice is because it is a middle-range theory, a definite strength of the model.
The background variables are inclusive of factors such as lower socioeconomic status (education, income, occupation), demographic characteristics (race, age, sex), and environmental resources (substandard neighborhoods, poor access to health care) that contribute to cardiovascular disease. The clients decision-making process about health behaviors may be affected by their background variables. Thus, it is the resultant choices, and not the background variables that influence health outcomes and become goals for nursing interventions (Cox & Wachs, 1985; Marion & Cox, 1996). Being able to research numerous background variables and the choices made as a result of the variables could provide insight into nonadherent behaviors in African Americans with illness such as HTN. New behavioral insights could help pinpoint specific interventions that may alter the client's motivation for adherence to health care regimes and improve health outcomes (Cox & Wachs, 1985). This demonstrates the model's strength in describing and predicting health behaviors and has implications for both practice and research.
In the model, the health outcomes are determined by the reciprocal interactions between the client and health care provider related to client health concerns (Cox & Roghmann, 1984). If interactions between the health care provider and the client are positive, then positive health outcomes may emerge and the opposite may occur if the interactions are negative. Consequently, the effect of the client-provider relationship on health outcomes could be perceived as both a strength and weakness.
Intrinsic motivation is a strength of the model that may explain reasons for nonadherence in individual clients. It may also predict why some clients adhere to health care interventions while others do not (Troumbley & Lenz, 1992). This portion of the model has both practice and research implications, especially for African Americans with HTN who may or may not adhere to prescribed antihypertension medications.
This model only focuses on elements of the client-professional interaction. This may be a limitation since nurses interact with other members of the interdisciplinary team, work with inanimate objects, and have various roles in the health care setting and profession organizations (Dickoff & James, 1968; Ohashi, 1985). All of these interactions may impact the client-professional interaction in various ways such as using another member of the health care team (chaplain) to provide affective support or getting patient health information from a professional nursing organization.
Since its inception, the IMCHB has remained stable without any modifications. This could attest to the strength of the models ability to accurately portray "what nursing is" and "what nursing does."
Relevance to African American Women with Hypertension
According to Cox (Cox, 2010, August 4), African Americans informed the IMCHB.
The complexity of the IMCHB creates the idea platform for African American women because they have an array of complex physical, psychosocial, and environmental factors that further complicate hypertension. In fact, hypertension is a multifactorial condition and this offers some support to the multifaceted nature of the treatment process (Gutierrez & Peterson, 2007). This gives some credence to the high prevalence of HTN in African American women and sheds light on the limited success of adherence interventions (Douglas, et al., 2003). Thus, the complexity of this disease process requires a model such as the IMCHB that allows for the study of multiple background variables along with dynamic variables to provide insight into complex, risky health behaviors. This model is relevant to the care of African American women with hypertension and has implications for both clinical practice and nursing research.
