In 1972 a military infantryman flew home alone from Vietnam. When he arrived in his hometown, San Antonio, TX, no one was there to greet him. His return was not communicated to his family, and his wife was at work in the mayor’s office while his six-year-old daughter and 10-year-old son were at school. Feeling confused and without family, friends, or military support, he took a bus to a nearby stop and walked the remainder of the way home. He searched out two guns in his home and asked his neighbor if he could borrow her car. He then left to pick up his children at school and walked into the school firing at faculty and students. Several teachers and students were gunned down. He found his two children, took them, and left for the San Antonio mayor’s office to find his wife. At that time he left his children in the car, re-loaded his guns, and went into his wife’s office, again firing his guns and apparently killing several individuals including a number of councilpersons, police officers, and the mayor. You are a Professor of Counselor Education and Supervision at a university in San Antonio, TX. Apply the Six-Step Model of Crisis Intervention for responding in this community. Addiction Research and Theory August 2008; 16(4): 305–307 Editorial The Hierarchy of Needs and care planning in addiction services: What Maslow can tell us about addressing competing priorities? D. BEST 1 , E. DAY 1 , T. McCARTHY 2 , I. DARLINGTON 3 , & K. PINCHBECK 1 1 Department of Psychiatry, University of Birmingham, Birmingham, B15 2QZ UK, 2 National Treatment Agency, Hercules House, London, UK, and 3 Homeless Link, London, UK (Received 17 December 2007; accepted 18 December 2007) ‘‘It is quite true that man lives by bread alone – when there is no bread. But what happens to man’s desire when there is plenty of bread and when his belly is chronically filled? At once other (and ‘higher’) needs emerge and these, rather than physiological hungers, dominate the organism. And when these in turn are satisfied, again new (and still ‘higher’) needs emerge and so on. This is what we mean by saying that the basic human needs are organised into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375) The recent publication of a series of documents providing guidance for practice in the drug misuse treatment field in the UK (Orange Guidelines, Department of Health, 2007) has raised questions as to the exact role of the ‘drug worker’. Guidance from the National Treatment Agency highlights the central role of key working and case management within drug treatment, and NICE guidelines about psychosocial treatments for drug user emphasises the effectiveness of brief and targeted interventions over broader and more humanistic psychological approaches. This will feel like a dramatic change in direction for many staff working in the field, and will not sit easily with many of them. However, such a strategy is part of a series of moves to standardise .

1. In 1972 a military infantryman flew home alone from Vietnam.
When he arrived in his hometown, San Antonio, TX, no one was
there to greet him. His return was not communicated to his
family, and his wife was at work in the mayor’s office while his
six-year-old daughter and 10-year-old son were at school.
Feeling confused and without family, friends, or military
support, he took a bus to a nearby stop and walked the
remainder of the way home. He searched out two guns in his
home and asked his neighbor if he could borrow her car. He
then left to pick up his children at school and walked into the
school firing at faculty and students. Several teachers and
students were gunned down. He found his two children, took
them, and left for the San Antonio mayor’s office to find his
wife. At that time he left his children in the car, re-loaded his
guns, and went into his wife’s office, again firing his guns and
apparently killing several individuals including a number of
councilpersons, police officers, and the mayor.
You are a Professor of Counselor Education and Supervision at
a university in San Antonio, TX. Apply the Six-Step Model of
Crisis Intervention for responding in this community.
Addiction Research and Theory
August 2008; 16(4): 305–307
Editorial
The Hierarchy of Needs and care planning in addiction
services: What Maslow can tell us about addressing
competing priorities?

2. D. BEST
1
, E. DAY
1
, T. McCARTHY
2
, I. DARLINGTON
3
,
& K. PINCHBECK
1
1
Department of Psychiatry, University of Birmingham,
Birmingham, B15 2QZ UK,
2
National Treatment Agency, Hercules House, London, UK, and
3
Homeless Link, London, UK
(Received 17 December 2007; accepted 18 December 2007)
‘‘It is quite true that man lives by bread alone – when there is
no bread. But what happens
to man’s desire when there is plenty of bread and when his belly
is chronically filled? At once
other (and ‘higher’) needs emerge and these, rather than
physiological hungers, dominate

3. the organism. And when these in turn are satisfied, again new
(and still ‘higher’) needs
emerge and so on. This is what we mean by saying that the basic
human needs are organised
into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375)
The recent publication of a series of documents providing
guidance for practice in the
drug misuse treatment field in the UK (Orange Guidelines,
Department of Health, 2007)
has raised questions as to the exact role of the ‘drug worker’.
Guidance from the National
Treatment Agency highlights the central role of key working
and case management within
drug treatment, and NICE guidelines about psychosocial
treatments for drug user
emphasises the effectiveness of brief and targeted interventions
over broader and more
humanistic psychological approaches. This will feel like a
dramatic change in direction for
many staff working in the field, and will not sit easily with
many of them. However, such a
strategy is part of a series of moves to standardise the quality of
drug treatment services in the

4. UK, and support for this broad strategy comes from a well
established source.
Abraham Maslow proposed his theory of a ‘Hierarchy of Needs’
in a paper entitled
A Theory of Human Motivation in 1943, and this is presented
graphically below. Although
later in his career, Maslow focussed increasingly on higher-
order needs and the relationship
Correspondence: Professor David Best, Department of
Psychiatry, University of Birmingham, Queen Elizabeth
Psychiatric
Hospital, Birmingham, B15 2QZ, UK. E-mail: [email protected]
ISSN 1606-6359 print/ISSN 1476-7392 online � 2008 Informa
UK Ltd.
DOI: 10.1080/16066350701875185
between self-actualisation and transcendence, from an
addictions treatment perspective we
should turn our attention to the base of the pyramid (Figure 1).
What is frequently described as a model of motivation, and
utilised in workplace theories
of staff functioning and drive, has considerable ramifications
for the treatment of individuals
with complex and multi-axial problems. The presenting needs of
drug users accessing adult

5. treatment services are frequently bewildering in their
complexity, often involving multiple
substance use, physical and psychological health problems,
relationship and family
difficulties and little stability provided by reliable
accommodation, regular employment or
non-using friendship networks. As Robins has argued in her
discussion of Vietnam veterans
returning to the US, ‘drug users who appear for treatments have
special problems that will
not be solved just by getting them off drugs’ (Robins 1993, p.
1050).
As Maslow went on to argue in the 1943 article, ‘If all other
needs are unsatisfied, and the
organism is then dominated by the physiological needs, all other
needs may become simply
non-existent or be pushed into the background. It is then fair to
characterise the whole
organism by saying simply that it is hungry, for consciousness
is almost completely pre-
empted by hunger’ (Maslow 1943, p. 372). The parallels with
drug-seeking are obvious, as
they are with the basic physiological problems associated with
drug deprivation, withdrawals,

6. craving and anhedonia. At initial treatment presentation, it is
therefore, likely that other key
issues are masked, and that only where equally pressing
deprivations, most likely those
caused by homelessness or significant mental or physical
morbidities, are met will these arise
as presenting needs.
There are two fundamental implications of the model for the
delivery of treatment – that
lower-level interventions must precede higher-order ones, and
second that higher-order
needs are unlikely to emerge in the initial contact stages. This
has fundamental implications
for what we are trying to achieve in drug treatment services and
places huge importance on
care planning and review as core components of the treatment
process. In other words, the
major emphasis on comprehensive assessment is misplaced
according to a hierarchy of needs
model, where needs other than the most urgent are unlikely to
emerge. Thus, it is only
through treating care planning as treatment that it is realistic to
expect a treatment journey to

7. be effective. As clients and workers manage the basic
physiological needs (through
prescribing, detoxification and so on), can treatment start to
look at issues of safety, then
belonging, esteem and addressing more spiritual needs.
Figure 1. The Hierarchy of needs.
306 D. Best et al.
The second implication of this model is for what treatment
workers do. While managing
the immediate physical distress of addiction is paramount, the
hierarchy of needs would
suggest that any further gains in treatment are predicated on a
care planning approach that is
not ‘addiction-specific’ but is trans-disciplinary and grounded
on the client’s emerging
pattern of needs. It would suggest that for many clients what is
needed initially is case-
support rather than ‘psychological change’ and clients will be
sceptical about the benefits of
counselling if their needs are not compatible with the middle
and higher-order levels of the
pyramid. For many clients, the key tasks will be around benefits

8. and housing, access to
psychiatric services and GPs, and with little need for targeting
lasting change in drug use
until these issues have been addressed.
However, it is not clear that statutory treatment services are
geared to this kind of
generic case working, with key worker appointment systems
based on an unrealistic model
of ‘therapeutic intervention’. As Carroll and Rounsaville (2003)
have argued, there are now
more than a dozen well-evidenced psychosocial interventions
with credible evidence bases,
yet their deployment is inconsistent and implementation fidelity
is poor. Part of this is
because we do not always account for the stage of the client (for
which the hierarchy offers a
heuristic method) and the abiding needs that should shape the
care planning process and, at
a team level, should shape workforce planning and team
training. The hierarchy of needs
also offers a model for clinical supervision and performance
management of services. The
aim of treatment should be a ‘hierarchical journey’ with care
plan reviews addressing

9. transitions in the level of need to be addressed and creating
resulting action plans.
Furthermore, in a drug treatment system dominated by
maintenance prescribing, it is a
model for change – the stabilising goal of maintenance is viable
for those struggling to
address safety and physiological needs, but once these are
achieved in a sustainable way,
then the rationale for maintenance is likely to diminish and
continued change, through
escalating the hierarchy, which should become a more primary
goal.
References
Carroll K, Rounsaville B. 2003. A vision of the next generation
of behavioral therapies research in the addictions.
Addiction 102(6):850–862.
Department of Health (England) and the devolved
administrations 2007. Drug Misuse and Dependence: UK
Guidelines on Clinical Management. London: Department of
Health (England), the Scottish Government,
Welsh Assembly Government and Northern Ireland Executive.
Maslow A. 1943. A theory of human motivation. Psychological
Review 50:370–396.

10. Robins L. 1993. Vietnam veterans’ rapid recovery from heroin
addiction: A fluke or normal expectation. Addiction
88:1041–1054.
The Hierarchy of Needs and care planning 307
Western Journal of Nursing Research
November 2000, Vol. 22, No. 7
Basic Need Status and
Health-Promoting Self-Care
Behavior in Adults1
Gayle J. Acton
Porntip Malathum
Health-promoting self-care behavior emphasizing positive
lifestyle practices may improve the
health and quality of life of adults. One variable that may
influence health-related decisions is
the status of basic needs as described by Maslow. The purpose
of this study was to investigate the
relationships among basic need satisfaction, health-promoting
self-care behavior, and selected
demographic variables in a sample of community-dwelling
adults. A convenience sample of 84
community-dwelling adults was recruited to complete the Basic

11. Need Satisfaction Inventory, the
Health-Promoting Lifestyle Profile II, and demographic
information. Results of the study indi-
cated that self-actualization, physical, and love/belonging need
satisfaction accounted for 64%
of the variance in health-promoting self-care behavior. The
findings of this study are consistent
with Maslow’s theory of human motivation and suggest that
persons who are more fulfilled and
content with themselves and their lives, have physical need
satisfaction, and have positive con-
nections with others may be able to make better decisions
regarding positive health-promoting
self-care behaviors.
Health-promoting self-care is a way for people to take control
of their
health (Haug, Wykle, & Namazi, 1989) and is a strategy for
attaining national
health goals (Pender, 1996). To date, however, much of the
research into
self-care behavior has been conducted within an illness or
problem-oriented
paradigm and has been designed to predict medical outcomes,
such as the use
of health care services, physician visits, and medical care
expenses. A variety
of factors, including a new emphasis on managing chronic
conditions rather
than curing disease, aging of the population, and increases in
expenditures of
health care dollars, have shifted the focus of health care
delivery away from
acute care toward health promotion and disease prevention
(McLeroy &
Crump, 1994). Research has demonstrated that lifestyle choices

12. may decrease
796
Western Journal of Nursing Research, 2000, 22(7), 796-811
Gayle J. Acton, Ph.D., R.N., Assistant Professor, The
University of Texas at Austin
School of Nursing; Porntip Malathum, M.Ed. (Nursing),
Doctoral Student, The University
of Texas at Austin School of Nursing.
© 2000 Sage Publications, Inc.
http://crossmark.crossref.org/dialog/?doi=10.1177%2F01939450
022044764&domain=pdf&date_stamp=2016-07-01
the incidence and severity of chronic conditions (Dean, 1989;
Paffenbarger &
Hyde, 1980; Paffenbarger, Hyde, Wing, & Hsieh, 1986;
Paffenbarger, Wing,
Hyde, & Jung, 1983; Rowe & Kahn, 1998). Thus, health
promotion empha-
sizing positive lifestyle practices may improve health and
quality of life and
decrease health care costs.
Embedded in the concept of health promotion is self-
responsibility, or
accountability for actions (or nonactions) regarding health. That
is, persons
are responsible for their health and health is largely self-
determined through
self-care actions. For individuals to engage in health-promoting
behavior,

13. they must be motivated to take personal responsibility for their
health.
Little research, however, has focused on health-promoting self-
care
actions to produce health-oriented outcomes and variables
related to posi-
tive self-care decisions. One variable that may influence health-
related deci-
sions is the status of basic needs as described by Maslow
(1970). According
to Maslow’s theory of human motivation, the actions one takes
are largely
motivated by the needs of the individual. Basic needs are
arranged in a hier-
archy as physical, safety/security, love/belonging, esteem/self-
esteem, and
self-actualization needs. The hierarchy implies that lower needs
must be met
before higher needs emerge. For example, if the human being is
deprived of
oxygen, then concerns about safety and belonging may not
matter. Needs
actually exist in a quasi-hierarchy, and when the most urgent
needs are par-
tially or fully satisfied the next level emerges, ending with the
search for
self-actualization. Unmet needs result in a state of tension or
anxiety; as the
deficit increases, so does the tension, which ultimately leads to
a state of per-
ceived deprivation. There is always an inherent drive to relieve
the tension
caused by unmet needs and achieve need satisfaction. When
relief occurs,
the tension is decreased and the person can focus on other

14. aspects of his or
her life, such as health promotion. Maslow’s theory of human
motivation
suggests that persons experiencing higher levels of need
satisfaction will
have lower levels of tension and will not be in a state of
deprivation; thus,
they might be motivated to make better decisions regarding self-
care and
health promotion. Therefore, the purpose of this study was to
(a) investigate
the relationships among basic need status, health-promoting
self-care be-
havior, and selected demographic variables and (b) determine
the best pre-
dictors (physical needs, safety/security needs, love/belonging
needs, esteem/
self-esteem needs, or self-actualization needs) of health-
promoting self-care
behavior in a sample of community-dwelling adults.
November 2000, Vol. 22, No. 7 797
Basic Needs and Health-Promoting Self-Care Behavior
Leidy (1994) found that a sample of healthy adults scored
higher in basic
need satisfaction than a group of chronically ill adults;
however, little
research has explored these variables. In one of the few studies
of the vari-
ables, Laffrey (1985) examined the relationship between
“promotiveness of
health behavior choice and self-actualization” (p. 290) in 95

15. adults ages 18
to 69 who were randomly selected from households in three
midwestern
suburban cities. Laffrey used the Personal Orientation Inventory
(POI)
(Shostrom, 1974) to measure values and behaviors important to
the develop-
ment of the self-actualized person and the Health Behavior
Choice Scale
(HBCS) to measure participants’ reasons for engaging in
sleep/rest, relaxation,
physical exercise, nutrition, and dental care. Laffrey’s findings,
however,
failed to support her hypothesis that there would be a
significant relationship
between self-actualization and promotiveness of health behavior
choice.
In a study similar to Laffrey’s (1985), Petosa (1984) examined
the rela-
tion between self-actualization and health practices in 421
college students.
Like Laffrey, Petosa used the POI to measure indicators of self-
actualization;
however, unlike Laffrey, Petosa used the Health Practices
Inventory (Baum,
1972) to measure actual health practices related to personal and
dental
health, rest and sleep, relaxation, chronic disease, family living,
environ-
mental health, safety and accident prevention, nutrition,
physical activity,
recreation, communicable disease, mental health, consumer
health, and drug
use. Petosa found a significant relationship between self-
actualization and

16. health promotion practices.
Whereas Laffrey’s (1985) and Petosa’s (1984) results may
appear to con-
flict, the difference may be explained by differences in the
study measures.
Laffrey’s study evaluated the reasons for engaging in a limited
scope of
health-promoting behaviors (sleep, relaxation, exercise,
nutrition, and den-
tal care), whereas Petosa measured the actual practice of a wide
variety of
health-promotion behaviors. Thus, the studies were evaluating
two different
conceptions of health promotion behavior. In addition, neither
Petosa nor
Laffrey examined the relationships among physiological needs,
safety/
security needs, love/belonging needs, esteem/self-esteem needs,
and health
behaviors. The present study examined the links between all of
Maslow’s
(1970) basic needs, including self-actualization and health-
promoting self-
care behavior.
798 Western Journal of Nursing Research
Demographic Variables and
Health-Promoting Self-Care Behavior
Support for the relationships among the demographic variables
and health-
promoting self-care can be found in several studies. Researchers

17. found that
increased self-care activities were related to higher social class
(Dean, 1989;
Hanucharurnkul, 1989; Weerdt, Visser, Kok, & van der Veen,
1990) and higher
income (Ahijevych & Bernhard, 1994; Ailinger, 1989). Several
researchers
(Ahijevych & Bernhard, 1994; Ailinger, 1989; Gottlieb &
Green, 1984;
Muhlenkamp & Sayles, 1986; Segall & Goldstein, 1989; Weerdt
et al., 1990)
found that more education and increasing age (Ailinger, 1989;
Bausell, 1986;
Gottlieb & Green, 1984; Muhlenkamp & Sayles, 1986;
Prochaska, Leventhal,
Leventhal, & Keller, 1985; Walker, Volkan, Sechrist, & Pender,
1988) were
also related to increased self-care activities. Regarding
employment and
self-care, Frank-Stromborg, Pender, Walker, and Sechrist
(1990) found
employment to be a significant predictor of a health-promoting
lifestyle in
persons with cancer, and Duffy, Rossow, and Hernandez (1996)
found
employment to be a significant predictor of a health-promoting
lifestyle in
Mexican-American women. Taken collectively, the research
indicates that
employed persons of higher social class and income who had
more educa-
tion tended to engage in more health-promoting self-care
behavior. In addi-
tion, as persons age, their health-promoting self-care behavior
tends to
increase.

18. METHOD
Procedure
Permission to conduct the study was granted by the appropriate
human par-
ticipants review committee. The sample for the study consisted
of community-
dwelling adults recruited from a conference for lay persons and
profession-
als interested in issues concerning older adults. Attendees
received the survey
questionnaires in their packet of registration materials. A cover
letter explained
the study and stated that return of the questionnaires to the
researcher indi-
cated consent to participate in the study. The participants
completed the
November 2000, Vol. 22, No. 7 799
questionnaires during breaks and/or at lunchtime during the
conference and
returned them to the researcher at a centrally located display
table.
Sample
Eighty-four adults completed the questionnaires. The ages of
the partici-
pants ranged from 21 to 79 years, with the average age being
48.49 years. Of
the sample, 87% were female. Most were White (84.5%), 7.1%

19. were Black,
3.6% were Hispanic, and 3.6% of the sample reported another
unspecified
ethnicity. Sixty-eight percent had a college education. Of the
sample, 69%
were employed and 53.6% reported their family annual income
as $36,000
or more (see Table 1).
Instruments
Basic needs. Basic needs status was measured by the Basic
Needs Satis-
faction Inventory (BNSI) developed by Leidy (1994). The BNSI
contains
subscales analogous to Maslow’s (1970) theoretical description
of the basic
needs categories: physical, safety/security, love/belonging,
esteem/self-esteem,
and self-actualization. Five subscale scores and a total scale
score can be
computed reflecting an individual’s need satisfaction status in
each category
and overall need status. The BNSI contains 27 items. The stem
for each item
asks how one feels about various aspects of life. Participants
respond on a
Likert-type scale ranging from 1 (terrible) to 7 (delighted). The
ratings are
summed for a possible range of scores from 27 to 189.
Extensive validity and
reliability testing of the BNSI has been described elsewhere by
Leidy (1994).
Cronbach’s alphas have been reported to range from .90 to .94
(Irvin &
Acton, 1996; Leidy, 1990, 1994). Reliability coefficients in this

20. study were
.90 for the total scale and .82, .85, .85, .82, and .88 for the
physical, safety/
security, love/belonging, esteem/self-esteem, and self-
actualization subscales,
respectively.
Health-promoting self-care behavior. The Health-Promoting
Lifestyle
Profile II (HPLP II) (Walker, Sechrist, & Pender, 1995) was
used to measure
health-promoting self-care behavior. The HPLP II is a revision
of the original
Health-Promoting Lifestyle Profile (Walker, Sechrist, & Pender,
1987) used
extensively in health promotion research. The HPLP II was
revised to better
reflect current practice related to health promotion activities.
The HPLP II
measures health-promoting self-care behavior conceptualized as
a multi-
800 Western Journal of Nursing Research
dimensional pattern of self-initiated actions that maintain or
enhance the
level of wellness and health potential of the individual. The 52-
item instru-
ment employs a 4-point response scale to measure the frequency
of
self-reported health-promoting behaviors in the areas of health
responsibil-
ity, physical activity, nutrition, spiritual growth, interpersonal
relations, and

21. stress management. Thus, the HPLP II represents a holistic
evaluation of
November 2000, Vol. 22, No. 7 801
TABLE 1: Demographic Characteristics
Characteristic n Percentage
Age
Less than 50 44 53.6
Greater than or equal to 50 38 46.3
Gender
Male 10 11.9
Female 73 86.9
Ethnicity
White 71 84.5
Black 6 7.1
Hispanic 3 3.6
Unspecified 3 3.6
Marital status
Married 53 63.1
Divorced 18 21.4
Widowed 4 4.8
Single 7 8.3
Educational level
Less than high school 1 1.2
High school graduate 10 11.9
Some post–high school or
graduate of technical school 15 17.8
College graduate 57 67.9

22. Employment status
Employed 58 69.0
Unemployed 6 7.1
Retired 11 13.1
Homemaker 2 2.4
Other 6 7.1
Family income (in dollars)
15,000 or less 7 8.4
16,000 to 25,000 20 23.8
26,000 to 49,000 25 29.8
50,000 to 75,000 19 22.6
76,000 or more 11 13.1
NOTE: The percentage columns may not total 100% due to
missing data.
health-promoting self-care behaviors. Cronbach’s alphas are
reported by
Walker and colleagues (1995) as follows: health responsibility
(.86), physi-
cal activity (.85), nutrition (.80), spiritual growth (.86),
interpersonal rela-
tions (.87), stress management (.79), and total scale (.94).
Cronbach’s alphas
in this study were .90 for the total scale and .88, .86, .83, .90,
.85, and .85 for
the health responsibility, physical activity, nutrition, spiritual
growth, inter-
personal relations, and stress management subscales,
respectively.
Demographic data. Participants completed a form containing

23. questions
concerning age, gender, ethnicity, marital status, education,
income, and
employment status. Research has shown these variables to be
linked to health
promotion activities.
RESULTS
With a possible range of 27 to 189 on the BNSI, the group mean
score of
137.71 (SD = 23.80) indicates that the participants in this study
were experi-
encing moderately high levels of basic need satisfaction. The
group mean of
138.90 (SD = 27.08, range = 52 to 208) on the HPLP II shows
that the partic-
ipants were engaging in moderate numbers of health-promoting
self-care
behaviors (see Table 2).
The correlations between the BNSI subscales and the HPLP II
are dis-
played in Table 3. Those persons who reported greater physical
(r = .66),
safety/security (r = .64), love/belonging (r = .68), esteem/self-
esteem (r =
.62), and self-actualization (r = .76) need status reported more
health-
promoting self-care behaviors. In addition, correlations among
the subscales
of the BNSI ranged from .48 to .76 (p < .001).
Stepwise regression analyses were used to examine the ability
of the
basic need subscales to predict health-promoting self-care

24. behavior. Tests
for violations of the multiple regression assumptions were
negative (Munro,
1997). Multicolinearity tests revealed that no correlation
coefficient
exceeded .80 and variance inflation factors for the regression
analyses
ranged from 1.000 to 2.506, far below the caution point of 10
(Stevens,
1996).
Data reporting the ability of the basic need subscales to predict
health-
promoting self-care behavior are displayed in Table 4. Self-
actualization
was the first variable to enter the equation, and it accounted for
58% of the
variation in health-promoting self-care behavior. Physical need
satisfaction
increased the variance by 5% and love/belonging satisfaction
increased
802 Western Journal of Nursing Research
November 2000, Vol. 22, No. 7 803
TABLE 2: Descriptive Data for the Basic Need Satisfaction
Inventory (BNSI)
Subscales and the Health-Promoting Lifestyle Profile II (HPLP
II)
Scale M SD Range
BNSI total 137.71 23.80 27 to 189

25. Self-actualization 31.15 6.04 6 to 42
Esteem/self-esteem 20.79 3.82 4 to 28
Love/belonging 26.99 5.28 5 to 35
Safety/security 29.90 6.14 6 to 42
Physical 28.88 6.39 6 to 42
HPLP II total 138.90 27.08 52 to 208
TABLE 3: Correlations Among the Health-Promoting Lifestyle
Profile II (HPLP II)
and the Basic Need Satisfaction Inventory (BNSI) Subscales
Safety/ Love/ Esteem/ Self- HPLP
Physical Security Belonging Self-Esteem Actualization II
Physical 1
Safety/
security .73 1
Love/
belonging .65 .72 1
Esteem/
self-esteem .54 .48 .75 1
Self-
actualization .66 .76 .71 .66 1
HPLP II .66 .64 .68 .62 .76 1
NOTE: All variables are correlated at p < .001, two-tailed.
TABLE 4: Stepwise Regression Predicting Health-Promoting
Self-Care Behav-
ior From the Basic Need Satisfaction Inventory (BNSI)
Subscales

26. Variable R2 Overall F Sig F R2 Change F Change Sig Change
Self-actualization .58 113.26 .000 .58 113.26 .000
Physical .63 67.66 .000 .05 9.84 .002
Love/belonging .64 48.13 .000 .02 4.03 .048
the variance by 1%. Together, these three variables accounted
for 64% of
the variance in predicting health-promoting self-care behavior.
Thus, self-
actualization, physical, and love/belonging need satisfaction
predicted
engagement in health-promoting self-care behavior.
Because there was some concern about overlap between the
self-
actualization subscale of the BNSI and the spiritual growth
subscale of the
HPLP II, the spiritual growth subscale was removed from the
HPLP II and
the stepwise regression analysis was repeated. The results
indicated that
self-actualization was still the first variable to enter (R2 = .52,
p < .01) the
regression equation; thus, concerns about the overlap were
allayed.
The relationships among the categorical demographic variables
(ethnic-
ity, marital status, education, employment, and income), health-
promoting
lifestyle, and basic need satisfaction were examined using t
tests and ANOVA.

27. Chi-square statistics were used to examine the relationships
among the cate-
gorical demographic variables. The categorical demographic
variables were
dichotomized as follows: White or other ethnicities, married or
unmarried
(divorced, separated, single, or single living with another), and
high school
education or college education. The income variable was
divided into three
groups—low income (less than $15,000), medium income
($15,001 to
$50,000), and high income (greater than $50,000)—as was the
employment
variable (employed, retired, or unemployed). Relationships
among age,
health-promoting self-care behavior, and basic need satisfaction
were exam-
ined using Pearson product-moment correlation.
Participants with a higher family income were more likely to be
married
(χ2 = 23.00, p < .001), had a higher educational level (χ2 =
6.40, p < .05), had
a higher basic need satisfaction (ANOVA: F(2, 79) = 3.39, p <
.05), and
engaged in more health-promoting behaviors (ANOVA: F(2, 79)
= 4.99, p <
.05). Participants who were currently married had a higher
education level
(χ2 = 6.40, p < .05) and higher basic need satisfaction (t test = –
.50, df = 80,
p < .05). Participants with higher education engaged in more
health-
promoting behaviors (t test = –3.26, df = 81, p < .05) and had
higher basic

28. need satisfaction (t test = –2.26, df = 81, p < .05). Participants
who were cur-
rently employed performed fewer health-promoting behaviors
(ANOVA:
F(2, 80) = 3.39, p < .05). Post hoc tests indicated that those
participants who
were retired engaged in more health-promoting behaviors than
those who
were employed. Participants who had higher basic need
satisfaction were
more likely to engage in health-promoting behaviors (r = .79).
There
were no significant associations between age, gender, ethnicity,
and health-
promoting self-care behavior or basic need satisfaction. In
addition,
there were no significant associations between marital status
and health-
804 Western Journal of Nursing Research
promoting self-care behavior or between employment status and
basic need
satisfaction.
DISCUSSION
Basic Needs and Health-Promoting Self-Care Behavior
The significant relationship between basic need satisfaction and
health-
promoting self-care supports Maslow’s (1970) theory of human
motivation.
Maslow hypothesized that unmet needs and the desire to grow

29. and move for-
ward in life are the stimuli for human motivation. Maslow
proposed that
higher levels of need satisfaction may lead to the development
of more
resources and increased motivation for individuals to make
better decisions
(e.g., healthy lifestyle choices). In contrast, Maslow argued that
unmet needs
may contribute to increasing anxiety and tensions that
theoretically might
lead to unhealthy practices and perhaps even increased illness.
The findings
of this study support Maslow’s hypothesis that need satisfaction
results in
positive behavior motivation. Results show that persons with
higher scores
on basic need satisfaction engaged in more health-promoting
self-care
behavior and those with lower levels of need satisfaction
reported fewer pos-
itive health-related behaviors. In addition, Maslow theorized
that basic need
satisfaction is positively associated with psychological health.
Better psy-
chological health might free people to make better decisions
about their
health. Findings that college students who reported higher basic
need satis-
faction had lower levels of anxiety (Kalliopuska, 1992) support
Maslow’s
theory, and although the study reported here did not measure
psychological
health, future research could test the relationships among need
satisfaction,
anxiety, and health-promoting self-care behavior.

30. Self-actualization is at the top of the basic needs hierarchy and
in this
study it emerged as the best predictor of health-promoting self-
care behav-
ior. Self-actualization is defined as the “ongoing actualization
of potentials,
capacities and talents, as fulfillment of mission (or call, fate,
destiny, or
vocation), as a fuller knowledge of, and acceptance of, the
person’s own
intrinsic nature” (Maslow, 1968, p. 25). Maslow (1970) says
that “what a
man can be, he must be” (p. 46) and suggests that self-
actualizing persons
are motivated to be the best they can be in multiple aspects of
their lives;
thus, data from this study indicate that they may be better able
to make
healthy lifestyle choices. Maslow also argues that self-
actualizing people
tend to be able to accept themselves—therefore, they might
have a better
November 2000, Vol. 22, No. 7 805
attitude toward themselves and their lives, so their ability to
engage in
health-promoting self-care may be increased. Laffrey (1985)
states that
health promotion behavior is indicative of a person’s striving to
attain high-
level health or increased general well-being. This is consistent
with increased

31. self-actualization need satisfaction when persons are
continually striving to
go forth in life, grow, develop, and be the best they can be.
Findings that self-
actualization was the best predictor of health-promoting self-
care behavior
is also consistent with Petosa’s (1984) finding that persons with
higher lev-
els of self-actualization were more likely to engage in healthier
lifestyle
behaviors. Persons who are more fulfilled and content with
themselves and
their lives may be better able to carry out health-promoting self-
care behaviors.
Maslow (1970) says that the physiological needs are usually the
starting
point for human motivation and that at least partial satisfaction
of physical
needs is necessary for an individual to move toward satisfaction
of higher
needs. Physical need satisfaction predicted engagement in
health-promoting
self-care behavior in this study. That seems logical because
when one does
not have to worry about physical needs, it may be easier to
focus on a healthy
lifestyle. Physical need satisfaction may free the person from
anxieties about
things such as hunger or finding shelter that might occupy the
mind and
reduce health-promoting actions.
Maslow (1970) states that persons have a need to love and be
loved and to
feel like they belong to a group or an organization larger than

32. the self. Per-
sons deprived of love/belonging needs may feel alone and
isolated, unable to
seek assistance and support that might facilitate better health-
related decision-
making. In this study, love/belonging need satisfaction
predicted engage-
ment in health-promoting self-care behaviors. It may be that
persons who
feel more supported are better able to make good decisions and
maintain a
healthier lifestyle. Findings that social support (connections
with others)
(Cohen & Syme, 1985; Dean, 1989) and family support
(Rakowski, Julius,
Hickey, & Holter, 1987) may enhance health strengthen this
conclusion.
Maslow (1970) states that as needs are met and persons do not
feel in a
state of deprivation, they are motivated to move toward more
social goals.
Health promotion may be considered a social goal. The
publication of
Healthy People 2000 is evidence of increased emphasis on
healthy lifestyles
in this country. Findings from this study show that as needs are
met, espe-
cially the higher needs, more attention may be paid to social
goals such as
health-promoting self-care behavior and perhaps healthier
lifestyles.
806 Western Journal of Nursing Research

33. Demographic Variables
Persons who were currently married and had higher incomes and
more
education had greater basic need satisfaction, which is not
surprising be-
cause being married and having a higher income and more
education may
mean that one has more resources to satisfy basic needs. The
results are con-
sistent with Laffrey’s (1985) finding that education and income
were posi-
tively related to self-actualization. In addition, participants in
the study who
had higher levels of basic need satisfaction engaged in more
health-promoting
self-care behaviors. This is consistent with Leidy’s (1994)
finding that
scores on basic need satisfaction could discriminate between
healthy and
chronically ill individuals. Persons with higher levels of basic
need satisfac-
tion may have more resources and may be able to engage in
more health-
promoting self-care behaviors than other individuals. As needs
are satisfied,
persons may be able to more easily move forward in life and
engage in
behavior that is growth motivated (Maslow, 1968).
Age was not related to either basic need satisfaction or health-
promoting be-
haviors. This is comparable to Laffrey’s (1985) finding that
self-actualization
was not significantly correlated with the age of the participants.

34. Leidy (1994)
also found that age was not significantly correlated with basic
need satisfac-
tion. Differing from the findings of this study, Walker and
colleagues (1988)
found that older persons had higher scores on health-promoting
self-care
behavior than did young or middle-aged adults. These
conflicting results
may be explained by the fact that 77% of the participants in this
study were
employed and engaged in fewer health-promoting self-care
behaviors, but
those persons who were retired engaged in more positive health
behaviors.
Perhaps those persons who were older but still employed
obscured a poten-
tial positive relationship between increased age and health-
promoting self-
care behavior.
Gender and ethnicity were not associated with either basic need
satisfac-
tion or health-promoting self-care behavior. This may be due to
the charac-
teristics of the sample, which was overwhelmingly female,
White, well edu-
cated, and with adequate incomes, thus obscuring the variability
that might
have been found in a more diverse sample.
Education was also related to health-promoting self-care
behavior, as in
the work of others (Ahijevych & Bernhard, 1994; Ailinger,
1989; Gottlieb &
Green, 1984; Muhlenkamp & Sayles, 1986; Segall & Goldstein,

35. 1989;
Weerdt et al., 1990). Uitenbroek, Kerekovska, and Festchieva
(1996) found
November 2000, Vol. 22, No. 7 807
that persons who were better educated and employed engaged in
healthier
behaviors in regard to cigarette smoking, diet, alcohol
consumption, and
exercise than those who were less educated and employed.
Conversely, par-
ticipants in this study who were employed tended to engage in
fewer health-
promoting behaviors than those who were retired. One possible
reason may
be that employed persons have less time or are too tired to
perform
health-promoting activities.
Findings from this study demonstrate the importance that need
satisfac-
tion may have on the decisions people make about lifestyle,
particularly
health-promoting self-care behavior. Generalizations from these
results
must be made cautiously because random sampling was not
employed and
the design was descriptive. The sample was recruited from
persons inter-
ested in issues concerning older adults and thus may be more
likely to be
concerned about health issues because health is particularly
important to

36. older adults. Also, because this sample reported relatively high
levels of
need satisfaction, those persons who might score lower on
Maslow’s (1968)
hierarchy of needs are left underrepresented. More research
(using random
sampling) is needed to confirm and clarify the findings of this
study. Sam-
ples from lower socioeconomic levels and minority populations
might also
enhance the findings.
Despite the limitations of the study, the relationship between
basic need
satisfaction and health-promoting self-care behavior is
intriguing and may
be helpful in designing interventions to facilitate health-
promoting self-care
behavior. Nurses should assess basic need status and intervene
to assist per-
sons to meet their basic need requirements, especially with
higher needs such
as self-actualization. Persons have an inherent ability to grow
and develop to
their highest capacity. To do so, however, they need
connections, support,
and good information regarding the changes they are seeking to
make.
Nurses can facilitate these needs and help persons grow,
develop, and realize
their potential, especially in the area of positive, healthy
lifestyles.
One other area of particular importance involves employed
persons who,
in this study, reported fewer health-promoting self-care

37. behaviors. Health
care professionals, particularly those working in occupational
health, must
help working adults build resources needed to engage in
activities to promote
health. Occupational health nurses may be able to suggest
health-promotion
strategies to employers. Activities such as health-related
support groups,
exercise time, health-related seminars, health fairs, and other
health-related
activities might assist working adults in increasing health-
promoting
self-care behavior.
808 Western Journal of Nursing Research
Nurses are educated to assist persons in meeting basic need
requirements.
Nurses may be able to help clients elevate themselves in the
basic need hier-
archy moving toward self-actualization and increasing the
likelihood that
they will perform health-promoting self-care behaviors. Maslow
(1970) states
that needs are satisfied through others by support, reassurance,
acceptance,
protection, willingness to listen, and kindness. Leidy (1994)
points out that
“these actions are the therapeutic essence of nursing practice”
(p. 279). As
nurses assist persons in achieving need satisfaction, they may
be helping
them move toward healthier lifestyles. More attention must be

38. directed
toward health promotion and ways to help people engage in
positive lifestyle
choices. This study indicates that one’s basic need status may
be related to
the choices and decisions one makes regarding health-promoting
self-care
behavior. Nurses and other health care professionals are in a
good position to
assess and intervene to influence positive need satisfaction and
thus healthy
lifestyle choices.
NOTE
1. This study was partially funded by the Luci Baines Johnson
Fellowship.
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