RHP 12 Learning Collaborative
Package Two (Topic One)
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Participants will be able to describe the transformation
for health model using the theories of Brazilian
Philosopher Paulo Freire
Participants will identify the stages and sequences of the
transformation for health model
Participants will describe the practical implementation of
the model in a chronic disease management program.
Participants will describe implementation of self
efficacious behaviors
Participants will demonstrate implementation of survey
tools utilized in the transformation for health
Determinants of Health Status
(from expert consensus; Shi;
Blum)
Medical Care
(10%)
Genetics
(10%)
Health Status (100%)
Environment
(40%)
Behavior
(40%)
Physical
Nutrition &
Exercise
Barriers
Financial
Lifestyle
choices
Education/Literacy
Employment
“An approach is needed to help patients
change or adopt healthy behaviors – by
themselves, not for them by others”
(Paulo Freire)
Issue
What is taught?
Traditional Patient Education
Self-Management Education
Information and technical skills
Skills on how to act on problems
Implementation
Constructs
How are problems formulated?
about the disease
Problems reflect inadequate control
of the disease
The patient identifies problems
he/she experiences that may or may
not be related to the disease
Education is disease-specific and
Education provides problem-solving
teaches information and Transformation
technical
skills that
are relevant to the
(Self
Cognition (Critical
consequences of chronic conditions
skills related to the disease
Guided Evaluation
&
in general
Consciousness)
Goal
Modification)
What is the theory underlying the
Disease-specific knowledge
creates
Greater patient confidence in
behavior change, which in turn
his/her capacity to make lifeeducation?
improving changes (self-efficacy)
produces better clinical outcomes
yields better clinical outcomes
Relation of education to the disease
What is the goal?
Who is the educator?
Compliance with the behavior
Increased self-efficacy to improve
Intention (SelfDecision
(Barriers
changes taught to the patient to
clinical outcomes
Efficacy & Social
improve clinical outcomesand Facilitators for
A health professional, peer leader,
A health professional
Support)
Goal Setting)
or other patients, often in a group
setting
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“CONSCIENTIZATION” – awakening of critical
consciousness, which is…
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A critical element of “LIBERATORY
EDUCATION”, which then leads to…
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PRAXIS – action needed for transformational
behavior
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The first and most important step in the
Transformational Process: facilitating
the patient’s movement from Preconsciousness to Critical
Consciousness….
MAGIC CONSCIOUSNESS
 A person simply faces facts and attributes to them a superior
power by which he is controlled and to which he must submit –
characterized by fatalism. Que sera, sera
NAÏVE CONSCIOUSNESS
 The person sees cause and effect as an unchanging established
fact which can be deceiving – a person with naïve consciousness
considers himself superior to facts, in control of facts, and thus
free to understand them as he pleases.
CRITICAL CONSCIOUSNESS
 A person who has reached the critical consciousness thinks of
things and facts as they are objectively in reality; it is integrated
with reality. Critical understanding leads to critical action.
THE NATURE OF HEALTH CARE RECEIVER
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Limited knowledge – naïve consciousness
Different competencies and skills in self-care and care
of others
Adherence skills to comply with treatment plan varies
along a range or continuum
Self-defeating and dysfunctional life styles may be
present driven by individual and family forces
Limited internal and external resources
Limited knowledge of internal and external resources
THE NATURE OF HEALTH CARE PROVIDER
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Specialized knowledge – expertise
Plenty of experience, frequently of a technical nature
Clinical skills vary along a range or extent
Level of compassion for others vary along a range or
extent
Works within a context of limited time and resources to
support task achievement
Works within a practice setting that frequently may not
be particularly supportive or compassionate
Applicable community resources are fragmented
and/or unknown
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Creating an environment where patients open up
to you as a provider
◦ How do you do this?
 Find out what patient expects from you as a
provider
 What patients needs?
 Get on the patient’s level – language barriers
 Find out what patient is willing to do
 Starts out with the very first encounter –
phone, face-to-face
 Identify with the patient – start where the
patient is, relationship-building
Creating an environment where patients open up to
you as a provider
How do you do this when you do not
speak the same language as the patient?
How do you do this when the patient is
hostile or uncooperative?
How do you do this when the patient is in
denial?
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Individual’s
motivational system
is awakened by
critical consciousness
Capacity for the
transformative
process is assessed
Development of selfefficacy to begin
changing lifestyles
and behaviors
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Actualization of
decision to change
Acceptance of
responsibility
Acceptance of
consequences and
outcomes
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Direct involvement
in the health care
process
Requires a great
deal of critical
awareness or
awakening
Requires
relationship
building
Implementation
Avoidance in Goal
Setting: Identify
Barriers and
Facilitators
Facilitation of
Evaluation of
Outcome
Motivational
Interviewing
Promotion of
Effective Use of Social
Support
Guidance in
Modification of Goals
if Outcomes Not Met
Self-Efficacy
Enhancement
Identification of
Social Support
SELF-EFFICACY
Choice behavior
 Effort expenditure and persistence
 Thought patterns and emotional
reactions
 Humans as producers rather than
simply foretellers of behavior
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 Mastery
experience
 Vicarious experience
 Social persuasion (including
verbal persuasions)
 Physiological states
 Self-Efficacy
for Managing
Chronic Disease 6-Item Scale
 Self-Efficacy for Diabetes
 Measure of Patient Adherence
(MOS)
Realistic goal setting
for behavior change
Maintenance of
Goals
Apprehension of
realities and
readiness to change
Effective use of
social support in
behavior change
Continued Positive
Behaviors
Enhanced Selfefficacy for health
behavior change
Intention to Adapt
Positive Changes
Behavoiral Outcomes
PROCHESKA & DICLEMENTE
permanent
exit
resumed use
pre-contemplation
contemplation
maintenance
preparation
preparation
action
Return to old habits
Change become
permanent
Not thinking
about change
Thinking
about change
Preparing for
change
Maintaining change
Taking action
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How important is it to you to change this?
0…..1…..2…..3…..4…..5…..6…..7…..8…..9….
.10
Not at all
Extremely
How confident are you that you can change
this?
0…..1…..2…..3…..4…..5…..6…..7…..8…..9….
.10
Not at all
Extremely
For individuals to progress, they need:
 A growing awareness that the advantages (the
“Pros”) of changing outweigh the disadvantages
(the “Cons”)—the TTM calls this decisional
balance
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Confidence that they can make and maintain
changes in situations that tempt them to return
to their old, unhealthy behavior—the TTM calls
this self-efficacy
Strategies that can help them make and maintain
change—the TTM calls these processes of
change. The ten processes include
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Consciousness-Raising
Dramatic Relief
Self-Reevaluation
Environmental Reevaluation
Social Liberation
Self-Liberation
Helping Relationships
Counter-Conditioning
Reinforcement Management
Stimulus Control
Constructs
Implementation
Behavioral
Outcomes
Targeted
Goals
Met