Goal Driven Treatment (Introduction to the Transformation for
Health Model)
RHP 12 Learning Collaborative Package Two (Topic One)
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
Objectives
Determinants of Health Status (from expert
consensus; Shi; Blum)
Health Status (100%)
Genetics (10%)
Medical Care (10%)
Environment (40%)
Behavior (40%)
Physical
Barriers
Financial
Education/Literacy
Nutrition & Exercise
Lifestyle choices
Employment
“An approach is needed to help patients change or adopt healthy behaviors – by
themselves, not for them by others” (Paulo Freire)
Transformation for Health
Transformation for Health Logic Model Phase One
Issue Traditional Patient Education Self-Management Education
What is taught? Information and technical skills about the disease
Skills on how to act on problems
How are problems formulated? Problems reflect inadequate control of the disease
The patient identifies problems he/she experiences that may or may not be related to the disease
Relation of education to the disease
Education is disease-specific and teaches information and technical skills related to the disease
Education provides problem-solving skills that are relevant to the consequences of chronic conditions in general
What is the theory underlying the education?
Disease-specific knowledge creates behavior change, which in turn produces better clinical outcomes
Greater patient confidence in his/her capacity to make life-improving changes (self-efficacy) yields better clinical outcomes
What is the goal? Compliance with the behavior changes taught to the patient to improve clinical outcomes
Increased self-efficacy to improve clinical outcomes
Who is the educator? A health professional A health professional, peer leader, or other patients, often in a group setting
Constructs
Cognition (Critical Consciousness)
Intention (Self-Efficacy & Social
Support)
Decision (Barriers and Facilitators for
Goal Setting)
Transformation (Self Guided Evaluation & Goal Modification)
Implementation
“CONSCIENTIZATION” – awakening of critical consciousness, which is…
A critical element of “LIBERATORY EDUCATION”, which then leads to…
PRAXIS – action needed for transformational behavior
Cognition Phase
The first and most important step in the Transformational Process: facilitating the patient’s movement from Pre-consciousness to Critical Consciousness….
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.
Stages in critical consciousness
THE NATURE OF HEALTH CARE RECEIVER
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
FACILITATING CRITICAL CONSCIOUSNESS
THE NATURE OF HEALTH CARE PROVIDER 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
FACILITATING CRITICAL CONSCIOUSNESS
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
Facilitating Critical Consciousness
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?
Facilitating Critical Consciousness
Creating an environment where patients open up to you as a provider
Individual’s motivational system is awakened by critical consciousness
Capacity for the transformative process is assessed
Development of self-efficacy to begin changing lifestyles and behaviors
Intention Phase
Actualization of decision to change
Acceptance of responsibility
Acceptance of consequences and outcomes
Decision Phase
Direct involvement in the health care process
Requires a great deal of critical awareness or awakening
Requires relationship building
Transformation Phase
Transformation for Health Logic Model Phase Two
Implementation
Motivational Interviewing
Self-Efficacy Enhancement
Identification of Social Support
Promotion of Effective Use of Social Support
Avoidance in Goal Setting: Identify
Barriers and Facilitators
Facilitation of Evaluation of
Outcome
Guidance in Modification of Goals if Outcomes Not Met
Choice behavior Effort expenditure and persistence Thought patterns and emotional
reactions Humans as producers rather than
simply foretellers of behavior
How does self efficacy affect behavior
Mastery experienceVicarious experience Social persuasion (including verbal persuasions)
Physiological states
SOURCES OF SELF EFFICACY INFORMATION
Self-Efficacy for Managing Chronic Disease 6-Item Scale
Self-Efficacy for DiabetesMeasure of Patient Adherence (MOS)
Self-Efficacy Measurement Tools
Transformation for Health Logic Model Phase Three
Behavoiral Outcomes
Apprehension of realities and
readiness to change
Enhanced Self-efficacy for health behavior change
Intention to Adapt Positive Changes
Effective use of social support in behavior change
Realistic goal setting for behavior
change
Maintenance of Goals
Continued Positive Behaviors
Transtheoretical Stages of ChangeProchaska & DiClemente
permanent exit
maintenance
resumed use pre-contemplation
contemplation
preparation
action
preparation
Adapted Stages of Change
Not thinking about change
Thinking about change
Preparing for change
Taking action
Maintaining change
Return to old habits
Change become permanent
Ruler Scale
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
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
Progression Through the Stages
Consciousness-Raising Dramatic Relief Self-Reevaluation Environmental Reevaluation Social Liberation Self-Liberation Helping Relationships Counter-Conditioning Reinforcement Management Stimulus Control
Strategies
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