HEALTH

EDUCATION

VENTURA, ANA KATRINA N.

BSN- 1 ERIKSSON
 Nuggets of Wisdom
“What you are is God’s gift to you. What you do with your life is your gift to God”.
-Danish proverb

CHAPTER 1
CONCEPTS OF HEALTH AND WELLNESS
Health is a word that was derived from the old English word for heal which is
HAEL. It means whole because health concerns the whole person and his/her integrity,
soundness or well-being and that the person functions as a complete entity or unit and
that the body, mind and spirit are one. “In the natural world, there is no mind-body
split. Rather, mind, body, and spirit are intricately connected.” (Edmands, et al,
1999).

Thus, holistic nursing intervention focuses on the total care of the individual as
a complete being rather than on fragmented care which focuses only on the part or
parts which are not healthy or functional. The nurse or health provider should always
keep in mind this intrictae relationship in providing nursing care. An example would be a
person who is physically ill may also experience psychosocial imbalance because he/she is
anxious of being absent from work and the resulting loss od income or work backlog. Thus,
the patient may appear uncooperative, hostile or even resentful of the care that is being
given by the healthcare provider. Knowledge of the theory of holism allows the nurse to
understand the patient with compassion and caring and to treat him/her as a family
member and not simply a “case” or “room number”.

Health is holistic (total health) and it includes the different dimensions of health
taking into account the separate influences and interaction of these dimensions
(Aggleton and Homans. 1987)

Figure 1.

DIMENSIONS OF HEALTH
The dimensions of health are composed of the:

1. Broader dimensions of health in the outer circle:

a. Societal health which is the link between the health and the way a society is
structured. This includes the basic infrastructure necessary for health (e.g.
shelter, peace, food, income) and the degree of integration or division within
the society; and,
b. Environmental health which refers to the physical environment where people
live; it involves housing, transport, sanitation, pollution and pure water facilities.
2. Individual dimensions of health in the inner circle:
a. Physical health which refer to the state of one’s body like its fitness and not
being ill;
b. Mental health referring to the positive sense of purpose and underlying belief in
one’s own worth (self-esteem) like feeling good and feeling able to cope;
c. Emotional health which is the ability to express one’s feelings appropriately and
to develop and sustain relationships. An example is the feeling of being loved;
d. Social health which involves the support system that is available from family
members and friends. Having friends to talk to and being involved with activities
in the community or school contributes to social health. Remember the adage,
“No man is an island”;
e. Spiritual health which is the recognition of a Supreme Being or Force and ability
to put into practice one’s moral principles or beliefs;
f. Sexual health which refers to the acceptance of and the ability to achieve a
satisfactory expression of one’s sexuality.

The World Health Organization (WHO, 1946) defines health as a “state of

complete physical, mental, and social well-being and not merely the absence of
disease and infirmity (weakness or inability to perform activities of daily living to
one’s fullest capacity due to lack of strength).

This concept of all dimensions beinng in a state of “completeness” seems

unattainable. Cottrell (2001) claims that the WHO definition is an ideal state which is just
a “goal to strive for” but can never be achieved since no one can ever attain a “state of
complete mental, physical and social well-being.

 Since there are different levels of health ranging from good health to poor health,
the the definition of health should be expressed as “ a state of mental, physical,
spiritual and social well-being and not merely the absence of disease or infirmity”
where it is conceptualized holistically.

Key words: Goodstadt, et al (1987) as cited by Cottrell (2001)

1. Physical health- is th biological integrity of an individual where there is optimum
functioning of his physical and physiological abilities and freedom from any disease or
disability
2. Mental health (or psychological health and emotional health)- is the subjective sense of
well-being; may also refer to intellectual capabilities
3. Social health- is the ability to interact effectively with other people and the social
environment; development and sustenance of satisfying interpersonal relationships; and
effective and efficient role fulfillment
4. Spiritual health or role personal health; it may be concerned with one’s belied in a
transcending, unifying force (whether its basis is in nature, scientific law or a godlike
source. It has also been associated with the concept of self-actualization and or
concern for issues which affect one’s value system

Orem defined health as “ a state characterized by soundness and wholeness of human

structures, bodily and mental functions.

Health is considered as the goal of public health in general and of community health
nursing in particular. The modern concept of health refers to the “optimum level of
functioning” (OLOF) of individuals, families and communities which is affected by several
factors in the ecosystem.

Factors in the Ecosystem which Affect the Optimum Level of Functioning (OLOF)
1. Political factors- refers to the power and authority to regulate the environment
and the social climate bu the politicians and decision makers especially on laws and
policies which impact on health, the health care delivery system and the practice of
nursing profession.
Ex. Safety, oppression, people empowerment, health care that is accessible
to all especially the marginalized sectors of society
2. Behavioral factor- a person’s level of functioning is affected by certain habits,
lifestyle, health care and child rearing practices which are determined by the
culture and ethnic heritage.
ex. Culture, mores or one’s way of life, ethnic customs and traditions
3. Heredity factor – factors which are determined by heredity which is the genetic
make-up of a person like inherited disease and genetic risks
Ex. Congenital defects. Risk which are familial, ethnic or racial
4. Health care delivery system- is the totality of all policies, infrastructures,
facilities, equipment, products, human resources and services which address the
health needs and concern of the people.
 Primary health care is a partnership approach to the effective provision of essential
health services that are community-based, accessible, acceptable, sustainable and
affordable. It is health care that is provided at the barangay health stations and rural
health units that is focused on prevention of illness and promotion of health.

a. Promotive care- which is concerned with the promotion of health through

health teachings and observance of healthy habits and lifestyle which is the
primary duty of the nurse and midwife in the community.
b. Preventive care-prevention or avoidance of illness through health teachings,
home visits by nurses/midwives and regular health check-ups, proper
implementation of EPI or expanded program of immunization and other
follow-up.
vaccinations, personal hygiene especially regular and proper handwashing,
observing environmental sanitation.
c. Curatuve care- this is usually the secondary level of care given by physicians
in privately owned or government opetated health facilities like infirmaries,
municipal and district hospitals and OPDs of provincial hospitals where sick
members of the community go for consultation or confinement or are
referred to by primary health facility.
d. Rehabilitative care- this involves more of the tertiary level of care for
patients who have incurred disability (partial or total) but who are subjected
to physical, psychological, emotional and spiritual therapy or treatment.
5. Environmental influences-menace of pollution, communicable diseases due to poor
sanitation, poir garbage collection, smoking, utilization of pesticides lack or absence
of proper and adequate waste and sewerage disposal system and management,
urban/rural milieu, noise, radiation and air and water pollution are just some of the
factors or situations which exert negative effects on the environment and the
destruction of the environmental resources
6. Socio-economic influence - families in lower income group are the ones mostly
served particularly those coming from the DOPE (depressed, oppressed, powerless
and exploited) sectors of society.
Ex. Availability and type of employment, level of education, the availability,
type and location if housint from work. Studies have shown that the high level of
pollution and the poor conditions of sanitation and ventilation in some factories ,
which are dubbed as "sweatshops", contribute to the high incidence of pulmonary
tuberculosis among Filipino breadwinners.
 Concepts of Health, Illness and Wellness in Relation to Health Education

Concepts of health and wellness

Health as a Basic Human Right is embodied in:

1. Universal declaration of Human Rights, article 25, section 1 which states that: "Everyone
has the right to a standard of living adequate for the health and well-being of himself and
of his family, including food, clothing, housing and medical care and necessary social
services and the right to security in the event of unemployment, sickness, disability,
widowhood, old age or lack of livelihood in circumstances beyond his control."

2. Philippine Constitution of 1987, Article XIII, section 11, states that: "The State shall
adopt an integrated and comprehensive approach to health development which shall
endeavor to make essential goods, health and other social services available to all the
people at affordable cost. There shall be priority for the needs of the underprivileged,
sick, elderly, disabled, women and children. The State shall endeavor to provide free
medical services to paupers.

3. WHO 1995 believes that "governments have a responsibility for the health of their
people which can be fulfilled only by the provision of adequate health and social measures.
It emphasizes three basic positive concepts of health which are:

a. Reflecting concern for the individual as a total person

b. Placing health in the context of the environment

c. Equating health with productive and creative living

Health and Wellness as Conceived in Today's World

 Greenberg (1992) and Donatelle and Davis (1996) viewed the philosophy of wellness
as a positive quality (as opposed to illness being always negative) and visualized it as
the integration of the spiritual, intellectual, physical, emotional, environmental and
social dimensions of health to form a whole "healthy person". This philosophy of
wellness is grounded on the belief that everyone can achieve optimal health and
achieve some level of wellness when they have developed the six dimensions of
health yo the best of their ability.
 Dunn (1977) emphasized high-level wellness (HLW) as "an integrated method of
functioning which is oriented toward maximizing the potential which the individual is
capable of. It is the ability to maintain a continuum of balance and purposeful
direction within the environment where he/she is functioning."
 Health and wellness are two concepts which have been used interchangeably to
mean the ability "to live life fully with vitality and meaning". But there is really a
difference. Some aspects of health are determined by genes, age and other factors
which may be beyond one's control. Whereas, wellness is largely determined by the
decisions you make about how to live your life.

Wellness is now the new health goal. It really is:

• a state of mind (awareness of the choices available for a healthy lifestyle), a way of life
which involves options that an individual takes to enjoy a healthy life

• the perception that one is capable of achieving one's full potentials through the options
one has in relation to being well.

• the integration of the mind, body and spirit

• the level of self-actualization where one feels that he has lived a full and accomplished
life.
 SUMMARY

The emphasis on the promotion of health and prevention of illness is the primary concern
of individuals, groups, communities and nations especially since today's demands on one's
health have posed a serious threat to the general population.

The D. O. P. E. (Depressed, oppressed, powerless and exploited) sector of society is

primarily victimized due to poverty, lack of education and opportunities for employment of
entrepreneurship. They are subjected to environmental conditions which are not even fit
for human habitation exposing them to the perils of disease and risks to their personal
safety.

The more affluent people are subjected to health risks and problems which are lifestyle-
related since they can buy expensive but cholesterol-rich foods, pack(s) of cigarettes per
day, alcoholic drinks and indulge in late-night to early-morning activities.

Health and wellness are often used interchangeably as being synonymous to "living life with
energy, meaning and fulfillment. But there is really a difference. On one hand, wellness is a
person's state of mind or perception which allows one to reach his/her potentials to the
maximum and be able to engage in healthy behaviors in order to live a full and healthy life.
On the other hand, contemporary definition of health is based on the concept of "optimum
level of functioning" (OLOF) of individuals, families and communities. Unlike wellness, one's
health is affected by several factors in the ecosystem which makes attainment of health
difficult or even beyond the control of the individual.
 CHAPTER II

HISTORICAL DEVELOPMENT AND CONCEPTS OF HEALTH EDUCATION

Health education is any combination of learning experiences designed to facilitate voluntary

adaptations of behavior conductive to health (Green, et al, 1980).

Health education is a science and a profession of teaching health concepts to promote,

maintain and enhance one’s health, prevent illness, disability and premature death through the
adoption of healthy behavior, attitudes and perspectives. It draws health models and theories from
the biological, environmental, psychological, physical and medical and even paramedical science like
nursing.

Health education is any combination of planned learning experiences based on sound

theories that provide individuals, groups and communities the opportunity to acquire information
and the skills needed to make quality health decisions. -Joint Committee on Health Education and
Promotion Terminology of 2001. The areas of concern are physical health, social health, emotional
health, intellectual health, environmental health and spiritual health.

Health Education (World Health Organization) “comprises of consciously constructed

opportunities for learning involving some form of communication designed to improve health
literacy, including improving knowledge and developing life skills which are conducive to individual
and community health.”

What is the purpose of health education?

Health education aims to positively influence the health behavior and health perspectives of
individuals and communities for them to develop self-efficacy to adopt healthy life styles resulting
to healthy communities.

Importance of health education

1. Health education empowers people to decide for themselves what options to choose to
enhance their quality life.
2. Health education equips people with knowledge and competencies to prevent illness, maintain
health or apply first aid measures to prevent complications or premature deaths and
improves the health status of individuals, families, communities, states and the nation.
3. Health education enhances the quality of life by promoting healthy lifestyles.
4. Health education creates awareness regarding the importance of preventive and promotive
care thereby avoiding or reducing the costs involved in medical treatment or hospitalization.
Legal Basis of Health Education in the Nursing Curriculum

The teaching function has always been viewed as an essential function of a nurse whether
she is taking care of a well or an ill person, patient’s family members, nursing students, hospital or
clinical staff nurses or a group of mothers in the community. Some authors have argued that nurses
may not be adequately prepared to assess the learner’s needs or even implement the appropriate
teaching strategies, approaches and use of learning materials.

One of the more important functions of the nurse is as a health educator and this is
explicitly stated in The Duties of a Nurse in Rule IV, Sec. 28 of the Philippine Nursing Act of 2002
also known as RA 9173, among which are to:

a. provide health education to individuals, families and communities

b. teach, guide and supervise students in nursing education
c. implement programs including the administration of nursing services in varied settings
like hospitals and clinics.

Specifically, it states that “The nursing education program shall provide sound general and
professional foundation for the practice of nursing taking into consideration the learning outcomes
based on national and universal nursing core competencies. The learning experience shall adhere
strictly to specific requirements embodies in the prescribed curriculum as promulgated by the
Commission on Higher Education’s policies and standards of nursing education”.

Functions of a Professional Health Educator

1. Assess individual and community needs and capabilities and identify both internal and
external resources in the community
2. Plan, develop and coordinate with the different health and government agencies and NGOs
regarding the health education programs
3. Do community organizing and outreach
4. Conduct staff training and consult with other health care providers about behavioral,
cultural or social barriers to health
5. Conduct regular periodic evaluation of health education programs
6. Make referrals
7. Develop audio, visual, print and electronic materials to be used for training and conduct of
health education classes
8. Conduct research work and write scholarly articles
 The role of the Health Educator

A health educator is “a professionally prepared individual who serves in a variety of roles and is
specifically trained to use appropriate educational strategies and methods to facilitate the
development of policies, procedures, interventions and systems conducive to the health of
individuals, groups and communities” (Joint Committee on Terminology, 2001, p 100). The Health
Educator’s role is to help promote, enhance and maintain the health of others.

In January 1979, the Role Delineation Project was undertaken to better understand the role
of a health educator. A framework for the Development of Competency-Based Curricula for Entry
Level Health Educators (NCHEC,1985) and the revised version, A Competency-Based Framework for
the Professional Development of Certified Health Education Specialists (NCHEC, 1996), identifies
the framework which consists of seven areas of responsibility of the health educator, namely:

7 Areas of responsibility

1. Implement health education strategies, interventions and programs

2. Administer health education strategies, interventions and programs
3. Conduct evaluation and research in relation to health education
4. Serve as a health education resource person
5. Assess individual and community needs for health education
6. Plan health education strategies, interventions and programs
7. Communicate and advocate for health and health education
 Seven areas of responsibility of a health educator

The Teaching of Health Education

In the United States some forty states require the teaching of health education. A
comprehensive health education curriculum consists of planned learning experiences which will
help students achieve desirable attitudes and practices related to critical health issues. Some
of these are:

1. Emotional health and a positive self-image

2. Appreciation and care of the human body and it’s vital organs
3. Physical fitness
4. Health issues if alcohol, tobacco, drug use and abuse
5. Health misconceptions and myths
6. Effects of exercise on the body systems and on general well-being.
7. Nutrition and weight control
8. Sexual relationship and sexuality
9. The scientific, social and economic aspects of community and ecological health
10. Communicable and degenerative disease including sexually transmitted infections
11. Disaster preparedness
12. Safety and driver education
13. Environmental factors and how those factors affect an individual’s or population’s
environmental health (ex. Air quality, water quality, food sanitation); life skills; choosing
professional medical and health services: and choices of health careers.
 Organizational and Agencies Promulgating Standards

In the Code of Ethics of the Society for Public Health Education, Inc. (SOPHE) it states
that “Health educators take on profound responsibilities in using educational processes to promote
health and influence well-being”. In the Code of Ethics (Unabridged Version), Society for Public
Health Education, Inc., Article IV deals with the Responsibility in Employing Educational Strategies
and methods and states that, “In designing strategies and methods, the health educator…. Should
be aware of his/her possible impact on the community and other health professionals and must not
place the burden of change solely on the target population but must involve other appropriate
groups to bring about effective change.

B. Issues and Trends in Health Education

Trends Impacting on Health Care

1. Social- demographic trends like aging of the population requires emphasis on self-reliance
and maintenance of a healthy life status over an extended lifespan particularly dealing with
degenerative disease and disabilities; lifestyle-related diseases which are the major causes
of morbidity and mortality are highly preventable and will need more intensive health
education efforts.
2. Economic- the shifts in payer coverage, emphasis on managed care and earlier hospital
discharge, and the issue on reimbursement for health services provided require more
intensive patient education to allow the patient and his family a more independent, compliant
and confident management of care.
3. Political- the federal government has formulated national goals and objectives directed
towards the development of effective health education programs which will create
awareness of health risks and encourage the adoption of healthy lifestyles. The role of
health education in promotion of health and prevention of illness in containing the cost of
hospitalization and healthcare expenses has already been recognized by politicians and
healthcare administrators.

Health Issues: Biological, Psychological and Sociological Aspects of Health and Disease
(Biopsychosocial model or BPS, Santrock, J.W. (2007).)
 George L. Engel, a psychiatrist at the University of Rochester, introduced the
Biopsychosocial model or “BPS” in 1977 (Engel, George L.) where he advocated the need for
a new medical model to explain health and disease. However, prior to this, evidence for the
application of the biopsychosocial model was already found in ancient Asian (2600 B. C.) and
Greek (500 B.C.). Although there have been criticisms posed against this model, it has
provided a general framework to guide a great deal of researchers on health behavior
models like the social-cognitive models which include Bandura’s Self-efficacy model, Health
Belief Model and others.

The biopsychosocial model (“BPS”) is an approach that states that human

experience of health or illness is greatly affected or determined by the interplay or
interrelatedness of the following factors:

1. Biological- concerned with the functioning of the different organ systems of the body and its
coping or adaptive mechanisms like immunity level, genetic susceptibility or predisposition
2. Psychological- perceptions, thoughts, emotions, attitudes and behaviors
3. Social factors- socioeconomic status, cultural beliefs and practices, poverty, technology,
environmental influences and conditions

This model shows a direct link between the mind and the body and an indirect link with the
intervening social or environmental factors to explain disease causation.
The biological component seeks to explain the cause of illness or disease as a result of the
breakdown in the physical or physiological functioning of the body.
The psychosocial aspect deals with how the individual perceives the health threats and the
state of emotional control, discipline and motivation to stay healthy. Psychosocial factors can
cause a biological effect by predisposing the patient to risk factors and risk-taking behaviors.

Example: A depressed person may become an alcoholic to temporarily forget his/her

problems which may lead to liver cirrhosis and even death.

The social or sociological factor is concerned with the individual’s perception of his/her
ability to deal with the health threats or health problems and the barriers posed by the society
or the environment towards the attainment of health and healthy lifestyle. This is in line with
Bandura’s social cognitive theory dealing with self-efficacy. In contrast to the traditional
approach which explained the disease process as a result of a malfunction or breakdown in the
biological functions of the body which is caused by pathogenic microorganisms, congenital
anomaly or trauma to the organ system(s), the Biopsychosocial model (BPS) states that the
disease process is due to the combination of all three factors. This is more in consonance with
Holism or the holistic approach to health which can only be done through the multidisciplinary
approach to healthcare which is being followed by US and other European countries.

Characteristics of Effective Health Education (Hubley, 1983):

 a. It is directed at people who are directly involved with health-related situations and
issues in the home and the community like parents and people who have influence in the
community or the so-called opinion makers
b. The lessons are repeated and reinforced over time using different methods
c. The lessons are adaptable and use existing channels of communication
Ex. Songs, drama and story telling
d. It is entertaining and attracts the community’s attention
e. Uses clear, simple language with local expressions
f. Emphasizes short term benefits of action
g. Provides opportunities for dialogue, discussion and learner participation and feedback
h. Uses demonstration to show the benefits of adopting the practices

Relationship Between Health Education and Health Promotion

The primary role of health educators is to develop appropriate health education programs in
consultation with the people they serve through:

a. Planning
b. Implementing
c. Evaluating the health plans/programs

Steps in developing a health education/promotion program (Cottrell et al, 2001):

a. Assessing the needs of the target population

b. Developing appropriate goals and objectives
c. Creating an intervention that considers the peculiarities of the setting
d. Implementing the intervention
e. Evaluating the results

Health Education Today and Future Trends

Due to the heightened technological advances which are occurring by the nanosecond, the
health educator is faced with enormous challenges as well as opportunities due to the increasing
demand of society for health education and preventive care and the heavy reliance on technology
for the delivery and acquisition of information via the information highway or internet.
 Today, we see a return to population-based health promotion and maintenance vis-à-vis the
hospital-based emphasis and preference for healthcare during the last few decades. Its emphasis is
on the health of the community and the adaptation of healthy behaviors and lifestyle through
health empowerment of the people.

Thus, today’s health educator is also considered as a Community Health Worker whose main
concern is to improve the health of the people by using different methods and strategies.

The call for developing global health strategies with the integration of health education and
action is now a clamor that can no longer be ignored. Globalization, war, terrorism, social instability,
disease, poverty and environmental degradation are among the key challenges facing the world
today (Otieno, 2005). The pandemic AH1N1 Influenza, HIV/AIDS and severe acute respiratory
syndrome (SARS), as well as bio-terrorism preparedness receive utmost priority and attention from
the governments of different nations. Clear strategies for global health capacity-building at the
national level must be developed as well as adequate training for public health professionals where
concerted action is undertaken to build their capacity must be given top priority. The development,
testing and validation of global health training and action are therefore necessary in integrating
theory, practice and policy domains. The outcomes of such initiatives have the potential for
facilitating learning and teaching on critical health challenges in the twenty-first century.

Emerging Trends in Health Care

In the United States of America, patients are being discharged quicker due to the

1. New “healthcare economics”

a. There is the present emphasis on primary care and the continuing development of
managed care which advocates the early discharge of clients from the hospital to
reduce healthcare insurance costs and prevent “overtreatment of patients” which are
unethical practices of some doctors and hospitals. This is mandated by the managed
care programs in the US (Rodwin 1993, Vandenburgh 1999)
A new stress on health outcomes, as opposed to structures or processes of care
(Health Outcomes Methodology, 2000) is being done to find out if the centers have
the requisite number of qualified medical directors, nurses, physical therapists,
autoclaves, elevating beds, policies and so forth. Recommendations were also issued
by the Agency for Health Care Research and Quality which attempted to
standardize medical practice for several diseases based on studies determining the
most effective care.
b. Providers will increasingly establish “centers of excellence” to provide services
effectively and at moderate cost (Weiss 1990). Only a few centers will perform given
operations. Physician resistance will occur, but the balance of power in health care has
already swung to payers (i.e., the insurance and managed care companies) who will use
these facilities instead of local hospitals, where cost and quality are currently not as
subject to the rigorous controls (Folland, Goodman and Stano 1997)
c. Decentralization of care, also known as Medical Prosumerism, is an emergent issue.
Prosumerism is a movement away from purchasing completed goods and services in favor
 of purchasing completed goods and services in favor of purchasing portions of them
piecemeal similar to the do-it-yourself movement in home improvement. “In health care.
Similar Prosumerism is encouraged by significant patient opportunities to gain knowledge
through the Internet and medical databases. Patients now frequently make their own
choices as to diagnoses, treatments, medical products and practitioners”. (Toffler 1980)
d. Alternative medicine is another form of Prosumerism (Goldstein 2000). Here, consumers
use a wide variety of folk practices to promote health and potentially cure diseases.
These practices range from the use of traditional herbs as medicines to the use of
meditation or guided imagery. Acupuncture, acupressure, aromatherapy, yoga and
massage therapy are other alternative interventions.
e. Medical Globalization. Like other industries, health care is increasingly subject to
globalization. Currently, U.S. citizens cross borders to purchase inexpensive medications
or ones not available in this country.
Increasingly, however, they also make the journey to Canada or Mexico to
obtain surgery or other complex procedures at cheaper prices. Savings result from
lower capital, administrative, nursing and other hospital staff costs in those
countries.
Medical globalization is a trend which is not new to the Philippines. This is
what now termed as medical tourism where centers of excellence or hospitals and
centers of excellence or hospitals and centers with world-class facilities or
amenities have become one of the foremost tourist attractions in the country.
Added to this is the reality that people from other countries obtain services and
costs of treatments and medications at a very reasonable and affordable price.
2. Advances in medical technology
The most current development in managed care is disease management (Hunter and
Fairfield 1997). Disease management system “seek to improve patient compliance with
optimal health behavior by promoting proper appointment keeping, self-administration of
treatments and proper general health behavior in terms of lifestyle issues.
These systems range from simple ticklers, where a nurse reminds patients to have
their lab values monitored, to home terminals or computers through which data are
monitored and clinical instructions received. It is not yet certain if disease management will
be cost saving and clinically effective, but there is potential for this to occur.
A common tool for patient education to conserve time and energy is closed-circuit
television where the patient stays in his room to watch the presentation. Drawbacks of this
methos include fixed or specific time of showing which may be not be conductive to learning,
absence of follow-up to clarify or explain grey areas and difficulty of assessing the
effectiveness of the program.

Future Directions for Patient Care

(Wasson and Anderson, 1993; Abruzzese, 1992; Anderson, 1990)

1. New settings and environmental linkages

a. Most teaching will occur in the ambulatory care setting
 b. Inter-organizational linkages to enhance cooperative endeavors in the patient education
enterprise will increase
c. More people are unhappy with orthodox medicine and are turning to alternative medicine
d. Changing demographics resulting in proportionally older population and a greater number
of minority (ethnic) groups with unique health challenges
2. New technologies
a. The use of computer-based instruction for hospitals, ambulatory care settings,
physician’s offices or homes will increase
b. The use od interactive video programs will increase resulting to greater access to
reliable information
3. Greater emphasis on wellness
a. Wellness screening programs will increase
b. Emphasis on illness prevention and health promotion such as nutrition, diet and exercise,
with various accompanying educational offerings, will increase
4. Increased third-party reimbursement as cost benefit ratios demonstrate the cost-
effectiveness of consumer education as shown by shorter hospital stay, effective and
efficient home and self-managed care, lesser incidence of complications and hospital
readmissions.

Theories in Health Education

One of the most common mistakes and sources of frustration of a health educator is to
“tell” the client what they need to know and expect them to obey and go through an attitude and
behavior change. More often than not, this produces negative results because the health educator
failed to conduct an assessment of the learning needs of that particular person or group which
could provide a sound basis for the teaching-learning activities.

In planning health education content, approaches, strategies and activities, there are
models or theories which explain human behavior in relation to health education.

These theories can be classified on the basis of being directed at the level of;

a. Individual (intrapersonal)
b. Interpersonal
c. Community

The most commonly used health theories are:

a. Pender’s Health Promotion Theory

b. Bandura’s Self-efficacy theory
c. Becker’s Health Belief Model
d. Green’s Precede-Proceed Model

1. Health Promotion Theory (Revised)

  This model was developed in 1987 and revised by Pender in 1996 “to increase the
utility of its predictions and interventions”. It is widely used in the field of nursing.
Salient points:
1. This model emphasizes “actualizing health potential and increasing the level of
well-being using approach behaviors rather than avoidance of disease that is why
it has been classified as a health promotion model rather than a disease
prevention model.
2. The six (6) major components and their variables (revised model) are:
A. Individual characteristics and experiences
a. Prior related behavior
b. Personal factors
B. Behavior-specific cognitions and affect
a. Perceived benefits of action
b. Perceived barriers to action
c. Perceived self-efficacy
d. Activity-related effect
e. Interpersonal influences
f. Situational influences
C. Behavioral outcome
a. Commitment to a plan of action
b. Immediate competing demands and preferences
c. Health-promoting behavior
D. Activity-related affect
E. Commitment to a plan of action

In nursing study (Johnson, et al, 1993), results showed that the modifying factors of age,
income, education and selected biological characteristics of body mass had indirect effects on
health-promoting lifestyles as proposed by the model.

2. Bandura’s Self-efficacy Theory (DeBarr K. A, 2004)

Social learning theory is the result of separate research by Rotter (1954) and Bandura
(1977). Bandura renamed the theory as Social Cognitive Theory to emphasize the cognitive aspect
of learning which explains human behavior by citing three factors which are in continuous
interaction resulting in a process of reciprocal determinism or triadic reciprocal causality namely:

1. Personal factors in the form of cognition, affect and biological events

2. Behavior
3. Environmental influences

These are very dynamic relationships where the person can shape the environment as well as
the environment as well as the environment shaping the person. Change is two-way or bi-directional.
 Social cognitive theory emphasizes that cognition plays a critical role in people’s capability
to construct reality, self-regulate, encode information and perform behaviors. In 1977, he
introduces the concept of self-efficacy into the theory (Pajares, 2002).

Self-efficacy is the single most important aspect of the sense that determines one’s effort
to change behavior according to Bandura. It is equated with self-confidence in one’s ability to
successfully perform a specific type of action.

Example: a person may experience high level of self-efficacy in preparing low salt, low
cholesterol diet but very little self-efficacy in performing the prescribed exercise regimen.

A person can increase self-efficacy through:

a. Personal mastery of a task

b. Observing the performance of others (vicarious experience)
c. Verbal persuasion, such as receiving suggestions from others
d. Arousal of her/his emotional state. In the construct of emotional coping responses, a
person must be able to deal with any sources of anxiety surrounding that behavior in
order to learn.

There are several constructs in Social Learning Theory (SLT) which help to explain learning.
One of these is the value expectancy theory:

Reinforcement=learning, but

Reinforcement + an individual’s expectations of the consequences of behavior=

behavior

According to SLT, reinforcement can be accomplished in one of the three ways:

1. Direct reinforcement-supplied directly to the person

2. Vicarious- the participant observes someone else being reinforced for behaving in an
appropriate or inappropriate manner. This has also been called social modeling or
observational learning.
3. Through self-management -involves record-keeping by the participant of her/his own
behavior. When the behavior is performed correctly, the person would reinforce or reward
herself/himself. The construct of self-control applies to this type of reinforcement since it
reflects the idea that individuals may gain control of their own behavior by monitoring it.

There are several other constructs which may be applicable to learning situations in health
education.

1. Behavioral capability refers to the knowledge and skills necessary to do a behavior which
influences actions. If individuals are to be able to perform specific behaviors, they must
first know what the behaviors are and how to perform them. Therefore, clear instructions
and/or training may be needed.
 2. Expectations refers to the ability of humans to think and therefore, to expect certain
situations.
3. Expectancies are the values that people place on an expected outcome. The more highly
valued the expected outcome, the more likely the person will perform the needed behavior
to yield that outcome.
4. Efficacy expectations- are feelings of competency
5. Outcome expectations- if a person believes that the outcome of the behavior
(reinforcement) is not great or good enough in terms of benefits, he/she may not attempt
the behavior inspite of the feeling of competency or efficacy expectations.

3.Health Belief Model (Rosenstock, Becker, Kirscht, et al.)

The health belief model (HBM) was one of the first models originally introduced by a group
of psychologists in the 1950’s to find out why people refused to use available preventive services,
such as chest x-rays for tuberculosis screening and immunizations for influenza. These researches
assumed that people feared diseases and that the health actions of people were motivated by the
degree of fear (perceived threat) and the expected fear reduction of actions, as long as that
possible reduction outweighed practical and psychological barriers to taking action (net benefits).

The HBM can be outlined using four constructs which represent the perceived threat and
net benefits:

1. Perceived susceptibility- a person’s opinion of the chances of getting a certain condition

2. Perceived severity- a person’s opinion of how serious the condition is
3. Perceived benefits- a person’s opinion of the effectiveness of some advised action to
reduce the risk or seriousness of the impact
4. Perceived barriers- a person’s opinion of the concrete and psychological costs of this
advised action

Another concept is known as cues to action. These are events (internal or external) which
can activate a person’s “readiness to act” and stimulate an observable behavior. Some examples
of external strategies to activate “readiness” are the information sought delivered in print with
educational materials or through any electronic mass media, reminders by powerful “others” or
persons of influence, persuasive communications, personal experiences and one-to-one
counseling.

Another concept that has been added to HBM since 1988 in order to better meet the
challenges of changing unhealthy habitual behaviors (such as being sedentary, smoking or
overeating) is self-efficacy. Self-efficacy, a concept originally developed by Albert Bandura in
social cognitive theory (social learning theory), is simply a person’s confidence in her/his ability
to successfully perform an action. Even though the HBM was originally developed to help explain
certain health related behaviors, it has also helped to guide the search for “why” these
behaviors occur and to identify points for possible change and to design change strategies like
developing messages that are likely to persuade an individual to make a healthy decision.
Health belief model
4.The PRECEDE-PROCEED Model (Bastable, 2003)
- was based on the epidemiological perspective on health promotion to combat the leading causes of
death. The acronym stands for the following:

PREEDE: Predisposing, Reinforcing and Enabling constructs in Educational Diagnosis and Evaluation.
This was developed by Greene, et al in 1980.

PROCEED: Policy, Regulatory and Organizational Constructs in Education and Environmental

Development. This component was added in 1999 by Green and Kreuter.

The core of this model is the definition of health education as “any combination of learning
experiences designed to facilitate voluntary actions conductive to health” (Greene and Kreuter,
1999). Health education is aimed primarily at planning experiences that are designed to “predispose,
enable and reinforce voluntary behavior conductive to the health of individuals, groups or
communities.” (Greene and Kreuter, 1999)

The phases in the PRECEDE component identify priorities and objectives while those in the
PROCEED component address criteria for policy, implementation and evaluation as influenced by the
diagnoses in the PRECEDE phases.

9 Phases of the PRECEDE-PROCEED Model:

1. Social diagnosis- begins with population self-study/assessment relative to the quality of life
2. Epidemiologic diagnoses
3. Behavior and environmental diagnoses
4. Educational and organizational diagnoses- addresses issues dealing with education
5. Administrative and policy diagnosis- addresses issues dealing with education
6. Implementation
7. Process evaluation
8. Impact evaluation
9. Outcome evaluation
 PRECEDE-PROCEED MODEL

Strength of this model: lies in its location of interventions from a population needs
perspective; has predictive value in predicting changes in health behavior.

Use of the theory: particularly relevant or useful to community health nurses since the
model notes that the “community is the center of gravity”
 SUMMARY

The health behavior of an individual is primarily influenced by the health

beliefs of the individual. Health beliefs are concepts or ideas about health which are
largely influenced by the individual’s physical, social, educational and cultural
backgrounds as well as his psychological status.

The health behavior models and theories can assist the nurses and other health
professionals from seeing the health concerns and problems from the client’s point of
view or perspective. These models provide a framework which guides the nurse in
assessing the learning needs of the patient and their family members and making
them active participants in planning the health instructions, interventions and outcome
expectation.

Assessing the client from a health belief perspective will provide the nurse with
a more complete insight into the clients into client’s specific concerns. Student nurses
can be trained using these models to teach in an interactive format by demonstrating
how the course content can be applied realistically in the clinical area and the
community
PAGES 71-97

CHAPTER IV

Applying Learning Principles and Theories to Healthcare Practice

Learning is a relatively permanent change in mental processing, emotional

functioning and/or behavior as a result of experience (Bastable, 2003). Learning is a
lasting or permanent change in behavior as a result of experience which is primarily
determined or influenced by the environment where the person is situated. It is a complex
process which involves changes in mental processing, development of emotional functioning
and social transactional skills which develop and evolve from birth to death.

Learning occurs as the individual interacts with his/her environment and

incorporates or applies new information or experiences to what he/she already knows or
has learned. Several environmental factors affect learning like society and culture, the
structure or pattern of the stimuli, the effectiveness or credibility of role models and
reinforcements, feedback for correct and incorrect responses and opportunities to
process and apply learning to new situations (Bastable, 2003). Learners also have their own
way of taking in and processing information (learning styles) and the type, nature and level
of motivation also affects learning.

Kinds of experiences facilitate or hinder the learning process

a. The teacher’s selection of learning theories to be applied and the structuring or

type of learning experience are very important considerations
b. The teacher’s knowledge of the nature of the learner, the materials to be learned,
teaching methods to be employed, communication skills and ability to motivate the
learner
c. The teacher’s ability to relate new knowledge to previous experiences, values, self-
perception and the learner’s readiness to learn are also some of the many factors
that may facilitate or hinder learning.
 I. COMMON PRINCIPLES OF LEARNING

There are ten (10) learning principles that can help motivate the learner (de Young., 2003).
Among these are:

a. Use several senses- when dealing with the question of how much people are able to
retain 10% of what they read, 20% of what they hear, 30% of what they see or
watch, 50% of what they see and hear, 70% of what they say and 90% of what they
say and do. This is shown by the learning experience cone below.

This is the importance of the RLE (Related Learning Experience) which nursing

students undergo in the Nursing Skills Laboratory where:

 They are made to imitate the procedures that are demonstrated by the instructors
(role-modeling)
 Are graded according to the skills they exhibit and the degree of comprehension of
the rationale behind the steps in the procedures as they perform the return
demonstration. It is expected that by imitating, they would be able to retain 70% of
the lesson.

By applying these skills and knowledge in the actual care of patients in the hospital, this
would be further reinforced by additional practice and review of the principles and
procedures and the extra care and caution in their application and performance resulting
to 90% retention.

b. involve the patients or clients in the learning process

 - Use more interactive methods involving the participation of the learners like
role-playing, buzz sessions, Q & A (questions and answer) format, case studies,
small group discussion, demonstration and return demonstration.
c. Provide an environment conductive learning
- Always consider the comfort and convenience of the learner (room temperature,
the chairs and seating arrangement or space, noise level, adequate acoustics and
sound system, and an environment that is clean, pleasant-smelling and smoke and
dust-free.
d. Assess the extent to which the learner is ready to learn
- Readiness to learn is affected by factors like emotional status (anxiety, fear
and depression) and physical conditions (pain, visual or auditory impairment,
anesthesia, etc.).
e. Determine the relevance of the information
- Anything that is perceived by the learner to be important or useful will be
easier to learn and retain.
f. Repeat the information
- Continuous repetition of information over a period of time enhances learning;
applying the information to a different situation or rewording it and giving
practical applications will help in the learning process.
g. Generalize information
- Cite applications of the information to a number of applications or situations
- Give examples which will illustrate or concretize the concept
h. Make learning a pleasant experience
- Give frequent encouragement, recognize accomplishments and give positive
feedback
i. Begin with what is known; move toward the unknown
- A pleasant and encouraging learning experience if information is presented in an
organized manner and with information that the learner already knows or is
familiar with.
j. Present information at an appropriate rate
- This refers to the pace in which the information is presented to the learner…
are you talking too fast so that the learner has a difficulty in catching up with
what you are saying or are you too slow because the learner is already
knowledgeable about the topic you are discussing?

4.) What helps ensure that the learning become relatively permanent?
 a. By organizing the learning experiences so that it becomes meaningful and
pleasurable; and by presenting the information at the learner’s pace to ensure
effective and efficient processing of information
b. Practicing or rehearsing new information mentally or physically to retain and
strengthen learning
c. Applying reinforcements through rewards or recognition to make the learner know
that learning has occurred
d. Assessing or evaluating whether learning has taken place immediately after the
experience or some later point in time. Evaluation feedback can be used to revise,
modify, revitalize or revamp the learning experiences.

II. Learning Theories

A learning theory is a coherent framework and set of integrated constructs and

principles that describe, explain or predict how people learn, how learning occurs and what
motivates people to learn and change (Bigge and Shermis,1992; Hilgard and Bower, 1996;
Hill, 1990). Some issues like how does learning take place, what ensure success or
contribute to failure in learning and what are the obstacles to learning have been the
concern of educators and educational psychologists.

Learning theories, teaching and learning techniques and strategies based on

scientific studies and principles and assessment and evaluation techniques have been given
more emphasis in what is now the trend of “mentoring the mentor” or “training the
trainer”.

Educational Psychology as Being Research-Based

 The start of the twentieth century saw the emergence of a new field known as
Educational Psychology which became the catalyst for the scientific study of
teaching, learning and assessment (Berliner and Calfee, 1996; Gage and Berliner,
1998; Woolfolk 2001). As such, it is concerned with systematic evidence and data-
gathering which are used to test theories and hypotheses about learning.

Why the Health Professional Needs to Know the Nature of the Learner

 Learning theories put together concepts and propositions to explain “why people
learn and predict under what circumstances they will learn” (de Young, 2003).
  There is no single theory that can be considered as the best answer to these
questions. The definition of learning generally depends on the perspective of the
learning theory that is being used.

Contributions of Learning Theories

1. Learning theories have helped us understand the process of teaching and learning
or how individuals acquire knowledge and change the way they think, feel and
behave.
2. In the practice of healthcare, these theories have helped the health professionals
to employ sound methods and rationales in their health education efforts involving
patients/clients, staff training and education and in carrying out continuing health
education and promotion programs.

To understand the nature of the learner, the health professional needs to know some basic
principles involved in the development and maturation of the individual. Human development
is the dynamic process of change that occurs in the physical, psychological, social, spiritual
and emotional constitution and make-up of an individual which starts from the time of
conception to death (from womb to tomb). It is the scientific study of the changes that
occur in people as they age or grow older in years. These changes may entail:

1. Growth which is quantitative involving increase in the size of the parts of the body.
2. Development which is qualitative involving gradual changes in character

As the person grows and develops, two (2) major processes take place which are:

1. Learning- any relatively permanent change in behavior brought about through

experience
2. Maturation- bodily changes which are primarily a result of heredity or the traits
that a person inherits from his parents which are genetically determined.
Preprogrammed inherited biological patterns are reflected in maturation.

The 5 major learning theories that are widely used in patient education and health care
practice are:

 Behaviorist
 Cognitive
 Social Learning
 Psychodynamic
 Humanistic
 I. BEHAVIORIST THEORIES OF LEARNING

John B. Watson is the proponent of behaviorist theory which emphasizes the importance
of observable behavior in the study of human beings. He defined behavior as muscle
movement and it came to be associated with the Stimulus-Response psychology. He
postulated that behavior results from a series of conditioned reflexes and that all
emotions and thoughts are a product of behavior learned through conditioning (de Young,
2003).

 Learning then, is a result of the conditions or stimuli (S) in the environment and the
learner’s response (R) that follow. This is known as the S-R model of learning or the
stimulus-response theory
 Behavioral scientists usually observe the responses and then manipulate the
environment to bring about the desired change. (Hilgard and Bower,1996; Bigge and
Shermis, 1992; Hill, 1990).
 To bring about the intended change in the attitudes and responses of the subject,
some stimuli in the environment are altered or the effects or consequences of a
response is changed.
 Motivation to change is brought about by the desire to reduce some drive or Drive-
reduction.
Consequences: Satisfied, complacent or satiated individuals have little motivation to
change and learn.
 For this behavior to be applied or transferred from the initial learning situation to
other settings or circumstances is possible through practice or formation of habits.

Behavioral learning is based on respondent conditioning and operant conditioning

procedures.

A.1. Respondent Conditioning

1. Classical or Pavlovian conditioning- a process which influences the acquisition of new

responses to environmental stimuli:

-a neutral stimulus (NS) elicits an unconditional response (UCR) through repeated

pairings with an unconditioned stimulus (UCS). A neutral stimulus (NS) is a stimulus
that has no particular value, significance or meaning to the learner. When the NS is
repeatedly paired with the unconditioned stimulus (UCS) and the unconditioned
response (UCR), there comes a time when the NS, even without the UCS, elicits the
same UCR.
Situation Illustration: Cecilia Belle, a pretty and lively three-year old, accidentally touched
the flame (NS) of the candle. She felt intense pain (UCS) and quickly withdrew her hand
(UCR). Two days later, the same experience happened and part of her finger was burned.
Consequently, the flame of the candle (NS) came to be associated with the pain (UCS)
that, even in its absence, just the sight of the flame makes her withdraw her hand. Hence,
the neutral stimulus (NS), which is the flame, has now become the conditioned stimulus
(CS) and the automatic withdrawal of her hand has become the learned response.

-Principles of respondent conditioning may also be used to extinguished a previously

learned response:

Learned responses may eventually be unlearned if the occurrence of a CS is not

accompanied by the UCS for a long period of time or interval.

2. Systematic desensitization is another technique based on respondent conditioning which

is widely used in psychology and even in medicine to reduce fear and anxiety in the patient
(Wolpe, 1982).

This is based on the principle that repeated and gradual exposure to fear-inducing
stimulus under relaxed and non-threatening circumstances will give the patient that sense
of security that no harm will come so that he or she no longer fears the stimulus.

This is also a stress-reducing strategy that is adapted to help preoperative

patients, rehabilitating drug addicts and tension headaches and phobias, among others
(Bastable, 2003).

3. Stimulus generalization is the tendency to apply to other similar stimuli what was
initially learned.
 Discrimination learning develops later when varied experiences eventually enable
the individual to differentiate among similar stimuli.
 Discrimination learning is often involved in professional education and clinical
practice.
4. Spontaneous recovery is usually applied in relapse prevention programs (rpp) and
may explain why it is quite difficult to completely eliminate “unhealthy habits and
addictive behaviors (alcoholism, drug abuse, smoking) which one may claim having
successfully “kicked the habit” or extinguished it only to find out that it may
recover or reappear any time, even years later.
 A.2. Operant Conditioning

-developed by B.F. Skinner which focuses on the behavior of the organism and the
reinforcement that follows after the response (Alberto and Troutman, 1990).

Reinforcements are events that strengthen responses. It is one of the most

powerful tools or procedure used in teaching and is a major condition for most learning to
take place. Its beginnings are traced back to Thorndike’s Law of Effect (1911) which
states that:

 “Of several responses made to the same situation, those which are accompanied or
closely followed by satisfaction will, other things being equal, be more firmly
connected with the situation so that when the situation recurs, these responses will
be more likely to recur
 Those responses which are accompanied or closely followed by discomfort will,
other things being equal, have their connections with that situation weakened, so
that when the situation recurs, the response will be less likely to recur.
 A reinforcer is a stimulus or event that is given, applied or elicited after a response
to strengthen or reinforce the possibility that the response will be repeated.
 When specific responses are reinforced on a proper schedule, the behaviors can be
increased or decreased.

Example: the child who is given a positive reinforcement like a reward or praise every time
he/she excels in school will be encouraged or motivated to maintain this behavior.

Operant Conditioning

 Learning in which the consequences of behavior lead to changes in the probability of

its occurrence.
 Thorndike’s puzzle box

Reinforcement in Learning: The teacher must know what behaviors should be

reinforced.

Positive Reinforcement

 Any consequences of behavior that leads to an increase in the probability of its

occurrence
 Timing
 Consistency
 Studies in positive reinforcement by Verplanck (1955) reveal that:
 In verbalization of opinions: each time the student says “I believe” or “I thinks
that” … and the experimenters would reinforce these by saying “You’re right” or “I
agree with you”, or they would smile or nod, the students would volunteer their
opinions more readily.
 When reinforcers were withdrawn and the answers were ignored or statements like
“I certainly disagree with you on that”, the number of opinion statements by the
students sharply declined. Anderson, White and Wash (1966) conducted studies
related to acts of praising vs. reproof:
a. Hypotheses:
H1 Praised students will perform better than reproved students
H2 Reproved low achievers and praised high achievers will perform better than
praised low achievers and reproved high achievers.
b. Subjects of the study: university students enrolled in a course in educational
psychology.
Testing and evaluation: An objective test of the subject matter was given as
criterion test and objective test in mathematics was given to determine if
behaviors would be transferred to a different subject area.
c. Results of the study:
There was greater achievement increment in performance affecting educational
psychology and mathematics using praise rather reproof with both the low
achieving and the high achieving students.

Application to Healthcare/Implications of the Study

1. Praise may assist in the transfer of learning from one area to another.
2. Learning under the control of reward is usually preferable to learning under the
control of punishment (Hilgard, 1956).

Ways of Employing Positive Reinforcement:

1. Verbal ways
 Saying praise words or phrases like “good”, “well-done” when the students
respond
 Statements like “That was a well-expressed opinion” or “I like the way you
answered the question of the patient’s mother” are morale-boosters.
  Requesting the student to share his success story with his classmates. This
gives recognition to the student and increases level of prestige with his
classmates
2. Non-verbal ways like nodding, smiling, looking pleased, writing student’s comments
on the board and giving the “thumbs up” sign especially where group work is
concerned.
3. Citing in class or publishing on the bulletin board exceptional works or outputs.

Classification of Educational Reinforcers (Tosti and Addison 1979)

1. Recognition includes
 Praise, certification of accomplishments
 Formal acknowledgements (awards, letters of recommendation,
testimonials)
 Informal acknowledgements (private conversations, “pat” on the
back
2. Tangible rewards- Grades, food (free lunch), prizes, certificates of
appreciation or citations
3. Learning activities- opportunity for desirable enrichment assignments
like membership in “honors” class, more interesting or more difficult
clinical assignments/
4. School responsibilities
 Opportunities for increased self-management and more
participation in decision-making
 Acceptance of suggestions for improving the curriculum
 Greater opportunity for selecting own goals for learning
experiences
 Greater opportunity to control own schedule and set own
priorities
5. Status indicators
 Appointment as a peer tutor
 Having own space (study corner, desk)
6. Incentive feedback
 Increased knowledge of examination scores
 Knowledge of individual contributions (helping others)
7. Personal activities
 Opportunity to engage in special projects
 Extra time off

NOTE: Remember that reinforcements should be appropriate or directly linked to the

learning tasks and student’s accomplishment. Its indiscriminate use may result to happy
students but not to productive students (Tosti and Addison, 1979). Negative
reinforcement is tantamount or synonymous to punishment. Behaviors may be decreased
through:

 Nonreinforcement by ignoring the behavior (whether it is desirable or undesirable)

 Or applying punishment immediately after the response and must be consistent and
at the highest “reasonable level. Cardinal rule of Operant conditioning is to punish
the behavior, not the person”.

II. Cognitive Theories of Learning

Cognition is more than knowledge acquisition. It stresses that mental processes or

cognition occurs between the stimulus (S) and the response (R).

 The learner’s goals and expectations are more important and the tension,
disequilibrium and imbalance that they cause which will act as their motivators.
 Transfer of learning occurs when the learner mediates or “acts on” the information
he/she gets or applies it in certain situations.
 It involves intelligence which is the ability to solve problems or fashion products
that are valued in more than one setting.
 It stresses the importance of “what goes on inside the learner” which involves the
individual’s cognitive processes of perception, thinking skills, memory and ways of
processing and structuring information (Palinscar, 1998) like:
 Perceiving the information
 Interpreting it based on what is already known and finally
 Reorganizing the information to come up with new insights or understanding

Perspectives of the Cognitive Learning Theory (Bastable, 2003)

I. Gestalt- refers to the configuration or patterned organization of cognitive

elements reflecting the maxim that the “whole is greater than the
sum of its parts.
- The gestalt perspective emphasizes the importance of perception in learning
which focuses on the configuration or organization of a pattern or stimulus.

Some principles of Gestalt which are related to healthcare:

1. Psychological organization is directed toward simplicity, equilibrium and regularity.

Example: Give the patient a clear and simple explanation of his disease
condition to allay his fears and uncertainties.
 2. Perception is selective which means that no one can attend or pay attention to all
the surrounding stimuli at the same time. An individual normally orients
himself/herself to particular stimuli and screens out other stimuli which is similar
to fine-tuning of perception
3. What individuals pay attention to or what they ignore may be affected by factors
like needs, personal motives, past experiences and the particular structure of the
stimulus or situation.
Example: A patient who is in pain or is worried about the payment of his/her
hospital bill may give very little attention to the health teachings that the
nurse is giving because at the moment, that is not his/her primary
considerations.

Implications to Health Care

Knowledge of this gestalt principle will help the health educator on how he/she approaches
any learning situation with an individual or group. One approach may be effective to a
particular client or group but may not work with another. Because individuals vary or differ
from one another, the way they perceive, interpret and respond to the same event may be
in different ways and manner.

II. Information-processing – is a cognitive perspective that emphasizes the thinking

processes like
a. Thought
b. Reasoning
c. The way information is encountered and stored
d. Memory functioning

This perspective is particularly useful for assessing problems in acquiring,

remembering and recalling information.

Stages in the memory process:

1st stage: involves paying attention to the environmental stimuli; attention is the key
to learning. Knowing this principle will help the health professionals to avoid some pitfalls
or difficulties when giving health teachings.

Example: A mother who is experiencing intense pain from her operation will not be able to
pay attention to the nurse who is demonstrating the proper positioning for successful
nipple latching. Her attention will be focused on the pain since this is stronger and more
dominant stimulus.

2nd stage: the information is processed by the senses. The client’s preferred mode of
sensory processing which may visual, auditory or motor manipulation must be considered by
the health educator.

3rd stage: the information is transformed and incorporated or encoded briefly into short-
term memory and later may be disregarded or forgotten or stored in long-term memory by
using strategies for storage like imagery, association, rehearsal, chunking (breaking the
information into smaller units or chunks).

4th stage: involves the action or response that the individual makes on the basis of how the
information was processed and stored.

III. Cognitive Development is a third perspective that focuses on qualitative changes in

perceiving, thinking and reasoning as individuals mature grow and mature (Baltes et
al, 1999).
Jean Piaget is the best-known cognitive developmental theorist. By watching,

listening and hearing children ask questions, Piaget found out children’s perception

at different ages and he identified four sequential stages of cognitive development.

Piaget’s Four Major Periods of Cognitive or Intellectual Development

1. Sensorimotor stage: Birth up to 2 years old. This is determined basically on actual

perception of the senses and the external or physical factors. Children think due to
coordination of sensory input and motor responses.

 intelligence is non-verbal or non-symbolic because the child has not developed

language yet.
 how learning takes place depends in what is experienced in the beginning which can
be learned through visual pursuits.
 this will be later known as "objective permanence (what and where it us seen for
the first time will still exist even though it disappears.
 it marks the development of memory for the nursing object who us usually the
mother.
2. Abstract thinking: represents reality using symbols that can be manipulated mentally.

Ex. Symbolism in bible stories; use of X in algebraic expressions.

-logical thinking is more systematic; uses scientific method

3. In formal operations, "perspective thought" or relativism is formed which is a new

perspective of other people possessing varied thinking on the same stimulus or situation.
There is awareness on different views rather than on one single thought.

 it recognizes individual differences and that "No two individuals are alike".

4. Assimilation and Accommodation- characterized by hypothesis testing... Before making

conclusions, things must be tested with logical pieces of evidence... in search of truth

 Being "teenagers" at this stage, they have their "own mind". Known as metacognition
(self-reflection) wherein ideas and imaginations are tried out to be aware of
existing realities; also known as internal dialogue.
 "Experience is the best teacher" where self-correction in solving problems is
applied. understands that "no two individual are alike."

Social Learning Theories

 Emphasize the importance of environmental or situational determinants of behavior

and their continuing interaction. Reciprocal Determinism by Albert Bandura states
that "environmental conditions shape behavior through learning and the person's
behavior through learning and the person's behavior, in return, shapes the
environment".
 Further believes that behavior need to be performed and reinforced for learning to
occur.
 Modeling or observational learning occurs vicariously, even in infants, where the
individuals learn of the consequences of a behavior by observing another person undergoing
the experience.

Four (4) operations involved in modeling are:

1. Attentional processes- which determine what a person can do and what he or she can
attend to

2. Retentional processes - which determine how experiences is encoded or retained in

memory

3. Motor reproduction processes - determine what behavior can be performed

4. Motivational and reinforcement processes - determine the circumstances under which

learning is translated into performance.

How Behavior Occurs (Bandura)

There are 3 interrelated determinants of behavior which are antecedents, consequence

and cognitive factors.

Behavior is based on the past (antecedents) as we have seen it, but is also influenced
by its result (consequence) and how we are motivated (cognitive factor).

The social learning theory of personality development by Bandura assumes that all
actual behavior patterns must be learned through traditional learning (by reinforcement)
and observational learning (by modeling). It emphasizes the role of modeling and other
types of learning with no direct rewards or reinforcements. Instead, behavior is shaped by
people's expectations. These expectations are formed from experience and by watching
other persons.

The social learning theory approach to personality focuses directly on a person's

behavior (what did he do?) And not on his motives. A relatively enduring quality or
characteristic is called a trait. Instead of traits, Walker Mischel (1993) dealt with
cognitive variables like:

a. Competencies which refer to various skills like intellectual abilities, social and physical
skills and other special abilities.

b. Encoding strategies and personal constructs-experiences that are retained and

categorized by the individual.
 Example: Being asked to sing in a big gathering nay be perceived by a person as a
welcomed opportunity to show off his talent in singing but may be seen by another
as a threat to his or her ego.

c. Subjective values - what a person considers as worth having or accomplishing

Example: A student may perform ingratiating tactics like giving food to the teacher
just so he or she can pass the course. Another student may also do the same but
his/her purpose is for the teacher go makes him or her number one in class.

d. Self-regulating systems or plans - people have different standards and rules for
regulating their behavior (like self-imposed rewards for successful behavior or punishment
for failures) including their plans for reaching his or her goals.

Humanistic Theory of Learning

People are seen rational (logical, reasonable, sensible), unique and are motivated by
each person's needs, self-perception or self-concept and the desire to grow positively.

 Maslow's theory of motivation which is based on the hierarchy of needs explains

why a hungry patient will not pay attention to health teachings until his/her
physiologic need of hunger is first met before meeting his/her need for
information or instruction.
 Humanistic theorists contend that positive self-concept and self-esteem enhances
the learner's enthusiasm to learn and the teacher's role is more of a facilitator of
learning rather than an authority on teaching.

Psychodynamic Theory of Learning

• This is more of a theory of motivation stressing emotions rather than cognition and
responses and emphasizes the importance of conscious or unconscious forces in guiding
behavior, personality conflicts and the enduring effects if childhood experiences.

• Behavior may be conscious or unconscious- individuals may or be aware of their

motivations and why they think, feel, and act as they do.

• The id is the most primitive source of motivation and is based on libidinal energy.
The id is composed of the basic instincts, impulses and desires we are born with and are
composed of:

a. Eros (or life force)-the desire for pleasure and sex

b. Thanatos (or death wish) - these are aggressive and destructive impulses.

•The id operates on the basis of the pleasure principle- to seek pleasure and avoid pain".

Implications to teaching-learning process:

The patient or client will neither listen to or heed the advice of the health
educator whose methods are boring, unenthusiastic and "not entertaining" in contrast to a
teaching-learning session where there is active participation of the learner and he/she is
made to feel in-charge of the situation and is an important player in the teaching-learning
process.

Learning Style Models

Two of the most commonly used learning style models that are frequently used in
Nursing are David Kolb's Cycle of Learning (1984) and Anthony Gregorc's Cognitive Styles
model (1982).

I. Kolb's model, also known as the Cycle of Learning, believes that the learned is
not a blank slate unlike the theory of tabula rasa by John Locke but that the
learner already has preconceived or predetermined ideas. According to Kolb,
learning is a continuous process which is a cumulative result of previous or past
experiences, heredity and interaction with the environment.

Impact of Kolb's learning style on the educator:

Knowing the learner's preferred learning style will enable the teacher to assist the
learner in modifying, refining or even changing these preconceived ideas so that real or
better learning can occur.

Kolb's Theory of Experiential learning- depicts a 4-stage cycle or four modes of

learning which reflect two major dimensions of perception or awareness of stimuli and
processing or dealing with the information.
Kolb describes each learning style as a combination of four basic learning modes which are:

1. Concrete experience (CE) abilities: Learning from actual experience

2. Reflective Observation (RO) abilities: Learning by observing others

3. Abstract conceptualization (AC) abilities: Creating theories to explain what is seen

4. Active experimentation (AE) abilities: Using theories to solve problems.

Kolb identified four learning styles and their corresponding characteristics where
one style type will be predominantly manifested by the learner:

1. Converger: learns by AC and AE: good at decision-making, problem-solving and

prefers dealing with technical work than interpersonal relationships; uses deductive
reasoning to solve problems; uses facts and data and has skills for technology and
specialist careers.

Learning methods: learns best through demonstration, return demonstration

methods assisted by handouts, diagrams, charts, illustrations.

2. Diverger: stresses CE and RO: people and feeling-oriented and likes to work in
groups;

Learning methods: learns best through group discussions and brainstorming

sessions; considers different perspectives and points if view when looking at a
concrete situation or experience

3. Accommodator: relies heavily on CE and AE: impatient with other people; a risk-
taker, often using trial and error methods of solving problems; acts more in
intuition, instinct or gut feelings rather than on logic; an achiever;

Learning methods: enjoys role-playing, gaming and computer simulations.

•These learners are the most challenging to educators because they learn best
through new and exciting learning experiences and are not afraid of taking risks
which may sometimes endanger their safety.

4. Assimilator: emphasizes AC and RO: more concerned with abstract ideas than
people; very good in inductive reasoning, creating theoretical models, and
integrating ideas and actively applying them; uses logical thinking.

Learning methods: They learn best through lectures, one-to-one instruction and
self-instruction methods with ample reading materials.
 Kolb's Learning Style Inventory (1984) is now a 12- item tool with sentence
completion items. The predominant score bases on the ranking process indicates the
learner's style (Diverger, assimilator, Converger or accommodator). This has been most
frequently used in measuring the learning styles of Nursing students (DeCoux, 1990). It is
based on Piaget's and Guilford's theories of thinking, creativity and intellect.

Implications:

By using different teaching strategies that are suited to these four learning styles,
a match or fit can be created by the teacher in relation to the methods of teaching that
will be used where, for every group of learners, 25% will fall into each of the four
categories. Using only one method, like the lecture method, will selectively exclude 75% of
all the learners in that particular class.

When teaching groups of learners, instruction should begin with activities suited to the...

1. Divergent thinker (group discussions and brainstorming sessions)

2. And progress sequentially to activities for assimilator (lectures, one-to-one instruction

and self-instruction methods with ample reading materials)

3. Converger (demonstration, return demonstration methods assisted by handouts,

diagrams, charts, illustrations.

4. And accommodator (enjoys role-playing, gaming and computer simulations) in that order
(Arnt and Underwood, 1990)
 Gregorc Cognitive Styles Model

Gregorc has identified four sets of dualities (situation that consist of two parts that are
complementary ot opposed to each other. The mind has the mediation abilities of:

1. Perception- the way one receives or grasps incoming information or stimulus in a

continuum ranging from abstractness to concreteness

2. Ordering of knowledge- the way one arranges and systematizes incoming stimuli
in a continuum or scale ranging from sequence to randomness which affects the way
a person learns.

According to Gregorc, everyone processes or deals with perception and ordering of

knowledge in all four dimensions but may have preferences or choices of doing ut which
may fall into 4 mediation channels, namely;

1. Concrete sequential (CS)- learners like highly structured, quiet learning

environments without interruptions; like concrete learning materials especially
visuals and gives focus on details; may interpret words literally

2. Concrete Random (CR)- Intuitive, trial-and-error method of learning, looks for

alternatives.

3. Abstract Sequential (AS)- learners are holistic thinkers and need consistency in
the learning environment; do not like interruptions; have good verbal skills, are
rational and logical.

4. Abstract Random (AR) - think holistically, learn a lot from visual stimuli; prefer
busy, unstructured learning environments; focused on personal relationships.

Gregorc developed the Gregorc Style Delineator, a self-report inventory where the
subject chooses the word that best describes him or her. The learning styles are scored
and the highest number of total scores indicates the preferred learning style.
 Gardner's Seven (7) Types of Intelligence

(A theory specific to children's learning styles)

The theory of multiple intelligence (Gardner) states that there are various types of
intelligence which may all be fully developed in a gifted child but on the average, about
three to four types may be possessed or developed by an individual or child. All learners
have all the seven kinds of intelligence but in different proportions (Bastable, 2003).
Another facet of intelligence is termed as Naturalist which refers to flora and fauna, has
green thumb, enjoys pets, enjoys nature, classifies species, discriminates among plants and
animals, concern for environment. These are presented below.

Types of intelligence Domains of intelligence and Description Facets of intelligence

area of the brain (Features, aspects or
characteristics of
intelligence)
1. Verbal/linguistic Reading, writing, speaking Deals with written and Understanding the order
-found in Broca’s area in spoken words or and meaning of words:
left side of brain language; convincing someone, verbal
The use and meaning debate; explaining in words,
of language teaching; telling or enjoying
verbal jokes; creative
writing and appreciation of
poetry
2. Logical/ Calculations, problem- Refers to inductive Pattern recognition, making
mathematical solving and analysis, and deductive predictions, estimating,
statistics reasoning: abstractions using inductive and
-involve both sides of the and discernment of deductive reasoning,
brain numerical patterns discerning relationships and
connections, performing
complex calculations,
scientific reasoning,
performs experiments,
seeking explanations,
categorizing information,
computer programming
3. Spatial/visual Arts, crafts, maps, Involves the ability to Recognizing relationships of
geometry, design visualize an object or objects in space, sense of
-right side of brain to create internal or direction, finding your way
mental images; ability around, drawing, painting,
to transform or re- sculpting; color
create images; forming discrimination, visual
and rotating mental perspective taking, active
images imagination
4. Musical/rhythmic Appreciation, vocal, Sensitivity to rhythm Understanding structure of
instrumental, composition and beat, recognition music, creating melodies/
and rhythm of tonal patterns and rhythms, sensing qualities
-found in the right side of pitch and appreciation of a tone, playing an
brain of musical expressions instrument, repeating a
tune, recognizing
composers
5. Bodily/kinesthetic Athletics, dance, acting, Taking in and Hand-eye coordination,
manual dexterity, exercise processing of mimetic (imitating or
-basal ganglia and knowledge through the impersonating) abilities,
cerebellum and other use of bodily speed, agility and strength;
structures sensation; learning is endurance, working with
accomplished through tools, need for constant
the use of body movement or exercise
language or physical
movement
6. Interpersonal Community service, role- Emphasis on Verbal/non-verbal
intelligence playing, conflict resolution, communication and communications, discerning
leadership, teamwork interpersonal underlying intentions,
-prefrontal lobes relationships behavior and perspectives,
empathy, working
cooperatively, sensitivity to
other’s moods motives and
feelings, leading others and
keeping friends.
7. Intrapersonal Journaling, personal Related to inner Accurate self-perception,
intelligence assessments, reflections, thought processes self-reflective, self-
goal setting, progress such as reflection and directed, sense of values,
reports metacognition; includes intuitive, independent,
-prefrontal lobes spiritual awareness/ awareness and expression
development and self- of feelings
knowledge
DETERMINANTS OF LEARNING

Learner’s characteristics:

▪ Learning needs

▪ Learner’s perceptual abilities

▪ Motivational abilities or readiness

▪ Reading abilities

▪ Developmental stage

✔ learning style/s

✔ Physical abilities

■ Accdg to Haggard (1989): the educator’s role in the learning process is primarily to
assess the learner in relation to the 3 factors that affect learning/determinants of
learning

a. Learning needs (what the learner needs to learn

b. Readiness (when the learner is receptive to learning)

c. Learning styles (how the learner best learns.)

Learning needs

■ Are gaps in knowledge that exist between a desired level of performance and the actual
level of performance ■ Gap or difference between what someone knows and what someone
needs to know due to lack of knowledge, attitudes or skills.

Assessing Learning needs (Bastable)

1. Identify the learner- who is the learner, is it an individual or a group, what are the
learning needs?

2. Choose the right setting- establish a trusting environment by ensuring privacy and
confidentiality especially if confidential info will be shared.

3. Collect data on the learner- by determining the characteristic learning needs of the
target population or any recipient of the learning material.

4. Include the learner as a source of information- allow the learner to actively participate
in identifying his needs and problems.
5. Include members of the healthcare team- collaborate with the other healthcare
professionals who may have knowledge of the patient.

6. Determine availability of educational resources- the materials and equipment used to

demonstrate procedures should be appropriate, available, affordable, easy and simple to
manipulate by the learner.

7. Assess demands of the organization-examine the organizational climate- its philosophy,

vision, mission and goals to know its educational focus. Is it more on health promotion and
disease prevention rather than rehabilitative care? Its focus or emphasis will delicate the
learning needs of its clients and staff.

8. Consider time management issues- allow learners to identify their learning goals

- identify potential opportunities to assess the patient anytime, anywhere

- Minimize distractions/interruptions during planned assessment interviews.

9. Prioritize needs- based on Maslow’s hierarchy of needs where the basic lower-level
physiologic needs must first be met before one can move up to higher, more abstract level
of need. It follows a hierarchy.

HIERARCHY OF NEEDS

Self-actualization needs (self-fulfillment)- recognition and realization of one’s potential,

growth, health and autonomy.

Esteem needs (self-respect, dignity, prestige)- Sense of self-worth, respect,

independence, dignity, privacy and self-reliance

Love and belonging- affiliation, affection, intimacy, support

Safety and security- safety from physiologic and psychological threats, protection,
stability

Physiologic needs- oxygen, food, elimination temperature control, sex, movement, rest,
comfort

Criteria for Prioritizing Learning needs

1. Mandatory- learning needs that must be immediately met since they are life threatening
or are needed for survival.

Ex. Patient with history of recent heart attack should be taught the signs and symptoms
of an impending attack and what the emergency measures are or what medicines to take.
2. Desirable- learning needs that must be met to promote well-being and are not life-
dependent.

Ex. Patient with pulmonary tuberculosis needs to understand and appreciate the
importance of taking her medicines regularly until the regimen ends to be totally cured.

3. Possible- “nice to know” learning needs which are not directly related to daily activities.

Ex. An obese patient who has just lost weight because of diabetes may not necessarily
need info on “tummy tucking” as a surgical and aesthetic procedure to remove the sagging
abdominal muscles. Her current mandatory learning needs are related to her illness which
is diabetes mellitus.

Methods of assessing learning needs

1. Informal conversation or interviews- between the nurse and the patient and/or the
family members or the other members of the health team by asking open-ended questions
where the learner may reveal information regarding their perceived learning needs.

2. Structured interviews- where the nurse asks the patient some predetermined questions
to gather information regarding learning needs; the answers may reveal uncertainties,
anxieties, fear, unexpected problems and present knowledge base; questions may include
“what do you think caused your problem?”, what does your illness/health mean to you?”,
what are your strengths and weaknesses?”.

3. Written pretests- can be given to identify the knowledge level of the potential learner
and to help in evaluating whether learning has taken place by comparing pre-test with the
post-test scores.

4. Observation of health behaviors over a period of different times- may help determine
established patterns of behavior like observing how a watcher does a procedure more than
once is an excellent way of assessing a psychomotor need; “are all the steps performed
correctly?’ or what additional learning or instruction is needed to improve the
performance?”

Advantages of assessing the learning needs

1. Allow the health educator to design her teaching plan according to what the client
already knows, what he/she still needs to know and to determine the approach, strategy,
methods and device to be used

2. Plan, introduce or even manipulate some factors In the learning environment or the
learner’s milieu

Readiness to learn
■ Is the time when the patient is willing to learn or is receptive to information

■ Teachable moment – point in time when the learner is most receptive to a teaching
situation.

■ When assessing readiness to learn, the health educator must:

1. Determine what needs to be taught

2. Find out exactly when the learner is ready to learn.

3. Discover what the patient wants to learn.

4. Identify what is required of the learner

✔ What needs to be learned

✔ What the learning objectives should be

✔ Which domain of learning and what level the lesson will be taught

EX. A procedure to be taught involves the psychomotor domain and will use strategies that
will require the learner to make a return demonstration to show acquisition of skills.

✔ Determine the timing (the point at which the nurse will conduct teaching) is right or
proper.

✔ Determine if rapport or interpersonal relationship has been established

✔ Motivation

✔ Plan for teaching matches the development level of the learner.

4 types of readiness to learn

1. P = Physical readiness

a. Measure of ability- adequate strength, flexibility and endurance is needed to teach a

patient how to walk on crutches and for him/her to be ready to learn while measures
requiring visual and auditory acuity of a patient also affect the learning readiness
especially if she senses of sight and hearing are impaired.

b. Complexity of task- difficulty of level of the subject or the task to be mastered;

psychomotor skills require varying degrees manual dexterity and physical energy output
but once required or mastered, they are usually retained better and longer than learning in
the cognitive and affective domains.
c. Environmental effects- refers to an environment that is conductive to learning, free
from noise and other distractions which mat affect the physical readiness to learn.

d. Health status- is the patient in a good state of good health or ill health? Does he still
have the energy or motivation to learn?

e. Gender- studies show that men are less inclined to seek health consultation or
intervention than women. Women on the other hand, are more health conscious and
receptive to medical care and health promotion teaching. There is a changing perspective
in attention-seeking behavior with the blending of roles in the home and workplace and the
increased attention to healthy lifestyles.

2. E = Emotional readiness

a. anxiety level- may or may not be a hindrance to learning

b. a moderate level of anxiety- contributes to successful learning and is the best time for
learning

c. support system- composed of the immediate family and friends, significant others, the
community and church

d. nurses who provide emotional support to the patient & family members go through what
is termed as teachable moments- which allow opportunity for both nurse and client to
mutually share and discuss concerns and possible solution or alternatives to care.

e. Motivation- strongly associated with emotional readiness or willing ness to learn. A

telling cue is when the learner starts asking questions and interest in what the teacher is
doing or saying.

f. Risk taking behaviors- are activities that are undertaken without much thought to what
their negative consequences or effects might be. The roles of health educator is to
develop awareness in the patient as to how this can shorten his lifespan.

g. Frame of mind- depends on what the priorities of the learner are in terms of his needs
which will determine his readiness to learn. An important consideration is Maslow’s
hierarchy of needs prioritization.

h. Developmental stage- determines the peak time for readiness to learn or teachable
moments.

3. E = Experiential Readiness- previous learning experiences which may positively or

negatively affect willing ness to learn.
a. Level of aspiration- depends on the short-term and long-term goals that the learner has
set which will influence his motivation to achieve.

b. Past coping mechanisms- refer to how the learner was able to cope with or handle
previous problems or situations and how effective were the strategies used.

c. Cultural background- is important to assess and know from the patient’s own cultural
perspective to determine readiness to learn.

d. Locus of control- motivation to learn which may be

internal locus of control or intrinsic (within the individual as he/she driven by the desire to
know or learn)

external locus of control or extrinsic (motivation to learn is influenced by others who

encourage the learner to learn.)

e. orientation- refers to a person’s point-of-view which may be

Parochial- close-minded thinking, conservative in their approach to new situations, less

willing to learn new materials and have great trust in physician.

Cosmopolitan orientation- more worldly perspective and more receptive to new innovative
ideas like the current trends and perspectives in health education.

4. K = knowledge readiness

Refers to

■ Present knowledge base- stock knowledge or how much one already knows about the
subject matter from previous actual or vicarious learning

■ Cognitive ability- involves lower level of learning which includes memorizing, recalling or
recognizing concepts and ideas and the extent to which this information is processed
indicated the level at which the learner is capable of learning.

MOTIVATION

■ Latin word “movere” which means to move or set into motion

■ Psychological force that moves a person to some kind of action

■ Willingness of the learner to embrace learning, with readiness as evidence of motivation

■ Moving forward to reach one’s goals or meet a need

■ Related to learning behavior or learning and behavior

■ Force that drives the learner to learn and to comply or apply the knowledge resulting to
a change in behavior.

LEARNING ASSESSMENT OF CLIENTS

Literacy

■ the ability of adults to read, understand and interpret information written at the 8th
grade level or above

■ The relative ability of person to use printed and written materials

Three factors to consider in assessing levels of literacy:

1. Reading or word recognition- the process of transforming letters into words and being
able to pronounce them correctly; “reading”

2. Readability- the ease with which written or printed information can be read

3. Comprehension- The degree to which individuals understand what they have read; the
ability to grasp that meaning of the message- to get the gist of it.

HEALTH LITERACY

■ How well an individual can read, interpret and comprehend health information for
maintaining a high level of wellness

Cues manifested by patients with low literacy

1. Not even attempting to read printed materials

2. asking to take PEM’s to discuss with significant others (printed educational materials) to
discuss with significant others

3. claiming the eyeglasses were left at home

4. staining they can’t read something because they are too tired or don’t feel well

5. avoiding discussion of written material or not asking any questions

6. mouthing words as they try to read

Test to measure patient literacy

1. REALM (Rapid estimate of Adult literacy in medicine)

■ Requires patient to pronounce common medical and anatomical words

■ Contains 66 words arranged in 3columns, in ascending order

2. WRAT (Wide range achievement test)

■ Asked to read aloud from a list of 42 words of increasing difficulty

■ If 10 consecutive words are mispronounced, test is stopped

TEACHING STRATEGIES FOR LOW LITERATE PATIENTS

1. Establish a trusting relationship before T-L process- undertake self-care activities

✔ Focus on the strengths

✔ Specifying what needs to be learned.

2. Use the smallest amount of information possible by teaching what the patient needs to
learn

✔ Prioritize behavioral objectives, 1 or 2 concepts/session

✔ Present context 1st before giving new info

✔ Teaching session to 20-30 min

3. Make points of info as vivid and as explicit

✔ Use simple terms

✔ Use visual aids & use explicit instructions

✔ Use highlighting, color coding, underlining

4. Teach one step at a time- by teaching increments, organizing information into chunks,
allow the nurse to evaluate progress and give positive reinforcements

5. Use multiple teaching methods and tools requiring fewer literacy skills

Story-typing- a strategy used for low-level readers which is very useful in teaching
functional skills.

6. Allow patient to restate info in their own words and to demonstrate any procedure

7. Keep motivation high

8. Build in coordination with procedures by using the principles of

a. Tailoring- coordinating the patient regimens into their daily schedules rather than
forcing them to adjust their lifestyles to regimens imposed on them
b. Cuing- focuses on the appropriate combination of time and situation using prompts and
reminders to get a person to perform a routine task.

9. Use repetition to reinforce info- repetition, in the form of saying the same thing in
different ways, is one of the most powerful tools to help patients understand their
problems and learn self-care.

DEVELOPING PRINTED EDUCATIONAL MATERIALS

1. Organizational factors- include a short but descriptive title.

- use brief headings and subheadings

- incorporate only one idea per paragraph and be sure that the first sentence is the topic
sentence

- divide complex instructions into small steps

- consider using question/ answer format

- address no more than three or four main points

- reinforce main points with a summary at the end

2. Linguistic factors- keep the reading level at grade 5 and 6 to make the material
understandable to most low literate patients. Use mostly one or two syllable words and
short sentences. Use personal and conversational style. Define technical terms. Use
graphics, incorporates examples

3. Appearance factors- avoid a cluttered, simple diagrams, upper- and lower-case letters,
10-14 point type, bold or underline, 50-60 characters

Role of the Nurse as a Health Educator (GFCA)

1. Giver of information

- educate people to make informed decisions about their health care treatment, health
promotion, disease prevention, and achieving peaceful death

- individuals have the right to know their diagnosis, treatment, risk, benefits, costs and
alternatives

- nurses provide health teachings and health counseling based on individual interest and
decision

2. Facilitator of learning
-facilitating health-related behavior change

3. Coordinator of learning

- nurses establish a partnership to guide the individual in the selection and use of relevant
health services

- coordinate educational services provided by a health agency

4. Client advocate

v The health educators have an obligation to 2 principles in implementing the strategies

and methods:

ü The people have the right to make decisions affecting their lives

ü There is moral imperative to provide people with all relevant information and resources
possible to make their choice freely and intelligently ( Cottrell, Girvan, Mckenzie)

Effective Teaching in Nursing

· Learners can always identify the best teacher who is also the most effective and the
worst who is also the weakest ( de Young, 2003)

Effective teacher – possesses certain qualities, characteristics and attitudes which makes
them one of the most approachable and respected members of the faculty

Effective teachers accdg to Flowers are: (CCI)

1. Committed- they don’t watch the clock, they go extra mile and work long hours.

2. Creative – they stimulate intellectual inquisitiveness, exploratory and critical thinking.

v What distinguishes a great teacher from ordinary or average mentors

ü unsparing gift of self and their capacity for caring for their students (Rodden)

ü always awaken the students to their awareness of their greater potential.

3. Intuitive- able to identify the student’s predominant style of intelligence and based on
this knowledge, the teacher is able to build on the student’s strength.

v In evaluating teacher effectiveness

ü there is no one style, skill or technique that is effective for all learners and all teaching
situations.

ü There is always a combination or a composite style that will eventually distinguish the
effective and efficient from the ordinary, run- of the mill instructor.

Six Hallmarks of Good or Effective Teaching in Nursing (Jacobsen) (TAPPED)

T -Teaching practices:

a. Mechanics

b. Methods

c. Skills in the classroom and clinical practice

d. Has thorough knowledge of the subject matter

e. Presents the materials in clear, interesting, logical and organized matter

A - Availability to students especially in the laboratory, clinical and other skills

application areas

P - Professional Competence evidenced by

a. Through knowledge of the subject matter and proper demonstration skills

b. Reading, researching, undertaking continuing professional education and has

clinical practice and expertise.

P - Possession of skillful interpersonal relationships with students which was rated as

the Most important. The teacher:

C – conveys a sense of warmth

A - Allows learners to freely express themselves and ask questions

R – respect, fair and just to students in giving grades and credits

E – easily accessible for conferences and consultations

S - sensitive to student’s feelings, problems, interest, and welfare

3 Basic approaches by which the instructor can increase self- esteem and reduce anxiety:

o Empathic listening- by listening to the learner and seeing the world through his own eyes.

o Accepting the learners as they are whether you like them or not; avoid imposing your own
prejudices or standards.

o Communicating honestly with your students by letting them know your expectations and
their responsibilities.

In loco parentis

ü gives the teacher the right to exercise the parental role in the absence of the real
parents.

ü Allows the teacher to impose appropriate disciplinary measures for minor offenses.

E - Evaluation practices

a. Clearly communicating expectations

b. Providing timely feedback on student progress

c. Correcting the students tactfully

d. Being fair in the evaluation processes

e. Giving tests that are pertinent to the subject matter and assignments

D - Desirable personal characteristics of the teacher which includes:

- Charisma or personal magnetism

- Enthusiasm

- Cheerfulness

- Self-control

- Patience

- Flexibility

- Sense of humor
- Good speaking voice

- Self-confidence

- Willingness to admit error or lack of knowledge

- Caring attitude

Other important characteristics of a teacher:

1. Teacher clarity

o One who logically organizes instruction

o explains what is to be learned

o uses simple terms in presenting new materials

o assesses whether student can understand and follow the teacher’s train of thought

o uses examples

o uses repetition and summarization

v Behavior= to make what is to be learned as intelligible, comprehensive and learnable as

possible.

2. Teacher style involves

ü Interpersonal

ü Professional

ü Personal and

a. Blend of form or content= combination of ways : talking, walking,

relating and thinking, scholarliness, intelligence and sincerity

b. Teaching persona= ability to stimulate the student’s interest and enthusiasm for the
subject

c. A pleasant speaking voice

d. Use of a variety of teaching strategies, jokes and humor

e. Good timing= the teacher knows how to adapt the speed of delivery foe the individual
learners and knowing when they are ready for a new material, when to stop and when to
shift gears.

Seven Principles of Good Practice Teaching in Undergraduate Education( Chickering and

Cameson)

1. encourage interaction between the teacher and the learner

ü refers to effective teacher characteristics

ü what the teacher do to motivate the student to participate and ask questions

2. elicit cooperation among the students to do collaborative learning

ü study groups

ü undertaking group projects/activities

v students learn more collaboratively than competitively.

3. Students should engage in active learning where they can pro-actively manipulate the
content of what they are learning by

ü talking about the material

ü writing about it

ü making an outline about it

ü asking questions about it

ü acting it out or just reflecting upon it.

4. Giving prompt feedback related to c

ü class recitations

ü quizzes

ü major exams or other written works and projects serves as a reward or

positive reinforcement for a job well done and for a commendable

behavior or attitudes exhibited by the learner.

5. Emphasizing time on task where the teacher makes sure that the student knows

how much time they should spend learning on a particular material and by using

time efficiently.

- Refers to a proper effective and intelligent time management.

6. Communicating higher expectations which refers to the challenge that the teacher gives
to the student and the student’s response to rise up to that challenge with the teacher’s
encouragement and support.

7. Respecting the diverse talents and ways of learning- learners have different learning
styles, use different teaching strategies, approachable and methods.

OPERANT CONDITIONING

- Burrhus Frederic Skinner

Focuses on reinforcement = events that strengthen responses

-believed that the best way to understand behavior is to look at the causes of an action
and its consequences.

-Powerful tool used in teaching

-Based on Thorndike’s Law of effect

-Skinner (1948) studied operant conditioning by conducting experiments using animals

which he placed in a “Skinner Box” which was similar to Thorndike’s puzzle box.

Ways of employing reinforcement

1. Verbal ways

- saying praise words or phrases like “good”, “well-done”

- “That was a well-expressed opinion”, “I like the ways you answered the question of the
patient’s mother” are morale-boosters

- requesting the student to share his success story with his classmates. This gives
recognition to the student and increases level of prestige with his classmates

2. Non-verbal ways- like nodding, smiling, looking pleased

3. Citing in class or publishing- on the bulletin board exceptional works or outputs.

Classification of Educational Reinforcers

1. Recognition

-praise, certification of accomplishments, formal acknowledgement (awards, letters of

recommendation, testimonials), informal acknowledgements (private conversations)

2. Tangible awards- grades, food, prizes, certificates of appreciation or citations

3. Learning activities- opportunity for desirable enrichment assignment like membership in

“honors” class, more interesting or more difficult clinical assignments.

4. School responsibilities- opportunities for increases self-management and more

participation in decision-making, acceptance of suggestions for improving the curriculum,
greater opportunity for selecting own goals, control own schedule and set own priorities

5. Status indicators- appointment as a peer tutor, having own space

6. Incentive feedback- increased knowledge of examination scores, knowledge of individual

contributions.

7.personal activities- opportunity to engage in special projects, extra time off

COGNITIVE THEORIES

• Stresses that mental processes or cognition occurs between the stimulus and the
response.

• The learner’s goals and expectations are more important

• Tension act as the motivator

• Disequilibrium

• imbalance

• Involves intelligence – which is the ability to solve problems

• It stresses the importance of what goes on inside the learner which involves:

a. perception

b. Thinking skills

c. memory

d. ways of processing and structuring information

4 Mediation Channels

1. Concrete Sequential (CS) - learners are highly structured, quiet learning environment
without

interruptions.

-like concrete learning materials (visuals) & give focus on details; may interpret words
literally

2. Abstract Random (AR) – learn a lot from visual stimuli, prefer busy, unstructured
learning environment, focused on personal relationships

- Think holistically

3. Abstract Sequential (AS) – learners are holistic thinkers and need consistency, do not
like interruptions, have good verbal skills, rational and logical

4. Concrete Random (CR) – intuitive, trial and error method of learning, looks for
alternative

-No one is a "pure" style. Each of us has a unique combination of natural strengths and
abilities

Kolb's Learning Styles

David Kolb's theorized that four combinations of perceiving and processing determine four
learning styles that make up a learning cycle.

According to Kolb, the learning cycle involves four processes that must be present for
learning to occur:

1. Converger: learns by AC and AE; good at decision-making, problem-solving and prefers

dealing with technical work than interpersonal relationships; uses deductive reasoning to
solve problems; uses facts and data and has skills for technology and specialist careers.

Learning methods- learns best through demonstration-return-demonstration methods

assisted by handouts, diagrams, charts, illustrations

2. Diverger- stresses CE and RO; people and feeling-oriented and likes to work in groups;

Learning method- learns best through group discussions and brainstorming sessions;
considers different perspectives and points of view when looking at a concrete situation
experience.
3. Accommodator- relies heavily on CE and AE; impatient with other people; risk-taker,
often using trial-and-error methods of solving problems; acts more on intuition, instinct or
gut feelings rather than on logic; an achiever

Learning method- enjoys role-playing, gaming and computer simulations

-these learners are the most challenging to educators because they learn best through
new and exciting learning experiences and are not afraid of taking risks which may
sometimes endanger their safety.

4. Assimilator- emphasizes AC and RO; more concerned with abstract ideas than people;
very good in inductive reasoning, creating theoretical models, and integrating ideas and
actively applying them; uses logical thinking

Learning methods; they learn best through lectures, one-to-one instruction, and self-
instruction methods with ample reading materials.

1. Concrete experience (CE) abilities: learning from actual experience

2. Reflective observation (RO) abilities: learning by observing others

3. Abstract conceptualization (AC) abilities: creating theories to explain what is seen

4. Active experimentation (AE) abilities: using theories to solve problems

Psychodynamic theory of learning

• Theory of motivation

• stressing emotions rather than cognition and responses

• Emphasizes the importance of conscious and unconscious forces in guiding behavior,

personality, conflicts and the enduring effects of childhood experiences.

ID – the most primitive source of motivation and is based on libidinal energy.

• Operate on the basis of pleasure principle and avoid pain.

Eros (life force)- the desire for pleasure and sex

Thanatos (death wish)- these are aggressive and destructive impulses

QUIZ 1

Praise may assist in the transfer of learning from one area to another
-true

Opportunity to engage in special projects and having extra time off fall under what
classification of educational reinforcer

-personal activities

In this stage, intelligence is non-verbal or non-ymboic because he has not developed

language yet

-sensorimotor

Prizes like food, pens, ticket and other tokens are examples of

-tangible rewards

The teachers ability to relate new knowledge to previous experiences value, self-
perception and the learners readiness to learn are also some of the many factors that may
facilitate or hinder learning

-True

_are events that strengthen responses. It is one of the most powerful tool or procedure
used in teaching and is a major condition for most learning to take place

-reinforcement

At this stage, hypothesis testing is characterized before making conclusions, and things
must be tested with logical; pieces of evidence in search of truth

- assimilation

This is usually applies in relapse prevention program and may explain why it is quite
difficult to completely eliminate unhealthy habits and addictive behaviors

-spontaneous recovery
Recognition includes

-praise, certification of accomplishments

-formal acknowledgements

-informal acknowledgements

Under respondent conditioning, refers to the process which influences the acquisition of
new responses to environmental; stimuli

-classical/pavlovian

Nodding, smiling, looking pleased and giving thumbs up sign are_ ways of employing positive
reinforcement

-non-verbal

There comes a time when the neutral stimulus, even without the unconditioned stimulus,
elicits the same unconditioned response

-True

A cardinal rule of operant conditioning is to punish the person committing an error, and not
the behavior

- False

Principles of gestalt which are related to health care include

-psychological organization is directed towards simplicity, equilibrium and regularity

-perception is selective

-What individuals pay attention to may be affected by factors like need, personal motives,
past experiences etc.
This is another technique based on the respondent conditioning which is widely used in
psychology and even in medicine to reduce fear and anxiety in the patient

- Systematic desensitization

A neutral stimulus elicits an unconditioned response through repeated pairings with a

unconditioned stimulus

-True

In jeans Piaget 4 major periods of cognitive development_ represents reality using

symbols that can be manipulated mentally

-abstract thinking

Learning under the control of reward is usually preferable to learning under the control of
punishment

-true

Reinforcement should be appropriate or directly linked to the learning tasks and students
accomplishment

-true

Correct statement about learning theories

-They have helped us understand the process of teaching and learning

-they have helped us understand how individuals acquire knowledge and change the way
they think, feel and behave

-They are set of integrated constructs and principles that describe, explain or predict how
people learn, how learning occurs and what motivates people to learn and change

_is developed by B.F skinner which focuses on the behavior of the organism and the
reinforcement that follows after the response
-operant conditioning

_refers to the configuration or patterned organization of the cognitive elements

reflecting the maxim that” the whole is greater than the sum of its part

-gestalt

He defines behavior as muscle movement and it came to be associated with the stimulus-
response psychology

-john b Watson

When one is appointed as a peer tutor or when one is given own space (like study corner or
desk) he receives what educational reinforcer

-status indicator

QUIZ 2

Social Learning Theory by Bandura assumes that all actual behavior patterns must be
learned through traditional learning and observational learning.

-TRUE

There are four operations involved in modeling---- processes determines what behavior can
be performed.

-MOTOR REPRODUCTION

This theory assumes emotions rather than cognition and responses.

-PSYCHODYNAMIC THEORY OF LEARNING

It refers to the most primitive source of motivation and is based on libidinal energy. It
operates on the basis of the pleasure principle- to seek pleasure and avoid pain. Write this
word in small letters
-id

What theory is applied in the situation where an individual is motivated by his needs, like
for example , patient donna will not be able to pay attention to nurse Ian’s health
teachings because she still needs to satisfy her need for food for she was not able to eat
for 3 consecutive meals?

-HUMANISTIC THEORY

------- are ways in which an individual processes information or different approaches or

methods of learning. Write these two words by capitalizing just the first letter of the
first word. Write your answer in plural form.

-LEARNING STYLES

They like role playing, gaming and computer simulations

-ACCOMODATORS

They like to design projects or experiments, lectures and one-to-one instruction

-ASSIMILATORS

They learn best through demonstration-return demonstration, handouts , charts and

illustrations

-CONVERGERS

They like activities like cooperative groups and brainstorming

-DIVERGERS

Learners are holistic thinkers, need consistency, do not like interruptions, are rational and
logical.

-ABSTRACT SEQUENTAL
They learn a lot from visual stimuli, prefer busy unstructured learning environment

-ABSTRACT RANDOM

Learners are highly structured and prefer quiet learning environment without any
interruptions

-CONCRETE SEQUENTAL

They are intuitive, love trial and error method of learning, and look for alternative

-CONCRETE RANDOM

Which does not belong to the group?

-COMPUTER SIMULATIONS

You have an assimilating ability if you enjoy the following. Select all that apply

-LECTURE

-SELF INSTRUCTION

ONE-TO-ONE INSTRUCTION

He identified 7 district types of intelligence in his Multiple Intelligence theory. Write his
name correctly-first name then family name

-HOWARD GARDNER

He is aware of his own feelings and is self-motivated

-INTRAPERSONAL

They are leaders among their peers, good at communicating and seem to understand
other`s feelings and motives

-INTERPERSONAL
They like mazes, jigsaw puzzles, spent time drawing, building leggos and daydreaming

-SPATIAL

They are drawn to arithmetic problems, strategies games and experiments

-LOGICAL-MATHEMATICAL

They enjoy writing, reading, telling stories or doing crossword puzzles

-LINGUISTIC

They are often athletic, dancers or good at crafts

-BODILY KINESTHETIC

They are always singing or drumming to themselves

-MUSICAL

All learners have all the seven kinds of intelligence but in different proportions

-TRUE

QUIZ 3

Select all that are included in emotional readiness

Support system

Motivation

Anxiety level

Frame of mind

This refers to how the learner was able to cope with or handle previous problems or
situations and how effective were the strategies used.
Past coping mechanism

This determinant refers to how the learner learns best

Learning style

Including the learner as a source of information is allowing the educator to actively

participate in identifying the learners need and problems.

False

The learner characteristics that will influence learning which an educator must be aware
of include ____________. SATA

Select all

Assessing learning needs will allow nurse james to design his teaching plan according to
what the client already knows, what the learner still neds to know, and determine the
approach, strategy, methids and device to be used.

True

In identifying what is required of the learner the following are included. SATA

Select all

A high level of anxiety contributes to successful learning and is the best time for learning.

False

Assessing learning need is based on Maslow’s hierarchy of need where the basic lower level
physiologic need must first be met before one can move up to the higher, more abstract
level of needs.

Prioritizing needs
It refers to the difficulty level of the task or the subject to be mastered.

Complexity of task

Nurse Rafael considers patient Johns strength, flexibility and endurance in teaching him
how to make use of the cane.

Measures of ability

When assessing readiness to learn, the health educator must_____. Which one is not
included?

Identify what is required of the teacher

This determinant of learning tells when the learner is receptive to learning. Write this
word by capitalizing the begging letter of the first word only. You may write your answer
in 1 or 3 words.

Readiness to learn

It refers to the time when the patient is willing to learn or is receptive to information.
Write your answers in small letters. You may write your answer in one or 3 words.

Readiness

Level of aspiration depends on the short term or long-term goals that the learner has set
which will influence his motivation to achieve.

True

These are the learning needs which are not directly related to daily activities.

Possible

Learning needs that must be met to promote well-being and are not life dependent fall
under what criterion.

Desirable
The materials and requirement used to demonstrate procedures should be appropriate,
available, affordable, easy and simple to manipulate by the learner.

Determining availability of educational resources.

Psychomotor skills require varying degrees of manual dexterity and physical energy output
but once acquired or mastered, they are usually retained better and longer that learning in
the cognitive and affective domain.

True

It refers to the persons point of view which may be parochial or cosmopolitan.

Orientation

It refers to the previous learning experience which may positive or negatively affect
willingness to learn. Write this in 2 words in small letters.

experiential readiness

This is done by determining the characteristics learning need of the target population or
any recipient of the learning material.

Collecting data on the learner

This refers to the gaps in knowledge that exist between a desired level of performance
and actual level of performance. Capital letters.

LEARNING NEEDS

The nurse asks the patient some predetermined questions to gather information regarding
learning needs.

Structured interviews
Patient mark, with pulmonary tuberculosis need to understand and appreciate the
importance of taking his medications regularly until the regimen and to be totally cured.

Desirable

A strong support system will give the patient increased sense of security and well-being
while a weak or absent support system elicits sense of insecurity, despair, frustrations and
anxiety.

True

Patient Michael, has a more worldly perspective or more receptive to new or innovative
ideas. He has a ________ orientation.

Cosmopolitan

Methods in assessing learning need include ____________ SATA.

Select all

The nurse ask open-ended questions where the learner may reveal information regarding
their perceived learning needs.

Informal conversations.

These are activities that are undertaken without much thought to what their negative
consequences or effects might be.

Risk taking behaviors

____________ is strongly associated with emotional readiness or willingness to learn.

Capital letters.

MOTIVATION

Developmental stage determines the peak time for readiness to learn or teachable
moment.
True

_____ refers to motivation to learn which may be intrinsic or extrinsic. Small letters

locus of control

this refers to what the priorities of the learner are in terms of his needs which will
determine his readiness to learn.

Frame of mind.

Learning Styles

-Are ways in which an individual processes information or different approaches or methods

of learning

-Involves affective, psychomotor and cognitive styles

Kolb's Learning Styles

-David Kolb's theorized that four combinations of perceiving and processing determine
four learning styles that make up a learning cycle.

-According to Kolb, the learning cycle involves four processes that must be present for
learning to occur:

Diverging (concrete, reflective)

- Emphasizes the innovative and imaginative approach to doing things. Views concrete
situations from many perspectives and adapts by observation rather than by action

-Interested in people and tends to be feeling-oriented.

-Likes such activities as cooperative groups and brainstorming.

Assimilating (abstract, reflective)

- Pulls a number of different observations and thoughts into an integrated whole

-Likes to reason inductively and create models and theories

-Likes to design projects and experiments, lectures, one to one instruction

-integrate ideas & actively apply them

-uses logical thinking

-learns best through lectures & self-instruction methods

Converging (abstract, active)

-Emphasizes the practical application of ideas and solving problems

-Likes decision-making, problem-solving, and the practicable application of ideas

-Prefers technical problems over interpersonal issues.

- Learns best through demonstrations, return demo. hand-outs, charts, illustrations

-Uses deductive reasoning to solve problems, uses facts & data & has skills for technology
& specialist careers

PIAGET’S FOUR MAJOOR PERIODS OF COGNITIVE

1. Sensorimotor stage- birth up to 2 years old- this is determined basically on actual

perception of the senses and the external or physical factors. Children think due to
coordination of sensory input and motor responses

- intelligence is non-verbal or non-symbolic because the child has not developed language
yet.

-it marks the development of memory for the nursing object who is usually the mother

-later be known “object permanence”

-how the learning takes place depends on what is experienced in the beginning which can be
learned through visual pursuits.

2. Abstract thinking- represents reality using symbols than can be manipulated mentally.

Ex. Symbolism in the bible stories; use of X in algebraic expressions

-logical thinking is more systematic; uses scientific method

3. Informal operations, “perspective thought” or relativism is formed which is a new

perspective of other people possessing varied thinking on the same stimulus or situation.
There is awareness on different views rather than on one single thought.

- recognizes individual differences and that “no two individuals are like”

4. Assimilation and accommodation- characterized by hypothesis testing… before making

conclusions, things must be tested with logical pieces of evidence
-being teenagers at this stage, they have their own mind. Known as metacognition (self-
reflection) wherein ideas and imaginations are tried out to aware of existing realities; also
known as internal dialogue)

- experience is the best teacher where self-correction in solving problems is applied

- understands that no two individuals are alike

-Jean Piaget is the best known cognitive developmental theorist, By watching, listening,
and hearing children ask questions, Piaget found out children’s perceptions at different
ages and he identified four sequential stages of cognitive development
 PPT NOTES

Health- old English HAEL which means whole

-concerns the whole person, integrity, soundness or well-being

-Holistic (Total health)

-goal of public health in general and of community health nursing

-optimum level of functioning (OLOF) of individuals, families and communities which

Affected by several factors in the ecosystem (modern concept)

Dimensions of health

Individual:

 Physical health
- state of one’s body like fitness and not being ill
-biological integrity of an individual where there is optimum functioning of the physical and
physiological abilities and freedom from disease or disability
 Mental (psychological/intellectual) health
-intellectual capabilities
-positive sense of purpose and underlying belief in one’s own worth like feeling good and feeling
able to cope
Emotional health -ability to express one’s feelings appropriately and to develop and sustain
relationships
 Social health
-involves the support system that is available from family members and friends
 Spiritual health
-recognition of a supreme being or force and the ability to put into practice one’s moral
principles or beliefs
 Sexual health
-acceptance of and the ability to achieve a satisfactory expression of one’s sexuality

Broader:

 Environmental
-physical environment where people live
-housing, transport, sanitation, pollution and pure water facilities
 Societal
-link between health and the way a society is structured
-includes basic infrastructure necessary for health (shelter, peace, food, income) and the degree
of integration or division within the society
 Health (WHO)
-state of complete physical, mental and social well-being and not merely the absence of disease
and infirmity.

 State characterized by soundness and wholeness of human structures, bodily and mental
functions. OREM

FACTORS WHICH AFFECT THE OPTIMUM LEVEL OF FUNCTIONING

 Political
-power and authority to regulate the environment or social climate
-safety, oppression, people empowerment
 Behavioral
-refers to a person’s level of functioning and is affected by certain habits, their lifestyle, health
care and child rearing practices which are determined by one’s culture and ethnic heritage
-culture, habits, mores, and ethnic customs
 Heredity
-understanding of genetically influenced diseases and genetic risks
-congenital defects, strengths, and health risk which can be familial, ethnic or racial
 Health care delivery system
-totality of all policies, infrastructures, facilities, equipment, products, human resource and
services which address the health needs and concerns of the people

Primary health care- partnership approach to the effective provision of essential health services
that are community-based, accessible, acceptable, sustainable and affordable
Focus of health care is in the promotive, preventive, curative and rehabilitative aspects of care
 Environmental influences
-menace of pollution, communicable diseases due to poor sanitation, poor garbage collection,
smoking, utilization of pesticides, lack or absence of proper and adequate waste and sewerage
disposal system and management, urban/rural milieu, noise, radiation, air and water pollution
 Socio-economic influence
-families in lower income group are the ones mostly served
-employment, education and housing
HEALTH THROUGH THE YEARS

1800s-health was associated with poor hygiene and unsanitary conditions: health
was the opposite of sickness
Medical model- health is an individual issue; the way to improve an
individual’s health was to treat the illness
Episodic care- seeking treatment for injury or illness

1900s- health was associated with an individual’s interaction with the

social/physical environment:
Ecological or public health model
– viewed diseases and other negative health events as a result of an individual’s
interaction with his/her social and physical environment
-considered factors such as air/water pollution, working conditions, substance
abuse, stress, diet, lifestyle, access to health care for both individuals and entire
populations
Prevention- identify risk factors to reduce risk of injury or illness
1947- world health organization (WHO) defined health as: health is the state of
complete physical, mental, and social well-being and not merely the absence of
disease and infirmity.
1960-1970- comprehensive ecological or public health mode
-adds to the definition of health the physical, social, and mental elements of life, as
well as environmental, spiritual, emotional and intellectual dimensions
Today- “quality” of life is considered just as important as years of life

Health as Basic Human Right

Article 25, Sec 1

Everyone has the right to a standard of living adequate for the health and
well-being of himself and of his family, including food, clothing, housing and medical
care and necessary social services and the right to security in the event of
unemployment, sickness, disability, widowhood, old age, or lack of livelihood in
circumstances beyond his control
 Philippine Constitution of 1987
Article XIII, Sec 11

The State shall adopt an integrated and comprehensive approach to health

development which shall endeavor to make essential goods, health and other social
services available to all the people at affordable cost. There shall be priority for
the needs of the underprivileged sick, elderly, disabled, women, and children. The
State shall endeavor to provide free medical services to paupers

World Health Organization (1995)

Believes that governments have a responsibility for the health of their people
which can be fulfilled only by the provision of adequate health and social measures.
3 basic positive concepts of health
o Reflecting concern for the individual as a total person
o Placing health in the context of the env’t.
o Equating health with productive & creative living

The Evolution Toward Wellness

 Many people have adopted a holistic approach to wellness, or a balance between
mind, body, and spirit
 This approach allows one to achieve wellness for any given limitation or strengths;
e.g., a person with a physical disability may still have a high degree of wellness if
they are able to find holistic balance.

Health and Wellness as Conceived in Today’s World

 Wellness is a positive quality and the integration of the physical, intellectual,
emotional, environmental, spiritual, and social dimensions of health to form a whole
“health person” (Greenberg, 1992 and Donatelle and Davis, 1996)

Health and Wellness?

 Health is the ever-changing process of achieving individual potential in the physical,
emotional, social, mental, spiritual, and environmental dimensions.
-some aspects of health are determined by genes, age and other factors which may
be beyond one’s control
 Wellness is the achievement of the highest level of health possible in each dimension
of health. It is a measure of our status in each of the dimensions of health and is
the key to unlocking an individual’s full potential
 -determined by the decisions one makes about how to live his/her life; it is now the
new health goal
-state of mind, a way of life which involves options that an individual takes to enjoy a
health life.
 High Level Wellness (HLW) is an integrated method of functioning. It is the ability
to maintain a continuum of balance and purposeful direction within the environment
where he/she is functioning. (Dunn, 1977)

History of Health Education as an Emerging Profession

Health Education

-A process concerned with designing, implementing and evaluating educational programs

that enable families, groups, organizations and communities to play active roles in
achieving, protecting and sustaining health.

-Any combination of learning experiences designed to facilitate voluntary adaptations of

behavior conducive to health (Green, et.al, 1980)

Purpose of Health Education

 To contribute to health and well-being by promoting lifestyles, community actions

and conditions that make it possible to live healthful lives
 Health Educators take on profound responsibilities in using educational processes to
promote health and influence well-being (Code of Ethics of the Society for Public
Health Education, Inc.-SOPHE)

Legal Basis of Health Education

The Philippine Constitution of 1987,

Art XI, Sec 15 The State shall protect and promote the right to health of the people
and instill health consciousness among them

Legal Basis of Health Education in the Nursing Curriculum

Scope of Nursing Practice- Rule IV, Art VI, Sec 28 of the Philippine Nursing Act of

2002(RA 9173). The nurse shall:

 Provide health education to individuals, families and communities

  Teach, guide and supervise students in nursing education programs including the
administration of nursing services in varied settings like hospitals and clinics
 The nursing education program shall provide sound general and professional
foundation for the practice of nursing taking into consideration the learning
outcomes based on national and universal nursing core competencies
 The learning experiences shall adhere strictly to specific requirements embodied in
the prescribed curriculum as promulgated by the CHED’s policies and standards of
nursing education
 The nurse educator must possess adequate knowledge of educational principles and

current trends and techniques to be applied in the classroom, clinical and hospital
setting and in their RLE in the Nursing Skills Laboratory and community which
should meet international standards and parameters

Why study health education?

 Education in health care today-both patient education and nursing staff/student

education

– is a topic of utmost interest to nurses in every setting in which they practice

 Teaching is a major aspect of the nurse’s professional role

 The current trends in health care are making it essential that clients be prepared
to assume responsibility for self-care management

Health Issues and Trends

1. US-patients are being discharged quicker and earlier due to (current trend)

 New healthcare economics

 Advances in medical technology
 Patients and their families have been burdened with the responsibility of continuing
the medical treatment/regimen at home, oftentimes under the supervision or care
of the nurse

2. Managed-Care- reform in the healthcare system

 Aimed at bridging the gap between in-patient services and community-based

services
 Requires nurses nowadays to have greater involvement in
 Client-teaching for self-care management
 Discharge planning
 Providing for continuing care
Social, Economic and Political Trends Affecting Healthcare

1. changed role of nurse - from one of wise healer to expert advisor/teacher to

facilitator of change

A. Empower patients to use their potentials, abilities and resources to the fullest

B. Role of educator today-training the trainer

Through: (1) continuing education

(2) in-service programs and

(3) staff development

2. Health education assists to accomplish the economic goal of reducing the high costs of
health services.

3. Continuing education – nurses

4. Increasing Consumers demands → increased knowledge and skills about how to care

for themselves and how to prevent disease

5. Demographic trends-aging population→ emphasizes self-reliance and maintenance of a

health status over an extended lifespan
6. Morbidity and mortality are those diseases now recognized as being lifestyle
related and preventable through educational interventions.
7. Advanced technology is increasing the complexity of care and treatment in-home
and community-based settings

Future Trends in Health Education

(1) Return to population-based health promotion and maintenance vis-à-vis the hospital-
based emphasis and preference for healthcare during the last few decade

Focus: health of the community healthy behaviors and lifestyle

How? Empowerment of the people and Health Educator-Community Health Worker

(2) Global health strategies-integration of health

education and action & issues – clamor………. Globalization, war, terrorism, social
instability, disease, poverty and environmental degradation is among the key challenges
facing the world today

(3) Clear strategies for global health capacity-building at the national level must be

developed as well as adequate training for public health professionals

HISTORY OF HEALTH EDUCATION

1800s -- Florence Nightingale – ULTIMATE EDUCATOR

 Developed the first school of nursing

 Devoted a large portion of her career to teaching nurses, physicians and health
officials about the importance of proper conditions in hospitals and homes to
improve the health of people
 Emphasized the importance of teaching patients of the need for adequate nutrition,
fresh air, exercise and personal hygiene to improve their well-being

Early 1900s

 public health nurses understood the significance of the role of the nurse as teacher
in preventing disease and in maintaining the health of society.
 For decades, patient teaching has been recognized as an independent nursing
function

1918

 The National League of Nursing Education (NLNE) in the United States (now the
National League for Nursing-NLN) observed the importance of health teaching as a
function within the scope of nursing practice
 Two decades after, this organization recognized nurses as agents for the promotion
of health and the prevention of illness in all settings in which they practiced

1950

 the NLNE had identified course content in nursing school curricula to prepare
nurses to assume the role of teachers of others
 Most recently – the NLNE developed the first certified nurse educator (CNE) exam
to raise the visibility and status of the academic nurse educator role as an
advanced professional practice discipline with a defined practice setting
 American Nurses Association (ANA)- put forth statements on the functions,
standards and qualifications for nursing practice of which patient teaching is a key
element
  International Council of Nurse (ICN) has long endorsed the nurse’s role as educator
to be an essential component of nursing care delivery
 Today, all state nurse practice acts include teaching with the scope of nursing
practice responsibilities
 Since 1980s-the role of the nurse as educator has undergone a paradigm shift-
from disease-oriented approach to a more prevention-oriented approach
 Focus is on teaching for the promotion and maintenance of
health
 Education has become part of a comprehensive plan of care

that occurs across the continuum of the healthcare delivery

process

 Transition toward wellness has entailed a progression from Disease-oriented

patient education (DOPE) to prevention-oriented patient education (POPE) to
ultimately become health-oriented patient education (HOPE)

Paradigm Shift (Grueninger)

 Disease-Oriented Patient Education (DOPE)

 Prevention-Oriented Patient Education (POPE)
 Health-Oriented Patient Education (HOPE)

1990s

 JCAHO-Joint Commission on Accreditation of Healthcare Organization

 Established nursing standards for patient education
 Describe the type and level of care, treatment and services that must be provided
by an agency or organization to receive accreditation
 Unit-based clinical staff education activities for the improvement of nursing
care interventions
 Interdisciplinary team approach in the provision of patient Education
 Patient’s Bill of Rights-first developed by the American Hospital Association, has
been adopted by hospitals nationwide

1995

 Pew Health Professions Commission published a broad set of competencies it

believed would mark the success of the health professions in the 21st century

1998
  PHPC proposed recommendations specific to the nursing profession of which more
than half of them pertain to the importance of patient and staff education

2006

 Institute for Healthcare Improvements announced the 5 million Lives campaign-aim

is to reduce the 15 mil incidents of medical harm that occur in US hospitals each
year
 Major implications for teaching patients and their families as well as nursing staff
and students the ways they can improve care to reduce injuries, save lives and
decrease costs of healthcare

Principles of Health education

 Health Education is an essential component of any program to improve the health of

a community and has the major role in promoting: (Hubley, 1983)
 Good health practices (Sanitation, clean drinking, water, good
hygiene, breast feeding, infant weaning, and oral rehydration
 The use of preventive services like immunization, screening, antenatal
and child health clinics
 The correct use of medications and the pursuit of rehabilitation
regimens (for TB and leprosy)

HISTORICAL DEVELOPMENT AND CONCEPTS OF HEALTH EDUCATION

Health Education

- combination of learning experiences designed to facilitate voluntary adaptations

of behaviors conducive to health

-science & a profession of teaching health concepts to promote, maintain and

enhance one’s health, prevent illness, disability & premature death through the
adoption of healthy behavior, attitudes &perspectives.

- Draws health models and theories from the biological, environmental,

psychological, physical and medical and even paramedical sciences like nursing
 - According to Committee on Health Education and Promotion Terminology (2001)

combination of planned learning experiences based on sound theories that provide

individuals, groups and communities the opportunity to acquire information and the
skills needed to make quality health decisions.

- WHO Comprises of consciously constructed opportunities for learning involving

some form of communication designed to improve health literacy including improving
knowledge and developing life skills which are conducive to individual and community
health.

Purpose of Health education:

 To positively influence the health behavior and health perspectives of individuals

and communities for them to develop self-efficacy to adopt healthy lifestyles
resulting to healthy communities.

Importance of Health Education

1. Empowers people to decide for themselves what options to choose to enhance their
quality of life,

2. Equips people with knowledge and competencies to prevent illness, maintain health or
apply first aid measures to prevent complications or premature deaths and improves health
status of individuals, families, communities, states and the nation.

3. Enhances the quality of life by promoting healthy lifestyles.

4. Creates awareness regarding the importance of preventive and promotive care thereby
avoiding or reducing the costs involved in medical treatment or hospitalization

Legal Basis of Health education in the nursing Curriculum:

Duties of a nurse in Rule IV, Art. VI, Sec 28 of the Philippine Nursing Act (RA 9173)

1. Provide health education to individuals, families and communities.

2. Teach, guide and supervise students in nursing education
3. Implement programs including the administration of nursing services in varied
settings like hospitals and clinics

Functions of a Professional Health Educator:

 1. Assess individual &community needs &capabilities & identify both internal &
external resources in the community.
2. Plan, develop & coordinate with the different health & government agencies &
NGO’s regarding the health education programs.
3. Do community organizing & outreach.
4. Conduct staff training & consult with other health care providers about behavioral,
cultural or social barriers to health.
5. Conduct regular periodic evaluation of health education programs
6. Make referrals
7. Develop audio, visual, print and electronic materials to be used for training and
conduct of health education classes.
8. Conduct research work and write scholarly articles.

Health Educator

 a professionally prepared individual who serves in a variety of roles & is specifically

trained to use appropriate educational strategies & methods to facilitate the
development of policies, procedures, interventions, &systems conducive to the
health of IFGC
 help promote, enhance &maintain the health of others

A comprehensive health education curriculum consists of planned learning experiences

which will help students achieve desirable attitudes and practices related to critical health
issue like:

1. Emotional health & positive self-image

2. Appreciation & care of the human body and its vital organs

3. Physical fitness

4. Health issues of alcohol, tobacco, drug use & abuse

5. Health misconceptions & myths.

6. Effects of exercise on the body’s systems & on general well being

7. Nutrition & weight control

8. Sexual relationships &sexuality

9. The scientific, social &economic aspects of community &ecological health

10. CD &degenerative diseases including sexually transmitted infections.

11. Disaster preparedness

12. Safety & driver education

13. Environmental factors & how those factors affect an individual’s or population’s
environmental health, life skills, choosing professional medical & health services & choices
o health careers.

Characteristics of Effective Health Education (Hubley)

1. Directed at people who are directly involved with health-related situations &issues in
the home & the community.

2. Lessons are repeated &reinforced over time using different methods.

3. Lessons are adaptable and use existing channels of communication (songs, drama,
storytelling)

4. Entertaining &attracts the community’s attention

5. Uses clear, simple language with local expressions

6. Emphasizes long term benefits of action

7. Provides opportunities for dialogue, discussion & learner participation & feedback

8. Uses demonstrations to show the benefits of adopting the practices

Steps in developing a health education/promotion program (Cottrell et. Al 2001)

1. Assessing needs of the target population

2. Developing appropriate goals and objectives

3. Creating an intervention that considers the peculiarities of the setting

4. Implementing the intervention

5. Evaluating the results

Theories on Health Education
Biopsychosocial Model

George Engel

 A psychiatrist at the University of Rochester

 Introduced the Biopsychosocial model or BPS in 1977
 He advocates the new medical model to explain health and disease.
 Guided the researches on health behavior models like the social cognitive models
of Bandura’s Self efficacy and health Belief model.

Biopsychosocial Model

 Is an approach that states that human experience of health or illness is greatly

affected or determined by the interplay or interrelatedness of the following
factors:

a. Biological

 Concerned with the functioning of the different organ systems of the body and its
coping or adapting mechanisms like immunity level, genetic susceptibility or
predisposition
 Seeks to explain the cause of illness or disease as a result of the breakdown in the
physical or environmental functioning of the body.

b. Psychological

 Perceptions, thoughts, emotions, attitude and behaviors

 Deals with how the individual perceives the health threat and the state of
emotional control, discipline and motivation to stay healthy

c. Social factors

 Socioeconomic status, cultural beliefs and practices, poverty, technology,

environmental influences and conditions.
 Concerned with the individual’s perception of his/her ability to deal with the health
threat or health problems and the barriers posed by the society or the environment
towards the attainment of health and healthy lifestyle. (in line with Bandura’s social
cognitive theory dealing with self-efficacy)

 Shows a direct link between the mind and the body and an indirect link with the
intervening social or environmental factors to explain disease causation.

Theories/Models in Health Education

 In planning health education content, approaches, strategies and activities, there

are models or theories which explain human behavior in relation to health education.
 Theories can be classified on the basis of being directed at the level of:

a. Individual (intrapersonal)

b. Interpersonal

c. Community

 4 most commonly used health theories are:

1. Pender’s health promotion theory- Nola J. Pender

2. Banduras self-efficacy theory- Albert Bandura

3. Becker’s health Belief Model-

4. Green’s PRECEDE-PROCEED Model

A. Health Promotion Theory

 Developed in 1987 and revised by Pender in 1996 to increase the utility of its
predictions and interventions.
 Widely used in the field of nursing Emphasizes actualizing health potential and
increasing the level of well-being using approach behaviors rather than avoidance of
disease.
 5 major components and their variables are:

a. Individual characteristics and experiences

- Prior related behavior

- Personal factors

b. Behavior specific cognition and effect

- Perceived benefits and action

- Perceived barriers to action

- Perceived self- efficacy

 - Activity related effect

-Interpersonal influences

-Situational influences

c. Behavioral outcome

-Commitment to plan of action

- Immediate competing demands and preferences

- Health promoting behavior

d. Activity related affect

e. Commitment to a plan of action

 In a nursing study, results showed that the modifying factors of age, income,
education and selected biological characteristic of body mass had indirect effects
on health promoting lifestyles as proposed by the model.

B. Bandura’s Self-Efficacy Theory

 Social learning theory is the result of separate research by Rotter and Bandura.
 Bandura renamed the theory as Social Cognitive Theory to emphasize the cognitive
aspect of learning which explains human behavior by citing three factors which are
in continuous interaction resulting in a process or reciprocal determinism or triadic
reciprocal causality namely:

a. Personal factors in the form of cognition, affect, and biologic events

b. Behavior

c. Environmental influences.

Social Cognitive theory

 Emphasizes that cognition plays a critical role in people’s capability to construct

reality, self-regulate, encode information and perform behaviors.

Self –efficacy

 Is the single most important aspect of the sense of self that determines one’s
effort to change behavior according to Bandura.
  Equated with self confidence in one’s ability to successfully perform a specific type
of action

Ex. a person may experience high level of self-efficacy in preparing low salt, low
cholesterol diet but very little self- efficacy in performing the prescribed exercise
regimen.

A person can increase self- efficacy through:

a. Personal mastery of a task

b. Observing the performance of others (vicarious experience)

c. Verbal persuasion such as receiving suggestions from others

d. Arousal of her/his emotional state.

 In the construct of emotional coping responses, a person must be able to deal with

any sources of anxiety surrounding that behavior in order to learn.

Constructs in Social learning theory

 Help to explain learning

1. Value expectancy theory

Reinforcement = learning but

Reinforcement + an individual’s expectations of the consequence of behavior = behavior

According to SLT, reinforcement can be accomplished in one of the three

ways:

a. Direct reinforcement

- Supplied directly to the person

b. Vicarious

- Participant observes someone else being reinforced for behaving in an appropriate or

inappropriate manner

-Also called social modeling or observational learning

c. Self-management
-Involves record keeping to the participant of her/his behavior

-When the behavior is performed correctly, the person would reinforce or reward
herself/himself

-Construct of self-control is applied

-Reflects the idea that individuals may gain control of their own behavior by monitoring it.

Other constructs applicable to learning situations in health education:

1. Behavioral capability

 Refers to the knowledge and skills necessary to do behavior which influences

actions
 Must know what the behavior are and how to perform them
 Needs Clear instructions or training

2. Expectations

 Refers to the ability of humans to think and to expect certain results in certain
situations.

3. Expectancies

 Are the values such as chest x-rays for tuberculosis screening that people place on
an expected outcome.
 The more highly valued the expected outcome, the more likely the person will
perform the needed behavior to yield that outcome.

4. Efficacy expectations

 Are feelings of competency

5. Outcome expectations

 If a person believes that the outcome of the behavior (reinforcement) is not great
or good enough in terms of benefits, he/she may not attempt the behavior in spite
of the feeling of competency or efficacy expectations.
C. Health Belief Model (Rosenstock, Becker, Kirscht, et al.)

 One of the 1st models originally introduced by a group of psychologists in 1950’s to

find out why people refused to use available preventive services such as chest x-rays for
tuberculosis screening and immunization for influenza.

 Researchers assumed that people feared diseases and that the health actions of
people were motivated by the degree of fear (perceived threat) and the expected
fear reduction of actions, as long as that possible reduction outweighed practical
and psychological barriers to taking actions (net benefits)

4 constructs:

1. Perceived susceptibility

 Person’s opinion of the chances of getting a certain condition

 People will not change their health behaviors unless they believe that they are at
risk.
 Those who does not think that they are at risk of acquiring HIV from unprotected
intercourse is unlikely to use a condom.

2. Perceived severity

 Person’s opinion of how serious the condition is

 The probability that a person will change his/her health behaviors to avoid a
consequence depends on how serious he or she considers the consequence to be.
 If you are young and in love, you are unlikely to avoid kissing your sweetheart on the
mouth just because he has the sniffles, and you might get his cold. On the other
hand, you probably would stop kissing if it might give you Ebola.

3. Perceived benefits

 Person’s opinion of the effectiveness of some advised action to reduce the risk of
seriousness of the impact
 It’s difficult to convince people to change a behavior if there isn’t something in it
for them.
 Your father probably won’t stop smoking if he doesn’t think that doing so will
improve his life in some way

4. Perceived barriers

 Person’s opinion of the concrete and psychological cost of this advised action
  One of the major reasons people don’t change their health behaviors is that they
think that doing so is going to be hard. Sometimes it’s not just a matter of physical
difficulty, but social difficulty as well. Changing your health behaviors can cost
effort, money, and time.
 If everyone from your office goes out drinking on Fridays, it may be very difficult
to cut down on your alcohol intake.

Cues to action

 These are events (internal or external) which can activate a person’s readiness to
act and stimulate an observable behavior.
 External strategies:
- Information sought delivered in print with educational materials or through
electronic mass media
-Reminders by powerful others or oersons of influence
-Persuasive communications
-Personal experiences
-One-to one counseling

Self-efficacy

 Person’s confidence in her ability to successfully perform an action.

 Explain certain health related behaviors
 Guide the search why these behaviors occur and to identify points for

possible change and to design change strategies.

D. PRECEDE-PROCEED Model (Bastable)

 Based on the epidemiological perspective on health promotion to combat the

leading causes of death.

 PRECEDE stands for:

o P – Predisposing

o R – Reinforcing

o E – Enabling

o C – constructs in
o E – educational

o D – Diagnosis and

o E – evaluation

 Developed by Green

 PROCEED stands for:

o P – policy

o R – Regulatory

o O – Organizationnal

o C- Constructs in

o E – Educational and

o E – Environmental

o D – Development

 Developed by Green and Kreuter

 The core of the model is the definition of health education as any combination of

learning experiences designed to facilitate voluntary actions conducive to health.

 Health education is aimed primarily at planning experiences that are designed to

predispose, enable and reinforce voluntary behavior conducive to the health of

individuals, groups or communities.

 The phases in the PRECEDE component identify priorities and objectives

 Phases in the PROCEED address criteria for policy, implementation and

evaluation as influenced by the diagnoses in the PRECEDE phases.

 The strength of the model lies in its inclusion of interventions from a population

needs perspective; has predictive value in predicting changes in health behavior.

 Relevant or useful to community health nurses since the model notes that the
community is the center of gravity.

9 Phases of the PRECEDE-PROCEED model:

1. Social diagnosis- begins with population self-study/assessment relative to the quality of

life.

2. Epidemiologic diagnosis

3. Behavior and environmental diagnosis

4. Educational and organizational diagnosis- addresses issues dealing with education

5. Administrative and policy diagnosis – addresses issues dealing with education

6. Implementation

7. Process evaluation

8. Impact evaluation

9. Outcome evaluation

I. Developmental Stages of the Learner across the Lifespan

1.Prenatal Development

 Conception occurs and development begins.

 All of the major structures of the body are forming and the health of the mother
is of primary concern.
 Understanding nutrition, teratogens (or environmental factors that can lead to
birth defects), and labor and delivery are primary concerns.

2. Infancy and Toddlerhood

 The first year and a half to two years of life are ones of dramatic growth and
change.
 A newborn, with a keen sense of hearing but very poor vision is transformed into a
walking, talking toddler within a relatively short period of time.
  Caregivers are also transformed from someone who manages feeding and sleep
schedules to a constantly moving guide and safety inspector for a mobile, energetic
child.

3. Early Childhood

 or preschool years consisting of the years which follow toddlerhood and precede
formal schooling
 3-5 y/o, busy learning language, gaining a sense of self and greater independence,
and beginning to learn the workings of the physical world.
 may initially have interesting conceptions of size, time, space and distance such as
fearing that they may go down the drain if they sit at the front of the bathtub
 A toddler’s fierce determination to do something may give way to a four-year-old’s
sense of guilt for doing something that brings the disapproval of others

4. Middle Childhood

 6-11 y/o comprise middle childhood and much of what children experience at this
age is connected to their involvement in the early grades of school
 Now the world becomes one of learning and testing new academic skills and by
assessing one’s abilities and accomplishments by making comparisons between self
and others.
 Schools compare students and make these comparisons public through team sports,
test scores, and other forms of recognition.
 Growth rates slow down and children are able to refine their motor skills at this
point in life.
 And children begin to learn about social relationships beyond the family through
interaction with friends and fellow students.

5.Adolescence

 period of dramatic physical change marked by an overall physical growth spurt and
sexual maturation, known as puberty.
 It is also a time of cognitive change as the adolescent begins to think of new
possibilities and to consider abstract concepts such as love, fear, and freedom.
 Ironically, adolescents have a sense of invincibility that puts them at greater risk
of dying from accidents or contracting sexually transmitted infections that can
have lifelong consequences.

6.Early Adulthood

 20s and 30s (Students who are in their mid-30s tend to love to hear that they are
a young adult!).
  It is a time when we are at our physiological peak but are most at risk for
involvement in violent crimes and substance abuse.
 It is a time of focusing on the future and putting a lot of energy into making
choices that will help one earn the status of a full adult in the eyes of others.
 Love and work are primary concerns at this stage of life.
8. Middle adulthood
 Late 30s to mid 60s
 period in which aging, that began earlier, becomes more noticeable and a period
at which many people are at their peak of productivity in love and work.
 may be a period of gaining expertise in certain fields and being able to
understand problems and find solutions with greater efficiency than before.
 can also be a time of becoming more realistic about possibilities in life
previously considered; of recognizing the difference between what is possible
and what is likely
 This is also the age group hardest hit by the AIDS epidemic in Africa resulting
in a substantial decrease in the number of workers in those economies (Weitz,
2007).
9. Late Adulthood
 This period of the life span has increased in the last 100 years, particularly in
industrialized countries.
 Late adulthood is sometimes subdivided into two or three categories such as
the
 2 categories 3 categories
 1. “young old” 1. “young old”
 2. “old old” 2. “old old
 3. “oldest old”
 “Young old”- between 65 and 79
 - very similar to midlife adults; still working, still relatively healthy, and still
interested in being productive and active
 “Old old” - 80 and older
 - remain productive & active & the majority continues to live
independently, but risks of the diseases of old age such as arteriosclerosis,
cancer, & cerebral vascular disease increases substantially for this age group
 - Issues of housing, healthcare, & extending active life expectancy are only a
few of the topics of concern for this age group.
 -better way to appreciate the diversity of people in late adulthood is to go
beyond chronological age & examine whether a person is experiencing optimal
aging
  (like the gentleman pictured above who is in very good health for his age and
continues to have an active, stimulating life), normal aging (in which the changes
are similar to most of those of the same age), or impaired aging (referring to
 someone who has more physical challenge & disease than others of the same
age).

NOT YET ORGANIZED!!!

CHAPTER IV

LEARNING

*relatively permanent change in mental processing,

emotional functioning and/or behavior as a result of

experience

*a lasting or permanent change in behavior as a result

of experience which is primarily determined or

influenced by the environment where the person is

situated

HOW DOES LEARNING OCCUR?

Learning occurs as the individual interacts with his

environment and incorporates or applies new information

or experience to what he already knows or has learned.

Environmental Factors that Affect Learning

1. society and culture

2. structure or pattern of the stimuli

3. effectiveness or credibility of role models

4. reinforcement

5. feedback for correct/incorrect responses

6. opportunities to process & apply learning to new situations

Experiences that Facilitate or

Hinder the Learning Process

1. teacher's selection of learning theories to be applied & the

structuring or type of learning experience

2. teacher's knowledge of the nature of the learner, the

materials to be learned, teaching methods, communication

skills, & ability to motivate the learner

3. teacher's ability to relate a new knowledge to previous

experiences, values, self-perception & the learner's

readiness to learn

TEN(10) Learning Principles

1. Use several senses

2. Actively involve the patients/clients in the learning process

3. Provide an environment conducive to learning

4. Assess the extent to which the learner is ready to learn

5. Determine the relevance of the information

6. Repeat the information

7. Generalize information

8. Make learning a pleasant experience

9.Begin with what is known; move toward the unknown

10. Present information at an appropriate rate

What helps ensure that learning becomes

relatively permanent?

1. by organizing the learning experience so that it becomes

meaningful and pleasurable; by presenting the information at

the learner's pace to ensure effective and efficient

processing of information

2. practicing or rehearsing new information mentally or

physically to retain & strengthen learning

3. applying reinforcements through rewards or recognition to

make the learner know that learning has occurred

4. assessing or evaluating whether learning has taken place

immediately after the experience or some later point in time

Learning

Theories

Framework and set of integrated constructs and

principles that describe, explain or

predict how people learn, how learning occurs

and what motivates people to learn and change.

Contributions of Learning theories

Helped us understand the process of

teaching-learning on how individuals acquire

Knowledge and change the way they think, feel

and behave.

Helped the health care professionals to employ

sound methods and rationales in their health

education

Behaviorist Theory

Introduced by John B. Watson

Postulated that behavior, emotions and thoughts are

products of conditioning.

Learning = result of the conditions or stimuli in the

environment and the learner’s response

S-R model

Observe the responses and manipulate the environment

to bring about the desired change

RESPONDENT CONDITIONING
Classical/Pavlovian

conditioning

Eg. presented dogs with a ringing bell

followed by food. [The food elicited

salivation, and after repeated bell-food

pairings the bell also caused the dogs to

salivate. In this experiment the food is

an unconditioned stimulus, salivation is

an unconditioned response, the bell is

neutral but then becomes a conditioned

stimulus, the salivation elicited by the

bell is a conditioned response.

Process which

influences the

acquisition of new

responses to

environmental stimuli

2. Stimulus generalization

Discrimination learning develops

when varied experiences eventually

enable the individual to differentiate

among similar stimuli

3. Systematic desensitization

4. Spontaneous recovery

To apply to other similar

stimuli what was initially

learned-tendency of the

conditioned stimulus to

evoke similar responses

after the response has

been conditioned

to reduce fear and anxiety

in the patient

Explain why it is difficult to

eliminate unhealthy habits

OPERANT CONDITIONING

by Burrhus Frederic Skinner

Focuses on reinforcement = events that

strengthen responses

believed that the best way to understand

behavior is to look at the causes of an action and

its consequences.

Powerful tool used in teaching

Based on Thorndike’s Law of effect

Skinner (1948) studied

operant conditioning by

conducting experiments

using animals which he

placed in a “Skinner Box”

which was similar to

Thorndike’s puzzle box.

The box contained a lever in the side and as the

rat moved about the box it would accidentally

knock the lever. Immediately it did so a food

pellet would drop into a container next to the

lever. The rats quickly learned to go straight to

the lever after a few times of being put in the

box. The consequence of receiving food if they

pressed the lever ensured that they would repeat

the action again and again.

Ways of employing reinforcement

Verbal ways

Non verbal ways

Citing in class or publishing

Classification of Educational

Reinforcers

Recognition

Tangible rewards

Learning activities

School responsibilities

Status indicators

Incentive feedback

Personal activities

Cognitive Theories
Stresses that mental processes or cognition

occurs between the stimulus and the response.

The learner’s goals and expectations are more

important

Tension

act as the motivator

Disequilibrium

imbalance

Involves intelligence – which is the ability to

solve problems

It stresses the importance of what goes on inside

the learner which involves:

a. perception

b. Thinking skills

c. memory

d. ways of processing and structuring

information

1. Gestalt psychology

The word Gestalt in German literally means

“shape” or “figure”.

believed learning is the result from good

perception, which enable an individual to form

correct concept in their mind.

configuration or patterned organization of

cognitive elements reflecting the maxim “ whole

is greater than the sum of its parts”

Principles of Gestalt related to HC

Psychological organization is directed toward simplicity, equilibrium and regularity.

Perception is selective- no one can attend or pay attention to all the surrounding stimuli at
the same time.

What individual’s pay attention to or what they ignore may be affected by factors like
needs, personal motives, past experiences and structure of the stimulus or situation.
2. Information processing

A cognitive perspective that emphasizes the thinking processes like:

 Thought
 Reasoning
 The way information is encountered and stored
 Memory functioning
 Useful for assessing problems in acquiring, remembering and recalling information

Stages of memory process:

1. paying attention to the environmental stimuli

2. Information is processed by the senses

3. Information is transformed and incorporated or encoded=short term or long

term

4. Involves the action or response the individual makes on the basis of how the
information was processed and stored.

3. Cognitive development

 Jean Piaget – best known cognitive developmental theorist

4 Major Periods of Cognitive /intellectual dev”t:

 Sensorimotor (birth-2 yrs.)- children think through the coordination of sensory

input and motor responses.
-The moro reflex
-Sucking reflex
-babinski
 Abstract thinking/Preoperational – using symbols that can be manipulated mentally

3. Concrete Operational
Perspective thought/relativism

Recognizes that no two individuals are alike

Awareness on different views rather than on one

single thought.

They begin to understand the concept of

conservation

4. Formal Operational

4. Assimilation and accommodation

 characterized by hypothesis testing before making conclusions
 Experience is the best teacher
 Understands that no two individuals are alike
 Teens begin to think more about moral, philosophical, ethical, social, and political
issues that require theoretical and abstract reasoning
 the adolescent or young adult begins to think abstractly and reason about
hypothetical problems

Social Learning Theories by Bandura

 Emphasized the importance of environmental or situational determinants of

behavior and their continuing interaction
 Assumes that all actual behavior patterns must be learned through traditional
learning (reinforcement) and observational learning (modeling)

Operations involved in modeling

 1. Attention processes- determines what a person can do
2. Retention processes-determines how experience is retained in memory
3. Motor reproduction processes-determine how behavior can be performed
4. Motivational or reinforcement processes- determines the circumstances

Humanistic theory of Learning

 Positive self-concept and self-esteem enhance the learner’s enthusiasm to learn and
the teacher’s role is more of a facilitator of learning rather than an authority on
teaching.
 Maslow’s…

Psychodynamic theory of learning

 Theory of motivation
 stressing emotions rather than cognition and responses
 Emphasizes the importance of conscious and unconscious forces in guiding behavior,
personality, conflicts and the enduring effects of childhood experiences.

ID – the most primitive source of motivation and is based on libidinal energy.

 Operate on the basis of pleasure principle and avoid pain.

a. Eros ( life force)- the desire for pleasure and sex
b. Thanatos (death wish)- these are aggressive and destructive impulses

Learning Styles

 Are ways in which an individual processes information or different approaches or

methods of learning
 Involves affective, psychomotor and cognitive styles

Kolb's Learning Styles

 David Kolb's theorized that four combinations of perceiving and processing

determine four learning styles that make up a learning cycle.
  According to Kolb, the learning cycle involves four processes that must be present
for learning to occur:

Diverging (concrete, reflective)

 Emphasizes the innovative and imaginative approach to doing things. Views concrete
situations from many perspectives and adapts by observation rather than by action
 Interested in people and tends to be feeling-oriented.
 Likes such activities as cooperative groups and brainstorming.

Assimilating (abstract, reflective)

- Pulls a number of different observations and

thoughts into an integrated whole

-Likes to reason inductively and create

models and theories

-Likes to design projects and experiments,

lectures, one to one instruction

-integrate ideas & actively apply them

-uses logical thinking

-learns best through lectures &

self-instruction methods

Converging (abstract, active)

Emphasizes the practical application of ideas and

solving problems

Likes decision-making, problem-solving, and the

practicable application of ideas

Prefers technical problems over interpersonal

issues.

Learns best through demonstrations , return demo.

hand-outs, charts, illustrations

Uses deductive reasoning to solve problems, uses

facts & data & has skills for technology & specialist

careers

Accommodating (concrete, active)

- Uses trial and error rather than thought and

reflection

Good at adapting to changing circumstances;

solves problems in an intuitive, trial-and-error

manner, such as discovery learning

Also tends to be at ease with people

Likes role playing, gaming & computer

simulations

Learners are the most challenging to

educators bec. they learn best through new &

exciting learning experiences & are not afraid

of taking risks

Gregorc Cognitive Styles Model

Anthony Gregorc's Mind Styles model provides an

organized way to consider how the mind works.

The mind has the mediation abilities of

Perception= the way one receives or grasps incoming

information or stimulus in a continuum ranging from

abstractness or concreteness

Ordering of knowledge= the way one arranges &

systematizes incoming stimuli in a continuum or scale

ranging from sequence to randomness which affects

the way a person learns

4 Mediation Channels
1. Concrete Sequential (CS) - learners are highly

structured, quiet learning environment without

interruptions.

-like concrete learning materials (visuals) & give focus on

details; may interpret words literally

2. Abstract Random (AR) – learn a lot from visual stimuli,

prefer busy, unstructured learning environment, focused

on personal relationships

Think holistically

3. Abstract Sequential (AS) – learners are

holistic thinkers and need consistency, do

not like interruptions, have good verbal

skills, rational and logical

4. Concrete Random (CR) – intuitive, trial

and error method of learning, looks for

alternative

No one is a "pure" style. Each of us has a

unique combination of natural strengths and

abilities
Gardner’s multiple intelligence

students possess different kinds of minds and therefore learn,

remember, perform, and understand in different ways,"

according to Gardner (1991).

According to this theory, "we are all able to know the world

through language, logical-mathematical analysis, spatial

representation, musical thinking, the use of the body to solve

problems or to make things, an understanding of other

individuals, and an understanding of ourselves

Individuals differ in the strength of these

intelligences - the so-called profile of

intelligences -and in the ways in which

such intelligences are invoked and

combined to carry out different tasks,

solve diverse problems, and progress in

various domains."

The Seven Types of Intelligence

Psychologist Howard Gardner has identified the

following distinct types of intelligence in his Multiple

Intelligences Theory ("MI Theory") in the book "Frames

of Mind." They are listed here with respect to gifted /

talented children.

1. Linguistic Children with this kind of intelligence enjoy

writing, reading, telling stories or doing crossword

puzzles.

2. Logical-Mathematical Children with lots of logical

intelligence are interested in patterns, categories and

relationships. They are drawn to arithmetic problems,

strategy games and experiments.

3. Bodily-Kinesthetic These kids process knowledge

through bodily sensations. They are often athletic,

dancers or good at crafts such as sewing or

woodworking.

4. Spatial These children think in images and pictures. They

may be fascinated with mazes or jigsaw puzzles, or spend

free time drawing, building with Leggos or daydreaming.

5. Musical Musical children are always singing or drumming

to themselves. They are usually quite aware of sounds

others may miss. These kids are often discriminating

listeners.
6. Interpersonal Children who are leaders

among their peers, who are good at

communicating and who seem to

understand others' feelings and motives

possess interpersonal intelligence.

7. Intrapersonal These children may be

shy. They are very aware of their own

feelings and are self-motivated.