HEALTH EDUCATION : NUR 101
COMPLIANCE, MOTIVATION, AND
HEALTH BEHAVIORS OF THE
LEARNER
Learning
After completing this chapter, the reader will be able to:
Outcomes
1) Define the terms compliance, adherence, and motivation relative to
behaviors of the learner.
2) Discuss compliance, adherence, and motivation concepts and theories.
3) Identify incentives and obstacles that affect motivation to learn.
4) State axioms of motivation relevant to learning.
5) Assess levels of learner motivation.
6) Outline strategies that facilitate motivation and improve compliance and
adherence.
7) Compare selected health behavior frameworks and their influence on
learning.
8) Recognize the role of the nurse as educator in health promotion.
COMPLIANCE AND
ADHERENCE
COMPLIANCE AND
ADHERENCE
• Compliance is defined as the
“extent to which the patient’s
behavior coincides with the clinical
advice”.
• Adherence, according to WHO, is
the “extent to which a person’s
behavior corresponds with agreed
recommendations from a healthcare
provider”.
COMPLIANCE AND
ADHERENCE
Compliance:
A patient takes medication exactly as
prescribed without questioning the
plan.
Adherence:
A patient and doctor discuss
medication options, and the patient
agrees to a plan he feel comfortable
following.
COMPLIANCE AND
ADHERENCE
Example:
A patient who is experiencing sleep disturbances may comply for a
short period of time with medication as directed.
The same patient, however, may not continue to adhere to the
regimen for an extended time, even though sleep disturbances
continue.
PERSPECTIVES ON
COMPLIANCE
Biomedical Theory
Behavioral/ Social Learning Theory
Communication Models
Rational Belief
Theory
Self-Regulatory
Systems
BIOMEDICAL THEORY
BIOMEDICAL THEORY
This theory links compliance with patient characteristics such as
demographics, severity of disease, and complexity of treatment
regimen.
Example:
A patient underwent a coronary artery bypass graft(CABG) following a
heart attack. He was discharged with instructions to take
anticoagulants, attend cardiac rehabilitation, stop smoking, and follow
a low-sodium diet.
BEHAVIORAL/SOCIAL
LEARNING THEORY
BEHAVIORAL/SOCIAL
LEARNING THEORY
This theory focuses on external factors that influence the patient’s
adherence, such as rewards, cues, contracts, and social supports.
Example:
A patient is overweight and has been recently diagnosed with hypertension. His
doctor recommends lifestyle changes. Despite understanding the risks, he
struggles to change his eating habits and avoids exercising.
COMMUNICATION MODELS
COMMUNICATION MODELS
Communication models attempt to explain compliance based on the
communication between the patient and healthcare professionals.
Example:
A patient with chronic heart failure and multiple comorbidities was
recently hospitalized for fluid overload. After discharge, he was
prescribed a complex care plan, including medications, diet changes,
and daily weight checks but destructed by environmental noise. At his
first follow-up, it's found he's not adhering to the regimen.
RATIONAL BELIEF THEORY
RATIONAL BELIEF
THEORY
This theory suggests that patients decide to comply or not comply by
weighing the benefits of treatment and the risks of disease through cost-
benefit logic.
Example:
A patient recently underwent a total knee replacement. Despite a successful
surgery, he is reluctant to attend physical therapy sessions and often skips
home exercises. He says “This pain is unbearable, and pushing through it is
pointless. I’ll never walk normally again.”
SELF-REGULATORY
SYSTEM
SELF-REGULATORY
SYSTEMS
Patients are seen as problem solvers whose regulation of behavior is
based on perception of illness, cognitive skills, and past experiences that
affect their ability to plan and cope with illness.
Example: A patient with moderate asthma, has frequent flare-ups. Her
parents report she often refuses to use her inhaler unless she’s having an
attack. She’s been to the ER twice in the last three months. Her care team
notices she is not using her maintenance inhaler as prescribed.
NONCOMPLIANCE AND
NONADHERENCE
NONCOMPLIANCE AND
NONADHERENCE
Noncompliance describes resistance of the individual to follow a
predetermined regimen. It’s intentional.
Nonadherence occurs when the patient does not follow treatment
recommendations that are mutually agreed upon. It can be intentional
and unintentional.
NONCOMPLIANCE AND
NONADHERENCE
Intentional Noncompliance:
Example: A patient refuses to take insulin because he fear injections.
Intentional Nonadherence
Example: The patient chooses not to follow the plan.
Unintentional Nonadherence
Example: The patients wants to follow the plan but fails due to
barriers.
WHY PATIENTS ARE
NON-COMPLIANT?
FACTORS RELATED
TO NONCOMPLIANCE
•Patient issues
•Health illiteracy
•Disease issues
•Lifestyle issues
•Treatment factors
•Sociodemographic factors
•Psychosocial variables
IS NON-COMPLIANT
BEHAVIOR
GOOD OR BAD?
IS NON-COMPLIANT
BEHAVIOR
GOOD OR BAD?
Example:
A patient with chronic back pain is prescribed daily opioids but finds
they cause drowsiness and interfere with caring for her children. She
chooses to take them only at night and manages daytime pain with
physical therapy and over-the-counter meds.
FACTORS RELATED
TO
NONADHERENCE
•Stress
•Forgetfulness
•Substance
•Abuse
•Multiple Medical Conditions
•Uncertainty about health beliefs and
practices
•Real or perceived stigma
LOCUS OF
CONTROL
LOCUS OF CONTROL
Locus of control refers to an individual’s sense of responsibility for his or her
own behavior and the extent to which motivation to act.
Health locus of control (HLOC):
Internals Externals
Example: Although there is a history of Example: Osteoporosis runs in
osteoporosis in my family, I will have my family, and it will catch up
necessary screenings, eat an appropriate with me.
diet, and do weight-bearing exercise to
prevent or control this problem.
FOUR DIMENSIONS OF
HEALTH LOCUS OF CONTROL
• Internal
•Chance External
•Others external
•Doctors External
Motivation —is defined as “an
internal state that arouses, directs, and sustains
human behavior” (Glynn, Aultman, & Owens,
2005, p. 150)
Motivational
factor
Factors that influence motivation can serve as
either incentives or obstacles to achieving de -
sired behaviors.
Motivational factors:
• The cognitive ( thinking
processes )
• The affective ( emotions and
feelings )
• The psychomotor ( skill
behavior )
Motivational incentives which are those
factors that influence motivation in the direc-
Motivational incentives tion of a desired goal, need to be considered in
the context of the individual. Which can be
classified into three:
• Physical attributes
• Environmental influence
• Relationship system
Motivational Axioms
Axioms are premises on which an
understanding of a phenomenon is
based.
Assessment of
• State of optimal anxiety Motivation
• learners readiness Redman (2001) views motivational
• Realistic goal setting assessment as a part of general health
• learners satisfaction assessment and states that it includes
such areas as level of knowledge, client
• uncertainty-reducing or
skills,decision-making capacity of the
uncertanty-maintainace individual, and screening of target
populations for educational programs.
MOTIVATIONAL STRATEGIES
What is Motivation?
Motivation = what makes us act and learn
Two kinds:
• Intrinsic - Internal (interest, goals,
satisfaction)
• Extrinsic - External (rewards, praise,
avoiding failure)
MOTIVATIONAL THEORIES & MODELS
Key Models:
Cognitive Evaluation Theory (Ryan & Deci) :
Support autonomy + competence = higher motivation
Maslow’s Hierarchy of Needs :
Meets basic needs first to unlock readiness to learn
Keller’s ARCS model:
A (Attention) R (Relevance) C (Confidence) S (Satisfaction)
People learn best when they are interested, see value, feel
capable, and get positive feedback
Motivational Teaching
Strategies
What helps learners stay motivated?
• Concept mapping
• Clear communication & feedback
• Environmental support
• Barrier removal
• Small wins = confidence boost
MOTIVATIONAL INTERVIEWING (MI)
• A client -centered communication style
• Helps people explore and resolve
ambivalence
• Encourages behavior change through
collaboration
MI TECHNIQUES
TOOLS USED IN MOTIVATIONAL INTERVIEWING
READS Principles OARS Tools
• R- oll with resistance • O- pen questions
• E- xpress empathy • A- ffirmation
• A- void argument • R- eflective listening
• D- evelop discrepancy • S - ummarize
• S - upport self - efficacy
SELECTED THEORIES
Self-Efficacy Theory
Protection Motivation Theory
Theory of Reasoned Action and
Theory of Planned Behavior
SELF-EFFICACY THEORY:
• based on a person’s expectations
relative to a specific course of
action
• it deals with the belief that one is
competent and capable of
accomplishing a specific behavior
• the belief of competency and
capability relative to certain
behaviors is a precursor to
expected outcomes.
PROTECTION MOTIVATION THEORY (PMT)
Protection Motivation Theory (PMT)
PMT explains why people change their behavior
in response to health threats. It focuses on two
main ideas:
Threat Appraisal: How serious the health
threat is and how vulnerable a person feels.
Coping Appraisal: How capable a person feels
in handling the threat (self-efficacy) and the
effectiveness of the recommended behavior.
PROTECTION MOTIVATION THEORY (PMT)
PMT HAS BEEN USED IN HEALTH AREAS LIKE:
• Internal Drug use and
trafficking prevention
• AIDS awareness
• Smoking, alcohol, and sun
protection behavior
THEORY OF REASONED ACTION (TRA)
Emerged from a research program that began in the 1950s
and is concerned with predicting and understanding any form
of human behavior within a social context (Ajzen & Fishbein,
1980).
• it is based on the premise that humans behave in a
rational way that is consisent with their beliefs (Fishbein,
2008).
THEORY OF PLANNED BEHAVIOR (TPB).
• theory of planned behavior (TPB). The TPB added a third element
to the TRA model—the concept of per?ceived behavioral control
(Ajzen, 1991).
• It adds a third key component Perceived Behavioral Control to
better account for behaviors not entirely under an individual’s
control.
• The TRA and the TPB have been used
determine nurses’ attitudes toward
teaching particular health education
topics (Kleier, 2004; Mullan &
Westwood, 2010).
SELECTED MODELS:
Health Benefit Model
Health Promotional Model
Stages of Change Model
Therapeutic Alliance Model
HEALTH BELIEF MODEL:
• The original health belief model (HBM) was developed in the
1950s from a social psychology perspective to examine why
people did not participate in health screening programs
(Rosenstock, 1974).
• The HBM explains and predicts health behaviors based on the
patients’ beliefs about the health problem and the health
behavior. The model relies on the assumptions that patients are
willing to participate and that they believe that health is highly
valued (Becker, 1990).
HEALTH PROMOTIONAL MODEL:
• used to assist nurses in understanding the major determinants of
health behaviors as a basis for behavioral counseling to promote
healthy lifestyles
• helps to provide an understanding of whether people choose to
engage in health-promoting behaviors
STAGES OF CHANGE MODEL
(TRANSTHEORETICAL MODEL - TTM)
This model describes the six stages people typically go
through when changing a behavior, especially for
addictions and health habits:
1. Pre contemplation: Individuals have no current intention of
changing.
2. Contemplation: Individuals accept or realize that they have
a problem and begin to think seriously about changing it.
3. Preparation: Individuals are planning to act within the time
frame of 1 month.
STAGES OF CHANGE MODEL
(TRANSTHEORETICAL MODEL - TTM)
This model describes the six stages people typically go
through when changing a behavior, especially for
addictions and health habits:
4. Action: There is overt/visible modification of behavior.
5. Maintenance: There are common challenges to this stage,
including overconfidence, daily temptation, and relapse self-
blame.
6. Termination: This stage occurs when the problem no
longer presents any temptation.
STAGES OF CHANGE MODEL
(TRANSTHEORETICAL MODEL - TTM)
This model helps health professionals assess a person’s
readiness to change and match strategies to each stage.
It has been used in areas like:
• Sun protection
• Weight management
• Exercise habits
• Nursing education
THERAPEUTIC ALLIANCE MODEL
Therapeutic Alliance Model, introduced by
Barofsky (1978), emphasizes a partnership
between the healthcare provider and the
patient. Unlike traditional models where the
provider holds more power, this model
promotes equal power and collaboration.
The patient is seen as active, responsible,
and capable of self-care, rather than
someone who simply follows orders.
THERAPEUTIC ALLIANCE MODEL
Other key points:
• Concordance, a concept proposed by Hobden (2006), supports mutual
respect and negotiation between patient and provider.
• The Kim Alliance Scale (KAS-R) measures the quality of the patient-
provider relationship. Studies show that a strong alliance increases patient
satisfaction.
• Motivational Interviewing (MI) fits well with this model, focusing on
understanding the patient and supporting their autonomy.
• Research shows that the provider’s behavior in the alliance is often more
important than the patient's in achieving better outcomes.
• The model has also been studied in mental health and eating disorder
treatments, with mixed results.
.
MODELS FOR HEALTH EDUCATION
Similarities and Dissimilarities of Models
Educator Agreement with Model Conceptualizations
Functional Utility of Models
Integration of Models for Use in Education
MODELS FOR HEALTH EDUCATION
Similarities and Dissimilarities of Health Behavior Models
Similar Models:
• Health Belief Model (HBM) and Health Promotion Model (HPM) both emphasize personal
perceptions and influencing factors.
• Self-Efficacy Theory, Theory of Reasoned Action (TRA), and Theory of Planned
Behavior (TPB) all emphasize behavioral intention and are more linear and easier to
test. They work well with clearly defined behaviors.
• Stages of Change Model shares a focus on intent but adds a time element to behavior
change and is less focused on personal background or experience.
• Protection Motivation Theory (PMT) is similar to TRA and TPB in that it uses cognitive
processing to lead to behavioral intent but stands out for its fear appraisal and focus on
specific vulnerability.
MODELS FOR HEALTH EDUCATION
Similarities and Dissimilarities of Health Behavior Models
• Common Ground:
⚬ All models recognize the impact of individual beliefs, external influences,
and the complex nature of health behavior.
⚬ They value the patient’s role in decision-making.
• Key Difference:
⚬ The Therapeutic Alliance Model stands apart as the most dissimilar. Instead
of focusing on predicting behavior, it emphasizes the relationship between
educator and patient, viewing both as equal partners. It’s useful in dealing
with noncompliance by understanding behavior from the patient’s
perspective.
MODELS FOR HEALTH EDUCATION
Educator Agreement with Model Conceptualizations
• The choice of a model, can be based on the educators level of
agreement with the ideas in the model.
• Health Belief Model - Best for predicting whether someone will take action.
• Protection Motivation Theory - Focuses on achieving positive health outcomes.
• Theory of Reasoned Action & Theory of Planned Behavior - Emphasize attitude and intention.
• Self-Efficacy Theory - Focuses on belief in one’s own ability to succeed.
• Therapeutic Alliance Model - Helps reduce noncompliance through cooperation between
educator and learner.
• Stages of Change Model - Useful for identifying a person’s readiness to change and planning
the right intervention.
FUNCTIONAL UTILITY OF MODELS
Model selection for educational purposes also an be based
on functional utility. The following questions may be asked
to determine functional utility:
Who is the target learner?
What is the focus of the learning?
When is the optimal time?
Where is the process to be carried out?
INTEGRATION OF MODELS FOR USE IN
EDUCATION
Theories provide blueprints for interventions corporate
principles of pedagogy (teaching (Molisani, 2015). From the
previous discussion, clearly the integration of various
components of health behavior models is advantageous in
the educational process. When salient factors are taken into
consideration in relation to the specific developmental stage
of the learner, an integrated motivational model of learning in
health promotion could emerge.
THE ROLE OF
NURSE AS EDUCATOR
IN HEALTH
PROMOTION
FACILITATOR OF
CHANGE
The nurse promotes positive behavior change by providing
health education as a planned intervention. Through teaching,
the nurse supports individuals in making informed decisions to
improve their health.
Example:
A nurse teaching a patient newly diagnosed with diabetes how
to manage their condition through proper diet, exercise, and
medication is helping the patient transition into a healthier
lifestyle.
CONTRACTOR
The nurse creates a learning agreement with the client, setting
shared goals and a clear plan of action. This involves collaboration,
respect, and trust, ensuring the education process is tailored to the
client’s needs and readiness to learn. Contracting allows the client to
take responsibility for their health decisions while feeling supported.
Example:
imagine a nurse working with a hypertensive patient to lower blood
pressure. Together, they set a goal: walk 30 minutes a day and
reduce salt intake. They write down the plan, agree on follow-ups,
and the nurse respects the patient’s pace and beliefs.
ORGANIZER
The nurse arranges learning sessions in a logical, comfortable, and
effective way. This includes preparing materials, setting up the
environment, and organizing content from simple to complex based
on what the learner needs most. A well-structured learning
experience reduces confusion and supports better retention.
Example:
For example, when teaching first-time mothers about baby care, a
nurse might begin with diapering and feeding before moving on to
recognizing signs of illness. By organizing the topics step-by-step in
a calm setting, the nurse makes it easier for mothers to learn and
apply new skills.
EVALUATO
The nurse checks whether the learning goals have been
R
achieved by assessing changes in the client’s knowledge,
behavior, and health status. Evaluation can be done through
observation, self-assessment, feedback, and outcome
tracking. It ensures that teaching has a meaningful impact on
the learner’s health.
Example:
For example, a nurse who has been teaching asthma
management to a young adult. The nurse checks if the patient
can now properly use an inhaler, avoid known triggers, and
recognize warning signs.
THANK YOU