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DEFINITIONS OF HEALTH EDUCATION According to Griffiths (1972), “health education attempts to close the gap between what is known about optimum health practice and that which is actually practiced.” Simonds (1976) defined health education as aimed at “bringing about behavioural changes in individuals, groups, and larger populations from behaviours that are presumed to be detrimental to health, to behaviors that are conducive topresent and future health.” Subsequent definitions of health education emphasized voluntary, informed behavior changes. In 1980, Green defined health education as “any combination of learning experiences designed to facilitate voluntary adaptations of behaviour conducive to health (Green, Kreuter, Partridge, and Deeds, 1980). The Role Delineation Project defined health education as “the process of assisting individuals, acting separately or collectively, to make informed decisions about matters affecting their personal health and that of others” (National Task Force on the Preparation and Practice of Health Educators, 1985). Health education evolved from three settings: communities, schools, and patient care sites. Kurt Lewin’s pioneering work in group process and his developmental field theory during the 1930s and 1940s form the intellectual roots of 8 Health Behavior and Health Education much of today’s health education practice. One of the earliest models developed to explain health behavior, the Health Belief Model, was developed during the 1950s to explain behavior related to tuberculosis screening (Hochbaum, 1958). Health education includes not only instructional activities and other strategies to change individual health behavior but also organizational efforts, policy directives, economic supports, environmental activities, mass media, and community- level programs. Two key ideas from an ecologic perspective help direct the identification of personal and environmental leverage points for health promotion and education interventions (Glanz and Rimer, 1995). First, behavior is viewed as being affected by, and affecting, multiple levels of influence. Five levels of influence for healthrelated behaviors and conditions have been identified. They are (1) intrapersonal, or individual factors; (2) interpersonal factors; (3) institutional, or organizational factors; (4) community factors; and (5) public policy factors (McLeroy, Bibeau, Steckler, and Glanz, 1988). The second key idea relates to the possibility of reciprocal causation between individuals and their environments; that is, behavior both influences and is influenced by the social environment (Stokols, 1992). Health education covers the continuum from disease prevention and promotion of optimal health to the detection of illness to treatment, rehabilitation, and long-term care. Health education is delivered in almost every conceivable setting—universities, schools, hospitals, pharmacies, grocery stores and shopping centers, recreation settings, community organizations, voluntary health agencies, worksites, churches, prisons, health maintenance organizations, migrant labor camps, advertising agencies, the Internet, people’s homes, and health departments at all levels of government.

DEFINITIONS OF HEALTH

Health is a quality of life involving social, mental, and biological fitness on the part of the individual which results from the adaptations to the environment (Shirrefs, 1982) Health refers to a condition of physical, mental, and social well-being and the absence of disease or other abnormal condition. It is not static condition; constant change and adaptation to stress result in homeostasis. Rene Dubor, often quoted in nursing education, says “The states of health or disease are the expression of the success or failure experienced by the organism in its efforts to respond adaptively to environmental challenges. Health is multi-dimensional, and includes vocational health as well as the more traditional health components (Eberst, 1985). Health as defined in the Constitution of the World Health Organization (1946) refers to that state of complete physical, mental, social well-being, and not merely the absence of disease and infirmity. It includes three basic concepts to a positive concept of health, such as: (a) reflecting concern for the individual as a total person; (b) placing health in the context of the environment, and (c) equating health with productive creative living. Dever (1980) summarizes the varying ways that health can be conceptualized when he describes the ecological, social ecological, World Health Organization holistic and high-level wellness models of health. Others write of health as being more holistic. Self-awareness as a key component of health includes skills development, values awareness, goal setting, positive self-concepts, cognitive, and will power development among numerous other variables. (Horowitz,1985). These definitions conceptualized health to be multi-dimensional, to include many components and to encompass, many different aspects of one’s life (e.g., vocational, spiritual, and interpersonal).

PHILOSOPHY AND PRINCIPLE IN HEALTH EDUCATION PHILOSOPHY: Comprehensive health education programs encourage students to take responsibility for their own lives by acting conscientiously in the present and by establishing positive health practices that will support and enhance lifelong wellness. Health education is a planned, sequential, k-12 curriculum that addresses the physical, mental, emotional, and social dimensions of health. The curriculum is designed to motivate and assist students to maintain and improve their health,

prevent disease, and reduce health-related risk behaviors. It allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills and practices. The comprehensive curriculum includes a variety of topics such as personal health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. Qualified, trained teacher provide health education.

PRINCIPLES: School health education should: - view health as more than the absence of disease - utilize all educational opportunities for health: formal and informal, traditional and alternative; inside and outside the school. - harmonize all of the health messages - empower students to act for healthy living and to promote conditions supportive of health - establish a basis for lifelong learning and promotion of health - foster interaction between schools, the community, parents and local services - ensure a healthy school environment

A BRIEF HISTORY OF HEALTH EDUCATION Historical accounts revealed that people of the ancient world were so concerned about their health. In the past, ancient Greek estates observed sports competitions in honor of their gods and goddesses. The competitors had to undergo rigorous physical and mental trainings in order to win. This could have been true since the early Greeks believed in what Plato had envisioned about health – a sound mind in a sound body; for the good of the soul. Tracing the history of health education to ancient times, Rubinson and Alles(1984) concluded that the health education profession has been helping people for a very long time now. In the 1970s, the Role Delineation Project, a national project and was designed to explore eventual credentialing or accrediting health educators, developed a specific description of the role of educators. In 1980, health education instruction was operationally defined by the members of the Role Delineation Project as: “the process of assisting individuals, acting separately and collectively, to make informed decisions on matters affecting

individual, family, and community health. Based upon scientific foundations, health education is a field of interest, a discipline, a profession.” In 1985, the Wisconsin Department of Public Instruction’s Guide to Curriculum Planning in Health Education adapted the term total health in connection with health education. The term refers to the lifelong interdependence, constant interaction, and balance of the physical, emotional, social and intellectual dimensions of human growth and development. Health education at present is conceived as any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health (Green, 1980). Hence, health education should be a planned change by the health educator himself (Breckon, 1985).

MYTHS ABOUT HEALTH EDUCATION EXAMPLES: 1. MYTH: Condoms are not very effective in preventing pregnancy and STI. FACT: Repeated studies show that condoms used consistently and correctly offer a high degree of protection against pregnancy and STI and HIV. The most common cause for failure is improper or inconsistent use. Using a condom is 10,000 times safer than not using a condom at all. That is why including condom instruction in sexuality education is so important. 2. MYTH: Childhood diseases are extremely dangerous. FACT: Dangers of childhood diseases are greatly exaggerated in order to scare parents into compliance with questionable but profitable procedure. 3. MYTH: Vaccines are very effective.

FACT: Evidence suggests that vaccination is an unreliable means of preventing disease. A recent study found that measles vaccination "produces immune suppression which contributes to an increased susceptibility to other infections."

THE SCOPE AND EVOLUTION OF HEALTH EDUCATION In the fields of health education and health behavior, the emphasis during the 1970s and 1980s on individuals’ behaviors as determinants of health status eclipsed attention to the broader social determinants of health. Advocates of system-level changes to improve health called for renewal of abroad vision of health education and promotion (Minkler, 1989). These calls for moving health education toward social action heralded a renewed enthusiasm for holistic approaches rather

than an entirely new worldview. They are well within the tradition of health education and are consistent with its long-standing concern with the impact of social, economic, and political forces on health. Over the past fifty years, outstanding leaders in health education repeatedly stressed the importance of political, economic, and social factors as determinants of health. Mayhew Derryberry (1960) noted that “health education . . . requires careful and thorough consideration of the present knowledge, attitudes, goals, perceptions, social status, power structure, cultural traditions, and other aspects of whatever public is to be addressed.” In 1966, Dorothy Nyswander spoke of the importance of attending to social justice and individuals’ sense of control and self-determination (Nyswander, 1966). These ideas were reiterated later when William Griffiths (1972) stressed that “health education is concerned not only with individuals and their families, but also with the institutions and social conditions that impede or facilitate individuals toward achieving optimum health” (emphasis added). The view of health education as an instrument of social change has been renewed and invigorated during the past decade. Policy, advocacy, and organizational change have been adopted as central activities of public health and health education. Most recently, experts have explicitly recommended that interventions on social and behavioral factors related to health should link multiple levels of influence, including the individual, interpersonal, institutional, community, and policy levels (Smedley and Syme, 2000).

SETTINGS, AUDIENCES AND TARGETS OF HEALTH EDUCATION During the past century and more specifically during the past few decades, the scope and methods of health education have broadened and diversified dramatically. This section briefly reviews the range of settings and audiences of health education today. Settings: Where Is Health Education Provided? Today, health education can be found nearly everywhere. The settings for health education areimportant because they provide channels for delivering programs,provide access to specific populations and gatekeepers, usually have existing communication systems for diffusion of programs, and facilitate development of policies and organizational change to support positive health practices (Mullen and others, 1995). Six major settings are particularly relevant to contemporary healtheducation: schools, communities, worksites, health care settings, homes, and theconsumer marketplace. Schools. Health education in the schools includes classroom teaching, teacher training, and changes in the school environment that support healthy behaviours (Luepker and others, 1996). To support long-term health enhancement initiatives, theories of organizational change are used to encourage adoption of comprehensive smoking control programs in schools (see Chapter Fifteen). Diffusion Theory and the Theory of Reasoned Action have been used to analyze factors associated with adoption of AIDS prevention curricula in Dutch schools (Paulussen, Kok, Schaalma, and Parcel, 1995).

Communities. Community-based health education draws on social relationships and organizations to reach large populations with media and interpersonal strategies. Models of community organization enable program planners both to gain support for and to design suitable health messages and delivery mechanisms. Community interventions in churches, clubs, recreation centers, and neighborhoods have been used to encourage healthful nutrition, reduce risk of cardiovascular disease, and use peer influence to promote breast cancer detection among minority women. Worksites. Since its emergence in the mid-1970s, worksite health promotion has grown and spawned new tools for health educators. Because people spend so much time at work, the workplace is both a source of stress and a source of social support (Israel and Schurman, 1990). Effective worksite programs can harness social support as a buffer to stress, with the goal of improving worker health and health practices. Today many businesses, particularly large corporations, provide health promotion programs for their employees (National Center for Health Statistics, 2001). Both high-risk and populationwide strategies have been used in programs to reduce the risk of cancer (Tilley, Glanz, and others, 1999; Tilley, Vernon, and others, 1999; Sorenson and others, 1996) and cardiovascular disease (Glasgow and others, 1995). Health Care Sites. Health education for high-risk persons, patients, their families, and the surrounding community and inservice training for health care providers are all part of health care today. The changing nature of health service delivery has stimulated greater emphasis on health education in physicians’ offices,health maintenance organizations, public health clinics, and hospitals (Walsh and McPhee, 1992; King and others, 1993). Primary care settings, in particular, provide an opportunity to reach a substantial number of people (Campbell and others, 1993; Glanz and others, 1990). Health education in these settings focuses on preventing and detecting disease, helping people make decisions about genetic testing, and managing acute and chronic illnesses. Homes. Health behavior change interventions are delivered to people in their homes, both through traditional public health means—home visits—and through a variety of communication channels and media such as the Internet, telephone, and mail (Science Panel on Interactive Communication and Health, 1999; McBride and Rimer, 1999). The use of strategies such as mailed tailored messages (Skinner, Campbell, Rimer, Curry, and Prochaska, 1999) and motivational interviewing by telephone (Emmons and Rollnick, 2001) makes it possible to reach larger groups and high-risk groups in a convenient way that reduces barriers to their receiving motivational messages. The Consumer Marketplace. The advent of home health and self-care products, as well as the use of “health” appeals to sell consumer goods, has created new opportunities both for health education and for misleading consumers about the potential health effects of items they can purchase (Glanz and others, 1995). Social marketing, with its roots in consumer behavior theory, is used increasingly by health educators to enhance the salience of health messages and to improve their persuasive impact. Theories of Consumer Information Processing (CIP) provide a framework for understanding why people do or do not pay attention to, understand, and make use of consumer health information such as nutrient labels on packaged food products (Rudd and Glanz, 1990).

Audiences: Who Are the Recipients of Health Education?

For health education to be effective, it should be designed with an understanding of the recipients, or target audiences, and their health and social characteristics as well as their beliefs, attitudes, values, skills, and past behaviors. These audiences consist of people who may be reached as individuals, in groups, through organizations, as communities or sociopolitical entities, or through some combination of these. They may be health professionals, clients, people at risk for disease, or patients. This section discusses four dimensions in which the potential audiences can be characterized: sociodemographic characteristics, ethnic or racial background, life cycle stage, and disease or at-risk status. Sociodemographic Characteristics and Ethnic or Racial Background. Socioeconomic status has been linked with both health status and health behavior, with less affluent persons consistently experiencing higher morbidity and mortality (Adler and others, 1994). The recognition of differences in disease and mortality rates across socioeconomic and ethnic or racial groups has led to increasing efforts to reduce or eliminate such health disparities (U.S. Department of Health and Human Services, 2000). For example, it has long been known that African Americans die at earlier ages than do whites. As of 1998, life expectancy for African American males was 67.6 years compared to 74.5 years for white males. The difference is slightly less for African American women, 74.8 versus 80 for white women, but still alarmingly discrepant (National Center for Health Statistics, 2000). A variety of sociodemographic characteristics such as gender, age, race, marital status, place of residence, and employment characterize health education audiences. These factors, while generally not modifiable within the bounds of health education programs, are useful in guiding the tailoring of strategies and educational material and identifying channels through which to reach consumers. Printed educational materials should be appropriate to, and, ideally, tailored to the educational and reading levels of particular target audiences and be consistent with their ethnic and cultural backgrounds. Chapter Twenty-One examines the role of culturally diverse and other unique populations in health behavior theory, research, and practice. Life Cycle Stage. Health education is provided for people at every stage of the life cycle, from childbirth education, the beneficiaries of which are not yet born, to selfcare education and rehabilitation for the very old. Developmental perspectives help guide the choice of intervention and research methods. Children may have misperceptions about health and illness, such as that illnesses are a punishment for bad behavior (Armsden and Lewis, 1993). Knowledge of children’s cognitive development helps provide a framework for understanding these beliefs and ways to respond to them. Adolescents may feel invulnerable to accidents and chronic diseases. The Health Belief Model (see Chapter Three) is a useful framework for understanding the factors that may predispose youth to engage in unsafe sexual practices. Older adults may attribute symptoms of cancer to the inexorable process of aging. Beliefs such as this must be considered in designing, implementing, and evaluating health education programs (Rimer and others 1983; Keintz, Rimer, Fleisher, and Engstrom, 1988). Disease and At-Risk Status. People who are diagnosed with specific diseases often experience not only symptoms but also the distress associated with their prognosis and with having to make decisions about medical. Thus, while they may benefit from receiving health education, their ability to attend to new information may be compromised at critical points due to their illness. Because of this, the timing, channels, and audiences for patient education need to be carefully

considered. Successful patient education depends on a sound understanding of the patient’s view of the world (Glanz and Oldenburg, 2001). For individuals at high risk due to family history or identified factors, health behavior change interventions may have heightened salience when linked to strategies for reducing individual risk (see Chapter Six, on the Precaution Adoption Process Model). Even so, strategies used to enable initial changes in behavior, such as quitting smoking, may be insufficient for maintaining behaviour change over the long term even in these persons. Models and theories of health behavior can suggest strategies for relapse prevention for high-risk individuals (Glanz and Oldenburg, 2001).

Health Target Health targets state, for a given population, the amount of change (using a health indicator) which could be reasonably expected within a defined time period. Targets are generally based on specific and measurable changes in health outcomes, or intermediate health outcomes. Health targets define the concrete steps which may be taken towards the achievement of health goals. Setting targets also provides one approach to the assessment of progress in relation to a defined health policy or programme by defining a benchmark against which progress can be measured. Setting targets requires the existence of a relevant health indicator and information on the distribution of that indicator within a population of interest. It also requires an estimate of current and likely future trends in relation to change in the distribution of the indicator, and an understanding of the potential to change the distribution of the indicator in the population of interest.

COMPONENTS OF HEALTH For health to be a quality of life it becomes the functions of: 1. Social Health. It refers to the ability to interact well with people and the environment and having satisfying interpersonal relationships. 2. Mental Health. It refers to the ability to learn; one’s intellectual capabilities. 3. Emotional Health. It refers to the ability to control emotions so that one feels comfortable expressing them when appropriate and does express them appropriately. Ability to not express emotions when it is appropriate to do so. 4. Spiritual Health. It refers to the beliefs in some unifying force. For some people that will be nature, for others it will be in scientific laws, and for others it will be a godlike force.

5. Physical Health. It refers to the ability to perform daily tasks without undue fatigue; biological integrity of the individual.

AREAS OF CLIENT EDUCATION Client education is provided by many healthcare practitioners, including nurse nephrologists, dieticians, and social workers. A literature search dealing with the area of client education often can be somewhat confusing. Historically, client education has been limited to issues relating to client adherence and client compliance, with the primary emphasis on medication and diet, thereby resulting in an omission of many other areas. The concept of client education takes on a much larger focus, being seen as the sharing of knowledge between a healthcare professional and a client.

DIMENSIONS OF HEALTH In 1946 the newly established World Health Organization (WHO) included a twentyword statement in its constitution which identified three dimensions of health: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. DISCUSSION: 1. Social Well-being Social dimension has been identified as the most ambiguous member of the triad. There is a reasonably firm acceptance of the reality of mental health; one who lacks the quality of mental health, such as someone with severe depression, is ill regardless of how healthy he or she may be physically. But what is social health? It may be argued that social maladjustment or deprivation, for instance, becomes a problem as it is reflected in reduced mental health. Good social interaction thus becomes analogous to good nutrition; the proper types and amounts, free of pathological contaminants, contribute to good health. However, according to this view, social interaction becomes a means for achieving health rather than a part of health itself. Another possible way of viewing social health is to take the position that to be healthy one must make a positive contribution to one’s family and community. The parent who does a responsible job of parenting is viewed as socially healthy; the abusive parent is deemed socially ill. 2. Physical and Mental Well-being

The general acceptance of mental well-being as a part of health has had a significant impact on many aspects of society, particularly on the health care industry. It seems clear that the acceptance of mental or emotional problems is much more certain when something “physical” is involved either as a causative factor or as a symptom. If the harassed businesswoman, for instance, develops a peptic ulcer big enough to reveal itself on an X ray, she will generally receive more sympathy and more thorough treatment than if her symptoms were expressed in insomnia and its resultant fatigue. Similarly, the school child whose behavioural problems result from brain damage incurred during birth may be regarded more sympathetically than if his or her behaviour resulted from long-term interpersonal conflicts. And this tendency to regard only physical problems as indicative of “real-illness” is not restricted to the lay public.

FACTORS INTEGRAL TO HEALTH EDUCATION AND HEALTH PROMOTION FOUNDATIONS OF HEALTH EDUCATION 1. Behavioral Science is concerned with how and why people behave as they do. Contributions from psychology, sociology, and anthropology have provided a substantial, growing body of literature on health behaviour. 2. Education is the study and practice of teaching and learning. Health education draws heavily on this foundation for its approach to education practice which includes curriculum development, teaching theories, educational methods, and evaluation research. 3. Public Health. Traditionally, public health has concerned itself primarily with prevention of disease and its sequelae. In modern public health practice health promotion is also included. Health education is an essential component of health promotion and disease prevention programs. Health promotion begins with people who are basically healthy and seeks to develop community and individual measures which can help them adopt lifestyles which maintain and enhance the state of wellbeing. Disease prevention begins with an identified threat to health such as a disease or environmental hazard or a documented risk factor.

THE PRACTICE OF HEALTH EDUCATION There are five broad categories of responsibilities of health educators, based in part on the Role Delineation Project (1980): 1. Planning Programs - allows for the gathering of baseline data which gives the program direction and sets up the eventual evaluation. Planning facilitates the selection of target behaviors and the determinants which influence these behaviors. Furthermore, planning aids in the selection of educational strategies and methods for use in teh program. 2. Implementing Programs – bringing programs into reality. It includes staff selection and training; the procurement of facilities, materials, and teaching aids; and the recruitment of learners into the program. 3. Delivering Direct Health Education Services: a. Teaching – gathering, interpreting, and disseminating information to those who have a need to know. b. Training – teaching health professionals how to carry out their health education responsibilities. c. Counseling – helping people to learn how to achieve personal growth, improve interpersonal relationships, resolve problems, make decisions, and change behaviour. d. Consulting – giving expert advice as a professional. e. Community Organizing – promoting better use, organization, and/or availability of resources. f. Using Media – television, radio, newspapers, the mail (e-mail), and locally employed audiovisual aid. 4. Administering Programs – promoting and coordinating the activities of the program. 5. Evaluating Programs – examining and judging the outcome of the program.