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Health education: nature and purpose
Even a limited discussion of the nature of health promotion is beyond the scope of this article.
We should, however, note that there is a divergence of opinion about its major goals and that it is not synonymous with health education. Its philosophy has been discussed in detail elsewhere.1-6
Health promotion may be viewed as a global strategy whichincorporates health education.
Health education is defined operationally as:
‘ .... any intentional activity which is designed to achieve health or illness related learning, ie, some relatively permanent change in an individual’s capability or disposition. Effective health education may, thus, produce changes in knowledge and understanding or ways of thinking; it may influence or clarify values; it may bring about some shift in belief or attitude; it may facilitate the acquisition of skills; it may even effect changes in behaviour or lifestyle’ (p11). 2
We are, at present, witnessing a demand for evidence-based medicine within a general climate of cost cutting and a concern to demonstrate ‘health gain’ and it is not surprising that health education should be subject to the same demands. The principles and practice of evaluating health education cannot be addressed here.2 7 8 It is, however, worth noting the fact that health education interventions are frequently under resourced and often fail to meet acceptable theoretical and professional standards; careful scrutiny of programme design is, therefore, essential before drawing conclusions about effectiveness and efficiency.9 The success of the programmes discussed below are, in no small way, due to their meeting minimum design standards.
Health education success: a selective review
Seven specific areas have been selected for review:
• Childhood asthma
• Oral health
• Accident prevention
• Breast feeding
• Nutrition education and children
• Sexual health
• Social and mental health in respect of bullying, child abuse, and preschool education.
These particular topics were selected because of their inclusion in three recent reviews of effectiveness: (i) a wide ranging 16 volume review Improvement of the Effectiveness of Health Education and Health Promotion published by the International Union for Health Promotion and Education (IUHPE),10 (ii) specific UK briefing reviews of breast feeding and child home accidents,11 12 and (iii) a major, comprehensive review of nutrition education.13 Exemplars have been included only if the reviewers judged the intervention to be effective and if the research designs were either true experimental or quasiexperimental.
Colland described an asthma intervention which met most programme design requirements14 : it was theory based and used relevant educational methods (namely 10 hourly sessions incorporating workshops, group discussion, role play, games, and skills training); it was also supported by an appropriate workbook learning resource. Eighty two children aged 8–13 received the educational programme and, by comparison with 30 controls, the experimental group demonstrated: greater knowledge of asthma and its management; better coping skills; fewer restrictions in daily activities; greater self confidence and a more positive attitude to their condition; reduction in anxiety; more effective problem solving; enhanced self efficacy beliefs; satisfaction with the programme and greater compliance; evidence of reduced morbidity.
The IUHPE review listed five examples of successful interventions in relation to oral health.15 The oral health studies demonstrated improvement in a number of general dental preventive measures16 and dietary change17 in secondary schoolchildren. One study revealed success in influencing pharmacists’ intentions to prescribe sugar free paediatric preparations18 and two other studies described effective interventions to promote water fluoridation.19 20
The IUHPE review21 also included evidence of success in increasing use of car seats for babies,22 reductions in home accidents,23 24 and scalding.25 A general review by Harker12 also described successful attempts to reduce tap water scalds26 and to improve skills and reported practices in road safety behaviours in schoolchildren.27
The decision to breast feed seems to depend substantially on beliefs about the relative costs and benefits of breast and bottle feeding. The benefits derive typically from the value attached to the health of the baby and the enhancement of bonding. On the other hand, the major cost is usually anticipated embarrassment. Normative pressures also play a part in determining behavioural intention while the provision of support after the decision has been made is of particular importance in determining whether or not breast feeding is maintained. In this latter context, success would seem to depend on the extent to which mothers are taught specific skills—such as the correct positioning of the baby—together with the provision of anticipatory guidance and arranging for a supportive environment both in and out of hospital— including both specific nursing support and more general social support. When favourable conditions are provided, there is evidence that health education can in fact result in success. For instance Jones et al demonstrated a difference of some 12% in breast feeding between intervention and controls when a lactation nurse provided appropriate support and education.28 The largest effect was in social groups IV and V.
Frank et al showed how counselling plus a support pack achieved a 43% rate of breast feeding at 23 months (compared with 30% controls) in a group of 343 low income mothers in a hospital context.29 In the intervention of Johnson et al, 67% of a group of women who received a referral card, ‘manual’ and bedside counselling, were breast feeding at the end of the fourth week compared with 16% of a minimal intervention group.30 Kistin et al used peer counselling with 59 mothers in a hospital setting and demonstrated a 93% incidence and 44% maintenance of breast feeding compared with 70% and 12% of controls.31
NUTRITION EDUCATION AND CHILDREN
Influencing dietary practices is not easy but it can be achieved in the right circumstances. Contento13 described two convincing interventions at the preschool and school level which demonstrated an improvement in the quality of food served by parents to their children32 and significant changes in knowledge, food preferences, and five out of 12 targeted behaviours in a school setting.33
The emergence of AIDS has added extra impetus to the need to provide effective sex education for young people. A number of studies—mainly from North America—have demonstrated that it is possible to achieve success in reducing the risk of HIV infection.
SOCIAL AND MENTAL HEALTH
The final three examples of effectiveness presented here relate to bullying, child abuse, and the effect of providing appropriate preschool education. They are especially significant in that they indicate the potential benefits of programmes that address socioeconomic factors.37
Olweus described the results of a major intervention designed to address the problem of bullying in a school district in Norway.38 The target groups were schoolchildren, parents, and teachers. A wide range of educational methods was employed: group discussion, workshops, role plays, games, one-to-one counselling, booklets, and videos. Staff were trained and supportive policies were developed at both school and national level. There was a 50% reduction in bullying both in and out of school; incidence of victimisation fell from 2.6% to 0.6% in boys and 1.7% to 0.59% in girls. There was a reduction in truanting and antisocial behaviour.
The study of Barker et al of the effect of a child development programme on the incidence of child abuse is of particular interest.39 Some 30 000 parents and children (largely from low socioeconomic groups) were involved in 24 UK health authorities. The programme centred on home visiting by ‘first parent visitors’ who made monthly visits lasting one hour over a period of a maximum of three years. Intervention methods were primarily counselling supported by cartoon books. A wide range of support skills were provided—including nutrition, health, language, and stress management—all within the context of an empowering relationship. There was a significant reduction in morbidity: 5.25 per 1000 of the experimental group (on child problem register) compared with 8.93 of the experimental group (general population); there was a 41% reduction in the incidence of physical abuse.
The Perry Preschool Program is the final study described here.40 Fifty eight black children received five weekly sessions lasting 30 minutes; parents received one 90 minute home visit. The programme focus was on ‘lifeskills’ designed to enhance children’s cognitive and social development. Special emphasis was placed on school adjustment and the acquisition of social and behaviour skills. By the time the children had reached the age of 19, 59% of those in the intervention group were employed (compared with 32% of controls); 38% had a college education (21% controls); 16% had special education (28% controls); there were 64 pregnancies (117 controls); they experienced a 31% arrest/detention rate (51% controls). The cost-benefit ratio was calculated as 9:1.
Requirements for effective programmes
Design sophistication is a characteristic features of the successful programmes described above. The requirements for efficient programmes might be summarised as follows:
• They should be based on relevant theory and, where possible, prior research
• They should be based on a sophisticated diagnosis of the social, psychological, and environmental determinants of the health or illness related behaviour
• Focus should not only be on knowledge but also on beliefs and relate to the individual’s developmental stage
• Full account should be taken of the various ‘pushes and pulls’ of competing motivations on intention to act
• The importance of social pressures should be acknowledged
• Barriers to adoption and maintenance should be identified—especially environmental barriers
• Empowerment factors should be emphasised
• Education must be complemented by achieving a ‘supportive environment’
• Interventions should be maximised by creating ‘coalitions’ between different settings and stakeholders. Maximum client participation should be a major goal. Coalitions should besupported by appropriate use of mass media.
• A sophisticated behavioural diagnosis should be matched by the use of appropriate education methods and learning resources
• Health staff must be trained to use the appropriate educational methods.