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Health education, as a discipline, is rooted in the behavioral sciences, public health and education. It can be defined as any combination of learned experiences designed to facilitate the adoption of behaviors and attitudes that encourage and sustain optimal levels of health in individuals, families and communities. Health education is a process of planned, sequential programs of learning, grounded in tested learning principles and behavior change theory. It involves interaction between the educator and the learner, and occurs in a specific time frame in a specific setting. Settings for health education are numerous, including schools, community centers, hospitals, workplaces, senior centers, clinics, youth organizations, hospitals, international organizations, health education centers, etc.
Effective health education reduces lifestyle-related diseases, social illness, and behaviors that lead to premature death and disability. It can improve the health and well being of individuals, families and communities, and has clear short and long-term economic benefits. Quality health education can help reduce health disparities and improve health and well-being in populations that suffer disproportionately and substantially from adverse health conditions, or those who lack access to adequate health care.
Learning is a dynamic process that begins with some motivation, but our values, knowledge, attitudes, and beliefs all facilitate actual learning. All learning can be categorized into three “domains”—the cognitive domain (acquiring knowledge), the affective domain (acquiring or changing emotions, feelings, attitudes) and the psychomotor domain (skills acquisition). While the overall goal of most health education programs is voluntary behavior change conducive to health, planning activities that will affect ALL three domains is important. For example, teaching active youth about eye health may encompass learning about eye anatomy, common types of sports-related eye injuries, and how they can be prevented. However, the ultimate goal may be to facilitate attitude change (i.e. wearing protective eye-wear can be “cool”), and skill development (i.e. purchasing and proper use of protective eye-wear).
The Health Belief Model (HBM) is one of the most influential and widely used psychosocial models in health education. HBM postulates that an individual’s likelihood of adopting healthy behaviors is related to general “beliefs” by individuals about their personal risk for disease or injury, the perceived seriousness and threat of disease or injury, cues to action from their environment, and whether the benefits of taking preventive action outweigh the barriers. Altogether, the HBM says it can predict the likelihood of an individual “taking action” that will result in preventing future disease or injury. HBM has been applied to ALL types of health behavior.
EXAMPLE:
John is an elderly gentleman who recently learned about
diabetic retinopathy from a television Public Service
Announcement (cue to action). He remembers that a family member
had diabetic retinopathy and perceives it as a serious condition
(perceived seriousness) when not detected early (perceived
severity). He decides that he is at risk for diabetic retinopathy
because he is over 60, is diabetic and has not had an eye exam in
the last decade (perceived risk). While he currently lacks
adequate health insurance and transportation (perceived
barriers), he learns from a friend that there is a free dilated
eye exam program in his community that can detect the condition
in its earliest stages (perceived benefits). He decides to make
an appointment the next day and asks his friend for a
ride.
When planning health education programs, the HBM is very useful. Programs that encourage learning about the seriousness and severity of the disease or condition, should also stress personal vulnerability. Cues to action can include pamphlets, posters, videos, and Public Service Announcements (PSA). Effective health education programs should also address any “barriers” to taking action, including transportation to a doctor’s office, financial issues, language barriers, etc.
Self-efficacy is one of the most important precursors to behavior change, is a good predictor of future behavior, and has many important implications in health education. It is one of the constructs of Bandura’s Social Cognitive Theory (SCT). Self-efficacy supports the notion that successful behavior change requires that a person have a strong belief in their ability to exercise control over a behavior, or learn a new behavior. Self-efficacy refers to the condition that a person experiences as feeling “competent” to perform a desired task. It is derived from successfully performing a skill, verbal persuasion, and a person’s emotional state. Lack of self-efficacy is seen as a “perceived barrier” to taking a recommended health action.
EXAMPLE:
John learns that he has early stage diabetic retinopathy. He
is instructed to tightly control his blood sugar to prevent
further damage. John nervously tells the nurse that he has tried
testing his own blood sugar in the past, but failed and gave up.
The nurse provides John with a new glucometer and instructs him
how to use it. She then instructs John to practice using the
meter several times in her presence. She also provides John with
lancets, test strips, a carrying case and where he can obtain
future supplies. John tells her he now feels confident that he
can test his own blood sugar.
Before the planning of a health education program begins, a needs assessment should be performed. A needs assessment is a process that identifies the health needs of a target population or group prior to implementing any kind of health education program. The target population is that at-risk sub-population from which all or some will be recipients of health education. For example, if you are conducting a program on diabetic retinopathy, your target population may be low-income African American adults with Type II diabetes in your community. The needs assessment is important because it guides you in planning programs, developing written materials and identifying gaps in health services. A needs assessment can be quite simple or complex, but at a minimum should include basic demographic information such as socioeconomic status, age, race, ethnicity, culture, health status, etc. Such information can be obtained through vital records, demographic data, hospital, medical records etc.
You can also gain additional valuable information about your target population via focus groups, surveys, and interviews. A focus group is used to explore attitudes, beliefs, and opinions from your target population and is a very effective tool in health education. Focus groups are small, ideally 8-10 individuals, and representative of the target population. A “recorder” takes notes while the group moderator, or leader, solicits opinions, behaviors, knowledge, and attitudes.
EXAMPLE:
Before implementing a health education program on diabetic
retinopathy at a large elderly housing complex, a focus group was
used to explore the existing level of knowledge about the
disease, existing protective behaviors (tightly monitoring blood
sugar, regular eye exams) and beliefs about prevention of the
disease (can or cannot be prevented). The focus group finds that
the existing level of knowledge is low and protective behaviors
are non-existent. The successful health education program for
this group should stress the seriousness of diabetic retinopathy,
its implications, the link with blood sugar monitoring, as well
as the importance of preventive screenings and exams.
Surveys are another effective tool for gathering information about the target population. Written surveys are inexpensive to produce and can be distributed to a large number of the target population. However they often have low return rates. Written surveys should be short (3 pages maximum), written in simple language and easy to read, with clear directions. Use of a Likert scale is a common practice with surveys. Mailed surveys often have low return rates. A cover letter informing the recipient of the purpose of the survey, university sponsorship, and offering a small incentive, (such as including a one dollar bill in the mailing), have all shown to be very effective in increasing return rates. Telephone surveys, while having a higher response rate than written surveys, are more time consuming and less accurate.
One-on-one interviews with members of the target population can also provide important subjective information. They allow for getting more complete information than a survey, however interviews require a skilled interviewer to gather and analyze qualitative data.
After gathering information about your target population, you may find a number of unmet health needs. Prioritizing which of those needs your program will tackle is very important to the success of your health education program. First, assign relative importance to each need, on a scale of 1 to 10, based on input from members of the target population and other collected data. Choosing those needs that are both important and will have the greatest impact on the target population is recommended.
EXAMPLE:
Your needs assessment reveals that your target population of
seniors with Type II diabetes lack basic information about
diabetic retinopathy. You also find that many of these seniors
are low income, have low literacy and lack comprehensive health
insurance to cover the cost of regular eye exams resulting in low
screening rates in this group. You decide that finding eye
physicians who can provide free or low cost screenings for your
target
population is your first priority. Then you will conduct a
health education program about eye disease tailored towards
persons with low literacy.
Once needs are prioritized, a written program plan should be developed. This includes: program goals and objectives, available monetary resources, training of educators, specifics on how the program will be marketed to target population (i.e. mailing flyers, media exposure, working through health care providers, health agencies, hospitals, etc.), type of methods that will be used to deliver the program, materials needed (written materials, audiovisual needs), where and when program will take place, time needed, number of participants, and evaluation methods. If a program is being offered for the first time, a pilot program should be conducted. A pilot is a program implemented on a small scale to a small group. Any written or audiovisual materials can be pre-tested at this time. It can reveal deficiencies in the program and materials that can be corrected before the entire project is put into place.
Writing of goals and objectives is an important component to the program plan. Goals and objectives guide program planning, selection of methods and materials, and provide a way to evaluate the program. Writing of goals and objectives is a skill that must be practiced. A program goal is a broad statement of what is to be accomplished without describing specific services or education methods. Objectives are more precise statements of the tasks necessary to reach the goal. Program or learning objectives should be written using an action verb and should have a time frame for completion. Usually, programs have one or two goals and many objectives.
Ideally, objectives should be written to address all of the domains of learning, the cognitive domain (acquiring knowledge), the affective domain (acquiring or changing emotions, feelings, attitudes) and the psychomotor domain (skills acquisition).
EXAMPLE:
Program Goal: The goal of this program is to reduce
blindness due to diabetic retinopathy. Program Objectives: At the
end of this program, the learner will…
The implementation of any health education program occurs after needs assessment, careful planning, and writing of goals and objectives for the program. At this point, the people involved must train staff and volunteers, obtain facilities, equipment, materials and other resources. It involves contracts, purchasing decisions, and budgets. When the program is finally implemented, it is very important to evaluate whether you have met your stated goals and objectives, stayed within your time frame and budget, and determine how the program can be improved.
Evaluating health education programs is a crucial component that is often overlooked. An evaluation plan should be part of the overall program plan. All actual program processes, not just program or learning objectives, should be evaluated. Such information can be qualitative (descriptive data such as demographic information about learners, self-report), or quantitative (numerical values such as how many questions were answered correctly). What were the strengths and weaknesses of the program? Were the educators effective in their presentation? Did the target audience respond to program methods? Did the target population understand the material covered? What percentage of the target audience met the stated objectives? Did the program stay within budget?
Several methods for evaluation should be utilized and may include pre and post tests of content knowledge, satisfaction surveys, self-report questionnaires, biomedical markers (cholesterol, weight, blood sugar, blood pressure pre and post), attendance sheets, etc. Evaluation is important in ascertaining future funding, determining level of learning taking place, predicting future health behaviors, and providing credibility for program.
There are many delivery methods of health education programs. A method is how you go about presenting information. Methods also dictate how well the information is received. Use of a variety of methods within a single program is optimal. Method selection should be based on the target audiences’ developmental stage, literacy level, time constraints, cultural context, etc. Consider learning and behavior change models when selecting methods. Some examples of methods in health education include oral lectures, posters, audiovisuals, written materials, guest speakers, demonstrations, group discussion, dramatizations, debates, games, problem solving, role playing and skills practice.
EXAMPLE:
You have decided that the best methods for your target
population of low literacy seniors are a short video about blood
sugar testing followed by skills practice and a guest
speaker. An
ophthalmologist will present a short lecture about the
seriousness of diabetic retinopathy and the importance of regular
eye exams. Written materials will also be
provided to reinforce
what was explained in the video.
Effective presentations involve the use of skills that MUST be practiced. General characteristics of an effective speaker include: being adequately prepared, knowing the target audience (via needs assessment), being proficient in the topic, being genuine and compassionate, and having enthusiasm for the topic. Effective presenters begin on time, and greet all participants. Use of an “icebreaker,” or opening, is critical to engaging the audience at the outset. Icebreakers may include telling a personal story, asking the audience questions, using humor such as a cartoon, or completing a short quiz. The presenter should end on time and deliver an effective closing including summarizing main points and offering a challenge to the audience (i.e. make an appointment for eye screening within a week). Time for questions and evaluations at the conclusion of the presentation should be included within the allotted time frame.
Effective presenters make good eye contact, smile often, and move about freely while speaking. Reading directly from slides or written text can create boredom and create the impression that you are unprepared. Instead, prepare a discussion guide ahead of time consisting of a brief outline and talking points or discussion questions. A list of resources for the audience is always appreciated. If Microsoft Power Point is to be used, create only short “bulleted” slides covering only main points. Word accentuation and repeating of key points are excellent ways of letting the listener know that a word or phrase is particularly important. Voice volume should be raised or lowered accordingly. Use of flip charts or chalkboard to reinforce key points is helpful. Poor grammar or inappropriate language can leave a negative impression of the presenter. The presenter should never sit while speaking, nor stand continuously behind a podium. Finally, effective presenters are continuously aware of verbal cues from audience such as boredom, fidgeting, facial expression, etc. and are able to adjust the presentation to the audience needs.
Group work can be a very effective method for learning and skill development if a skilled facilitator is present. Skilled facilitators allow the group to do the work, while nurturing and guiding them to learn from each other. Groups can be very educational as in learning how to manage a particular disease, while at the same time providing a supportive, trusting environment where members can share thoughts, feelings, disappointments and successes.
Group facilitation strategies are the same in every setting. Remaining neutral and allowing the group to accomplish its tasks are crucial. Facilitators become more active, however, when problems arise, helping the group to see both successes and missteps. Effective facilitators have a sense of humor and establish a climate of inclusion at all times. They keep discussions “on task” and establish rules at the outset for all group members (i.e. everything said is confidential, only one person speaking at a time, etc).
Effective health education programs should use a variety of print materials to augment a presentation. The most common types of materials include pamphlets, newsletters, shower cards, posters, and flyers. They are useful in providing useful messages about diseases and self-care in a tangible take-home format. Unfortunately, most health education materials are poorly written or written with high literacy demand. Remember: The average reading level in the United States is at a 8th-9th grade level, while twenty percent of Americans read at or below a 5th grade reading level.
Health education is an important tool in prevention of disease through planned, sequential educational interventions. Effective health education programming requires careful planning, including a needs assessment, identification of the target population, a realistic budget, trained presenters and facilitators, and a program plan with goals and objectives. Learning and behavioral change principles, theories and models should be utilized. Method and material selection and development should be deliberate and determined by needs of target population. Finally, the continuous evaluation and adjustment of programs is a critical component of effective health education programming.
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Gilbert, G., & Sawyer, R., (1995). Health education: Creating strategies for school and community health. Boston: Jones and Bartlett.
McKenzie, J., & Smelzter, J.L., (2001). Planning, implementing and evaluating health promotion programs: A primer (3rd Ed). Boston: Allyn and Bacon.