AMERICAN JOURNAL OF
r~T s Editorials May 1976 Number 5 66, Volume
1~ Oie
Healths Established 191 1
Complex Issues Facing Health Education EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairman Faye G. Abdellah, PhD (1977) Rashi Fein, PhD (1978) Ruth B. Galanter, MCP(1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) M. Allen Pond, MPH (1976) Pauline 0. Roberts, MD, MPH (1976) Ruth Roemer, JD (1978) Sam Shapiro (1976) Robert Sigmond (1976) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1976) RobertJ. Weiss, MD(1977) STAFF William H. McBeath, MD, MPH Executive Director/Managing Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now1 William J. Curran, JD, SMHyg Public Health and the Law
AJPH May, 1976, Vol. 66, No. 5
In the past few years health education has received national attention as a poorly financed and administratively neglected area. Many leaders are now stating that it is an essential component of all health programming. I Support for health education can be found in statements made by professional organizations, legislative acts, reimbursement by third party payers, and through the introduction of numerous bills in the 94th Congress. These are enumerated in the October 1975 AJPH Supplement.2 It is heartening to note that the importance of health education has captured the interest of many policy makers, administrators, and health workers. A number of cautions need to be raised, however, if the movement is to proceed on a conceptually sound and relevant basis. The potential of large sums of money being made available could foster a great deal of inappropriate action taken under the "guise of education. " My fears are aroused because past history has been replete with simplistic approaches to very complex educational problems. Millions of dollars have been spent on program efforts and activities which have been labeled health education when they have embodied no behavioral science concepts nor health education principles in their planning, implementation, or assessment of results. Two articles in this issue of the Journal raise a number of educational and ethical concerns.3' 4These center around where we place the burden for instituting changes in health education, what methods are used to influence behavior change, and who controls the decision making with regard to outcomes or goals. If health workers are truly interested in using an educational approach to influence behavior, they might wish to explore some of the ideas suggested in the references cited in this editorial. Individual responsibility for "moderating self-imposed risks"5 is a current theme in many publications, which raises both educational and ethical questions. White6 states that the "real malpractice problem in this country today is not one described on the front pages of daily newspapers but rather the malpractice that people are performing on themselves and on each other." White suggests that "in the battle to modify life style, a major enemy to be conquered is advertising" as well as a number of industries whose products are injurious to health. A different perspective on the changing of life styles is developed by Meenan7 who points out that "although the role of education is usually stressed, there is an We as individuals and as a implied role for sanctions against unhealthy practice. society must strike a balance between the value we place on health and that which we place on the freedom to make certain choices. In addition, Meenan points out that the traditional patient-doctor relationship is one of expecting the patient to comply with the prescriptions of the doctor. Thus, he questions the likelihood that "an educational program designed by the professional to promote individual responsibility" will emphasize the decision-making role of the patient. "Professionally dominated educational efforts to alter life styles will walk a thin line between informing and expropriating. The margin is apparent from recent discussions of such practices as the use of behavioral-modification technics in preventive medicine." The control of decision-making in behavior change and the potential effective of behavioral sciences "in ways which will free, not control; bring about conuse 429
EDITORIALS
structive variability, not conformity; develop creativity, not contentment; and which will facilitate each person to become self-transcending in freshly adaptive ways of meeting life and its problems" was described by Carl Rogers8 in a dialogue with B. F. Skinner. The Report of the National Heart and Lung Institute Working Conference on Health Behavior Management9 "acknowledges that the state of ethical concerns is always fluid, reflecting cultural values at a particular point on time." The participants discussed a variety of ethical issues regarding health behavior. George Rosen10 provides an excellent historical perspective on the evolution of social medicine from the "medical police" development of the late 18th century to the present. He states that: "To understand our society, the times in which we live, to be capable of playing an intelligent role in shaping our civilization toward the future, we must have knowledge, not only of the actions of the past, but of the mental struggles, the ideological and philosophical conflicts that preceded action, and the groups of interests they represent." Small groups are frequently used as an educational method; however, very often the description of how and when they are used indicates that the user does not understand the body of theoretical principles associated with small learning groups. Lewin's' 1 formulation of the causal processes which need to be present to generate individual decisionmaking for the action include key elements which I do not see present in the "study sessions" conducted by the barefoot doctors in China. Lewin's group discussion-group decision theory and descriptions of its application emphasize the need for the group to arrive at its own goal, the discussion is open to all inputs, and the participants own the option for decision-making. Wang3 describes the study session as being based on "Mao's thoughts and ideologies in relation to a specific event, program, or act," and the national pre-set goal for family planning, indicating that the group does not have such freedom. In the use of educational methodology one must always be concerned about when one is "educating" and when one is "manipulating". The other community pressures for conformity described by Wang should be given considerable weight in terms of China's impressive achievements influencing population control. In a UNESCO document Karl2 presents a systems approach to the development of programs in family planning. The author presents many points of view on the "complexities of the ethical dilemma in the control of human behavior" and suggests a scheme for examining intervention models by causal conditions. A consideration of the factors identified by Kar for the development of an educational intervention could greatly minimize the inadequate interventions cited by Milio.4 In Lewin's1" words, "In social management as in medicine, there are not patent medicines and each case demands careful diagnosis."
430
Although space limitations do not permit the citing of many articles which have been written over the past 25 years by professional health educators, it is indeed heartening to find many other disciplines expressing their concerns about the complexities involved in trying to influence health behavior in a free society. The challenge to be directed back to the policy makers is whether they are willing to provide the funds, talent, and time which is necessary to develop the knowledge base and skills essential to a long-term comprehensive educational effort. Researchers and practitioners need to maintain an open feedback system so that strategies developed can respond to the continuously changing constellation of factors which create health problems and the societal forces which influence health behavior. The goal is for individuals to internalize the values and patterns of behavior associated with healthful living and to build these into child rearing practices so that future generations will not be faced with the same illness conditions. JEANNE1TE SIMMONS, MPH, DSc
REFERENCES 1. Cooper, T., Testimony before the Subcommittee on Health, Committee on Labor and Public Welfare. U.S. Senate, 94th Congress, May 7, 1975. 2. Simmons, J. Ed., Making Health Education Work. Am. J. Pub. Health. Supplement, 65:(10) 1975. 3. Wang, V. L. Application of social science theories on health education in family planning in the People's Republic of China, Am. J. Pub. Health; 66:440-445, 1976. 4. Milio, N. A Framework for prevention: changing health-damaging to health-generating life patterns. Am. J. Pub. Health 66:435-439, 1976. 5. Lalonde, M. A New Perspective on the Health of Canadians. Ottawa, Canada. Ministry of National Health and Welfare, 1974, p. 18. 6. White, L. S. How to impress the public's health. N. Engl. J. Med. 293:773-774, 1975. 7. Meenan, R. F. Improving the public health... .some further reflections. N. Engl. J. Med. 294:45-47, 1976. 8. Evans, R. I. Carl Rogers: The Man and His Ideas. E. P. Dutton Co. New York, 1975. p. LXXIV. 9. Report of the National Heart and Lung Institute Working Conference on Health Behavior Management. May 12-15, 1975. DHEW (NIH) No. 76-868, p. 37. 10. Rosen, G. From Medical Police to Social Medicine: Essays on the History of Health Care. Science History Publications, N.Y. 1974, p. 2. 11. Lewin, K. Group Decision and Social Change in Readings in Social Psychology G. E. Swanson, T. M. Newcomb and E. L. Hartley. Eds. Henry Holt & Co., New York, 1952. 12. Kar, S. B., Demange, D. M., and Kar, B. B. Communication research in Family Planning; an analytical framework. No. 2 Technical Documentation: a series on Population Communication. UNESCO, Paris, 1975. Dr. Simmons is Associate Professor of Health Education, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115.
AJPH
May, 1976, Vol. 66, No. 5
r~T s Editorials May 1976 Number 5 66, Volume
1~ Oie
Healths Established 191 1
Complex Issues Facing Health Education EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairman Faye G. Abdellah, PhD (1977) Rashi Fein, PhD (1978) Ruth B. Galanter, MCP(1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) M. Allen Pond, MPH (1976) Pauline 0. Roberts, MD, MPH (1976) Ruth Roemer, JD (1978) Sam Shapiro (1976) Robert Sigmond (1976) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1976) RobertJ. Weiss, MD(1977) STAFF William H. McBeath, MD, MPH Executive Director/Managing Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now1 William J. Curran, JD, SMHyg Public Health and the Law
AJPH May, 1976, Vol. 66, No. 5
In the past few years health education has received national attention as a poorly financed and administratively neglected area. Many leaders are now stating that it is an essential component of all health programming. I Support for health education can be found in statements made by professional organizations, legislative acts, reimbursement by third party payers, and through the introduction of numerous bills in the 94th Congress. These are enumerated in the October 1975 AJPH Supplement.2 It is heartening to note that the importance of health education has captured the interest of many policy makers, administrators, and health workers. A number of cautions need to be raised, however, if the movement is to proceed on a conceptually sound and relevant basis. The potential of large sums of money being made available could foster a great deal of inappropriate action taken under the "guise of education. " My fears are aroused because past history has been replete with simplistic approaches to very complex educational problems. Millions of dollars have been spent on program efforts and activities which have been labeled health education when they have embodied no behavioral science concepts nor health education principles in their planning, implementation, or assessment of results. Two articles in this issue of the Journal raise a number of educational and ethical concerns.3' 4These center around where we place the burden for instituting changes in health education, what methods are used to influence behavior change, and who controls the decision making with regard to outcomes or goals. If health workers are truly interested in using an educational approach to influence behavior, they might wish to explore some of the ideas suggested in the references cited in this editorial. Individual responsibility for "moderating self-imposed risks"5 is a current theme in many publications, which raises both educational and ethical questions. White6 states that the "real malpractice problem in this country today is not one described on the front pages of daily newspapers but rather the malpractice that people are performing on themselves and on each other." White suggests that "in the battle to modify life style, a major enemy to be conquered is advertising" as well as a number of industries whose products are injurious to health. A different perspective on the changing of life styles is developed by Meenan7 who points out that "although the role of education is usually stressed, there is an We as individuals and as a implied role for sanctions against unhealthy practice. society must strike a balance between the value we place on health and that which we place on the freedom to make certain choices. In addition, Meenan points out that the traditional patient-doctor relationship is one of expecting the patient to comply with the prescriptions of the doctor. Thus, he questions the likelihood that "an educational program designed by the professional to promote individual responsibility" will emphasize the decision-making role of the patient. "Professionally dominated educational efforts to alter life styles will walk a thin line between informing and expropriating. The margin is apparent from recent discussions of such practices as the use of behavioral-modification technics in preventive medicine." The control of decision-making in behavior change and the potential effective of behavioral sciences "in ways which will free, not control; bring about conuse 429
EDITORIALS
structive variability, not conformity; develop creativity, not contentment; and which will facilitate each person to become self-transcending in freshly adaptive ways of meeting life and its problems" was described by Carl Rogers8 in a dialogue with B. F. Skinner. The Report of the National Heart and Lung Institute Working Conference on Health Behavior Management9 "acknowledges that the state of ethical concerns is always fluid, reflecting cultural values at a particular point on time." The participants discussed a variety of ethical issues regarding health behavior. George Rosen10 provides an excellent historical perspective on the evolution of social medicine from the "medical police" development of the late 18th century to the present. He states that: "To understand our society, the times in which we live, to be capable of playing an intelligent role in shaping our civilization toward the future, we must have knowledge, not only of the actions of the past, but of the mental struggles, the ideological and philosophical conflicts that preceded action, and the groups of interests they represent." Small groups are frequently used as an educational method; however, very often the description of how and when they are used indicates that the user does not understand the body of theoretical principles associated with small learning groups. Lewin's' 1 formulation of the causal processes which need to be present to generate individual decisionmaking for the action include key elements which I do not see present in the "study sessions" conducted by the barefoot doctors in China. Lewin's group discussion-group decision theory and descriptions of its application emphasize the need for the group to arrive at its own goal, the discussion is open to all inputs, and the participants own the option for decision-making. Wang3 describes the study session as being based on "Mao's thoughts and ideologies in relation to a specific event, program, or act," and the national pre-set goal for family planning, indicating that the group does not have such freedom. In the use of educational methodology one must always be concerned about when one is "educating" and when one is "manipulating". The other community pressures for conformity described by Wang should be given considerable weight in terms of China's impressive achievements influencing population control. In a UNESCO document Karl2 presents a systems approach to the development of programs in family planning. The author presents many points of view on the "complexities of the ethical dilemma in the control of human behavior" and suggests a scheme for examining intervention models by causal conditions. A consideration of the factors identified by Kar for the development of an educational intervention could greatly minimize the inadequate interventions cited by Milio.4 In Lewin's1" words, "In social management as in medicine, there are not patent medicines and each case demands careful diagnosis."
430
Although space limitations do not permit the citing of many articles which have been written over the past 25 years by professional health educators, it is indeed heartening to find many other disciplines expressing their concerns about the complexities involved in trying to influence health behavior in a free society. The challenge to be directed back to the policy makers is whether they are willing to provide the funds, talent, and time which is necessary to develop the knowledge base and skills essential to a long-term comprehensive educational effort. Researchers and practitioners need to maintain an open feedback system so that strategies developed can respond to the continuously changing constellation of factors which create health problems and the societal forces which influence health behavior. The goal is for individuals to internalize the values and patterns of behavior associated with healthful living and to build these into child rearing practices so that future generations will not be faced with the same illness conditions. JEANNE1TE SIMMONS, MPH, DSc
REFERENCES 1. Cooper, T., Testimony before the Subcommittee on Health, Committee on Labor and Public Welfare. U.S. Senate, 94th Congress, May 7, 1975. 2. Simmons, J. Ed., Making Health Education Work. Am. J. Pub. Health. Supplement, 65:(10) 1975. 3. Wang, V. L. Application of social science theories on health education in family planning in the People's Republic of China, Am. J. Pub. Health; 66:440-445, 1976. 4. Milio, N. A Framework for prevention: changing health-damaging to health-generating life patterns. Am. J. Pub. Health 66:435-439, 1976. 5. Lalonde, M. A New Perspective on the Health of Canadians. Ottawa, Canada. Ministry of National Health and Welfare, 1974, p. 18. 6. White, L. S. How to impress the public's health. N. Engl. J. Med. 293:773-774, 1975. 7. Meenan, R. F. Improving the public health... .some further reflections. N. Engl. J. Med. 294:45-47, 1976. 8. Evans, R. I. Carl Rogers: The Man and His Ideas. E. P. Dutton Co. New York, 1975. p. LXXIV. 9. Report of the National Heart and Lung Institute Working Conference on Health Behavior Management. May 12-15, 1975. DHEW (NIH) No. 76-868, p. 37. 10. Rosen, G. From Medical Police to Social Medicine: Essays on the History of Health Care. Science History Publications, N.Y. 1974, p. 2. 11. Lewin, K. Group Decision and Social Change in Readings in Social Psychology G. E. Swanson, T. M. Newcomb and E. L. Hartley. Eds. Henry Holt & Co., New York, 1952. 12. Kar, S. B., Demange, D. M., and Kar, B. B. Communication research in Family Planning; an analytical framework. No. 2 Technical Documentation: a series on Population Communication. UNESCO, Paris, 1975. Dr. Simmons is Associate Professor of Health Education, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115.
AJPH
May, 1976, Vol. 66, No. 5
