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Health Education in Higher Education's Future William David Burns
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a
Rutgers University in New Brunswick , New Jersey, USA Published online: 09 Jul 2010.
To cite this article: William David Burns (1990) Health Education in Higher Education's Future, Journal of American College Health, 39:2, 103-108, DOI: 10.1080/07448481.1990.9936221 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936221
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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Health Education in Higher Education’s Future WILLIAM DAVID BURNS
Without being an expert on the future-although such experts surely abound-it is possible to know something about the past and a little more about the present. From this knowledge and from trends others identify,’ we can make some predictions. Those who talk about higher education‘s future tend to stress a few themes, which are suggested to me, in part, by the book The Future of State Universities.2These include: 1. Increased competition for decreasing enrollments; 2. A change in the population being served-to one that is older, more female, more minority, more part-time-unless financial circumstances caused by’ diminishing compensatory and financial aid programs limit these essentially ”demographically determined” trends; 3. More graduate study in the sciences and high technology; 4. More specialization and, where there i s collaboration, more collaboration with others at other institutions, one consequence of which may be even less ”community of interest” at any individual institution, particularly so-called research institutions; 5. Increased costs and higher student expenses; 6. Increased competition from outside vendors to provide services on contract for institutions, to replace services colleges now provide themselves, a dimension of the “privatization” argument popular in some circles;
William David Burns is assistant vice president for student life, policy and services at Rutgers University in New 6run.swick, New Jersey. This article is a revised version of the keynote address he gave at the annual meeting of the American College Health A‘;sociation in New Orleans-in 1986:
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7. Increased cooperation between industry and higher education, resulting in more off-campus activity; 8. A more international student body and an internationalized perspective; 9. Increased emphasis on accountability and evaluation of effectiveness and results-always a byproduct of shrinking resources or changing priorities on their allocation; and last, 10. One theme of my own, a tendency to take students less seriously as experts on their own needs and desires, in spite of the emphasis on active learning and other buzz words. The importance of any one trend to any one institution will vary to the degree that any school is subject to a particular influence. Some of these changes will profoundly affect college health, either by creating new needs that will have to be addressed or by threatening existing support for programs undertaken, or both. What knowing something about the past and something more about the present tells me is that, first, although times are changing, our response is likely to lag behind (failure to adapt, however, can lead to very grim consequences: brittleness and a fall). Second, no one can really predict the future, and if someone really did, the chances that we would believe him or her are remote (but maybe we should at least learn to listen for the voice that promises to let us know). Third, although there will certainly be changes, much of our mission will remain essentially unchanged. (Hence, one thing we can surely do is to make sure that what we are doing now, we ’are really doing well.) Regardless of the changes for higher education and the implications Of those changesfor college health and college health education, we cannot achieve the mission of college health without doing health education. If
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COLLEGE HEALTH we think we can, we risk doing something like educational malpractice, and we may risk medical malpractice, as well. (One year after I gave this speech, Ernest Boyer, president of the Carnegie Foundation for the Advancement of Teachers, wrote: "Most encouraging is the emerging emphasis on wellness. More and more colleges see health and body care as an important educational objective. This, in our opinion, should be a high priority on every c a m p ~ s . " ~ ) Regardless of the changes for higher education, as long as we believe that education has something to do with helping individuals achieve their maximum potential for self-development, the development of connection to others, and effective contribution to a lively democracy and its institutions, we cannot achieve the missiori of higher education without dealing in some way with health. If we believe we can, we do so at the risk of ignoring major personal, environmental, and political dimensions of education. Health Center or Health Service Without making a claim to empirical research, let me construct a mythical scenario, one that may not be either true or false, but whose elements may help us understand something about ourselves. Let us say that college health is practiced in infirmaries, which, as the name implies, are centers for the infirm: the sick, the wounded, maybe even the disoriented. Medical practice is, for the most part, paternalistic and authoritarian. Colleges stand in the place of parents and, when it comes to matters of health, a college does what a parent might do under the same circumstances. Upon illness or injury of one of the children, the college provides care for the child by delegating this duty to the infirmary. The patients use the infirmary when they are sick or are thought to be a threat to others who have not yet succumbed to the episodic illness possessing the iniirmed person. Patients are given attention, given care, treated, even occasionally cured-especially in those rare cases that do not follow the famous aphorism of Voltaire that the physician's role is to amuse the patient while Nature cures the di~ease.~ I choose these passive constructions to make two probably obvious points: first, the patient is a passive recipient of care, even care that she or he could manage alone and without any systematic attention paid to assuring that she or he is any better prepared to deal with a recurrence of this problem in the future. Second, the center itself, therefore, becomes passive. In ihis mythological scenario, health centers can become places where students go when they want medical care or are sent to when someone who possesses the authority to do so compels them to go. Staff at the centers "are available" to see students, and that availability is what counts. In a sense, the staff could be doing its job just so long as it is giving the party; whether the guests come or not does not matter.
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Such a center would hardly seem to be an optimal, or even a barely suitable, arrangement for meeting a student's needs-although it might serve a college's needs if the college took a rather narrow view of its mission or its students. It would surely be a health center, for it is the only place where "healthcare," in the narrow meaning of the term, is given. But it is not health service. What would a health service be like? First, a service would be active. It would not wait for things to happen, but would seek to make some kinds of things happen and prevent others from happening. To do so means that a health service cannot stay in a health center; it must get out and around, it must be where students are before they need to come to a center. It must be where those who are deciding things that will make life better or worse for students are when those decisions are being made. Second, a service would be knowledgeable. It would know, or find a way to come to know, many things. It would know its student body-its patient population. It would know something about its patients' mothers and fathers, medical needs, myths, moods, manners, morals and mores, and even, perhaps, its music. Its programs would be conscious of what it learned about these things and tailored to the needs implied by them. Third, a service would be flexible. It would adjust to the circumstances of its patients, it would be where they are, it would alter its offerings to meet changing circumstances. It would recognize that students learn in many ways, that no one way of educating is likely to work for all students, and that some ways work better than others. Fourth, a service would be involved (actually, risking pretension, I prefer the French engage?, signifying as it does something that i s not simply involved-or implicated-but actively responding, tuned in, to the world in question). It would identify the conditions in a college's environment that were creating health risks, it would communicate those findings to those who can make necessary changes. It would not shy away from the hard issues on campus, but would contribute its own special expertise in policy development, staff development, and community relations. Of course, this service would also be prepared to provide high quality healthcare in a health center, and it would have made suitable arrangements for such care if resources or demand did not afford or warrant an oncampus program. Each encounter with a member of the healthcare staff would result in a patient's acquiring appropriate information sufficient to understand his or her condition or particular circumstance and to manage that care responsibly at the moment and for the future. The staff of such a service would stay current with medical and nursing developments as well as developments in appropriate mental health areas. Of course, this service sounds very good-because it is very good. A number of colleges have moved from a
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HEALTH EDUCAT/ON IN HIGHER EDUCATION'S FUTURE situation very much like the one I described in the mythical scenario to something very much like the humane, student-oriented service I have briefly sketched. Most of us are moving in that direction. I would like to suggest that health education is what can make this transition possible. Health education, as a habit of practice for physicians and nurses and as a discrete discipline practiced by people called health educators, can turn a health center into a health service. It can do this in several ways. In what I call its "public relations" role, health education can help create a market for change. It can create an enlightened consumer "pull" that, along with some attention to changing the service itself, can create conditions auguring for change. This can be done by making sure that consumers know what services are available and by finding out (assessing) what services consumers want and need. This i s active. In what I call its "free-standing program" role, health education moves healthcare beyond the walls of a health center building and out onto the campus-to the points of contact where certain kinds of health behavior actually take place (the dining halls for nutrition, the playing fields for exercise and conditioning, the residence halls for personal/sexual healthcare, the classrooms for stress management). Doing health education in these places moves the health service to where the students are. This is flexible. In what I call its "integrative" role, health education provides materials and programs directly in support of and complementary to clinical activities, forging a series of links and paths to and from the health center to the campus and its many offices. Each clinical encounter should have a health-teaching dimension, supported by the best teaching materials available and taught in a way that is effective. These materials should be prepared by educators in collaboration with other healthcare providers, they should reflect the best information available, and they should be tailored to the specific audience intended. This is knowledgeable. Further, there are a variety of "conditions" that can benefit from professionally or peer-taught programs in support of a clinically indicated or self-initiated mission (weight gain or loss, alcohol education, stress management, to name a few). These programs are services. They can be either the entrCe to the health center from the campus or the place where a student can be referred in follow-up to clinical care provided by the health center. This is involved. There should be little doubt where I believe health services need to be in the future, and it is not just in health centers. Health education provides a theoretical framework and some of the methodologies to make the transition to the health service-a service that can meet changing conditions because it is engaged with students who are well and with the campus life-its purposes, people, policies, and maybe even its parties.
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MindIBody or Both Aristotle's advice for health educators, given at the end of his Politics in the unfinished chapter on the training of youth, is as follows: It is not right to work with the mind and the body at the same time. The two different sorts of work tend naturally to produce different, and indeed opposite, effects. Physical work clogs the mind; and mental work hampers the body.5
I quote from Aristotle to show an antique source, 2,OOO years or so before Descartes, that introduces the mind/ body distinction, a distinction that still haunts us today. Surely this i s not the place to indulge in a thorough treatment of a distinction that is at the base of many of our healthcare arrangements (the "mental health unit" as opposed to, shall we say, "women's health"). Indeed, I have even seen it creep into budget discussions. There is something very compelling to some "accountants" about a toe break or sprain that needs an x ray but will be treated the same regardless of the finding. Those same accountants may regard "stress" as some popular artifice, at least the stress in someone else's life. Somehow things that happen to and in the body are more real, more measurable, at least. The mind-that is another story. The mind/body distinction seems an especially troubling one for adolescent medicine. Certainly the classic episodic infectious diseases and many injuries and accidents are events in the body, although even they have a mental dimension. For me, though, adolescent medicine, and especially college healthcare, is care for matters sexual and matters mental. Many see these two as one. But I need not fall into this distinction because both are important. That is where health education comes in. Our mission in higher education is education-education in all that we do. Our college mission statements sometimes indicate that we intend to provide students with knowledge, or at least competence to acquire knowledge, to enable them to participate as citizens in a free society. Most of the mission statements see individuals as ends in themselves, morally equal to one another. These mission statements give us a way of suggesting that health education i s necessary because (1) health is an important dimension of life and, if college i s about preparation for active life in a free society, then it is surely also about health, as well; and (2) colleges believe that education matters, and that knowledge can, indeed, have an effect on what we do to ourselves and to others. At the clinical level, I believe that we cannot do college health well without doing health education. The mental component-the feelings, thoughts, myths, half-truths, fears-that accompany most of the health issues for adolescents can dominate the clinical situation. They are not "treatable" in a traditional sense, except with a sustained and engaged educational effort.
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COLLEGE HEALTH One important dimension of prevention is health education, and prevention is the best that can be done in a number of "diseases" facing us-AIDS, unwanted pregnancy, suicide, sexual assault, substance abuse, racism, sexism, homophobia, and eating disorders, to name a few. Even if we can distinguish a mind from a body for philosophical purposes, the two seem to be locked together developmentally in adolescents-at least one is fascinated with the other, and the body keeps playing tricks on the mind. Much of the current ideology in college student affairs is concerned with "development" tasks that adolescents engage in to emerge, somehow, as adults. College health, and health education particularly, must move toward a medicine concerned with the individual as well as with the individual's relations to others, and not just a version of the individual that is the sum of his or her few or many random visits to a clinic. A health education program (along with a decent health history and problem-oriented record) can s~ipportthis developmental approach. This moves from a medical model concerned with illness and injury to a developmental model concerned with wellness and a variety of clinical services associated with maintenance of health. To sum up: Colleges would be well advised to disagree with hristotle that we should concentrate on the mind and take care of the body later. That is not possible; and besides, the students I know just will not comply. Mind and body are linked, especially in college health. Health education is the best "remedy" for many of the "troubles" college students have. If we feel obligated to educate "the whole person," then we should do health education: not mind or body, but both.
Rigidity or Rigor Perhaps it is a defensive reaction to the shoot-fromthe-hip importunings of every doctor, nurse, or administrator who believes she or he is a health educator and has just thought of the only way to educate students on some matter of importance to the doctor, nurse, or administrator. Perhaps it is the status insecurity that may pertain to this newer health profession called health education. Perhaps it is one or several of the rather tedious "models" or methods of education (the preplanning, the goals and objectives, and so forth) that educators might tend to employ, taking time and creating a product. Perhaps it is something else. But I have sometimes had the feeling, and I get the same feeling now from talking with my colleagues at my own university and at many others, that we sometimes tend to think that health educators are a little rigid. They do things their own way-and sometimes at their own pace. Is this rigidity or is this rigor? I will hazard an answer to the rigidlrigor dilemma: Perhaps the "necessity" of evaluation creates the appearance of rigidity. Health educators are expected to
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deliver products-completed packages accomplishing a given task (a brochure, a program, sometimes, to my horror, a health fair or an "awareness" day). These products are to be "effective"-they must achieve their intended results. If they fail to achieve the result, they fail. Given the kinds of health and human-life issues that health education has been given to deal with-alcoho1 use, obesity, smoking, stress, nutrition, safety-it is no wonder that most human observers expect lessthan-perfect results. After all, almost all of the treatments of respiratory infections by clinicians are unqualified successes, but a cure for college drinking is not as likely. Many of the health educators I know insist on evaluation; they want to know how what they are doing is doing. But evaluation research i s not "up" or "down" research, it is not either succeeding or failing. As Carol H. Weiss, author of Evaluation Research,' points out: most evaluation research of social service programs (and although health education is not mentioned, it is closely related to the activities that are) shows little dramatic effect or change. She writes: "One of the most serious impediments to putting evaluation results to use is their dismaying tendency to show that the program has had little effect" (p 126). Does this mean that there is no reason to do the program that produces only a little change? Not necessarily. We may be obligated to teach, even though we cannot be certain that we are having an effect, because not to teach would be negligent. What Weiss tells us, and what we should know ourselves, is that we need to evaluate to determine whether there is a better way to teach. But the knowledge that one i s going to evaluate something often has a significant impact on how that thing is designed and constructed-so that it can be evaluated, or, heaven forbid, so that we can predict its success, or worse yet, guarantee ourselves an article in a refereed journal. The retreat to so-called process evaluation (how did the participants like the performance?) is a necessary but, by itself, insufficient component of evaluation. Is this problem-the skepticism about the efficacy of education, coupled with the complexity and elusiveness of the behaviors to be changed, coupled with a misunderstanding about the purpose of research as whether to do something, not how to do it, coupled with the narrow construction of projects or studies-is this what may be behind what I think of as a bit of rigidity, a little of the brittleness of some health education? If it is, then the answer lies partly in the next section of this article and partly with what I call "becoming rigorous." First, let us realize that "evaluation" is not equal: Some things always seem to need to be evaluated, other things never seem to. Higher education is notorious for the unevenness of its self-evaluation. Much in traditional medicine never gets evaluated (recall Voltaire). The problem with health education is that it believes, to some extent, in evaluation, but it exists in a world where to be evaluated and found to be accom-
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HEALTH EDUCATION IN HIGHER EDUCATION'S FUTURE plishing little could mean very bad things to people who like to draw a paycheck at reasonable intervals. Rigorous evaluation, even with "small" results, is, in my view, better than shabby evaluation. But small results should be seen not as failings, but, rather, as causes for adjustment and further refinement. One role for the health educator is to be actively involved in the health service's overall quality assurance effort-itself a form of evaluation-to help the whole service understand the meaning of evaluation, the limits of expectations, and the process of self-assessment and change. This is an opportunity for rigor. The alternative-to retreat into self-absorption and isolation-into a narcissistic professionalism-is not rigor, it is rigidity, and it creates real vulnerability. Health education may be a discipline, but, to me, it makes no sense alone, apart from other enterprises, other activities, in health or in college generally. It has a larger role. Alone or in Partnerships I think it is clear that I believe that health services should have a fairly lively role on campus and that health education is one of the ways to achieve that vitality. I think it is also pretty clear that health education should have an active partnership with the more traditional elements in the health service. Let me go a bit further and suggest that if health services and health education fail to make these partnerships, they will not be able to meet many opportunities for partnerships that will secure the presence of services for students. Recalling some of the predictions I recited about the future, let me suggest a few: There is a role for health education in increasing awareness and availability of service. In the world of competition for enrollment, service matched to needs is an important dimension in attracting and retaining students. This may entail forging partnerships with admissions, campus information, student press, parents, and alumni organizations. It will also entail activities within the service to insure that the message conveyed really represents the services available. New populations may mean the need for new health services, so health educators can assist by discovering needs. To discover the changes in the student population, the health educator should form a partnership with admissions and institutional research and with appropriate community groups, where indicated. .Once these needs are discovered, the health educator will have to work in partnership with the various planning efforts on the campus and in the health service. Increased graduate study may imply a change in needs and in risks; the health educator can assist by helping to evaluate and change policies and tailor messages to the special needs of this population. Some of the traditional assumptions and the sometimes "juvenile" health education messages will need to be changed. Health educators can form partnerships with
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graduate student organizations and graduate faculty to insure appropriate service to this population and advocacy in other campus policy-making bodies. Specialization and the disappearance of a facultyinspired community leaves to the nonfaculty members at an institution the task of helping to create a community, a climate for learning and growth. Health education should come close to being involved in those things that are on students' minds, reaching them where they are, and promoting a sense of commonality and community. In partnership with student affairs, counseling, security, and other services, health educators can help create a community. Higher costs (and possibly diminishing financial assistance) make prevention extremely important and costavoidance a necessity. Health education, coupled with clinical and other services, should be able to reduce some costs (reduce visits to the clinic, reduce personal injury, reduce vandalism, and reduce unplanned pregnancy). Such reduction should help hold costs down. A major expense is attrition. In partnership with the enrollment management staff, the retention committee, or other efforts, health education and health services can be sources of valuable information (of a general, not confidential nature) and may play a vital role in getting out messages designed to increase retention and student success (stress reduction, contraception, rape awareness, and substance abuse programs are o b vious candidates for inclusion in a retention program). Privatization i s a threat to college health, especially if by health all we mean is having someone treat a patient when she or he is sick or injured. The growing trend to "contract out'' makes it extremely important to be sure that colleges understand just what health services are all about. Very few private health providers do any substantial health education, in the sense of health education as a free-standing program (even the health maintenance organizations seem to be doing less of it). Students, as consumers, are the obvious partners here; we must make sure that their needs are being met, not trivialized. Health educators and health service personnel should seek to be involved in college planning committees to insure that the needs of students are being understood and accommodated. The increased cooperation between colleges and industry offers many opportunities for health education, chief among them the chance to collaborate with industrial wellness efforts. In many areas, industry is ahead of higher education in its attention to fitness and employee health. A variety of partnerships, with an institution's industrial or community relations department as well as with cooperating industries, offer potentially fruitful opportunities for joint program development, resource sharing, and other ventures. Internationalization will require a broader perspective on what both health and medicine are. Health educators will be challenged with both having to achieve adequate understanding of other cultures to provide ef-
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COl LEG€ HEALTH fective service and with the obligation to offer effective orientation to American medicine to increasing numbers of foreign nationals. Partnerships with language departments, international student services, and students themselves may provide some help in meeting this new trend. Increasing calls for accountability and evaluation suggest the need to form coalitions with other evaluators and to secure an understanding of the purposes (expectations) of evaluation. Linkages with academic departments, institutional research, and other health service staff are important partnerships to consider. If I am right in predicting that students will be taken less seriously, then surely there is a role for a health education effort to help restore integrity to the relationship between college and student. In the flight from the alleged terror of the yet-to-be-understood sixties, some college officials join some politicians in wanting to assert a little more control over students. The evidence for thiis i s varied and spotty. Consider, as examples, the reemergence of directed curricula, limitations on choice, and a variety of well-intentioned but somewhat constraining “orientation” to college programs. On the national scene, consider the restrictions on drinking by emancipated adults over 18 but yet to achieve 21 years of age, the proposed squeal laws requiring parental consent prior to acquisition of contraceptive services and abortion, and the mandated drug surveillance of athletes. If these trends continue, students will feel more and more isolated, more and more like the ”conquered people” in a passage from Machiavelli’s Discourses.’ They will be neither slaves nor free men and women, neither enjoying the rights of citizenship nor the benefits of beneficent protection. Will they grow? Can they develop? Or will they just emerge some day from the adolescent state into some new transformation, like moths from chrysalises? The advocates of control lack a theory on this-at least one that accounts for the acquisition of a responsible self or a self in relation to others. The obvious role for health educators here, to borrow words from Karen Gordon, the director of health education at Princeton University, is the “silent partnership”-not silent in the sense of mute, but quiet, not strident. Health educators can know a lot about development, how students think, what convinces them to act in one way or another, what forces they identify in their lives and in their school. By insinuating themselves into a variety of decision-making bodies and by
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providing a glimpse of the lives of students to those who make policies about them, health educators can be partners of both the institutions and students they serve. To do this effectively, health educators must possess the same qualities that I said characterized a health service: First, they must be active (energetic and almost tireless, I would say). Second, they must be knowledgeable (of their students, their school, their profession). Third, they must be flexible (here, versatile would also apply: ready to adapt, innovate, experiment). Last, they must be involved, engaged. This may mean serving on anything from protocol committees to dorm councils to being in alumni parades: they must be engaged with what is happening on the campus and with those who are causing it to happen and aware of those who are being passed by. What I mean by engaged is not just a program, a flier, a study published in a journal read by colleagues, or an awareness day, or mocktails, or T-shirts, or occasional chats with fellow staff. What I mean was best put by a late colleague of mine, the cultural historian Warren Susman, who defined education as “a continuing conversation.” I think that the conversation image suits my meaning here: responsive and responding, on-going, understanding, generous, and always conscious that something we have thought of will be the next product of our discourse. 1 hope these thoughts will help health educators to do the very important work they are doing because, in my judgment, there i s a very large role for them to play i n higher education’s future.
REFERENCES 1. Zapka JG, Love MB. College health services: Setting for community, organizational, and individual change. Am Coll Health. 1986;35(2):81-91. 2. Koepplin LW, Wilson DA, eds. The Future of State Universities. New Brunswick, NJ: Rutgers University Press; 1985. 3. Boyer E. College: The Undergraduate Experience in America. New York: Harper & Row; 1987:189. 4. Brussell EE, ed. Webster’s New World Dictionary of Quotable Definitions. 2nd ed. New York: Webster’s New World; 1988:360. 5. Barker E, trans. The Politics of Aristotle. Oxford: Clarendon Press; 1960:399. 6. Weiss CH. Evaluation Research: Methods for Assessing Program Effectiveness. Englewood Cliffs, NJ: Prentice-Hall; 1972: 126. 7. Machiavelli N; Bernard Crick, ed. The Discourses. Harmondsworth: Penguin Books; 1970.
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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Health Education in Higher Education's Future William David Burns
a
a
Rutgers University in New Brunswick , New Jersey, USA Published online: 09 Jul 2010.
To cite this article: William David Burns (1990) Health Education in Higher Education's Future, Journal of American College Health, 39:2, 103-108, DOI: 10.1080/07448481.1990.9936221 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936221
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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Health Education in Higher Education’s Future WILLIAM DAVID BURNS
Without being an expert on the future-although such experts surely abound-it is possible to know something about the past and a little more about the present. From this knowledge and from trends others identify,’ we can make some predictions. Those who talk about higher education‘s future tend to stress a few themes, which are suggested to me, in part, by the book The Future of State Universities.2These include: 1. Increased competition for decreasing enrollments; 2. A change in the population being served-to one that is older, more female, more minority, more part-time-unless financial circumstances caused by’ diminishing compensatory and financial aid programs limit these essentially ”demographically determined” trends; 3. More graduate study in the sciences and high technology; 4. More specialization and, where there i s collaboration, more collaboration with others at other institutions, one consequence of which may be even less ”community of interest” at any individual institution, particularly so-called research institutions; 5. Increased costs and higher student expenses; 6. Increased competition from outside vendors to provide services on contract for institutions, to replace services colleges now provide themselves, a dimension of the “privatization” argument popular in some circles;
William David Burns is assistant vice president for student life, policy and services at Rutgers University in New 6run.swick, New Jersey. This article is a revised version of the keynote address he gave at the annual meeting of the American College Health A‘;sociation in New Orleans-in 1986:
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7. Increased cooperation between industry and higher education, resulting in more off-campus activity; 8. A more international student body and an internationalized perspective; 9. Increased emphasis on accountability and evaluation of effectiveness and results-always a byproduct of shrinking resources or changing priorities on their allocation; and last, 10. One theme of my own, a tendency to take students less seriously as experts on their own needs and desires, in spite of the emphasis on active learning and other buzz words. The importance of any one trend to any one institution will vary to the degree that any school is subject to a particular influence. Some of these changes will profoundly affect college health, either by creating new needs that will have to be addressed or by threatening existing support for programs undertaken, or both. What knowing something about the past and something more about the present tells me is that, first, although times are changing, our response is likely to lag behind (failure to adapt, however, can lead to very grim consequences: brittleness and a fall). Second, no one can really predict the future, and if someone really did, the chances that we would believe him or her are remote (but maybe we should at least learn to listen for the voice that promises to let us know). Third, although there will certainly be changes, much of our mission will remain essentially unchanged. (Hence, one thing we can surely do is to make sure that what we are doing now, we ’are really doing well.) Regardless of the changes for higher education and the implications Of those changesfor college health and college health education, we cannot achieve the mission of college health without doing health education. If
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COLLEGE HEALTH we think we can, we risk doing something like educational malpractice, and we may risk medical malpractice, as well. (One year after I gave this speech, Ernest Boyer, president of the Carnegie Foundation for the Advancement of Teachers, wrote: "Most encouraging is the emerging emphasis on wellness. More and more colleges see health and body care as an important educational objective. This, in our opinion, should be a high priority on every c a m p ~ s . " ~ ) Regardless of the changes for higher education, as long as we believe that education has something to do with helping individuals achieve their maximum potential for self-development, the development of connection to others, and effective contribution to a lively democracy and its institutions, we cannot achieve the missiori of higher education without dealing in some way with health. If we believe we can, we do so at the risk of ignoring major personal, environmental, and political dimensions of education. Health Center or Health Service Without making a claim to empirical research, let me construct a mythical scenario, one that may not be either true or false, but whose elements may help us understand something about ourselves. Let us say that college health is practiced in infirmaries, which, as the name implies, are centers for the infirm: the sick, the wounded, maybe even the disoriented. Medical practice is, for the most part, paternalistic and authoritarian. Colleges stand in the place of parents and, when it comes to matters of health, a college does what a parent might do under the same circumstances. Upon illness or injury of one of the children, the college provides care for the child by delegating this duty to the infirmary. The patients use the infirmary when they are sick or are thought to be a threat to others who have not yet succumbed to the episodic illness possessing the iniirmed person. Patients are given attention, given care, treated, even occasionally cured-especially in those rare cases that do not follow the famous aphorism of Voltaire that the physician's role is to amuse the patient while Nature cures the di~ease.~ I choose these passive constructions to make two probably obvious points: first, the patient is a passive recipient of care, even care that she or he could manage alone and without any systematic attention paid to assuring that she or he is any better prepared to deal with a recurrence of this problem in the future. Second, the center itself, therefore, becomes passive. In ihis mythological scenario, health centers can become places where students go when they want medical care or are sent to when someone who possesses the authority to do so compels them to go. Staff at the centers "are available" to see students, and that availability is what counts. In a sense, the staff could be doing its job just so long as it is giving the party; whether the guests come or not does not matter.
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Such a center would hardly seem to be an optimal, or even a barely suitable, arrangement for meeting a student's needs-although it might serve a college's needs if the college took a rather narrow view of its mission or its students. It would surely be a health center, for it is the only place where "healthcare," in the narrow meaning of the term, is given. But it is not health service. What would a health service be like? First, a service would be active. It would not wait for things to happen, but would seek to make some kinds of things happen and prevent others from happening. To do so means that a health service cannot stay in a health center; it must get out and around, it must be where students are before they need to come to a center. It must be where those who are deciding things that will make life better or worse for students are when those decisions are being made. Second, a service would be knowledgeable. It would know, or find a way to come to know, many things. It would know its student body-its patient population. It would know something about its patients' mothers and fathers, medical needs, myths, moods, manners, morals and mores, and even, perhaps, its music. Its programs would be conscious of what it learned about these things and tailored to the needs implied by them. Third, a service would be flexible. It would adjust to the circumstances of its patients, it would be where they are, it would alter its offerings to meet changing circumstances. It would recognize that students learn in many ways, that no one way of educating is likely to work for all students, and that some ways work better than others. Fourth, a service would be involved (actually, risking pretension, I prefer the French engage?, signifying as it does something that i s not simply involved-or implicated-but actively responding, tuned in, to the world in question). It would identify the conditions in a college's environment that were creating health risks, it would communicate those findings to those who can make necessary changes. It would not shy away from the hard issues on campus, but would contribute its own special expertise in policy development, staff development, and community relations. Of course, this service would also be prepared to provide high quality healthcare in a health center, and it would have made suitable arrangements for such care if resources or demand did not afford or warrant an oncampus program. Each encounter with a member of the healthcare staff would result in a patient's acquiring appropriate information sufficient to understand his or her condition or particular circumstance and to manage that care responsibly at the moment and for the future. The staff of such a service would stay current with medical and nursing developments as well as developments in appropriate mental health areas. Of course, this service sounds very good-because it is very good. A number of colleges have moved from a
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HEALTH EDUCAT/ON IN HIGHER EDUCATION'S FUTURE situation very much like the one I described in the mythical scenario to something very much like the humane, student-oriented service I have briefly sketched. Most of us are moving in that direction. I would like to suggest that health education is what can make this transition possible. Health education, as a habit of practice for physicians and nurses and as a discrete discipline practiced by people called health educators, can turn a health center into a health service. It can do this in several ways. In what I call its "public relations" role, health education can help create a market for change. It can create an enlightened consumer "pull" that, along with some attention to changing the service itself, can create conditions auguring for change. This can be done by making sure that consumers know what services are available and by finding out (assessing) what services consumers want and need. This i s active. In what I call its "free-standing program" role, health education moves healthcare beyond the walls of a health center building and out onto the campus-to the points of contact where certain kinds of health behavior actually take place (the dining halls for nutrition, the playing fields for exercise and conditioning, the residence halls for personal/sexual healthcare, the classrooms for stress management). Doing health education in these places moves the health service to where the students are. This is flexible. In what I call its "integrative" role, health education provides materials and programs directly in support of and complementary to clinical activities, forging a series of links and paths to and from the health center to the campus and its many offices. Each clinical encounter should have a health-teaching dimension, supported by the best teaching materials available and taught in a way that is effective. These materials should be prepared by educators in collaboration with other healthcare providers, they should reflect the best information available, and they should be tailored to the specific audience intended. This is knowledgeable. Further, there are a variety of "conditions" that can benefit from professionally or peer-taught programs in support of a clinically indicated or self-initiated mission (weight gain or loss, alcohol education, stress management, to name a few). These programs are services. They can be either the entrCe to the health center from the campus or the place where a student can be referred in follow-up to clinical care provided by the health center. This is involved. There should be little doubt where I believe health services need to be in the future, and it is not just in health centers. Health education provides a theoretical framework and some of the methodologies to make the transition to the health service-a service that can meet changing conditions because it is engaged with students who are well and with the campus life-its purposes, people, policies, and maybe even its parties.
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MindIBody or Both Aristotle's advice for health educators, given at the end of his Politics in the unfinished chapter on the training of youth, is as follows: It is not right to work with the mind and the body at the same time. The two different sorts of work tend naturally to produce different, and indeed opposite, effects. Physical work clogs the mind; and mental work hampers the body.5
I quote from Aristotle to show an antique source, 2,OOO years or so before Descartes, that introduces the mind/ body distinction, a distinction that still haunts us today. Surely this i s not the place to indulge in a thorough treatment of a distinction that is at the base of many of our healthcare arrangements (the "mental health unit" as opposed to, shall we say, "women's health"). Indeed, I have even seen it creep into budget discussions. There is something very compelling to some "accountants" about a toe break or sprain that needs an x ray but will be treated the same regardless of the finding. Those same accountants may regard "stress" as some popular artifice, at least the stress in someone else's life. Somehow things that happen to and in the body are more real, more measurable, at least. The mind-that is another story. The mind/body distinction seems an especially troubling one for adolescent medicine. Certainly the classic episodic infectious diseases and many injuries and accidents are events in the body, although even they have a mental dimension. For me, though, adolescent medicine, and especially college healthcare, is care for matters sexual and matters mental. Many see these two as one. But I need not fall into this distinction because both are important. That is where health education comes in. Our mission in higher education is education-education in all that we do. Our college mission statements sometimes indicate that we intend to provide students with knowledge, or at least competence to acquire knowledge, to enable them to participate as citizens in a free society. Most of the mission statements see individuals as ends in themselves, morally equal to one another. These mission statements give us a way of suggesting that health education i s necessary because (1) health is an important dimension of life and, if college i s about preparation for active life in a free society, then it is surely also about health, as well; and (2) colleges believe that education matters, and that knowledge can, indeed, have an effect on what we do to ourselves and to others. At the clinical level, I believe that we cannot do college health well without doing health education. The mental component-the feelings, thoughts, myths, half-truths, fears-that accompany most of the health issues for adolescents can dominate the clinical situation. They are not "treatable" in a traditional sense, except with a sustained and engaged educational effort.
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COLLEGE HEALTH One important dimension of prevention is health education, and prevention is the best that can be done in a number of "diseases" facing us-AIDS, unwanted pregnancy, suicide, sexual assault, substance abuse, racism, sexism, homophobia, and eating disorders, to name a few. Even if we can distinguish a mind from a body for philosophical purposes, the two seem to be locked together developmentally in adolescents-at least one is fascinated with the other, and the body keeps playing tricks on the mind. Much of the current ideology in college student affairs is concerned with "development" tasks that adolescents engage in to emerge, somehow, as adults. College health, and health education particularly, must move toward a medicine concerned with the individual as well as with the individual's relations to others, and not just a version of the individual that is the sum of his or her few or many random visits to a clinic. A health education program (along with a decent health history and problem-oriented record) can s~ipportthis developmental approach. This moves from a medical model concerned with illness and injury to a developmental model concerned with wellness and a variety of clinical services associated with maintenance of health. To sum up: Colleges would be well advised to disagree with hristotle that we should concentrate on the mind and take care of the body later. That is not possible; and besides, the students I know just will not comply. Mind and body are linked, especially in college health. Health education is the best "remedy" for many of the "troubles" college students have. If we feel obligated to educate "the whole person," then we should do health education: not mind or body, but both.
Rigidity or Rigor Perhaps it is a defensive reaction to the shoot-fromthe-hip importunings of every doctor, nurse, or administrator who believes she or he is a health educator and has just thought of the only way to educate students on some matter of importance to the doctor, nurse, or administrator. Perhaps it is the status insecurity that may pertain to this newer health profession called health education. Perhaps it is one or several of the rather tedious "models" or methods of education (the preplanning, the goals and objectives, and so forth) that educators might tend to employ, taking time and creating a product. Perhaps it is something else. But I have sometimes had the feeling, and I get the same feeling now from talking with my colleagues at my own university and at many others, that we sometimes tend to think that health educators are a little rigid. They do things their own way-and sometimes at their own pace. Is this rigidity or is this rigor? I will hazard an answer to the rigidlrigor dilemma: Perhaps the "necessity" of evaluation creates the appearance of rigidity. Health educators are expected to
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deliver products-completed packages accomplishing a given task (a brochure, a program, sometimes, to my horror, a health fair or an "awareness" day). These products are to be "effective"-they must achieve their intended results. If they fail to achieve the result, they fail. Given the kinds of health and human-life issues that health education has been given to deal with-alcoho1 use, obesity, smoking, stress, nutrition, safety-it is no wonder that most human observers expect lessthan-perfect results. After all, almost all of the treatments of respiratory infections by clinicians are unqualified successes, but a cure for college drinking is not as likely. Many of the health educators I know insist on evaluation; they want to know how what they are doing is doing. But evaluation research i s not "up" or "down" research, it is not either succeeding or failing. As Carol H. Weiss, author of Evaluation Research,' points out: most evaluation research of social service programs (and although health education is not mentioned, it is closely related to the activities that are) shows little dramatic effect or change. She writes: "One of the most serious impediments to putting evaluation results to use is their dismaying tendency to show that the program has had little effect" (p 126). Does this mean that there is no reason to do the program that produces only a little change? Not necessarily. We may be obligated to teach, even though we cannot be certain that we are having an effect, because not to teach would be negligent. What Weiss tells us, and what we should know ourselves, is that we need to evaluate to determine whether there is a better way to teach. But the knowledge that one i s going to evaluate something often has a significant impact on how that thing is designed and constructed-so that it can be evaluated, or, heaven forbid, so that we can predict its success, or worse yet, guarantee ourselves an article in a refereed journal. The retreat to so-called process evaluation (how did the participants like the performance?) is a necessary but, by itself, insufficient component of evaluation. Is this problem-the skepticism about the efficacy of education, coupled with the complexity and elusiveness of the behaviors to be changed, coupled with a misunderstanding about the purpose of research as whether to do something, not how to do it, coupled with the narrow construction of projects or studies-is this what may be behind what I think of as a bit of rigidity, a little of the brittleness of some health education? If it is, then the answer lies partly in the next section of this article and partly with what I call "becoming rigorous." First, let us realize that "evaluation" is not equal: Some things always seem to need to be evaluated, other things never seem to. Higher education is notorious for the unevenness of its self-evaluation. Much in traditional medicine never gets evaluated (recall Voltaire). The problem with health education is that it believes, to some extent, in evaluation, but it exists in a world where to be evaluated and found to be accom-
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HEALTH EDUCATION IN HIGHER EDUCATION'S FUTURE plishing little could mean very bad things to people who like to draw a paycheck at reasonable intervals. Rigorous evaluation, even with "small" results, is, in my view, better than shabby evaluation. But small results should be seen not as failings, but, rather, as causes for adjustment and further refinement. One role for the health educator is to be actively involved in the health service's overall quality assurance effort-itself a form of evaluation-to help the whole service understand the meaning of evaluation, the limits of expectations, and the process of self-assessment and change. This is an opportunity for rigor. The alternative-to retreat into self-absorption and isolation-into a narcissistic professionalism-is not rigor, it is rigidity, and it creates real vulnerability. Health education may be a discipline, but, to me, it makes no sense alone, apart from other enterprises, other activities, in health or in college generally. It has a larger role. Alone or in Partnerships I think it is clear that I believe that health services should have a fairly lively role on campus and that health education is one of the ways to achieve that vitality. I think it is also pretty clear that health education should have an active partnership with the more traditional elements in the health service. Let me go a bit further and suggest that if health services and health education fail to make these partnerships, they will not be able to meet many opportunities for partnerships that will secure the presence of services for students. Recalling some of the predictions I recited about the future, let me suggest a few: There is a role for health education in increasing awareness and availability of service. In the world of competition for enrollment, service matched to needs is an important dimension in attracting and retaining students. This may entail forging partnerships with admissions, campus information, student press, parents, and alumni organizations. It will also entail activities within the service to insure that the message conveyed really represents the services available. New populations may mean the need for new health services, so health educators can assist by discovering needs. To discover the changes in the student population, the health educator should form a partnership with admissions and institutional research and with appropriate community groups, where indicated. .Once these needs are discovered, the health educator will have to work in partnership with the various planning efforts on the campus and in the health service. Increased graduate study may imply a change in needs and in risks; the health educator can assist by helping to evaluate and change policies and tailor messages to the special needs of this population. Some of the traditional assumptions and the sometimes "juvenile" health education messages will need to be changed. Health educators can form partnerships with
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graduate student organizations and graduate faculty to insure appropriate service to this population and advocacy in other campus policy-making bodies. Specialization and the disappearance of a facultyinspired community leaves to the nonfaculty members at an institution the task of helping to create a community, a climate for learning and growth. Health education should come close to being involved in those things that are on students' minds, reaching them where they are, and promoting a sense of commonality and community. In partnership with student affairs, counseling, security, and other services, health educators can help create a community. Higher costs (and possibly diminishing financial assistance) make prevention extremely important and costavoidance a necessity. Health education, coupled with clinical and other services, should be able to reduce some costs (reduce visits to the clinic, reduce personal injury, reduce vandalism, and reduce unplanned pregnancy). Such reduction should help hold costs down. A major expense is attrition. In partnership with the enrollment management staff, the retention committee, or other efforts, health education and health services can be sources of valuable information (of a general, not confidential nature) and may play a vital role in getting out messages designed to increase retention and student success (stress reduction, contraception, rape awareness, and substance abuse programs are o b vious candidates for inclusion in a retention program). Privatization i s a threat to college health, especially if by health all we mean is having someone treat a patient when she or he is sick or injured. The growing trend to "contract out'' makes it extremely important to be sure that colleges understand just what health services are all about. Very few private health providers do any substantial health education, in the sense of health education as a free-standing program (even the health maintenance organizations seem to be doing less of it). Students, as consumers, are the obvious partners here; we must make sure that their needs are being met, not trivialized. Health educators and health service personnel should seek to be involved in college planning committees to insure that the needs of students are being understood and accommodated. The increased cooperation between colleges and industry offers many opportunities for health education, chief among them the chance to collaborate with industrial wellness efforts. In many areas, industry is ahead of higher education in its attention to fitness and employee health. A variety of partnerships, with an institution's industrial or community relations department as well as with cooperating industries, offer potentially fruitful opportunities for joint program development, resource sharing, and other ventures. Internationalization will require a broader perspective on what both health and medicine are. Health educators will be challenged with both having to achieve adequate understanding of other cultures to provide ef-
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COl LEG€ HEALTH fective service and with the obligation to offer effective orientation to American medicine to increasing numbers of foreign nationals. Partnerships with language departments, international student services, and students themselves may provide some help in meeting this new trend. Increasing calls for accountability and evaluation suggest the need to form coalitions with other evaluators and to secure an understanding of the purposes (expectations) of evaluation. Linkages with academic departments, institutional research, and other health service staff are important partnerships to consider. If I am right in predicting that students will be taken less seriously, then surely there is a role for a health education effort to help restore integrity to the relationship between college and student. In the flight from the alleged terror of the yet-to-be-understood sixties, some college officials join some politicians in wanting to assert a little more control over students. The evidence for thiis i s varied and spotty. Consider, as examples, the reemergence of directed curricula, limitations on choice, and a variety of well-intentioned but somewhat constraining “orientation” to college programs. On the national scene, consider the restrictions on drinking by emancipated adults over 18 but yet to achieve 21 years of age, the proposed squeal laws requiring parental consent prior to acquisition of contraceptive services and abortion, and the mandated drug surveillance of athletes. If these trends continue, students will feel more and more isolated, more and more like the ”conquered people” in a passage from Machiavelli’s Discourses.’ They will be neither slaves nor free men and women, neither enjoying the rights of citizenship nor the benefits of beneficent protection. Will they grow? Can they develop? Or will they just emerge some day from the adolescent state into some new transformation, like moths from chrysalises? The advocates of control lack a theory on this-at least one that accounts for the acquisition of a responsible self or a self in relation to others. The obvious role for health educators here, to borrow words from Karen Gordon, the director of health education at Princeton University, is the “silent partnership”-not silent in the sense of mute, but quiet, not strident. Health educators can know a lot about development, how students think, what convinces them to act in one way or another, what forces they identify in their lives and in their school. By insinuating themselves into a variety of decision-making bodies and by
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providing a glimpse of the lives of students to those who make policies about them, health educators can be partners of both the institutions and students they serve. To do this effectively, health educators must possess the same qualities that I said characterized a health service: First, they must be active (energetic and almost tireless, I would say). Second, they must be knowledgeable (of their students, their school, their profession). Third, they must be flexible (here, versatile would also apply: ready to adapt, innovate, experiment). Last, they must be involved, engaged. This may mean serving on anything from protocol committees to dorm councils to being in alumni parades: they must be engaged with what is happening on the campus and with those who are causing it to happen and aware of those who are being passed by. What I mean by engaged is not just a program, a flier, a study published in a journal read by colleagues, or an awareness day, or mocktails, or T-shirts, or occasional chats with fellow staff. What I mean was best put by a late colleague of mine, the cultural historian Warren Susman, who defined education as “a continuing conversation.” I think that the conversation image suits my meaning here: responsive and responding, on-going, understanding, generous, and always conscious that something we have thought of will be the next product of our discourse. 1 hope these thoughts will help health educators to do the very important work they are doing because, in my judgment, there i s a very large role for them to play i n higher education’s future.
REFERENCES 1. Zapka JG, Love MB. College health services: Setting for community, organizational, and individual change. Am Coll Health. 1986;35(2):81-91. 2. Koepplin LW, Wilson DA, eds. The Future of State Universities. New Brunswick, NJ: Rutgers University Press; 1985. 3. Boyer E. College: The Undergraduate Experience in America. New York: Harper & Row; 1987:189. 4. Brussell EE, ed. Webster’s New World Dictionary of Quotable Definitions. 2nd ed. New York: Webster’s New World; 1988:360. 5. Barker E, trans. The Politics of Aristotle. Oxford: Clarendon Press; 1960:399. 6. Weiss CH. Evaluation Research: Methods for Assessing Program Effectiveness. Englewood Cliffs, NJ: Prentice-Hall; 1972: 126. 7. Machiavelli N; Bernard Crick, ed. The Discourses. Harmondsworth: Penguin Books; 1970.
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