EDITORIALS
Le*sons for Health Educators The two articles which appear in this issue of the journal' 2 provide a unique opportunity to highlight some important considerations in health education program planning and evaluation. Why did one study produce positive results and the other admit failure? To what extent were these outcomes the result of methodological rather than substantive issues? In a 1975 Journal supplement, Making Health Education Work,3 an outline was presented which proposed steps in program planning for effective health education efforts. Several of these steps are used here in an analysis and comparison of the two studies appearing in the current issue. The strategies employed by the two studies to bring about change reflect the differences in the way the authors approached the initial definition of the problem. A comparison can be made on what was done in each study to document the nature of the problem, the resources needed to solve the problem, and possible options to be considered in implementing a program. In the New York City study of window falls described by Spiegel and Lindaman,I data were collected and analyzed to pinpoint several items: the factors associated with the problem, the specific segment of the population who were at risk, and the many community groups and individuals who were or should be involved in obtaining a resolution of the problem. Outreach workers were used to collect specific information about the home conditions and behaviors of the population at risk. The detailed program plan prpsented in their article reflects how the information gained in the definition of the problem was used. Multiple educational modalities were developed, and each was directly related to the actions that a group or an individual needed to take to contribute to the solution of the problem. The messages were delivered through existing channels of communication appropriate for the intended audience. A prevention device (window guards) was selected which met the conditions of feasibility, acceptability, and availability for the population at risk. An ongoing data gathering system was used to keep the actions on target. Another feature of the NYC Study was the use of a series of different types of interventions over time. The accident prevention program was built into an existing agency's service program so it was possible to institute follow-up procedures, provide comprehensive coverage, and broaden the program from a highly specific action to a more extensive approach to other hazardous conditions in the home. Whether the more extensive program was as successful is not reported. Spiegel and Lindaman, in their evaluation, provide evidence that a unique combination of educational and organizational measures can have a significant impact on a problem. Unfortunately, no attempts were made to try and determine how and to what degree each of the several educational and service modalities contributed to the achievement of a reduction in childhood morbidity and mortality from window falls. Others who decide to replicate the study might considAJPH December 1977, Vol. 67, No. 12
er Green's factorial design4 in an attempt to obtain more de-
finitive programmatic intelligence for health education. The Maryland Controlled Clinical Trial Study by Dershewitz and Williamson2 presents a rationale for the development of a plan to reduce common household injuries in a target population which is described as a high socioeconomic group. The definition of the problem was based on national statistics of childhood injuries associated with household hazards. The practical intervention model included a two stage educational intervention in which the mothers were given specific ways to eliminate a broad range of common household hazards and then supplied with electric outlet covers and plastic locking devices for cabinets. The educational messages were provided the mothers by a research assistant through an individual 20-minute conference, a booklet specially designed for the project, and a follow-up telephone call. In examining the Dershewitz and Williamson study2 several questions can be posed. Did the messages relate to relevant concerns and specific problems of the target population? How acceptable were the proposed solutions for these households? Did the mothers view the conference with the research assistant as an appropriate source to provide the "unsolicited" advice? The authors present inconsistent information about their attempts to relate the messages to relevant concerns and specific problems of the target population. In the discussion section of the article, they state that, "From April 1975 to March 1976, less than 2 per cent of the children enrolled in the Columbia Medical Plan (CMP) had more than two reported injuries of any type." No analysis of these data is presented nor is any indication given that this information or data on children with one injury were used in analyzing the problem and selecting relevant measures for the educational intervention. In the mothers' educational conference with the research assistant the authors state that "the mothers were encouraged to be as active as possible by exploring such areas as past injury experience and perceived benefits and barriers to preventive action." However, the mothers in the same conference were also instructed to work through the booklet which provided "ten specific recommendations to the mother for eliminating a broad range of common household child health hazards." One wonders whether consideration was given to the relationship of accident hazards to age of child and to the specific hazards of the environment of this sub-population. The procedures suggest that the authors decided that national statistics presented an accurate picture of household hazards and the probability of risk for the CMP population. Such a decision may not have been justified. McFarland and Moore in their analysis of the problem state, "Preventing children's accidents requires a knowledge of the frequencies with which various agents produce accidental injury, and relating this information to circumstances of the children and the environmental situation." These same au1 137
EDITORIALS
thors cite statistics which show an extremely low incidence of accidental poisoning from household products and bums among children in higher socioeconomic households.5 Hence one must question the relevance of the items listed in their Table 2 as types of hazards for the CMP population. Another important perspective on the factors which influence childhood injuries was described by McFarland and Moore5 which may help explain the lack of compliance by the mothers in the CMP study. They cite two studies6 7 in which the researchers attempted to identify the differences between families whose children ingested noxious substances and those who did not. The findings showed no differences among the families in regard to the degree of availability of noxious substances and the mothers' awareness of the potential hazards. The evidence did suggest that "children of this age (two to three years) may often be neither innocent nor ignorant when they consume a bottle of aspirin or drink kerosene. While they do not know the unhealthy consequences of their actions, they may often be well aware that they are doing something forbidden. Thus, at this age, factors of self-control in the face of negativistic impulses, and the interpersonal relationship within the psychological climate of the family may be important." The above observation suggests that differences in child rearing practices should be a consideration in'the selection of actions for mothers in the control of household hazards. A current book for parents of toddlers (ages one to three years) written by Brazelton8 stresses the need for parents to provide young children with opportunities to explore dangerous situations and learn how to avoid trouble. One of the incidents described in the book is about how a father turned a young child's obsession with electric cords and plugs from a dangerous situation into a valuable learning experience. Brazelton comments, "Since there are an impredictable number of dangerous tasks which children find and want to get involved with this is a valuable lesson for avoiding trouble. If they are prohibited from exploring, children try to sneak off to find out for themselves.... The big job for the child of this age is that of resolving the struggle between being controlled by outsiders and of learning controls for himself. The sense of autonomy which comes from resolution of this struggle leads to the feeling of competence which is at the root of any child's future progress." The literature cited herein is merely illustrative of what information might have been obtained from members of the target population in the pre-planning stage if a representative sample of the mothers had been asked what they are currently doing to protect their children in their homes from household hazards, what concerns they have, and what actions they think would be relevant to overcome these problems. Parents should have had a role in setting priorities, locating resources, and selecting practical solutions. Finally, it must be pointed out that Dershewitz and Williamson do not describe the characteristics of the research
1138
assistant or indicate whether an effort was made to observe the interactions in the educational conferences. Lack oi documentation of the characteristics of key aspects of the independent variable (how and by whom the education waw provided) severely limits a critical analysis of the intervention. The lessons to be learned from this comparison are thal the education provided to learners must be perceived by them as relevant to their values, concerns, goals, past experience, and present circumstances. If the learner does nol have a role in specifying what is and is not relevant to his/het life space, the likelihood that the educator will be able tc design an appropriate or effective plan for influencing the learner's behavior is indeed very small. The learner as used here refers to all persons who need to act in the solu'tions of a problem. The study design and analysis presented by the two articles in this issue1- 2 are important contributions to the documentation and evaluation of health education. They offer the reader an opportunity to examine a number of methodological issues. The advice given by Lewin 25 years ago should still be heeded: "In social management as in medicine, there are not patent medicines and each case demands careful diagnosis."9
JEANNETTE J. SIMMONS, MPH, DSc Address reprint requests to Dr. Jeanette J. Simmons, Assistanl Dean for Student Affairs, and Member of the Faculty, Harvard School of Public Health, 55 Shattuck Street, Boston, MA 02115. Dr. Simmons is a member of the Journal Editorial Board.
REFERENCES 1. Spiegel, C. N., and Lindaman, F. C. Children can't fly: A program to prevent childhood morbidity and mortality from window falls. Am. J. Public Health, 67:1143-1147, 1977. 2. Dershewitz, R. A., and Williamson, J. W. Prevention of childhood household injuries: A controlled clinical trial. Am. J. Public Health, 67:1148-1153, 1977. 3. Simmons, J. Ed. Making Health Education Work. Am. J. Public Health, Supplement, 65:(10), 1975. 4. Green, L. W. Evaluation and measurement: Some dilemmas for health education. Am. J. Public Health, 67:155-161, 1977. 5. McFarland, R. A., and Moore, R. C. Childhood Accidents and Injuries. In Talbot, N. B., Kagan, J., Eisenberg, L. Behavioral Science in Pediatric Medicine. Philadelphia: W. B. Saunders Co., 1971. 6. Baltimore, C. Jr., and Meyer, R. J. A study of storage, child behavioral traits, and mothers' knowledge of toxicology in 52 poisoned families and 52 comparison families. Pediatrics 44:(Part II Suppl.) 816, 1969. 7. Sobel, R. Traditional safety measures and accidental poisoning in childhood. Pediatrics 44:(Part II Suppl.) 811, 1969. 8. Brazelton, T. B. Toddlers and Parents: A Declaration of Independence. New York: Delacarte Press/Seymour Lawrence, 1974. 9. Lewin, K. Group Decision and Social Change in Social Psychology. G. E. Swanson, T. M. Newcomb and E. L. Hartley, Eds. New York: Henry Holt Co., 1952.
AJPH December 1977, Vol. 67, No. 12
Le*sons for Health Educators The two articles which appear in this issue of the journal' 2 provide a unique opportunity to highlight some important considerations in health education program planning and evaluation. Why did one study produce positive results and the other admit failure? To what extent were these outcomes the result of methodological rather than substantive issues? In a 1975 Journal supplement, Making Health Education Work,3 an outline was presented which proposed steps in program planning for effective health education efforts. Several of these steps are used here in an analysis and comparison of the two studies appearing in the current issue. The strategies employed by the two studies to bring about change reflect the differences in the way the authors approached the initial definition of the problem. A comparison can be made on what was done in each study to document the nature of the problem, the resources needed to solve the problem, and possible options to be considered in implementing a program. In the New York City study of window falls described by Spiegel and Lindaman,I data were collected and analyzed to pinpoint several items: the factors associated with the problem, the specific segment of the population who were at risk, and the many community groups and individuals who were or should be involved in obtaining a resolution of the problem. Outreach workers were used to collect specific information about the home conditions and behaviors of the population at risk. The detailed program plan prpsented in their article reflects how the information gained in the definition of the problem was used. Multiple educational modalities were developed, and each was directly related to the actions that a group or an individual needed to take to contribute to the solution of the problem. The messages were delivered through existing channels of communication appropriate for the intended audience. A prevention device (window guards) was selected which met the conditions of feasibility, acceptability, and availability for the population at risk. An ongoing data gathering system was used to keep the actions on target. Another feature of the NYC Study was the use of a series of different types of interventions over time. The accident prevention program was built into an existing agency's service program so it was possible to institute follow-up procedures, provide comprehensive coverage, and broaden the program from a highly specific action to a more extensive approach to other hazardous conditions in the home. Whether the more extensive program was as successful is not reported. Spiegel and Lindaman, in their evaluation, provide evidence that a unique combination of educational and organizational measures can have a significant impact on a problem. Unfortunately, no attempts were made to try and determine how and to what degree each of the several educational and service modalities contributed to the achievement of a reduction in childhood morbidity and mortality from window falls. Others who decide to replicate the study might considAJPH December 1977, Vol. 67, No. 12
er Green's factorial design4 in an attempt to obtain more de-
finitive programmatic intelligence for health education. The Maryland Controlled Clinical Trial Study by Dershewitz and Williamson2 presents a rationale for the development of a plan to reduce common household injuries in a target population which is described as a high socioeconomic group. The definition of the problem was based on national statistics of childhood injuries associated with household hazards. The practical intervention model included a two stage educational intervention in which the mothers were given specific ways to eliminate a broad range of common household hazards and then supplied with electric outlet covers and plastic locking devices for cabinets. The educational messages were provided the mothers by a research assistant through an individual 20-minute conference, a booklet specially designed for the project, and a follow-up telephone call. In examining the Dershewitz and Williamson study2 several questions can be posed. Did the messages relate to relevant concerns and specific problems of the target population? How acceptable were the proposed solutions for these households? Did the mothers view the conference with the research assistant as an appropriate source to provide the "unsolicited" advice? The authors present inconsistent information about their attempts to relate the messages to relevant concerns and specific problems of the target population. In the discussion section of the article, they state that, "From April 1975 to March 1976, less than 2 per cent of the children enrolled in the Columbia Medical Plan (CMP) had more than two reported injuries of any type." No analysis of these data is presented nor is any indication given that this information or data on children with one injury were used in analyzing the problem and selecting relevant measures for the educational intervention. In the mothers' educational conference with the research assistant the authors state that "the mothers were encouraged to be as active as possible by exploring such areas as past injury experience and perceived benefits and barriers to preventive action." However, the mothers in the same conference were also instructed to work through the booklet which provided "ten specific recommendations to the mother for eliminating a broad range of common household child health hazards." One wonders whether consideration was given to the relationship of accident hazards to age of child and to the specific hazards of the environment of this sub-population. The procedures suggest that the authors decided that national statistics presented an accurate picture of household hazards and the probability of risk for the CMP population. Such a decision may not have been justified. McFarland and Moore in their analysis of the problem state, "Preventing children's accidents requires a knowledge of the frequencies with which various agents produce accidental injury, and relating this information to circumstances of the children and the environmental situation." These same au1 137
EDITORIALS
thors cite statistics which show an extremely low incidence of accidental poisoning from household products and bums among children in higher socioeconomic households.5 Hence one must question the relevance of the items listed in their Table 2 as types of hazards for the CMP population. Another important perspective on the factors which influence childhood injuries was described by McFarland and Moore5 which may help explain the lack of compliance by the mothers in the CMP study. They cite two studies6 7 in which the researchers attempted to identify the differences between families whose children ingested noxious substances and those who did not. The findings showed no differences among the families in regard to the degree of availability of noxious substances and the mothers' awareness of the potential hazards. The evidence did suggest that "children of this age (two to three years) may often be neither innocent nor ignorant when they consume a bottle of aspirin or drink kerosene. While they do not know the unhealthy consequences of their actions, they may often be well aware that they are doing something forbidden. Thus, at this age, factors of self-control in the face of negativistic impulses, and the interpersonal relationship within the psychological climate of the family may be important." The above observation suggests that differences in child rearing practices should be a consideration in'the selection of actions for mothers in the control of household hazards. A current book for parents of toddlers (ages one to three years) written by Brazelton8 stresses the need for parents to provide young children with opportunities to explore dangerous situations and learn how to avoid trouble. One of the incidents described in the book is about how a father turned a young child's obsession with electric cords and plugs from a dangerous situation into a valuable learning experience. Brazelton comments, "Since there are an impredictable number of dangerous tasks which children find and want to get involved with this is a valuable lesson for avoiding trouble. If they are prohibited from exploring, children try to sneak off to find out for themselves.... The big job for the child of this age is that of resolving the struggle between being controlled by outsiders and of learning controls for himself. The sense of autonomy which comes from resolution of this struggle leads to the feeling of competence which is at the root of any child's future progress." The literature cited herein is merely illustrative of what information might have been obtained from members of the target population in the pre-planning stage if a representative sample of the mothers had been asked what they are currently doing to protect their children in their homes from household hazards, what concerns they have, and what actions they think would be relevant to overcome these problems. Parents should have had a role in setting priorities, locating resources, and selecting practical solutions. Finally, it must be pointed out that Dershewitz and Williamson do not describe the characteristics of the research
1138
assistant or indicate whether an effort was made to observe the interactions in the educational conferences. Lack oi documentation of the characteristics of key aspects of the independent variable (how and by whom the education waw provided) severely limits a critical analysis of the intervention. The lessons to be learned from this comparison are thal the education provided to learners must be perceived by them as relevant to their values, concerns, goals, past experience, and present circumstances. If the learner does nol have a role in specifying what is and is not relevant to his/het life space, the likelihood that the educator will be able tc design an appropriate or effective plan for influencing the learner's behavior is indeed very small. The learner as used here refers to all persons who need to act in the solu'tions of a problem. The study design and analysis presented by the two articles in this issue1- 2 are important contributions to the documentation and evaluation of health education. They offer the reader an opportunity to examine a number of methodological issues. The advice given by Lewin 25 years ago should still be heeded: "In social management as in medicine, there are not patent medicines and each case demands careful diagnosis."9
JEANNETTE J. SIMMONS, MPH, DSc Address reprint requests to Dr. Jeanette J. Simmons, Assistanl Dean for Student Affairs, and Member of the Faculty, Harvard School of Public Health, 55 Shattuck Street, Boston, MA 02115. Dr. Simmons is a member of the Journal Editorial Board.
REFERENCES 1. Spiegel, C. N., and Lindaman, F. C. Children can't fly: A program to prevent childhood morbidity and mortality from window falls. Am. J. Public Health, 67:1143-1147, 1977. 2. Dershewitz, R. A., and Williamson, J. W. Prevention of childhood household injuries: A controlled clinical trial. Am. J. Public Health, 67:1148-1153, 1977. 3. Simmons, J. Ed. Making Health Education Work. Am. J. Public Health, Supplement, 65:(10), 1975. 4. Green, L. W. Evaluation and measurement: Some dilemmas for health education. Am. J. Public Health, 67:155-161, 1977. 5. McFarland, R. A., and Moore, R. C. Childhood Accidents and Injuries. In Talbot, N. B., Kagan, J., Eisenberg, L. Behavioral Science in Pediatric Medicine. Philadelphia: W. B. Saunders Co., 1971. 6. Baltimore, C. Jr., and Meyer, R. J. A study of storage, child behavioral traits, and mothers' knowledge of toxicology in 52 poisoned families and 52 comparison families. Pediatrics 44:(Part II Suppl.) 816, 1969. 7. Sobel, R. Traditional safety measures and accidental poisoning in childhood. Pediatrics 44:(Part II Suppl.) 811, 1969. 8. Brazelton, T. B. Toddlers and Parents: A Declaration of Independence. New York: Delacarte Press/Seymour Lawrence, 1974. 9. Lewin, K. Group Decision and Social Change in Social Psychology. G. E. Swanson, T. M. Newcomb and E. L. Hartley, Eds. New York: Henry Holt Co., 1952.
AJPH December 1977, Vol. 67, No. 12
