of Manpower for A ComparativeView Education: Health
Preparation
Leo Baric, Ph.D.* Department of Community Medicine
University of Manchester
Differences between various models in the organization of health education services are explored. New developments in health education approaches used in training, career structures, and job definitions in some European countries are summarized. Problem areas have been defined and recommendations have been produced by numerous activities of the World Health Organization in recent years. At a 1974 symposium, it became obvious that no planned manpower development is feasible without a job definition of the health educator as an educational product. The need to specify the aims of future developments requires taking a critical view of past developments and spelling out existing
differences. Most of us, when starting in health education, entered the field with zeal and dedication to promote and practice what we believed was &dquo;right&dquo; in terms of helping people to be healthier and lead a happier life. The opportunities for this were limited and concealed our lack of knowledge about the ways in which this general and worthy cause could and should be pursued. During this period, we were mainly preoccupied with two problems: how to gain recognition for the work (expressed in terms of more funds and personnel) and how to increase our knowledge concerning the effectiveness of our methods. Any developments in methodology were greated with enthusiasm and avidly put into practice. This was the time of rapid growth of numerous &dquo;schemas,&dquo; defining the steps in a process to be used, as for example in community development and organization, in group work, in face-to-face interactions, etc. These schemas were widely applied in the field and at the same time made up the body of knowledge representing the core of training programs. *Medical Faculty University of Manchester, Department of Community Medicine, Stopford Oxford Road, Manchester England M139PT. Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
254
everybody’s dream, seldom attempted and achieved; the reasons given were that the great practically number of variables involved did not make evaluation possible. Health education was considered to be a &dquo;good&dquo; thing by definition, and it was assumed that &dquo;some good must come from it&dquo; even if it could not be measured. The complacency received its first shock when health education failed in the field of birth control, population control, family planning, birth spacing, or whatever the reduction in birth rate was called according to the policy of the country. The Evaluation
was
never
margin of error in this field was probably passed over before &dquo;formal&dquo; health education entered on the scene. Now we are becomii3g increasingly aware that failure is not acceptable, since as a result of and the limited resources available, the know them today is in doubt. In consequence, a number of people active in health education felt the need to take a long and critical look at what went wrong. Gradually, a redefinition of health education has come about, changing from concern with the effectiveness of methods to an examination of the whole conceptualization of health behavior, how it comes about and how it can be influenced and/or modified. The previous conceptualization represented man as a free agent who makes decisions about his actions based on a rational assessment of the utility of the existing choices and supported by his knowledge about the health threats, risk involved and the available outcomes. In other words, it was based on the model of the &dquo;economic man,&dquo; although it was accepted that man’s knowledge is never absolute and that his rationality is colored by his feelings. This &dquo;idealistic&dquo; way of looking at health education has influenced the development of our methodology, the selection and job definition of our agents and the organizational structure of the health education services. It is furthermore reflected in most of the contents of various training courses as well as in the aims of the activity. A comprehensive review of some of the most popular models of this type can be found in the recent SOPHE publication, edited by Becker 1 including critical assessments of each one with recommendations for improvement. They all have one thing in common, i.e., the impossibility of operationalizing them and using them in a predictive manner. The disappointments with these models based on treating man as independent decision-maker (and thus the main target for health education) have resulted in abandoning the idea of tinkering with these models and, instead, concentrating on changing the whole conceptualization in order to develop a new understanding of health behavior. In some European countries this new way of looking at health education is considered to be more &dquo;social reality-oriented,&dquo; to use a term which does not already have some previous connotation the
population explosion
survival of life patterns
as we
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
255
attached to it. Man is considered as a product of the society he is born brought up in. During the process of socialization he internalizes the values and norms of that society, which provide the constraints and expectations within which man can execute his &dquo;heedom&dquo; of choice concerning his actions. Since norms are defined as shared expectations prevalent in a society, most of the people, by definition, conform to them. This conformity is considered to be a unifying characteristic although each individual in that society may conform for various reasons, having different beliefs and attitudes, motivations and so on. Because of this change in conceptualization, the new approach to health education shifted the emphasis from &dquo;choice&dquo; to ‘‘norms,&dquo; from reasons behind a &dquo;choice&dquo; to reasons behind &dquo;conformity,&dquo; and from influencing the psychological mechanism in order to create preference for a particular &dquo;choice&dquo; to influencing societal mechanisms to produce conformity to &dquo;norms:’ The advantage of using a societal approach when dealing with behavioral problems related to illness and health lies in its power of prediction. By introducing appropriate norms concerning certain health behavior, we can predict that in time the majority of people (if not the present then the next generation) will conform, since society can apply sanctions to deal with deviants. Consequently health education can set its aims to influence norms and values in a society (according to the WHO definition of the aims of health education) and as a consequence to influence individual into and
behavior. SERVICES AND AGENTS At the
of the WHO
(EURO) working group on the place of meeting health education in health administration the fact was established that there are at present many different types of organization of health education activities.8 At one time the trend was to promote health education services only by health education specialists. Some countries adopted this organizational form and still have it, while others, after trying it out, have abandoned it, and still others never accepted it. The Cologne WHO Symposium examined the different developments in the hope of coming to some agreement about the future? ’
Services So far no agreement has been reached as to who should carry out formal health education and within what organizational structure. At present there are a number of organizational forms within which health education is being carried out. These to a great extent reflect the socio-political system of the country and the ideologies that govern the organization of health services and the WHO health care delivery
system. 256
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
It is, however, possible to recognize several dominant models each of which has certain advantages as well as limitations: 1. The Specialr;st model: In some countries most &dquo;formal&dquo; health education is exclusively in the hands of health education specialists who operate within a formal health education service. Their claim to the title &dquo;specialist&dquo; is derived from a number of sources, such as specialization on a postgraduate level in a formally recognized academic institution, or at the other end of the spectrum, from a long experience obtained by working in the field. All the official programs, financing and training are in their hands, and they are most recently noticed because of their attempts to gain formal professional recognition. In their work they may collaborate with other professions, either by helping them with speakers, methodological instructions or audio-visual aids, or by making use of them as experts and speakers within their own health education programs. 2. The I3ispersed model: In countries where there is no formal health education service, the health education activity and responsibility is dispersed among all the professions that have something to do with health and illness. In these countries (Sweden, Switzerland etc.) the main agents are public health doctors and nurses, general practitioners, teachers and others. The hope is that each will carry out health education as a part of their regular activities. Sometimes in such a situation, there is a central body, often mainly concerned with publications and production of audio-visual aids. In such a situation there is a growth of voluntary agencies or societies which are concerned with one health problem and which become involved with specific health education programs or campaigns. 3. The Coexisting model: Where there is a formal health education service, run by health education specialists, as well as health education integrated into the daily activities of other professions, we find that both systems coexist, but that there is little cooperation in these activities. An example is Great Britain where the Area Medical Officer is responsible for health education but an Area Health Education Officer is appointed to organize it and carry it out. With the reorganization of the National Health Service, the three branches (curative, preventive and hospital) of health services have been integrated which should result in the integration of health education activities as well. At present there is little sign of this happening, mainly because there is very little experience of how it could be achieved. The result is that the health education services and the health education of others runs parallel with each one using the other from time to time, but without any joint activity related to various health problems associated with people’s behavior. 4. The Coopemtivè model: This is the dream of the future in most of the countries, where both systems coexist. It implies that health Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
257
education specialists and other professions should complement each other in tackling behavioral problems related to health and illness. For this to be achieved it will be necessary to analyze and define the role of each of the agents involved, based on the understanding of the various processes which influence the acquisition, maintenance and change of health-related and health-directed behavior. In addition to the need for job definition within the system of formal health education, ways and means will have to be found for the integration of the formal with the informal system of health education. Beyond cooperation between health educators and doctors, nurses, or teachers, ways will have to be found for cooperation with parents, peer and reference groups as well as others in the lay referral system, within which the health behavior is molded and manifested. The first three models at present coexist in Europe and any future development will have to take this fact into consideration. Treating health education as one activity and attempting to raise it to the level of a specialty has so far caused numerous problems, as can be seen if we critically examine the advantages and disadvantages of each of the models. For example, the creation of health education as a specialty improved the quality of the health education activity, but in some instances relieved the other professions of this responsibility. The result was that health educators were left on their own to tackle the problems of behavioral change, which they could not do with great success because of their isolation from other relevant activities and because of their small numbers. On the other hand the integration of health education into all relevant activities meant that there was no coordination or control and that the activity was dependent on personal preferences of individuals as to the methods and problem areas chosen. As was shown at the WHO (EURO) working group, we in Europe are now more inclined to look at &dquo;health education&dquo; not as one activity carried out by different agents, but as a whole set of qualitatively different activities, with different aims, methods, and professions involved e Instead of believing that health education specialists should and can solve most of the health education problems related to health and illness, it is being increasingly recognized that each agent involved in health care maintenance, prevention and cure of illness has to deal with behavioral aspects of his problem and that he should do it in a specific way according to the problem and to his recognized professional status when dealing with it. Consequently, we are dealing with a whole set of different &dquo;health educations,&dquo; each of which will require a separate and specific approach. The task - facing us today is to adjust the existing variety of organizational models to this new outlook on health education as a set of specific and often qualitatively different activities. The existence of ’
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
258
unqualified health education specialists in some European countries is a fact which cannot be disregarded. What has to be done is to define each activity separately and to work out a job definition for each specific agent involved. This implies that we have to learn to live with a &dquo;co-existing&dquo; model of health education and gradually direct any future developments towards a planned organization of various health education activities within each specific area, emphasizing those shown to be most effective in solving a specific problem, and thus gradually achieve the &dquo;cooperative&dquo; model of organization. Agents If we accept the general idea that there is not one but many &dquo;health educations,&dquo; then we are faced with the need to define the roles of the agents active in each of these different areas. One way of doing it is by looking at the different needs of the client-population for whose benefit the whole activity exists. People may be either healthy, at-risk, ill or convalescent. In each of these different states they will require specific services in terms of health education. People who are healthy have an average level of risk from various health threats and have no specific behavioral patterns which would increase this risk to a higher than average level, require support and reinforcement of their existing behavioral patterns, as well as information about potential risks, to be able to avoid them in the future. This support will come from general values and specific norms on a societal level, from preventive check-ups confirming their status of being healthy and by updating knowledge about potential risks. These people are the target-population for preventing illness-inducing
behavior. In behavioral terms, people at risk manifest certain behavioral patterns which increase their risk from a health threat to above average. They need to modify their behavior which can be achieved in many different ways, from information and counseling to special treatment in clinics. To be willing to act on information and to submit to such a treatment and utilize the health education services if necessary, the society will have to exert pressure by means of appropriate norms, accompanied by effective sanctions for deviants. It will be also necessary for their at-risk state to be legitimized by a socially formal agent, so as to know who the target population is. Ill or chronically ill people suffer already from certain symptoms or disease processes. They need knowledge to be able to interpret certain signs and symptoms, awareness of the existence of the legitimizing agent for their special status, as well as the availability of the relevant health services. They must be exposed to a cue which will trigger their utilization of these services as well as have willingness to persist with the treatment. The chronically ill and debilitated in addition need Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
259
rehabilitation to be able to return to normal life within the scope of their limitations. The convalescent will need to know what caused their illness to prevent its future occurrence; if the cause was due to some behavioral pattern, they need behavior change as well as supportive services for the maintenance of new behavioral patterns. In any other respect their needs will be equal to those of healthy people. To get a complete picture of the possible job definition of health education agents, it is necessary to examine, in addition to their role relating to the client population, their two other important areas of . activity: the administration of health education services and teaching and research. To sum up, we are faced with the preparation of health education agents, able to satisfy the different requirements of the client population, manage the health education services, do the teaching and carry out research in the field. This raises several questions which need to be answered for a successful planned and coordinated development of health education. The first, which must be decided upon as soon as possible, is whether all these tasks can be carried out by one person, a specialist, or whether it is a task that must be shared among a set of people with different backgrounds, professions and statuses. The answer is urgent, because we are
continuing to produce specialists, although we are no longer certain where they fit into the system and whether they are the best means of solving problems which cannot be postponed and cannot be allowed to fail. Until we have answers which have been tested and evaluated, we will have to be satisfied by intermediate solutions with a built-in feedback, to enable a gradual and progressive development, instead of expecting an instant and perfect solution. The new developments in Europe represent such an intermediate step, and should be assessed as such. We believe that there are two main factors that influence health behavior: social forces and individual decisions. Neither alone can provide the desired outcome, but jointly they can produce a synergistic effect. The effectiveness of these two factors will depend on existing knowledge, social recognition of risk and the provision of services. At present, the agents involved are health education specialists, health, teaching and other personnel. Each of them must play a specific role and have appropriate training. Health educatiori specialists (without a medical, nursing or teaching background) can successfully manage the health education services where
they exist,
can
carry out
teaching
and
research,
and
can
transmit information, thus influencing social norms and providing necessary knowledge about health problems. If they have a recognized professional status, based on their basic training in medicine, nursing, Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
260
on a colleges level, and graduates can obtain master’s degrees and doctorates on a higher academic level.
organized
recognition of different kinds of health education and the specific needs of its different agents implies that teaching programs should be carried out, not by one but by a whole range of institutions. Only if teachers can specialize in health education in teaching institutions, doctors in medical schools, nurses in nursing colleges etc., will the qualification be recognized by the relevant professional body and graduates be able to fulfill their professional commitments towards their clients. At the University of Manchester the situation is favorable, since the Medical Faculty includes the professional preparation of doctors, nurses, dentists and pharmacists, on an undergraduate and postgraduate level and this covers a wide range of possibilities. In addition, the Faculty of Education can provide health education specialization for teachers. At present we are still too centralized, and provide teaching in the Department of Community Medicine for doctors, nurses, dentists and pharmacists as well as health educators with an appropriate first degree and/or experience. The
The ideal solution would be to have teachers of health education in each of the relevant faculties and departments.
PROFESSIONALIZATION The implications of professionalism are twofold: to protect the members of the profession and give them certain rights in relation to their clients, and at the same time to protect the clients and their rights as well. If health education is to become a full profession or professional activity, these rights and obligations will have to be formalized and strictly observed. From the point of view of today’s health education practice, this would mean that no health education interventions become acceptable for transmission to students; the individual’s behavior or practice should be allowed without a built-in evaluation, not only to make certain that it is successful, but at the same time to ensure that it does not cause any harm or damage. The consequences of such an approach are far-reaching and will affect many aspects of the teaching in so far as only tested and evaluated inteventions become acceptable for transmission to students; the practice of health education will become restricted by the limited amount of data available at present to support the claim that a planned intervention will be beneficial for the client. Professionalization of health education will, furthermore, have farreaching implications for any future research. So far, research has been mostly concerned with the study of a problem or the effectiveness of the methods of intervention, but now the study of solutions will also Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
262
have to be included in order to establish all the possible negative byside-effects. Only in this way will health education as an concerned with behavioral aspects of health and illness be in a activity to position comply with the general standards required from any other
products or
medical intervention. Professionalization will also affect the organization of health education services. People at-risk require behavioral treatment in addition to information about the health hazards. Consequently, any health education intervention will have to be backed up by appropriate services (such as behavior change clinics) to which the generalist-health educator or any other health education agent (such as a general practitioner or a teacher) will be able to refer a client who is willing to change his behavior but cannot do so on his own. Professionalization of the health education activity implies institutionalization and provisions for formalized educational system with a body of legitimized knowledge. There is, however, an inherent danger in the institutionalization of a discipline without a paradigmatic basis. As Heyl says &dquo;When institutionalization and professionalization precede achievement of a paradigmatic structure in a discipline, that structure is unlikely ever to appear, at least in the form in which it has appeared in certain physical sciences.&dquo;2 To avoid this danger, the attempts at institutionalization and professionalization of health education as a discipline will have to go together with the achievement of a certain amount of research consensus relevant to that discipline. Any future research in the field of health education will have to prove sufficiently fruitful in producing concrete research approaches upon which a ~disciplinary tradition might be built. The consequence should be to bring together various schools and sub-schools of thought, reflecting basically accepted paradigms parallel with the process of institutionalization of the
discipline. Any narrowly sociological, psychological or medical treatment of the subject matter of health behavior now appears decidely parochial. Interdisciplinary discussions and standards of judgement are a requirement. From this it follows that health education must be considered as a hybird subject, on the meeting point between older established fields of study: it should be defined as a &dquo;bridgediscipline,&dquo; linking together medicine, sociology and psychology. Only in this way can health education aspire to a scientific respectability and acceptance by academic institutions. Without academic recognition health education can make little progress in the transition from a skill to a scientific subject, and without this transition, which is the main aim of our efforts at Manchester, health education can never hope to become a recognized part of a graduate or postgraduate curriculum in a medical faculty. Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
263
SUMMARY In this article I have tried to describe
some
of the recent
developments in Europe and offered an explanation of how and why they differ from the &dquo;American Model.&dquo; I am aware that this statement is based on very wide generalizations: the developments described are taking place only in some parts of Europe; and the American model is not in fact recognized as such because of wide variations within America in approaches used in promoting health education. By the American model in this context, I mean the conceptualization of health education generated in some American schools of public health, and propagated by WHO in other parts of the world. Its basic characteristics are: special health education services; health education specialists; and the emphasis on psychological mechanisms in changing health behavior. We in Manchester, supported by the European Office of WHO; are trying to develop health education,,~drawing on American experiences, but hoping to avoid their mistakes. This conceptualization is based on a &dquo;social reality&dquo; approach which takes into account existing different models of organization and tries to reach a consensus of opinions for the future. Its main characteristics are: emphasis on social forces which influence health behavior; specialization of various agents instead of the emphasis on specialists; treating health education as a composite activity, carried out by many agents, involving many processes and methods; critical assessment of the contributions of various behavioral sciences; and emphasis on the professionalization of the activity, even though the agents may not have a professional status.
The consequences of such a development can be far-researching; we may lose &dquo;health education&dquo; as we know it today, but we may gain in effectiveness of influencing human health behavior. We must try to avoid the errors made in the past. Since many of the past approaches have been found to be lacking, the need was felt to reconsider the whole conceptualization, instead of trying to improve a faulty set of models, for which there is so far little empirical support. The new developments will be successful only if they avoid the rigidity of one of the old approaches, and include feedback, enabling testing and readjustments as we progress. REFERENCES (ed): The Health Belief Model and Personal Health Behavior. Health Educ Monogr 2:4, Winter 1974. 2. Heyl. JD: Paradigms in social science. Society 12:5, July-August 1975. 3. WHO: Expert Committee on Health Education of the Public, First Report. Geneva (WHO Tech Rep Ser No 89) 1954. 4. WHO: Expert Committee on Training of Health Personnel in Health Education of 1. Becker MH
264
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
Report. Geneva (WHO Tech Rep Ser No 156) 1958. PAHO/WHO Inter-Regional Conference on the Postgraduate Preparation of Health Workers for Health Education, Phila 8-17 July, 1962, Report. Geneva (WHO Tech Rep Ser No 278) 1964. the Public,
5. WHO:
6. WHO: The Social Sciences in Medical Education, Report on a Seminar in Hanover, 7-10 October, 1969. Copenhagen, Regional Office for Europe, 1969. 7. WHO: The Preparation of Health Personnel in Health Education, with Special
Postgraduate Education Programs, Report on a Symposium held in Cologne, 10-14 November, 1974. Copenhagen, Regional Office for Europe, 1974. 8. WHO: Report on the Working Group on the Place of Health Education in Health Administration, Manchester (UK) 3/29-4/1, 1976. (In preparation WHO Regional Office for Europe, Copenhagen) 1976. Reference to
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
265
Preparation
Leo Baric, Ph.D.* Department of Community Medicine
University of Manchester
Differences between various models in the organization of health education services are explored. New developments in health education approaches used in training, career structures, and job definitions in some European countries are summarized. Problem areas have been defined and recommendations have been produced by numerous activities of the World Health Organization in recent years. At a 1974 symposium, it became obvious that no planned manpower development is feasible without a job definition of the health educator as an educational product. The need to specify the aims of future developments requires taking a critical view of past developments and spelling out existing
differences. Most of us, when starting in health education, entered the field with zeal and dedication to promote and practice what we believed was &dquo;right&dquo; in terms of helping people to be healthier and lead a happier life. The opportunities for this were limited and concealed our lack of knowledge about the ways in which this general and worthy cause could and should be pursued. During this period, we were mainly preoccupied with two problems: how to gain recognition for the work (expressed in terms of more funds and personnel) and how to increase our knowledge concerning the effectiveness of our methods. Any developments in methodology were greated with enthusiasm and avidly put into practice. This was the time of rapid growth of numerous &dquo;schemas,&dquo; defining the steps in a process to be used, as for example in community development and organization, in group work, in face-to-face interactions, etc. These schemas were widely applied in the field and at the same time made up the body of knowledge representing the core of training programs. *Medical Faculty University of Manchester, Department of Community Medicine, Stopford Oxford Road, Manchester England M139PT. Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
254
everybody’s dream, seldom attempted and achieved; the reasons given were that the great practically number of variables involved did not make evaluation possible. Health education was considered to be a &dquo;good&dquo; thing by definition, and it was assumed that &dquo;some good must come from it&dquo; even if it could not be measured. The complacency received its first shock when health education failed in the field of birth control, population control, family planning, birth spacing, or whatever the reduction in birth rate was called according to the policy of the country. The Evaluation
was
never
margin of error in this field was probably passed over before &dquo;formal&dquo; health education entered on the scene. Now we are becomii3g increasingly aware that failure is not acceptable, since as a result of and the limited resources available, the know them today is in doubt. In consequence, a number of people active in health education felt the need to take a long and critical look at what went wrong. Gradually, a redefinition of health education has come about, changing from concern with the effectiveness of methods to an examination of the whole conceptualization of health behavior, how it comes about and how it can be influenced and/or modified. The previous conceptualization represented man as a free agent who makes decisions about his actions based on a rational assessment of the utility of the existing choices and supported by his knowledge about the health threats, risk involved and the available outcomes. In other words, it was based on the model of the &dquo;economic man,&dquo; although it was accepted that man’s knowledge is never absolute and that his rationality is colored by his feelings. This &dquo;idealistic&dquo; way of looking at health education has influenced the development of our methodology, the selection and job definition of our agents and the organizational structure of the health education services. It is furthermore reflected in most of the contents of various training courses as well as in the aims of the activity. A comprehensive review of some of the most popular models of this type can be found in the recent SOPHE publication, edited by Becker 1 including critical assessments of each one with recommendations for improvement. They all have one thing in common, i.e., the impossibility of operationalizing them and using them in a predictive manner. The disappointments with these models based on treating man as independent decision-maker (and thus the main target for health education) have resulted in abandoning the idea of tinkering with these models and, instead, concentrating on changing the whole conceptualization in order to develop a new understanding of health behavior. In some European countries this new way of looking at health education is considered to be more &dquo;social reality-oriented,&dquo; to use a term which does not already have some previous connotation the
population explosion
survival of life patterns
as we
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
255
attached to it. Man is considered as a product of the society he is born brought up in. During the process of socialization he internalizes the values and norms of that society, which provide the constraints and expectations within which man can execute his &dquo;heedom&dquo; of choice concerning his actions. Since norms are defined as shared expectations prevalent in a society, most of the people, by definition, conform to them. This conformity is considered to be a unifying characteristic although each individual in that society may conform for various reasons, having different beliefs and attitudes, motivations and so on. Because of this change in conceptualization, the new approach to health education shifted the emphasis from &dquo;choice&dquo; to ‘‘norms,&dquo; from reasons behind a &dquo;choice&dquo; to reasons behind &dquo;conformity,&dquo; and from influencing the psychological mechanism in order to create preference for a particular &dquo;choice&dquo; to influencing societal mechanisms to produce conformity to &dquo;norms:’ The advantage of using a societal approach when dealing with behavioral problems related to illness and health lies in its power of prediction. By introducing appropriate norms concerning certain health behavior, we can predict that in time the majority of people (if not the present then the next generation) will conform, since society can apply sanctions to deal with deviants. Consequently health education can set its aims to influence norms and values in a society (according to the WHO definition of the aims of health education) and as a consequence to influence individual into and
behavior. SERVICES AND AGENTS At the
of the WHO
(EURO) working group on the place of meeting health education in health administration the fact was established that there are at present many different types of organization of health education activities.8 At one time the trend was to promote health education services only by health education specialists. Some countries adopted this organizational form and still have it, while others, after trying it out, have abandoned it, and still others never accepted it. The Cologne WHO Symposium examined the different developments in the hope of coming to some agreement about the future? ’
Services So far no agreement has been reached as to who should carry out formal health education and within what organizational structure. At present there are a number of organizational forms within which health education is being carried out. These to a great extent reflect the socio-political system of the country and the ideologies that govern the organization of health services and the WHO health care delivery
system. 256
Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
It is, however, possible to recognize several dominant models each of which has certain advantages as well as limitations: 1. The Specialr;st model: In some countries most &dquo;formal&dquo; health education is exclusively in the hands of health education specialists who operate within a formal health education service. Their claim to the title &dquo;specialist&dquo; is derived from a number of sources, such as specialization on a postgraduate level in a formally recognized academic institution, or at the other end of the spectrum, from a long experience obtained by working in the field. All the official programs, financing and training are in their hands, and they are most recently noticed because of their attempts to gain formal professional recognition. In their work they may collaborate with other professions, either by helping them with speakers, methodological instructions or audio-visual aids, or by making use of them as experts and speakers within their own health education programs. 2. The I3ispersed model: In countries where there is no formal health education service, the health education activity and responsibility is dispersed among all the professions that have something to do with health and illness. In these countries (Sweden, Switzerland etc.) the main agents are public health doctors and nurses, general practitioners, teachers and others. The hope is that each will carry out health education as a part of their regular activities. Sometimes in such a situation, there is a central body, often mainly concerned with publications and production of audio-visual aids. In such a situation there is a growth of voluntary agencies or societies which are concerned with one health problem and which become involved with specific health education programs or campaigns. 3. The Coexisting model: Where there is a formal health education service, run by health education specialists, as well as health education integrated into the daily activities of other professions, we find that both systems coexist, but that there is little cooperation in these activities. An example is Great Britain where the Area Medical Officer is responsible for health education but an Area Health Education Officer is appointed to organize it and carry it out. With the reorganization of the National Health Service, the three branches (curative, preventive and hospital) of health services have been integrated which should result in the integration of health education activities as well. At present there is little sign of this happening, mainly because there is very little experience of how it could be achieved. The result is that the health education services and the health education of others runs parallel with each one using the other from time to time, but without any joint activity related to various health problems associated with people’s behavior. 4. The Coopemtivè model: This is the dream of the future in most of the countries, where both systems coexist. It implies that health Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
257
education specialists and other professions should complement each other in tackling behavioral problems related to health and illness. For this to be achieved it will be necessary to analyze and define the role of each of the agents involved, based on the understanding of the various processes which influence the acquisition, maintenance and change of health-related and health-directed behavior. In addition to the need for job definition within the system of formal health education, ways and means will have to be found for the integration of the formal with the informal system of health education. Beyond cooperation between health educators and doctors, nurses, or teachers, ways will have to be found for cooperation with parents, peer and reference groups as well as others in the lay referral system, within which the health behavior is molded and manifested. The first three models at present coexist in Europe and any future development will have to take this fact into consideration. Treating health education as one activity and attempting to raise it to the level of a specialty has so far caused numerous problems, as can be seen if we critically examine the advantages and disadvantages of each of the models. For example, the creation of health education as a specialty improved the quality of the health education activity, but in some instances relieved the other professions of this responsibility. The result was that health educators were left on their own to tackle the problems of behavioral change, which they could not do with great success because of their isolation from other relevant activities and because of their small numbers. On the other hand the integration of health education into all relevant activities meant that there was no coordination or control and that the activity was dependent on personal preferences of individuals as to the methods and problem areas chosen. As was shown at the WHO (EURO) working group, we in Europe are now more inclined to look at &dquo;health education&dquo; not as one activity carried out by different agents, but as a whole set of qualitatively different activities, with different aims, methods, and professions involved e Instead of believing that health education specialists should and can solve most of the health education problems related to health and illness, it is being increasingly recognized that each agent involved in health care maintenance, prevention and cure of illness has to deal with behavioral aspects of his problem and that he should do it in a specific way according to the problem and to his recognized professional status when dealing with it. Consequently, we are dealing with a whole set of different &dquo;health educations,&dquo; each of which will require a separate and specific approach. The task - facing us today is to adjust the existing variety of organizational models to this new outlook on health education as a set of specific and often qualitatively different activities. The existence of ’
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unqualified health education specialists in some European countries is a fact which cannot be disregarded. What has to be done is to define each activity separately and to work out a job definition for each specific agent involved. This implies that we have to learn to live with a &dquo;co-existing&dquo; model of health education and gradually direct any future developments towards a planned organization of various health education activities within each specific area, emphasizing those shown to be most effective in solving a specific problem, and thus gradually achieve the &dquo;cooperative&dquo; model of organization. Agents If we accept the general idea that there is not one but many &dquo;health educations,&dquo; then we are faced with the need to define the roles of the agents active in each of these different areas. One way of doing it is by looking at the different needs of the client-population for whose benefit the whole activity exists. People may be either healthy, at-risk, ill or convalescent. In each of these different states they will require specific services in terms of health education. People who are healthy have an average level of risk from various health threats and have no specific behavioral patterns which would increase this risk to a higher than average level, require support and reinforcement of their existing behavioral patterns, as well as information about potential risks, to be able to avoid them in the future. This support will come from general values and specific norms on a societal level, from preventive check-ups confirming their status of being healthy and by updating knowledge about potential risks. These people are the target-population for preventing illness-inducing
behavior. In behavioral terms, people at risk manifest certain behavioral patterns which increase their risk from a health threat to above average. They need to modify their behavior which can be achieved in many different ways, from information and counseling to special treatment in clinics. To be willing to act on information and to submit to such a treatment and utilize the health education services if necessary, the society will have to exert pressure by means of appropriate norms, accompanied by effective sanctions for deviants. It will be also necessary for their at-risk state to be legitimized by a socially formal agent, so as to know who the target population is. Ill or chronically ill people suffer already from certain symptoms or disease processes. They need knowledge to be able to interpret certain signs and symptoms, awareness of the existence of the legitimizing agent for their special status, as well as the availability of the relevant health services. They must be exposed to a cue which will trigger their utilization of these services as well as have willingness to persist with the treatment. The chronically ill and debilitated in addition need Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
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rehabilitation to be able to return to normal life within the scope of their limitations. The convalescent will need to know what caused their illness to prevent its future occurrence; if the cause was due to some behavioral pattern, they need behavior change as well as supportive services for the maintenance of new behavioral patterns. In any other respect their needs will be equal to those of healthy people. To get a complete picture of the possible job definition of health education agents, it is necessary to examine, in addition to their role relating to the client population, their two other important areas of . activity: the administration of health education services and teaching and research. To sum up, we are faced with the preparation of health education agents, able to satisfy the different requirements of the client population, manage the health education services, do the teaching and carry out research in the field. This raises several questions which need to be answered for a successful planned and coordinated development of health education. The first, which must be decided upon as soon as possible, is whether all these tasks can be carried out by one person, a specialist, or whether it is a task that must be shared among a set of people with different backgrounds, professions and statuses. The answer is urgent, because we are
continuing to produce specialists, although we are no longer certain where they fit into the system and whether they are the best means of solving problems which cannot be postponed and cannot be allowed to fail. Until we have answers which have been tested and evaluated, we will have to be satisfied by intermediate solutions with a built-in feedback, to enable a gradual and progressive development, instead of expecting an instant and perfect solution. The new developments in Europe represent such an intermediate step, and should be assessed as such. We believe that there are two main factors that influence health behavior: social forces and individual decisions. Neither alone can provide the desired outcome, but jointly they can produce a synergistic effect. The effectiveness of these two factors will depend on existing knowledge, social recognition of risk and the provision of services. At present, the agents involved are health education specialists, health, teaching and other personnel. Each of them must play a specific role and have appropriate training. Health educatiori specialists (without a medical, nursing or teaching background) can successfully manage the health education services where
they exist,
can
carry out
teaching
and
research,
and
can
transmit information, thus influencing social norms and providing necessary knowledge about health problems. If they have a recognized professional status, based on their basic training in medicine, nursing, Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
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on a colleges level, and graduates can obtain master’s degrees and doctorates on a higher academic level.
organized
recognition of different kinds of health education and the specific needs of its different agents implies that teaching programs should be carried out, not by one but by a whole range of institutions. Only if teachers can specialize in health education in teaching institutions, doctors in medical schools, nurses in nursing colleges etc., will the qualification be recognized by the relevant professional body and graduates be able to fulfill their professional commitments towards their clients. At the University of Manchester the situation is favorable, since the Medical Faculty includes the professional preparation of doctors, nurses, dentists and pharmacists, on an undergraduate and postgraduate level and this covers a wide range of possibilities. In addition, the Faculty of Education can provide health education specialization for teachers. At present we are still too centralized, and provide teaching in the Department of Community Medicine for doctors, nurses, dentists and pharmacists as well as health educators with an appropriate first degree and/or experience. The
The ideal solution would be to have teachers of health education in each of the relevant faculties and departments.
PROFESSIONALIZATION The implications of professionalism are twofold: to protect the members of the profession and give them certain rights in relation to their clients, and at the same time to protect the clients and their rights as well. If health education is to become a full profession or professional activity, these rights and obligations will have to be formalized and strictly observed. From the point of view of today’s health education practice, this would mean that no health education interventions become acceptable for transmission to students; the individual’s behavior or practice should be allowed without a built-in evaluation, not only to make certain that it is successful, but at the same time to ensure that it does not cause any harm or damage. The consequences of such an approach are far-reaching and will affect many aspects of the teaching in so far as only tested and evaluated inteventions become acceptable for transmission to students; the practice of health education will become restricted by the limited amount of data available at present to support the claim that a planned intervention will be beneficial for the client. Professionalization of health education will, furthermore, have farreaching implications for any future research. So far, research has been mostly concerned with the study of a problem or the effectiveness of the methods of intervention, but now the study of solutions will also Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
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have to be included in order to establish all the possible negative byside-effects. Only in this way will health education as an concerned with behavioral aspects of health and illness be in a activity to position comply with the general standards required from any other
products or
medical intervention. Professionalization will also affect the organization of health education services. People at-risk require behavioral treatment in addition to information about the health hazards. Consequently, any health education intervention will have to be backed up by appropriate services (such as behavior change clinics) to which the generalist-health educator or any other health education agent (such as a general practitioner or a teacher) will be able to refer a client who is willing to change his behavior but cannot do so on his own. Professionalization of the health education activity implies institutionalization and provisions for formalized educational system with a body of legitimized knowledge. There is, however, an inherent danger in the institutionalization of a discipline without a paradigmatic basis. As Heyl says &dquo;When institutionalization and professionalization precede achievement of a paradigmatic structure in a discipline, that structure is unlikely ever to appear, at least in the form in which it has appeared in certain physical sciences.&dquo;2 To avoid this danger, the attempts at institutionalization and professionalization of health education as a discipline will have to go together with the achievement of a certain amount of research consensus relevant to that discipline. Any future research in the field of health education will have to prove sufficiently fruitful in producing concrete research approaches upon which a ~disciplinary tradition might be built. The consequence should be to bring together various schools and sub-schools of thought, reflecting basically accepted paradigms parallel with the process of institutionalization of the
discipline. Any narrowly sociological, psychological or medical treatment of the subject matter of health behavior now appears decidely parochial. Interdisciplinary discussions and standards of judgement are a requirement. From this it follows that health education must be considered as a hybird subject, on the meeting point between older established fields of study: it should be defined as a &dquo;bridgediscipline,&dquo; linking together medicine, sociology and psychology. Only in this way can health education aspire to a scientific respectability and acceptance by academic institutions. Without academic recognition health education can make little progress in the transition from a skill to a scientific subject, and without this transition, which is the main aim of our efforts at Manchester, health education can never hope to become a recognized part of a graduate or postgraduate curriculum in a medical faculty. Downloaded from heb.sagepub.com at OAKLAND UNIV on May 31, 2015
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SUMMARY In this article I have tried to describe
some
of the recent
developments in Europe and offered an explanation of how and why they differ from the &dquo;American Model.&dquo; I am aware that this statement is based on very wide generalizations: the developments described are taking place only in some parts of Europe; and the American model is not in fact recognized as such because of wide variations within America in approaches used in promoting health education. By the American model in this context, I mean the conceptualization of health education generated in some American schools of public health, and propagated by WHO in other parts of the world. Its basic characteristics are: special health education services; health education specialists; and the emphasis on psychological mechanisms in changing health behavior. We in Manchester, supported by the European Office of WHO; are trying to develop health education,,~drawing on American experiences, but hoping to avoid their mistakes. This conceptualization is based on a &dquo;social reality&dquo; approach which takes into account existing different models of organization and tries to reach a consensus of opinions for the future. Its main characteristics are: emphasis on social forces which influence health behavior; specialization of various agents instead of the emphasis on specialists; treating health education as a composite activity, carried out by many agents, involving many processes and methods; critical assessment of the contributions of various behavioral sciences; and emphasis on the professionalization of the activity, even though the agents may not have a professional status.
The consequences of such a development can be far-researching; we may lose &dquo;health education&dquo; as we know it today, but we may gain in effectiveness of influencing human health behavior. We must try to avoid the errors made in the past. Since many of the past approaches have been found to be lacking, the need was felt to reconsider the whole conceptualization, instead of trying to improve a faulty set of models, for which there is so far little empirical support. The new developments will be successful only if they avoid the rigidity of one of the old approaches, and include feedback, enabling testing and readjustments as we progress. REFERENCES (ed): The Health Belief Model and Personal Health Behavior. Health Educ Monogr 2:4, Winter 1974. 2. Heyl. JD: Paradigms in social science. Society 12:5, July-August 1975. 3. WHO: Expert Committee on Health Education of the Public, First Report. Geneva (WHO Tech Rep Ser No 89) 1954. 4. WHO: Expert Committee on Training of Health Personnel in Health Education of 1. Becker MH
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Report. Geneva (WHO Tech Rep Ser No 156) 1958. PAHO/WHO Inter-Regional Conference on the Postgraduate Preparation of Health Workers for Health Education, Phila 8-17 July, 1962, Report. Geneva (WHO Tech Rep Ser No 278) 1964. the Public,
5. WHO:
6. WHO: The Social Sciences in Medical Education, Report on a Seminar in Hanover, 7-10 October, 1969. Copenhagen, Regional Office for Europe, 1969. 7. WHO: The Preparation of Health Personnel in Health Education, with Special
Postgraduate Education Programs, Report on a Symposium held in Cologne, 10-14 November, 1974. Copenhagen, Regional Office for Europe, 1974. 8. WHO: Report on the Working Group on the Place of Health Education in Health Administration, Manchester (UK) 3/29-4/1, 1976. (In preparation WHO Regional Office for Europe, Copenhagen) 1976. Reference to
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