8. Community Health Education

Community Health Education

Cathy D. Meade


Upon completion of this chapter, the reader will be able to do the following:

1. Describe the goals of health education within the community setting.

2. Examine the nurse’s role in community education within a sociopolitical and cultural context.

3. Select a learning theory, and describe its application to the individual, family, or aggregate.

4. Examine innovative and effective teaching and learning strategies that exemplify community-centered health education for the individual, family, or aggregate.

5. Compare and contrast Freire’s approach to health education with an individualistic health education model.

6. Examine the importance of community engagement for having an impact on health disparities.

7. Outline a systematic process for developing culturally and literacy relevant health education materials, messages, media, and programs.

8. Relate and apply factors that enhance the suitability of health education materials, messages, media, and programs for an intended audience.

9. Prepare an appropriate and meaningful teaching plan and evaluation criteria for the individual, family, and group.

Key terms

cognitive theory

community empowerment

community-based participatory methods

culturally effective care

health disparities

health education

health literacy

humanistic theories

learner verification


materials and media

participatory action research (PAR)

problem-solving education

social learning theory

Additional Material for Study, Review, and Further Exploration

Connecting with everyday realities

The nurse may be tempted to often ask the following questions:

Although these questions represent the nurse’s intense desire to understand the link between health behavior and health education, they do not yield answers or empower individuals or families. In fact, such questions do not address the root health issues and create a “blaming the victim” approach (Israel et al., 1994). The nurse might reframe the previous questions to better get at the root reasons and, in turn, empower individuals, families, and groups. Instead, ask the following questions:

• What life stressors are getting in the way of the expectant mom from quitting smoking for good? What stage of quitting might she be in? What factors might motivate her to stop?

• What factors might be preventing the senior man from getting a follow-up test (colonoscopy)? Might the colonoscopy procedure be scary? What beliefs might the man have about such tests? Might the instructions be difficult to understand? Does he have money for the prep? What can I do to verify understanding of the situation and better connect with his beliefs, motivations, and current knowledge?

• How does the young man with diabetes prefer to learn? What makes it difficult for him to know when to take his meds? What can I do to better connect the lifesaving instructions about insulin to his everyday activities? Could finances be an issue?

• What types of barriers might prevent the family from getting their kids immunized on time? Do they understand the schedule? Could I do a better job of explaining the importance of childhood immunizations? Might the family be confused about the different types of immunizations, especially in light of media attention about H1N1 (swine flu)? Could a personalized chart record help?

• What kinds of outreach methods might better attract community members to the free cancer screening? In what way could sustained relationships with community stakeholders and community members make a difference? How might I further engage community members in planning health events and screenings?

• What role might I play in developing links with schools, grocery stores, churches, and community centers to reach families with nutrition messages that are easy to understand and that fit their cultural background? What social, physical, cultural, linguistic, or structural factors should be considered when developing health messages?

Health education in the community

Historically, teaching has been a significant nursing responsibility since Florence Nightingale’s (1859) early work. Gardner (1936) emphasized that health teaching is one of the most fundamental nursing principles and that “a nurse, in even the most obscure position must be a teacher of no mean order.” There is much support for the nurse’s involvement in health education, including the nurse practice acts, professional statements of the American Nurses Association (ANA) (1975), the patient’s bill of rights of the American Hospital Association (AHA) (1975), the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission, 1995), national standards on culturally and linguistically appropriate services of the Office of Minority Health (OMH) (1999), and the Healthy People 2020 objectives of the U.S. Department of Health and Human Services (USDHHS) (2000) (see proposed communication objectives at www.healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=25&TopicArea=Health+Communication+and+Health+IT). Health education is an integral part of the nurse’s role in the community for promoting health, preventing disease, and maintaining optimal wellness (Box 8-1). Moreover, the community is a vital link for the delivery of effective and equitable health care and offers the nurse multiple opportunities for providing appropriate health education within the context of a setting that is familiar to community members (Meade et al., 2002a).

The role of the nurse as health educator is especially important in light of the increasing diversity and demographically changing population in the United States, the increasingly technological advancements in health care, and the need to reduce the disconnect between scientific discovery and the delivery of interventions in the community (Freeman, 2004; Chu et al., 2008). More than ever before, health education activities and services are taking place outside the walls of hospitals in such settings as missions, YMCAs, beauty and barber shops, grocery stores, homeless shelters, community-based clinics, health maintenance organizations, schools, work sites, senior centers, mobile health units, homes, and Women, Infants, and Children (WIC) sites. At the core of health education is the development of trusting relationships based on nurturing interactions, the use of community-based participatory methods that highlight community strengths, and the creation of sustainable collaborations and partnerships (Gwede et al., 2009; Leung, Yen, and Minkler, 2004; Luque et al., 2010; Martinez et al., 2008; Meade et al., 2009; Minkler, 2005; Olshansky et al., 2005; Smedley et al., 2003).

Health education’s goal is to understand health behavior and to translate knowledge into relevant interventions and strategies for health enhancement, disease prevention, and chronic illness management. Health education aims to enhance wellness and decrease disability; attempts to actualize the health potential of individuals, families, communities, and society; and includes a broad and varied set of strategies aimed at influencing individuals within their social environment for improved health and well-being (Green and Kreuter, 2004). The nurse is ideally situated to bring together the necessary skills, knowledge, and community resources to impact the health of the community.

Health education is any combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities (Green and Kreuter, 2004). Steuart and Kark (1962) state that “health education must achieve its ends through means that leave inviolate the rights of self-determination of the individuals and their community.” A major challenge for community health nurse educators is to address the complex and intersecting sociopolitical conditions that affect community health by placing value on the contributions of community members and building on their strengths. The lasting effect of cognitive and behavioral changes relies heavily on learner participation to influence change in health behaviors and practices (Green and Kreuter, 2004; Leung et al., 2004; MacLeod and Zimmer, 2005; Cashman et al., 2008; Wallerstein and Duran, 2006; Kannan et al., 2008). In this manner, nurses alone cannot set individual, family, or community priorities. Rather, learners (community members) must be involved in determining their health education needs and priorities.

Community health education is based on practical, relevant, and scientifically sound methods and widely accessible technology. In the late 1970s, Kleinman (1978) described a social and cultural community health care system that related external factors (e.g., economical, political, and epidemiological) to internal factors (e.g., behavioral and communicative). This view of a sociocultural health care system grounds health education activities within sociopolitical structures, especially within local environmental settings, and views the community as client (Coleman et al., 2009; Giachello et al., 2003; Horowitz et al., 2004; Kobetz et al., 2009; Martyn et al., 2009; Meade et al., 2007; Petersen et al., 2004; Villarruel et al., 2007). As such, because the community level is often the location of health prevention and health intervention programs, it is significant for obtaining positive health outcomes. Moreover, the creation and delivery of relevant health education interventions and communications within the community setting is a national imperative as outlined by Healthy People 2020, OMH’s Standards for the Provision of Culturally Competent Health Care (1999), and several Institute of Medicine reports (e.g., Nielsen-Bohlman et al., 2004; Smedley et al., 2003). Nurses are uniquely qualified to influence the health and well-being of community members’ health behaviors through original and inventive activities that incorporate culturally, linguistically, and educationally relevant health education and outreach communications (Meade et al., 2007; Watters, 2003).

Learning theories, principles, and health education models

Learning Theories

Learning theories are helpful in understanding how individuals, families, and groups learn. The field of psychology provides the basis for these theories and illustrates how environmental stimuli elicit specific responses. Such theories can aid nurses to recognize the mechanisms that potentially modify knowledge, attitude, and behavior. Bigge and Shermis (2004) assert that learning is an enduring change that involves the modification of insights, behaviors, perceptions, or motivations. Although psychology textbooks describe learning theories in great detail, the following broad categories relate to the nursing application in a community setting: stimulus-response (S-R) conditioning (i.e., behavioristic), cognitive, humanistic, and social learning. Resource Tool 8A imageLearning Theories and Their Relationship to Health Education on the book’s Evolve website at evolve.elsevier.com/Nies outlines these learning theories.

Research Highlights

Linking Theory to Practice: An Example of a Sexually Transmitted Infection/Human Immunodeficiency Virus Risk Reduction Intervention in a Primary Care Setting

Reducing sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) is a national imperative. Responding to this priority, the “Sister to Sister: Respect Yourself! Protect Yourself! Because You Are Worth It!” program was created. This counseling theory–based intervention consists of a single 20-minute one- on-one nurse-led intervention and addresses three key themes: family/community, caring, and self-worth. The intervention includes counseling strategies, videos, condom demonstration, and client role-plays to support behavioral change through practice (Jemmott et al., 2008). As background, this educational, skill-based HIV risk-reduction intervention was previously designed and evaluated using a randomized controlled trial among African-American women (Jemmott, Jemmott, and O’Leary, 2007). Based on the Social Cognitive Theory and Theory of Planned Behavior, the curriculum targets risky sexual behaviors and women’s control beliefs about factors that would facilitate and/or hinder their abilities to perform them. The nurses evaluated the effectiveness of four theory-based interventions: skill-building vs. information only, and two methods of intervention delivery (one-on-one vs. group) against a control group among a sample of 564 Black women (mean age 27.2 years) seeking outpatient care in a primary care clinic. Primary outcomes were self-reported sexual behaviors, and the secondary outcome was sexually transmitted disease (STD) incidence. Results indicated that the “Sister to Sister” one-on-one brief skill-building and group skill-building interventions were both effective at reducing sexual risk behaviors and STI occurrence, and that these effects lasted at the 12-month follow-up point. Findings showed that the skill-building group intervention did not produce superior outcomes to the one-on-one intervention. Even though the group intervention was lengthier and one might posit that greater benefit would be gained from interactions with other group members, the personalized nature of the one-on-one intervention may have been more customized to meet the specific risks of the women. Thus, the authors concluded that the brief nurse-led one-on-one and group skill-building interventions were effective in reducing STI/HIV sexual risk behaviors and STI incidence. One limitation of the study is that the primary measure was assessed by self-report. Overall, the findings are similar to those of other studies that support the use of cognitive behavioral skill-building interventions for reducing sexual risk behavior among women. Although continued research is necessary to replicate the study with other populations of women in other settings, there is high potential for application for brief nurse-led theory-based interventions for reducing the spread of sexually transmitted HIV infection.

From Jemmott JB et al: Sexually transmitted infection/HIV risk reduction interventions in clinical practice settings, J Obstet Gynecol Neonatal Nurs 37:137-145, 2008; and Jemmott LS, Jemmott JB, O’Leary A: A randomized controlled trial of brief HIV/STD prevention interventions for African American women in primary care settings: effects on sexual risk behavior and STD rate, Am J Public Health 97:1034-1040, 2007.

The nurse should remember that theories are not completely right or wrong. Different theories work well in different situations. Knowles (1989) relates that behaviorists program individuals through S-R mechanisms to behave in a certain fashion. Humanistic theories help individuals develop their potential in self-directing and holistic manners. Cognitive theorists recognize the brain’s ability to think, feel, learn, and solve problems and train the brain to maximize these functions. Although social learning theory is largely a cognitive theory, it also includes elements of behaviorism (Bandura, 1977b). Social learning theory’s premise is based on behavior explaining and enhancing learning through the concepts of efficacy, outcome expectation, and incentives

Clinical Example

Application of Characteristics of Adult Learners to the Development of a Community Support Group

The following example illustrates the long-standing value of incorporating theoretical underpinnings in the development of community activities designed to meet specific learning needs. It provides a description of how nurses can play an active role in bolstering the community capacity and health of their community. Although this example dates back to the 1980s, it serves as an important reminder of the value of applying learning theories to one’s work. As viewed later in this chapter, LUNA (Latinas Unidas por un Nuevo Amanecer, Inc., a nonprofit organization), whose mission is to provide support and offer culturally and linguistically relevant education to Hispanic breast cancer survivors and their families, was created based on similar tenets.

As background, the author and a colleague began a community support group for individuals with amyotrophic lateral sclerosis (ALS), more commonly known as Lou Gehrig’s disease based on an identified community need. The support group was open to family members and friends. ALS is an incurable degenerative neuromuscular disease that affects nerve and muscle function and the brain’s ability to control muscle movement. Community members provided feedback and identified the need for specific education topics and support for ALS. At that time, southeast Wisconsin did not have a support group. This initial dialogue provided the organizing framework for the inception of the first support group and, based on observations and interactions at the monthly meetings, an illustration of Knowles’ assumptions follows:

Need to know: At the first support groups, the facilitator nurses introduce topics by describing the reason for the discussion and rationale for the selected subject (e.g., common concerns of patients and family members and informal assessments based on conversations). To prepare for discussion, group members introduce themselves, and the nurse asks what they hope to learn from the presentation. In some cases, members are unsure why they desire more information on a given topic but indicate that they want to listen. Progression of the disease is variable; therefore the need to know is often facilitated by the nurses and other patients who have already noted the importance of specific learning tasks (e.g., need for assistive walking device, need for financial planning, or need for information on assistive breathing devices).

Self-concept: A comfortable, informal environment allows patients to express feelings, emotions, and frustrations about this disease. Participants are encouraged to express themselves. Participants cultivate mutual respect and trust, and hugs are common as members begin to understand that others share similar situations and concerns. Group members have an opportunity to speak out about ways to manage and cope with their disease (e.g., decisions about life support and feeding tubes). Even if their choices are not the same as others’, participants recognize and acknowledge these decisions without imposing their own value judgments. Facilitators and group members become equal partners in the learning process. At the core of the meetings was the formation of therapeutic healing relationships.

Experiences: Some patients and family members have gone through other difficult life experiences and stressors (e.g., other illnesses or deaths in the family) and can help others cope with the management of ALS. Patients share the strengths gained from such experiences with other support group members. Additionally, individuals and family members who are going through varying stages of the disease process can share their experiences (e.g., obtaining home care, selecting a computer, and managing breathing difficulties). They share tips and timesaving strategies with each other and newly diagnosed families and can learn from those experiences.

Readiness to learn: Family members often assume many roles when someone is ill, especially with a chronic illness such as ALS. The redefinition of roles creates new learning opportunities; however, this may hinder learning if it is too overwhelming. For example, the well spouse may assume the roles of caregiver, parent, and financial supporter. It is helpful to identify resources to help the family cope with new roles (e.g., respite care).

Orientation to learning: Learning a variety of psychomotor skills is necessary to care for the patient with ALS (e.g., suctioning, positioning, using a feeding tube, and toileting). The timeframe for learning such skills varies depending on the course of illness. Presenting information about such skills too early in the course of the disease may cause fear and anxiety. Families are often resistant to learning such tasks until the need is apparent. In some cases, this may be evident at a crisis point (e.g., a fall, a choking incident, or severe respiratory distress). However, nurse facilitators introduce these topics slowly by providing information via the support group, newsletter, e-mails, printed brochures, and personal one-on-one discussions.

Motivation: Individuals and families experience a shift in life goals when facing ALS. Such shifts may create learning opportunities aimed at enhancing quality of life, survivorship, and maintaining self-esteem. For example, a college professor with ALS kept his link to the university. He was highly motivated to continue his research work and supervise his graduate students. To continue his academic work, he learned to manage his breathing by using a ventilator, arranging transportation to the university, obtaining nursing care, and creating communication methods by using a computer.

Today, there are more than eight ALS support/caregiver groups in Wisconsin that grew from just a few who recognized an unmet need in the community. The ALS Association (ALSA) Wisconsin Chapter evolved from a local support group and became an official ALSA chapter in 1987. The chapter has four primary goals: (1) provide education, guidance, services, and support to patients with ALS, their families, and their caregivers; (2) promote public awareness of ALS; (3) raise funds for ALS research; and (4) establish an ALS-certified, multidisciplinary clinic to provide the highest level of care to the patients served by the chapter. For more information on services, go to alsawi.org/hopeline.php.


Knowles’ Assumptions About Adult Learners

Knowles (1988, 1989) outlined several assumptions about adult learners. He contends that adults, like children, learn better in a facilitative, nonrestrictive, and nonstructured environment. Nurses who are familiar with these assumptions can develop teaching strategies that motivate and interest individuals, families, and groups and encourage active and full participation in the learning process. Nurses can help to create a self-directing, self-empowering learning environment. The following characteristics impact learning: the client’s need to know, concept of self, readiness to learn, orientation to learning, experience, and motivation. Table 8-1 expands on these characteristics.


Characteristics of Adult Learners

Characteristics Application to Health Education
Need to Know
Adults must know why they need to learn.
Concept of Self

The nurse acknowledges that individuals, families, and groups are able to make choices and decisions. The nurse creates an environment in which patients can express themselves. The nurse recognizes that individuals, families, and groups can learn from their selected actions and can take self-direction and responsibility for such behaviors.
Adults may draw upon many life experiences. Such experiences are enriching and are powerful learning resources. The nurse assesses individuals, families, and groups for life experiences related to health issues. The nurse helps facilitate connections between previous and present experiences. The nurse allows individuals, families, and groups to share experiences with others in a supportive manner. Experiential methods, problem solving, case methods, and discussion can help uncover the learner’s experiences. The nurse clarifies previous and present experiences; this is especially helpful with negative or biased experiences.
Readiness to Learn
Developmental tasks and social roles affect readiness to learn. The timing of learning experiences with developmental tasks is important. The nurse assesses and identifies individual, family, and group roles (e.g., caregivers or single parents) and key developmental tasks. The nurse seeks to understand the impact of roles and tasks on learning. The nurse creates role-modeling experiences.
Orientation to Learning

The nurse assesses the learning needs of individuals, families, and groups on the basis of their priority. The nurse recognizes everyday stresses and hassles and addresses them within their learning context. The nurse provides health information, gives responses to their immediate needs, offers/provides health information, and offers problem-solving skills.
Internal drivers and factors are powerful motivators (e.g., self-esteem, life goals, quality of life, and responsibility). The nurse determines individual, family, and group motivators. The nurse assesses for barriers that block motivation (e.g., poor self-esteem or lack of resources) and provides appropriate education, counseling, and referrals.


Modified from Knowles MS: The making of an adult educator: an autobiographical journey, San Francisco, 1989, Jossey-Bass; and Knowles MS: The modern practice of adult education: from pedagogy to andragogy, Chicago, 1988, Cambridge Press.

Health Education Models

In addition to learning theories, applying education theories and principles to situations involving individuals, families, and groups illustrates how ideas fit together, offers explanations for health behaviors or actions, and helps direct community nursing interventions. Such theoretical elements form the basis of understanding health behavior. Glanz and colleagues (2008) state that theories give educators the power to assess an intervention’s strength and impact, and they serve to enrich, inform, and complement practice. Theoretical frameworks offer nurses an intervention blueprint that promotes learning and provides them with an organized approach to explaining concept relationships (Padilla and Bulcavage, 1991).

What the nurse needs is often not a single theory that would explain all that he or she hears, but rather a framework with meaningful hooks and rubrics on which to hang the new variables and insights offered by different theories. With this customized metatheory or framework, the nurse can triage new ideas into categories that have personal utility in his or her practice and everyday realities. (Green, 1998, p. 2)

Models of Individual Behavior

Two models that explain preventive behavior determinants are the Health Belief Model (HBM), which is presented in Table 8-2 (Becker et al., 1977; Hochbaum, 1958; Kegeles et al., 1965; Rosenstock, 1966), and the Health Promotion Model (HPM) (Pender, Murdaugh, and Parsons, 2005). Both models are multifactorial, are based on value expectancy, and address individual perceptions, modifying factors, and likelihood of action. The HBM is based on social psychology and has undergone much empirical testing to predict compliance on singular preventive measures. The initial purpose of the HBM was to explain why people did not participate in health education programs to prevent or detect disease, in particular, tuberculosis (TB) screening programs (Hochbaum, 1958). Subsequent studies addressed other preventive actions and factors related to adherence to medical regimens (Becker, 1974). Primarily, the HBM is a value expectancy theory that addresses factors that promote health-enhancing behavior. It is disease specific and focuses on avoidance orientation. The HBM considers perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and other sociopsychological and structural variables. In an early review of 46 studies using the HBM, perceived benefits were found to be the most powerful predictive element within the model, whereas perceived severity had the lowest associative value (Janz and Becker, 1984). Self-efficacy, or the notion that an individual can act successfully on a given behavior to produce the desired outcome (Bandura, 1977a, 1977b), was later added to the HBM (Rosenstock, Strecher, and Becker, 1988; Strecher et al., 1986).

Champion and Skinner (2008) point out that one of the limitations of the HBM is the variability in measurement of the central HBM constructs, which include the inconsistent measurement of HBM concepts and the lack of establishing validity and reliability of the measures prior to testing. For example, applying similar construct measures across different behaviors, such as barriers for mammography and colonoscopy, may be quite different. Although the past decade has produced some good examples of HBM scale development (Champion, 1999; Champion et al., 2008; Joseph et al., 2007; Rawl et al., 2000), caution should be taken when applying the HBM in multicultural settings. It would be important to determine whether the overall assumptions of the HBM—assumptions related to the value of health and illness—are similar to those of the particular racial/ethnic group under study. Further, checking wording for cultural distinctions is critical to the model’s usefulness (Janz, Champion, and Strecher, 2002). Although the HBM identifies an array of variables important in explaining individual health, nurses should view these variables within a larger societal perspective.

Pender’s Health Promotion Model (HPM) is a competence or approach-oriented model and, unlike the HBM, does not rely on personal threat as a motivating factor. The HPM brings together a number of constructs from expectancy-value theory and social cognitive theory within a holistic nursing framework (Pender et al., 2005). Gillis (1993) reviewed 23 studies conducted between 1983 and 1992 and reported that Pender’s HPM was the most common theoretical framework in health promotion studies. Gillis identified that self-efficacy was the strongest determinant of participation in a health-promoting lifestyle, followed by social support, perceived benefits, perceived barriers, and an individual’s definition of health education. Locus of control was the least important determinant, although it is the most studied.

The HPM is meant to provide an organizing framework to explain why individuals engage in health actions. It is applicable across the lifespan and has been used to examine the multidimensional nature of persons interacting with their physical and interpersonal environments, such as bicycle helmet use (Lohse, 2003) or health-promoting behaviors among Hispanics (Hulme et al., 2003), as a causal model of commitment to a plan for exercise in a sample of 400 Korean adults (Shin et al., 2005), and use of hearing protection devices by 703 construction workers (Ronis, Hong, and Lusk, 2006). Table 8-3 lists the main HPM components with behavioral action as the desired output.

The HBM and HPM can assist community health nurses in examining an individual’s health choices and decisions for influencing health-related behaviors. The models offer nurses a cluster of variables that provide interesting insights into explaining health behavior. These variables are helpful cues; the nurse should consider them in planning and interacting with health education interventions but not try to fit an individual into all the categories. Simply put, models are aids that guide nurses in assessing patients and in developing, selecting, and implementing relevant educational interventions. In applying the models, a nurse might consider the following questions in relation to his or her own health behavior:

• Do you strive for improved health?

• Are you or your family susceptible to heart disease or obesity?

• Does a family history of cardiovascular disease motivate you or your family to exercise?

• Does looking fit and toned and having energy motivate you to exercise?

• Do work, school, or family responsibilities get in the way of your exercise plans?

• Has a family member, friend, or health professional recently reminded you of the benefits of exercise and encouraged you to start exercising?

• Do you believe you can initiate and incorporate an exercise program into your lifestyle, or do you need external reinforcement and cues?

• Do money, safety, and time pose barriers to planning an exercise program?

• Do you see any benefits to exercise, for example, looking and feeling better and more energized?

• In modifying your health behaviors, how important is exercise compared with other behaviors (e.g., getting relief from work and school stresses, cutting down on snacks, spending quality time with your family)?

Think about these questions and consider your answers. Talk about these issues with a colleague and try to develop an action plan tailored to your own priorities, needs, and capabilities.

Model of Health Education Empowerment

The HBM and HPM focus on individual strategies for achieving optimal health and well-being. The models are similar in that they are multifactorial, are based on the idea of value expectancy, and address individual perceptions, modifying factors, and likelihood of action. Although such approaches may be appropriate in changing individual behaviors, they do not address the complex relationships among social, structural, and physical factors in the environment, such as racism, lack of social support systems, and inaccessible health services (Israel et al., 1998; Smedley et al., 2003). Van Wyk (1999) suggests that nurses cannot assign power and control to the individual within the community but rather that the “power” must be taken on by the individual with the nurse guiding the dynamic process. This process includes examining such factors as education, health literacy, gender, and class and recognizing the structural and foundational changes that are needed to elicit change for socially and politically disenfranchised groups. Thus, knowledge is produced in a social context, and it is inextricably bound to relations of power.

An appropriate health education model is one that embraces a broader definition of health and addresses social, political, and economic aspects of health. This view of the health care system as a sociocultural system better grounds health education interventions within the sociopolitical structure, especially within local environmental settings (Goodman et al., 1998; Labonte, 1994). Such a theoretical perspective is congruent with community health education because it supports learner participation and involvement and emphasizes empowerment.

Empowerment and literacy are two concepts that share a common history: The concept of empowerment can be traced back to Paulo Freire, a Brazilian educator in the 1950s who sought to promote literacy among the poorest of the poor, most oppressed members of the population. He based his work on a problem-solving approach to education, which contrasts with the banking education approach that places the learner in a passive role. Problem-solving education allows active participation and ongoing dialogue and encourages learners to be critical and reflective about health issues. Freire suggested that when individuals assume the role of objects, they become powerless and allow the environment to control them. However, when individuals become subjects, they influence environmental factors that affect their lives and community. Thus community members, or subjects, are the best resources to elicit change (Freire, 2000, 2005).

Freire’s methodology, often referred to as critical consciousness, involves not only education but also activism on the part of the educator. The basic tenet of Freire’s work centers on empowerment, the contextualization of peoples’ daily experiences, and collaborative, collegial dialogue in adult education. Freire’s work speaks to a variety of action research applications, including those that relate to improving community health of marginalized populations. Freire’s approach to health education increases health knowledge through a participatory group process and emphasizes establishing sustainable lateral relationships. This process explores the problem’s nature and addresses the problem’s deeper issues. The nurse, or facilitator-educator, is a resource person and is an equal partner with the other group members. Listening is the first phase and is essential to understanding the issues. The exchange of ideas and concerns creates a problem-posing dialogue and identifies root problems or generative themes. The group discusses and explores the problem’s root causes. Finally, group members create relevant action plans that are congruent with their own reality (Freire, 2000).

The goal of participatory action research (PAR) is social change. It is consistent with the role and responsibilities of the community nurse (Olshansky et al., 2005) and embraces the use of community-based participatory methods. What this means is that participation and action from stakeholders and important knowledge about conditions and issues gained facilitates strategies reached collectively (e.g., access to care, access to information). In this manner, the value of communities’ experiential knowledge is affirmed (Leung et al., 2004). Examples of the use of PAR include Horowitz et al. (2004), who describe the use of combining local and academic expertise to study health disparities and create peer-led classes to improve chronic disease management in East and Central Harlem; Edgren and colleagues (2005), who offered suggestions for involving the community in fighting against asthma; English and colleagues (2004), who developed the REACH 2010 program to build a public health community capacity program with a tribal community in the Southwest; and Giachello et al., (2003), who addressed the disproportionately high rate of diabetes in southeast Chicago through community-led activities.

At the core of empowerment are information, communication, and health education (World Health Organization [WHO], 1994). When nurses involve individuals, families, and groups in their learning, it validates their role and helps ensure the intervention’s relevance (Leung et al., 2004; Meade et al., 2003; Minkler, Wallerstein, and Wilson, 2008; Olshansky et al., 2005). Nurses can use empowerment strategies to help people develop skills in problem solving, critical thinking, networking, negotiating, lobbying, and information seeking to enhance health. Freire’s approach may seem similar to health education’s emphasis on helping people take responsibility for their health by providing them with information, skills, reinforcement, and support. However, Freire purports that knowledge imparted by the collective group is significantly more powerful than information provided by health educators. Freire’s approach attempts to uncover the social and political aspects of problems and encourages group members to define and develop action strategies. Hence, health changes are complex and usually do not have immediate solutions; therefore the term problem posing, rather than problem solving, may better describe this empowerment process (Minkler, Wallerstein, and Wilson, 2008).

Examples of Empowerment Education and Participatory Methods

1. López and colleagues (2005) relate how photovoice was used as a participatory action research method with African-American breast cancer survivors in rural east North Carolina, referred to as the “inspirational images project.” The aim of the study was to use this research method to allow women to convey the social and cultural meaning of silence about breast cancer and to voice their survivorship concerns so that relevant interventions could be developed to meet their needs. The task of the women was to take at least six pictures of people, places, or things that they enjoyed in life; significant things they encountered as a survivor; and what was used to cope. Discussion of photographs (e.g., picture of church) led to discussions including a six-step inductive questioning technique suggested by Wallerstein and Bernstein (1988), which helps participants in framing educational strategies:

• What do you SEE in this photograph?

• What is HAPPENING in the photograph?

• How does this relate to OUR lives?

• WHY do these issues exist?

• How can we become EMPOWERED by our new social understanding?

• What can we DO to address these issues?
The use of photovoice offers an important and creative way to facilitate shared knowledge to achieve social change.

2. N. Wilson and colleagues (2008) describe YES! (Youth Empowerment Strategies), an after-school program for underserved elementary and middle school youth. Designed to reduce risky behaviors including drug, alcohol, and tobacco use, YES! combines multiple youth empowerment strategies to bolster youth’s capacities and strengths to build problem-solving skills. A number of empowerment education projects including photovoice and social action projects (e.g., awareness campaigns, projects to improve school spirit) were developed that involved members of the intended audience in the planning and implementation.

3. Luque et al. (2010) report the use of empowering processes based on Freire’s Popular Education principles (Freire, 2000) and Social Cognitive Theory, which focused on the constructs of environment, behavioral capability, observational learning, and self-efficacy (Bandura, 1977a, 1977b) for creating a barbershop training program about prostate cancer. By employing techniques borrowed from empowerment education (Wallerstein and Bernstein, 1988), barbers were engaged in group learning activities and problem-posing exercises around preferences and values related to prostate cancer health. Once the training and curriculum was completed among eight barbers, the team worked closely with the barbers to modify and create a supportive workplace environment for new health education tools (easy-to-read posters, brochures, DVD player, prostate cancer display model) to fuel discussions about prostate cancer health and decision making. Once the barbers were trained, structured surveys with barbershop clients (N = 40) were conducted. Results showed a significant increase in participants’ self-reported knowledge of prostate cancer and an increased likelihood of discussing prostate cancer with a health care provider (P <.001). In conclusion, the barber-administered pilot intervention appears to be an appropriate and viable communication strategy for promoting prostate knowledge to a priority population in a convenient and familiar setting.

Community Empowerment

Community empowerment is a central tenet of community organization, whereby community members take on greater power to create change. It is based on community cultural strengths and assets. An empowerment continuum acknowledges the value and interdependence of individual and political action strategies aimed at the collective while maintaining the community organization as central (Minkler, Wallerstein, and Wilson, 2008). As such, community organization reinforces one of the field’s underlying premises as outlined by Nyswander (1956): “Start where the people are.” Meade and Calvo (2001) point out that attention must be given to collective rather than individual efforts to ensure that the outcomes reflect the voices of the community and truly make a difference in people’s lives. Further, Labonte (1994) states that the community is the engine of health promotion and a vehicle of empowerment. He describes five spheres of an empowerment model, which focus on the following levels of social organization: interpersonal (personal empowerment), intragroup (small-group development), intergroup (community), interorganizational (coalition building), and political action. A multilevel empowerment model allows us to consider both macro-level and micro-level forces that combine to create both health and disease. Therefore, it seems that both micro and macro viewpoints on health education provide nurses with multiple opportunities for intervention across a broad continuum.

In summary, health education activities that respond to McKinlay’s (1979) call to study “upstream,” that is, to examine the underlying causes of health inequalities, through multilevel education and research allow nurses to be informed by critical perspectives from education, anthropology, and public health. For more extensive readings on this topic, see Methods in Community-based Participatory Research for Health (Israel et al., 2005) and Community-Based Participatory Research for Health: From Process to Outcomes (Minkler and Wallerstein, 2008).

To effect change at the community level, nurses must be knowledgeable about key concepts central to community organization (Table 8-4). This approach is an effective methodological tool that enables nurses to partner with the community, identify common goals, develop strategies, and mobilize resources to increase community empowerment, capacity, and community competence. Key concepts inherent in community health education programming are empowerment, principle of participation, issue selection, principle of relevance, social capital, and creation of critical consciousness (Minkler, Wallerstein, and Wilson, 2008).


Community Organization Practice

Key Concepts Application to Health Education (Nursing Actions)
Help individuals, families, and groups gain insight and mastery over life situations through problem solving and dialogue The nurse works with community members in identifying and defining issues and creates mechanisms for discussion and problem solving and identification of other factors that have an impact on everyday lives.
Principle of Relevancy
Know what issues are important to community members (these may differ from the issues important to nurses)
Principle of Participation
Learn by doing
Issue Selection
Identify community problems that the community believes are specific, meaningful, and attainable The nurse uses problem-solving techniques to help group members identify relevant issues vs. troubling problems (e.g., door-to-door surveys and group process activities).
Creation of Critical Consciousness
Encourage relationships of equality and mutual respect among group members and educators to identify root problems and generate appropriate action plans The nurse uses problem-posing dialogue (Freire, 2005) to understand root issues and devises creative and innovative methods to transform situations.
Social Capital
Relationships (networks) between community members (i.e., trust, engagement) The nurse encourages community members to work together to improve social networks: they work together on a particular health gap in their community through partnership activities.


Modified from Minkler M, Wallerstein N, Wilson N: Improving health through community organization and community building. In Glanz K et al., editors: Health behavior and health education: theory, research and practice, ed 4, San Francisco, 2008, Jossey-Bass, pp. 288-312.

Keck (1994) indicated that successful community health relies on empowering citizens to make decisions about individual and community health. Empowering citizens causes power to shift from health providers to community members in addressing health priorities. Collaboration and cooperation among community members, academicians, clinicians, health agencies, and businesses help ensure that scientific advances, community needs, sociopolitical needs, and environmental needs converge in a humanistic manner. The development of LUNA (Latinas Unidas por un Nuevo Amanecer, Inc.) in Tampa, Florida, illustrates how the basic tenets of community need and organization fuel the development of a locally initiated group. LUNA represents a grassroots initiative to meet the needs of Hispanic breast cancer survivors and serves as a model for nurses, researchers, and community advocates working with underserved groups of cancer survivors

Clinical Example

Example of Community Empowerment-Collaboration-Participation: LUNA

In 2002, a Latina nurse (Melba Martinez, RN, BSN), who had had breast cancer diagnosed in 1995, started the first grassroots support group for Latinas with breast cancer in West Central Florida. The group began with five members and within the first year had 38 active members who attended monthly meetings. The group was initiated in response to an unmet need in the Tampa Bay area, that is, lack of education services for Latinas with breast cancer diagnosed and who primarily spoke Spanish. Over the years, LUNA has created a network of more than 200 Latina survivors and has grown and become Latinas Unidas por un Nuevo Amanecer, Inc., a nonprofit organization whose mission is to provide support and offer culturally and linguistically relevant education to Hispanic breast cancer survivors and their families, friends, and caregivers. The organization primarily serves underserved, immigrant, low-income Latinas with limited English proficiency, assists with navigating the health care system, and serves as a community resource. LUNA draws on the tenets of community organization and empowerment fueled by problem-posing education. The three components of the LUNA model are (1) education (e.g., classes and presentations, Spanish cancer information, health care navigation, community outreach), (2) support (e.g., peer to peer, home, hospital and phone visits, communications), and (3) social reintegration (e.g., celebration of life events such as birthdays, cancer camps, walks, and other social events), very similar to the start-up of the ALS Support group previously described.

Outcomes From LUNA

1. Campamento Alegria: The first-ever Spanish-language oncology camp for Latina cancer survivors. A biennial program designed to provide Latinas in whom cancer has been diagnosed a positive and unforgettable experience through a variety of activities that help sustain them through their cancer journey (Martinez et al., 2008). Campamento Alegria aims to serve 100 women, who would otherwise not have this opportunity to participate in such activities. There are no fees for the patients/survivors for a 3-day/2-night stay at the retreat facility, meals and related activities, orientation, and reunion meeting.

2. Community education and outreach: Attendance at various community events and health fairs to increase breast cancer screening awareness and provide cancer information and resources in Spanish.

3. Ongoing monthly educational support group meetings: Presentations and classes provided by Spanish-speaking health professionals on various survivorship issues and cancer-related topics.

4. Plans to develop a patient navigator program for Latina patients with newly diagnosed cancer.

The process for creating LUNA began with one nurse who, through dedication and dialogue with others in the same situation, began taking charge of the situation based on input from other community members. From both her nursing and personal experiences she knew how hard it was for Hispanic women in whom cancer has been diagnosed to navigate the health care system, how difficult it was to take time for self-care, and how challenging it was for Hispanic women to talk about their fears. She recognized that Latinas with breast cancer should reach out to each other with understanding and compassion in their own language to move toward self-education and self-actualization. Since its inception, LUNA has partnered with various community-based organizations, hospitals, academic centers, churches, and other social support services to create a strong web of support. For example, LUNA has a strong partnership with the Tampa Bay Community Cancer Network (TBCCN), a community network program, funded by the National Cancer Institute’s Center to Reduce Cancer Health Disparities, and local hospitals. Together they have worked with researchers to adapt a stress management program for Latinas undergoing chemotherapy. LUNA represents a ground-up effort, which got its start by addressing an unmet need of Hispanic breast cancer survivors. It serves as an excellent model and reminder for nurses, researchers, and community advocates that the best ideas come from the soul. For more information: hispanicbreastcancer.org/ (in Spanish).

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

Margaret Mead

Acknowledgments: Melba Martinez, RN, BSN, and Dinorah (Dina) Martinez, MA, MPH.


The nurse’s role in health education

Although learning theories and health education models provide a useful framework for planning health interventions, the nurse’s ability to facilitate the education process and become a partner with individuals and communities is key to the method’s application. At the core of health education is the therapeutic and healing relationship between the nurse and individuals, families, and the community. Simply put, nurses hold the process together and are catalysts for change in delivering humanistic care. Nurses activate ideas, offer appropriate interventions, identify resources, and facilitate group empowerment. Rankin and Stallings (2000) describe the following key characteristics of nurses in facilitating the teacher-learner process: confidence, competence, caring, and communication. It is beyond the scope of this chapter to describe multiple communication techniques in detail, but the reader is reminded about the value of establishing inclusion and trust before delivering the health education content

Clinical Example

Mr. Chen often visits the neighborhood senior center weekly to play cards and have lunch with several of his longtime friends. Once a month he takes part in the blood pressure clinic offered by the health department. The health department’s outreach services offers clinics in community-based centers, and an increased number of community members use this free service on an ongoing basis. Mr. Chen has limited resources, so the clinic provides him with valuable access to health information. On his first visit to the clinic, his blood pressure is 178/88 mm Hg. On his second visit, his reading is 188/94. He states that the city hospital has treated him for high blood pressure for more than 5 years, that doctors prescribed several medications 6 months earlier, and that he received some written materials to read (they were all in English). Although he reads somewhat in English, he tells the nurse that it would have been nice to see materials in his familiar language.

The nurse’s assessment reveals that Mr. Chen takes his medication only when he does not “feel so good.” He said his doctor advises him to take his medicines regularly, and he states that he takes them faithfully when he does not feel well. He tells the nurse that he remembers getting some booklets about his medications and “blood,” but he found them too long and tiring to read. The nurse’s educational assessment reveals that Mr. Chen has completed 8 years of schooling, does not read much, enjoys television over print, and prefers to learn from pictures or from other people in groups. He states that he likes to get his health information in English but would prefer to get some materials in Chinese. His low reading skills impact his ability to get health instructions in a meaningful way. He has taken the health instruction literally (e.g., he interprets “take regularly” to mean take consistently when “I don’t feel right” vs. take the pills on a regular schedule).

To facilitate learning, the nurse establishes a teaching plan with Mr. Chen’s input. This plan involves communicating health instructions in more relevant ways (e.g., using pictures, drawings, mnemonics, videotapes), providing some word cards for him in Chinese, and putting him in touch with county financial resources to assist in buying his medicines. The nurse also establishes a follow-up plan with a bilingual nurse to verify Mr. Chen’s understanding of how to take his meds by asking him to repeat back in his own words when/how he takes his meds (teach-back methods). She also plans to develop a series of health education group classes for the seniors about health and wellness, with high blood pressure being one of the topics of discussion.

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Aug 1, 2016 | Posted by in NURSING | Comments Off on 8. Community Health Education
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