Education for health

CHAPTER 7 Education for health

In Chapter 7 we move along the continuum of health promotion approaches outlined in Chapter 1 and begin to examine the behavioural approaches to health promotion. There is a range of behaviour change approaches, including education strategies, which will be the focus of this chapter. The importance of these strategies is recognised in the UN Declaration of Human Rights and the WHO Primary Health Care Declaration of Alma-Ata; they fit well with the Ottawa Charter for Health Promotion’s action area of developing personal skills.

Education plays a central role in health promotion. Not only is education itself a common health promotion strategy, but working for public policy change, community development, using the mass media, and working with individuals and groups, all involve education in some form or another — whether it be education of policy-makers, health workers or community members. Education is therefore inextricably linked with all other forms of health promotion. This chapter reviews some of the principles of education for health and considers the particular approaches to education that sit most comfortably with the Primary Health Care approach.


Some theorists use the terms ‘health promotion’ and ‘health education’ interchangeably. As our continuum of health promotion practice illustrates, health education is one approach embedded in the broad discipline of health promotion.

Health education has been defined as ‘. . . any combination of learning experiences designed to facilitate voluntary actions conducive to health’ (Green & Kreuter 1999). There are two important elements in this definition. The first is that health education entails much more than the formal ‘teaching’ sessions that we may traditionally expect to undertake in this role. This point is emphasised by Bedworth and Bedworth (1992: 7) in their definition of health education:

The second important point in Green & Kreuter’s (1999) definition (cited earlier) is that the focus of health education must be on skills enhancement to facilitate informed decision-making about health. Health education is not a matter of ‘telling’ people what they ‘need to know’. Health education opportunities can arise on unexpected and serendipitous occasions, as well as in more planned and structured sessions. All health workers have an important role to play in enhancing knowledge and in assisting people to make informed decisions about their health-promoting activities. It is essential that health workers have the ability to competently assess educational needs and to be able to enhance learning in the most appropriate manner for individuals, groups and communities.

This chapter allows health workers to explore the teaching and learning role in a variety of health-related settings and campaigns. To enhance understanding, analysis and wider application of health education approaches, health workers should become familiar with core concepts and some selected educational models widely applicable in health education practice.


In recent times there has been criticism of the use of health education approaches, particularly when they are conducted instead of, or at the expense of, social and structural changes. These issues are dealt with briefly below. However, there are important reasons why health education still forms an essential component of the health promotion workers’ ‘toolkit’, and these relate to the concept of health literacy.

Health literacy

Recent research ‘has found that individuals’ health-related decisions and actions are strongly associated with their level of education and literacy skills’ (ABS 2006a). The Australian government has recently taken part in an international health literacy survey, using 91 items to assess people’s knowledge of how to undertake health-related activities about health promotion, health protection, disease prevention, health care maintenance, and their ability to navigate health information sources (ABS 2006b).

The survey adopted the following definition of health literacy which draws on the range of literacy skills an individual may have and their ability to use them in practical ways in a range of settings, including the internet, community and complementary health settings, and also the traditional medical care agencies. Health literacy is:

Results indicated that health literacy is a social determinant of health. The most vulnerable members of Australian society in terms of educational attainment, labour force participation and skill level, parental education, social or geographic isolation, and cultural minority status also had the lowest health literacy. The results are comparable to those from Canada (ABS 2006b).

Enhancing health literacy for community members is an important health promotion tool firstly because health knowledge is in itself empowering; health outcomes are influenced by a person’s ability to use a wide range of health-related materials (Kickbusch 2001). Knowledge about health is a basic human right. People have the right to accurate information about issues that affect their health, in a form that is accessible and appropriate to their learning needs. Without knowledge people cannot make decisions about their own lifestyles or be equipped for political or social lobbying to change things for society generally. The second reason is that health education can enable people to make changes in their activities to reduce the risks to their health. In this way, some of the morbidity that is associated with chronic illnesses that affect many people later in life, such as heart and lung diseases, can be reduced. This has clear personal health benefits and economic benefits for the whole population in terms of reduced expenditure on medical care and pharmaceuticals.

Thus, the purposes of health education are to promote the presence of conditions that assist people in creating health-enhancing conditions for personal and community health. It is useful to think of health education as a function of health literacy.


Education for critical consciousness

The concept of education for critical consciousness, critical consciousness-raising, or conscientisation was developed in its original form by Freire (1974), although similar ways of working have also been developed by others. For example, the consciousness-raising techniques of the women’s movement have much in common with Freire’s education process. This approach to education offers a great deal to Primary Health Care because of the focus on working with people and because it provides a framework for action in dealing with the root causes of problems as recognised by people themselves. It provides an important link between the lives and experiences of individuals and change at a structural level.

Freire (1974: 13) criticised traditional notions of education for amounting to cultural invasion, as representatives of powerful groups impose their view of the ‘facts’ on less powerful members of society. He argued that education is never neutral because it in some way either confirms or challenges the status quo. On the basis of this premise, he argued for education that challenges the status quo and thus enables the empowerment of oppressed members of society and the development of a more just social system. Education for critical consciousness focuses on changing the environment rather than the individual alone, by working with people to examine the underlying issues behind their problems and to change the structures around them.

Freire (1968, cited by Minkler & Cox 1980: 312) argued that social change can only be achieved by the active participation of the people as a whole — it cannot be achieved by strong leaders alone. Therefore, action for change must be built on critical reflection and action by everyone concerned. This process of critical reflection and action is described by Freire as ‘dialogue’, a two-way process occurring between ‘teachers’ and ‘learners’, in which both are teacher–learners. Education for critical consciousness is a process of problem-posing that leads people through analysis of their personal situation, and then of the underlying social issues, to making a plan for action to address the issues they have discovered. The four steps involved in the process are:

Before such a process can occur, however, health workers need to listen carefully to the needs articulated by community members and take the time to understand their problems as they see them (Wallerstein & Bernstein 1988: 382). They also need to observe the dynamics of the groups and individuals concerned to determine what sense of belonging or community exists. Some sense of community or group belonging seems to be important for the conscientisation process to work effectively (Minkler & Cox 1980: 320). It is for this reason that education for critical consciousness often goes hand in hand with community development.

Education for critical consciousness as described by Freire may not fit every learning situation that arises. However, the principles of problem-posing, two-way communication and sensitivity to people can be used in any learning situation, so that it becomes an enabling process for the people involved. Friere’s guidelines are congruent with adult learning principles presented later in this chapter. The following general guidelines for empowering health education give some indication of how this can occur.

Health education planning frameworks

By now you will be familiar with the continuum of health promotion approaches, first presented in Chapter 1. Other chapters in this text present approaches to health promotion, according to the particular focus of the activity. Community development and health policy approaches are most appropriate to address the social determinants of health, because they are most likely to lead to sustainable changes in the social context of people’s lives. However, as we have argued above, there are times when a different focus is necessary and the aim of the health worker becomes one of enhancing the health literacy of individuals and groups. When planning health education strategies for individuals and groups it is useful to ‘map’ the activity, to ensure it meets the educational needs of the group, and that it enables them to make informed decisions affecting their health.

A clear understanding of the educational purpose is essential if we are to be effective in educating for health. A number of conceptual models have been used in order to understand the characteristics of the participants in an education program, to involve them in planning and to enhance planning of activities that meet their educational needs. A conceptual model can be defined as ‘a diagram of proposed causal linkages among a set of concepts believed to be related to a particular health problem’ (Earp & Ennett 1991: 164). In a model the concepts or factors of influence are denoted by bordered shapes, such as boxes, and the processes or relations between the concepts are delineated by arrows. Arrows are used to indicate the direction and strength of the relations between concepts. In this way a model presents a visual image of the reasoned explanation of a hypothesis about a series of abstract principles — a theory. Models are based on theories.

The Health Belief Model is one health educational planning model (see Figure 7.1). While the Health Belief Model has been presented in some detail here, because it is widely used and has been extensively validated, it is by no means the only useful model for health education planning. A number of other planning models are widely used in health behaviour approaches, such as the Transtheoretical (Stages of Change) Model (Prochaska & DiClimente 1984) and the Theory of Reasoned Action and Planned Behaviour (Ajzen & Fishbein 1980). Nutbeam and Harris (2004) and Naidoo & Wills (2000) both provide very useful overviews of a range of commonly used planning models.

The Health Belief Model is based on social learning theory (Nutbeam & Harris 2004) and was developed to provide a framework for explaining why some people take action to avoid a specific illness or condition and others do not. The model can be used to suggest interventions that would make some individuals more likely to engage in health protective behaviours. The Health Belief Model is useful when planning health protective activities for particular groups in relation to a specific condition (Becker et al 1974), because it guides the health educator to consider the social context of people’s health behaviours. It is not designed for use in social change movements or community development approaches. Nutbeam and Harris (2004: xii) caution that ‘unless behavioural theories are put into the broader context in which the individual is living, many factors that influence health will remain unexplained’ or un-addressed. This is an important point to consider when choosing which model best applies in health education planning.

The Health Belief Model predicts that an individual is likely to take action based on the interaction between four conceptual areas. Refer to the Figure 7.1 as you read the description.

1. The individual’s perceptions about the seriousness of a given condition. Perceived susceptibility is a person’s estimate of their probability of encountering the health condition. This estimate is dependent on their knowledge, and thus it is an important function of health education to provide accessible, reliable information as required.

2. The individual’s perceptions about the severity of the condition. Perceived seriousness relates to the difficulties that individuals believe a given health condition would create. These difficulties may include the implications for work, family and social life, so the emotional response of an individual to a condition is significant here. It is only when the perceived seriousness is manageable — neither too low to be insignificant, nor too challenging or frightening to contemplate — that a person can consider a change in behaviour. Thus, launching into a health education message when a person is overwhelmed by other issues and needs support is not only unethical but also ineffective.

3. The individual’s perceptions about the benefits of taking action to avoid or detect the condition. The perceived benefits of recommended preventive actions are important determinants of health protective behaviours. For example, women who believe Pap smears can detect cancer early, and this results in a good prognosis, are more likely to take part in screening.

4. Perceived barriers may be personal — such as the embarrassment or unpleasantness of having the procedure — or they may be social — such as cost, inconvenience or the frequency of the desired behaviours that are required, and the extent of life changes. These barriers give important guidelines for health workers on planning their sessions according to the needs and characteristics of their audience.

People weigh up the benefits of the action against their perceptions about the barriers to them taking action to avoid the condition. Perceived barriers may also provoke anxiety for the person, which prevents objective analysis of the choice of action. Hence, it is important to always provide an ‘action-plan’ when giving a health education message (Leventhal et al 1984).

The Health Belief Model predicts that people’s perceptions in these four areas are influenced by a range of modifying factors — internal factors, such as personality, and external factors, especially socio-demographic and cultural factors. For example, women are predisposed to prevention more than men; peer groups can force conformity. Some factors such as age, sex, income, education and health literacy have been correlated with health service use. To a lesser extent perceptions about particular health conditions, and undertaking the desired activity are also influenced by a number of internal and external cues. It may be that an internal cue, such as a physical discomfort, or a feeling of discomfort when a person thinks about a threat to their health, triggers them to act. It may also be that an external cue, such as mass media, advice from others or the illness of another person, triggers the activity. The cues to action make the person aware of their own feelings about the health behaviour. It is not clear how strong the trigger needs to be or the specific timing. A good example of the use of cues is the use of roadside billboards by the Transport Accident Commission (TAC) with graphic images of car accidents used to prompt drivers to act safely. When all these influences on health action are taken into account and understood about the participant group it is then possible to make assumptions about their likelihood of engaging in preventive action. Of course, health education alone may not be sufficient to overcome the barriers to change for some people. Issues such as addictions and social, economic, environmental and psychological barriers may be understood by using the model, but they may not be able to be altered to a sufficient degree to enable the person to change their behaviour.

The conceptual areas encompassed in a planning model such as this can assist health education planners to understand the needs and characteristics of their audience or learning community. When community members and the wisdom of experience from the literature are used to guide the development of educational content it will be an empowering outcome.


In the past, the role of the health educator was to give (tell) people information so they would comply with the instructions from an expert. This can be represented by a simple linear diagram:


It is clear that the assumptions inherent in this diagram fail to encompass the complexity of what is required to adopt a new health behaviour. Is there accurate or inaccurate information about the risks to health? What factors influence the value a person places on the desired change — peer or social pressure, media? What factors enhance or inhibit the desire for change — costs, family social circumstance?

The health educator’s role is to generate competence and health literacy and to assist people to access and apply their knowledge under changing conditions. There is now an added focus on what happens inside the ‘learner’, rather than what the ‘teacher’ does. Learners are no longer expected to be passive recipients of information delivered by experts. They have an active role in the teaching–learning process.

The teaching—learning process

Leddy and Pepper describe three key assumptions that should underpin effective teaching–learning (1989: 317–33):

These principles demonstrate the importance of a partnership approach to working with community members. Both the community member (or members), and the health worker contribute to the discovery of potential solutions in a supportive atmosphere in which learners are allowed the dignity of risk and assume responsibility for decisions they make (Ewles & Simnett 1999: 174–6). In such an approach, education is a guided problem-solving process in which both ‘teacher’ and ‘learner’ are open to learning from each other. It is worthwhile considering briefly the two major philosophical approaches to education that continue to underpin the way health education practitioners undertake their role.

Facilitating the teaching—learning process

Adult learning principles

Several principles guide effective teaching–learning and build on the philosophical base of the teaching–learning process described above. They provide some general guidelines that can be applied to any teaching–learning situation:

Each will be explored briefly in the following section.

Allow people to direct the learning process

Active participation of community members in the education process is paramount to successful education. Involve the learners in planning, carrying out and evaluating their own learning (Knowles 1980). Participation to the point of control over the education process fits comfortably with the Primary Health Care approach. People will learn most effectively when the learning opportunities address the questions raised by them and when they can decide on the learning processes they would prefer. This principle was originally thought to apply only to adult learners, but there is growing recognition that it is just as relevant to child learners (Kalnins et al 1992).

Individual or group-controlled learning is most likely to occur if people themselves set the goals of learning. Helping people clarify just what it is they want to learn is therefore an important part of the education process. Active participation can also be encouraged by maximising interactive teaching techniques and activities, rather than taking an ‘empty vessel’ approach and ‘filling’ passive recipients with information. People need to be able to have their say, use their initiative, experiment and find out what works for them. Structuring education so that these things are possible is therefore another priority for health workers who are eager to facilitate learning. Which interactive techniques and activities are appropriate will vary depending on the situation, the people involved, and on whether it is education for individual change or education for social change. Commonly used interactive activities include debating contentious issues, using structured group activities, planning action to address a problem and practising the action required (whether that be drafting a letter to a local councillor, role-playing the negotiation between work colleagues about smoking in the workplace, or preparing a low-fat meal). It is important to point out, though, that interactive techniques do not by themselves ensure interactive learning, nor is interactive learning precluded by the use of what are traditionally regarded as non-interactive techniques, such as lectures. Rather, it is how teaching techniques are used that ultimately determines the extent and success of interactive learning. Once again, emphasis should focus on how the health worker and learners use the teaching techniques, rather than solely on which techniques are used.

Facilitating adult learning

When working with any audience, including adult learners, it is important to value and respect the wisdom that participants bring to the learning environment. In addition, we must recognise that many learners are challenged and unnerved by being placed in a learning setting, especially if they are made to feel inferior. The following points provide guidance as to how the facilitator can manage the environment positively.


Learning theories can help us to interpret the learners’ behaviours, and help us assist learners overcome learning barriers (Kiger 2004). In this chapter so far we have emphasised two important considerations when planning health education: firstly to consider the social context of the learner and the factors that impinge upon them adopting healthy behaviours, and secondly that adopting that behaviour is much more complicated than merely being told to do it by an expert. The Health Belief Model, presented earlier in the chapter, is one model that can be used to understand the learner’s needs in their social context. Once the learner’s current perceptions and factors influencing the likelihood to take action are understood, these can be used as a guide for what educational strategies can be used. Accurate information, as a component of health literacy, is the basis on which a person develops their likelihood to take health-enhancing action. Positive perceptions about taking that action are heavily influenced by interpersonal factors and social cues, such as the advice or behaviour of others or the media. Educational approaches need to acknowledge the importance of these influences and assist the learners to negotiate their way through these challenges. Adopting different health behaviour frequently requires new personal or physical competencies. Learning of facts does not necessarily alter behaviour. Personal attitudes and values about the health issue and knowing you can do it, have the greatest influence on eventual health behaviour.

Domains of learning

Learning a new concept or skill may involve moving through progressive levels of understanding. Bloom (1964) developed a ‘taxonomy of educational objectives’. A taxonomy is a system of classification. Bloom argued that learning can be classified into three domains (cognitive, affective and psychomotor) according to the type of learning that is taking place. Each domain is further categorised according to the level or complexity of the concept that is being learned, progressing from the simple to the most complex. Classifying learning processes into these three domains serves to strengthen the understanding of the learning processes which are still relevant in a range of settings (Kiger 2004). The domains can be used as a framework for writing learning objectives, based on the adult learning principles presented earlier. As argued there, it is not appropriate to develop separate activities for learning knowledge (cognitive), attitudes (affective) and behaviour (psychomotor), because the concepts are interwoven. The domains are presented here in the sequence set out above as a simple linear statement. However they could just as easily represent learning by being presented in the opposite order.


Each domain is related to a holistic process and to the individual needs and developmental tasks. It is clear that if one uses the Health Belief Model as a basis for planning health education activities, that each of the three domains is relevant to facilitating participant learning.

Cognitive domain

The cognitive domain describes learning which relates to the recall and recognition of knowledge and the development of intellectual abilities. This is a hierarchical domain, in that each level of learning becomes more complex and builds on the learning processes of the prior level (Bloom 1964). The hierarchical arrangement with illustrative examples is set out in Box 7.1.

Apr 17, 2017 | Posted by in NURSING | Comments Off on Education for health
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