Dr. Lancaster is the Medical Center Professor of Nursing at the University of Virginia. She has edited this book with Dr. Marcia Stanhope through its previous seven editions. Appreciation is extended to Professor Lisa Onega, Radford University and Assistant Professor Edie Devers Barbero, University of Virginia, who authored this chapter in the previous edition.

ADDITIONAL RESOURCES

Website

http://evolve.elsevier.com/Stanhope

• Healthy People 2020

• Answers to Practice Application

Appendix

• Appendix H: Focus on Quality and Safety Education for Nurses

Amajor goal of health care reform is to reduce costs, and one way to do so is to help people stay healthy and to reduce illness and disability. Nurses can play a key role in this aspect of health care reform by teaching individuals, families, groups, and communities how to promote better health. Nurses are ideal health care practitioners to lead in health promotion through health education since: (1) they educate clients across all three levels of prevention: primary, secondary, and tertiary (see Levels of Prevention box), and (2) they work with individuals, families, groups, and communities. The goal is to enable clients to attain optimal health, prevent health problems, identify and treat health problems early, and minimize disability. Education allows individuals to make knowledgeable health-related decisions, assume personal responsibility for their health, and cope effectively with alterations in their health and lifestyles.

LEVELS OF PREVENTION

Related to Community Health Education

Primary Prevention

Provide education at health fairs about diet, exercise, or environmental hazards.

Secondary Prevention

Provide both education and health screenings at health fairs for such health issues as early diagnosis and treatment of diabetes and hypercholesterolemia in order to shorten the duration and severity of the disease.

Tertiary Prevention

Provide education in rehabilitation centers to teach individuals who have been in an accident that left them with either an amputation or some paralysis ways to increase their functioning.

This chapter discusses ways to develop individual, group, and community health promotion programs. Specific content in the chapter includes information about how people learn, the sequence of actions that a nurse follows when developing an educational program, selected models of health promotion, and the important topic of literacy, especially health literacy. The role of groups in health promotion is also presented. Many of the objectives of Healthy People 2020 address the importance of health promotion, and selected objectives are cited in this chapter.

Healthy People 2020 Objectives For Health Education

As mentioned previously, the document Healthy People 2020 lists national health needs and outlines goals and objectives designed to improve health. The Healthy People 2020 educational objectives emphasize the importance of educating various populations (based on age and ethnicity) about health promotion activities in the priority areas of unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; and inadequate physical activity (USDHHS, 2010).

HEALTHY PEOPLE 2020

Selected examples of Healthy People 2020 are provided here.

•ECBP-2: Increase the proportion of elementary, middle, and senior high schools that provide comprehensive school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy, HIV/AIDS, and STDs; unhealthy dietary patterns; and inadequate physical activity.

•ECBP-3: Increase the proportion of college and university students who receive information from their institution on each of the priority health-risk behavior areas listed above.

•ECBP-8: Increase the proportion of worksites that offer a comprehensive employee health promotion program to their employees.

•ECBP-9: Increase the proportion of employees who participate in employer-sponsored health promotion activities.

•ECBP-11: Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs.

From U.S. Department of Health and Human Services: Healthy People 2020: understanding and improving health promotion and disease prevention objectives, Washington, DC, 2010, U.S. Government Printing Office.

In designing, implementing, and evaluating health education activities, it is useful to understand the primary health problems in the community as well as education principles related to both learning and teaching. Also, effective educational programs are built upon the premise that the best approach is to teach what people think they want to learn and in ways that facilitate their learning. For this reason, a core public health principle relates to asking the learners to participate in identifying their learning needs. Then health education programs are designed to meet the health need or problem in that population. Generally these programs involve educating individual members of the population about health promotion, illness prevention, and treatment. For example, in a community where childhood and adolescent asthma is a problem, a community-based asthma education and training program can be developed. If childhood obesity is a major health concern, a program to educate children in their schools about healthy eating, cooking, and exercise may be useful.

Education And Learning

When we think about helping people change their behavior, it is important to remember that people can most easily change their own level of knowledge. The next step is to help people change their attitudes, and the most difficult area to change is behavior. For this reason, nurses provide people with health information so they can improve their decision-making abilities and thereby decide if they will change their behavior. There is a difference between education and learning and between knowing and doing. Education is an activity “undertaken or initiated by one or more agents that is designed to effect changes in the knowledge, skill and attitudes of individuals, groups, or communities” (Knowles, Holton, and Swanson, 2005, p 10). Education emphasizes the provider of knowledge and skills. In contrast, learning emphasizes the recipient of knowledge and skills and the person(s) in whom a change is expected to occur. Remember that learning involves change.

How People Learn

People learn in a variety of ways. Many people learn best through active involvement in their learning, which contrasts with the belief that learners are like sponges who simply soak up the information that is presented. Learners accept information based on many factors including what they already know, what they believe, the culture in which they have been raised, as well as how well they can understand and relate to the information that they receive. What a person hears is filtered through his past experiences, the social groups to which he belongs, assumptions, values, level of attention and knowledge, and the esteem with which he holds the person communicating the information. In some cultures, elders are considered to be valued sources of information. In other cultures, people value individuals with more education than they have. Also, since social groups play a critical role in the development of understanding or learning, concepts related to groups will be discussed later in the chapter (Wilson and Peterson, 2006). Effective health education is a competency that is included in many documents that describe the role of public health professionals, including nurses. The Linking Content to Practice box illustrates the relationship between health education and selected standards, expectations, and competencies in public health.

LINKING CONTENT TO PRACTICE

Just as objectives in Healthy People 2020 recommend that health education and promotion be used to provide public health care, so do other key documents such as the American Nurses Association’s Scope & Standards of Practice: Public Health Nursing. Standard 5b, labeled “Health Education and Health Promotion,” says that the “public health nurse employs multiple strategies to promote health, prevent disease, and ensure a safe environment for populations,” (ANA, 2007, p 23). Similarly, the Core Competences for Public Health Professionals of the Council on Linkages Between Academia and Public Health Practice (2010) lists six competencies related to communication skills; five of them relate directly to this chapter. These competencies, listed below, are discussed and illustrated throughout the chapter:

1. Assesses the health literacy of populations served

2. Communicates in writing and orally, in person, and through electronic means, with linguistic and cultural proficiency

3. Solicits input from individuals and organizations

4. Uses a variety of approaches to disseminate public health information

5. Applies communication strategies in interactions with individuals and groups

A variety of educational principles can be used to guide the selection of health information for individuals, families, communities, and populations. Three of the most useful categories of educational principles include those associated with the nature of learning, the educational process, and the skills of effective educators.

The Nature of Learning

One way to think about the nature of learning is to examine the cognitive (thinking), affective (feeling), and psychomotor (acting) domains of learning. Each domain has specific behavioral components that form a hierarchy of steps, or levels. Each level builds on the previous one. Understanding these three learning domains is crucial in providing effective health education (Bloom et al, 1956). First, consider assumptions about how adults learn. Specifically, adults are motivated to learn when: (1) they think they need to know something, (2) the new information is compatible with their prior life experiences, (3) they value the person(s) providing the information, and (4) they believe they can make any necessary changes that are implied by the new information (Knowles, Holton, and Swanson, 2005).

Cognitive Domain

The cognitive domain includes memory, recognition, understanding, reasoning, application, and problem solving and is divided into a hierarchical classification of behaviors. Learners master each level of cognition in order of difficulty (Bloom et al, 1956; Dembo, 1994). Start by assessing the cognitive abilities of the learners. This is especially important when learners have a limited level of literacy either of the language used in the instruction or of the content that is presented. A later section will talk both about literacy in general and health literacy in particular. Teaching above or below a person’s level of understanding can lead to frustration and discouragement. It is therefore important to be sensitive to the value of the cognitive domain in learning. The cognitive domain consists of these components (Bloom et al, 1956):

1. Knowledge: requires recall of information

2. Comprehension: combines recall with understanding

3. Application: new information taken in and used in a different way

4. Analysis: breaks communication down into parts in order to understand both the parts and their relationships to one another

5. Synthesis: builds on the first four levels by assembling them into a new whole

6. Evaluation: learners judge the value of what has been learned

Affective Domain

The affective domain includes changes in attitudes and the development of values. For affective learning to take place, nurses consider and attempt to influence what learners feel, think, and value. Because the attitudes and values of nurses may differ from those of their clients, it is important to listen carefully to detect clues to feelings that learners have that may influence learning. It is difficult to change deeply rooted attitudes, beliefs, interests, and values. To make such changes, people need support and encouragement from those around them. Affective learning, like cognitive learning, consists of a series of steps that the learner takes:

1. Knowledge: receives the information

2. Comprehension: responds to the information received

3. Application: values the information

4. Analysis: makes sense of the information

5. Synthesis: organizes the information

6. Evaluation: adopts behaviors consistent with new values

Psychomotor Domain

The psychomotor domain includes the performance of skills that require some degree of neuromuscular coordination and emphasizes motor skills (Bloom et al, 1956). Clients are taught a variety of psychomotor skills including bathing infants, changing dressings, giving injections, measuring blood glucose levels, taking blood pressures, walking with crutches, as well as many skills related to health promotion exercises.

In teaching a skill, first show clients how to do the skill, whether through pictures, a model, or a device, or via a live demonstration, video, CD, or the Internet. Next, allow clients to practice, which is a repeat demonstration approach to validate that what was being taught was actually learned. Also, if the teaching is being done in a class, participants may learn by observing one another master a task. Psychomotor learning is dependent on learners meeting the following three conditions (Bloom et al, 1956; Dembo, 1994):

• The learner must have the necessary ability. This will include both cognitive and psychomotor ability. For example, you may find that a person with Alzheimer’s disease can follow only one-step instructions. Thus, you need to tailor your education plan to that person.

• The learner must have a sensory image of how to carry out the skill. For example, when teaching a group of women how to cook in a more heart-healthy manner, ask the women to describe their kitchen and how they would actually go about the cooking process.

• The learner must have opportunities to practice the new skills. Provide practice sessions during the program to help the client adapt the skill to the home or work environment where the skill will be performed.

In assessing a client’s ability to learn a skill, be sure to evaluate intellectual, emotional, and physical ability, and then teach at the level of the learner’s ability. Some clients do not have the intellectual ability to learn the steps that make up a complex procedure. Others may have cultural beliefs that conflict with healthy behaviors. Another client may be a tremulous person and have poor eyesight, making him incapable of learning insulin self-injection.

The Educational Process

The educational process builds on an understanding of education, learning and how people learn. The five steps of the educational process (identify educational needs, establish educational goals and objectives, select appropriate educational methods, implement the educational plan, and evaluate the educational process) are discussed next.

Identify Educational Needs

To learn about the health education needs of clients, begin by conducting a systematic and thorough needs assessment (Bartholomew et al, 2000). The steps of such an assessment are listed in Box 16-1. Once needs have been identified, they are prioritized. The goal of the prioritization is to meet the most critical educational needs first (Wolf, 2001).

BOX 16-1

STEPS OF A NEEDS ASSESSMENT

1. Identify what the client wants to know. (Consider Healthy People 2020 educational objectives.)

2. Collect data systematically to obtain information about learning needs, readiness to learn, and barriers to learning.

3. Analyze assessment data that have been collected and identify cognitive, affective, and psychomotor learning needs.

4. Think about what will increase the client’s ability and motivation to learn.

5. Assist the client to prioritize learning needs.

As has been discussed, many factors influence a person’s learning needs and the ability to learn. These factors include demographic, physical, geographic, economic, psychological, social, and spiritual characteristics of the learners (Bartholomew et al, 2000). It is also important to consider the learner’s knowledge, skills, and his or her motivation to learn, as well as what resources are available to support and possibly prevent learning. Resources include printed, audio or visual materials, equipment, agencies, and other individuals. Barriers for the presenter include lack of time, skill and/or confidence, money, space, energy, and organizational support.

NURSING TIP

Consider the target audience carefully when developing a community health education project. Determine educational needs, educational and literacy levels, cultural backgrounds, and health beliefs. Consider also your skills and the type of program or project you can most effectively deliver.

Establish Educational Goals and Objectives

Goals and objectives to guide the educational program are identified once you identify the learners’ needs. Goals are broad, long-term expected outcomes such as, “Each child in the third-grade class will participate in 30 minutes of daily physical exercise, 4 days per week for 2 months.” Your program goals should deal directly with the clients’ overall learning needs. In regard to the third graders, their learning need is to know how important exercise is to their health and level of fitness.

Objectives are specific, short-term criteria that need to be met as steps toward achieving the long-term goal such as, “Within 2 weeks, each of the children will be able to demonstrate at least two exercises that they have learned.” Objectives are written statements of an intended outcome or expected change in behavior and should define the minimum degree of knowledge or ability needed by a client. Objectives must be stated clearly and defined in measurable terms, and they typically imply an action (Knowles, Holton, and Swanson, 2005).

Select Appropriate Educational Methods

Educational methods should be chosen to facilitate the efficient and successful accomplishment of program goals and objectives. The methods should also be appropriately matched to the client’s strengths and needs as well as those of the presenter. Choose the simplest, clearest, and most succinct manner of presentation and avoid complex program designs. Try to vary the methods in order to hold the attention of the learners and to meet the needs of different learners. Some people learn best by being actively involved in the program. Others learn by a more solitary approach such as watching a video and reflecting on how he or she might apply the content to his health situation. A few examples of strategies that may be used to enhance learning are listed in Box 16-2.

BOX 16-2

STRATEGIES TO ENHANCE LEARNING

• Audiovisual materials including videos, CDs, DVDs, personal digital assistants or the Internet

• Group participation

• Guest speakers

• Peer presentations, counseling, and tutoring

• Printed materials

• Role plays

• Simulation

Educators also need to be able to deliver presentations, lead group discussions, organize role plays, provide feedback to learners, share case studies, use media and materials, and, where indicated, administer examinations. You will want to think about what content to include, how to organize and sequence the information, what your rate of delivery will be, whether or not you need to include repetition, how much practice time should be included, how you will evaluate the effectiveness of the teaching, and ways that you can provide reinforcement and rewards (Knowles, Holton, and Swanson, 2005) (Box 16-3).

BOX 16-3

HOW TO EFFECTIVELY TEACH CLIENTS

Use the TEACH mnemonic:

Tune in. Listen before you start teaching. Client’s needs should direct the content.

Edit information. Teach necessary information first. Be specific.

Act on each teaching moment. Teach whenever possible. Develop a good relationship.

Clarify often. Make sure your assumptions are correct. Seek feedback.

Honor the client as a partner. Build on the client’s experience. Share responsibility with the client.

Modified from Hansen M, Fisher J: Patient-centered teaching from theory to practice, Am J Nurs 98:56-60, 1998.

When choosing educational methods, consider age, gender, culture, developmental disabilities or special learning needs, educational level, knowledge of the subject, and size of the group. For example, clients with a visual impairment need more verbal description than those with no impairment in sight. Persons who have hearing impairments or language deficits need more visual material and speakers or translators who can use sign language or speak their native language. Also, when the learners have limitations in attention and concentration, the educator will need to use creative methods and tools to keep them focused. For example, you might include frequent breaks; simple surroundings with few or no distractions; use of small-group interactions to keep learners involved and interested; and the use of hands-on equipment such as mannequins, models, interactive games, and other materials and devices that the learner can physically manipulate. Try to involve the learner appropriately, actively, and creatively in learning. Interactive educational programs may be more effective than non-interactive ones. Interactive strategies include discussion, small group work, games, and role playing, whereas non-interactive strategies are lectures, videos, or demonstrations. Box 16-4 details descriptions of learning formats.

BOX 16-4

EXAMPLES OF LEARNING FORMATS

Presentation: This method can be used when the group is large and you want to be consistent in the message that is delivered to all participants. Remember, people tend to have a short attention span, so what can you do to keep them engaged? You might ask them to spend some time talking with one another in small groups and then have the group respond to questions or ask attendees to write answers to questions and invite several to share their answers.

Demonstration: This technique is often used to show attendees how to perform a task. For example, insulin injection demonstration, heart-healthy food preparation, and breastfeeding may be demonstrated.

Small Informal Group: Since learners often learn as much from one another as from the instructor, small groups can be valuable. This is especially true when the content lends itself to members sharing their own experiences. For example, in working with women in a shelter for abused women, participants may be able to share with one another actions they took to remove themselves safely from the violent environment. They might also be able to jointly plan how each might move to the stage of independent living outside the shelter.

Health Fair: See the How To box below on ways to plan, implement, and evaluate a health fair. For example, you might offer a health fair in a Senior Center and have displays such as posters; videos; live demonstrations; handouts on such topics as reducing fat in selected recipes (including samples) and age-appropriate exercises for flexibility; as well as screenings for elevated blood pressure, glucose, or cholesterol or for osteoporosis and vision.

Non-native Language Sessions: You could adapt the health fair approach for a Hispanic group by holding the session in Spanish and providing all of the materials in Spanish. Then ask Spanish-speaking nurses to staff each of the stations for health learning.

The goal of nurses who use Healthy People 2020 as a guide in educating clients is to foster healthy communities mainly through primary and secondary prevention. Health fairs are a popular way to provide primary and secondary health education. The objectives of holding health fairs are to increase awareness by providing health screenings, activities, information and educational materials, and demonstrations. A health fair can target a specific population or focus on a specific health issue, as well as target a range of groups and cover a variety of health education and health promotion topics. The fair can be held in many locations and can be either inside or outside. The How To box lists guidelines to assist nurses who chair, co-chair, or serve on a planning committee for a health fair.

HOW TO

Plan, Implement, and Evaluate a Health Fair

1. Form a planning committee: 2-12 people who represent the groups who will be part of the health fair. Possibilities: health professionals, representatives from health agencies, schools, churches, employers, the media, and the target audience.

2. Identify the target group. Develop a theme.

3. Establish goals, expected outcomes, and screening activities consistent with the needs and wishes of the target group. Your primary goal might be to improve the health of a specific population such as workers at one plant or children in one school. You might have secondary goals such as for the workers to reduce health care costs and for the children to reduce absenteeism.

4. Develop a timeline and schedule.

5. Choose a site and consider the site logistics: Do this about 1 year ahead. Think about the size of the site you will need and the traffic flow from one booth or demonstration to another, whether parking is available and free or low cost, and whether there are toilets and places to get food and drinks. If the site is inside, consider adequate exits; the possible risks to children, the elderly, or handicapped people; and other safety and security issues. You may need to create a map both for how to get to the fair and another one to help attendees get from one table, exhibit, or screening station to another. Be sure to include on the map the location of amenities like toilets and food vendors.

6. Plan for supplies that you will need: tables, chairs, electronic equipment, and accessories such as extension cords, office supplies, sign-in sheets (and what information should be included), release forms for screenings, name tags, bags for attendees to gather the educational information, and evaluation forms. Set your budget. Obtain these supplies in advance.

7. Recruit and manage exhibitors: Do this about 4 months ahead. Develop a list of possible exhibitors, sponsors, and contact them via letter, fax, e-mail, telephone, or in person. Follow up with a confirmation letter (or fax) that outlines the details of the health fair.

8. Publicize the health fair: the planning committee will have many good ideas about how to publicize in the specific community. Examples might be: fliers/posters, memos, brochures, e-mail blasts, local print, or radio/television.

9. On the day of the fair: greet health care professionals, agency representatives, sponsors, and members of the population being served.

10. Evaluate the health fair: by exhibitors, participants and volunteers. You will need a specific form for each of these groups.

11. Between 1 week and 1 month after the fair: send thank-you letters to health care professionals, sponsors, and agencies, and pay bills associated with the fair.

From Rice CA, Pollard JM: Health fair planning guide, AgriLIFE EXTENSION Texas A&M System, September 16, 2009. Available at http://fcs.tamu.edu/health/health_fair_planning_guide/index.php. Accessed January 22, 2011; United HealthCare: Health fair planning guide: wellness toolkit, 2005. Available at www.uhctool.com. Accessed January 27, 2010.

Skills of the Effective Educator

The educator needs to understand the basic sequence of instruction. The following nine steps are useful in planning an educational program (Driscoll, 2005; Knowles, Holton, and Swanson, 1998):

1. Gain attention. Begin by gaining the learner’s attention and helping the learner believe that the information being presented is important and beneficial to him.

2. Inform the learner of the objectives of instruction. Discuss the major goals and objectives of the instruction so learners can develop expectations about what they are supposed to learn.

3. Stimulate recall of prior learning. Ask learners to recall previous knowledge related to the topic of interest. This assists them to link new knowledge with prior knowledge.

4. Present the material. Present the essential elements of the topic in a clear, organized, and simple manner and in a way congruent with the learner’s strengths, needs, and limitations.

5. Provide learning guidance. Help the learner store information in long-term memory. You can help the learner transform general information that has been presented into meaningful information for that specific learner to facilitate later recall. You can do this by providing ways in which the learner can apply the information to his or her life and situation.

6. Elicit performance. Encourage learners to demonstrate what they have learned. This will help you correct any errors and improve skills.

7. Provide feedback. Provide feedback to help learners improve their knowledge and skills. They can then modify their thinking patterns and behaviors on the basis of the feedback.

8. Assess performance. Evaluate the learning by assessing if the knowledge has been gained and if the skills can be performed.

9. Enhance retention and transfer of knowledge. Once a baseline level of knowledge and skills is reached, help learners apply this information to new situations.

By using these steps, nurses may help clients to maximize learning experiences. If steps of this process are omitted, superficial and fragmented learning may occur. The Did You Know box includes principles to guide the educator through these steps. The next phase of the educational process is to design, deliver, and evaluate a program tailored to the needs of the learners.

DID YOU KNOW?

Six Principles that Guide the Educator

1. Message: Send a clear message to the learners

2. Format: Select the best learning format for the learners

3. Environment: Create a positive learning environment

4. Experience: Organize positive and meaningful learning experiences

5. Participation: Engage learners in their learning

6. Evaluation: Evaluate and give clear and objective feedback to learners

Developing Effective Health Education Programs

The program should include a clear message conveyed in a format appropriate to the learners and in an environment that is free from distractions and consistent with the message. In regard to the message, it is important to remember that emotions such as anxiety, stress, anger, or fear can interfere with the listener actually hearing the message being sent. Also, provide information that is understandable to the listener. Use plain language and avoid jargon and complex medical terms. Use words that the listener will know and recognize. For example, some people are more familiar with terms like high blood pressure and high blood sugar levels rather than hypertension and increased glucose levels. On the other hand, be careful not to oversimplify your terms if your audience is knowledgeable about health care. You want to avoid “talking down” or “over the head” of your listeners.

The type of learning format that you select will depend on the learners. If they are young, you will want an interactive format and many of your options will include the use of technology. You could use a game such as developing a bingo game with food groups to teach about healthy eating. The old adage “A picture is worth a 1000 words” still holds true. People tend to remember what they see or hear; a lively format rather than a passive one encourages learning. Most people have a short attention span, so you need to make your point quickly and directly. It may help to provide take home written materials or a CD for further reminders and follow-up of what is taught. Since people often learn better when they are actively engaged in the learning, having small group discussion, role playing, and question-and-answer sessions may reinforce learning. Figure 16-1 shows a community group being educated, and Box 16-5 lists ways to design clear educational programs.

HOW TO

Develop Print Materials