ERIC EJ792821: Health Education and Behavior: Are School Health Educators in Denial?

2005·0.12 MB·English

by  ERIC

Health Education and Behavior:
Are School Health Educators in Denial?
Joseph F. Governali, Bonni C. Hodges, and Donna M. Videto
ABSTRACT
School health education has been and still is guided by a number of different and often competing philosophical
orientations. The field seems to be moving toward a skills-based philosophy, but the adoption of this approach is
taking place with little discussion or analysis in the professional health education literature. The purpose of this
article is to propose an integrated behavioral alternative to the present skills-based trend and to encourage the
health education profession to examine school health education philosophy critically. The nature and scope of the
educational reform that is sweeping the country makes the need for a critical examination of school health educa-
tion philosophy, with accompanying dialog about goals and purposes, crucial to the growth and viability of school
health education.
“…it is suggested that health education be concerned with cognitive development while leaving attitudinal
development and behaviors to other institutions in our society.”1
“Although in the long run health education must contribute to people’s health…its specific goal is to im-
prove people’s health behaviour and the measure of effectiveness is to be sought in changes of behaviour…”2
“I propose that health education be considered a process in which the goal is to free people so that they may
make health-related decisions based upon their needs and interests as long as these decisions do not ad-
versely affect others.”3
“Health literacy requires educators to switch from a content-driven to a skills-driven approach. Young people
need to learn, practice and apply skills successfully, numerous times, with positive reinforcement and social
support to maintain personal health and safety.”4
“The role of the health educator is to motivate students to put into practice what is learned in class, while at
the same time teaching moral responsibility, conscience, and self-discipline.”5
“…we should be including not only self-help/self-care, but also the promotion of a healthful environment, a
safer work place, a caring medical care system; the promotion of public participation; the development of
healthful public policy, a community approach to health status improvement, a caring and sharing philoso-
phy, and not a focus that is overly reliant on individual effort.”6
INTRODUCTION vibrant, and evolving profession. Others
In the course of its history, health edu- might argue that this situation is a sign of Joseph F. Governali, PhD, is professor, Health
cation has operated under a number of dif- confusion, an indicator of unclear focus, or Department, Moffett Center, State University
ferent and often competing philosophical a complete absence of consensus on pur- of New York College at Cortland, Cortland, New
positions. The present situation is a micro- pose. In 1995, Welle, Russell, and Kittleson,7 York 13045; E-mail: [email protected].
cosm of the past in that each of these dif- conducted research to determine if there Bonni C. Hodges, PhD, is associate professor
fering positions is alive and well in various was a dominant philosophy among health and chair, Health Department, SUNY College
corners of health education practice today. educators and operationally described five at Cortland, Cortland, NY 13045. Donna M.
Some might conclude that such diversity of philosophical positions present in health Videto, PhD, is associate professor, Health
viewpoints, or philosophies, indicates a rich, education. Those five positions were: cog- Department, SUNY College at Cortland.
210 American Journal of Health Education — July/August 2005, Volume 36, No. 4
Joseph F. Governali, Bonni C. Hodges, and Donna M. Videto
nitive-based, decision making, behavior task very difficult. to all settings and have served to provide
change, freeing/functioning and social The search for a coherent, understand- some unified face to health education. Al-
change. These positions continue to serve able, and defensible philosophy of health though it is clear that the CHES “generic”
as the basis of philosophical discussions in education is not a new area of scholarship. skills and competencies can serve as a foun-
health education professional preparation Unfortunately, the past high level of inter- dation for achieving outcomes that are
programs at the graduate and undergradu- est in philosophical discourse and debate related to a variety of philosophical posi-
ate levels across the nation. seems to have diminished. When articles tions, the same cannot be said about the
It is clear that having an understanding have been written, or presentations given, application of a “generic” philosophy to a
of the major health education philosophies that offer a clear and thoughtful philosophi- variety of practice settings. The “real world”
and a grasp of philosophical trends is ex- cal position,5,6,9,10,11 they seem to have cre- is composed of many different delivery
tremely important.7 However, it is also im- ated very little professional dialogue at the sites, clients and practitioners, and a “one
portant to recognize that of the five posi- national level. A specific, recent example of size fits all” philosophy is neither realistic
tions described in the Welle, et al., article, this silence can be observed in the lack of nor appropriate. Therefore, the focus of this
the behavioral philosophy seems to provide discussion surrounding the promotion and paper is on school health education and on
school health education in a K–12 setting acceptance of the skills-based philosophy. a philosophy to guide school health educa-
with the most reasonable and supportable This philosophy appears to be gaining in tion practice.
position from which to operate in today’s popularity, but is being accepted with very An Integrated Approach to Philosophy:
climate. The apparent lack of focus, or con- little critical analysis in the professional lit- First Some Background
sensus, that characterizes school health edu- erature. It seems as though health educa- A problem with trying to view health
cation philosophical discussions seems tors are either no longer interested in such education philosophy from an integrated
more related to denial than to establishing a discussion, or have concluded that the dif- perspective is that this orientation is not
a positive diversity of thought. It is the ferent and sometimes contradictory philo- consistent with either past or present ap-
authors’ position that by adopting non-be- sophical positions can exist side by side, or proaches. The profession traditionally has
havioral philosophies, these K–12 school have decided that the best that can be ac- focused on differences in philosophical
health educators are denying the impor- complished is to “agree to disagree.” thought, rather than looking for common-
tance of their role in influencing youth be- This current situation is both disap- alities and trying to develop a perspective
havior, ignoring the needs of students and pointing and professionally dangerous. It is that would accommodate very different
failing to address the expectations of par- disappointing because debating differing viewpoints. Looking at the application of
ents and communities. points of view, which is related to the pro- four of the “traditional” philosophies in
Philosophical orientations that focus on fessional self-criticism that Carlyon once school health education can help in under-
such outcomes as skills development, described as “critical dialogue,”12 can ad- standing where schools have been and
knowledge, attitudes, values, social factors, vance professional thinking, refine ideas where they need to go.
or similar ends deny the centrality of be- about mission, and help a profession rein- The view that the role of health educa-
havior as the “appropriate” philosophical vent itself in the face of changing times and tion is to disseminate information, increase
foundation for school health education issues. This situation is dangerous because the knowledge base, or provide the student
practice. Philosophies that support such philosophical thought is central to the de- with information needed to make decisions
school health education program outcomes velopment and delivery of health education. has been a long-standing health education
as knowledge gain, attitude change, or value For a profession to stay vital and relevant, philosophy. The cognitive-based philosophy
development alone do not accurately reflect it is important to assess its activities, regu- can be traced back to Mann and Shattuck
current health education needs, such as larly evaluate its goals, and assess its philo- at the dawn of school health education.14
meeting Healthy People 2010 objectives.8 As sophical direction. This article is an attempt Information acquisition as the mission of
school health education competes for in- to help stimulate such an examination and the schools has been supported in the past
structional time and budgetary dollars, it is to propose a behaviorally focused, ecologi- by Greenberg1 and was more recently dis-
crucial that the field has a clear, consistent, cally grounded, integrated philosophy for cussed in a paper by Gold and Kelly.9
and supportable operating philosophy that school health education. The skills development philosophy focuses
reflects individual and societal health needs, There may be some support for the view- on the importance of students developing
identifies an important and relevant pur- point that a philosophy should be broad skills that could be applied in a variety of
pose, and emphasizes its unique contribu- enough to apply to health education regard- health-related settings. Similar to the deci-
tion to children and schools. Failing to ac- less of practice setting. After all, the respon- sion-making approach supported by
knowledge the importance of behavior in sibilities and competencies that emerged Kolbe, Iverson, Kreuter, Hochbaum, and
health education programming makes this from the Role Delineation Project13 apply Christensen,15 the criterion for a successful
American Journal of Health Education — July/August 2005, Volume 36, No. 4 211
Joseph F. Governali, Bonni C. Hodges, and Donna M. Videto
program under the skills-based philosophy this model, the school health education lit- health-enhancing behaviors, operates from
is the degree to which a student can perform erature shows little interest in discussing a broad ecological perspective and integrates
a skill in the classroom. The skills-based this perspective. sound thinking from other philosophies.
approach appears to be the direction being A variety of different authors have pro- Therefore, under this behavioral philoso-
taken by many school health education pro- posed, supported, or described other phy, the process of health education in-
grams and can be clearly observed as a driv- philosophical directions or themes for volves:
ing force behind the National Health Edu- school health education. Some of these • Encouraging the adoption of health-
cation Standards,16 in state level health themes included values clarification, affec- enhancing lifestyles.
education documents4,30,32 and in health tive education,27 freeing and functioning,3,7 • Focusing on content and experiences
education textbooks.17 character education,28,29 and moral develop- designed to affect understandings, beliefs,
To some extent, influencing health-re- ment.5 Although these orientations may attitudes, values, practices, and behaviors.
lated behavior has been a rationale for health have played some role in health education, • Identifying consequences of health-
education for as long as schools have been they have not been as significant as those threatening behaviors.
involved with the health programming. For already discussed or they may be more rea- • Providing class activities to develop
example, it can be observed in the type of sonably viewed as a part of another more health-related skills.
health education that grew out of the Tem- dominant philosophy. • Working to create an environment that
perance Movement of the late 1800s,14 the An Integrated/Ecological Behavioral supports and promotes health-enhancing
health habit development approach of the Philosophy of Health Education behavioral choices.
early 1900s,18 portions of the Report of the In simple terms, the philosophy that is Professionals who have not thought
President’s Committee on Health Educa- being proposed is focused on influencing philosophically about health education or
tion,19 and in Hochbaum’s2 quote at the health-related behavior. This philosophy, in parents who are trying to understand the
beginning of this paper. Examples of inter- addition to being behavior-based, is eco- process of health education might look at
est in behavior and behavioral outcomes logically grounded and integrates outcomes this description and conclude that the state-
can be observed in sex education with such of other philosophies as steps or mediators ment is rather intuitive, asking, for
programs as “Reducing the Risk” and “Post- needed to influence behavior. The behav- example,“Isn’t this what school health edu-
poning Sexual Involvement.”20 More recent ioral focus of this philosophy means that the cation has been doing all of these years?”
examples include a focus on preventing or purpose and goal of health education is to The answer to this question is yes and no.
reducing childhood obesity and the wide- influence the health-related behavior of To be sure, there are health educators who
spread application of behavior-based data students. The ecologic focus or orientation may have been operating in this manner
collection as is illustrated by the Youth Risk means that the process of health education and for them this integrative, ecologically
Behavior Survey.21 must be multidimensional, recognizes that based philosophy is nothing new. There are
At the heart of the social change philoso- the individual and the environment are others who certainly will see this as a philo-
phy is the belief that health education needs interdependent, and conceives of health sophical elaboration or extension of con-
to consider societal, environmental, and and health status as the result of interac- cepts underlying the PRECEDE/PROCEED
social factors in its programming for influ- tions between the individual and the envi- Model,25 specifically the diagnostic portion
encing health, rather than narrowly focus- ronment.22,23,24 Stated another way, “…be- of that model. The behavioral focus of this
ing on the individual and personal at- cause health and health risks are determined philosophy, contrary to what might seem
tributes such as knowledge, skills, attitudes, by multiple causes, efforts to effect behav- somewhat intuitive, is not at all common
values, and behaviors.6,10,11 Recognition of ioral, environmental and social changes in school health education today and does
the importance of a societal/environmen- must be multi-dimensional or multi- not appear to be the course promoted for
tal perspective is not new to the general field sectoral.”25 The integrated dimension of this its future direction.4,16,17
of health education and can be observed behavioral philosophy views the desired Recent literature suggests that school
readily in the early ecologic model of outcomes of other philosophical perspec- health education is in the midst of a “para-
health proposed by Hoyman,22,23,24 writings tives (e.g., knowledge or skills) not as ends digm shift” and moving away from a phi-
by Minkler,10,11 the orientation and con- in themselves, but as integral mediators of losophy based on knowledge development
ceptual framework underlying the the behavioral outcome. to one focusing on skills develop-
PRECEDE/PROCEED Model,25 and in Since a philosophy of health education ment.4,30,31,32 Skills development is impor-
O’Rourke’s 1988 AAHE Scholar’s address.6 should serve as the framework from which tant for the development of health literacy
The Coordinated School Health Program everything in a program emanates, the pro- and should be assessed as part of determin-
Model26 provides many opportunities to cess of health education under this pro- ing program impact. However, as the philo-
implement this philosophy, but outside of posed philosophy focuses on promoting sophical orientation for school health
212 American Journal of Health Education — July/August 2005, Volume 36, No. 4
Joseph F. Governali, Bonni C. Hodges, and Donna M. Videto
education, skills development alone is too pressure on school health education pro- education have an operating philosophy
narrow and proponents of this approach gramming. While the health education that clearly identifies program goals or a
often seem to confuse the development of needs of children are well documented and hierarchy of goals. In addition, the philoso-
skills with “real-life” behavior. This deemed to be important, the need to im- phy must be reasonable, defensible, and help
approach seems to lack a commitment to prove “academic” performance has become to unify its practitioners.
actually influencing the out-of-class behav- the highest educational priority and is
ior of children. The focus on skills devel- sweeping aside almost all other aspects of CONCLUSION
opment is laudable, but it is difficult to be- schooling. Areas outside of the “3Rs” are The proposed ecological/integrated be-
lieve that health educators or parents would often viewed as competing for valuable havioral philosophy draws from a variety
view a program as successful if students school time and limited resources. Such of sources. As noted above, Hoyman,22,23,24
gained skills, but were still involved with “non-testing” areas, which include health O’Rourke,6 Minkler,10,11 Green and
health- threatening behaviors. If skills were education, are often perceived as barriers to Kreuter,25,34 and a variety of other authors
really at the core of societal concern over gaining more time for the 3Rs, remediation have addressed various aspects of this ap-
health problems of youth, there would be programs and various activities related to proach to health education. Clearly, its com-
no national debate about abstinence versus preparing students for tests. ponents are not really new to the field. What
comprehensive sex education programs; It is very difficult to refute arguments is different is an attempt to draw the com-
HIV/AIDS education programs would not aimed at reducing or eliminating health ponents together into an integrated school
be trying to convince young people to ab- education programming and to explain its health education philosophy.
stain from sexual activity or use condoms; importance related to educational reform What is being proposed is certainly at
and programs would not have been devel- when school health educators are unclear variance with current trends in school
oped to prevent violence and bullying. From about their philosophy and goals. Since it health education practice. The skills-based
a political and parental perspective, a phi- is almost certain that health education pro- philosophy is being promoted as an appro-
losophy that would be satisfied with skills grams will face increasing pressure to jus- priate guiding framework for school health
outcomes in the absence of application and tify their existence as a result of the narrow education practitioners and curriculum
behavior would make program justification focus of educational reform, it is impera- coordinators, despite examples in the litera-
very difficult. To believe otherwise seems to tive that school health educators be able to ture of school programs in specific content
deny reality. describe what they are trying to accomplish areas, research projects, and school-based
A behaviorally focused, ecologically in a clear, defensible, and logical manner. A initiatives that focus on behavioral out-
grounded, integrated philosophy is more school health education philosophy must comes. Moreover, much of the behavioral-
consistent with student needs, societal in- reflect a full understanding of schools and focused discussion in the literature is of a
terests and health education’s long-term the reform movement, the needs of chil- categorical nature rather than emerging
goals. Additionally, it focuses directly on dren, and the real problems being faced by from an overarching philosophical orien-
health-related behavior, which traditionally health education today. The philosophy also tation. The behavioral philosophy espoused
has been, and often still is, the justification must provide a foundation upon which to in this paper is not consistent with the skills-
for including health education in school develop a justification for the class time that based movement, but does not necessarily
programs. If there are doubts about the re- would be devoted to health education, must contradict or disagree with programs em-
lationship between present-day health edu- be viewed as appropriate by parents, and phasizing skills development, because skills
cation and concerns about health-related must be consistent with the goals espoused are important in applying knowledge and
behavior, consider how the course of health by the community and state. can be precursors to health-related behav-
education has been impacted by adolescent Although it may be viewed by some ior. At issue is what school health educa-
behavior related to alcohol, tobacco and health educators as reasonable and intellec- tion publicly and universally acknowledges
other drugs; teen pregnancy; HIV/AIDS; tually appropriate for the profession to to be its philosophical purpose and goal.
and violence. Further evidence of this im- “agree to disagree,” this position provides The viewpoint of this paper is that the goal
portant connection can be observed in the no guidance for the school-based practitio- of school health education should not end
CDC Risk Behaviors,21 Healthy People 2010,8 ners who are trying to explain and defend with skills development, knowledge acqui-
the National Health Education Standards,16 their programs. Such a position provides no sition, personal disposition modification or
and Health is Academic.33 assistance in helping practitioners articu- environmental change. Rather, these ele-
Why examine school health education late the relationship between what they are ments should be viewed as important pre-
philosophy now? doing in class, the health problems of cursors to behavior and as significant con-
American education is in the midst of a children and the health needs of society. tributors to the goal of students adopting a
reform movement that is placing significant Simply put, it is crucial that school health health-promoting lifestyle. At the same
American Journal of Health Education — July/August 2005, Volume 36, No. 4 213
Joseph F. Governali, Bonni C. Hodges, and Donna M. Videto
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