Modelo evaluativo

Health education has traditionally focused on particular illnesses ⎯ cause, effect, treatment and prevention ⎯ that is, their aetiology. In particular the focus on health

education in schools has dealt with illness at a behavioural and (isolated) personal level. As already discussed, the recognition of health as a social construct has lead to the development of health promotion as the product of both health education and public health (Baric 1995). Where public health encompasses action to safeguard the health of the population (Baum et al.1992), health promotion is about strategies that change the physical, social and economic environment in which people live in order to prevent or limit illness (AIWH 1996). However, health education is still heavily imbedded in the biomedical model thus the purpose of health education ‘to improve health by producing changes in health related behaviours’ (Goltz, Colquhoun & Sheehan 1997 , p.5) remains.

Health education has a long history in schools, although it has not always primarily been about meeting curriculum imperatives and providing opportunity for schooling. Instead, the history of health education has more often than not reflected the

prevailing concerns and understanding being derived from research that in turn reflected the hegemony of the time. Crotty (1995) and Santich (1995), in their explorations of the development of dietary advice, food trends and health in Australia, make many links including those between the scientific understanding about nutrients and their biochemistry within the body, the development of dietary selection models that reflected not only the science but also the food choices preferred by the middle and upper social classes, and the changes in food selection, preparation and cooking.

The most common approaches to health education essentially fall into one of three styles: the traditional approach, the self-empowerment approach and the radical or collective-action approach. These are represented in the following table.

Table 3.1 Approaches to Health Education (based upon Colquhoun, Goltz and Sheehan, 1997)

Approach Goals Methods Key ideas / Associated concepts Measures of success Traditional • behaviour change • conducive to disease prevention • mass media campaigns • counselling &/or small groups • attitude and behaviour modification • knowledge = attitude = behaviour • victim blaming • compliance rates • reduced morbidity and mortality rates Self

empowerment • values clarification • decision making • self-esteem • life skills • understanding of decision making process • individuals have the ability to understand and control health status within their environmental circumstances • life skilling • modification of self-concept • role plays • pastoral care • assertiveness skills Radical or collective action • production of socio-cultural changes which are conducive to health • empowerment of the individual • political action • health is primarily shaped by factors outside the control of individuals • associated changes in knowledge and attitude to facilitate involvement in collective action for health • reduction in morbidity and mortality rates

These three models of health education are neither necessarily exclusive nor antagonistic; Tones (1987) suggests that there are times when each approach is appropriate. Colquhoun’s (1990, 1992) concerns about health promotion arose out of his belief that it has for too long lacked a theoretical basis. The focus has been upon ‘practicalities, content and process without out any real cause to do so’ (1992, p.4).

Critiques of the limitations of health education contend not only that it has been centered on specific health issues, but also that it is premised on the notion that it is the choices made by individuals that influence their health. French and Adams (1986) argue that health education has been characterised as medical intervention, where the theoretical model of lifestyle (also known as the behaviour-change model) and has had the most number of planning models developed for its implementation. They point out that health education should be based on the philosophical premise that recognises the interrelationship of health with a person’s lifestyle.

There is a need to push this perspective further still. The provision of health

education needs to go well beyond behaviour change; it needs to be linked with wider social issues including political change (Combes 1989; Cribb 1986; Grebow 2000), empowerment (Hagqvist & Starrin 1997; Keiffer 1984; Tones 1987; Wallerstein & Bernstein, 1988), and consideration of how inequity contributes to varying levels of health (Riska 1982; Pattison & Player, 1990).

Ritchie (1991) provides a framework that identifies the development of health education in Australia from a historical perspective. She provides four stages in its development and links these to the contemporary focus of public health. Table 3.2 is a synthesis of her work.

This perspective on the relationship between public health and health education is important. What is evident is that until the development of the principles in the Ottawa Charter, health education was largely the reinvention of the ‘medical model’. What the Ottawa Charter offers is a genuinely new perspective where personal skills are promoted along with environments that enable individuals and communities to live healthier lifestyles. Lobbying, advocacy and mediation are new tools in the health educator’s basket (Tones 1987).

Table 3.2 Evolution of health education within Australia

Stage Focus of public health Focus of health education

1. Education through health information

• The ‘medical model’ prevails. Health experts and authorities were perceived as being invested with all pertinent knowledge, and health-care workers were seen as the prime group responsible for the health of individuals in society.

• Education is based on the assumption that if the relevant information is placed before an individual, that person will, almost unquestionably, adopt the appropriate 'knowledge, attitudes and behaviour' to do as expected.

2. Education through varied audio-visual channels

• In response to poor patient compliance, health educators became more creative about enabling patients to more effectively hear and act upon the information that they ‘needed’.

• Pertinent information was presented in alternative forms, trying to tap into whatever cues the person responded to. Skill development was based upon the assumption that desired

behaviour would follow. Talking heads, lots of jargon and uninspiring print material dominated.

3. Education through incorporating adult learning principles

• There is a recognition that people could change their health-related behaviour, but not on their own terms.

• Health educators had to develop facilitation skills to enable individuals to develop more self-reliance and responsibility for their health. • It was often characterised by victim-

blaming because it was premised on change as a voluntary choice.

4. Education for health within the Ottawa Charter framework

• Health is an outcome of interacting social and environmental factors as opposed to the medical concept of single causative agents in disease.

• Health is no longer focused on disease prevention or management, but instead acknowledges that determinants of health are social and environmental.

• Knowledge is no longer the key, which is rather taking control of and improving one’s own health.

Davis, Linford and Williams (1997), in discussing health education for young people and exploring these ‘new tools’ for health educators, explore the relationship between curriculum and life practices. They challenge health education to be empowering and

enriching by:

recognising that young people are a part of the community and are entitled to have input;

encouraging young people to take an empowering role and political action; enabling young people to decide their own priorities and needs;

viewing health education as a lived experience and as a social activity (p.97).

Health promotion is put forward as the ‘new’ public health, and there is a relationship between the development of health policy and health education. The emergence of the settings approach in health promotion has lead to, in particular, a focus on schools as health promotion sites and therefore the development of the health promoting school.