lecture as a method of health education

Health Education: Some Principles and Practice

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Committee on Public Education of the Commission on Cancer Control

Part of the book series: UICC Monograph Series ((UICC,volume 5))

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For a comprehensive yet manageable review of the principles of health education, as derived from behavioural studies, we can do no better than refer the reader to Section III of Health Education Monographs , Supplement No. 1, published by S. O. P. H. E. 1 This excellent work reviews the “Methods and Materials in Health Education (Communication)” with separate sections on: (a) fear — arousing communications; (b) pretesting and readability; (c) audio-visual methods and materials (d) group techniques, and (e) the comparative effectiveness of different methods. Perhaps even more important than the section on methods and materials is Section IV of the Monograph dealing with programme planning and evaluation. We have not repeated references included in the S.O.P.H.E. review .

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References: Principles of health education

Aitken-Swan , J. , and Paterson , R. (1959). Assessment of the resuts of five years of cancer education. Brit. med. J . i , 708. The assessment of five years of cancer education showed that the number of patients with breast cancer who delayed more than one month decreased. No such decrease was noted in a control area, nor did the delay for cancer of the cervix uteri decline. There was an increase in the experimental area of those with breast and cervix uteri cancer who presented themselves when the growths were of limited extent. Finally, from an interview inquiry it was found that the campaign made more impact on those with breast cancer than with cancer of the cervix uteri. One third of the patients in contact with the campaign were too afraid to act upon the advice given. Talks were more influential than articles, but reached a smaller public.

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Baric , L. , and Wakefield , J. (1965). A reappraisal of cancer education. Int. J. Hlth Educ . 8 , 78. After reviewing the present scientific knowledge, the authors make a clear case for the role of education in cancer prevention, and pinpoint five areas where further testing and evaluation are urgently needed.

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Bharara , S. S. (1963). Joining science and tradition. Int. J. Hlth Educ . 6 , 106.

Biocca , S. M. , and Joly , D. (1960). Fighting cancer in Argentina. Int. J. Hlth Educ . 3 , 174. To succeed in the battle against cancer it is necessary to have available: (1) a qualified medical staff, able to make an accurate diagnosis; (2) a well-informed population, aware of the importance of early diagnosis; (3) a medical network that provides the essential facilities for such a diagnosis. The authors describe a campaign carried out in Argentina.

Blokhin , N. N. (Ed.) (1962). Methodological Handbook of anti-cancer propaganda . Moscow: Institute of Health Education (Russian Text). This book contains articles on aetiology, pathogenesis, diagnosis, treatment and prophylaxis. It also deals directly with cancer education in two chapters and four appendices.

Bogolepova , L. (1962). The people’s health culture. Proceedings of the Internat. Conf. on Health and Health Education , vol. 5 , p. 520. Geneva: Int. J. Hlth Educ. (French text, English and Spanish Summaries).

Bond , B. W. (1958). A study in health education methods. Int. J. Hlth Educ . 1 , 41. This study compared the effectiveness of the two methods of education, namely group-discussion plus decision and a straightforward lecture, in a health education programme concerned with breast cancer. (See page 52, col. 1 of this monograph.)

Brotherston , J. (1963). Aimless benevolence. .. . a box of tricks. .. . or? Int. J. Hlth Educ . 6 , 158. In a compact but pertinent article the author considers the aims and methods of health education. The objectives are both particular and general. “The real difficulty is not to find good deeds to do, but to know where, when and with what to begin”. The author is in favour of tackling the “more circumscribed but necessary area [of] the quality and efficiency of the communication between the health worker and his patient or client”. He condemns the authoritarian attitude of nurse and doctor; they must be made to realise the need to educate — the rest will follow. With respect to the behavioural sciences, “the need now is for a statement of applied social science carefully related to the needs of health practitioners.” Training is a cornerstone to progress, and a scientific approach to the choice of objectives is required.

Burton , J. (1964). Three uses of health education in clinical preventive and public health practice. II. The role of education in cancer prevention. Int. J. Hlth Educ . 7 , 68. This is a background paper prepared by the author for the Who expert committee responsible for the technical report from which we have quoted extensively in the text of this chapter. The author’s paper is used almost in its entirety for the sections on health education within the technical report.

Cameron , C. S. (1956). The truth about cancer , New York: Prentice-Hall, Inc., A thoughtful round up of information about cancer and its control by the then medical director of the American Cancer Society. A vigorous expression of an aggressive philosophy of public education in cancer with emphasis on the concept that “only when everyone recognizes and accepts the importance of personal responsibility will the control of cancer become a living reality.” The book has been brought up to date by the author and will be reissued by Collier Books (paperback) in 1966.

Clemmesen , J. , and Stancke , B. (1965). The effect of a cancer campaign in Denmark. S. A f r. Cancer Bull . 9 , 100. Analysis of the long-term effects of an educational campaign for breast self-examination conducted between 1951 and 1955. The years of the campaign saw more cases, and more of them suited to treatment, than previous years. An improvement in survival was observed over the subsequent 9-year follow-up.

Costalat , P. (1958). Survey on Health Attitudes. Int. J. Hlth Educ . 1 , 207. The inquiry proved that the health assumptions of the young Moroccan women interviewed fitted in neither with modern concepts nor with the former popular traditions. They generally combine both, with resulting incoherence and a stagnant health behaviour. Group education is the best method in these circumstances to crystallize the information spread by mass media. Simultaneous education of parents and children is needed. The author stresses the value of interviews, and the value of sometimes appealing to ideas already accepted by some numbers of the group or basing arguments on a related subject.

Derryberry , M. (1958). Some Problems Faced in Educating for Health. Int. J. Hlth Educ . 1 , 178. Why are people so willing to take chances with their health? There is evidence of an educational need to help people relate in a more positive way to their doctors. The “teachable moment” was immediately after the condition was diagnosed: information was sought from many sources at this point, and this, as well as misinformation, was exchanged. We must prepare people to react intelligently and healthfully when they or their relatives and friends are sick; we must help people find the information they want from a reliable source. There are many examples of the risks people take with their health, why do they do so? The author takes smoking as an example of this and considers it in terms of habit formation and society. There is need for more than a statistical demonstration; the chance element is not referred to self, the emotional, irrational elements weigh strongly against the intellectual, rational arguments. We do not know nearly enough about the factors involved. There is a need for research into methods, and careful planning.

Derryberry , M. (1960). Research: Retrospective and Perspective. Int. J. Hlth Educ . 3 , 164. The primary goal of health education is to increase people’s knowledge of the scientific facts about health and to stimulate them to apply the knowledge in improved health practices. Research in health education is concerned with the process by which people change their health behavior. It includes study of all the various factors in the process and the dynamics of the relationship between these factors..... The importance of knowledge, .... of social factors; .... individual factors. It is also concerned with the character of the action that is being advocated. We need to learn what educational methods work with what kinds of people to produce what kinds of actions. It is in the dynamics of these interrelationships that much intensive work is needed. We must not mistake effort for accomplishment: evaluation is essential both in pretesting and in objective evidence of the increased information and for performance of the recommended action.

Derrberry , M. (1960). Health education — its objectives and methods. Hlth Education Monographs No 8 . The author draws an analogy between health education and medicine in their diagnostic and therapeutic processes. He further considers health education as involving forces which must be analysed, a thorough consideration being given to existing “knowledge, attitudes, goals, perceptions, social status, power structure, cultural traditions and other aspects of whatever public is to be reached. Only in terms of these elements can a successful program be built”.

Donaldson , M. (1962). The cancer riddle: a message of hope . London: Arthur Barker. A broad presentation of information about cancer and its treatment for the general public. It includes a discussion (Chapter 18) of the role of “cancer education among the public”. Dr. Donaldson’s ardent advocacy of public education in Britain began in the early 1930s, when his views received little or no support from professional colleagues. Such programmes as exist in Britain today stem from Donaldson’s pioneer work. A number of his articles are listed in other sections.

Ennes , H. (1958). Teachable Moments. Int. J. Hlth Educ . 1 , 70. The educational component of health activity, although continous, may vary in intensity, as, for example, in emergencies. At such moments people are potentially more amenable to education. “Our experience in 1957–58 with the influenza outbreak indicates to us that a specific health threat increases public receptivity to information, and facilitates programs of action for improving general health behavior as well as protection against the present danger.”

Erdmann , Fr . (1960). Öffentliche Krebsaufklärung als Mittel zur Prophylaxe. [Inf ormation on Cancer as a Prophylactic Means in the Fight against Cancer]. Krebsarzt 15 , 240. The author describes the educational aims and methods of his department for “inf ormation on cancer and advanced training in oncology”.

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Hammond , E. C . (1959). Cancer education for the public in the U. S. A. In: Cancer , vol. 3 , ed. by R. W. Raven. London: Butterworth & Co. (Publ.) Ltd.

Hochbaum , G. M. (1959) Some implications of theories of communication to health education practice . Paper presented at the Seminar on Communication in Public Health Education Practice, School of Public Health and Center for Continuation Study, University of Minnesota, Minneapolis, Minnesota, June 1959 (Mimeo). In this excellent paper the author deals with “ some practical implications of some of the principles of effective communication”. He begins by considering the meaning of “communication”, which can be looked on as having three levels, depending on its purpose — the mere communication of information, the performance of some fairly immediate and specific action, and, thirdly, the more fundamental change of the communicant’s attitudes, beliefs, and motivational patterns leading eventually to behavioural changes. Of fundamental importance is the subjective meaning of a message and how it fits into the already existing frame-work of a person’s attitudes, interests and needs; information may be necessary in bringing about rational behaviour, but it is not usually sufficient by itself. The author continues with a very useful consideration of the timing of a communication and the best use of the “teachable moments”, which are those moments created by certain circumstances (e.g. an epidemic) when there is an increased readiness to learn. Of importance for the continued effect of health communications is the sustaining of the emotional impact not only by correct timing but also by correctly spaced follow-up communications. Action should be provided while motivation is still close to the peak. Motivation is strengthened when an action is carried out freely and for reasons that are perceived by the individual as good and acceptable, especially where such reasons are explicitly stated. These considerations also have implications for the long-term planning and integration of programmes. The author goes on to consider the role of anxiety in health communications, its uses and abuses, and its use in cancer education. An important principle in this connection is that “the anxious person looks for reasurance and not for facts”. The advantages and drawbacks of mass media are critically reviewed. Finally a very useful section considers the relative merits of educating the public to accept broad principles concerning health, and programmes aimed at producing isolated actions.

Hochbaum , G. M. (1960a). Research relating to health education. Hlth Education Monograph No 8 . The author considers his topic in two parts. Firstly, the importance of discovering the attitudes, beliefs, needs, fears etc. of the individuals and social groups, prior to any attempt to influence them educationally: such factors influence what will be accepted or rejected, by whom, and under what circumstances. Having thus considered the “whys” of human behaviour, the author goes on to consider the ways and means of changing it: topics covered include mass media, group dynamics, and the theory of cognitive dissonance.

Hochbaum , G. M. (1960b). Modern Theories of Communication. Children 7 , 13. Based on Hochbaum (1959a).

Hochbaum , G. M. (1960c). Behavior in response to health threats . Paper presented at the 1960 Annual Meeting of the Amer. Psychol. Ass. in Chicago, September 2nd. 1960. (Mimeo). See text of this chapter for summary.

Hochbaum , G. M. (1962). Evaluation: A diagnostic procedure. Proceedings of the Internat. Conf. on Health and Health Education , vol. 5 , 636. Geneva: Int. J Hlth Educ. The author summarizes the critical aspects in the evaluation of health education programmes as:” (1) Decisions on programme goals and methods, and decisions on evaluation techniques should go hand—in— hand. (2) Both the .... goals and the evaluation measures should be concerned with human behaviour. Non-observable aspects of behaviour, such as changes in knowledge and attitudes are only intermediary or substitute criteria. (3) Evaluation should be carried out as a continuous process [i. e. before, during and after the programme]. (4) Evaluation should not be considered as a measure of success, but as a diagnostic procedure that helps to identify effective and ineffective aspects of the programme”. Health education objectives differ from those of a health programme: the former is concerned with the behaviour which is of help in achieving the latter (which are more concerned with medical statistics).

Hochbaum , G. M. (1965). Research to improve health education. Int. J. Hlth Educ . 8 , 141. Insufficient attention is paid to differentiating between the two kinds of research: (1) aimed at improving health education, and (2) aimed mainly at advancing knowledge. The two may differ in objectives, methodology, design, and analysis and treatment of data. Much health educational research fails because it does not adhere to principles of sound scientific research; but much fails because it adheres to them too compulsively, despite the obvious limitations imposed by field conditions. In this case compromise is necessary, but with a clear realization of how compromise will affect the interpretation of data.

Hopper , J. M. H. (1960). The value of various forms of publicity. Int. J. Hlth Educ . 3 , 143. This study supports the view that “the best way of publicising health problems is to use all the forms available, as when the four selected forms of publicity [press, bus posters, hoardings or posters at place of work, and letter to parents of tuberculin positive children] were used, attendance dropped to 88 per cent of the total attendance when the sixteen forms” as used in the 1957 campaign were employed. The results also showed that some forms of publicity attract the attention of far greater numbers of people (the first three mentioned above); prominence should be given to these in future campaigns.

Horn , D. (1956). The attitudes of psychiatrists on the effect of cancer propaganda . Amer. Cancer Soc. (Mimeo). The results of a survey of 387 psychiatrists carried out in 1955 show that since 1949 (when there was also a “deliberate effort .... to de-emphasize the more fear-provoking aspects of cancer and to emphasize a “note of hope. ...”) there has been a significant decrease in the number of psychiatrists that believe American Cancer Society literature has increased anxiety among psychiatric patients (from 35 % to 25 %). Among those believing that there has been an increase in anxiety, there has been a decrease in the number believing that such anxiety results in greater harm than good.

Hyman , H. H. , and Sheatsley , P. B. (1958). Some reasons why information campaigns fail. In: Readings in social psychology , ed. by E. E. Maccoby et al . New York: Holt, Rinehart & Winton.

James , W. (1964). The American Cancer Society’s school education program. J. Sch. Hlth 34 , 466. The ACS public education director outlines concepts in a continuing programme aimed first at school administrators and teachers, to bring cancer instruction to students (down to Junior high school) “while they are in an active learning situation and before they have developed obstructive fears and misconceptions”.

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Johns , E. (1962). The Los Angeles evaluative study. Proceedings of the International Conference on Health and Health Education , vol. 5 , 514. Geneva: Int. J. Hlth Educ. This study was designed to evaluate the effectiveness of school health education. The effectiveness of health education was judged by means of an appraisal of the programme activities and the health behaviour of pupils in terms of knowledge, attitudes and practices.

Katsunuma , H. (1958). Before planning: a survey. Int. J. Hlth Educ . 1 , 151. To help determine the best health education approach in a rural community, a survey on family attitudes regarding health problems was recently undertaken in a district near Tokyo.

King , S. H. (1958). What we can learn from the behavioural sciences. Int. J. Hlth Educ . 1 , 194. The author stresses the importance of familiarity with the major concepts of the behavioural sciences, and their integration across the biological, psychological and social-cultural levels. “They [public health workers] also need to be introduced to the findings of research projects that are pertinent to an understanding of disease and of social factors that inhibit or facilitate health programmes.” The major concepts considered are: social perception or definition of the situation, homeostasis or a striving towards a balance, beliefs and attitudes, and political structures and communication lines.

Knutson , A. L . (1952a). Evaluating health education. Publ. Hlth Rep . 67 , 73. In the evaluation of any health education programme one should consider the following points: adequate preliminary investigation should be made to ascertain needs and behaviour; goals must be specified, but evaluated in relation to the overall aims; concrete evidence that an objective has been achieved is the only realistic criterion for measuring effectiveness; methods of evaluation must be chosen in terms of the specific goals; a baseline of zero cannot be presumed; evaluative measurements are nearly always indirect measures; long-term needs should be borne in mind apart from the immediate goals.

Knutson , A. L . (1952b). Pretesting: A positive approach to evaluation. Publ. Hlth Rep . 67 , 699. A critical review should be made prior to pretesting a programme so that the needs, objectives, methods, and subject matter are clearly defined, accurate and likely to be most successful. The pretest should be planned in terms of certain specific conditions that need to be satisfied in order to achieve programme goals; the programme will then be more likely to succeed. The conditions to be satisfied include: amount of public exposure, attention and interest, motivation, pattern of behaviour, comprehension, understanding of purpose, learning and retention.

Knutson , A. L. , Shimberg , B. , Harris , J. S. , and Derryberry , M. (1952). Pretesting and evaluating health education. Publ. Hlth Monograph No 8 . Washington, D. C.: United States Public Health Service Publication No 212 .

Koch , F. , and Stakemann , G. (1964). A population screening for carcinoma of the uterus with the irrigation smear technique. Dan. med. Bull . 11 , 209. A remarkable project in the borough of Frederiksberg, Copenhagen, appears to demonstrate the acceptability of self-obtained smears (by pipette) without major educational effort. Of 11,192 selected women, 82.2 % used and returned the pipettes. Propaganda limited to one 3-minute interview on T. V. and a few items in newspapers. The authors suggest this success is due to the fact that women can undertake the procedure in the privacy of their homes, and without the inconvenience or embarrassment of making an appointment for examination.

La Pointe , J. L. , Wittkower , E. D. , and Lougheed , M. N. (1959). Psychiatric evaluation of the effect of cancer education on the lay public. Cancer (Philad.) 12 , 1200. The authors believe that cancer education and many other forms of health education have relatively little effect considering the amounts of time, money and skill spent on them. There is a reliance on the mass media, merely presenting material to large groups of individuals regardless of their receptivity. A more personal approach through discussion groups and the like may produce a lessening of resistances and thus reduce the blocking reactions. Once the general public has allowed itself to be exposed to education, greater resistances might be overcome if other factors, such as the different needs of the population, or which person is more liable to be heard and understood in specific groups, were known. “The real problem is not whether enough information is put across to the general public, but how and how successfully the information is communicated. There is little doubt in our minds, for instance, that propaganda based on curability through early treatment is more likely to be successful than is propaganda based on fear.”

Lifson , S. S . (1958). Do they understand what they read? Int. J. Hlth Educ . 1 , 100. Giving literature to patients in hospitals is not enough. We must find out if they understand what they read. An interesting survey was carried out in this connection by the U. S. Tuberculosis Association, making use of reading tests. It proved two things: the need for hospital personnel to be aware of the level of vocabulary comprehension of their patients; and, secondly, that we should not rely mainly on the printed word for our educational effort.

McCormick , G. (1964). Programme planning — An organized approach. Int. J. Hlth Educ . 7 , 91. The author discusses how he used the W. H. O. guide to programme — planning when he was co-ordinator of a community nursing-home demonstration programme. The W. H. O. guide enumerated the following five steps:(1) collecting information essential for planning; (2) establishment of objectives; (3) assessing the barriers to health education and how they may be overcome; (4) appraising apparent and potential resources (organisations, personnel, materials and funds); (5) developing the detailed educational plan of operations (including a definite mechanism for continuous evaluation).

Maclaine , A. G. (1965). Lay education in cancer control. Med. J. Aust . 2 , 171. A succinct review of experience elsewhere and discussion of possible applications to the situation in Australia. This article is not written from a limited parochial point of view, and its interest is therefore not confined to the country of origin.

McNickle , d’ A. , and Pfrommer , V. G. (1959). It takes two to communicate. Int. J. Hlth Educ . 2 , 136.

Nix , M. E. (1961). Health education and human motivation. Int. J. Hlth Educ . 4 , 192. Although the importance of health and illness has global significance, attitudes regarding these will vary according to the cultural ideals of a community. Therefore, although the problem of the control of tuberculosis is universal, it can be solved by giving careful consideration to the fixed customs of the group. The author considers the different types of atmosphere of a group associated with the types of leadership, and the consequences for human motivation and behaviour. If the leader is authoritarian or laissez—faire the positive results, if any, are unlikely to be permanent. Ideally the relationship should be one of educated self-determination, in which a person follows a responsible leader with understanding and the realization that the programme will benefit him and those around him.

Osborn , G. R. , and Leyshon , V. N. (1966). Domiciliary testing of cervical smears by home nurses. Lancet 1 , 256.

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Public health nurses in Derby were used in a cervical cytology programme (a) to identify the high-risk women (multiparous, low on socio-economic scale) in their care; (b) to persuade them to have a smear taken; (c) to take smears (after careful training) in the home. The value of this highly personal form of selective health education was shown by results. Moreover, a positive smear rate of 26.5 per 1000 was found in this group, almost four times greater than the rate recorded for the general population at clinics in the same town.

Paterson , R. , and Aitken-Swan , J . (1954). Public opinion on cancer: A survey among women in the Manchester area. Lancet ii , 857. A report of the first survey carried out at the beginning of the experimental cancer education programme by the Manchester Committee on Cancer. (See Chapter I of this Monograph).

Paterson , R. , and Aitken-Swan , J. (1958). Public opinion on cancer: Changes following five years of cancer education. Lancet ii . 791. This is a repeat survey of the one carried out in 1953 (Paterson and Aitken-Swan 1954) and showed a good general improvement in attitudes to cancer. (See Chapter I of this Monograph).

Paterson , R. , Brown , C. M. , and Wakefield , J. (1954). An experiment in cancer education. Brit. med. J . ii , 1219. This is an early article describing the cancer education programme of the Manchester Committee on Cancer.

Phillips , A. J . (1955). Public opinion on cancer in Canada. Canad. med. Ass. J . 73 , 639. (See Chapter I of this report).

Phillips , A. J. , and Taylor , R. M. (1961). Public opinion on cancer in Canada; a second survey. Canad. med. Ass. J . 84 , 142. This is a report on a repeat of the 1955 survey (Phillips 1955), and shows an improvement in public opinion concerning cancer after a carefully planned educational campaign. (See Chapter I of this report).

Popma , A. M. (1962). Public education and cancer control. Acta Uni. int. Cancr . 18 , 723. The author deals with the history of public cancer education both in the United States and Great Britain. Fear of cancer needs to be eradicated by education organised by the medical profession. Much evidence is cited to show the value of early diagnosis of cancer of all sites, especially asymptomatic cancer. Cancerophobia, the most common objection to education, is not a true problem. It should be guided by education into a salutary fear of undue delay in seeking adequate treatment.

Price-Williams , D. R. (1962). New attitudes emerge from the old. Proceedings of the International Conference on Health and Health Education , vol. 5 , 554. Geneva: International Journal of Health Education. The author emphasizes the importance of taking into account the background of ideas and practices in health education. New ideas must be seen in relation to the old ones that they are disrupting or replacing. The author illustrates his points with examples from a tribe he studied in Nigeria.

Rankin , D. W. , and Brown , A. J . (1964). Cancer education in Victoria. Med. J. Aust . 1 , 357. A description of five years of intensive cancer education of the public by the Anti-cancer Council of Australia, its organization objectives, methods and evaluation.

Raven , R. W. , (1953). Cancer and the community. Brit. med. J . ii , 850. Among other topics, he discusses a cancer education programme. Telling the public the symptons is not enough, they must also be told how to act in certain circumstances, and what can be done to help them. This must be done wisely and in stages throughout the country.

Read , C. R. (1965). The control of neoplasia — education for prevention. In: The social responsibility of gynecology and obstetrics . Baltimore: Johns Hopkins Press. The American Cancer Society’s vice president for public education and information reviews his and the Society’s experience in many years of education against cancer of the uterus. He emphasizes the need for physician leadership, the importance of terminology acceptable to the media and meaningful to the public, the need to use both media and person-to-person approaches through informal networks of communication, (churches, unions, women’s clubs, neighbourhoods, etc.), the educational stress on “hope, on the peace of mind the Pap test can give”. Many millions in America have learned a new health habit, but there has been too little success with low-income groups and women over the age of 65. The diffusion process in health education is slow.

Roberts , B. J. (1965). A framework for consideration of forces in achieving earliness of treatment. Hlth Education Monographs No 19 . A stimulating analysis of the motivational and other forces involved in achieving early detection and treatment, particularly of breast cancer, by health educational methods. Invaluable because it offers for the first time a holistic view of the decision-making forces that lead to action, rather than the usual fragmentary examination of some aspects of the problem.

Roberts , B. J. (1962). Concepts and methods of evaluation in health education. Int. J. Hlth Educ . 5 , 52. In this article the author attempts to clarify the concepts surrounding evaluation in health education, and considers the problems of measurement involved in such evaluation.

Rosenstock , I. M. , Hochbaum , G. M. , and Kegeles , S. S. (1960). Determinants of health behavior . Golden Anniversary White House Conference on Children and Youth. See the text of this chapter for a summary.

Rosenstock , I. M. (1960). Gaps and potentials in health education research. Hlth Education Monographs No 8 . The author considers that applied research is needed to “develop simple, economical and valid methods for diagnosing health education problems; [and also] ... to develop valid methods for educating individuals and groups in a real life health setting”. Further “basic research is needed to increase our growing knowledge of why people do what they do”. Finally, much more programme evaluation is required to help in improving programmes.

Rosenstock , I. M. (1961). Decisionmaking by individuals. Hlth Education Monographs No 11 . See the text of this chapter for summary.

Rosenstock , I. M. (1962). Many opinnions.. . Few Hard Facts. Proceedings of the International Conference on Health and Health Education , vol. 5 , 565. Geneva: Int. J. Hlth Educ. The author is of the opinion that “what we still do not know .... is how best to diagnose and use existing motivational states and existing social structures to change behaviour”.

Rosenstock , I. M. (1963). Public response to cancer screening and detection programs. J. chron. Dis . 16 , 407. In the second part of the paper, Rosenstock attempts to apply the behavioural model already developed (see text of chapter) to cancer detection. The research that is required should be directed at the groups shown to be in need of it by a consideration of their health behaviour status — e. g. the undermotivated. The author concludes with recommendations for (a) a fact-finding phase; and (b) an action phase.

Ross , W. S. (1965). The climate is hope — How they triumphed over cancer , New York: Prentice-Hall, Inc. The book reports the personal attitudes to cancer of physicians, their patients, most of whom have been cured, and researchers. Sixteen rambling chapters — largely taped interviews — reflect the fears and guilt of some patients, the courage of others. Physicians speak candidly of their limitations as well as their successes: one is deeply interested in problems of stress and cancer, another in the value of a cancer detection examination, a third in the philosophy of radical operations, a fourth in the unbearable family tensions that often develop when a child has cancer. “Cancer is a highly complex group of diseases, each with its own course and prognosis ... Hence the reactions and the judgements of both patients and therapists often vary greatly and may be controversial.”

Sandman , I. (1962). Parent education in the U. S. A: Some impressions on methods. Int. J. Hlth Educ . 5 , 34. The author examined whether group discussions would produce better results than the traditional courses in health education of expectant mothers. The answer appears to be in the affirmative. Although factual information is important, an understanding of one’s feelings is also important and both are achieved in discussions.

Seppilli , A. (1962). A community survey — First step towards a film. Proceedings of the International Conference on Health and Health Education , vol. 5 , 527. Geneva: Int. J. Hlth Education. (French text, English and Spanish Summaries).

Spillius , J. (1962). The impact of social structure. Proceedings of the International Conference on Health and Health Education , vol. 5 , 560. Geneva: Int. J. Hlth Educ. The author suggests “(1) that the health educator may have to redefine the kind of system he is dealing with; (2) that a health education programme may constitute a direct attack on some of the individuals in the community, especially those who hold some kind of medical lore; (3) that it is necessary to study the customary ways of imparting information, recognizing that there may be an informal [social] structure, such as a network of kin which is just as potent as the formal structure in imparting information and shaping opinion; (4) that it is necessary to make a distinction between decision-making and choices ...,(5) that cultures change, customs change, and in some societies at a more rapid rate than in others .... it should [therefore] be possible to change ideas on health and disease if we analyse the social patterns, see who is responsible for health practices, and whether or not the community’s ideas are really as irrational as they appear. In attempting to promote change, we should obviously use the existing social structure as much as possible”. Society should not be looked at in terms of social structure alone; health education programmes affect the social, economic and technological structures, and these three aspects must be included in the planning and execution of the programme. The physical and economic burden placed on the people of a developing country must be borne in mind in any health education programme.

Steuart , G. (1965). The physician and health education. Brit. med. J . ii , 590. The author considers that the passive role of the patient is not conducive to good health education via the doctor, and recommends that the relationship be changed to a more patient-oriented one, in which the latter plays an active part. Steuart deals with the reasons why a patient should be educated, possible objections to his proposals, and the part played in all this by basic medical education of the doctor.

Steuart , G. (1959). The importance of programme planning. Int. J. Hlth Educ . 2 , 94. Systematic and intelligent planning are essential for successful health education. (See text of this chapter). Illustrations are taken from a programme concerning ante-natal and maternity care in a South African Indian community.

Steuart , G. (1962). A slender store of studies.. . Proceedings of the International Conference on Health andHealth Education , vol. 5 , 608. Geneva: Int. J. Hlth Educ. In this very instructive article the author reviews the studies of the educational content of health education programmes. Such studies are concerned with evaluation of the effectiveness of programmes, the existence and extent of the problem in the community or group, the establishment of criteria or baselines against which to measure and compare results, the comparative effectiveness of methods and the use of methods appropriate to the population and problem. More such studies are needed, and the help of the pure scientist must be used wherever possible. This article includes a bibliography of nearly fifty articles.

Suchman , E. (1962). More scientific rigour is needed. Proceedings of the International Conference on Health and Health Education , vol. 5 , 533. Geneva: Int. J. Hlth Educ. A great deal more thought might be given to the problem of classification of research findings, but this would involve the clarification of the basic dimensions underlying its fundamental concepts. Only by attempting to relate findings to such concepts will the results of applied research be of use outside the limited experimental situation. The research design of most health education studies is weak, owing to lack of underlying theory; they also lack scientific rigour. There are many possible criteria for the evaluation of an educational programme — in terms of effort, performance, adequacy, efficiency —, effort is the most common. Health education must develop its objectives more specifically according to different degrees of immediacy; this will necessitate an examination of the basic assumptions concerning the goals involved.

Sustaita Seeber , A. de (1963). Changing attitudes to cancer. Int. J. Hlth Educ. , 6 , 88. The results of a cancer education campaign in Argentina showed that attitudes to cancer have improved: information was sought and accepted more frequently, there was less delay by patients, conversations about cancer were considered more natural, and the educational approach is much more optimistic in outlook.

Tentori , F. V. (1962). Their needs and knowledge. Int. J. Hlth Educ. , 5 , 10. With ample illustration the author emphasizes the importance of preliminary research and evaluation in the careful planning of a programme. The research should include an examination of the characteristics and attitudes of the cornrnunity.

Tentori , F. V. (1963). Audio-visual materials: an experiment in pretesting. Int. J. Hlth Educ. , 6 , 180. This article sums up ... the results of a study carried out by the author in Mexico. The purpose was to pretest audio-visual materials being planned to support a public health programme.. .. The results emphasize the value of such tests and pinpoint some important principles.

Wakefield , J. (1959). The case for cancer education. Monthly Bulletin of the Ministry of Health and the Public Health Laboratory Service 18 , 146. The arguments for and against public education about cancer are presented and examined in the light of available evidence. The evidence shows that a carefully conceived and tactfully executed programme of education does not have undesirable effects, and that it can favourably influence public attitudes to cancer.

Wakefield , J. (1963). Cancer and public education . London: Pitman Med. Publ. Co. Ltd; Springfield (Ill.): Ch. C. Thomas. This volume summarizes many years in the field of cancer education in England. Probably the only work devoted solely to cancer education. Topics covered in the different chapters include: the principles and practice of cancer education — the problem, delay in seeking treatment, the content of a programme, informing the public by mass-media and person-toperson methods, cancer education in schools and the smoking problem —, and the organization of public education schemes. The appendices contain notes for lecturers, a reprint of the Paterson and Aitken-Swan (1954) survey, notes on the use of visual aids, and a list of educational materials and sources.

Wakefield , J. (1966). The role of public education in cancer detection. In: Chap.-VI., UICC Monograph Ser., vol. 4. Berlin-Heidelberg-New York: Springer 1966. The author emphasises that detection programmes must be accompanied by public education. The objectives of such education must be “to persuade people to seek prompt medical advice when certain warning signs appear; and to persuade them particularly those in high-risk groups, to take part in screening programmes”; emphasis on the hopeful and reassuring aspects of cancer and cancer detection tests is important. The author deals with the functions of the physician, other medical staff, and mass-media in education for detection of cancer. Crucial, however, in any such education is the state of the attitudes, beliefs and health practices in the community or group being educated. Wakefield draws attention to the need for examining the qualities of detection tests that attract or repel an individual, and cause him to accept or reject the test. The article is supported with evidence from a number of relevant studies.

Wakefield , J. , and Davison , R. L . (1958). An answer to some criticisms of cancer education: A survey among general practitioners. Brit. med. J . i , 96. This is a report of a survey carried out after five years of public education. It was designed to test the validity of the criticisms “that cancer education would create cancerophobia among the public and add unnecessarily to the work of the general practitioners”. Such criticisms were shown to be invalid for the kind of educational programme used.

WHO (1963). Cancer control. Wld Hlth Org. Tech. Rep. Ser . No 251M . This report contains a short section on education of the public, in which a few notes are made on the most important points of such education: necessity, form and operation of cancer education.

WHO (1964). Prevention of cancer. Wld Hlth Org. Rep. Ser . No 276 . This report contains an excellent section on public education, which we have quoted extensively in the text of the chapter.

Young , M. A. C. , Dicicco , L. M. , Paul , A. M. , and Skiff , A. W. (1963). Review of research related to health education practice. Hlth Education Monographs , Suppl. No 1 . New York: Society of Public Educators, Inc.

Zabolotskaia , L. (1965). The integration of health education in preventive and curative medicine in the U.S.S.R. Int. J. Hlth Educ. , 8 , 41. Prophylactic examination of healthy people is carried out in various selected categories of the population. A widespread educational effort precedes such examination programmes to ensure maximum participation. Follow-up of the chronic sick revealed by examination is tackled systematically, with health education playing a major role.

Ministry of Health, London (1964). Health education . Report of a Joint Committee of the Central and Scottish Health Services Councils. London: Her Majesty’s Stationery Office. This excellent report deals with the aims and achievements of health education. The need for evaluation is stressed and the future organization of health education in Britain is considered. Finally, the report deals with the techniques of health educators, the part played by general practitioners, and health education in schools. An appendix on health education in the United States is included. There are several lengthy comments on health education about cancer. Many methods useful for evaluation in health education. Int. J. Hlth Educ . 5 , 93. [Editorial annotation]. Lists ten of a variety of methods that have been used to check changes in knowledge, attitudes and behaviour of students relating to health. Health Education: a selected bibliography prepared by the World Health Organization. (1956). Educational Studies and Documents . No XIX. Paris: UNESCO. 174 entries on (1) General background; (2) Health education; (3) Methods and techniques; (4) Training; (5) Evaluation (6) Periodicals.

Health Education (1962), Education Abstracts , vol. XVI, No 1, compiled by Winifred Warden . Paris: UNESCO. An annotated bibliography of 398 entries on (1) Philosophy and background; (2) school health; (3) Programme planning; (4) Problems in special fields (including smoking); (5) Books for children; (6) Periodicals of interest.

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Committee on Public Education of the Commission on Cancer Control. (1967). Health Education: Some Principles and Practice. In: Public Education about Cancer. UICC Monograph Series, vol 5. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-88006-3_5

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Characteristics of an Effective Health Education Curriculum

Today’s state-of-the-art health education curricula reflect the growing body of research that emphasizes:

• Teaching functional health information (essential knowledge).
• Shaping personal values and beliefs that support healthy behaviors.
• Shaping group norms that value a healthy lifestyle.
• Developing the essential health skills necessary to adopt, practice, and maintain health-enhancing behaviors.

Less effective curricula often overemphasize teaching scientific facts and increasing student knowledge. An effective health education curriculum has the following characteristics, according to reviews of effective programs and curricula and experts in the field of health education  1-14 :

An effective curriculum has clear health-related goals and behavioral outcomes that are directly related to these goals. Instructional strategies and learning experiences are directly related to the behavioral outcomes.

An effective curriculum has instructional strategies and learning experiences built on theoretical approaches (for example, social cognitive theory and social inoculation theory) that have effectively influenced health-related behaviors among youth. The most promising curriculum goes beyond the cognitive level and addresses health determinants, social factors, attitudes, values, norms, and skills that influence specific health-related behaviors.

An effective curriculum fosters attitudes, values, and beliefs that support positive health behaviors. It provides instructional strategies and learning experiences that motivate students to critically examine personal perspectives, thoughtfully consider new arguments that support health-promoting attitudes and values, and generate positive perceptions about protective behaviors and negative perceptions about risk behaviors.

An effective curriculum provides instructional strategies and learning experiences to help students accurately assess the level of risk-taking behavior among their peers (for example, how many of their peers use illegal drugs), correct misperceptions of peer and social norms, emphasizes the value of good health, and reinforces health-enhancing attitudes and beliefs.

An effective curriculum provides opportunities for students to validate positive health-promoting beliefs, intentions, and behaviors. It provides opportunities for students to assess their vulnerability to health problems, actual risk of engaging in harmful health behaviors, and exposure to unhealthy situations.

An effective curriculum provides opportunities for students to analyze personal and social pressures to engage in risky behaviors, such as media influence, peer pressure, and social barriers.

An effective curriculum builds essential skills — including communication, refusal, assessing accuracy of information, decision-making, planning and goal-setting, self-control, and self-management — that enable students to build their personal confidence, deal with social pressures, and avoid or reduce risk behaviors.

For each skill, students are guided through a series of developmental steps:

• Discussing the importance of the skill, its relevance, and relationship to other learned skills.
• Presenting steps for developing the skill.
• Modeling the skill.
• Practicing and rehearsing the skill using real–life scenarios.
• Providing feedback and reinforcement.

An effective curriculum provides accurate, reliable, and credible information for usable purposes so students can assess risk, clarify attitudes and beliefs, correct misperceptions about social norms, identify ways to avoid or minimize risky situations, examine internal and external influences, make behaviorally relevant decisions, and build personal and social competence. A curriculum that provides information for the sole purpose of improving knowledge of factual information will not change behavior.

An effective curriculum includes instructional strategies and learning experiences that are student-centered, interactive, and experiential (for example, group discussions, cooperative learning, problem solving, role playing, and peer-led activities). Learning experiences correspond with students’ cognitive and emotional development, help them personalize information, and maintain their interest and motivation while accommodating diverse capabilities and learning styles. Instructional strategies and learning experiences include methods for

• Addressing key health-related concepts.
• Encouraging creative expression.
• Sharing personal thoughts, feelings, and opinions.
• Thoughtfully considering new arguments.
• Developing critical thinking skills.

An effective curriculum addresses students’ needs, interests, concerns, developmental and emotional maturity levels, experiences, and current knowledge and skill levels. Learning is relevant and applicable to students’ daily lives. Concepts and skills are covered in a logical sequence.

An effective curriculum has materials that are free of culturally biased information but includes information, activities, and examples that are inclusive of diverse cultures and lifestyles (such as gender, race, ethnicity, religion, age, physical/mental ability, appearance, and sexual orientation). Strategies promote values, attitudes, and behaviors that acknowledge the cultural diversity of students; optimize relevance to students from multiple cultures in the school community; strengthen students’ skills necessary to engage in intercultural interactions; and build on the cultural resources of families and communities.

An effective curriculum provides enough time to promote understanding of key health concepts and practice skills. Behavior change requires an intensive and sustained effort. A short-term or “one shot” curriculum, delivered for a few hours at one grade level, is generally insufficient to support the adoption and maintenance of healthy behaviors.

An effective curriculum builds on previously learned concepts and skills and provides opportunities to reinforce health-promoting skills across health topics and grade levels. This can include incorporating more than one practice application of a skill, adding “skill booster” sessions at subsequent grade levels, or integrating skill application opportunities in other academic areas. A curriculum that addresses age-appropriate determinants of behavior across grade levels and reinforces and builds on learning is more likely to achieve longer-lasting results.

An effective curriculum links students to other influential persons who affirm and reinforce health–promoting norms, attitudes, values, beliefs, and behaviors. Instructional strategies build on protective factors that promote healthy behaviors and enable students to avoid or reduce health risk behaviors by engaging peers, parents, families, and other positive adult role models in student learning.

An effective curriculum is implemented by teachers who have a personal interest in promoting positive health behaviors, believe in what they are teaching, are knowledgeable about the curriculum content, and are comfortable and skilled in implementing expected instructional strategies. Ongoing professional development and training is critical for helping teachers implement a new curriculum or implement strategies that require new skills in teaching or assessment.

• Botvin GJ, Botvin EM, Ruchlin H. School-Based Approaches to Drug Abuse Prevention: Evidence for Effectiveness and Suggestions for Determining Cost-Effectiveness [pdf 85K] -->. In: Bukoski WJ, editor. Cost-Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implications for Programming and Policy . NIDA Research Monograph, Washington, DC: U.S. Department of Health and Human Services, 1998;176:59–82.
• Contento I, Balch GI, Bronner YL. Nutrition education for school-aged children. Journal of Nutrition Education 1995;27(6):298–311.
• Eisen M, Pallitto C, Bradner C, Bolshun N. Teen Risk-Taking: Promising Prevention Programs and Approaches --> . Washington, DC: Urban Institute; 2000.
• Gottfredson DC. School-Based Crime Prevention. In: Sherman LW, Gottfredson D, MacKenzie D, Eck J, Reuter P, Bushway S, editors. Preventing Crime: What Works, What Doesn’t, What’s Promising [pdf 100K] -->. National Institute of Justice; 1998.
• Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 2001.
• Kirby D, Coyle K, Alton F, Rolleri L, Robin L. Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs . Scotts Valley, CA: ETR Associates; 2011.
• Lohrmann DK, Wooley SF. Comprehensive School Health Education. In: Marx E, Wooley S, Northrop D, editors. Health Is Academic: A Guide to Coordinated School Health Programs . New York: Teachers College Press; 1998:43–45.
• Lytle L, Achterberg C. Changing the diet of America’s children: what works and why? Journal of Nutrition Education 1995;27(5):250–60.
• Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane, E, Davino K. What works: principles of effective prevention programs. American Psychologist 2003;58(6/7):449–456.
• Stone EJ, McKenzie TL, Welk GJ, Booth ML. Effects of physical activity interventions in youth. Review and synthesis. American Journal of Preventive Medicine 1998;15(4):298–315.
• Sussman, S. Risk factors for and prevention of tobacco use. Review. Pediatric Blood and Cancer 2005;44:614–619.
• Tobler NS, Stratton HH. Effectiveness of school-based drug prevention programs: a meta-analysis of the research. Journal of Primary Prevention 1997;18(1):71–128.
• U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People–An Update: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2011: 6-22–6-45.
• Weed SE, Ericksen I. A Model for Influencing Adolescent Sexual Behavior . Salt Lake City, UT: Institute for Research and Evaluation; 2005. Unpublished manuscript.

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Teaching methods in health education

Common group health education methods.

A lecture is usually a spoken, simple, quick and traditional way of presenting your subject matter, but there are strengths and limitations to this approach. The advantages include the efficient introduction of factual material in a direct and logical manner. However, this method is ineffective where the audience is passive, and learning is difficult to gauge. Experts are not always good teachers and communication in a lecture may be one- way with no feedback from the audience.

B) Lecture With Discussion

This approach is critical because it always involves your audience after the lecture in asking questions, seeking clarification and challenging and reflecting on the subject matter. There always become active participation from the side of the attendants. i.e., participants are not passive as in the case of lecture method.

C) Group Discussions

Discussion in a group allows people to say what is in their minds. They can talk about their problems, share ideas, support and encourage each other to solve problems and change their behaviour (Figure 7.2).

Planning a Discussion:

• Identification of the discussants that do have a common interest E.g. mothers whose child suffers from diarrhoea.
• Getting a group together
• Identification of a comfortable place and time.

Conducting the Discussion:

• An introduction of group members to each other.
• Allow group discussion to begin with general knowledge E.g. any health problems they have ever faced.
• Encourage everyone to participate.
• Have a group act out some activity (drama, role play).
• Limit the duration of discussion to the shortest possible, usually 1 -2 hrs.
• Check for satisfaction before concluding the session. E.g. Do they think that they are learning? Do they think the group should continue?.

D) Buzz Group

It is a type of group discussion In which a large group will be divided into several small groups, of not more than 10 or 12 people (buzz groups). You can then give each small buzz group a certain amount of time to discuss the problem. Then, the whole group comes together again, and the reporters from the small group report their findings and recommendations back to the entire audience. A buzz group is also something you can do after giving a lecture to a large number of people, so you get useful feedback

E) Meetings

Meetings are good for teaching something of importance to a large group of people. They are held to gather information, share ideas, take decisions, and make plans to solve problems. Meetings are different from group discussions. A group discussion is free and informal, while meetings are more organised. Meetings are an important part of successful self-help projects.When you are planning a meeting, it should be need based, determine the time and place announce the meeting through village criers or word of mouth and prepare a relevant and a limited number of agendas.

There are many kinds of organizations to which women, men and young people belong. Clubs are becoming popular in many areas. They provide an opportunity for a systematic way of teaching over an extended period of time. E.g. a group of citizens could form an association to deal with problems related to a major local disease or to protect the environment. For example anti-HIV/AIDS club

G) Demonstrations

A demonstration is a step-by step procedure that is performed before a group. They involve a mixture of theoretical teaching and of practical work, which makes them lively. It is used to show how to do something. The main purpose of demonstrations is helping people learn new skills. The size of the group should be small to let members get the chance to practice. It is particularly useful when combined with a home visit. This allows people to work with familiar materials available in the locality.

Although demonstration sessions usually focus on practice, they also involve theoretical teaching as well 'showing how is better than telling how' (Figure 7.3). This is because you can remember 20% of what you hear, you remember 50% of what you hear and see, you remember 90% of what you hear, and see and do- with repetition, close to 100% is remembered.

Procedures and Steps of Demonstration:

• Introduction : Explain the ideas and skills that you will demonstrate and the need for it.
• Do the demonstration: Do one step at a time, slowly. Make sure everyone can see what you are doing. Give explanations as you go along.
• Questions: Encourage discussion either during or at the end of the demonstration. Ask them to demonstrate back to you or to explain the steps.
• Summarise: Review.

Qualities of Good and Effective Demonstrations:

• Identify the needs of the group to learn.
• Collect the necessary materials such as models and real objects or posters and photographs.
• Make sure that it fits with the local culture. E.g. for nutrition demonstration you have to use the common food items and local cooking methods.
• Prepare adequate space so that everyone could see and practice the skill.
• Choose the time that is convenient for everyone.

H) Role - Playing

Role-playing consists of the unrehearsed and spontaneous acting out of real-life situations and problems. The player tries to behave in a way that the character might behave when faced with a given situation or problem. Role-playing can be used to start off a discussion, to see what possible consequences of a certain action are, and to develop a better understanding of why people feel as they do.

We learn about our own behaviour during a role-play, we can discover how our attitudes and values encourage cooperation and problem solving or, how our attitude and values create problems. During a role-playing participants are selected randomly or blindly and are given a role or character and have to think and speak immediately without detailed planning, because there is usually no script.

Role play is usually undertaken in small groups of 4 to 6 people. Remember role play is a very powerful thing and works best when people know each other, don't ask people to take a role that might embarrass them. Sometimes role play involves some risk of misunderstanding, because people may interpret things differently.

Dramas need script, rehearsal and preparation which done on one main learning objective but can often include 2 or 3 other less important objectives as well. Alike stories, dramas make us look at our own behavior, attitudes, beliefs and values in the light of what we are told or shown. Plays are interesting because you can both see and hear them. It is a suitable teaching method for people who cannot read , because they often experience things visually. However the preparation and practice for a drama may cost time and money.

Let us look at some of the following traditional means of communications which are used by the community to express their local culture such as their knowledge, feelings, happiness, sadness or any life situations to others.

J) Songs and Dances

In addition to expression of feelings, songs can also be used to give ideas about health with dances or some times without dances. For example, the following issues could be entertained: The village without safe water, the malnourished child who got well with the proper food to eat, the village girl who went to school to become a health extension worker.

Stories often tell about the deeds of famous heroes or of people who lived in the village long ago. Story telling is highly effective, can be developed in any situation or culture, and requires no money or equipment. It should include some strong emotions like sadness, anger; humor, or happiness as well as some tension and surprise. An older person, instead of directly criticizing the behavior of youth, may tell stories to make his/her points. She/he may start by saying, "I remember some years ago there were young people just about your age..." and then continue to describe what these young people did that caused trouble.

l) Proverbs

They are short common-sense sayings that are handed down from generation to generation. For example:

• Amharic proverb "TamoKememakekAskedimoMetenkek" specify "prevention is better than cure".
• "Dirbiyabranbessayasir" Amharic proverb.
• "A single bracelet does not jingle" African proverb.
• "If I hear, I forget, If I see, I remember If I do, I know". A Chinese proverb which states about active learning or learning by doing.
• "One does not go in search of a cure for ringworm while leaving leprosy unattended." This means that trying to solve the most serious problem must come first.

Health Education, Advocacy and Community Mobilisation Module: 10. How to Teach Health Education and Health Promotion

Study session 10  how to teach health education and health promotion, introduction.

This study session focuses on your work as a health educator. Health education is a very important part of your work and if you do it well it will help you improve the health of the people for whom you are responsible. In this session you will learn about teaching methods as well as some of the teaching materials you will be using in your work. Teaching methods refers to ways through which health messages are used to help solve problems related to health behaviours. Teaching materials or aids are used to help you and support the communication process in order to bring about desired health changes in the audience.

In this study session you will be able to learn about those concepts and definitions (Figure 10.1), as well as the practical application of teaching methods and health learning materials that will help you in your work.

Learning Outcomes for Study Session 10

When you have studied this session, you should be able to:

10.1  Define and use correctly all of the key words printed in bold . (SAQ 10.1)

10.2  Discuss some of the most important types of teaching methods. (SAQs 10.1 and 10.2)

10.3  Describe the advantages and limitations of various teaching methods. (SAQs 10.1 and 10.2)

10.3  Discuss the various types of Information Education Communication (IEC) or health learning materials. (SAQs 10.1 and 10.2)

10.4  Describe the role of IEC materials in disease prevention and health promotion. (SAQs 10.1, 10.2 and 10.3)

10.1  Teaching methods

There is a wide variety of teaching methods that you will be able to use in your health education work. You will be able to adapt these methods to your own situation, so that you can use the most effective way of communicating your health education messages.

10.1.1  Health talks

You may consider that the best way of communicating your health messages in certain situations is by using health talks. Talking is often the most natural way of communicating with people to share health knowledge and facts. In the part of your job that involves health education, there will always be many opportunities to talk with people.

Group size is also important . The number of people who you are able to engage in a health talk depends on the group size. However, you will find talks are most effective if conducted with small gatherings (5–10 people), because the larger the group the less chance that each person has to participate (Figure 10.2).

Think of some situations when you think it might be best to use health talks to get across your health education messages.

Talking is a very flexible form of communication. Talks can be conducted with one person, or with a family or a group of people, and you can adjust your message to fit the needs of that group. One example of this would be communicating a health message to a group of young mothers about their use of contraception. Even informal talks can include information about the benefits and side-effects of using contraception.

Talking to a person who has come for help is much like giving advice. But as you will see, advice is not the same as health education. To make a talk educational rather than just a chat you will find it beneficial if it is combined with other methods, especially visual aids, such as posters or audiovisual material. Also a talk can be tied into the local setting by the use of proverbs and local stories that carry a positive health message.

Preparing a talk

When you are preparing a talk there are many things to consider:

Detailed knowledge on these topics is covered in the Nutrition Module.

• Begin by getting to know the group . Find out its needs and interests and discover which groups are active in your locality.
• Then select an appropriate topic . The topic should be about a single issue or a simple topic. For example, although local people need help about nutrition, this is too big as a single topic to address in one session. So it should be broken down into simple topics such as breastfeeding, weaning foods, balanced diets, or the food needs of older people. Always ensure that you have correct and up-to-date information and look for sources of recent information. There may be leaflets available that can support your health messages .
• List the points you will talk about : Prepare only a few main points and make sure that you are clear about them.
• Next, write down what you will say : If you do not like writing, you must think carefully what to include in your talk. Think of examples, proverbs and local stories to emphasise your points and which include positive health messages
• Visual aids are a good way to capture people’s attention and make messages easer to understand. Think of what you have available to illustrate your talk. Well-chosen posters and photos that carry important health messages will help people to learn.
• Practice your talk beforehand : This should include rehearsing the telling of stories and the showing of posters and pictures.
• Determine the amount of time you need : The complete talk including showing all your visual aids should take not more than about 20 minutes. Allow another 15 minutes or more for questions and discussions. If the talk is too long people may lose interest.

Look again at the list of seven features of preparing a talk. Think about those areas in this list that you are confident about, and then those areas where you feel you will have to do some learning and practising.

The list shows the benefits of being well prepared. As you will see, only point 6 is actually about rehearsals! Most of the list is about being sure you know your audience and that you are well informed and know what you want to say and show. So, if you are nervous, then remember that you can cut down on anxiety by taking this list seriously and being very well prepared.

There are, of course other variations on talking. But all of them rely on the same key features, which are knowing your audience, being well prepared and practising.

10.1.2  Lecture

You may have the opportunity to give a lecture, perhaps in your local school or in another formal setting. A lecture is usually a spoken, simple, quick and traditional way of presenting your subject matter, but there are strengths and limitations to this approach. The strengths include the efficient introduction of factual material in a direct and logical manner. However, this method is generally ineffective where the audience is passive and learning is difficult to gauge. Experts are not always good teachers and communication in a lecture may be one-way with no feedback from the audience.

Lecture with discussion

You may have the opportunity to give a lecture and include a follow-up discussion, perhaps in a local formal setting or during a public meeting (Figure 10.3).

However there are also strengths and limitations to this approach. It is always useful to involve your audience after the lecture in asking questions, seeking clarification and challenging and reflecting on the subject matter. It’s important though to make sure discussion does happen and not just points of clarification.

10.1.3  Group discussion

Group discussion involves the free flow of communication between a facilitator and two or more participants (Figure 10.4). Often a discussion of this type is used after a slide show or following a more formal presentation. This type of teaching method is characterised by participants having an equal chance to talk freely and exchange ideas with each other. In most group discussions the subject of the discussion can be taken up and shared equally by all the members of the group. In the best group discussions, collective thinking processes can be used to solve problems. These discussions often develop a common goal and are useful in collective planning and implementation of health plans. Group discussions do not always go smoothly and sometimes a few people dominate the discussion and do not allow others to join in. Your job as the facilitator is to establish ground rules and use strategies to prevent this from happening.

Handling group members requires patience, politeness, the avoidance of arguments and an ability to deal with different people without excessive authority or belittling them publicly. Think for a moment about how you might prevent a few people from dominating a group discussion.

The key skill in group work that may prevent such domination is by encouraging full participation of everyone in the group. You may be able to ensure participation in several ways, for example by using questioning and by using other methods that facilitate active participation and interaction. Quiet or unresponsive participants need to be brought into the discussion, perhaps by asking them easy questions so that they gain in confidence. Conversely, any community member dominating the discussion excessively should be restrained, possibly by recognising his or her contribution, but requesting information from someone who has yet to be heard. Sometimes it may be necessary to be more assertive, by reminding a dominant member of the objectives of the meeting and the limited time available.

Box 10.1 gives more ideas about managing disruptive group discussions.

Box 10.1  Group disruption

Groups can be disrupted by several types of behaviour:

• People who want a fight : Do not get involved. Explore their ideas, but let the group decide their value.
• Would like t o help : Encourage them frequently to give ideas, and use them to build on in the discussion.
• Focuses on small details : Acknowledge his or her point but remind them of the objective and the time limit for the discussion.
• Just keeps talking : Interrupt tactfully. Ask a question to bring him or her back to the point being discussed and thank them for their contribution.
• Seems afraid to speak : Ask easy questions. Give them credit to raise their confidence.
• Insists on their own agenda : Recognise the person’s self-interest. Ask him or her to focus on the topic agreed by the group.
• Is just not interested : Ask about their work and how the group discussion could help.

10.1.4  Buzz group

A buzz group is a way of coping if a meeting is too large for you. In this situation it is better to divide the group into several small groups, of not more than 10 or 12 people. These are called buzz groups . You can then give each small buzz group a certain amount of time to discuss the problem. Then, the whole group comes together again and the reporters from the small groups report their findings and recommendations back to the entire audience. A buzz group is also something you can do after giving a lecture to a large number of people, so you get useful feedback.

10.1.5  Demonstration

In your work as a health educator you will often find yourself giving a demonstration (Figure 10.5). This form of health education is based on learning through observation. There is a difference between knowing how to do something and actually being able to do it. The aim of a demonstration is to help learners become able to do the skills themselves, not just know how to do them.

Can you think of health related things that would be best taught through demonstration?

The whole process of measuring blood pressure, how to use a mosquito net, putting on a condom, giving a child some medicine, etc. can be best illustrated through a demonstration.

You should be able to find ways to make health related demonstrations a pleasant way of sharing skills and knowledge. Although demonstration sessions usually focus on practice — they also involve theoretical teaching as well ‘showing how is better than telling how’.

If I hear, I forget If I see, I remember If I do, I know. Chinese proverb

• You remember 20% of what you hear
• You remember 50% of what you hear and see
• You remember 90% of what you hear, see and do — with repetition, close to 100% is remembered.

Giving a demonstration

There are four steps to a demonstration:

• Explaining the ideas and skills that you will be demonstrating
• Giving the actual demonstration
• Giving an explanation as you go along, doing one step at a time
• Asking one person to repeat the demonstration and giving everyone a chance to repeat the process (Figure 10.6).

Qualities of a good demonstration

For an effective demonstration you should consider the following features: the demonstration must be realistic, it should fit with the local culture and it should use familiar materials. You will need to arrange to have enough materials for everyone to practice and have adequate space for everyone to see or practice. People need to take enough time for practice and for you to check that everyone has acquired the appropriate skill.

Zahara is a Health Extension Practitioner. She is working in Asendabo kebele . During home visits she educates the families by showing them demonstrations on how to prevent malaria. List at least three features of an effective demonstration that Zahara should follow during her health education activities.

For the demonstration to be effective Zahara should consider the following important points: the materials that she might use and the demonstration process should be real. So, for example, she should have real bed netting with her and at least something she can use that is like a bed. The demonstration should fit with the local culture and she should explain what she is doing as she goes along. She should make sure that there is enough time for at least one person to repeat the demonstration of fitting the bed netting and, if at all possible, for everyone to practice doing it.

10.1.6  Role play

In role play, some of the participants take the roles of other people and act accordingly. Role play is usually a spontaneous or unrehearsed acting out of real-life situations where others watch and learn by seeing and discussing how people might behave in certain situations. Learning takes place through active experience; it is not passive. It uses situations that the members of the group are likely to find themselves in during their lives. You use role playing because it shows real situations. It is a very direct way of learning; participants are given a role or character and have to think and speak immediately without detailed planning, because there is usually no script. In a role playing situation people volunteer to play the parts in a natural way, while other people watch carefully and may offer suggestions to the players. Some of the people watching may decide to join in with the play.

The purpose of role play is that it is acting out real-life situations in order that people can better understand their problems and the behaviour associated with the problem. For example, they can explore ways of improving relationships with other people and gain the support of others as well. They can develop empathy, or sympathy, with the points of view of other people. Role play can give people experiences in communication, planning and decision making. For example it could provide the opportunity to practice a particular activity such as coping with a difficult home situation. Using this method may help people to re-evaluate their values and attitudes, as the examples in Box 10.2 illustrate.

Box 10.2  Examples of role play

• Ask a person to get into a wheelchair and move around a building to develop an understanding of what it feels like to have limited mobility.
• Ask the group to take up the roles of different members of a district health committee. One person acts as the health educator and tries to convince the people to work together and support health education programmes in the community. Problems of implementing health education programmes and overcoming resistance can be explored in the discussion afterwards.
• Ask a man to act out the role of woman, perhaps during pregnancy, to develop an understanding of the difficulties that women face.

Role play is usually undertaken in small groups of 4 to 6 people. Remember role play is a very powerful thing.

• Role play works best when people know each other.
• Don’t ask people to take a role that might embarrass them.
• Role play involves some risk of misunderstanding, because people may interpret things differently.

Look at the three examples of role play in Box 10.2. What dilemmas might arise in each situation?

Here are some possible dilemmas. If a person in your group is already in a wheelchair you would need to handle the role play very carefully. If anyone in your group is in a dispute with someone on the health education committee they might take the opportunity to be spiteful. If a man is acting the role of a woman he would need to feel comfortable doing this. If it looks as though he is very embarrassed you would need to ask for another volunteer or change what you are doing.

10.1.7  Drama

Drama is a very valuable method that you can use to discuss subjects where personal and social relationships are involved. Basic ideas, feelings, beliefs and values about health can be communicated to people of different ages, education and experience. It is a suitable teaching method for people who cannot read, because they often experience things visually. However the preparation and practice for a drama may cost time and money.

The general principles in drama are:

• Keep the script simple and clear
• Identify an appropriate site
• Say a few words at the beginning of the play to introduce the subject and give the reasons for the drama
• Encourage questions and discussions at the end.

10.1.8  Traditional means of communication

Traditional means of communication exploit and develop the local means, materials and methods of communication, such as poems, stories, songs and dances, games, fables and puppet shows.

Some of the benefits of traditional means of communication are that they are realistic and based on the daily lives of ordinary people; they can communicate attitudes, beliefs, values and feelings in powerful ways; they do not require understanding that comes with modern education in the majority of instances; they can communicate problems of community life; they can motivate people to change their behaviour and they can show ways to solve problems. Local traditional events are usually very popular and they can be funny, sad, serious or happy. Also, they are easily understood and they usually cost little or no money. All they require is imagination and practice.

Remember that effective health education is seldom achieved through the use of one method alone. Therefore, a combination or variety of methods should be used to make sure that people really understand your health education messages.

Think of an important health issue in your own community. What methods do you think might be best to deliver health messages about this subject to members of your own community? Read Section 10.1 again and see which methods seem to fit in with your community.

Your answer will be different depending on factors that affect the message you want to deliver. For example, if skills need to be taught then a demonstration is a good method. If your objective is to improve awareness, lecturing may be a good method. Your methods may also vary depending on your own knowledge of your community. For example, you may know several people who enjoy ‘play acting’ and this would make drama and role play quite attractive methods. Also if you have someone in your community who is very good at telling stories or fables, or singing, then you may be able to work with them to help you deliver your messages.

10.2  Health learning materials

Health learning materials are those teaching aids that give information and instruction about health specifically directed to a clearly defined group or audience. The health learning materials that can be used in health education and promotion are usually broadly classified into four categories: printed materials, visual materials, audio and audio-visual materials.

10.2.1  Printed materials

Printed health learning materials can be used as a medium in their own right or as support for other kinds of media. Some printed health learning materials that you will already be familiar with include posters, leaflets and flip charts.

In recent years, the use of posters in communicating health messages has increased dramatically (Figure 10.7). Since a poster consists of pictures or symbols and words, it communicates health messages both to literate and illiterate people. It has high value to communicate messages to illiterate people because it can serve as a visual aid .

The main purposes of posters are to reinforce or remind people of a message received through other channels, and to give information and advice — for example to advise people to learn more about malaria. They also function to give directions and instructions for actions, such as a poster about practical malaria prevention methods. Posters can also serve to announce important events and programmes such as World Malaria Day.

Visual aids like posters explain, enhance, and emphasise key points of your health messages. They allow the audience to see your ideas in pictures and words. Box 10.3 gives some tips on preparing posters.

Box 10.3  Preparing a poster

• Written messages should be synchronised with pictures or symbols.
• All words in a poster should be in the local language or two languages.
• The words should be few and simple to understand. A slogan might contain a maximum of seven words.
• The symbols used should be understood by everyone, whatever their educational status.
• The colours and pictures should be ‘eye-catching’ and meaningful to local people.
• Put only one idea on a poster. If you have several ideas, use a flip chart (see below).
• The poster should encourage practice-action oriented messages.
• It is better to use real-life pictures if possible.
• It should attract attention from at least 10 metres away.

Flip charts are useful to present several steps or aspects that are relevant to a central topic, such as, demonstration of the proper use of mosquito nets or how HIV is transmitted. When you use the flip chart in health education you must discuss each page completely before you turn to the next and then make sure that everyone understands each message. At the end you can go back to the first charts to review the subject and help people remember the ideas.

Leaflets are the most common way of using print media in health education. They can be a useful reinforcement for individual and group sessions and serve as a reminder of the main points that you have made. They are also helpful for sensitive subjects such as sexual health education. When people are too shy to ask for advice they can pick up a leaflet and read it privately.

In terms of content , leaflets, booklets or pamphlets are best when they are brief, written in simple words and understandable language. A relevant address should be included at the back to indicate where people can get further information.

Think for a moment about how you have seen printed materials used for health education messages. Think about posters which have been successful and made an impact, about how other health educators have used flip charts. So you can always ‘copy’ the way that other people do things. If you have a talent yourself or know someone else who does, you can experiment with posters and flip charts (Figure 10.8).

10.2.2  Visual materials

Visuals materials are one of the strongest methods of communicating messages, especially where literacy is low amongst the population. They are good when they are accompanied with interactive methods. It is said that a picture tells a thousand words. Real objects, audio and video do the same. They are immediate and powerful and people can play with them!

Think about what real visual materials you might take with you to a health education meeting. We’ve already mentioned bed netting for demonstrating prevention of malaria, but there are other real objects too. Think about family planning, nutrition, hygiene and so on.

If your display is on ‘family planning methods’, display real contraceptives, such as pills (Figure 10.9), condoms, diaphragms, and foams. If your display is on weaning foods, display the real foods and the equipment used to prepare them.

10.2.3  Audio and audio-visual materials

Audio material includes anything heard such as the spoken word, a health talk or music. Radio and audio cassettes are good examples of audio aids. As the name implies, audio-visual materials combine both seeing and listening. These materials include TV, films or videos which provide a wide range of interest and can convey messages with high motivational appeal. They are good when they are accompanied with interactive methods. Audio-visual health learning materials can arouse interest if they are of high quality and provide a clear mental picture of the message. They may also speed up and enhance understanding or stimulate active thinking and learning and help develop memory.

Summary of Study Session 10

In Study Session 10, you have learned that:

• To be most effective you will have to decide which type of teaching methods and materials will suit the specific messages that you want to convey. It is also important to understand who your target groups are and what resources you have at hand to meet your communication objectives.
• The most important teaching methods are talks, lectures, group discussions, buzz groups, demonstrations, role-plays, dramas and traditional means of communication such as poems, stories, songs, dances and puppet shows.
• Health learning materials include posters, flip charts and leaflets, visual materials such as real objects, and audio-visual material such as TV, films and videos.
• Often more than one approach is more effective than a single type of activity. Using the right teaching methods and learning materials for the right target group in your health education programme helps you to convey effective messages to individuals and communities. This stands the best chance of bringing about health-related behavioural change.

Self-Assessment Questions (SAQs) for Study Session 10

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 10.1 (tests Learning Outcomes 10.1, 10.2, 10.3 and 10.4)

Explain the difference between teaching methods and health learning materials and give examples of each of them.

Teaching methods are ways through which health messages are conveyed. Learning materials are printed, visual or audio-visual aids that are used to help you and support the communication process, in order to bring about desired health changes in the audience. Examples of learning methods are: lecture, lecture with discussion, role play and drama. Examples of teaching materials are: posters, leaflets and flipcharts.

SAQ 10.2 (tests Learning Outcomes 10.2, 10.3 and 10.4)

Which of the following statements is false ? In each case explain why it is incorrect.

A  The health education method which is superior to any other method is drama.

B  The lecture method is good for helping an individual with their health problems.

C  Role play is a method which is spontaneous and often unscripted.

D  The teaching method that has the saying ‘Telling how is better than showing how?’ is the demonstration method.

E  A poster should contain more than one idea and its importance is to give information only.

A is false . In health education there is no method which is superior to any other method. Choice of methods depends on some important points that need to be taken into consideration. The method must suit the situation and the problem, so before choosing a method the person delivering health education must understand the problem at hand and the background of the audience.

B is false . A lecture is usually a spoken, factual way of presentation of the subject matter to many people. It is passive teaching because there is no opportunity for individual health problems to be discussed in lecture methods.

C is true . Role play is a spontaneous or unrehearsed acting out of real-life situations where others watch and learn by seeing and discussing how people behave in a certain situations. There is usually no script.

D is false . In a demonstration ‘showing how’, is better than ‘telling how’.

E is false . Each poster should contain one idea. Its importance is more than just giving information. A poster can reinforce or remind people about a message that has been received through other channels; give information and advice; or give directions and instructions for actions. It may also announce important events and programmes.

SAQ 10.3 (tests Learning Outcome 10.4)

A  Audio-visual materials and real objects are particularly useful in situations where the literacy rate of a group is very high.

B  Real objects are useful learning aids because people can actually see and touch them — and they are immediate.

C  Audio-visual materials and real objects are used only as a last resort when there are not enough posters to show.

D  Demonstrations are activities where the use of real objects enhances the learning that people achieve.

A is false . In fact just the opposite is true. It is generally thought that audio-visual materials and real objects work well with audiences where the level of literacy is low.

B is true . Real objects can help people literally have a ‘hands on’ learning experience which can be very powerful.

C is false . Real objects and audio-visual materials are suitable for some circumstances and posters for others. Sometimes you will want to use all of them. It is a matter of knowing what will be effective for your audience.

D is true . Demonstrations are the ideal place to use real objects. In fact if you do not use real objects (or models) in demonstrations then you will not be able to show how to do something in a convincing way.

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8 Health education

• Published: November 2014
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Health education has sometimes fallen out of fashion but this chapter argues that it is an essential element in health promotion. Health education is a process which seeks to empower individuals and build health literacy. It seeks to help people acquire the knowledge and skills needed to maintain and improve their health. Though health education may be delivered one to one this chapter deals with working with groups.

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Health education for young people: Approaches and methods

INSERM Collective Expertise Centre .

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This document presents the synthesis and recommendations of the expert advisory group brought together by Institut national de la santé et de la recherche médicale (INSERM), in the framework of the procedure for expert advisory opinions to respond to the questions asked by Caisse nationale d'assurance maladie des professions indépendantes (CANAM; national health insurance fund for independent workers) about the developments and appropriateness of methods of health education for young people.

The Centre d'expertise collective * (center for expert advisory opinions) of INSERM coordinated this expert advisory group, in collaboration with the Departement du partenariat economique et social (department for economic and social partnership) for the preparation of the file and the documentation department of Departement de l'information scientifique et de la communication (DISC; department of scientific information and communication) for the research bibliography.

Recent decades have seen major changes in health issues. This development has been marked by the relative increase in diseases associated with lifestyles or with behaviors considered to be "at risk" for negative health consequences and by skyrocketing health costs that exhaust the funds available.

Prevention, health education, health promotion—these are some of the diverse labels of the numerous activities involved in reducing risks and modifying behaviors with the aim of improving the quality of life and prolonging it. In 1986, in the Ottawa Charter, the World Health Organization (WHO) defined health promotion as "the process of enabling people to increase control over, and to improve their health". In France, the National conference on health for the year 2000, stressing the importance of developing prevention and education as an approach to health promotion, emphasized the need to work more deeply on the behavioral and environmental determinants of health. It observed that France lacked a legislatively imposed legal basis for setting the boundaries for health education activities and for establishing a minimum of quantitative or qualitative requirements.

In French, two expressions—literally translated as "education for health" and "education to health"—are used interchangeably in official texts and publications. In fact, however, they cover two different practices. Health professionals, who consider health to be a process of permanent adaptation, prefer education "for" health to stress the maintenance of this process. On the other hand, education professionals, use the preposition "to", by analogy with education "to" citizenship and the environment, to underline the educational dimension of this mission. The 1998 establishment of committees of health and civic education inside schools and the introduction of health education into school curricula marked an important step forward. Nonetheless, both the means and the skills available are frequently inadequate.

The multiplicity of bodies involved in these programs and interventions does not facilitate the system's consistency or its ability to capitalize on its experience. The lack of coordination between various public agencies and the lack of relationships between researchers and field workers are reflected in the difficulty of developing evaluation methods and of the minimal visibility of most activities in this domain. For example, there is no specialist journal publishing research and innovative actions implemented in health education in the countries of the European Community, although it would enrich the literature in this field, a literature that today is essentially North American.

CANAM sought information and advice from INSERM, through the expert advisory group procedure, on the recent scientific data about the quality, consistency, and effectiveness of health education methods for young people, both nationally and internationally, with particular attention to the methods intended to prevent risk behaviors in the areas of sex and psychoactive substance use.

To respond to CANAM, INSERM established a multidisciplinary group of experts that brought together scholars with expertise in the domains of health education, public health, public law, epidemiology, psychosociology, and pedagogy. The group's analysis was structured around the following questions:

• What are currently the principal concepts in health education? What observations have structured their development?
• How is health education implemented within the educational system? How do the institutional solutions in France compare to those in other countries?
• What legislative and regulatory framework circumscribes health education for youth in France?
• How do different methods take into account the background items, objective or subjective, that justify particular activities in health education?
• What elements are recognized to determine the quality and effectiveness of interventions in health education? Are there any forms of health education intervention that have been reported to have attained all or part of their objectives? Under what conditions can these activities be perpetuated? Under what conditions are various activities transferrable?
• What are the specific factors involved in the effectiveness of educational activities in preventing "at-risk" behaviors that endanger health, in the domains of sex and psychoactive substance use?

Querying databases and searching for unpublished documents allowed us to construct a corpus of approximately 1,400 documents, including articles published in scientific journals, reference works, reports of interventions, the gray literature, and official texts. Approximately 900 documents, more specifically focused on activities in school settings, were analyzed by the expert advisory group.

During six working sessions organized between November 1999 and September 2000, the panel members presented a critical analysis and synthesis of the works published in their fields of expertise. The last two sessions were devoted to the collective validation of the synthesis and to drafting the recommendations.

• Expert advisory group and authors

Expert group and authors

Pierre ARWIDSON , assessment and studies department, French committee for health education (CFES), Vanves

Jacques A. BURY , public health, Institute of social and preventive medicine, University of Geneva

Marie CHOQUET , adolescent health, psychology and epidemiology, INSERM Unit 472, Villejuif

Christine DE PERETTI , department of education policy, practice, and participants, School and health unit, INRP, Paris

Alain DECCACHE , director of the RESO-education for health unit, Catholic University of Louvain (UCL), Brussels

Marie-Laure MOQUET-ANGER , director of the public law study laboratory, School of law, Rennes 1

Geneviève PAICHELER , sociology, Public policy and health, CNRS-CERMES UMR 8559, INSERM Unit 502, Paris

Scientific and editorial coordinators

Jeanne ETIEMBLE , director of the Center for expert advisory opinions of Inserm

Martine MUFFAT-JOLY , scientific attaché, Center for expert advisory opinions

Marie-Josée PRIGENT , chargé d'expertise, Center for expert advisory opinions

Bibliographic and technical assistance

Chantal GRELLIER et Florence LESECQ , Center for expert advisory opinions

English translation

Jo Ann CAHN , independent scientific editor and translator

According to the French Treatise on Public Health, there are three categories of health education: primary, secondary, and tertiary. Primary education is that aimed at reinforcing the students' good health. Secondary education involves measures intended to avoid accidents to health or, if such an accident has already occurred, to restore good health as rapidly as possible. Tertiary education is any educational intervention aimed at rehabilitation and adaptation to the sequelae of an accident. Health education thus intervenes both before and after any disease or injury.

Its justification is found today in public health data stressing the importance of behavior as an explanatory factor in most deaths that are considered premature and avoidable, particularly among the young. The cost of health education is generally agreed to be quite low in relation to the potential savings and is trivial compared with the costs of other sectors of the healthcare system. In France each year we spend, on average, per inhabitant: 10 F for health information and education, 250 F for preventive medicine, and 11,000 F for treatment of diseases.

Moreover, the value of health education is not only collective and economic; it also serves definite individual and personal interests. It allows each individual to develop his or her capacity to improve both longevity and quality of life, in the holistic vision of health as defined by WHO: "Health is a state of complete physical, mental and social well-being and does not consist only in an absence of disease or infirmity."

Health education is not the monopoly of government: it concerns all the players in the healthcare system, and, when young people are involved, all those in the educational system. Because it is everyone's business and involves a mission of general interest, it is performed by a multitude of participants often ignorant of one another, and it raises legal, ethical, and economic questions. We note, however, that in France the few scattered dispositions mentioning health education in the overall legislative and regulatory scheme provide a badly structured and poorly defined framework—helpful neither to its credibility nor its relevance.

A curative or treatment approach and a preventive approach, although different, are naturally complementary. The ethical codes of the medical and paramedical professions make health education a professional obligation, as do the regulatory texts. Moreover, the Public Health Code contains very explicit provisions endowing all health facilities, public and private, whether or not they participate in the public service of hospitals, with a mission of health education in addition to their primary treatment mission. In the last decade, some health insurance funds have created departments of health education and promotion, in accordance with the priorities defined by their Boards of Directors.

The role of schools was redefined in the 1989 framework law on education that first introduced health education into the school setting. A set of provisions in 1998 inserted health education into the nationally mandated curricula of primary and middle schools. Within schools, Committees for health and civics education were charged with the mission of health education and with organizing the prevention of substance abuse, other risk behaviors, and violence within the framework of the school's project or plan.

Traditional health education is the set of educational interventions intended to provide individuals with information about health and to induce them to adopt attitudes and behaviors that are good for their health. More recently, health education has broadened to include social and environmental aspects. The concept of "health promotion" was formalized in 1986 in the Ottowa Charter, still the international reference; it enlarged the educational approach by focusing on collective responsibility. It involves not only educating individuals but promoting collective mobilization and changes, while bearing in mind the psychosocial and societal determinants at the origin of behaviors and attitudes unfavorable to health. Health promotion includes health education, which is one of its essential components.

The ethical question of whether changes, of attitude or behavior, should be promoted is central to the debate about health education. In principle, the desire to change others can be considered ethical if the individual or group is conscious of this influence and if the change benefits the individual or group. Most health educators are averse to normalizing behavior, inducing guilt about health-related subjects, and relying on individual responsibility as the sole motor of change. A conference on health education and ethics held in January 2000 reviewed the four general principles used to guide health education interventions in North America: respect for social justice, respect for individual autonomy, the requirement that the program or intervention be beneficial, and the requirement that it not do harm. The debate on the construction of an appropriate ethic here has begun.

• From prevention to health education and promotion: a conceptual and methodological development

There is no single unequivocal definition of the concept of health, which has several senses: absence of disease; desirable biological state; biological, psychological, and social well-being; individual capacity to manage one's own life and environment; and more.

Health can be defined by physiological criteria and thus assessed by objective (or objectivated) indicators of this type. These are expressed essentially in terms of normal or at risk, as are the objectives of acts involving treatment and care. From this viewpoint, health is especially the concern of healthcare professionals.

Perceived simultaneously as a state and as a capacity, health is assessed in terms of power to mobilize and of social interactions. Health education therefore is not limited to learning which behaviors are risky and which protective but integrates other items, including an understanding of the place health has in life and the power one has over one's own health. Healthcare professionals and educators thus have a joint role.

Prevention has specific objects, disease and risk; it is thus related to a particular concept of health: the absence of disease. As such, it has two important advantages: it focuses attention on the problem that must be solved, and it has a prospective viewpoint (foresee and prevent). The disadvantage of this concept is that the subject matter is restricted to risks, that is, to behaviors judged to be negative and to their dangers. What health education requires, however, is as much the promotion and maintenance of health as the prevention of disease (and risk). Positive or protective health behaviors, such as physical exercise and good nutrition, are adopted more often for reasons of pleasure or health than to prevent risks.

During the last quarter century, the concept of prevention has slowly been enriched by the concept of "health promotion". Accordingly, prevention has grown progressively, from the avoidance of harmful agents in the biophysical environment to that of associated individual behaviors. This trend, which has shown that, beyond individual behaviors, social conditions play an important role, has been accompanied by a reduction in the incidence of infectious diseases, due to vaccination and improved hygiene. A "positive" vision of health has arisen, in particular, as a resource for life. The aim of health promotion is to increase this "health potential" or "health capital," individually and collectively.

Generically, health education can be defined as a set of intentional activities designed to transfer or construct knowledge about health to or for a person, a social group, or a community. Two concepts of health education prevail today. The first perceives health as involving the successful operation of the human organism in all its aspects—biological, mental, and social. This position is held by the health sciences, whose legitimacy in education rests on this definition. In the second concept, health education is considered one aspect of general education—education in or training for life. This concept is held by those in the field of educational science (or pedagogy): for them health is one of the components and themes of education. It is important to stress that these two approaches are complementary. The first is more biological but also more immediate: it corresponds to concerns about existing risks. The second involves long-term education: alone, it cannot respond to immediate risk situations.

All those who play a role in the lives of children and adolescents are concerned about health education: parents, teachers, youth workers, members of youth movements, family physicians, pediatricians, paramedical staff, and school doctors and nurses. At the intersection of these two fields (education and health), we find the professionals of health education. "Health educators" are defined by their training, their experience, and especially by their ability to go beyond professional divides, both occupational and disciplinary, because of their skills in the domains of education, health, communication, psychology, and sociology. They are the principal "interface" between the other participants. In addition to these direct participants, others have indirect contact with the young: health and prevention agencies, patient and consumer associations, and others who transmit messages about and influence health behaviors. These different groups of players represent different stakes and the possibilities of various kinds of interventions. Their respective responsibilities, roles, and boundary lines must therefore be defined.

The role of parents and other family members is highlighted today. Parents and other family members must be perceived not only as a possible target audience for health education—but secondary to children, who are the principal target audience—but also as co-participants, players in their own right, and even in some cases, as the principal players in their children's health education. Several experiences have shown that children's health problems can be prevented or solved through interventions conducted only with the parents.

The approach known as "health promotion," defined in the Ottawa Charter, offers a theoretical framework, and interventions are intended to be comprehensive and consistent; it designs strategies (that is, convergent and concerted interventions) synergistically with an interdisciplinary approach that takes into consideration the multicausality of health determinants. The reality of interventions, however, is often more fragmented and accordingly less conclusive. It takes a long time to modify professional practices. Nonetheless, support for the validity of the Charter principles comes from the changes in individual and collective practices that can be seen nearly everywhere.

The principles invoked for health promotion involve the concept of "environments" or life "settings" (cities, communities, schools, workplaces, healthcare facilities, prisons, etc.). Intervention in such settings is facilitated, not only by the existence of a "captive" population, but also because the community is structured by a strong shared identity, vigorous interactions, and communications between members; it also has networks to finance it. For interventions planned in these settings and in particular in schools, the process developed to reach the objective is also important. Because the aim is to increase individuals' capacity for self-direction, the approach must not be directive: it must accompany the individual's development. Therefore, the subjects participate in the very planning of the project, which aims to create conditions favorable to the emergence of changes in their skills and eventually, their behavior. This approach, summarized by many authors by the terms "enabling" and "empowerment", is appropriate for the educational enterprise in general and for health education in particular.

Health education contains an individual and a collective component, which ought not be separated: the learning of health and lifestyle behaviors must be approached from both angles at the same time. To develop interventions relevant to health education, it is first necessary to understand the factors that cause and those that influence health behaviors, as well as the processes of health learning. We must therefore analyze the educational needs and reach an "educational and/or behavioral diagnosis".

Any method for analyzing these needs must be based on a model or theory that explains health behaviors. More than 20 models have been developed or used in the field of health education. They can be sorted into eight major categories according to their principal characteristics, as summarized in the following table.

Principal categories of psychosocial theories and models explaining health and lifestyle behaviors

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We can add to these models those that touch upon the processes of individual change but do not constitute explanatory or comprehensive frameworks for understanding health behaviors. These models are most often elaborated by specialists from a single discipline, based upon observations and experimentation, without any interdisciplinary connections. Although their principal use is the deterministic prediction of health behaviors, they can be used to understand influencing factors (social representations, lay skills) adaptable to each audience.

Because health education is a discipline oriented toward practice with the living human being as its subject matter, research in this field is applied: research in development (programs, interventions), evaluation research and research-action are its principal trends. Whereas the subject of evaluation research is the processes and effects of educational activities, the other two types simultaneously touch upon the analysis of needs and the setting up of interventions and programs.

The first programs were designed from a prevention perspective, and accordingly the method of their evaluation was most commonly the quantitative experiment (randomized trial with control groups) and the quasi experiment (without randomization). Nonetheless, controlling variables reduces the complexity of the reality and, by that very fact, modifies the object of study. Later, sociology, pedagogy, and psychology contributed their methods and tools (qualitative approaches with semi-structured interviews and discussion groups). The current trend is to combine these approaches, thereby introducing the difficulties inherent in any truly interdisciplinary study.

Moreover, evaluation and evaluation research have long focused on changes in knowledge, health and epidemiologic results, and economic aspects, while ignoring the role played by the overall set of factors, processes, and organizational aspects in the quality and effectiveness of health education. The concept of health promotion with a goal of increasing "health potential" implies that indicators of individuals' "action skill levels" be defined and used in evaluation research.

• Youth and their health: perceptions and representations

Although our knowledge of the epidemiology of young people continues to increase, we are far from understanding the psychosocial aspects without which no effective health education is possible. This "psychosocial-epidemiology" is the simultaneous study of the health of the young (and not only of their health problems), of its political, environmental, and organizational (how does school contribute to children's health?) determinants, of their representations, concerns, knowledge, attitudes, priorities, and their own resources in health matters.

In France, information about the health and health behaviors of the young comes from various types of surveys. The methods used to collect these data vary substantially, which may be responsible for differences between the various results.

Examples of sources of information about the young and their health behavior in France

• Implementation of health education: the institutional framework of the educational system

Our analysis of the literature relative to health education for the young reveals some consensus about key elements (place, means, contents) that should be taken into account in designing and implementing programs.

School is recognized as the preferred (but not sole) place for health education and promotion because of the important interactions between health, academic success, and education, and also because it is where a vast majority of an age group can be reached.

We note that the planning and organization of programs require a substantial investment of time and resources. The training of adults, and particularly of teachers and multiprofessional teams, is determinative and often considered to have the highest priority. The collection of resources (sources of reference material, documentation, methodological guides) and pedagogical tools and their availability to teachers is also fundamental. Adequate time must be allocated to the program. Moreover, the general observation that the effects of programs diminish with time suggests that progressive programs ought to be implemented to extend from kindergarten through high school, in coordination with academic curricula.

Overall, the authors agree that information is necessary, but not sufficient. It is easier and faster to improve knowledge than behaviors, but improved knowledge does not necessarily lead to changes in behavior. The methods used must be diverse; they must solicit the active participation and interaction of students to involve them in their learning, as well as in the choices of the health themes and subjects that they want to study. The clarification of values and attitudes and the development of self-esteem are not only ethical factors but also factors critical to effectiveness.

The enrichment of students' psychosocial skills, such as negotiation, problem resolution, creative thinking, decision-making, coping, interpersonal relationships and communication is an important element in the success of health education programs.

Health education as a subject matter for instruction is not enough. The school's "hidden curriculum"—that is, values, interpersonal climate, and daily educational practices—influences learning as well as the construction of identity. Health education cannot be dissociated from health promotion, of which it is one aspect. National policies defining orientations in this domain now link health education closely with health promotion. For schools, this approach is based on a combination of various components and responsibilities in different registers: curriculum (the content of instruction); environment (physical, organizational and psychosocial, integrating values and interpersonal aspects); health services; partnerships (with parents and local communities, including local health professionals and volunteer groups); and school operations.

The health education/promotion policies, programs, and projects in a school system, like the conditions of their implementation, depend on the organization of the educational system and of the healthcare system, as well as on the culture of interinstitutional partnerships.

• Four examples of context: implementing health education in school settings

In the United States, the Comprehensive School Health Education model was introduced at the end of the 1980s by the Centers for Disease Control and Prevention (CDC), a federal health agency; its goal was to unify and connect federal objectives with those of the different states, in a country with substantial local diversity. Its objective was to improve health as well as attitudes, practices, and skills that affect health. The general principles of this approach stress its behavioral dimension and the coordination between school and community. Such a comprehensive program includes eight complementary components.

Components of the comprehensive school health education model, developed in the United States

A national study by the CDC in 1994 measured the extent to which this policy was applied and, more particularly, the development of health education teaching. Within schools, the director of health policy is often the school head, sometimes helped by an assistant or a nurse. In elementary schools, health education mainly occurs as lessons integrated into the standard curriculum, whereas in secondary schools, school districts require that health education be part of a specific course devoted almost entirely to health. In practice, secondary schools teach health education either in specific courses or within the framework of subjects such as biology or home economics. The themes covered most frequently are the prevention of AIDS and of alcohol and drug use; accidents, violence, and contraception are covered less often. When health education is proposed as part of a specific course, more time is devoted to it and more aspects are developed. Teacher training for physical education focuses mainly on sports and competition, although, according to the authors, physical education ought better to consist of increasing physical activity during the course and adapting methods to help each student reach his or her personal best physical condition. Health education is taught not only by physical education teachers but by those from various disciplines: religion, home economics, social studies, life sciences, and languages. The authors underline the importance of training teachers in health education and the states' responsibility in this area. They point out that this policy must be accompanied at different levels (federal, state, and local) by incentives and by funding for the financial and personnel requirements (training, coordination, evaluation).

The European Network of Health-Promoting Schools, created in 1991, is a project financed jointly by the Council of Europe, the European regional office of WHO and the European Commission. This network places its stress on the psychological and social dimensions of health, improvement in self-esteem, skills, student and staff wellness, and on links between the school and the community. Holistic by nature, the objective of this model is to improve the social and physical environment of the school community at the same time as it develops health education for these different target populations. The teaching is directed toward active learning and involves the teachers in innovative approaches. The Ministries of Health and of Education of the member nations were prompt to collaborate in promoting the development of this model.

Criteria initially proposed to schools in the European Network of Health-Promoting Schools as a frame of reference

A recent evaluation of Network development in member countries showed contrasts from one nation to another: in some countries, the network has tended to generalize, while in others, including France, it is small, little known, and isolated.

The network schools most often work on the following aspects: relationships between students and between students and adults, educational activities and the question of nutrition in relation to the school cafeteria. Associations with elementary schools, staff health promotion and school health facilities were considered more irregularly. The aspect that most often posed a problem was the question of adults' roles as models. In secondary schools, the themes treated most often in specific lessons were drugs, AIDS, and reproduction, while in the primary schools, it was more often nutrition and accident prevention.

This evaluation identified effects in terms of improvement in the quality of relationships, of nutrition, instructional content, and reduced absenteeism (a good indicator of the quality of life in a school). It observed that the point of view of the players from the educational and health care systems on the evaluation diverges on many points; accordingly, it recommended a reinforcement of the relations between the educational and health sectors to promote the emergence of a common culture.

The United Kingdom has a tradition of collaboration between the health and educational sectors. The program-framework Healthy Schools Award began at the beginning of the 1990s and was intended to stimulate the approach to health promotion in UK schools. A 1998 evaluation of this program-framework found increasing consensus about the value of the approach. The program's implementation has tended to promote health education. The authors argue that other aspects of health promotion should also be developed, in particular, staff health and the involvement of non-teaching staff, parents and the larger community. They then raised the question of evaluation and stressed the need for tools able to apprehend the program's processes and structural changes as well as its effects on knowledge, attitudes, and behaviors.

In October 1999, government health and educational officials together launched a national school health program (National Healthy Schools Scheme); its objectives were to involve all local educational agencies in a partnership with the National Health Service to establish local programs and eventually to involve all schools in this approach. The program defines a variety of key themes in the area of community involvement and in specific educational domains.

Principal key themes of the national healthy schools scheme applied in the United Kingdom

In Switzerland, in a federal setting where diverse initiatives for health education and promotion abound, the federal Office of Public Health and the Swiss Conference of Cantonal Public Instruction directors jointly decided in 1995 to launch a program-framework named "School and Health". This program is causing health education and promotion to be recognized throughout the entire country as an integral part of the school's mission of education and training and is intended to extend this impetus. It finances research projects on health promotion in the school system by call-for-proposal procedures that favor interdisciplinary projects based upon the establishment of networks and likely to be extended permanently to a cantonal, even regional, level. This program-framework is intended to promote exchanges of information and to guarantee the follow-up and evaluation of the projects selected, by generating a process of development over the long term and involving various administrative levels.

• Institutional measures in France for establishing health education in schools

In France, the 1989 Education Law, which placed the student at the center of the educational system, inscribed health education as a priority of the school community. In November 1998, the Ministry of National Education (MEN) defined new national orientations in health education with the goal of reinforcing the school's role in this domain and making these practices more widespread. This document redefined the framework at the same time as it placed it into "a perspective of comprehensive education and civics instruction".

The directive focuses on the objectives, defined as skills of savoir-faire (know-how) and savoirêtre (personal and interpersonal skills). For each course and each discipline, the directive describes the skills that are its health educational objectives: knowledge and control of the body, sexuality and reproduction, environment and social life. At the same time, it specifies the transversal personal and interpersonal skills— savoirêtre —that must be developed throughout each student's school career: self-image, autonomy, and personal initiative, relationships with others and solidarity, critical thinking, and responsibility.

Health education in the primary and middle school curriculum in France

The novelty of these directives is that they anchor health education within several disciplines (in particular, civics, life sciences, earth sciences, physical education, and sports) and no longer only biology. Moreover, these directives require middle schools to program "educational encounters about health" on a multi-year basis.

The ministry stresses that this educational approach must begin early and be progressive. It also requires that the health education be consistent with the school's educational plan, in liaison with the CESC (committee on health and civics education).

The CESC is the body that replaced the CES (committee for the social environment) in 1998. The latter, created in 1990, had begun a partnership policy intended to prevent risk behaviors and violence and to ensure necessary follow-up.

A 1997 evaluation of these earlier committees found they had operational value by their consistency in the organization of prevention activities that had previously been scattered, their mobilization of all the players: adults and students, improvement of relations, and reinforcement of partnerships. This committee, based in each school, is adaptable and flexible, but also fragile if those involved are not trained, recognized, and supported. Examination of the operation of these CES showed a great diversity in their modes and levels of action, as well as several weak points: students were not sufficiently involved, and internal communication and visibility were often absent. In addition, the participants would have liked a larger investment by government agencies and a clear definition of the priorities and criteria for evaluating the relevance of its activities.

The missions of the CESC have been enlarged, and the importance of two items has been underscored: the organization of the school's educational plan in the areas of health, civics, and the fight against social exclusion; and the need for a positive approach that values students' abilities.

Mission of the Committee for health and civics education

These committees involve mainly secondary (middle and high) schools, but coverage is still imperfect, including in sensitive areas. Different levels of guidance and support are now necessary for the development and activation of this framework. The schools need diverse types of assistance to accomplish this new mission (consistency in the various directives, incentives and encouragement, information, idea and practice exchanges, methodological help for activities and evaluation, tools, etc.).

The French educational system has thus chosen to promote synergy between the school's educational mission and its health promotion mission, while taking into account the important interactions between health, school attendance, education and social integration. This choice is similar to those directing the strategies of health promotion in school settings in countries comparable to France from the point of view of health, economics, and culture.

• Peer approaches: students as players in health education and promotion

Among the methods used to try to reinforce the position of students as participants in health education and promotion, peer approaches have been very much in vogue for the past two decades. Initially used for primary prevention, these methods have also developed in particular groups for secondary prevention and for risk reduction.

The diverse peer approaches represent complementary methods for health education and promotion that are likely to reinforce students' involvement in the educational process that targets them. Of the various functions assigned to peers, we can distinguish peer "prevention players" participating in the development and implementation of projects, peer "educators" responsible for transmitting information, recommendations, and even skills, and peer "counselors", whose role is to identify, counsel, or support other youth who need help.

It is important to underline from the start that, regardless of the functions performed by the peers, this demanding approach requires the mobilization of a team to train and supervise the youth involved throughout the process. The position of the adults must also be considered, especially in school settings where they are asked to adjust to changes in the students' status, to their empowerment. Nonetheless, the analysis of peer approaches has shown that they increase exchanges between adults and youth, and that the latter's contribution in adapting projects, programs, procedures, tools, etc. is generally recognized and appreciated.

The experiences with "peer educators" do not show that this peer intervention is superior in an absolute sense in terms of success in reducing risk behaviors (reduction in substance use, protection against AIDS). Nonetheless, these interventions can prove to be as "effective" as those by adults, especially when the peers succeed in sparking interaction among the young people. Moreover, peers seem more likely to provide information on existing resources (professional services) and to help increase their use by the young. Exploiting this effect can be important, especially among populations that are difficult to reach directly, such as dropouts.

It is essential to note that the principal beneficiaries of these approaches are the involved peers themselves. Their achievements are substantial and go far beyond the issue of risk behaviors. Their investment in the process and training has repercussions on their personal development, self-esteem, and empowerment. This experience very often gives them the occasion to acquire interpersonal skills, especially in terms of communication, listening, and openness to others.

These results lead us to wonder about the possible value of these procedures for the highest-risk youth, especially in terms of reducing health-related inequalities. Until now, these approaches have been developed primarily to induce changes within the broader youth community, and peers have been chosen most often for their interpersonal skills, good from the beginning. To the extent that the principal beneficiaries of this approach are the selected peers themselves, we wonder whether it might not be appropriate to reconsider the objectives, and to redirect them toward the more fragile youths, to train them in a framework that often operates like a support group.

• Principal characteristics of intervention programs

Looking at the different approaches, we note that the health sciences are more rooted in the experimental sciences, while education follows instead the tradition of observational sciences. This double origin maintains a constant tension between the different centers of attraction within the field of health education.

Education and health are permanently at the heart of social and political debate today, but education has been the object of such reflection since ancient times, whereas the social dimension of health is only beginning to be understood.

Characteristics of the health sciences and the educational sciences

An abundant scientific literature reports evaluations of health education programs. What is striking is the extreme diversity of the objectives, educational approaches, and methods for measuring results. We do nonetheless observe a convergence, both in educational approaches and evaluation methods.

The convergences in educational approaches involve both theory and practice.

• A consensus asserts that any intervention must be based upon a theory. The most open and oft-cited theory is social cognitive theory (Self-Efficacy). It has two simple postulates: we learn through imitation; consequently, young people must see action models that they can imitate (role playing, videos); the more we believe ourselves capable of adopting a behavior, the more likely it is that we will try it and persevere if we fail initially.
• It is essential to take into account the social influences that affect the adoption of behaviors: approaches that help communication within a group must replace the simplistic "Just say no". Personal problems must be taken into account in psychosocial learning (decision-making, stress management, relaxation techniques, etc.). Success appears to require that the educator or leader affirm values congruent with those upon which the program is based. Greater involvement of the social environment is also helpful.
• The type of knowledge that a program should provide is becoming more precise, in particular about the short-term effects of psychoactive substances. Programs are lasting longer: one-time interventions are disappearing, replaced by interventions of at least 10 hours per year repeated over several years. The need to repeat and rehearse is often seen as analogous to the need to train for a sport or practice and rehearse for musical performances.

Overly comprehensive approaches have failed, probably because there are specificities inherent in each theme, and because the comprehensive approach often involves the dilution of objectives.

• Evaluating the effectiveness of health education

The methods for evaluating the effectiveness of health education have been the object of intense debate. One school, which uses an "epidemiological" approach, measures the degree to which objectives, determined in advance, have been reached for a given population (for example, increase the non-smoker rate in a given student population). A second school, using a "community-based" approach, argues that the objectives and the means used to reach them, and even the evaluation methods, should be determined by the population itself. It is inherent in this approach that no intervention or assessment protocol can be defined in advance. Accordingly, the evaluation process is indissociable from the program's approach.

Principal characteristics of evaluations as a function of the type of program

The first school uses the experimental method, comparing the development of a population that underwent an educational program with that of a population that either had no or a different program. The second school stresses the evaluation of the process, that is, the detailed management of activities, in particular by qualitative evaluations that do not measure changes but instead help to understand how the program was applied, understood, experienced, and accepted. One way to express the difference might be to say that the first school demands that effectiveness be scientifically determined, and the second, democratically.

The first school considers the comparison of experimental and control groups as the ideal model; its gold standard remains a pure experimental protocol with random assignment of subjects into the different programs. In many studies, however, it is the site that is randomly selected, whereas the analysis concerns individuals. Analyses of results grouped by (a small number of) sites would have little statistical power. Various solutions can compensate for these disadvantages (increasing the number of sites by diminishing their size, controlling for the sources of variation between sites, taking a group effect into account).

As in every form of education, the effects of interventions, unless they are regularly reinforced, tend to fade in the long run. The observation of this phenomenon has led: for evaluations, to considering a result invalid if its only evaluation occurred immediately after the intervention, and to favoring long-term follow-ups; for processes, to promoting programs spaced out over time with "review" sessions. In this situation, however, the higher number of cases "lost to follow-up" offsets the increased duration of the follow-up, and those "lost" are often the youth at the highest risk of social or school problems. Several strategies are possible for dealing with the "lost to follow-up" problem: eliminate them from the cohort if they are not different from the active cohort, or attribute a replacement value for them in the post-test.

The adaptation of the intervention protocol to the particular target population and the consistency of its application are now studied in advance. A program may fail simply because it was inappropriate or not applied. Discussion groups (in particular, focus groups ) are organized simultaneously to understand the position of the target youth and also to test the proposed educational material.

The effect measures are most often assessed from a self-administered questionnaire. The change indicators are objective but somewhat less than totally reliable because they are based on self-report. Nonetheless, specific studies on the validity of responses, including every study that could confirm responses with laboratory tests, have shown that responses to these questionnaires are, on the whole, reliable.

The literature produced by the second school is often framed as argument or general recommendations about interventions and evaluation. Detailed reports of interventions are extremely rare, in part because the workers involved in the very numerous micro-interventions carried out according to this philosophy are neither trained nor motivated to publish such reports.

These two schools are nonetheless beginning to converge. Some teams that advocate the community-based approach nonetheless try whenever possible to use epidemiologic evaluation tools. Moreover, those using the "epidemiologic" approach are adapting their approaches according to their target populations.

• Prevention of risks related to sexual behavior

The literature about the prevention of sexual risk-taking behaviors in adolescents is particularly abundant and clearly dominated by North American researchers. The most widespread concern is primary prevention of AIDS, which is the major objective of educational programs about sex-related risks aimed at the young.

The answer to the question "Why teach adolescents about sex-related risks?" seems to be considered self-evident in many publications that present "young people" as a population at risk. Adolescence, the life stage when sexuality is discovered, is traditionally described as an unstable period, psychologically, socially, and even sexually; for this reason, it is a preferential target for prevention. Moreover, the young, as a captive population in school, are easy to reach by educational programs.

In the United States, the risks associated with sexually transmitted diseases (STDs) and unwanted pregnancies in young girls are indeed very high: one adolescent in four contracts an STD during secondary school; 10% of the girls 15–19 years of age become pregnant, for a total of 1 million pregnancies a year in this age group. In France, on the other hand, persons younger than 18 years do not appear to be a particularly exposed group. According to the ACSJ (analysis of sexual behavior in youths 15 to 18 years of age) survey, carried out in 1994 and published in 1997: 1.1% of the young people in this age bracket had an STD other than a yeast infection; 3.3% of the girls in this age group became pregnant. Currently, the number of annual pregnancies among those younger than 18 years is estimated at approximately 10,000, of which 6,500 are terminated by an elective abortion.

In Western nations, no notable increase has been observed in the risk factors that may be associated with earlier sexual activity: the mean age of first intercourse is around 17 years (in France, 17 years 3 months for boys and 17 years 6 months for girls). Sexual risk, however, differs according to social class. Like the risk of sexual violence, it is clearly greater in situations of vulnerability due to social problems. The use of drugs, including excessive alcohol intake, appears to multiply sexual risk.

Data on the risk behaviors of sexually active youths 15–18 years of age – according to the ACSJ survey (analysis of sexual behavior in youths)

* 1,883 boys and 1,384 girls who have had sexual intercourse at least once in their lives.

There is overwhelming recognition that school is the place for sex education and its progression to education about sexual risks (this does, however, raise questions about the young people who have been excluded from the school system). Some publications recommend that education about sex-related risks begin in primary school. Nonetheless, if it is to be understood, sex education must be appropriate to the age and interests of the children; the issue of risks should of course be covered before the adolescent begins sexual activity. This education is included in numerous school curricula, where it is not limited to biology classes; the question, however, is: who teaches it? The teachers are not always well prepared to do so; they are often reticent, more at ease discussing the question of the risks associated with AIDS and other STDs than in dealing with sexuality.

In some countries, the school health department, school dispensaries, physicians, nurses, and other members of the medical community are brought in. Other experiments and players have been tried in the area of AIDS prevention: a variety of organizations and associations, people with AIDS or HIV, peer groups, medical students. Peer education benefits from favorable preconceptions: it is presented as simultaneously allowing adaptation of risk information to meet the expectations of the peer group and direct action on the norms that influence sexual conduct. Research does not justify this prejudice, however, and the peer approach cannot replace other educational approaches. It can be considered only as a complementary strategy.

Most interventions are based upon a theoretical framework. These can be divided into two main categories: the individualistic approaches that use the Health Belief Model or the theory of reasoned action, and the interactional and comprehensive approaches. The individualistic approaches, which predominate, are based on models of learning and individual decision-making. In the interventions based on these models described in the North American literature, the different objectives all involve, depending on the program, teaching the teen abstinence, or waiting, or saying no, or , finally, discussing condom use with a sexual partner. These procedures do not really take account of the facts that a sexual situation is a social interaction and that the decision is not individual only. For this reason, they have proved inadequate in terms of stabilizing behavior. They define sexuality only functionally, thereby neglecting its affective aspects, its relation to feelings. Comprehensive approaches have replaced these hortatory approaches. These involve starting from what teens say and express and thus being able to capture the social and affective experience of sexuality, understand its normative dimension, anchor it in a social context, and provide responses to the questions that emerge, at the level at which they are expressed.

The existing literature pays little attention to the associations between sex education and gender identity. The very simple idea of conducting risk education separately with girls and boys, thereby taking into account the ideologies associated with male and female roles in sexuality, is recommended by the authors of a very recent North American study, performed jointly by a prevention group and a research center.

Another frequent question involves pedagogical tools, including games, marionettes, comic books, audiovisual media, and computer programs. The usefulness of these media does not mean that we can dispense with a serious reflection about the type of program or the framework in which they are used. Regardless of the tools, they should never be used outside of a comprehensive strategy with explicit objectives, nor without pre-testing.

Too many programs have been set up but not controlled, with free rein left to their staff's preconceptions, of whatever flavor. Nonetheless, the consistency of the data, over time and in different countries, shows changes towards better prevention of sexual risk-taking by teens. It is difficult, though, to attribute these behavioral changes to the effectiveness of any specific programs, to the prevention programs aimed at the general public or to the prevention messages broadcast by the media and relayed at many levels. Adolescents are the population group that has best adapted to the AIDS threat. The rate of condoms use at the first act of intercourse is climbing regularly. In France, according to the ACSJ survey, 78.9% of the boys and 74.4% of the girls 15 to 18 years of age who reported sexual activity had used a condom at their first act of intercourse. The corresponding data for the 97/98 Youth Health Barometer were 88.6% and 85.4%, respectively, in boys and girls 15 to 19 years of age. The decline, consistently observed, of condom use at last intercourse must be related, among other things, to a stabilization of young couples.

Frequency of condom use at first intercourse in youths 15 to 18 years of age in France – Data from the ACSJ survey (Analysis of sexual behavior in youth).

It is expected that educational interventions about the risks of AIDS transmission will delay the onset of sexual activity or diminish it, induce greater selectivity of partners, and induce condom use. We might also wonder about the possible adverse effects of some prevention programs. Sometimes based on the anticipation of regretting starting sexual activity too early, they end up increasing fear and even intolerance of others' nonconformist actions, without necessarily inducing a more rational attitude toward protection, contraception in particular.

Teen pregnancy and motherhood are generally considered to be a failure of sexual risk prevention or of contraception and are associated with immaturity and academic and social problems. Nonetheless, these precocious pregnancies are sometimes desired and can be structuring for some young women. This fact, however, must not mask the need to transmit to young women the resources that enable them to avoid unwanted pregnancies—a much more real risk than AIDS among the young. What is needed is contraceptive education that takes into account their expectations and their sexual trajectories.

One of the principal lacunae of sex education programs concerns teaching children and adolescents about the risk of sexual violence. The frequency of forcible "sexual relations", reported by 15.4% of the girls questioned in the ACSJ survey, is worrisome. These girls, however, were more often those who were no longer in school or were in low-prestige tracks; it is therefore associated with social vulnerability.

• Prevention of the risks associated with smoking

In the domain of risks associated with the consumption of psychoactive substances, most interventions aimed at young people began by focusing on a specific product (tobacco, alcohol, drugs). Slowly, experimental findings led to a comprehensive approach to prevention aimed at changing behavior. In all cases, the timing of the prevention activity, its participants, and the type of intervention are all important factors in its effectiveness.

International data indicate that smoking prevention should have higher priority than other types: smoking is the behavior that causes the most deaths in the long run; tobacco is also considered an introduction to other products, especially cannabis and alcohol. Moreover, the percentage of girls and women smoking is increasing, for reasons not yet explained.

Smoking prevention interventions, which began in the 1950s, generally discuss smoking from the perspective of preventing cardiovascular diseases and cancer. Only recently has the prevention of drug addiction has been added.

The process of nicotine addition can be broken down into five stages: a preparatory stage, initiation, experimentation, a phase of regular use without dependence, and a phase of dependence with daily use.

The objectives of most prevention activities are to avoid or delay smoking initiation or to help in smoking cessation. In the first case, the activity may be at the individual, family, or collective level. The factors influencing the beginning of the process differ according to sex, academic status, and period. For smoking cessation, the help may involve the youth or the parents; in any case, it should occur before the youth becomes addicted to nicotine. The study of the subject's motivation is an essential prerequisite. Alongside these programs, a newer emerging objective is the prevention of regular smoking, that is, reducing risks.

The objectives of the first interventions were simply to provide information on the dangers of smoking, and then, starting in the 1960s, to teach students how to resist social influences. Since the 1970s, programs have been based upon the reinforcement of "general social skills" or "life skills", including cognitive components, decision-making, coping skills, and assertiveness. All of these strategies were developed to prevent smoking initiation. Currently, two other types of activities are being developed: one to reduce the risk of progression from occasional to regular use, and one to promote teens' psychological well-being as a means of preventing any kind of substance use.

Prevention of smoking initiation is often a failure in the long term, regardless of the technique used: after 4 years, no differences are observed between those who did and did not attend a prevention program. Currently being promoted are activities that take cognitive and social development into account, including the youth's experiments with the products throughout adolescence. Nonetheless the contents of the "pitch" of the intervention continue to be addressed more to boys than girls.

Programs based on ability to cope with stress can only be effective when they take place before initiation: once smoking has become a habit, the physiological process seems to gain the upper hand over the psychological process.

Of the players in prevention, teachers have an important role, and their training is essential. An antismoking intervention, by class or grade level, includes at least five sessions, occurring between the end of primary school and the first 2 years of secondary school. The intervention of clinicians among at-risk youth and families and among school officials for maintaining antismoking programs in schools has proved to be more effective than the school programs themselves. Combined interventions by peers and adults yield better results than intervention by peers alone. Interventions involving parents appear to be the most effective.

Public policies have proved more effective in stopping smoking initiation when they raise prices for and limit access to tobacco than when they ban smoking. Interventions at the school, family, and community levels have proved more effective than isolated activities in preventing initiation and in promoting cessation.

• Prevention of risks associated with alcohol use

The prevention of problem drinking is more complex than the prevention of smoking because excessive alcohol consumption, even only occasional, can have harmful social, medical, and personal effects and because alcohol is more widely used and more prestigious than tobacco. It is also a more feared product because of the accidents and the violence it can cause. Individual factors of sensitivity to the effects of alcohol play a role, as do sex, weight, and genetic polymorphisms.

Several theories of how problem drinking develops have been proposed: one for "normally socialized" adolescents, and another for "problem" adolescents, who progress more rapidly toward more severe alcohol abuse. Psychic factors are often underestimated in explaining the beginning of problem drinking. These factors are associated with diminished skills, especially academic skills. Accordingly, early academic problems and low academic expectations by both parents and children are important indicators of risk.

Prevention activities more often involve the prevention of risks than of drinking itself. Their aim is to limit the risks associated with drunkenness (traffic accidents, sexual conduct), promote responsible drinking, and reduce juvenile alcohol abuse. Interventions that focus on alcohol initiation have been directed toward the reinforcement of general social skills, but have rarely involved the family. Because moderate consumption is considered to be a criterion of social integration, few programs try to prevent all alcohol use.

Most school interventions involving youths 10 to 18 years of age are too late, according to the authors, because they take place after initiation has occurred. Interventions in primary school have not been evaluated. For high-risk groups, school does not provide adequate guarantees of confidentiality. Television and other mass media can be considered to be an effective channel of information in that they help modify social standards.

Among those involved in prevention, school nurses are recognized as positive sources of individual preventive activity against excess drinking. The family must be truly involved and informed about teaching "responsible drinking" at home. The improvement of intrafamily relations remains an important means of prevention. An essential point in program success is the understanding by adults that young people are mature and responsible and therefore can be partners in real discussions. Because girls and boys have different ways of drinking and different reasons for drinking, interventions must take these specificities into account to modify consumption. Interventions among "high-risk" groups have proven more effective than those among more mixed populations. Teens prefer brief interventions that take place in stages. Programs that include individual treatment have not been especially successful; this must be proposed later, when the adolescents have grown aware of their problem with alcohol.

Of the interventions directed toward prevention of accidents associated with excess drinking, one of the more promising is special training for various night workers to identify signs of early drunkenness. Concrete measures, such as a "zero" blood alcohol level for youth, higher drink prices in bars, and the organization of rides home at the end of the evening, have yielded good results.

• Prevention of the risks associated with "drug" use

The term "drugs" most often includes alcohol and illegal drugs, that is, consciousness-altering products. Several interventions target illegal drugs exclusively, and more specifically, cannabis.

For a long time, the objective of anti-drug prevention was abstinence. Because the consumption of drugs has not stopped increasing, other objectives related to risk reduction, such as preventing abuse or promoting risk management, have been advanced.

The process of drug use is rarely defined. In studies, as in prevention programs, the terms use, abuse, and dependence are often confused and used interchangeably. A new trend takes into account the experience young people have with drugs and the difficulties they have encountered.

The various types of prevention activities have two objectives: diminish drug use by direct or indirect strategies, or improve the quality of life. The most widespread strategies are those based on information. The KAB (Knowledge, Attitudes, Behavior) model is used to inform young people about the negative consequences of drugs to induce changes in their behavior. It has often been combined with programs about life choices. Around 1970, a psychosocial model, the DARE (Drug Abuse Resistance Education) project was used by more than 50% of schools in the United States: its objective was to train young people to resist pressure to use drugs from those close to them (peers, siblings, adult family members or friends) and the media. Programs with a more comprehensive perspective, such as Life Skills Training, were established to teach the young to communicate, to resolve interpersonal conflicts, and to cope with the difficulties of daily life.

Prevention activities must be timed according to the usual age at which young people begin using each of these drugs. The optimum age is considered to be between 12 and 14 years. From 10 to 60 sessions seem necessary, distributed over several years. The Life Skills Training program is composed of 15 sessions the first year, 10 the second, and 8 the third. Teachers and other school professional staff intervene in most of these programs. The better trained the teachers are, the more capable of intervening they feel. Mobilization of health care professionals at the school is important for this strategy to succeed. The participation of parents is not sought in these drug prevention strategies, although the importance of parents in education is well known. Interventions by police officers (DARE) appear ineffective in reducing drug use. Interventions by physicians questioning young patients during medical consultations have proved effective.

Programs that use interactive methods and enable teens to acquire general skills have proved more effective than those programs offering information and values. Because all activities include some information, it is difficult to say that it is useless. It is, however, clearly insufficient by itself. Generally, the youth with the lowest use levels have a more positive opinion of the strategies than those who use more.

• The prevention of risks associated with psychoactive substance use in France

Recent data on trends in the use of psychoactive substances by young students, presented in the figure below, show that repetitive use is climbing. For tobacco, this increase involves mainly girls. The prevalence of alcohol use appears to be stabilizing. Cannabis use is increasing among girls and boys of all ages. Moreover, published studies show that such use is clearly associated with subjects' social (age, sex, school status, lifestyle) and psychological (self-esteem, quality of relationships with parents and friends, depressive state) characteristics.

Trends from 1993 to 1999 of repetitive use of substances among secondary school students. 1993 data: Choquet and Ledoux, Inserm U472; 1998 data: Youth health barometer, CFES; 1999 data: ESPAD 99, Inserm/OFDT/MENRT.

Most strategies are based on reports by field staff that are often "impressionistic" and qualitative. The diversity of these personnel orients the type of strategy: teachers provide information, health professionals "listen", and social workers pay attention to the isolated, most vulnerable youth. The "program" approach is generally resented by all of these participants, who prefer an intervention or a strategy. The content of the documents that accompany these interventions is often very vague, unsupported, and sometimes incomprehensible for an "average" educator or counselor. Evaluation is rarely planned together with the intervention. When it is finally set up, it is often limited to irrelevant or vague indicators. It is most often qualitative, and external evaluation remains exceptional.

An evaluation of 12 interventions in school settings showed multiple contradictions between the prevention practices and the conclusions of evaluation studies published in international journals: student involvement was low, although considered essential; none dealt with the psychological, emotional, affective, or behavioral aspects, although these too were considered essential; none was audited by outside experts; and only one included a bibliography to justify the intervention. Nonetheless, according to this same analysis, these prevention activities had strong community bases, good involvement of various school staff, and the desire to involve parents and improve school life.

In France, as elsewhere, we have moved from the prevention of any use of psychoactive substances to the prevention of risk behaviors; in so doing, the place accorded to the products themselves has almost disappeared. In relation to earlier policies, this turn toward the prevention of dependence on any product, regardless of which, rather than the use of a particular product raises several practical problems: young people are rarely dependent on substances in general, and the use of each substance has a specific social and cultural value.

Several original interventions directed at non-student populations should be pointed out: interventions targeted at "wandering" youth; interventions carried out by local teams; and "reception and listening posts" aimed at enabling the youth to put their problems into words.

• Recommendations

During the past quarter century, the concept of prevention has gradually grown into the concept of health promotion, including an educational dimension. This trend, formalized by the Ottawa Charter (1986), focuses on the development of the "health capital" of individuals by integrating the role played by the relevant social conditions. This approach proposes a framework, intended to be comprehensive and consistent, for theory and interventions, as well as strategies in which the concepts of enabling and empowerment are the basis of a process for education in general and health education in particular.

The industrialized countries have established health education programs that are generally based on these new concepts. Our analysis of these programs leads us to several conclusions. School is recognized as the preferred (but not sole) place for health education and promotion for the young, because of the important interactions between health, academic success and education, and because a vast majority of this age group can be reached there. The planning and organization of programs require a substantial investment of time and resources. The training of adults, and particularly of teachers and educational teams, is determinative. The acquisition of resources (sources of reference material, documentation, methodological guides) and pedagogical tools and their availability to teachers is fundamental. Adequate time must be allocated for the program; the general observation that the effects of interventions diminish with time suggests that progressive programs ought to be implemented from kindergarten through high school, in coordination with academic curricula. Partnerships with families and local communities reinforce the effects of the programs.

In France, many institutions, agencies, and individuals participate in health education. There is nonetheless a contrast between the obvious vigor of the health education network, testimony to the mobilization of all the stakeholders and of the populations, and the failure to capitalize on the achievements of diverse experiences.

The expert advisory group, after analysis and synthesis of the international literature and examination of reports about various experiments and experiences in the domain of health education, proposes several lines of recommendations: establish the consistency and continuity of programs by instituting a permanent system from kindergarten through secondary school; develop the skills appropriate to health education by setting up training defined by a framework of skills and recognized by a degree, as in other countries; adapt the methods of intervention evaluation to the changes in educational methods; promote the results of research among those active in health education, and capitalize on field experiences to feed this research.

Establish the consistency and continuity of programs, integrating screening, prevention and education

Define an overall strategy and programs.

One factor in the quality and effectiveness of prevention and health education services for the young lies in the continuity of programs, simultaneously within the school and from the school toward families and community.

In France, the 1989 Education Law, which placed the student at the center of the educational system, inscribed health education as a priority of the school community. In 1998, new directives defined the basic policies for health education "in the perspective of overall education and the teaching of civics"; health education became a part of the school plan, in liaison with each school's CESC (committee on health and civics education). Health education is now a part of several disciplines within school curricula. The curricula define not only the knowledge but also the personal and interpersonal skills to be acquired. Moreover, for middle schools, the Ministry has recommended that "educational encounters about health" be programmed. For these dispositions to take root and be consistently applied, those involved in this education must be trained, recognized, supported in this mission, and have at their disposition a partnership between the educational and health sectors.

Outside school, a number of public institutions, social agencies, interest groups, and associations intervene concretely, alone or in partnership, in the area of health education for young people. These include: the CFES (French committee for health education) as principal agency, the Ministry of youth and sports (youth councils, the national institute of youth and popular education), the Directorate of social affairs (youth listening posts), the ENSP (national school of public health) and the various university departments of public health and preventive and social medicine, the Foundation of France ("Youth health" program), CRIPS (the regional center for AIDS information and prevention), the prevention and health promotion departments of the national health insurance funds and insurance companies, family planning centers, some non-governmental organizations, as well as a great number of community organizations and associations with very diverse objectives. The result is a multiplicity of initiatives and participants, with boundary lines not always defined by the legislative framework for health education.

The expert advisory group emphasizes the need for a real institutional strategy, in the form of a national program-framework for health education that will avoid the fragmentation of activities and ensure the consistency and continuity of the approaches. The establishment of such a program would demonstrate the will of the authorities to confer on health education the role it deserves in health policy.

develop and reinforce appropriate bodies, staff them with qualified personnel

School is a privileged place for health education interventions. In France, the CESC (committee on health and civics education) is one of the bodies established to develop health promotion and education in school settings. Currently, this committee is planned only for secondary schools. Parents, who are part of the educational community, are often absent from these processes, although studies have shown that their participation is important in maximizing the effectiveness of interventions. There is a shortage of school physicians and nurses, with their crucial missions of prevention, counsel, and health education. Like other networks and organizations, the CESCs require adequate materials and funding.

The expert advisory group recommends the establishment of multi-year projects at the school level to ensure the continuity of health education programs from kindergarten through high school. It proposes that each CESC be provided with a qualified coordinator. It recommends stimulating family participation by offering open and motivating programs that should, as their initial priority, collect information about parents' concerns about their children's health, and should work in close liaison with the prevention and care services existing in the community.

The openness and professionalization of the mission of health education require qualified trained participants. The expert advisory group would prefer that those who come from outside the school be accredited at the district level by a committee representing the health and education sectors as well as the community.

Multiple educational activities are regularly conducted as one-time events, based on individual initiatives within the community. This is particularly true in primary schools where, from the point of view of institutional directives, health education is recommended but optional. These experiences, whose yield is most often nonexistent, could provide information useful to the school and other community institutions.

The expert advisory group recommends that an assessment be carried out on how teachers, health staff, and schools carry out ministerial directives (especially the most recent, such as the educational encounters), by following the recommendations or by original local initiatives.

develop the skills appropriate to health education

The skills of participants is universally mentioned as a factor that helps determine the quality of programs of heath education and promotion for young people. In many countries, including Belgium, Spain, the Netherlands, the United Kingdom, and the United States, health education is the subject of specific training, defined by a framework of abilities and recognized by a degree. In France, the professionalization of health educators has not yet occurred. The skills of the participants, who come principally from the health and education fields, are generally acquired in short-term training courses. University programs (DU, DESS) specializing in health education are rare.

The expert advisory group recommends that a consistent set of training courses adapted to different levels of involvement in health education be established.

The skills of the health educators are a priority for funding, if the new bodies are to operate effective programs on a permanent basis. They must have access to a degree program in the various relevant fields: program design, network and activity coordination, educational interventions, intervention evaluation. Another level of training can be planned for the participants who already belong to the educational community (e.g., teachers, social workers, psychologists, and parents), on a volunteer basis, for a course of 20 hours, for example. Moreover, all teachers, including school directors, must be sensitized to health education, in, for example, sessions of 2 hours.

Adapt educational methods to the concept of health promotion

Modernize and develop educational methods.

Despite the diversity of educational approaches used in school settings and described in the literature, convergences about some fundamental items must be taken into account to optimize the quality and effectiveness of the methods used in health education.

Information that is necessary, but not sufficient, for better knowledge does not necessarily lead to changing behavior. Pedagogical tools are necessary but must not be used outside of a comprehensive strategy. For this reason, a diversity of methods is required: these must motivate the active and interactive participation of the young people to involve them in their learning.

Because group values influence health behaviors, individuals must always be considered in their social context. The development and enrichment of psychosocial skills are important elements in the effectiveness of programs. Similarly, the leader's affirmation of values in accordance with the program is recognized as a factor in its success.

To integrate the various aspects reported to influence program effectiveness, the expert advisory group recommends the implementation of multimodal educational methods: the provision of information, active participation of the various audiences, development of psychosocial skills. This approach can only work as a long-range project, and one-time interventions must cease, to be replaced by programs of at least 10 hours per year that last for several years.

There is a rich and updated panoply of pedagogical tools available; they must be used after "quality control" for their appropriateness for various audiences (e.g., age, type of schooling, culture) and by the results of pilot testing. The CFES (French committee for health education) has a pedagogical library and an internal department charged with expert analysis of these tools.

The expert advisory group recommends careful monitoring of the quality, relevance, and proper use of these pedagogical tools for health education. It proposes that these tools and the contexts of their use be catalogued. The analysis by a multidisciplinary team of a sample of school textbooks should make it possible to identify the strong and weak points of their health educational contents.

evaluate the educational methods

The literature on the evaluation of health education interventions is abundant, and the methods of measurement and analysis of the results are diverse. For purposes of evaluation, the comparison of experimental and control groups remains the ideal model but is not always easy to set up. Tools and methods specific to disciplines such as sociology, pedagogy, and psychology have introduced the evaluation of the qualitative effects of interventions.

The effect measures are most often assessed from self-administered questionnaires; the data are, therefore, somewhat less than totally reliable because they are based on self-report. Nonetheless, studies, including every study that could confirm responses with laboratory tests, have shown that responses to these questionnaires are, on the whole, reliable.

Because the effects of interventions without reinforcement tend to fade over the long term, review sessions are generally programmed. The next question is that of the optimal moment for evaluation.

The expert advisory group recommends pilot studies to adapt the intervention protocol to the target audience and to test the proposed material. It also points out the importance of defining the type of evaluation before the program is set up and of planning appropriate tools for this evaluation. In view of the development of health education methods that integrate the concepts of enabling and empowerment, new indicators must be defined and used to assess the acquisition of personal skills and the capacity of young people to take action affecting their health.

adapt the themes of prevention and health education to different target populations

Studies show that many of the subjects of prevention (e.g., infectious and cardiovascular diseases, psychoactive substance use, and sexual risk-taking behaviors), or health education (e.g., oral hygiene, body hygiene, life hygiene, sleep-wake rhythms, and household safety) are approached in programs developed in school settings. Ideally, the choice is made according to the context: children's age (kindergarten, primary, middle, or high school), the socioeconomic and ecological environment, and specific problems at a given moment.

The option of "an early start" for education about health risks is always the subject of debate. Some feel that the appropriate age should be defined as a function of the presence of the risk. Others accept this option when the approach is progressive and is part of a continuous program throughout the children's academic careers. In all cases, the parents must be questioned and informed about the programs, and the values affirmed by the educator/leader must be consistent with the prevention message.

The expert advisory group recommends that educational interventions take into account specificities related to age, sex, academic, psychological, and social status of the young people. It recommends the use of thematic preventive/educational approaches as entryways for education in the global area of health.

define characteristics of the interventions according to the prevention themes

The highest priorities, both perceived and in practice, are the prevention of risk behaviors, especially those related to sexuality and to use of psychoactive substances. In these areas, perceptions differ very clearly between girls and boys; taking gender identity into consideration appears to affect the efficacy of interventions.

Education to prevent sexual risk-taking behaviors must not be limited to the prevention of sexually transmitted diseases (STDs) but must be accompanied by an education about sexuality that integrates its affective dimension. The expert advisory group recommends that this begin in mixed-sex classes in kindergarten and be based upon images of and respect for the body. It also recommends that when the risks linked to sexuality emerge, in adolescence, prevention of STDs and unintended pregnancies (contraception) be discussed, with the development of specific approaches, both gender specific and mixed, to prevent excessive submission to the standards of their own sex. These interventions should be relayed by other participants at the community level, including family planning centers and prevention and treatment services.

Education for the prevention of psychoactive substance (alcohol, tobacco, drugs) use must not be limited to information about the products and their effects but must concentrate on information about its short-term consequences, the progression from experimental to regular use, and the risks of regular and abusive use. The interventions must be timed as closely as possible to the moment of experimentation and give teens information appropriate to their immediate concerns. In particular, this information must provide accurate prevalence data to correct the exaggerated perceptions young people have of their peers' use, which they consider standard. The education/prevention approach must take into account the psychological and social determinants of use. Regardless of the product, the expert advisory group recommends that the educator take into account—and pay attention to—the differences between boys and girls as to the context and levels of use.

The expert advisory group recommends that prevention concerning the three types of products (alcohol, tobacco, drugs) occur throughout schooling, and that the legal products be discussed earlier than the illegal drugs. The educational/prevention approach must be based on promotion of the young people's physical and psychic health, by improving their individual skills (for dealing with stress, anxiety, inhibitions, and social relationships) and their self-esteem; the development of these types of individual and social skills must be the object of specific programs in primary school. This approach must integrate thinking about the representations and perceptions of substances among adults (teachers, guest speakers, parents, etc.), as well as among the young people themselves. Each professional must intervene within the framework of his or her own skills; for example, if police officers and representatives of the criminal justice system are invited, they should focus their talk on the law and crimes. In the continuity of prevention/education, thought is also required about the specific modes of management for youth who are regular users of these products.

Smoking-prevention programs must recall that collective strategies have been proved more effective than isolated activities. The intervention of clinicians is more effective for high-risk groups than school programs are. Public measures such as price increases and regulated sales are more effective strategies against initiation than banning smoking. For alcohol, what is most important is to prevent the risks associated with its excess use (accidents, violence by or against the drinker, sexual risk-taking, etc.), and therefore to develop concrete situational prevention, such as the organization of rides home after events such as parties, sports, or concerts. Effective prevention of drug use is possible only if the educators are credible, and they will be credible only if the difference between the products is clearly explained, the amalgamation of use, abuse, and dependence carefully avoided, and the institutional discourse consistent.

Develop and enhance research in health education

Create and coordinate interdisciplinary research.

Health education as a field and a practice has its roots in several disciplines: pedagogy, medicine, epidemiology, clinical and social psychology, social communication, and sociology, but it is not attached to any of them in particular. It borrows their frames of reference and their methods, all the while trying to build a specific theoretical framework for itself. Each of these disciplines brings distinct, even conflicting, perspectives. The diverse pedagogical schools each proceed from different models of education.

Unlike any other European country (Belgium, Netherlands, United Kingdom, Spain, Italy), Canada, the United States, or Australia, France has no university tradition of health education, nor any special chairs.

The expert advisory group recommends the development of interdisciplinary research based upon the existing corpus of knowledge in health education.

This research, which should concern intervention methods, must take into consideration scientific knowledge about behavioral factors and the attitudes and representations of young people. To this end, the expert advisory group recommends the creation of inter-UFR (training and research units) centers, which would confer health education with university status; these centers would be able to work in partnership with department and associations active in this domain. In this perspective of interdisciplinary work and the development of research neither exclusively experimental nor participatory, it would be desirable that the national research institutes (INSERM, CNRS, INRP, etc.) also be associated with it, together with the organizations that develop field activities and strategies. Because of the lack of resources, the health education research activities that already exist are not adequately coordinated or exploited. The expert advisory group proposes the creation of an institutional body—a national agency—with the mission of bringing together the teams and skills necessary (teachers, researchers, field workers) to set up projects with the funds and staff they need.

develop new evaluation tools

Evaluations of prevention programs essentially concern health and epidemiologic results, together with economic aspects. Evaluations of educational interventions have long focused on changes in knowledge while ignoring the role of the entire set of players, processes, and organizational aspects in the quality and effectiveness of health education. Tools and methods from the social sciences have gradually modified the objectives of evaluation research and made place for "qualitative" assessments.

Evaluation in health education must have as its object educational requirements, intervention programs, and their effects. The expert advisory group recommends that the quantitative and qualitative approaches to evaluation research be combined and that tools be developed that can take all of these concepts into account. In this field, it is important to promote the evaluation of measurement scales in the French context, qualitative and quantitative effect indicators (including unanticipated effects), and most especially, the definition of new indicators, such as individuals' "action capacity levels".

promote the transfer of experimental findings and research

In France, despite the numerous studies published, both epidemiologic and psychosociologic, prevention strategies for young target groups are not sufficiently based on scientific data. This gap between the complexity of research and what is understood at the field level suggests the need to improve the image and appreciation of research work among workers in the field. Workers must be able to have access to the conclusions of the scientific literature in a form understandable by all. It could be useful for them to rely on questionnaire and/or pre-estimated evaluation modules. Moreover, the reading and writing work of field workers and researchers could be facilitated by the drafting of templates and models for evaluation studies.

The expert advisory group recommends that the results of programs, evaluation studies in particular, be made rapidly available and capitalized upon. It also recommends encouraging multidisciplinary meta-analysis, in particular of the evaluations of aspects transferrable between programs. Finally, it also calls to the attention of the bodies that evaluate researchers the fact that activities involving the transfer of research achievements must be recognized and financed.

Centre d'expertise collective (INSERM SC14), Faculté de Medecine Xavier Bichat, 16 rue Henri Huchard, 75018 PARIS, tel 01 44 85 61 65

Created: 2001.

• Cite this Page INSERM Collective Expertise Centre. Health education for young people: Approaches and methods [Internet]. Paris (FR): Institut national de la santé et de la recherche médicale; 2001.
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Methods and Materials of Health Education

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

This new book constitutes a practical compendium of techniques and procedures for improving the quality of school health education. It also provides detailed descriptions of resources for health education and illustrations of the applications of method to the use of these materials. Although school health education is seldom planned and carried on with the same intensity as the more traditional subjects, life science deserves equal emphasis in the curriculum in terms of attention to materials and methods as these influence the general quality of instruction. Without minimizing the value of factual approaches, the volume stresses the need to provide concrete and realistic health education experiences for children and youth. The book is divided into five parts, the first of which is concerned with definition and delineation of the school health program; part 2 deals with curriculum formulation and development, part 3 with teaching techniques and procedures, part 4 with materials

Methods and Materials of Health Education. JAMA. 1958;167(11):1442–1443. doi:10.1001/jama.1958.02990280128031

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Chapter: 11th Nursing : Chapter 10 : Health Education and Audio visual Aids

Methods & approaches of health education.

Methods & Approaches of Health Education

Methods of health education

Health education is carried out at 3 main levels;

·            Individual Approach.

·            Group Approach.

·            General Approach/Mass.

Individual Health Education:

Doctors and nurses, who are in direct contact with patients and their relatives, have opportunities for much individual health education. The topic selected should be relevant to the situation. For instance, a mother who has come for delivery should be told about child birth-not about malaria eradication.

The biggest advantage of individual health teaching is that we can discuss, argue and persuade the individual to change his behaviour. The disadvantage is that the numbers we reach are small.

Group Health Education:

The groups are many – mothers, school children, patients, industrial workers – to whom we can direct health teaching. The choice of subject in group health teaching is very important; it must relate directly to the interest of the group. For instance, mothers may be taught about baby care; school children about oral hygiene; a group of TB patients about tuberculosis, and industrial workers about accidents.

Methods of Group Teaching

These have been classified as below:

One – way or didactic methods:

·            Lecture

·            Films

·            Charts

·            Flannel graph

·            Exhibits

·            Flashcards

1.         Lectures:

Lectures are the most popular method of health teaching. In this, communication is mostly one-way, i.e., the people are only passive listeners; there is no active participation on their part in learning. How impressive and effective the lecture is, depends upon the personality and reputation of the speaker. A lecture does provide basic information on the subject, but it may fail to change the health behaviour of the people. Nevertheless lectures have an important place in the health education of small groups.

2.         Films, charts & Puppets:

These are mass media of communica-tion. They can be of value in educat-ing small groups.

Suspense Charts:

Each section of the charts is covered and is exposed one by one to reveal the story or ideas without exposing the whole chart at a time.

Puppets are dolls made by hand and a story can be narrated using them it is a popular teaching aid to health teaching.

3.         Flannel graph:

A flannel graph consists of a wooden board over which is pasted or fixed a piece of rough flannel cloth or khadi. It provides an excellent background for displaying cut out pictures and other illustrations. These illustrations and cut out pictures are provided with a rough surface at the back by pasting pieces of sand-paper, felt or rough cloth, and they adhere at once, put on the flannel. Flannel graph is a very chief medium, easy to transport and promotes thought and criticism. The pictures must be arranged in proper sequence based on the talk to be given.

4.         Exhibits:

These consist of objects, models, specimens, etc. They convey a specific message to the observer. They are essentially mass media of communication .

5.         Flash Cards:

They consist of a series of cards, approximately 10 x 12 inches – each with an illustration pertaining to a story or talk to be given. Each card is “flashed” or displayed before a group as the talk is in progress. The message on the cards must be brief and to the point.

They are pictures arranged in sequence, which illustrate a story support the cards in front of the chest and practice in order to make the teaching effective. Use a Pointer so that the picture is not covered by your hand.

Two-way or Socratic Methods:

·            Group discussion

·            Panel Discussion

·            Symposium

·            Workshop

·            Role playing

·            Demonstration

1.         Group Discussion:

Group discussion is considered a very effective method of health teaching. It is a tow-way teaching method. People learn by exchanging their views and experiences.

·            To be effective, the group should comprise not less than 6, and not more than 12 people.

·            There should be a group leader who initiates the subject, helps the discussion in the proper manner, prevents side-conversations, encourages everyone to participate and sums up the discussion in the end.

·            The proceedings of the group discussion are recorded by a “recorder”, who prepares a report on the subject and agreements reached.

2.         Panel Discussion:

Panel discussion is a novel method of health education. The success of the panel depends upon the Chairman.

·            The Panel consists of a Chairman or Moderator, and 4 to 8 speakers.

·            The Panel sits and discusses a given problem in front of a group or audience.

·            The Chairman opens the meeting, welcomes the group and introduces the panel speakers who are experts on the subject.

·            He introduces the topic briefly and invites the panel speakers to present their points of view. There are no set speeches, but only informal discussion among the panel speakers.

·            It is said that the discussion should be spontaneous and natural.

·            After the subject has been discussed by the panel speakers, the audience is invited to take part. If properly planned and guided, panel discussion can be an effective method of health education.

3.         Symposium:

A Symposium is a series of speeches on the selected subject by experts. There is no discussion on the subject by the experts. In the end, the audience may raise questions and contribute to the Symposium.

4.         Workshop:

The Workshop consists of a series of meetings. The total workshop is divided into small groups, and each group will choose a Chairman and a recorder. Each group solves a part of the problem with the help of consultants and resource personnel. Learning takes place in a friendly, happy and democratic atmosphere under expert guidance.

5.         Role Play:

Role Play or socio-drama is a particularly useful device for putting up problems of human relationship. The group members enact the roles as they have observed or experienced them, e.g. the expectant mother in an antenatal clinic, the public health nurse on a home visit, etc. The size of the group should not be more than 25. Role play is followed by a discussion of the problem.

6.         Demonstrations:

Practicaldemonstrationisanimportant technique of the health education. We show people how a particular thing is done – using a tooth-brush, bathing a child, feeding an infant, etc. A demonstration leaves a visual impression in the minds of the people.

Education of the general public(Mass Approach) :

For the education of the general public, we employ “mass media of communication’ – Posters, health magazines, films, radio, television, health exhibitions and health museums. Mass media are generally less effective in changing human behaviour than individual or group methods. But however, they are very useful in reaching large numbers of people with whom otherwise there could be no contact. For effective health education mass media should be used in combination with other methods.

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• Published: 24 May 2024

For the rural curious: mixed methods evaluation of a rural pharmacy practice elective

• Timothy P. Stratton 1  

BMC Medical Education volume  24 , Article number:  573 ( 2024 ) Cite this article

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Metrics details

As of 2020, 20% of people residing in the United States of America (U.S.) lived in rural communities. Despite rural residents tending to be older, poorer, and having greater disease burden than their urban counterparts, the number of rural primary care providers continues to decline. Nearly 66% of U.S. Primary Care Health Professional Shortage Areas are designated as rural. Pharmacists can help address this shortage of rural primary care providers, often serving as providers of first-contact care; however, only 12% of U.S. pharmacists practice in rural communities. To help address this gap, in 2022 an elective Rural Pharmacy course was created at the University of Minnesota College of Pharmacy by a faculty member who has rural practice experience.

The course combines formal lectures, guest presentations by rural pharmacists and student interviews with additional rural pharmacists. For the 42 students enrolled in the course in 2022 and 2023, non-parametric statistics were used to compare the percentage of students who were raised in rural communities or who otherwise had extensive exposure to rural, and compare student interest ratings (1 to 7) about practicing/living rural at the beginning and end of the course. Students also wrote end-of-course reflection papers, commenting on the course and their interviews with rural pharmacists.

Across both years, 45% of the enrolled students had previous experience in rural communities. The net change in Rural Interest scores among students completing both questionnaires was + 5 in 2022 and + 2 in 2023, both non-significant differences. The largest shifts in student interest were from “Not Sure” at the start of the course to “Interested” or “Not Interested” at the end of the course, and from “Interested” to “Very Interested.” In their reflection papers nearly 60% of students reported being most impressed by their interviews with rural pharmacists.

Conclusions

A course addressing the benefits and challenges of practicing pharmacy in rural communities was well-received by pharmacy students. Even students who have little interest in living in a rural community can benefit from being introduced to rural culture, enabling them to provide more culturally-responsive care for patients from rural communities.

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Introduction

The Unites States (U.S.) Census Bureau redefined “rural” for the 2020 census as communities with populations of fewer than 5,000 people (fewer than 2,000 housing units) and located more than 1.5 miles (2.4 km) from a high-density urban area. Based on this revised definition, 20% of the U.S. population in 2020 lived in rural communities [ 1 ]. The percentage of rural residents varied greatly by region, with only 11% of people in the West Region residing in rural areas, followed by 16% in the Northeast Region, 24% in the South Region and 26% in the Midwest Region [ 2 ]. At the extremes, fewer than 6% of people in California lived in rural areas, while nearly 65% of Vermont residents lived in rural areas [ 1 ]. In contrast, as of 2021 the U.S. Bureau of Labor Statistics reported that only 12% of the nation’s pharmacists practiced in nonmetro (rural) communities [ 3 ].

On average, rural residents tend to be older [ 4 ], poorer [ 5 ], experience greater disease burden [ 6 ] and lack health insurance or be underinsured [ 7 ] than residents of urban communities. The average age and disease burden among rural residents is increasing due to outmigration of young adults from rural to urban communities and the in-migration of older adults to rural communities following retirement [ 4 ]. Yet as the proportion of older residents in rural communities continues to increase, the availability of primary care providers in rural communities continues to decrease. Nearly 66% of Primary Care Health Professional Shortage Areas in 2023 are designated as rural [ 8 ]. Pharmacists can be part of the solution to address the existing and anticipated shortage of primary care providers in rural communities [ 9 ]. Rural pharmacists often serve as “providers of first-contact care” for patients who are seeking to self-treat a health condition [ 10 ]. Where self-treatment is inappropriate, the pharmacist is in a position to refer the patient to appropriate professional care.

This paper describes a new course taught in the Doctor of Pharmacy (PharmD) program in the University of Minnesota College of Pharmacy that introduces students to the unique benefits and challenges of practicing pharmacy in rural communities.

One college, two campuses

The University of Minnesota (UMN) is a public, research-intensive (Carnegie R1) institution. The UMN College of Pharmacy opened on the Minneapolis campus in 1892 [ 11 ]. Prior to 2003, the College of Pharmacy included four departments: Experimental & Clinical Pharmacology, Medicinal Chemistry, Pharmaceutics, and Pharmacy Care & Health Systems. However, to address a shortage of pharmacists in Greater Minnesota – counties outside of the seven-county Minneapolis-St. Paul Twin Cities Metro Area [ 12 ] – in 2003 the College of Pharmacy expanded its program 150 miles (241 km) north to Duluth on the University of Minnesota Duluth campus, adding a fifth department to the College, Pharmacy Practice and Pharmaceutical Sciences (PPPS).

The specific multi-campus model used by the UMN College of Pharmacy is somewhat unique among multi-campus pharmacy programs in the U.S. The PPPS department includes faculty representing Biochemistry and each of the major Pharmacy disciplines (Clinical Pharmacy, Medicinal Chemistry, Pharmaceutics, Pharmacology, Pharmacy Practice, and Social & Administrative Pharmacy). Didactic courses within the College are taught using videoconferencing technology, with classroom presentations/lectures originating from either Minneapolis or Duluth and being broadcast to the other campus.

The mission of the PPPS department includes preparing pharmacists to provide patient care in rural and Indigenous communities [ 13 ]. PPPS faculty embody this mission in all four areas of an academic health professions program, highlighting the unique health needs of rural residents in their teaching, addressing these needs through community-based participatory research [ 14 ], conducting service activities in rural communities, and providing clinical services. Until 2022, however, no single course in the College of Pharmacy’s curriculum was devoted specifically to rural health.

Rural pharmacy elective-course description and structure

To help address this gap in the College of Pharmacy curriculum, the author – a pharmacist who has practiced hospital, community and long-term care pharmacy in frontier/Indigenous communities in Alaska [ 10 ], Eastern Montana and Minnesota – created a two-credit elective course (two hours per week for 15 weeks) in Rural Pharmacy to introduce students to the benefits and challenges of living and practicing in rural communities. Development of the course was guided by the author’s teaching philosophy; to paraphrase Confucian philosopher Xun Kuang [ 15 ]: “Tell me and I will forget. Show me and I will remember. Involve me and I will understand.”

The Rural Pharmacy course was designed as a HyFlex course [ 16 ] that allows the learner to choose by which content delivery method they would like to learn. Learners in a Hyflex course may elect to attend a live class session in person in a classroom, may attend a live class session remotely via videoconference, or may learn online anytime. Each live class session is recorded to accommodate students who prefer to learn online during a given week, or throughout the entire course.

The Rural Pharmacy elective is a “modified” HyFlex design in that no in-person option is available. University of Minnesota College of Pharmacy faculty and students are accustomed to videoconferencing as a course delivery method, the college having used videoconference technology since 2003 to conduct live, in-person sessions for learners on campuses located 2.5 h apart from one other. Required and elective didactic courses delivered by videoconference are always recorded, enabling learners to view the recording at a more convenient time if they are unable to attend the live class session. Another reason that an in-person option for the Rural Pharmacy elective is not offered is that live course sessions are conducted in the evening to accommodate students from different years in the pharmacy program (P2 and P3) whose other courses are all on different schedules, and Minnesota’s frequent snowy and icy winter conditions are not always conducive to safe travel to and from campus, especially at night.

At the time of this writing, during the first three pre-clinical years University of Minnesota College of Pharmacy students are required to complete 15 credits of elective courses above and beyond their required courses. The Rural Pharmacy elective is open to students in the final two pre-clinical years of the PharmD program (P2 and P3), but enrollment is capped by the instructor at 25 students per offering. Live class sessions are conducted once weekly for two hours in the early evening by videoconference for all students, whether based in Duluth or in the Minneapolis-St. Paul Twin Cities area. The early evening hours avoid conflicts with students’ other courses, which are on different schedules between 8:00 am and 5:30 pm for both of the two years. Students are encouraged to attend as many live videoconference sessions as possible, especially when a guest presenter is scheduled; however, as noted above all class sessions are recorded for viewing or reviewing at a more convenient time. The recordings accommodate students who may be working in a pharmacy as a Pharmacy Intern or Pharmacy Technician at the time class is scheduled, or students who desire to review one or more recorded class sessions prior to the written midterm examination.

A University of Minnesota Post-Graduate Year 1 (PGY1) Rural Pharmacy Resident [ 17 ] serves as the Teaching Assistant for the course each year, participating in the live class sessions via videoconference. The Pharmacy Resident is based out of a rural community in central Minnesota, traveling to two other rural communities and providing comprehensive medication management services [ 18 ] to residents of all three communities. While maintaining patient confidentiality, the Resident shares with students their experiences caring for patients in rural communities, some stories being only a few hours old. In addition to regularly participating in live class sessions, the TA prepares and leads a class session on their own, and conducts the live session interviews with guest rural pharmacists as described below.

About half of the class sessions feature guest pharmacists who currently practice in rural communities, guests joining the live class sessions via videoconference. When a guest pharmacist is invited to participate in the course, the instructor provides the pharmacist with a list of potential interview questions that they would be asked to address during the class session. On rare occasions the visits with pharmacist(s) are pre-recorded either to better accommodate the pharmacist’s work schedule or because of time zone differences between Minnesota and the states where the pharmacists live/work. Pre-recorded interviews are played during the live class session, and students submit questions they would have asked the pharmacist had the pharmacist been able to join the class session in real time. Those questions are then summarized by the instructor and forwarded to the guest pharmacist to respond to as the pharmacist’s time allows. Pharmacists living and practicing in rural and Indigenous communities from throughout Minnesota and from as far away as Alaska have participated in the live sessions, either pre-recorded or in real time. In addition to rural pharmacists, guest presenters have included Advance Practice Nurses [ 19 ] from rural communities, and a Biologist who works with an Indigenous community on the impacts of climate change on the health of the community.

A variety of assessments are utilized in the course including reflection papers, an online multiple-choice/true–false/short answer midterm exam, written participation in online discussions, in-class student presentations and written summaries of interviews with pharmacists practicing in rural communities. The course is graded on a A,B,C,D,F letter grade scale. A total of 300 points are available across nine activities in the course, ranging in value from 5–50 points. The grading scale used in the course is the professional scale used in all of the college’s courses, an A grade being attained by students who earn at least 93% of the available points while students earning fewer than 60% of available points do not receive a passing grade. The possible number of points available on individual assignments are assigned by the instructor based on the amount of time and effort students are expected to expend on the assignment as well as the quality of each assignment’s deliverable.

At the start of the course students complete a brief 7-point Likert-type questionnaire regarding their familiarity with rural communities and interest in possibly practicing in a rural community. The questionnaires are confidential rather than anonymous as students complete the same questionnaire again at the end of the course. The course director uses student names to match start-of-course and end-of-course questionnaires to measure changes in student attitudes. Students also write a brief paper describing their experiences with rural communities and the reason for their interest in learning (or learning more) about living and practicing in rural communities. The instructor uses this information to tailor presentations in the course for the entire class based on the students’ familiarity with rural communities. This information also familiarizes the instructor with students’ backgrounds, enabling the instructor to invite specific students to share their rural experiences as relevant opportunities arise during live class sessions. The initial questionnaire and interest paper collectively constitute 8.37% of the course grade.

The online midterm examination is based on material provided in the textbook [ 20 ] or during instructor or Resident presentations. Students are tested on their knowledge about what constitutes “rural” as defined by several different U.S. government agencies, rural culture, challenges in rural public health, and opportunities and challenges related to practicing pharmacy in rural communities. The midterm exam score constitutes 16.7% of the course grade.

As mentioned previously, the HyFlex nature of the course accommodates students who are unable to attend the live videoconference sessions. All students, however, participate in weekly written online discussions based on the live videoconference session from that week. Live sessions are recorded so that any student may view and listen to the session at their leisure. In the online discussion, students are asked to respond to an instructor-generated question based on that week’s live class session. Students are asked to post their response first, then comment on the response of at least one other classmate. The Canvas learning management system [ 21 ] facilitates this learning approach, providing the instructor the option to require a student to post their response before reading the responses of classmates. Students who post their responses by the weekly deadline receive full participation credit for the week, rather than being graded on the length of their response or on the number of responses they make to classmates’ postings. As a HyFlex course, students are not awarded extra points for attending the live videoconference session, nor are they penalized for not participating in the live videoconference session. Participation constitutes 16.7% of the course grade.

Indigenous people began living in what today is referred to as Minnesota some 13,000 years ago. Among the earliest identifiable tribes in Minnesota were the Dakota (Sioux) circa 1000 CE and the Anishinaabe (Chippewa, Ojibwe) who arrived in the mid-1700s [ 22 ]. Today, Minnesota is home to four Dakota and seven Anishibaabe reservations [ 23 ], most of these communities being located in rural or frontier Minnesota counties. In contrast to these early inhabitants whose ancestors have lived in Minnesota for hundreds of years, today foreign immigrants are arriving in Minnesota in increasing numbers [ 24 ]. Many of these new arrivals settle in communities outside of the Twin Cities Metro Area [ 25 ]. This spectrum of diversity underlies the importance for healthcare providers to learn to provide culturally-responsive care [ 26 ]; therefore, students in the course learn about Indigenous people or foreign-born immigrants they might encounter if practicing in rural Minnesota. Each student is assigned a particular culture (not their own), and through readings about and/or interviews with members from that culture prepares a brief presentation they share with the class during a live videoconference session. Again, because this is a HyFlex course a student who knows in advance that they will be unable to attend class when they are scheduled to present are able to pre-record their presentation. Pre-recorded student presentations are played during the live course session. This exercise constitutes 16.7% of the course grade.

As students in this course are training to become pharmacists, they interview pharmacists who currently practice in rural communities (or who have practiced in a rural community in the recent past). These interviews supplement the rural pharmacy practice stories provided by the instructor, the Resident, and the pharmacists who present during class videoconference sessions. Most, but not all, of the pharmacists who participate in the course are the instructor’s former students from the UMN College of Pharmacy, Duluth. In addition to pharmacists with practice experience in rural Minnesota, pharmacists in the instructor’s circle of contacts from rural Alaska, Wisconsin and Michigan have participated in the course, as have pharmacists from four different rural Indian Health Service [ 27 ] /Tribal Health Clinics. Potential pharmacist participants are contacted by the course instructor before the course begins to gauge their interest and willingness to participate in a live class session or be interviewed by the students, and are provided with the list of interview questions that will be asked. Characteristics and practice settings of the pharmacists who participated during the first two offerings of the course are presented in Table  1 .

The instructor assigns the students to interview teams of two to three students who conduct structured interviews with the rural pharmacists who practice in community, critical access hospital [ 28 ], health system hospital or Indian Health Service/Tribal Health settings. Each student is assigned to one team to interview a community pharmacist, and then to a different team to interview the health system pharmacist. Where possible, teams are structured to reflect gender diversity and include students from different years in the pharmacy program. Each student team contacts their assigned pharmacist and schedules a telephone or videoconference interview. Interviews are intended to last no more than 30 min, but oftentimes go longer as the conversations between the students and the pharmacist range far beyond the structured questions provided by the instructor.

Each student submits written summaries of their two interviews. Each interview team provides informal presentations about their interviews to the class during a live videoconference class session. Each interview assignment constitutes 16.7% of the course grade.

At the end of the course, students once again complete the 7-point Likert-type questionnaire regarding their interest in possibly practicing in a rural community. The numerical results from this questionnaire are compared to the numerical results of the interest questionnaire that the student completed at the start of the course. Each student also writes a brief reflection paper regarding what they learned in the course about practicing pharmacy in a rural community, and what aspect of the course they found most interesting/helpful in their learning. As with the similar assignments at the beginning of the course, the final questionnaire and final reflection paper constitutes 8.37% of the course grade.

Rural pharmacy elective-topics

Topics presented in the course are listed in Table  2 . Topics for didactic sessions early in the course are based on selected chapters from the textbook required for the course, Foundations of Rural Public Health in America (2022), by Joseph N. Inungu and Mark J. Minelli [ 20 ]. The course also features interdisciplinary and interprofessional components. As noted earlier, one guest presenter is a PhD Biologist employed by one of Minnesota’s American Indian tribes. That individual addresses Climate Justice, explaining the impact of climate change on rural Indigenous communities. Also as noted earlier, a group of rural Advanced Practice Nurses in different subspecialties present a panel session addressing the challenges faced by the communities they serve, and describe how they interact with rural pharmacists in their communities.

Assessing course outcomes

The percentages of students enrolled in the course on each campus who reported growing up in a rural community or having spent considerable time visiting relatives who lived in rural communities were compared using Fisher’s exact test [ 29 ]. For students completing rural interest questionnaires both at the beginning and the end of the course, rating scores from both years and both campuses were combined and paired. Given the ordinal nature of the data, beginning/end of course ratings were evaluated using the Wilcoxon signed-rank test [ 30 ]. A two-tailed alpha value of 0.05 was selected as the criterion to indicate significance in all numerical comparisons.

For the first offering of the course in Spring, 2022 a total of 25 students completed the course. Spring 2023 had 17 students in the course. The demographics of the students in these two cohorts are summarized in Table  3 .

Between the first two offerings of this course, 25 students on the Minneapolis campus enrolled in the course. Of these 25, 10 (40%) reported growing up in a rural community or having spent considerable time visiting relatives who lived in rural communities. Among the 17 Duluth students enrolled in the course between the two years, nine (53%) reported having grown up or otherwise spent considerable time in rural areas. This difference was not statistically significant.

At the beginning and end of the course, students rated their interest in living/practicing in rural community using a 7-point Likert-type scale ranging from “1-No interest” to “7-When can I start?!” The results from the 36 students who completed both the pre and post questionnaires are presented in Fig.  1 .

Interest in Practicing Pharmacy in Rural Communities ( n  = 36)

The total net change in Rural Interest scores across all students completing both questionnaires was + 5 in 2022 and + 2 in 2023, some student scores increasing, others decreasing, and still others remaining the same. Results of the Wilcoxon Signed-Ranks Test were non-significant ( z  = -1.5903; p  = 0.112).

The largest change in scores occurred in the “Not sure” category (middle choice), with only one student remaining unsure of their interest in practicing in a rural community at the end of the course compared to six students at the beginning of the course. Four students who selected “Not sure” at the start of the course expressed lower interest in practicing in a rural community at the end of the course, one of these students moving down three levels from “Not sure” to “No interest.” One student who had selected “Interested” at the beginning of the course also dropped three levels at the end of the course to “Slight interest.” In contrast, several students who had selected “Interested” at the start of the course moved up to “Very Interested” or “When can I start?!”.

At the end of the course, students were asked to reflect on the impact of the course on their interest in practicing pharmacy in a rural community. Among the 42 students enrolled in the course during the first two years, 25 students in their reflection papers explicitly expressed appreciation for being able to interview pharmacists currently practicing in rural communities, while 20 explicitly expressed appreciation for having rural pharmacists and other professionals as guest speakers during class sessions. Two word clouds were generated from students’ reflection papers, one based on student perceptions of the benefits of living/practicing in a rural community (Fig.  2 ), and the other based on student perceptions of the challenges of living/practicing in a rural community (Fig.  3 ).

Word cloud featuring perceived benefits of living and practicing pharmacy mentioned in Rural Pharmacy students’ end-of-course reflection papers. “Courtesy of FreeWordCloudGenerator.com”

Word cloud featuring perceived challenges of living and practicing pharmacy mentioned in Rural Pharmacy students’ end-of-course reflection papers. “Courtesy of FreeWordCloudGenerator.com”

Representative student comments excerpted from their reflection papers regarding what they had heard from rural pharmacists who participated in the course are provided below. Each student’s comment is followed by that student’s final rating of their interest in practicing pharmacy in a rural community (1 = No interest, 7 = When can I start?!):

Before this course I had no interest in practicing rural before but now I’d at least entertain the idea after speaking and interviewing pharmacists that did or currently practice there. (Student selected ratings of 1 and 2) Hearing so many amazing stories, pharmacists are truly more than just “pill counting” because a single pharmacy can connect them with other rural health professionals, expanding the capabilities of rural pharmacists…. (2) If you can dream it you can do it in rural pharmacy. (5) It was great to have [the pharmacist I interviewed] in my network, as [they] said I can contact [them] anytime with questions outside… [of] my interview. I learned that having many contacts in your network, especially in rural areas, is so important…. (6) This class stimulated a future career interest that I already had, but was not sure exactly how to get started and who to ask if I had any questions. I feel like I now have many resources to reach out to when it comes to my future career, which makes me incredibly happy and comfortable. (7)

Students also expressed appreciation for other aspects of the course, whether the students were interested in practicing in a rural community at the end of the course or not. Again, each student’s comment is followed by that student’s final rating of their interest in practicing pharmacy in a rural community (1 = No interest, 7 = When can I start?!):

Even if I do not practice as a rural pharmacist, I will value the exposure and learning that has come from the topics covered in this course. (3) To be frank, I never even entertained the idea of practicing as a rural pharmacist. I’ve always wanted to work in an urban ambulatory care setting…. I did not expect the class to be as eye opening as it truly was…. I’m much more open to serving in a rural community and may consider it strongly . (3) It would be a huge adjustment to move to a rural area since I have grown up in [an urban community] my whole life. I want to work in a rural community since it is rewarding, but it is difficult to leave family behind and essentially start a new life with new people. (4) This is a rural pharmacy class, but it did not feel biased towards only working rural…. I came into this class knowing that I had an interest in rural pharmacy, but I did not expect to come out of this class even more interested in what rural areas have to offer. (6) Before starting this course, I knew that I wanted to practice pharmacy in a rural community…. Many times during this course we stated, “When you’ve seen one rural community, you’ve seen one rural community.” I did not know how true this statement was before this course…. Despite their vast differences, one common underlying theme is the health disparities seen in rural areas. (7)

It is important that health professions students be introduced to rural culture, even if they are “never” going to live/practice in a rural community themselves. With 5–64% of states’ populations living in rural communities [ 1 ], the odds are good that at some point in their careers, health professionals living in large urban centers are going to care for patients who have come from rural communities to receive more specialized care than is available locally [ 31 ]. Being introduced to rural culture can help students provide more culturally responsive care [ 32 ] to patients from rural communities during their careers.

The purpose of this course was to introduce pharmacy students to the advantages and challenges of practicing and living in rural communities. The course was not intended to “change hearts and minds” of students regarding their possible interest in practicing in a rural setting, and as can be seen from the results, students’ “interest in rural” ratings collectively neither significantly increased nor decreased between the beginning and the end of the course. Regardless, from comments in their reflection papers students generally appreciated the course, finding the interviews with rural pharmacists to be particularly valuable. This finding was heartening to the instructor who was initially concerned about the amount of out-of-class work being asked of the students.

Likewise, guest presenters who participated in the live class sessions and pharmacists interviewed by the students informally expressed their satisfaction with participating in the course, and expressed gratitude that this course was being offered. One pharmacist who previously practiced in a remote Alaska community but had recently moved to a major urban center in the “Lower 48” (Alaskan reference to states in the contiguous United States south of the 49th Parallel) expressed how much they enjoyed sharing their stories with the Rural Pharmacy students. The students with which this pharmacist currently works all desire to practice in large urban centers and are not particularly interested in hearing about the pharmacist’s experiences practicing in small, isolated communities. Another pharmacist noted that they really appreciated joining the students virtually in the live classroom, and was going to recommend this approach to other pharmacy schools with which they work as a way to generate interest in rural pharmacy in general, as well as interest in their particular pharmacy as a clinical rotation site.

A few changes were made in the roster of pharmacists participating in the course from year to year; however, most of the guest speakers and pharmacists who were interviewed by the students participated in the course both years. Another change being considered for the next offering of the course is to add a live videoconference session with a Minnesota Department of Agriculture “Farm Counselor” (a Licensed Professional Counselor) who makes in-person “farm calls” to address farm families’ mental health needs within the unique context of farm culture [ 33 ] (MN Dept of Ag, 2023).

A course specifically addressing the benefits and challenges of practicing pharmacy in rural communities was well-received by pharmacy students enrolled in the course, and by the rural guest presenters and rural pharmacists who were interviewed by the students. Even students who have little interest in living or practicing in a rural community can benefit from being introduced to rural culture, helping all students provide more culturally-responsive care for patients from rural communities.

Availability of data and materials

The data analyzed during the current study are not publicly available due to stipulations in the U.S. Family Educational Rights and Privacy Act (FERPA), but are available in de-identified form from the corresponding author on reasonable request.

Abbreviations

Students enrolled in years 1, 2 or 3 of the Doctor of Pharmacy (PharmD) program

Post-Graduate Year 1

Doctor of Pharmacy

Doctor of Philosophy

Pharmacy Practice and Pharmaceutical Sciences

Teaching Assistant

University of Minnesota

United States of America

United States Census Bureau. Nation’s urban and rural populations shift following 2020 Census. Press Release Number CB22-CN.25. Suitland (MD): U.S. Census Bureau; 2022. Available from: https://www.census.gov/newsroom/press-releases/2022/urban-rural-populations.html . Cited 2023 Aug 29.

United States National Center for Health Statistics. Health, United States, 2020-2021. Hyattsville (MD): U.S. Centers for Disease Control and Prevention; 2023. Available from: https://www.cdc.gov/nchs/hus/sources-definitions/geographic-region.htm . Cited 2024 Jan 22.

RHIhub. Rural Pharmacy and Prescription Drugs. [Internet]. Rural Health Information Hub. Available from: https://www.ruralhealthinfo.org/topics/pharmacy-and-prescription-drugs . Updated 2023 Jan 26; cited 2023 Aug 29.

Davis JC, Rupasingha A, Cromartie J, Sanders A. Rural America at a glance. Washington, DC: U.S: Department of Agriculture, Economic Research Service; 2022. Available from: Rural America at a Glance: 2022 Edition (usda.gov) . Cited 2023 Aug 29.

Google Scholar  

United States Department of Agriculture Economic Research Service. Rural poverty & well-being. Washington, DC: U.S. Department of Agriculture; [updated 2022 Nov 29. Available from: USDA ERS - Rural Poverty & Well-Being . Cited 2023 Aug 29.

United States Centers for Disease Control and Prevention. About rural health. [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Available from: About Rural Health | CSELS | Rural Health | CDC . Updated 2023 May 09; cited 2023 Aug 29.

Turrini G, Branham DK, Chen L, Conmy AB, Chappel AR, De Lew N, Sommers BD. Access to Affordable Care in Rural America: Current Trends and Key Challenges. Washington, DC: United State Department of Health & Human Services, Assistant Secretary for Planning and Evaluation. Available from: https://aspe.hhs.gov/sites/default/files/2021-07/rural-health-rr.pdf . 2021 July 09; Cited 23 Aug 29.

United States. Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Workforce. Designated health professional shortage areas statistics. Washington, DC: U.S. Department of Health & Human Services. Available from: BCD_HPSA_SCR50_Qtr_Smry.pdf . Updated, 2023 Mar 31; cited 2023 Aug 29.  https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport .

Council on Graduate Medical Education. Rural health policy brief 1. Special needs in rural America: Implications for healthcare workforce education, training and practice. Washington, DC: Health Resources & Services Administration. Available from: COGME Rural Health Policy Brief 1 (hrsa.gov) . Updated 2020 July 17; cited 2023 Aug 29.

Stratton TP. The economic realities of rural pharmacy practice. J Rural Health. 2001;17(2):77–81. https://doi.org/10.1111/j.1748-0361.2001.tb00261.x .

Article   Google Scholar  

Speedie MK, Ruhrold LN. A history of the University of Minnesota College of Pharmacy, 1892–2017. Research Triangle (NC): Lulu Press, Inc.; 2021. p. 285.

Nagel P, Yuan F. High-resolution land cover and impervious surface classifications in the twin cities metropolitan area with NAIP imagery. Photogrammet Eng Remote Sensing. 2016;82(1):63–71. Available from: https://www.researchgate.net/publication/288684001_High-resolution_Land_Cover_and_Impervious_Surface_Classifications_in_the_Twin_Cities_Metropolitan_Area_with_NAIP_Imagery .

University of Minnesota, College of Pharmacy, Department of Pharmacy Practice and Pharmaceutical Sciences. Minneapolis (MN): University of Minnesota College of Pharmacy; c2023. Available from: https://www.pharmacy.umn.edu/pharmacy-practice-pharmaceutical-sciences . Cited 2023 Aug 29.

United States Department of Health & Human Services, National Institute on Minority Health and Health Disparities. Community-Based Participatory Research Program (CBPR). NIH Guide No. RFA-MD-15-010. [Internet]. Bethesda (MD): National Institutes of Health. Available from: https://www.nimhd.nih.gov/programs/extramural/community-based-participatory.html . Updated 2018 Oct 02; cited 2023 Aug 29.

O’Toole, G. Quote Investigator. Xun Kuang. 2023. Available from: https://www.goodreads.com/quotes/7565817-tell-me-and-i-forget-teach-me-and-i-may . Cited 2023 Aug 29.

Beatty BJ. Hybrid-flexible course design: Implementing student-directed hybrid classes. 2019. Available from: https://edtechbooks.org/hyflex . Cited 2023 Aug 29.

University of Minnesota College of Pharmacy. Residency Sites & Emphasis Areas. Minneapolis (MN): University of Minnesota College of Pharmacy; c2023. Available from: https://www.pharmacy.umn.edu/degrees-programs/postgraduate-pharmacy-residency-program/residency-sites-emphasis-areas-2 . Cited 2023 Aug 29.

GTMRx Institute. c2019. Available from: https://gtmr.org/what-is-the-comprehensive-medication-management-process/ . Cited 2023 Aug 29.

American Nurses Association. Advanced practice registered nurse (APRN). [Internet]. Silver Spring (MD): American Nurses Association. Available from: https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/aprn/ .

Ingunu JN, Minelli MJ. Foundations of rural public health in America. Burlington: Jones & Bartlett Learning; 2022. p. 491.

Canvas LMS. Salt Lake City (UT): Instructure. c2008-2023. Available from: https://www.instructure.com/canvas . Cited 2023 Aug 29.

Furst R. Which Indigenous tribes first called Minnesota home? Star Tribune [Internet] (Minneapolis, Minnesota). 2021. Available from: https://www.startribune.com/native-american-dakota-ojibwe-history/600097050/#:~:text=The%20earliest%20identifiable%20tribe%20in,Ojibwe%20in%20the%20mid%2D1700s . Cited 2023 Aug 29.

State of Minnesota. Minnesota Indian Tribes. St. Paul (MN): State of Minnesota. Available from: https://mn.gov/portal/government/tribal/mn-indian-tribes/#:~:text=In%20Minnesota%2C%20there%20are%20seven,links%20to%20other%20valuable%20resources.&text=What%20does%20the%20term%20Federally%20Recognized%20mean%3F . Cited 2023 Aug 29.

American Immigration Council. Immigrants in Minnesota. Washington, DC: American Immigration Council. c2023. Available from: https://map.americanimmigrationcouncil.org/locations/minnesota/?_gl=1*5ervbb*_ga*MTYyMDYyNjcyNy4xNjkyMjExNzI4*_ga_W0MSMD2GPV*MTY5MjIxMTcyOC4xLjEuMTY5MjIxMTk3Mi4wLjAuMA . Cited 2023 Aug 29.

Minnesota Chamber of Commerce. Economic contributions by region. St. Paul (MN): Minnesota Chamber of Commerce. 2021 Mar 23. Available from: https://www.mnchamber.com/blog/economic-contributions-region . Cited 2023 Aug 29.

Prasad SJ, Nari P, Gadhvi, K, Barai I, Danish H, Philip AB. Cultural humility: treating the patient, not the illness. Med Educ Online. 2016 Feb 3;216;21: 10.3402/meo.v21.30908. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4742464/ . Cited 2023 Aug 29.

U.S. Department of Health and Human Services, Indian Health Service. Rockville (MD): U.S. Department of Health & Human Services. Available from: https://www.ihs.gov/ .

Centers for Medicare and Medicaid Services. Critical Access Hospitals. Woodlawn (MD): Centers for Medicare and Medicaid Services; [updated 2021 Dec 12. Available from: https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/cahs . Cited 2023 Aug 29.

Siegel S. Fisher’s exact test. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill. 1956. pp 96–104.

Siegel S. Wilcoxon signed-rank test. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill; 1956. pp. 75–83.

Casey M, McCullough J, Kreiger R. Which Medicare patients are transferred from rural emergency departments? [Internet]. Minneapolis (MN): University of Minnesota Rural Health Research Center. 2014. p. 19. Available from: https://rhrc.umn.edu/wp-content/uploads/2017/11/whichmedicarepatientsaretransferred.pdf . Cited 2023 Aug 29.

Minnesota Department of Health. Culturally responsive care. St. Paul (MN): Minnesota Department of Health. 2019 May 01. Available from: https://www.health.state.mn.us/docs/communities/titlev/cultresponsive.pdf . Cited 2023 Aug 29.

Minnesota Department of Agriculture. Stress&Crisis: Get Help Now. St. Paul (MN): Minnesota Department of Agriculture. c2023. Available from: https://www.mda.state.mn.us/about/mnfarmerstress/copingstress . Cited 2023 Aug 29.

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TPS is Professor of Pharmacy Practice in the University of Minnesota College of Pharmacy, Duluth. He has practiced community, hospital and long-term care pharmacy in frontier communities in Southeast Alaska, and at Indian Health Service/Tribal Health clinics in frontier Alaska and eastern Montana, and in rural Minnesota. He is a member of the Rural Pharmacy Consortium , a Past Chair of the Small and Rural Hospital Section Advisory Group for the American Society of Health-System Pharmacists, and a Past President of the Minnesota Rural Health Association.

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Stratton, T.P. For the rural curious: mixed methods evaluation of a rural pharmacy practice elective. BMC Med Educ 24 , 573 (2024). https://doi.org/10.1186/s12909-024-05539-3

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A new era for clinical education at Cornell

"It’s exciting to see the community come together to think creatively and work collaboratively to improve clinical education at Cornell." -Jodi Korich, D.V.M. ’97, associate dean for education. Image: CVM Educational Support Services

Clinical rotations are an eagerly anticipated portion of a veterinary student’s training. Fourth-year students join integrated healthcare teams to serve a diverse array of animal patients throughout Cornell’s teaching hospitals and ambulatory services. In May 2023, the college launched a multi-year initiative to strengthen both teaching and learning on clinical rotations.

“Feedback from students and clinical instructors indicated that it was time for the college to undertake a re-design of the clinical curriculum to take advantage of advancements in clinical education and technologies, and to keep pace with the changing veterinary industry,” says Jodi Korich, D.V.M. ’97, associate dean for education. “A logical first step was to improve clinical assessment and trainee feedback to align with the college’s new competency-based curriculum. We also saw opportunities to provide more customized support to help all students reach their full potential.”

A new assessment scale

A team of faculty, administration and curriculum support staff was assembled in February, 2023 to begin the process of transforming the clinical curriculum. Letter grades were replaced with a five-point entrustment scale to allow clinical instructors to evaluate each student’s ability to perform a set of attributes safely and effectively. Standardized universal attributes are now evaluated on all rotations to provide consistency, allowing the program to track student performance longitudinally over time. Specialized attributes and service-specific attributes also allow rotations to assess additional attributes that are relevant to their rotation.  “The goal is to have a system that allows for longitudinal tracking, thereby increasing the sensitivity and reliability of assessment. This sequential evaluation allows for early identification and targeted support of students that may be struggling with a certain component of clinical medicine,” says Daniel Lopez ’12, D.V.M. ’16, assistant clinical professor of small animal surgery and course leader for clinical rotations.

The new entrustment scale brings many benefits, including a more meaningful evaluation of the student’s readiness for day-one practice and greater insight into what they need to focus on to progress in their development. Instructors appreciate the simplicity of the new entrustment scale, which is more feasible to implement in the busy clinical workplace.

Broader feedback, better engagement

Another change in the assessment system is the breadth of feedback provided to students; now, all members of the clinical care team, including clinical faculty, Licensed Veterinary Technicians, interns and residents can score students on the attributes they have observed and provide written feedback on student performance using a new web-based assessment platform. “Multi-source feedback improves the reliability of student assessment and increases the volume of feedback provided,” says Lopez. “We’ve also seen the clinical community become more engaged in teaching and supporting students now that they have a more formal role to play in their assessment.”

Personal improvement plans

The student’s assessment scores are captured in a web-based reporting system; scores that do not meet the minimum performance level are flagged with students entering into a coaching program. The tiered coaching program begins with Tier 1, which pairs students with one of the five academic coaches who guides them through a self reflection exercise called a professional improvement plan. Students analyze their deficiency, develop a plan for improvement, and then implement their plan, monitoring their progress on subsequent rotations.

The goal of Tier 1 is to provide students with the time, support, and skills to self-evaluate their performance and make adjustments as needed moving forward. Ricardo de Matos , associate clinical professor of competency-based veterinary education curriculum development, who leads the academic coaching program, says, “We are pleased to see that students are approaching their professional improvement plans with a growth mindset. It’s not always easy for students to hear feedback that they need to improve. However, with the support of our coaches, students recognize the college is doing this to help them develop into competent and confident clinicians that can manage the challenges and demands of the veterinary profession. ”

Students who continue to struggle with a given attribute enter Tier 2 where they are paired with the Clinical Assessment and Teaching Support (CATS) team. The CATS system is designed to provide more intensive, one-on-one attribute-specific support to students. These students are given focused assignments and evaluations to monitor their progress more closely as they work to achieve competency by graduation.

“Ultimately, this new program provides the ability for students to accurately track their progress throughout their clinical year and implement feedback to improve,” says Jonathan Wood ’07, assistant clinical professor of neurology/neurosurgery and lead for the Stage 3 Clinical Redesign Team. “It also allows the college to identify and support struggling students in a tailored way, helping them become practice-ready.”

Community response

The D.V.M. Class of 2024 is the first class to engage with the new system and early feedback has been positive from across the community. “I think this has catalyzed some positive changes in our clinical community — we’ve moved away from a system where students were overly-focused on achieving letter grades and were rewarded for hiding gaps in their knowledge and skills,” says Korich. “Now, we have a system that meets each student where they are at and provides personalized support to help them work towards clinical proficiency. Our clinicians say that students are now asking more questions and being proactive about how they want to use their rotation to improve.”

Faculty feedback on the new approach has also been positive. “I appreciate the ability to give much more helpful feedback without automatically failing an underperforming student,” says Dr. Ursula Krotscheck, section chief of small animal surgery. “I anticipate that the usefulness of this system and the feedback it naturally generates will be much more likely to create practice-ready veterinarians than the previous grading system.”

While this is only the first step in reimagining clinical education at Cornell, it represents a significant advancement in our D.V.M. curriculum. “Making major changes like these requires teamwork. It’s exciting to see the community come together to think creatively and work collaboratively to improve clinical education at Cornell,” says Korich.

Written by Lauren Cahoon Roberts

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Marines say no more ‘death by PowerPoint’ as Corps overhauls education

WASHINGTON, D.C. ― Marines and those who teach them will see more direct, problem-solving approaches to how they learn and far less “death by PowerPoint” as the Corps overhauls its education methods .

Decades of lecturers “foot stomping” material for Marines to learn, recall and regurgitate on a test before forgetting most of what they heard is being replaced by “outcomes-based” learning, a method that’s been in use in other fields but only recently brought into military training.

“Instead of teaching them what to think, we’re teaching them how to think,” said Col. Karl Arbogast, director of the policy and standards division at training and education command .

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Arbogast laid out some of the new methods that the command is using at the center for learning and faculty development while speaking at the Modern Day Marine Expo.

“No more death by PowerPoint,” Arbogast said. “No more ‘sage on the stage’ anymore, it’s the ‘guide on the side.’”

To do that, Lt. Col. Chris Devries, director of the learning and faculty center, is a multiyear process in which the Marines have developed two new military occupational specialties, 0951 and 0952.

The exceptional MOS is in addition to their primary MOS but allows the Marines to quickly identify who among their ranks is qualified to teach using the new methods.

Training for those jobs gives instructors, now called facilitators, an entry-level understanding of how to teach in an outcomes-based learning model.

Devries said the long-term goal is to create two more levels of instructor/facilitator that a Marine could return to in their career, a journeyman level and a master level. Those curricula are still under development.

The new method helps facilitators first learn the technology they’ll need to share material with and guide students. It also teaches them more formal assessment tools so they can gauge how well students are performing.

For the students, they can learn at their own pace. If they grasp the material the group is covering, they’re encouraged to advance in their study, rather than wait for the entire group to master the introductory material.

More responsibility is placed on the students. For example, in a land navigation class, a facilitator might share materials for students to review before class on their own and then immediately jump into working with maps, compasses and protractors on land navigation projects in the next class period, said John deForest, learning and development officer at the center.

That creates more time in the field for those Marines to practice the skills in a realistic setting.

Marines with Marine Medium Tiltrotor Squadron (VMM) 268, Marine Aircraft Group 24, 1st Marine Aircraft Wing, fire M240-B machine guns at the Marine Corps Air Station Kaneohe Bay range, Hawaii, March 5. (Lance Cpl. Tania Guerrero/Marine Corps)

For the infantry Marine course, the school split up the large classroom into squad-sized groups led by a sergeant or staff sergeant, allowing for more individual focus and participation among the students, Arbogast said.

“They have to now prepare activities for the learner to be directly involved in their own learning and then they have to steer and guide the learners correct outcome,” said Timothy Heck, director of the center’s West Coast detachment.

The students are creating products and portfolios of activities in their training instead of simply taking a written test, said Justina Kirkland, a facilitator at the West Coast detachment.

Students are also pushed to discuss problems among themselves and troubleshoot scenarios. The role of the facilitator then is to monitor the conversation and ask probing questions to redirect the group if they get off course, Heck said.

That involves more decision games, decision forcing cases and even wargaming, deForest said.

We “put the student in an active learning experience where they have to grapple with uncertainty, where they have to grapple with the technical skills and the knowledge they need,” deForest said.

That makes the learning more about application than recall, he said.

Todd South has written about crime, courts, government and the military for multiple publications since 2004 and was named a 2014 Pulitzer finalist for a co-written project on witness intimidation. Todd is a Marine veteran of the Iraq War.

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