This paper offers a critique of present research methods used in the literature drawn upon by health education practitioners, students, and teachers. Weaknesses of deductive methods and of theory which is highly general are noted in terms of their implications for the advancement of health education theory and practice, and in terms of their consistency with traditional principles of practice. The grounded theory method—an inductive approach usually used with participant observation and interview data—is described, and the major arguments for its value are presented. In particular, the empirical generation of middle-range theory can provide a strong link between more general theory and situations faced by practitioners, and definitions of problems are not prematurely closed to reinterpretation from other perspectives. Several recommendations are given for changing the research orientation of health education.
Given the startling number of job-related illnesses and injuries which occur every year, occupational health and safety, a hitherto neglected topic, deserves significant attention in the school health education curriculum. Youngsters need to be exposed to this field before they become indifferent or callous toward diseases and accidents in the workplace and while the opportunity still exists to weigh health and safety considerations in selecting a career. In addition, when students take up regular employment, they cannot rely on industry, government, or organized labor to protect them fully from occupational illnesses and accidents; they must possess the skills and attitudes necessary to safeguard themselves. Occupational health and safety education in the schools can focus on general awareness, skill development, and job- specific information. The field can be easily and appropriately integrated with a number of current health education topics. Examples of integration are provided for eleven typical areas of a school health education curriculum.
The view that individual behavior change is the primary goal of health education presents several serious problems. Although individual behavior does contribute to health and disease, social organization is perhaps a more powerful influence. The use of behavior change as the primary tool for health education raises grave ethical issues. Health education which seeks to change individual behavior has also failed to have a significant impact on public health. An alternative strategy is health education for social change. The goal of this approach is to involve people in collective action to create health promoting environments and life-styles. Several contemporary models for and principles characteristic of health education for social change are described.
A multitrait-multimethod design was employed to assess the construct validity of the Health Belief Model. The data were obtained from a non-representative sample of 85 graduate students at The University of Michigan's School of Public Health. The traits consisted of the respondents' perceptions of: health interest, locus of control, susceptibility to influenza, severity of influenza, benefits provided by a flu shot, and the barriers or costs associated with getting a flu shot. Each trait was measured by three methods: a seven-point Likert scale, a fixed-alternative multiple choice scale, and a vignette. The results indicate that the Health Belief Model variables can be measured with a substantial amount of convergent validity using Likert or multiple choice questionnaire items. With regard to discriminant validity, evidence suggests that subjects' perceptions of barriers and benefits are quite different from their perceptions of susceptibility and severity. Perceptions of susceptibility and severity are substantially but not entirely independent. Perceived benefits and barriers demonstrate a strong negative relationship which suggests the possibility that these two variables represent opposite ends of a single continuum and not separate health beliefs. These preliminary results provide the basis for developing brief health belief scales that may be administered to samples of consumers and providers to assess educational needs. Such needs assessment, in turn, could then be used to tailor messages and programs to meet the particular needs of a client group.
The concept of voluntariness is central to an understanding of ethical considerations in two aspects of public health education practice: (1) the selection of appropriate interventions, and (2) the selection of appropriate targets for such interventions. The position is taken that most mass communications programs in public health education are persuasive as well as informative in intent. It is argued that the impact of such programs on voluntariness can be analyzed with regard to the rationality and resistibility of the persuasive appeals involved. Considerations of justice, as well as voluntariness and liberty, are reviewed in the discussion of appropriate targets for intervention. The issue of victim-blaming in public health education is explored, and conditions under which behavioral public health programs may be morally justifiable are suggested.
An 18-month study of consumer participation and influence in a Health Systems Agency (HSA) found consumer board members to be less influential than provider board members in agency decision-making. In an effort to investigate causes of the influence deficit experienced by consumer HSA board members three issues were studied: staff attitudes toward consumer participation; board member degree of representative accountability; and board member attitudes concerning commitment to consumer participation, commitment to health planning, health services attitude, and feelings of social powerlessness. Results indicated that staff members were favorable toward the concept of consumer participation. They recognized a lack of low-income minority participation, but they did not provide support or allocate resources to enhance consumers' ability to participate. Providers were less committed to consumer participation, felt more socially powerful, and had greater representative accountability than did consumers. Several strategies for increasing consumer influence in HSA decision-making processes are proposed.
The health educator's role as a community organizer raises a number of ethical dilemmas for the practitioner. Such basic prescriptions given the health educator as "start where the people are" 15 and "change by choice, not by coercion" 22 must be carefully examined in light of the realities which sometimes make strict adherence to these theoretical goals difficult in practice and problematic from an ethical perspective. The importance of avoiding unintentional "victim-blaming" in the selection of targets for community organization and the necessity of acquainting communities with possible negative or unanticipated out comes of organizing efforts are underscored as critical ethical issues for the health educator engaged in community organization activities.
Knowledge-attitude-behavior and values-based models are analyzed with regard to their application to development and evaluation of drug education programs; theoretical problems of these models are identified. The experimental evidence regarding the application of these models to drug education is reviewed. Recommendations are made concerning theoretical, programming, and research implications for drug education and for health education in general.
The relative importance of personal attitudes toward losing weight and the social pressures for weight loss in determining intentions to lose weight was compared for locus of control internals and externals who valued health and/or physical appearance highly. Findings consistent with the hypothesized differential importance of these two predictors of behavior intention for individuals designated internal and external by a behavior-specific locus of control scale are presented. Theoretical and practical applications of the findings are discussed.
The development of the Multidimensional Health Locus of Control scales is described. Scales have been developed to tap beliefs that the source of reinforcements for health-related behaviors is primarily in ternal, a matter of chance, or under the control of powerful others. These scales are based on earlier work with a general Health Locus of Control scale, which, in turn, was developed from Rotter's social learn ing theory. Equivalent forms of the scales are presented along with initial internal consistency and validity data. Possible means of utilizing these scales are provided.
Increasingly, health workers are concerned with the alteration of complex and deeply embedded behaviors; essential to these tasks is an understanding of the other's situation as he or she views it. This study took the perspective of the patient, inductively generating a conceptual formulation to explain and understand life after a heart attack. The basic problem of minimizing losses under conditions of uncertainty and unknown parameters of action is confronted. Resolution is achieved through "cutting back," which has three major stages: (1) immobilization, characterized by explaining and estimating the damage; (2) resumption, in which patients figure the complex calculus of the new situation to determine what they must cut back, what they should cut back, and what they will and will not cut back; and (3) new normal, when the major work is that of adjusting to the permanent changes wrought by the heart attack experience which affect identity. Exploratory diagnosis of complex health education problems through a "grounded theory" approach is demonstrated by the study.
Though environmental hazards and lack of medical care continue to threaten the public's health, much recent attention has turned to the role of destructive health-related behavior. If, as Fuchs suggests, changing behavior patterns is the most powerful alternative open to advanced countries in the pursuit of health, the role of the health educator is likely to grow more prominent relative to other health-care professionals. At the same time, that role may change. A campaign to solve the nation's health problems by altering habits of living may require methods which are stronger than the traditional health educator's efforts to facilitate and inform. This paper examines the coercive aspects of some of these possible measures and surveys the moral justifications for a policy of using coercion to bring about the desired changes in health-related behavior. Three such arguments are most plausible: that the coercion is justified by the social benefit; by the benefit to the coerced; and by a right of others in society to prevent the self-destructive individual from placing unfair burdens upon them.
Public health programs to prevent disease and promote health are constrained by legal doctrines that protect individuals from intrusive regulation of their health-influencing behaviors. This paper outlines the parameters of acceptable interventions in the context of antismoking legislation and motorcycle helmet safety laws. The authors discuss recent court decisions challenging the constitutionality of these laws and identify criteria the courts apply in reviewing governmental attempts to protect the public from disease or trauma.
Thirty-five participants in a smoking cessation program met weekly for seven weeks in small groups and then were assigned to one of four follow-up procedures for an additional eight weeks. Information on smoking levels was obtained at the beginning of the program, at the end of the seven-week treatment period, at the end of the two-month follow- up period, and during an additional five-month extended follow-up period. As hypothesized from social learning theory, individuals who held internally-oriented health locus of control beliefs and who valued health highly were most successful in achieving and maintaining changes in their smoking behavior. These results are discussed in terms of their implications for the problem of maintenance of behavior changes achieved by smoking cessation programs.
