Thursday, December 18, 2014

Public Health Intervention Critique: A Traditional Approach to Health Education in Schools – Sarah Benes

Introduction: What is Traditional Health Education?

Health education is an integral component of an effective educational program. It has the ability to “reduce the prevalence of health risk behaviors among students and have a positive influence on students’ academic performance” (1). Moreover, many studies and articles support the idea that good health can help students perform better in school because they are more likely to attend school, to be able to concentrate, and to perform well - healthy children are more ready and able to learn (2-6). The Centers for Disease Control and Prevention (CDC) also suggest that academic success can be an “indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes” (2). Health and academic outcomes are linked in a way that improving one is likely to positively influence the other. Health education has the potential to be an effective public health intervention which can improve the current health behaviors of students, future health outcomes as well as positively contribute to learning.

Despite the potential for health education, data from CDC from both the School Health Profiles and the Youth Risk Behavior Surveillance Survey (YRBSS), suggest that there are many students not receiving health education and that the current approach to health education may not be effective in decreasing risky behaviors. The 2012 School Health Profiles reveal that the percentage of states that require health education ranges from 51.3% offering a health education course in 6th grade, to 63.9% in 8th grade, to 57.2% in 9th grade and down to 47.1% in 10th grade (7). There are many states that still do not have health education requirements for grades at the secondary level which means that the reach of school based health education is limited. As a public health approach, it is clear that there is untapped potential for health education to impact students at a critical time when they are engaging in behaviors and forming behavior patterns that are likely to continue into adulthood.

While health education alone cannot directly impact the multiple influences on adolescent health behaviors (such as policies, environment, media, family and peers), it can be one aspect of an effective public health approach (8-10). Youth are engaging in a range of risky health behaviors many of which contribute to leading causes of death in the United States. Select data from the 2013 survey includes: 35% of high school students “currently drank alcohol”, 21% had 5 or more drinks in a row within the last 30 days, 23% currently use marijuana, 47% have ever had sexual intercourse, 34% are currently sexually active and only 59% used a condom during their last sexual intercourse (11). While this is a limited glance into the range of risky behaviors, this data supports the need for interventions which help students develop the knowledge and skills they need to choose health-enhancing behaviors and avoid risky behaviors. One way to do this is through effective health education in schools; however, a traditional approach to health education is not likely to help achieve these outcomes and yet this appears to be the current trend in schools in the US.

According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), traditional health education involves “learning about the human body, food nutrition, the importance of work and exercise and the problems of smoking, drugs and alcohol” (12). UNESCO further breaks down traditional health education into the following characteristics (12): Focus on disease; Moralistic tone;  Focus on individual behavior; Didactic teaching methods; Emphasis on “doing the right thing”;
Health experts as guest lecturers; Focus on health education (as opposed to a healthy school approach); A biomedical view of health; Teacher to model “right” behavior (as opposed to enquiry methods); Students adopt prescribed attitudes and values.

Traditional health education has also been characterized by being “like any other lesson,” by teaching issues that are not always relevant for the students, and by focusing on future outcomes rather than present outcomes which is not as effective with adolescents (13).

While it can be challenging to collect data as to approaches actually implemented in classrooms (reported versus actual), data that is available supports that health education reflects a traditional approach. The median percentage of secondary schools that “have tried to increase student knowledge on health-related topics” are: 75.5% for suicide prevention, 81.8% pregnancy prevention, 88.7% STD prevention, 93.1% violence prevention, 93.5% tobacco-use prevention, 96.2% nutrition and dietary behavior and 98.5% for physical activity and fitness (7). In addition, the median for percentage of secondary schools with a health education curriculum that addresses all eight skills of the National Health Education standards (which is one way to determine the health education approach) is only 61.5%. It is important to note the language of the survey results/questions. In the “health topics” question it specifically asks if schools have tried to increase student knowledge whereas the skills question is much more general relating to having a health education curriculum which “addresses” skills. The phrasing “address skills” is more vague than “increasing student knowledge” and leaves room for interpretation about the extent to which the skills are “addressed” and how much emphasis is actually placed on the skills. For example, a more revealing question could be the extent to which the schools have “tried to develop the following skills in students” or the extent to which schools have “tried to increase students’ ability to demonstrate the following skills.” These questions would be more aligned with the “topic” question and get a better sense of what might actually be happening in classrooms. Nonetheless, the larger percentages of schools increasing student knowledge around health topics and the relatively low percentage of schools teaching skills suggests that there is still an emphasis on more traditional methods in health education.

Health education has the potential to be an effective strategy for both improving students’ academic and health outcomes. However, in its current state, health education is not in a position to be a meaningful public health intervention. The three main critiques of the current approach are: 1) an emphasis on knowledge, 2) an emphasis on didactic methods and 3) the current framing of health education. However, there is a potential solution that is support by social science theory and research and which could be the approach that could help bring health education to the forefront as an effective intervention to address the health of today’s youth: a skills-based approach to health education.

Critique 1: Emphasis on Knowledge

There is limited evidence to support that knowledge of health topics will lead to behavior change (14-16). There needs to be more to health education than teaching “about” health topics (UNESCO). Health education should leverage the current research and theory about health behaviors which emphasizes an ecological approach to promoting health in which individual factors are only one piece of a larger puzzle rather than focusing on knowledge acquisition.

To rely on increasing knowledge as the main intervention in health education ignores many of the more potent influences on behaviors such as peer influence, media and  norms (both real and perceived). Even health behavior theories that focus on the individual still include more than knowledge alone. For example, the Health Behavior Model includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. While knowledge might impact perceived susceptibility, benefits and barriers it will not address cues to action or self-efficacy, both critical components of the model. In another common theory, the Transtheoretical Model, knowledge might be used to help someone move through a stage or between stages it would be most likely to have an impact on the earlier stages of precontemplation and contemplation. Clearly, knowledge is not the most important factor even within individual health behavior theories.

Perhaps even more compelling is the fact that many have suggested that health behaviors are strongly influenced by social influences such as peers and the media. Thaler and Sunstein suggest that in order to “nudge” people into action three social influences should be addressed: information, peer pressure and priming (15). They argue that people are motivated to conform to social norms and to others behaviors whether real or perceived as well as the fact that people can be “primed” by providing them with cues and a channel to facilitate an action. The only knowledge involved here is in the form of “information” of social norms or of actions of others. Another example comes from Florida’s “truth” campaign in which they found that students did know the dangers of tobacco – “knowledge was not the problem” (17). As a result, the campaign focused in part on setting a tone that would connect with youth and making “truth” a brand in order to connect with the youth’s identify formation (17). Again, knowledge did not play a role in the campaign, in fact, it was clear that youth knew the dangers and that some still chose to smoke for reasons such as rebellion and as a way of asserting ownership over their decisions (17).

There is much evidence to support that knowledge is not a key determinant in behavior from health behavior theories to research from the field. Therefore, health education fails to be effective, in part, due to its reliance on knowledge as the main focus. Teaching students about health is not going to impact behavior. Health education needs to move away from a foundation of knowledge to a foundation that is aligned with current theory and research.

Critique 2: Emphasis on didactic methods

Similarly, a focus on didactic, teacher-directed methods is equally as ineffective. Talking “at” people, especially youth, is not going to engage them. Didactic teaching is also more aligned with the idea that people make rational decisions – if we tell people how bad a certain behavior is, logically they will not engage in the behavior or, more broadly, if we give people all the information about certain health topics, they will have what they need and logically, they will make the right decision. As with the focus on knowledge, this approach neglects to take into account the irrationality of people’s decision making.

Teaching health education can be compared to “selling” health much like many public health campaigns aim to sell a healthy behavior (not smoking, wearing condoms, etc.). Successful campaigns do not rely on “telling” people about the behavior, rather they engage an emotional appeal and use marketing techniques. For example, Randolph and Viswanath created a list of criteria necessary for successful public health campaigns including: ensuring exposure of messaging, creative marketing and messaging, a supportive environment, theory-based and targeted to the audience (18). If this is translated into the classroom one might expect to see a teacher who uses these methods in their instruction. For example, teachers have one advantage in that they can control the exposure to the message in their classroom and may also be able to impact messaging in the school. The teacher can create a supportive environment in which students feel safe and in which there is some ownership. The teacher can use participatory methods which engage students in order to create messages that will resonate with students and they could target their curriculum and their teaching to meet the needs of their students. This cannot occur in a didactic classroom where the teacher is mainly “giving” information to students through teacher-directed messages. In many ways, this is in contrast to what is known about how to compel an audience to change behavior or to “buy into” an idea or concept.

Didactic teaching also goes against the principles in the ecological approach to health education. In particular, didactic teaching is less likely to meaningfully address perceptions, skills, motivations and the social environment (19). While there are multiple ways to address these factors, participatory teaching methods are more effective than didactic. Participatory teaching techniques include the use of techniques for skill development, interactive teaching, and a social context for learning (6). This results in instruction that allows students to see change in the present, as opposed to teaching them knowledge that might help them in the future. Students are directly involved in their learning experiences and much of the instruction is focused on giving students the knowledge and skills they need now and in the future. These ideas are much different than those presented above regarding traditional health education which focuses on didactic learning and fact acquisition. When one engages students through a participatory approach, students can explore and discuss their perceptions. The teacher can also use principles of social influence to “nudge” students toward health-enhancing behaviors and attitudes. The teacher can create a social environment that is supportive (successful public health campaigns), that focuses on health enhancing norms and behaviors and which provides opportunities for students to positive influence one another. Finally, participatory methods provide opportunities for students to develop skills, another key determinant in an ecological approach to health behavior.

Didactic methods are not aligned with practices in public health campaigns or an ecological approach to health behavior. While health education is not a traditional public health campaign, lessons learned from the public health field can be directly applied to health education in the classroom. Upon evaluation, a didactic approach is not aligned with current practice in the public health field. Lessons learned from the public health field should be applied, where appropriate, in the health education classroom which would include moving away from a didactic approach which is a second reason why health education is not currently an effective public health intervention.

Critique 3: Current Framing of Health Education

A third critique of health education is the weak framing of health education in schools. There are four main frames for school-based health education described here:
Frame: 1) Health Education Matters – Really! 2) Health and Academics 3) Health Education on the Periphery  4) Not the school’s job

Core Position: Health education, despite current opinion, does make a difference and belongs in schools. Health contributes to academic success (and alternately negative health behaviors negatively impacts academic success). Health education is not a core part of a quality education.
Parents/families, not teachers and schools, should be educating students about health.
The main issues with these frames are that three are defensive frames and one is a frame against health education in schools. It not surprising then that health education is not a requirement in more schools and why greater attention hasn’t been paid to health education as a viable public health approach.

Health education is fighting an uphill battle to begin with and when the main messaging relies on a defensive stance it serves as a cycle where people’s ideas that health education doesn’t matter are essentially reinforced since the frames seem to acknowledge the same facts – that health education is on the periphery in schools, that health but not necessarily health education can support academics and that despite what people think, it does matter – really. With weak frames like these, it would follow that there isn’t strong support for health education and then that there would be a lack of attention paid to health education. Instead of these frames, health education should use a value frame and an offensive stance that health education belongs in schools and is an effective intervention. There is data that supports health education in schools that should be leveraged to create a frame which has a core position that health education is a core subject which can provide students with the knowledge and skills necessary to be healthy now and in the future. Finally, there is also data to support that parents do want health education in schools (20) and the frame could use a “right to education” core value to argue that students have the right to health education delivered by a qualified teacher who has been trained in health education. Relying on outside sources can lead to misconceptions, misinformation and a lack of development of skills and attitudes needed to be healthy. The current framing is a third problem with health education in its current form.

Proposed Intervention: A skills-based approach to health education

The first major aspect of skills-based health education is the content – the actual subject matter that is taught to students – which includes both health-related concepts and skills. The National Health Education Standards (NHES) were created by the Joint Committee on National Health Education Standards to provide a framework for “aligning curriculum, instruction, and assessment practices” in health education (21).  The standards were recently revised from the original published in 1995 to reflect the need for “health-related knowledge, skills and healthy beliefs, and values and norms” in school curricula (22). The standards themselves also reflect this need as only one of the standards relates to health-related concepts, the other seven relate to the following skills: analyzing skills, accessing information, interpersonal communication, decision-making, goal-setting, practicing health-enhancing behaviors and advocacy (21).
Health educators using a skills-based approach should use these national standards as a foundation on which to build their curriculum. The health-related concepts to be included in the curriculum should be integrated into these skill areas, should be appropriate for local needs, should be relevant for the students and the times, and should meet the needs of the students (21). Knowledge in skills-based health education should not be limited to health-related concepts for the purposes of learning facts because that makes the curriculum “incomplete and inadequate” (23).

Instructional methods in skills-based health education should be “student-centered, interactive and experiential” (23). This includes, but is not limited to, the following instructional strategies: role play, large and small group discussions, debates, cooperative learning, problem solving, brainstorming, and games/simulations (6, 23). Lecture or direct instruction, usually associated with disseminating factual knowledge or concepts, is not included in this list. The implication is that the focus in skills-based health education is not on the acquisition of facts/concepts alone, but on the larger aim of teaching skills, changing attitudes and influencing behaviors through the use of more interactive teaching methods.

The instructional methods used in skills-based health education are based around the premise that learning occurs in a social context and that the learning environment is student-centered and allows for social interactions (24). Students learn from the people around them including their teachers, peers, parents and other role models in their lives. This is especially important to consider due to the fact that during adolescence peer pressure and the perception of peer behaviors have been found to influence behavior (25). It would follow that it is important to address norms of health-related behaviors to help influence students’ attitudes towards certain behaviors, to acknowledge and listen to what students’ believe are the behaviors their peers are engaging in, to allow time for practice and feedback so that students can see each other applying skills successfully, and to address the influences in their lives that will guide their decisions. Direct instruction may not have the same impact on the students because it eliminates much of the social context of learning. Student centered learning environments and social interaction can be facilitated best through participatory learning through the use of discussion, brainstorming, role plays, and other techniques discussed above (6, 24).

Defense of Intervention 1: Effective Health Education IS Skills-Based

Research examining effective prevention programs (not just school-based) also supports the fact that skills are a core component of effective programming. Nation et al. discussed five principles of effective programs: varied teaching methods, comprehensive, theory driven, opportunities for positive relationships and sufficient dosage (26). Most relevant to health education are varied teaching methods, comprehensive programs and opportunities for positive relationships. Teaching methods found to be most successful are active, skill-based approaches that include interactive, hands-on experiences that increase participants’ skills (26). Greenberg et al. support this finding as they found that modeling behaviors with opportunity for rehearsal and feedback, having students set behavioral goals, and including cues to prompt behavior in a variety of settings are effective techniques in prevention programs (27). These are all methods of the participatory learning style that is associated with skills-based health education.

Nation et al. identified comprehensive programs as ones that have multiple interventions and multiple settings (26). “Multiple interventions” refers to addressing issues from multiple perspectives such as increasing awareness and skill teaching (26). Skills-based health education uses a variety of learning experiences and interventions from skill teaching and practice, to providing relevant information about the health-related concepts, to addressing norms about behaviors, to using group processes for learning. Research about prevention programs has revealed that teaching across multiple settings (school, community, peers) improves outcomes. In skills-based health education, health-related concepts and skills should be taught and applied in a variety of settings. One of the most important is the peer setting because of the significant influence peers have on health behaviors especially during adolescence. Finally, the interactive nature of participatory teaching methods used in skills-based health education provide an opportunity to work with other students in a safe environment through role play, small and large group discussions and other group processes that allow students to foster positive relationships.

Defense of Intervention 2: Theory Supports It

This skills-based approach is also supported by Bandura’s Social Cognitive Theory (SCT) (14). The multifaceted components of SCT are an effective framework for supporting the three main aspects of a skills-based health education approach which are: knowledge, skills and attitudes/beliefs. SCT suggests that health behavior is determined by the following influences: knowledge, self-efficacy, outcome expectations, goals and perceived facilitators and impediments (14).

The knowledge component of SCT addresses the fact that skills-based health education includes both content and skill knowledge because students need to know and understand certain concepts before they can apply them in their own lives and/or demonstrate their learning in the classroom. Skills-based health education also helps students develop self-efficacy through the opportunity for skill practice and evaluation of their skill performance. These opportunities also allow for teaching and learning regarding the attitudes and beliefs of certain health behaviors (both health-enhancing and risky behaviors) and the potential effects (or outcomes) of performing a certain skill or health behavior. Skills-based health education offers the opportunity for that type of learning to occur.

Lastly, certain skills included in the standards, specifically: goal-setting, analyzing influences, accessing information, and advocating for self and others, can help students learn to set goals and recognize facilitators and impediments in their lives. Goals along with facilitators and impediments are the remaining two determinants of health behavior according to SCT (14, 21). In addition to the research that supports the use of skills-based health education, SCT supplies a theoretical framework which furthers the case for skills-based health education.
In addition, unlike a traditional approach to health education, a skills-based approach also addresses multiple components of an ecological approach to health promotion as well as provides opportunities to use principles of effective public health campaigning such as social influences, targeted messages, branding, etc. This approach to health education is directly supported by SCT but also includes many opportunities to bring in core components of other health behavior theories and public health approaches.

Defense of Intervention 3: Provides a New Frame

Shifting from a traditional approach to health education to a skills-based health approach provides an opportunity to reframe the discussion from trying to justify why an approach which is not support by research or public health best practice (traditional) really does belong in schools – really! Instead, health education can be framed as an engaging, relevant, current and research-based approach which combines research and best practice from education and public health to meet the needs of students.

The frame could be “Students Need Skills” with a core position that a skills-based approach is a core subject that teaches students essential skills which they need in order to be healthy for life. This frame would be a position of strength and could build on some of the key points of the current frames but use them in a more proactive and positive way. It would also weaken the “it doesn’t belong in schools” frame as the core skills included (i.e., goal-setting, decision-making) are all skills included in the 21st century skills framework and are all included in other core subjects. This would change the language used in discussions since the argument would no longer be about who should be providing students with information or whether it belongs in schools, rather it will be that schools are a place where students develop skills that they need to be successful which also supports the relevance and place for a skills-based approach to health education in schools.

Conclusion

Health education has the potential to be an effective public health intervention which can make an impact on the health of youth. However, the current emphasis on a traditional approach which focuses on disseminating information through a didactic approach is not working. The proposed intervention is a skills-based approach to health education which would address the main critiques of the traditional approach and provide an opportunity for a new frame which will further strengthen the proposed approach.


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