Health Education: Theoretical Concepts, Effective Strategies and Core Competencies

"The health educator who uses targeted, theory-based interventions, embraces concepts of participation and voluntary change, and includes health literacy and individual capacity-building within health programmes and services, is a valuable and essential member of the health promotion team."

To address a perceived limited interest in health education, the World Health Organization (WHO) Regional Office for the Eastern Mediterranean conducted a situation analysis to assess the health education capacity, programmes, and activities in Member States of the Region. The findings showed challenges such as access to and knowledge of up-to-date tools that can help educators engage in effective health education practice, as well as confusion about how health education can meaningfully contribute to the goals of health promotion. To that end, this document seeks to provide a common understanding of health education disciplines and related concepts by providing a review of the various health education theories, identifying the components of evidence-based health education, outlining the competencies necessary to engage in effective practice, and offering a framework that is designed to clarify the relationship between health literacy, health promotion, determinants of health, and healthy public policy and health outcomes.

The United States National Commission for Health Education Credentialing (NCHEC) has identified 7 major responsibilities for the health educator as well as the competencies and sub-competencies that demonstrate competency under each responsibility: assessing individual and community needs for health education; planning effective health education programmes; implementing health education programmes; evaluating the effectiveness of health education programmes; communicating health and health education needs, concerns, and resources; coordinating the provision of health education services; and acting as resource people in health education.

For context (footnote numbers have been removed): "Health education has been defined in many ways over the years. For example Green et al. in their earlier work...concluded that health education was limited to conscious health-directed behaviour and was most effective when 'people were clearly oriented to solve a discrete and immediate behavioural or health problem of importance to them'...(for example immunization programmes in which people want to avoid an imminent threat or family planning programmes in which people want to delay or avoid pregnancy). Shortly after this definition was proposed, a growing recognition emerged that much of the more pervasive behaviour had to do more with patterns and conditions of living than the simple imparting of information directed at a specific health behaviour. Health behaviour, after all, is not based solely on isolated acts under the autonomous control of the individual, but rather is defined by patterns of living that are socially conditioned, culturally embedded and economically constrained."

Planning theories and models being used by health educators that are outlined in this document include:

• The rational model (also known as the knowledge, attitudes, and practices, or KAP) model, which is based on the premise that increasing a person's knowledge will prompt a behaviour change.
• The health belief model, which is based on the following 6 constructs: perceived susceptibility, severity, benefits and barriers, cues to action, and self-efficacy.
• The extended parallel process model, which proposes that people, when presented with a risk message, engage in 2 appraisal processes: (i) a determination of whether they are susceptible to an identified threat and whether the threat is severe; and (ii) whether the recommended action can reduce that threat (i.e., response efficacy) and whether they can successfully perform the recommended action (i.e., self-efficacy).
• The transtheoretical model of change, whereby behaviour change is viewed as a progression through a series of 5 stages: pre-contemplation, contemplation, preparation, action, and maintenance. "People have specific informational needs at each stage, and health educators can offer the most effective intervention strategies based on the recipients' stage of change."
• The theory of planned behaviour, which holds that intent is influenced not only by the attitude towards behaviour but also the perception of social norms (the strength of others' opinions on the behaviour and a person's own motivation to comply with those of significant others) and the degree of perceived behavioural control.
• The activated health education model, which is a 3-phase model that is designed to: actively engage individuals in the assessment of their health (experiential phase); present information and create awareness of the target behaviour (awareness phase); and facilitate its identification and clarification of personal health values, developing a customised plan for behaviour change (responsibility phase).
• Social cognitive theory, whereby 3 main factors affect the likelihood that a person will change health behaviour: self-efficacy, goals, and outcome expectancies. "If individuals have a sense of self-efficacy, they can change behaviour even when faced with obstacles."
• Communication theory, which holds that multi-level strategies are necessary depending upon whom is being reached with what kinds of messages - for example, tailored messages at the individual individual level, targeted messages at the group level, social marketing at the community level, media advocacy at the policy level, and mass media campaigns at the population level.
• Diffusion of innovation theory, which holds that there are 5 categories of people: innovators, early adopters, early majority adopters, late majority adopters, and laggards. "By identifying the characteristics of people in each adopter category, health educators can more effectively plan and implement strategies that are customized to their needs."

According to the report, the following methods that have stood the test of time and seem to be essential components of health education programmes and services:

• Participant involvement - "Community members should be involved in all phases of a programme's development: identifying community needs, enlisting the aid of community organizations, planning and implementing programme activities, and evaluating results."
• Planning, which involves: identifying the health problems in the community that are preventable through community intervention, formulating goals, identifying target behaviour and environmental characteristics that will be the focus of the intervention efforts, deciding how stakeholders will be involved, and building a cohesive planning group.
• Needs and resources assessment to identify the health needs and capacities of the community and the resources that are available.
• A comprehensive programme that: deals with multiple risk factors; uses several different channels of programme delivery; focuses on reaching several different levels (individuals, families, social networks, organisations, the community as a whole); and is designed to change not only risk behaviour but also the factors and conditions that sustain this behaviour (e.g., motivation, social environment).
• An integrated programme whereby each component reinforces the other components, and the programme is physically integrated into the settings where people live their lives (e.g., worksites).
• Long-term change, which "requires longer-term funding of programmes and the development of a permanent health education infrastructure within the community."
• Efforts to alter community norms, which "requires that a substantial proportion of the community's or organization's members be exposed to programme messages or, preferably, be involved in programme activities in some way."
• Research and evaluation, which should be designed "not only to document programme outcomes and effects, but to describe its formation and process and its cost-effectiveness and benefits."

As outlined here, the NCHEC has proposed a profession-wide standard code of ethics for health educators that includes responsibility to the public, the profession, and employers, as well as attention to the delivery of health education, research and evaluation, and professional preparation.