Chapter 12 - Health Education

Title	Section
Purpose, Basic Consideration, Definitions and Methods	3-12.1
Purpose	3-12.1A
Basic Consideration	3-12.1B
Definition and Methods	3-12.1C
Providers of Health Education Services	3-12.2
Planning Health Education Programs and Interventions	3-12.3
Functions and Operating Relationships	3-12.4
Headquarters	3-12.4A
Area Offices	3-12.4B
Field Offices	3-12.4C
Documentation of Community Data	3-12.5
Orientation and On-The-Job Training	3-12.6
Evaluation and Research	3-12.7
Report	3-12.8
Area and Program Office Public Health Educators	3-12.8A
Service Unit Public Health Educator, Community Educator, and Community Health Educator Assistant	3-12.8B

Exhibit	Description
Exhibit 3-12.8A	Area Health Educator Quarterly Report Form
Exhibit 3-12.8B	Community Health Educator Quarterly Report Form
Exhibit 3-12.8AB	Master Mark Record

3-12.1  PURPOSE, BASIC CONSIDERATION, DEFINITION AND METHODS1/

1. Purpose.  This chapter establishes general policy and procedures pertaining to health education activities.
2. Basic Consideration.  The attainment of health at its highest acceptable level is the goal of the Indian Health Service.  Today, more than ever before, examination of the causes of ill health and of the means available for improving health status is focusing on health education as a way to achieve public health goals.  The conviction is growing that the next major advances in health will come from changes in the lifestyles of individuals and from control of health hazards in the environment.  The educational process is a way of alerting people to personal and societal obstacles to good health and offers a channel for achieving needed change.  For health education can help prepare people to take greater responsibility for their own health and that of their families and communities.  Through health education, individuals acquire the information, skills, and values for making responsible decisions about their personal health.  Since health is influenced by environment, social conditions, institutions, and economic polices, solutions to complicated health problems often require coordinated citizen action.

   The goal of health education in the Indian Health Service is to assist the Indian people 2/ to adopt health-promoting lifestyles; wisely select and use health care resources, products and services; and influence policy and planning on health care issues and larger environmental matters that affect health.

   Many forces have converged to create a resurgence of interest in stronger, more comprehensive, and more imaginative health education efforts.  Among the reasons for strengthening health education are:

   A shift in leading causes of death and disability from acute disease to chronic conditions which requires increased individual involvement in prevention, in recognition of illness, and in care;

   Growing awareness among health professions that many health problems such as smoking, poor nutrition, overweight, lack of exercise and recreation, abuse of drugs and alcohol, and dangerous driving involve behavior patterns and lifestyle choices which individuals can to a great extent control;

   Acceptance by environmentalists and others that if control of many environmental hazards such as air and water pollution, occupational risks, and toxic substances are to occur, group action by informed citizens is required;

   Concern about the high cost of health care which has resulted in efforts to recognize and prevent health problems and to promote more effective planning and use of health care resources as ways of achieving savings and obtaining maximum benefit from expenditures;

   Recognition by health care providers that improved communication and understanding help consumers to accept their share of responsibility for both personal and community health;

   The growth of Indian Health Boards and Committees with resulting pressure for consumer involvement in all levels of health decision-making.

3. Definition and Methods

   Health education is the term applied to the Planned use of educational processes to attain health goals.  It includes any combination of learning opportunities designed to facilitate voluntary adoption of behavior which will improve or maintain health.  The APHA Joint Committee on Health Education Terminology, 1972-73, defines health education as "a process with intellectual, psychological, and social dimensions relating to activities which increase the abilities of people to make informed decisions affecting their personal, family, and community well-being.  This process, based on scientific principles, facilitates learning and behavioral change in both health personnel and consumers, including children and youth."

   Health education is more than the provision of information.  While health education includes acquiring knowledge about health matters, its purpose is the use of that knowledge.  It addresses the formation of values, the acquisition of decision-making skills and the adoption or reinforcement of desirable health practices.  Health education honors individuals' right to privacy, their right to meaningful information, and their right to make their own choices.

   Health education is one very promising approach to health improvement, but it has only limited power to counteract the health impact of such factors as economic deprivation, poor housing, and persuasive media.

   There are health education needs throughout the life span and through all stages of health and illness.  School-aged children and pre-school children and their parents present especially important targets and opportunities for education about health.

   Since all parents provide role models and establish basic health practices, and because attitudes and beliefs about health are early developed in the home, parents also need to be assisted in their role as health "teachers."  College students, families, men and women in the middle years and senior citizens in their turn have special health education needs.

   Health education is an essential ingredient in programs for promotion of wellness, prevention of illness and disability, and for the control of disease.  Because the need for health education is interwoven throughout the life span, it should be provided in a variety of settings:  In the home, in the school, in programs for senior citizens, in the workplace, in offices, institutions and agencies where medical care is provided, in community and social organizations, and through mass media.

   The implementation of a health education program requires the use of a variety of methods, since no single method can be expected to be effective with all persons under all circumstances.  A combination of methods organized in a systems approach is more likely to achieve a desired result.

   Methods are selected following an analytical process which includes consideration of the needs and characteristics of the target group, the goal to be achieved, and the nature of the learning issue to be addressed.  For example, an anti-smoking campaign, driver safety, nutrition, gun safety, and school health instruction are so different in nature that each requires a separate educational approach.

   Methods available include health counseling and other one-to-one exchanges, formal and informal instruction, community organization, written and audiovisual communication, use of mass media, and group interaction.  Involuntary methods, such as some forms of behavior modification, are not health education.

3-12.2  PROVIDERS OF HEALTH EDUCATION SERVICES

Health education is carried out by people in a variety of settings, i.e., home, school and health facilities.  Preparation for fulfilling this function should be a part of both pre-service and in-service training for all health care practitioners and health administrators.  Some personnel are also recruited from Indian communities for outreach and other special health education purposes.  In many cases they are prepared for particular assignments.

In addition to these health workers, professional public health educators (having graduate degrees in public health education) are prepared, by education and experience, to identify health needs, plan, carry out and evaluate health education programs.  They provide information about health, illness, and disability, and help people to acquire the necessary skills to adopt and maintain healthful practices and lifestyles.

Health educators also assist other workers in health care, education, and community organizations to provide education directed towards health goals.  They establish programs and curricula suitable for various settings, assist communities to make changes in the environment in order to promote health, and stimulate and conduct research and evaluation in relation to education for health.

3-12.3  PLANNING HEALTH EDUCATION PROGRAMS OR INTERVENTIONS

Crucial to the success of an educational endeavor are the managerial elements common to all program planning.  These are:  Identification of problems, analysis of alternative approaches, setting objectives, assignment of resources, preparation of staff to carry out the function, and monitoring performance.  An organization base and sustained administrative and budgetary support are required.

The focus of an education program may be on individual and family practices.  Different timetables, target audiences, and methods may need to be selected depending on the problems and objectives.  In developing the education program design, special attention must be given to involving members of the target population in the planning process and to determining their previous social, environmental, and educational experiences.

The educational process can also be used along with other forms of intervention to bring change to systems, institutions, and social conditions.  Such educational goals may be sought directly through education for tribal policy makers, administrators, or indirectly through educating citizens about health problems and ways of solving them.

Education programs must be adequately staffed with individuals having appropriate education and technical expertise, to help insure desired learning outcomes.  Staffing plans should carefully consider the match of personnel to targeted groups to insure clear communication and receptivity.

Because of the long neglect in support of health education, in many cases planning for expanded educational services will need to include in-service education and mid-career retraining of many existing health practitioners as well as the preparation of a large cadre of well-trained health education workers at all levels.

Because of the complex issues that health education must address, programs must be supported and nurtured over time.  Experience has shown that, while some results of education can be observed immediately, many are slow to occur.  Thus, in planning programs and evaluations, distinctions must be made as to the time period in which results can be realistically achieved or assessed.

3-12.4  FUNCTIONS AND OPERATIONS RELATIONSHIPS

Joint staff planning in the formulation of health education plans at each level of operation is necessary for the coordination of the multiplicity of educational activities in which all health staff engage to a greater or lesser degree.

Staff members must see the full circle of problems and program plans, reinforce each other, and interchange information so that the health educational work of each closely relates to the work of another.

1. Headquarters
   1. Chief, Health Education Branch, acts as a consultant and advisor in Health Education matters to the Director, Indian Health Service, and his staff through the Director, Office of Professional Standards and Evaluation to whom he is directly responsible for the over-all planning, development, coordination, and evaluation of Health Education service throughout the Indian Health program.  This includes:
      1. Formulation of the Health Education section of the budget and the staffing patterns it supports, based on program deficiencies and needs as indicated by the various Area program plans.
      2. Development and implementation of standards for the placement of Public Health Educators, Community Health Educators, and Community Health Education Technicians (aides) which comprise the Health Education staff.
      3. Assistance in the recruitment of qualified Public Health Educators for vacancies occurring in the Area and Service Unit Offices.
      4. Provide through the Indian Health Area Directors and Chiefs Area Health Education Branches technical support for the total Indian Health Service Health Education Program.
      5. Development of basic policies, program guidelines, objectives, reports, and procedures for the supervision and control of the Health Education aspects of the program.
      6. Establish and maintain working relationships with National Health Agencies through which Health Education activities may be enhanced.
      7. Participates with Directors of Education and their respective staff in the development of the educational phases of school health programs with particular reference to Indian school children.
      8. Provision of technical guidance to disciplines on educational methods and principles, development, utilization and evaluation of health education materials.
      9. Representation of the health education interests of the Indian Health Service when appropriate through committee assignments, conferences, institutes, and meetings of national organization.
      10. Provision of a plan for career development of staff.
2. Area Offices.  In line with policy and procedural instructions issued by Headquarters, the responsibility for administration of the program at the Area level is vested with the Indian Health Area Director, who shall discharge this responsibility with the assistance of his staff which shall include a Chief, Area Health Education Branch who, depending on Area organization, may also be referred to as Area Public Health Educator or Area Health Education Consultant.
   1. Chief, Area Health Education Branch shall plan jointly with the Indian Health Area Director and his staff in the development and implementation of educational activities according to the needs of the particular Area.  The Branch Chief will:
      1. Provide information and guidance on comprehensive health education functions, standards and norms.
      2. Provide technical guidance in educational procedure and public health education content to the field health education program through the Service Unit Director.
      3. Be responsible for recruitment, placement, and the provision of in-service educational and technical supervision of the health education staff.
      4. Participate in program planning to present and develop the education aspects and needs of respective programs and formulating the health education section of the Area budget and the staffing patterns it supports.
      5. Provide service in educational procedures, methods, techniques, and materials for other disciplines and assist in establishing and maintaining a reference library on Indians and Alaska Natives, education and social sciences.
      6. Develop educational materials for staff use in orientation, in-service training, conferences with tribal leaders, and on special health problems for distribution, to the Indian or Alaska Native group concerned.
      7. Collaborate with regional and state health agencies on educational aspects of Indian and Alaska Native health and participate in institutes, conferences, and meetings of these organizations.
      8. Develop ways and means to obtain increased Indian and Alaska Native participation in the solution of their health problems.
      9. Conduct demonstration programs in health education through pilot projects on special problems.
      10. Evaluate program activity and reporting progress.
      11. Promote the opportunity for persons of Indian and Alaskan Native descent to enter health positions of the Indian Health Service.
      12. Serve as advisors/consultants in health education to tribal health programs and personnel.
3. Field Facilities.  In line with policy and procedural instructions issued by Headquarters and the Area Office, and in accord with generally accepted standards and norms for health education functions and services, the responsibility for administration of health education activities at the field level is vested with the Service Unit Director, who shall discharge this responsibility with the assistance of his staff which may include the Community Health Educator or Public Health Educator.
   1. Community Health Educator and/or Public Health Educator shall plan jointly with the Service Unit Director or designee and his staff in the coordination, adaptation and execution of comprehensive health education services according to local needs.  This position will:
      1. Participate in study and analysis of local health needs in relation to problems, resources, and understanding of the tribal groups.
      2. Design and/or select, utilize, and evaluate educational approaches, activities, and materials that will be effective in meeting the health situations in terms of cultural, sociological, and psychological factors.
      3. Participate with professional and other staff in development of health education content for informational and educational materials for program use.
      4. Promote and coordinate educational activities of various community agencies and facilities in the interest of Indian and Alaska Native health and in obtaining increased health content in their educational programs.
      5. Develop Indian and Alaska Native participation in identifying health problems toward the objective of increased understanding and responsibility in the solution of these problems.
      6. Serves as cross-cultural interpreters of Indian and Alaska Native attitudes and understanding to other health workers and of current health concepts and health procedures and resources to Indians and Alaska Natives.
      7. Establish and develop on a continuing basis, a documentation file on the programs and activities of the communities within the jurisdiction.
      8. Assist in recruitment, placement, and provision of in-service training and supervision of community health education aides.
      9. Maintain records and reports for evaluation of health activities and reporting progress.  Maintain a basic reference library and supplies of approved materials.
      10. Work with groups to help them understand healthful ways of living and make adaption in their practices toward these ends.
      11. Promote opportunities for person of Indian and Alaskan Native descent to enter the health professions.
   2. Community Health Education Assistants shall work under the supervision and technical direction of the Community Health Education Public Health Educator and assist in collecting, examining, and utilizing the data necessary for health education activities as described under the functions of the Community Health Educator.  This shall include:
      1. Participation in program planning, training programs, interpreters courses, contributing their knowledge of the communities and their cultural knowledge of health habits, beliefs.
      2. Serving as cross-culture interpreters of Indian and Alaskan Native attitudes and understandings to other health workers.
      3. Use of their bilingual skill in interviewing and talking informally with the leaders in communities to secure their understanding and acceptance of health concepts and practices and their participation in community health programs.
      4. Work with groups to help them understand healthful ways of living and make adaption in their practices toward these ends.
      5. Serving as an important communication link between staff and community through effectively conveying the more subtle reactions of the tribal people; locating leaders in the community membership.

3-12.5  DOCUMENTATION OF COMMUNITY DATA

Professionally, it is essential that a pattern of continuity be established for community health education activities that will pass along to each succeeding health education staff member, knowledge about work done, the social intelligence gained about a community, previous methods used, and progress made within a period of time.  The health education staff member should have at his disposal a community profile.  Such information about the community is contained in Service Unit and Tribal health plans.

3-12.6  ORIENTATION AND ON-THE-JOB TRAINING

Orientation and on-the-job training, for full effectiveness, must be a continual process with the method and materials adapted to the kind of situation being presented and the background of education and experiences of the individuals concerned.  This requires careful planning with a continual flow of information between the various segments of the program.  Plans for orientation and on-the-job training of the Health Education staff include both formal and informal arrangements.

1. Arrangements for Training (In-Service).  Training activities for the Community Health Educators and Community Health Education Assistants shall be the responsibility of the Chief, Area Health Education Branch, and should include the following:
   1. Plans for initial orientation upon employment and continual activities directed toward the assessment of educational needs based upon the program of the Area and staff responsibilities.
   2. Periodic professional meetings within the Area.
   3. Workshop with the staff members from an Area or several Areas joining together for a more intensive coverage of some educational problem and seeking a workable approach to handling it within the program.
2. Arrangements for Training (Outside the Service).  As Division, Area or outside resources permit and need arises in relation to program plans and development, find and arrange for appropriate training outside the service.

3-12.7  EVALUATION AND RESEARCH

A number of means are available for evaluating health education programs.  Progress is being made in developing ever more useful approaches to evaluation and research by applying procedures adapted from standard social research and health services research methods.  The results of research and evaluation can guide planners and administrators and enhance the state of the art of health education by further clarifying what health education can or cannot do and by validating which methods are effective.

Support for carefully designed health education research and demonstration is needed to provide a stronger base for practice.  This support should be of sufficient magnitude, continuity, and planning to assure the production of results.

3-12.8  REPORT

1. Area and Program Office Public Health Educators.
   1. Quarterly Activity Report.  A memorandum report of activity shall be submitted quarterly.  The report shall follow the general format prescribed in Exhibit 3-12.8A of this chapter and shall be forwarded, through channels, to the Director, Indian Health Service, Attention:  Chief, Health Education Branch, by the 20th working day of the month following the completion of the quarter.
   2. Project Report.  Project reports that cite the total planning involved and the educational implications of a major activity shall be prepared and attached to the quarterly reports.  The project report shall include the following kinds of information:
      1. How and why project was initiated.
      2. Persons (by titles) involved in project.
      3. Steps taken and by whom.
      4. Accomplishments.
      5. Amount of time and resources used by Health Education staff.
      6. Example of any materials developed.
   3. Health Educator's Activity Report, (HSA 81 - page 1 & 2).

      When the Area or Program Office Health Educator performs direct health education services in the field, it is also appropriate to use the computerized reporting system (HSA 81).  These reports, along with those received from Service Unit Staff, are due at the Albuquerque Data Processing Center by the 7th day after the end of the month being reported.

2. Service Unit Public Health Educator, Community Health Educator, and Community Health Education Assistant.
   1. Quarterly Activity Report.  Narrative type reports following the general format prescribed in Exhibit 3-12.8B shall be submitted, through channels; to the Chief, Area Health Education Branch by the 5th working day of the month following the close of the one covered by the report.
   2. Project Reports.  Project reports, with consultation from the Chief, Area Health Education Branch, shall be prepared and submitted in accordance with instructions contained in Section 3-12.8A(2).
   3. Health Educator's Activity Report, (HSA 81 - page 1 & 2).  The Health Educator will submit activity reports monthly.  The reports are due in the Area Office, Indian Health Service, by the third working day after the end of the month being reported.  There is a separate instructional manual for this computerized reporting system.

Footnotes:

1/  The material in 3-12.1 was adapted from "Toward a Policy on Health Education and Public Health", a position paper adapted by the Governing Council of the American Public Health Association, November 2, 1977.

2/  Where the terms "Indian" or "Indian people" are used in this chapter, application to Alaska Natives is also intended.