This document discusses the shifting philosophies of health education over the past century. It describes how the focus has changed from communicable diseases and hygiene to behaviors contributing to chronic diseases. This led to an emphasis on individual behavior change and lifestyle modification through programs like Healthy People. However, this narrow "micro" focus fails to consider broader social and environmental influences. The document argues for expanding the philosophy to incorporate a "macro" perspective that acknowledges both individual and societal responsibilities for health.
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Original Title
Philosophical Reflections on Health Education: Shifting Sands and Ebbing Tides
This document discusses the shifting philosophies of health education over the past century. It describes how the focus has changed from communicable diseases and hygiene to behaviors contributing to chronic diseases. This led to an emphasis on individual behavior change and lifestyle modification through programs like Healthy People. However, this narrow "micro" focus fails to consider broader social and environmental influences. The document argues for expanding the philosophy to incorporate a "macro" perspective that acknowledges both individual and societal responsibilities for health.
This document discusses the shifting philosophies of health education over the past century. It describes how the focus has changed from communicable diseases and hygiene to behaviors contributing to chronic diseases. This led to an emphasis on individual behavior change and lifestyle modification through programs like Healthy People. However, this narrow "micro" focus fails to consider broader social and environmental influences. The document argues for expanding the philosophy to incorporate a "macro" perspective that acknowledges both individual and societal responsibilities for health.
THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Number 1, 2006
Philosophical Reections on Health Education
and Health Promotion: Shifting Sands and Ebbing Tides Thomas ORourke Abstract Philosophy, which plays an important role in any feld, continually evolves. The purpose oI this paper is to describe and critique several oI the major shiIts in health education philosophy over the past century and suggest the potential merits oI an expanded macro philosophy. It is doubtIul that our present health education philosophy, with its emphasis on improving health through individual behavior and liIestyle modifcation, is suIfcient. Its Iocus is narrow and prevents us Irom considering more eIIective and eIfcient approaches in health education and health promotion. The outcomes oI this tunnel philosophy are a less caring and healthy society and a narrow, less eIIective health education agenda. A change in philosophy is essential to maximize opportunities for a more healthIul society on individual and community levels. This paper also presents Ior consideration several other philoso- phies that may provide additional insights to contemporary health education philosophies. Introduction Philosophy may be defned as 'a statement summarizing the attitudes, principles, belieIs, values, and concepts held by an individual or a group (Cottrell, Girvan, & McKen- zie, 2006, p. 77). Philosophy plays an important role in any feld, be it health, medicine, politics, or economics, and it continually evolves. Most felds will be infuenced by several philosophies, some more dominant than others at any given time. Sometimes, new philosophies emerge and Iorgotten or dismissed philosophies are rediscovered. In any event, philosophy guides thoughts, perceptions, and activities in health education. The purpose oI this paper is to describe and critique several oI the major shiIts in health education philosophy over the past century and suggest the potential merits oI an expanded macro philosophy. This paper also presents Ior consideration several other philosophies that go beyond the existing dominant health education philosophies oI the past century. These philosophies may provide additional insights to contemporary health education philosophies.
The Changing Landscape Throughout the past century, the import and use oI various philosophies has changed. In the early part oI the last century, health education Iocused on personal hygiene and communi- cable diseases (Regney, 1922). Much oI health education was cognitive-based and many health educators emphasized Iac- tual learning. As many communicable diseases were brought under control and longevity dramatically increased, the importance oI chronic diseases, or 'diseases oI civilization, such as heart disease, cancer, and stroke emerged. Later in the last century, the Iocus shiIted Irom diseases to behaviors considered responsible Ior the diseases. This change in Iocus was highlighted by several events that led to and resulted in the predominance oI the behavior change health education philosophy emphasizing an individual (micro) perspective. The frst event was the 1979 publication oI Healthy People: The Surgeon General`s Report On Health Promotion and Disease Prevention (U.S. Department oI Health Education and WelIare, 1979). In the Iorward, Joseph CaliIano, acting Secretary oI the Department oI Health Education and WelIare, stated, 'You, the individual, can do more Ior your own health and well-being than any doctor, any hospital, any drug, any exotic medical device (p. viii). This IorceIul statement was based on a group oI American experts that suggested that perhaps 'as much as halI oI U.S. mortality in 1976 was due to unhealthy behavior or lifestyle; 20 % to environmental Iactors; 20 to human biological Iactors; and only 10 to inadequacies in health care (p. 9). The second event was the Reagan era. Even though the emphasis on individual responsibility was initiated during the previous Carter administration, the Reagan era had a deep impact on the philosophy oI health education and health promotion (Allegrante, 1986). The notion oI health as a collective responsibility was replaced by an emphasis on social Darwinism, where individual responsibility and initiative prevailed. As Beauchamp (1984) clearly stated, '.the norm oI market justice is still dominant and the primary duty to avert disease and injury still rests with the individual. The individual is ultimately alone in his or her struggle against death (p. 308). Not only was col- lective responsibility downplayed by the government, but the government also was Irequently portrayed as a source of problems or, at least, Page 8 THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Num- an obstacle to a more responsible and productive citizenry and society. The importance oI individual responsibility was emphasized by Iormer Secretary oI Health and Human Services, Louis Sullivan (1990), who stated: For the harsh truth is that a high percentage oI the dis- ease and disability aIIlicting the American people is a conse- quence oI unwise choices oI behavior and liIestyle. Those poor choices result in lives that are blighted, stunted, and l e s s Iulflling, and they cause an unnecessary, costly drain on the resources available Ior health care. (p. 2) The Trilogy Not surprisingly, the micro behavioral change philosophy oI the late 1970s and early 1980s gave rise to Promoting Health/Preventing Disease: Objectives Ior the Nation (U.S. Department oI Health and Human Services |USDHHS|, 1980) and Healthy People: Health Objectives oI the Na- tion 2000 |USDHHS, 1990| and 2010 |USDHHS, 2000|. During the 1990s, another stimulus Ior a micro behavioral change Iocus was the seminal publication, 'Real Causes oI Death by McGinnis and Foege (1993). The authors oI this publication contrasted the previous perspective oI viewing the leading causes oI death, such as heart disease, cancer, and stroke, to a perspective that highlighted the number oI deaths attributable to tobacco, poor diet, physical inactivity, motor vehicles, frearms, sexual behavior, and other be- haviors. These publications redefned the concept oI health promotion to that oI health improvement through individual responsibility and personal behaviors. A review oI several hundred objectives outlined in the Healthy People documents reveals much less awareness to improving health through government involvement in the area oI health protection or collective responsibility Ior its citizenry. With an emphasis on empowerment and selI-interest, the government Iailed to adequately acknowledge the economic, political, and environmental Iorces that infuence and reinIorce unhealthy behaviors. As such, health promotion underwent a transition Irom the classic defnition Iorwarded by Siegrist (1946): 'Health is promoted by providing a decent standard oI liv- ing, good labor conditions, education, physical culture, and means oI rest and relaxation. (p. 127). In essence, Healthy People (U.S. Public Health Services, 1979) and the subsequent trilogy (USDHHS 1980, 1990 and 2000) instituted parameters by redefning health promotion Irom a broad perspective to a narrow concept encompass- ing liIestyle modifcation with an emphasis on individual responsibility. This redefnition was not a minor philosophi- cal change; it had a major impact on the concepts oI health education and health promotion, the types oI activities and programs Iunded, the research activities conducted, and the missions oI proIessional preparation programs. This transi- tion did not occur without criticism and debate (Allegrante, portance oI individual responsibility and personal behavior, O`Rourke (1989) labeled this paradigm shiIt as 'micro-myo- pia and highlighted two signifcant negative implications: (1) it Iocused health promotion eIIorts inwardly, thus com- promising support Ior population approaches at the collective community/societal level; and (2) it laid an ideal groundwork Ior 'victim blaming, while defecting societal responsibility. Allegrante and Green (1981) noted: One danger oI such a policy is that the Iederal govern- ment will abrogate its responsibility to provide the social and economic supports Ior necessary organizational and environmental changes. . . . Education oI the public is an essential component (and perhaps the most important component) oI a national program to strengthen behav- ior conducive to health. But without the organizational, eco- nomic, and environmental supports for such behavior, health education will appear to be government propaganda a smoke screen to cover the cuts in health services and the proposed regulatory reIorms. (p. 1529) The emphasis on individual responsibility coupled with the lack oI governmental response Ior health promotion reinIorced what O`Rourke (1989) called the 'emerging mo- rality oI health behavior. That is, the use oI stigmatic labels to describe health behaviors became commonplace. Obese people were labeled as weak, inactive people as lazy, smok- ers as selI-indulgent, and AIDS victims as immoral and/or worthy oI their plight. The Macro Perspective The philosophical pendulum continues to Iocus on risk tak- ing with risk imposing a blink on the radar screen oI thought, debate, and scientifc inquiry. The past and present Iocus oI health promotion is on the individual to reduce smoking, improve diet, and increase physical activity. There remains Iar less Iocus or discussion on societal policies in the area oI health promotion such as mandating physical activity pro- grams in schools, increasing incentives Ior worksite health promotion programs, improving school lunch programs, banning junk Ioods in school vending machines, eliminating tobacco exports, and using increased tobacco taxes Ior initiat- ing smoking prevention and cessation programs as opposed to balancing state budgets. In contrast to the atomistic micro-myopia view of health education and health promotion as a synonym Ior individual responsibility, the macro philosophy oI health education and promotion (O`Rourke, 1989; O`Rourke & Macrina, 1989; O`Rourke, 2005) encompasses collective responsibility and community involvement through participation in the political process andservice on county health boards, city councils, and school boards. In these capacities, health educators can infuence the health oI entire communities and not rely on the 'one person at a time model oI improving health through
THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Number 1, 2006 ing bans inpublic places can be enacted, school lunch pro- grams can be improved, tobacco vending machines can be eliminated, and bans on tobacco sales to minors can be en- Iorced. At the macro level, fuoridation oI water supply can be implemented to substitute the Iar more expensive individual fuoride treatment by a dentist or the use oI fuoride-added toothpaste. At the macro level, community recreation op- portunities can be enhanced and coordinated school health curricula can be implemented. The term 'leverage is sometimes used to indicate how goals can be achieved by using collective power. The same concept is true in promoting healthy people and healthy com- munities through collective rather than individual eIIort. It is generally accepted that the whole is greater than the sum oI its parts and that teams can achieve better results than their members acting individually. Yet, health promotion has been guided more by an emphasis on individual rather than collective action, with the macro approach playing a distant second fddle to micro approaches. The Functional/Utilitarian Philosophy Let me suggest two other philosophical approaches that may be useIul Ior health education. The frst is the Iunctional or utilitarian philosophical perspective (O`Rourke, 2005). Here the Iocus oI health education/health promotion is not on individual behavior or liIestyle modifcation. Rather, the purpose is to improve the health of the citizenry for the purposes oI promoting a healthy workIorce or a healthier school-aged population to enhance learning and then as productive members oI the workIorce, community and society. This philosophy views health education/promotion as a means to an end (a healthier, more productive society) and not the end in terms oI healthier people. For example, with respect to school health: Coordinated school health is an essential contributor to the three R`s. Coordinated school health is an important element in promoting critical thinking, analysis, deci- sion- making, and problem solving. Coordinated school health is an important element for our youth oI today securing employment Ior tomor- row (O`Rourke, 2005, p. 113). In generating community support Ior a school health cen- ter, We didn`t achieve this by Iocusing upon primarily on hav- ing health children. Rather, we Iocused on the immediate benefts oI having healthier chil- dren, such as reduced ab- senteeism, reduced dis- cipline problems, enhanced ability to learn, higher test scores, Iewer students leIt behind, higher graduation rates, and so Iorth. (O`Rourke, 2005, p. The Egalitarian Philosophy Another more conceptual philosophy advanced by Ber- zuchka (2001) is the notion oI improving health through an egalitarian perspective in lieu oI individual liIestyle modifca- tion. Berzuchka, a medical doctor, contends that, 'Research during this last decade has shown the health oI a group oI people is not aIIected substantially by individual behaviors such as smoking, diet and exercise, by genetics or by the use oI health care. In countries where basic goods are read- ily available, people`s liIe span depends on the hierarchical structure oI their society; that is, the size oI the gap between rich and poor (Berzuchka, 2001, p.14) For those on top in a hierarchical situation Ieelings oI power, domination and coercion predominate while Ieelings oI resignation, resent- ment and submission predominate Ior those at the bottom. In contrast an egalitarian environment is characterized by Ieelings oI support, Iriendship, cooperation and sociability. Summary In conclusion, it might be benefcial to resurrect the Siegrist philosophy that health education and health promotion are not exclusively synonymous with liIestyle modifcation or the do- main oI behavioral theorists, but rather the result oI a decent standard oI living, a saIe environment, a good education, and meaningIul employment in a society that values collective responsibility, promotes solidarity, rejects social Darwinism, and encourages its citizens to care Ior one another, while respecting individual contributions. It is doubtIul that our present health education philosophy, with its emphasis on improving health through individual behavior and liIestyle modifcation, is suIfcient. Its Iocus is narrow and prevents us Irom considering more eIIective and eIfcient approaches in health education and health promotion. The outcomes oI this tunnel philosophy are a less caring and healthy society and a narrow, less eIIective health education agenda. A change in philosophy is essential to maximize opportunities for a more healthIul society on individual and community levels. References Allegrante, J. P. (1986). Potential uses and misuses oI edu- ca- tion in health promotion and disease prevention. The Eta Sigma Gamman, Spring/Summer, 2-8. Allegrante, J. P., & Green, L. W. (1981). When health policy becomes victim blaming. New England Journal of Medi- cine,305,1528-1529. Beauchamp, D. E. (1984). Public health as social justice. In P. R. Lee, C. L. Estes, & N. B. Ramsay (Eds.), The nations health (2 nd ed.). San Francisco: Boyd & Fraser Publish ing Company. Page 10 THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Number Becker, M. (1986). The tyranny oI health promotion. Pub- lic Health Review,14, 15-16. Bezruchka, S. (2001, February 26). Is our society making you sick? Blech, B. (1998, September 19). Don`t blame the victim. Newsweek, 112(12),10. Cottrell, R., Girvan, J. T., & McKenzie, J. F. (2006). Prin- ciples and foundations of health promotion and education (3 rd ed.). San Francisco: Pearson Benjamin Cummings. McGinnis, J. M., & Foege, W. H. (1993). Actual causes oI death in the United States. Journal of American Medi cal Association, 270, 2207-2212. O`Rourke, T. (1989). Refections on directions in health edu- cation: Implications Ior policy and practice. Journal of Health Education, 20(6), 4-13. O`Rourke, T. (2005). Promoting school health: An ex- panded paradigm. Journal of School Health, 75(3), 112-114. O`Rourke, T., & Macrina, D. (1989). Beyond victim blam- ing: Examining the micro-macro issue in health promotion. Wellness Perspectives: Research, Theory and Practice, 6(1), 7-17. Regney, B. (1922). Rules of the health game: Milk and our school children (No. 11). Washington, DC: U.S. De- Siegrist, H. (1946). The university at the crossroads: Ad- dresses and essays. New York: Henry Schuman. Sullivan, L. (1990). Remarks by Louis Sullivan M.D., Se- cre- tary oI Health and Human Services, Tetelman Lecture, Yale University, New Haven, CT, Novem- ber 28, 1990, 1- 15. U.S. Department oI Health and Human Services. (1980). Pro- moting health/preventing disease: Objec- tives for the nation. Washington, DC: U.S. Government Printing OI- fce. U.S. Department oI Health and Human Services. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Gov ernment Printing OIfce. U.S. Department oI Health and Human Services. (2000). Healthy people 2010: Understanding and improving health (2 nd ed.). Washington, DC: U.S. Government Print- ing OIfce. U.S. Department oI Health Education and WelIare. (1979). Healthy people: The surgeon generals report on health promotion and disease preven- tion. Washington, DC: Government Printing OIfce.