What is education? four incomplete answers
- Education is the system used for passing down, from one generation to the next, society's values, attitudes, and culture. Thus are crime, duplicity and double standards (and, on a good day, idealism) perpetuated in a kind of cultural inheritance.
- Education is about changing people. It usually ends up implying change your waysor else. The most extreme form of education is prison.1
- Education performed on one mind by another, under duress, is indoctrination. Indoctrination has its uses. Its value is measured by its propensity to encourage self-education, through, for example, travel, reading, or dialogue. Self-education is the food of the mind: the procedure by which we can touch the great minds of the dead and know we are not alone in all our confusions and questionings. By standing on their shoulders we can find a new view of our world sometimes, even, new worlds to view.
Health education messages
These must be specific and direct. Eg in getting people to sign on for help for drinking problems, it is of little use saying If you don't stop drinking you'll get these diseases (~25% respond); saying Signing on is good for you because of these benefits (~50% respond); saying If you don't sign here, you've had it brings the biggest response. A certain amount of fear in the message is not bad: in enlisting patients for a tetanus vaccine a low fear message gets a 30% response, while a more fear gets a 60%. Optimum messages must be very specific about dates, times, and places of help. Too high a level of fear is counter-productive. A gruesome film about the worst effects of caries produces petrified immobility, not self-help or trips to dentists.
The messenger
Peers may be better than authority-figures (eg in stop smoking messages). A message about breast feeding will come best from a mother. However, if the issues are not well understood, authority may be helpful (the BMJ is more effective than Woman's Own in suggesting to mothers that a new formulation of aspirin should not be taken).
Changing attitudes
The following paradigm holds sway: knowledge attitudes intentions behaviour. As Chinese thought reformers knew so well, attitude changes depend on a high level of emotional involvement. In questions of belief, as in so many other questions, emotion trumps reason people don't demand that a thing be reasonable if their emotions are touched. Lovers aren't reasonable, are they?2 Only resort to applying reason to attitudes if emotions are too hot to handle. NB: the arrows in the model above may be reversed: if our behaviour is inconsistent with our ideas (cognitive dissonance) it is often our ideas, not our behaviour which change.
Health education officers
are likely to have a nursing, teaching, or health visiting background. They may have a postgraduate diploma in health education. There are ~300 in England and Wales. Teams comprise a technician and a graphic artist, as well as clerical staff. One role is to give information and Health Education Authority leaflets. They also liaise with health visitors and primary care trusts, as well as engaging in planning and research.
Examples of health education at work
- Education about safer sex and the prevention of AIDS.
- Leaflets and tape/slide programmes can (slightly) increase knowledge of breast self-examination (which is associated with smaller tumours and less spread in those presenting with breast cancer).
- Radio dramas with health issues reaching millions, eg Soul City in S Africa.
P Theroux Down the Yangtze, Penguin ISBN 0-14-600032-3, page 35-6
Graham Greene 1951 The End Of the Affair, page 115, Heinemann
Nurses are the experts in this field but even they are not very effective in reducing coronary risk. In the community-based OXCHECK randomized trial (N = 6124, aged 35-64) serum cholesterol fell by only 0.08-0.2mmol/L and there was no significant difference in rates of giving up smoking, or in body mass index. Systolic (and diastolic) BP fell by ~2.5% in the intervention group receiving dietary and lifestyle advice. Blanket health promotion may not be a complete waste of resources, but it is certainly expensive for rather limited gains. Similar results have been obtained by the Family Heart Study Group. Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranges from £34,800 if interventional benefits last for 1 year, compared with £1500 for 20-year duration. Corresponding OXCHECK figures are £29,300 and £900. These figures exclude broader long-term cost effects other than coronary mortality.
The conclusion may be that energies are best spent on those with highest risk as determined in routine consultations by a few simple questions about smoking, family history, etc. One trouble is that these questions are not always innocuous. It is not necessarily a good thing to bring up strokes and heart attacks in the family in, for example, consultations about tension headaches. OXCHECK is not the last word and there is evidence that if lipid-lowering drugs were used very much more extensively, cholesterol (and cardiac events) could fall by 30%.
Novel ways of delivering health education messages
- For those who have difficulty in accessing health services, eg those in rural areas, videoconferencing and the internet may be a good way forward. Sustainability of these programmes depends upon the following issues: cost, delivery style, and availability of appropriate technology and patient-friendly internet sites.
- Traditionally, health education has been given by experts, partly because they can answer questions authoritatively. But this authority is itself a problem. Risk-takers are unlikely to listen to the prim and proper. So peer-education has been developed as a tool to reach certain groups, and evidence suggests that this is a promising way forward.
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