HEALTH EDUCATION: THE ROLE AND FUNCTIONS OF THE SPECIALISTAND THE GENERALIST

Helen P. Cleary*

CLEARY, H. P. Health education: the role and functions of the specialist and the gene-ralist. Rev. Saúde públ., S. Paulo, 22:64-72, 1988.

ABSTRACT: Education for health is a process in which all public health and medicalcare personnel are involved. People learn both formally (planned learning experiences)and informally (unplanned learning experiences). Since the patient, the client, the con-summer and the community expect public health and medical care personnel to assistthem with health and disease issues and problems, the response of the professional "edu-cates" the customer whether the professional intends to educate or not. Therefore, it isincumbent on all public health and medical care professionals to understand their educa-tional functions and their role in health education. It is also important that the role ofthe specialist in education be clear. The specialist, as to all other specialists, has an in-depthknowledge of his area of expertise, i.e., the teaching/learning process; s/he may functionas a consultant to others to enhance the educational potential of their role or s/he maywork with a team or with communities or groups of patients. Specific competencies andknowledge are required of the health education specialist; and there is a body of learningand social change theory which provides a frame of reference for planning, implementingand evaluating educational programs. Working with others to enhance their potential tolearn and to make informed decisions about health/disease issues is the hallmark of thehealth education specialist.

UNITERMS: Health education. Health manpower. Interprofessional relations.

* Family & Community Medicine. University of Massachusetts Medical School. Worcester, Massachusetts01655.

INTRODUCTION

Education as a viable intervention for themaintenance of health and the prevention ofdisease has received increasing attention inthe last decade. In the United States onefactor which has brought education to the foreis the recognition that both individual andcollective behavior contribute to the high rateof chronic disease. Behaviors such as ove-reating, smoking or lack of exercise, all ofwhich have been determined to be major riskfactors for cardiovascular disease and cancer,are ameanable to educational interventions.

In public health and medical care, the goalof most of the educational programs is somekind of behavioral change. We look to theelimination of a behavior, such as smoking,or the modification of a behavior, such asdietary practices, or the addition of a newbehavior, such as, physical activity.

Many programs with a behavioral changegoal, assume that the giving of informationabout the behavior and its relation to anillness is all that is needed. Information can

be useful in the learning process but it is notthe total process. If behavior is to be in-fluenced, i.e., people do something differentfrom what they have been doing, additionalvariables must be considered.

Since education has an excellent potentialfor the maintenance of health and the pre-vention of disease and since all health per-sonnel are educators, it is important that therebe a common understanding of their educa-tional role versus the role of the health edu-cation specialist. It is equally important thatall public health and medical care personnelhave a grasp of basic learning principles andthe application of these principles to theirspecific setting.

This paper will define education as itapplies to health/disease issues and conceptsoften used synonomously with health educa-tion, i.e., learning, social change and com-pliance. It will describe the educational com-ponent of the role of all health professionals,and the difference between that role and therole of the health education specialist. The

knowledge and skills required of the healtheducation specialist role, the process by whichthat role was developed and the workingrelationship between other health professionalsand the health education specialist will bedetailed. Finally theories and learning prin-ciples basic to the practice of health educationwill be set forth.

DEFINITIONS

Health Education

Health education as applied to health anddisease issues is defined as "A process withintellectual, psychological, and social dimen-sions relating to activities which increase theabilities of people to make informed decisionsaffecting their personal, family, and commu-nity well being. This process, based on scien-tific principles facilitates learning and beha-vioral change in both health personnel andconsumers, including children and youth,"(Joint Committee8, 1973).

Learning and Social Change

There is sometimes confusion about thedifference between "learning" and "socialchange". That is understandable since theexperts have difficulty defining either termprecisely. The fact is these concepts are twosides of the same coin.

Learning

Kidd10 (1977:24, 15, 16) suggests thatalthough "we cannot pin down anything asdynamic as learning. . .we can observe it, noteits course and its cha rac te r . . . Learning... isnot simply a matter of accretion — of addingsomething....Learning involves a change inbehavior: [it] may make us respond differen-t ly . . . These [responses] may be primarily inte-lectual changes — the acquiring of new ideasor some reorganization of presently heldi d e a s . . . The changes may be in attitudewhere we hope that people will come to adifferent appreciation and more positive feel-ings about a subject . . . Or they may be chan-ges in skill where we expect the learner tobecome more efficient in performing certainacts. . . Much of learning is related to shifts inthe tasks or roles that a person performs."Other educators agree with Kidd's description(Darkenwald and Merriam5 1982:8; Knowles11

1970:50-52).From this definition, the reader will re-

cognize that "learning" occurs within theindividual; whereas education is often definedas teaching the learner or the process of

helping the learner, learn. However, somedefinitions of education include both teachingand learning.

Social Change

Zaltman and Duncan27 (1977:6,9) state that"perhaps the most difficult conceptual issuein studying social chance is to adequatelydefine social change. There is a wide array oftheories focusing on the process of socialchange, leaving the definition implicit in thetheory." Further, persons or groups changetheir behavior "when they define the situationas being different and now requiring differentbehavior." Rogers20 (1983) describes socialchange as "the process by which alterationsoccur in the structure and function of a socialsys tem. . . . The structure of a social system isprovided by the various individual and groupstatuses which compose it. The functioningelement within this structure of status is arole, or the actual behavior of the individualin a given status."

Although both processes, learning andsocial change, require individual change, theydiffer significantly in their central focus:learning tends to focus on change as it relatesto the individual; social change tends to focuson change as it occurs in groups or socialsystems or society. There are, however, socialchange theories about individual change (We-ber26, 1958). Both perspectives recognize thatindividual learning can result in societalchange, and that societal change does requirethat a certain number of individuals havelearned. The similarity between these twoconcepts is clear. It is also obvious that, inregard to health education activities, in thecommunity setting it is often more appropriateto use social change principles rather thanlearning principles, whereas in a school ormedical care setting, learning principles areapt to be more useful than social changeprinciples.

Compliance

The term "compliance" is used in medicalcare settings to describe a patient's adherencee or leack of adherence to a medical regimen.It is often used in public health circles todescribe a community's adherence to certainregulations. Compliance and learning are diffe-rent concepts. They represent essentially diffe-rent processes which can be, but are notnecessarily related.

Although Haynes et al.7 (1979) have writtena valuable literature review on compliance,

nothing in the literature links the complianceprocess with the learning/change process.Lewin12 (1951:77-81) provides us with anexplanation of this relationship. He speaks of"imposed" learning and "learned" learning.Imposed learning is applied to those indivi-duals who either are not interested in changeor are learning against their will. Kelman9

(1958) calls this process "forced compliance".People can be forced to comply if they feelthat the reward or punishment is great enough,that the proposed action is the lesser of twoevils, that they face legal constraints, or thatthey are not totally aware of the end resultof the involvement.

Compliance is sometimes the only course bywhich people can be helped to alter theirbehavior in order to protect the public healthor welfare or to defend human dignity. If thetime bought by compliance helps people learnthe relevance of a new behavior to their goals,it may lead to the acceptance of the newbehavior. Adoption of a practice, therefore,does not necessarily mean that individualshave learned. It may mean they are complyingmerely because they have no other choice.

Lewin's "learned" learning refers to theprocess that occurs when someone decides heor she wants to learn/change. An individualchanges because the new behavior is seen asconsonant with personal goals, it is identifiedwith a person or thing that he or she admiresand wishes to imitate, or the locus of thebehavior changes so that the meaning of thebehavior takes on a new significance.

Educational Role of Health Professionals

Public health and medical care professionalswill identify with these definitions. For exam-ple, with regard to the definition of healtheducation, the nutritionist, environmentalist,physician, nurse, physical therapist, do "in-crease the abilities of people to make informeddecisions affecting their personal, family andcommunity well being." Education is clearlyintegral do the role of all health professionals.In fact the providers of public health andmedical care are usually the first line edu-cators of the patient, the consumer, thecommunity.

Role theory holds that the occupation of aposition in a social system is a role thatcarries with it expectations from those whointeract with it (Merton14, 1957). Thus pa-tients and consumer have expectations ofdoctors, nurses, dietitians, environmentalists,

physical therapists, and other providers ofpublic health and medical care. One of theseexpectations is that the provider will helpthem learn to cope with their illness or theircommunity health problem. The provider ful-fills this expectation either positively or nega-tively in every encounter with a patient, orcommunity by what is said and done and bywhat is unsaid and not done. There is noway a provider can avoid this expectation.

The second theory that supports this pers-pective is the concept of informal learning(Hall6, 1973). Informal learning, commonlyreferred to as modeling, is a major conceptof Bandura's2 (1977) social learning theory.Modeling, or social learning, means that indi-viduals and communities learn from their envi-ronment through what they see being done,what they hear, and what they feel. Theapplication of informal learning to the pro-vider's role in public health and medical careis clear. Learning occurs during the patient/doctor interaction — that is, history taking,physical examination, and the diagnosticprocess. Learning occurs during the provider/community interaction — that is, analysis anddiscussion of a community health problem,development of a plan to deal with theproblem implementation of the plan.

The physician, the nurse, and other pro-viders tell the patient whether they care andgive the patient clues about the seriousnessof the condition through their body languageand what they do or do not say to the patient(Redman19, 1976:10). The community healthworker, whether nurse, physician or envi-ronmentalist, tell the community whether theyare genuinely concerned about the healthproblem and give the community clues abouttheir willingness and capability to help withit by their behavior.

The expectations attached to the role ofproviders of public health and medical careand the fact that learning occurs informallywill not change. Education, therefore, cannotbe considered an appendage to public healthand medical care; it is an integral part ofboth.

The two major differences between theeducational function of the providers of publichealth and medical care and the functions ofa health education specialist is their roleidentification and job responsibilities. Thephysician's primary professional identity is inthe area of medicine, the nurses is nursing,and the dietitian's is nutrition, and the health

educator's is in the area of education. Theprimary responsibility of physicians, nurses,and others in a medical care setting (a hospitalor ambulatory center) is to provide medicalcare for the patient. In carrying out theirspecific patient-care role, they are all respon-sible for educating the patients with whomthey come in contact. In a public healthsetting the physician or nurse may work di-rectly with individual patients in the clinic orthey may work with groups of consumers orwith the community leadership in assessingpublic health problems, and ways in which thecommunity and the public health personnelcan work together to alleviate or eliminate theproblems.

In contrast the primary responsibility ofthe health education specialist in a hospitalor other medical care setting is the overallplanning, implementation and evaluation ofeducation programs for a variety of patientneeds. In a public health setting, the role issimilar, that is, the overall planning andimplementation of the educational componentof the public health programs. A second res-ponsibility in both settings is to function asa consultant to other medical care and publichealth personnel relative to their use of edu-cation. The health educator can help otherhealth professionals enhance and maximizethe educational potential of their role. Thisfunction is analogous to consultation offeredthe family physician by the cardiologist — orconsultation offered the classroom teacher bythe reading expert.

Health Education Specialist

Allegrante1 (1986) has expressed the uni-queness of education in the health field in thisway:

"The goal of health education is to pro-mote, maintain, and improve individual andcommunity health through the educationalprocess. The conceptual hallmarks and socialagenda that differentiate the practice of healtheducation from that of other helping pro-fessions in achieving this goal include: (1)using consensus to identify health needs andproblems; (2) voluntariness of participationas an ethical requirement; and (3) a focus onstimulating social and organizational behaviorchange in defined populations. Like the otherhelping professions, our methodologies alsorequire that we enter into a social contract indealing with people; however, it is the empha-sis on the teaching — learning process —the inherent belief in the individual's capacity

to learn and assume responsibility — thatcomprises the raison d'etre of health educationand which sets it apart from the other fields.Health education is eminently interested ingiving people the empowered role of definingtheir problems, setting the priorities, andcreating the practical solutions by which theyachieve a sense of interest in, commitment to,and ownership over the efforts used to addresshealth issues."

"The nature of work in health educationis thus respectful of the individual as anactively involved learner, a full partner in thechange process who is a rational, purposefulperson capable of acting on and responding toone's environment in the best tradition ofDewey's, Bruner's, Freire's, and Bandura'snotions of self-determinism. While the frameof reference in health education is that ofhealth, the principles, processes and habits ofmind are essentially those derived from theequalitarian spirit and progressive theories ofeducation and the fundamental theories of thebehavioral sciences." (Allegrante1, 1986).

Therefore, the distinguishing characteristicof the health education specialist is understand-ing and skill in applying the teaching/learningprocess to health and disease issues. In 1978,a group of health educators in the UnitedStates saw the need for a definition of thespecific responsibilities and competencies re-quired of the health education specialist toimplement the teaching/learning process (USPublic Health Service24, 1978). In other words,what specifically does a health educator do.

The first step in dealing with this needwas an agreement that there were a sufficientnumber of commonalities in the practice ofhealth education in all settings to call allhealth educators members of one professionregardless of whether they taugh or coordi-nated health education in the schools, deve-loped health education programs in medicalcare institutions, communities or worksites(US Public Health Service24, 1978). Thesecond step was the definition of the role ofthe health educator. Seven responsibilities andrelated competencies and sub-competencieswere identified by a committee of experts.The responsibilities and related competencieswere defined in terms of what individualhealth educators should be able to do; notwhat they knew, but the skills or competenciesthey had (US Public Health Service25, 1980).

A second committee of experts developeda process for verifying this definition of the

role in which several steps were taken. Onewas a survey of practicing health educatorsworking in schools, community, medical careand worksite settings, in which they wereasked whether they did the things the expertssaid they did, and if they did, how importantwere these to them on a day-to-day basis,The data from this survey indicated that allhealth educators in all settings used all sevenresponsibilities and related competencies. Thedifference among settings was one of emphasis.In some settings some competencies were usedmore often than another (US DepartmentCommerce23, 1982). Following the survey,there was a series of workshops for facultypreparing health educators who providedfeedback on the defined role from theirperspective. The defined role was also dis-cussed at professional meetings for two years.

As a result of the verification process, theinitial definition of the role was simplifiedsince it was considered too complex for entry-level. The seven responsibilities, 27 compe-tencies and 77 sub-competencies, were re-tained, but the language was simplified. Basedon the verified role, a curriculum frameworkwas developed as a guide for institutions pre-paring health educators (NTFPPHE, 1985).The verified role is also the basis for self-assessment instruments and a continuing edu-cation model to assist practitioners in identi-fying their skills (NTFPPHE17, 1987).

The final step in this process is the deve-lopment of a credentialing or accountabilitysystem. This will include a series of exami-nations required for acceptance as a certifiedhealth education specialist. That step is inprocess at this time.

The responsibilities and competencies ofthe health education specialists as currentlydefined operationalize learning principles.They are for the entry-level health educatorand they are generic, that is, they apply tothe practice of health education in all settings.At the advanced level, the health educationspecialist carries out the same responsibilitiesbut at a greater degree of complexity. And, atthat level, additional competencies in manage-ment and research are needed.

Valuable as these competencies are in de-fining the role of the health educator, theyconstitute only one component of the foun-dation of this profession. Knowledge of currenthealth/disease issues and of the epidemiologyof current health topics, biostatistics, learningtheory, a philosophical framework and a va-

riety of strategies and methods useful in thepractice of health education, are equally es-sential.

In addition, professional operating proce-dures such as building relationships and deve-loping credibility are as essential to carryingout daily activities as knowledge and skills.Finally, one needs practice management tech-niques to facilitate the accomplishment oftasks; for example, an appropriate filing sys-tem, and a system for communication withadministration.

Figure illustrates the linkage between thecomponent parts of the day-to-day activity ofa health education specialist.

Relationship Between Health EducationSpecialist and Other Health Professionals

The responsibilities, skills and knowledgerequired of the health education specialist,described above, can be carried out in manydifferent ways depending on the setting andthe needs of the institution, consumers orcommunity. The education specialist mayfunction as a consultant to other health pro-fessionals or to a community. For example,s/he may work with public health nurses insetting up an educational program in a clinicfor mothers and infants; or with physiciansand nurses in a cardiac care unit developingmaterials for patients' families. Or s/he mayfunction as a member of a public health ormedical care team in a hospital or clinic. Forexample, a team for educating diabetic pa-tients could include a physician, nurse, dieti-tician and a health educator; or a public healthteam concerned with pollution of a rivercould include an environmentalist, a toxico-logist, a public health physician and a healtheducator. Or the health educator may be theonly health professional working with a com-munity to help the community understand theneed for draining small pools of stagnantwater, and devise a plan with the ocmmunityfor doing so.

As the definition of health educationsuggests, the primary role of the health edu-cation specialist is to facilitate the learningprocess and help the individual or communityto make informed decisions about health/disease issues. The health educator, therefore,never works alone but always together withindividuals, groups or communities to assistthem in dealing with health/disease issues andto facilitate their learning.

Theory

All professions require a comprehensivestatement of essential theory recognized by theindividual practitioner as their base of opera-tion. Health education does not have a theo-retical base separate and distinct from otherprofessions that deal with human services. Itis drawn from education and the social andbehavioral sciences. All human service pro-fessions operate on a similar theoretical basebecause they all deal with human behavior.Many of their social, behavioral, and educa-tional theories have been derived from obser-vations and maxims of human behavior thatwere described by ancient masters, that is,the biblical writers and the Greek and Romanphilosophers (Ulich22, 1971). Each of the pro-fessions has adapted, refined, and expandedthese descriptions and formulated principlesbased on the language of its own specialty.

Because health education draws its theore-tical base from education and the social and

behavioral sciences, a large resource of de-veloped theory is already available to thehealth educator. To eliminate potential con-fusion, it is important to remember three factsabout theory development.

1. Theories relevant to the practice ofhealth education deal with human be-havior (individual, group, and organi-zational) and with ways that peoplelearn/change.

2. Theories are formulated from differentperspectives; for example; psycholo-gists look at individuals, sociologistslook at communities, and anthropolo-gists look at cultures.

3. Theories formulated by the variousbranches of education and the behavio-ral and social sciences often deal withidentical or similar concepts at differentlevels of abstraction.

Theories can be applied to either a specificor a broad-based area. Mullen's15 (1978) work,

which explains the specific responses of post-myocardial infarction patients to their disease,is an example of a specific application, andRoger's explanation of the phenomenon ofadoption-diffusion concepts covers a widespectrum.

Learning theories, espoused by educationalpsychologists, and social change theories de-fined by sociologists are useful in establishingexplanation and prediction of human behavior.Kidd10 (1977) has identified theories oflearning stated by psychologists. The threeclasses of theories most useful in the practiceof health education are cognitive theories,field theories and social learning theories. Bru-ner's3 (1966) theory of instruction, his con-cepts of the process of education, his views oncurriculum development, and his ideas aboutreadiness to learn offer guides and explanationfor practitioners. Lewin's12 (1951) field theoryof learning, including the concepts of life spaceand "learned" learning versus "imposed"learning (discussed above), offers explanationsand guides for the health education specialists.Bandura's2 (1977) social learning theory for-malizes the concept of modeling, long recogni-zed as a way by which people learn.

The sociological theory of social changemost useful in the practice of health education

is that of adoption-diffusion (Rogers20, 1983).As Martindale12 (1972:18) points out, socialaction theorists have not generated a well-formulated theory of social change but have"produced a large number of generalizationsusually employed by sociology at present toaccount for various special changes withoutanchoring these ideas in a single identifiabletheory of social change."

In addition to these theories that have beendrawn from the behavioral and social sciencesand have proven useful in the practice ofhealth education, there are several principlesof learning and social change. Taba21 (1962)and others identified principles of learningderived from well-developed learning theory.Pine and Home18 (1969) identified a similarset of principles through their experience inworking with antipoverty aids. Zaltman andDuncan27 (1977) developed a set of principlesof social change derived from the experiencesof many people. Table I presents a synthesisof learning/social change principles, found inthe literature, which are directly related to thepractice of health education. These principlesare as relevant to the educational componentof the role of the health professional as theyare for the health educational specialist.

Mullen et al.16 (1985) expressed similar prin-ciples in different terms (Table 2). The diffe-rence in the terminology does not mean thatthe basic concepts are different. Mullen'schoice of learning principles was dictated bysetting and program. She was discussing edu-cation of patients in hospitals about takingmedication; for the most part, this was one-to-one education, and nurses were the edu-

cators. The learning principles expressed inTable 1 provide a good fit for a communitysetting. It is critical that those involved ineducating patients or the public about health/disease not be confused by terminology butrather look beyond the words to the meaning.There are many different ways to expresssimilar concepts; what is important is to graspthe meaning of the concept regardless of thewords used to express it.

CLEARY, H. P. Educação em saúde: papel e funções do especialista e do generalista.Rev. Saúde públ., S. Paulo, 22:64-72, 1988.

RESUMO: A Educação em Saúde é um processo no qual todo o pessoal dasaúde pública e do atendimento médico estão envolvidos. As pessoas aprendem ouformalmente (experiências de aprendizagem planejadas) ou informalmente (experiênciasde aprendizagem não planejadas). Na medida em que o paciente, o cliente, o usuárioe a comunidade esperam que o pessoal da saúde pública e o pessoal do atendimentomédico os auxiliem, no que diz respeito a assuntos e a problemas da saúde, a respostado profissional "educa" o usuário, quer o profissional tenha ou não tenha a intençãode o fazer. Portanto, cabe a todos os profissionais da saúde pública e do atendimentomédico entender suas funções educativas e seu papel na Educação em Saúde. É tam-bém importante que o papel do especialista em educação esteja claro. O especialista,tanto quanto os outros especialistas, possui um profundo conhecimento na sua áreatécnica como, por exemplo, o processo de ensino-aprendizagem; pode trabalhar comoum consultor para ampliar o potencial educativo de outros ou pode trabalhar com equipes,com comunidades ou com grupos de pacientes. É preciso que o especialista em Educaçãoem Saúde tenha conhecimentos e competências específicos e há um conjunto de teoriasde aprendizagem e de mudança social que proporcionam um esquema de referência paraplanejar, implementar e avaliar programas educativos. Trabalhar com pessoas para ampliarseu potencial quanto à aprendizagem e a tomar decisões informadas a respeito de assuntosrelacionados à saúde/doença é o objetivo do especialista em Educação em Saúde.

UNITERMOS: Educação em Saúde. Recursos humanos em saúde. Relações interpro-fissionais.

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Received for publication: 16/7/1987Accepted for publication: 14/10/1987