Philosophical Foundations of Health Education

In the foreword of Philosophical Foundations of Health Education, the author proposes that health educators are more than practitioners and leaders in the field; they are also ambassadors of the profession to those outside the profession. The book’s editors, Jill Black, Steven Furney, Helen Graf, and Ann Nolte, are not only luminaries in the field but also themselves acting as ambassadors of the field of health education. It is the first collection of the personal and professional philosophies from many published works of the field’s leaders. It presents philosophies from 1953 to the present and provides a scholarly discourse of related health education philosophical ideas across time from various perspectives.

Over the past 30 years, health education has experienced dramatic expansion and attention. Many health educators expressed the need for a “clear delineation of the major existing philosophies and an analysis of the current trends in health education philosophies [Welle, Russell, & Kittleson, 1995]” (p. xvii). This publication facilitates the process for professionals to do just that. A theme espoused by various authors throughout the book is that a person must develop his or her own philosophy about health and education before he or she can develop a philosophy about the profession.

The editors provide key published articles, grouped into six parts, each with its own introduction to establish a context for articles included in that part. Perhaps the most distinctive characteristic of the book is that the previously published articles were all written by authors who were well-known leaders of health education but who often had quite different perspectives about health and education. The juxtaposition of these ideas provides the reader with disparate personal and professional philosophies on some of the key health education issues. This gives readers different views, which can facilitate development of their own personal and professional philosophies of health education.

Part 1 is titled “Philosophical Perspectives in Health Education.” The authors include Loren Bensley, Keogh Rash, Morgan Pigg, Carl Willgoose, Charles Carroll, and Stephen Thomas. Part 1 consists of six reprinted articles of selected health education leaders that address their personal philosophies and why each believed that a personal philosophy of health education is a necessary foundation to developing one for the profession. “My personal philosophy of health education includes all of what I am, what I value, and what I believe and stand for in relation to health and education [Bensley, 1993]” (p. 4). Another author quotes the World Health Organization’s definition of health as “complete physical, mental, and social well-being, and not merely freedom from disease or infirmity [Rash, 1993]” (p. 7). Recently, many have added the word spiritual to that definition. The authors also discuss the foundations and guiding principles of health and education, which one author identifies as personal empowerment, life affirmation, interconnectedness, and an admission of some of the limitations of health education. Last, a foundational philosophy discussed in some detail is holism. The holistic concept of a human being is described as an integrated whole that is closely related to the environment. Holism can be a different framework to view the mind and body as integrated elements. Holistic health presents the opportunity to view the ideological struggle between the concepts of health and primary prevention versus problem-oriented health care.

Part 2 is titled “Developing a Philosophy of Health Education.” The authors include Becky Smith, Noreen Clark, Thomas Timmreck, and Helen Welle. The basic premise of Part 2 is that education and philosophy are inseparable. The belief is expressed that within an educational context, philosophy is a way of explaining the end and means of education and thereby guiding actions. A health educator’s philosophical approach drives the educational action, including his basic beliefs about the purpose of health education, the roles of the learner and the teacher, education methods, and instructional materials. Noreen Clark discusses leadership for health education and proposes that “[a] leader shows the way, guides, causes progress, creates a path, influences, begins [Clark, 1994]” (p. 63). Health educators must be both leaders within the profession and ambassadors of the profession to other disciplines.

Each article in Part 2 presents different personal views of each of the authors. The gathering of these articles into one section creates a bridge between concepts that influence the development of a personal philosophy and how they can guide the emerging professional philosophies of health education. For example, past and current health educators have identified philosophical tenets and strategies that reflect their individual beliefs. For some health educators, the focus has been on unhealthy habits and behavior modification techniques. Others have focused on individuals’ attitudes about lifestyles (e.g., smoking, nutrition, exercise). Still others have focused on credible information and learning skills to use the information for decision making (health literacy). Part 2 also discusses the unprecedented changes in the world, which include minorities (who are becoming majorities), aging, new types of families, and activism. Health education is, and will be, called on to facilitate and clarify some of the major changes going on and how the profession can consider and address them. These changes include values, process (e.g., how to learn), technology, relationship of health costs to prevention, and quality of life. The authors present the belief that health education must create leadership to help shape the changes so that the health and well-being of individuals and communities are well served. Health education’s failure to provide invigorated leadership (based on the science of the profession) means that others without the insights of health education and will be leading. As Noreen Clark states, “No person can lead other people except by showing them a future. A leader is a merchant of hope [Clark, 1994]” (pp. 65-66).

Having established the philosophical foundations of health and health education in Parts 1 and 2, Parts 3 to 6 focus on four distinct philosophical approaches and philosophies on the practice of health education: cognitive approaches, changing behavior, freeing and functioning in health education, and social change.

Part 3 explores the “Cognitive Approaches in Health Education,” which have served as a foundation for many other philosophies. The authors include Valerie Ubbes, Jill Black (also an editor of the book), Bette Keyser, Kenneth Veselak, and Delbert Oberteuffer. Part 3 focuses on using the cognitive approach of providing information on the best scientific health practices. This approach does not ensure the adaptation of healthy lifestyles, but it does enable learners to think critically and teaches decision-making for appropriate choices, based on up-to-date facts. Health literacy is a good example of a cognitive approach in health education. The primary purpose of this philosophy is to impart knowledge, coupled with decision-making and critical-thinking skills. Part 3 includes samples of applied cognitive-based health education philosophies and emphasizes school health education, with elaboration on collaborative learning, systems thinking, and critical thinking. The paradigm shift toward teaching for thinking is discussed, including perspectives, barriers, solutions, and accountability.

Part 4 is titled “Changing Behavior in Health Education.” The authors include Carl Fertman, Don Read, Frederick Garman, and Ronald Labonte. Proponents of this methodology believe that although cognitive approaches are important, the psychomotor domain is the ultimate objective, as facts alone may not be sufficient. In 1980, Green, Kreuter, Deeds, and Partridge brought this philosophy into the limelight for health education. They defined health education as “any combination of learning experiences designed to facilitate adaptations of behavior conducive to health (p. 7)” (p. 135). Major components of this methodology are motivation, behavior modification, goal setting, positive reinforcement, behavior contracting, self-monitoring and management of skills, and modeling behavior. This approach’s major advantage is its versatility for use in various health content areas and settings. It can also produce lifestyle changes in a relatively short time period. Furthermore, behaviorally based programs are easy to evaluate. Part 4 examines mind–body connection, an aspect of changing behavior that blossomed in the 1990s, and problem-based learning as a catalyst for behavioral change. The transtheoretical model (also known as the stages of change model) is used as an example. Learning versus teaching is also explored, including distance learning, along with empowerment in relation to health promotion. One article in Part 4 compares health education approaches in medical, behavioral, and socioenvironmental fields as they relate to empowerment.

Part 5 is titled “Freeing/Functioning in Health Education.” The authors include Jerrold Greenberg, Andy Anderson, Barbara Ronson, Howard Hoyman, and Steven Hawks. The freeing/functioning philosophy offers an alternative purpose and approach in health education. Perhaps less well-known in relation to health education than other philosophies discussed, this philosophy’s focus is the holistic and humanistic approach, grounded in the principles of humanistic psychology. The freeing/functioning philosophy promotes the development of the entire person. Russell, Nolte, and Greenberg were early pioneers in adopting this philosophy in the 1970s. The basic premise of this philosophy is that people who have a positive, holistic perception of self are more likely to practice healthier lifestyles. The discussion begins with a focus on the whole person and the reasons behind the health decisions, moving away from focusing on details of health behaviors. The chapter also emphasizes the importance of following democratic principles in health promotion, including autonomy in which people are encouraged to take control over their lives. Also discussed is ecology, focusing on ecosystems and the functional relationship between man and the physical environment. Human ecology is concerned with the unique individual, as well as with populations and the population’s representative “statistical man [Hoyman, 1971],” a theoretical individual, composed of the characteristics of that population (p. 229). The author contends that public health is one of the major sectors of human ecology and that health is a multidimensional unit, including physical fitness, mental health, psychosocial well-being, and an ethical/spiritual outlook. “Health is much more than the absence of disease, disability, pain and decay; it encompasses physical fitness, social well-being, personality development and a zest for full, fruitful, creative living [Hoyman, 1971]” (p. 231). Finally, Part 5 encourages health educators to take a holistic approach to the profession itself, addressing multidimensional wellness in practicing health education, including incorporating nonphysical outcomes into national and local health objectives. The author proposes that good health practices will follow if the educator builds into the profession holistic purpose, self-fulfillment and meaningful life.

Part 6, the final section, is titled “Social Change in Health Education.” The authors include Ann Robertson, Meredith Minkler, Daniel Leviton, Martha Coulter, Thomas O’Rourke, Elaine Auld, John Allegrante, Donald Morisky, Behjat Sharif, and Helda Pinzon-Perez. Part 6 studies social change philosophy, with the intent to advocate for environmental, economic, and political conditions that make healthy choices possible. This approach proposes that it is ineffective to focus on an individual’s responsibility for health, which distracts from the environmental and economic factors that have larger effects on a nation’s health. Furthermore, this philosophy contends that emphasizing an individual’s health fails to acknowledge inequalities in society that effectively determine individuals’ health. Health education programs designed around this philosophy are based on social morality and justice in order to influence social determinants of health and illness. This macro-level approach does not blame individuals for poor health choices but instead works to change the context in which they make their choices. This is a fundamental shift in the ways that many health professionals think, talk, and write about health, the determinants of health, and the strategies for achieving health. Empowerment is the central component. One article focuses on global peace, the ultimate social change, and the prevention of horrendous death, especially as caused by terrorism. Putting politics back in public health education is also addressed, including the proposal that leaders in the field have an obligation to be advocates and to lead efforts to assure that the public’s health is protected and improved. Another article on health care reform goes beyond defining health as medical care and addresses making health care affordable. The role of health education associations and their use of the philosophy and principles to advocate for the profession of health education and the ultimate goals of health are discussed. Yet another article addresses using the principles of social change to advocate for removing the causes of disparities in health care, including race and ethnicity, socioeconomic status, gender, age, geographic location, insurance coverage, and political will. Advocacy has been effective in shaping public health policies related to the environment, tobacco control, alcohol, elderly health (e.g., poor health conditions, social isolation, unsafe environments, and access to health care), HIV/AIDS, racial and ethnic minorities, and youth violence. The last article addresses lessons learned from developing countries related to health education. This article examines the interconnectedness of health care systems globally.