Health & Nutrition:
Human Health

AN EXTENSION SERVICE HEALTH EDUCATION MODEL

Contents

• Introduction
• The Vision
• Origins of the Model
• Assumptions
• The Background Investigation
• Inventory of Health Infrastructure
• Health Status
• Community Resource Profile
• Community Demographics
• Needs Assessment
• Establishing Goals and Objectives
• Program Delivery
• Program Evaluation
• Appendix A: Review of the Literature - Part 1
• Appendix A: Review of the Literature - Part 2
• Appendix B
• Appendix C
• Appendix D
• References

Introduction

The history of Extension Service has included a vital role in sharing general health information with clients, especially among rural mothers, children, and agricultural workers. The major messages of health information have been to promote good health through nutrition and to prevent injury. With a current focus on health the Extension system mission has expanded to address health system problems, health consumerism, as well as statiscally important individual health concerns.

The Vision

Health education is viewed as any combination of learning experiences designed to encourage people and/or groups to voluntarily practice healthy behaviors. Health education is an integral strategy to be used in toward realization of the following goals:

• Citizens will maintain healthy lifestyles and affordable health care will be available to each community.
• People will learn ways to reduce health risks and take an active part in personal health decisions.
• As informed community members, people will use commmunity wide planning and decision-making processes to analyze and take action related to health infrastructure.

A legal mandate to protect the public health rests with the official public health agencies, and health providers have professional responsibilities for health care of their clients. In addition, there are myriad public and private agencies and private groups operating in the health arena. Each of these health sectors is involved in the health education and/or health care of consumers, but the unique role of Extension is to create the learning experiences that not only provide the information necessary for healthy behaviors, but also the learning experiences which empower individuals and communities to use their acquired knowledge in the most effective ways.

Origins of the Model

While much of the educational content of Extension health programming is drawn from the health sciences, Extension aims to carefully target an audience and use educational methods to create learning experiences. This Health Education Model is an attempt to link the strengths of Extension community networks and educational delivery systems with successful methods of health education.

Elements of the model were found in Extension health programs that have long benefitted clients. Other elements derive from a review of health education research and the reported experiences of nurses, physicians, health educators, and public health professionals. For the information of those who are interested, a separate review of the literature of behavioral theories, health and planning models is appended (Appendix A, Parts I & II). The use of the model does not depend on an in-depth understanding of the theories involved in changing a health behavior, but such an understanding can help the educator and program planner to avoid common sources of difficulty in the delivery of health education.

The combined elements of the Health Education Model create a comprehensive process that will build on existing health education and community organization models, and allow the Extension professional to be highly effective as a change agent in the health arena. This comprehensive process of gathering data, assessing needs and planning a program according to the model is a time intensive process. The time spent in a community evaluation, however, can be justified when the process helps to identify effective and efficient uses of limited resources. It should be emphasized that comprehensive assessment and planning do not necessarily lead to complicated and expensive programs...sometimes the process will simplify the end product.

Assumptions

The assumptions integral to this model are defined here. The assumptions are essentially those of a behavioral model of healthy acts. It is also assumed that no health behaviors are not learned or practiced in isolation...that the timing, content, and people involved are critical to the process.

Specifically, it is assumed that health promoting actions are a function of awareness, knowledge, attitudes, skills, culture, opportunities, and/or motivation. The elements in this behavioral model are both causal and interrelated. For example, an increase in awareness may lead to health promoting activities on the part of the individual and/or community. Awareness may also stimulate curiosity and lead to an increase in knowledge or motivation.

Awareness is the alerting of the target group or individual to a danger or a positive factor. Knowledge is more than simple awareness. Knowledge could be described as awareness with understanding.

Skills are the specific tools which equip the individual or target group with the means to solve a problem, take advantage of an opportunity, or otherwise improve a health situation.

Attitudes may be positive or negative in regard to their effect on health behaviors. Attitudes have been viewed as a function of a person's beliefs. If an individual believes that performing a certain behavior will lead to, on the whole, positive outcomes, then that person will tend to hold a favorable attitude toward that behavior. The converse of this idea is that a person who believes that performing the behavior will have no effect or a negative effect will view the behavior as having no value for them personally.

Culture is made up of common sets of symbols, beliefs, rituals, and community norms. Culture has been included in this model since it can reinforce, limit or enable the health behaviors necessary for good health. Cultural health behavior change requires the non-conformist community member to adopt health behavior changes and to demonstrate a positive effect over time to many people within his or her sphere of influence.

Lack of Opportunity to participate in related health activities or services will limit the effectiveness of any program regardless of the presence of other factors. The primary limit to opportunity occurs when the health infrastructure is lacking or inaccessible to the community. Community organization and development processes may be the most appropriate intervention when community members identify limited opportunities for health services.

Motivation is included here as an element specific to the individual. Motivation, an internalized construct of self-reinforcement, is necessary before an individual can take responsible actions. A person's health beliefs and attitudes must be influenced in a positive manner before a person becomes motivated to change a behavior in the direction of better health. If an individual is made aware, given relevant knowledge and skills, and has the opportunity to make necessary changes in attitude and participate in related health services, it is possible that motivation toward healthy behaviors will improve. Motivation is also assumed to be a process that involves stages of change which can be targeted with specific educational methods. However, it is certain that without motivation, the rest of the elements of health education will not be effective in changing health behaviors.

The Background Investigation

The background investigation is used to determine an overall direction for health education. It includes an inventory of the health care system and community resources, demographics of the community, and an examination of the health status of the community residents. Coupled with the vision behind the effort, this should help target specific audiences and perhaps identify some broad goals. The overall strategy should be based upon the existing situation, needs realized on the part of the planner after careful evaluation of relevant data.

The first step in conducting a background investigation is to gather and analyze both quantitative and qualitative data. After analyzing that data, the planner determines what problems exist and the nature of the target population(s). Some of this data is readily available as secondary data, but other data must be primary data and will necessarily be gathered at a local level, usually by the agent dealing closely with the local community and local organizations. There is a multitude of data that could be included in the background investigation, but it must include both local data and data from outside sources. An index of epidemiological terms, techniques, and resources for data which may be used in gathering and analyzing data the health infrastructure is provided in Appendix B.

Inventory of Health Infrastructure

An essential category of the data to be gathered includes an inventory of the health infrastructure. Initially, this inventory might cover the entire state. It will later be necessary to look more closely at local levels when appropriate target populations have been established. The inventory should include:

1. Doctors per 1,000 population
2. Hospitals by category of care available (primary, secondary, tertiary) within a reasonable driving distance
3. Hospital beds per 1,000 population
4. Dentists per 1,000 population
5. Mental care facilities
6. Clinics
7. Low income health facilities
8. Psychological Counseling facilities
9. Wellness Centers (and Capacity)
10. State Public Health Centers;
11. Other agencies providing information or training (for example, American Heart Association, American Diabetes Association, American Lung Association, etc.)

Health Status

Once the health infrastructure has been inventoried, it is necessary to gather information considering the health of individuals in the state, county, or community. The data for this analysis will usually be secondary data which can be gathered from the Centers for Disease Control, the State Public Health Departments, and Vital Statistics gathered by national census and health agencies. Additional data is increasingly being placed on the Internet and is available on the World Wide Web. When data is gathered with respect to location, population size, age, gender and other like criteria, there is some basis for comparison.

Common categories of health status data include:

1. Death by primary cause (including infant mortality)
2. Average age of death
3. Immunization rates by type of immunization
4. Percentage of population over and under weight
5. Percentage of premature births
6. Prevalence and Incidence of hypertension
7. Prevalence and Incidence of sexually transmitted diseases (and trends)
8. Percentage of population that smokes (within age groups)
9. Estimates of prevalence/incidence of alcoholism and other drug abuse
10. Suicide rates
11. Percentage of mothers age 19 and under, and/or unwed
12. Estimates of prevalence and incidence of mental health problems

For examples of background investigations of health infrastructure and health status indicators (on natality and mortality factors only) and some demographic assessment using the Geographic Information System (GIS) see Appendix C, Parts 1 & 2.

Community Resource Profile

This profile should include the organizations, programs, and the target population that address the health-related issues and might also be called a directory of services. Some of the information will be useful later as the target population identifies needs and programs. In addition, any directory is developed as a result of the background investigation will be useful to the community.

Categories of populations should be separated in a community profile and might include age categories. Examples of age categories include ages in years): Infancy (0-1),Early Childhood (1-4), School-Age Children (5-18), Young Adults (19-34), Middle Adults (35-64), Older Adults (65 and over). Special needs programs and services such as those targeting minorities, the physically disabled, those living at or below the poverty level, and issue driven programs/services on chronic diseases, crime, and suicides should also be separate categories of the profile.

This profile should become an important resource as the county or community needs are determined and addressed. Potential issues may be identified in this process, and possible resources for meeting specific needs of the community will become more evident to planners.

Community Demographics

The demographic characteristics of the county or community should also help to identify a target population:

1. Age Characteristics (include year of data) Percentage of Population in Various Age Categories (such as, in years, 0-4, 5-19, 20-34, 35-49, 50-64, and 65 and over)
2. Percent Below the Poverty Level for the total population, for the elderly (age 65 and over), and for female head of household.
3. Life Expectancy (in years)
4. Leading Causes of Death (Heart Disease, Cancer, Strokes, Motor Vehicle, Other Injuries, and Poisonings)

Stages of Life characteristics for the county should include:

1. Young Population Infant (less than 1 year) Death Rate; Early Childhood (1-4 years) Leading Cause of Death; Later Childhood and Adolescence (5-19 years) Leading Cause of Death. Include race and sex for each category.
2. Early Adulthood (20-29 years) Leading Cause of Death. If Motor Vehicle Accidents is the leading cause, include DUI arrests, and other Crimes (violent, property, and total). Include race and sex for each category.
3. Young Adulthood (30-44 years) Leading Cause of Death which should include information by race and sex.

Other social characteristics about the county or community should include:

1. Births (Total Number and Number by Race; Also compare County Rate to State Rate for Total and by Race)
2. Live Births to Unwed Teenage Mothers (For County and for State include Total Number, Number by Race, and as a Percentage of the Total)
3. Low Birth Weight Babies (For County and for State, include Total by Race, Percentage of Total by Race, and as a Percentage of the Total (all races) Live Births)
4. Divorces (Total Number and Number by Race; Also compare County Rate to State Rate for Total and by Race)
5. Marriages (Total Number and Number by Race; Also compare County Rate to State Rate for Total and by Race)
6. Educational Level (Include County and State Data for Categories by Years of Formal Schooling for Adults as a Percentage of the Total. Categories could include 0-8 years, 9-11 years, H.S. Degree, Some College, College Degree.
7. Medical Services (For Hospitals, include Number of Facilities, Bed Capacity, Admissions/Discharges, Percent Occupancy, and Average Stay; For Nursing Homes, include Number of Facilities, Bed Capacity, New Admissions, and Percent Occupancy.)
8. Licensed Health Professionals (Include totals for the following categories: Chiropractors, Dentists, Osteopaths, Physicians, Public Health Nurses, Veterinarians.)

Needs Assessment

Once a target population has been identified, the planner attempts to determine perceived or felt needs of the audience in the areas of awareness, knowledge, skills and opportunities (health infrastructure). It is also at this point that it is crucial for county level agents to initiate meetings with local groups, companies, and/or individuals in the target population in order to determine the felt needs.

While validated survey tools to determine felt needs are available, other effective, simple techniques can be used. To identify felt needs, interview key natural and official leaders of the targeted group, asking them to describe the open and hidden health behaviors of the group, valued and condemned health behaviors, and how the group defines itself, what the group "knows", and how it came to know "it". A focus group of the targeted audience, asking for the same information, may elicit different responses.

A verbal or written survey of the targeted audience may provide even more information about felt needs. Sample survey questions are included to illustrate the type of social information that will limit or enable the success of a health education project¹:

1. Identify the level or levels of the program outcome desired:
   • Individual changes in behavior
   • Social changes in working with other agencies
   • Service delivery changes in the structure of any agencies
   • Community changes in problem-solving ability
2. Give any network intervention strategies which will be used, such as:
   • Strengthen existing networks
   • Enhance the total network
   • Organize new community efforts
3. Identify any existing social structures which will be targeted specifically to begin change:
   • Family and friends
   • Neighborhoods
   • Religious organizations
   • Social organizations
   • Civic organizations
   • Service organizations
   • Businesses
   • Other
4. Give support functions and list human and financial resources which are available to reach the goals and objectives of the program.
   • Emotional (Listening, showing trust or concern)
   • Instrumental (Real help in the form of labor, time, or money)
   • Informational (Providing advice, suggestions, directives, or referrals)
   • Appraisal (Affirming and giving feedback to each other)

¹This list of the social aspects of programs is based upon a planning process model by Eng and Young (1992) for use in lay health advisor programs. It has been adapted for use in the Extension Health Education Model. See Health Education Behavior Models and Theories for more information.

The felt or perceived needs are compared with the real or service needs to determine high priority health education needs. Real/service needs are those which are determined by health officials and are supported by the available data already examined. Those needs which are identified by officials, data and demographics as high priority, high rate of occurrence and which are perceived as important to the target audience, should be discussed further.

The task assessing needs and identifying programs in health can be facilitated through the use of any available Extension Service Community Development resources and materials on Community Strategic Health Planning. Examples of Extension Service Health Strategic Planning materials are listed with contact information in Appendix D.

Health is part of the overall quality of life and economic well-being and, should be an important component in any community development effort. Moreover, community development professionals are experienced in facilitating local groups such as task forces, committees, volunteer projects, and coalitions to accomplish goals. Where such efforts are on-going, it should be fairly easy to include a health education component in the effort, if such a component does not already exist.

One way to build local health groups would be to apply the Community Wellness Model², a four-stage model, which uses progressive involvement by members of the community in a problem-solving approach. An example of the Community Wellness County Health Profile is included in Appendix C-PART II. The County Health Profile includes some of the elements of the Health Education Model Background Investigation and Program Identification, and has been used effectively in many Extension Services efforts.

²Community Wellness is a process-oriented program designed by Dr. Susan Jenkins during her employment as a Community Development Specialist with the Georgia Cooperative Extension Service. Details of this community-based model are located in APPENDIX A, Part II.

Establishing Goals and Objectives

Goals, Objectives, Impact Indicators, and Evaluation Methods can be developed by the planners after the process has targeted an audience and identified a potential health education program/or project.

A goal in health education can be identified as a desired behavior or health task. It should be the type of broad goal illustrated by the three major Decisions for Health goals which are included in the resources section of this model. Each goal is achieved through an action plan of measurable, quantifiable objectives which can be accomplished within a specified time frame. Examples of a set of goals/ objectives might be:

Health Task:
People will stop using tobacco products.

Objectives:
Extension Agents will design and implement lay health advisor training on tobacco cessation techniques to 24 lay health advisors in the month of October. Each trained lay health advisor will provide social support and information about tobacco cessation to 10 tobacco users over the months of October and November. Local media will collaborate with health organizations to conduct an intensive tobacco cessation awareness campaign beginning in November and culminating on November 19th with the Great American Smokeout.

Impact Indicators:

1. The percent of smokers who enroll in stop smoking clinics (within some defined group or area) will increase by 30 percent by December, and
2. Three years after the end of the program, the percent of individuals who smoke (within some defined group or area) will be 10 percent lower than before the program.
3. Six month follow-up contact of tobacco users who have been supported by lay health advisors will reveal that 10 percent have ceased to use tobacco.

Evaluation Methods:

• Advance contact and request for participation data of tobacco cessation programs.
• Review of epidemiological data such as the Health and Human Services survey, BRFFUS.
• Six month follow up phone call to lay health advisor contacts by an objective third party.

Once goals and objectives have been identified, along with the criteria and methods for judging impact (evaluation), the planning group should take a fresh look at the overall direction. For any given set of objectives, there are numerous possible programs. For the person(s) attempting to design such programs and curricula, there are several questions which should be asked and answered in determining the viability of such a program before work begins on the actual program. One way of summarizing the work that has been done to this point and answering these questions is the project brief. The general format of such a project brief includes the health task or broad goal,a brief (25 words or less) description of the program/project which includes relevant data,geographical scope, time frame, and the goals and assessed needs for awareness/knowledge,skills,and opportunities,a description of the target population, demographic and supporting data,impact or outcome indicators with specific criteria and time frame,limiting and enabling factors such as human and financial resources,attitudes,cultural factors,available materials, the educational content,and delivery and evaluation methods.

When project briefs have been completed, some projects will immediately appear not to be viable because of constraints, costs, lack of human resources, or other reasons. The number of projects which survive should then be prioritized based upon likely effects and cost effectiveness. Prioritization, along with total available resources, will finally indicate which and how many projects should be pursued.

Program Delivery

Project implementation follows the project planning phases and has standard elements which are not enumerated here. Appendix E provides a list of ideas for educational delivery methods.

Program Evaluation

A step-by-step question approach which might be helpful in impact evaluation could include the following:

1. What specific objectives did you set for your program?
2. What were the means specified in order to achieve those objectives?
3. What criteria were established to determine whether or not each objective was achieved?
4. Overall, what percentage of your objectives did you achieve? (You may wish to weigh some objectives as greater in importance than others.)
5. Given your successes and failures, should some of your objectives be considered unattainable, or should you change the means and/or criteria?
6. Given your responses to #4 and #5, what goals should be or need to be reformulated?
7. Given your responses to the above six questions, how should you modify and revise the program/project?

Evaluation is an ongoing process that can interact with other elements of planning, assessment and implementation at several points, as illustrated in the diagrammatic Extension Health Education Model. Other resources dealing with evaluation are included in the resource Appendix F.

October 12, 1995
Mrs. Linda Patterson
Mrs. Carol Campbell, Research Assistant