Planning, Implementing, and Evaluating Health Promotion Programs
Planning, Implementing, and Evaluating Health Promotion Programs
A Primer
SeVenth edition
James F. McKenzie, Ph.d., M.P.h., M.C.h.e.S. Ball State University
Brad L. neiger, Ph.d., M.C.h.e.S. Brigham Young University
Rosemary thackeray, Ph.d., M.P.h. Brigham Young University
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Library of Congress Cataloging-in-Publication Data
McKenzie, James F. Planning, implementing, and evaluating health promotion programs: a primer/ James F. McKenzie, Brad L. Neiger, Rosemary Thackeray.—7th ed. p. ; cm. Includes bibliographical references. ISBN 978-0-13-421992-9—ISBN 0-13-421992-9 I. Neiger, Brad L. II. Thackeray, Rosemary. III. Title. [DNLM: 1. Health Promotion—United States. 2. Health Education—United States. 3. Health Planning—United States. 4. Program Evaluation—United States. WA 590] 613.0973—dc23 2015044450
ISBN-10: 0-13-421992-9 ISBN-13: 978-0-13-421992-9
1 2 3 4 5 6 7 8 9 10—V355—20 19 18 17 16
www.pearsonhighered.com
Acknowledgments of third party content appear on pages 477–478, which constitutes an extension of this copyright page.
This book is dedicated to seven special people—
Bonnie, Anne, Greg, Mitchell, Julia, Sherry, and Callie Rose
and to our teachers and mentors—
Marshall H. Becker (deceased), Mary K. Beyer, Noreen Clark (deceased), Enrico A. Leopardi, Brad L. Neiger, Lynne Nilson, Terry W. Parsons,
Glenn E. Richardson, Irwin M. Rosenstock (deceased), Yuzuru Takeshita, and Doug Vilnius
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Preface xiii
Acknowledgments xvii
Chapter 1 health education, health Promotion, health education Specialists, and Program Planning 1 Health Education and Health Promotion 4 Health Education Specialists 4 Assumptions of Health Promotion 9 Program Planning 10 Summary 13 Review Questions 13 Activities 13 Weblinks 14
PART I Planning a HealtH Promotion Program 15
Chapter 2 Starting the Planning Process 17 The Need for Creating a Rationale to Gain the Support
of Decision Makers 18 Steps in Creating a Program Rationale 20
Step 1: identify Appropriate Background information 20 Step 2: title the Rationale 26 Step 3: Writing the Content of the Rationale 26 Step 4: Listing the References Used to Create the Rationale 30
Planning Committee 33 Parameters for Planning 36 Summary 37 Review Questions 37 Activities 37 Weblinks 38
Chapter 3 Program Planning Models in health Promotion 41 Evidence-Based Planning Framework for Public Health 43 Mobilizing for Action Through Planning and Partnerships (MAPP) 45
Contents
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vi Contents
MAP-IT 46 PRECEDE-PROCEED 48
the eight Phases of PReCede-PRoCeed 48
Intervention Mapping 50 Healthy Communities 51 SMART 53
the Phases of SMARt 55
Other Planning Models 57 An Application of the Generalized Model 58 Final Thoughts on Choosing a Planning Model 62 Summary 63 Review Questions 63 Activities 64 Weblinks 64
Chapter 4 Assessing needs 67 What to Expect from a Needs Assessment 70 Acquiring Needs Assessment Data 71
Sources of Primary data 71 Sources of Secondary data 82 Steps for Conducting a Literature Search 87 Using technology to Map needs Assessment data 88
Conducting a Needs Assessment 90 Step 1: determining the Purpose and Scope of the needs
Assessment 91 Step 2: Gathering data 91 Step 3: Analyzing the data 93 Step 4: identifying the Risk Factors Linked to the health Problem 96 Step 5: identifying the Program Focus 97 Step 6: Validating the Prioritized needs 98 Application of the Six-Step needs Assessment Process 98
Special Types of Health Assessments 100 health impact Assessment 100 organizational health Assessment 101
Summary 102 Review Questions 102 Activities 103 Weblinks 103
Chapter 5 Measurement, Measures, Measurement instruments, and Sampling 105 Measurement 106
the importance of Measurement in Program Planning and evaluation 107 Levels of Measurement 108 types of Measures 111
Contents vii
Desirable Characteristics of Data 111 Reliability 112 Validity 114 Bias Free 117
Measurement Instruments 117 Using an existing Measurement instrument 117 Creating a Measurement instrument 118
Sampling 121 Probability Sample 123 nonprobability Sample 126 Sample Size 127
Pilot Testing 127 Ethical Issues Associated with Measurement 129 Summary 130 Review Questions 130 Activities 131 Weblinks 131
Chapter 6 Mission Statement, Goals, and objectives 133 Mission Statement 134 Program Goals 135 Objectives 136
different Levels of objectives 136 Consideration of the time needed to Reach the outcome
of an objective 138 developing objectives 139 Questions to be Answered When developing objectives 139 elements of an objective 139
Goals and Objectives for the Nation 142 Summary 148 Review Questions 149 Activities 149 Weblinks 150
Chapter 7 theories and Models Commonly Used for health Promotion interventions 151 Types of Theories and Models 154 Behavior Change Theories 154
intrapersonal Level theories 157 interpersonal Level theories 176 Community Level theories 182
Cognitive-Behavioral Model of the Relapse Process 186 Limitations of Theory 187 Summary 188
viii Contents
Review Questions 188 Activities 189 Weblinks 190
Chapter 8 interventions 191 Types of Intervention Strategies 193
health Communication Strategies 194 health education Strategies 203 health Policy/enforcement Strategies 206 environmental Change Strategies 210 health-Related Community Service Strategies 211 Community Mobilization Strategies 212 other Strategies 215
Creating Health Promotion Interventions 225 intervention Planning 225 Adopting a health Promotion intervention 226 Adapting a health Promotion intervention 226 designing a new health Promotion intervention 228
Limtations of Interventions 233 Summary 234 Review Questions 234 Activities 235 Weblinks 236
Chapter 9 Community organizing and Community Building 237 Community Organizing Background and Assumptions 238 The Processes of Community Organizing and Community Building 241
Recognizing the issue 244 Gaining entry into the Community 244 organizing the People 245 Assessing the Community 248 determining Priorities and Setting Goals 252 Arriving at a Solution and Selecting intervention Strategies 254 Final Steps in the Community organizing and Building Processes 254
Summary 255 Review Questions 255 Activities 255 Weblinks 256
PART II imPlementing a HealtH Promotion Program 259
Chapter 10 identification and Allocation of Resources 261 Personnel 264
internal Personnel 264
Contents ix
external Personnel 265 Combination of internal and external Personnel 266 items Related to Personnel 267
Curricula and Other Instructional Resources 272 Space 275 Equipment and Supplies 276 Financial Resources 276
Participant Fee 277 third-Party Support 277 Cost Sharing 278 Cooperative Agreements 278 organization/Agency Sponsorship 278 Grants and Gifts 279 Combining Sources 282 Preparing and Monitoring a Budget 282
Summary 287 Review Questions 287 Activities 287 Weblinks 288
Chapter 11 Marketing: developing Programs that Respond to the Wants and needs of the Priority Population 291 Marketing and Social Marketing 291 The Marketing Process and Health Promotion Programs 293
exchange 293 Consumer orientation 294 Segmentation 296 Marketing Mix 301 Pretesting 310 Continuous Monitoring 312
Summary 314 Review Questions 314 Activities 315 Weblinks 316
Chapter 12 implementation: Strategies and Associated Concerns 319 Logic Models 321 Defining Implementation 322 Phases of Program Implementation 322
Phase 1: Adoption of the Program 323 Phase 2: identifying and Prioritizing the tasks to Be Completed 323 Phase 3: establishing a System of Management 326 Phase 4: Putting the Plans into Action 331 Phase 5: ending or Sustaining a Program 335
Implementation of Evidence-Based Interventions 335
x Contents
Concerns Associated with Implementation 336 Safety and Medical Concerns 336 ethical issues 338 Legal Concerns 340 Program Registration and Fee Collection 341 Procedures for Record Keeping 341 Procedural Manual and/or Participants’ Manual 341 Program Participants with disabilities 342 training for Facilitators 342 dealing with Problems 345 documenting and Reporting 345
Summary 346 Review Questions 346 Activities 347 Weblinks 348
PART III evaluating a HealtH Promotion Program 349
Chapter 13 evaluation: An overview 351 Basic Terminology 352 Purpose of Evaluation 354 Framework for Program Evaluation 356 Practical Problems or Barriers in Conducting an Evaluation 358 Evaluation in the Program Planning Stages 360 Ethical Considerations 360 Who Will Conduct the Evaluation? 361 Evaluation Results 362 Summary 362 Review Questions 363 Activities 363 Weblinks 363
Chapter 14 evaluation Approaches and designs 365 Formative Evaluation 366
Pretesting 373 Pilot testing 373
Summative Evaluation 374 Selecting an Evaluation Design 375 Experimental, Control, and Comparison Groups 376 Evaluation Designs 378 Internal Validity 381 External Validity 382
Contents xi
Summary 383 Review Questions 383 Activities 384 Weblinks 384
Chapter 15 data Analysis and Reporting 387 Data Management 388 Data Analysis 389
Univariate data Analyses 390 Bivariate data Analyses 391 Multivariate data Analyses 392 Applications of data Analyses 393
Interpreting the Data 394 Evaluation Reporting 396
designing the Written Report 397 Presenting data 397 how and When to Present the Report 398
Increasing Utilization of the Results 399 Summary 400 Review Questions 400 Activities 400 Weblinks 401
Appendix A Code of ethics for the health education Profession 403
Appendix B health education Specialist Practice Analysis (heSPA 2015)– Responsibilities, Competencies and Sub-competencies 409
Glossary 419
References 433
Name Index 459
Subject Index 465
Text Credits 477
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this book is written for students who are enrolled in a professional course in health promotion program planning. It is designed to help them understand and develop the skills necessary to carry out program planning regardless of the setting. The book is unique among the health promotion planning textbooks on the market in that it provides readers with both theoretical and practical information. A straightforward, step-by-step format is used to make concepts clear and the full process of health promotion planning understandable. This book provides, under a single cover, material on all three areas of program development: planning, implementing, and evaluating.
Learning Aids
Each chapter includes chapter objectives, a list of key terms, presentation of content, chapter summary, review questions, activities, and Weblinks. In addition, many of the key concepts are further explained with information presented in boxes, figures, and tables. There are also two appendixes: Code of Ethics for the Health Education Profession and Health Education Specialist Practice Analysis 2015—Responsibilities, Competencies, and Sub-competencies; an extensive list of references; and a Glossary.
Chapter Objectives
The chapter objectives identify the content and skills that should be mastered after read- ing the chapter, answering the review questions, completing the activities, and using the Weblinks. Most of the objectives are written using the cognitive and psychomotor (behavior) educational domains. For most effective use of the objectives, we suggest that they be reviewed before reading the chapter. This will help readers focus on the major points in each chapter and facilitate answering the questions and completing the activi- ties at the end.
Key Terms
Key terms are introduced in each chapter and are important to the understanding of the content. The terms are presented in a list at the beginning of each chapter and are printed in boldface at the appropriate points within the chapter. In addition, all the key terms are presented in the Glossary. Again, as with the chapter objectives, we suggest that readers skim
PrefaCe
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xiv Preface
the key terms list before reading the chapter. Then, as the chapter is read, particular attention should be paid to the definition of each term.
Presentation of Content
Although each chapter could be expanded—in some cases, entire books have been written on topics we have covered in a chapter or less—we believe that each chapter contains the necessary information to help students understand and develop many of the skills required to be successful health promotion planners, implementers, and evaluators.
Responsibilities and Competencies Boxes
Within the first few pages of all except the first chapter, readers will find a box that contains the responsibilities and competencies for health education specialists that are applicable to the content of the chapter. The responsibilities and competencies presented in each chapter are the result of the most recent practice analysis—the Health Education Specialist Practice Analysis 2015 (HESPA 2015), which is published in A Competency-Based Framework for Health Education Specialists—2015 (NCHEC & SOPHE, 2015). These boxes will help readers under- stand how the chapter content applies to the responsibilities and competencies required of health education specialists. In addition, these boxes should help guide candidates as they prepare to take either the Certified Health Education Specialist (CHES) or Master Certified Health Education Specialist (MCHES) exam. A complete listing of the Responsibilities, Competencies, and Sub-competencies are presented in Appendix B.
Chapter Summary
At the end of each chapter, readers will find a one- or two-paragraph review of the major con- cepts covered in the chapter.
Review Questions
The questions at the end of each chapter provide readers with some feedback regarding their mastery of the content. These questions also reinforce the objectives and key terms presented in each chapter.
Activities
Each chapter includes several activities that allow students to use their new knowledge and skills. The activities are presented in several different formats for the sake of variety and to ap- peal to the different learning styles of students. It should be noted that, depending on the ones selected for completion, the activities in one chapter can build on those in a previous chapter and lead to the final product of a completely developed health promotion program plan.
Weblinks
The final portion of each chapter consists of a list of updated links on the World Wide Web. These links encourage students to explore a number of different Websites that are available to support planning, implementing, and evaluating programs.
Preface xv
new to this edition
In revising this textbook, we incorporated as many suggestions from reviewers, colleagues, and former students as possible. In addition to updating material throughout the text, the follow- ing points reflect the major changes in this new edition:
⦁ Chapter 1 has been updated to include information about the revised areas of responsibility, competencies, and subcompetencies based on the Health Education Specialist Practice Analysis (HESPA 2015) (NCHEC & SOPHE, 2015), and the implications of HESPA 2015 for the Health Education Profession.
⦁ Chapter 2 has been expanded to include additional information on sources of evidence to support a program rationale, additional information on determining the financial burden of ill health, a new example of a written program rationale, and information on the importance of partnering with others when creating a program.
⦁ Chapter 3 has been restructured to place more emphasis on the prominent planning models used in health promotion. The chapter also now includes the Evidence- Based Planning Framework in Public Health, the CHANGE tool used to plan healthy community initiatives, and more evidence-based examples of how planning models are used in practice.
⦁ Chapter 4 has new information on the importance of needs assessment in the accredita- tion of health departments and the IRS requirement for not-for-profit hospitals, new information on using technology while conducting a needs assessment, and a new section on organizational health assessments.
⦁ Chapter 5 includes new information on wording questions for different levels of measurement, how to present data in charts and graphs, how to write questions and response items for data collection instruments, and guidelines for the layout and visual presentation of data collection instruments.
⦁ Chapter 6 now includes a new section on short-term, intermediate, and long-term objectives, and a new SMART objective checklist.
⦁ Chapter 7 includes additional information on the expansion of the socio-ecological approach, additional information on the constructs of the social cognitive theory, the inclusion of the diffusion of innovations theory which was previously found in Chapter 11, and a new section on the limitations of theory.
⦁ Chapter 8 features new information on motivational interviewing, new content on the built environment, new content on behavioral economics, information on the Affordable Care Act and its impact on incentives, and new content on the limitations of interventions.
⦁ Chapter 9 includes new information on the renaming of community organizing strategies and updated figures on community organizing and community building typology and on mapping community capacity.
⦁ Chapter 10 now includes expanded information on using volunteers as a program resource, and program funding by governmental agencies.
⦁ Chapter 11 has been reworked and now has several new boxes and tables that include a social marketing planning sheet, factors to consider when selecting pre-testing methods, a 4Ps marketing mix example, types of questions to ask for formative research, and examples of segmentation.
xvi Preface
⦁ Chapter 12 content includes expanded information on logic models, new content on professional development including a template for a professional development plan, new content on monitoring implementation, and new content on the implementation of an evidence-based intervention.
⦁ Chapter 13 now includes updated information on CDC’s Framework for Program Evaluation and new information on CDC’s characteristics of a good evaluator. In addition, new information has been added to support the importance of evaluation and the use of evaluation standards.
⦁ Chapter 14 includes updated terminology and context for internal and external validity, and updated context for experimental, quasi-experimental, and non-experimental evaluation designs.
⦁ Chapter 15 includes updated information for data management, data cleaning, and the transition to data analysis. In addition, new information is presented to show the relationship between levels of measurement and the selection of statistical tests including parametric and non-parametric tests.
⦁ All chapters include more practical planning examples and, where appropriate, new application boxes have been added to chapters.
⦁ A new appendix has been added that contains all of the Responsibilities, Competencies, and Sub-competencies that resulted from the Health Education Specialist Practice Analysis 2015.
⦁ To assist students, the Companion Website (https://media.pearsoncmg.com/bc/bc_ mckenzie_health_7) has been updated and includes chapter objectives, practice quizzes, Responsibilities and Competencies boxes, Weblinks, a new example program plan, the Glossary, and flashcards.
⦁ To assist instructors, all of the teaching resources have been updated by Michelle LaClair, Pennsylvania State College of Medicine. These resources are available for download on the Pearson Instructor Resource Center. Go to http://www.pearsonhighered.com and search for the title to access and download the PowerPoint® presentations, electronic Instructor Manual and Test Bank, and TestGen Computerized Test Bank.
Students will find this book easy to understand and use. We are confident that if the chapters are carefully read and an honest effort is put into completing the activities and visiting the Weblinks, students will gain the essential knowledge and skills for program planning, implementation, and evaluation.
A project of this nature could not have been completed without the assistance and understanding of many individuals. First, we thank all our past and present students, who have had to put up with our working drafts of the manuscript.
Second, we are grateful to those professionals who took the time and effort to review and comment on various editions of this book. For the first edition, they included Vicki Keanz, Eastern Kentucky University; Susan Cross Lipnickey, Miami University; Fred Pearson, Ricks College; Kerry Redican, Virginia Tech; John Sciacca, Northern Arizona University; and William K. Spath, Montana Tech. For the second edition, reviewers included Gordon James, Weber State; John Sciacca, Northern Arizona University; and Mark Wilson, University of Georgia. For the third edition, reviewers included Joanna Hayden, William Paterson University; Raffy Luquis, Southern Connecticut State University; Teresa Shattuck, University of Maryland; Thomas Syre, James Madison University; and Esther Weekes, Texas Women’s University. For the fourth edition, reviewers included Robert G. LaChausse, California State University, San Bernardino; Julie Shepard, Director of Health Promotion, Adams County Health Department; Sherm Sowby, California State University, Fresno; and William Kane, University of New Mexico. For the fifth edition, the reviewers included Sally Black, St. Joseph’s University; Denise Colaianni, Western Connecticut State University; Sue Forster- Cox, New Mexico State University; Julie Gast, Utah State University; Ray Manes, York College CUNY; and Lois Ritter, California State University East Bay. For the sixth edi- tion, reviewers included Jacquie Rainey, University of Central Arkansas; Bridget Melton, Georgia Southern University; Marylen Rimando, University of Iowa; Beth Orsega-Smith, University of Delaware; Aimee Richardson, American University; Heather Diaz, California State University, Sacramento; Steve McKenzie, Purdue University; Aly Williams, Indiana Wesleyan University; Jennifer Banas, Northeastern Illinois University; and Heidi Fowler, Georgia College and State University. For this edition, reviewers included Kimberly A. Parker, Texas Woman’s University; Steven A. Branstetter, Pennsylvania State University; Jennifer Marshall, University of South Florida; Jordana Harshman, George Mason University; Tara Tietjen-Smith, Texas A & M University, Commerce; Amy L. Versnik Nowak, University of Minnesota, Duluth; Amanda Tanner, University of North Carolina, Greensboro; Deric R. Kenne, Kent State University; and Deborah J. Gibson, University of Tennessee, Martin.
Third, we thank our friends for providing valuable feedback on various editions of this book: Robert J. Yonker, Ph.D., Professor Emeritus in the Department of Educational Foundations and Inquiry, Bowling Green State University; Lawrence W. Green, Dr. P. H., Professor, Department of Epidemiology and Biostatistics, School of Medicine, University
aCknowledgments
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xviii Acknowledgments
of California, San Francisco (UCSF); Bruce G. Simons-Morton, Ed.D., M.P.H., Senior Investigator, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health; and Jerome E. Kotecki, H.S.D., Professor, Department of Physiology and Health Science, Ball State University. We would also like to thank Jan L. Smeltzer, Ph.D., coauthor, for her contributions to the first four editions of the book.
Fourth, we appreciate the work of the Pearson employees Michelle Cadden, Senior Acquisitions Editor for Health, Kinesiology, and Nutrition who has been very supportive of our work, and Susan Malloy, Program Manager, whose hard work and encouragement ensured we created a quality product. We also appreciate the careful work of Allison Campbell and Charles Fisher from Integra–Chicago.
Finally, we express our deepest appreciation to our families for their support, encourage- ment, and understanding of the time that writing takes away from our family activities.
J. F. M. B. L. N.
R. T.
1
1
Chapter Health Education, Health Promotion, Health Education Specialists, and Program Planning
Chapter Objectives
After reading this chapter and answering the questions at the end, you should be able to:
⦁⦁ Explain the relationship among good health behavior, health education, and health promotion.
⦁⦁ Explain the difference between health education and health promotion.
⦁⦁ Write your own definition of health education.
⦁⦁ Explain the role of the health educator as defined by the Role Delineation Project.
⦁⦁ Explain how a person becomes a Certified Health Education Specialist or a Master Certified Health Education Specialist.
⦁⦁ Explain what the Competencies Update Project (CUP), Health Educators Job Analysis (HEJA-2010), and Health Education Specialists Practice Analysis (HESPA-2015) have in common.
⦁⦁ Explain how the Competency-Based Framework for Health Education Specialist is used by colleges and universities, the National Commission for Health Education Credentialing, Inc. (NCHEC), Council for the Accreditation of Educator Preparation (CAEP), and the Council on Education for Public Health (CEPH)
⦁⦁ Identify the assumptions upon which health education is based.
⦁⦁ Define the term pre-planning.
Key Terms
Advanced level 1-health education specialist
Advanced level-2 health education specialist
community decision makers entry-level health
education specialist
Framework health behavior health education
health education specialist
health promotion Healthy People pre-planning primary prevention priority population Role Delineation
Project secondary
prevention stakeholders tertiary prevention
2 Chapter 1
History has shown that much progress was made in the health and life expectancy of Americans since 1900. During these 116+ years, we have seen a sharp drop in infant mortality (NCHS, 2015); the eradication of smallpox; the elimination of poliomyelitis in the Americas; the control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b, and other infectious diseases; better family planning (CDC, 2001); and an increase of 31.5 years in the average life span of a person in the United States (CDC, 2015e). Over this same time, we have witnessed disease prevention change “from focusing on reducing environmental exposures over which the individual had little control, such as providing potable water, to emphasizing behaviors such as avoiding use of tobacco, fatty foods, and a sedentary lifestyle” (Breslow, 1999, p. 1030). Yet, even with this change in focus we, as a society, have done little to encourage health community design, and as individuals, most Americans have not changed their lifestyle enough to reduce their risk of illness, disability, and premature death. As a result, unhealthy lifestyle characteristics have lead to the United States ranking 94th (out of 225 countries) in crude death rate; 42nd (out of 224 countries) in life expectancy at birth; and 1st in health care spending (CIA, 2015).
Today in the United States, much of the death and disability of Americans is associated with chronic diseases. Seven out of every 10 deaths among Americans each year are from chronic diseases, while heart disease, cancer, and stroke account for approximately 50% of deaths each year (CDC, 2015b). In addition, more than 86% of all health care spending in the United States is on people with chronic conditions (CDC, 2015b). Chronic diseases are not only the most common, deadly, and costly, they are also the most preventable of all health problems in the United States (CDC, 2105b). They are the most preventable because four modifiable risk behaviors—lack of exercise or physical activity, poor nutrition, tobacco use, and exces- sive alcohol use—are responsible for much of the illness, suffering, and early death related to chronic diseases (CDC, 2015b) (see Table 1.1). In fact, one study estimates that all causes of mortality could be cut by 55% by never smoking, engaging in regular physical activity, eating a healthy diet, and avoiding being overweight (van Dam, Li, Spiegelman, Franco, & Hu, 2008).
TablE 1.1 Comparison of Most Common Causes of Death and Actual Causes of Death
Most Common Causes of Death, United States, 2013* Actual Causes of Death, United States, 2000**
1. Heart disease 1. Tobacco 2. Cancer 2. Poor diet and physical inactivity 3. Chronic lower respiratory diseases 3. Alcohol consumption 4. Unintentional injuries 4. Microbial agents 5. Stroke 5. Toxic agents 6. Alzheimer’s disease 6. Motor vehicles 7. Diabetes 7. Firearms 8. Influenza and pneumonia 8. Sexual behavior 9. Kidney disease 9. Illicit drug use 10. Suicide
*Kochanek, Murphy, Xu, & Arias (2014).
**Mokdad, Marks, Stroup, & Greberding (2004, 2005).
Health Education, Health Promotion, Health Education Specialists, and Program Planning 3
But modifying risk behaviors does not come easy to Americans. One study (Reeves & Rafferty, 2005) has shown that only 3% of U.S. adults adhere to four healthy lifestyle characteristics (not smoking, engaging in regular physical activity, maintaining a healthy weight, and eating five fruits and vegetables a day). If moderate alcohol use were included in the healthy lifestyle characteristics the percentage would be even lower (King, Mainous, Carnemolla, & Everett, 2009). Now in the second decade of the twenty-first century, behav- ior patterns continue to “represent the single most prominent domain of influence over health prospects in the United States” (McGinnis, Williams-Russo, & Knickman, 2002, p. 82).
Though the focus on good health, wellness, and health behavior (those behaviors that impact a person’s health) seem commonplace in our lives today, it was not until the last fourth of the twentieth century that health promotion was recognized for its potential to help control injury and disease and to promote health.
Most scholars, policymakers, and practitioners in health promotion would pick 1974 as the turning point that marks the beginning of health promotion as a significant component of national health policy in the twentieth century. That year Canada published its landmark policy statement, A New Perspective on the Health of Canadians (Lalonde, 1974). In the United States, Congress passed PL 94-317, the Health Information and Health Promotion Act, which created the Office of Health Information and Health Promotion, later renamed the Office of Disease Prevention and Health Promotion (Green 1999, p. 69).
This paved the way for the U.S. government’s Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (USDHEW, 1979), which brought together much of what was known about the relationship of personal behavior and health status. The docu- ment also presented a “personal responsibility” model that provided Americans with a pre- scription for reducing their health risks and increasing their chances for good health.
It may not have been the content of Healthy People that made the publication so sig- nificant, because several publications written before it provided a similar message. Rather, Healthy People was important because it summarized the research available up to that point, presented it in a very readable format, and made the information available to the general public. Healthy People was followed by the release of the first set of health goals and objectives for the nation, titled Promoting Health/Preventing Disease: Objectives for the Nation (USDHHS, 1980).
These goals and objectives, now in their fourth generation (USDHHS, 2015c), have de- fined the nation’s health agenda and guided its health policy since their inception. And, in part, they have kept the importance of good health visible to all Americans.
This focus on good health has given many people in the United States a desire to do some- thing about their health. This desire, in turn, has increased the need for good health informa- tion that can be easily understood by the average person. One need only look at the Internet, current best-seller list, read the daily newspaper, observe the health advertisements delivered via electronic mass media, or consider the increase in the number of health-promoting facilities (not illness or sickness facilities) to verify the interest that American consumers have in health. Because of the increased interest in health and changing health behavior, health professionals are now faced with providing the public with information. However, obtaining good informa- tion does not mean that those who receive it will make healthy decisions and then act on those decisions. Good health education and health promotion programs are needed to assist people in reducing their health risks in order to obtain and maintain good health.
4 Chapter 1
⦁ Health Education and Health Promotion
There is more to health education than simply disseminating health information (Auld et al., 2011). Health education is a much more involved process. Two formal definitions of health education have been frequently cited in the literature. The first comes from the Report of the 2011 Joint Committee on Health Education and Promotion Terminology (Joint Committee on Health Education and Promotion Terminology [known hereafter as the Joint Committee on Terminology], 2012). The committee defined health education as “[a]ny combination of planned learning experiences using evidence-based practices and/or sound theories that provide the opportunity to acquire knowledge, attitudes, and skills needed to adopt and maintain healthy behaviors” (Joint Committee on Terminology, 2012, p. S17). The second definition was presented by Green and Kreuter (2005), who defined health education as “any planned combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities” (p. G-4).
Another term that is closely related to health education, and sometimes incorrectly used in its place, is health promotion. Health promotion is a broader term than health education. In the Report of the 2011 Joint Committee on Health Education and Promotion Terminology (Joint Committee on Terminology, 2012, p. S19) health promotion is defined as “[a]ny planned combination of educational, political, environmental, regulatory, or organizational mecha- nisms that support actions and conditions of living conducive to the health of individuals, groups, and communities.” Green and Kreuter (2005) offered a slightly different definition of health promotion, calling it “any planned combination of educational, political, regulatory and organizational supports for actions and conditions of living conducive to the health of individuals, groups, and communities” (p. G-4).
To help us further understand and operationalize the term health promotion, Breslow (1999) has stated, “Each person has a certain degree of health that may be expressed as a place in a spec- trum. From that perspective, promoting health must focus on enhancing people’s capacities for living. That means moving them toward the health end of the spectrum, just as prevention is aimed at avoiding disease that can move people toward the opposite end of the spectrum” (p. 1031). According to these definitions of health promotion, health education is an important component of health promotion and firmly implanted in it (see Figure 1.1). “Health promotion takes into account that human behavior is not only governed by personal factors (e.g., knowl- edge, expectancies, competencies, and well-being), but also by structural aspects of the environ- ment” (Vogele, 2005, p. 272). However, “without health education, health promotion would be a manipulative social engineering enterprise” (Green & Kreuter, 1999, p. 19).
The effectiveness of health promotion programs can vary greatly. However, the success of a program can usually be linked to the planning that takes place before implementation of the program. Programs that have undergone a thorough planning process are usually the most successful. As the old saying goes, “If you fail to plan, your plan will fail.”
⦁ Health Education Specialists
The individuals best qualified to plan health promotion programs are health education special- ists. A health education specialist has been defined as “[a]n individual who has met, at a minimum, baccalaureate-level required health education academic preparation qualifications,
Health Education, Health Promotion, Health Education Specialists, and Program Planning 5
who serves in a variety of settings, and is able to use appropriate educational strategies and methods to facilitate the development of policies, procedures, interventions, and systems conducive to the health of individuals, groups, and communities” (Joint Committee on Terminology, 2012, p. S18). Today, health education specialists can be found working in a vari- ety of settings, including schools (K–12, colleges, and universities), community health agencies (governmental and nongovernmental), worksites (business, industry, and other work set- tings), and health care settings (e.g., clinics, hospitals, and managed care organizations). (Note: Prior to the term health education specialists being used by the health education profession, health education specialists were referred to as health educators. Throughout the remainder of this book the term health education specialist will be used except when the term health educator is part of a title or when the term carries historical relevance.)
The role of the health education specialist in the United States as we know it today is one that has evolved over time based on the need to provide people with educational interventions to enhance their health. The earliest signs of the role of the health educa- tion specialist appeared in the mid-1800s with school hygiene education, which was closely associated with physical activity. By the early 1900s, the need for health educa- tion spread to the public health arena, but it was the writers, journalists, social workers, and visiting nurses who were doing the educating—not health education specialists as we know them today (Deeds, 1992). As we gained more knowledge about the relationship between health, disease, and health behavior, it was obvious that the writers, journal- ists, social workers, visiting nurses, and primary caregivers—mainly physicians, dentists, other independent practitioners, and nurses—were unable to provide the needed health
Environ-
mental
Environ-
mental
E nv
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m en
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E nviron-
m entalE
nv iro
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en ta
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Policy Social
Regulatory Organi- zational
Political Economic
HEA LTH PROMOTION
HEALTH PROMOTIO N
Health Education
⦁▲ Figure 1.1 Relationship of Health Education and Health Promotion
6 Chapter 1
education. The combination of the heavy workload of the primary caregivers, the lack of formal training in the process of educating others, and the need for education at all levels of prevention—primary, secondary, and tertiary—(see Table 1.2) created a need for health education specialists.
As the role of the health educator grew over the years, there was a movement by those in the discipline to clearly define their role so that people inside and outside the profession would have a better understanding of what the health education specialist did. In January 1979, the Role Delineation Project began (National Task Force on the Preparation and Practice of Health Educators, 1985). Through a comprehensive process, this project yielded a generic role for the entry-level health educator—that is, responsibilities for health education specialists taking their first job regardless of their work setting. Once the role of the entry-level health educator was delineated, the task became to translate the role into a structure that professional preparation programs in health education could use to design competency-based curricula. The resulting document, A Framework for the Development of Competency-Based Curricula for Entry Level Health Educators (NCHEC, 1985), and its revised version, A Competency-Based Framework for the Professional Development of Certified Health Education Specialists (NCHEC, 1996), provided such a structure. These documents, simply referred to as the Framework were comprised of the seven major areas of responsibility,
TablE 1.2 Levels of Prevention
Level of Prevention Health Status Example Interventions
Primary prevention – measures that forestall the onset of a disease, illness, or injury
Healthy, without signs and symptoms of disease, illness or injury
Activities directed at improving well-being while preventing specific health problems, e.g., legislation to mandate safe practices, exercise programs, immunizations, fluoride treatments
Secondary prevention – measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to minimize progression of health problem
Presence of disease, illness, or injury
Activities directed at early diagnosis, referral, and prompt treatment, e.g., mammograms, self-testicular exam, laboratory tests to diagnosis diabetes, hypercholesterolemia, hypothyroidism, programs to prevent reinjury
Tertiary prevention – measures aimed at rehabilitation following significant disease, illness, or injury
Disability, impairment, or dependency
Activities directed at rehabilitation to return a person to maximum usefulness, e.g., disease management programs, support groups, cardiac rehabilitation programs
Health Education, Health Promotion, Health Education Specialists, and Program Planning 7
which defined the scope of practice, and several different competencies and subcompeten- cies, which further delineated the responsibilities.
Even though the seven areas of responsibility defined the role of the entry-level health educator, they did not fully express the work of the health education specialist with an advanced degree. Thus, over a four-year period beginning in 1992, the profession worked to define the role of an advanced-level practitioner. By July 1997, the governing boards of the National Commission for Health Education Credentialing, Inc. (NCHEC), the American Association of Health Education (AAHE), and the Society for Public Health Education (SOPHE) had endorsed three additional responsibilities for the advanced-level health educa- tor. Those responsibilities revolved around research, administration, and the advancement of the profession (AAHE, NCHEC, & SOPHE, 1999).
The seven entry-level and three additional advanced-level responsibilities served the profession well, but during the mid- to late-1990s it became obvious that there was a need to revisit the responsibilities and competencies and to make sure that they still defined the role of the health educator. Thus in 1998, the profession launched a six-year multi- phase research study known as the National Health Educator Competencies Update Project (CUP) to reverify the entry-level health educator responsibilities, competencies, and subcompetencies and to verify the advanced-level competencies and subcompetencies (Airhihenbuwa et al., 2005).
What became obvious from the analysis of the CUP data was that the seven respon- sibilities and many of the competencies and subcompetencies identified in the earlier Role Delineation Project were still valid. However, the wording of the responsibilities was changed slightly, some competencies and subcompetencies were dropped, and a few new ones were added. Also, certain subcompetencies were reported as more important and per- formed more regularly by health education specialists who had both more work experience and academic degrees beyond the baccalaureate level. Thus, the CUP model that emerged included responsibilities, competencies, and subcompetencies and the development of a three-tiered (i.e., Entry, Advanced Level-1, and Advanced Level-2) hierarchical model reflecting the role of the health educator. The results of the CUP, which were published approximately 20 years after the initial role delineation project, lead to the creation of a revised framework titled A Competency-Based Framework for Health Educators (NCHEC, SOPHE, & AAHE, 2006).
To keep the role of the health education specialist contemporary and to meet best practice guidelines of the National Commission for Certifying Agencies (NCCA), a third national research study known as the Health Educator Job Analysis (HEJA-2010) was conducted. The results of this study generated a new Framework titled A Competency-Based Framework for Health Education Specialist–2010 (NCHEC, SOPHE, AAHE, 2010). The NCCA, the agency that accredits the Certified Health Education Specialist (CHES) and the Master Certified Health Education Specialist (MCHES) exam programs, has a standard that requires periodic updates of a job/practice analysis to keep the practice of the profession contemporary.
The most recent edition of the Framework titled A Competency-Based Framework for Health Education Specialist–2015 (NCHEC & SOPHE, 2015) is the result of the Health Education Specialist Practice Analysis (HESPA-2015). Over the years, the number of Areas of Responsibility outlined in the Framework have remained fairly consistent (see Box 1.1). What has changed over the years is the wording of the Areas of Responsibilities and the number and wording
8 Chapter 1
of the competencies and subcompetencies found under the Areas of Responsibility. In the 2015 Framework, there are 36 competencies and 258 subcompetencies (141 Entry-level, 76 Advanced 1-level, and 41 Advanced 2-level ) (NCHEC & SOPHE, 2015).
In reviewing the current seven areas of responsibility, it is obvious that four of the seven are directly related to program planning, implementation, and evaluation and that the other three could be associated with these processes, depending on the type of program being planned. In effect, these responsibilities distinguish health education specialists from other professionals who try to provide health education experiences.
The importance of the defined role of the health education specialist is becoming greater as the profession of health promotion continues to mature. This is exhibited by its use in several major professional activities. First, the Framework has provided a guide for all colleges and universities to use when designing and revising their curricula in health education to prepare future health education specialists. Second, the Framework was used by the National Commission for Health Education Credentialing, Inc. (NCHEC) to develop the core criteria for certifying individuals as health education specialists (Certified Health Education Specialists, or CHES). The first group of individuals (N=1,558) to receive the CHES credential did so be- tween October 1988 and December 1989, during the charter certification period. “Charter certification allows qualified individuals to be certified based on their academic training, work experience, and references without taking the exam” (Cottrell, Girvan, McKenzie & Seabert, 2015, p. 171). In 1990, using a criterion-referenced examination based on the Framework, the nationwide testing program to certify health education specialists was begun by NCHEC, Inc.
In 2011, again using a criterion-referenced examination based on the Framework, NCHEC began offering an examination to certify advanced-level health education spe- cialists. Those who passed the examination were awarded the Master Certified Health Education Specialist (MCHES) credential. Prior to the first MCHES examination, this new certification was made available to those who had held active CHES status since 2005 and who could demonstrate that they were practicing health education at an advanced-level. This process was known as the Experience Documentation Opportunity (EDO). All those
1.1
Box Areas of Responsibility for Health Education Specialists
AREA oF RESponSiBiliTy i: Assess Needs, Resources, and Capacity for Health Education/ Promotion
AREA oF RESponSiBiliTy ii: Plan Health Education/Promotion
AREA oF RESponSiBiliTy iii: Implement Health Education/Promotion
AREA oF RESponSiBiliTy iV: Conduct Evaluation and Research Related to Health Education/Promotion
AREA oF RESponSiBiliTy V: Administer and Manage Health Education/Promotion
AREA oF RESponSiBiliTy Vi: Serve as a Health Education/Promotion Resource Person
AREA oF RESponSiBiliTy Vii: Communicate, Promote, and Advocate for Health, Health Education/Promotion, and the Profession
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Health Education, Health Promotion, Health Education Specialists, and Program Planning 9
who successfully completed the EDO were granted the MCHES credential in April 2011. Currently, both the CHES and MCHES examinations are given twice a year—once in April and once in October—at approximately 130 college-campus locations around the United States. Both examinations are composed of 165 questions (150 are scored and 15 are pi- lot questions) and are offered in a paper-and-pencil format (NCHEC, 2015). Information about eligibility for the examinations and the percentage of questions from each Area of Responsibility are available on the NCHEC Website (see the link for the Website in the Weblinks section at the end of the chapter).
Third, the Framework is used by program accrediting bodies to review college and uni- versity academic programs in health education. Both the Council for the Accreditation of Educator Preparation (CAEP), which accredits teacher education programs, and the Council on Education for Public Health (CEPH), which accredits public health programs, use components of the Framework when accrediting programs that have a focus on health education. The accrediting processes used by both CAEP and CEPH are based on programs conducting a self-study by comparing components of their program to accrediting body criteria or standards. After the self-study is completed, peer external reviewers visit the cam- pus of the college or university seeking accreditation to verify the contents of the self-study. The governing boards of CAEP and CEPH review the findings of the self-study and external reviewers report and vote on awarding accreditation.
The use of the Framework by the profession to guide academic curricula, provide the core criteria for the health education specialist examinations, and form the basis of pro- gram accreditation processes has done much to advance the health education profession. “In 1998 the U.S. Department of Commerce and Labor formally acknowledged ‘health educator’ as a distinct occupation. Such recognition was justified, based to a large extent, on the ability of the profession to specify its unique skills” (AAHE, NCHEC, & SOPHE, 1999, p. 9). In 2010, in its most recent update, the U.S. Department of Labor Bureau of Labor Statistics (BLS) described the work of health educators (Standard Occupation Classification [SOC] 21-1091) using the following language:
Provide and manage health education programs that help individuals, families, and their communities maximize and maintain healthy lifestyles. Collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments. May serve as resource to assist individuals, other health professionals, or the community, and may administer fiscal resources for health education programs (USDOL, BLS, 2015, para. 1).
⦁ Assumptions of Health Promotion
So far, we have discussed the need for health, what health education and health promotion are, and the role health education specialists play in delivering successful health promotion programs. We have not yet discussed the assumptions that underlie health promotion—all the things that must be in place before the whole process of health promotion begins. In the mid-1980s, Bates and Winder (1984) outlined what they saw as four critical assumptions of health education. Their list has been modified by adding several items, rewording others, and referring to them as “assumptions of health promotion.” This expanded list of assump- tions is critical to understanding what we can expect from health promotion programs.
10 Chapter 1
Health promotion is by no means the sole answer to the nation’s health problems or, for that matter, the sole means of getting a smoker to stop smoking or a nonexerciser to exercise. Health promotion is an important part of the health system, but it does have limitations. Here are the assumptions:
1. Health status can be changed.
2. “Health and disease are determined by dynamic interactions among biological, psychological, behavioral, and social factors” (Pellmar, Brandt, & Baird, 2002, p. 217).
3. “Behavior can be changed and those changes can influence health” (IOM, 2001, p. 333).
4. “Individual behavior, family interactions, community and workplace relationships and resources, and public policy all contribute to health and influence behavior change” (Pellmar et al., 2002, p. 217).
5. “Interventions can successfully teach health-promoting behaviors or attenuate risky behaviors” (IOM, 2001, p. 333).
6. Before health behavior is changed, the determinants of behavior, the nature of the behavior, and the motivation for the behavior must be understood (DiClemente, Salazar, & Crosby, 2013).
7. “Initiating and maintaining a behavior change is difficult” (Pellmar et al., 2002, p. 217).
8. Individual responsibility should not be viewed as victim blaming, yet the importance of health behavior to health status must be understood.
9. For health behavior change to be permanent, an individual must be motivated and ready to change.
The importance of these assumptions is made clearer if we refer to the definitions of health education and health promotion presented earlier in the chapter. Implicit in those definitions is the goal of having program participants voluntarily adopt actions conducive to health. To achieve such a goal, the assumptions must indeed be in place. We cannot ex- pect people to adopt lifelong health-enhancing behavior if we force them into such change. Nor can we expect people to change their behavior just because they have been exposed to a health promotion program. Health behavior change is very complex, and health educa- tion specialists should not expect to change every person with whom they come in contact. However, the greatest chance for success will come to those who have the knowledge and skills to plan, implement, and evaluate appropriate programs.
⦁ Program Planning
Because many of health education specialists’ responsibilities are involved in some way with program planning, implementation, and evaluation, health education specialists need to become well versed in these processes. “Planning an effective program is more difficult than implementing it. Planning, implementing, and evaluating programs are all interrelated, but good planning skills are prerequisite to programs worthy of evaluation” (Minelli & Breckon, 2009, p. 137). All three processes are very involved, and much time, effort, practice, and on- the-job training are required to do them well. Even the most experienced health education specialists find program planning challenging because of the constant changes in settings, resources, and priority populations.
Health Education, Health Promotion, Health Education Specialists, and Program Planning 11
Hunnicutt (2007) offered four reasons why systematic planning is important. The first is that planning forces planners to think through details in advance. Detailed plans can help to avoid future problems. Second, planning helps to make a program transparent. Good planning keeps the program stakeholders (any person, community, or organization with a vested interest in a program; e.g., decision makers, partners, clients) informed. The plan- ning process should not be mysterious or secretive. Third, planning is empowering. Once decision makers (those who have the authority to approve a plan; e.g., administrator of an organization, governing board, chief executive officer) give approval to the resulting comprehensive program plan, planners and facilitators are empowered to implement the program. Without an approved plan, planners will spend a great deal of time waiting for the “next step” to be approved and risk losing program momentum. And fourth, planning creates alignment. Once the decision makers have approved the program, all organization members have a better understanding of where it “fits” in the organization and the impor- tance that the plan carries.
A general understanding of all that is involved in creating a health promotion program can be obtained by reviewing the Generalized Model (see Figure 1.2). (A more in-depth explanation of this model can be found in Chapter 3.) This model includes the five major steps involved in planning a program. However, prior to undertaking the first step in the Generalized Model, it is important to do some pre-planning. Pre-planning allows a core group of people (or steering committee) to gather answers to key questions (see Box 1.2) that are critical to the planning process before the actual planning process begins. It also helps to clarify and give direction to planning, and helps stakeholders avoid confusion as the planning progresses.
Also prior to starting the actual planning process, planners need to have a very good understanding of the “community” where the program will be implemented. When we say community, do not think of just a geographic area with specific boundaries like a neighborhood, city, county, or state. Community should be defined as “a collective body of individuals identified by common characteristics such as geography, interests, experi- ences, concerns, or values” (Joint Committee on Terminology, 2012, p. S15). For example, a community could be a religious community, a cancer-survivor community, a workplace community, or even a cyber community. Understanding the community means finding out as much as possible about the priority population (those for whom the program is intended to serve) and the environment in which it exists. Each setting and group is unique with its own nuances, resources, and culture. These are important to know at the beginning of the process. Planners should never assume they “know” a community. The more background information that planners secure, the better the resulting program can be. However, it is not enough to understand the community, planners also need to engage members of the priority population. Engaging the priority population means involving
Assessing needs
Setting goals and objectives
Developing an intervention
Implementing the intervention
Evaluating the results
⦁▲ Figure 1.2 Generalized Model
12 Chapter 1
those in the priority population or a representative group from the priority population in the planning process.
Finally, before the actual planning begins thought must be given to “when the best time is to plan such a program, what data are needed, where the planning should occur, what resistance can be expected, and generally, what will enhance the success of the project” (Minelli & Breckon, 2009, p. 138).
The remaining chapters of this book present a process that health education specialists can use to plan, implement, and evaluate successful health promotion programs and will introduce you to the necessary knowledge and skills to carry out these tasks.
1.2
Box Example Key Questions to Be Answered in the pre-planning process
purpose of program
⦁⦁ How is the community defined?
⦁⦁ What are the desired health outcomes?
⦁⦁ Does the community have the capacity and infrastructure to address the problem?
⦁⦁ Is a policy change needed?
Scope of the planning process
⦁⦁ Is it intra- or inter-organizational?
⦁⦁ What is the time frame for completing the project?
planning process outcomes (deliverables)
⦁⦁ Written plan?
⦁⦁ Program proposal?
⦁⦁ Program documentation or justification?
leadership and structure
⦁⦁ What authority, if any, will the planners have?
⦁⦁ How will the planners be organized?
⦁⦁ What is expected of those who participate in the planning process?
identifying and engaging partners
⦁⦁ How will the partners be selected?
⦁⦁ Will the planning process use a top-down or bottom-up approach?
identifying and securing resources
⦁⦁ How will the budget be determined?
⦁⦁ Will a written agreement (i.e., MOA—memorandum of agreement) outlining responsibilities be needed?
⦁⦁ If MOA is needed, what will it include?
⦁⦁ Will external funding (i.e., grants or contracts) be needed?
⦁⦁ Are there community resources (e.g., volunteers, space, donations) to support the planned program?
⦁⦁ How will the resources be obtained?
Fo cu
s O
n
Health Education, Health Promotion, Health Education Specialists, and Program Planning 13
Summary
The increased interest in personal health and behavior change, and the flood of new health information have expanded the need for quality health promotion programs. Individuals are seeking guidance to enable them to make sound decisions about behavior that is conducive to their health. Those best prepared to help these people are health education specialists who complete a curriculum based upon the role defined by the profession. Properly trained health education specialists are aware of the limitations of the discipline and understand the assumptions on which health promotion is based. They also know that good planning does not happen by accident. Much time, effort, practice, and on-the-job training are needed to plan an effective program. The planning process begins with pre-planning.
Review Questions
1. Explain the role Healthy People played in the relationship between the American people and health.
2. How is health education defined by the Joint Committee on Terminology (2012)?
3. What are the key phrases in the definition of health education presented by Green and Kreuter (2005)?
4. What is the relationship between health education and health promotion?
5. Why is there a need for health education specialists?
6. What is the Role Delineation Project?
7. How is the Competency-Based Framework for Health Education Specialists used by colleges and universities? By NCHEC? By CAEP? By CEPH?
8. How does one become a Certified Health Education Specialist (CHES)?
9. How does one become a Master Certified Health Specialist (MCHES)?
10. What are the seven Areas of Responsibilities of health education specialists?
11. What is the National Health Educator Competencies Update Project (CUP)?
12. What is the Health Educator Job Analysis – 2010 (HEJA-2010)?
13. What is the Health Education Specialist Practice Analysis – 2015 (HESPA-2015)?
14. What assumptions are critical to health promotion?
15. What are the steps in the Generalized Model?
16. What is meant by the term pre-planning? Why is it important? What are some questions that should be answered during the pre-planning process?
17. How have stakeholders, decision makers, and community been defined in this chapter?
Activities
1. Based on what you have read in this chapter and your knowledge of the profession of health education, write your own definitions for health, health education, health promotion, and health promotion program.
14 Chapter 1
2. Write a response indicating what you see as the importance of each of the nine assumptions presented in the chapter. Write no more than one paragraph per assumption.
3. With your knowledge of health promotion, what other assumptions would you add to the list presented in this chapter? Provide a one-paragraph rationale for each.
4. If you have not already done so, go online (http://profiles.nlm.nih.gov/ps/access /NNBBGK.pdf) or to the government documents section of the library on your campus and read Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (USDHEW, 1979).
5. Say you are in your senior year and will graduate next May with a bachelor’s degree in health education. What steps would you have to take in order to be able to take the CHES exam in April prior to your graduation? (Hint: Check the Website of the National Commission for Health Education Credentialing, Inc.)
6. In a one-page paper describe the differences and similarities in the two credentials— CHES and MCHES—available to health education specialists. (Hint: Check the Website of the National Commission for Health Education Credentialing, Inc.)
7. In a one-page paper describe what the job outlook is projected to be for health education specialists for the next ten years. (Hint: Check the Website of the Bureau of Labor Statistics Occupational Outlook Handbook.)
Weblinks
1. http://www.healthypeople.gov Healthy People
This is the Webpage for the U.S. government’s Healthy People initiative including a complete presentation of Healthy People 2020.
2. http://www.nchec.org/ National Commission for Health Education Credentialing, Inc. (NCHEC) The NCHEC, Inc. Website provides the most current information about the CHES and MCHES credentials.
3. http://www.bls.gov/ooh/community-and-social-service/health-educators.htm Occupational Outlook Handbook This is a Webpage provided by the Bureau of Labor Statistics that describes the occupation outlook for health educators and community health workers.
The chapters in this section of the book provide the basic information needed to plan a health promotion program. Each chapter presents readers with the information they will need to build the knowledge to develop the skills to create a successful program in a variety of settings.
Part I Planning a HealtH Promotion Program
Chapter 2 17
Starting the Planning Process
Chapter 3 41
Program Planning Models in Health Promotion
Chapter 4 67
assessing Needs
Chapter 5 105
Measurement, Measures, Measurement Instruments, and Sampling
Chapter 6 133
Mission Statement, Goals, and Objectives
Chapter 7 151
theories and Models Commonly Used for Health Promotion Interventions
Chapter 8 191
Interventions
Chapter 9 237
Community Organizing and Community Building
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17
As noted earlier (Chapter 1), planning a health promotion program is a multistep process that begins after doing pre-planning. “To plan is to engage in a process or a proce- dure to develop a method of achieving an end” (Minelli & Breckon, 2009, p. 137). However, because of the many different variables and circumstances of any one setting, the multistep process of planning does not always begin the same way. There are times when the need for a program is obvious and there is recognition that a new program should be put in place. For example, if a community’s immunization rate for its children is less than half the national average, a program should be created. There are other times when a program has been suc- cessful in the past but needs to be changed or reworked slightly before being implemented again. And, there are situations where planners have been given the independence and authority to create the programs that are needed in a community in order to improve the health and quality of life. However, when the need is not so obvious, or when there has not been successful health promotion programming in the past or decision makers want “proof” (i.e., evidence) that a program is needed and will be successful, the planning process often begins with the planners creating a rationale to gain the support of key people in or- der to obtain the necessary resources to ensure that the planning process and the eventual implementation proceed as smoothly as possible.
literature organizational
culture planning committee planning parameters planning team program ownership return on investment
(ROI) social math steering committee
Key Terms
advisory board cost-benefit analysis
(CBA) doers epidemiology evidence evidence-based
practice Guide to Community
Preventive Services influencers institutionalized
Chapter Objectives
After reading this chapter and answering the questions at the end, you should be able to:
⦁⦁ Develop a rationale for planning and implementing a health promotion program.
⦁⦁ Explain the importance of gaining the support of decision makers.
⦁⦁ Identify the individuals who could make up a planning committee.
⦁⦁ Explain what planning parameters are and the impact they have on program planning.
Starting the Planning Process 2
Chapter
18 Part 1 Planning a Health Promotion Program
This chapter presents the steps of creating a program rationale to obtain the support of decision makers, identifying those who may be interested in helping to plan the program, and establishing the parameters in which the planners must work. Box 2.1 identifies the responsibilities and competencies for health education specialists that pertain to the mate- rial presented in this chapter.
The Need for Creating a Rationale to Gain the Support of Decision Makers
No matter what the setting of a health promotion program—whether a business, an in- dustry, the community, a clinic, a hospital, or a school—it is most important that the program have support from the highest level (e.g., the administration, chief executive
2.1
Box Responsibilities and Competencies for Health Education Specialists
The content of this chapter includes information on several tasks that occur early in the program planning process. These tasks are not associated with a single area of responsibility, but rather five areas of responsibility of the health education specialist:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/ Promotion
Competency 1.2: Access existing information and data related to health
Competency 1.6: Examine factors that enhance or impede the process of health education/promotion
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and other stakeholders in the planning process
RESponSiBility V: Administer and Manage Health Education/Promotion
Competency 5.3: Manage relationships with partners and other stakeholders
Competency 5.4: Gain acceptance and support for health education/ promotion
Competency 5.5: Demonstrate leadership
RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person
Competency 6.1: Obtain and disseminate health-related information
Competency 6.3: Provide advice and consultation on health education/ promotion issues
RESponSiBility Vii: Communicate, Promote, and Advocate for Health and Health Education/ Promotion, and the Profession
Competency 7.2: Engage in advocacy for health education/promotion
Competency 7.3: Influence policy and/or systems change to promote health and health education/promotion
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Chapter 2 Starting the Planning Process 19
officer, church elders, board of health, or board of directors) of the “community” for which the program is being planned (Allen & Hunnicutt, 2007; Chapman, 1997, 2006; Hunnicutt & Leffelman, 2006; Ryan, Chapman, & Rink, 2008). It is the individuals in these top-level decision-making positions who are able to provide the necessary resource support for the program.
“Resources” usually means money, which can be turned into staff, facilities, materials, supplies, utilities, and all the myriad number of things that enable organized activity to take place over time. “Support” usually means a range of things: congruent organizational policies, program and concept visibility, expressions of priority value, personal involvement of key managers, a place at the table of organizational power, organizational credibility, and a role in integrated functioning (Chapman, 1997, p. 1).
There will be times when the idea for, or the motivating force behind, a program comes from the top-level people. When this happens, it is a real boon for the program planners because they do not have to sell the idea to these people to gain their support. However, this scenario does not occur frequently.
Often, the idea or the big push for a health promotion program comes from someone other than one who is part of the top-level of the “community.” The idea could start with an employee, an interested parent, a health education specialist within the organization, a member of the parish or congregation, or a concerned individual or group from within the community. The idea might even be generated by an individual outside the “community,” such as one who may have administrative or oversight responsibilities for activities in a community. An example of this arrangement is the employee of a state health department who provides consultative services to a local health department. Or it may be an individual from a regional agency who is partnering with a group within the community to carry out a collaborative project. When the scenario begins at a level below the decision makers, those who want to create a program must “sell” it to the decision makers. In other words, in order for resources and support to flow into health promotion programming, decision makers need to clearly perceive a set of values or benefits associated with the proposed program (Chapman, 2006). Without the support of decision makers, it becomes more difficult, if not impossible, to plan and implement a program. A number of years ago, Behrens (1983) stated that health promotion programs in business and industry have a greater chance for success if all levels of management, including the top, are committed and supportive. This is still true today of health promotion programs in all settings, not just programs in busi- ness and industry (see Box 2.2).
If they need to gain the support of decision makers, program planners should de- velop a rationale for the program’s existence. Why is it necessary to sell something that everyone knows is worthwhile? After all, does anyone doubt the value of trying to help people gain and maintain good health? The answer to these and similar questions is that few people are motivated by health concerns alone. Decisions by top-level management to develop new programs are based on a variety of factors, including finances, policies, public image, and politics, to name a few. Thus to sell the program to those at the top, planners need to develop a rationale that shows how the new program will help decision makers to meet the organization’s goals and, in turn, to carry out its mission. In other words, planners need to position their program rationale politically, in line with the organization.
20 Part 1 Planning a Health Promotion Program
Steps in Creating a Program Rationale
Planners must understand that gaining the support of decision makers is one of the most important steps in the planning process and it should not be taken lightly. Many program ideas have died at this stage because the planners were not well prepared to sell the program to decision makers. Thus, before making an appeal to decision makers, planners need to have a sound rationale for creating a program that is supported by evidence that the proposed pro- gram will benefit those for whom it is planned.
There is no formula or recipe for writing a rationale, but through experience, the authors have found a logical format for putting ideas together to help guide planners (see Figure 2.1). Note that Figure 2.1 is presented as an inverted triangle. This inverted triangle is symbolic in design to reflect the flow of a program rationale beginning at the top by identifying a health problem in global terms and moving toward a more focused solution at the bottom of the triangle.
Step 1: identify Appropriate Background information
Before planners begin to write a program rationale, they need to identify appropriate sources of information and data that can be used to sell program development. The place to begin the process of identifying appropriate sources of information and data to support the devel- opment of a program rationale is to conduct a search of the existing literature. Literature includes the articles, books, government publications, and other documents that explain the past and current knowledge about a particular topic. By conducting a search, planners gain a better understanding of the health problem(s) of concern, approaches to reducing or eliminating the health problem, and an understanding of the people for whom the program is intended (remember these individuals are referred to as the priority population). There are a number of different ways that planners can carry out a review of the literature (see Chapter 4 for an explanation of the literature search process).
2.2
Box
Though the importance of decision makers’ support to the success of health promotion programs has been known for a number of years, it is only recently that efforts have been put forth to actually measure decision makers’ support for health promotion programs. Della, DeJoy, Goetzel, Ozminkowski, and Wilson (2008) created a valid instrument to assess leadership support for health promotion programs in work settings. The measurement tool, referred to as the Leading by Example (LBE) Instrument, is a four-factor scale. The four factors are (1) business assignment with health
Measuring Decision Makers’ Support for Health promotion
promotion objectives, (2) awareness of the economics of health and worker productivity, (3) worksite support for health promotion, and (4) leadership support for health promotion (Della et al., 2010). Della and colleagues feel that the LBE could be used in two ways. The first would be through a single administration “to assess specific areas in which the health promotion climate might support/ hinder programmatic efforts” (p. 139). The second would be to administer the LBE two different times to monitor change in support for health promotion programs over time.
Fo cu
s O
n
Chapter 2 Starting the Planning Process 21
In general, the types of information and data that are useful in writing a rationale in- clude those that (1) express the needs and wants of the priority population, (2) describe the status of the health problem(s) within a given population, (3) show how the potential outcomes of the proposed program align with what the decision makers feel is important, (4) show compatibility with the health plan of a state or the nation, (5) provide evidence that the proposed program will make a difference, and (6) show how the proposed program will protect and preserve the single biggest asset of most organizations and communities— the people. Though many of these types of information and data are generated through a review of the literature, the first one discussed below—needs and wants of the priority population—is not.
Information and data that express the needs and wants of the priority population can be gen- erated through a needs assessment. A needs assessment is the process of identifying, analyzing, and prioritizing the needs of a priority population. Needs assessments are carried out through a multiple-step process in which data are collected and analyzed. The analysis generates a
Title the work “A rationale for the development of . . .” and indicate who is submitting the work.
Identify the health problem in global terms, backing it up with appropriate (international, national, or state) data. If possible, also include
the economic costs of the problem.
Narrow the health problem by showing its relationship to the proposed priority population. Create a problem statement. State why it is a problem and why it should be dealt with.
Again, back up the statement with appropriate data.
State a proposed solution to the problem (name and purpose of the proposed health promotion
program). Provide a general overview of the program.
State what can be gained from such a program in terms of the values and
benefits to the decision makers.
State why the program will be successful.
Provide the references
used in preparing
the rationale.
⦁▲ Figure 2.1 Creating a rationale
22 Part 1 Planning a Health Promotion Program
prioritized list of needs of the priority population (see Chapter 4 for a detailed explanation of the needs assessment process). Even though information and data that express the needs and wants of the priority population can be very useful in generating a rationale for a proposed program, more than likely at this point in the planning process, a formal needs assessment will not have been completed. Often, a complete needs assessment does not take place until decision mak- ers give permission for the planning to begin. However, the review of literature may generate information about a needs assessment of another related or similar program. If so, it can provide valuable information and data that can help to develop the rationale.
Information and data that describe the status of a health problem within a population can be obtained by analyzing epidemiological data. Epidemiologic data are those that result from the process of epidemiology, which has been defined as “[t]he study of the occurrence and distribution of health-related events, states and processes in specific populations, including the study of determinants influencing such processes, and the application of this knowledge to control relevant health problems” (Porta, 2014, p. 95). Epidemiological data are available from a number of different sources including governmental agencies, governmental health agencies, non-governmental health agencies, and health care systems. table 2.1 provides some examples of useful sources of epidemiological data.
taBle 2.1 example Sources of epidemiological Data
Source example Data
International World Health organization World Health Statistics Report
(http://www.who.int/gho/publications/ world_health_statistics/en/)
Country Statistics (http://www.who.int/gho/countries/en/)
National Centers for Disease Control and Prevention
National Center for Health Statistics
National Health and Nutrition Examination Survey (NHANES) (http://www.cdc.gov/nchs/nhanes.htm)
National Health Interview Survey (NHIS) (http://www.cdc.gov/nchs/nhis.htm)
State Centers for Disease Control and Prevention
Behavioral Risk Factor Surveillance System (BRFSS) (http://www.cdc.gov/brfss/about/index.htm)
Youth Risk Behavior Surveillance System (YRBSS) http://www.cdc.gov/healthyyouth/data/yrbs/index.htm
Pennsylvania Department of Health
Health Statistics (http://www.portal.state.pa.us/portal/server.pt/community/ health_statistics/14136)
Local Robert Wood Johnson Foundation & University of Wisconsin Population Health Institute
County Health Rankings & Roadmaps (http://www.countyhealthrankings.org/)
Chapter 2 Starting the Planning Process 23
Epidemiologic data gain additional significance when it can be shown that the described health problem(s) is(are) the result of modifiable health behaviors and that spending money to promote healthy lifestyles and prevent health problems makes good economic sense. Here are a couple examples where modifiable health behaviors and health-related costs have been connected. The first deals with smoking. Approximately 17.8% of U.S. adults 18 years of age and older are cigarette smokers (CDC, 2015g). It has been estimated that the cost of ill effects from smoking in the United States totals approximately $300 billion per year. Almost equal amounts are spent on direct medical care ($170 billion) and productivity losses due to pre- mature death and exposure to secondhand smoke ($156 billion) (CDC, 2015g). The second example deals with diabetes. It has been estimated that annual costs associated with diabetes are approximately $245 billion; $176 billion from direct medical costs and $69 billion indirect costs related to disability, work loss, and premature death (CDC, 2014a). We know that not all cases of diabetes are related to health behavior, but it is known for people with prediabetes, lifestyle changes, including a 5%–7% weight loss and at least 150 minutes of physical activity per week, can reduce the rate of onset of type 2 diabetes by 58% (CDC, 2012b). In addition, we know people with diagnosed diabetes have medical expenditures that are about 2.3 times higher than medical expenditures for people without diabetes (CDC, 2012b). When a ratio- nale includes an economic component it is often reported based on a cost-benefit analysis (CBA). A CBA of a health promotion program will yield the dollar benefit received from the dollars invested in the program. A common way of reporting a CBA is through a metric called return on investment (ROI). ROI “measures the costs of a program (i.e., the investment) versus the financial return realized by that program” (Cavallo, 2006, p. 1) (see Box 2.3 for formulas to calculate ROI). An example of ROI is a study that examined the economic impact of an investment of $10 per person per year in a proven community-based program to in- crease physical activity, improve nutrition, and prevent smoking and other tobacco use. The results of the study showed that the nation could save billions of dollars annually and have an ROI in one year of 0.96 to 1, 5.6 to 1 in 5 years, and 6.2 to 1 in 10–20 years (TFAH, 2009).
However, it should be noted that “proving” the economic impact of many health pro- motion programs is not easy. There are a number of reasons for this including the multiple
2.3
Box Return on investment
In general, ROI compares the dollars invested in something to the benefits produced by that investment:
ROI = (benefits of investment – amount invested)
amount invested
