CALIFORNIA ST.i\TE UNIVERSITY, NORTHRLDGE
AN ADAPTATION MODEL
OF HEALTH EDUCATION PLANNING
A graduate project submitted in partial satisfaction
of the requirements of Master of Public Health in
Community Health Education
by
Nancy Crawford Seck
.-----
~1ay,
'
~
1983
ihe graduate project of;{a)cy Crawford Seck is approved:
R.N., M.S.
Goteti B. Krishnamurty, Dr.
Michael V. Kl1ne, ur.
Committee Chairman
t'.M.
California State University, Northridge
•
j)
i i
ACKNOWLEDGEMENTS
I would like to formally express my sincere
appreciation and gratitude to the following persons:
To Colleen Blair who provided valuable input and
spent many late nights reviewing my initial chapter drafts.
In addition, the
11
moral support
11
she has provided during
my entire master's program has been more helpful to me
than she will ever know.
To Dr. Krishnamurty for stimulating my intellect
very early in this program; without his mental exercise
I couldn't have conceived of this topic for my project.
To Dr. Kline for the hours he spent with me
during a very stressful period for him; he always met my
needs, sometimes at the expense of his own.
To my parents who always told me that I could do
anything or· be anyone that I wanted to be,
11
Thank you."
And finally, to my husband Terry, "Thank you
your patience, support, and love that enabled me to
complete my master's work.
i i i
11
for
TABLE OF CONTENTS
Page
ACKNOHLEDGEMENT
i i i
LIST OF FIGURES
vi i
ABSTRACT
vii
·j
Chapter
1.
2.
INTRODUCTION
1
Statement of the Problem
3
Purpose of the Project
3
Assumptions
4
Limitations •
5
Definition of Terms • . .
5
REVIEW OF THE LITERATURE
6
Philosophical Definition
of Function . • . . • •
7
The Importance of Client
Involvement . . • . . •
11
Definition of Key Concepts
14
Goals of the Model
16
Identification of Problematic
Behavior . . . • . . • . . . . . .
18
Priority Setting
21
Resources to the System • .
23
Evaluation
24
i v
Chapter
3.
4.
Page
METHODOLOGY • . . . • .
27
Phase One: Review of the
Literature . • . • . . . • • • .
27
Phase Two: Development of Criteria
for an Ideal Model of Health
Education Planning . • . . •
29
Phase Three: Development of a
Proposed Model of Health
Education Planning • . • • •
30
Phase Four: Validation of the
Utility of the Proposed Model
31
A HEALTH EDUCATION PLANNING MODEL
35
Function of the Model . . .
Definition of Key Concepts
5.
35
• . • . . .
37
Steps for Using the Adaptation Model
of Health Education Framework • • . .
41
Step One: Assessment of Behaviors
and Stimuli • • • • . •
41
Step Two:
48
Planning •
Step Three: Intervention
Specification and Performance
54
Step Four:
55
Evaluation and Revision
Resources to the System •
61
Conclusion
61
RESULTS AND DISCUSSION
62
Function of the Model
Definition of Key Concepts
62
• . • • • .
63
Steps for Using the Adaptation Model
of Health Education Planning . • • •
64
v
Page
Chapter
6.
Resources to the System •
67
General Items . • .
67
SUMMARY, CONCLUSIONS, AND
RECOMMENDATIONS • . .
70
Summary . • .
70
Conclusions •
71
Recommendations
72
BIBLIOGRAPHY
75
APPENDICES
A.
B.
SAMPLE BEHAVIORAL CONTRACT AND SAMPLE
ADAPTATION MODEL OF HEALTH
EDUCATION WORKSHEET . . • . . . . . .
82
CONTENTS OF INFORMATIONAL PACKET
86
vi
. . .
LIST OF FIGURES
Figures
Page
Effect of Response Type on
Homeostasis • . . • • . •
39
Adaptive Responses Balance Changes
in the Environment • • . . • . . . .
40
Four Modes of Behavioral Response and
Their Relationship to Man . • • • • .
43
The Relationship of Stimuli
to Behavior • . . . • . • . . . . • .
46
Relationship of Goal Statements to
the Diagnostic Statement . • . . . •
53
Adaptation Model of Health Education
Worksheet . . . . • . • . • • • . • •
56
P.E.R.T. Diagram for Interventions
for Figure 4.6 . • . • . . • .
57
8.
Checklist for Evaluation Foci
58
9.
Steps of the Framework
60
1•
2.
3.
4.
5.
6.
7.
vi i
ABSTRACT
AN ADAPTATION MODEL
OF HEALTH EDUCATION PLANNING
by
Nancy Crawford Seck
Master of Public Health
in
Community Health Education
There is currently, in the field of health education, a wide range of planning approaches available to
the health educator.
However, few of these methodologies
are organized in a manner which enables conversion to
actual field application.
The primary purpose of this project was to
develop a rational framework which facilitates the health
education planning process, and which specifies the
activities to be completed by the health educator.
The review of the literature identified and
discussed existing planning models within the field of
<l
vi i i
health education and related fields such as nursing.
Existing planning models were assessed for acceptability
based upon eight criteria of an "ideal" model derived
primarily from social science literature.
include:
These criteria
1) presence of a philosophical definition of
function, 2) specification of the importance of client
involvement, 3) definitions of key concepts, 4) delineation of the goals of the model, 5) listing of criteria
for selection of target behaviors, 6) guidelines for
priority setting, 7) resources to the system, and 8) procedure for evaluation.
The health education planning model that was
developed utilized the Roy Adaptation Model of Nursing
as the basic framework for integrating relevant health
education material.
This proposed model specified four
steps to be completed during the educational process:
Assessment, Planning, Intervention, and Evaluation and
Revision.
The utility of the proposed model was evaluated
by means of a questionnaire mailed to a purposive sample
of respondents.
These respondents were health educators
in the Greater Los Angeles area that were thought to be
representative of various types of health care agencies.
Response to the model was generally positive.
Recommendations for further study of the proposed Model
were made regarding clarification of techniques for data
i
X
collection, evaluative component placement, specification
of areas to assess in the Interdependency mode, and
validation of the Model through field testing.
The proposed Model will provide a basic framework
for the planning function and will be valuable to the
neophyte practitioner as well as the experienced health
educator.
The steps delineated will guide the user
through the process while allowing freedom for creativity
by the individual practitioner.
X
Chapter 1
INTRODUCTION
The President's Committee on Health Education
/
defined health education as
. . . a process which bridges the gap between
health information and health practices. Health
education motivates the person to take the information and do something with it-- to keep himself
healthier by avoiding actions that are harmful and
by forming habits that are beneficial. (63)
The comprehensive range of this definition stresses the
nature of health education as a process and not merely as
a series of actions.
The word "process" denotes a specific course of
action to be taken.
Therefore, within this process-bound
definition of "health education" lies an unstated premise
-- health education activities have a common basis
regardless of the setting in which they occur.
(32:7-10)
A conception of process is usually embodied in a
framework or model, which conceptualizes the specific
act~ons
to be taken as well as their appropriate
sequenc~.
(32) (65)
A framework or model is necessary to describe
several functions to be carried out by a health educator,
and as explicated within the Initial Role Delineation
1
2
Project for Health Education:
1.
Determining the appropriate focus for health
instruction.
2.
Planning health education programs in response
to identified needs.
ties.
3.
Implementing planned health education programs.
4.
Evaluating health education.
5.
Coordinating selected health education activi-
(41)
11
Planning
11
is a common ingredient in all these
above functions; it provides the central impetus around
which health education activities take place.
Ideally, a framework or model which could describe
the steps or activities to be performed during the planning process, the appropriate order in which to accomplish
these tasks, and the underlying premises which guide
these behaviors, would be helpful.
Sechrist has set forth seven characteristics of a
profession.
One of these vital criterion is a theoretical
basis which underlines practice.
(67:99-103)
In order to
meet this criterion, health educators need to solidify,
specify,
and integrate their process into recognizable
and utilitarian frameworks.
For the neophyte practitioner the process of
health education may seem tenuous at best.
Armed with an
arsenal of educational theory. they endeavor to discover
3
a framework within which to structure this wealth of
information.
(32) (75) (11)
However, there appears to
be a gap within the field of health education which is
directly related to the utilization or application of any
specific framework for planning.
No one planning model
in existence has been shown to be consistently valid and
reliable.
The variety of background experiences and
education of health educators coupled with this lack of
a specific valid and reliable model does not support uniformity; there is no common model of operation.
(18:179-
188) (20:35-42) (23:10-15) (35:82-86)
v
Statement Q.i the Problem
There is a need to develop a model which identifies and organizes the elements of the health education
planning process.
This model should be utilitarian
within different health care settings and sufficiently
directive for the neophyte as well as allowing flexibility
for the experienced practitioner.
Purpos~
Qi the Project
The purposes of this project are:
1.
to identify, review, and assess the efficacy
of existing health education planning models;
2.
to develop criteria for an
11
ideal" health
education planning model including objectives, functions,
4
resources, relationships, and linkages;
3.
to develop a framework for health education
which sets forth the processes and direction for health
education activities, and meets the criteria of an "ideal"
planning model;
4.
to validate the utility of the proposed
planning model/framework to health educators; and
5.
to suggest limitations and recommend further
refinement of the proposed planning model.
Assumptions
Four assumptions underly this study which is
theoretical in nature:
1.
Existing models of health education practice
are inadequate in meeting planning needs.
(17:179-188)
(19:35-42) (34:82-86)
2.
It is possible to identify major criteria for
the development of an "ideal" planning model.
3.
A model for health education planning can be
developed that satisfies the criteria of an
4.
11
ideal" model.
The theoretical basis of planning within
nursing practice can be rationally integrated into the
health education planning model.
5
Limitations
1.
The inquiry is limited to available literature
and therefore, the entire spectrum of material available
on the subject may not be represented.
2.
The proposed model will not be field tested,
and thus will not be generalizable to all health education
settings.
Definition of Terms
It is necessary to define the following terms
relevant to the development of an
11
ideal
11
theoretical
health education planning model:
Theory:
A grouping of related facts which pro-
vides guidance to the discovery of new and more powerful
generalizations.
(60) (31:7-8)
Framework:
A specification of the steps and
actions to be taken to complete the educational process.
Model:
A model is designed to incorporate theory
and the specifications of a framework into an aggregate
that assists the user in the clarification of purpose,
identification of relationships between components,
formulation of action plans, and prediction of outcomes
of action plans.
(65:5) (32:4-6) (16:11,61)
Chapter 2
REVIEW OF THE LITERATURE
The primary purpose of this project was to
develop an ideal framework for health education planning.
This chapter will seek to review pertinent literature that
was drawn from the following areas of study:
1.
literature within the field of health educa-
tion related to existing planning models;
2.
literature outside the field of health educa-
tion that had applicability to health education planning;
3.
literature within the fields of health educa-
tion and social sciences pertaining ·to model development;
and
4.
literature within the field of nursing per-
taining to the Roy "Adaptation Model of Nursing Practice."
Existing planning models were assessed with regard
to eight criteria of an "ideal" model.
These criteria
were derived primarily from social science literature
written between 1950 and the present, and include:
1.
presence of a philosophical definition of
function;
2.
specification of the importance of client
involvement;
6
7
3.
definition of key concepts;
4.
specification of the goals of the model;
5.
criteria for the identification of problematic
behavior;
6.
guidelines for priDrity setting;
7.
statement of resources to the system; and
8.
procedure for evaluation of the program.
Each planning model will be referred to by a
generic name and assigned to a primary author, or a name
chosen as descriptive of the content.
Model names or
acronyms are used to facilitate repeated reference during
the literature review.
Philosophical Definition of Function
An
11
ideal
11
model must provide a philosophical
definition of the function of the model or system, what,
specifically, the model is supposed to do, and how it is
applicable to the user.
(31:29-30)
The function of the
whole of the mode1 is greater than that of the parts from
which it is derived.
fu~ction
(16:11)
Specification of the
of the model in terms of the whole will assist
in the-comprehension of the contribution of the individual
components that merge to create that whole.
This defini-
tion should describe the function in simple and concrete
terms.
8
The PRECEDE framework developed in the 1970's by
Green, Kreuter, Deeds, and Partridge provided a philosophical definition of function of health and health education activities through a diagnostic framework.
17)
(32:1-
PRECEDE stressed the attainment of outcomes that
were conducive to health as the primary function of the
model.
Although the definition is not stated separately
from the "goal'' of health education activities, it is
implied.
(32:1-17)
In 1981, Niddleton published a "r1odel for Health
Education Lesson Planning."
(55:4-8)
This model speci-
fied the function of each individual lesson as an integral
component of the entire curriculum; when each lesson is
planned, the what, whom, and how of the lesson in relation
to the whole must be considered.
(55:4-5)
However. the
overall function of the curriculum for health education
is not described and, therefore, the reader is left to
ponder this unstated function.
Several nursing theorists have included health
education within the philosophical definition of function
of the professional nurse.
Nightingale, the first recog-
n i z e d n u r s e t h e o r i s t , d e f i ne d t h e go a 1 o f --n u r s i n g t c " p u t
man in the best condition for nature to act upon him.
(65:7) (22:11)
11
This has been expanded to include pro-
viding for physical comfort as well as providing knowledge of health practices conducive to health.
(65:6-7)
9
Henderson, in 1966, specified education as a
treatment modality designed to assist the client toward
independence; it is the basis of all nursing activities
for the "Man as a Whole Model.
11
Orem's
11
Self-Care Model"
identified education as one of five helping behaviors that
provide the basis for all nursing activities.
Roy's "Adaptation
~1odel
of Nursing Practice"
included an extensive definition of function within the
framework; to assist the client toward the attainment and
maintenance of homeostasis in life.
(65:1-20)
All
activities in which the nurse may engage are to assist
that client or client group with the attainment of their
own goals and fulfillment of individual needs.
The notion of patient education has become
implicit within the definition of nursing practice by
individual state licensure laws.
The California Nurse
Practice Act holds the professional nurse accountable for
the provision of education as an "indirect patient care
service."
(20:9)
PADFRAME was originally developed in 1977 to
assist the Planning and Development Committee of the
Denver Medical Society to design a "contemporary role" for
the Society and to specify effective means to fulfill
that role.
(73:1590)
In essence, it was to reorganize,
organized medicine, clarify a purpose for the Medical
Society, set its future direction, and to delineate
10
specific programs, activities, and organizational
arrangements that would contribute to the success of the
Society.
(73:1589)
PADFRAME prescribed the user to formalize a
statement of purpose or function, but did not clearly
integrate the elements of the framework into a whole,
nor did it specify "who" was the "general population"
from which this purpose was to be derived.
(73:1580-
1593)
Systems analysis, although not a planning model
per se, provided a pragmatic foundation for a thinking
process related to the development of a philosophical
definition of function.
This approach stressed the
function of the whole system as opposed to a focus on
the individual elements; the function of the whole is
the relevant statement and not the function of each
individual part.
(16:11, 29)
This systems analysis frame
of reference provided the criteria from which the activit i es of an
11
i de a 1 " mo d e 1 u n f o 1 d e d .
( 2 1 : 69 ) ( 3 1 : 43 )
(59:3-5' 21)
In summary, although present in some form in many
planning models, the statement of the philosophical
definition of function was generally found to be incomplete or not pragmatic for a health education planning
model.
Systems analysis provided a frame of reference
for the development of a definition of function for an
11
11
ideal" health education planning model.
The Importance of Client Involvement
The relationship between the health educator and
the client should be specified.
Responsibilities of each
as well as communication networks should be addressed.
(59:26-28) (65:29)
As the ultimate control of the results of the
health educator's intervention 1 ies with the client, it
is appropriate to include the client at all stages of the
planning process.
(39:6)
The degree of client involve-
ment should be based upon the need for control by that
c 1 i en t or c 1 i en t g r o u p ; an '' i n tern a 1 1 o c us o f con t r o 1 "
client, that is, one that believes he has control over
what happens in his life, will accept and benefit from
increased involvement in the planning process.
(32:9)
An
11
(13:5-8)
ideal" model should specify client involvement
within its basic tenets.
It is important to note that few of the planning
models reviewed made specific reference to client involvement in the planning process.
Often this reference to
client participation was implied but not succinctly
stated.
PRECEDE recognized that active participation by
the learner is vital to the durability of cognitive and
behavioral change.
(32:8)
This learner involvement will
12
aiso assist in public acceptance of the program.
(32:9)
Despite this discussion relative to the importance of
client involvement, the model did not address how and when
this was to occur at all steps of the framework, but
rather, only specified this involvement at the outset of
planning.
(32:18-51)
8 1 u m• s
11
Pr o t o t y p i c
~1 o d e s
o f P1 a n n i n g
11
,
1 97 4 ,
delineated eight planning frameworks from extreme client
i n vo 1 v em en t i n the
11
La i s s e z- Fa i r e t1o de " i n whi c h the
client was allowed to choose among alternatives to the
•• To t a 1 P1 a n n i n g Mod e
11
i n wh i c h a 1 1 c h o i c e s a n d d e c i s i o n s
were made by the health educator.
(11:54-66)
Blum
further implied that planning include a conversion of the
goals of the community into specific objectives and
criteria for health and health services.
(11 :5)
However,
this community goal conversion would require some degree
of input from the community, at least in the initial
statement of goals.
Varying degrees of client involvement, at the
conscious level, were identified in behavioral science
literature.
For example, Behavior Modification techniques,
from their inception, have been critiGized for the potential of manipulation of client freedom of choice, but
when entered into by a client cognizant of the procedure,
the techniques have provided an avenue for behavioral
change.
(2:5-32) (3:89) (46:367-368) (37:78)
13
Modeling and Desensitization Frameworks for planning behavioral change programs included the client
member of the planning team.
(71 :15)
as a
Successful alter-
ation of health related behaviors have been reported· in
relation to cardiovascular risk behavior
alcohol, and drug abuse
(25), smoking,
(52:89-102) (53:650-658), and
adherence to medical regimens
(18).
Although client involvemerit was identified by
specific examples of literature from the behavioral
sciences, there is no universal step-by-step procedure
to guide the neophyte health education practitioner
through the entire planning cycle.
Social learning theory incorporated, in some
degree, client involvement through the process of operant
conditioning.
(57:14)
Progressive reward of behaviors
approximating the desired behavior, called "shaping",
are used in conjunction with other techniques in a
behavioral change program.
(57:14)
Self-management, a
form of social modeling, may also provide a useful
strategy to increase client involvement for selected
groups.
(36:206-250, 561-566)
Social learning tech-
niques of modeling, skill training, contracting, and
self-monitoring have been successfully addressed by
health educators in a variety of settings including
medical office settings, acute care hospitals, and
schools.
(14:23-24) (15:35-36) (26:1034) (30:23-25)
14
(69:37-39)
As client involvement is crucial to the success
of a behavioral change program, it should be specifically
stated within the description of an "ideal" model.
Many
of the planning models reviewed alluded to this involvement but few identified it as crucial, nor did they
describe the manner in which it was to be addressed within
the
framewot~k.
Definition of Key Concepts
All primary concepts utilized by the model should
be defined at the outset to facilitate comprehension.
This provides a conceptual scheme, or frame of reference,
by which to intellectually order relevant phenomena, to
systematize, and classify it.
(31:8, 56) (60:18) (45:24)
Concept definition must occur early within the developmental or explanatory phase of the model.
Alterations
or further clarification of definitions should be made
as necessary.
The "Prototypic Modes of Planning" are well
defined within Blum's 1974 work.
Each mode is described
in relation to the change from the previously described
mode.
(11 :54-61)
This comparative method of definition
allowed the learner to compare differences and similarities between the modes more easily.
15
The "Health Belief Model" proposed five key concepts or factors which influenced behavioral decision;
these factors included:
pe r c e i v e d sus c e pta b i 1 i ty" ;
1.
11
2.
"perceived seriousness";
3•
"perceived benefits of taking action";
4.
"perceived barriers to action"; and
5•
"cues to action".
(64:331-333)
Clarification and reiteration of the meaning of these
factors occurred in the literary treatment of the model
by different authors.
(7:6-13) (33:26-27) (64:329-333)
Roy defined primary concepts very early in the
development of the "Adaptation Model of Nursing."
(65)
The initial key concepts, such as homeostasis, are reinforced and additional concepts defined throughout the
step-by-step description regarding the use of the framework.
Additional key concepts defined include:
1.
the "nature of man";
2.
"adaptation";
3.
"stimuli";
4.
"role conflict"; and
5.
"support systems".
(65)
The "Problem Oriented Med·ical Record Model" (POMR),
although not a planning model, defined primary concepts
needed to utilize this record keeping system effectively.
The system, originally introduced in 1969 by Weed, was
16
designed to simplify the documentation of medical information and specified four primary components or concepts.
(74) (62:43-55)
Bal~anowski,
1979, proposed a "Four Phase
Directed Behavioral Change Process Model"; each phase
was defined in terms of the tasks required of the educator to fulfill the components of the phase.
(5)
Phase
definition in terms of the tasks required provided the
reader with an action plan as well as a comprehension of
the term used to denote the phase.
The phases identified
vJere termed
11
and
11
11
pretraining", "training
,
"Initial testing 11
,
Continued performance."
Concept definition occured frequently within the
models reviewed.
This process should occur both at the
beginning of the description of the model and concurrently
with the step-by-step description of the framework of an
"ideal
11
model • . Definition of concepts in terms of tasks
to be completed or differences from previously described
terms is helpful to the reader in the comprehension of
the material.
This format for definition of key concepts
would be useful in an "ideal" model.
Goals of the t1ode1
The overall goals of the activities specified
in the model should be delineated.
In addition, the
model should stipulate both short term and long term
17
goals of the health education program; these goals
describe the desired result of the health education
activity.
(55:5)
Goals assist in the evaluation of the
planning process by providing an objective measure or
standard of performance.
(65:37) (43:23-24)
Therefore,
goasl for health education intervention should be written
in concrete, behavioral terms.
Th~
(47:6-7)
specification of goals as a component of the
planning process was addressed by numerous authors of
planning literature.
tion Skills
r~odel
11
,
Bennett's
11
Teaching Health Educa-
1981, identified six standards or
goals by which students were to be evaluated.
(10:18}
These criteria were not written in objective terms and,
therefore, would require subjective decision by the
evaluator.
The
11
Prototypic
~1odes
of Planning 11 offered the
goals of the general community as the evaluative criteria
of health services planning activities.
(11 :5)
As the
anticipated effect of the planning modes was to achieve
deliberate social change conducive to an improvement of
health status, this goal conversion seemed necessary.
(11 :54-62) .
The
11
Model for Health Education Lesson Planning 11
,
Middleton, 1981, specified the inclusion of both short
and long term goals in the planning process.
(55:5)
bilevel goal setting activity provided for a future
'
I
This
18
orientation as opposed to a here-and-now orientation.
The health lesson was thus integrated into a long range
plan for the ·student.
The "Adaptation
(55:4-5)
~1odel
of Nursing 11 also identified
the need for bilevel goal setting for the client.
(65:35)
These goals then served as the guide for nursing activities in the immediate time frame (short term goals) as
well as long term time frame (long term goals).
These
goals also became the evaluative criteria for the success
of the nursing care provided to the patient.
An example of a goal able to function as evaluative criteria is "visits to the health center for immunization will increase by 20% over the next 60 days."
Although goal statements were included in many
models reviewed, they were not always written in objectively worded language.
Goals applicable to health edu-
cation planning should be worded objectively and contain
both short and long term objectives within an
11
ideal"
model for planning.
Identification of Problematic
Behavior
The "ideal" model should provide for the selection
of behaviors to be targeted for intervention.
These
behaviors may reflect health habits of an individual or
group and should be of concern to the client as well as
6
19
the health educator.
Penland and Bryrer identified four categories of
ethical issues in health education.
The fourth of these,
simply stated, was "Do we have the right to try and change
another•s behavior?"
(61 :7)
This issue challenges the
authority of the health educator to alter another•s. life
style based upon one•s own value system and beliefs.
Hochbaum has also addressed the issue of ethical
r i gh t of the he a 1 t h educator to act as a
agent.
11
(39:5)
11
be h a vi or a 1 change
Not only does this question relate to the
mission of health education, but also the methods by
which behavioral change is achieved.
(39:5) (6:7)
Ethi-
cal justification for intervention as well as criteria
for the identification of target behaviors must be
included within the
11
ideal" model.
The ethical question
of client•s rights must be specifically addressed within
the framework.
A method of identification of problematic behaviors
or target behaviors appropriate for intervention was often
neglected in the planning models reviewed.
The following
models failed to provide criteria for behavioral selection:
1.
Me Guire•s
11
Communication Model", in 1981,
identified a seven step framework for designing a public
health communication campaign but did not provide any
criteria for selection of behaviors conducive to remedy
by that campaign.
(54)
20
2.
Middleton's
11
Model for Health Education Lesson
Planning .. described how to organize a lesson based upon a
total curriculum but failed to describe the development
to that curriculum or its
the target group.
3.
The
11
relatio~ship
to behaviors of
(55)
Teaching Health Education Skills Model ..
proposed by Bennett, 1977, began the first step with
assessing the client's knowledge of the illness but did
not identify how or why this illness was selected for
intervention.
4.
(10)
Blum's
11
Prototypic Modes of Planning 11 delin-
eated five modes of planning or styles of intervention
once the target behavior was specified but did not
describe how this target was selected.
(11)
The PRECEDE model based behavioral decision on
sociological and epidemiological diagnosis.
(32:18-51)
This diagnosis included both the client group's perceptions as well as literature review of statistical data
regarding the target population.
Roy • s
11
Ad a pta t i on Mode 1 o f Nu r s i n g 11 eva 1 u ate d
behavior by considering the ability of the behavior to
assist the client in the maintenance of homeostasis.
The
behavioral diagnosis, then, is based on the effect of
the behavior of each individual client or client group.
Behaviors appropriate for intervention are those that
decrease the level of homeostasis or those that need
21
reinforcement to maintain homeostasis.
(65:24-29)
Many models described planning activities to be
completed once a decision regarding the behavior to be
targeted had been made but only PRECEDE and the "Adaptation Model of Nursing" specified how to identify these
target behaviors.
Priority Setting
During the identification of client problems, the
health educator is apt to arrive at a list of many areas
from which to choose a target behavior for intervention.
Therefore, the "ideal" model should describe a method
for priority setting.
This method can
assi~t
the health
educator in decision making related to time expenditures
and resource allocation.
This priority setting process should provide
assistance but not be so prescriptive as to stifle individual case judgments by the educator.
Flexibility must
be incorporated into the criteria for the designation of
priority number for intervention.
Flexible criteria for
priority setting will a1so enable the educator to intervefle in phases to augment program effectiveness.
(70:42)
PRECEDE and the "Adaptation Model of Nursing"
both prescribed criteria for the designation of priorities for intervention.
Examples of the criteria
22
included:
1.
Problems that threaten the life or integrity
of the individual, family, or community should receive
the first priority.
2.
(65:34)
Problems that have the greatest impact in
terms of days lost from work, rehabilitation costs,
disability (temporary or permanent), and costs to community and agencies, in terms of repa.iring damage or
recovering losses, should receive second priority.
(32:47)
These criteria are offered as "general" guidelines
for decision making and allow a degree of flexibility to
the educator.
(32:47) (64:34)
"Program Evaluation and Review Technique" (PERT)
allowed for the visualization of priority activities once
the decision had been made.
Originally developed as a
management tool, the diagrammatic representation can be
used to identify all activities needed, including their
priority sequency, to achieve the desired end event or
result.
(1 :18-19) (70:272-277) (72:33, 40-43)
Priority setting criteria should provide a basic
guideline for the assigning of resources and time.
criteria should be flexible.
These
PERT diagrammatization
would also be helpful to visualize the activities needed
to accomplish the desired end result once the decision
regarding sequence of activities has been made; this
23
visualization would be a helpful control technique for the
health educator.
Resources to the System
Churchman's 1968 approach to system's analysis
identified five considerations in thinking about systems.
The third of these is the specification of the resources
available to the system.
(16:24-30)
Resources consist
of the general reservoir out of which specific actions of
the system can be shaped.
(16:39)
Resources provide
options for intervention from which the health educator
ma.y choose.
An "ideal" model should specify resources
as well as provide a source description.
System's analysis models function as a resource
to planning via a frame of reference from which to view
the process of planning; the function of each part must
be derived from its contribution to the whole.
(21 :57-58)
(16:29)
Analysis of any behavioral "problem" may be
conducted along the same lines; what and how are the
factors, such as those specified in the "Health Belief
Model", \'IOrking together to produce the observable
behavior.
PRECEDE specified the use of biomedical, health
education, or behavioral science literature as well as
group process techniques as resources to the user of the
model.
(32:23, 24-28)
The "Adaptation Model of Nursing"
24
recommended literature in the areas of role mastery,
self-concept; and dependency as useful to the user of
that model.
(65:178-179, 254-255, 301)
Resources to the model should be specified to
assist the user in comprehension by providing additional
reference material to the model and in the formulation of
interventions by providing a reservoir of options.
The
"ideal" model should provide resources in the form or a
listing or an extensive bibliography.
Evaluation
The final criterion of an "ideal" model is that
it must provide a basis for the evaluation of the effectiveness of the educational process.
(70:42)
Evaluation
provides for accountability of the health educator for
their actions and may justify their role to the sponsoring
agency.
(32:132)
Evaluation should be concurrent with all steps of
the framework.
By evaluating the goals of the process,
one can estimate the worth of any single activity to the
whole system.
(16:41)
The interrelatedness between
components should be evaluated as to their contribution
to the system's function.
Interrelationships should be
specified explicitly within the framework.
The ultimate evaluation of the health education
process can b~ defined as the achievement of the client's
. "'
25
goals.
(65:37)
In this respect, the goal statements
become the evaluative criteria of the educational process.
(43:91)
This evaluation thus becomes the basis for
revision of interventions and should generate this
revision as a natural outgrowth of the evaluation activity.
(65:37)
As a constituent of the step, goals should also
be evaluated for appropriateness in light of new information; perhaps the original goals are obsolete at this
time.
Many of the planning models utilized evaluative
criteria bases upon goals or objectives specified during
early steps of the framework.
(54:13) (55:4-5) (65:35)
(10:18) (32:132-141)
Although evaluation of the
educational program is suggested and included in the
necessary steps of the models, rarely is follow-up action
to the evaluation specified; revision of the plan is not
specifically addressed in the models except for the
"Adaptation Model of Nursing."
(65:37)
Evaluation processes in an
11
ideal" model should
not only address the criteria for evaluation but also
follow-up action to the results of this evaluation activity; revision of the plan should be specifically addressed.
The literature reviewed was evaluated on the
ability of each planning model or related work to fulfill
eight criteria of an "ideal" model derived from social
'
~
26
science literature.
Frequently, a model would partially
or completely fulfill one or more criteria but fail to
fulfill others.
Based upon these eight criteria, the Roy
"Adaptation r1odel of Nursing" was felt to be the most
complete of the planning models reviewed by this Investigator.
Therefore, this model will be used to provide the
basic framework into which other, relevant, health education literature will be integrated during the development
of the proposed "ideal" model of health education planning.
~
Chapter 3
METHODOLOGY
The primary purpose of this chapter is to
describe the process used in carrying out data collection
activities and in the design and development of the proposed ideal model of health education planning.
The
methodology involved four distinct phases which included:
1.
Phase One:
Review of the Literature;
2.
Phase Two:
Development of Criteria for an
Ideal Model of Health Education Planning;
3.
Phase Three:
Development of a Proposed Model
of Health Education Planning; and
4.
Validation of the Utility of the Proposed
Mode 1 .
Since this study is theoretical in nature, emphasis is
placed upon the description of the processes required to
build a model for health education planning.
Phase One:
Review of the Literature
Phase One and Phase Two were completed _simultaneously.
The field of health education currently utilizes
a variety of planning models.
The variety of background
experience of health educators and a lack of specific
27
28
valid and reliable models does not support uniformity in
planning.
(17) (19) (22) (34)
The primary purpose of
Phase One was to review and assess the utility of existing
planning models within the field of health education and
within related fields such as nursing and the behavioral
sciences.
Strengths, weaknesses, and the utility of these
planning models in fulfilling the functions of a health
educator explicated within the Initial Role Delineation
Project were assessed.
(41)
The secondary purpose of this phase of the methodology was to review literature descriptive of model
development.
Studies within the fields of social sciences
were also utilized during Phase Two:
''Development of
Criteria for an Ideal Model of Health Education Planning.
11
The evaluative criteria which were developed by
this Investigator during the study of the planning models
were derived from criteria of an
in Phase Two.
11
ideal
11
model developed
In this manner, the first two phases of
this project were completed concurrently; Chapter Two
(Review of the Literature) was organized and sub-sectioned
based upon the criteria established within Phase Two.
29
Phase Two: Development of Criteria
for an Ideal Model of Health
Education Planning
Assessment of social science literature concerned
with the development of models resulted in the establishment of eight criteria or components of an "ideal" model;
it became evident to this Investigator that these camponents should be present in any conceptual model regardless
of the field from which the model is derived.
The cri-
teria certainly are not representative of all possible
criteria, but do provide both evaluative criteria and a
basis for the development of a planning model for health
education.
1.
These criteria include:
a "philosophical definition of function"
should be present that describes the overall function of
the model as a system and how the model is useful to the
user or consumer;
2.
the
11
importance of client involvement 11 should
be specifically addressed as well as how this involvement
is to be achieved;
3.
11
definition of key concepts,
11
should occur
early within the explanatory phase of the development of
the model and additional concepts described as they occur
within the framework;
4.
the
11
goals of the mode1" should be described
in objective language to provide the objective evaluation;
30
5.
the "ideal" model should provide "criteria for
the identification of problematic behaviors" to be targeted
for ethically motivated intervention;
6.
"guidelines for priority setting" should be
present and provide flexibility to the educator for the
allocation of fiscal and human resources;
7.
"resources to the system" should be provided
to assist the user in comprehension and utilization of the
framework; and
8.
a specific "procedure for evaluation of the
program" should be included as well as follow-up activities to the evaluation process.
Phase Three: Development of a
Proposed Model of Health
Education Planning
During the review of the existing planning models,
the Roy
11
Adaptation Model of Nursing .. appeared to con-
sistently be the most complete of the models reviewed.
It met the majority of the criteria established during
Phase Two.
Therefore, the Roy "Adaptation Model of
Nursing" was used as the basic framework for developing
th~
proposed health education planning model.
Useful components from other planning models were
integrated into the steps of the nursing process as specified by Roy.
These steps of the nursing process include:
31
1.
2.
Assessment
A.
Behaviors
B.
Stimuli
Planning
A.
Nursing Diagnosis
B•
Go a 1 s
3.
Implementation
4.
Evaluation and Revision
Additionally~
(65:24-37)
worksheets were developed to assist
the user of the model to complete the specific steps of
the framework.
These worksheets also served to clarify
the steps through a one page, diagrammatic summation of
the framework in its entirety.
(See Appendix A)
Phase Four: Validation of the
Utility of the Proposed f>1odel
The utility of the proposed health education
planning model was evaluated by administering a brief
questionnaire to selected health education practitioners
who worked in a variety of health settings.
A.
The Informational Packet:
Selected health educators were sent an informationa1 packet consisting of:
1.
A cover letter which described the purpose
of the project and instructions for completing the questionnaire (See Appendix B);
32
2.
The proposed model as it appears in Chap-
ter Four of this project;
3.
The bibliography for the research with
asterisks on specific resources of special benefit to the
user of the Model;
4.
A brief questionnaire related to the
utility of the t1odel;
5.
A sample behavioral contract and work-
sheets for the Model (See Appendix A); and
6.
A postage paid envelope for return of
the questionnaire.
B.
The Questionnaire
The questionnarie included items that were
designed to evaluate the Model's fulfillment of the
eight criteria of an "ideal" model developed during Phase
Two (See Appendix B).
The respondents were requested to
rate each criteria related item on a 1-4 scale indicating
their agreement or disagreement with each item statement.
It was requested that a written explanation for any
nstrongly
Agre~"
(Response Category) or
"Stt~ongly
Dis-
agreelf (Response Category 4) should be given by them in
the space provided at the end of each item.
The questionnaire was divided into the same subsections as the description of the Model itself to assist
the respondent to answer the items.
In the cover
letter~
it was suggested that the respondent stop at the end of
"'
33
each section and respond to the corresponding items while
the material was still fresh in their mind.
Results of
the questionnaire are presented in Chapter Five of this
research.
C.
Selection of Respondents
The purposive sample of respondents was designed
to include health educators in the Greater Los Angeles
area working within various types of health agencies.
All posssessed a Master of Public Health degree and
several served as Field Training Supervisors for the
graduate program at California State University, Northridge.
Twelve health educators were selected from among
a list of thirty-eight field training supervisors.
Those
selected represented the following types of agencies:
1.
Acute Care Hospital - H.M.O.:
2.
Acute Care Hospital - Non-Profit;
3.
Acute Care Hospital -County Facility;
4.
Public Health Department;
5.
Voluntary Agency;
6.
Health Educator - University Setting; and
7.
Hospital Corporation - For Profit.
A listing of respondents and their agencies is included
in Appendix B.
D.
~ailing
of the Packets:
Informational packets were mailed on
April
27~
1983.
Response was requested no later than
34
May 10, 1983.
The relatively short response time was
selected to encourage rapid assimilation and reaction to
the material.
It was felt that those who were committed
to response would do so within ten days while those
reluctant to response would not respond regardless of the
time allotment.
Chapter 4
A HEALTH EDUCATION PLANNING MODEL
The following pages describe a model or framework
for health education planning.
This description includes:
1.
functions of the model,
2.
definition of key concepts,
3.
specific steps to follow for health education
planning,
4.
resources to health education planning, and
5.
worksheets for the user of this model.
Function of the Model
The function of the proposed health education
planning model is to provide a systematic step-by-step
framework for conceptualizing the process of health
education.
This framework will delineate specific
activities to be performed at each step of the process.
It is also designed to provide sufficient flexibility
so that each user may adopt the model to their own
situational setting.
For the neophyte practitioner, the model will
serve to provide an anchor point around which educational
theory can be structured.
The model will attempt to
provide a needed frame of reference for the designing of
35
36
interventions relevant to the alteration of health related
behaviors.
A major tenet of the proposed model is that client
involvement is important during all phases of planning
health education interventions.
The client should be
included as an integral component of the planning team.
Without client cooperation, the health educator cannot
expect to obtain lasting behavioral change; therefore,
the client must be included.
Clients possessing an
(29:591)
11
internal locus of control,
11
that is, feeling that they control the events in their
own lives, should be allowed as much input and control of
the interaction as possible.
It is suggested that this
approach can better meet their innate needs and, at the
same time, improve the ultimate educator/client relationship.
(13:44-66)
The health educator is in the position to become
the central coordinating force of the health behavior
team, providing knowledge, guidance, and resources for
the effective change of behavior toward a goal of improved
health status; the educator acts as the
the team.
11
Consultant 11 to
As an active team member, the client is
responsible for seeking assistance, evaluating own
behavior, and complying with any formal agreement for
treatment.
The health educator's role is to assist the
client to achieve these responsibilities.
37
When appropriate, behavioral contracts should be
negotiated, formally, between the health educator and
the client.
This contract should explicitly delineate
the responsibilities of each member of the team as well
as the criteria of accountability of each.
(23:518-526)
For example, if the team identifies C.P.R. training as
needed, the educator provides the course, the client
attends, studies, and practices, and is accountable for
the technique on the mannequin.
A sample behavioral
contract is provided in Appendix A.
In summary, the overall function of the model is
to assist the health educator with the planning of
behavioral change processes for the purpose of improving
the quality of life for the client.
It is designed to
systematize the activities needed to obtain this objective.
Definition of Key Concepts
The following concepts are essential in order to
comprehend the model's components and are, therefore,
included here.
Additional concepts will be defined as
they occur during the description of the activities of
the framework.
11
Health Education .. is any combination of learning
experiences designed to facilitate voluntary adaptations
or alterations of behavior conducive to health.
(32:7)
38
As this definition stresses the voluntary nature of
behavioral change, client involvement becomes more crucial
to achieving effective process.
11
Learning Experiences 11 are any activities, either
planned or occurring naturally, that influence behavioral
alteration.
Therefore, the educator must be cognizant of
the unplanned consequences of interventions.
11
Man" is a biopsychosocial being in constant
interaction with a changing environment.
Man's biological
nature includes his anatomy and the function of his glands
and organs.
Psychologically, man possesses intelligence
and emotion.
Together, the biological and psychological
natures interact to produce observable behavior that is
organized in such a manner so-as-to provide consistency
or homeostasis in life.
Socially, man interacts with
others on a group or individual level, such as in families
or work settings.
(65:11)
Man is in constant interaction with the changing
environment and this correspondingly necessitates alterations of behavior, called "adaptation. 11
Adaptation may
occur within the biological, psychological, or social
arenas and is designed to maintain homeostasis.
Responses to changes in the environment may
either be positive (adaptive) or negative (maladaptive).
Adaptive changes promote homeostasis while maladaptive
changes decrease the state of homeostasis and encourage
39
the onset of illness or disability.
For example, suicidal
thoughts are a maladaptive response to stress; crying may
be an adaptive response to a loss.
in the ability of
~he
The distinction is
behavior to promote homeostasis.
Figure 4.1 depicts the effect of each type of response
on the ultimate state of the person.
Figure 4.2 con-
ceptualizes homeostasis as the effective balancing of
responses to the changes in the environment.
CHANGE IN THE ENVIRONMENT + ADAPTIVE RESPONSE
= Hm·1EOSTAS IS
(POTENTIAL FOR HEALTH)
CHANGE IN THE ENVIRON ME NT +
~1ALADAPTI
VE RESPONSE
= OISEQUI LIBRI UM
(POTENTIAL FOR ILLNESS)
Effect of Response Type on Homeostasis
Figure 4.1
The determination of the adaptive status of a
behavior is the effect on the state of homeostasis for
that individual.
Adaptive and maladaptive responses are coping
mechanisms.
Some of these are involuntary, such as
peripheral venous system reaction to head and cold, and
many are learned, such as the use of drugs or alcohol to
combat feelings of helplessness.
The positive (adaptive)
or negative (maladaptive) effect of a behavior for the
individual must be judged on the basis of the effect of
the behavior on the homeostasis of the client, and not
~
40
merely on the connotation of the behavior to the health
educator.
For example, use of tranquilizers may be the
only coping mechanism a client group possesses to reduce
stress until other strategies for stress reduction are
learned.
Therefore, the educator must identify and
legitimate "new" coping mechanisms before extinguishing
the old.
HOMEOSTASIS
CHANGING
ADAPTIVE
RESPONSE
(MAN)
ENVIRONMENT
Figure 4.2 Adaptive Responses Balance
Changes in the Environment (65:12)
.
~
41
Steps for Using the Adaptation Model
of Health Education Framework
The following 14 pages discuss the specific
steps of the proposed model.
Each step of the planning
process will be discussed separately including the phases
necessary to complete the step.
The steps are in sequen-
tial order; each step is to be completed before going on
to the next.
rn steps that consist of more than one
phase, each phase is to be completed before going on to
the next, as it provides input for the next phase of that
step.
A sample worksheet is provided in Appendix A, and
this worksheet depicts the activities of the total
process.
Step One: Assessment of
Behaviors and Stimuli
This initial step consists of two phases and
involves the development of a firm, extensive, and
accessible data
~ase
which will guide the health educator
throughout the educational process specified by the model.
Phase One: First Level
Assessment
The initial activity of the health educator is
to assess the client group for problematic behaviors.
This "first level
11
assessment consists of direct observa-
tion of the group, examination of morbidity and mortality
42
statistics for indications of health problems, verbal
interaction with the client group for the purpose of
identifying their perceptions of unmet health needs, and
to carry out an intensive literature review regarding
health and wellness status of the target population.
Behaviors can be defined as actions or reactions
under specified circumstances.
(65:11)
They are both
internal, .such as psychological states, and external,
such as health practices.
(44:19)
The health educator
needs to examine the client group's responses that can
be directly observed, measured, or subjectively reported.
During this initial data collection period, concentration
is placed on identification of behaviors without respect
to adaptation characteristics.
That is, in accordance
with the biopsychosocial nature of man, the investigator
should search for and identify behaviors in at least four
areas:
physiological responses, self-concept diffi.cul-
ties, role mastery behaviors, and interdependency
behaviors.
Generally, man will adapt to changes in his
environment in one or more of these areas in an attempt
to maintain homeostasis.
(65:24-25)
The physiological mode includes the biological
responses to changes in the external and internal environment, such as skin reactions to external heat or cold or
the physical changes due to pregnancy.
Self-concept
change behaviors are related to body image, moral/ethical
43
belief systems, and self-esteem.
(65:175-176)
Fulfillment of both societal and self expectations related to specific roles is evaluated in the role
function mode; for
example~
is the client able to perform
the duties of the role of wife and provider of income
simultaneously?
Dependency and independency needs and
behaviors are studied in the interdependence, socially
oriented mode.
Figure 4.3 depicts the relationship of
these four modes of behavioral response to the whole of
man as a being.
PHYSIOLOGICAL
MODE
SELF-CONCEPT
ROLE FUNCTION
MODE
INTERDEPENDENCE
~~0 DE
~10DE
~~-----------
~--~------------·
-------- --··
---
MAN
Figure 4.3 Four Modes of Behavioral Response
and Their Relationship to Man
After the educator has accumulate relevant
behavioral data, consideration should be given to the
adaptation status of the individual behaviors.
That is,
does a specific behavior promote homeostasis or not. and
why.
This judgment is somewhat subjective and, therefore,
44
the judgment should be validated by statistical data,
literary evidence, or client agreement.
(65:28-29)
Maladaptive behaviors may require intervention to improve
the quality of life of the client and adaptive behaviors
may require reinforcement.
A behavior that is recognized by the literature
as not healthy, such as smoking, may require alteration
even though it promotes some degree of homeostasis for
an individual client.
In this instance, the health
educator should assess for other behaviors that deter
from the smoking behavior and may encourage quitting.
A
health habit generally accepted as detrimental should
be addressed, but £Qly with the knowledge and cooperation
of the client.
Thus, this first level assessment provides the
health educator with a list of specific health behaviors
that are appropriate for intervention.
Behaviors that
have been identified include those that need to be
altered or extinguished to improve the health status of
the client as well as those that need reinforcement to
maintai.n homeostasis.
The assignment of priority order
to the identified behaviors will be discussed later in
the Model.
45
Phase Two: Second Level
Assessment
During the
11
Second 1 evel
11
assessment, the health
educator uncovers contributing causes of the problematic
behaviors identified during the first level assessment.
These causes, termed
categories:
11
Stimuli,
11
are divided into three
primary stimuli, secondary stimuli, and
tertiary stimuli.
Figure 4.4 diagrams the relationship
of stimuli to the occurrence of the behavior.
11
Primary Stimuli
11
are the most immediate causes
of the target behavior, such as loss of a loved one
(primary stimuli) for suicidal thoughts and behaviors
(target behavior).
Primary stimuli should be objectively
verified, if possible, with the client; does the client
believe that it is the main cause of the behavior in
question.
~~secondary
Stimuli
11
include additional contribu-
ting causes that are important to the onset and duration
of the behavior, but are not the most central.
That is,
these causes contribute to the occurrence of the behavior,
but are not the primary stimuli, such as a family history
of suicidal threats or actions to the occurrence of the
suicidal thoughts in the previous example.
stimuli
11
11
Secondary
may also include factors that affect the
behavioral decision-making process or actually discourage
the occurrence of the behavior.
(65:32)
46
11
Tertiary Stimuli
11
are those elements believed
to be important by the health educator, but which cannot
be directly validated at the time of the second level
assessment.
These include, but are not limited to,
beliefs, attitudes, or
11
gut feelings
11
that have not been
justified by study with recognized instruments.
In the
previous example of a client with suicidal thoughts,
11
tertiary stimuli" may include things such as beliefs in
afterlife or reincarnation, beliefs that he cannot die,
or attitude of indifference toward life.
(objectively
veri fi able)
Figure 4.4 The Relationship of
Stimuli to Behavior
Location of Probl2matic Behavior
.
~
47
Com po ne n t s o f the He a 1 t h Be 1 i e f
r~ o de 1
pe r c e pt i o n
:
of severity, susceptibility, urgency, and barriers can
directly or indirectly provide input related to the
client's ultimate health decision and should be considered
as stimuli.
The placement of these factors into the
appropriate category of stimuli will depend on their
importance to the specific client group involved and the
ability of the educator to validate their importance to
the occurrence of the behavior; stimuli that are verified
are either primary or secondary in nature while unverified
stimuli are always tertiary.
Briefly, the purpose of categorizing the stimuli
is to s1mplify the designing of alternate intervention
strategies since intervention should be based upon
removing the stimuli that contribute to the occurrence
of the behavior and reinforcing the stimuli that deter
from the occurrence of the behavior.
Intervention, then.
is not based on the behavior itself, but rather on the
causes, stimuli, of that behavior.
"Primary stimuli"
are the most important targets for intervention, "secondary stimuli" the next most important, and "tertiary
stimuli" least important.
The concept of planned,
stimuli-dependent intervention will be dealt
with
completely at a 1 a ter point in the Hodel.
The second level assessment consists of assessing
the causes of the behavior for the target group.
6
These
48
causes are divided into three categories:
11
primary
stimuli , 11 or the most immediate cause/s of the behavior,
"secondary stimuli,
11
or important contributing causes of
the behavior that can be verified, and
11
tertiary stimuli,
11
those factors believed to be important by the health
educator, but are not verified.
Once the health educator has completed the first
and second level assessment and identified potential
target behaviors and their causes, then the actual comprehensive program planning activities can begin.
The data base collected during the two phases of
the
11
Assessment 11 step provide the necessary background
information from which the health educator will draw to
design and implement a behavioral change program.
Step Two:
Planning
During this, the second step of the framework,
the educator will complete three phases of planning
leading to the third step, that of intervention specification and performance.
The data collected in the first
step will be used during this and all
remainin~
steps
of the framework.
Phase One:
Setting
Priority
During the first step of the framework, the
educator should have discovered many behaviors that are
49
appropriate for intervention.
Priorities, then, need to
be established regarding the order in which these
behavioral problems will be addressed.
The following
problem areas can serve as criteria and are offered as
guides for priority setting, but are not inclusive of
all possible criteria and, therefore, the judgment-of the
health educator and/or sponsoring agency may take precedence.
These include:
1.
Problems that threaten the life or integrity
of the individual, family, or community should receive
the first priority.
2.
(12:14)
Problems that have the greatest impact in
terms of days lost from work, rehabilitation costs,
disability (temporary or permanent), and costs to the
community and agencies, in terms of repairing damage or
recovering losses, shoald receive second priority.
(32:47}
3.
Problems that threaten to bring about
destructive changes to the individual, family, or
community structure; (12:14)
or
4.
Problems that affect the normal growth and
development or causes significant risk to a large subgroup of the population; (12:14) (32:47)
or
50
5.
Problems that, when properly addressed, have
the greatest potential for attractive yield; (32:47)
or
6.
Problems that reflect a regional or national
priority should receive consideration next.
7.
(32:14)
Above all, the desires and wishes of the
client group should become the most important prioritysetting criterion (if at all possible).
Phase Two: Formulation of a
Diagnostic Statement
After specific target behaviors have been selected
based on the priority setting phase, a diagnostic statement should be written.
the results of the
11
This statement will summarize
Assessment 11 step and provide the
basis for the goal setting activity that follows.
A
diagnostic statement should at least include the target
behavio-r and the contributing causes that will be
addressed in the
11
lntervention 11 ·step.
Examples of diagnostic statements include:
1.
Suicidal thoughts and behaviors owing to loss
in personal life and lack of knowledge of support systems
available in the community.
2.
High blood pressure (168/98) owing to non-
compliance with medication regimen and stemming in part
from language barrier between client and physician.
51
3.
Residents of East Los Angeles Census Tract 12
have incomplete immunization status owing to lack of
awareness of importance and attitudes regarding the health
care system and cost.
This type of diagnostic statement summarizes the
activities of Step One and concretely directs the remaining activities of the framework.
Phase Three:
Goal Setting
The goal setting phase provides the evaluative
criteria relevant to the educational results to be
achieved and should be written in behavioral terms.
(32:49) (43:26-32) (51:23)
The goals of the planned
interventions should include a specific description of
the behavioral change desired, time limit for the change
to occur, and under what conditions, if appropriate.
Figure 4.5 provides examples of goal format and also
demonstrated the relationship of the goals to the diagnostic statement.
The goal should specify who will achieve the
behavioral change; the target population and any geographical or demographic information appropriate should
be included.
The desired behavioral change should be
described in concrete and objectively measurable terms.
The extent of the change desired should be noted as
appropriate; for example, a "40% decrease in the reported
.
~
52
occurrence of disease X over the next 12 months."
The goal statements of a health education program
should address both long and short term results (outcomes).
This hi-phasic goal specification lends itself
to intervening in phases.
It also provides intermediate
closure and intermediate feedback for the educator and
client; satisfaction is provided early in the program, as
well as late in the process for the health educator and
client alike.
Finally, goals should be established with the
client, if possible.
This partnership in goal setting is
congruent with the basic philosophy of client involvement
reflected throughout this model.
A client that has
actively participated in the designation of goals will be
more apt to strive to achieve those goals.
(49:130-132)
The second step of this framework, "Planning,"
consists of the assigning of priority order to behaviors
identified in the first step, formulation of a diagnostic
statment that summarizes the activities of the first
step for the targeted behaviors, and designing of formal
short and long term goal statements that will guide the
planning and implementation of the interventions that
will alter the problem behavior •
.
~
53
!)I
T•,:;~i[l$11
C
STf\i[l~E!iT
GO.~~S
S u 'i :· T 1 ~ Q f~
t~i{J!Jgllt.~.
)tjicirial
b~haviors
in
o~ing
and
to 10;s
p~rson~l.ltfe
a~d
The clien"": .... -;11
ab1e tc
n~~e
L'l!it: TEP.r.
bf::
The c1 ier.t
ttree
complete the
agencies
c~mmunity
~>ill
grievdnce ?rocess,
lack of lnowledge of
to ca 11
~~pport
or thinking suicidal
Y..ubl er-?.oss,
thougt,ts within
~ithin
syste~.s
in the
availa~le
comfllunity.
~l3h
t\'IO
bl~0d
163/,!,
?ressure,
c~ing
to non-
with medi-
~'•Gn
feel; n;
s~eci
fled by
one munth.
r.ays.
The c 1 t ~n
able b
~
wi 11 be
The client's blood
pressurt wi 11 be
ver~a11y
describe his medi-
belo;., 140/90
cation regimen and
Cdtion schedule,
witt.·:n
stemming in part
~i~
cc~pllanre
1an~~?9P
~etwecn
f~,Q
in
~iY.
..,_·F:ek.s.
own language,
witnin two days or
barrier
client and
two visits.
ohnic;an.
in East Los
Pes~~~nt~
Ang~les
Census Tract
tncon'pl~te
12 hdve ar.
A
ra~dc~
comnunity residents
for
w1ll
..... 111
t•~
il"'muflizat:on· st.' tus
the
ow.;n~
vi:Je ... of
t-:.
1ac~·
uf
ab1 e
Clin~c
~s
lo~-J
dware:1(SS of impcr-
immuniza~ion
ta~ce
days.
a~d
a!tittl~~s
Visits to the C1in;c
sample vf
~o
r;,me
a orocos-t
~n
30~
syste~
~nd
l!
cost.
Figure
to
\)
t~e
~-~
~~lati0ns~iD of
StJt~~~nt
"tagnos:it
Gca1
i~cre:::s~
Statements
by
over the next
thr;;e C'onths.
regu··jing tr.e hea I th
care
in1~u~ization
54
Step Three:
Intervention Specification
and Performance
The formal specification of interve1tions and
their performance should occur at this point in the
process.
Interventions are designed to alter primary,
secondary, or tertiary stimuli identified during the
"Second Level Assessment" phase of Step One.
By el imi-
nating the cause of a behavior or by reinforcing factors
that deter from the behavior, the behavior should be
extinguished.
(32:36)
During this step, the health educator is
encouraged to draw upon theory, experience with the client
group, and creativity to design alternative approaches
that achieve the desired result
the goal as stated.
These interventions should reflect ethical awareness as
well as client preferences; there should be respect for
the individual's right to adopt or not to adopt the
behavioral change.
If the behavior is threatening to
others, then justification may exist for the use of more
forceful non-client centered interventions.
(39:6)
As the degree of "voluntariness" depends on the
amount of relevant information provided to the client
regarding health issues and alternatives, intervention
strategies should contain an informal component.
(27:182)
55
Figure 4.6 provides a sample of a completed worksheet for a problem client behavior of high blood pressure.
The completed sample worksheet culminates all of
the activities of the framework to this point.
Another tool that the user of this model may find
helpful is the concept of P.E.R.T. diagramatization of
planned activities.
mance
Evalu~tion
P.E.R.T. is the acronym for Perfor-
Review Technique.
It is useful as a
control device for the educator as it provides a map of
what activities need to be accomplished by what date for
the final goal (event) to be achieved.
(72)
P.E.R.T.
diagrams will provide for intermediate evaluation of
longer term intervention strategies, particularly when·
the educator is in conjunction with other members of the
health care team.
Figure 4.7 provides a simplistic sample
of a P.E.R.T. diagram for the interventions identified
in Figure 4.6.
Step Four:
Evaluation and Revision
After the intervention step is complete, each
goal statement is examined and evaluated for achievement;
was the
fied?
goa~
achieved during the time parameters speci-
This evaluation should include quantitative (sta-
tistical) as well as qualitative (descriptive) data.
(44:20)
Not only is the attainment of the goal important,
but the ci ient's reactions to the change as well.
This
--~~~~"!!:1'1!!."'
._!£1<chc<:t
mJ;:,vwn
I\IJI\f'l'IVE
Sil\.11.1.i
(jjpn@
nr 168/90
H
1
Prlli'J'JW
~:;;~T;Ial ~,
__!?_tl!.:/\l:t'll nU:~::IITJOI ~J~~rg-'.!___
1
=ww
I
TrmrM~
Cl.l1>L
llEII.WIOML
DTJ-.?llSJ:;
r----:::mc;:---
1
-------1------·-------bl-ct ~·t>l iarn!l
~ill\"""
·oqjttr:>Jl.
J • l ..li~Ju.uJtl
h.u.
it~r
C ).IC~Ht /1-fl,
2. l..lck of
1. ()pficf olb:ll.lt
I
lliCJI& hlu:-.1 l'l'l~~;~;urc, ll,0/98J ~~lE_Z!•!:
wath n.-:-J t"nJim.!n ~"lnd StO'I\-
I
W
tH.n.
I
m.irll) in 1\.tl"t. fran l<mq'\.Jo1<Jo!
I
lll.)\1 SL'h('tlulc, in hh o ...n
1 2.
I'Jovill~~ ...•dtlt.·.~ m11l'ri.ll
I
b.1n i1~r bct~·en client ilnd
I
lc~ncJ.l.:I•Jt.!, wiUain 2 (by·;
I
rc u• .Js .:w.! Ill• ill Jlicol
~.hy::.ici.m.
i
or vi:>its.
I
Hln~~s.
2. CUlturd.l
SUJp>rl
OO!icb r\l
sy":itcnt ...
m..~ical
:-:f\IIH•.,h f,j\.'.li..illq
cl
11111:a~
()ii,JJI"')
cart!l
to , ... •n-<..ntpl i<ull:~
l. Assirpl
' 'Jhc ct icnl wj 11 be ~'ililc
r"'~vcl"jLy of
vcrl~tlly dc~•crillC' his
livcg
.!!!!-~
...!.r.n;.:
1'1•)\'i•!·~
to
Jr":tnK:-
l'fr·~;:;un" jH :;p.1:11~h.
.), II,J\'c· cJ
ala'IO.
i~·ut ~k·~;rnl..:.·
~l.._'h,,J,,}c~
ltl (.._'1'1
11\.:d
l;'HJ•I..IlC·
1lk: cl ic:rcl's blvol pcc>s-4. UJt....Hn b."h.lVH>I.ll :t.·;r •.,,IL!lt
sure wi.ll 1){~ lclw 140/~0
(ci•l'l clH'nL.
witl1i.r. (, \o.(.'.:.·J\.s.
1, 5d U,:O
t,h.,,!t~kly ol;•,·lS.
for
1\.P, dl(Ck.
2. 1•/'V.I.'-"""
('oll'h
),
fl1·ll ~.cho.!ul,...
ll.t
\IJ:..i.t.
('!'lrJiol.~ C}U:Ul With
V•'ft,ll
ft:r,U..Hck ,1t t:.1c;h vis1t rc
(1.1' •• uxiJH'U«Iio:lt.y h) (1f•l~.
4. i\ll(.N cl.iC"Ill .u ch~.c·u~a
D
x·..;c.•n:S-I•LUVJtl.! S\11-1-"l,;.l·t.
(.J1
0'1
Jan. 4
Jan. 2
1st
visit:
I en
Assign
Spanish
speaking
RN to
instruct
Review
Med
schedule
T
Behavioral
contract
reached
re Med
taking
J
J,
Provide
literatu1~e
in
Spanish
Cl i en t
seen/called
l\ble to
~I v e r b a. 1 i z e
Med schedule
Jan. 9
BP
checkedfeedback
to
client
Feb. 1 5
Jan. 25
Feb. 8
Review
~1ed schedule
Feedback to
Client re
BP
Review
Med
schedule
Feedback
to client
re BP
--
BP
140/90
Jt..
-
Allow
client
to
discuss
concerns
All ow
client
to
discuss
concerns
Figure 4.7 - P.E.R.T. Diagram for Interventions for Figure 4.6
<.TI
-....J
58
evaluation component of the model, again, stresses the
client-centered philosophy.
Statistical evaluation may be obtained from differences in the morbidity and mortality information about
the client group or manipulation of the data obtained from
pre- and post-test instruments.
There are actually at least six foci of evaluation
that can and should be reviewed during this process.
Figure 4.8 conceptualizes these foci into a checklist
format to simplify review.
QUANTITATIVE
EVALUATION
TYPE
RESULT
FOCUS OF
EVALUATION
QUALITATIVE
EVALUATION
TYPE
RESULT
CLIENT
FAt~ILY
OF CLIENT
COMMUNITY
PHYSICIAN
NURSE
HEALTH EDUCATOR
-~------------------
---
---
- - L_________ _ _ _ _
- - - - - - - -----------------
-- - -
- - - - - - - - . ----
----------
--
Figure 4.8- Checklist for Evaluation Foci
'
~
-----
59
A formal, written discussion of the results of the
evaluation process should be kept with the planning worksheet for the program.
(See Appendix A for sample work-
sheet and evaluation form).
This written evaluation
should also be transmitted to supervisory personnel at
the sponsoring agency, along with plans for needed
revisions to the program.
Revision may be needed in the areas of goals or
interventions.
If interventions that were based upon
identified stimuli were ineffective in achieving the
goal, additional second level assessment may be required;
the behaviDr may be reinforced by stimuli that were not
identified during the initial second level assessment
and further assessment is needed.
Goals may have been impractical during the first
goal specification phase and require revision.
When
investigating for reasons for non-attainment of goals,
examine the specific behavioral component, as well as
the time parameter specified.
Is the goal acceptable
and valid, but needs more time to be attained?
Is the
potential end result worth additional time expended?
The need for revision to the original plan does
not c on note f ai 1 u r e by the he a 1 t h e d uc a tor , b u t r a the r
is a request for further creativity.
As the educator
is dealing with human beings, total control of all the
variables in the educational process is impossible.
60
Therefore, the health educator should not belittle himself for the need to revise the initial plan, but should
view this as a learning experience that will be valuable
in the planning of further programs with this or other
client groups.
The framework of this model consists of four
steps with phases within Steps One and Two.
A summary
table of the steps and phases of the model is provided
in Figure 4.9.
STEP ONE:
ASSESSMENT OF BEHAVIORS AND STIMULI
Phase One:
First Level Assessment
Phase Two:
Second Level Assessment
STEP TWO:
PLANNING
Phase One:
Priority Setting
Phase Two:
Formulation of a Diagnostic Statement
Phase Three:
STEP THREE:
STEP FOUR:
Goal Setting
INTERVENTION SPECIFICATION AND PERFORMANCE
EVALUATION AND REVISION
Figure 4.9 - Steps of the Framework
The activities specified in each step are
dependent on the effective implementation of the prior
'
~
61
steps.
The
framework~
thus~
functions as a system for the
purpose of planning behavioral change processes and programs for the purpose of improving the quality of life
of the client group.
Resources to the System
Resources to a system consist of the general
reservoir out of which the specific actions of intervention can be shaped.
(16:24-30)
Resources to this
model are provided in the bibliography.
These resources
are provided so that the potential user may easily locate
materials from which to draw to fulfill the activities of
the planning model.
Conclusion
The preceding model is called the Adaptation
Model for Health Education by this investigator.
based on criteria of an
11
ideal
11
It is
model developed during
an extensive earlier literature review for this graduate
paper.
It is designed to provide direction for the
neophyte practitioner of health education, as well as
allowin~
flexibility to those experienced in health
education planning.
Worksheets are appended and should
assist a user to follow the steps of the framework.
This
investigator hopes that the model will provide a useful
tool for those searching for a p1 anning model.
II
Chapter 5
RESULTS AND DISCUSSION
This chapter will present the results of the
questionnaire.
Six questionnaires were returned.
represented a fifty percent response rate.
This
Respondents
represented the following types of agencies:
1.
International Hospital Corporation:
For-
2.
University Health Education Department;
3.
Voluntary Agencies;
4.
Hospital Education Director:
5.
Public Health Agency.
profit;
Not-for-profit;
and
Each component of the Model will be presented
and discussed as it appeared on the questionnaire.
Function of the Model
Item One:
The function of the model is clearly
stated.
There was unanimous agreement by respondents that
the function of the Model was clearly stated; that is,
one hundred percent of respondents indicated Category 3
(Agree) or Category 4 (Strong1y Agree) responses.
additional comments or clarifications were made.
62
No
63
Item Two:
The statement of function is congruent
with my beliefs concerning the appropriate role of such
a model.
Again, there was unanimous agreement with this
statement.
Additional comments included
stated and defined".
11
Very well
Generally the respondents agreed
with the importance of client involvement even though
they indicated this was difficult to achieve within the
Public Health Department setting.
Definitions of Key Concepts
Item Three:
The concepts defined are understood.
All respondents agreed with this statement, and
eighty-three percent indicated Category 4 (Strongly
Agree) response.
No additional comments were provided.
'·
Item Four:
The difference between adaptive and
maladaptive responses to changes in the environment is
clearly explained.
All respondents indicated Category 3 (Agree) or
Category 4 (Strongly Agree) responses and none provided
further comments.
64
Steps for Using the Adaptation Model
of Health Education Planning
Item Five:
The steps of the framework follow a
logical progression.
Eighty-three percent of the respondents strongly
agreed with this item; the remaining seventeen percent
agreed.
One respondent suggested that a further descrip-
tion of how-to collect data would be helpful.
Assessment of Behaviors
and Stimuli
Item Six:
The description of the four modes of
behavioral response {physioiogical, psychological, role
mastery, and interdependency) is helpful to the conducting
of a full client group assessment.
Sixty-seven percent of the respondents felt that
the four mode description was very useful.
The remaining
thirty-three percent indicated agreement with this item.
Although indicating agreement, two respondents, thirtythree percent, commented that the interdependency mode
needed further clarification and that additional examples
would have been
heloful.
.
.
Item Seven:
Assessment for stimuli or causes of
behavior is an appropriate action for a health educator
to take.
65
All respondents agreed with this statement with
sixty-seven percent indicating strong agreement.
Addi-
tional comments related to a need for more clarification
of how data is to be collected and questions as to the
realistic application of this assessment for stimuli or
causes of behavior in actual practice; that is, is this
approach practical or appropriate for the health educator
in a work environment?
Planning
Item Eight:
Priorities seem to be in the appro-
priate order of importance.
This was the first item on the questionnaire to
receive a Category Two (Disagree) response.
One respon-
dent (seventeen percent) disagreed with this statement.
Additionally, forty percent agreed and forty
strongly agreed.
pe~·cent
One respondent felt that the item was
not applicable.
Based upon comments provided by respondents,
there appears to be confusion caused by the presentation
of priority setting criteria by this Investigator.
Priority setting criterion #7 was actually the overall
priority but was listed last, and therefore lost impact.
Also, the
11
0r 11 between #3, 4, 5, and 6 left concern as
to which was truly the more important.
'
I)
66
Item Nine:
Priority setting is based upon usable
criteria and is useful/applicable to my setting.
Fifty percent of respondents felt the criteria
were either too broad or inappropriate to their setting;
two indicated the item was not applicable and one agree
although finding the criteria inappropriate to their
setting.
Remaining respondents felt these criteria were
very applicable and recorded Category 4 (Strongly Agree)
response.
Item Ten:
Goal setting is well explained and the
relationship to the diagnostic statement clear.
All respondents indicated strong agreement with
this statement and none provided additional comment.
Intervention Specification
and Performance
Item Eleven:
Interventions based upon identified
stimuli should, logically, achieve the
de~ired
behavioral
modification.
All respondents agreed with this statement.
Eighty-three percent indicated strong agreement.
additional comments were provided.
'
~
No
67
Evaluation and Revision
Item Twelve:
The purpose of the evaluation and
revision step is clear.
Eighty-three percent of the respondents indicated
agreement (Category 3 or 4 response) with this item and
seventeen percent disagreed.
Explanation for disagree-
ment cited a lack of understanding of how the
focus of evaluation
11
11
Community
could be quantified or qualified
with an individual client as the basis for this Category
2 response.
Additional comments reflected a personal
belief that evaluation should be included in the very
first planning activity of the health educator.
Resources to the System
Item Thirteen:
Resources to the system that are
provided in the bibliography are helpful.
All respondents recorded a Category 3 (Agree) or
Category 4 (Strongly Agree) response.
None provided
additional comment.
General Items
Item Fourteen:
The figures and worksheets pro-
vided aid in the reader's understanding of the model.
Response to this item was equally divided between
Category 3 (Agree) and Category 4 (Strongly Agree).
No
68
additional comments were provided.
Item Fifteen:
The model can fulfill the function
as stat0d in the description of the model.
Sixty-six percent of the respondents agreed with
this item while thirty-three percent strongly agreed.
No further comments were made.
Item Sixteen:
This will be a useful model for me
to use in the future for planning.
Although sixty-six percent of the respondents
felt the model would be useful, seventeen percent (one
respondent) felt that it would not be useful because the
mechanisms of data collection were uncleir, and seventeen
percent (one respondent) indicated it would not be useful
in their· current setting and therefore responded "not
applicable" to this item.
An additional positive comment was provided:
"entry level health educators will· benefit greatly from
this model as a tool for planning and intervention ...
Item Seventeen:
Please indicate the model that
you currently use, if any.
Only one respondent indicated a specific planning
model in current use, the
11
Preplan Model."
Two respon-
dents indicated a use of features from various planning
models based on the specific activities undertaken.
~
69
The overall responses to the Adaptation Model of
Health Education Planning was favorable.
items received
11
Only three
0isagree 11 responses; items 8, 12, and 16
received one Category 2 response each.
Other favorable
comments provided at the conclusion of the questionnaire
included:
1.
11
Well organized.
2.
11
Th e mode 1 i s we 1 1 developed and we 1 1
11
Very impressive paper.
presented.
11
11
3.
It will serve as a
very fine guide for an effort of value.
4.
11
0verall, very well done.
5.
11
Practical application will teach what
modifications are needed.
6.
useful
11
tool
11
11
11
I think overall you came up with a very
for health education planning.
11
Chapter 6
SUMMARY, CONCLUSIONS, AND
RECOMMENDATIONS
This chapter will summarize this graduate project;
it will provide a synopsis of the process of the development of the proposed Model as well as draw conclusions
and provide recommendations for further study of the
Model.
Summary
The primary purpose of this project was to
develop a model for health education planning that specified the steps necessary to design health education programs.
This framework was to provide guidance but not
be so proscriptive as to stifle the creativity of the
health educator.
The review of the literature pertained to an
assessment of existing planning models both from within
the field of health education and from related fields
such as nursing.
Assessment for acceptability was based
upon eight criteria of an "ideal" model derived primarily from social science literature.
These criteria
include:
1.
presence of a philosophical definition of
70
71
function;
2.
specification of the importance of client
involvement;
3r
definition of key concepts;
4.
delineation of goals;
5.
listing of criteria for selection of target
behaviors;
6.
guidelines for priority setting;
7.
resources to the system; and
8.
procedure for evaluation.
A model for health education planning was
developed that utilized the Roy Adaptation Model of
Nursing as the basic framework into which relevant
health education literature was integrated.
The proposed
Model identified four steps of the planning process:
Assessment, Planning, Intervention, and Evaluation and
Revision.
Response to the Model was generally positive
and recommendations for further study were made based
upon comments provided by respondents to a questionnaire.
Conclusions
1.
There are very few health education planning
models in existence and little effort had been made to
encourage application of these models by health educators.
72
2.
There is very little consistency within the
field of health education regarding field application of
planning models; that is, there are no widely used or
uniformly used planning models in a field of study that
relies greatly on the need for achieving effective planning process.
3.
Very little effort to establish a singular
mode of planning within health education is noted in the
literature.
4.
The basic framework of the Roy Adaptation
Model of Nursing was easily adapted to form the foundation for a health education planning tool.
5.
The Adaptation Model of Health Education
Planning developed by this Investigator was generally
accepted by a sample of practicing health educators.
Their response to this conceptual framework supported
the need for a single utilitarian model to facilitate
health education planning processes.
Recommendations
Based upon comments provided by respondents, the
following are forewarded as recommendations for further
study and refinement of this proposed model:
1.
Existing criteria for priority setting should
be clarified or additional valid criteria be established.
Respondents noted that the format in which the criteria
'
~
73
within the model description were presented left confusion as to the appropriate order for selection of
behaviors for intervention.
2.
Specific suggestions and techniques for data
collection during the Assessment step should be delineated.
This will assist the user to determine how to
collect the data needed to complete the process as specified by the Model; this was a need felt by one respondent.
3.
The evaluation component should be integrated
into the framework earlier as then it can be used in the
first planning phases; one respondent felt by placing it
at the end of the model description, it became an afterthought.
4.
Specific areas to assess in the Interdepen-
dency mode should be delineated.
This concept of inter-
dependency was foreign to one respondent and therefore
the respondent could not identify, specifically, what
to assess.
5.
The Model developed by this Investigator
should be validated by field testing in a variety of
health care settings both for use with groups and
individual clients.
The Adaptation Model of Health Education Pianning,
it is suggested, could serve as an effective bridge
between the fields of health education and nursing by
using nursing theory to provide a foundation for a model
'
~
vL
75
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21.
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11
23.
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11
24.
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The
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11
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The Contract for Health Care.
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27.
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The Ethics of Health
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11
11
11
11
28.
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29.
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c
PP. 591-597.
11
30.
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31.
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11
78
32.
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33.
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"Operationalizing the Health Belief Model in a
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35.
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37.
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38.
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39.
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40.
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41.
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National Center for Health Education,
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42.
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79
43.
Kemp, Jerrold E. Instructional Design: A Plan for
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1977.
44.
King, Karen; Taylor, r·1ary; and Dignan, Mark.
Health Education Evaluation: Improving the
Product.
Health Education, September/October,
1982, pp. 19-20.
•,
11
11
45.
Kolbe, Lloyd J.; Iverson, Donald C.; Kreuter,
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Gregory.
Propositions for an Alternative and
Complimentary Health Education Paradigm.
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11
11
46.
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0n the Death of Behavior Modification:
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American
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11
11
47.
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48.
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11
49.
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50.
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51.
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52.
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80
53.
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54.
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55.
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56.
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57.
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58.
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81
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66.
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• 0
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70.
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71.
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74.
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75.
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Basic Health Education Planning Methods.
Aspen Systems Corp., Germantown, Maryland,
1978.
Z8
133HS>I~OM
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lJ~~lNOJ
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83
SAMPLE BEHAVIORAL CONTRACT
HEALTH EDUCATOR: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
CLIENT: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
DATE: _ _ _ _ _ _ _ _ _ _ _ _ __
1. Behavior to be changed:
--------------------------------
RESPONSIBILITIES
HEALTH EDUCATOR
CLIENT
1•
2.
1.
2.
3.
3.
4.
4.
5.
5.
ACCOUNTABILITIES
1.
2.
1.
2.
3.
3.
4.
5.
4.
5.
EVALUATION DATv/S:
,.
SIGNATURES:
Health Educator: _____________________________________
Client:
-------------------------------------------
-
~
~
~
'""
0
~
~
;:;
.:·
~
§
~
"'i
r::
~
~
>
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~
~
~
~'
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z~
:0:
u
~
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..
178
: NOI SI/\3~
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S8
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87
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-.......""""".... ~J
"""'"'
CALIFORNIA STATE UN!VtRSITy. NORTH"liOGE
Northridga. Cahfarr.ia S1330
Oepar unent of H•alth Science
(213) 88S.3101
Dear
As a recognized practitio:-1er in health E..;lncation, I am asl<:ing for your
evaluation and conn:.nts regarding the health education planr.in<;~ m::del that
I am proposing. This pros:c!k.-xi :rode! w::>Uld assisL the health eeucator by
specifying the activities nee<Lnd to plan health education progra,.s.
Enclosed you will find <1 copy of the m::dcl and a brief questionna.i...'"e
related to the utility of the m::xlel. .'\5 you read through ~a'-'h secti.on of
the m::del di..:scription, resp:md to the items related to W.t. S(..><..~ion while
the ma.terlal is still fresh in your wind. i'l.::ase ans.,>?r all it..c.-:~.:: o:-. the
questionnaire. I would app:ceciate your canpleted questionnaire ret".JXT!ed
in the enclosed envelope no later than May 10, 1983.
If you r.eed clarification about any item, please feel froo to c.all rre
at (213} 701-0757 (evenings) or (213) 881-0800, EXtensicn 5191 (days), or
my thesis advisor, Dr. Michael Kline, (213) 885-3101.
I sincerely appreciate your "taking the tirre needed to read the I!Odel
description a."'1Ci an~ the questionnaire. I knew that there are rrany
clairr.s to your titre, but your efforts will be used to further dt•!:ir.e the
ncdel for potential use by "new" health educat.ors.
'ltlank you very llUCh for your help.
Yours very truly,
Nancy Seck, R.N., BSN
GraduaO! Student
California State University
Northridge
Depilrt:Irent of Health Science
cc:
Dr. Micr.acl V. Kline, Directcr
Master of. Public Health Program
THC. CA.LIFOHNIA ~T-4 TE UNI','t.HSIT'\' ANO COL~EGfS
6
88
LIST OF HEALTH EDUCATORS SELECTED TO
RECEIVE INFORMATIONAL PACKETS
NAME
'
~
AGENCY
Mei-Ling Schwartz, MPH
Kaiser Permanente - Panorama City
Arthur Weinstein, MPH
Hollywood-Wilshire Health Center
Robert Huff, MPH
Ventura County General Hospital
Janet Brady, MPH
Northridge Hospital
Mitzi McClanahan, MPH
High Blood Pressure Council of
Los Angeles
Gail Pokras, MPH
Van Nuys Health Center
Julie Aldrich, MPH
American Cancer Society - Coastal
Mary Frances Flynn, MPH
American Heart Association
Barbara Kar, MPH
American Cancer Society - SFV Unit
Frank Stafford, MPH
California State University,
Northridge
Barbara Vosen, MPH
INA Health Plan of California
Ellen Eiseman, MPH
American Medical InternationalCorporate
89
POOF0S!D HE.'IL'I'H ED!JC.'\~ION
P~!~~ING ~lJD~
Quest ion!"1.c-'lir e
NA."£:
TITLE:
TYPE OF
~CY:
Hos~ital,
(-:heck one)
Volunta..ry Agcn...-y
net-for-profit
Hospital, for-profit
School
Public Health Dcpa.rt:nent
Other (pleaSE> s-;:eci.:yl
~~.:.. ;-t!.,:..:~.:.c~~i.rc i!i t.J.sed. o•~ ~'I.e r.u.~C!:"i..:.!. F:"csc.··~::cd ~~·~ ~1U Ccsc:..·i?s..:ic~
of the
p~u;:oscd
health education planning ::odcl.
in th-= evaluation of tre utility of
Please stop at t!-.e
~
~-.c
pro;X>s<Yl rrodel to he.:llth educators.
of eac.'-. SL--ction of ::he m:xl.el description and ar1svr_r
the corrcsp:>nding ite.'l'.s on t.'Us questionnaire.
Please circle t.'-.c
It is d.asigncd to assist
n~ber
of the res;:onse trat
·1'hiJ.n;<
~st
feel.in;s abcut each of ti:c follcMing state.-:-c:-.ts as
de"-elop.-rc."'lt of t..\;e prcr:oseC. .. Ad.J.;:-~~ic:1 :·b'"..le:l of
you "Disagree" or "Stro:.gly
Disa~:r~"
the reasons fo= the disagrecrru..'1t. in
you.
closely reflects
th;:·:: c.:"r.':.ribute to t.!-;e
H~th
&ucation."
t..~e sp~ce
provided.
1.
S'I'RCt-lGLY DISi\Gi<EF
3.
AGREE
2.
015.-\GREE
4•
SI'IDNGLl AGREE
~I:¥1'
If
·N-it.l' ar.y stat-..e..,..,..n.t, please provide
POSSIBLE HF.SPONSES
N.A.
yo~
APPL.IC;.BLE
90
QUFSl'IONN.-\IRE
Page 'l....u
.f(R"''Ic.N 0::' T!!E mcEL
1.
The function of tm rro::'.el is
1
2 3 4
N.A.
1
2 3 4
N.A.
1
2
N.A.
clearly stated.
2.
'l11e statarent of function i:s
congrue:1t with my beliefs
concerning the a;::?ropri.ate
role of such a rrodel.
DEF'Jlli'riO-; OF i<El" catic::?!'S
3.
The
~~epts
tinder stood.
defined are
3 4
91
QJESTICt~!AIFZ
Page ·n.::ce
4.
'l.he difference bc':".><X!."l adaptive
1
2
3
4
N.A.
and llC'.lada?tivc rcsp::nscs to
ch3.nges in the envirc.,rurcnt is
cl&.dy 8<.-pla.i."'led.
US!~lG
sr:::?S FOR
5.
'mE AD;..PTATICt·l :·VDEL OF ZtEALTil
The ste;;:;s of the
falloN a
A5Sf~?E,"T
6.
OF
f:-z.."L~.ork
1 2 3 4
N.A.
1
N.A.
logi~l p~o~=2ss~cn.
8!::~'\\l'IiJRS ~~YO
STDfu"i.!
'l'ne deS<..-ription of the four
modes of
t:!:>.:<::.WIC~i FR;·:·lE',!·~RK
~vioral
(~:hy~<io.l ogic.:;,l,
response
psyc:holcgic:al,
!:ole mast:P..rJ, and inte:-C:.:;:c:d•2!:cy)
:.S helpful to the conduct..i.nq of
a full client
gro~? assessmc~~.
2
3
4
92
QlJF.Sf10NNi'U:RZ
Page Four
7.
f.s~~ssrent
for stir.uli cr
1 2 3 4
N.A.
1
2 3
4
N.A.
1
2 3
4
N.A.
causes of bc..'B.·Jior is an
awr::>prj ate action for a
health edue<i tor to take.
!'!.ANNI:~9_
8.
Priorities
sea!l
to J:.e in t.'Je
awropriate cde.r cf
9.
i.r~-.=ortance.
Priorh:y setti.:1g is based -::n
usable criteria and t.'"..ese
cri.teri.a are usefuJ./3pplicablE<
to rey setti.ny.
93
QUESTIONN!JRE
?age Five
10.
G.:lal set.ting is '-"!11
=;>lain~
1
2
3
4
N.A.
1
2 3
4
N.A.
1
2
4
N.A.
and thF:: r:el.3.tior.shir- trJ ':he
d.iagrt:>stic
st.atc:c~1t.:. ..
I:·n'"ER•./E':':'ICN SPEC.IFICA':.'F:':!
ll.
.~:0 PE...0~~:·t-..,SCE
Intc:..-vc::tions b:ised on iccntifi<.<i
stiJTuli soo'.!ld, logically,
achieve the desired behavioral
m::rlification.
£;\lAWATIOO
12.
:::o
R£\'ISIC~
'It-e ?="'..ose of t."Je evaluation
and revision
.
~
s~p
is clear •
3
94
Qt.iESTIC.'Wl1\IPE
Page Six
RES':XJRCES '1'0 TE'..::: SYS'I'!':-1
13.
Resources to !:!'•.:. system +.:nt
1
2 3 4
N.A.
1
2 3 4
N.A.
are provided in the bihliograPf'y
are help=ul.
re;ERJ~.L
14.
ITEr'S
'r'he
ficp..~res
and \>.O;·k::!1•=cts
provided aid in
~~e
reacer's
understandir.g of the r:OCeL
15.
'ftlC m:::Ce1 can fulfill the
function as s+.:atc-:1 in t.!.e
description of the m:x'.el .
~
1 2
3 4
N.A.
95
QUESTTC~'O:JJ
Page
RF
3ev~~
1'>. 'Ihis wil.l be
il
u::e!'ul ;rodcl
1
2 3 4
for rrc to use in ::he f-..:ture
for planning.
17.
Please ir.dicate the r.a:el that you C'..lLTently use, if ar.y.
A..T"JDl TIO)l.l\L
~
CO~t'8-JT:S:
!-I.A.