CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
HEALTH EDUCATION:
A PROCESS TOWARD SOCIAL CHANGE
A thesis submitted in partial satisfaction of
the requirements for the degree of
Master of Public Health
by
Jill Beth Hyman
June, 1981
The Thesis of Jill Beth Hyman is approved:
Antfiony
AJcoc~r~
Michael V.
Dr.P.H.
Kline~ ~r.P.H.
Waleed Alkhateeb, Dr.P.H.
Chairman
California State University, Northridge
i i
DEDICATION
To all mankind, for without them
personal and social
challenge~
progress and triumph does not exist.
i ii
ACKNOWLEDGEMENTS
The following individuals deserve warm
recognition and appreciation for their prominent
contributions to this thesis:
My thesis committee, Dr. Waleed Alkhateeb,
Dr. Michael V. Kline and Dr. Anthony Alcocer,
who allowed me the opportunity to express my
contributions to health education with a new
approach.
Mariette Krecicki-Aleksinski, who as my
friend shares her loving spirit and as my
mentor generates the process of education
within myself.
Mother and Dad, whose aspirations deserve
this reward and whose allowance of freedom
has always provided the determination to
produce.
iv
TABLE OF CONTENTS
Page
APPROVAL .
i i
DEDICATION
i ii
iv
ACKNOWLEDGEMENTS
LIST OF CHARTS
vii
ABSTRACT
vi i i
Chapter
1.
2.
3.
INTRODUCTION . . . . . . .
Statement of the Problem
Purpose of the Project
Assumptions . . . .
Limitations . . . . . .
Definition of Terms
OVERVIEW OF PHILOSOPHICAL
TH EO RI E"S . . . . . . .
Philosophical Theories
Idealism . . . . .
Rea 1 ism . . . . .
Logical Positivism
Pragmatism . . .
Existentialism .
HEALTH EDUCATION: A PROCESS
MODEL
. . .
Philosophy of Health . . .
Philosophy of Education
Philosophy of Health
Education . . . .
Validation of Health
Education . . . .
v
1
6
6
7
8
9
12
15
15
17
20
23
26
29
30
34
34
35
Page
Chapter
4.
CONSCIOUSNESS AS A BASIS FOR
SOCIAL CHANGE . . . . . . .
Individual Consciousness
Community Consciousness
Values and Incentives
For Change . . . .
Social Awareness and
Social Change . . .
Health Education and
Social Change . .
Plan For Change . .
5.
SUMMARY, CONCLUSIONS,
RECOMMENDATIONS .
Summary . . . .
Conclusions . .
Recommendations
BIBLIOGRAPHY
40
41
45
49
52
53
64
68"
68
70
73
74
APPENDIX
I
THE RELATIONSHIP BETWEEN
POVERTY AND HEALTH
vi
83
LIST 0 F CHARTS
Chart
I.
II.
Page
THE SCHEMA OF THE MORBID
EPISODE . . . . . . . .
91
THE PLACE OF THE MORBID EPISODE
IN THE SOCIAL INTERACTION
PATTERN . . . . . . . . . . .
93
vii
ABSTRACT
HEALTH EDUCATION:
A PROCESS TOWARD SOCIAL CHANGE
by
Jill Beth Hyman
Master of Public Health
The role of health education in the process of
social change has become a subject of much inquiry.
While this role has been defined and re-defined, health
education has not been fully recognized as a process
which has the potential to modify individual and social
afflictions.
This study explored the notion that health
education can elicit social consciousness which in turn
can induce social action resulting in social change.
Health education has been described as a process used to
develop this change.
Poverty has been used as an
example of a social problem that is seemingly amenable
to social change efforts and its intrinsic relation to
health status.
viii
Five philosophies have been identified which can
be used to produce a frame of reference for the reader's
own philosophy.
Examples of Idealism, Realism, Empiri-
cism, Pragmatism and Existentialism have been described,
with special attention paid to their implications in
health education practice.
The philosophy of health as a right and as a
state of being have been examined and the philosophy of
education has been addressed.
Jointly, the health educa-
tion philosophy has been regarded as the process which
has the potential to elicit social change.
This work is designed as a compilation of philosophies and topics for use in the continuation of the
generation of the education process of all peoples to
promote a productive society.
Health education is examined as a process which
may induce social change.
Poverty, a social issue which
impedes health is a variable which may be manipulated by
the health education process.
Social consciousness and
social change are processes which are expected to result
from the process of health education and which in turn
may diminish the poverty condition.
The literature has verified that health education
is a valid means of providing individuals the information
necessary to initiate decisions concerning health
ix
behavior.
The literature also substantiates health
education as a process which is necessary and successful
in producing better health in America.
Consciousness has been presented as a basis for
social change.
Individual and group consciousness are
described as the initial steps in the process of social
change, where awareness of self and community are motivating variables in the organized efforts to elicit
social and political change.
Examples of health educa-
tion eliciting social change have been presented and
failure of health education as a process in social
change has been discussed.
Incentives devised to over-
come obstacles in change have been provided.
A plan for
change which utilizes major health organizations as
facilitators in educating the public for change has been
devised.
The literature strongly supported the hypothesis
that poverty represents a specific social condition
which affects most aspects of life including health,
illness and related behavior.
Aspects of poverty and
health have been discussed according to medical and
social models to aid in the understanding of poverty and
health as interdependent concepts.
The Author concluded that health professionals
should redefine the scope and methods of disease
X
prevention and treatment to make them consistent with
knowledge about causes of disease.
responsibility 9f
11
It is not the
Someone else .. to deal with social and
economic factors while physicians and other health professionals emphasize such variables as early detection,
sanitation, immunization or health compliance.
These concepts are not new.
It is not expected
that every health professional abandon their profession
to lead a social movement.
Nor does the Author recommend
the abandonment of proven medical technologies and therapies.
It is suggested, however, that evaluation take
place with regard to each set of methods in relation to
the larger physical, social and economic contexts which
propagate disease.
Recommendations are included which provide health
educators with suggestions for follow-up or extending
the exploratory areas initiated in this work.
xi
Chapter 1
INTRODUCTION
Since the emergence of health education as a
discipline, health educators have searched for an
accepted role.
During this period of self-identification,
several educational and social functions have developed
into a professional role.
Spokespersons for this pro-
fession conceive health education to be both a part of
the health care delivery system and a mechanism for
social change.
However, structural and ideological
forces anchor the profession's practice more in
system
11
11
than among the forces for change (37:67).
the
In
its frustrated drive for professional autonomy, health
education has become a conservative agent in the very
arena in which it claims expertise and leadership as a
catalyst toward progressive social change (9:3).
Most
practitioners have seen community-wide problems as maladaptions of groups to society which are correctable
through professional community intervention.
Seldom
have public health professionals considered the social
conditions and structures as the primary causes of social
problems (9:4,5).
2
Theories from social psychology, sociology and
social welfare together formed health education•s
munity organization theory ...
11
com-
Community organization is
often claimed to be a technique of social change but
more often becomes a conservative social adjustment
role (115:39-58).
Health educators have applied these
community organization concepts of planned change to the
health field.
Community organization provided an ideo-
logical justification for administrative techniques
masquerading as methods of social change.
of the health educator to regard
s~cial
The tendency
class differ-
ences as sources of conflict and the treatment of these
differences as influences on behavior is an example
(9:7).
Health educators have been concerned less with
what should be changed than with how the change should
be accomplished.
The concern of process, has overridden
the concern for enabling people to develop rational insight into their lives on which to base personal and
community decision.
Behavior change has been the index
of health education and the effectiveness of health education has been measured by this change, not in reducing
morbidity and mortality statistics alone (40:13-17).
focusing on behavior alone, health educators have
neglected the social relations and structures that may
underlie and contribute to the behavior patterns
By
3
they find objectionable and diseases they wish to prevent.
Factors such as the alienation of people from
their bodies, stressful working conditions and inadequate
nutrition due to insufficient income or food supply have
not adequately been considered.
The classic study of
lead poisoning among Black children in a Cleveland ghetto
is an example (13:324).
blamed
11
The eating of lead paint was
permissive socialization of oral behavior 11 by
Blacks, rather than inadequate building maintenance of
the slumlord.
Health education programs often rely on techniques that manipulate behavior rather than facilitating
an individual or group's ability to influence and control
their environments.
Such programs reinforce the notion
that the individual becomes responsible for his own
victimization.
For example, persuading smokers to quit
is in the interest of health education.
Yet, when
smoking behavior is in response to stressful conditions
and smokers are not encouraged to examine or change the
conditions which create stress, then anti-smoking campaigns become victim-blaming campaigns.
The practice of
displacing people's attention and energy from changing
the social context of behavior to changing individual
behavior
le~ves
a major problem area untouched.
4
It has been shown that
11
Crash 11 public health pro-
grams such as anti-smoking campaigns and weight loss programs have little effect in teaching health values or
commitment to action to dissatisfied individuals of society (64:10).
People at some time in their lives may
encounter what they may perceive as an injustice or indignity.
Each may have a different method of response
to these conditions.
The commonality among any method of
response is the emergence of awareness by society of
dissatisfaction among its people.
The literature contains many attempts to explore
the relationship between health education and social
change.
Some 1 iterature emphasizes community organiza-
tion as a technique used to achieve social change.
Other
sources describe the processes of health education and
use of specific programs as techniques which may alter
social problems.
Still other references discuss indivi-
dual and/or group behavior change as it relates to social
change.
This literature contributes to the understanding
of the social change process.
It appears, however, that
the concept that health education induces individual or
group consciousness, and this consciousness activates the
process of social change is analyzed in a fragmented
manner.
It seems that there is a major gap in the liter-
ature which relates the different components as they may
5
be involved individually or in combination with social
change.
For example, the literature discusses poverty
as a social problem.
The literature also discusses
poverty as a major cause of ill health.
However, the
relationship between health education as a process used
to change the poverty condition is explored in a limited
manner.
The individual components of health, poverty
and social change are approached in a one-dimensional
manner.
It appears there is a failure in relating the
processes of health education, individual consciousness,
group consciousness and social change as inter- as well
as intrarelated processes.
It is the Author•s belief that the functions of
health educators must include more than the design and
implementation of specialized health education programs
and that the goals of health education must represent
more than the attainment of good health.
The need
exists to increase both the ability of people to exert
maximum power over their individual lives and increase
their ability to change the social relations and structures in which they live and work.
6
Statement of the Problem
There is a need to further explore the relationships between health educaton, social change and the
modifying elements, components and forces which may
affect these processes.
The added dimensions of sex,
age, culture, ethnicity, value orientations, training,
experience, levels of knowledge and individual philosophies contributes to the way in which health educators
attempt to tailor their "product
11
or process to achieve
individual and/or group consciousness. Thus, there is a
f u r t he r n e e d to a n a 1y z.e the s e d i me n s i o n s wi t h reg a r d to
their impact on and involvement with the ultimate process(es) of social change.
Pu~pos~
of the Project
It is the purpose of the project to:
1.
Develop a theoretical framework which ex-
plores and analyzes the postulate:
Health education may
induce individual and/or group consciousness, and these
forms of consciousness may be involved in activating the
process(es) of social change.
2.
Identify some of the important modifying
elements and forces which bridge the existing gap
between the techniques of health education used and
7
their possible impact in achieving social change processes.
3.
Demonstrate the utility of the theoretical
framework which is developed by presenting selected
examples which illustrate the potential that health
education may contribute in the achievement of social
change.
As~umptions
Three assumptions underly the development of the
theoretical framework which will be developed.
The
nature of these assumptions infer that social change can
occur as a function of utilizing
tion techniques.
1.
s~lected
health educa-
The assumptions are:
Health education techniques increase social
consciousness;
2.
There is a direct relationship between
social consciousness and social change.
A corollary pre-
supposition regarding social consciousness is the assumption that:
man is a learning, becoming animal. that man•s
essence, his being, is a self-affirmation of power
which makes it possible to speculate about the
impingement of demands of our culture on him (64:7).
This capacity to learn, this need within each
individual to form the individual lifestyle that is selfaware, self-critical and self-enhancing is the beginning
8
of becoming.
It is this part of that nature of man which
is in direct conflict with imposed values (43:7).
3.
The research literature surveyed is assumed
to be current, accurate and objective and demonstrates
the highest level of social scientific competency within
the scope of the behavioral sciences.
/support for these assumptions will be obtained
from the following sources:
a.
literature relating to the philosophy
of health, education, and health education;
b.
literature pertaining to the definitions
and functions of individual and social
consciousness;
c.
literature which exemplifies specific
health education programs and their
relationships to social change, and;
d.
literature which substantiates the
relationship between poverty and health.
/Limitations
1.
The inquiry is limited to the current litera-
ture reasonably available to the Author on health
9
education, individual and group consciousness, social
change and the relationship between poverty and health.
2.
The above mentioned topics have been
selected to support the postulate that health education
may ultimately initiate social change.
They are selected
topics only and do not represent the entire scope of
thought.
3.
The interrelatedness of the selected topics
limits the parameters of the investigation and the amount
of content to be reviewed and discussed.
Definition of Terms
The following definitions have been established
to standardize the meaning of terms so they may be used
consistently throughout the project.
Health.
The condition best suited to reach the
goals that each individual formulates for himself
(21 :279) so that he can function in a manner acceptable
to himself and to the group of which he is a part
(21:261).
Educatfon.
The scientific process by which
every human being, no matter how ignorant or submerged
in the culture of silence he may be, is capable of
looking critically at the world in a dialogical
encounter with others.
Provided with the proper tools
10
for such encounter he can gradually perceive his personal
and social reality as well as the contradictions in it,
become conscious of his/her own perception of that reality and deal critically with it (24:13).
Povetty.
A relative term that reflects a judg-
ment made on the basis of standards prevailing in the
community.
The standards change in time and place.
The
poor are those who, by these prevailing standards, are
found to be deficient in means of subsistence and privileges of life (44:2).
Organization.
A means of achieving and guiding
local control over problems that originate elsewhere in
society (22:11).
Community.
The combination of social units and
systems which perform the major social functions having
locality relevance; the organization of social activities
to afford people daily access to those broad areas of
activity which are necessary in day to day living (96:9).
Change.
The process in which an organization
is formed to redress a power imbalance or open up a
service network.
Specific social structures are con-
fronted to modify functions within the social system
(22:12).
Community Health Action.
a) the altering of
human attitudes and behavioral patterns through
11
education, exhortation and a number of other methods for
stimulating self-development and fulfillment;
b) the
altering of social conditions by changing the policies
of formal organizations.
amount, the
quality~
It is undertaken to modify the
the accessibility and the ringe of
goods, services and facilities provided for people;
c) the reformation in major legal and functional systems
of a society.
It relies upon political agitation and a
host of other instruments for coping with powerful trends
and developments (15:23).
Social Consciousness.
The learning to perceive
social, political and economic contradictions and to
take action against the oppressive elements of reality.
The deepening of the attitude of awareness characteristic
of all emergence (24:19,101).
Social
C~ange.
The altering or modification of
a social discontent by individuals or communities in an
effort to produce results which are beneficial to those
individuals or communities.
Process Model.
A method of education which is
a series of actions and operations leading to advancement and growth.
Chapter 2
OVERVIEW OF PHILOSOPHICAL THEORIES
Because each health educator operates from an
individual value system, it is necessary to establish
guidelines which identify the author•s frame of reference.
Prior to the establishment of any frame of reference, it
is important to develop a philosophy on which to base
beliefs and actions.
Since the beginning of time man has searched for
ways to improve the quality of life.
In his search, he
has faced choices and decisions which have had an impact
on individual and societal betterment.
It is assumed
that man desires a choice which results in the most positive consequences.
Thus, of primary importance is the
search of knowledge which helps to reduce the element of
error and risk in his decisions and choices.
A continu-
ing concern in his search for self-development is the
acquisition of knowledge and understanding upon which he
can rely for guidance and direction and which can serve
his immediate needs and purposes.
In short, the central concern of man in all ages
has been the search for the good life and the development
of guiding principles, sets of answers, processes or
12
13
procedures and ways of obtaining knowledge that would
guide his way to his attainment (25:93).
In an effort to achieve the good life, man has
sought guidance and direction from different sources.
Such traditional methods have included the interpretation
of storm signals in the heavens and changing of the seasons.
Witch doctors and voodoo have been replaced by
religion and government.
For some, these methods have
generally failed to work and some individuals have
realized that the quality of life may not be found through
these means.
As a result, other sources of direction and
guidance have been adopted.
Since the future remains
unknown, the act of decision making without knowledge
of consequences becomes a difficult task.
In an effort to reduce decision errors and to
increase the chances of self-fulfillment, individuals
have developed elaborate theories explaining the quality
of life and ways to achieve that state.
These theories
are termed "systems of philosophic thought" and are based
on known and unknown assumptions about what is best
( 25: 94) .
Several competing theories have arisen which are
used as guides to the individual's future.
All are
important because the theories influence each individual's
actions and decisions in improving the self and society.
14
Since each philosophy vies for man•s trust and claims
itself as the sole process toward self-actualization, man
himself must choose the philosophy best suited to his
needs.
Each philosophy results in different consequences,
life implications and problematic solutions which have
affected individuals throughout time.
It has been mentioned that bne•s search for selfactualization contains the scientific process of education
by which individuals are provided with a variety of alternatives from which to choose.
The decision to adhere to
a particular philosophy is the decision upon which education depends.
Education by its very nature is concerned
with the achievement of quality life.
Health by its very
nature is the precedent to quality life.
Thus, in the
utilization of public health techniques to increase personal and social advancement, a philosophical base on
which to build viable programs is necessary.
The impor-
tance of philosophic thought in health education is succinctly verbalized in the following statement:
Man at long last realizes that philosophizing
is not merely an academic exercise but is a process by which he generates the ideas and forces
that literally guide and shape the development
of all mankind (25:95).
15
Philosophic Theories
Since health education can be a process which
shapes the development of mankind, it too must originate
with a philosophical system of-thought.
The health educa-
tor who desires to provide effective leadership and
meaningful information must determine for himself beliefs
and values with which he faces the future.
One must place
their own confidence in the philosophical system which is
believed to pave the way to their perception of quality
life.
The philosophies of Idealism, Realism, Logical
Positivism (Scientific Empiricism), Pragmatism and Existentialism will be reviewed.
After careful analysis of
each system of thought, the author will choose a philosophy on which to base this exploration of social change
through public health education.
Idealism
The philosophy of idealism is deeply imbedded in
Western Civilization.
Ancient Greek scholars developed
the philosophy of Idealism.
The influence of Idealism
was further perpetuated by the Hebrew-Christian tradition
(10:134).
Modern idealism was developed by German
scholars, of which Kant and Hegel were among the most
prominent.
16
Ideological Assumptions
The idealist assumes that ultimate reality consists of a system of great ideas that are universal,
enduring and absolute.
These ideas, by some universal
spirit or mystical power transcend everyday experiences.
The universal system of ideas that come before experience
is the only real existence.
That part of life which is
exposed to empirical scrutiny is not the real world.
The
real and ideal worlds exist in a separate sphere and are
systems of perfect ideas which can only be reached by
intellectual activity.
Thus, the first assumption of
Idealism is the dual nature of the universe:
World I is
a perfect (real) world of ideas and World II is the world
of everyday experiences.
It is the major objective of
education to assist the mind in narrowing the gap which
exists between these two worlds (25:102-03).
The implication of this philosophy to health is
the universal assumption that health and health care are
rights to which all individuals are entitled.
A second assumption of Idealism is the dual nature
of man.
Man is seen to possess a two part personality;
the mind or soul (which is the real self) and the body.
The third assumption of Idealism explains the
universal nature of truth.
The Idealist believes that
since truth exists in another world and is not a creation
17
of the individual or society, it is absolute and universal.
Man is said to establish contact with this world
through pure reason, intuition or transcendental reality,
which is uncontaminated by empirical data.
The ultimate
truth is validated by the use of rigorous systems of
logic.
If the test of logic was agreed upon by the great
thinkers of the time, then the truth was valid (25:110).
The nature of values is the last assumption underlying Idealism.
Idealists profess that man must strive
for values in order to avoid immoral experiences.
The
idealist assumes that ultimate values exist and that these
values are unchangable and defy the methods of science
(25:112).
The Idealists• rrature of values can also be applied
to the health field.
Values clarification in health,
health care delivery and health education is a popular
method used in these fields to identify and elicit
consciousness of individual feelings and values.
Some
controversial subjects addressed in values clarification
are pre-marital sex, birth control, abortion, drug abuse,
euthanasia and cancer therapy.
Realism
The growth of realism has paralleled the development of the sciences.
The early descriptions of Realism
18
were exemplified in the writings of Comenius, Locke and
Herbart (26).
These realists viewed the scientific me-
thod as the means by which true knowledge in the universe
could be discovered.
Ideological Assumptions
The realist believes that the physical world in
which man lives is the constitution of reality.
Reality
exists on its own; it is not dependent of man's knowledge
of it.
Reality exists
11
0ut there .. to be discovered.
It -
may be d i s covered , but even i f i t i s no t, i t s t i 1 1 ex i s t s .
An application of this concept in health can be exemplified by diseases.
Diseases are concepts, not:·things.
They are physical realities which are manifested by observable sfgns and symptoms which come to be labeled as
a specific disease._ For example, sickle cell anemia is a
genetic reality.
reality.
Yet a
carri~r
may be unaware of this
Upon recognition, behavior of the carrier may
change, but the physical reality remains the same.
The realist assumes a rational world, characterized by orderliness, in which many realities may exist.
By scientific analysis one can discover certain regularities characterized by this orderliness which are universal truths or natural laws.
of consciousness.
the universe.
The laws exist independently
These laws govern the operations of
The phenomenon of change or evolution is
19
explained as a change in process but not a change in
truth itself (25:127).
Man•s mind at birth is viewed as a blank state.
It does not have within itself dormant ideas which are
later released.
Instead, the mind is an accumulation of
sensory experiences stored in an
11
appercepti ve mass.
11
Stored knowledge which has been proven by universal
scientific analysis is released by the process of thinking.
Answers are only previous experiences stored in
the apperceptive mass.
Idealistic thought describes the nature of truth
as being embedded in matter.
one
The more objective knowledge
can obtain about the universe, the close he comes to
the truth.
By utilizing the scientific method, man ap-
proaches the universal truths (25:130).
The nature of society is not discussed by the
Idealists.
It is approached in the same manner as all
concerns of the Realist:
objective evidence about society
will reveal common universal truths.
These truths are
passed on in the form of cultural heritage.
The realists
concept of society is composed of three basic beliefs:
1)
2)
3)
There is a world of real existence
which men have not made or constructed;
This real existence can be known by the
human mind, and;
Such knowledge is the only reliable guide
to human conduct, individual and social
(99:6).
20
The realist assumes that the universal laws of
group behavior can be discovered.
Society is perceived
as operating according to natural law.
As man understands
and obeys 1 aw, soc i e ty wi 11 fun c t i o n i n an o r de r 1y fa s h i on.
Man mus t de t e rm i n e where he as an i n d i vi d u a1 f i t s i nto
society as prescribed by natural law.
Regarding the nature of values, two theories are
represented by Realism.
First is the theory that values
are indefinable elements which cause the individual to
prefer one thing over another.
Second, values represent
attitudes of the being who is experiencing them.
Regarding ethical values, the natural law is the
moral law.
Man lives the moral life to the extent that
he is capable of obeying the natural laws.
values the same applies.
For aesthetic
Anything that can be objecti-
fied may become value, but such emotions as pain, sorrow
or terror can also be aesthetic if they are adequately
objectified (25:134).
l:Q_gical Positivism (Scientific Empiricism)
Logical Positivism claims inseparability from
modern science.
Auguste Comte is accorded credit for
originating the early positivist philosophy.
Modern
development is credited to a group known as the Vienna
Circle (1920).
Most logical positivists are analytic.
21
Analysis of minute details of philosophy is characteristic
of this philosophy rather than a general development of a
philosophical world view.
Logical positivism may be re-
ferred to as an epistemology because its major contribution has been the development of methods for analyzing
and clarifying ideas, concepts and assumptions.
IdeolDgical Assumptions
Logical positivist do not speculate about a two
world reality or a dual nature of man.
Once the necessity
of empirical verification for knowledge is accepted,
speculations about the existence of entities such as God
or the soul·become' logically meaningless and impossible
to verify.
The empiricist attacks all philosophical
thought which does use empirical validation for analysis
of all that exists.
Logical Positivism views any assump-
tion about the nature of reality with skepticism.
The
only meaningful way to discern reality is in terms of
what is knowable.
The elements that are known are repre-
sented themselves in the reality that is known.
Any
other concept of reality is merely a speculative illusion (25:150-51).
The empiricist would defy the concepts of spiritual
healing or wholistic medicine because these treatments
are not identifiable by empirical evidence.
that mental illness may be viewed similarly.
It is likely
Since
22
certain behaviors are not microscopically recognized,
these behaviors may be said to be a speculative illusion.
Scientific empiricism utilizes empirical verification to identify truths.
Since much of what individuals
assume to be truth is not really so, it is difficult to
comprehend this empi.rical scrutiny.
From a positivist
position, much of what is termed knowledge is in fact,
meaningless.
For example, religion, poetry or ethics
have no cognitive validation and are therefore unverifiable.
Because they cannot be verified, they are meaning-
less and thus cannot possibly be true.
incapable of
bei~g
Because they are
true they cannot possibly pose a
rational or logical choice for humans (49:377).
According to Levi (1959) logical empiricists
identify three basic themes:
language.
logic, perception and
These interests defy the belief that hypotheses,
propositions and assumptions constitute true knowledge.
Thus, to the positivist, anything meaningful must be
verified by empirical data.
The method of verification
must be clearly stated in empirical terms and this is
knowledge.
This scientific knowledge which is the body
of empirically verified data and which has been clarified
by logical analysis is the only genuine knowledge.
For the empiricist, values are also meaningless.
Empiricism argues that scientific method cannot operate
23
in the area of morals and values because they are metaphysical elements.
Empirically speaking the concept of
knowledge exists independently of any value judgment.
As
soon as one imposes values, one has diverged from the
techniques of science and has entered into speculative
thinking.
Value judgments cannot be validated by empiri-
cal scrutiny.
This philosophy cannot be scientific and
answer questions of
11
0ught 11 and "should 11 simultaneously
(25:156).
For the empiricist then, values clarification in
health education would not be a logical or rational
choice.
Pragmatism
Two of the early promoters of this philosophy were
William James and John Dewey.
These men followed the
Heraclitian philosophy which was the forerunner of modern
Pragmatism.
The Pragmatic philosophy maintains that:
the real essence of ideas is to be found in
their utilization as guides and behaviors. That
is, the meaning of an idea is to be found in how
the idea operates when put into practice (25:167).
Butler further clarified this point by eiplaining that
whenever an idea is put into practice, the consequences
of that experience constitute the meaning of that idea
( 1 0) .
24
Ideological Assumptions
According to Graff (1966) the Pragmatic philosophy
rests upon five general concepts:
1.
In terms of present understanding of our
it is impossible for human beings to
gain knowledge of ultimate reality. There is no
evidence that ultimate truths have in fact been
established. History is filled with examples of
"ultimate truths 11 that have been disproved or have
otherwise fallen into disrepute.
2. The universe is in a constant state of
change and motion. Nothing remains the same. The
universe is expanding and is in a state of continuous creation.
3. The world of ideas as we know it is incorporated in systems of symbols, letters, words and
mathematical formulations. These symbols as such
have no reality in themselves but refer to items
of practice and ways of doing things. To test
the meaning of an idea it must be put into practice.
The consequences that follow will reveal the meaning
of the idea.
4. The scientific method is the most valid way
of testing ideas. When ideas are translated into
hypotheses and these hypotheses are tested by
experience, the result is the nearest approach to
real knowledge available to man.
5. The sacial aspects of living are important
to man. Without social contact man•s development
would be limited.
universe~
Pragmatists apply these principles to areas of
human existence.
When describing the nature of the uni-
verse, pragmatists accept the world of sense impressions
and scientific study and reject the supernatural notions
of perfect ideas as ultimate reality.
The pragmatist is
concerned with scientific facts within the universe:
interstellar measurement, theories of relativity and
forces of energy.
The Pragmatic philosophy accepts
25
evidence that the universe is in a state of continuing
creation.
From the pragmatic viewpoint, reality cannot
be defined.
To know reality is to immerse oneself in
experience.
Pragmatism is concerned with the search for truth
and knowledge.
However, pragmatic philosophers reject
the concept of a pure and unalterable truth.
Rather, in
the changing and creative universe of pragmatism, the
possibility exists that man does not follow
11
Ultimate
laws 11 but participates in the creative process and shares
in the determination of his destiny (25:175).
Hansen
(1960) summarized the pragmatic philosophy as it applied
to the natures of truth.
experiencial.
He described the pragmatist as
Although scientific validation is
importan~
the principal method for discovering the truth is the
intelligent experience of human reasoning (26:77).
Application of this philosophy to the nature of
man results in the perception of each individual as a
unique part of nature.
Man's mind and body are integral
parts of the organism.
These mechanisms allow man to
cope effectively with the environment.
Social interaction is of basic importance in this
philosophy.
In man•s interaction the moral one is that
person who considers the consequences of behavior and
assumes responsibility for actions.
26
Pragmatists may feel that ill health is among the
social problems potentially remedied by scientific knowledge.
If illness is indeed a social problem, then sci-
ence can be utilized for asserting action on a given
health dilemma.
There is a cyclical relationship between
individual health needs and scientific procedure.
Health
needs prompt scientific exploration and correspondingly
scientific exploration can be beneficial in minimizing
ill health.
Thus, individual health needs taken col-
lectively are the determinants of the social parameters
of the health continuum.
The pragmatic individual prac-
tices both self-direction and self-discipline with regard
to health behavior.
Exi~t~rttialfsm
The father of existentialism is thought to be
Soren Kirkegaard (1800's), followed by Frederich Nietzche
and Jean-Paul Sarte (1900's).
The philosophy places com-
plete freedom to choose as its highest priority.
Man,
when free from extraneous influences, will exercise his
freedom in making choices necessary to become what he
wants himself to be.
IdeOlOgical
A~sumptions
Existentialists view reality as an entity which
must be discovered, not by empirical evidence, but by
27
man 1 s own-decisions of what he is, who he is and what his
reality is (61:76).
tial reality is
11
According to Kneller (1958) existen-
the world of existing.
11
In order to
know reality, one must meet, experience and become involved with it (42:3).
Man is the definer; nothing has
meaning except as man gives it meaning.
exists, nothing is real.
Except as man
If man is to know reality, it
is with his knowledge of self, emotions and soul, without
outside influences of God, government, science or social
conformity.
The existential view of the nature of man was best
articulated by Sarte (1947).
only after he defines himself.
He proposed that man exists
Man is what he conceives
of himself; he is what he wills himself to be.
He is
nothing other than what he makes of himself (80:18).
The application of this concept can be exemplified
by the
11
Sick role" as described by Talcott Parsons earlier
in this work.
When an individual defines himself as
ailing, he then occupies the sick role.
Wild (1955) proposed that the question of what man
is can be given no definitive answer.
he is, but that is all.
It is certain that
No superior intelligence con-
ceived of the idea of man prior to his existence.
Thus,
there is no point of reference for man to shape his
destiny.
If one seeks guidance or direction from God,
28
science, cultural beliefs or valuesr or any other external
force, he deprives himself of his dignity and freedom
(15:202).
The major concern of existential. values is man's
complete freedom to choose the values by which he lives,
without having them first assigned the values of good or
evil.
For the existentialist, values are dependent upon
the definition given to them by each individual.
Indi-
viduals would never choose -what is undesirable, so no
value is ever bad.
Congruent with Pragmatism, existen-
tialists advocate personal commitment and responsibility
to the values chosen and the consequences resulting from
those chosen values.
After determining health values. the existentialist
will always choose the most beneficial health decisions
because existentialists avoid undesirable choices and
thus a desirable choice is preceeded by
11
Correct 11 values.
Existentialist philosophy proposes that everything
that happens to man happens because of man.
Man inter-
prets all evidence as he wishes so empirical evidence is
useless.
Every man chooses, without extraneous influences
the values which have individual meaning.
Chapter 3
HEALTH EDUCATION:
A PROCESS MODEL
Before utilizing health education as a method to
elicit social change and improve health status.(the philo- ~
"
'
sophies of health and health education will be ;eviewed_)
It is difficult to separate the two philosophies, as each
contributes greatly to man's thinking.
philosophy penetrates this work.
The Pragmatic
The marriage of theory
and practice in Pragmatism is important in its application
to health education.
The aspects of practical experience
and scientific experiment are the roots on which health
education programs and social change are anchored.
existential view is also relevant:
freedom of choice is important.
An
For the existentialist,
The health educator
should always respect freedom of choice in eliciting
behavior change.
The "practice of freedom 11 is the means
by which individuals may participate in the transformation
of their world (24:13).
Pragmatism and Existentialism
view man as the determining agent of existence.
Freedom
of choice is a motivating factor in man's struggle for
self-enrichment.
Thus, these philosophies describe the
all-encompassing nature of man in the attempt to modify
the physical, social and/or economic environments in which
29
30
he lives and works.
The definitions, philosophies and strategies of
health education and the health educator have repeatedly
been analyzed.
disputed.
The need for health education cannot be
Nor can it be denied that there has, to date,
been novel concepts hypothesized, innovative techniques
applied and health behavior advanced in the field of
public health education.
The aim is not to redefine
existing definitions but to formulate some basic ideologies of health and education as concepts on which to base
health education as a necessary vehicle for social change.
lHealth education becomes the unifying process which not
\
only induces social change but which also aids in the
establishment of health education as an individual entity
wi t h a p r o f e s s i o n a 1 i d en t i t /.--\
~
Philo~ophy
of Health
This section will discuss the philosophies of
health and education as separate disciplines.
The com-
bined science of health education will then be reviewed.
After clarification of these concepts, the validity of
health education will be evaluated.
Antecedent to the combined concept "health education" are the philosophies of "health" and "education
independent disciplines.
11
as
It has been said that "neither
31
health nor education are ends in themselves, but both
are essential to realization of the human potential
(20:955).
11
A brief ideological description of each subject
independently helps to visualize the concepts together as
the process of health education.
Dubas {1959) viewed
health as a right, while Knowles {1975) and Kass {1975)
described health as a state of being.
Health as a Right
According to Rene Dubas, man's instinctive desire
for health and well being originated from the Greek goddess Hygeia, who represented health as the natural order
of things (21:131).
Health is a positive attribute to
which individuals are entitled if they govern their lives
wisely (21:131).
health as a right.
Dubas explained a second notion of
For some, the belief in life as a
.. golden age .. meant an existence free from grief and despair.
The
11
golden age 11 concept meant many different
things to many different people but the very belief in
its existence implied the conviction that health and
happiness were birthrights of men {21:1).
Concominant
with this view was the belief that good health was equivalent to medical care.
The process of prevention re-
placed the process of cure.
Today people's expectations
32
of medical care are so high that medical care is also seen
as a right (16:667).
Health as a State of Being
Knowles (1975) and Kass (1975) summarized the conflicting view of health and medical care as rights.
They
questioned the existing idea that individual responsibility has been submerged in individual rights to be
guaranteed by a beneficent
11
big brother
11
public and private institutions (16:669).
and delivered by
Kass supported
the view of health as a state of being:
... but if health is what we say it is, it is
an unlikely subject of a right in either sense.
Health is a state of being, not something that
can be given, and only in indirect ways something
that can be taken away or undermined by other
human beings. This excellence of soul and body
requires natural gift, attention, effort and
discipline on the part of each individual who
desires them. To make health someone else•s
duty is not only unfair, it is to impose a duty
impossible to fill. Health is a duty; one has
an obligation to preserve one•s own good health.
The theory of a right to health serves to undermine personal responsibility, and in addition,
places obligation where it cannot help be unfillable (16:669).
The health education process is utilized according
to the philosophy of health imposed by different health
educators at different times.
It is assumed that man instinctively desires health
and well-being (21:279).
However, for some, indeed for
33
most, the definition of health is not limited exclusively
to biological or physiological vigor.
It is, instead
the condition best suited to reach goals that
each individual formulates for himself. Usually
these goals bear no relation to biological usefulness. More often, the pursuit of health and happiness is guided by urges which are social rather
than biological, urges which are so peculiar to
man as to be meaningless for other living things
because they are of no importance for the survival of the individual or the species (21:279).
In accordance with the Pragmatic view, health is
an active entity.
Man•s individual definition of health
flexes with the changes in his environment.
Each person•s
pursuit of health is accomplished by exposure to a variety of positive or negative experiences.
These experi-
ences are internalized and analyzed according to its
merits and is acted upon to suit one•s needs.
To promote positive health behavior one must function on more than common knowledge.
must be utilized as well.
Scientific knowledge
On this premise, health should
ideally be a science, though it is not always considered
as such.
The study of health takes scientific laboratory
data and translates it in terms of its effect on the
human organism.
34
Philosophy of Education
For the purposes of this project, it has been
established that
the scientific process by which every human
no matter how ignorant or submerged in
the culture of silence he may be, is capable of
looking critically at his world in a dialogical
encounter with others. Provided with the proper
tools for such encounter, he can gradually perceive his personal and social reality as well as
the contradictions in it, become conscious of
his own perception of that reality and deal
critically with it (24:13).
being~
Education, then, is seen as the means by which one
deals critically and creatively with reality (24:13).
A
practical definition of education is described by Raikes
(1976) as a systematic course of training and instruction.
Philosophy 6f Health Education
Via the Pragmatic viewpoint, if science is a social
vehicle necessary in solving social maladies and both
health and education are scientific processes which provide the instruments by which social man can perceive,
evaluate and act upon his changing environment (24:13)
then health education is a vehicle by which health educators provide the individual with the components needed
to both confront and remedy potential or existing conflicts as well as manipulate his condition.
35
Critics of the
11
freedom of choice 11 philosophy may
argue that giving individuals a multiplicity of variables
from which to choose may be non-directive in nature.
How-
ever, Pragmatism argues that although one should supply
several avenues of experience, these experiences can be
directive in nature.
The information provided to indivi-
duals in health education should not only be descriptive,
but should take into account the consequences of one•s
behavior contingent upon that information.
It is the author•s belief that man•s action can be
directed through education.
Control should not be mis-
construed to imply constraint of freedom.
Health educa-
tion, while being directive, provides for freedom among
those directive choices.
Ideally, health education
attempts to artfully influence the individual•s responsibility of suitable and desireable health actions.
Validity of Health Education
If health education is one technique used to elicit social change, its validity must be substantiated.
According to the philosophies of health and education as
described, there is little doubt that one would reject
the process of educating the public towards better health.
The conflict stems from the implementation of health
education practices to date.
Nyswander
(1~67)
36
exemplified this point.
According to Nyswander, health
of the public is not a necessary and sufficient goal
(64:3).
Her position originated from the belief that
public health practice today is much removed from people
and the human condition.
In other words, public health
has emphasized the World Health Organization•s definition
of physical and emotional health but lacks needed emphasis
on social health (64:3).
Public health, seen by
Nyswander is disease-oriented rather than people-oriented
(64:4).
Metzler (1966) and Nyswander shared parallel views
regarding the
tion.
absen~e
of public health in social evolu-
In 1930, 72% of all health programs in the United
States were conducted by health departments.
In 1950
only 27% of health professionals were in health-departments (59:161-8).
Metzler•s opinion was that health
needs associated with social needs were the kinds of
programs that were taken over by other agencies (64:4).
For Nyswander, the health educator by professional
commitment is concerned with all sources of health care
in the community, its interrelationships and its means
of communicating.
cratic society.
cient (64:5).
This is health for an open and demoThis goal is both necessary and suffi-
37
If the existence of health education as proposed
by Nyswander were to be determined, the decision would be
affirmative.
The most marked trend in current health
education is the effects of rapid change on the health of
the people (19:668).
We are aware of results of change
on health and we are also aware of ways to improve health.
Yet paradoxically, the health of any person as yet remains
one 1 s own business (19:668).
Health education should be
geared for desired change and should be an integral part
of all health planning (19:668):
health education should
be informative as well as motivational in nature (18:2845)
and health education should be dependent on the understanding and cooperation of the target population.
The
ultimate realization of a strong and viable health education process has one constraint:
it will not work until
it is seen to work and it will not be seen to work until
it works.
This paradox is the educational challenge of
today (19:668).
Apart from a conceptual need for health education,
statistics warrant the need for health education as well.
According to Beverly Ware, results from a Texas study
indicated that over 20% of the U.S. population is functionally incompetent to maintain good health (95:247).
It could be argued that the authority to judge what good
health and good health maintenance is, is not restricted
38
to particular individuals.
Yet statistically speaking,
20% incompetency justifies the need for an increase in
health education.
Tomes stated three premises on which the case for
expansion and development of health education is based.
These are:
1. Despite the spiralling costs of curative
medicine, there has been little improvement in
community health in terms of such measures as
improved life expectancy at age 45 and sick
absence rates. Moreover, there appears to have
been a substantial increase in chronic illness
among men in their late sixties. Increases of
mental illness and social malaise have also
occurred.
2.
The major health problems are largely
behavioral in origin and therefore are, in
principal, preventable.
3. Health education is the application of
behavioral science to health problems with a
view to modify behaviors which militates against
the achievements of physical, mental and social
well-being. Health education is therefore, by
definition, concerned with the prevention of
contemporary pandemics of self-inflicted diseases
(91:2).
Previous achievements in health education are
catalysts to the future expansion, development and need
for health education.
The decrease in infant and maternal
deaths, communicable diseases and accidents and the advances in child health have been accomplished through
health education (54:95).
Health education not only
saves lives; it saves money and staff as well (54:95).
If society is concerned with upgrading the quality
of life (20:1972) then health education may be a process
39
used in this improvement.
The literature suggests that
consumers have the right to be educated in areas of weakness (95:1751).
Increases in the cost of medical care and
skepticism concerning the ability of medical technology to
provide more than marginal improvements in health are
among the factors contributing to the interest in health
education (36:466).
An important aspect of health educa-
tion is the need not for more right information, but for
less wrong information (17:63).
The literature supported the need and desire for
health education.
The norms of American society support
educational intervention and quality health maintenance.
The seeds have been planted.
The implementation of health
education as a vehicle for social change must now grow
from these anchored roots.
Chapter 4
CONSCIOUSNESS AS A BASIS FOR
SOCIAL CHANGE
The health education process as a means to elicit
social change does not exist independently from people,
programs or procedures.
The focus of this section is the
people, their role and their responsibilities in the initiation of active health programs.
A basic assumption on which programs for change
exist is man's awareness of reality and the desire to
alter this reality for a fuller and richer life, individually and collectively.
It has been discussed that
inherent in every individual is the ability to critically
perceive and evaluate personal and social reality, become
conscious of that reality and confront it (24:13).
To educe one•s consciousness is the beginning
step in the perception of individual and social reality.
The awakening of critical consciousness inspires the
expression of social discontents.
This consciousness-
raising is the deepening of the attitude of awareness
characteristic of all emergence {24:56).
Examining consciousness necessitates defining the
phenomenon itself.
In determining consciousness one must
40
41
be able in some way to conceptualize a sense of reality.
This is most appropriately done through the use of
language.
Language serves to label stimuli which become
symbols to help organize behavior.
Consciousness implies
thinking:
Thinking is most mysterious by far and the
greatest light upon it we have is thrown by the
study of language. The forms of a person's
thoughts are controlled by inexorable laws of
pattern of which he is unconscious. These patterns are the unperceived intricate systemizations of his own language-shown readily enough
by a candid comparison and contrast with other
languages. His thinking itself is in a language.
And every language is a vast pattern system in
which are culturally ordained the forms and
categories by which the personality not only
communicates, but also analyzes nature, notices
or neglects types of relationship and phenomenon,
channels his reasoning and builds the house of
his consciousness (98:33-39).
Thus, language and symbols serve to organize
perceptual stimuli and determine reactions to individual
and collective reality.
Individual Consciousness
One of many definitions of consciousness has been
postulated by Freud (1895).
The Psychoanalytic Theory
of Consciousness described two basic biological concepts
regarding human behavior.
The first concept described
attention as a function of consciousness which was one
of three systems of neurones in the mental apparatus.
(The remaining two are perception and memory).
Freud
I
42
termed this system
ception.
11
W' for the German word meaning per-
He conceived this system to be a sense organ
which perceived qualities.
The conscience is a function
which causes a cathexis to occur regarding experiences
with qualities that bring it into awareness.
Freud refer-
red to these qualities as conscious sensations.
This
function of consciousness was conceived of as a process
in which something becomes conscious as a specific psychical act, distinct from and independent of a process
of the formation of an idea.
Consciousness was regarded
as a sense organ for the apprehension of psychical qualities (6:169).
Consciousness is a way toward something apart from
itself, outside itself, which surrounds it and which i t
apprehends by means of its ideational capacity.
Con-
sciousness is thus by definition a method which serves to
deepen the attitude of awareness characteristic of all
emergence (24:56, 101).
Present day psychoanalytic theory presents three
concepts of consciousness.
The historical concept refers
to an autonomous structure and function of the ego which
dispenses energies of attention.
This structure is vital
for awareness and conscious experience.
The second con-
cept regards consciousness as a state.of the total organism.
States of consciousness range along a continuum
'
43
of full alertness to sleep which vary according to
factors such as mode of the conscious experience, the
manner in which the attention is dispensed, the awareness
of one's identity or the differentiation between self and
non-self.
The third type of consciousness is the organization of mental operations in terms of a hierarchy of cognitive and fantasy organizations.
Below is a description
of the states of consciousness:
Major Parameters of Waking States
of Consciousness
1. Thought: controlled, specific, verbal
and differentiated.
2. Reality oriented
3. Single meaning
4. Secondary-process mode
5. Explicit meaning
6. Can turn around on itself-one can be aware
of being aware.
7. Can separate: fact assumption, memorypercept, hope-actualization, certainty-doubt,
reality-fantasy.
8. Frames of reference clear
9. Full adequate controls of drives with a full
sense of control.
10. Fu 11 range of awareness
11. Clear personal identity
12. Willed control over thoughts
13. Can reflect on contents and/or modify them.
(6:174)
These definitions of consciousness are scientific
explanations to symbolize an intangible phenomenon which
is the basic foundation for every experience of reality.
(It is assumed that each person's reality is unique and
that a normal reality to one may be abnormal tb another).
44
With regard to individual consciousness, the concepts of Freud and Royce (1908) paralleled each other.
Both men believed self-identification to be found within
groups.
In 1894 Royce claimed that to be healthy, self-
consciousness must continually balance two identifications:
the self's of himself within the group and the group's of
him within itself.
This claim operates in Royce's theory
of the origin of our ideas of
11
!
11
and
11
0ther
11
(ego and
alter), which is also characteristic of Freud's concept
of the Id and ego mechanisms (52:180).
Royce saw opera-
ting a conscious much like Freud's superego concept,
where an ambivalence occurred between self and conscience.
The self-identification theory was also shared by the
two men.
Distinctive of this theory was the idea that the
self, previously alienated from the community, could only
achieve self-identification if, in addition to its own
dedication to the community it received the communityls
acceptance of the particular self into its communal
life (52:181).
Great scholars throughout time such as Hegel and
Marx concurred that the individual consciousness was the
foundation for social change.
development as involving
11
Hegel saw consciousness
the existence of a latent germ
of being a capacity or potentiality striving to realize
itself (29:14).
45
The term
11
Consciousness discipl ine 11 refers to a
set of practices and philosophies of primarily Asian
origin and represents a specific mental training designed
to enhance perception and consciousness (94:663).
Vari-
ous approaches to identify our own individual assumptions
and beliefs have been utilized to obtain such enlightenment.
Meditation, psychology and transcendental experi-
ences are a few examples.
Eastern traditions have re-
garded consciousness in a more fluid vein and are now
being utilized by Western psychologies to provide insight
into the nature of mental processes, consciousness and
reality.
A variety of perspectives are now being used in
the assessment of consciousness (94:668).
With a limited understanding of individual consciousness stems a foundation from which a community
awareness may develop to initiate social action and
change.
Community (Social) Consciousness
Much of human life remains a mystery to the social
sciences.
The nature of social behavior, which rests
upon and conveys subjectively intended meanings suggests
that human life can never be fathomed in its full complexity and subtlety
(55:144~62).
Yet throughout history
there have been searches for general laws which make life
46
intelligible.
This section discusses the concept that it
is community consciousness which has arisen from individual
awareness and on which social change is based.
Hegel saw the destiny of man as arising from the
mind which manifests a real capacity for change and an
impulse of perfectibility (29:178).
From Hegel's philo-
sophy that the individual develops by striving to realize
himself stems his concept that through successive stages
emerges an advancing consciousness which allows freedom.
For Hegel, individuals and societies are always the unconscious tools of the world mind at work within them.
The shapes which they take pass away while the absolute
mind prepares and works out is transition to a next
higher stage (28:111).
Marxian tendency ascribed to the individual the
power to change the world and make his own history consciously and freely (86:xxviin).
Marx assumed that the
mind discovers development of consciousness by a method
of thought that is appropriate to the discovery.
It is
an interpretation of social reality that rests on an unspoken faith in the validity of one's insight into the
social processes (86:xxvin).
Through class conflict,
man develops an existential drive toward freedom and
rationality.
Once consciousness ceases to merely reflect
social circumstances and instead produces them, men will
47
be free (51 : 7 3-7 4) •
Royce (1888-98) developed philosophies on social
consciousness and elaborated upon the concept of an
11
awareness of we:
totally alone.
11
man's undeniable sense of not being
This controls one's basic rapport with
the universe (78:7-8).
Royce held that a self begiris its inarticulate
conscious life with a vague awareness of living with
6ther selves before he has any definite awareness of
himself or anyone else (77:100-102).
The self has in-
nate social potentials which permeate every emotion and
interest of the individual with a social tone and requires that the community ideal be present in his consciousness.
In addition, they require one to refuse to
consider the self as a hermetically isolated individual
and to appraise the individual's alienated consciousness
as a result of repression of social thoughts (76:187-191).
The innate social potentials are affected by experiences.
We experience other selves as sources of ideas.
The
encountering of different and foreign ideas awakens in
the self a curiosity which activates one's social sense.
At first, one's sense of being with others is merely a
primitive instinct.
Later, expressions of this feeling
determines one's ideas of others and of one's social self
in relation to others (78:171-72).
48
Royce proposed five conditions for community consciousness:
1. Each participating self can and does consciously extend its individual life ideally so as
to interpret some remote past or future events and
deeds as part of one's own life. By including
these events into self identification e~ch member
becomes worthy to belong to a signficant community
within traditions and goals.
2. Each self can and usually does communicate
with other members.
3. Each self interprets the same past and
future events as belonging to one's own life and
share in at least nearly the same interpretation
of these common events with each other.
4. The cooperating selves must have enough
understanding to direct their own deeds of cooperation, to observe the deeds of their fellow
workers and to appreciate the interaction of the
two. Each person's shared identification with
community life requires a desire to be directed
by its own values, view these values as linked
to the community's goals, and identifies his own
life with this ongoing life of the community.
5. Dedication of oneself to the community
and love of community itself enough to transcend
the love of one member for another. It relates
a member to community as something beyond another
human individual, as a higher reality which alone
is the source of a noncapricious, non self-centered
loving loyalty (65:178).
Talcott Parsons presented a view of social consciousness similar to Royce.
Awareness was seen not as
an entity separate from societies or self, but as a
"rippling effect."
External (community) and internal
(self) awareness occurred simultaneously.
One became a
catalyst of and for the other and a cyclical process of
identification and awareness occured.
Parsons contended
that these internal and external processes of change
49
occurred throughout time in any society and resulted in
an upgrading of that society (68:114).
The
11
Social
system 11 for Parsons is the· vehicle for discovering the
universal properties of human existence which when formulated as laws or prerequisites, and properly understood,
enabled men to determine how society worked and what
ideas, actions and values were necessary and functional.
Personal and social consciousness overlap.
a person who
When
is self-conscious becomes aware of others
who share the same consciousness, and the individual is
motivated to join group forces (such as Royce explained
in his conditions for community consciousness) than
social awareness occurs.
Group awareness may or may not
induce social action, depending on the amount of change
warranted by the particular social issue.
Values and Incentives
for Change
It has been mentioned that social action is the
process in which an organized group is formed to redress
a power imbalance or open up a service network in which
specific social structures are confronted to modify functions within the social system (22:12).
The premise
throughout this work is that eventual modification of
society occurs by discovering a social consciousness which
50
initiates social action.
The concept that social awareness can be a vehicle
for social action
~nd
change is inextricably tied to
changes in personality structures and individual values
(90:404-14).
A change in one's beliefs is dependent upon
the incentives presented by society.
If society legiti-
mates the change the individual may find sufficient motivation to act upon this changed belief.
If the incentive
does not hold importance than change may not occur.
Smoking and obesity may be used to exemplify this point.
Perhaps an individual may wish to cease smoking or overeating, but the
physi~al,
social and emotional stresses
of society may outweigh individual incentives.
Therefore
change may not occur.
Hegel presented a theory which emphasized man's
growing awareness of his role in creating the world
(50:xv).
The theory described man's emergence of social
consciousness as a process in which the individual loses
self consciousness to the more important concept of social
consciousness and social processes in which he has become
involved.
This theory parallels Royce's conditions for
community consciousness.
Once this societal awareness has emerged, a tendency toward what sociologists term secularization occurs
(27:146).
This is the tendency of society's activities
51
and institutions to become organized around impersonal
and utilitarian values instead of cultural or religious
ones.
There are however, constraints to the development
of impersonal biases.
The belief and value system was
described by Rokeach as concentric layers, with the outermost layers being most amenable to change and the core
beliefs around which the whole system forms and from which
it derives its internal consistency the most resistent to
change (74).
Many of these outermost values are conscious,
such as desire to use birth control or avoid mind altering
substances.
Core values may be conscious or unconscious
and one must take into account the fact that a very significant part of individual experience is not conscious
(74:146).
Part of this is subconscious and includes re-
pression, defense mechanisms, habits and direction by the
superego.
Another part is supra-consciousness:
intui-
tion, imagination, aesthetic and spiritual senses.
It
has been suggested that the unconscious processes may
play a significant role in influencing the behavior of
societies as well as individuals (70).
It is difficult
to verify the role of unconscious processes in social
change, but it is opinion of the Author that at some time
they will be developed and we cannot satisfactorily understand social change without them.
52
Social Awareness and Social Change
The development of individual and social consciousness, the commitment to community and the urgency to
organize is described by Alinsky (2).
His perspective
paralleled the value-incentive process described earlier.
Alinsky suggested that the fundamental perspective in
regard to social change is the notion of individual means
and ends (2).
If the particular end is justified by the
particular means the individual may have incentive for
change.
The interest of this work is in the advancement of
public health and social change.
Yet before specific
examples of health education eliciting social change are
mentioned, an issue of general importance must be considered.
That issue is human rights and it is the central
theme of current efforts toward societal change (60:56).
Human rights efforts have been organized by the Civil
Rights movement, Black Power and Chicano movements,
Youth rebellion, women's movement, aged, and disabled
persons programs (60:156).
based on the
11
The process of social action
individual social awareness principle
be interpreted by the use of a
11
11
can
ripple" analogy, as when
a stone is tossed into water resulting in circles throughout the water.
In the case of human rights, there is
pressure by a group to act upon an individual.
53
Simultaneously, the individual exerts pressure on the
group to act in the individual's behalf.
The result is
an external and internal process which is the catalyst
and cyclical process for social change.
For any group
or individual who perceives any injustice toward themself may come this process.
An example of the Black move-
ment illustrates this point.
A
Bl~ck
person may become
aware of his individual prejudice against him.
then perceive group injustice.
He may
His incentive for change
is his dislike of unequal treatment.
To be treated as
just in society is for this person a justifiable end.
The means to achieve the end may vary but the external
(group) and internal (individual) awareness may be enough
to elicit change for human equality.
Health Education and Social Change
We now arrive at the central theme of this inquiry.
Can health education indeed elicit social change?
This
Chapter presents examples of the established theoretical
framework upon which health education for social change
is based.
The concluding portion of this chapter presents
suggestions of specific strategies which support the
likelihood that health education induces social change.
The socially sanctioned process of education has
been discussed as a vehicle which provides man the
54
opportunity to perceive, evaluate and act upon the environment (24:13).
Health has been discussed as a condition
best suited to reach goals that each individual formulates
for himself (21 :279).
There is a positive correlation
between poverty and health status (see Appendix 1).
Because we are functioning within the context of a dynamic
health education process and because we know that poverty
and health are related, then it follows that it would be
highly desirable to develop
and initiate health education
techniques that provide groups with increased capability
to intitiate social change processes which can alleviate
their poverty condition.
Health education has been
viewed as a vehicle by which the health educator provides
the individual with the components needed to both confront
and remedy potential or existing conflicts as well as
manipulates one's condition.
The Planned Parenthood Organization has been
selected as an example because the relationship between
poverty and health is clearly examined and has been an
important aspect of Planned Parenthood's philosophy.
The
United States Planned Parenthood movement historically
has been committed to two central theses:
1) that
rational and efficient control over fertility is an
instrumental intervention necessary for individual and
societal welfare and 2) that a voluntary organization such
55
as Planned Parenthood, acting as an agent of change, is
necessary to accelerate achievement of rational fertility
control (35:287).
It sees as its main roles the education
of the public and professional sectors to strive for the
full legitimacy of birth control in law, policy and public
opinion as well as the "democratization of birth control".
This is the extension to low income persons scientific
methods of fertility regulation (30).
Planned Parent-
hood's first role was exemplified by the sponsorship of
a major conference on legal and illegal abortion in 1955
(11).
The second role encompassed efforts to invalidate
restrictive laws, gain acceptance among community councils and initiate a national campaign to promote birth
control discussion in the mass media.
couraged to serve needy groups.
Clinics were en-
It became evident that
such a task of provision of services to needy individuals
could not be accomplished by Planned Parenthood alone
and instead needed an established health system, specifically a government financed system to serve the poverty
population.
Planned Parenthood was discussed as an agent of
social change (35:286-99).
Because fertility control
remains a controversial issue-laden with conscious and
unconscious values, the social change and innovation
required to meet its goals and objectives would be
56
restricted by existing institutions.
Planned Parenthood
viewed its potential as constrained by technologic, political and sociological factors essentially beyond its
control.
At the time of origini Planned Parenthood was
dominated by obstetricians and gynecologists and depended
almost entirely on the diaphragm-jelly technique.
Clini-
cal experience proved that this was unsuitable for many
couples.
Without better technology many Planned Parent-
hood leaders did not expect progress.
The major political problem was Catholic opposition
to birth control and was seen as having sufficient power
and influence to prevent both governmental and private
institutions from
ado~ting
more favorable policies.
Two sociological constraints prevailed.
The first
was the notion that the poor would reject contraception
even if they had it.
This was a philosophy encountered
by Sanger four decades earlier (79:93).
The second
constraint was the feeling that the medical professions
would not incorporate social aspects into the medical
model (66).
Technological barriers were overcome with the invention and use of oral hormones and intra-uterine devices.
Political constraints of Catholic opposition to
birth control for the most part collapsed in the mid
196o•s.
Sociological problems were the most difficult
57
to overcome.
Yet, contrary to popular belief, studies
indicated that the low-income population had considerable
desire to limit fertility and experienced failures in
trying different methods of contraception.
Studies also
revealed that the low income population had misinformation
about contraception and that their life circumstances made
it difficult to adapt to the
methods of contraception.
requi~ements
of existing
The myth of non-motivation
among the poor to utilize birth control was dispelled by
findings that the rate of return for postpartum exams
among women testing new contraceptive and consultation
procedures in wards significantly increased.
The inci-
dence of unwanted and mistimed fertility was particularly
high among low income and poorly educated persons and was
related to their reliance on less effective nonmedical
methods of contraception (71:362).
These advances may have been seen as challenging
elitist biases about the poor and confirmation of the
technological change leading to behavioral change.
Sta-
tistics such as 78% of low income persons approving of
birth control and 71% already using some method of contraception was the basis for the implication that what
was needed was a focused effort to identify and overcome
the obstacles which prevented low income persons from
obtaining and using effective methods (35:295).
It
58
became clear that the problem of effective contraception
for low income Americans could not be solved unless public policy and the way in which the health system functioned in the area of birth control could be changed.
The notion of community consciousness interweaves
this program with the general awakening of interest in
the problems of poverty in the United States during the
mid 1960's.
National programs to provide family services
to low income persons through governmental funding were
established (69).
It is possible that the broad politi-
cal interest in poverty and population growth was the
critical factor in policy change.
The 1955 and 1960
growth of American Families Study and the 1965 and 1970
National Fertility Study presented a detailed picture of
fertility attitudes and practices of the American people
over a twenty year period.
They were invaluable in modi-
fying the outlook of the United States birth control
organization, in changing public policy and in guiding
action programs to improve the regulation of fertility
(35:298).
Planned Parenthood is an example of success.
Soci-
etal incentive of timed and regulated fertility warranted
public cooperation and participation in changing political, technical and social policies.
Education, stemming
from individual and social awareness created action for
59
change.
There are other health related examples which succeeded in promoting change.
a
m~jor
In the United States today,
value has been the incentive to be attractive and
physically fit.
most classes.
This motivation has filtered through
Proper diet, aerobic exercise and jogging
are all incentives to produce attractiveness of body and
fitness of heart and lungs.
Perhaps formalized programs
akin to Planned Parenthood have not been established (although much education and many sports facilities have
been promoted).
Yet individual consciousness of body has
produced the ''ripple effect" to community members and
behavior has changed.
A hypothetical program exemplifies a successful
change agent.
The model is occupation-based and is
geared to the specific health needs of a particular set
of workers and the conditions in which they work and
live.
Toxic chemicals, radioactivity,
contaminated air,
tension among workers, excessive noise may all contribute
to stress, accidents, hypertension or general debilitation
of mind and body.
The health educator and workers may evaluate the
most immediate problems.
The health educator could train
the workers to measure health hazards and educate them
to the dangers of particular health problems.
The workers
60
might be enrolled in particular treatment programs and
procedures may be established to continue the abatement
of subsequently identified health hazards.
In sum, as a health professional, the educator
provides technical information and resources with easy
access.
The educator also provides knowledge of and ex-
perience with educational tecniques, group processes,
health institutions, project design and grant proposals
to facilitate action.
The encouragement, facilitation
and teaching of self organization to change unhealthful
conditions is the maj6r role.
A nutritional program serves as another successful
change agent.
Imagine a health educator hired to develop
a program to improve the nutritional status of a working
class and poor neighborhood.
Since the health educator
does not have an already existing organization to work
with, the person must go into the community and talk with
community organizations such as women•s organizations,
sports leagues, senior and youth groups, ethnic and
religious groups and neighborhood associations.
After
reviewing evidence of local problems, data might indicate
problems such as the lack of financial resources needed
to obtain adequate meals, inadequate diets and prenatal
care or the consumption of too many carbohydrates, fats
and sugars.
61
Proposals for meals-on-wheels, governmental funded
health clinics and nutritional education programs can be
initiated by the health educator.
to transcend individual change.
Direct action is needed
Groups can develop com-
munity support for non accessible food stamps programs to
local government.
With the consciousness of community
members already raised by educational programs for nutrition, experiments such as demanding. markets to remove
candy displays are tried.
citizen boycott.
Uncooperative markets face
Cooperative markets might be proposed
to better serve community needs.
Both illustrations define the health educator as
a technical advisor and process facilitator, but never a
director of the community's campaign.
ceed while others fail.
Some efforts suc-
The commonality among all pro-
grams is the aid to people by the health educator in the
articulation of health needs and development of programs
for individual and societal change.
Failure of health education as an incentive to community organization must also be confronted.
Lipsky,
in his article "Citizen Participation and Health Care:
Problems of Government Induced Participation" discussed
the obstacles in community health organization.
62
1. People do not use health services regularly.
Treatment rather than prevention occurs. If Saul
Alinsky is correct in his means versus ends concept, then the fundamental aspect of peoples 1 ives
is definately related to community organization.
Lack of material or monetary resources are more
immediate and visible problems than is the utilization of health services. An incentive to
change might be the incorporation of the awareness
of health concerns into the basic needs of individuals. Maslow's hierarchy of needs have been utilized in most every academic discipline to describe
the relationship between motivation and personality.
The concept that the basic physiological needs
must be met before one reaches higher levels of
safety, love, esteem and self-actualization was
identified by Maslow (1954). It is assumed that
before community organization occurs, the basic
needs must be met. To explain to an individual
that unhealthful conditions can decrease individual
and societal productivity may motivate a person to
incorporate health behaviors and concerns into the
basic need levels.
2. Health inthe United States is generally not
regarded as a public responsibility. Those people
with emerging health needs, like the poor and the
aged are among those least susceptible to mobiliza~
tion. An incentive for change might be the recognition of oppression or deprivation within these
groups, which might lead to organization for political and social change.
3. Health care is not generally accepted. as community problem, which inhibits organization. An
incentive for change could be to bring to attention
to community members that its progress depends
upon healthy members for individual, group and
community welfare.
4. Discrepancies in quality care among different
socioeconomic groups is not as visible as mortality
and disease rates. While they do provide a case of
social injustice, they are not visible enough to
energize organization efforts. Awareness by lower
economic groups that institutions which provide
quality care are accessible to them may aid them
in generating motivation to utilize these services.
5. It is difficult to identify the health community from which to recruit constituents. It
cannot be expected that people currently most
exploited or neglected by institutions will provide
63
the pool of organizational recruits. For this
population, dependence on health facilities is
so great that risking alienation of these facilities does not warrant organization. For example, illegal aliens today are afraid of their
status being discovered, and therefore do not
utilize governmental health facilities. Alleviating this fear might be established by agencies
not incurring any recrimination of ethnic origin.
With this elimination of fear could produce a
motivation to utilize health services.
6. Tactics to achieve more responsive health
facilities are difficult to de~elop or implement.
Protest of health services can only be effective
if alternative means of assisting people are produced. Assisting individuals to be aware of self
care, prevention or wholistic treatment are
alternatives to health services. A vital role
of the health educator is to provide alternatives
of different services and where these services
are obtainable.
7. Medical authority limits citizen participation and decision making. Health education is
a key role in regard to this notion. The health
educator can be the facilitator and catalyst to
the individual in making him understand his ability to choose and make decisions regarding health.
8. Community residents may have difficulty
in distinguishing between a new service and an
old service which they have rejected. An example
is the mental health field. The establishment
of mental health programs have been by citizen
impressions that mental health health programs
inevitably imply custodial care. The health
educator can help the individual to differentiate
between programs and educate to alleviate misconceptions and misinformation of any health problem.
9. Health care is costly. The greater the
cost, the less can community organizations realistically entertain the option to establish alternative
services to compete or supplement existing facilities. The health educator can provide the individual with different existing options to basic health
care and perhaps encourage to organization to
elicit legislative changes in health services,
approaching a more socialistic plan in medicine.
64
These problems have a common weakness.
There is
not enough individual and societal motivation to change
the attitudes and social maladies which exist.
The in-
centives devised to help correct these problems is the
task of the health educator.
The control of sexually transmissable diseases in
the United States is another example of basic failure in
health education.
Although advances have been made in
prevention and treatment, the incidence of sexually
transmissible diseases remains high.
In our hedonistic
society, the incentive of pleasure far outweighs the
threat of disability or death.
An incentive for change
might be the emphasis of how the future pursuit of pleasure may be stifled if communicable diseases are allowed
to progress.
Plan For Change
It has become evident that political institutions,
economic organizations and disease are so interrelated
that any general social change produces changes in health
(75:398).
Accordingly, the need to increase both the
ability of people to take maximum power over their individual lives and their ability to change the social relations and structures in which they live and work exists
(9:10).
These are important and feasable roles for
65
health educators.
Many health organizations exist which can initiate
change on a mass scale while health educators are simultaneously acting as facilitators of consciousness-raising
and social participation.
cussed.
of
11
Two institutions will be dis-
The World Health Organization has set the goal
health for all by the year 2000.
has been called the
11
11
This achievement
Mahler Revolution 11 in recognition
of the Director General of the World Health Organization.
He perceived past health strategies as failures in the
organization of health care to more than half of the
world•s population living in rural areas and slums
(1:206).
The new
11
grass roots 11 approach visualizes pri-
mary and preventive health care based upon past taboo
ideas of community participation in health services,
self-coping and self-care,
tional medicine.
11
barefoot doctorS,
11
and tradi-
The inclination at present is to pro-
vide to the people the opportunity to understand their
own predicament and make conscious decisions to effect
those predicaments.
The World Health Organization has
committed itself to overcoming two major contradictions.
The first is the contradiction between people and the
medical consumer markets that they are provided with.
More simply, the availability of medicines and services
with a high degree of consistency.
The second constraint
66
is the present utilization of 80-90% of medical resources
being used for only 10-15% of health problems (1 :207).
Mahler emphasizes strong political commitment which he
believes can be found everywhere in the world.
Technology
will not be compromised, in fact more scientific imagination should be utilized to relate more meaningfully to the
broader social perspectives.
The objectives of the World
Health Organization are now advancing toward helping
people identify their own people, programs and procedures.
The American Public Health Association is another
institution which has the power to initiate change because
it represents an organized marriage of academics, political awareness and technology.
In the Presidential address
for the 103rd annual meeting of the American Public
Health Association, C. Arden Miller generated new concepts attainable by that organization to advance societal
reform.
Miller suggested five initiatives to advance
these causes:
1. The American Public Health Association should
become more active in providing direct help to support local governmental health departments. Experts
from this organization may act as consultants for
monitoring· and evaluating matters pertaining to
health law, occupational health, environmental
protection and personal health services.
2. The American Public Health Association has
the potential to initiate a coalition of reformist
groups to begin systematic challenges to self-serving
interests that weaken public service agencies.
Assistance to courts in the elimination of conflicts
of interests as well as challenging political units
67
in areas such as pollution or nutrition programs
could be initiated.
3. At a national level the American Public
Health Association could develop a campaign to
force federal commitment of shared revenues designed to improve health in areas such as epidemic control, preventive health services and
human rights initiatives.
4. Public health impact studies could be
implemented by the American Public Health Association and public health department participants.
Any program spending federal funds would require
a study to evaluate the impact of the program on
the people's health.
5. The American Public Health Association
should continue to pressure governments for
national health insurance and the expansion of
public health services under this insurance plan.
Community services such as home health care,
family counseling, preparation for parenthood,
recreation, school health, social casework and
day cares should supplement private modes of
care (60:58-59).
The American Public Health Association, in its
promotion of social reform does not deemphasize scientific advancement.
On the contrary, the responsiblity of
the scientist remians the provision of wisdom, around
which the standards and goals of health services are
established.
Herein lies the greatest strength of health organization and health educators:
the diversity among pro-
fessions with the central concern for the well-being of
people.
Health organizations and the health education
profess are the foundations for the unity required to
work and achieve the shared convictions of health professionals.
Chapter 5
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Summary
The preceding inquiry has explored the notions
that health education can elicit social consciousness
which in turn can induce social action resulting in
social change.
Health educatio-n has been described as
a process used to develop this change.
Poverty has been
used as an example of a social problem that is seemingly
amenable to social change efforts and its intrinsic relation to health status.
Five philosophies have been identified which can
be used to produce a frame of reference for the reader's
own philosophy.
Examples of Idealism, Realism, Empiri-
cism, Pragmatism and Existentialism in health have been
described.
The philosophy of health as a right and as a state
of being have been explained.
has been addressed.
The philosophy of education
Jointly, the health education philo-
sophy has been regarded as the process which has the potential to elicit social change.
The literature has verified that health education
is a valid means of providing individuals the information
68
69
necessary to initiate decisions concerning health behavior.
The literature also substantiates health education as a
process which is necessary and successful in producing
better health in America.
Consciousness has been presented as a basis for
social change.
Individual and group consciousness are
described as the initial steps in the process of social
change, where awareness of self and community are motivating variables in the organized efforts to elicit social
and political change.
Examples of health education
eliciting social change have been presented.
Failure of
health education as a process in social change has also
been discussed.
Incentives devised to overcome obstacles
in change have been provided and a plan for change has
been devised utilizing major health organizations as
facilitators in educating the public for change.
The literature verified the hypothesis that poverty
represents a specific social condition which effects most
aspects of life including health, illness and related
behavior.
Aspects of poverty and health have been dis-
cussed according to medical and social models to aid in
the understanding of poverty and health as interdependent
concepts.
70
Conclusions
The predisposition in man of the capacity to
learn enables him to become something more than a carbon
copy of the species to which he belongs.
It is a need
within each individual to form a lifestyle that is selfaware and self-critical.
This inborn capacity to learn
is the beginning of the becoming of self.
It is this part
of the nature of man which is in direct conflict with the
imposed rights and wrongs of entrenched middle-class
values (64:7).
This theoretical assumption that man is a learning
becoming animal, that his essence and being is a selfaffirmation of power, makes it possible to speculate
about the impingement of the demands of culture and society upon him (64:7).
The continuing loss of creative manpower through
social illness is the concern as health educators.
Po-
verty has been verified as one of the most powerful determinants of altered health status and clinical disease
today (100:69-47).
The process of education can be used
to organize individuals to obtain power and use it.
Health educators, individually and as a profession can
work for the interest of communities, individuals, workers
and consumer groups.
It is believed that health education
71
is the role of choice in motivating people to organize
for change.
Three assumptions are made in developing this
role:
1. Health educators bring to their work a
greater knowledge of health and health care than
most lay persons;
2. People dispossessed from power over ·their
social lives should learn how to determine what
is in their best interest and how to struggle to
achieve it. The health educator can organize
persons around common interests relating to health,
use their process skills to facilitate group decisions for their best interests and be a resource
in developing methods to realize those goals, and;
3. The process skills of health educators can
be effective in confrontation between community
constituencies and people in authority by clarifying issues that divide the group (9:21-22).
Essentially, this Author believes that health professionals should redefine the scope and methods of disease prevention and treatment to make them consistent
with knowledge about causes of disease.
responsibility of
11
It is not the
Someone else 11 to deal with social and
economic factors while physicians and other health professionals emphasize such variables as early detection,
sanitation, immunization or health compliance.
These concepts are not new.
It is not expected
that every health professional abandon their profession
to lead a social movement.
Nor is it recommended to
abandon proven medical technologies and therapies.
It is
suggested, however, that evaluation take place of each
set of methods in relation to the larger physical, social
72
and economic contexts which propagate disease.
It may well be that a society based on profit and
private control of resources will always breed more disease than necessary.
When profit is the primary goal,
those who control resources tend to have a careless attitude toward workers' lives and the physical environment.
It may be necessary to replace private control with societal ownership and democratic control of resources in
order to eliminate assaults on health.
If socialism is
a pre-condition to a healthful culture, than health professionals must confront this
challen~e.
Socialism, how-
ever is not preciously the issue addressed in this thesis.
One answer does not exist.
This inquiry for fu-
ture philosophic thought is a foundation for future educators to reflect upon and use to continue the generation
of education of all peoples for a better society.
a reference to remind us that:
Man is in process, as is the whole of life.
He may survive or he may not, but so long as he
survives he will be part of the changing, onrushing future. He, too, will be subject to
alteration. In fact, he may now be approaching
the point of consciously inducing his own
modification (8:27).
It is
73
Recommendations
The following recommendations for health educators
are suggested as follow-up to this exploratory endeavor:
1.
Continual literature review in order to keep
abreast of health education and social science materials
for studying the relationships between health education
and social change.
2.
Continuing focus and sensitivity toward the
need to educate individuals and communities with regard
to their need to organize for social reform.
3.
Continuation of health education efforts which
facilitate the recognition of oppression or deprivation
as a step toward social and political reform.
4.
Assistance in facilitating individuals' under-
standing of their ability to choose among a variety of
decisions which affect their own health behavior.
5.
Continue efforts to provide alternative ser-
vices relevant to the alleviation of health misinformation, and stereotypic notions.
6.
Serve as an advocate in stimulating legisla-
tive alternatives toward improving traditional methods of
health delivery and care.
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APPENDIX 1
INTERPRETATIONS OF POVERTY AND HEALTH
A REVIEW OF LITERATURE
83
p •
INTERPRETATIONS OF POVERTY AND HEALTH
A REVIEW OF LITERATURE
Introduction
Exploration of the concepts of poverty and health
results in varied definitions.
It is virtually impossible
to consider the relationship between poverty and health
without examining the whole of contemporary society, for
there is no isolation of poverty and health from their
interlocking positions in society.
This appendix contains a comprehensive review
of literature relating to poverty and health.
Individual
sections will include (1) a review of the existing models
and definitions of poverty.
The definitions
~nd
philo-
sophies of health have been reviewed in Chapter 1.
Re-
ference should be made to this section for definitions
of health; (2) a framework for the interpretation of
poverty and health and; (3) specific literature supporting the positive correlation between poverty and illness.
Two assumptions underly this literature summary.
First is the assumption that poverty represents a specific social environment which affects most aspects of life
including health, illness and related behavior.
Second
is the assumption that the social significance of health
related events are analyzed according to many variables
84
85
and determinants within society at large.
These assump-
tions will be addressed in specific literature review
sections.
Definitions of Poverty
Throughout time the definitions of poverty have
been modified and altered with the fluctuation standards
and aspirations of society.
The word "poor" denoted an
ancient concept for expressing social differences between
man and man:
a concept coined before the social sciences
created their notion of social stratification (44:1).
In
1914, Jacob Hollander defined the poor as the portion of
the population who were inadequately fed, clad and sheltered (47:591).
Poverty has been interpreted according
to economic terms; specifically the unequal distribution
of means and privileges.
Another view described poverty
as the condition of those who, by prevailing standards,
were found to be deficient in means of subsistence and
privileges of life (44:2).
The general federal definition
of poverty is a formula based on three times the minimum
number of dollars needed to feed a family of given size
and location (23:2424). Another version of the formula
defined the "low-income" population including the "near
poor".
Poverty is generally viewed in our economy as a
lack of means and privileges available in the community
(44:2-5).
There is general agreement in economic terms
that poverty is at least some minimum access to a bundle
86
of goods and services (47 in 61:316-29).
The social view of poverty and health incorporates
two major theoretical interpretations:
the medical and
sociological aspects of poverty and illness.
Dubos (1959)
described the two viewpoints according to Greek legend.
The Greek goddesses Hygeia and Asclepius symbolized the
oscillation between the two medical viewpoints.
For
worshipers of Hygeia, health was the natural and organic
order of things; a positive attribute to which men were
entitled if they governed their lives wisely.
According
to this view, the most important function of medicine
was to discover and teach the natural laws which ensured
to man a healthy mind and body.
Conversly, the followers
of Asclepius believed that the physician's chief role
was to treat disease and restore health by correcting
imperfections caused by accidents of birth of life
(13:131).
The Medica 1 View of r1 1 ness
Physicians engaged in clinical work have been
interested in specific theories of illness to explain
medical phenomenon and promote effective treatment.
The
theories developed in modern medicine since the time of
Louis Pasteur have solved numerous health problems and
87
pathological conditions and have advanced the clinical
conquest of disease.
The germ theory of disease helped
to vanish many dreaded infectuous diseases.
The epidemio-
logical theory, which viewed illness as a battle of interaction between the host, agent and environment, aided in
the decrease of epidemics.
The cellular concept of dis-
ease which emphasized cellular changes as the components
of disease was associated with the rapid progress of
biological science.
The mechanistic concept, which
viewed the body as a machine and viewed disease as a defective part of that machine reflected progress in surgical procedures (82).
The Sociological View of Illness
The behavioral sciences, not being directly
involved in clinical work and not necessarily oriented
toward an organic view of illness have been interested
in a model for human behavior in health and illness which
fits statistical requirements for empirical research.
Sociology has been considered a useful discipline to deal
with the multi-facets of health since it places health
and illness in a social context in which the sick person,
as well as the environment are considered.
It regards
the problems of health as parts of a dynamic interaction
process, views illness relatively and assumes that the
88
extent and meaning of any illness can be understood only
in relation to other healthy and sick persons (44:47).
Henry Sigerist presented the concept of the
position of the sick.
11
11
Special
He regarded illness as a privi-
ledged status in society and viewed the ill person as
occupying a priviledged position which received welfare
and concern (73:9-22).
Talcott Parsons elaborated and
placed this concept in the framework of a theory of social
systems.
In this estimation, a person's illness needed
to be legitimized by a medical professional.
After legi-
timization of illness, the person assumed the sick role
which replaced his usual social duties.
The sick role
permitted freedom from obligatory duties and imposed
specific norms on himself as well as associates close to
him (67:31-44; 66:165-87).
More recent theories have attempted to address
the problems imposed by the
11
Sick role 11 such as the un-
stable and temporary conditions caused by illness.
King
emphasized the perceptual component of illness and described a very crucial variable in health related action
as being the way one perceives the situation of disease
and all of the social ramifications that accompany it
(41).
From this
11
illness perception 11 view, Mechanic
generated the concept of illness behavior which emphasized the ways in which particular symptoms may be
89
differently perceived, evaluated and acted upon by different individuals (57:189-94; 56:244-47).
Suchman presented
a theory of stages of illness and cure which included the
stages of symptom experience, assumption of the sick role,
medical care contact, dependent patient role and rehabilitation (88:114-28).
Finally, Stanisly and Cobb distin-
guished health behavior, illness behavior and sick role
behavior as actions which occur depending on the perceived amount of threat and the attractiveness or value
of the behavior.
These theories share elements.
They relegate the
sick role to a restricted place, emphasize the nature of
health related episodes and regard the alternatives of
good and ill health as a continuous process evolving
within a social context.
These concepts in conjunction
with the views of the medical model may serve as variables in the formulation of a general and flexible
theory to explain health related phenomenon.
Kosa and Roberston (1969) have created two
models which become the theory that explains health
related phenomenon.
The first is the "Schema of the
Morbid Episode" and the second is the "Place of the
Morbid Episodes in the Social Interaction Pattern."
Herein lies the assumption that the social significance
of health related events can be analyzed in terms of the
90
individual and society.
The concept
11
morbid episode 11
represents the medical and sociological viewpoints, their
measure, conditions and variables which affect health
and illness behavior.
11
Morbid 11 refers to morbidity; the
extent is assessed by the layman and the health care
professional.
11
Episode 11 refers to man's view that the
condition of illness is an interruption of normal events,
because the normal or desired state is characterized by
freedom from such episodes.
One may argue that physio-
logical normality does not exclude repeated occurrences
of symptoms, illness or disability, but the health behavior of people seems to be governed by the belief in
a desired state of health rather than by the teaching of
biological sciences (44:50).
The models, adapted from
Kosa and Robertson appear in Kosa, Jon; Antonovsky, Aaron
and Zola, Kenneth.
Analysis Mass.:
Poverty and Health:
A Sociological
Harvard Univ. Press, 1969, pg. 59, 66.
Chart I shows the schematic representation of the
morbid episode as the patient's experience.
From the
viewpoint of the patient, the elements of perception,
anxiety, knowledge and manipulation are interrelated.
Thus, existing medical knowledge, while alleviating
anxiety, also modifies the perception and manipulation
and is, in turn, modified by experience gained in each
morbid episode.
Chart I.
Health Disturbance
(threat)
Perception
Disturbance
not
•perceived
(subliminal
symptoms)
The Schema of the Morbid Episode
Anxiety Aroused
Floating
Assessment
Non-serious
<
PJ
(
Pertaining
Knowledge
Specific
Gra ti fi catory
Little
Requiring
None
~
0"
'<
fT1
X
c+
~
PJ
~
I
s::
'<
I
.
~
(11
~
_..
([)
,
([)
-'·
n
0..
0..
([)
0
c+
([)
~
(11
(/)
~
([)
<
([)
rl-
-'·
Requiring emotional
manipulation of the
anxiety only
I
'<
<
([)
3:
([)
PJ
(11
s::
~
([)
(11
lC
PJ
<
,.._
~
0
n
-o
~
I
PJ
([)
-o
([)
Therapeutic
None
~
--'·
lC
Manipulation
Respondinh to 1ay
man i pul at ion
(home treatment)
3
........
.p.
.p.
00
()1
1..0
..._,.
"0
c+
0
3(11
\.
Great
Serious
-~------~------
--
-~--
----
-----------
-------
Professional
Knowledge
Requiring
medical attention
I
1..0
_.
92
Chart II is a schematic representation of the
place of the morbid episodes in the social interaction
pattern.
It indicates that the morbid episode individu-
alisttc and unique in its physiological and psychological
origin has to be fitted into the social interaction pattern of the patient with family and health problems
while treatment and cure occurs.
The patient must comply
with the demands originating in the inhibitory system
and society itself.
Chart II The Place of Morbid Episodes in the
Social Interaction Pattern
Interactions in
the primary
group
"~
The patient
of a health
disturbance
.J,
Gratificatory
mani pul at ions ,
\. Cure .
Instinctual
response
...
KSpecific~
anxiety
4
~
/
Interactions in
the secondary
group
Home
Treatment
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family life
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94
The Relationship Between
Poverty and Health
The preceeding discussion highlighted various
aspects of poverty and health using the views of the
medical and social sciences to help in the understanding
of poverty and health as interdependent concepts.
lowing the two
p~evious
Fol-
assumptions that 1) poverty
represents a specific social environment which affects
most apsects of life including health, illness and related behavior and that 2) the social significance of
health related events can be analyzed according to morbid
episodes within the individual and society, the result to
consider is the effects of poverty on the health and
illness of the individual.
Poverty is said to be a social condition outside
individual choice which is central in determining who
will live and die {7:12).
Despite increasing standards
of living throughout society, great social and economic
disparities pervade advanced capitalistic countries and
are associated with similiar disparities in morbidity and
mortality (4:12).
Within the United States social class,
race, education and occupation are very much related to
rates of sickness and death (89:18; 63:449-65; 4:31-73).
A study of causes and rates of mortality in Los Angeles
County found that low birth weight, infant mortality and
95
death from all causes were positively correlated with
income (12:75-81).
Similiarly, the probability of being
disabled is negatively related to income and education,
but positively related to being black (53:10-12).
Epi-
demiological evidence forces the conclusion that poverty
remains among the most powerful determinants of altered
health status and clinical disease today (100:69-74).
Poverty has been identified as a disease in itself
(84:25).
Economic growth in industrial nations poses an
undeniable threat to the environment and to the health
of man (46:15).
Underdeveloped nations are also affected.
An appraisal of the overall state of development throughout most of the developing world revealed it to be unacceptable because millions of people continue to live
at levels of deprivation that cannot be reconciled with
any rational definition of human decency.
Throughout the
developing world the 1974 estimates were well over 1000
million were hungry or malnourished.
There are 100 mil-
lion more illiterates than there were twenty years ago.
Underemployment and unemployment accounts for one out of
every five in the labor force.
Infant and child mortal-
ity is four times greater than in the developed world
and life expectancy is 40% shorter.
Population in-
creases are highest in those countries with the lowest
96
per capita income and food production (46:15).
cycle of poverty and health is circular.
The
The symbiotic
relationship between poverty and health perpetuate the
other's condition.
Certain conditions seem to result from economic
deprivation.
Lee has compiled several social problems
which result from economic deprivation.
Throughout the
developing nations:
Hunger and malnutrition drain energy, stunt
growth and impede thinking.
Illiteracy slows learning and paralyses the
opportunity to learn.
Unemployment not only robs individuals of the
minimal means to make a living but leaves them without
pride and ambition, condemning their children to continuing poverty.
Preventable diseases are injuring infants,
killing children, disabling productive workers and aging
adults before their time.
Population increases are weakening
e~onomic
gains and adding extra burdens to poor countries who are
striving to rid themselves of the poverty condition
(46:14-15}.
In sum, millions of people, despite inherent
potential, are being affected by poverty which degrades
a 11 that it touches.
97
Skeet outlined certain conditions which result
from poverty:
Malnutrition may cause marasmus, kwashiorkor,
hunger oedema, dehydration, vitamin deficiencies, retarded
bone growth and learning deficiencies.
Nearly 40% of
the world population eat less than 2200 calories per day
and two-thirds of the world eat less than 15 grams of
protein per day (84:25).
These dietary failures are
predisposers to infection.
Population control.
Technical advances tend to
move faster than changes in social customs and family
patterns.
In developing areas, if birth rates are not
reduced to match the decreased mortality rate, the present supply of food will not equal the needs of the population.
The corollary of infant lives saved from in-
fection may result in starvation in childhood.
Health
problems are therefore intrinsically linked to problems
of food supply.
Slum Conditions.
Today nearly one-third of people
living in cities and in developing countries live in
slums.
Experiments with animals has shown that as living·
space becomes more cramped, the tendency to aggression
rises, resulting in crime and violence which become causes
of stress and poor mental health.
98
Drug Abuse.
Another effect of close living
quarters, unemployment, poverty, malnutrition and other
stresses is that man tries to find peace and identity
through pollution such as tobacco, alcohol or drugs.
Man's behavior becomes the basis of disease.
The effects
of drug dependence is an example of man becoming the
victim of his own behavior.
Lerner and Freid (1969) surveyed the morbidity
status in the fields of physical and mental health to
find that the poverty population is considerably less
healthy than the rest of the U.S. population.
The lowest
social classes have the highest rates of severe psychiatric disorder, communicable diseases and infant mortality (44:230).
George James (1964) gathered statistics from four
low income and for high income areas of New York City
to show the correlation between poverty and death.
The
infant mortality was more than twice as high in the poor
sections of the city as in the well to do sections.
The
maternal mortality was seven times as high and the death
rate from tuberculosis was five times as high in the poor
areas.
When studies were made of the mortality statistics
for heart, artery and kidney disease, cancer, diabetes,
pneumonia, influenza and accidents, the death rates were
higher in the poor district of Bedford and lower in the
99
high income suburb of Flushing.
From statistical evi-
dence, James suspected that poverty should be considered
as the third ranking cause of death (3:82).
Recognizing the existence of American poverty
also means recognition of it's heterogeneity.
The Blacks,
Browns, aged, disabled and unskilled are not poor for the
same reasons, but low income and dependence on assistance
may be some common factors in their condition.
Likewise,
their health needs lack a common etiology and their
responses to remedy may vary.
Nonwhites are twice as
likely to be poor as Whites.
Urban cities contain 54%
of the poor.
by women.
One-fourth of all poor families are headed
The aged and children comprise the largest
single group within the poverty profile.
The effects of
poverty and racism have combined to produce an appalling
mortality and morbidity gap between White and Nonwhite
Americans.
The basis for these statistics may be found
in reports conducted by all major agencies at the federal,
state and local levels (47).
If we come to regard poverty as a cause of
morbidity, it should be remembered that poverty is a
social environment of many facets.
It can be measured
in terms of subsistence (income, education, social class,
occupation, residence) and in terms referring to the lack
of privileges in life (unemployment, powerlessness, loss
100
of status, inadequacy, social disruption).
Poverty
remains a collective noun which covers a wide variety
of undesirable features of social life.
It is, therefore,
difficult to isolate the cause among it's numerous facets.
When health is clasified as a general entity, it
may be impossible to determine whether income, education
or any of the above factors is the most responsible agent
and in all probability, the importance of each factor
varies with each specific health problem under investigation.
Thus, both poverty and health have multiple
causes which are interrelated and effect in varying degress the different facets of poverty and health.
A
prominent inquiry appears to be the causation that exists
between poverty and health.
It is evident that poverty
is neither a necessary nor a sufficient cause of poor
health:
rich people too suffer from disease.
Can po-
verty, however, be a necessary or sufficient cause of a
specific deficit characterizing a poverty population?
An
example of dental caries aids in formulating an answer.
Dental caries is noticeable related to lower socioeconomic status in communities which do not have flouridated water, but in communities which use flouridation,
the social class differential in caries tends to disappear (44:330).
1 01
Poverty is a specific social environment, but the
elements of this environment change and vary; through
man's work such as flouridation they may improve.
Hence,
poverty must be considered a contributory cause in the
health deficit of the poor.
A contributory relationship
might be enough to appeal to emotion and prompt intervention.
Through proper actions, it is believed that the
povery-health complexity can be improved (44).