|
For Whose Benefit? The Politics of Developing A Health Education
Curriculum
Directions for a new health education curriculum: Concepts of
health education
In the last twenty five years there has been a significant shift
in the dominant concept of health, from a notable "absence of disease"
to a more holistic concept of "wellness". How society views health
is, of course, central to the processes and practices of health
education. The dominant approaches to health education employed
through the 1970s and early 1980s were based on a medicalised disease-prevention
view, often delivered to students by health professionals devoid
of teaching skills and any personal knowledge of their pupils. In
the absence of any clear curriculum models for health education
the hegemonic approach became one of information overkill,
found to have minimal pedagogical success (Abelin, 1987; Green,
1980; Green and Lewis, 1986).
During the 1980s a number of central theoretical constructs for
health education began to emerge. Glanz (1988) identifies fifty-one
of these, most of which could be described as linear, rather than
multi-dimensional.1 Three
dominant theories were the social learning theory, dating back to
Miller and Dollard (1941) and further developed by Bandura (1977);
the health belief model based on the work of Kurt Lewin (1951);
and the theory of reasoned action (Fishbein and Ajzen, 1975).
In New Zealand, the 1985 revision of the New Zealand Health
Education Syllabus 2 was
a major step forward for health education as it partly reflected
a more expansive, multidimensional approach to health teaching.
For example, it maintained that:
Health is a state of well-being, and in the context of this
syllabus it encompasses physical, mental, and social health (Department
of Education, 1985, p. 4).
This syllabus was also innovative in that it promoted a needs-based
approach to health education, and incorporated concepts of home
and community involvement. This curriculum has never been implemented
in schools to the extent that was originally envisaged. The underlying
emphasis of this multidimensional approach was primarily individualistic,
implying that individuals can and should take responsibility for
their own health, and to some extent, the health of others. For
example, it stated that:
Health education is the process through which people develop the
understandings, skills and motivation to act in a responsible way
for their own health and the health of others (Ibid.).
The syllabus described the learning outcomes or behaviours which
were considered to be achievable by all members of the community.
There was little overt acknowledgment of the complex interplay of
economic, socio-political, cultural and environmental factors which
impact on an individual's health status, nor was there any substantive
recognition of the bicultural nature of New Zealand. Interestingly,
in contrast to the individualistic philosophical underpinnings of
this syllabus, Māori conceptualisations of health are more
holistic. Durie (1994) describes the concept of Hauora (total wellbeing)
in terms of four interwoven cornerstones: taha wairua (spiritual);
taha hinengaro (mental and emotional); taha tinana (physical); and
taha whānau (social); and Durie emphasises collective responsibility,
the significance of te reo (language) and te whenua (the land).
Clearly, such conceptualisations embody a more comprehensive understanding
of the meaning, breadth and significance of health education than
that which a predominant focus on the individual can provide.
Individualistic approaches to health and health education, described
as healthism by Crawford (1980), identify the individual
as the major determinant of personal health. Such approaches target
behaviour and life-style changes as key ways of improving personal
and, ultimately, societal health status. Crawford maintains that
such an approach involves a:
... preoccupation with personal health as a primary –
often the primary – focus for the definition and achievement
of personal wellbeing; a goal which is attained primarily through
the modification of lifestyles, with or without therapeutic help.
The etiology of disease may be seen as complex, but healthism
treats individual behaviour, attitudes and emotions as the relevant
symptoms needing attention. Healthism will acknowledge in other
words, that health problems may originate outside the individual,
e.g. in the American diet, but since these problems are behavioural,
the solutions are seen to lie within the realm of individual choice.
Hence, they require above all else the assumption of individual
responsibility (1980, p. 368).
From an individualistic perspective, health education is seen
as the promotion and eventual adoption of particular health behaviours
for the purposes of preventative health care. In some cases, such
behaviours are seen as offering one way of managing public health
crises (e.g. HIV and AIDS or levels of legal and illicit drug use).
The adoption of personalised preventative behaviours, while important,
are frequently regarded, particularly by those in power, as key
ways to reduce health care costs by shifting the focus of treatment
from centralised, and frequently expensive, technology-laden, curative
medical procedures onto the individual. Deinstitutionalisation and
community-care policies throughout all sectors of the health system
are now widely known examples of the extension of this kind of logic
i.e. the transfer of responsibility for health and welfare from
the state to the community and the individual. Indeed, another example
of the pervasiveness of this discourse in health has been the widespread
public perception that the development of the health and physical
education curriculum area, as a component of The
New Zealand Curriculum Framework (Ministry of Education,
1993), was accelerated ahead of the Arts Curriculum due to public
concern for the declining health status of New Zealand's children
and adolescents.
While the focus on individual responsibility and behavioural outcomes
is an important epidemiological strategy, it ignores environmental
factors and deflects attention away from the structural/social dynamics
which affect health status (e.g. class, gender and ethnic locations,
and the role of other social processes and institutions such as
the state). A curriculum which emphasises individualism and healthism
fits well with the philosophy and practice of a market driven society
where the primacy of the individual, as an isolated social and economic
unit making choices in the market place, is now one of the main
discursive features of our social and educational landscape. Such
a model sits well with the changing concept of education that this
embodies; one which emphasises the acquisition of skills deemed
necessary "in order to enhance the economic prospects of a particular
nation" (Tones, 1996, p. 3). Not surprisingly, a wide range of research
has demonstrated that health improvements, which focus primarily
on health behaviours only work for those in the upper and middle
class populations (Baumann, 1989; Kickbusch, 1989; Green and Kreuter,
1990). As Naidoo (1986), Combes (1989), and Colquhoun (1990) have
argued, such programmes have disadvantaged half of the children
in Australian schools through their failure to address health issues
in relation to their causal antecedents, those based in the socio-environmental
contexts in which those children live and develop.
A major global shift forward in developing effective models for
(school) health education came in 1986 with the development of the
World Health Organisation's (WHO) Ottawa Charter. This recognised
that major health gains were linked not so much to advances in medical
knowledge but, rather, to increases in wages and living standards
coupled with improvements in public health services and health oriented
legislative requirements. The Ottawa Charter (1986) identified
nine broad pre-requisites for health. These were: peace, education,
food, shelter, income, a stable ecosystem, sustainable resources,
social justice and equity. It also identified five areas for action
in societal health promotion. These were: the building of healthy
public policies; the creation of supportive environments; the strengthening
of community actions; the development of personal skills, and a
re-orientation of health services (WHO, 1986, p.1-2). One consequence
of this WHO initiative has been a movement involving thirty nine
countries in a European network with the addition of many Pacific
Rim and other countries which has translated these principles into
the concept of the health-promoting school. This model, as
described by Green et al. (1996), identifies three complementary
and interlinked contexts for effective health education in a school
setting. These are:
- the taught health education classroom programmes;
- the school environment and milieu; and
- links with and support from the family and community.
Supportive school health policies and environments are seen as
essential in establishing and maintaining congruence between these
three contexts.
Recent health-focussed curriculum models such as Jewitt's (1994)
"ecological integrative perspective" and Lawson's (1992) "socio-ecological
conception" of health also advocate these kinds of interlinked requirements.
They place emphasis on the importance of addressing the personal,
interpersonal, and societal aspects of health and on recognising
the complex inter-connections between individuals and the environment.
As Lawson maintains:
A socio-ecological conception of health calls attention to patterned
interdependecies among individuals, groups, their lifestyle choices
and stages, societal institutions, and the economic, spatial-communal,
and natural-environmental contexts (i.e. human ecosystems). It
also includes cultural influences and definitions, including meanings
associated with health, fitness, beauty, virtue and the "good
life". This conception acknowledges gradients of choice, the multiple
dimensions of responsibility and the meanings and functions of
health-related behaviours (1992, p. 111).
Whilst it is essential to address the concerns of the individual
(recognising that all students are unique individuals engaged in
a search for personal meaning in a constantly changing world), a
shift away from individualism still allows the acknowledgement of
the individual within their wider social context. The behavioural,
biological, cultural, economic, environmental and social factors
which interact to enhance, or detract from personal well-being must
be taken into account and in essence must be treated as having or
contributing to real health effects. A socio-ecological perspective
thus requires balance and integration between individual and societal
considerations. It encourages self-reflection, critical thinking
and critical action. It is designed to remove barriers to total
or holistic wellbeing through the empowerment of individuals and
communities to create societal conditions conducive to health for
all.
previous / back
to index / next
Footnotes
1. A linear approach focuses on only one or two dimensions of the
multifaceted aspects which constitute a personal understanding of
health problems and issues. For example, a health belief model
implies that individuals need knowledge in order to change their
beliefs and thus change their behaviour, as opposed to a recognition
and understanding of the multiple aspects of their lives which might
need to be addressed for change to happen.
2. The 1985 revision of the New Zealand Health
Education Syllabus is the current official syllabus.
|
