Health Education: Bridging the Gap between Knowing and Doing

H ierdie artikel gaan hoofsaaklik oor form ele gesondheidsvoorligting in vinnig veranderende oorgangs-tydperke in die sam eling. 'n Kort beskry wing word g eg ee van die veranderingsproses, verwant aan sek ere begrippe m et betrekking tot gesondheidsvoorligting — g em een sk ap sb etrok k en h eid , vryw illige gesondheidsvoorligters, groep b e-sprekings en gem eenskapsleiers. D ie afleiding word gem aak dat, slegs waar die gesondheidw erker, gem eenskapsleiers en led e van die g em een sk ap , d eel het aan gem eensk ap lik e b elan ge, 'n gem eenskaplike taal praat en daar 'n onderlinge ooreen k om s is in persoon lik e-en sosiale karaktereienskappe — die aanvaarding van nuw e begrippe 'n m eer blyw ende uitwerking tot gevolg het ten opsigte van die verbreding van kennis, houdingsvorm ing en verandering in openbare optrede. " Changing people's custom s is an even m ore delicate process than su rgery " Edward H. Spicer (1952) T HE aim o f health education is to influence or even change behaviour affecting people's health. It must at all times be intrinsically valuable and w orthw hile. M any aspects o f health behaviour are part o f m an's norm al everyday life, other aspects how ever, require conscious efforts based on know ledge. All aspects are directed tow ards preserving health and avoiding illness. Leo Baric (1972) — 2 describes two concepts o f health education, the first one denoting the contents (health) and the second one the process (education). He then defines health education as two separate (but often parallel) processes:-Inform al health education, considered to be concerned with transm itting knowledge about health and disease as a planned process. IN FO RM A L HEALTH EDU CA TIO N Inform al health is part o f an evolutionary process which involves the transm ission from one generation to another, or from one peer to another, o f R ELEV A N T health inform ation based on accum ulated em pirical know ledge. This is m ostly

T HE aim o f health education is to influence or even change behaviour affecting people's health.It must at all times be intrinsically valuable and w orthw hile.M any aspects o f health behaviour are part o f m an's norm al everyday life, other aspects how ever, require conscious efforts based on know ledge.All aspects are directed tow ards preserving health and avoiding illness.
Leo Baric (1972) -2 describes two concepts o f health education, the first one denoting the contents (health) and the second one the process (education).He then defines health education as two separate (but often parallel) processes:-Inform al health education, considered to be concerned with transm itting knowledge about health and disease as a planned process.

IN FO RM A L HEALTH EDU CA TIO N
Inform al health is part o f an evolutionary process which involves the transm ission from one generation to another, or from one peer to another, o f R ELEV A N T health inform ation based on accum ulated em pirical know ledge.This is m ostly learnt in the fam ily, the home and the com m unity.Empirical knowledge o f one generation or peer group, if shared by most people, can becom e part o f 'norm al' behaviour for future generations.

FO RM AL H EALTH EDUCATION
Formal health education, in transm itting knowledge to one generation can influence informal health education o f the next, creating new 'norm al' ways o f dealing with healthrelated problem s.In our western society, accum ulation and updating o f medical know ledge has been entrusted to the medical profession, who can carry out this activity directly in the health care delivery system or indirectly by initiating health education services in the hom es, schools and other community groups.Form al health education is usually in itiated by health professionals and aims to influence attitudes and practices related to individual, family and community health.Health know ledge is mainly gained in schools, in the health care delivery system and from the m edia from a wide range o f professional workers.Most health education prog rammes are form ally constructed and provide information about health threats and desired behaviour changes.
This paper is mainly concerned with formal health educa tion in rapidly changing transitional societies, where new and rational decisions regarding health behaviour have to be made by fam ilies and com m unities living in their new envi ronm ent, and, where innovative decision-m aking has to take place, where new ideas need to replace some of the old ones, and where new alternatives must be wisely chosen.
I intend describing certain theoretical aspects basic to m odem health education taken from comm unication and educational theory.I have applied these to concepts we so com m only hear -com m unity involvem ent, grass-root w orkers, group discussion, and community leaders.

THE IN N OV A TION PROCESS
For people to learn to practise new health behaviours, a certain period o f tim e has to pass -from the first knowledge o f an innovation to the decision to adopt or reject it.
Basically there are several stages.People hear and then becom e aware o f the existence o f a new idea but they do not yet have any inform ation on it.They becom e interested and may actively seek further inform ation, which they will evaluate by applying the idea to their present and possibly future life situation.Then they will decide whether they will or will not try it.Usually people will prelim inarily apply the new idea on a small scale or for a short time to see if it is of use.Ultim ately they will decide to either continually use it on a full scale or totally to reject it.
Generally people tend to expose them selves to those ideas which are in accord with their interests, needs and existing attitudes.Individuals need to perceive the innovation relev ant to their needs, attitudes and beliefs.People with little education are often still more deeply rooted in their tradi tional attitudes and values, and stand a greater chance not to perceive new ideas.W hat is m ore, later they tend to discon tinue a health practice they had tem porarily adopted.

K N OW LED G E -
A stage o f cognitive thinking, where the individual has gained new know ledge from the mass m edia or in his daily contact with others, and where he gains some understanding o f how the new idea functions.It is at this stage that people develop perceived needs for an innova tion.Shoem aker defines a need as follows: A need is a state of dissatisfaction or frustration and occurs when one's desires outweigh one's actualitieswhen 'w ants' outrun 'gets'.The problem o f w hether 'new ' knowledge creates an awareness of 'new ' needs, or whether felt needs create a desire to seek new know ledge, leads to the question: Which cam e first -the chicken or the egg?
Often new ideas may not be seen as potentially useful by the individual or may be even irrelevant or not relevant enough for his particular social situation, and therefore of no interest to him at the time.
W hat is crucially im portant, is that KNOW ING about an idea is often quite different from USING the idea.Professor Ryle (1972) -4 distinguished between knowing that and knowing how: To be intelligent is not merely to satisfy criteria but to apply them.

K N OW IN G THAT
Knowing that leads to awareness o f an idea and to intellig ently grasping the situation.Until one knows about an idea, one cannot start to form an attitude towards it.Once the individual knows about a possible innovation, he may ac tively seek more information about it.W hat messages he receives depend on his existing network of concepts.How he interprets the new messages depends on his personality and his norms with his particular social system.

KNOW ING HOW
Knowing how really means putting the prescription or new idea into practice, as Ryle states: We learn how by practice, schooled indeed by criticism and exam ple, often quite unaided by any lesson in the theory.
Already in 400 BC Sophocles was thinking very similarly when he said: One must learn by doing the thing.Although you think you know it -you have no certainty until you have tried it.

PERSUASION -
The individual now forms a favourable or unfavourable attitude towards the innovation.This takes place mainly with interpersonal exchange o f ideas and feelings.The individual may feel some risks.He may be unsure o f the idea's possible results and feel a need to seek support from his fam ily, peers or a friendly health professional, on a interpersonal basis, in an attempt to confirm his new beliefs.

DECISION -
The individual now engages in activities which lead to his choice to adopt or to reject the innovation.The individual may decide on his ow n, but often his decision-m aking will be facilitated by peer and family group decision-m aking.

CO N FIRM ATION -
The individual seeks reinforcement of the innovation he has made.He will seek out interpersonal situations to gain further know ledge and re-confirm his new beliefs and attitudes.He or she will continue to m ake sure that the decision made is still a good and valuable one.
Let us have a look to see what is important in all this theory.M any o f us have experienced patients repeating to us alm ost word for word how to carry out an instruction.BUT later we find that they did not actually practise in their daily lives what they had been taught.Perhaps we have been concentrating too much on telling, on too much 'know ing that', and have om itted to really involve ourselves deeply enough with our patients to learn what 'knowing how ' means to them.
A ccepted and com m only used health practices have over the centuries developed in families and com m unities, where people and their teachers and innovators were living in daily close contact with each other and knew how their fellow men felt about many particular health m atters.As people moved to live in larger and larger urban com plexes, and as medical technology developed, doctors and nurses through their long training have m oved further and further from their com munities.In m any cases they do not share attitudes to health practices with their patients any longer.They do not know any more exactly who makes the decisions in the community they serve, and why they are made.Health professionals have had to resort to teaching m ore and more 'that' and to move further and further away from 'how '.
In recent years this trend is being reversed.W e have all becom e aware o f the important role informal health educa tion plays in influencing community health behaviour.We have learnt through bitter experience o f non-com pliance that new health norm s cannot be imposed by us as health profes sionals.

COM M U N ITY INVOLVEM ENT
In this process we set out to involve people in their own developm ent.W e educate them to make and carry out deci sions which would affect and further their own health status and that of their com m unities.
Gradually several main strategies evolved.O ne o f these, the use o f 'grass-root' workers has been used in many coun tries with great success.These com m unity health workers live in many cases much closer to their com m unities than the doctors and nurses in the area, and often take care o f their families and them selves in ways which are very sim ilar to those practised by their friends and neighbours.They know the 'how ' more intimately than the highly trained nurse or doctor.The m odem Health Education motto: 'Every health w orker a health educator -from the professor to the ward m aid' holds today, as it did before.In many countries, comm unity developing agents have gone into the community to look for volunteers, or paid community workers to enlist their help in closing the gaps between know ing and doingbetw een 'know ing that' and 'knowing h ow '.These new health care workers are often able to evolve practical and acceptable ways o f changing and m oulding existing health practices to accom m odate new ideas which have become necessary in new and changing environm ents.
But this is not enough.If people are going to be persuaded to form favourable attitudes to an innovation, they must have many opportunities to discuss this with each other.Again this is nothing new , for people have com m only done this in the past -at the m arket place when they were shopping, at the wells when they were draw ing w ater and on riverbanks when they were washing their laundry.This is where people tried to confirm their beliefs and to seek support from each other before deciding to accept or reject a new idea.These people in their particular social system s actively participated and were involved in the decision-m aking process, and thus found it easier to accept new ideas and often felt more satisfied with the innovation once they had accepted it.
Kurt Lewin (1943) -5 illustrated that group discussion m ethods are much more successful in convincing house wives to adopt new food products.The above diagram illustrates that there is a m uch higher degree o f acceptance of an innovation, w hen m em bers of the audience are more highly involved in the decision-m aking process.
Ideally, people them selves should initiate innovation to bring about better standards o f living for them selves.But, if there are no such activities spontaneously forthcom ing from the com m unity, they can be aroused and stim ulated.Doctors and nurses can move into their com m unities and can together with the leaders define priorities, objectives and desired action.But in large urban areas, where com plex collections o f groups and sub-groups o f people live together, this is not always easy to achieve.Com m only the term 'com m unity' applies to a specific area.One can, how ever, not assum e that because people share a com m on adm inistrative boundary that they will necessarily share com m on interests, values and goals.Some sub-groups, how ever, may share a common goal for a particular purpose.
H ow ever, dom inant groups, people in positions o f leader ship or pow er, in the churches, business and voluntary as sociations, may well be interested in health problem s in their area.The most important factor is this people-to-people contact, to identify persons who are enthusiastic about a particular proposed health activity.This can be achieved by feeding back information to com m unity leaders, by form ing joint com m ittees, interest groups or task forces o f com m un ity leaders and health workers.U ltim ately, joint planning com m ittees can be form ulated and gradually local men and w om en, speaking the local language, know n and trusted and easily available for consultation, can actively participate in health education.
. . .education provided to learners must be perceived by them as relevant to their values, concerns, goals, past experiences and present circum stances.If the learner does not have a role in specifying what is and is not relevant to his or her lifespace, the likelihood that the educator will be able to design an appropriate or effec tive plan for influencing the learner's behaviour, is in deed very small.
In the above quotation, Professor Sim mons .(1977)-6 actually takes us one step further, when he states that learners have a definite role in specifying what is relevant in their daily lives.This may perhaps apply in the still developing societies more to the com m unity leaders, but ultimately and ideally, must apply to many if not most mem bers of a com munity.This is the only way to ensure that health education projects fit com fortably into the established order.
John W akefield (1974) -7 stresses that the first moves in planning a health education project are crucial: The com m unity leaders will want to know to whom , and in what form , and how a health education program m e is to be im plem ented.It must be made clear that the pro posals are open to discussion and revision in the light of their advice.
This implies that the com m unity leaders m ust be consulted right at the start o f a new health education programmebefore we as doctors and nurses have 'decided' what would be good for our com m unity and before we have prescribed to the community and have tried to impose our values upon them.Only then will change be generated from withinwhen needs, expectations, attitudes and behaviour are taken full cognisance of, and can real developm ent com mence.In this way, we may be able to develop responsible, active and informed com m unities.

O PIN IO N LEA D ERSH IP
In all societies there are a small num ber o f innovatorspeople who are eager to try a new idea.H ow ever, often this interest 'leads them out o f their local circle of peers and into a more cosm opolitan social relationship' (Shoem aker -8).M ost innovators show too much venturesomeness to be seen as opinion leaders by their com munities.On the other hand, there are the laggards -often people deeply rooted in their particular way o f life and thus slow to adopt new and differ ent ideas.In betw een these two lies a broad spectrum o f early and late adoptors o f new ideas.Opinion leaders are found amongst the early adoptors -people o f great respectability, who are more integrated into the com m unity than the in novators, and who serve as role models for many other members o f their social system.Opinion leaders have often received a better education but this is not necessarily so.Usually opinion leaders are technically more competent and are socially available to their com m unity for advice and guidance.Opinion leaders may be trendsetters on one hand, but on the other may be quite traditional.
Even if we have sought out the opinion leaders in a particu lar com m unity, and have involved them fully in our health education project, we still need to begin with ideas and innovations which possess a high degree o f advantage for the people at the tim e, and which are com patible with existing beliefs.If these considerations are taken into account, a new health education program m e has a much higher likelihood of success.

COM M U N ICA TIO N CHANNELS
The nature o f the social relationship between two people determ ines the conditions under which they will tell each other about their new ideas, and further, it influences the effect the telling will have one on the other.
If one wishes to merely inform another person, m ass m edia channels -radio, television, film s, new spapers, m agazines, and pam phlets -are very useful and often the best method for reaching larger audiences.On the other hand, if one wants to persuade the other person to form a favourable attitude to a new idea, the interpersonal channel o f face-to-face interchange is far more effective.
In our health education programs we must therefore allow for both -the formal education and the informal one.W e must design our programs in such a manner that people can gain new knowledge about certain health problem s AND that they continually have opportunities for discussion -to be persuaded by each other and their health workers in the interpersonal situation.W e m ust also design teaching methods which will facilitate the trials o f innovations to make it easier to adopt a new idea.There must be som eone on hand to provide continuing support while people are trying to make up their minds.W ithout this support there is no assur ance against discontinuing because of the many negative messages which exist in the individual's social system.Smoking is a classical exam ple o f this where both advertise ments and peers pressurise the individual to such an extent, that he gives up his innovation.
Late or slow adopters may well accept a new idea, but often they discontinue early because they are disenchanted with the effect or lack o f effect of the innovation on their daily way of life.
Often laggards merely pay lip service to a new idea and have no intention really o f complying with the practice.Sometimes they lack the educational background to com prehend the implication o f a proposed innovation.Very often the problem is not really a confusion o f values, but the need to reconcile several new values with old existing ones.D ur ing this time o f consolidation, an individual is likely to drop out o f a health programme if he has not had further adequate learning opportunities to strengthen his new convictions.
W here the health workërs, the community leaders and the members of the community share common meanings, share a mutual sub-cultural language and are alike in personal and social characteristics, the communication of new ideas is likely to have a lasting effect in terms o f gain in know ledge, attitude formation and change in overt behaviour Every health w orker must involve him self with his com m unity, must seek out the opinion leaders and must invite com m unity leaders to participate fully in the planning and decision-m aking process.If this is not done well and effi ciently, an educational project may easily fail.The gap between knowing and doing must be narrowed by taking full cognisance of the importance of both 'knowing that' and 'know ing how '.
E R , E .H .(1952).H um an P roblem s in T echnological C h an g e. N ew Y ork: R u ssell S age F o undation, pg 13. 2. B A R IC , L. ed.(1972).B ehavioural Sciences in H ealth and D isease.Published by the International Jo u rn al o f H ealth E ducation, pg 20. 3. R O G E R S , E .M .& S h o em ak er F .F .C om m unications o f Innovation -A C ro ss-cu ltu ral A pp ro ach .2nd E d. T h e F ree Press.N ew Y ork. 4. R Y L E , G .(1949).T h e C o n cep t o f M ind, H arm ondsw orth: P enguin, pg 28. 5. L E W IN , K. (1943).G roup D ecision and Social C hange.N E W C O M B , T h e o d o re M .and H A R T L E Y , E ugene L. E d s.R eadings in Social P sy ch o lo g y .N ew Y ork. 6. S IM M O N S , J .J .(1977).A .J.P .M .6 7 , 12, pg 1138 7. W A K E F IE L D , G (1974).C om m unity Involvem ent: R hetoric o r R eality .In ter n atio n al Jo u rn al H ealth E d u catio n ., X V II, pg 100.8. R O G E R S , E .M .& S h o em ak er, F .F .(1976) ibid