Chapter 8Community Health EducationCopyright © 2015, 2011, 2.docx

Chapter 8
Community Health Education
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,
an imprint of Elsevier Inc.
Health Education …
… is any combination of learning experiences designed to
predispose, enable, and reinforce voluntary behavior conducive
to health in individuals, groups or communities.
– Green and Kreuter, 2004
2
Health Education’s Goals
To understand health behavior and to translate knowledge into
relevant interventions and strategies for health enhancement,
disease prevention, and chronic illness management
To enhance wellness and decrease disability
3

Health Education’s Goals (Cont.)
Attempts to actualize the health potential of individuals,
families, communities, and society
Includes a broad and varied set of strategies aimed at
influencing individuals within their social environment for
improved health and well-being
4
Learning Theories
Humanistic theory helps individuals develop their potential in a
self-directing and holistic manner.
Cognitive theory recognizes the brain’s ability to think, feel,
learn, and solve problems; theorists in this area train the brain
to maximize these functions.
Social learning is based on behavior that explains and enhances
learning through the concepts of efficacy, outcome expectation,
and incentives.
5
Adult Learners
Need to know
Concept of self
Experience
Readiness to learn

Orientation to learning
Motivation
– Knowles (1980, 1989)
6
Health Education Models
Health Belief Model (HBM)
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Self-efficacy
Demographics
Cues to action
7
Health Education Models (Cont.)
Health Promotion Model (HPM)
Individual characteristics and behaviors
Prior behaviors, personal factors
Behavior—specific cognitions and affect
Activity-related affect, interpersonal influences, situational
factors, commitment to plan of action, perceived self-efficacy,

immediate competing demands and preferences, perceived
benefits of health-promoting behaviors, perceived barriers to
health-promoting behaviors
Behavioral outcome
Health-promoting behavior
8
Model of Health Education Empowerment
… nurses cannot assign power and control to the individual
within the community but rather … the “power” must be taken
on by the individual and community with the nurse guiding this
dynamic process.
– Van Wyk, 1999
9
Model of Health Education Empowerment (Cont.)
Process includes examining
Education
Health literacy
Gender
Racism
Class
Recognizes the structural and foundational changes that are
needed to elicit change for socially and politically
disenfranchised groups

10
Problem-Solving Education …
…centers on empowerment (Freire, 2005)
Allows active participation and ongoing dialogue
Encourages learners to be critical and reflective about health
issues
Involves individuals as subjects, not objects
Increases health knowledge through a participatory group
process
Involves activism on the part of the educator
Facilitator-educator is a resource person and is an equal partner
with the other group members
Leads to sustainable lateral relationships
11
Participatory Action Research (PAR)
Goal of PAR is social change
Embraces the use of community-based participatory methods
Participation and action from stakeholders and knowledge about
conditions and issues helps to facilitate strategies reached
collectively
12

Community Empowerment
Community members take on greater power to create change
Based on community cultural strengths and assets
Attention must be given to collective rather than individual
efforts to ensure that outcomes reflect voices of the community
and truly make a difference in people’s lives
13
The Nurse’s Role in Health Education
Become a partner with individuals and communities
Serve as catalyst for change
Activate ideas
Offer appropriate interventions
Identify resources
Facilitate group empowerment
14
Framework for Developing
Health Communications
15

Figure 8-1
Health Education Model
Stage I: Planning and strategy selection
Questions to Ask
Who is the intended audience?
What is known about the audience and from what sources?
What are the communication and education objectives and
goals?
What evaluation strategies will the nurse use?
What are the issues of most concern?
What is the health issue of interest?
16
Stage I: Planning and strategy selection (Cont.)
Collaborative Actions to Take
Review the available data.
Get community partners involved.
Obtain new data.
Determine perceptions of health problems.
Determine the community’s assets and strengths.
Identify underlying issues and knowledge gaps.
Establish goals and objectives.
Assess resources.

17
Stage II: Developing and pretesting concepts, messages, and
materials
Questions to Ask
What channels are best?
What formats should be used?
Are there existing resources?
How can the nurse present the message?
How will the intended audience react to the message?
Will the audience understand, accept, and use the message?
What changes may improve the message?
18
Stage II: Developing and pretesting concepts, messages, and
materials (Cont.)
Identify the messages and materials.
Decide whether to use existing materials or produce new ones.
Select channels and formats.
Develop relevant materials with the target audience.
Pretest the message and materials and obtain audience feedback.
19

Stage III: Implementing the program
Questions to Ask
How should we launch the health education program?
How do we maintain interest and sustainability?
How can we use process evaluation?
What are the strengths of the health program?
How can we keep on track within timeline and budget?
How do we know if we have reached our intended audience?
How well did each step work (process evaluation)?
Are we maintaining good relationships with partners?
20
Stage III: Implementing the program (Cont.)
Work with community organizations to enhance effectiveness.
Monitor and track progress.
Establish process evaluation measures.
21

Stage IV: Assessing effectiveness and making refinements
Questions to Ask
What was learned?
How can outcome evaluation be used to assess effectiveness?
What worked well, and what did not work well?
Has anything changed about the intended audience?
How can we refine methods, channels, and formats?
What lessons were learned? What modifications could
strengthen the health education activity?
22
22
Stage IV: Assessing effectiveness and making refinements
(Cont.)
Conduct outcome evaluations.
Reassess and revise goals and objectives.
Modify unsuccessful strategies or activities.
Generate continual support from community groups.
Provide justification for continuing/ending the program.
Summarize in an evaluation report.
23
23
Health Literacy Definitions Evolved Over Time

National Literacy Act (1991)
Literacy is operationally defined as the ability to read and write
at the fifth-grade reading level in any language and can be
measured according to a continuum.
IOM Report (2004)
The capacity to obtain, interpret, and understand basic health
information and services and the competence to use such
information and services to enhance health
24
In 1999, the AMA’s Report of the Council on Scientific Affairs
reported that patients with the most health care needs are often
the least able to read and understand information that would
enable them to function successfully within
the health care system.
25
Health Literacy
Health Literacy (Cont.)
Health literacy is about empowerment …
Having access to information, knowledge, and innovations
Increasingly important for social, economic, and health
development
A key public health issue in the delivery of safe, effective care

26
Low Literacy
Increases the use of health care services
Decreases self-esteem; increases shame and stigma
Adversely affects outcomes and treatment of some medical
conditions
Poses barriers to obtaining informed consent
Impacts participation in research
Leads to health care and linguistic isolation
Impedes patient-provider communication
27
Literacy Concerns
Serious mismatch exists between the reading levels of materials
and patient’s reading skills.
Materials often fail to incorporate the intended audience’s
cultural beliefs, values, languages, and attitudes.
Low literacy prevents many from gaining the full benefits of
health care.
28

Literacy Concerns (Cont.)
Inability to read and understand instructions influences self-care
abilities and health and wellness.
Individuals with very low literacy skills are at an increased risk
for poor health, which contributes to health disparities.
29
Levels for Interventions
Functional/basic literacy
Increasing basic reading/writing skills
Communicative/interactive literacy
Understanding and using information with providers
Critical literacy*
Analyzing and using information in life situations
*Most important because it increases empowerment and success
in everyday situations
30
Helpful Tips for Effective Teaching
Assess reading skills
Determine what client needs to know
Identify motivating factors

Stick with essentials
Set realistic goals and objectives
Use clear and concise language
Develop a glossary of common words
Space teaching over time
Personalize health messages
Incorporate methods of illustration, demonstration, and real-
life examples
Give and get
31
Helpful Tips for Effective Teaching (Cont.)
Summarize often
Be creative
Use appropriate resources and materials
Put patients at ease
Praise patients
Be encouraging
Allow time for questions
Employ teach-back methods
Remember that comprehension and understanding take time and
practice
Conduct learner verification
Evaluate the teaching plan
32
Assess Materials
Become a Wise Consumer and User
Evaluate health materials, including websites, before
disseminating them

Materials should strengthen previous teaching
Materials should be used as an adjunct to health instruction
33
Assessing the Relevancy of Health Materials
Do materials match the intended audience?
Are materials appealing and culturally and linguistically
relevant?
Do they convey accurate and up-to-date information?
Are messages clear and understandable?
Do messages promote self-efficacy and motivation?
34
Assessment of Reading Level
Assess reading levels of intended audience
Rapid estimate of adult literacy in medicine (REALM)
Single Item Literacy Screener (SILS)
Short Assessment of Health Literacy for Spanish-Speaking
Adults (SAHLSA)
Assess readability of educational resources
SMOG readability formula
Flesch-Kincaid formula (on most computers)
Verify understanding of learner
35

Role of Social Media
Numerous platforms now available
May reach diverse community constituents with important
public health messages
Potential to…
Facilitate interactive communication
Increase sharing of health information
Personalize and reinforce health messages
Can empower community members to make informed health
decisions
36
Chapter 7
Community Health Planning, Implementation, and Evaluation
The Community as Client
2
Figure 7-1

Levels of
Community Health Nursing Practice
3ClientExampleCharacteristicsHealth AssessmentNursing
InvolvementIndividualLisa McDonaldIndividual with various
needsIndividual strengths, problems, and needsClient-nurse
interactionFamilyMoniz familyFamily system with individual
and group needsIndividual and family strengths, problems, and
needsInteractions with individuals and the family
groupGroupBoy Scout troop
Alzheimer’s support groupCommon interests, problems, and
needs
InterdependencyGroup dynamics
Fulfillment of goalsGroup member and leaderPopulation
groupAIDS patients in a given state
Pregnant adolescents in a school districtLarge, unorganized
group with common interests, problems, and needsAssessment
of common problems, needs, and vital statisticsApplication of
nursing process to identified needsOrganizationA workplace
A schoolOrganized group in a common location with shared
governance and goalsRelationship of goals, structure,
communication, patterns of organization to its strengths,
problems and needsConsultant and/or employee application of
nursing process to identified needsCommunityItalian
neighborhood
Anytown, USAAn aggregate of people in a common location
with organized social systemsAnalysis of systems, strengths,
characteristics, problems, and needsCommunity leader,
participant, and health care provider

Health Planning Model
4
Figure 7-2
Hogue (1985)
Steps in the Health Planning Model
Assessment
Meet with group leaders of aggregate to clarify mutual
expectations
Determine sociodemographic characteristics
Interview a key informant
Consider both positive and negative factors
Compare the aggregate with the “norm”
Research potential problems
Identify health problems and needs
Prioritize the identified problems and needs to create an
effective plan
5
Four Types of Needs to Assess
Expressed needs
Demand for services and the market behavior of the targeted
population
Normative needs

Lack, deficit, or inadequacy of services determined by health
professionals
Perceived needs
Wants and desires expressed by audience
Relative needs
Gap showing health disparities between advantaged and
disadvantaged population
6
Factors for Determining Priorities
Aggregates preferences
Number of individuals affected by the health problem
Severity of the health need or problem
Availability of potential solutions
Practical considerations such as skills, time, and available
resources
May use Maslow’s hierarchy of needs or levels of prevention to
further refine priorities
7
Community Involvement Is Essential
“Start where the people are!”
Five spheres of empowerment
Interpersonal (personal empowerment)
Intragroup (small group development)
Intergroup (community)

Interorganizational (coalition building)
Political action
– Labonte (1994)
8
Steps in the Health Planning Model (Cont.)
Planning
Determine the intervention levels
Subsystem, aggregate system, and/or suprasystem
Plan interventions for each system level
Primary, secondary, or tertiary levels of prevention
Validate the practicality of the planned interventions according
to available resources
Personal, aggregate, and suprasystem
9
Development of Goals and Objectives
Goals—where we want to be
Objectives—steps needed to get there
Measurable
Specific measures
Instructions to guide population
Used to measure outcomes

10
Intervention
Often the most enjoyable stage for the nurse and the clients
Implementation should follow the initial plan
Should include a variety of strategies
Prepare for unexpected problems
11
Interventions by
Type of Aggregate and System Level
12ProjectType of AggregateSystem Level for
InterventionRehabilitation groupGroupSubsystem and aggregate
systemTextile industryOrganizationAggregate system and
suprasystemCrime watchGroup, organization, and population
groupAggregate system and suprasystemBilingual students
(case study)CommunityAggregate system and suprasystem

Evaluation
Include the participant’s verbal or written feedback and the
nurse’s detailed analysis
Reflect on each previous stage to determine the plan’s strengths
and weaknesses
Evaluate both formative (process) and summative
(product/outcome) aspects
Communicate follow-up recommendations
13
Importance of Each Step in the Nursing Process
Aggregate assessments must be thorough.
Should elicit answers to key questions about the aggregate’s
health and demographic profile
Should compare this information with similar aggregates
presented in the literature
The nurse must complete careful planning and set goals that the
nurse and the aggregate accept.
Mutual planning is very important.
Interventions must include aggregate participation and must
meet the mutual goals.
Evaluation must include process and product evaluation and
aggregate input.
14

PRECEDE-PROCEED Model
15
Federal Legislation Affecting Health Planning
Hill-Burton Act
Regional Medical Programs (RMP)
Partnership for Health Program (PHP)
Certificate of Need (CON)
National Health Planning and Resources Development Act
16
Comprehensive Health Reform
Patient Protection and Affordable Care Act (2010)
Preventive services based on evidence-based recommendations
National strategy to improve the nation’s health
CMMS innovation center
National quality improvement strategy for services and
population health
Improved access to care
Reduction in the growth of Medicare spending
National workforce strategy
17

Nurses’ Role
Work collaboratively with health planners to improve aggregate
health
Fuse technology with knowledge of health care needs and skills
Become directly involved in the planning process
Engage in aggregate-level projects
18
Chapter 5
Epidemiology
Epidemiology Is …
… the study of the distribution and determinants of health and
disease in human populations
(Harkness, 1995)
… the principal science of public health
2

Historical Perspective
Investigations of disease pattern in the community; comparing
people who had disease or who remained healthy
Person-Place-Time Model
Person: “Who” factors, such as demographic characteristics,
health, and disease status
Place: “Where” factors, such as geographic location, climate
and environmental conditions, political and social environment
Time: “When” factors, such as times of day, week, or month and
secular trends over months and year
3
Different Types of Epidemiology
Descriptive Epidemiology
Study of the amount and distribution of disease
Used by public health professionals
Identified patterns frequently indicate possible causes of disease
Analytic Epidemiology
Examine complex relationships among the many determinants of
disease
Investigation of the causes of disease, or etiology
4

Epidemiological Triangle
5
Figure 5-1
Agent of Disease
(Etiologic Factors)
Nutritive elements
Excesses, deficiencies
Chemical agents
Poisons, allergens
Physical agents
Ionizing radiation, mechanical
Infectious agents
Metazoa, protozoa, bacteria, fungi, rickettsia, viruses
6
Host Factors–Intrinsic Factors
(Susceptibility, or Response to Agent)
Genetic
Age
Sex
Ethnic group
Physiological state

Prior immunological experience
Active/, passive
Intercurrent or preexisting disease
Human behavior
7
Environmental Factors— Extrinsic Factors…
… influence existence of the agent, exposure, or susceptibility
to agent
Physical environment
Biological environment
Human populations, flora, fauna
Socioeconomic environment
Occupation, urbanization and economic development, disruption
8
Wheel Model of
Human-Environment Interaction
9
Figure 5-2

Redrawn from Mausner JS, Kramer S: Mausner and Bahn
epidemiology: an introductory text, ed 2, Philadelphia, 1985,
Saunders.
Web of Causation
10
Figure 5-3
From Friedman GD: Primer of epidemiology, ed 4, New York,
1994, McGraw-Hill.
Ecosocial Approach
Emphasize the role of evolving macro-level socioenvironmental
factors along with microbiological process in understanding
health and illness (Smith & Lincoln, 2011)
Challenges the more individually focused risk factor approach
to understanding disease origins
11
Calculation of Rates
Rates are arithmetic expressions that help practitioners consider
a count of an event relative to the size of the population from
which it is extracted
Number of health events in a specified period
Population in same area in same specified period

Proportion multiplied by a constant (k)
For example, the rate can be the number of cases of a disease
occurring for every 1000, 10,000 or 100,000 people in the
population
Can make meaningful comparisons
12
Morbidity Rates
Incidence rates
New cases or conditions
Attack rate
Number of new cases of those
exposed to the disease
Prevalence rates
All cases of a specific
disease or condition at
a given time
13
Prevalence Pot
The relationship between incidence
and prevalence
Figure 5-4
Redrawn from Morton RF, Hebel JR, McCarter RJ: A study
guide to epidemiology and biostatistics, ed 3, Gaithersburg,
MD, 1990, Aspen Publishers.

14
Morbidity Rates (Cont.)
Incidence Rate
Prevalence Rate
Number of existing cases
Total Population
_____
Number of new cases
_in given time period

Population at risk in
same time period
___75___
4000–250
× 1000
= 0.02
0.02 × 1,000 = 20 per 1000 per time period
250
4000
= 0.0625
0.0625 × 1000 = 62.5 per 1000
Mortality Rates
(routinely collected birth and death rates)
Other rates
Crude rates
Age-specific rates
Age-adjusted rates or standardization of rates
Proportionate mortality ratio (PMR)
15
16

Number of deaths in year
Total population size
_1720_
200,000
× 100,000
= 0.0086
Number of births in year
Total population size
_2900_
200,000
× 100,000
= 0.0145
Concept of Risk
Risk—probability of an adverse event
Risk factor
Refers to the specific exposure factor
Often external to the individual
Attributable risk
Estimate of the disease burden in a population
Relative risk ratio
Divide the incidence rate of disease in the exposed population
by the incidence rate of disease in the nonexposed population.
17
Use of Epidemiology
Disease prevention

Primary prevention
Health promotion and specific prevention
Secondary and tertiary prevention
Establishing causality
Screening
Surveillance
18
Use of Epidemiology (Cont.)
Health services
Used to describe the distribution of disease and its determinants
in populations
Study population health care delivery
Evaluate use of community health services
Nurses must apply findings in practice
Incorporate results into prevention programs for communities
and at-risk populations
Extend application into major health policy decisions
19
Community health nurses should exercise “social responsibility”
in applying epidemiological findings, but this will require the
active involvement of the consumer.

Community health nurses collaborating with community
members can combine epidemiological knowledge and
aggregate-level strategies to affect change on the broadest scale.
20
Epidemiological Methods
Descriptive epidemiology
Focuses on the amount and distribution of health and health
problems within a population
Analytic epidemiology
Investigates the causes of disease by determining why a disease
rate is lower in one population group than in another
21
Analytic Epidemiology
Observational studies
Descriptive purposes
Etiology of disease
No manipulation by investigator
Cross-sectional studies
Sometimes called prevalence or correlational studies
Examine relationships between potential causal factors and
disease at a specific time
Impossible to make causal inferences
22

Analytic Epidemiology (Cont.)
Retrospective studies
Compare individuals with a particular condition or disease with
those who do not have the disease
Data collection extends back in time
Prospective studies
Monitor a group of disease-free individuals to determine if and
when disease occurs
Cohort shares a common experience within a defined time
period
Monitors cohort for disease development
23
Analytic Epidemiology (Cont.)
Experimental design
Also called a Randomized Clinical Trial (RCT)
Subjects assigned to experimental or control group
Apply experimental methods to test treatment and prevention
strategies
Ethical considerations with human subject rights review
Also useful for investigating chronic disease prevention
24

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