I am currently doing a systematic review of health education programmes among music students in higher education (i.e. conservatoire students), but the way in which I define such a programme is essential to what papers I include.
Health education initiatives were eligible if they represented stand-alone interventions or were part of wider health promotion programmes. Health education programmes were defined according to WHO (1998) and had to be any planned activity or set of activities aimed at increasing health literacy and developing life skills conducing to health (e.g. decision making, problem solving, critical thinking, interpersonal skills, stress management, coping with emotions). The content of such programmes could comprise counseling, teaching, training or other educational processes such as guided group discussions or behavioural modification strategies (Zhu, Ho, & Wong, 2013). Such programmes could be part of or separate from the formal curriculum, yet taking place in a formal education music institution (college, high-school, conservatoire or university, not clinics) incorporating any relevant health-related content (focusing on psychological and/or physical issues), multi-component or formed of a single session, of any frequency and/or length and provided via any delivery method (i.e. face-to-face, via telephone or internet). Only studies focusing on universal preventative interventions were included (i.e. ‘a measure that is desirable for everybody in the eligible population’ [Mrazek & Haggerty, 1994]).
Now, according to this definition, health education (unlike health promotion) should be aimed primarily at outcomes such as increasing knowledge and/or awareness, changing attitudes, beliefs, perceived responsibility, self-efficacy, as well as training relevant skills/abilities such as critical thinking, decision-making or problem-solving. It should not necessarily or on its own be aimed, at changing actual health-related outcomes such as reducing risk of injury or lowering depression/anxiety - for such outcomes, we are talking about health promotion (which incorporates health education but goes beyond it, also encompassing changing the broader environment and ensuring relevant services are in place). However, many authors use health promotion when they only mean health education.
I have two questions:
1. Where should I draw the line given that using such a broad definition for health education programmes (aimed at developing health literacy and life skills) means I need to include both evaluations of formal health courses (that come in the traditional format of a series of lectures and seminars) and evaluations of interventions involving group discussions, more applied sessions and more focused training of specific skills, albeit with music students in a higher education institution? They both fit into the WHO definition!
2. Given that so many authors use health promotion and health education interchangeably and that only one evaluation of a health education programme looked at knowledge, attitudes and beliefs while all the others looked at health-related outcomes (although all were described as health courses), can I include all these outcomes as part of my systematic review? After all, I am looking at the effectiveness of health education programmes with regards to any outcomes! (health literacy and attitude change on one hand, and changes in actual health outcomes on the other hand)
Many thanks! I am really curious to read your views on the above!
Hi Raluca,
It's very complex. It's mainly due to the interchangeability of the terms health education and health health promotion by many disciplines. My site may well help to illustrate - as I've tried hard over the last decade or more too unravel this problem and issue. I am relatively confident as to what I consider health education versus health promotion. The attached might assist.
Health education may target individuals as almost all doctors do when seeing patients, or may target groups(population). For your purpose you probably mean the latter as an organized effort by by governmental or private or NGOs agencies to enhance knowledge, attitude, practice and behaviour of people towards a specific issue. If such programme exists then it must have objectives, inputs, process and output (outcome). These are the components which could be evaluated
Whilst there is no universally accepted definition of health education the term is traditionally regarded to represent planned opportunities for people to learn about health and to make changes to their behaviour (Naidoo and Wills, 2009, p. 58).
You have used the WHO's interpretation of health education-this therefore has an emphasis on concepts such as health literacy-not necessarily central to this discussion.
Health education activities include raising awareness of health issues and those risk factors that contribute to ill health. Awareness or consciousness raising refers to the efforts of one group of people or organisation attempting to focus the attention of a wider group of people on some cause or issue such as disease prevention, human conflicts or political movements. It is often considered to be the first step to changing attitudes towards engagement and action. Health education provides the latest technical information, motivating people to change unhealthy behaviours and giving people the necessary skills and confidence to make those changes. Because of the nature of the activities carried out in health education it is also associated with the concepts of Behaviour Change Communication, Information, Education and Communication, health literacy and health communication.
The role of the health educator is to design and implement learning activities, provide training, instruction and skills development. The health educator is an enabler and not an ‘expert’ who takes an authoritarian role and tells people what they should do. The guiding principle of health education is to facilitate people to make individual informed choices about their health behaviours. An informed choice is one that is based on relevant knowledge about a health behaviour and the perceived risk associated with a wrong choice, consistent with the decision-maker’s values and behaviours. People change their behaviour by identifying their own needs and then by taking personal actions to resolve them, such as improving their ability to perform a particular skill.
The most practical way forward in differentiating between health education and health promotion is to view the latter as encompassing the former as a range of educational and skills developing activities.
From the standpoint of injury prevention for example, health promotion fits what we do better than health education since health promotion is much broader and includes several determinants-we especially focus on the environmental, technological, and political contributions in our programs.
You did not state your purpose in undertaking this review. You need to decide on your purpose and this will help you decide if you need to narrow and/or change your definition. The important thing will be to define both your purpose and your definition. Then you can develop criteria on whether to include any particular study in your review. Your report will need to include a statement of the purpose, definition, and criteria for inclusion and exclusion.
You can have two sections to your review or you include all in one section. Those which measured KAB resulting from the intervention and those which included health outcome changes. Some/many of the studies will report on both while some will focus just on one or the other.
I would suggest creating a table which includes information about the study. Initially include all studies which you look and mark in a column whether they meet your criteria fully, partially or not at all. Reviewing this table will help you decide how narrow or wide you want your inclusion to be.
WHO is right. Even political polices related to our daily life, such as the minimum wage, tax policies, etc. can help people to relive stress, diseases or cause stress and diseases. That means every field of life can relate to the health to sickness.
In Chinese medicine, sound also can treat diseases. We can use different sound to detoxify a specific organ. If you go to the YouTube, and use earphone to listen to different frequency musics, you can feel they can activate different parts of the brain i.e. it can activate or damage different parts of the brain.
Therefore, I will define a broad definition of health care, education program is based on each individual's professional to create a most valuable product or work to benefit people's health either promote health further improvement/maintenance or reduce/eliminate illnesses.
Even, to stimulate people's good characters and dream count. It's due to moral cultivation directly related to a person's health.
Mary Morrissey defines a dream should match 5 test questions:
As Joyce said - what is the purpose of your review. Often a systematic review has a question such as: does participation in a health education programme improve health behaviours and/or health outcomes; or does the availability of a health education programme in a music school affect school-wide knowledge and behaviours whether or not an individual participates, and so on. The review question guides the rest. If you haven't already have a look at Cochrane review methodology and the sections on developing the protocol.
The outcomes of a health education program are:
1. That the target group has grasped the health concepts that were taught - make sure that the comprehensive definition of health was used in the education program
2. That the target group has internalized the health concepts that have been taught
3. That the target group can independently choose to apply/or not apply the acquired knowledge to their life situations
4. That a measurable change should occur re: unhealthy situation/condition
Melanie, how would you measure "grasped" and "internalized" ?
If persons in the target group "independently chose" not to apply the acquired knowledge how then could you measure the change in the situation?
Grasp can be measured using knowledge and attitudes questions.
Internalization can be measured by using questions on attitudes and practices and observation of behavior. So choosing not to apply for example can be deduced from high knowledge score versus no change in attitudes or behavior. BUT - include intervening factors (e.g socio-economic) in your analysis
Really interesting answers - thank you immensely to all of you!
I do understand that one can look at a range of outcomes when assessing health education programmes (from changes in attitude and beliefs, to preventative behaviour and actual health related outcomes). However, I am struggling with the following aspect. I am using the WHO definition for health education which incorporates providing students with relevant health information (about risks, health determinants, etc.) as well as training relevant skills such as decision making, problem solving, critical thinking, coping with emotions/stress. However, this definition is so broad, that I would need to include both health courses that cover health broadly (mental health, physical health, etc.) and which come in the format of lectures and seminars, but also programmes that are much more specific and might focus on anxiety only and are delivered in group sessions, based on the cognitive-behavioural therapy (CBT) model. Both would include health information and the training of relevant skills, and yet it seems like I would be comparing apples with oranges. I am not sure where to draw the line... any suggestions?
Perhaps I could include only health courses that are aimed at health more broadly (both physical and psychological), and which come under the standard higher education curriculum format (lectures and seminars), but this seems entirely arbitrary to me. I have no justification for this.
I would immensely appreciate your suggestions!
I believe the WHO definition is meant to cover this topic broadly and you would not need to cover detailed information related to mental health such as CBT, ABA, etc. Health education is greatly focused on the provision of health education information and that is why health promotion is much more encompassing as it brings in so many additional determinants.
Is this your PhD research? If so, one aspect is to demonstrate that you are able to take a broad topic (health ed/promotion), outline you systematic protocol, carry it out, and produce a useful review. You can say that this is a broad topic (examples of definitions/scope) including many activities (examples). For YOUR review you have included (published) study reports (RCTs, observational research ...) of (general health & wellness, mental health, as part of treatment of a specific condition ...) programmes that involved (methods) carried out with/by (population - are you interested in the providers of the ed/promotion or the recipients) in (geographical area) during (years). YOU excluded studies (where participants had a diagnosed medical condition, not carried out in English, whatever); then your search strategy.
Getting the review protocol right is often rushed but is the most important part of the systematic review because if it isn't right you spend the search, extraction, analysis and writing up trying to overcome the gaps or problems in the protocol. Best wishes
To some extent everything is arbitrary since for every research project there are probably an infinite number of aspects which could be examined. You simply have to define what you are interested in or which slice of the pie you are going to look at for this study. You define it and state your limitations are what you did not look at.
One thing to do would be to ask why you are doing this study. How do you expect the results will be used? What would be most useful to your purpose? It does not mean that what you are not looking at would not be useful. It just means that for your purposes at this point in time that this is the most useful. In another study/ies you or others can tackle the other aspects.
Sometimes you choose your limitations because it is the lowest hanging fruit and so can be done easily and quickly. Sometimes you choose your limitations because it is feasible. Sometimes you choose them because they provide the richest study results. Sometimes you choose the limitations because of your personal interests. Sometimes it is because of your funder's interests or your organization interests. Sometimes you choose because your results for this study will feed what you want to do in other studies.
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