How the policy of action and professional standards have influenced the development and decentralization of health education is discussed. It is concluded that a review of policies both of developing as well as of developed countries could help to put some observations into a perspective that is closer to the Brazilian reality.Discute-se como a política de ação e os padrões profissionais têm influenciado o desenvolvimento e a descentralização da Educação em Saúde. Conclui-se que estudos sobre política de ação em países desenvolvidos e em desenvolvimento contribuem para observações a partir de uma perspectiva mais próxima à realidade brasileira

Green, Lawrence W.

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Discute-se como a política de ação e os padrões profissionais têm influenciado o desenvolvimento e a descentralização da Educação em Saúde. Conclui-se que estudos sobre política de ação em países desenvolvidos e em desenvolvimento contribuem para observações a partir de uma perspectiva mais próxima à realidade brasileira.How the policy of action and professional standards have influenced the development and decentralization of health education is discussed. It is concluded that a review of policies both of developing as well as of developed countries could help to put some observations into a perspective that is closer to the Brazilian reality

Cadernos Espinosanos (E-Journal)

POLICIES FOR DECENTRALIZATION AND DEVELOPMENT OF HEALTH EDUCATION*Lawrence W. Green**GREEN, L.W. Policies for decentralization and development of health education. Rev. Saúde públ.,S.Paulo, 22:217-20,1988.ABSTRACT: How the policy of action and professional standards have influenced the develop-ment and decentralization of health education is discussed. It is concluded that a review of policiesboth of developing as well as of developed countries could help to put some observations into aperspective that is closer to the Brazilian reality.UNITERMS: Health education, trends. Health policy. Decentralization.* Presented at the Conference on Minimum Standards in Health Education Practice, Itu, S.Paulo, Brazil, 1987.** Center for Health Promotion Research and Development. P.O. Box 20186. Houston, Texas. 77225 - USA.INTRODUCTIONEight years ago, efforts were underway to de-fine the role and minimum standards for the en-try-level health education specialist, under theleadership of Dr. Helen Cleary 2,13,26. At the sametime, our federal government was making a ma-jor commitment to health education with ten-year goals in disease prevention and health pro-motion 24. I was asked by our Assistant Secretaryfor Health to take a leave of absence from myuniversity to direct the federal office with majorresponsibility for the national policy initiative inhealth promotion. We defined health promo-tion as "any combination of health educationand related organizational, economic and envi-ronmental supports for behavior conducive tohealth"7,9,10.My purpose here is to draw from our Ameri-can experience to see how policy has influencedthe development and decentralization of healtheducation, and how professional standards, inturn, have influenced policy. To apply this toBrazil, I will draw from my more recent expe-rience in preparing for World Health Organiza-tion (WHO) the report of the Technical Discus-sions of the 36th World Health Assembly whichwere held in 1983 on the topic, "New Policies forHealth Education in Primary Health Care" 8. Thisreview of policies in the developing as well asdeveloped countries around the world shouldhelp put my observations from the United Statesinto a perspective that is closer to the Brazilianreality.The Professional Development CycleBehind every policy is a theory. Sometimesthe theory is explicit, such as the theory thatparticipation of people in setting their ownpriorities and goals will enhance their commit-ment to the programs. This theory has providedthe justification for many policies that supporthealth education 8. Other theories are sometimesimplicit in policies, such as the economic theo-ries of capitalism and socialism. Long-standingpolicies are based on well-grounded theories andconsistent with prevailing cultural ideologies;short-term policies are based more on politicalideologies with implicit theories.Policies, in turn, influence professionalpractice. Professionals and research scientistsevaluate practice, which leads to modifications oftheory, as shown in Figure 1. Evaluation alsoprovides immediate feedback to practice.Training, the fifth element, shown in the middleof the cycle, is influenced directly by theory,policy and evaluation, and directly influencespractice11.In the short history of the recent disease pre-vention and health promotion initiative in theUnited States, we saw a theory of "lifestyle as amajor determinant of health" become policy em-phasizing health education to modify lifestyle. Arapid escalation of health education programsand practice led to increased evaluation. Theevaluations showed that complex lifestyles ofsmoking, sedentary living and substance abusedid not change readily in response to simplehealth education messages. This led to an elabo-ration of the theories and consequent modifica-tion of the policies supporting health promotionprograms. More emphasis was then placed onlaws restricting smoking in public places,penalizing drunk drivers and drug dealers moreseverely, and providing incentives for worksitehealth promotion programs 16,19.The initial policy initiatives also resulted in arapid increase in the number of professionaltraining programs in health education. With themodification of the policies described abovecame modifications in training and consequentlyin practice. We see in the American example,then, a series of cyclical patterns of relationshipsamong theory, policy, training, professional prac-tice and evaluation. Significant change in anyone of these has the potential of affecting all theothers. Obviously, policy changes exert the mostpowerful influence, but professional initiativesto change the training and practice of health edu-cation specialists also can exert their indirect in-fluence on policy.The Cycle of Professional PovertyHealth education in most countries has longlabored under an impoverished state of policysupport17. Inadequate support has led to pro-grams and practices that attempted to meet toomany needs with too few resources. Objectiveswere vague, consequently practice was diffuseand not well targeted or focused. The results ofscattered efforts were barely measurable, andwithout measurable results, the case could barelybe made for more support6.Breaking the Cycle of Professional PovertyThe cycle of professional poverty for healtheducation has been broken at five points in re-cent years in the United States. The first has beenwith improved and increased research andevaluation 11.This began most notably with the familyplanning and immunization programs of the1960s, strengthened with the hypertension andother patient education programs of the 1970s,and continues with increasingly complexcommunity health education and health promo-tion programs for chronic disease control in the1980s3,4.The second intervention that helped to breakthe cycle of professional poverty for health edu-cation was the increased involvement of otherdisciplines in the study of health education prob-lems. The growing interest of sociologists, an-thropologists and demographers during the in-ternational health and family planning move-ments of the 1950s and the poverty programs ofthe '60s stimulated new ways of analyzing healtheducation problems in terms of social structural,cultural and demographic realities and theories5.The emergence of psychologists in the PublicHealth Service to study the reasons people ac-cepted x-ray screening for tuberculosis in the1950s 14 and immunizations in the 1960s23, builtupon the earlier value-expectancy theories of Le-win18 and others1 to produce the Health BeliefModel. This model has given health education amore specific theoretical base to guide policy andpractice than did the earlier philosophical andsocial theories 20,25.But sociology remained a wellspring of con-cepts and theories guiding public health educa-tion. Community organization and diffusiontheories contributed significantly to the formula-tion of policies and professional training pro-grams in health education, and through theseto the practice of health education 12.The third point of intervention on the profes-sional poverty cycle for health education was thepreparation of a series of significant policy analy-ses in the 1970s. These began with the President'sCommitee on Health Education, which reportedits findings in 197121; continued through "WhitePapers" by the American Hospital Association,the Health Insurance Institute of America, theAmerican College of Preventive Medicine, andothers; and culminated with the Institute ofMedicine's background papers for the SurgeonGeneral's Report on Health Promotion and Dis-ease Prevention in 197915. The case was built sys-tematically for greater policy emphasis on healtheducation.The third point of intervention came with thenew policy initiatives stimulated by theforegoing analyses. In particular, health educa-tion was given a place in the Office of the Assist-ant Secretary of Health where policy is shapedand promulgated for the U.S. Public Health Ser-vice. This Office of Disease Prevention andHealth Promotion, together with the Centers forDisease Control which coordinates relationshipsbetween federal and state health agencies, spon-sored a consensus process to produce quantita-tive objectives for the nation in disease preven-tion and health promotion22. These objectivesconstituted policy for a decade, reaffirmed by thenew federal administration in 1981 with instruc-tions to the agencies of the Public Health Serviceto prepare their budget requests by showing howtheir budgets would contribute to accomplish-ment of the objectives by 1990.The Importance of Professional Training andStandards of PracticeCentral to the cycles show in Figures 1 and 2 istraining. Health education depends for its sucesson the adaptation of theory and policy to produceappropriate programs and effective delivery ofresources at regional and local levels. Policy canonly improve the quality of health education ifthose who implement the policies know how totransform them into effective programs. This re-quires knowledge, skill and professional disci-pline. These require training.Training seeks to produce professional whocan meet at least minimum standards of practice.This is what we have been struggling to defineover the past several years in the United States.GREEN, L.W. Políticas de descentralização e desenvolvimento da educação em saúde. Rev. Saúdepúbl., S.Paulo, 22:217 - 20,1988.RESUMO: Discute-se como a política de ação e os padrões profissionais têm influenciado o de-senvolvimento e a descentralização da Educação em Saúde. Conclui-se que estudos sobre política deação em países desenvolvidos e em desenvolvimento contribuem para observações a partir de umaperspectiva mais próxima à realidade brasileira.UNITERMOS: Educação em saúde, tendências. Política de saúde. Descentralização.REFERENCES1. BECKER, M., ed. The health belief model and personalhealth behavior. Hlth Educ. Monogr., 2 (4) 1974.2. CLEARY, H. P. Issues in the credentialing of health edu-cation specialists: a review of the state of the an. Adv.Hlth Educ. Promotion, 1 (Part A): 129-54, 1986.3. CULLEN, J.; FOX, B.; ISOM, R., ed. Cancer: the be-havioral dimensions. New York, Raven Press, 1976.4. ENELOW, A. J. & HENDERSON, J. B., eds. Applyingbehavioral science to cardiovascular risk. New York,American Heart Association, 1975.5. GOODENOUGH, W. H. Cooperation in change: an an-thropological approach to community development.New York, Russell Sage Foundation, 1963.6. GREEN, L. W. Determining the impact and effectivenessof health education as it relates to federal policy. HlthEduc. Monogr., 6: 28-66, 1978.7. GREEN, L. W. Healthy people: the Surgeon General's Re-port and the prospects. In: McNemey, W. K., ed Work-ing for a healthier America. Cambridge, Mass., Bal-linger Publ., 1980.8. GREEN, L. W., ed. New policies for health education inprimary health care. Geneva, World Health Organiza-tion, 1986. (WHO/HED/86.1).9. GREEN, L. W. A participant-observer during a period ofprofessional change. In: Cleary, H. P. et al., eds. Ad-vancing health through education: a case study ap-proach. Palo Alto, Cal., Mayfield Publ., 1984. p. 374-81.10. GREEN, L. W. & JOHNSON, K. W. Health educationand health promotion. In: Mechanic, D., ed. Handbookof health, health care, and the health professions. NewYork, John Wiley, 1983. p. 744-65.11. GREEN, L. W. & LEWIS, F. M. Measurement and evalu-ation in health education and health promotion. PaloAlto, Cal., Mayfield Publ., 1986.12. GREEN, L. W. & McALISTER, A. L Macro-interventionto support health behavior: some theoretical perspec-tives and practical reflections. Hlth Educ. Quart., 11:323-39, 1984.13. GUIDELINES for the preparation and practice of profes-sional health educators. Hlth Educ. Monogr., 5: 75-89,1977.14. HOCHBAUM, G. Public participation in medical screen-ing programs: a sociopsychological study. Washington,D. C., U. S. Government Printing Office, 1959.(Public Health Service Publication, 572).15. INSTITUTE OF MEDICINE. Healthy people: backgroundpapers for the Surgeon General's Report on health pro-motion and disease prevention. Washington, D. C.,Public Health Service, 1979.16. KOLBE, L. J. & IVERSON, D. C. Integrating school andcommunity efforts to promote health: strategies, poli-cies and methods. Hygie: int. J. Hlth Educ., 2: 40-7,1983.17. KREUTER, M. W. & GREEN, L. W. Evaluation ofschool health education: identifying purpose, keepingperspective. J. Sch. Hlth, 48: 228-35, 1978.18. LEWIN, K. A dynamic theory of personality: selected pa-pers. New York, McGraw-Hill, 1935.19. McALISTER, A. L. & GREEN, L. W. New approachesto the promotion of public health and safety. Publ. Af-fairs Comment., 30: 1-11, 1984.20. MILLER, N. E.; MATARAZZO, J. D.; WEISS, S. M.;HERD, J. A.; WEISS, S., eds. Behavioral health: ahandbook of health enhancement and disease preven-tion. New York, Jonh Wiley, 1984.21. PRESIDENT'S COMMITEE ON HEALTH EDUCA-TION. Report of the President's Committee HealthEducation. New York, National Center for Health Edu-cation, 1971.22. PROMOTING Health/Preventing Disease: Objectives forthe Nation for 1990. Washington, D. C., Public HealthService, 1980.23. ROSENSTOCK, I. M. Why people use health services.Milbank mem. Fd. Quart., 44: 94-127,1966.24. U. S. DEPARTMENT OF HEALTH AND HUMANSERVICES. Healthy people: the Surgeon General's Re-port on the health promotion and disease prevention.Washington, D. C., Public Health Service, Office ofDisease Prevention and Health Promotion, 1979.25. WEISS, S.; HERD, A.; FOX, B.; eds. Perspectives of be-havioral medicine. New York, Academic Press, 1981.26. WOLLE, J. Activities of the APHA Advisory Committeeon Community Health Education Accreditation. HlthEduc. Monogr., 4: 276-7, 1976.Received for publication: 14/8/1987Accepted for publication: 22/12/1987

Policies for decentralization and development of health education

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Políticas de descentralização e desenvolvimento da educação em saúde

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Políticas de descentralização e desenvolvimento da educação em saúde

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