Health Education Research Advance Access published online on September 7, 2007
Health Education Research, doi:10.1093/her/cym035
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The forgotten dimensions in health education research
Department of Health Science, College of Health and Human Performance, Brigham Young University, Provo, UT 84602, USA
Correspondence to: * Correspondence to: S. R. Hawks. E-mail: steve_hawks{at}byu.edu
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Abstract |
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This paper evaluates the content focus of health education research as presented in the professional literature over a 6-year period (2000–2005). The majority of research (1365 papers) addresses the physical dimension of health (79%), while other health dimensions receive less attention. It is argued that the current content focus of research in health education fails to harmonize with the multidimensional, dynamic and functional nature of health as generally defined. The goal of health education, positive behavior change, also seems less reachable without a better understanding of how nonphysical dimensions of health influence wellness behaviors. At present, there exists an opportunity for health educators to move toward research agendas that more fully appreciate the interconnectedness of various dimensions of health and that evaluate them evenhandedly. Practical application of this approach will require a partial break from the biological orientations of other health professions, new research agendas that clarify multidimensional health relationships and new programs that seek to influence outcomes in a variety of dimensions.
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Introduction |
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Our goal in this paper is to analyze the content focus of health education research over a 6-year period (2000–2005) as reflected in a number of professional journals. Results are discussed as they relate to standard definitions of health, the stated goals of health education and possible strategies for overcoming barriers to a more balanced research agenda in health education.
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Method |
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Articles in every issue of 12 professional health education journals were reviewed for the years 2000–2005. In order to obtain a broad sample of published health education research, journal selection was designed to include output from prominent professional associations, leading academic publishers, a variety of health education settings and both domestic and international contexts. Each article was first categorized into one of four types: research (with a content focus), practice (including program or process evaluation research), theory or literature review. Research articles with a content focus were further categorized into one of five content areas: physical health, social health, emotional health, intellectual health or spiritual health. Assignment of research articles to specific content areas was based on the match between dependent research variables and published definitions of health dimensions [1]. Assignment of research articles was done by advanced undergraduate students in health education and later rechecked by a graduate student in public health education. Difficult assignments were reviewed by four students and a graduate faculty member in public health education. Research articles that addressed more than one dimension of health were given multiple content assignments.
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Results |
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A total of 2610 articles were reviewed. Approximately 52% of these articles were research reports with an identifiable content focus, while 28% dealt with the practice of health education (including planning and process evaluation research), 11% represented theoretical discussions and 9% were reviews of the literature (Table 1).
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The vast majority of content-specific research articles (79%) focused on outcome variables associated with the physical dimension of health (fitness, strength, body mass index, diet composition, blood pressure, activity level, cholesterol, etc.). Another 12% of research articles measured outcomes associated with social health (loneliness, parental interactions, social alienation, peer influences, etc.). Emotional health was addressed by 5% of research reports (stress, anxiety, resilience, self-esteem, hardiness, depression, etc.). Three percent of research papers measured variables associated with intellectual health (mental skills, learning styles, teaching techniques, etc.). The final 1% of research dealt with the spiritual dimension of health (purpose and meaning in life, connectedness with a higher power, spiritual well-being, etc.) (Figure 1).
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Discussion |
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It is the general goal of health education to improve the health knowledge and attitudes of individuals and thereby promote personal behaviors that will lead to optimal health and wellness or high levels of functioning in all of the various dimensions of health [2]. Underlying this goal are several assumptions or beliefs about the nature of health. First, health is typically defined in the literature as being multidimensional, the realization of which requires a degree of depth and balance among such diverse elements as physical health, emotional health, intellectual health, social health and spiritual health [3]. Further, these dimensions are considered to be dynamic in as much as the status of one dimension will often influence the condition of another [2]. Finally, it is argued that health is functional as most people value it primarily for its usefulness in the pursuit of higher aims, rather than merely as an end in itself [4].
The profession of health education seems philosophically inconsistent in that health education research often ignores all three of the concepts presented in the above definition. First, the multidimensional nature of health is effectively discounted as most published health education objectives include only physical health variables as primary outcome measures (e.g. Healthy People 2010). Outside of educational settings that offer courses on personal health, it is difficult to identify more than a few health education interventions that target, say, intellectual health, social health or spiritual health as principal dimensions of interest with specific impact or outcome objectives.
Secondly, if the multidimensional nature of health is disregarded, then its dynamic nature cannot be fully appreciated. It is well documented, for example, that emotional well-being exerts a profound influence on cardiovascular health [5]. Similarly, social support is a significant factor in understanding a multitude of health outcomes, including various types of cancer, cardiovascular disease, immune function [6, 7], women's health [8] and positive health practices [9]. And spiritual well-being influences such diverse outcomes as recovery from addiction [10], teen sexual activity [11], depression [12], eating disorders [13], breast cancer [14], long survival with acquired immune deficiency syndrome [15] and a number of health behaviors [16]. With few exceptions [17, 18], however, health education research seldom attempts to measure the dynamic nature of social support, emotional well-being or spirituality in health education contexts [19].
Physical health is possibly being promoted by health educators as a sufficient end in itself, without consideration for some larger purpose that might justify its need in the first place. The functional nature of health, its basic role of serving higher human interests, is thus discounted. In contrast, it seems likely that most individuals become interested in improving health behaviors only when they see a vital connection between enhanced health status and the realization of a self-defined, higher purpose in life [1, 20].
By failing to equitably evaluate and promote all dimensions of health, and without appreciating the functional motivation that must underlie successful health behavior change, the realization of health education goals is substantially hindered. Indeed, as currently approached the primary goal of health education may be largely unreachable.
Inconsistencies in theory and practice
A preoccupation with physical health is not hard to understand given the foundational influence of the 17th century Cartesian duality that firmly separated mind and body [21, 22]. The subsequent development of physical medicine, and the later emergence of public health and health education professions that primarily target the prevention of physical illness, was perhaps inevitable [23, 24]. The national health objectives for most developed nations (e.g. Healthy People 2010), and thus their public health funding mechanisms, continue to revolve almost exclusively around the prevention and treatment of physical illness [25].
Such a one-dimensional, fractured approach, however, is inconsistent with our philosophical allegiance to holistic health promotion [23]. We now have firm evidence that the mind and body, far from being separate, are intimately interwoven—and that there truly are many dimensions of health that interact with each other [19]. It is therefore less effective, if not negligent, to research and promote physical health without simultaneously addressing the ‘duality’ of other dimensions of health in a truly integrative fashion [26].
Barriers to promoting multidimensional wellness
There are several barriers that hinder progress toward a health education research agenda that actively investigates a dynamic, multidimensional wellness from a functional perspective. Perhaps the most daunting barrier is the inertia of a vast public health system that has settled around the focal point of physical health as the ultimate outcome objective. Physical health is tangible, understandable, measurable and objective—and it is therefore easy to target (blood pressure, blood lipid profiles, morbidity and mortality rates, energy expenditure, body mass index, etc.). Given this reality, national physical health objectives that drive funding and other resource allocation mechanisms place inescapable pressure on health educators to pursue research and practice agendas that are consistent with those objectives [25].
A second barrier is the ambiguity of dealing with dimensions of health that have not achieved a consensus definition, are less tangible and seemingly immeasurable. One introductory health education text, for example, presents a standard overview of the five dimensions of health but concludes that the meaning of spiritual health must ‘be left to the individual reader’ [3]. As opposed to this hopeless ambiguity, each dimension of health must be acceptably defined, operationalized and have a means of valid, reliable measurement so that it can become a legitimate outcome goal for health education research and programming. This has yet to happen for many of the core dimensions of health.
Finally, the trepidation of stepping into such politically charged arenas as the promotion of spirituality leaves the profession hesitant in acting upon its own definition of health. One school health educator complained to the authors that use of the word condom in a public secondary school classroom posed far fewer ramifications than use of the word spirituality. Even though it seems clear that spirituality can be promoted without violating the separation of church and state [17], discomfort with this dimension remains even higher than other controversial arenas such as sexuality education.
Overcoming barriers
Several steps will have to be taken to bring the research agenda of health education into harmony with its philosophical foundations. The first step is to pursue organized efforts to clearly define the various dimensions of health in a way that builds consensus. Numerous scholarly articles have been written about the nature of spiritual health [20, 27–31], for example, but a lack of professional consensus forces readers of introductory texts to come to their own conclusions as to what it really represents and whether or not it is important. The recent process used to bring about consensus in relation to a professional code of ethics might represent a useful pattern for defining each health dimension [3]. Likewise, previous efforts by jointly established professional committees to achieve consensus in health education standards and terminology might offer another plausible approach [32, 33].
The second step is to place pressure on the crafters of national health objectives to develop objectives that represent a dynamic, multidimensional view of health. They should be encouraged further to design a stronger mechanism for increased local control over resource allocation that might include intervention and evaluation priorities that target nonphysical dimensions of health. While the value of such guiding documents as Healthy People 2010 cannot be overestimated in terms of their ability to focus multilevel efforts on urgent problems [3], the process that leads to national objectives can be criticized as being too top–down in its orientation and too focused on the physical dimension of health.
Third, there is a need for individual health education researchers who are willing to commit time and energy to designing, implementing and evaluating the impact of programs that target various nonphysical dimensions of health [20]. Ideally, such a research agenda would lead to valid, reliable measures of these dimensions that included both quantitative and qualitative instruments and methodologies. In 1990, J. R. Bloom challenged medical care researchers to develop a body of knowledge in relation to social support and health [34]. Within a few years, dozens of research reports were published that clearly documented several mechanisms by which social support might be influencing health [7]. As a result, the medical care community is working diligently to incorporate social support into treatment protocols [8, 35]. Based on more recent research efforts there are also growing interest in incorporating such dimensions as spiritual support into patient care strategies [36–41].
The three steps outlined above might be taken conjointly by professional associations, professional organizations in a variety of public health settings, preservice and in-service training programs for health education practitioners and individual health education researchers. Without such steps, there will continue to be substantial inconsistencies between research focus, theoretical orientation and subsequent practice in health education.
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Conclusion |
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The same research and practice efforts that are taking place in patient care settings should also be taking place in health education and health promotion settings [20, 42, 43]. There exists an opportunity to embrace our current definition of health, initiate research agendas that will help us to better understand the interconnectedness of all dimensions of health and implement theory-based educational programs that might advance all health dimensions more evenhandedly. Such an effort will bring greater consistency to the theory, philosophy and practice of health education; and will contribute to greater success in achieving the goals of health education.
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Conflict of interest statement |
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None declared.
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References |
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Received on January 25, 2007; accepted on May 23, 2007
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