VALUES IN HEALTH EDUCATION

The delivery and acceptance of health-education and health-promotion programs are influenced by personal, religious, environmental, cultural, political, and economic factors, all of which help create and are affected by individual and societal values. Values are an integral part of people's everyday lives, even though individuals do not often consciously determine how their values influence their ideas or behavior. One common definition of values is that they are notions or ideas upon which we place worth. Values are influenced by cultural background, gender, religious affiliation, and membership in social groups. Values therefore become internalized and affect motivation, thoughts, and behavior. In other words, they become standards that guide one's behavior and they are part of one's identity. Undergoing a values clarification process helps individuals to not only recognize their own values, but understand how their values can assist in making future choices.

A "value system" is the organization of beliefs that guide individual behavior. This system is composed of instrumental and terminal values. Instrumental values are those that involve modes of behavior such as honesty, cheerfulness, independence, and obedience. These values lead to terminal values, or endstates, which include happiness, pleasure, social recognition, and wisdom. Both levels of values affect behavior, and conflicts between opposing values need resolution. Consider the conflict adolescents experience when they are told by their parents not to smoke but are encouraged to do so by their peers. In this instance, there is a conflict between obedience, an instrumental value, and social recognition, a terminal value. Resolving such a conflict becomes an individual decision based upon prioritized values. If an adolescent determines that obedience is more important than social recognition, acting on this choice and making related decisions will follow.

Two pairs of contrasting values are significant for this discussion: contentment versus attainment, and pleasure versus self-fulfillment and growth. Contentment can be accomplished by a reduction of desires. The satisfaction received from one desire will lead to more desires, which can lead to discontent if the desires are not attained. On the other hand, attainment of specific objects or goals may lead to a better or healthier life. Focusing on achieving pleasure, such as physical or emotional pleasure, is often given precedent over achieving self-fulfillment and growth, which relies more on internal, self-evaluation processes. However, when the latter occurs, new goals, or the restructuring of previously developed goals, results. When health is considered in light of the above information, the following observations can be made: (1) attaining a life that is rich in variety and activities may be considered healthy; and (2) one's experiences of poor health, either having poor health oneself, or being exposed to other's experiences of poor health, can be the stimulus to evaluate how one attains self-fulfillment through the creation of more appropriate goals.

Values that affect health also affect health education and health promotion on two levels—the individual level and the societal level. At the individual level, values determine whether certain health behaviors are acceptable, whether the individual will engage in them, and whether health education and health-promotion programs are acceptable. As already stated, once values are established, they need to be acted upon through decisions that are made by the individual. Returning to the example of the adolescent conflicted over smoking, while prioritizing values may lead an individual to choose not to smoke, exposure to a variety of health messages through the media or through the school environment may also influence this decision. The adolescent may have come to value having a physically fit and healthy body and decided to engage in healthful behaviors. In doing so this individual will have undergone self-evaluation and created goals for specific health behaviors.

When health-education and health-promotion programs are being developed, the audience's values need to be considered. This will affect, among other things, what topics are included, the way in which the topics are presented, and whether both genders or certain age groups will be included in the planning and delivery phases. Consider a health-education project that was conducted with a Hutterite colony. This religious sect lives a communal agrarian lifestyle, separate from mainstream society. An assessment of health issues within the colony generated information about their values and how these influenced their lifestyle and behaviors. Based upon this information, health-education sessions were planned and implemented regarding the handling of life-threatening emergencies. Because Hutterites value self-sustaining behaviors such as farming over academic learning, the colony members do not complete high school. Therefore, when the sessions were planned, handouts were prepared in easily understood terms with numerous diagrams to illustrate the points. The colony is governed through an internal system that includes several men within key positions. These individuals were consulted when planning the health-education sessions to ensure their acceptance. Research that focuses on health assessments can be conducted in a manner that links the findings to the individual's values, thereby ensuring that new or refined health-education and health-promotion resources are appropriately determined.

At the societal level, values make a significant contribution to public health. Two basic values in public health are cooperation and collaboration. Health care systems in most countries, regardless of whether or not they are based upon the principles of universal accessibility or affordability, focus upon an illness-care system. Illness-care is only directed at those experiencing ill health, either acute or chronic. This is an expensive system to maintain, forcing the numerous caregiving agencies in countries with a large private sector to compete for clients for financial reimbursement rather than collaborate with other agencies in providing care. Even in countries with a publicly funded health system, there is competition for adequate resources to maintain both an illnesscare and a wellness-care system. Wellness-care is focused on healthy individuals to assist them in maintaining or improving their health. Not surprisingly, regardless of what system is available, illness-care is given the priority. Hence, although health-education and health-promotion programs exist, they are not always given a high priority within health agencies. The public at large also has difficulty in creating a societal value which emphasizes wellness-care for several reasons. First, illness-care is more visible through the presence of acute health facilities and the media attention given to medical breakthroughs. Second, the lack of extensive and prolonged exposure to a variety of health-education and health-promotion programs lessens the overall benefits and the integration of such programs into the public's everyday lives. Despite these limitations, such programs have the potential to influence and alter individual and societal values and subsequent behaviors, if they are appropriately delivered. One example is the public acceptance of the use of seat belts, a practice which has become commonplace due to the implementation of various health-education programs and strategies as well as the public's prioritization of values related to health and safety.

More recent discussions of values and their impact on health have called into question the manner in which health education and health promotion is being delivered. In an issue of Social Science Medicine, in 1998, Olav Forde discussed at length the emphasis on achieving a lifestyle that is free of risk. Forde wrote that life has become medicalized due in part to an increase in health and risk awareness, which stems from the media concentration on diseases that capture the public's attention and concern. Such attention is enhanced by health professionals who encourage the continual flow of health information to the public while continuing to base their interventions on people's fear of disease and obsession with health. Thus, engaging in a healthy lifestyle, and in certain behaviors, becomes parallel to avoiding risk. The more crucial concern is the link between the unnecessary emphasis on the prevention of risk and the inappropriate change in societal values in relation to health. Consequently, healthism is becoming the principal life value. Values such as tolerance and nonconformity are questioned when there is such emphasis on avoiding risk because there is an expectation that everyone will act in a manner that will lower individual risk and, ultimately, the public's risk. A shift such as this can lead individuals to experience guilt, blame, and intolerance if they do not adhere to such values and behaviors. Diversity of thoughts and action is less acceptable because conformity becomes the expectation. Health-education and health-promotion workers, unconsciously or not, incorporate these attitudes in their work with individuals and communities, further contributing to this shift in values.

Values are constantly being altered according to the changing context within which they are located. It has been suggested that values for the twenty-first century will be empowering, caring, and cooperating. Such changes will likely be debated and examined to ensure that the relationships between values and health education and health promotion are sound ones and that they can lead to health behaviors that will result in an optimal level of health for the public.

Judith C. Kulig

(see also: Anthropology in Public Health; Cultural Anthropology; Cultural Appropriateness; Cultural Identity; Cultural Norms; Customs )

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