lecture as a method of health education

• Research article
• Open access
• Published: 23 September 2019

Comparison of the effectiveness of lectures based on problems and traditional lectures in physiology teaching in Sudan

• Nouralsalhin Abdalhamid Alaagib 1 ,
• Omer Abdelaziz Musa 2 &
• Amal Mahmoud Saeed 1  

BMC Medical Education volume  19 , Article number:  365 ( 2019 ) Cite this article

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Lectures are one of the most common teaching methods in medical education. Didactic lectures were perceived by the students as the least effective method. Teaching methods that encourage self-directed learning can be effective in delivering core knowledge leading to increased learning. Problem based learning has been introduced as an active way of learning but it has some obstacles in developing countries where the intake is huge with minimum resources. This study introduces a new teaching approach: lectures based on problems (LBP) and evaluates their effectiveness compared to traditional lectures (TL) in physiology teaching.

LBP and TL were applied in physiology teaching of medical students at University of Science and Technology during their study of introduction to physiology and respiratory physiology courses. Equal number of lectures was given as LBP and as TL in each course. Students were given quizzes at the end of each course which were used to compare the effectiveness of the two types of lectures. A questionnaire was used to assess students’ satisfaction about LBP and the perceived effects of the two methods on the students’ attitude and practice towards learning physiology.

In LBP the students have better attention ( P  = 0.002) and more active role ( P  = 0.003) than in TL. Higher percentage of students think that LBP stimulated them to use references more ( P  = 0.00006) and to use the lecture time more effectively ( P  = 0.0001) compared to TL. However, there was no significant difference between LBP and TL in the awareness of the learning objectives. About 64% of students think that LBP is more enjoyable and it improved their understanding of physiology concepts. Comparison of the students’ quiz marks showed that the means of the students’ marks in the introduction to physiology and respiratory courses were higher in the quizzes of LBP than in TL with a significant difference between them (( P  = .000), ( P  = .006) respectively.

Conclusions

LBP improved students’ understanding of physiology concepts and increased students’ satisfaction about physiology learning. LBP achieved some of the objectives of PBL with the minimum resources and it can be used to improve the effectiveness of the lectures.

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Lectures are one of the most common teaching methods in medical education. It has been suggested that teaching methods that enhance engagement and encourage self-directed learning can be effective in delivering core knowledge and explaining difficult concepts leading to increased learning [ 1 ]. Transformation began with the introduction of problem-based learning (PBL) in some medical schools; more recently, lectures has increasingly been replaced by team-based learning.

Traditional, didactic lectures were perceived by the students as the least effective method used, yet involving students actively within the lecture time was regarded as a more effective learning tool [ 2 ]. Lectures have the advantage of sharing information with a large number of students and it can be effective in transmitting factual information [ 3 ]. Thus, lectures can be an effective teaching method when the lecture is given as large-group interactive learning sessions with discussion and frequent questions to students who have prepared in advance [ 4 , 5 ]. Although the term “effective” has been widely used, the definitions of effectiveness is inescapably linked to the outcomes of educational activity through evaluation of the extent to which an activity approximates the achievement of its goals [ 6 ]. Generally some of the characteristics of effective teaching focus on teacher performance while others focus on student learning needs and outcomes [ 7 ]. Young and Shaw proposed six major dimensions of effective teaching: value of the subject, motivating students, a comfortable learning atmosphere, organization of the subject, effective communication, and concern for student learning [ 8 ]. Moreover, effective learning actively involves the student in metacognitive processes of planning, monitoring and reflecting. It is promoted by activity with reflection, collaboration for learning, learner responsibility for learning and learning about learning [ 9 ].

Lecturing, whether effective or not, is still the most commonly used learning method as it is an economical and practical method; especially when the number of students is large and the available resources are limited. For effective learning educationalists must change their use of the lecture time and make use of methods and techniques in which students are more active, communicating and collaborating for learning; with evaluation of the effectiveness of these methods by the students on their learning. Interactive lecture is an example of how knowledge about meaningful learning can be implemented in the lecture hall [ 10 ]. In interactive lecture students are asked to actively participate and process knowledge throughout the lecture. They also take an active part in contextualizing the content and directing the focus of the lecture towards areas they find difficult to understand [ 11 ]. Therefore, teachers can use the lecture to encourage students to construct their own understanding of concepts, relationships, and enhance application of theories by choosing suitable student centered learning approaches [ 12 ]. Chilwant compared structured interactive lectures with conventional lectures in two groups of second year medical students. The effect of two methods was evaluated by giving questionnaire and MCQs. Although their results showed no significant difference in average MCQ marks of two groups, students in the interactive group enjoyed being actively involved in the lecture which increased their engagement, attention during the lecture and stimulated their critical thinking [ 5 ]. Fyrenius et. al. presented a structure of organizing lectures into three phases, based on the theoretical prerequisites of meaningful learning like pre-understanding, relevance and active involvement [ 11 ]. The three phases are: introductory lecture (1–2 h), in-depth lecture (1–2 h) and application lecture (1–2 h) [ 11 ]. Moreover, lectures can be enriched by the use of educational media. Some studies showed that involvement of students in a large room or a lecture hall through voluntary participation in additional active learning exercises with aid of software [ 13 ] and use of game-like format of the review session and its custom-designed software, that combines interactivity, team learning and peer-to-peer instruction [ 14 ], resulted in an improvement in understanding and application of physiological concepts and enriched students’ learning experiences. Many Studies showed that students prefer learning approaches in which the students have more active role than the TL like case based learning [ 15 ], team based learning [ 16 ], small group discussion [ 17 ] and flipped classroom.

It is not only the method of teaching that affects the learning process; students’ own learning approaches influence their learning significantly . The learning approach adopted by students appears to be an important factor in determining both the quantity and the quality of their learning resulting in different learning outcomes [ 18 ]. Learning styles and learning approaches differ among medical students [ 19 ], and this could be partly attributable to their preferred learning style and partly to the context in which the learning takes place. Three basic approaches have been identified: surface, deep and strategic approaches [ 18 ]. The most desirable and successful is the deep approach in which students are motivated by an interest in the subject material. Their intention is to understand the material, to recognize its vocational relevance and to relate it to previous knowledge and personal experiences. The surface approach is rote learning in which students focus is on memorization pieces of information in isolation from the wider context motivated by either a desire to complete the course or a fear of failure. The main motivation of students using the strategic approach is achievement of high grades so they use either the surface or deep approach depending on what they feel would produce the most successful results [ 18 ]. They are much more influenced by the context than by the nature of the task itself. In TL students are passive recipient of information and have insufficient exposure to the content which encourages superficial learning. Abraham et. al. found that PBL promotes a deep approach to physiology learning and they suggested that physiology teaching outcomes could be improved through the use of the PBL teaching model [ 20 ]. Numerous studies that compared lecture-based learning (LBL) models to the PBL model showed certain advantages of PBL with respect to improving student abilities in active learning, critical thinking, communication skills, teamwork, critical thinking, peer-learning, self-learning and research skills [ 21 , 22 , 23 , 24 ]. However, a number of disadvantages of PBL were reported like: time constraints, inadequate resources, inconsistency in knowledge acquisition, inadequate contribution of clinicians and lack of required faculty training on PBL facilitation and required student preparation and motivation [ 24 ]. Moreover, PBL model seems difficult to apply in educational context with the large number of students and limited resources.

The main critique for LBL is the passive delivery of knowledge in a teacher centered approach; and students have insufficient exposure to the content which encourages superficial learning. However, interactive lectures proved to be effective in learning. For effective learning educators may need to use a variety of learning experiences [ 25 ]. A teaching model that combines the benefits of PBL and interactive lecture, by delivering lectures based on problems (LBP), may lead to better learning outcome with more active role of students during the lecture. This study introduces a new teaching approach LBP; to our knowledge they have not been used anywhere before. The aim of this study is to assess the effectiveness of LBP compared to TL and to evaluate the perceived effects of the two methods on the students’ attitude and practice towards learning physiology.

Study design

This is an interventional quasi study done in University of Science and Technology in Sudan in 2018. In this university, physiology is taught by the traditional curriculum and the duration of the lecture is 2 h. The study was done during the introduction to physiology course in the second semester of the first year and the respiratory course during the third semester in the second year for the same batch of medical students. In the introduction to physiology and the respiratory courses equal numbers of lectures were taught in a form of TL and LBP and both types were delivered by the same course instructor. Two of the authors contributed in teaching of the lectures by the two methods and each course was taught by a different instructor.

Steps of LBP:

Step 1: Introducing the clinical problem to the whole class in 5 min.

Step 2: Clarifying what is not clear in the scenario within the class in 5 min.

Step 3: Paired student analysis of the problem for clues and key words and suggesting generally what the problem is about in 15 min. In this step students can use their books or mobile phones to search in the internet.

Step 4: In the class, students share with the instructor what they have worked out in step 3. This takes about 10 min.

Step 5: Students are given 10 min to formulate learning objectives based on the scenario and each pair of students should write down at least two learning objectives.

Step 6: The instructor goes through the learning objectives in a 45–50 min lecture. The objectives of the problem can be taught in more than one lecture with reference to the same problem.

Step 7: Later in the small groups tutorial after the students studied the learning resources they discuss the problem again and answer some short answer questions based on the scenario.

Step 8: At the start of the next lecture, students are given quizzes on the previous one in 15–20 min. Each student has to solve these quizzes alone and then the answers are shared with the class.

Inclusion criteria

All medical students in Batch 21 at University of Science and Technology. Each student should have attended at least 3 lectures of each of the TL and LBP in each course.

Exclusion criteria

Students who did not attend 25% of the lectures in any of the two courses or did not attend the end of course test were excluded. Students who refused to participate or did not sign the informed consent were also excluded from the study.

Sampling technique

By the end of the two courses, students were contacted by the investigator in the lecture hall. They were informed about the study and its objectives. To avoid measurement bias it was stated clearly that participation in the study will not affect their exam performance or grades by any means. Moreover, the data was collected using self– administered questionnaire that contains no names or identifiable information. An informed consent form attached with the questionnaire was passed by a teacher assistant to the students in the lecture hall after completion of the two courses. One hundred and forty six out of 183 students responded and agreed to fill the questionnaire.

To compare the effectiveness of the two methods quizzes were given to the students at the end of each course; in a form of multiple choice questions and short answer questions; covering the topics given as LBP and TL with equal weight. The quizzes tested some factual knowledge in addition to application of knowledge to explain some clinical signs and symptoms. Most questions asked were “how,” “what is the cause”, “what would happen if” or “explain” questions in addition to some questions to “define”, to “classify” or to draw a schematic diagram to explain a mechanism. All students were subjected to the same end of course quizzes with no difference between the groups regarding the kinds of knowledge tested. The results of these quizzes were used to compare the effectiveness of the two methods. The marks of the quizzes were taken from the secretary office in a form of excel sheet that doesn’t contain any names only the results of the whole class.

A questionnaire was filled by each participant to assess the perceived effect of the two methods on the students’ attitude and practice towards learning physiology through questions that determined the type of lectures in which the students had more active role and in which they were more aware to the learning objectives. Students were also asked about the type of lectures which stimulated them to use the lecture time more effectively, to use references and study resources and the type of lecture students think will enable them to score higher marks in the exam. Likert scale rating questions were used to assess students’ satisfaction about LBP and whether LBP improved their understanding of physiology concepts.

Results were saved and analyzed using SPSS version 23. Descriptive statistics were displayed in percentages and means ± SD. To evaluate the effectiveness of LBP, comparisons of students’ perception to certain items regarding LBP and TL were done using Z- test. According to Bonferroni criteria when assessing multiple tests for the same variable the level of significance should be adjusted by number of tests. Here the level of significance was adjusted as 0.05/6 = 0.0083 (where 6 is the number of tested items). Therefore, P value < 0.0083 is significant and P value < 0.0016 is considered highly significant. Comparison of the effectiveness of the two methods regarding students’ performance was done using independent t- test and a P value of ≤0.05 was taken as significant. Students’ satisfaction about LBP in physiology teaching was displayed as proportions.

One hundred and forty six out of 183 students responded and filled the questionnaire with a participation rate of 79.8%. Their age ranged between 17 and 24 years; 88.3% with age of 18–20 and the mean age was 18.7 ± 1.1 years. Two third of the class (62%) were females and 38% were males.

Comparison of the effect of the type of the lecture on students’ attitude and practice towards learning physiology is shown in Table  1 .

Results showed that in LBP students have significantly better attention ( P  = 0.002) and more active role ( P  = 0.003) than in TL. Fifty one percent of students think that they have better attention in LBP compared to 24% in the TL. Almost half the class (53.4%) have more active role in the LBP compared to 27.6% in the TL.

Higher percentage of students think that LBP stimulated them to use references more ( P  = 0.00006) and to use the lecture time more effectively ( P  = 0.0001) compared to TL with statistically highly significant difference between the two methods. Fifty eight percent of students think that they use the lecture time more effectively in the LBP and that the LBP stimulated them more to use the references and study resources to answer the questions more than the TL (Table 1 ). However, there was no significant difference between LBP and TL in the awareness of the learning objectives and the type of the lecture which students think will enable them to score higher marks in the exam (Table 1 ). Almost 20% of students found no difference between the two lectures methods regarding parameters reported in Table 1 .

Reflections of students about LBP using the Likert scale rating (Table  2 ) showed that about 64% agreed that LBP improved their understanding of physiology concepts and that LBP are more enjoyable than TL. Almost two third of the class (64.4%) think that LBP should be continued and improved; 13% disagreed and 22.6% couldn’t decide.

Comparison of students’ quiz marks on the two methods was done using independent t-test (Table  3 ). The means of students’ marks in the introduction to physiology course ( n  = 101) and respiratory course ( n  = 146) were higher in the quizzes of LBP than in traditional lectures with a significant difference between the two methods (( P  = .000), ( P  = .006) respectively).

In the introductory course 13/101 (12.87%) had the same score in the quizzes of the two methods. In the respiratory course 15/146 students (10.27%) score the same in the quizzes of the two methods.

The results of this study showed that about half the class thinks that they have more active role and better attention in the LBP compared to the TL. Although TL allow sharing a large body of content with a large number of students, they often promote passive and superficial learning. In TL the objectives of the lecture are shown at the start of the lecture and they are covered adequately by the teacher. However, students sitting passively may find difficulty in paying attention throughout the lecture. In LBP, when students are analyzing the problem for key words, searching the internet to know what is the problem about and during writing the learning objectives the instructor had to move throughout the lecture hall to monitor the class. It was rare to find a pair of students who were not seriously involved in the process. Throughout the lecture the instructor and the students try to link the lecture contents to the learning objectives and to the clinical scenario which contributed to the increase in students’ attention during the lecture. One of the most active interactions during LBP occurred when students shared the key words they have worked out and their suggestions of what the clinical problem could be about. This encouraged them to follow the lecture with enthusiasm and curiosity to find out whether they were right and to add what they missed. These results support the idea that the culture of the lecture is still acceptable by the students and that it can be an effective learning mechanism given that the students are engaged actively within the lecture [ 2 ].

In this study assessment of students attitude and practice towards learning physiology showed that a significantly higher percentage of students (58.2%) think that they use the lecture time more effectively in LBP than in TL and that LBP stimulated them more to use the references and study resources to learn physiology. By highly structuring the activities in LBP e.g. introducing a clinical problem, identifying difficult terminologies, analyzing the problem for clues and key words, formulating the learning objectives by the students and sharing the answers of the quizzes with the whole class, an active learning environment was created that enabled students to think, seek for information and use references, speak, and question freely. In LBP, the instructor may need to adopt an informal approach that promotes active learning through pair student interaction and discussion. Thus, the lecture became intellectually stimulating and challenging, as well as highly interactive. In LBP students are busy and participating actively in the lecture without significant loss of time. However, when more than hundred student talk at the same time the lecture hall may become noisy; that the instructor has to take control of the class and may need to use a signal to end conversations to be able to proceed [ 10 ]. TL seem easier for the instructor in controlling the class and managing the lecture time than LBP. In LBP highly structured classroom monitoring and time management is necessary to facilitate students’ interactions within the class and to proceed with the steps of LBP. Actually, the large number of students in the lecture hall is a major challenge for most educators who wish to innovate in teaching to make the lectures interactive and student centered. The use of student-centered active-learning instructional approaches, such as active- and inquiry-oriented learning in the classroom, improved student attitudes and increased learning outcomes relative to a standard lecture format [ 26 , 27 ]. Students centered learning approach shifts the focus from teaching to learning and promotes a learning environment favorable of the metacognitive development necessary for students to become active independent learners and critical thinkers.

In this study 64.3% of students think that LBP improved their understanding of physiology concepts. In step7 of LBP, in the small groups tutorials after the students studied the learning resources and revised what they have learned in the lecture, they discuss the problem again and answer some questions based on the scenario. The interactions in this step with peers and facilitators give opportunities to the learners to apply what they have learned and allow exchange of information and construction of knowledge. In the lecture hall, students were given quizzes on the previous lesson and each student had to solve and then the answers were shared with the whole class. This can be considered a type of test-enhanced learning which facilitates retention of factual knowledge and it binds testing directly to teaching and the educational process. Larsen et al. reported that being tested on the material after reading it or hearing a lecture about a topic, enhance later retention of information and it is a better way to learn material than rereading it [ 28 ]. It was suggested that this technique may be particularly effective as students struggle to master complex and extensive sets of information, such as in physiology or pharmacology [ 28 ]. In addition, if students test themselves as a strategy for learning, they can discover their own areas of weakness and re-study material in a purposeful way. In LBP quizzes are given at the start of the next lecture about the previous lesson. It was suggested that for tests to enhance memory, they should be given relatively soon after learning and should be derived specifically from the information learned [ 29 ].

Sharing the answers of the quizzes with the whole class and providing feedback led, in most of the times, to discussion among the students in the class and this provided a good material for later discussion in the tutorial session. However, most likely it is the peer interaction rather than knowing the correct answer per se that promotes student learning [ 30 ] simply from peer influence of knowledgeable students on their neighbors. Furthermore, providing feedback enhances the benefits of testing by correcting errors and confirming correct responses [ 31 ]. This feedback and the short discussion that occurred in the lecture theatre allowed the instructor to have an idea about the depth of student understanding and the areas that need further clarification to be included in the tutorial’s questions.

We found that 58.9% of students think that LBP are more satisfactory. Two third of the students (about 64%) found LBP more enjoyable than TL and that LBP should be continued and improved. Moreover, comparison of the effectiveness of the two methods showed that the performance of students was significantly higher in the quizzes of LBP than those of TL in both the introduction to physiology and respiratory physiology courses. In LBP the use of quizzes and sharing and discussing the answers enhanced students’ learning and contributed to the better performance. However, the satisfaction most likely came from the problems introduced at the start of the lecture and the ability to apply knowledge of basic science on clinical setting which encourage deep learning approach. By using a clinical problem in LBP, students became clinically oriented and they appreciated the value of the basic information given at their level. Horne and Rosdahl showed that students found the case-based sessions better than TL format with respect to the overall learning experience, enjoyment of learning and increasing retention and ability to apply knowledge [ 32 ]. Basic science knowledge learned in the context of a clinical case is better comprehended and more easily applied by medical students than learning pure basic science knowledge [ 33 , 34 ]. In medical education, physiology is not just the acquisition of fact and the understanding of the physiological mechanisms, but rather the ability to use this basic knowledge to understand the process of diseases, to explain some symptoms and signs, to suggest treatment and to acquire the skill of critical thinking and problem solving.

In spite of the fact that students’ performance was significantly better in the quizzes following LBP than the TL, assessment of students’ perception about their exam performance showed that higher percentage of students (38.4%) thinks that they will score better in the exam when they had TL compared to 35.6% who choose LBP and 26% think their score will be the same when they are taught by LBP or TL. This can be explained by the familiarity of the student to the didactic learning approach. Generally the means of learning in secondary education in Sudan put more responsibility on the teacher mainly ‘chalk and talk’ experience. Students in the first year in the university think that in the TL, they are given all the information needed to answer the exam questions unlike LBP in which they need to be self-learners and to solve questions and to use the references to reach the level of understanding needed to answer the exam questions. A second reason might be the anxiety felt by the students at time of exams. In this study students were more satisfied and enjoyed LBP more than TL; but when it comes to the exam students may become uncomfortable with LBP and may feel uncertain about what they have learned. They may think that they have wasted time on activities without knowing exactly what they have learned. Therefore, students may prefer more concrete and defined blocks of information given in the TL. They think their performance in the exam will be better when they know exactly the limits and boundaries of the subject they are going to be tested on.

In this study we found about 25% of students couldn’t decide and were neutral in all the investigated items regarding their satisfaction about LBP. This can be explained by the fact that students in this study were in the first year of their university study and they might be unaware of the benefits of the new active method and some students may be resistant to the active learning methods due to the increased self-learning and work outside the class. One of the studies that investigated student responses to active learning tasks showed that on initial exposure to the method, the majority of students found active methods strange, threatening and ineffectual. It is only with time and exposure to the method a change in students behavior may occur and students become comfortable and confident both with the method and their role [ 2 ]. However, most medical students later know that they must become lifelong learners to continue and succeed in their career. Therefore, students need the help of the educators to develop their skills in active self-directed learning and to practice more techniques of active learning.

Limitation of the study

For LBP to be applied efficiently the teachers may need training on the steps of LBP. Like most of the active learning approaches time management is a challenge for educators who wish to use LBP. In this study students were given the clinical problem in the lecture. It would have been better if they were given the problem before the lecture to be prepared in advance. Also the use of clickers or colored cards would have improved sharing of answers for within the class questions.

LBP is an effective active learning method which increased students’ satisfaction about physiology learning and improved students’ learning outcome in physiology. LBP achieved some of the objectives of PBL with the minimum resources and it can also be used by educators who want to improve the effectiveness of their lectures in medical schools that use the traditional curriculum.

The use of active student centered learning approaches in medical schools with large number of students should be evaluated by researches and should not be hindered by students’ resistance and complaint as they might not be familiar with these styles of learning and they may not be aware of the long term value of self- directed learning.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Lecture Based Learning

Lectures Based on Problems

Problem Based Learning

Traditional Lectures

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Acknowledgements

We would like to thank the staff members of the Physiology Department of Faculty of Medicine University of Science and Technology, for their assistance throughout this study and all the students who took part in this research.

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Nouralsalhin Abdalhamid Alaagib & Amal Mahmoud Saeed

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The lectures for students were performed by NA and OM. NA collected the data, did statistical analysis and wrote the manuscript. OM formulated the research idea and critically edited the draft of the paper. AS supervised the whole work and revised the manuscript. All authors approved the final manuscript.

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Correspondence to Nouralsalhin Abdalhamid Alaagib .

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Alaagib, N.A., Musa, O.A. & Saeed, A.M. Comparison of the effectiveness of lectures based on problems and traditional lectures in physiology teaching in Sudan. BMC Med Educ 19 , 365 (2019). https://doi.org/10.1186/s12909-019-1799-0

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DOI : https://doi.org/10.1186/s12909-019-1799-0

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• Traditional lectures
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Public Education about Cancer pp 68–99 Cite as

Health Education: Some Principles and Practice

Committee on public education of the commission on cancer control.

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Part of the book series: UICC Monograph Series ((UICC,volume 5))

For a comprehensive yet manageable review of the principles of health education, as derived from behavioural studies, we can do no better than refer the reader to Section III of Health Education Monographs , Supplement No. 1, published by S. O. P. H. E. 1 This excellent work reviews the “Methods and Materials in Health Education (Communication)” with separate sections on: (a) fear — arousing communications; (b) pretesting and readability; (c) audio-visual methods and materials (d) group techniques, and (e) the comparative effectiveness of different methods. Perhaps even more important than the section on methods and materials is Section IV of the Monograph dealing with programme planning and evaluation. We have not repeated references included in the S.O.P.H.E. review .

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References: Principles of health education

Aitken-Swan , J. , and Paterson , R. (1959). Assessment of the resuts of five years of cancer education. Brit. med. J . i , 708. The assessment of five years of cancer education showed that the number of patients with breast cancer who delayed more than one month decreased. No such decrease was noted in a control area, nor did the delay for cancer of the cervix uteri decline. There was an increase in the experimental area of those with breast and cervix uteri cancer who presented themselves when the growths were of limited extent. Finally, from an interview inquiry it was found that the campaign made more impact on those with breast cancer than with cancer of the cervix uteri. One third of the patients in contact with the campaign were too afraid to act upon the advice given. Talks were more influential than articles, but reached a smaller public.

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Baric , L. , and Wakefield , J. (1965). A reappraisal of cancer education. Int. J. Hlth Educ . 8 , 78. After reviewing the present scientific knowledge, the authors make a clear case for the role of education in cancer prevention, and pinpoint five areas where further testing and evaluation are urgently needed.

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Bharara , S. S. (1963). Joining science and tradition. Int. J. Hlth Educ . 6 , 106.

Biocca , S. M. , and Joly , D. (1960). Fighting cancer in Argentina. Int. J. Hlth Educ . 3 , 174. To succeed in the battle against cancer it is necessary to have available: (1) a qualified medical staff, able to make an accurate diagnosis; (2) a well-informed population, aware of the importance of early diagnosis; (3) a medical network that provides the essential facilities for such a diagnosis. The authors describe a campaign carried out in Argentina.

Blokhin , N. N. (Ed.) (1962). Methodological Handbook of anti-cancer propaganda . Moscow: Institute of Health Education (Russian Text). This book contains articles on aetiology, pathogenesis, diagnosis, treatment and prophylaxis. It also deals directly with cancer education in two chapters and four appendices.

Bogolepova , L. (1962). The people’s health culture. Proceedings of the Internat. Conf. on Health and Health Education , vol. 5 , p. 520. Geneva: Int. J. Hlth Educ. (French text, English and Spanish Summaries).

Bond , B. W. (1958). A study in health education methods. Int. J. Hlth Educ . 1 , 41. This study compared the effectiveness of the two methods of education, namely group-discussion plus decision and a straightforward lecture, in a health education programme concerned with breast cancer. (See page 52, col. 1 of this monograph.)

Brotherston , J. (1963). Aimless benevolence. .. . a box of tricks. .. . or? Int. J. Hlth Educ . 6 , 158. In a compact but pertinent article the author considers the aims and methods of health education. The objectives are both particular and general. “The real difficulty is not to find good deeds to do, but to know where, when and with what to begin”. The author is in favour of tackling the “more circumscribed but necessary area [of] the quality and efficiency of the communication between the health worker and his patient or client”. He condemns the authoritarian attitude of nurse and doctor; they must be made to realise the need to educate — the rest will follow. With respect to the behavioural sciences, “the need now is for a statement of applied social science carefully related to the needs of health practitioners.” Training is a cornerstone to progress, and a scientific approach to the choice of objectives is required.

Burton , J. (1964). Three uses of health education in clinical preventive and public health practice. II. The role of education in cancer prevention. Int. J. Hlth Educ . 7 , 68. This is a background paper prepared by the author for the Who expert committee responsible for the technical report from which we have quoted extensively in the text of this chapter. The author’s paper is used almost in its entirety for the sections on health education within the technical report.

Cameron , C. S. (1956). The truth about cancer , New York: Prentice-Hall, Inc., A thoughtful round up of information about cancer and its control by the then medical director of the American Cancer Society. A vigorous expression of an aggressive philosophy of public education in cancer with emphasis on the concept that “only when everyone recognizes and accepts the importance of personal responsibility will the control of cancer become a living reality.” The book has been brought up to date by the author and will be reissued by Collier Books (paperback) in 1966.

Clemmesen , J. , and Stancke , B. (1965). The effect of a cancer campaign in Denmark. S. A f r. Cancer Bull . 9 , 100. Analysis of the long-term effects of an educational campaign for breast self-examination conducted between 1951 and 1955. The years of the campaign saw more cases, and more of them suited to treatment, than previous years. An improvement in survival was observed over the subsequent 9-year follow-up.

Costalat , P. (1958). Survey on Health Attitudes. Int. J. Hlth Educ . 1 , 207. The inquiry proved that the health assumptions of the young Moroccan women interviewed fitted in neither with modern concepts nor with the former popular traditions. They generally combine both, with resulting incoherence and a stagnant health behaviour. Group education is the best method in these circumstances to crystallize the information spread by mass media. Simultaneous education of parents and children is needed. The author stresses the value of interviews, and the value of sometimes appealing to ideas already accepted by some numbers of the group or basing arguments on a related subject.

Derryberry , M. (1958). Some Problems Faced in Educating for Health. Int. J. Hlth Educ . 1 , 178. Why are people so willing to take chances with their health? There is evidence of an educational need to help people relate in a more positive way to their doctors. The “teachable moment” was immediately after the condition was diagnosed: information was sought from many sources at this point, and this, as well as misinformation, was exchanged. We must prepare people to react intelligently and healthfully when they or their relatives and friends are sick; we must help people find the information they want from a reliable source. There are many examples of the risks people take with their health, why do they do so? The author takes smoking as an example of this and considers it in terms of habit formation and society. There is need for more than a statistical demonstration; the chance element is not referred to self, the emotional, irrational elements weigh strongly against the intellectual, rational arguments. We do not know nearly enough about the factors involved. There is a need for research into methods, and careful planning.

Derryberry , M. (1960). Research: Retrospective and Perspective. Int. J. Hlth Educ . 3 , 164. The primary goal of health education is to increase people’s knowledge of the scientific facts about health and to stimulate them to apply the knowledge in improved health practices. Research in health education is concerned with the process by which people change their health behavior. It includes study of all the various factors in the process and the dynamics of the relationship between these factors..... The importance of knowledge, .... of social factors; .... individual factors. It is also concerned with the character of the action that is being advocated. We need to learn what educational methods work with what kinds of people to produce what kinds of actions. It is in the dynamics of these interrelationships that much intensive work is needed. We must not mistake effort for accomplishment: evaluation is essential both in pretesting and in objective evidence of the increased information and for performance of the recommended action.

Derrberry , M. (1960). Health education — its objectives and methods. Hlth Education Monographs No 8 . The author draws an analogy between health education and medicine in their diagnostic and therapeutic processes. He further considers health education as involving forces which must be analysed, a thorough consideration being given to existing “knowledge, attitudes, goals, perceptions, social status, power structure, cultural traditions and other aspects of whatever public is to be reached. Only in terms of these elements can a successful program be built”.

Donaldson , M. (1962). The cancer riddle: a message of hope . London: Arthur Barker. A broad presentation of information about cancer and its treatment for the general public. It includes a discussion (Chapter 18) of the role of “cancer education among the public”. Dr. Donaldson’s ardent advocacy of public education in Britain began in the early 1930s, when his views received little or no support from professional colleagues. Such programmes as exist in Britain today stem from Donaldson’s pioneer work. A number of his articles are listed in other sections.

Ennes , H. (1958). Teachable Moments. Int. J. Hlth Educ . 1 , 70. The educational component of health activity, although continous, may vary in intensity, as, for example, in emergencies. At such moments people are potentially more amenable to education. “Our experience in 1957–58 with the influenza outbreak indicates to us that a specific health threat increases public receptivity to information, and facilitates programs of action for improving general health behavior as well as protection against the present danger.”

Erdmann , Fr . (1960). Öffentliche Krebsaufklärung als Mittel zur Prophylaxe. [Inf ormation on Cancer as a Prophylactic Means in the Fight against Cancer]. Krebsarzt 15 , 240. The author describes the educational aims and methods of his department for “inf ormation on cancer and advanced training in oncology”.

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Hammond , E. C . (1959). Cancer education for the public in the U. S. A. In: Cancer , vol. 3 , ed. by R. W. Raven. London: Butterworth & Co. (Publ.) Ltd.

Hochbaum , G. M. (1959) Some implications of theories of communication to health education practice . Paper presented at the Seminar on Communication in Public Health Education Practice, School of Public Health and Center for Continuation Study, University of Minnesota, Minneapolis, Minnesota, June 1959 (Mimeo). In this excellent paper the author deals with “ some practical implications of some of the principles of effective communication”. He begins by considering the meaning of “communication”, which can be looked on as having three levels, depending on its purpose — the mere communication of information, the performance of some fairly immediate and specific action, and, thirdly, the more fundamental change of the communicant’s attitudes, beliefs, and motivational patterns leading eventually to behavioural changes. Of fundamental importance is the subjective meaning of a message and how it fits into the already existing frame-work of a person’s attitudes, interests and needs; information may be necessary in bringing about rational behaviour, but it is not usually sufficient by itself. The author continues with a very useful consideration of the timing of a communication and the best use of the “teachable moments”, which are those moments created by certain circumstances (e.g. an epidemic) when there is an increased readiness to learn. Of importance for the continued effect of health communications is the sustaining of the emotional impact not only by correct timing but also by correctly spaced follow-up communications. Action should be provided while motivation is still close to the peak. Motivation is strengthened when an action is carried out freely and for reasons that are perceived by the individual as good and acceptable, especially where such reasons are explicitly stated. These considerations also have implications for the long-term planning and integration of programmes. The author goes on to consider the role of anxiety in health communications, its uses and abuses, and its use in cancer education. An important principle in this connection is that “the anxious person looks for reasurance and not for facts”. The advantages and drawbacks of mass media are critically reviewed. Finally a very useful section considers the relative merits of educating the public to accept broad principles concerning health, and programmes aimed at producing isolated actions.

Hochbaum , G. M. (1960a). Research relating to health education. Hlth Education Monograph No 8 . The author considers his topic in two parts. Firstly, the importance of discovering the attitudes, beliefs, needs, fears etc. of the individuals and social groups, prior to any attempt to influence them educationally: such factors influence what will be accepted or rejected, by whom, and under what circumstances. Having thus considered the “whys” of human behaviour, the author goes on to consider the ways and means of changing it: topics covered include mass media, group dynamics, and the theory of cognitive dissonance.

Hochbaum , G. M. (1960b). Modern Theories of Communication. Children 7 , 13. Based on Hochbaum (1959a).

Hochbaum , G. M. (1960c). Behavior in response to health threats . Paper presented at the 1960 Annual Meeting of the Amer. Psychol. Ass. in Chicago, September 2nd. 1960. (Mimeo). See text of this chapter for summary.

Hochbaum , G. M. (1962). Evaluation: A diagnostic procedure. Proceedings of the Internat. Conf. on Health and Health Education , vol. 5 , 636. Geneva: Int. J Hlth Educ. The author summarizes the critical aspects in the evaluation of health education programmes as:” (1) Decisions on programme goals and methods, and decisions on evaluation techniques should go hand—in— hand. (2) Both the .... goals and the evaluation measures should be concerned with human behaviour. Non-observable aspects of behaviour, such as changes in knowledge and attitudes are only intermediary or substitute criteria. (3) Evaluation should be carried out as a continuous process [i. e. before, during and after the programme]. (4) Evaluation should not be considered as a measure of success, but as a diagnostic procedure that helps to identify effective and ineffective aspects of the programme”. Health education objectives differ from those of a health programme: the former is concerned with the behaviour which is of help in achieving the latter (which are more concerned with medical statistics).

Hochbaum , G. M. (1965). Research to improve health education. Int. J. Hlth Educ . 8 , 141. Insufficient attention is paid to differentiating between the two kinds of research: (1) aimed at improving health education, and (2) aimed mainly at advancing knowledge. The two may differ in objectives, methodology, design, and analysis and treatment of data. Much health educational research fails because it does not adhere to principles of sound scientific research; but much fails because it adheres to them too compulsively, despite the obvious limitations imposed by field conditions. In this case compromise is necessary, but with a clear realization of how compromise will affect the interpretation of data.

Hopper , J. M. H. (1960). The value of various forms of publicity. Int. J. Hlth Educ . 3 , 143. This study supports the view that “the best way of publicising health problems is to use all the forms available, as when the four selected forms of publicity [press, bus posters, hoardings or posters at place of work, and letter to parents of tuberculin positive children] were used, attendance dropped to 88 per cent of the total attendance when the sixteen forms” as used in the 1957 campaign were employed. The results also showed that some forms of publicity attract the attention of far greater numbers of people (the first three mentioned above); prominence should be given to these in future campaigns.

Horn , D. (1956). The attitudes of psychiatrists on the effect of cancer propaganda . Amer. Cancer Soc. (Mimeo). The results of a survey of 387 psychiatrists carried out in 1955 show that since 1949 (when there was also a “deliberate effort .... to de-emphasize the more fear-provoking aspects of cancer and to emphasize a “note of hope. ...”) there has been a significant decrease in the number of psychiatrists that believe American Cancer Society literature has increased anxiety among psychiatric patients (from 35 % to 25 %). Among those believing that there has been an increase in anxiety, there has been a decrease in the number believing that such anxiety results in greater harm than good.

Hyman , H. H. , and Sheatsley , P. B. (1958). Some reasons why information campaigns fail. In: Readings in social psychology , ed. by E. E. Maccoby et al . New York: Holt, Rinehart & Winton.

James , W. (1964). The American Cancer Society’s school education program. J. Sch. Hlth 34 , 466. The ACS public education director outlines concepts in a continuing programme aimed first at school administrators and teachers, to bring cancer instruction to students (down to Junior high school) “while they are in an active learning situation and before they have developed obstructive fears and misconceptions”.

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Johns , E. (1962). The Los Angeles evaluative study. Proceedings of the International Conference on Health and Health Education , vol. 5 , 514. Geneva: Int. J. Hlth Educ. This study was designed to evaluate the effectiveness of school health education. The effectiveness of health education was judged by means of an appraisal of the programme activities and the health behaviour of pupils in terms of knowledge, attitudes and practices.

Katsunuma , H. (1958). Before planning: a survey. Int. J. Hlth Educ . 1 , 151. To help determine the best health education approach in a rural community, a survey on family attitudes regarding health problems was recently undertaken in a district near Tokyo.

King , S. H. (1958). What we can learn from the behavioural sciences. Int. J. Hlth Educ . 1 , 194. The author stresses the importance of familiarity with the major concepts of the behavioural sciences, and their integration across the biological, psychological and social-cultural levels. “They [public health workers] also need to be introduced to the findings of research projects that are pertinent to an understanding of disease and of social factors that inhibit or facilitate health programmes.” The major concepts considered are: social perception or definition of the situation, homeostasis or a striving towards a balance, beliefs and attitudes, and political structures and communication lines.

Knutson , A. L . (1952a). Evaluating health education. Publ. Hlth Rep . 67 , 73. In the evaluation of any health education programme one should consider the following points: adequate preliminary investigation should be made to ascertain needs and behaviour; goals must be specified, but evaluated in relation to the overall aims; concrete evidence that an objective has been achieved is the only realistic criterion for measuring effectiveness; methods of evaluation must be chosen in terms of the specific goals; a baseline of zero cannot be presumed; evaluative measurements are nearly always indirect measures; long-term needs should be borne in mind apart from the immediate goals.

Knutson , A. L . (1952b). Pretesting: A positive approach to evaluation. Publ. Hlth Rep . 67 , 699. A critical review should be made prior to pretesting a programme so that the needs, objectives, methods, and subject matter are clearly defined, accurate and likely to be most successful. The pretest should be planned in terms of certain specific conditions that need to be satisfied in order to achieve programme goals; the programme will then be more likely to succeed. The conditions to be satisfied include: amount of public exposure, attention and interest, motivation, pattern of behaviour, comprehension, understanding of purpose, learning and retention.

Knutson , A. L. , Shimberg , B. , Harris , J. S. , and Derryberry , M. (1952). Pretesting and evaluating health education. Publ. Hlth Monograph No 8 . Washington, D. C.: United States Public Health Service Publication No 212 .

Koch , F. , and Stakemann , G. (1964). A population screening for carcinoma of the uterus with the irrigation smear technique. Dan. med. Bull . 11 , 209. A remarkable project in the borough of Frederiksberg, Copenhagen, appears to demonstrate the acceptability of self-obtained smears (by pipette) without major educational effort. Of 11,192 selected women, 82.2 % used and returned the pipettes. Propaganda limited to one 3-minute interview on T. V. and a few items in newspapers. The authors suggest this success is due to the fact that women can undertake the procedure in the privacy of their homes, and without the inconvenience or embarrassment of making an appointment for examination.

La Pointe , J. L. , Wittkower , E. D. , and Lougheed , M. N. (1959). Psychiatric evaluation of the effect of cancer education on the lay public. Cancer (Philad.) 12 , 1200. The authors believe that cancer education and many other forms of health education have relatively little effect considering the amounts of time, money and skill spent on them. There is a reliance on the mass media, merely presenting material to large groups of individuals regardless of their receptivity. A more personal approach through discussion groups and the like may produce a lessening of resistances and thus reduce the blocking reactions. Once the general public has allowed itself to be exposed to education, greater resistances might be overcome if other factors, such as the different needs of the population, or which person is more liable to be heard and understood in specific groups, were known. “The real problem is not whether enough information is put across to the general public, but how and how successfully the information is communicated. There is little doubt in our minds, for instance, that propaganda based on curability through early treatment is more likely to be successful than is propaganda based on fear.”

Lifson , S. S . (1958). Do they understand what they read? Int. J. Hlth Educ . 1 , 100. Giving literature to patients in hospitals is not enough. We must find out if they understand what they read. An interesting survey was carried out in this connection by the U. S. Tuberculosis Association, making use of reading tests. It proved two things: the need for hospital personnel to be aware of the level of vocabulary comprehension of their patients; and, secondly, that we should not rely mainly on the printed word for our educational effort.

McCormick , G. (1964). Programme planning — An organized approach. Int. J. Hlth Educ . 7 , 91. The author discusses how he used the W. H. O. guide to programme — planning when he was co-ordinator of a community nursing-home demonstration programme. The W. H. O. guide enumerated the following five steps:(1) collecting information essential for planning; (2) establishment of objectives; (3) assessing the barriers to health education and how they may be overcome; (4) appraising apparent and potential resources (organisations, personnel, materials and funds); (5) developing the detailed educational plan of operations (including a definite mechanism for continuous evaluation).

Maclaine , A. G. (1965). Lay education in cancer control. Med. J. Aust . 2 , 171. A succinct review of experience elsewhere and discussion of possible applications to the situation in Australia. This article is not written from a limited parochial point of view, and its interest is therefore not confined to the country of origin.

McNickle , d’ A. , and Pfrommer , V. G. (1959). It takes two to communicate. Int. J. Hlth Educ . 2 , 136.

Nix , M. E. (1961). Health education and human motivation. Int. J. Hlth Educ . 4 , 192. Although the importance of health and illness has global significance, attitudes regarding these will vary according to the cultural ideals of a community. Therefore, although the problem of the control of tuberculosis is universal, it can be solved by giving careful consideration to the fixed customs of the group. The author considers the different types of atmosphere of a group associated with the types of leadership, and the consequences for human motivation and behaviour. If the leader is authoritarian or laissez—faire the positive results, if any, are unlikely to be permanent. Ideally the relationship should be one of educated self-determination, in which a person follows a responsible leader with understanding and the realization that the programme will benefit him and those around him.

Osborn , G. R. , and Leyshon , V. N. (1966). Domiciliary testing of cervical smears by home nurses. Lancet 1 , 256.

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Public health nurses in Derby were used in a cervical cytology programme (a) to identify the high-risk women (multiparous, low on socio-economic scale) in their care; (b) to persuade them to have a smear taken; (c) to take smears (after careful training) in the home. The value of this highly personal form of selective health education was shown by results. Moreover, a positive smear rate of 26.5 per 1000 was found in this group, almost four times greater than the rate recorded for the general population at clinics in the same town.

Paterson , R. , and Aitken-Swan , J . (1954). Public opinion on cancer: A survey among women in the Manchester area. Lancet ii , 857. A report of the first survey carried out at the beginning of the experimental cancer education programme by the Manchester Committee on Cancer. (See Chapter I of this Monograph).

Paterson , R. , and Aitken-Swan , J. (1958). Public opinion on cancer: Changes following five years of cancer education. Lancet ii . 791. This is a repeat survey of the one carried out in 1953 (Paterson and Aitken-Swan 1954) and showed a good general improvement in attitudes to cancer. (See Chapter I of this Monograph).

Paterson , R. , Brown , C. M. , and Wakefield , J. (1954). An experiment in cancer education. Brit. med. J . ii , 1219. This is an early article describing the cancer education programme of the Manchester Committee on Cancer.

Phillips , A. J . (1955). Public opinion on cancer in Canada. Canad. med. Ass. J . 73 , 639. (See Chapter I of this report).

Phillips , A. J. , and Taylor , R. M. (1961). Public opinion on cancer in Canada; a second survey. Canad. med. Ass. J . 84 , 142. This is a report on a repeat of the 1955 survey (Phillips 1955), and shows an improvement in public opinion concerning cancer after a carefully planned educational campaign. (See Chapter I of this report).

Popma , A. M. (1962). Public education and cancer control. Acta Uni. int. Cancr . 18 , 723. The author deals with the history of public cancer education both in the United States and Great Britain. Fear of cancer needs to be eradicated by education organised by the medical profession. Much evidence is cited to show the value of early diagnosis of cancer of all sites, especially asymptomatic cancer. Cancerophobia, the most common objection to education, is not a true problem. It should be guided by education into a salutary fear of undue delay in seeking adequate treatment.

Price-Williams , D. R. (1962). New attitudes emerge from the old. Proceedings of the International Conference on Health and Health Education , vol. 5 , 554. Geneva: International Journal of Health Education. The author emphasizes the importance of taking into account the background of ideas and practices in health education. New ideas must be seen in relation to the old ones that they are disrupting or replacing. The author illustrates his points with examples from a tribe he studied in Nigeria.

Rankin , D. W. , and Brown , A. J . (1964). Cancer education in Victoria. Med. J. Aust . 1 , 357. A description of five years of intensive cancer education of the public by the Anti-cancer Council of Australia, its organization objectives, methods and evaluation.

Raven , R. W. , (1953). Cancer and the community. Brit. med. J . ii , 850. Among other topics, he discusses a cancer education programme. Telling the public the symptons is not enough, they must also be told how to act in certain circumstances, and what can be done to help them. This must be done wisely and in stages throughout the country.

Read , C. R. (1965). The control of neoplasia — education for prevention. In: The social responsibility of gynecology and obstetrics . Baltimore: Johns Hopkins Press. The American Cancer Society’s vice president for public education and information reviews his and the Society’s experience in many years of education against cancer of the uterus. He emphasizes the need for physician leadership, the importance of terminology acceptable to the media and meaningful to the public, the need to use both media and person-to-person approaches through informal networks of communication, (churches, unions, women’s clubs, neighbourhoods, etc.), the educational stress on “hope, on the peace of mind the Pap test can give”. Many millions in America have learned a new health habit, but there has been too little success with low-income groups and women over the age of 65. The diffusion process in health education is slow.

Roberts , B. J. (1965). A framework for consideration of forces in achieving earliness of treatment. Hlth Education Monographs No 19 . A stimulating analysis of the motivational and other forces involved in achieving early detection and treatment, particularly of breast cancer, by health educational methods. Invaluable because it offers for the first time a holistic view of the decision-making forces that lead to action, rather than the usual fragmentary examination of some aspects of the problem.

Roberts , B. J. (1962). Concepts and methods of evaluation in health education. Int. J. Hlth Educ . 5 , 52. In this article the author attempts to clarify the concepts surrounding evaluation in health education, and considers the problems of measurement involved in such evaluation.

Rosenstock , I. M. , Hochbaum , G. M. , and Kegeles , S. S. (1960). Determinants of health behavior . Golden Anniversary White House Conference on Children and Youth. See the text of this chapter for a summary.

Rosenstock , I. M. (1960). Gaps and potentials in health education research. Hlth Education Monographs No 8 . The author considers that applied research is needed to “develop simple, economical and valid methods for diagnosing health education problems; [and also] ... to develop valid methods for educating individuals and groups in a real life health setting”. Further “basic research is needed to increase our growing knowledge of why people do what they do”. Finally, much more programme evaluation is required to help in improving programmes.

Rosenstock , I. M. (1961). Decisionmaking by individuals. Hlth Education Monographs No 11 . See the text of this chapter for summary.

Rosenstock , I. M. (1962). Many opinnions.. . Few Hard Facts. Proceedings of the International Conference on Health and Health Education , vol. 5 , 565. Geneva: Int. J. Hlth Educ. The author is of the opinion that “what we still do not know .... is how best to diagnose and use existing motivational states and existing social structures to change behaviour”.

Rosenstock , I. M. (1963). Public response to cancer screening and detection programs. J. chron. Dis . 16 , 407. In the second part of the paper, Rosenstock attempts to apply the behavioural model already developed (see text of chapter) to cancer detection. The research that is required should be directed at the groups shown to be in need of it by a consideration of their health behaviour status — e. g. the undermotivated. The author concludes with recommendations for (a) a fact-finding phase; and (b) an action phase.

Ross , W. S. (1965). The climate is hope — How they triumphed over cancer , New York: Prentice-Hall, Inc. The book reports the personal attitudes to cancer of physicians, their patients, most of whom have been cured, and researchers. Sixteen rambling chapters — largely taped interviews — reflect the fears and guilt of some patients, the courage of others. Physicians speak candidly of their limitations as well as their successes: one is deeply interested in problems of stress and cancer, another in the value of a cancer detection examination, a third in the philosophy of radical operations, a fourth in the unbearable family tensions that often develop when a child has cancer. “Cancer is a highly complex group of diseases, each with its own course and prognosis ... Hence the reactions and the judgements of both patients and therapists often vary greatly and may be controversial.”

Sandman , I. (1962). Parent education in the U. S. A: Some impressions on methods. Int. J. Hlth Educ . 5 , 34. The author examined whether group discussions would produce better results than the traditional courses in health education of expectant mothers. The answer appears to be in the affirmative. Although factual information is important, an understanding of one’s feelings is also important and both are achieved in discussions.

Seppilli , A. (1962). A community survey — First step towards a film. Proceedings of the International Conference on Health and Health Education , vol. 5 , 527. Geneva: Int. J. Hlth Education. (French text, English and Spanish Summaries).

Spillius , J. (1962). The impact of social structure. Proceedings of the International Conference on Health and Health Education , vol. 5 , 560. Geneva: Int. J. Hlth Educ. The author suggests “(1) that the health educator may have to redefine the kind of system he is dealing with; (2) that a health education programme may constitute a direct attack on some of the individuals in the community, especially those who hold some kind of medical lore; (3) that it is necessary to study the customary ways of imparting information, recognizing that there may be an informal [social] structure, such as a network of kin which is just as potent as the formal structure in imparting information and shaping opinion; (4) that it is necessary to make a distinction between decision-making and choices ...,(5) that cultures change, customs change, and in some societies at a more rapid rate than in others .... it should [therefore] be possible to change ideas on health and disease if we analyse the social patterns, see who is responsible for health practices, and whether or not the community’s ideas are really as irrational as they appear. In attempting to promote change, we should obviously use the existing social structure as much as possible”. Society should not be looked at in terms of social structure alone; health education programmes affect the social, economic and technological structures, and these three aspects must be included in the planning and execution of the programme. The physical and economic burden placed on the people of a developing country must be borne in mind in any health education programme.

Steuart , G. (1965). The physician and health education. Brit. med. J . ii , 590. The author considers that the passive role of the patient is not conducive to good health education via the doctor, and recommends that the relationship be changed to a more patient-oriented one, in which the latter plays an active part. Steuart deals with the reasons why a patient should be educated, possible objections to his proposals, and the part played in all this by basic medical education of the doctor.

Steuart , G. (1959). The importance of programme planning. Int. J. Hlth Educ . 2 , 94. Systematic and intelligent planning are essential for successful health education. (See text of this chapter). Illustrations are taken from a programme concerning ante-natal and maternity care in a South African Indian community.

Steuart , G. (1962). A slender store of studies.. . Proceedings of the International Conference on Health andHealth Education , vol. 5 , 608. Geneva: Int. J. Hlth Educ. In this very instructive article the author reviews the studies of the educational content of health education programmes. Such studies are concerned with evaluation of the effectiveness of programmes, the existence and extent of the problem in the community or group, the establishment of criteria or baselines against which to measure and compare results, the comparative effectiveness of methods and the use of methods appropriate to the population and problem. More such studies are needed, and the help of the pure scientist must be used wherever possible. This article includes a bibliography of nearly fifty articles.

Suchman , E. (1962). More scientific rigour is needed. Proceedings of the International Conference on Health and Health Education , vol. 5 , 533. Geneva: Int. J. Hlth Educ. A great deal more thought might be given to the problem of classification of research findings, but this would involve the clarification of the basic dimensions underlying its fundamental concepts. Only by attempting to relate findings to such concepts will the results of applied research be of use outside the limited experimental situation. The research design of most health education studies is weak, owing to lack of underlying theory; they also lack scientific rigour. There are many possible criteria for the evaluation of an educational programme — in terms of effort, performance, adequacy, efficiency —, effort is the most common. Health education must develop its objectives more specifically according to different degrees of immediacy; this will necessitate an examination of the basic assumptions concerning the goals involved.

Sustaita Seeber , A. de (1963). Changing attitudes to cancer. Int. J. Hlth Educ. , 6 , 88. The results of a cancer education campaign in Argentina showed that attitudes to cancer have improved: information was sought and accepted more frequently, there was less delay by patients, conversations about cancer were considered more natural, and the educational approach is much more optimistic in outlook.

Tentori , F. V. (1962). Their needs and knowledge. Int. J. Hlth Educ. , 5 , 10. With ample illustration the author emphasizes the importance of preliminary research and evaluation in the careful planning of a programme. The research should include an examination of the characteristics and attitudes of the cornrnunity.

Tentori , F. V. (1963). Audio-visual materials: an experiment in pretesting. Int. J. Hlth Educ. , 6 , 180. This article sums up ... the results of a study carried out by the author in Mexico. The purpose was to pretest audio-visual materials being planned to support a public health programme.. .. The results emphasize the value of such tests and pinpoint some important principles.

Wakefield , J. (1959). The case for cancer education. Monthly Bulletin of the Ministry of Health and the Public Health Laboratory Service 18 , 146. The arguments for and against public education about cancer are presented and examined in the light of available evidence. The evidence shows that a carefully conceived and tactfully executed programme of education does not have undesirable effects, and that it can favourably influence public attitudes to cancer.

Wakefield , J. (1963). Cancer and public education . London: Pitman Med. Publ. Co. Ltd; Springfield (Ill.): Ch. C. Thomas. This volume summarizes many years in the field of cancer education in England. Probably the only work devoted solely to cancer education. Topics covered in the different chapters include: the principles and practice of cancer education — the problem, delay in seeking treatment, the content of a programme, informing the public by mass-media and person-toperson methods, cancer education in schools and the smoking problem —, and the organization of public education schemes. The appendices contain notes for lecturers, a reprint of the Paterson and Aitken-Swan (1954) survey, notes on the use of visual aids, and a list of educational materials and sources.

Wakefield , J. (1966). The role of public education in cancer detection. In: Chap.-VI., UICC Monograph Ser., vol. 4. Berlin-Heidelberg-New York: Springer 1966. The author emphasises that detection programmes must be accompanied by public education. The objectives of such education must be “to persuade people to seek prompt medical advice when certain warning signs appear; and to persuade them particularly those in high-risk groups, to take part in screening programmes”; emphasis on the hopeful and reassuring aspects of cancer and cancer detection tests is important. The author deals with the functions of the physician, other medical staff, and mass-media in education for detection of cancer. Crucial, however, in any such education is the state of the attitudes, beliefs and health practices in the community or group being educated. Wakefield draws attention to the need for examining the qualities of detection tests that attract or repel an individual, and cause him to accept or reject the test. The article is supported with evidence from a number of relevant studies.

Wakefield , J. , and Davison , R. L . (1958). An answer to some criticisms of cancer education: A survey among general practitioners. Brit. med. J . i , 96. This is a report of a survey carried out after five years of public education. It was designed to test the validity of the criticisms “that cancer education would create cancerophobia among the public and add unnecessarily to the work of the general practitioners”. Such criticisms were shown to be invalid for the kind of educational programme used.

WHO (1963). Cancer control. Wld Hlth Org. Tech. Rep. Ser . No 251M . This report contains a short section on education of the public, in which a few notes are made on the most important points of such education: necessity, form and operation of cancer education.

WHO (1964). Prevention of cancer. Wld Hlth Org. Rep. Ser . No 276 . This report contains an excellent section on public education, which we have quoted extensively in the text of the chapter.

Young , M. A. C. , Dicicco , L. M. , Paul , A. M. , and Skiff , A. W. (1963). Review of research related to health education practice. Hlth Education Monographs , Suppl. No 1 . New York: Society of Public Educators, Inc.

Zabolotskaia , L. (1965). The integration of health education in preventive and curative medicine in the U.S.S.R. Int. J. Hlth Educ. , 8 , 41. Prophylactic examination of healthy people is carried out in various selected categories of the population. A widespread educational effort precedes such examination programmes to ensure maximum participation. Follow-up of the chronic sick revealed by examination is tackled systematically, with health education playing a major role.

Ministry of Health, London (1964). Health education . Report of a Joint Committee of the Central and Scottish Health Services Councils. London: Her Majesty’s Stationery Office. This excellent report deals with the aims and achievements of health education. The need for evaluation is stressed and the future organization of health education in Britain is considered. Finally, the report deals with the techniques of health educators, the part played by general practitioners, and health education in schools. An appendix on health education in the United States is included. There are several lengthy comments on health education about cancer. Many methods useful for evaluation in health education. Int. J. Hlth Educ . 5 , 93. [Editorial annotation]. Lists ten of a variety of methods that have been used to check changes in knowledge, attitudes and behaviour of students relating to health. Health Education: a selected bibliography prepared by the World Health Organization. (1956). Educational Studies and Documents . No XIX. Paris: UNESCO. 174 entries on (1) General background; (2) Health education; (3) Methods and techniques; (4) Training; (5) Evaluation (6) Periodicals.

Health Education (1962), Education Abstracts , vol. XVI, No 1, compiled by Winifred Warden . Paris: UNESCO. An annotated bibliography of 398 entries on (1) Philosophy and background; (2) school health; (3) Programme planning; (4) Problems in special fields (including smoking); (5) Books for children; (6) Periodicals of interest.

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Committee on Public Education of the Commission on Cancer Control. (1967). Health Education: Some Principles and Practice. In: Public Education about Cancer. UICC Monograph Series, vol 5. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-88006-3_5

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Health education: theoretical concepts, effective strategies and core competencies: a foundation document to guide capacity development of health educators.

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Teaching methods in health education

Common group health education methods.

A lecture is usually a spoken, simple, quick and traditional way of presenting your subject matter, but there are strengths and limitations to this approach. The advantages include the efficient introduction of factual material in a direct and logical manner. However, this method is ineffective where the audience is passive, and learning is difficult to gauge. Experts are not always good teachers and communication in a lecture may be one- way with no feedback from the audience.

B) Lecture With Discussion

This approach is critical because it always involves your audience after the lecture in asking questions, seeking clarification and challenging and reflecting on the subject matter. There always become active participation from the side of the attendants. i.e., participants are not passive as in the case of lecture method.

C) Group Discussions

Discussion in a group allows people to say what is in their minds. They can talk about their problems, share ideas, support and encourage each other to solve problems and change their behaviour (Figure 7.2).

Planning a Discussion:

• Identification of the discussants that do have a common interest E.g. mothers whose child suffers from diarrhoea.
• Getting a group together
• Identification of a comfortable place and time.

Conducting the Discussion:

• An introduction of group members to each other.
• Allow group discussion to begin with general knowledge E.g. any health problems they have ever faced.
• Encourage everyone to participate.
• Have a group act out some activity (drama, role play).
• Limit the duration of discussion to the shortest possible, usually 1 -2 hrs.
• Check for satisfaction before concluding the session. E.g. Do they think that they are learning? Do they think the group should continue?.

D) Buzz Group

It is a type of group discussion In which a large group will be divided into several small groups, of not more than 10 or 12 people (buzz groups). You can then give each small buzz group a certain amount of time to discuss the problem. Then, the whole group comes together again, and the reporters from the small group report their findings and recommendations back to the entire audience. A buzz group is also something you can do after giving a lecture to a large number of people, so you get useful feedback

E) Meetings

Meetings are good for teaching something of importance to a large group of people. They are held to gather information, share ideas, take decisions, and make plans to solve problems. Meetings are different from group discussions. A group discussion is free and informal, while meetings are more organised. Meetings are an important part of successful self-help projects.When you are planning a meeting, it should be need based, determine the time and place announce the meeting through village criers or word of mouth and prepare a relevant and a limited number of agendas.

There are many kinds of organizations to which women, men and young people belong. Clubs are becoming popular in many areas. They provide an opportunity for a systematic way of teaching over an extended period of time. E.g. a group of citizens could form an association to deal with problems related to a major local disease or to protect the environment. For example anti-HIV/AIDS club

G) Demonstrations

A demonstration is a step-by step procedure that is performed before a group. They involve a mixture of theoretical teaching and of practical work, which makes them lively. It is used to show how to do something. The main purpose of demonstrations is helping people learn new skills. The size of the group should be small to let members get the chance to practice. It is particularly useful when combined with a home visit. This allows people to work with familiar materials available in the locality.

Although demonstration sessions usually focus on practice, they also involve theoretical teaching as well 'showing how is better than telling how' (Figure 7.3). This is because you can remember 20% of what you hear, you remember 50% of what you hear and see, you remember 90% of what you hear, and see and do- with repetition, close to 100% is remembered.

Procedures and Steps of Demonstration:

• Introduction : Explain the ideas and skills that you will demonstrate and the need for it.
• Do the demonstration: Do one step at a time, slowly. Make sure everyone can see what you are doing. Give explanations as you go along.
• Questions: Encourage discussion either during or at the end of the demonstration. Ask them to demonstrate back to you or to explain the steps.
• Summarise: Review.

Qualities of Good and Effective Demonstrations:

• Identify the needs of the group to learn.
• Collect the necessary materials such as models and real objects or posters and photographs.
• Make sure that it fits with the local culture. E.g. for nutrition demonstration you have to use the common food items and local cooking methods.
• Prepare adequate space so that everyone could see and practice the skill.
• Choose the time that is convenient for everyone.

H) Role - Playing

Role-playing consists of the unrehearsed and spontaneous acting out of real-life situations and problems. The player tries to behave in a way that the character might behave when faced with a given situation or problem. Role-playing can be used to start off a discussion, to see what possible consequences of a certain action are, and to develop a better understanding of why people feel as they do.

We learn about our own behaviour during a role-play, we can discover how our attitudes and values encourage cooperation and problem solving or, how our attitude and values create problems. During a role-playing participants are selected randomly or blindly and are given a role or character and have to think and speak immediately without detailed planning, because there is usually no script.

Role play is usually undertaken in small groups of 4 to 6 people. Remember role play is a very powerful thing and works best when people know each other, don't ask people to take a role that might embarrass them. Sometimes role play involves some risk of misunderstanding, because people may interpret things differently.

Dramas need script, rehearsal and preparation which done on one main learning objective but can often include 2 or 3 other less important objectives as well. Alike stories, dramas make us look at our own behavior, attitudes, beliefs and values in the light of what we are told or shown. Plays are interesting because you can both see and hear them. It is a suitable teaching method for people who cannot read , because they often experience things visually. However the preparation and practice for a drama may cost time and money.

Let us look at some of the following traditional means of communications which are used by the community to express their local culture such as their knowledge, feelings, happiness, sadness or any life situations to others.

J) Songs and Dances

In addition to expression of feelings, songs can also be used to give ideas about health with dances or some times without dances. For example, the following issues could be entertained: The village without safe water, the malnourished child who got well with the proper food to eat, the village girl who went to school to become a health extension worker.

Stories often tell about the deeds of famous heroes or of people who lived in the village long ago. Story telling is highly effective, can be developed in any situation or culture, and requires no money or equipment. It should include some strong emotions like sadness, anger; humor, or happiness as well as some tension and surprise. An older person, instead of directly criticizing the behavior of youth, may tell stories to make his/her points. She/he may start by saying, "I remember some years ago there were young people just about your age..." and then continue to describe what these young people did that caused trouble.

l) Proverbs

They are short common-sense sayings that are handed down from generation to generation. For example:

• Amharic proverb "TamoKememakekAskedimoMetenkek" specify "prevention is better than cure".
• "Dirbiyabranbessayasir" Amharic proverb.
• "A single bracelet does not jingle" African proverb.
• "If I hear, I forget, If I see, I remember If I do, I know". A Chinese proverb which states about active learning or learning by doing.
• "One does not go in search of a cure for ringworm while leaving leprosy unattended." This means that trying to solve the most serious problem must come first.

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Methods and Materials of Health Education

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

This new book constitutes a practical compendium of techniques and procedures for improving the quality of school health education. It also provides detailed descriptions of resources for health education and illustrations of the applications of method to the use of these materials. Although school health education is seldom planned and carried on with the same intensity as the more traditional subjects, life science deserves equal emphasis in the curriculum in terms of attention to materials and methods as these influence the general quality of instruction. Without minimizing the value of factual approaches, the volume stresses the need to provide concrete and realistic health education experiences for children and youth. The book is divided into five parts, the first of which is concerned with definition and delineation of the school health program; part 2 deals with curriculum formulation and development, part 3 with teaching techniques and procedures, part 4 with materials

Methods and Materials of Health Education. JAMA. 1958;167(11):1442–1443. doi:10.1001/jama.1958.02990280128031

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Health Education, Advocacy and Community Mobilisation Module: 10. How to Teach Health Education and Health Promotion

Study session 10  how to teach health education and health promotion, introduction.

This study session focuses on your work as a health educator. Health education is a very important part of your work and if you do it well it will help you improve the health of the people for whom you are responsible. In this session you will learn about teaching methods as well as some of the teaching materials you will be using in your work. Teaching methods refers to ways through which health messages are used to help solve problems related to health behaviours. Teaching materials or aids are used to help you and support the communication process in order to bring about desired health changes in the audience.

In this study session you will be able to learn about those concepts and definitions (Figure 10.1), as well as the practical application of teaching methods and health learning materials that will help you in your work.

Learning Outcomes for Study Session 10

When you have studied this session, you should be able to:

10.1  Define and use correctly all of the key words printed in bold . (SAQ 10.1)

10.2  Discuss some of the most important types of teaching methods. (SAQs 10.1 and 10.2)

10.3  Describe the advantages and limitations of various teaching methods. (SAQs 10.1 and 10.2)

10.3  Discuss the various types of Information Education Communication (IEC) or health learning materials. (SAQs 10.1 and 10.2)

10.4  Describe the role of IEC materials in disease prevention and health promotion. (SAQs 10.1, 10.2 and 10.3)

10.1  Teaching methods

There is a wide variety of teaching methods that you will be able to use in your health education work. You will be able to adapt these methods to your own situation, so that you can use the most effective way of communicating your health education messages.

10.1.1  Health talks

You may consider that the best way of communicating your health messages in certain situations is by using health talks. Talking is often the most natural way of communicating with people to share health knowledge and facts. In the part of your job that involves health education, there will always be many opportunities to talk with people.

Group size is also important . The number of people who you are able to engage in a health talk depends on the group size. However, you will find talks are most effective if conducted with small gatherings (5–10 people), because the larger the group the less chance that each person has to participate (Figure 10.2).

Think of some situations when you think it might be best to use health talks to get across your health education messages.

Talking is a very flexible form of communication. Talks can be conducted with one person, or with a family or a group of people, and you can adjust your message to fit the needs of that group. One example of this would be communicating a health message to a group of young mothers about their use of contraception. Even informal talks can include information about the benefits and side-effects of using contraception.

Talking to a person who has come for help is much like giving advice. But as you will see, advice is not the same as health education. To make a talk educational rather than just a chat you will find it beneficial if it is combined with other methods, especially visual aids, such as posters or audiovisual material. Also a talk can be tied into the local setting by the use of proverbs and local stories that carry a positive health message.

Preparing a talk

When you are preparing a talk there are many things to consider:

Detailed knowledge on these topics is covered in the Nutrition Module.

• Begin by getting to know the group . Find out its needs and interests and discover which groups are active in your locality.
• Then select an appropriate topic . The topic should be about a single issue or a simple topic. For example, although local people need help about nutrition, this is too big as a single topic to address in one session. So it should be broken down into simple topics such as breastfeeding, weaning foods, balanced diets, or the food needs of older people. Always ensure that you have correct and up-to-date information and look for sources of recent information. There may be leaflets available that can support your health messages .
• List the points you will talk about : Prepare only a few main points and make sure that you are clear about them.
• Next, write down what you will say : If you do not like writing, you must think carefully what to include in your talk. Think of examples, proverbs and local stories to emphasise your points and which include positive health messages
• Visual aids are a good way to capture people’s attention and make messages easer to understand. Think of what you have available to illustrate your talk. Well-chosen posters and photos that carry important health messages will help people to learn.
• Practice your talk beforehand : This should include rehearsing the telling of stories and the showing of posters and pictures.
• Determine the amount of time you need : The complete talk including showing all your visual aids should take not more than about 20 minutes. Allow another 15 minutes or more for questions and discussions. If the talk is too long people may lose interest.

Look again at the list of seven features of preparing a talk. Think about those areas in this list that you are confident about, and then those areas where you feel you will have to do some learning and practising.

The list shows the benefits of being well prepared. As you will see, only point 6 is actually about rehearsals! Most of the list is about being sure you know your audience and that you are well informed and know what you want to say and show. So, if you are nervous, then remember that you can cut down on anxiety by taking this list seriously and being very well prepared.

There are, of course other variations on talking. But all of them rely on the same key features, which are knowing your audience, being well prepared and practising.

10.1.2  Lecture

You may have the opportunity to give a lecture, perhaps in your local school or in another formal setting. A lecture is usually a spoken, simple, quick and traditional way of presenting your subject matter, but there are strengths and limitations to this approach. The strengths include the efficient introduction of factual material in a direct and logical manner. However, this method is generally ineffective where the audience is passive and learning is difficult to gauge. Experts are not always good teachers and communication in a lecture may be one-way with no feedback from the audience.

Lecture with discussion

You may have the opportunity to give a lecture and include a follow-up discussion, perhaps in a local formal setting or during a public meeting (Figure 10.3).

However there are also strengths and limitations to this approach. It is always useful to involve your audience after the lecture in asking questions, seeking clarification and challenging and reflecting on the subject matter. It’s important though to make sure discussion does happen and not just points of clarification.

10.1.3  Group discussion

Group discussion involves the free flow of communication between a facilitator and two or more participants (Figure 10.4). Often a discussion of this type is used after a slide show or following a more formal presentation. This type of teaching method is characterised by participants having an equal chance to talk freely and exchange ideas with each other. In most group discussions the subject of the discussion can be taken up and shared equally by all the members of the group. In the best group discussions, collective thinking processes can be used to solve problems. These discussions often develop a common goal and are useful in collective planning and implementation of health plans. Group discussions do not always go smoothly and sometimes a few people dominate the discussion and do not allow others to join in. Your job as the facilitator is to establish ground rules and use strategies to prevent this from happening.

Handling group members requires patience, politeness, the avoidance of arguments and an ability to deal with different people without excessive authority or belittling them publicly. Think for a moment about how you might prevent a few people from dominating a group discussion.

The key skill in group work that may prevent such domination is by encouraging full participation of everyone in the group. You may be able to ensure participation in several ways, for example by using questioning and by using other methods that facilitate active participation and interaction. Quiet or unresponsive participants need to be brought into the discussion, perhaps by asking them easy questions so that they gain in confidence. Conversely, any community member dominating the discussion excessively should be restrained, possibly by recognising his or her contribution, but requesting information from someone who has yet to be heard. Sometimes it may be necessary to be more assertive, by reminding a dominant member of the objectives of the meeting and the limited time available.

Box 10.1 gives more ideas about managing disruptive group discussions.

Box 10.1  Group disruption

Groups can be disrupted by several types of behaviour:

• People who want a fight : Do not get involved. Explore their ideas, but let the group decide their value.
• Would like t o help : Encourage them frequently to give ideas, and use them to build on in the discussion.
• Focuses on small details : Acknowledge his or her point but remind them of the objective and the time limit for the discussion.
• Just keeps talking : Interrupt tactfully. Ask a question to bring him or her back to the point being discussed and thank them for their contribution.
• Seems afraid to speak : Ask easy questions. Give them credit to raise their confidence.
• Insists on their own agenda : Recognise the person’s self-interest. Ask him or her to focus on the topic agreed by the group.
• Is just not interested : Ask about their work and how the group discussion could help.

10.1.4  Buzz group

A buzz group is a way of coping if a meeting is too large for you. In this situation it is better to divide the group into several small groups, of not more than 10 or 12 people. These are called buzz groups . You can then give each small buzz group a certain amount of time to discuss the problem. Then, the whole group comes together again and the reporters from the small groups report their findings and recommendations back to the entire audience. A buzz group is also something you can do after giving a lecture to a large number of people, so you get useful feedback.

10.1.5  Demonstration

In your work as a health educator you will often find yourself giving a demonstration (Figure 10.5). This form of health education is based on learning through observation. There is a difference between knowing how to do something and actually being able to do it. The aim of a demonstration is to help learners become able to do the skills themselves, not just know how to do them.

Can you think of health related things that would be best taught through demonstration?

The whole process of measuring blood pressure, how to use a mosquito net, putting on a condom, giving a child some medicine, etc. can be best illustrated through a demonstration.

You should be able to find ways to make health related demonstrations a pleasant way of sharing skills and knowledge. Although demonstration sessions usually focus on practice — they also involve theoretical teaching as well ‘showing how is better than telling how’.

If I hear, I forget If I see, I remember If I do, I know. Chinese proverb

• You remember 20% of what you hear
• You remember 50% of what you hear and see
• You remember 90% of what you hear, see and do — with repetition, close to 100% is remembered.

Giving a demonstration

There are four steps to a demonstration:

• Explaining the ideas and skills that you will be demonstrating
• Giving the actual demonstration
• Giving an explanation as you go along, doing one step at a time
• Asking one person to repeat the demonstration and giving everyone a chance to repeat the process (Figure 10.6).

Qualities of a good demonstration

For an effective demonstration you should consider the following features: the demonstration must be realistic, it should fit with the local culture and it should use familiar materials. You will need to arrange to have enough materials for everyone to practice and have adequate space for everyone to see or practice. People need to take enough time for practice and for you to check that everyone has acquired the appropriate skill.

Zahara is a Health Extension Practitioner. She is working in Asendabo kebele . During home visits she educates the families by showing them demonstrations on how to prevent malaria. List at least three features of an effective demonstration that Zahara should follow during her health education activities.

For the demonstration to be effective Zahara should consider the following important points: the materials that she might use and the demonstration process should be real. So, for example, she should have real bed netting with her and at least something she can use that is like a bed. The demonstration should fit with the local culture and she should explain what she is doing as she goes along. She should make sure that there is enough time for at least one person to repeat the demonstration of fitting the bed netting and, if at all possible, for everyone to practice doing it.

10.1.6  Role play

In role play, some of the participants take the roles of other people and act accordingly. Role play is usually a spontaneous or unrehearsed acting out of real-life situations where others watch and learn by seeing and discussing how people might behave in certain situations. Learning takes place through active experience; it is not passive. It uses situations that the members of the group are likely to find themselves in during their lives. You use role playing because it shows real situations. It is a very direct way of learning; participants are given a role or character and have to think and speak immediately without detailed planning, because there is usually no script. In a role playing situation people volunteer to play the parts in a natural way, while other people watch carefully and may offer suggestions to the players. Some of the people watching may decide to join in with the play.

The purpose of role play is that it is acting out real-life situations in order that people can better understand their problems and the behaviour associated with the problem. For example, they can explore ways of improving relationships with other people and gain the support of others as well. They can develop empathy, or sympathy, with the points of view of other people. Role play can give people experiences in communication, planning and decision making. For example it could provide the opportunity to practice a particular activity such as coping with a difficult home situation. Using this method may help people to re-evaluate their values and attitudes, as the examples in Box 10.2 illustrate.

Box 10.2  Examples of role play

• Ask a person to get into a wheelchair and move around a building to develop an understanding of what it feels like to have limited mobility.
• Ask the group to take up the roles of different members of a district health committee. One person acts as the health educator and tries to convince the people to work together and support health education programmes in the community. Problems of implementing health education programmes and overcoming resistance can be explored in the discussion afterwards.
• Ask a man to act out the role of woman, perhaps during pregnancy, to develop an understanding of the difficulties that women face.

Role play is usually undertaken in small groups of 4 to 6 people. Remember role play is a very powerful thing.

• Role play works best when people know each other.
• Don’t ask people to take a role that might embarrass them.
• Role play involves some risk of misunderstanding, because people may interpret things differently.

Look at the three examples of role play in Box 10.2. What dilemmas might arise in each situation?

Here are some possible dilemmas. If a person in your group is already in a wheelchair you would need to handle the role play very carefully. If anyone in your group is in a dispute with someone on the health education committee they might take the opportunity to be spiteful. If a man is acting the role of a woman he would need to feel comfortable doing this. If it looks as though he is very embarrassed you would need to ask for another volunteer or change what you are doing.

10.1.7  Drama

Drama is a very valuable method that you can use to discuss subjects where personal and social relationships are involved. Basic ideas, feelings, beliefs and values about health can be communicated to people of different ages, education and experience. It is a suitable teaching method for people who cannot read, because they often experience things visually. However the preparation and practice for a drama may cost time and money.

The general principles in drama are:

• Keep the script simple and clear
• Identify an appropriate site
• Say a few words at the beginning of the play to introduce the subject and give the reasons for the drama
• Encourage questions and discussions at the end.

10.1.8  Traditional means of communication

Traditional means of communication exploit and develop the local means, materials and methods of communication, such as poems, stories, songs and dances, games, fables and puppet shows.

Some of the benefits of traditional means of communication are that they are realistic and based on the daily lives of ordinary people; they can communicate attitudes, beliefs, values and feelings in powerful ways; they do not require understanding that comes with modern education in the majority of instances; they can communicate problems of community life; they can motivate people to change their behaviour and they can show ways to solve problems. Local traditional events are usually very popular and they can be funny, sad, serious or happy. Also, they are easily understood and they usually cost little or no money. All they require is imagination and practice.

Remember that effective health education is seldom achieved through the use of one method alone. Therefore, a combination or variety of methods should be used to make sure that people really understand your health education messages.

Think of an important health issue in your own community. What methods do you think might be best to deliver health messages about this subject to members of your own community? Read Section 10.1 again and see which methods seem to fit in with your community.

Your answer will be different depending on factors that affect the message you want to deliver. For example, if skills need to be taught then a demonstration is a good method. If your objective is to improve awareness, lecturing may be a good method. Your methods may also vary depending on your own knowledge of your community. For example, you may know several people who enjoy ‘play acting’ and this would make drama and role play quite attractive methods. Also if you have someone in your community who is very good at telling stories or fables, or singing, then you may be able to work with them to help you deliver your messages.

10.2  Health learning materials

Health learning materials are those teaching aids that give information and instruction about health specifically directed to a clearly defined group or audience. The health learning materials that can be used in health education and promotion are usually broadly classified into four categories: printed materials, visual materials, audio and audio-visual materials.

10.2.1  Printed materials

Printed health learning materials can be used as a medium in their own right or as support for other kinds of media. Some printed health learning materials that you will already be familiar with include posters, leaflets and flip charts.

In recent years, the use of posters in communicating health messages has increased dramatically (Figure 10.7). Since a poster consists of pictures or symbols and words, it communicates health messages both to literate and illiterate people. It has high value to communicate messages to illiterate people because it can serve as a visual aid .

The main purposes of posters are to reinforce or remind people of a message received through other channels, and to give information and advice — for example to advise people to learn more about malaria. They also function to give directions and instructions for actions, such as a poster about practical malaria prevention methods. Posters can also serve to announce important events and programmes such as World Malaria Day.

Visual aids like posters explain, enhance, and emphasise key points of your health messages. They allow the audience to see your ideas in pictures and words. Box 10.3 gives some tips on preparing posters.

Box 10.3  Preparing a poster

• Written messages should be synchronised with pictures or symbols.
• All words in a poster should be in the local language or two languages.
• The words should be few and simple to understand. A slogan might contain a maximum of seven words.
• The symbols used should be understood by everyone, whatever their educational status.
• The colours and pictures should be ‘eye-catching’ and meaningful to local people.
• Put only one idea on a poster. If you have several ideas, use a flip chart (see below).
• The poster should encourage practice-action oriented messages.
• It is better to use real-life pictures if possible.
• It should attract attention from at least 10 metres away.

Flip charts are useful to present several steps or aspects that are relevant to a central topic, such as, demonstration of the proper use of mosquito nets or how HIV is transmitted. When you use the flip chart in health education you must discuss each page completely before you turn to the next and then make sure that everyone understands each message. At the end you can go back to the first charts to review the subject and help people remember the ideas.

Leaflets are the most common way of using print media in health education. They can be a useful reinforcement for individual and group sessions and serve as a reminder of the main points that you have made. They are also helpful for sensitive subjects such as sexual health education. When people are too shy to ask for advice they can pick up a leaflet and read it privately.

In terms of content , leaflets, booklets or pamphlets are best when they are brief, written in simple words and understandable language. A relevant address should be included at the back to indicate where people can get further information.

Think for a moment about how you have seen printed materials used for health education messages. Think about posters which have been successful and made an impact, about how other health educators have used flip charts. So you can always ‘copy’ the way that other people do things. If you have a talent yourself or know someone else who does, you can experiment with posters and flip charts (Figure 10.8).

10.2.2  Visual materials

Visuals materials are one of the strongest methods of communicating messages, especially where literacy is low amongst the population. They are good when they are accompanied with interactive methods. It is said that a picture tells a thousand words. Real objects, audio and video do the same. They are immediate and powerful and people can play with them!

Think about what real visual materials you might take with you to a health education meeting. We’ve already mentioned bed netting for demonstrating prevention of malaria, but there are other real objects too. Think about family planning, nutrition, hygiene and so on.

If your display is on ‘family planning methods’, display real contraceptives, such as pills (Figure 10.9), condoms, diaphragms, and foams. If your display is on weaning foods, display the real foods and the equipment used to prepare them.

10.2.3  Audio and audio-visual materials

Audio material includes anything heard such as the spoken word, a health talk or music. Radio and audio cassettes are good examples of audio aids. As the name implies, audio-visual materials combine both seeing and listening. These materials include TV, films or videos which provide a wide range of interest and can convey messages with high motivational appeal. They are good when they are accompanied with interactive methods. Audio-visual health learning materials can arouse interest if they are of high quality and provide a clear mental picture of the message. They may also speed up and enhance understanding or stimulate active thinking and learning and help develop memory.

Summary of Study Session 10

In Study Session 10, you have learned that:

• To be most effective you will have to decide which type of teaching methods and materials will suit the specific messages that you want to convey. It is also important to understand who your target groups are and what resources you have at hand to meet your communication objectives.
• The most important teaching methods are talks, lectures, group discussions, buzz groups, demonstrations, role-plays, dramas and traditional means of communication such as poems, stories, songs, dances and puppet shows.
• Health learning materials include posters, flip charts and leaflets, visual materials such as real objects, and audio-visual material such as TV, films and videos.
• Often more than one approach is more effective than a single type of activity. Using the right teaching methods and learning materials for the right target group in your health education programme helps you to convey effective messages to individuals and communities. This stands the best chance of bringing about health-related behavioural change.

Self-Assessment Questions (SAQs) for Study Session 10

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 10.1 (tests Learning Outcomes 10.1, 10.2, 10.3 and 10.4)

Explain the difference between teaching methods and health learning materials and give examples of each of them.

Teaching methods are ways through which health messages are conveyed. Learning materials are printed, visual or audio-visual aids that are used to help you and support the communication process, in order to bring about desired health changes in the audience. Examples of learning methods are: lecture, lecture with discussion, role play and drama. Examples of teaching materials are: posters, leaflets and flipcharts.

SAQ 10.2 (tests Learning Outcomes 10.2, 10.3 and 10.4)

Which of the following statements is false ? In each case explain why it is incorrect.

A  The health education method which is superior to any other method is drama.

B  The lecture method is good for helping an individual with their health problems.

C  Role play is a method which is spontaneous and often unscripted.

D  The teaching method that has the saying ‘Telling how is better than showing how?’ is the demonstration method.

E  A poster should contain more than one idea and its importance is to give information only.

A is false . In health education there is no method which is superior to any other method. Choice of methods depends on some important points that need to be taken into consideration. The method must suit the situation and the problem, so before choosing a method the person delivering health education must understand the problem at hand and the background of the audience.

B is false . A lecture is usually a spoken, factual way of presentation of the subject matter to many people. It is passive teaching because there is no opportunity for individual health problems to be discussed in lecture methods.

C is true . Role play is a spontaneous or unrehearsed acting out of real-life situations where others watch and learn by seeing and discussing how people behave in a certain situations. There is usually no script.

D is false . In a demonstration ‘showing how’, is better than ‘telling how’.

E is false . Each poster should contain one idea. Its importance is more than just giving information. A poster can reinforce or remind people about a message that has been received through other channels; give information and advice; or give directions and instructions for actions. It may also announce important events and programmes.

SAQ 10.3 (tests Learning Outcome 10.4)

A  Audio-visual materials and real objects are particularly useful in situations where the literacy rate of a group is very high.

B  Real objects are useful learning aids because people can actually see and touch them — and they are immediate.

C  Audio-visual materials and real objects are used only as a last resort when there are not enough posters to show.

D  Demonstrations are activities where the use of real objects enhances the learning that people achieve.

A is false . In fact just the opposite is true. It is generally thought that audio-visual materials and real objects work well with audiences where the level of literacy is low.

B is true . Real objects can help people literally have a ‘hands on’ learning experience which can be very powerful.

C is false . Real objects and audio-visual materials are suitable for some circumstances and posters for others. Sometimes you will want to use all of them. It is a matter of knowing what will be effective for your audience.

D is true . Demonstrations are the ideal place to use real objects. In fact if you do not use real objects (or models) in demonstrations then you will not be able to show how to do something in a convincing way.

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Chapter: 11th Nursing : Chapter 10 : Health Education and Audio visual Aids

Methods & approaches of health education.

Methods & Approaches of Health Education

Methods of health education

Health education is carried out at 3 main levels;

·            Individual Approach.

·            Group Approach.

·            General Approach/Mass.

Individual Health Education:

Doctors and nurses, who are in direct contact with patients and their relatives, have opportunities for much individual health education. The topic selected should be relevant to the situation. For instance, a mother who has come for delivery should be told about child birth-not about malaria eradication.

The biggest advantage of individual health teaching is that we can discuss, argue and persuade the individual to change his behaviour. The disadvantage is that the numbers we reach are small.

Group Health Education:

The groups are many – mothers, school children, patients, industrial workers – to whom we can direct health teaching. The choice of subject in group health teaching is very important; it must relate directly to the interest of the group. For instance, mothers may be taught about baby care; school children about oral hygiene; a group of TB patients about tuberculosis, and industrial workers about accidents.

Methods of Group Teaching

These have been classified as below:

One – way or didactic methods:

·            Lecture

·            Films

·            Charts

·            Flannel graph

·            Exhibits

·            Flashcards

1.         Lectures:

Lectures are the most popular method of health teaching. In this, communication is mostly one-way, i.e., the people are only passive listeners; there is no active participation on their part in learning. How impressive and effective the lecture is, depends upon the personality and reputation of the speaker. A lecture does provide basic information on the subject, but it may fail to change the health behaviour of the people. Nevertheless lectures have an important place in the health education of small groups.

2.         Films, charts & Puppets:

These are mass media of communica-tion. They can be of value in educat-ing small groups.

Suspense Charts:

Each section of the charts is covered and is exposed one by one to reveal the story or ideas without exposing the whole chart at a time.

Puppets are dolls made by hand and a story can be narrated using them it is a popular teaching aid to health teaching.

3.         Flannel graph:

A flannel graph consists of a wooden board over which is pasted or fixed a piece of rough flannel cloth or khadi. It provides an excellent background for displaying cut out pictures and other illustrations. These illustrations and cut out pictures are provided with a rough surface at the back by pasting pieces of sand-paper, felt or rough cloth, and they adhere at once, put on the flannel. Flannel graph is a very chief medium, easy to transport and promotes thought and criticism. The pictures must be arranged in proper sequence based on the talk to be given.

4.         Exhibits:

These consist of objects, models, specimens, etc. They convey a specific message to the observer. They are essentially mass media of communication .

5.         Flash Cards:

They consist of a series of cards, approximately 10 x 12 inches – each with an illustration pertaining to a story or talk to be given. Each card is “flashed” or displayed before a group as the talk is in progress. The message on the cards must be brief and to the point.

They are pictures arranged in sequence, which illustrate a story support the cards in front of the chest and practice in order to make the teaching effective. Use a Pointer so that the picture is not covered by your hand.

Two-way or Socratic Methods:

·            Group discussion

·            Panel Discussion

·            Symposium

·            Workshop

·            Role playing

·            Demonstration

1.         Group Discussion:

Group discussion is considered a very effective method of health teaching. It is a tow-way teaching method. People learn by exchanging their views and experiences.

·            To be effective, the group should comprise not less than 6, and not more than 12 people.

·            There should be a group leader who initiates the subject, helps the discussion in the proper manner, prevents side-conversations, encourages everyone to participate and sums up the discussion in the end.

·            The proceedings of the group discussion are recorded by a “recorder”, who prepares a report on the subject and agreements reached.

2.         Panel Discussion:

Panel discussion is a novel method of health education. The success of the panel depends upon the Chairman.

·            The Panel consists of a Chairman or Moderator, and 4 to 8 speakers.

·            The Panel sits and discusses a given problem in front of a group or audience.

·            The Chairman opens the meeting, welcomes the group and introduces the panel speakers who are experts on the subject.

·            He introduces the topic briefly and invites the panel speakers to present their points of view. There are no set speeches, but only informal discussion among the panel speakers.

·            It is said that the discussion should be spontaneous and natural.

·            After the subject has been discussed by the panel speakers, the audience is invited to take part. If properly planned and guided, panel discussion can be an effective method of health education.

3.         Symposium:

A Symposium is a series of speeches on the selected subject by experts. There is no discussion on the subject by the experts. In the end, the audience may raise questions and contribute to the Symposium.

4.         Workshop:

The Workshop consists of a series of meetings. The total workshop is divided into small groups, and each group will choose a Chairman and a recorder. Each group solves a part of the problem with the help of consultants and resource personnel. Learning takes place in a friendly, happy and democratic atmosphere under expert guidance.

5.         Role Play:

Role Play or socio-drama is a particularly useful device for putting up problems of human relationship. The group members enact the roles as they have observed or experienced them, e.g. the expectant mother in an antenatal clinic, the public health nurse on a home visit, etc. The size of the group should not be more than 25. Role play is followed by a discussion of the problem.

6.         Demonstrations:

Practicaldemonstrationisanimportant technique of the health education. We show people how a particular thing is done – using a tooth-brush, bathing a child, feeding an infant, etc. A demonstration leaves a visual impression in the minds of the people.

Education of the general public(Mass Approach) :

For the education of the general public, we employ “mass media of communication’ – Posters, health magazines, films, radio, television, health exhibitions and health museums. Mass media are generally less effective in changing human behaviour than individual or group methods. But however, they are very useful in reaching large numbers of people with whom otherwise there could be no contact. For effective health education mass media should be used in combination with other methods.

Individual Approach

Group Approach

Mass Approach

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‘We get to learn as we move’: effects and feasibility of lesson-integrated physical activity in a Swedish primary school

• Robert Larsson   ORCID: orcid.org/0000-0002-1965-7147 1 ,
• Eva Ljung 2 ,
• Sara Josefsson 2 &
• Thomas Ljung 1  

BMC Public Health volume  24 , Article number:  1087 ( 2024 ) Cite this article

Metrics details

Physical activity (PA) promotes health in adults as well as children. At the same time, a large proportion of children do not meet the recommendations for PA, and more school-based efforts to increase PA are needed. This study investigates the effectiveness and feasibility of lesson-integrated PA in a Swedish primary school.

We evaluate a new method called ‘Physical Activity and Lesson in Combination’ (abbreviated FALK in Swedish) using a mixed methods approach; a quasi-experimental study followed by qualitative interviews. Two schools participated in the study, one constituting the intervention group (I-school, n  = 83) and the other the control group (C-school, n  = 81). In addition to regular physical education, the I-school had three 30-minute FALK lessons each week. A total of 164 students aged 7–9 years wore pedometers for a whole week, four times over two semesters, and the number of steps per day (SPD) and the proportion of students with < 10,000 SPD were compared. Statistical differences between the schools were tested with ANOVA, Chi2, t-tests, and ANCOVA. Interviews with students ( n  = 17), parents ( n  = 9) and teachers ( n  = 9) were conducted and analysed using qualitative content analysis.

The results show that FALK led to the I-school getting more SPD and fewer students with < 10,000 SPD. Also, FALK was experienced as a positive, clear, and flexible method, simultaneously encouraging PA and learning. Challenges experienced concerned the teachers’ work situation, time, finding suitable learning activities, outdoor school environment changes, and extreme weather conditions.

Conclusions

This study indicates that FALK has the desired effects on PA and is a feasible method of integrating PA into theoretical teaching. We conclude that FALK is worth testing at more schools, given that implementation and sustainment of FALK considers both general enablers and barriers, as well as context-specific factors at the individual school.

Peer Review reports

In recent years, there has been a stream of reports and surveys showing that children and young people have limited physical activity (PA) [ 1 , 2 ]. For example, a Swedish study shows that only 43 per cent of adolescent boys and 23 per cent of girls of the same age meet the World Health Organisation (WHO) recommendations of engaging in at least 60 minutes of PA a day of moderate to vigorous intensity [ 3 ]. Physical inactivity is a well-known risk factor for ill health and disease; at the same time, there is strong scientific evidence for PA and its health-promoting and preventing effects among children and adolescents [ 4 , 5 ]. Additionally, previous research shows that PA can have positive effects on cognitive abilities and academic achievements [ 6 , 7 , 8 ].

As children spend a lot of time in school, it is an important health-promoting arena and a supportive environment for developing both positive health-related behaviours and learning [ 9 ]. The school is also important for health equity given that physical inactivity is more common among families and children where the parents have lower education and socioeconomic status [ 3 , 10 ].

Previous research shows that school-based health interventions focusing on PA can have beneficial effects on physical and mental health among children and adolescents [ 3 , 11 ]. Some research has focused on increasing PA during physical education lessons [ 12 ]. At the same time, it does not seem to be enough to increase PA during physical education lessons; school children also need to increase PA outside physical education lessons to increase their total level of PA.

Both internationally and in Sweden, various projects and studies have explored new ways to increase PA before , during and after school. A well-known Swedish example is the Bunkeflo project, which aimed to increase the daily PA among school children [ 13 ]. Other initiatives deal with lesson-integrated PA (also called movement integration), which incorporates PA, at any intensity level, within normal classroom education and in other school subjects than physical education [ 14 ]. Among these initiatives, there is a wide range of activities including active lessons and active breaks [ 14 , 15 ]. Research shows that active lessons can have positive effects on both PA and academic achievement [ 8 , 16 ]. However, there are also challenges with implementing active lessons and lesson-integrated PA in primary schools. One challenge is the limited time for physical education in the curriculum, and conducting PA within other lessons can create tensions as lesson-integrated PA can be perceived as stealing valuable time from teaching the subject. Previous research shows several enablers and barriers when lesson-integrated PA is implemented in primary schools. In a systematic review by Michael et al. [ 17 ], teachers’ motivation and self-confidence together with organisational support, time and resources are crucial factors. However, there is a need for further research about what effects can be expected under real-world circumstances (effectiveness) and how lesson-integrated PA works in practice. The latter involves the need for in-depth knowledge about the feasibility and implementation of lesson-integrated PA [ 18 ].

The present study investigates the effects and experiences of a new method integrating PA into theoretical teaching. The method is called ‘Physical Activity and Lesson in Combination’ (abbreviated FALK in Swedish; hereafter we use the Swedish abbreviation) [ 19 , 20 ]. FALK is intended to encourage students to be physically active, and to practice pulse-raising activities during theoretical teaching in all subjects. The overall goal of FALK is to develop a pragmatic method for increased total PA among students. Thereby, the FALK method follows calls for pragmatic approaches in public health research, meaning interventions focusing on issues and information relevant to decision-making and action-taking, and balancing results relevant to stakeholders without abandoning scientific rigour [ 21 ]. Consequently, the study aims to investigate the effectiveness and feasibility of lesson-integrated PA in a primary school. The following research questions are explored:

To what extent does lesson-integrated PA affect the students’ total PA?

How are enablers and barriers experienced by students, parents and teachers when conducting lesson-integrated PA?

What improvements regarding lesson-integrated PA do students, parents and teachers identify?

A mixed methods approach was used to investigate the effects of FALK and the experiences of lesson-integrated PA. More specifically, the study used an explanatory sequential mixed methods design [ 22 ] in which a quasi-experimental study of PA effects was followed by qualitative interviews, focusing on experiences of FALK under real-world conditions in a primary school setting.

Intervention characteristics and research setting

The goal of FALK was to develop a pragmatic method that increases student’s total level of PA by integrating PA in ordinary lessons, thereby achieving lesson-integrated PA (i.e. FALK lessons; see Additional file 1 ). The intervention used a quasi-experimental design with students in the intervention school completing three FALK lessons for 30 minutes a week, in addition to regular physical education lessons (two 40 minute lessons per week). Students from another primary school served as a control group and participated in regular physical education (two 40 minute lessons per week). PA was the primary outcome measure of the intervention and was objectively measured using pedometers.

In the present study, the FALK intervention was conducted with students in grades 1 to 3 (7–9 years old) at a municipal primary school located in a small community outside a medium-sized city in Sweden. The intervention took place during the academic year, in the autumn of 2020 and spring of 2021. Before the FALK intervention began the principal gave her approval and support. Two teachers (SJ and EL), who had participated in a pilot study, informed all teachers at both the intervention and control school (I-school and C-school) about FALK, and at the I-school, a total of twelve teachers conducted FALK lessons. Several FALK lessons, and related work materials, had already been prepared from the pilot study. Thereafter, more FALK lessons and work materials were developed, in preparation for the start of FALK at the intervention school. The FALK study was approved by the Swedish Ethical Review Authority in Stockholm (dnr 2020 − 00922).

Participants

In the quasi-experimental study, students from two primary schools were recruited (7–9 years old) and with one school’s students participating in the FALK intervention (i.e. intervention group, I-school) and the other school’s students acting as the control group (C-school). A total of 164 students participated (see Table  1 ).

The I-school and C-school are located a few kilometres apart in a rural community outside the city. The two schools showed no major differences in terms of lesson content, outdoor school environment or student living conditions. The same principal is responsible for both schools, the teachers at the two schools have common planning of the educational content and the students at both schools engage in the same kind of leisure activities both during warm and cold seasons. Therefore, we consider the risk of selection bias to be small. In more detail, the groups at the C-school and I-school participated in the FALK study as follows:

C-school (control group)

Regular physical education lessons twice a week for 40 minutes, plus the possibility of voluntary or organised recreational activities with physical movement.

I-school (intervention group)

In addition to regular physical education lessons, and the possibility of voluntary or organised recreational activities with physical movement, three FALK lessons of 30 minutes each were carried out continuously every week over two semesters (i.e. one academic year). Class teachers, leisure leaders and/or physical education teachers organised and carried out the FALK lessons based on the curriculum for each grade and the student’s knowledge levels and maturity.

The qualitative interview study involved three groups of participants: students, parents (guardians), and teachers. Purposeful sampling was used to select the participants based on their experience of FALK [ 23 ]. In practice, the sampling was made by selecting students who had participated in FALK lessons, parents of students participating in FALK lessons, and teachers responsible for conducting FALK lessons.

Data collection

The quantitative data collection was conducted using a pedometer (Yamax LS2000/SW200). Students and parents were instructed on how to use the pedometer. All readings and documentation of pedometer data were carried out by staff at the I-school and C-school. The pedometers were worn by students at both schools during all waking hours for seven consecutive days on four measurement occasions:

Sep-20 (week 37) immediately before the start of the intervention (baseline measurement).

Nov-20 (week 46) at the end of the autumn term.

Feb-21 (week 6) at the beginning of the spring term.

May-21 (week 18) at the end of the intervention.

Qualitative data were collected by semi-structured interviews [ 24 ], and in total, 17 students (nine girls and eight boys representing grades 1 to 3), nine parents (five women and four men), and nine teachers (eight women and one man) were interviewed. All interviews were individual, face-to-face, and conducted using an interview guide with open-ended questions. The interview questions were straightforward and focused on what had worked well, less well, and what could be improved in FALK. The interviews were conducted by two of the authors (EL and SJ) and were documented by taking notes. For interviews with students, written informed consent was obtained from parents (guardians) and verbal consent was obtained for interviews with parents and teachers. All interviews were conducted after the intervention (i.e. May-June 2021).

In the study design phase, sample size and power were calculated. Based on a previously conducted pilot study (2018, unpublished), the approximate mean number of steps per day (SPD) was expected to be 11,000 and the standard deviation 3,000. Clinically relevant differences/changes were estimated to be 1,500 SPD (equivalent to, approximately, a one-kilometre walk). Sample size calculations showed that with a statistical power of 80% and α = 0.05, 63 students per group were required.

The statistical analysis began with calculating an average value for the number of SPD for each student. Calculations were conducted for weekdays (Monday morning to Friday afternoon), weekend days (Friday afternoon to Monday morning) and all seven days of the week (total PA of the week). An analysis of variance, specifically a mixed between-within-subjects ANOVA, was conducted to examine differences in total PA (measured as the average number of SPD for the entire week) between schools over time. Independent t-tests were then carried out on each of the four measurement occasions to examine the difference in SPD average values between the I-school and C-school on weekdays, weekends, and for all seven days in the current measurement week. A one-way between-groups analysis of covariance (ANCOVA) was conducted to adjust for the (non-significant) baseline difference in SPD. Finally, we examined the percentage of students at each school who did not achieve 10,000 SPD per day on average for the entire week at each measurement time. These results are presented in cross tables, for all students and girls and boys separately. Differences in these proportions were analysed with the Chi2 test on each of the four measurement occasions. All statistical analyses were conducted using SPSS Statistics version 26.

The interview data were analysed using qualitative content analysis [ 25 ]. We started the analysis by reading the interview notes to familiarise ourselves with the data, and thereafter we started the open coding by searching for keywords, phrases, and meaningful sentences. In the open coding process, initial codes were identified and sorted into potential subcategories, which were later collapsed into broader generic categories. After this process, subcategories and categories were reviewed and further refined. The interview material was first analysed inductively and separately for the three interview groups (i.e. students, parents, and teachers) and then brought together to form a holistic picture. All authors were involved in the final stages of the analysis, and the results were discussed to ensure credibility.

First, the quantitative results are presented, followed by the qualitative results. All results are interpreted and discussed in the discussion section.

Quantitative results

Differences in PA between the I-school and the C-school are reported here first as SPD, then as the proportion of students with fewer than 10,000 SPD. The analysis of variance showed no significant interaction between measurement time and school, Wilk’s Lambda = 0.93, F(3.83) = 2.06, p  = 0.11, partial eta squared = 0.07. There was a significant main effect of measurement occasion, Wilk’s Lambda = 0.57, F(3.83) = 20.50, p  < 0.01, partial eta squared = 0.43. There was also a significant main effect of school, F(1.85) = 4.64, p  < 0.05, partial eta squared = 0.05. This indicates that FALK contributes to increased total PA. The students included in the analysis of variance and their SPD at each measurement point are presented in Table  2 .

On weekdays, there was no statistically significant difference in mean SPD at the baseline measurement (i.e. immediately before the intervention), but when the FALK lessons were ongoing (measurements 2 to 4), the I-school had more SPD than the C-school. On weekends, the I-school had more SPD than the C-school at all four measurements, a difference that was statistically significant at measurements 3 and 4. For total PA (‘whole week’), there was no statistically significant difference between the I-school and C-school students at the first measurement, but at the three subsequent measurement weeks, the I-school had more SPD than the C-school (see Table  3 ; Fig.  1 ).

Average number of SPD for students at I-school and C-school at each measurement occasion for weekdays, weekend days and the whole week (SD shown in Table  3 )

At the first measurement (M1 Whole week, before the start of the intervention), the I-school had an average of 886 more SPDs than the C-school. Although this difference was not statistically significant, one could argue for using statistical methods to adjust for differences between the groups in baseline values. A one-way between-groups analysis of covariance (ANCOVA) was conducted. After adjusting for the difference in pre-intervention SPDs between the groups at M1, there was no longer a statistically significant difference between the groups at M2 ( p  = 0.08) but the statistically significant differences remained at M3 and M4 ( p  < 0,01).

Moreover, girls had fewer SPD on average than boys (Table  4 ). There was also a higher proportion of girls, compared to boys, who did not reach 10,000 SPD (Table  5 ). A large proportion of students fell below 10,000 SPD. Before the intervention, the proportion was similar in both schools. During the weeks of measurement when FALK lessons were taking place, the I-school had significantly fewer students with less than 10,000 SPD (Table  5 ).

Qualitative results

In the analysis, three descriptive categories were created. The categories focus on the students’, parents’, and teachers’ experiences with FALK illustrated with quotes.

A new way of working meets students, parents, and teachers

Students, parents, and teachers express positivity about the new way of working that FALK entails. The students experience FALK as rewarding: “We get to learn a lot of things at the same time as we move” (student, grade 2). Also, students enjoy the fun aspects and appreciate participating in developing PA exercises. Like the students, parents support FALK for combining movement and learning, expressing a need for increased student movement during school days.

Teachers perceive FALK as clear, flexible, and enhancing the joy of movement and learning. Teachers emphasise that FALK does not need to be complicated, but instead FALK is seen as a flexible method that can be varied based on subject, class size, weather, and season. Also, teachers value that FALK lessons are explicitly integrated into schedules, emphasizing their compulsory nature akin to other subjects.

A positive effect of FALK emphasised by all involved is the calming influence on the classroom after the FALK lesson. Both students and parents say it is positive for students to reduce excess energy, and the teachers emphasise the students’ enhanced educational focus in subsequent lessons.

“I think they [the students] are calmer after an outdoor lesson. We have good lessons afterwards in the classroom.” Teacher.

The students talk about challenges in FALK with inattentive classmates creating anxiety when the teacher gives instructions and FALK lessons being less enjoyable when they perceive the learning activities as too difficult. A few teachers also find FALK too ‘controlled’ and struggle with the integration of pulse-raising activities with subject teaching, such as finding the right balance between PA and relevant learning activities.

“To combine this [traditional lesson] with the fact that it has to be physical activity with increased heart rate… This has become a bit too artificial for me to achieve.” Teacher.

Teachers can also face challenges in fostering motivation, commitment, and calm during FALK briefings. Despite these challenges, the teachers note that achieving student motivation and calmness during lessons are universal and not exclusive to FALK teaching.

Parents see improved information dissemination as desirable; they wish to know more about FALK and are curious about the results. Parents find FALK inspiring and advocate sharing information with other classes and schools in the municipality.

A new way of working meets the school and the teacher’s working day

The new way of working that FALK entails influences how the teachers work. Teachers express that FALK foster innovative thinking on combining PA and teaching. FALK encourages collaboration, allowing teachers to share work material, draw inspiration, and create new material together.

“We have taken turns to make different materials, and it has been rewarding to get new ideas from another colleague.” Teacher.

Collaboration is also encouraged by two teachers facilitating FALK lessons. For example, tasks can be divided between the teachers, simplifying student reporting of assignments, and making it easier to support students.

A challenge teachers describe is FALK lesson planning, requiring time to adopt the ‘FALK mindset’ and creating work materials for lessons. Also, it can be challenging to introduce substitutes in the FALK way of working if regular teaching staff is absent.

While FALK enhances collaboration, teachers working alone with FALK lessons ask for more cooperation and collegial support. Some teachers suggest better informing on FALK in the teaching team before implementation and call for improved structuring and organisation of work material by grade and subject.

The influence of the surrounding school environment

Changes in the surrounding school environment and weather conditions affects FALK implementation. According to students and teachers, a schoolyard rebuilding has occasionally made FALK lessons challenging, with the schoolyard temporarily reduced and having other students in the schoolyard. This posed difficulties for students to concentrate on the FALK lesson due to distractions in the schoolyard.

“It was tough in the fall when there were several students who couldn’t focus due to various reasons and it made it difficult to be out with many distractions. The rebuilding of the schoolyard has made the work somewhat difficult”. Teacher.

Concerning the external school environment, teachers suggest a dedicated pre-lesson gathering spot where students can meet before FALK lessons, like the football field or a nearby wooded area. Heavy rain and cold winter days sometimes pose challenges in carrying out FALK lessons as planned. Teachers have on occasions been forced to rethink, leading to indoor PA activities like active breaks as part of regular lessons. Students also express less enjoyment in FALK lessons during wet and cold conditions.

In this study, we investigate the effects of FALK and how students, parents and teachers have experienced its feasibility at a municipal primary school. As far as we know, our study is the first Swedish study exploring lesson-integrated PA in primary schools, and one of just a few European studies investigating movement integration (MI) interventions in a primary school setting using a researcher-teacher collaboration approach [ 15 ].

It is recommended that children and adolescents 6–17 years of age should be physically active for at least 60 minutes every day [ 4 ]. This equates to just over 10,000 SPD, slightly more for boys than girls [ 26 ]. To detect students who are most likely to fall short of the recommendations, this study used an average value of 10,000 SPD for both girls and boys as the upper limit for insufficient PA.

The reason for measuring the number of steps on seven consecutive days (i.e. also on weekends although the FALK lessons were conducted during school hours on weekdays) is that we wanted to measure children’s total PA during the whole week. This is in line with the ActivityStat Hypothesis [ 27 ], which states that if you increase your PA in one area (e.g., during school hours), you will compensatively decrease your PA in another area (e.g., during the weekend) to maintain a stable level of total PA (or energy consumption). Therefore, we wanted to know whether increasing PA at school would lead to less PA during the weekend (which would be undesirable).

One might think it is a given that the total PA level will increase if school-based interventions to increase PA are implemented. However, it must be remembered that a small ‘dose’ of increased PA during the school day is still a relatively limited fraction of the total time available to be physically active, or inactive, which again relates to the the ActivityStat Hypothesis [ 27 ]. Previous research shows that the majority of MI interventions have a PA dose of 10–20 minutes per day [ 15 ], and while interventions can have positive impacts on total PA, there is also variability and uncertainties in results [ 8 , 16 ]. With this said, the quantitative results show that FALK increased the proportion of students exceeding 10,000 SPD. We see this result as an indication that FALK has a positive and significant effect on PA among students who, for various reasons, are at risk of falling short of the recommended PA level [ 4 ]. The ambition of FALK is not for students to become athletes, but rather for the students ‘most in need’ to move enough to reach a minimum level of PA from a health perspective.

It has been shown that school children move less on weekends compared to school days [ 3 , 28 ], which is consistent with our results. This further underlines the importance of the school as a health-promoting setting enabling PA for all students, making the school setting especially important for those students most in need of increased PA.

Not surprisingly our results show that outdoor temperature appears to impact the SPD among the students. Compared to the first measurement (week 37), the average SPD at both schools decreased at the second and third measurements (week 46 and week 6 respectively) and then increased at the final measurement (week 18). However, there was a large difference between schools in terms of seasonal variation in the proportion of students with less than 10,000 SPD. At the C-school, this proportion increased sharply in late autumn (measurement 2) and winter (measurement 3), while the change in the I-school was comparatively small.

The quantitative results demonstrate significant differences in average SPD between the two schools at the measurements when FALK is ongoing at the I-school, which we believe helps to provide a clearer picture of the effects of FALK. The difference between our two schools in SPD for the ‘whole week’ increases with the duration of the FALK intervention, and we believe that comparison at measurement 4 is the most interesting, as students at the I-school had conducted FALK lessons for almost two full semesters. At the fourth measurement, the difference between the schools was 2,495 SPD and adjusted for baseline values (i.e. the difference of 886 SPD at measurement 1), the difference at measurement 4 is 1,609 SPD. One might think that a difference in total PA of just over 1,600 SPD on average is not very impressive, but the change contributed by FALK seems to have occurred mainly in students with less than 10,000 SPD, which means it can improve health among students most in need.

Several studies have shown that girls are less physically active than boys [ 2 , 3 , 10 ], and we found the same pattern in our study. The FALK intervention did not close the gender gap in total PA, but we did see a step in the closing direction as there was a significant reduction in the proportion of girls at the I-school who did not reach 10,000 SPD. The latter, to some extent, contradicts previous studies suggesting that school-based interventions increase PA and produce the desired results for boys, but not to the same extent for girls [ 29 , 30 ].

Moreover, the qualitative results are well in line with previous research on enablers and barriers in the implementation of lesson-integrated PA in primary schools [ 17 ]. FALK is perceived as a clear and flexible method by teachers, and positive perceptions and ease of implementation of the new method are among the enablers in previous studies [ 17 ]. The results that teachers consider FALK as a clear and flexible method is important as one goal of FALK is to provide a pragmatic method for the integration of PA and learning. Another important result is that FALK contributes to the students being calmer in the classroom after FALK lessons. This creates a learning environment that, most likely, is more beneficial for student learning. However, how FALK influences the learning environment and learning is a question for future research.

The qualitative results also reveal challenges (barriers) mostly linked to the teachers’ work situation, working time and practical challenges in combining PA and teaching. Time constraints and competing demands to meet the curriculum are highlighted in previous research [ 17 , 31 , 32 ]. In our study, competing demands are not so prominent, but a few teachers perceive FALK as ‘controlling’ because pulse-raising PA needs to be combined with theoretical teaching. This kind of challenge could possibly be solved with the help of other teachers finding suitable FALK lessons for the subject concerned. However, the teachers’ work situation needs to be considered when deciding to implement FALK in schools. As with any organisational change, it is important to have a dialogue and involve those affected by the change, which in the long run paves the way for successful implementation [ 33 ].

The qualitative results also point towards possible improvements in FALK, with the teachers emphasising the need for even more consensus on the method and better coordination of work materials. Improvements involve better communication in the teaching team and organising work materials more clearly by subject and grade. We believe these improvements are ‘low-hanging fruits’ and are relatively easy to improve. Furthermore, the need for improvements will most likely emerge when FALK is tested on a larger scale in more schools with varying preconditions.

Finally, we want to discuss FALK in relation to the school leader role and sustainability. Leadership, organisational support, and resources are factors commonly reported on in implementation research [ 34 ], as well as research on implementation of school-based health interventions [ 35 , 36 ] and successful implementation of lesson-integrated PA [ 17 ]. Even though the school leader’s role was not evident in our results, it was fundamental for setting up our researcher-teacher collaboration and for providing resources and thereby creating good conditions for staff to put FALK into practice. As indicated in previous research, attitudes among school leaders are crucial for implementing health-promoting initiatives in schools in general [ 37 ], as well as for providing resources and creating structures and processes for lesson-integrated PA to be sustainable over time [ 14 , 15 ]. Sustainability is an urgent research task in school-based health interventions, and this also applies to FALK to become part of organisational routines in schools and result in long-lasting effects on the children’s total PA levels [ 35 , 38 ].

Strengths and limitations

We consider the mixed methods approach a strength of the study as the explanatory sequential design contributes to a more in-depth understanding of the effectiveness and implementation of the FALK intervention. Below, we discuss the strengths and limitations of the included quantitative and qualitative approaches.

The study was conducted on a limited number of students and with only two primary schools involved. The relatively small size of the study and the fact that schools in Sweden have varying preconditions means that the generalisability of the study is somewhat limited. Another limitation of the study could be the quasi-experimental design, i.e. individual students were not randomised to the intervention group or the control group. For obvious reasons, it is difficult to randomise students when the groups are located in different schools. The fact that the intervention and control groups were in different schools can also be considered a strength of the study because the groups did not affect each other (i.e. there was no ‘spillover effect’).

Different methods can be used to objectively measure PA. Pedometers measure the number of steps while accelerometers measure changes in the speed of movement. The advantages of pedometers used in the present study are that participants can monitor their own activity progress, and pedometers are suitable for use in interventions. On the other hand, a disadvantage of the ‘number of steps’ measure is that it does not tell us anything about intensity, but pedometers can still be used to measure an individual’s total PA over time. An advantage of the accelerometer is that in addition to total PA, it also shows intensity, duration, and frequency. A disadvantage of the accelerometer is its price. Both pedometers and accelerometers are insensitive to activities such as swimming, cycling and arm movements. Nevertheless, both devices can provide a good picture of total PA [ 39 , 40 ].

It is common practice to report the results of intervention studies, such as the evaluation of a new drug or a manual-based programme, with a detailed description of the methods so that other researchers can repeat (replicate) the study. The FALK method has to be adapted to the different conditions in different schools and is therefore difficult to describe in detail, using a step-by-step approach. The core of FALK is to integrate PA into theoretical, compulsory lessons. In addition to the influence of the level of knowledge and maturity of the students, the implementation of FALK is also influenced by the individual school’s staffing resources, the availability of outdoor activities, the composition of the student group, the group dynamics, the preferences of students and teachers, and the current weather conditions.

The FALK lessons in the present study are designed for students in grades 1–3, i.e. children aged 7–9 years (see Additional file 1 ). For other age groups, the content of the lessons needs to be adapted. The proportion of students with insufficient PA increases in higher grades [ 3 ], which motivates the development of school-based methods that increase PA also in older students.

A strength of the interview study is that it explores enablers and barriers of lesson-integrated PA from three perspectives. The interviews with students, parents and teachers contribute to a more nuanced and credible picture of the implementation process [ 23 ], and it is a strength that the voices of students are heard because they are the ones participating in the FALK lessons.

A limitation is that the study only reflects experiences from one medium-sized municipal primary school in Sweden. At the same time, the study’s results can be transferable to similar methods (interventions) within primary schools given that contextual conditions are considered [ 18 , 23 ]. Finally, a limitation is the short and non-recorded interviews. A consequence of this approach is that it provides a more limited interview material compared to audio-recorded interviews, which can affect the depth of the qualitative analysis. Another risk is bias, with notetaking being influenced by the researcher’s preunderstanding and interpretations. We have handled this risk by having interviews and research questions covering both enablers and barriers with FALK, as well as being several authors involved in both taking notes and the analysis. However, the difficulty of capturing all the details when taking notes should be taken into account. Considering that the interview questions were straightforward (what was good, less good and suggestions for improvement) and did not touch on sensitive issues, we still deemed it sufficient and pragmatic to document the interviews through notes. A recent review shows that rapid (interview) methods, despite their limitations, can be an alternative to traditional qualitative methods [ 41 ].

Future research and practical implications

We have four suggestions for future research in addition to investigating the sustainability of FALK. First, we suggest investigating FALK effectiveness in older age groups and under varying circumstances, meaning schools located in both high and low socioeconomic areas. This is important as we know from previous research that a student’s PA follows a social gradient, with students from high-income areas having higher levels of PA [ 3 , 10 ]. Second, to explore the effectiveness of FALK for students with special needs, and to study the implementation of FALK in special needs education and what kind of adaptations are needed. Third, although FALK is not a manual-based method, the balance between fidelity and adaptation in varying school contexts needs further study [ 42 ]. Fourth, to explore how FALK influences the learning environment in the schools and how FALK influences the student’s learning.

Under the right circumstances, the practical implication of FALK is that it is a method worth trying. FALK does not require extensive financial investment, extra facilities, extra school staff or lessons outside the regular schedule. However, what is needed is the courage to think ‘outside the box’ in teaching– implying that teaching can take place in other ways than sitting indoors in a classroom. Also needed are acceptance among teaching staff, and support from the school leader.

We conclude that FALK is a useful and feasible method for integrating PA into theoretical teaching. FALK effectively increases the average number of SPD and reduces the number of students not reaching the recommended level of PA. Moreover, FALK is experienced as a positive, clear, and flexible method encouraging PA and concurrent learning. FALK also contributes to professional development, collegial learning, and collaboration among teachers. Challenges experienced concern the teachers’ work situation, time, finding suitable learning activities, outdoor school environment changes, and extreme weather conditions. Suggested improvements in FALK include consensus on the way of working among teachers, and better organisation of work materials. The results taken together, we conclude that FALK is worth testing at more schools, given that implementation and sustainment of FALK considers both general enablers and barriers, as well as context-specific factors at the individual school.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Swedish abbreviation for ‘Physical Activity and Lesson in Combination’

• Movement integration
• Physical activity

Steps per day

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Acknowledgements

The authors thank all students, parents and teachers participating in the study. Special thanks to Karin Wäckelgård Nordin, Principal at both the intervention and the control school, for making the study possible.

This research was funded by Folksam Research Foundation. The research funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Open access funding provided by Mälardalen University.

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Division of Public Health Sciences, School of Health, Care and Social Welfare, Mälardalen University, 721 23, Västerås, Box 883, Sweden

Robert Larsson & Thomas Ljung

Borlänge municipality, Borlänge, Sweden

Eva Ljung & Sara Josefsson

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Contributions

TL, EL, and SJ conceptualised, designed, and collected the data of the study. The formal analysis was performed by TL and RL, with EL and SJ providing reviewing comments on the quantitative and qualitative results. The first draft of the manuscript was written by RL and TL. All authors read, reviewed, and approved the final manuscript.

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Correspondence to Robert Larsson .

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The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Swedish Ethical Review Authority (dnr 2020 − 00922). Informed consent was obtained from all participants or their legal guardian(s).

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The first author (RL) is a senior lecturer in public health sciences with experience in health promotion, implementation, evaluation, and qualitative research. The second (EL) and third (SJ) authors are teachers working in a primary school in Borlänge municipality, Sweden. EL is a registered teacher with over 38 years of experience in teaching physical education and health. SJ is also a registered teacher with 16 years of teaching experience and with an interest in PA. The fourth author (TL) is a licensed physician by profession and an associate professor and senior lecturer in public health sciences with extensive experience in teaching and research on lifestyle factors, especially PA, and health.

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The authors declare no competing interests.

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Larsson, R., Ljung, E., Josefsson, S. et al. ‘We get to learn as we move’: effects and feasibility of lesson-integrated physical activity in a Swedish primary school. BMC Public Health 24 , 1087 (2024). https://doi.org/10.1186/s12889-024-18509-7

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Received : 04 April 2023

Accepted : 03 April 2024

Published : 19 April 2024

DOI : https://doi.org/10.1186/s12889-024-18509-7

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