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vl~ international journal Of e halth In this issue: Some Problems Faced in Educating for Health Teaching Health in Schools Health : A Concern of Social Welfare? What We Can Learn From the Behavioural Sciences Survey on Health Attitudes The Dangerous World of a Child IVth International Conference on Health Education ~ VOL. I No 4 OCTOBER 1958 1 t ~ . ~ 0_14S999

I " It is not sufficient that the national health services should be developed and re-organized. The population must accept the necessity for the measures taken. This implies that they must understand them, and under- standing could come only by education of the public. " This statement, made some 40 years ago by Dr. Rocco Santoloquido, representing Italy at the first session of the Office international d'hygiene publique in June 1919, shortly after World War I, still holds true today. Strengthening of national health services and development of health education activities - these appear to me to be the directing lines which should guide our work, the common goals towards which all our pro- grammes should converge. They have a common denominator-the availability of an adequate number of properly trained medical and auxiliary personnel ...prepared to face the new responsibilities which have to be taken by the medical and paramedical professions in the modern world. The base of our work is the individual, the family, the community. We must work for them and with them. If we want to promote better health, the understanding and the co-operation of the population is of primary importance. One of the happy provisions in the WHO charter expresses the need for co-operation with all the non-governmental orga- nizations working in the broad field of public health. The support that these voluntary agencies can give us in stimulating public interest in our programme, in promoting the co-operation and support of the communities, is of great value and the success of our efforts will benefit very much from this co-operation. Prof. Giovanni Canaperia Statement made by the Chief Delegate to WHO from Italy at the Commemorative Session of the WHO Tenth Anniversary, 27 May, Minneapolis. This international Journal is YOUR Journal and we need your help to make it a truly international forum for the exchange of experiences, ideas and professional materials. Send us short news and reports on health education activities in your country. Tell us also what you would like to read in this publication. VOL. I No Honorary P Prof. Jacqu, Chief Couns Prof. Clair E President Prol. Giova Secretary 0 Mr. Lucien Editorial Cc Dr. John IUHEP Prof. Pierr Regional H~ 1re, Lyons, Prof. Clair Advisor, IU Mr. Lucien General, IU Miss Anneti Chief of Pu Red Cross Natlonal Cc Australia, D Austria. Belgium, P. Burma, Dr. Canada, Dr Costa Rica, - Ecuador, P. - Fran borel - C public, Dr. Britain, Dr Greece, Prc - Hondura: ro - Iran, Prof. 0. C Dr. Tadao M Dr. Ben Hi lands, Mr. Philippines, serio - Po Fraire - SF Swilserland, Turkey, Dr. United pointed - Bogolepova Jose- Sarale Dr:'plga /` h °~.

r , international journal of health education VOL. I No 4 OCTOBER 1958 Some Problems Faced In Educating for Health Honorary President Mayhew Derryberry 178 oped Prof. Jacques Parisot (France) Teaching Health in Schools Annie Ray Moore 184 the ider- Chief Counselor Prof. Clair E. Turner (USA) Health : A Concern of Social Welfare I . Ludwig Preller 188 ido. President Prof. Giovanni L'Elfore (Italy) Asian Notebook Janus 192 ;ibne )day. Secretary General Mr. Lucien Viborel (France) What We Can Learn From the Behavioural Sciences Stanley King 194 ealth rhich Editorial Committee Dr. John Burton, Counsellor, Did You Know I... 201 pro- IUHEP Prof. Pierre Delore, Director, Exploring Health Education at Pan Chio 202 - the liary Regional Health Education Cen- tre, Lyons, France Prof. Clair E. Turner, Chief Health Broadcasting in Australia C. R. Bull 204 :) be Id. Advisor, IUHEP Mr. Lucien Viborel, Secretary General, IUHEP Survey on Health Attitudes Pierre Costalat 207 nity. atter Miss Annette Le Meitour, Editor, Chief of Publications, League of Red Cross Societies IVfh International Conference on Health Education Clair E. Turner 213 is of irter WHO Panorama 216 xga- that National Correspondants Australia, Dr. Fred W. Clements The Dangerous World of a Ch ild 218 our ities, "rom Austria, Dr. Wildner - Belgium, Prof. M. De Laef - Burma, Dr. Kyaw Myint - Canada, Dr. Gordon Bates - Costa Rica, Graciela Carrillo C. - Ecuador, Jorge Enrique Swett Travel Notes : Health Education in the US Lucien Viborel 221 USSR Holds Congress L. Bogolepova 223 P. - France, Mr. Lucien Vi- borel - German Federal Re- public, Dr. G. Adrian - Great i J h B it D B t At Istanbul : A Double Task Tevfik Isma71 Gokye 225 from -enth r. o n r a n, ur on Greece, Prof. George Pangalos - Honduras, Ernestina Caballe- Books 228 ro - Iran, Dr. Chadi - Italy, Prof. G. Canaperia - Japan, Dr. Tadao Miyasaka - Morocco, Films and Visual Aids 233 Dr. Ben Hima - The Nether- lands, Mr. Jean de Vreeze - Philippines, Carmen del Ro- 1958 Index 23S sario - Portugal, Dr. Francisco Freire - Spain, Dr. Bosch-Marin Switzerland, Dr. Hans Wespi - Quarterly Journal published In English and French. Official 0 Turkey, Dr. Tevfik Ismail Gok;e - United Slates to be ap- organ of the Inlernationat Union lor Health Educatlon h l f `-J , pointed - USSR, Prof. (Mrs.) Bogolepova - Uruguay, Dr. D. Jose- Saralegui - Yugoslavia, t e Pub ic. o General Secretariat, 92, rue SI. Denis, Paris, 1er. Publishers : Studer S. A., Geneva, Switzerland. Dr.' Olga Milosevic. Editorial Office : 3, rue Viollier, Geneva.

I f a Some ; problems in educating for health by Mayhew Derryberry Why are people so willing to take chances with their health ? Is it that health is not considered very important ? Or is it that our health education methods are not effective enough ? Safe vaccine is available against polio, yet 1/3 of the most-susceptible group under 40 years of age in the United States has not had any shots. The public has been warned against tranquillizing drugs, yet over $150 million are spent yearly on these drugs in the US. There is increasing evidence that cigarette smoking is one of the causative factors in lung cancer, yet the consumption of cigarettes continues to increase. Those of us engaged in the task of educating for health are becoming increas- ingly analytical and critical of our efforts. Although we are to see many changes in health behavior which result in improve- ment in the people's health, we cannot be satisfied because there are still a large number of individuals who neglect to put into practice those scientific findings which if properly used would enhance their health. Our dissatisfaction is a healthy attitude and can be turned to constructive action. But to do so, we must intensify out efforts in analyzing how we can be more effective. One approach to analyzing the problem is a review of what we know or don't Note - This article is based on an address given by the author at the 29th Annual Meeting of the American Academy of Physical Edu- cation, 29 March, 1958, in Kansas City, Missouri, USA. know about how people behave when faced with situations requiring health deci- sions. An increasing number of studies of the health behavior of people under a variety of circumstances are being under- taken. Such studies should be most help- ful to health educators in locating the places where improved educational expe- riences are indicated. He's so busy... they never ask questions... In a study (unpublished) of an explo- ratory nature, Dan Sullivan-working with the staff of the Wichita-Sedgwick, Kansas Health Department-uncovered a number of behaviors among the people that have meaning for health education. Their study was concerned with the educational problems that arise in the control of rheumatic fever. Interviews were made of doctors, parents, public health nurses, school principals, concerning the respective `~J N .C+ C C N cer as wee of abl we b Uer (M. and t tion 194 Ass Chi ben den. in I Sec Nai tnsJ ofc

i ? Is it :r health available rs of age warned on these ioking is igarettes , when ',th deci- studies a under ; under- ist help- ing the il expe- stions... i explo- ing with Kansas number iat have Their cational itrol of - made nurses, spectwe C~•~j .~ ~ 0 0 ~ understanding of the condition and needs of specific children who had had acute attacks of rheumatic fever. Some of the findings from the family interviews signify important health education problems. Some of the parents reported they were afraid to ask their doctors about matters that worried them because they felt the physicians were too busy to answer their questions. A similar finding (unpublish- ed) is reported by Elsa Nelson from her explorations in a medical ward of a hospital. She interviewed patients and the doctors who attended these patients. The patients stated that they would like to know about their disease and condition from the doctor. When questioned about whether they had asked the doctor anything about what they wanted to know, they said: " No, he is always so busy. I don't want to impose on his time. " When the doc- tors were asked whether they ever talked with the patients regarding their disease or prognosis, they replied :" No ! They don't seem to want to know. They never ask any questions. " These case reports certainly do not meet the requirement of a scientific sample, but since these reports were made I have encountered a number of my friends who have not felt comfort- able asking their doctor questions that were bothering them. Born on Christmas Day in Tennessee, Mayhew Derryberry came to New York as a student (M.A. Teachers College, Columbia University, and Ph. D. New York University). He has been the Chief ofPublic Health Educa- tion Services, US Public Health Service, since 1942, after a career in health which began as Associate Director of Research, American Child Health Association in 1926. Later he became Secretary to the Sanitary Superinten- dent, New York City Health Department, and in 1936, Chief of the Health Education Studies Section, Division of Public Health Methods, National Institute of Health. He was also Instructor in Health Education at the University of 4'alifornia during its 1940 Summer Session, I feel certain that most doctors would respond to the people's questions. In fact, it has been observed that one phy- sician has placed a sign on his desk encouraging people to ask him about any problem that was concerning them. Do not these findings suggest an edu- cational need to help people relate in a more positive way to the doctors? Do we include some help on such problems in our health education? Information 'over the back fence' In Wichita they also found, as one would expect, that the " teachable mo- ment " was immediately after the condition was diagnosed. Those who had never heard of rheumatic fever sought informa- tion at this time. They sought it from neighbors (the " over the back fence " phenomenon we all deplore), from others who had experienced rheumatic fever in the family and from publications. Some of the publications they mentioned were " Today's Health ", " McCalls ", encyclo- pedia, dictionary, nurses' magazines and doctor's medical books. Elsa Nelson found that patients with similar diagnoses exchanged information as well as misinformation they gleaned from the doctors' consultations near the bed-side. To be sure educators can't be at the side of every person when they or their close relatives or friends are sick, but are we doing any preparation of people to react intelligently and healthfully in such and Lecturer in Preventive Medicine and Public Health at the University of Minnesota during its 1942 Summer Session. Gardening is his,favourite hobby with another which he describes as " continually fussing around with electronic reproduction equipment without really enjoying the quality of music that might be produced with good equipment "- in other words he is a hi-fi fan. (For the uninitia- ted, this means that lre is a high-frdelity fan !) 179

T r , situations? How can we help people find the information they want from a reliable source? Polio vaccine remains unused Now, let us look at a gross analysis of the public's reactions to some recent research findings. Four years ago a paper presented to this Academy carried this statement from an outstanding epidemio- logist :" If the polio vaccine proves success- ful, then public health as I have known it, is a thing of the past. " In the interven- ing period the vaccine has proved its effectiveness in greatly reducing paralytic polio, if individuals are vaccinated as recommended. Yet over one-fourth of the population under 20 have not had a single injection, and less than one-half of this age group have had all three shots, It is estimated that about a third of the population over 20 have had shots. At the same time there are approximately 29 million ccs. of vaccine available.* The American Medical Association, the Natio- nal Foundation for Infantile Paralysis and the Public Health Service are engaged in the promotion of this very simple and safe preventive measure. Yet the public's res- ponse is certainly far from enthusiastic. Another similar situation needs consi- deration. Within the year scientists have developed the Asian influenza vaccine and the pharmaceutical companies have manu- factured it in tremendous quantities. Approximately 45 million ccs. of vaccine were used within a few weeks last fall in one cc. and 1/10 cc. injections. Although the threat of Asian influenza has subsided, the deaths from respiratory illness during the first two months of this year were * The data given reflect the situation as of October 1, 1957. AsofJuly 1, 1958 66,000,000 persons under the age of 40 had had one or more shots and 45,000,000 had had none. 180 approximately double the usual number occuring this time of year. But very few people were vaccinated during that time -even though vaccine was abundantly available. They refuse five more years of life Here is still anUther finding. A compre- hensive statistical study of cancer in Con- necticut for the 17-year period 1935-1951 showed that 66 % of the women with early diagnosis of breast cancer survived five years, whereas the percentage is only 33 for those where the diagnosis was made in a later stage of the disease'. To facilitate early detection the practice of monthly self-examination of the breast has been widely advocated. Visual aids have been made available and extensively used. No reliable data is available on the number of women who consistently make such exa- mination of their breasts. But some of our female health educators have inquired among their associates only to find that those women who began to examine their breasts followed the practice for a few months, and then discontinued it. Soon the cytological test for early dis- covery of cancer of the cervix uteri will become widely available. Here again the survival rate for early detected (localized) cancer far exceeds that of the more exten- sive cancer a. To what extent will women consistently submit to this test when it becomes available? Taking chances with tranquillizers There are two other recent findings of a somewhat different character. The first of these is the tranquillizing drugs. These first appeared on the commercial markets in 1954. Since that time they have been taken by at least 20 million Americans. Accurate estimates of their use are not available, but in 1956, $150,000,000 was spent on tranquillizers and 34,000,00@r^ ~.~ ~ prescriptions i! vember 1957, 4 been issued. include the am ing drugs whicl without being This extensi many of the p the informatioi In all the autl the point has effects of thesc that there may damage. Smoking label sales increas The problen another case ii smoking and h 1956 to review of tobacco sm at least 16 ind in five countri that show a st smoking and tl Following this issued a state which he sai( studies, it is c: ing and consi excessive cigar causative fact One might straightforwar by the findinf study group use of cigarett sumption cert reduction in : 1956, people States smoke, 'which they spe the number cc the amount Even though 1

1 J .isual number But very few ing that time s abundantly of life .. A compre- .incer in Con- od 1935-1951 ien with early survived five : is only 33 for as made in a To facilitate : of monthly ast has been ds have been ,ly used. No he number of .ke such exa- But some of have inquired to find that -xamine their :e for a few ed it. for early dis- vix uteri will ere again the -d (localized) ; more exten- t will women test when it illizers .t findings of ~r. The first rugs. These rcial markets ;y have been i Americans. use are not .000,000 was l 34,000,00C /-~ Cr 0 ~ i prescriptions issued. By the. end of No- vember 1957, 40,000,000 prescriptions had been issued. These estimates do not include the amount of pseudo-tranquilliz- ing drugs which are being widely consumed without being prescribed s. This extensive use of these drugs by many of the public is being made despite the informational advice that has gone out. In all the authentic information put out, the point has been stressed that the full effects of these drugs are not known and that there may be temporary or permanent damage. Smoking labelled dangerous: cigarette sales increase The problem of smoking and cancer is another case in point. A study group on smoking and health was organized in June, 1956 to review the problem of the effects of tobacco smoking on health. It found at least 16 independent studies carried on in five countries during the past 18 years that show a statistical association between smoking and the occurrence of lung cancer. Following this report the Surgeon General issued a statement on July 12, 1957 in which he said :" In the light of these studies, it is clear that there is an increas- ing and consistent body of evidence that excessive cigarette smoking is one of the causative factors in lung cancer. "•4 5° One might have expected that such a straightforward presentation of fact backed by the findings of the highly competent study group would have influenced the use of cigarettes. However, data on con- sumption certainly do not indicate any reduction in smoking. In calendar year 1956, people of the Continental United States smoked 393 billion cigarettes for which they spent $ 4,840,000,000. In 1957, the number consumed was 409 billions and the amount spent was $5,115,000,000'. Even though the Surgeon General's state- 4 ment was not released until July of '57, if it had had real impact, the number of cigarettes consumed last year should have been less. Is health unimportant 1 The reactions of the people to these research findings raise serious questions for us as educators. Why are people so apathetic towards actions which have proven health value? Certainly it could scacely be said that the information about their value has not been disseminated. On the other hand, why are such high amounts spent for tobacco? Why are people so willing to take chances with the tranquillizing drugs before all the evidence is in? Can it be that health is not very impor- tant in the value systems of our people? If so, what is our responsibility in trying to change value systems? What are the determinants of various kinds of health behavior ? So far as smoking is concern- ed, should we focus on helping youngsters not to start the habit? Or do we need much more definitive data on smoking and the need it serves? In connection with these last two questions consider the comments of Raymond Firth, Head of the Department of Anthropology, London School of Economics 8. " The first attempts of any person to smoke are usually unpleasing, the practice is an economic drain, the provision of smoking materials may need a lot of time and energy, the residues of smoking are dirty and may be dangerous because of fire. Apart from any medical implica- tions, these might be good reasons for not smoking. " What are the positive satisfactions? They vary, according to temperament and personality, but may include labial and oral stimulation, occupational activity of the fingers, and other physiological reac-

T tions. There may also be socio-a;sthetic satisfaction in the stylized behaviour in- volved. There is an idea current that smoking is above all a habit of civilization, in large measure a soothing response to the unsettled nerves of Western urbanized, industrialized man. Smoking may on the whole help to settle the nerves-but they are almost universal nerves. We remem- ber that tobacco was brought over to the West from the aboriginal peoples of Ame- rica. Moreover, there is hardly a primi- tive community in the world today which has not taken keenly to the smoking habit : with some, it is almost a ferocious pursuit. In such a primitive community one may see at work the processes of habit for- mation in regard to smoking. Among the elements are : the curiosity of young people to experiment in a novel procedure; the imitation of their elders as part of the social maturation process; imitation of others in their own peer group in order to have social status by demonstrating possession of equal skill. " But apart from this, smoking is a social habit; it is part of a recognized social institution. Hospitality at any social gathering includes the provision of tobacco, and a gift of tobacco is one way in which services are requited and social status is recognized. Smoking toge- ther is treated as a social emollient, almost as a social sedative. It occurs especially after a meal. It is regarded as a pleasur- able pastime, to be exercised in common. There is no id6a that the formation of the habit is in any way morally or medically to be stigmatized-although local practice may be to pass pipes from mouth to mouth regardless of any infections that may be current in the community at the time. " To change the smoking habits of such a community would be very difficult indeed. It would need more than the statistical demonstration of a relation between smok- ing and chronic disease to make these people abandon the practice. It must be remembered, too, that any such statistical demonstration poses for an individual the problem of chance. In the case of any habit which yields valued satisfactions, the individual is drawn to argue that in the operation of chance others, not himself, will probably be sufferers. This is simply another way of stating how strongly the emotional, irrational elements may weigh against the intellectual, rational arguments. I. " Cancer in Connecticut 1935-1951. " Connecticut State Department of Health, 1955. 2. " Population Screening for Uterine Cancer by Vaginal Cytology. " Journal of American Medical Association, 15 September, 1956. 3. " The Tranquillizing Drugs "Progress Report, National Institute of Health, No. 65, Decem- ber 1956. 4. Statement by Surgeon General Leroy E. Burney of the Public Health Service, Department of Health, Education and Welfare, on Excessive Cigarette Smoking and Health, 12 July 1957. 5. " Effect of Cigarette Smoking on Gastric Secretions of Patients with Duodenal Ulcers " Cooper and Knight, New England Journal of Medicine, Vol. 255, No. 1, 5 July 1956. 6. " Report of Study Group on Smoking and Health," American Cancer Society-American Heart Association, 6 March 1957. 7. " Annual Report on Tobacco Statistics," US Department of Agriculture, Agricultural Marketing Service, September 1957. 8. " Habits and Ways of Life in Relation to the Development of Chronic Diseases " Raymond Firth. Working Paper for Symposium on the Public Health Aspects of Chronic Disease, ^ Amsterdam, September/October 1957. ~A 182 " The trut know, in i enough abc people to sm after they ha effects." Is this nc analyses anc engage befoi the effective education? Arab r du evc Ra Sei Th thr of for mi edi de, fln: prt gui Co Ar trit he: of to Ar cia as

bacco is one •equited and noking toge- Ilient, almost irs especially as a pleasur- in common. lation of the or medically ocal practice -ith to mouth that may be the time. zbits of such ficult indeed. ie statistical tween smok- make these It must be ch statistical idiVidual the case of any factions, the that in the not himself, his is simply strongly the : may weigh I arguments. lealth, 1955. oJ' American ). 65, Decem- , Department 12 July 1957. -nal Ulcers " 1956. : ty-American Agricultural : " The truth is, surely, that we do not know, in any systematic way, nearly enough about the factors which lead people to smoke and to persist in smoking after they have been warned of the possible effects." . : : Is this not suggestive of the type of analyses and research in which we must engage before we can expect to improve the effectiveness of our efforts in health education? Or is health education at fault? There is a real need to diagnose the problem of health education in order to determine the content that will have mean- ing to a particular audience and to select those methods which will provide the most appropriate learning experiences if we are to become increasingly effective. There is urgent need for more definitive research on which to plan competently and carry out effectively programs of health education. Arab medical congress adopts "Ettathqif Essahhi " Health education was highlighted in the Arab medical world during the recent Arab Medical Congress held in Tunis, 26-30 June. The importance of health education in countries of rapid evolution and its influence on such evolution was stressed by the Rapporteur to the Congress, Dr. Mahmoud Slim, Head of Technical Services at the Public Health and Social Affairs Ministry of Tunisia. The speaker also drew attention to the value of close cooperation through regional meetings, the exchange of health workers and of materials. Other points considered by participants concerned the need for increasing the number of national and inter-regional com- mittees for health education, for long-term planning of health education as part of public health, social welfare and community development programmes, for frequent evaluation of projects and, finally, for closer contacts with international health education organizations in order to share experiences with them and to receive guidance from their experts. As a result of these discussions the Congress unanimously : (1) recommended the use of the term Ettathqif Essahhi in all Arab countries, as meaning " health education "; (2) stressed the lack of qualified health educators in Arab coun- tries and asked, in view of the need to build all health action on health education, that every effort be made to increase the number of health education specialists and improve their training in order to be able to carry out public health programmes more effectively; (3) recommended the creation of an organization grouping all Arab countries to facilitate the exchange of health education spe- cialists and of documents, and to promote mutual technical assistance as well as unified efforts in health education. 183

Health education in action Educators around the world carry a great responsibility in helping each child to reach the highest possible level of physical, mental, social and emotional well-being. Here a health ed8cator discusses how to relate health instruction to the natural interests of children and its integration in the curriculum. When and how health teaching is to be done will, of course, vary in each area and even in each school. Teaching health in schools How will we make health instruction interesting and find suitable places for it in the school curriculum ? This is a very vital question and one to which there are many answers. It seems to me that " interesting " is the key word in our question. The teacher who knows the major interests and con- cerns of boys and girls at the different age levels, such as their strong desire to grow, and builds health teaching around these interests will have stimulating lessons. On my visits to classrooms, I ask children to give me evidences that they are growing. They usually begin by telling me that they Annie Ray Moore taught high school for four years and served as elementary school principal for seven years in North Carolina, where she was born, before she decided to take her Master's Degree of Public Health at the University of North Carolina. Since 1947 she has worked as health educator with the State Department of Public Instruction, Raleigh, N. C. For many summers during these ten years she has assisted with health workshops for teachers, serving on the staff of the University of North Carolina, while two mid-year vacations were taken up with service on the staff of Yale University Summer School on Alcohol Studies. 184 by Annie Ray Moore have been measured and are inches taller than last year. They weigh more. Many have outgrown their clothes. Others talk about things they can do this year which they were unable to do before. When a six-year-old mentions his new tooth, all the mouths come open to show the new teeth. Teachers can easily make use of the children's interest and pride in the " new tooth " to tell them what they should do to keep the " new tooth " strong and pretty : what are some good foods to eat, how to brush the teeth, the need to visit the dentist regularly to see that the teeth stay healthy. More recently, from August 1955 to July 1956, she has served with WHO in Burma and by the time this issue comes off the press, she will have reached New Delhi where she has accepted a WHO assignment as Health Education Consultant to advise the State Ministry of Education in cooperation with the Ministry of Health in developing health educa- tion in the training of teachers. ~.~ w1 CD 0 ao Children the change ing up, spe stand thes are develoi growing th ing slowest the childre up with i tremendou those who readily abc is needed t, adulthood. Cleanliness Another lescent anc to be in a and loved and girls w they do be kinds of c' in our sch( things. Tt cation mo approval i; liness and taught mu pupils are help them group. I ; social out because of In the s( teaching is interest of ' health hab and courte, with this in ' Doing thi Another quickly is well as lec e,xample :