Soc. Sci. Med. Vol. 16. pp. 609 to 617. 1982 Pergamon Press Ltd. Printed in Great Britain

BOOK REVIEWS

Health Education Planning: A Diagnostic Approach, by LAWRENCE W. GREEN, MARSHALL W. KREUTER, SIGRID G. DEEDS and KAY B. PARTRIDGE. Mayfield, Pale Alto, CA, 1980. 306 pp. No price given.

In 1976 when the U.S. Congress passed Public Law 94-317, the National Health Promotion Act, it signified the first federal commitment to recognize health education as a national priority. Since then, succeeding administrative and legislative actions have continued to provide a clear man- date, accompanied by federal funding, to develop public and private sector initiatives in health education.

How is this money being spent and what will the long term effects of these expenditures be on the nation's health?

The authors of Health Education Planning: A Diagnostic Approach, collaborated at Johns Hopkins University and address these questions. Dr Green, in his current capacity as Director of the Office of Health Information and Health Promotion in the Office of the Assistant Secretary for Health, has responsibility for national policy development in this area. He is actively involved with the funding and evaluation of more than 200 state and local Health Edu- cation Risk Reduction Programs, including several million dollars in contracts for development, and grants for research in health education.

The goals of the recently funded Risk Reduction pro- grams parallel the practice goals of health education, defined here as organized intervention in the process of voluntary health behavior to reduce r isks 'and promote health. The research grants in disease prevention and health promotion are designed to stimulate the use of exist- ing data and record systems to evaluate existing programs in health education and to analyze social and economic determinants of health behavior.

How does an educational planner, an administrator, a social scientist or a clinician determine the objectives and evaluate criteria for a program designed to promote a change in health behavior?

The importance of Health Education Planning: A Diag- nostic Approach is that it recognizes the fallacy of equating education with providing information, and introduces a systematic framework with which to analyze and predict the relationships between health education and behavior change, and between behavior and health outcomes. Cur- rent behavioral science theory as expressed in the Health Belief Model asserts that an individual's decision to make a change in health behavior is influenced by a combination of factors, including perceived personal risk and the per- ceived costs and benefits of making the behavioral change.

In Health Education Planning: A Diagnostic Approach, the authors extend and apply behavioral science to the process of planned health change with the introduction of the PRECEDE Framework. In this model, "inputs" are interventions related to the determinants of behavior con- ducive to health, and "outcomes" are the intended results of the interventions leading to reduced health risks and improved health and quality of life.

To begin the seven-step PRECEDE process, the prob- lems or aspirations of the community or target population are stated in social or quality-of-life terms. These are related to health through an epidemiologieal diagnosis, and the health problems in turn are related to behavioral objectives. A combination of social and epidemiologieal diagnoses analyzes the relationship of the health problem to factors beyond the individual's direct control. The lines

blurring individual responsibility and "blaming the victim" are delineated. Where appropriate, health education goals include collective behavior directed at modifying social, economic and environmental factors which affect the indi- vidual's health.

In the behavioral diagnosis, the behavioral and non- behavioral factors that contribute to the health problem are isolated. A behavioral matrix determines the relative importance and susceptibility to change of behaviors which put the individual at risk.

To target the educational intervention, three factors which have a direct impact on behavior change are addressed in the educational diagnosis. Predisposing factors, which are deeply held values and beliefs, can hinder or facilitate change. Enabling factors which include an individual's skills, knowledge, and resources will allow the motivated behavior to occur. Reinforcing factors are the tangible rewards and social supports from people im- portant in the individual's life, which will maintain, or con- versely, sabotage the new behavior change. Based on care- ful analysis of these factors, resources to promote health behavior change can be directed effectively. The remaining steps include an administrative diagnosis and assessment of methods appropriate to the target behaviors, objectives and resources identified in previous steps.

Educational strategies for the implementation stage of the program are critiqued later in the book, with the caveat that a caring teacher can be as influential as a specific method. Briefly summarized, mass media are noted to be effective where the purpose is to increase awareness or re- inforce previously-held attitudes. In individuals who have a psychological predisposition to change, mass media can sometimes lead to behavior change. Audio-visual methods have proven most effective in changing behavior when fol- lowed by face-to-face interpersonal communication. Small group discussion can be very effective in the context of strong peer support. Behavior modification is regarded as a last resort for behaviors that cannot be altered through cognitive control and require a trained therapist. In this chapter, an extensive flow chart categorizes the effective- ness of educational strategies based on the characteristics of the health problem.

In the context of the PRECEDE framework, program evaluation takes place in three stages. Process evaluation requires monitoring program quality on the basis of administrative or peer review criteria. Impact evaluation asks, has the program met its immediate goals and is it cost effective? Finally, in outcome evaluation, changes in the incidence and prevalence of the condition in the population are assessed.

At the conclusion of this book, the PRECEDE frame- work is applied to specific health care settings. A chapter of Patient Education stresses the clinical application of the PRECEDE framework to the problem-oriented medical record.

For the frustrated health provider who complains "I give all my patients my rap on smoking, a few quit, most don't", this book can perhaps begin to answer what the difference is between the two groups. With this analysis available, clinicians can learn to make an educational diagnosis which will link the health message to the patient's own life goals, and greatly increase the probability of successful patient education and behavior change.

As a supplement to Health Education Planning: A Diag- nostic Approach, the "Physicians Patient Education News-

6O9

610 Book Reviews

letter" is suggested. Published by the University of Ala- bama it offers an update of clinical and community health education programs nationally, and reviews new research and national legislation on the expanding practice of health education.

In the physician's office, or in public debate over national health care priorities, health education is demon- strating itself to he more than a popular ideology. As cost effective preventive mecl~cine, health education is succeed- ing at improving compliance with medical regimens, reduc- ing hospital days, and promoting preventive behavior to reduce health risks. In the legal sphere, educating individ- uals to make responsible decisions based on an informed partnership with their health care provider, has been linked to a reduction in the costs of malpractice litigation. For administrators, educators, social scientists and clinicians Health Education Planning: A Diagnostic Approach offers a blueprint for the application of behavioral science theory to the political problems of planned change in public health and preventive medicine.

Tufts Unirersit)" School of Medicine Department of Community Medicine Boston. MA. U.S.A.

STEPHANIE EVANS

Patteras of Time in Hospital Life: A Sociological Perspec- five, by EVIATAR ZERUBAVEL. University of Chicago Press, IL, 1979. 157 pp. $13.50

Patterns of Time in Hospital Life describes the multitude of overlapping and interacting schedules within a university hospital in order to portray the "sociotemporal" order of the organization. The task is well done and the observa- tions made are incisive.

The book is based on a detailed observation and inter- view study of the medical ward and emergency room of an American teaching hospital. The first chapter presents the various work schedules and describes the "rigid rhythmi- ctty Of the hospital life: the daily, weekly, monthly, and year long schedules which predict an individual's life in great detail at the start of each year. The second chapter outlines the many interactions of physician and nursing schedules. In particular, the author explains the pattern of abutting work loads that allows the institution to provide for the continuous "coverage" of patients and the smooth transition between providers. Chapter 3 carries the theme of work load distribution to the levd of individual groups; the hospital teams. In Chapter 4, the author discusses how hospital life has engendered its own set of time descriptors based on different aspects of institutional life, such as resi- dent schedules ('the rotation'), nights on call. and even patients (the "quick' admission).

The final chapter focuses on the dynamic aspects of hos- pital's 'sociot.emporai" order. Sp~fically. the impersonality of the system that allows doctors and nurses to shift from one job to the next. Since the institution requires only that some intern, any intern, does a given job, the unique attri- butes of a given worker become unimportant. Though this would appear to sterilize the hospital environment even further, without these enormously complex, interacting and overlapping schedules, hospital routine as it is known today would be impossible. From these observations, the author argues that the sociotemporal order of hospital schedules, forms the foundation for the equitable distribu- tion and the 'temporal anchoring" of the work within the institution. In other words, it underlies the 'moral' and "cognitive" order of the organization.

This simple Observation slices to the center of hospital life. By laying out and rationalizing the scheduling morass, the author has demystified it. The process opens opportu- nities to challenge th~ current organizational structure with

the hope of redesigning modern hospital routine to better serve the needs of patients and staff.

Patterns is a slender, quickly-read volume but its simple message offers insight into some of the more sacred aspects of hospital life. It is recommended to hospital planners and academics and especially to those who, like the reviewer, make up the schedules.

Primary Care Program Massachusetts General Hospital Harrard Medical School Boston, MA. U.S.A.

JOHN D. GOODSON

Birth Control An International Assessment, edited by M. POTTS and P. BHIWANDIWALA, MTP Press, Lancaster, England, 1979. 305 pp. £12.95

This collection of 17 essays, many by prominent figures in the international family planning movement, treats two main topics: family planning programmes in six Asian countries, and the status of birth control technology. There are also chapters on the family planning aspects of mater- nal and child health, law, research, and programme fund- ing. The country accounts are the core of the book: their purpose is to show that, despite extensive evidence of fail- ure, family planning programmes can succeed. Readers should be alert to the social costs of such success, which are either minimized or dismissed by the authors.

There are two main interpretations of the phenbmenon of rapid population growth. The international family plan- ning movement, as represented by the agencies contribut- ing to this book (Population Crisis Committee, Inter- national Fertility Research Program, Population Services International, International Planned Parenthood Federa- tion. and the United Nations Fund for Population Activi- ties), believes that population growth causes underdevelop- ment. As expressed by Datta Pal in his report on the Indian sterilization programme, "large scale unemploy- ment and destitution in the country [are] due to tremen- dous increase in population growth". (p. 116).

A second view sees population growth as a symptom of underdevelopment. If many underdeveloped countries are experiencing more poverty and joblessness, it is because economic growth, in the context of existing national and international structures, is accompanied by increasing ine- quality, as many ILO World Employment Programme studies have shown [1]. To attribute all third world prob- lems to overpopulation is reductionist; to imply that struc- tural problems can be solved by birth control is tanta- mount to proposing a "technological fix'. According to the symptomatic view. people have large families because they are poor [2]; even young children contribute their labour and may mean the difference between survival and econ- omic disaster. In the absence of genuine, redistributive economic development, programmes to limit family size will make these people poorer.

Belief in the causal role of population growth in under- development is so strong in family planning circles that the movement is closed to economic, social and political view- points that conflict with or challenge its objectives. The consequent isolation is manifest in each of the chapters of this book, as the examples given below will show. The movement is deaf to even the most vociferous of popular protests. In the past decade, opposition to birth control as a new form of domination increased in both the first and third worlds. At the 1974 World Population Conference in Bucharest, a number of underdeveloped countries pro- tested against the imposition of population control pro- grammes by industrialized market economies as solutions to third world problems. This repudiation impressed UNFPA Director Rafael Salas as merely "a series of acri-