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Importance of Health Education Research to Health Education
Objective: To focus on the benefits and importance of research to the practice of health education. Methods: The paper discussed the potential of quality research as well as the barriers that keep health educators from using, applying, and sharing their work. Results: The basic challenges health educators face in translating their research into practice relate to: becoming well-versed in the science base and previous lessons learned; collaborating effectively; and passing on knowledge by mentoring. Conclusions: To move forward, health educators need to organize their knowledge and make it accessible. This includes explicit and tacit knowledge, work in progress, and a coordinated research agenda. Finally, health educators need to be flexible so they can enable future research needs. In presenting this closing keynote address, I'm following in the footsteps of some true giants in health education research and practice. You'll remember that Larry Green opened this inaugural conference as its first award winner. He talked about this "relaxed venue" and then proceeded to raise the stakes for all other speakers by taking on the challenges posited by the Ottawa Charter and illustrating the landmark applications of best practices in health promotion and public health while explaining both the virtues and the problems of generating best practices1 but that was just the beginning. Glover, Leischow, Sussman, Elder, Werch, DiClemente, Hansen, Holder, Rainey, Jeffery, Black, Peng, Hobbs, and Torabi all showed why there was a need for, and a benefit to the creation of the American Academy of Health Behavior (AAHB). Glover's vision, and the hard work of the people attending and wishing to attend this inaugural meeting of AAHB, have made this a wonderful experience. We would like to express our appreciation for the opportunity to participate in both The Academy and this first of many very successful meetings. The Hedgehog and the Fox Sometimes there are models that are worth following. Today, ours is a series of speeches delivered in 1998 by Donna Shalala. On October 15 of that year, she delivered the Millenium Address at Hunter College, New York. Her address was titled "The Hedgehog and the Fox."2 We thought of that address for 2 reasons: a) because addressing the topic for today requires some stretching of the imagination and b) because she borrowed from a great philosopher to make her points at the leading edge of the new millennium. Shalala related the story of Isaiah Berlin, the brilliant social and political theorist who tried to address some questions in his famous essay on Tolstoy's view of history: "The Hedgehog and the Fox." The title comes from a line in an ancient Greek poem: "The Fox knows many things, but the Hedgehog knows one big thing." According to Berlin, Tolstoy desperately wanted to be a hedgehog. He wanted to see and understand the world according to a central vision, one universal organizing principle that would explain the direction of history. As luck would have it, he had the soul of a fox, divining from his deep understanding of human relationships a mosaic world of unrelated experiences and beliefs that did not fit into any single precept. This led Tolstoy to draw 2 important conclusions. First, no individual — even a Napoleon — can control the course of human events. Second, to paraphrase Berlin's critique of Tolstoy, "the higher we are in the pyramid of authority, the farther we must be from its base — the ordinary men and women whose lives are the actual stuff of history." In other words, it is the will of nations — as expressed in the countless actions, thoughts, loves, dreams and beliefs of people — not the will of kings or presidents or CEOs that ultimately forces change and moves history. Such is the story with research in health education. Its potential will never be realized unless we link researchers with populations and practitioners. As a New Yorker, I believe that most people in this country recognize Yogi Berra for his unintentionally witty philosophy — sayings like "90% of the game is half mental," "It's déjà vu all over again," and "It ain't over `til the fat lady sings." If you think about it, some of his best lines offer important lessons when it comes to explaining the importance of research to health education. So as we move on, let me offer "Five Lessons from Yogi Berra." Potential of Research "It gets late early out there." Yogi once described how left field in Yankee Stadium is tough to play during the World Series because the late autumn sun casts deep shadows across the field. As Yogi explained, "It gets late early out there." That's Yogi Lesson Number 1: My father used to say, "The days are long, but the years are short." Notwithstanding the long days, research projects pass more quickly than we expect. Before you know it, we are trying to get continuation grants to finish the original work we proposed. It would be nice if we could begin with a crystal ball that allows us to ask the important questions — and to figure out ways to answer them. Why do research? When it works well, we engage in research to answer questions of importance. Most important, well-crafted research in health education puts us in a position to act prospectively rather than reactively to health needs. It also allows us to act in an informed manner.
Ordinarily, the major objective of research is to describe or explain phenomena for prediction, control, or understanding of causal mechanisms. We attempt to predict the circumstances under which health consequences will occur or the likely health outcomes of choices or prevention programs, to control causal chains of events to reduce the potential for health risks, or to gain a better understanding of how these causes operate. Our attempts to study relationships between presumed risks and their subsequent effects on health, factors that influence individual decision making, or potential success of interventions designed to enhance the health of individuals are all related to these 3 activities. Usually, the research process in health education will attempt only one of these 3 key objectives because to do more in one study would be difficult, unmanageable, or unnecessary. Finally, to do more than one of these may come from failing to recognize that they build upon one another.
Research as a way of knowing. In order to deliver on this promise, we need some attention to detail. An American philosopher, Charles Pierce, suggested that there are 4 ways of "knowing," or "fixing belief."3 A way of knowing is sometimes called a metaphor, and metaphors themselves are not necessarily clearly understood. This does not prevent our use of them to establish meaning, and metaphors are widely used despite our lack of understanding of them.4 The principal metaphors mentioned by Pierce3 include the method of tenacity, the method of authority, the a priori method, and the method of science. It is worth reviewing these methods of knowing as a backdrop to our intent and purpose here.
Research as a scientific process provides certain advantages over other means of "knowing," or of answering pertinent questions. The scientific process is a logical process with procedural specifications that provide a framework for gathering information in many forms. It is reductive, in that it allows us to amass large amounts of information and extract meaningful generalizations. The scientific process is also objective. Objectivity means that the process and outcomes should be independent of the individuals conducting that process. The scientific process is empirical, in that conclusions are based on relevant data collected for specific purposes. Note carefully that the definition of empirical does not describe the nature of the data itself. Both quantitative and qualitative strategies can be used to provide empirical evidence. The scientific process is benefited by replication. Replication enhances the confidence in the conclusions we draw from the data collected, but perhaps most important, the scientific process is a self-correcting process. More than any other way of knowing, we depend on the continued process to guide us in our beliefs in theory and process. Further work in any area provides more support for those theories or raises more questions that then must be examined by the same process. Quality research. Research design is defined as a series of systematic compromises between what is desirable and what is realistic in any given research situation. Kish5 suggests:
The importance and potential of research design, then, comes from 2 different elements: (a) improving the power of design by making appropriate and systematic compromises and (b) enhancing the replicability of research by documenting the nature of the compromises made and the reasons for making those choices. Based on these 2 points, the issue of appropriate compromise is a most critical element in research design. Our capacity to do these 2 things may, in fact, reduce the gap between the presumption of hard and soft science. Participatory research. This circumstance sets up a classic good-news, bad-news situation. The good news is that the notions of participatory research and engagement of audiences in the planning phases of research are well developed. The bad news is that many of our public institutions, policies, programs, and our very assumptions may not be ready for engagement with a larger population of diverse people than ever before. Barriers to Effective Research "We were the overwhelming underdogs." Yogi Berra's fond description of his baseball team one year leads to Yogi Lesson Number 2. He said, "We were the overwhelming underdogs." We may feel that just getting our research funded is enough, but we must not become comfortable with an underdog role, of settling for the status quo. Here are some threats to escaping this mire. Not using what we know. Dr. William Foege has been known to say that 90% of what we know is not used. There are some researchable questions that arise out of that assertion, but we can easily think of several reasons why. One is that we are too busy in the present to recollect the past. At numerous conferences, I have been struck by the number of papers I hear that repeat a seminal idea from 20 years ago, yet give no recognition that they are repeating past work. This shows that we have no institutional memory and, even worse, that we are wasting resources recreating the wheel. Why are we wasting our time and efforts like this? Largely, the problem is that it is not easy to use the knowledge we have because it is fragmented and disorganized. The closest thing we have to a taxonomic structure is the Medline thesaurus. We have not taken the time as a field to organize our knowledge.
Not applying what we know. Besides not using what we know, we would add a further assertion that less than 50% of practicing health educators are effectively applying the 10% of what we do know. This issue is clearly illustrated by the Prevention Research Center (PRC) Program. This is a network of 23 PRCs and 3 Urban Research Centers (URCs) focusing on community-based prevention research centered on research themes that are specific to each Center. The overarching goal of this network is best characterized by the interaction of 3 specific tasks: (a) conducting innovative prevention research, (b) generating new knowledge, and (c) translating knowledge into improved public health practice and policies. In 1997, the Institute of Medicine (IOM) conducted a formal assessment of the PRC Program. The IOM documented many strengths of the PRC program, while pointing out a weakness in documenting the translation of knowledge gained from research into public health programs and policy: "PRCs have not regularly and systematically reported their findings concerning research dissemination and implementation to CDC, and CDC does not have a mechanism for assembling findings from the PRCs in order to promote such activities." What are the barriers? Weiss6 provided 5 suggestions on the inherent limitations with utilization issues related to evaluation, but they may be extended even now to health education research: (a) unclear direction or answers to research questions due to inconclusive evidence from studies, (b) conflicting findings from multiple studies, (c) postponement of action to a more appropriate time, the result of lack of motivation or opportunity, (d) annulment of research recommendations due to competing operational and programmatic constraints, and (e) use of evaluation results to justify predetermined program changes. Health education research involves the translation of established and promising methods of disease prevention and health promotion to communities. Despite its importance, relatively little attention has been paid to systematic approaches to determining the impact of health education research on health education practice. Evaluation of these effects is challenging, particularly in light of multifactor causation, long time periods between the conduct of research and its subsequent publication, and difficulties in determining the influence of other factors such as costs. Greater translation of research findings is needed to accomplish our broad health education goals. These efforts may be enhanced by academic-practice partnerships.7 Not asking what others know. Our effective use of the results of research is dependent upon the effective integration of behavioral science advances with much other promising genetic, medical, nutritional, technology, health care, and policy research in order to broaden our understanding of the underlying mechanisms of behavior that might be amenable to health education and promotion, but also to improve quality of life and public health for all persons.8 Although so necessary to a field such as ours, interdisciplinary study is difficult. The difficulty comes from having to integrate what we hear from others into our thinking, which can represent a loss of control. Making the commitment to ask, it should not be an empty gesture, or it is simply a waste of time (eg, "Don't ask if you've already made up your mind"). Another fear in asking others for input or participation is that it sometimes results in the loss of control over a project, sometimes loss of a project altogether. For example, our university encourages interdepartmental research, but each player inevitably counts the number of collaborators and thinks how working with others will affect his or her own piece of the pie, both the size and the quality of the slice. Academic arrogance is another barrier to asking others what they know. We must be less concerned about the letters after someone's name (or lack thereof) than about their experience, insight, and abilities. Participatory research principles show that we have come a long way from research on to research with. However, we may not extend the same courtesy to those with whom we work, whether they are students, staff, colleagues, or partners. We lose the opportunity to learn from them or to teach them, and they are less likely to be fully engaged in the effort. Not telling others what we know. Changes are required on the part of behavioral scientists in how they organize and present their research and on the part of potential users of this knowledge, including other health professions, organizations, and funding agencies and communities. Research is often a competitive process in which we hold our own knowledge close to us, lest we give away our advantage. We also may not share what we know when we report on our research because—if things go wrong—we may be perceived negatively, even lose funding. Further, sharing what we know takes time, and there are only so many days, hours, and minutes. For example, I was supposed to be at 2 other meetings today! The Challenge "You can observe a lot by watching." We, as researchers, can take several steps right now to enhance the practice of health education and to engage other health education researchers as partners in that endeavor. That leads to the next lesson from Yogi Berra. He once said, "You can observe a lot by watching." When it comes to making the millennium a golden age for the collaboration of research and practice, we can also observe a lot by listening — Listening to the research as well as listening to each other. Research experts—yes. Practitioners—yes. Populations, service providers, advocates, and others—whether public, private, or NGO—from nations all over the world.
How do we prepare for this eventuality? How do we make sure our researchers, research institutions, and assumptions keep up with practitioners and the potential recipients of health education? How can we make sure we all enjoy the benefits of a sound research agenda? How do we create "best practices" that are alive and able to evolve over time, across populations and settings? Organizing our research. There are different types of research, and they are not all as useful to health education as they have the potential to be (eg, the Behavioral Risk Surveillance System [BRFSS] and other survey research may be very useful; some outcome studies should be).9 Access and ease of use are primary tasks in making research useful. It is worth distinguishing between the 2 different types of knowledge we need to move forward. One of these is the explicit knowledge that can be found in our collective literature resulting from active research. All of our documented knowledge is explicit and potentially accessible to all. Access to such knowledge would be improved immensely by giving it structure so it can be reviewed and searched in a meaningful way. Access would further be enhanced if all the literature were made available, not just those with significant results. Not only is research limited by publication bias, but it is also months or years old by the time it reaches us. Theses and dissertations reflect a less biased pool of research knowledge because they escape from publication bias. However, we also need a process for making research available, even while in process and when it is published elsewhere (eg, final reports, progress reports). The other type of knowledge is tacit knowledge, which is contained in only a few places—the gut, instincts, and intuition that guides some of our unconscious or subconscious processes as professional health educators and researchers. This kind of knowledge is not documented well—if at all—and we do not often know how to communicate it or share it with others because we often use it without recognition. One of our biggest challenges is to begin documenting these heuristics so we may pass them on to colleagues and succeeding generations of health educators. Another challenge is encouraging those with the tacit knowledge to share it, given their time constraints and level of willingness. Organizing our knowledge base is also a challenge because it is constantly evolving. Even if well structured, the research base will be worthless and unused if it is not current. Therefore, we have to commit to knowledge development and sharing as a way of life. Learning how to apply it. Having access to the research is not sufficient to guide health education researchers. Part of the reason is that research is studied within a context of a specific population, community, and situation. Even replicated research may not explain fully how the research would change, given a new context. We recently did a consensus development process that, in part, looked at the types of information researchers and community practitioners needed the most. We found the following top 10 content areas on prevention research, in priority order: 1. Describing what happened. 2. Describing barriers and their solutions. 3. Describing what works and how it can be made to work in your community. 4. Describing what has been tried. 5. Including interventions aimed at a broad spectrum of health conditions or at promoting health. 6. Providing information on the sustainability of interventions and on strategies for sustaining them after initial grant funding runs out 7. Describing unintended consequences of actions. 8. Providing the outcomes of prevention programs (data) in forms that are usable within lay community groups 9. Describing what does/does not work. 10. Describing how to deal with challenges. What is clear from this list is that much of this information is hard to find because published literature does not focus on these issues. Tacit knowledge provides at least one strategy to develop and deliver this information. Researchers simply query each other about what works in which situations and how to solve problems that present themselves. The challenge will be developing a mechanism that researchers will know and trust. Collaborating. Despite the real and perceived barriers to collaboration, we must also be committed to overcoming those barriers in order to produce valid, useful, and used research. In terms of validity, collaborating in teams or with colleagues also provides a check and balance on the research we propose and conduct. This is clearly a step in the publication of research, but it begins much earlier. For example, one of the important lessons in grantwriting is the need to let peers review and comment on the work we propose before we turn it in. Sidney McNairy, the director of Research Infrastructure at NIH's National Center for Research Resources, makes a point of asking young investigators if anyone besides themselves read their proposal. However, collaboration is not only important for success in publication and funding, but it is also essential for the validity of the research to our populations of interest. As we have said before, multidisciplinary, multiprofessional teams allow us to create research that looks at all sides of a health issue and is, therefore, able to reflect it and the needs of target audiences completely and clearly. Beyond validity, collaboration makes research more useful by assuring the questions we ask are important and the procedures we use are acceptable. For example, we know that our instruments must be reliable and valid, but increasing emphasis is on their acceptability to the target audience. Specifically, the target audience must accept the way in which questions are stated, or their responses may be influenced. Including the needs and concerns of the target audience, practitioners, and other researchers throughout the research process through collaboration is a hallmark of participatory research. Active collaboration between researchers and service agencies also results in more successful program adoption than distribution of implementation packages alone.10 Therefore, we should look at ways to engage researchers actively with the practice community. Larry Green, with the work done at his Institute for Health Promotion Research (IHPR) at the University of British Columbia provided a model. Not only did the IHPR have a network of high quality of researchers from throughout the university, but that research network also had effective collaborations with most local, Provincial, and national agencies in Canada. Mentoring. It is our belief that there are many methods of technology transfer. Training is one of them, but the technology transfer literature suggests that the best way to transfer technology is to transfer people. One of the most powerful strategies for professional development and technology transfer is mentoring, which gives us an important clue about the importance of research mentorship. The "health education family tree"—the active engagement of students in the research of their mentors—has a profound effect on the practice of health education. Students not only learn the methodologies, but they also learn the application of results, adaptation and evolution of research questions, and expanded scope of impact on health education (Matt Kreuter/Vic Strecher; Becky Smith/Ann Nolte).11 To that end, we each have a professional responsibility to be the best mentors we can, and we would suggest that we offer each of our mentees a lifetime guarantee. Recommendations When you come to a fork, take it. Now Yogi Lesson Number 4: "When you come to a fork in the road, take it." Right now, many researchers and practitioners are at a fork in the road when it comes to their potential for collaboration. Many of us are staring at the 2 paths: One fork is called the "Status Quo." On that road, it's research as usual. The other fork — the fork — can be called "The Future."
Call to Action Researchers can't ask questions that only benefit them. These conclusions are exactly why the lessons learned from those like Larry are so important. Researchers cannot — and should not — ask questions of interest only to them, conduct research in such a way that neither the subjects nor the intended recipients of the results understand or benefit from the work, nor engage in research on populations rather than with populations. Leaders need to create opportunity for growth. Today, all leaders — whether in politics, education, or business — have a moral obligation to create opportunity for growth. This is the case for researchers as well. That's a truth we should all hold to be self-evident, but in addition to moral obligation, what about self-interest? For those of us in positions of leadership in research and/or practice, is our ability to direct our discipline's destiny so firmly within our grasp that we can afford to do anything less than what is right? As leaders in health education research, we have an obligation to actively support and participate in efforts to organize research, collaborate, and mentor. To that end, we make the following recommendations. Recommendation -- To deal with the need to manage knowledge, create a system of knowledge growth, including both explicit and tacit knowledge. Recommendation -- Support not only the publication of research literature, but also the active participation with practitioners on the application of research results. Recommendation -- Create a Web-based look-up system for all MA, MPH, PhD, DrPH, ScD work in progress. As soon as it is approved for conduct, submit an abstract and related information. Recommendation -- To deal with the kind of technology transfer that comes from mentoring, create a health education family research and practice genealogy. If we do this, we have a database of the origin of ideas in health education. From this, let us examine the origin of conceptual lines of research to help us understand how to improve the efficiency and effectiveness of such relationships. Recommendation -- Create a national coordinated research agenda. Provide a road map showing were independent researchers can contribute. In each of the more than 200 academic departments of health education in our nation's colleges and universities that offer graduate degrees in health education and public health, there are many independent researchers - graduate students doing thesis and dissertation research and faculty members whose promotion and tenure efforts are tied to their scholarly activities. For many of these independent researchers, the identification of a researchable problem and a desire to contribute to the field are difficult tasks. An effective agenda will provide guidance to these researchers. Recommendation -- Create a consensus process to organize what has been accomplished to date. Recommendation -- Take advantage of research networks already in place. Take a look at the research network that already exists. Figure 1 contains a map of the location of CDC's Prevention Research Centers (PRC). There are 23 PRCs and 3 Urban Research Centers (URCs). If we were to overlay this with the more than 200 college and university-based health education training and degree programs, imagine the potential network that would be. Imagine how telementoring/knowledge management systems would help this network reach the practitioner in the field in communities outside this network.
Preparing for the Future Stay flexible to the unforeseen future so we can enable it. Finally, Yogi Lesson Number 5: "The future ain't what it used to be." Most people who have dabbled with futures work recognize that there is no single future. The future keeps changing based on the outcomes of events in the present. In complex societal and health events, stochastic processes ensure that randomness often plays a role in these outcomes. Antoine de Saint-Exupery, in The Wisdom of the Sands, tells us: "As for the future, your task is not to foresee, but to enable it." From our perspective, one of the most important lessons to be learned is that we cannot just let the future happen to us or let others determine what it will be. It is time for us to establish and act on a vision of a health education research and development paradigm that propels health education into its future of choice.
No longer will we have to explain ourselves, redefine ourselves, or provide a rationale for our existence as a profession. Rather, the soundness of our research agenda will allow us to be better prepared, able to act with knowledge and timeliness, make more informed choices, and improve the quality of our work as a discipline. By applying sound research collaboration and participatory models, we will provide a role model for our practice outside the research arena. Summary We have identified 5 benefits of research to health education:
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