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health education emerald article health knowledge and health education in the democratic health-promoting school bjarne bruun jensen article information to cite this document bjarne bruun jensen 2000 health knowledge and health education in the democratic health-promoting school health education vol 100 iss 4 pp 146 154 permanent link to this document http dx.doi.org/10.1108/09654280010330900 downloaded on 15-04-2012 references this document contains references to 14 other documents citations this document has been cited by 4 other documents to copy this document permissions@emeraldinsight.com this document has been downloaded 1413 times access to this document was granted through an emerald subscription provided by victoria university of technology for authors if you would like to write for this or any other emerald publication then please use our emerald for authors service information about how to choose which publication to write for and submission guidelines are available for all additional help for authors is available for emerald subscribers please visit www.emeraldinsight.com/authors for more information about emerald www.emeraldinsight.com with over forty years experience emerald group publishing is a leading independent publisher of global research with impact in business society public policy and education in total emerald publishes over 275 journals and more than 130 book series as well as an extensive range of online products and services emerald is both counter 3 and transfer compliant the organization is a partner of the committee on publication ethics cope and also works with portico and the lockss initiative for digital archive preservation related content and download information correct at time of download.

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health knowledge and health education in the democratic healthpromoting school bjarne bruun jensen introduction within both health education and health promotion we are currently witnessing a strong reaction to working with a concept of health which emphasises illness instead many have begun working on alternative approaches which include more positive models of health the development of attitudes and values and working with rather than for people within the danish network of health promoting schools work is being carried out which aims at helping students develop their own action competence through the teaching they receive and their experience at the school a number of different components such as students self-esteem motivation and their ability to co-operate are often in focus in the schools work in the following i will stress the necessity of including a knowledge-dimension in the concept of action competence but the type of knowledge and insight must be appropriate for the overall purpose of the healthpromoting school traditional health education delivers knowledge but it may be the type of knowledge which on its own increases students worries and feelings of powerlessness within the health area for example hillcoat et al 1995 in their study of attitudes and knowledge of young people aged 15-17 years in brisbane demonstrate how knowledge and investigation about how bad things actually are can contribute to the feeling of powerlessness if the purpose is to support students in developing their abilities to intervene in their own lives and the surrounding world then knowledge and insight should be explored and defined from an action and change perspective the author bjarne bruun jensen is associate professor at the research centre for environmental and health education the royal danish school of educational studies copenhagen nv denmark keywords health promotion schools competence knowledge abstract this paper suggests that there are two different paradigms within health education and the healthpromoting school the traditional/moralistic paradigm and the democratic paradigm the danish network of health promoting schools favours the democratic paradigm within which the overall aim is to develop students abilities to influence their own life and the society ± their so-called action competence the nature of an action is defined here as being purposefully directed at solving a problem or facilitating change and consciously decided upon by those carrying out the action the key factors which influence action are discussed they are insight and knowledge vision commitment experience and social skills the paper then looks more deeply at insight and knowledge suggesting that it has four different dimensions knowledge of effects causes the processes of change and vision of future possibilities it suggests that teachers themselves need both the educational competence to facilitate the education of others and high levels of action-oriented knowledge and insight electronic access the current issue and full text archive of this journal is available at http www.emerald-library.com two paradigms one of the important research outcomes from projects within the danish network of healthpromoting schools has been the recognition of two different approaches in schools work with health namely a moralistic and a democratic approach jensen 1997 for reasons of clarity the two approaches will be presented here as two ends of a continuum but in practice there are many different potential positions existing in between health education volume 100 number 4 2000 pp 146±153 mcb university press issn 0965-4283 146

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 table i outlines a range of the distinguishing characteristics of the moralistic and democratic health education paradigms the two paradigms differ in their concepts of health and their educational approach while crucial differences also exist in relation to issues such as the hidden curriculum settings evaluation and collaboration with the local community for instance the democratic approach builds on a broader concept of health embracing living conditions as well as life style there are also key paradigmatic differences between education and information education emphasises the active involvement of students in constructing their own knowledge and action competence in contrast to the passive view of the learner in information-based programmes a more detailed discussion of the two paradigms can be found in jensen 1997 the moralistic paradigm is dominant in many current health education programmes in schools it has been subject to strong criticism in denmark from both health and educational practitioners who see it as being ineffective in producing behavioural changes in pupils it can also provide an obstacle for developing a democratic school in a democratic society as there is no space left within this approach for pupils own decision making consequently the danish public health programme published by the table i two paradigms related to health-promoting schools moralistic health concept behaviour/life-style absence of disease health as a closed concept pedagogical approach aim behaviour changes moralistic/totalitarian healthy school setting approach teacher as role model smoking alcohol nutrition the school environment canteen s food smoke-free areas/smoking forbidden etc school/society medical professionals from the society are used in the school and in class settings evaluation measurement of students behavioural changes government in 1999 states that the development has f f f decreased the trends for an individualistic and moralising approach to public health work danish ministry of health 1999 p 110 the second paradigm focuses on democratic health education and is advocated in this paper as a valuable alternative to the moralistic paradigm the democratic paradigm has been explored and developed in close collaboration with the participating schools in the danish network of healthpromoting schools the assumptions behind the democratic paradigm of health education are health in our societies is influenced by living conditions as well as life-style choices as the world health organisation who in the health for all strategy who 1985 and the ottawa charter who 1986 emphasise solutions to health problems must be sought both at the structural/societal level of living conditions and at the level of a personal/life-style if people are to contribute to the solutions of health problems they have to be able to identify both personal and structural causes and to develop their own abilities to influence and change these conditions democratic living conditions and life-style wellbeing and absence of disease health as an open concept aim action competence democratic/participatory health-promoting school teacher open democratic listening co-operative etc the school environment challenging stimulating students council etc school/society schools and students are viewed as social agents in the society by key people in the society of students competencies thinking visions commitment 147

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 as institutions for general education schools have a responsibility to help equip their students with the knowledge and commitment to make decisions and actions to address the challenges posed by both lifestyle and societal conditions consequently the overall aim of school health education is to develop the abilities of students to act at the personal and societal levels that is to increase their socalled action competence within this framework health education and the health-promoting school aim at influencing factors not only in the school but also in the surrounding society the importance of action competence the concept of action competence has been taken up by several of the countries within the european network of health-promoting schools for instance by the network in macedonia simovska and kostarovaunkovska 1998 the concept was integrated into the conference resolution of the first conference of the european network of health-promoting schools which was held in greece in may 1997 principle no 3 out of ten states empowerment and action competence ± the health-promoting school improves young people s abilities to take action and generate change it provides a setting within which they working together with teachers and others can gain a sense of achievement young people s empowerment linked to their visions and ideas enables them to influence their lives and living conditions this is achieved through quality educational policies and practices which provide opportunities for participation in critical decision making who 1997 this conference resolution can be seen as a sign of an increasing recognition of actionoriented teaching and of the democratic paradigm within the european network of health-promoting schools the definition of an action given that the concept of action competence is key to the democratic approach to health promotion in schools it may be helpful to make some observations on the definition of action action is deeper than behaviour it involves inner decision making there is a tendency to equate actions with behaviour given that we know that knowledge does not necessarily lead to behaviour change efforts are then often concentrated on developing other methods to influence students behaviour for example there have been attempts to fight the influence of advertisements by smart counter-advertising against smoking for instance while other efforts have been to made to use the teacher as a role model however such strategies continue to fall within the moralising approach as they are all characterised by the fact that the pupils do not necessarily make up their own minds and decide on the behavioural change in question the difference between behaviour and action lies precisely here before an action there must always be a conscious making-up of one s mind which is not always the case in behavioural change this is the inner component of the action concept which is very important to the democratic dimension action is more than busy activity it involves an external goal there has been a strong tendency for those keen on health education to promote the importance of involving pupils in practical activities to motivate pupils and to make teaching more varied this is often as a reaction to the school s academically-oriented content for example when looking at the effect of exercise on the body pupils might be involved in measuring pulse and blood pressure while pupils studying the health of the physical environment might engage in physical chemical and biological investigation of a polluted stream involving pupils in such different activities can be fruitful if it contributes perceptibly to motivation and acquisition of knowledge but for such activity to be characterised as an action it must be directed towards a solution of a problem in the outside world this is the outer component of the action concept for example when pupils are engaged with investigating an environmental problem such as the use of fertilisers in agriculture the activities in question must have the aim of contributing to a solution of that problem in order to have the character of actions investigating how much nitrate there is in the drinking water cannot therefore be characterised as an action but rather as an activity which however can easily have a 148

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 value in the educational context an example of an action in that area would be to work at boycotting products from conventional agriculture and instead promoting opportunities for products from ecological agriculture so an action must be goal-oriented towards the solution of a problem that is the other element in the action definition expressed briefly an action as defined by the democratic paradigm has two key characteristics it should be purposefully directed at solving a problem or facilitating change and it should be consciously decided on by those carrying out the action in other words an action is targeted at change which may be a change in one s own life-style in the school in the local society or in the global society and an action is intentional jensen and schnack 1997 action competence expresses pupils commitment will and ability to take action the concept has become central in danish discussions about health education and the health-promoting school in contrast to the moralistic behaviour modification approach the democratic approach involves students making their own decisions about health according to their own perceptions of a healthy life and a healthy environment students are thus involved in developing visions for the future and in clarifying the personal and societal changes and actions necessary to move towards their visions commitment pupils need the motivation to become involved in change in relation to their own lives and in creating a dynamic society it is important to build up this component if the knowledge acquired should be transformed into health-promoting actions commitment is often developed within a social context so group work is an essential part of the learning environment of a health-promoting school vision pupils need the ability to go behind the health issues and think creatively this involves developing visions of what their own life could be like and how society and environment could be improved in relation to the particular problem of concern this component deals with the development of students ideas dreams and their perceptions about their future life and the society in which they will be growing up it is for instance important that students who work with improving the school s playground are given time and possibilities to develop their own dreams of a future school ground perhaps they will visit other schools to learn about existing alternatives or perhaps they will hold a drawing contest among the students at the school about my dream school playground it has been found that class projects which purposely and systematically give time and space for students to develop their visions have had a very positive effect on the level of students commitment and motivation jensen 1998 the fact that pupils have been given the opportunity to develop discuss and share their visions with others or even participate in developing a common vision is one of the most important prerequisites or precursors of the desire to act and to build up a sense of ownership examples within the danish healthpromoting school network have been student work on topics such as peace on earth drug abuse in the local community the social life of the class my future family or health conditions in the local community as one group of teachers within the danish network of health-promoting schools wrote in their final evaluation report it is during this phase that the children really experience the thrill it is here the ideas are developed in a fun and creative process here ideas are created which are very wild and crazy ± some key components of action competence several attempts have been made to operationalise the concept of action competence five elements have been seen as central insight and knowledge pupils need a broad positive coherent and action-oriented understanding of health this component involves students acquiring a coherent knowledge of the problem of concern to them a knowledge about the nature and scope of the problem how it arose whom it affects and the range of possibilities existing for solving it this component will be dealt with in more detail later in this paper 149

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 animal park with zebras in the school playground swimming pool underground traintrack etc but the more realistic ideas also crop up here children enjoy immensely working with these things and discovering new things and elements along the way ± things which are realistic and easily put into practice we feel that this develops and justifies their fantasy it is our experience that children use each other during this phase what one of them does not figure out will be discovered by another they find out that together they can develop ideas and utopia they can work together towards a goal hillgaard and jensen 2000 experience pupils need real-life experiences participating individually or collectively in healthpromoting changes and considering how barriers can be overcome this component stresses the benefit from taking concrete action during the learning process teachers and students experiences within the danish network of health-promoting schools support the view that participating in a wide range of different types of actions is a vital step in the development of action competence indeed some of the teachers from the network believe that action competence can be developed through concrete actions only social skills a number of basic social skills can be added to the list of components of action competence these include among others self-esteem the ability to co-operate selfconcept and self-confidence critical thinking or critical decision making has been suggested as an independent component and the danish national curriculum for health education which has been strongly influenced by the danish network of healthpromoting schools includes critical decision making as an important skill closely linked to visionary thinking danish ministry of education 1995 of course be the overall aim of the activity having argued that the main goal of the democratic health-promoting school should be the development of the student s ability to act and change we can conclude that knowledge and insight should in essence be action-oriented this point of departure has great consequences for which kind of knowledge will be focused on in planning implementing and evaluating the democratic health-promoting school four different aspects of action-oriented knowledge can be illustrated using the model in figure 1 the four dimensions illustrate different perspectives on the types of knowledge through which a given health topic can be viewed and analysed first dimension what kind of problem is it ± knowledge about effects the first dimension deals with knowledge about the existence and spread of health problems for example about the healthrelated effects of conditions in the environment in personal lifestyles and in social relationships this type of knowledge can for example be about the consequences of a given behaviour such as drug abuse or too much fat in our diet or the consequences of acid rain or bad air quality in city areas or workplaces or it could be about how bullying behaviour in a school affects students health and wellbeing this type of knowledge will typically make us able to make statements such as if we do this then this happens or if the conditions or circumstances are these then the risk of this will increase this knowledge is figure 1 four dimensions of health-related knowledge four dimensions of health-related knowledge in the following section the component that is concerned with knowledge/insight will be discussed further in a discussion of the content and basic health knowledge that underlie content and process in healthpromoting schools the starting point should 150

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 important as it is the kind that awakens our concern and attention and creates the starting point for us to act so this type of knowledge can be one of the prerequisites for developing action competence however this form of knowledge is mainly of a scientific nature and on its own risks contributing to developing concern and action paralysis among students as it gives no explanation for why we have these problems or even how we can contribute to solving them second dimension why do we have the problems we have ± knowledge about root causes the next aspect deals with the cause dimension of our health problems such as why and under what conditions do we become ill and what factors threaten our quality of life such causes include the associated social factors existing behind our behaviour and might include questions such as the following why is smoking more common in certain social groups which aspects of our living conditions influence whether the use of alcohol leads to abuse what contributes to the fact that a taxi driver is almost twice as much at risk of dying of heart disease as an architect why is unemployment connected with a greatly increased illness and risk of death in our societies what conditions in a school contribute to whether bullying takes place this knowledge belongs mainly in the sociological cultural and economic areas explanations about the increasing inequalities in health are to be found within this area third dimension how do we change things ± knowledge about change strategies this dimension deals with knowledge both about how to control one s own life and about how to contribute to changing living conditions in society for example what psychological processes are at work within a group which is trying to get members to live their lives in a particular way or maybe even change their way of living how do we change surrounding structures for example in a school a workplace or a local community whom do we turn to and whom could we ally ourselves with this type of knowledge also includes knowing how to encourage co-operation how to analyse power relations and so on it is often to be found within psychological and sociological studies and is central to an action-oriented health education within a democratic health-promoting school fourth dimension where do we want to go ± knowledge about alternatives and visions the fourth and last dimension deals with the necessity of developing one s own visions seeing real possibilities for forming and developing one s own dreams and ideas for the future in relation to one s own life work family and society and having the support and surplus energy to realise them is an important pre-requisite for will and ability to act and change this dimension includes knowing about how people go about things in other cultures and other places both near and far as knowledge about other possibilities can be strong sources of inspiration for developing one s own visions from action paralysis to action competence ± two landscapes of knowledge if we look at figure 1 with its four dimensions traditional health information would be placed along the first dimension axis the one which is concerned with knowledge of effects of health conditions in this type of information the scientific approach is dominant and the focus is on students attaining knowledge about the serious health problems that might affect them how quickly such problems are evolving what behaviour leads to risks of illness and so on this type of knowledge is not necessarily action promoting especially when it stands alone indeed such knowledge can create a great sense of worry and if this type of knowledge is not followed up by knowledge about causes and strategies for change then it can be associated with breaking down commitment and contributing to action paralysis we need to insist on including causal analyses and ways of producing change within health education this is particularly important at a time when increasing globalisation and individualisation are leading to habitual ways of thinking and action paralysis as the danish psychologist carsten rene joergensen says it seems as if  151

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 f f f we have lost our eye for noticing that certain problems arise and appear more frequently and how this can be related to cultural and societal factors ± and that the solution of such factors should therefore be found in taking a starting point in how we live our lives and organise our society which could be potentially different the point is of course not that it should be simple and straightforward to agree on carrying out greater societal changes ± but that we think and behave as if we live in the only possible world and that this can hardly be different which is clearly wrong joergensen 1999 an action and change-perspective a democratic health-promoting school is not without basic health knowledge and insight on the contrary it demands that a new landscape of extensive and coherent knowledge and insight is developed educational competences and basic health knowledge in this paper i have argued for the necessity of developing alternatives to the traditional moralising behaviour modifying approach to health information and outlined a democratic and action-oriented alternative i have tried to give an indication of content of this approach and stressed that the principle of including students as active partners in the health education process does not make the health content of health education and promotion superfluous but instead it has to be re-thought from an action-perspective such an alternative should be built on a qualified professional foundation the democratic paradigm makes extra demands on the health facilitator often the teacher involved and well-qualified staff are a necessary condition for democratic health education let alone a democratic healthpromoting school to work at all for only if staff possess such highly-qualified professionalism will they have the energy to tackle the difficult but necessary problems that will arise when choosing to co-operate with the students in the health education dialogue the danish psychologist steen larsen argues for the necessity of f f f the professional experienced teacher being in natural control of the substance and what does that mean that means that the content substance is controlled at a level such that it looking at figure 2 the left side illustrates the landscape of knowledge within which traditional health information exists and which tends to result in the paralysis and fatalism described in contrast the right side of the figure indicates the landscape of knowledge which an action-oriented healthpromoting school should research and develop the model has been used in several different projects by school health nurses as well as by various schools within the danish network of health-promoting schools both students and teachers have used it for analysis and questionnaires in their work for example a student from the ninth grade comments on how using the model influenced her thinking processes the material which i had collected was given more structure now i was able to sort the material based on the four areas in the model and this forced me to not only look at the effects and causes in relation to my subject concerning co2 pollution and the greenhouse effect i was also forced to deal with alternatives and possibilities for change the model is also good when you re stuck in a rut the model shows other ways of getting along schmidt 1999 p 12 therefore knowledge-based aspects should be thoroughly thought through in the light of figure 2 landscapes for traditional and action-oriented knowledge 152

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health knowledge and health education bjarne bruun jensen health education volume 100 number 4 2000 146±153 becomes an integral part of the teacher s personality so he does not need to use attention and resources on the professional side but can concentrate all his energy on choreographing the educational process larsen 1998 p 22 we are naturally left with the question of what this substance should contain i have argued for an action-oriented substance which means that the health pedagogical professionalism should be an interdisciplinary subject this inter-disciplinary insight should mainly deal with insights into the connection between health people culture and society if we use the who s definition of health as a resource who 1986 which introduces a subjective dimension of quality of life it hardly makes any sense to operate with the concept health expert instead it makes more sense to talk of an expert in health pedagogy such a person has the qualifications to provoke challenge stimulate and support students in the development of their own visions of a healthy life and the healthy society together with organising strategies for action towards attaining these goals this does not however mean that demands on the teachers are lessened and that the teacher s knowledge regarding health issues should play a less important role in this work indeed it may well be that the opposite is true the teacher should both be in a position to fulfil the consultant role and furthermore from his own experience and talent be able to perceive today s health conditions and health problems from an intersubject and action-oriented point of view these are the main challenges for future inservice and pre-service teacher training in health education and for educational research references danish ministry of education 1995 curriculum guide for health and sexual education and family knowledge ministry of education copenhagen danish ministry of health 1999 the government s public health programme 1999-2008 the ministry of health copenhagen hillcoat j forge k fien j and baker e 1995 i think it is really great that someone is listening to us f f f environmental education research vol 1 pp 159-71 jensen b.b 1997 a case of two paradigms within health education health education research vol 12 no 4 pp 419-28 jensen b.b 1998 action health and education experience from the danish network of healthpromoting schools research journal from the royal danish school of educational studies no 2 pp 61-80 jensen b.b and schnack k 1997 the action competence approach in environmental education environmental education research vol 3 no 2 pp 163-78 hillgaard p and jensen b.b 2000 we decide ± a case story from gandrup school in jensen b.b ed case stories from the danish network of healthpromoting schools komiteen for sundhedsoplysning copenhagen in press joergensen c.r 1999 identity of globalisation chronicle in politiken 16 may larsen s 1998 the ultimate formula ± for efficient teaching processes steen larsen publishing firm hellerup denmark schmidt s.e 1999 experiences using the extended concept of professionalism newsletter for the danish network of health-promoting schools no 3 research centre for environmental and health education the royal danish school of educational studies simovska v and kostarova-unkovska l 1998 conceptual framework for the macedonian network of health-promoting schools in simovska v ed the european network of health-promoting schools in macedonia faculty of philosophy institute of psychology skopje macedonia who 1985 targets for health for all by the year 2000 2nd edition who regional office for europe copenhagen who 1986 the ottawa charter for health promotion who regional office for europe copenhagen who world health organisation 1997 conference resolution the health-promoting school ± an investment in education health and democracy 1st conference of the european network of healthpromoting schools who regional office for europe copenhagen 153

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