Health Education as a preventive measure

Health education, a preventive measure and an essential part of treatment

Willem Bohlmeijer, October 2013

Health Education as a preventive measure

Prevention has been traditionally divided into primary -, secondary -, tertiary – and quaternary prevention.

  • Primary prevention means applying methods to avoid occurrence of disease.
  • Secondary prevention means applying methods to diagnose and treat existent disease in early stages before it causes significant morbidity.
  • Tertiary prevention means applying methods to reduce negative impact of existent disease by restoring function and reducing disease-related complications.
  • Quaternary prevention means applying methods to mitigate or avoid results of unnecessary or excessive interventions in the health system.

Primary prevention, also secondary and even tertiary prevention can be attained by public awareness programs aimed at the general population making use of mass media.

The form differs much depending on the subject.

The content is largely similar to the content used in health education as applied as a first step in treatment.

In the consultation room the aim will mainly be secondary – and tertiary prevention. We know any subsequent episode or new outburst of the disease may leave scars in the system and increases vulnerability. Therefore this should be avoided.

Secondary – and tertiary prevention form an essential part of adequate health education. The aim of proper health education should not be confined to compliance but should also prevent new episodes or worsening of the disease by adequate learning.

Health Education as a key to treatment success

Educating patients in a proper way is the foundation of treatment success.

In psychiatry this is defined as psycho education.

The first step in the treatment program. It involves educating the patient and, ideally, also the partner or family.

Psycho education should include the following content:

  • Symptoms and impairment
  • Prevalence
  • Co morbidity
  • Heritability and other causes
  • Brian dysfunction/ neurobiology
  • Treatment options
  • Life style contribution
  • Outcome of research data
  • Long-term prognosis

Tutorial variability and other obstacles

Doctors are trained to speak about the different aspects of disease and it’s treatment to the patient. However not every doctor may be capable to do so in an adequate way as tutorial talents may not be equally distributed. Not to speak of the lack of time in the consultation room to explain the different features listed above.

To rule out the differences between the tutorial skills of doctors, standardisation comes into the picture. It would be quite an improvement when in every consultation room the same information about a certain disease is given.

This has been overcome by brochures about certain diseases that are sometimes distributed to the patient and/or it’s family. More often these are kept in a brochure stand in the waiting room to be randomly picked by anyone who is interested in the subject. However this implies the capability to learn the sometimes very complex content through reading which is a talent that is not available to everyone.

Narrow casting in waiting rooms is emerging in the GP practice. However the content can not be very specific, due to the diversity of patients. This may be different in the waiting room of the outpatient clinic of the medical specialist. Although even then there may be a great variety of patients waiting.

In general there is little time for doctors or little time is taken by doctors to inform patients adequately about their disease as described above.

In some institutions there are special programs to educate patients and the surrounding system in a group. However not every institution has these possibilities and if there are quite often they are whittled down due to lack of funding as a result of the development in the remuneration system.

Visual Learning

Making use of visual learning may contribute vastly to the learning process. The old saying, "A picture is worth a thousand words" probably could be modified slightly based on recent brain research, "A picture improves memory by a thousand-fold." Drawings and illustrations can be applied to learning vocabulary or depicting concepts and content.

People think using pictures. John Berger, media theorist, writes in his book Ways of Seeing (Penguin Books, 1972), "Seeing comes before words. The child looks and recognizes before it can speak." Watching the BBC episodes after his book on YouTube are still very impressive. Dr. Lynell Burmark, Ph.D. Associate at the Thornburg Center for Professional Development and writer of several books and papers on visual literacy, said, "...unless our words, concepts, ideas are hooked onto an image, they will go in one ear, sail through the brain, and go out the other ear. Words are processed by our short-term memory where we can only retain about 7 bits of information (plus or minus 2). This is why, by the way, that we have 7-digit phone numbers. Images, on the other hand, go directly into long-term memory where they are indelibly etched." Therefore, it is not surprising that it is much easier to show a circle than describe it.

Visual learning engages the use of visual aids like video to deliver educational content even more effectively. It greatly benefits and enhances the learning process as interactive effects are used to reinforce the material being studied. Visual learning is a great way of learning as it aids to increase the patient’s interest in a certain subject, makes the learning process more enjoyable, and retains the patient’s interest for longer periods.

By using visual learning, the audience in the consultation room is better served when they are provided certain elements that brochures cannot fully convey. These visual elements include video with patient narratives, naturalistic 3D animation, graphs, images and charts. The patient is capable of retaining more information through visual learning than in written text.

While some people may attempt to deny the essential value of visual learning, the fact that the pro-inclination of the vast majority of adults and children when seeking more information about a hobby, or subject of interest, turn immediately to video, television and computers, demonstrates the value of compelling nature of visual learning as an enjoyable and very effective learning tool.

Relying on text, like written material in a brochure, is similar to expecting patients to overcome their disease while they are in the waiting room. While being ill, and this is especially the case when having a psychiatric disease, but applies also to many somatic diseases, people are less capable to make use of their cognitive capacity. They suffer from distracting symptoms and emotions. So they may not understand fully what is conveyed to them. Visual learning is a more effective way to overcome this problem.

Learning, for visual learners, takes place all at once, with large chunks of information grasped in intuitive leaps, rather than in the gradual accretion of isolated facts, small steps or habit patterns gained through practice.

A host of scientific articles has been published on the benefits (mostly) of visual aids in the learning process in school and academic environment. Apparently if the visual aid is used interactively as described above this enhances the learning process.

Bloom (1987) offered the following regarding engaging individuals actively in learning. Learners will retain:

  • 10% of what they READ
  • 20% of what they HEAR
  • 30% of what they SEE
  • 50% of what they SEE & HEAR
  • 70% of what they SAY
  • 90% of what they SAY & DO.

Information circles

The patient is not alone as it comes to convey adequate information about the disease, its course and treatment options. The surrounding system, like close relatives, play an important role too. Especially as it comes to helping the patient in continuing treatment when adverse events should be overcome. It helps anyone to understand what may be the cause of possible adverse events during treatment and what could be the meaning and consequence of these events. In some cases the information about disease and treatment options should be more widespread than the small circle of the patient and its surrounding system alone. For instance if local authorities are involved in decision making about a certain type of treatment or even where the treatment should take place.

Media approaches

How to bring the content to a chosen audience. Whether this audience is the patient in the consulting room or the general public may differ the approach. Although information rendered to the general public will probably reinforce the individual approach of the patient.

Thus Health Education as a preventive measure, as described in the first chapter, is very important in our view, as it reinforces the information given to the patient and its surrounding system.

Approaches to transfer health education:

  1. Mass media through radio and television
  2. Specialised or aimed websites can serve for patients and direct surrounding systems
  3. App’s
  4. DVD, USB stick or other media storage devices
  5. Display screens in the consultation room or a secluded area preserved for health education
  6. Narrow Casting in waiting rooms of GP’s, Medical Specialists, Nurse Practitioners, etc.

1 Radio in general has a more limited scope than television as it lacks the visual aspect of the message. The way it is brought to the footlight however may trigger one’s imagination till such an extend that the message is retained even better than sustained with images like in television. Also radio can reach different places than television, for instance while driving. Television is of course the mass media of choice especially when complex messages, like health education aimed at amplifying public awareness, are intended. As described before images, especially moving images, whether these are film or 3D animations, enhance the learning process.

2 Specialised websites can contain almost any visual and auditory information that is necessary to fulfil the requirements of spreading health education content. It may also be used, and often is used in such a way, to reinforce mass media messages on television and/or radio. The problem if used as a single approach for health education to enhance treatment success is that the patient and/or the family do have to play an active role, putting on the computer, searching the web link, and reading all the message. More often people will just search the web on a subject. The probability the specialised website is found may rather small. Although visual aids, like short video messages complemented with 3D animation, can be used, just as graphics, it requires an active role of the spectator. The more interactive, the more appealing, the better the message will be adjoined. Definitely specialised websites will reinforce other messages on health education, however as a stand alone measure they require too much of the patient and it’s surrounding system in terms of willing to understand a disease in full.

3 App’s are the new information containers of any kind. Ready applicable to anyone who has an android telephone. App’s can be designed to fit any platform. Future limitations are probably none, but with limited coverage of providers and limited 3G networks and 4G just starting to emerge, at present only short video messages can be conveyed.

4 DVD, USB sticks or other mass media storage have the disadvantage of being dependent on the system quality of the care providers or hospital. Usage of stored media burdens the multitask overload of the care provider even more. The chance the multimedia health education is used in this case is rather low. Furthermore the expectation of the care provider being provided with the next DVD or USB stick is low as far as quality concerns. Most DVD and/or USB messages are too long, lack visual appeal and have none or limited 3D animated content.

5 Display screens in the consultation room, especially if the content can be used interactively by the care provider, e.g. doctors, medical specialists or nurse practitioners, is a preferable means of bringing information to the footlight. The messages should be conveyed as powerful clear stories and should be of limited duration. The care provider can use the screen with internal multimedia as a reinforcement and illustration of one’s own health education. It is especially effective if a simple button click enables the care provider to show different parts of the health education story. So every visit a different part of the list of health education subjects as mentioned before. On it’s own, or preferably grouped in accessible chunks, for the brain to retain adequately.

6 Narrow Casting is seen more and more in waiting rooms. As the group may not be very specific, like the waiting room population of the GP, the information should be kept quite in general. Therefore it may lack a certain depth, on the other hand Narrow Casting may be unique to evoke interest among the viewers. If followed up by more specific information in the consultation room, an app or a website, it will reinforce the information as the patient becomes more curious by Narrow Casting.

How it is done.

In short it is wrapping up content in an agreeable form and unwrapping that part of the content that is hard to be understood.

The message and the story

The story itself should be told in a limited time. If multimedia are applied in the consultation room only 8 till 10 minutes will suffice at the max. Therefore we make use of condensed but recognizable and understandable information. Although the information might be quite comprehensive the message should be clear and powerful enough to literally keep in mind.

The story should be based on correct scientific evidence, as described further, and should be distilled form this evidence in such a way that the message will be clear to all spectators, being the patient, the surrounding system and others.

The story should be interesting to look at. This comes down to many factors like actor selection as mentioned further, dynamic camera movement and dynamic editing. Fortunately 3D animation has made a giant leap forward the last ten years or so. Therefore it is possible to make the invisible visible in a naturalistic way by using exploded views and tissue transparency. Also special camera techniques can reveal things that are unseen before. For instance high speed cameras provide quality images on their own by recording very fast movement that Is otherwise invisible to the human eye. The dynamics and appeals of moving images can be used to store the message right into the long term memory.

Scientifically correct

The information we deliver should be scientifically correct. Therefore careful research is indispensable in many fields, like anatomy, biochemistry, pharmacology, human behaviour, just to name a few. Having medical knowledge onboard is an advantage. The access to various scientific sources is unlimited nowadays. However the possibility to discriminate proven and unproven is only reserved to real science. Therefore the general public knows a lot but also very little. It is our task to guide our spectators in the right direction and to reveal if conclusions are ill proven.

If all the information is put together we make the script and present it to our client to be discussed. It is our clients and our own interest to base our multimedia production on solid scientific evidence. Therefore the pre production process may take quite some time, to line up all the evidence and distilling the message form it. After this process the message should be considered again in regard to scientific evidence.

After this a legal assessment should take place as the content should not in any regard being promotional or otherwise provocative that it will lead to legal claims.

In projects we have to deal with future clients. In this situation we gather information as we get along. Still then all information should be covered by scientific evidence. If not we reveal our doubts or show the proof of evidence in progress.

Actor selection

The story should be interesting and appealing to the spectator in order to lock the message in the memory. We select people that tell the story, whether we make use of actors or others, on looks and verbal quality. That doesn’t mean we seek for a line up of top models. The criterion is: “interesting to look at” in such a way that anyone can identify this person as someone being a representative of a certain group. This is most important in psychiatry as most health education multimedia productions position the patient as “a typical loser”. Exactly what we want to avoid. Psychiatric symptoms can happen to anyone, regardless race, family background or education. We apply the same starting point for the expert or professional: “Interesting enough to look at and/or of outstanding verbal quality”. Someone with enough charisma to emit the knowledge. A trusted figure, someone you’d like to believe.


A study to analyze the effectiveness of audio visual aids in teaching learning process at university level, S. Rasul, et al., Procedia – Social and Behavioral Sciences, Vol. 28, 2011, Pages 78-81

Instructional video in e-learning: Assessing the impact of interactive video on learning effectiveness, D. Zhang, et al., Information & Management, Vol. 43, 2006, Pages 15-27

Strategies to enhance memory based on brain research, A.K. Banikowsky, Focus on exceptional children, Vol 32, Issue 2, 1999

Ways of Seeing, J. Berger, Penguin Books, 1972

Outline study proposal

“Field investigations in Hirundo rustica: does cyclic daylight rythm initiate migratory behaviour through the vit D/vit D receptor axis causing downstream effects in serum prolactin concentrations?".
Studying the biological/ physiological changes that occur in migrating birds may be helpful to understand the need of humans living in latitudes that are avoided by migrating birds in Southern or Northern hemisphere winter periods.

In human beings vitamin D3 or cholecalciferol is synthesised in the skin by exposure to sunlight. This is hydroxilated in the liver to 25 hydroxycholecalciferol or 25-hydroxy vitamin D and transformed by further hydroxylation in the kidney till the active form of vitamin D: 1,25-dihydroxycholecalciferol or 1,25-dihydroxy vitamin D or alternatively called cholecalcitriol. At latitudes higher than 37 degrees the sunlight radiation is insufficient to produce adequate vitamin D levels in the skin during winter periods. Many factors influence adequate sunlight exposure in humans, like domestic behaviour and/ or clothing habits due to cultural and/or religious influences, skin aging or skin pigmentation and the use of cosmetics and sun protectives. In earlier days humans living at higher latitudes provided extra vitamin D by taking cod-liver oil. Also dietary intake of herring and salmon in these days provided quite some vitamin D .

Vitamin D levels in modern man living at higher latitudes are dramatically low. This may be due to altered behaviour. Computerisation and modern media have led to spending more time inside thus leading to less time in the open, providing less chance to sun exposure. Also health education on skin cancer had led to more frequent use of sun protectives and less sun exposure.

Public awareness on the need of vitamin D which can be added by doctors prescription is still low, despite being a hot topic in the medical world since 2010.

If bird migration in relation to vitamin D status is studied properly this may provide clues for human health and possibly attributes to understanding processes that underlie healthy aging. Sessile birds living at high latitudes live rather short compared to migrating birds. The latter have a decreased rate of senescence in relation to increasing migrating distance. Whether North or South of the equator photorefractoriness seems to start the mechanism that triggers the impulse to set off migration. The question is: Does photorefractoriness play a direct role in altering the vitamin D status in the migrating bird itself or an indirect role by altering the vitamin D load in insects that provide the main diet of migrating birds. Thus the vitamin D status in migrating birds might be influenced by their dietary intake instead of a direct effect through sun radiation.

Photorefractoriness influences the cortisol/ prolactin balance in favour of cortisol and in cost of prolactin. As prolactin stimulates the expression of parental behaviours, such as incubating, brooding and feeding, the opposite effect is generated by photorefractoriness. Parental behaviours diminish and this might be the first signal for the chicks to be less dependent and search for food. This will eventually lead to migration. Photorefractoriness also influences the vitamin D status in a negative way. Whether or not a correlation between the vitamin D status (direct or indirect through dietary intake) and the cortisol/prolactin balance exists, this line of thinking warrant further investigations. Several studies in domesticated birds show that prolactin facilitates the vitamin D hydroxylation in the kidneys. Will elevation of the vitamin D status lead to an alteration in the cortisol/ prolactin balance? Whether this study sheds light on the role of vitamin D in migration signals can only be established by field experiment. As far as we know vitamin D, although an important factor, has a facilitating role in restoring balances in the body and has not necessarily a causal relevance as a migration signal.

Study design:
In this study we propose to evaluate the vitamin D status and several other, possibly with vitamin D related, parameters in the Barn swallow Hirundo rustica, at several stages during migration.

Although there is a decline in the population of Barn swallow, the species is still rather abundant. Hirundo rustica is easy to catch making use of nets. Although these birds are very small, average 20 grams, in previous publications blood samples were taken in sufficient quantities ( ca. 15 ul for ♂ and ca. 10 ul for ♀) for laboratory tests to be performed. In this study only a small blood blot will be taken from the brachial vein (one drop) to be stored on a FTA card. The FTA cards will be kept into 1,5 ml sterile tubes to be analysed later.

We will sample Hirundo rustica from rural areas in Eastern regions in the Netherlands in the province of Overijssel and Gelderland. We will do the same in Zambia (depending on the presence at roosts of the Hirundo rustica in Chisamba, Kabwe and Kasanka National Park as well as Blue Lagoon and/or Lochinvar National Park). According to data of migration studies the main population of Hirundo rustica from Northern Europe migrates to areas around or south of the equator in Africa during the Northerly winter. The moment of sampling may be critical depending on the elaboration of the work hypothesis.

W.C. Bohlmeijer, MD, psychiatrist