Health education:
New opportunities for pediatric practice

By Ian M. Newman, PhD, and Mary L. Breetzke-Augustin, MEd

The pioneering use of a health educator has helped this small, rural pediatric practice realize its medical mission and its business goals. The clinic's experience, the authors assert, can be applied anywhere.

Traditionally, health educators have been employed to provide information in city, county, and state health departments; schools; work-site health and wellness programs; and voluntary agencies such as the American Cancer Society. Today, they are finding their way into the health-care delivery system—into hospitals and health maintenance organizations and, occasionally, into private group practices.^1–3 This article describes the evolving role of a health educator in a private three-physician pediatric practice in a rural prairie community in Nebraska.

Who are health educators?

Health education is a newly recognized nonmedical specialty.⁴ Health educators typically hold at least a bachelor's degree in health education and have passed a nationally recognized examination to become a certified health education specialist (CHES).⁵ Their salary ranges from $32,000 to $37,000 a year.⁶

Health educators have, as noted, traditionally focused on providing information. Today, they design activities specifically to encourage changes in behaviors that will ultimately improve and protect health, either by making treatment more effective or reducing behaviors that could lead to future health problems. Health educators develop educational programs aimed either directly at effecting behavior change or indirectly at changing the environment in ways that reduce risks and promote and support behavior change.

The setting

Hastings, Nebraska, and the surrounding county has a population of 30,000. Like many rural places, the county has no public health department. The health needs of children and adolescents there are met by pediatricians in a private practice clinic and by three family practice clinics. The private pediatric practice serves approximately 16,000 families.

Twelve years ago, the pediatric clinic hired a half-time health educator to help meet patient needs and bring a public health perspective to the clinic and the community. Today, the health educator is responsible for a range of activities that are recognized as essential to the clinic and the community. This experience could, we believe, be replicated almost anywhere.

First step: Surveying needs and interests

Health educators are trained to identify health service and information needs and interests of a population.⁷ One of the first projects undertaken by the pediatric clinic's health educator was to conduct a survey to identify the perceived needs and interests of the clinic's clients. It was distributed by the clinic staff to families as they checked in for their appointment. In addition to health-related questions, the survey asked about such matters as reasons for choosing the clinic, preferred appointment times, and the choice of magazines in the waiting room.

Results of the interest survey indicated that families came to the clinic "for its reputation"; that many wanted appointments late in the afternoon; and that they appreciated the reading materials in the waiting room. Many families suggested a separate waiting room for children and adolescents. The clinic was reorganized to address responses to the survey, and patient satisfaction improved. Why probe the connection between satisfaction and the quality of care? Research suggests that satisfied patients are more likely to adhere to treatment regimens and seek early help when a problem occurs.^8–10 The interest survey has been repeated from time to time; it should be an annual event so that trends can be tracked and responded to.

The adolescent survey. Regrettably, pediatricians do not always see adolescents on a regular basis. Parents do not perceive a need for regular checkups for teenagers, as they do for infants and children. To better meet the health needs of adolescents when they were seen at the clinic, the health educator developed a 27-item adolescent questionnaire and anticipatory guidance sheet. Questions covered the use of seat belts and bicycle helmets; sexual behavior; fears associated with HIV infection and AIDS; and how comfortable adolescents felt discussing health-related and other matters with parents.

Results of the survey suggested that many adolescents did not wear seat belts (30%), were afraid of contracting AIDS and were uninformed about the disease (25%), and did not discuss sexual matters with their parents (54%). The clinic pediatricians used the responses to develop better ways to communicate with teenagers and parents and better understand adolescent health practices. The survey is now given to seventh, ninth, and 11th graders.

The kindergarten survey. A survey was distributed to parents of 5-year-olds at the time of their prekindergarten physical. The 13-item questionnaire asked parents such questions as whether members of the household smoked, whether the family had safety-proofed its home, and whether the child knew one safe person to call in an emergency. The information was used to identify potential problems and health concerns and develop specific health education programs. The survey has been repeated each year.

Improving education: Pamphlets and beyond

Many patient education materials are available for use by pediatric practices. These materials cover a variety of treatment and prevention options. Although they are generally written at a sixth- to eighth-grade reading comprehension level, many—in the form of pamphlets, handout sheets, and even audiovisual materials— still use medical terminology that is difficult for parents and patients to understand.^11,12 To make educational materials more accessible, the pediatric clinic purchased two computer-based patient education programs—Clinical Reference Systems' Pediatrics Advisor¹³ and The American Academy of Pediatrics' Patient Education On CD ROM.¹⁴ In addition, the health educator edited or rewrote a number of pamphlets already in use, based on the need for information uncovered through the findings of patient surveys. Several strategies helped increase the effectiveness and clarity of the pamphlets:

• Providing simple graphs and charts. A chart added to a pamphlet for parents of children having frequent night awakenings, for example, showed parents a behavior modification plan—consoling the child at increasing intervals of one minute, five minutes, 15 minutes, and so on—to help them reach the goal of getting the child to sleep through the night.

• Offering directions geared to the specific environment and culture. Instructions on how to increase the intake of dietary fiber for children who are constipated included specific mention of locally available foods.

• Conducting brief demonstrations to accompany the distribution of pamphlets. Mothers who received a pamphlet on cleaning and wiping their baby during diapering also watched a brief demonstration by a nurse.

In the process of rewriting educational pamphlets, it became clear that patients sought information on topics that were not covered by existing materials. The health educator responded by, first, developing new materials on such subjects as how to foster behavior changes and prevent certain illnesses and, second, producing more detailed instructions on how to solve various health problems. Topics included school problems, learning disorders, temper tantrums, common contagious diseases, and discipline.

The health educator also put together well-baby packets for distribution at the 2-week, 2-month, 4-month, 6-month, 9-month, and 12-month checkups, and is developing brief verbal messages that clinic staff can give to parents when handing them the packets. The packets contain an introduction to normal development and other age-appropriate information—teething information in the 6-month packet and information on giving solid food in the 4-and 6-month packets, for example. A short questionnaire is planned to assess the effectiveness of the well-baby packets.

Educational materials that were most appreciated by patients and parents were those describing clear, specific actions and demonstrating how to carry them out. When a staff member took time to review the materials and demonstrate the actions that were proposed, patient satisfaction and outcomes improved significantly. Follow-up activities, such as telephone calls and mailings, enhanced the effectiveness of the materials.^15,16

Monitoring patient concerns

The health educator routinely monitors patterns of requests for educational materials because this information gives pediatricians and staff insights into patients' and parents' concerns and interests. Adolescents who fill out the adolescent survey can request information sheets on various health topics listed on the questionnaire. The health educator keeps track of these requests and recommends to the pediatricians questions to ask adolescent patients during clinic visits. This has helped improve doctor-patient relations and the quality of care and identify health problems early.

Parents filling out the kindergarten survey also have an opportunity to request educational materials from a list of health topics. Monitoring their selections provides a profile of the interests, concerns, and questions of parents of preschool and kindergarten-age children.

At another clinic where one of us worked, staff monitored pamphlet selection and information requests; this activity, combined with what is known about adolescent risk factors,¹⁷ laid the groundwork on which the physicians developed a set of questions asked routinely of all adolescent patients at the beginning of the office visit. The questions include "Did you wear your seat belt driving to my office today?" and "Have you used alcohol in the last 30 days?" Questions such as "Have you taken a nonprescription drug in the last 30 days?" and—depending on the comfort level of the physician—"Have you ever had sexual intercourse?" could also be included.

Defining measurable goals

The health educator's original responsibilities at the pediatric clinic included bringing an educational emphasis to the clinic and a public health emphasis to the community. To focus the clinic's health education efforts and integrate education into the clinic's provision of quality medical care, the health educator wrote measurable objectives for the education program.

Written objectives were of two types. The first focused on learning outcomes, describing a specific change in patient behavior. For example:

• "Increase the percentage of adolescent patients who routinely use safety belts."

• "Increase the percent of mothers who breastfeed."

• "Increase the mother's confidence in her ability to breastfeed at the 1-month and 6-month visits."

The second type of objective focused on processes or tasks needed to achieve the learning outcomes. Examples of process objectives included:

• The physician asks about seat belt use at the beginning of each adolescent office visit.

• All clinic breastfeeding educators provide consistent, high-quality, behavior-focused training.

• Other clinic professionals reinforce breastfeeding messages at every opportunity.

To achieve the learning outcome objectives on breastfeeding, the health educator involved all clinic staff in reaching the learning goals, developed a breastfeeding teaching protocol so that all five of the clinic's breastfeeding educators taught consistent quality and content, and monitored the process over the course of one year. Although this effort met with staff resistance at first, it did provide better breastfeeding outcomes for mothers and eventually received staff support. Other written objectives addressed HIV and AIDS prevention, hand washing, immunizations, upper respiratory tract infection, simple gastrointestinal conditions, success in school, and parent–child communication.

Developing objectives also aided in making decisions about allocation of time and resources to meet special needs. For example, improving the quality and effectiveness of health education and health promotion materials (pamphlets and checklists) had been identified as a specific objective to be completed by the end of the first year. Focusing time and resources on that goal resulted in better-informed patients (and parents), better physician-patient communication, and more informed decisions by patients about when to seek medical care and what to do before seeking care.

Clinic staff have to deal routinely with clinic management and delivery-of-care issues. The health educator brings to discussions of these issues a fresh perspective—unlike the perspective of staff members who provide direct medical services. The health educator is knowledgeable about, and can offer encouragement on seeking, supportive community programs outside the clinic—such as YMCA and YWCA fitness programs and child safety seat checks sponsored by the state highway patrol—that can contribute to the patient's care and long-term health.

Reaching out to the community

The health educator and clinic staff have initiated several outreach projects, including:

• A "parenting university," which enrolled 25 to 45 parents per class in classes such as School Success; Infant Care Basics; Twos, Toddlers and Beyond; Daddy's A Partner In Parenthood; and Is Your Child Y2K Compliant? The clinic charged a fee for the classes, which were taught at local hospitals by clinic pediatricians and experts from the community. The clinic also routinely co-sponsored speakers for a variety of community events and organizations.

• Lunch-hour work-site education programs for employees of local companies covered such topics as Creating School Success; Developing The Role of The Nurturing Father; Discipline; Adolescent Issues; and Common Childhood Diseases: What To Know About Them.

• Special needs registry. The health educator put together information packages for families of children with special health-care needs. A registry of such children is being developed so that families have access to all available services, including services from outside the county.

• News releases. Because the county has no public health department, private practice clinics are the only source of information on children's health issues. During a typical year, the clinic distributes press releases to the local media on "hot topics." Recent topics included ticks and Lyme disease, changes to the state's motor vehicle law on child restraint, summer safety ideas, and Halloween safety. Although Lyme disease is not widespread, media reports of 30 to 40 suspected cases in the late 1990s (Dr. Wayne Kramer, epidemiologist, Nebraska Health and Human Services System, personal communication, 2002) raised fears among parents. As a result of press releases issued by the practice, media contacted and interviewed clinic staff, which generated publicity for the clinic and led to recognition by the public that the clinic could provide health information as well as medical care.

Grant writing. Successful grant writing is one way private practice clinics can provide services and special programs for patients and community at no cost to the clinic. In one such instance, the health educator obtained a grant from a community coalition to develop and evaluate sexual abstinence and healthy relationship programs for adolescents. Although the grant was for a community-wide program, the materials could also be used in the clinic with patients. Taken together, the community program and the materials for clinic use represented a significant return on the cost of the health educator's time needed to write the grant proposal.

Looking to the future

Clinic management is planning to organize focus group discussions with, and surveys of, middle-class families to assess their needs and interests to identify ways to attract more of them to the clinic. This project was grounded in the observation that patient distribution clustered mainly at the upper and lower ends of the socioeconomic scale with a noticeable absence of the middle group. Clinic staff believe this is because middle-class families perceive the pediatric clinic as more expensive than the family practice clinic and believe that their children only need to see a pediatrician for complicated health problems. The results of the focus groups and survey may suggest ways to reach out to this important segment of the population.

In another new initiative, the health educator, with the help of the local community college, has completed a series of 12 telephone "messages on hold." Patients hear health messages, music, and information while waiting on hold to talk to a nurse or doctor. "Message on hold" topics include:

• Help your child succeed in school by limiting television and video game time to two hours daily or less

• Read with your child every day

• October is National Family Sexuality Education Month

• Ask your pediatrician for more information about health-care concerns

• Think your child can't drown in one inch of water? Always supervise your child near water.

Studies have associated health information lines with increased patient satisfaction and decreased phone calls and visits to the pediatrician.¹⁸ One study suggested that automated telephone messages improved immunization rates, that sending letters followed by telephone messages was more effective than either type of message alone, and that tailoring messages to the population served was important.¹⁹

The clinic plans to use its computer system to examine its patient profiles for additional clues to health education planning and programming. How can the pattern of the most common presenting problems be used to improve clinic-based services, for example, and how can programs to prevent these problems be developed and introduced?

Clinic staff also are discussing the potential usefulness of a Web site. Plans are under way to study after-hours and daytime phone calls to the office with the aim of putting the most-often-requested health information on a Web site as well as in a newsletter. The study could result in a plan to reduce the number of phone calls to the office for information and free the office phone line and staff for more urgent medical calls.

The clinic has submitted a mini-grant proposal to the American Academy of Pediatrics' Community Access to Child Health (CATCH) program to study how to improve care for the growing Hispanic population in the area. If the clinic receives the grant, it will survey a portion of the Hispanic community to determine how to better meet their health needs and provide them with better incentives for following care instructions. The objective of this project is to develop a plan to provide more effective, more culturally sensitive care. The health educator is also applying for a grant to train all staff in customer service skills, interpersonal skills, conflict resolution, and teaching skills to improve patient outcomes.

Counting the costs and benefits

Because the health educator is not involved in the direct delivery of medical services, questions about cost-effectiveness arise. The cost of a health educator must be weighed carefully against the potential benefits. One of the health educator's tasks is to maintain good records of educational programs provided and the results, both tangible and intangible, of those programs. These records can help the clinic answer the inevitable bottom-line questions. So can available studies of the contribution of health education to patient care^20,21 and reports on the creative use of health educators.^22–25

Costs. Obvious costs of a health educator are salary, benefits, and, possibly, clerical support. Nonmonetary costs must also be considered: Pediatricians need to take time to collaborate in project planning to ensure that the clinic's health education and medical care goals mesh. (They also must be comfortable allowing the health educator to work somewhat independently.) The health educator has to take time to develop skills in measuring outcomes and providing project evaluation to the clinic to justify health education costs.

It takes creativity and imagination to accept a health educator as a member of the clinic team. It can take some time for medical staff to understand the benefits of health education and health promotion.

For the lone health educator in a private pediatric practice in a rural area, one of the nonmonetary costs is isolation. The health educator needs opportunities to develop links to professional associations and resources that can provide assistance, camaraderie, and materials.

Benefits. Community programs organized by the pediatric clinic health educator attract new patients to the practice. Clinic programs that promote health and increase the likelihood of a successful outcome increase patient satisfaction and customer loyalty. Many patients have remarked that they appreciate the health education resources and materials they receive from the clinic.

As patients become better educated, they make fewer routine inquiries. This saves pediatricians time on return telephone calls and increases time available for visits. This is an important consideration in a rural area, where pediatricians are in short supply.

The health educator brings an emphasis on prevention to the clinic's staff and medical services. Information that the educator provides at well-baby visits and school checkups increases parents' knowledge and confidence, which, in turn, increases satisfaction with care.

The health educator's knowledge of private and government resources enables grant seeking to offset salary costs and provide more innovative programming. Grant-funded programs described earlier in this article have fostered a perception across the county that the private practice clinic is a community resource for child and adolescent health issues.

A cost-effective asset

As the pediatrician's role is to protect and improve children's health, the health educator works to pinpoint how education can strengthen that role. Health educators, who carry a knowledge of individual and community health issues and an understanding of human behavior and pedagogy, can work with pediatricians and their nursing staff to develop programs to improve health and prevent illness. This, we have found, is particularly important in a rural area, where educational, social, and other medical services, as well as the funding for them, are often scarce. In short, our experience has been that a competent health educator can be a cost-effective asset to a pediatric clinic in a rural area. The same may well be true wherever you practice.

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24. McVea LSP, Vanugopal M, Crabtree BF, et al: The organization and distribution of patient education materials in family medicine practices. J Fam Pract 2000;49:319

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DR. NEWMAN is professor of health education, University of Nebraska, Lincoln. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

MS. BREETZKE-AUGUSTIN is health education coordinator at Children and Adolescent Clinic, Hastings, Neb., the clinic discussed in this article.

Ian Newman, Mary Breetzke-Augustin. Health education: New opportunities for pediatric practice.

Contemporary Pediatrics

November 2003;20:81.