1. Is health education a useful tool for EH Officers? LCDR Troy Ritter, REHS, MPH, DAAS  907.729.5683  tlritter@anthc.org

2. Effectiveness of EH-related health education programs A 1990 review of over 500 EH health education programs found only 3 that provided evidence of behavior change A 1999 review applied the same methodology for the 1990-1999 and found similar results “…a depressing picture of very little behavior change for a lot of invested resources.”

3. Amygdala (fear) Cortex (Logic & reasoning) Hypothalamus (information entry-point) This is you our brain on change

4. Hope for success *Curtis V, Kanki B, Cousens S, Diallo I, Kpozenhouen A, Morike S and Nikiema M. Evidence of behavior change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization 2001; 79: 518-527. A 2001 publication demonstrated increased hand washing and provided recommendations for future success.

5. Education vs. Promotion Education: –Involves giving people information in hopes of raising awareness –Is most effective when people simply don’t have the information needed to make healthy choices –Assumes no other barriers to action Promotion: –Combines provision of information with modifications to the environment and/or policy

6. Education or promotion?

8. Formative Research “A common theme among newer [more successful] programs is the critical importance of knowing the audience and developing targeted programs for that population.” *Figueroa ME & Kincaid DL. Social, cultural and behavioral correlates of household water treatment and storage. Center for Publication HCI 2010-1: Health Communication Insights, Baltimore: Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs.

9. Questions for formative research What are the risky practices? Who carries out the risky practices? What are acceptable target practices? What do people like about the target practices? How do people get information?

10. An Alaskan Challenge Government programs have invested about $3 billion to establish potable water service in Alaska Native villages. Many residents continue to drink untreated water.

11. Summary of formative research findings 87% of households (n=210) reported consuming untreated water. Six motives for drinking untreated water. Patriarch makes water use decisions for the household. Most people get information from sources within the village.

12. Thematic analysis: analyzing the qualitative data Chemicals (46%): "We don't like chemical water." Taste (45%): “River water doesn't taste like slimy treated water." Health (27%): "Too much [treated water] will kill anybody.“ Cost (18%): "You have to have money to buy treated water." Access (17%): "Water points are too far from home." Tradition (9%): "That's how we were born and raised." O&M (sub-theme): “I know the guys that do the testing...”

13. Focus on educating women Recruit influential women elders Highlight training and competency of WPOs Target barriers of “chemicals” and “health” Address both sides of the dichotomy Using formative assessment to develop the Promotion Plan

18. Evaluating Behavior Change Programs

19. Pre-and post surveys to determine behavior change * P-value <0.0001 *

20. Post-intervention structured interviews “We haven’t gotten sick in a long time. My son’s kids hardly get sick and they drink treated water.” “People never use river water anymore because it’s bad.” When we drank from the river, we used to have sickness. [We have] less sickness than when we drank river water.” “[Treated water is] too good. I quit drinking river water.”

21. Health outcomes: infectious diarrhea

22. Conclusion Is health education a useful tool for EH Officers? In the absence of physical or economic barriers, carefully designed and executed programs based on formative research can be successful.

23. “Does water ever take a nap?” Calie Ritter, age 6