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Health Education

Beate Blättner

(last update 20 December 2014)

Health education concerns the organized learning and developmental processes that allow us to influence those factors that determine health status; in other words, to influence our life circumstances and our health behavior (determinants of health). Health education has the goal of affecting how we perceive healthy living and how we communicate this idea in the context of our social surroundings, how we react to and how we cope with health issues. Also involved are strategies for dealing with life circumstances (cf. Figure 1). Health education expands the range of action of individuals and groups with respect to health matters by providing them with suitable skills.

Figure 1. Ways in which health education can be effective. Source: own depiction.

Figure 1. Ways in which health education can be effective. Source: own depiction.

The term health education emphasizes the self-determined nature of well-informed and independent subjects living under specific circumstances that they are able to help shape. This approach dissolves the conceptual dichotomy of prevention on a relationship and a behavioral basis. Rather, health education is concerned with behavior as a form of social interaction, not just with modifications to behavior. Health education implies that there is a process going on that enables people to make use of their increasing power to decide and act of their own accord. However, it differs from the term empowerment in that it also describes less the informal and more the formal learning processes.

Since the mid-1980s the concept of health behavior has been largely seen in the scope of adult education centers, which has contributed to a concentration on the learning and educational processes that are part of overall health promotion. One catalyst in this process was the criticism directed at the mechanistic view of human affairs - at a solely preventative pathogenetic orientation and at a reduction of health education to behavioral concerns. This criticism first led to the exclusion of pedagogic contributions to the conceptual development of health promotion, whereas the practice of health promotion was dominated by pedagogical measures.

The development of the term “health education” occurred parallel to the creation of the Ottawa Charta in a workgroup supported by the German Association of Adult Education Centers, to which the Federal Centre for Health Education (BZgA) belonged. The result was the 1985 “Master Plan for Health Education at Adult Education Centers,” which served as a basis for the quality development of health education at the German adult education centers for over 30 years. The ensuing pedagogical discussion understood education in the sense of “Erziehung” to be the attempt at steering the attitudes and behaviors in the socialization of an individual; education in the sense of “Bildung,” on the other hand, focused on the processes and results of self-determined, individual processes and acquisitions as part of personality development. Thus, the latter concept of education agrees more with the idea of health promotion and the emphasis placed on self-determination found in the Ottawa Charta than does the former definition. A second milestone in the conceptual development was a congress held by the Association of Adult Education Centers in conjunction with the WHO, which as part of its preparation and execution was concerned with narrowing down the definition of the term to reflect the discussions going on around the world on the subject of health promotion.

That the concept of health education would receive so much conceptual attention at the adult education centers may be traced back to their historical roots. At the beginning of the 20th century the adult education centers held to the view that all societal groups should participate in social life. The adult education centers were thus structurally predestined to seize on the new social developments that came along particularly in the 1970s and 1980s, such as the women’s liberation and ecological movements. Thus, self-determination and participation became integral parts of their understanding of education, which was above all directed toward building the competences of those concerned.

The theoretical suggestions concerning education that emerged in the following years tended to emerge from the pedagogical reception of constructivism and systems theory. These theories negate the possibility of establishing goal-directed and foreseeable pedagogical interventions; rather, they emphasize the influence of social systems on learning processes - and thus also on the learning processes involved in health matters. In this sense, interactions in social systems are not (pre)determinable but highly dependent on the respective context. Putting these theoretical approaches into practicable concepts in adult education, however, is limited by the formal conditions found in organized educational processes. The political decisions made in the realm of education caused adult education to be concerned more with market necessities, which in turn led to a conceptual fuzziness. On the other hand, the strong leverage present in adult education led some authors to differentiate education in the sense of “Bildung” and “Erziehung” solely on whether it was concerned with adults or with children and adolescents, respectively. The conceptual framework faded into the background.

Although the conceptual basis is much broader, in recent years the actual demand for courses in health education has become limited to the promotion of physical activities and coping with stress through relaxation techniques. Even questions surrounding maintaining a proper diet have receded. Of course, many different interests may lie at the crux of this development.
Presently the following may be considered the tasks of health education:

  1. Both men and women need to be equipped with the skills necessary to allow them to find their way through the jungle of modern healthcare. They must be able to make decisions concerning their consent to preventative, curative, rehabilitative and caretaking measures, based on the information they have acquired in their interactions with the healthcare system. They must be able to adequately work together with health workers to overcome in particular chronic diseases. To this end, health education has established its own independent organizational structures that are presently used overproportionately by women. In this context pedagogical concepts and insights are discussed less than are matters concerning the evidence of statements and the transparency of informational sources. In addition to their contributions to the course of recovery, chronically ill persons and their relatives also contribute to the biographical and practical as well as organizational tasks of connecting the three approaches.
  2. Education is a central indicator of quality of life, morbidity and mortality. The high correlation between health-based outcome and education may be traced back only in part to factors such as income and social status. Rather, education appears to have a greater influence on which strategies are chosen when establishing one’s own personal life circumstances (including health concerns). What is necessary is the ability to influence the central organizational tasks in everyday settings (so-called Setting Approach) as well as to participate in the social discourse concerning how we choose to live and how we view the values and norms of society. This type of learning process belongs to the mandate of learning institutions of all kinds, though they must strive in particular to reach those who otherwise have little access to formal education. Organizing and designing such participatory processes in the sense of health promotion in the respective settings as well as promoting empowerment processes are the prototypical tasks of health education. Seen in the light of gender equality, however, it is also interesting to note that today women are achieving better school qualifications than men, whereas the creative processes are still being dominated by men.
  3. Both men and women are in need of skills that enable them to decide whether, when and how they can adjust their everyday behavior to ensure their health status. The goal cannot be simply to base every decision on whether it affects their health, nor can the goal be to ignore possible health hazards. Rather, what is needed is (a) knowledge about the possible health effects of one’s behavior, (b) the skills to carry out such actions (e.g., the ability to make one’s own meals or to balance oneself on a bicycle), (c) when faced with complex circumstances and insufficient information the ability to make decisions that affect one’s health, (d) the ability to communicate these decisions within one’s direct social environment, and (e) the ability to acquire on one’s own all necessary information. These skills are still more likely than not the domain of women, whereas men tend to lag behind. However, women are presently “catching up” with men in their adoption of health-damaging behaviors (e.g., smoking).

A central point of criticism of the practice of health education lies in the empirically backed finding that learning activities that are organized on a volunteer basis tend to be attended more by women with a higher level of education and relatively low levels of health deficits ( equal opportunity). The high number of female participants was an early impetus to develop a clear conceptual focus of health education toward the needs of women as a contribution to gender equality (gender-conscious health promotion/gender mainstreaming). In recent years there has been an increased effort to address the needs of men. Also, there have long been conceptual efforts to reach people living under difficult social circumstances with offers of health education, although these efforts quickly reach both structural and financial limitations. Organized learning processes for adults are generally based on voluntary participation and thus primarily reach those groups that are directly open to such offers and otherwise generally have access to education - not the demographic groups with the greatest needs. For this reason health education can make only a limited contribution toward offsetting social inequalities in health concerns (equal opportunity).

Recent studies have concluded that health competence ( health literacy/knowledge-based health competence) is deficient in large portions of the population. This may lend the discussion of health education a new facet in the future. In adult education health competence is understood as part of overall life skills and not as the ability of patients to properly judge their treatment alternatives. New impulses will arise from the expanding use of the internet as a forum for digital prevention.

The discussion surrounding the definition of health education in the sense of “Bildung” and “Erziehung” is primarily being held in the German-speaking countries. In English, the term “health education” comprises both German concepts of these educational processes. Further, the adult education movement, as was present in Scandinavia and the German-speaking countries of Europe, played no role in the Anglo-American countries. The closest concept in the Anglo-American countries may be found in the discussion of the term health literacy (= the creation of health-based skills) as part of the overall discussion of health education. The term health literacy is related to that of empowerment in as much as it extends the definition to include whole communities and groups in the learning processes. Wulfhorst and Hurrelmann (2009) consider the delineation of the terms “Gesundheitsbildung” and “Gesundheitserziehung” to be historically founded. They suggest employing the term “Gesundheitserziehung” as the standard German translation of the English term “health education,” which would then exclude some of the conceptual aspects found in the German term “Gesundheitsbildung.”

Arbeitskreis Gesundheitsbildung, Rahmenplangesundheitsbildung an Volkshochschulen, Pädagogische Arbeitsstelle des Deutschen Volkshochschulverbandes, Bonn 1985.
Blättner B, Paradigmenwechsel: von der Gesundheitsaufklärung und -erziehung zur Gesundheitsbildung und -förderung, in: Weitkunat R/Haisch J/Kesseler M (eds.), Public Health und Gesundheitspsychologie, Verlag Hans Huber, Bern 1997, 119-125.
Blättner B, Gesundheit läßt sich nicht lehren: professionelles Handeln von KursleiterInnen in der Gesundheitsbildung aus systemisch-konstruktivistischer Sicht, Klinkhardt, Bad Heilbrunn 1998.
Blättner B/Borkel A/Venth A, Anders leben lernen. Beiträge der Erwachsenenbildung zur Gesundheitsförderung, DIE, Frankfurt/M. 1996.
Wulfhorst B/Hurrelmann K, Gesundheitserziehung: Konzeptionelle und disziplinäre Grundlagen, in: Wulfhorst B/Hurrelmann K (eds.): Handbuch Gesundheitserziehung, Verlag Hans Huber, Bern 2009, 9-34.

Internet addresses:
www.berlin.de/vhs/kurse/gesundheit/leitbild.html (Berlin Adult Education Centers)

Links: Setting Approach

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Federal Centre for Health Education (BZgA) / Maarweg 149-161 / 50825 Köln / Tel +49 221 8992-0 / Fax +49 221 8992-300 /
poststelle(at)bzga.de / E-Mail for Orders: order(at)bzga.de

The Federal Centre for Health Education (BZgA) is a specialist authority within the portfolio of the Federal Ministry of Health.