Infusing critical thinking into health education.

Abstract

With the continued interest in, and school-system mandates for standard-based instruction, it is imperative that teachers have the necessary tools to ensure student success. One of the many strategies available to that end is the development of critical thinking skills, and nowhere are these skills more important than in health education. This article provides a review of the meaning and importance of critical thinking to health education and an interactive, practical strategy that uses Bloom's Taxonomy to develop these skills.

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Critical Thinking Revisited

The critical thinking movement, begun more than 20 years ago, places critical thinking as the focus of learning. Scriven and Paul (2004, 1) define critical thinking as "the process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action." Although there are other definitions, viewpoints, or conceptualizations, this one will serve as the basis for this article.

Critical thinking also involves improving one's thinking while thinking, and reasoning things out based on the evidence and reasons given (Paul, 1992). If we expect students to think about their thinking, they must be taught how to both ask and answer thought-provoking questions. Students must first think a problem through before trying to figure it out. To learn content, students must understand the questions and figure out reasonable answers in order to understand the connection between parts of the content (Paul, 2004; Sunda, 2003).

The use of critical thinking skills reinforces the way the brain functions in its capability to acquire and store knowledge. Freire and Shor (1987) and Paul (1990) advocate proactive learning that encompasses problem solving and social issues. Hart (1989) concurs, and further states that good teaching also engages students in reflection and thought (Kies, 1998; Paul, 1990; Shor & Freire, 1987). "The content is in fact learned more deeply as a result of being part of, and relevant to, an evolving thought process. Content comes alive in the form of thinking, and dies when one tries to learn it without thinking" (Celuch & Slama, 1999, 135).

Infusion of Critical Thinking in the Curriculum

Critical thinking is most effective when it is embedded in subjects already taught, not as a separate concept. To use critical thinking effectively, teachers must be willing to give up the limelight and incorporate lessons which are student-centered (Celuch & Slama, 1999; Weinstein, 2000). The infusion of critical thinking skills will enable students to solve future problems, and proficiency in critical thinking is essential to lifelong learning and to dealing with a rapidly changing world (Celuch & Slama, 1999; Sunda, 2003).

According to Elder and Paul (1998, 297), "Thinking is driven not by answers but by questions." Questions help delineate issues, identify problems and define specific tasks. To enable students to deal with complexity and force them to complete the requisite thought processes, specific questions should be posed. These questions include:

1. questions of purpose: define the tasks

2. questions of information: look at both sources and quality of information

3. questions of interpretation: examine how one organizes or gives meaning to information and consider alternative meanings

4. questions of assumption: examine what we take for granted

5. questions of implication: follow where thinking is going

6. questions of point of view: examine one's point of view and examine where one's thinking is going

7. questions of accuracy: evaluate and test for truth and correctness

8. questions of precision: give details and be specific

9. questions of consistency: examine our thinking for contradictions

10. questions of logic: consider how one is putting all thought together. (Sunda, 2003)

It is imperative that teachers stimulate students to ask additional questions to increase their depth of understanding. Questions should be followed by more questions, leading students on a quest for deeper meaning. Crucial to the future success of students in all aspects of personal and professional life is the ability to think critically.

Meeting the National Health Education Standards

In 1995, the National Health Education Standards were developed, and Standard Six identifies health-literate people as critical thinkers and problem solvers. In the furore, the ability to solve complex problems and communicate effectively will be necessary for students to achieve their potential and develop into responsible and productive citizens. The need for students to become lifelong learners capable of using new information and technologies in a rapidly-changing world is recognized by parents, teachers, and future employers alike. Therefore, physical, mental/emotional health, and social health are critical components of a student's ability to learn, achieve, and succeed (CCSSO, 2004).

It is becoming obvious that employees' poor health status negatively affects this nation's economic competiveness. Factors contributing to the decline in health status include poor nutrition and eating habits; inadequate physical activity; accidental and other injuries; tobacco, alcohol, and other dug use; and non-job-related stress. The escalating cost of treating preventable diseases, the loss of productivity, efficiency and work time, as well as increased medical and insurance coverage costs are directly linked to poor health status. Students who develop critical thinking skills at a developmentally appropriate level are prepared to assume responsibility for their own personal health and well-being. This supports one of the goals of Healthy People 2010, a U.S. government program that established health goals for the nation (HHS, 2000). Critical thinkers have developed the requisite skills needed to use quality health care services efficiently and effectively in a world of accelerating health knowledge and disease prevention techniques.

The following strategy is but one method of enabling students to become health literate and critical thinkers. Bloom's Taxonomy provides the basis for this example, and may be adapted to answer the aforementioned questions and modified according to content and grade level. This example may be used as a concluding activity for review of material to assess students' level of comprehension. For each question asked, subsequent questions may be asked by either students or teachers. Examples of Bloom's Taxonomy questions are provided by the authors at the end of this article for elementary, middle and high school grade levels, each with a different health-related topic.

Applying Bloom's Taxonomy in Health Education

The information and technological explosion of the 21st century is especially apparent in the health and medical field. No one can possibly memorize all of the "facts" that are needed to achieve optimal health. However, in addition to "teaching content," today's teachers must also be responsible for developing skills in their students that will allow them to create new, and appropriately modify old solutions to ongoing health risks. The use of Bloom's Taxonomy enables students to synthesize and apply new knowledge and decision-making skills to improve health status and reduce risk-taking behaviors.

Note: Developmentally, elementary children may not be ready to use cooperative groups for this activity. Instead, teachers who have a teaching assistant or paraprofessional may simply divide the class into two groups and facilitate the activity in that manner.

Working in small cooperative groups (middle or high school), this activity uses a cube which must be tossed and caught by students. Handling a manipulative in this manner addresses multiple learning styles--visual, auditory, and kinesthetic. Each side of the cube is labeled with a word representing one level of Bloom's Taxonomy. We would suggest using Velcro so that words may be changed according to content, purpose, and age of students. The example provided is at the middle school level and focuses on the heart and cardiovascular system. Begin by modeling how the activity will be conducted, showing each side of the cube, and explaining how each of the words will be used. The use of the cube will allow students to look at the heart and cardiovascular system at different levels which increases their depth of understanding. Depending on the words selected, critical thinking related to reducing health risks may also be addressed. Demonstrate how the activity begins by having one student gently toss the cube to the teacher. The teacher reads the word facing her/him and then shows it to the class. For example, if "Describe" is the word shown, the teacher would describe the functions of the heart valves. Additional questions may then be asked: What would happen if we didn't have these valves? Do you think one valve is more important than another? Which one and why? If not, why? How can we keep the heart valves healthy? Show each side of the cube, explaining how each of the words will be used.

Note: Prepare several statements/questions for each side of the cube as the same word may "appear" more than once as the cube is caught. The original and additional statements may be prepared ahead of time, placed on a transparency and shown to the class. The teacher may also instruct groups that if a word appears a second time, the student who catches the cube must flip it to a new side.

Place students in cooperative groups (4-5 students) and give one cube to each group. As the cube is tossed, each student who catches it is given several seconds to compose a response. Remaining members of the group are responsible for providing appropriate feedback: complement/congratulate a correct answer, ask for more information or an explanation (for incomplete responses), or correct wrong answers/misinformation. Group members may ask other questions that come to mind as the response is given. As the teacher circulates among the groups, s/he may also ask additional questions which require critical thinking skills and are related to the topic. Process the lesson by reviewing the information provided by the students. Ask the class if there are other areas about the heart and cardiovascular system that were not mentioned and review these. (You may need to give clues to stimulate this discussion.) Discuss answers that differed between the groups, clarify misconceptions, and explore reasons for differences (for example, a group of athletes v. a group of less active students or groups with cultural differences).

Conclusion

Nowhere in the curriculum is the development of critical thinking skills more "critical" than in health education. These skills, learned in school, influence knowledge, attitudes and behaviors. There is nothing more basic than health for the citizens of the future. How these future adults make decisions, choose behaviors and select the lifestyles they lead will have significant impact on the nation's social structure, workforce, production output, and competitiveness. Listed below are examples of how to implement Bloom's Taxonomy using the cube. Questions for exploration are provided for each component of the Taxonomy. These questions may be asked by the teacher or classmates.

Bloom's Taxonomy--Elementary Grades Topic: Germs

1. Name: three parts of your body germs can spread to.

Are there other parts of the body germs can spread to? Which ones?

How can you keep germs from getting on your body?

2. Describe: how someone feels when s/he is sick.

How else can you tell if you are sick?

Do you feel worse with some illnesses than others? Which ones? Why?

3. Show: the correct way to wash your hands.

What would happen if you skipped a step?

Why is it important to wash your hands correctly?

4. Contrast: good germs and bad germs.

What can you do to keep the good germs strong and to kill the bad germs?

How can you tell if it is a good germ or bad germ?

5. Create: a plan for preventing the spread of germs. When should you always wash your hands?

When should you wash your hands at school?

6. Decide: the type of soap to use (or when to wash your hands).

Does it matter what type of soap you use to wash your hands? Why/why not?

What is antibacterial soap?

Bloom's Taxonomy--Middle School Topic: The heart and cardiovascular system.

1. Identify: the four chambers of the heart.

Which chambers are on top and which ones are on the bottom?

Which chamber is the most important? Why?

What does each chamber of the heart do?

2. Describe: the functions of the heart valves.

What would happen if we didn't have these valves?

Do you think one valve is more important than another'? Which one and why? If not, why?

How can we keep the heart valves healthy?

What would happen if one of the valves stopped working?

What are the names of the heart valves?

3. Compute: the number of beats in an hour for a normal heart (80 beats/minute).

What could cause the number beats/minute to change?

What can you do to increase the number of beats/minute?

When you are resting, is it better for the heart to beat faster or slower? Why?

4. Distinguish: between arteries and veins.

What does it mean to have coronary artery disease?

Which of the arteries of the heart do you think are most important? Why?

5. Compare: the heart to a water pump.

What is another machine or piece of equipment that is comparable to the heart?

How is the heart different from these machines or pieces of equipment?

6. Recommend: an exercise to keep the heart healthy.

What is the best type of exercise for the heart? Explain.

How long should you exercise each day to keep your heart healthy?

Bloom's Taxonomy--High School Topic: HIV/AIDS 

1. List: two of the methods for transmission of HIV.

What are the remaining methods for transmission of HIV?

Which method is most common for adolescents? Why?

2. How: can HIV be transmitted through blood?

What tests are conducted to determine HIV status?

What are the tests looking for?

3. Show: the relationship between the spread of STIs and AIDS.

What behaviors are common between the two?

How does each affect the immune system?

4. Separate: myths from facts regarding the transmission of AIDS.

Why would these myths be associated with the transmission of HIV?

How can you overcome the perpetuation of these myths?

5. What: steps could an adolescent take to prevent the transmission of HIV?

What is the most effective way to prevent the transmission of HIV?

How would you decide which prevention method is best for you?

6. Weigh: the consequences of beginning sexual intercourse at an early age, having multiple partners, engaging in unprotected sexual intercourse versus abstaining from sexual intercourse until marriage.

What could influence your decision to become sexually active?

Would you tell your partner that you were HIV positive? Why/why not?

Why does having multiple partners put you at risk for HIV?

References

Broadbear, J.T., & Keyse, B.B. (2000). An approach to teaching critical thinking in health education. Journal of School Health, 70(8), 322-6.

Celuch, K., & Slama, M. (1999). Teaching critical thinking skills for the 21st century: An advertising principles case study. Journal of Education for Business, 74(3), 134-9.

Council of Chief State School Officers. (2004). Assessing Health Literacy: Assessment Tools for High School Teachers. 2nd Ed. Santa Cruz, CA: ToucanEd.

Elder, L., & Paul, R. (1998). The role of Socratic questioning in thinking, teaching and learning. The Clearing House, 71(5), 297-301.

Joint Committee on National Health Education Standards. (1995). Atlanta, GA: American Cancer Society, Inc.

Kies, D. (1998). Developing critical thinking through probative questioning. Reading Improvement, 35(2), 80-9.

Paul, R. (1990). Critical thinking: What every person needs to survive in a rapidly changing world. Center for Critical Thinking and Moral Critique. Rohnert Park, CA: Sonoma State University.

Scriven, M., & Paul, R. Defining Critical Thinking. National Council for Excellence in Critical Thinking Instruction, 1. Retrieved June 15, 2004, from http://www.criticalthinking.org/University/defining.html

Shor, I., & Freire, P. (1987). A pedagogy for liberation: Dialogues on transforming education. South Hadley, MA: Bergin and Garvey.

Sunda, R. (2003). Thinking about thinking: What makes a good question? Learning and Leading with Technology, 30(5), 10-15.

U.S. Department of Health and Human Services (2000). Healthy People 2010: Understanding and improving health. 2nd Ed. Washington, DC: U.S. Government Printing Office.

Weinstein, M. (2000). A framework for critical thinking. High School Magazine, 7(8), 40-3.

Ellis, Ph.D, CHES; is Assistant Professor of Health Education, and Miller, Ph.D., CHES, is Professor and Coordinator of Health Education.