Health and Adult Learning

Generally absent until now from the International Encyclopedia Education, the theme adult learning and health is taking momentum in many countries as well as in international multilateral networks (UNESCO, 1997; US Dept. of Health, 2000; ICAE, 2001; WHO, 2005b). The growing recognition of ‘‘health as a basic human right’’ and the appeal for ‘‘relevant, equitable and sustainable access to health knowledge’’ (UNESCO, 1997), as well as the crisis of the welfare state, particularly with regard to health systems, is driving up the social demand for lifelong health education throughout life.

A new policy context is emerging linking health and lifelong learning policies. The call for Health For All, heard increasingly over the last two decades in multilateral organizations (European Commission, 2004; WHO, 2005a) finds growing legitimacy in positioning health as a key aspect of human development. In 2000, for example, the United Nations Economic and Social Council adopted a resolution recognizing the right to health, a state of physical andmental well-being, as ‘‘essential to the exercise of other rights.’’

However, the attainment of this overall objective and of the more specific health-related Millennium Development Goals (to reduce infant mortality, improve maternal health, and fight world pandemia such as HIV/AIDS, malaria, and tuberculosis) could be severely hampered if the increasing cost of current curative policy cannot be controlled and the productivity of the health system is not improved. Researchers and policymakers are exploring ways to solve this predicament by pursuing the Health For All objectives while paradoxically searching to curb the increasing demand for curative services. One of the key responses to this contradiction has to do with adult learning.

Two major trends are emerging linking health and adult learning. First, health promotion is increasingly acknowledged as a critical component of health policies. It refers to the documented impact that general levels of health competency and knowledge have on both the social demand for health and the cost of curative services among different strata of a population.Health literacy and health promotion thus becomes mounting issues in national health policies. A second significant tendency relates to continuing medical education of health personnel. Intensive research and development in this domain is transforming the long-existing perspective and practices within medical and paramedical professions and, as a result, may turn medical and nursing continuing education into a prototype of a much larger trend in continuing professional development (CPD) among other professions and occupations.

Health Literacy

In a time when an ever-growing part of public budgets is allocated to health services, the rapidly increasing need for healthcare tends to change the relations between health professionals and the public. In the context of a welfare state, already under pressure from neoliberal forces and now confronted by a continuously growing demand for healthcare services, the former pattern of interrelation between health professionals and patients is increasingly under time and economic pressure. Medical doctors, nurses, and therapists have less time available to spend with each of their clients who at the same time tend to question their traditional identity as patients. The tendency is, on the one hand, to reduce direct contact time by passing on more information through printed or electronic communication (pamphlet of information about the preparation of a coming surgery or treatment, instructions on direction for use of prescribed drugs, public vaccination campaign, information on preventative measures) and, on the other hand, to acknowledge ambiguity in past modes of unilateral relation between professionals and the public.

The trend toward written communication has the unexpected consequence of relying on people’s capacity for initiative to be informed sufficiently and properly, and it does so without fully recognizing the impact of uneven distribution of health cultural capital. A mismatch is thus being created in these new healthcare systems between the growing complicated demand with which national health systems are confronted, and the average basic competency of the public for whom more selfgathering and treatment of information is required (Rudd et al., 2004).

This unspoken transition in the mode of interaction between health professionals and people is bound to produce inequalities and puts at risk the attainment of the Health For All objective. In such a context, equitable and sustainable development of health literacy and health-related adult learning in general may become a key element of future public health and lifelong learning policy.

Of course, the association between formal education and health status is known in both developed and developing countries (Kickbusch, 2001), as well as between adult learning and socioeconomic benefit. What is new is the impact of various levels of health skills and knowledge on health condition. Health literacy represents the cognitive and social skills that determine the curiosity and ability of individuals to gain access to understand and use information in away that will promote and maintain good health. It involves the ability to judge, sift, and act in the context of one’s own life on the information provided (Kickbusch, 2001).

New inquiries on health literacy and more precisely on the direct assessment of people’s health-related basic skills and knowledge are revealing a relation between levels of such competency and levels of education and income (Murray et al., 2007). According to these surveys, between a third and half of all adults in postindustrial societies struggle with low levels of health literacy, a percentage much higher among the aging population. They have difficulty understanding and acting on currently available health information.

Health literacy levels tend, in many ways, to influence people’s ability to benefit from healthcare and to prevent illness and avoid pandemic diseases. It affects the capacity to discriminate information printed on drugs or food labels, to search and use accessible information in order to prevent sickness. Health literacy also has an influence on the ability to navigate into the labyrinth of current healthcare services. This has to do, of course, with the capacity to read written dietary or medical advice, complete open entry forms, understand complementary professional advice given on paper, grasp the importance of danger notices found on domestic product packaging, access critical information on health and safety at home or at the workplace, and to read about disease prevention.

However, health literacy is more complex. It means not only to read messages, but also to interpret them and proceed accordingly in one’s specific life context. It means to be able to draw consequences from consent forms, deal with health alerts conveyed in the media, and detect in one’s own immediate environment early signs of emerging sickness. It means to have skills to interpret symptoms and be able to tell a professional one’s health story or the story of a family member in order to inform him appropriately. Health competency is needed also to benefit proactively from preventive services operating increasingly through distance communication. Thus, health literacy impacts directly on the accessibility of the health system through people’s capacity to get, screen, and mobilize information now mostly delivered not only in print, but also in a more diffuse way, through broader consequences of cultural and educational advantages or disadvantages throughout the life course.

Medical journals are beginning to address this issue. Uneven distribution of health competency is challenging not only the functioning of current healthcare systems, but also its universal accessibility (Sentell and Halpin, 2006; Somnath, 2006; Paasche-Orlow et al., 2006). The practice of including an adult literacy variable in health disparity research is increasing; it reduces the explanatory power of the already known variables (Nutbeam, 2000). Because health literacy significantly affects people’s health and the ability of a system to provide effective quality healthcare (Institute of Medicine of the National Academies, 2004), it is of no surprise that growing awareness on the impact of heath literacy is giving new impetus to the already well-known domain of public health. Health promotion comprises efforts to enhance positive health and prevent ill health, through the overlapping spheres of health education, prevention, and health protection (Downie et al., 1990), and it is often centered on lifestyle diseases. However, following the horizontal perspective developed in health literacy, health promotion tends now to be extended to the full continuum of healthrelated activities and tends to rely more on interactive communication and adult learning approaches (see, e.g., Davis et al., 2003b, 1999).

We observe, in the last few decades, a diffuse but growing demand for health-related adult learning, either through structured activities or through supported and nonsupported self- and informal learning. Associated with shifts in attitudes and behaviors during adulthood, participation in adult learning is seen as an important element of health prevention policies (Feinstein and Hammond, 2004). A growing number of study circles in Nordic countries (Swedish National Council for Adult Education, 2005: 24–26) and already nearly one-fourth of night courses in the German adult education centers are related to health issues (Reichart and Huntemann, 2006; Nuissl and Pohl, 2004). A similar emerging trend is observed in adult literacy where some education ministries are introducing health and hygiene modules in their adult literacy programs (ICAE, 2001). Studies on informal learning in Canada indicate similar content interest (Livingstone, 1999). National health departments are developing evidence- based health education programs (Bartholomew et al., 2001). They are setting up nutritional education programs, environmental sanitation training, prenatal courses, etc. Studies are made on patterns of health information handling in order to improve health education interventions (Zanchetta et al., 2007; Kok et al., 2004; Zorn et al., 2004).

However, health literacy is more than functional; it means more than transmitting information and developing skills to be able to read pamphlets and successfully make significant appointments with physicians. It is also to be interpreted in the emerging expectation of people to participate in decision making related to their own health and to follow through on these decisions. In discourse and research on literacy in general, and also in health literacy in particular, we observe ‘‘a new introduction of humans as active agents in the construction, negotiation over, and transformation of their social worlds’’ (Barton et al., 2000: 5). Some refer to this as a paradigm shift from pathology to empowerment (Shernoff, 1997). Hohn (2002), a wellknown author in this field of health literacy, refers to ‘‘empowerment health education.’’ The reality of health literacy is complex in another dimension. Current health literacy skills assessments tend often to ignore the multicultural dimension of health reality, the many social health literacies (Street, 1995), the popular knowledge, ‘‘the different medical traditions’’ and complementary ‘‘local ways of healing’’ (UNESCO, 1997: 6). In that sense, interactive and critical health literacy does not focus only on compliance, it relates to the autonomy of the subject, with the capacity of a local community to act on their health conditions, with people better equipped to overcome structural barriers to health (Nutbeam, 2000) and modify the relation between professionals and the subjects.

Aware of the important gap between the complexity of current health materials and the basic skills of the intended public (Rudd, 2004), public health agencies are looking not only on people’s capacity to participate in this evolving system, but also on communication and practice of institutions and health personnel. Public health agencies tend to revise accordingly their information–education–communication (IEC) plan. Communication strategies are developed using plain-language or clearcommunication approaches. In the same perspective, new continuing education programs are created to help physicians, dentists, and nurses better interact and communicate with their various patients. Some journals of continuing medical education (e.g., the American Journal of General Internal Medicine) are even proposing proxy measures or screening items to help professionals identify patients with limited health literacy skills.

The issue of the various levels of health literacy and more broadly of its consequence on equity, quality, and productivity of health services is making a big push for stronger investment in health-related education and adult learning, particularly in low-income communities (Rudd et al., 2004). Paradoxically, the recommendation of WHO to allocate 5% of national health budgets to health promotion, prevention, and education may put a strain on the already tight public finances, but in the long term may be the best strategy to bend demand for curative services as well as reduce the cost of those services precisely among people at risk. In this new context, prescription of learning (Institute of Medicine of the National Academies, 2004; James, 2001) may well become an integral part of national health policy: prescription of lifelong learning not only among the public, but also among the professionals. Already in 1986, WHO insisted, in its Ottawa Declaration, on the necessity of a two-pronged approach: individual participation and structural change. People cannot assume more responsibility for more aspects of their health without more protection and better opportunities to improve their health competency (Gruman, 2003).

Professional Continuing Education in the Health Sector: In Transition

Professional continuing education is in transition (Cervero, 2001), particularly in the health domain. It is one of the fastest growing areas of adult learning. The number of hours spent on continuing education activities in the course of both medical doctors and nurses’ occupational careers, after their certification and licensure, tends to exceed the duration of their initial education and training (Davis et al., 2003a). In many countries already, taking part in continuing education has been made obligatory for professionals and conditional to keeping their certification. Continuing medical education (CME) has become an essential effector arm in complex healthcare systems (Davis et al., 1999). The demand for continuing education among health professionals is expected to grow even further. The accelerating pace of clinical and biopharmaceutical or medical research as well as of epidemiological studies requires doctors and other professionals to update their knowledge on indicators of disease predictability and on new practices or medication. It explains in part the growing demand for continuing education. Indeed, more than 80% of physicians as well as nurses of the coming decade have already left universities or colleges and have terminated their initial education. In fact, CME has already become in the United States alone an industry producing more than $3 billion of activities every year. CME has even become a recognized international discipline (Davis, 1998) with its scientific journals like the Journal of Continuing Education of Health Professions, the Canadian Journal of Continuing Medical Education, and the Journal of Advanced Nursing.

What is of particular interest in the continuing education of health professions is not its expansion, which constitutes a trend that one could observe, though at different pace, in other professional fields, together with the typical diversity of the education agencies involved.

More significant is the shift in orientation of activities within the health sector. Up to the mid-1990s, CME activities tended to take the form of obligatory or voluntary information and formal education sessions aiming at updating knowledge among field practitioners. The logic of action tended to be one of passive dissemination of information and knowledge transfer in order to keep professionals up to date with the recent developments in their field of practice (Bero et al., 1998).

Particularly because CME, together with the continuing education of nurses, became an intensive area of activities involving a growing amount of financial resources, many studies have been requested to assess the acceptability and effectiveness of prevailing approaches (Thomas et al., 2006; Davis et al., 2003b, 2003a, 1999, 1995; Elwyn and Hocking, 2000; Brigley et al., 1997; Kok et al., 1997). Various aspects were scrutinized: continuing education practices, knowledge transfer, impact of various formal and nonformal strategies, contexts and conditions differently conducive to efficient linking between CME and practice, uneven circulation of clinical and scientific knowledge, as well as required alteration of initial education.Most of these assessments came to the same conclusion: formal and didactic transfer of information tends to have low educational value. They have little effect on professional practice. Attendance at passive educational events, even when reaching most practitioners through incentive, tends to have limited impact on individual practice and on the activity of health services involved.

Since then, a shift of orientation is taking place with new approaches being assessed for their impact not only on upgrading the knowledge of practitioners, but also on their daily practice as well as the operation of medical units and clinics. The aim is to make interventions relevant to the identified individual and organizational needs (Elwyn and Hocking, 2000). Some researchers have translated this change as a transition from CME to CPD (Du Boulay, 2000; Peck et al., 2000). Essentially, what is going on is a shift in logic of action through which priority is given to supporting individual professionals in the ongoing development of their capacity to act, observe systematically, gather evidence, and co-produce research or at least be able to discriminate in one’s context new knowledge relevant for one’s practice. Then, validation and certification could be done but a posteriori, separated from the situated learning process.

Such approaches tend to be more tailor-made, more situated in their content and in their process, referring to both the perceived needs of professionals and local organization’s demand. The input of recent scientific evidence produced by research networks remains central, but the question raised concerns the mobilization or appropriation of such external knowledge and its transfer into new capacity for action. However, such transition takes time and, even though more effective approaches have been proven, use of least-effective approaches still continues (Bloom, 2005).

A recent trend has emerged trying to create organic links between scientific institutional research, clinical observation, and practice. The aim is to connect more closely formal research agendas with questions emerging from practice, while simultaneously training field professionals on evidence-based medicine (Cusick and McCluskey, 2000), and offer advice and guidance to practitioners interested in research (Bateman and Kinmonth, 2001). This shift of orientation, bound to take place eventually among other professions, is happening earlier among the health professions for many contextual factors. The first one, already mentioned, is the huge investment in time and money that has been made in CME. This considerable effort has urged agencies to assess its impact. The result was to look for CPD strategies that could be less focused on logic of education supply then on logic of individual and organization demand.

The very specific nature of practice in health professions and of its recent developments has also played an important catalytic role in its shift of orientation. First, the context of health service is changing. The multidisciplinary profile of today’s health personnel (doctors, nurses, therapists, epidemiologists and sociologists, physical educators, dieticians, social workers, learning advisers, etc.) in clinics or hospitals, together with the increasing cooperation required from different departments (health, education, industry, sport, social affairs, etc.) raise questions about the monodisciplinary orientation of traditional CME and, more importantly, have put the focus on cooperation between these different content and agency inputs. Second, the relationships between health professionals and among health professionals and the public are changing.The health profession is relational in character; it is a profession of contact. At the core of their practice, health professionals have to relate directly with people coming from all social strata; they are working in close proximity with the general public. As such, this relational character is not new; the relation with patients has always characterized the practice of these professions.What has changed is the nature of these relations through external pressure to request more autonomy from the public, and through rising aspirations of patients to have their say and negotiate their life course, more so when it encounters health problems.

The reduction of time available in the relation between professionals and patients has tended to integrate health professions in a wider web of specialties. It has also created a demand for more capacity of initiative among a public having various levels of health literacy, with important consequences in daily practice of health professions, and therefore in CPD: necessity to acquire new relational skills and to practice new forms of cooperation with various agencies and professions. Relations between professionals are also changing to take into account social demand coming either from new social movements or simply from genuine aspirations of more literate patients eager to pilot their life, body, and soul. An interesting new phenomenon in this area is the emergence around typical sicknesses or pandemics of networks of patients and patients’ relatives or peers who look for new information and review research reports in order to validate diagnoses, explore and suggest new therapies, and even discriminate, in given diagnoses, between scientific evidence and cultural bias. A good example is the role of gay movement supporting their members in their relations with health professionals more so at a time when research on AIDS was proposing various curative procedures and some interpretations of AIDS occurrence amounted to discrimination (Epstein, 1995, 2000). The same can be said about the role of the women’s movement questioning the handling of breast cancer (Lantz and Booth, 1998). Becoming credible participants in the process of knowledge construction, these movements, entering a realm traditionally restricted to the medical experts (Kleinman, 2000), bring about changes in the practices of biomedical research and of health professionals; they thus become complementary agencies of CPD.

The continuing education of health professionals, having to practice in such a changing social and scientific environment and being in daily intimate relations with a public also in transition, could not remain an updating unidirectional process. Hence, the shift in orientation of CME toward contextualized CPD was somewhat predictable. Of course, CPD of physicians and other health professionals is not without ambiguity. The interest of the biopharmaceutical industry to promote their brevetted drugs may explain their quasi-predominant role in nonobligatory CME (Relman, 2001). The vast resources involved in this new market tend also to create a tension between a logic of supply in the provision of courses and self-learning kits and the emerging logic, of a more reflexive nature, aiming to integrate more closely ongoing research with the specific concern of each practitioner, clinic, or hospital department.

Conclusion

A shift is emerging in national health policies that tend to balance their historically dominant remedial and prophylactic orientation with new concerns for health promotion and consideration of the health literacy dimension in public health strategies. Similarly, professional continuing development within health professions is reframing professional practices of physicians and transforming their initial and further education career. A timid but steady transition, not unrelated to the tension between functional and empowerment-driven health literacy, is thus taking place from the prevalent health welfare organization to a health participative and learnfare system.

More rapidly developed than in many other professional fields, CME is currently undergoing important changes that may be prototypal of similar developments taking place in other professions and occupations.

These two trends in health-related adult learning are indicative of the enlarged vision of adult learning policy that is currently taking place. Adult learning policy environment has indeed to be rethought and reconstructed; it can no more exclude indirect lifelong learning policies (Be´langer and Federighi, 2000), like the learning component of health policies described in this article. The demand for health-related learning throughout one’s life course both within health professions and among the general public may very well be, after workrelated adult education and training, the strongest forces driving up the demand for adult learning in decades to come.

See also: Wider Benefits of Adult Education.

P Bélanger, UNESCO Institute for Education, Hamburg, Germany

M Robitaille, University of Quebec in Montreal, Montreal, QC, Canada

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