Portuguese Catholic University
Abstract – This article outlines the impact that adult education can have on our health. It is time to place preventive healthcare education in the same category as literacy and numeracy, and to re-evaluate the importance of lifelong learning for our survival.
Every country around the world faces major problems over managing their healthcare systems. This is so in some countries because they lack the economic, technical and human resources to provide their populations with appropriate levels of care. Others have vast service provision networks endowed with highly-qualified professionals, but are not able to keep up with the financial requirements, given the nature of the prevailing “summative innovation”, which implies that every advance and innovation results in increased costs.
There are countries spending a lot of money on healthcare. They tend to have well-equipped hospitals, with the United States heading the field in this group. In spite of this, they do not obtain healthcare results and indicators that are as good as other countries which spend less than half as much, with European countries being the most known of the latter case.
In other words, healthcare-related issues cannot be reduced to a question of resources. Putting more money and resources into the classical model only guarantees the maintenance of performance in terms of health indicators, and eventually a slow decline as the population ages.
Simple historical analysis reveals how around 80 % of the progress in health that has been achieved over the last two centuries stems from the mass availability of clean drinking water, good food and hygienic habits. All the panoply of resources sunk into medication and establishing networks of modern hospitals is very useful, but this is not where we should look when seeking to take qualitative steps forward in the healthcare of populations. The only exception has been the vaccination campaigns, for reasons to which we will return below.
The scientific literature underpinning the field of disease and public health management conveys how the morbidity profile of any given population may largely be explained by lifestyle and the notion of implicit risk attaching to the behaviours of its citizens.
It is easy to show examples of how lifestyles impact: Around 90 % of type 2 diabetes, the most expensive disease for Western countries’ healthcare systems, can be avoided through educating people about food and diet and combating sedentary life styles. There is an identical situation for many of the circulatory diseases that account for around a third of all deaths in these same countries. Furthermore, many cancers of the digestive tract are susceptible to prevention through minor dietary alterations which involve replacing some higher-risk foodstuffs with other, healthier alternatives that are often also cheaper and more widely accessible.
In the second component, that of the perception or notion of risk-incurring behaviours, we may point to the huge numbers of people who lose their lives or are injured in road, work and domestic accidents, particularly children and young persons. There are also millions of people worldwide experiencing substance dependence on the most varied of products because they were not brought up or educated to grasp the notion that addiction is a disease and that the consumption of addictive products only increases the risk of becoming ill. This simplistic idea does not explain the extent of this reality, but it does reflect the core of the problem.
Thousands of examples might be put forward as regards both lifestyles and risky behaviours, and always with the same final result: undermining the healthcare profiles of both the persons portrayed and their respective populations.
Changing this scenario, which is more than a simple question of resources, represents a political option over the choice of paradigm. We can either keep spending rising sums of money to offset that which has already happened, or we can educate populations so that their health remains as good as is possible, hoping to thereby prevent what may otherwise happen in the future. It is in these terms that adult education constitutes a core healthcare tool for supporting a new paradigm underpinning the state of health through the management of knowledge.
The current health service paradigm fundamentally incorporates a reactive attitude towards the appearance of disease, and receives around 98 % of the total available healthcare budget. Prevention very often fails to expand significantly beyond vaccination campaigns, thus accounting for a very small proportion of state spending that is earmarked for heath.
The idea that citizens must learn health in the way that is already accepted in the case of literacy and numeracy is still lacking. Undoubtedly, while knowing how to read and count are essential facets, being alive provides a pre-condition for even being able to read and count. Therefore, developing healthcare literacy is essential and worthy of the same level of dissemination as both literacy and numeracy. Avoiding a life of dependence or even premature death is far more important than reciting the most beautiful of poems or calculating advanced theorems. There is clearly a hierarchy of priorities, and life is certainly at the top of that pyramid.
The nature of this learning differs from the usual education processes. It is not possible to learn as a child and expect that such knowledge may be used throughout life, as is the case with learning how to read for example. The very nature of health determines that a person is potentially subject to different problems in each different phase of life, coupled with variations not only in the levels and types of social responsibilities, but also in physical and intellectual capacities. Therefore, while we do need basic training and education at younger ages, there is other knowledge that it is only worth providing at later stages of life. For example, there is no sense in educating a child about geriatric care, as decades will pass before such knowledge ever becomes relevant.
Furthermore, knowledge about health has been evolving at a very swift pace, and it is only worth conveying contents that are of value to the user. Healthcare literacy thus becomes an education process that needs to stretch from the cradle to the grave, with each phase of life requiring specific training, be it in the respective social roles that a person plays, or in the specific needs with which he or she has to deal.
This is the reason why adult education is key to healthcare literacy, without underestimating the set of contents that children and young people need to learn.
There is a cycle of nature that must be integrated into the search for answers, and it deals with parenthood. It is necessary to know how to be a parent. If a licence is (understandably) required to be able to drive, why should the necessary learning and education not also be extended in this direction, to becoming a mother or father, which equally represents a major challenge on which the health of the baby depends. For example, a significant proportion of infant mortality might be avoided through small changes in diet and the rapid recognition of danger signs in the baby.
© Shira Bentley
For adults, there is a need to know how to deal with the range of care that a person ends up providing to children, to sick persons in our care (with each disease requiring different types of knowledge in keeping with how caring represents a complex and demanding task), the elderly that we need to support, the notion of risk whenever we are driving or walking along a street, or any of the numerous other risks that we incur daily. A trained and informed citizen will know in his or her later years how to preserve the years of potential life, and especially the quality of life in these years.
To sum it up, citizens educated in healthcare literacy tend to adopt healthier lifestyles, enjoy better mental health, and engage in fewer types of risky behaviour. Faced by illness, they tend to be patients or carers who react in the earlier stages of the disease, mitigating severe situations and intervening in the disease when it is easiest to do so, thereby resulting not only in lower levels of healthcare expenditure, but also better recoveries, both faster and with less suffering.
Adult education aligns very closely with these healthcare goals, standing out as a natural partner. Non-formal and informal adult education are particularly suitable to offer learning at the time when a person falls ill or has sick persons in his or her care. Adult education also provides constant access to the contents deemed appropriate to their particular phases in the life cycle, the social roles they perform and the specific pathologies with which they have to cope. Furthermore, training the elderly holds special relevance, as this is the phase in life when most illnesses emerge, alongside the corresponding needs for managing not only the disease and the medication required, but also everything else that life entails.
Ongoing and lifelong training and education proves equally essential for healthcare professionals. We have long since abandoned the idea that when you gain a qualification in a field of health, you are set up to be a potentially good professional for the rest of your career. Several associations representing the various healthcare professions determined between 2000 and 2005 that a need was arising for regular training and education through formal, informal and non-formal means, as the valid knowledge any specialist receives at one particular moment in time is now out of date within an average of four years. Some associations now stipulate that, in order to retain their professional licences, members have to participate in training on a regular basis (commonly between one and four years) or run the risk of having their licences suspended.
Another aspect in the relationship between health and adult education stems from the SDGs (Sustainable Development Goals). The SDG that specifically targets health contains a total of thirteen objectives to be attained by 2030. Of these, only two do not entail a direct relationship (substantially increase health financing and the recruitment; support the research and development of vaccines and medicines). In three instances, healthcare literacy is absolutely critical to attaining the set objectives: end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases, and combat hepatitis, water-borne diseases and other communicable diseases; reduce by one-third premature mortality from non-communicable diseases through prevention and treatment; promote mental health and well-being; reduction and management of national and global health risks. In the remaining eight objectives, there are differentiated levels of alignment, albeit they are always positive. The conclusion is that the SDGs will only ever be achieved through an active contribution from healthcare literacy.
It is important to note that healthcare literacy is not an issue for the future. This already exists even while still in an initial and early phase, with the exception of vaccination campaigns. What is being done in terms of vaccinations, and has saved millions of human lives, can also be done in the area of chronic diseases, ageing, accidents and addictions.
Let us now consider some brief examples of the developments at our Research Unit that demonstrate how adult education contributes towards improving health and health outcomes.
Adult women returning to education make a very significant improvement to their levels of self-esteem, extroversion and citizenship participation rates1. This study took place in Portugal and involved around 3,500 women. They made their own self-evaluations in relation to a set of indicators covering the three interrelated concepts before and after participating in adult education. The aspects covered self-esteem and extroversion (the two pillars of mental health), demonstrating how adult education contributes directly to improving and preserving mental health.
Oral health in Guinea Bissau. This was a joint project with a specialist oral health non-governmental organisation in the poorest region of Guinea Bissau, the Bijagós Islands. The project established an informal training programme for teachers, mothers (the local ethnic group lives in a matriarchal structure), and relevant social actors, on the importance of good oral hygiene and health. The NGO provided a full-time dentist free of charge who was also tasked with undertakingthe training campaign. This included monitoring some primary school classes on some of the islands. At the end of three years, the project was able to ascertain that the average level of oral health of children in these schools was close to levels in Europe. Furthermore, the teeth brushing behaviours also spread throughout the children’s families. This resulted in new problems, such as every family member using the same toothbrush.
Seventy-one million people suffer from Hepatitis C worldwide. This is one of the easiest diseases to prevent whenever basic healthcare measures are adopted. Twenty-four public healthcare policies have had their effects fully validated, not only in terms of prevention, but also improving diagnoses and the treatment of this disease. This project developed a tool incorporating epidemiological characteristics with the taking of health-related decisions. This was then made available across multiple digital platforms (smartphones, tablets and computers), helping anyone with an interest to simulate which policies are most suitable, to ascertain the level of intensity of their application, and to see how this then impacts on the number of diseases, new outbreaks, the number of transplants, the number of patients requiring treatment, etc.
This type of tool may transform the regular citizen into a potential defender of the best healthcare causes and practices, of particular use to patient associations, decisionmakers, professionals, etc., in order to ascertain whether they are heading down the best path. You may test this out at http://letsendhepc.com. The tool can be downloaded free of charge.
There is a bridge under construction between healthcare and adult education which, once completed, will support qualitative improvements in populations’ general state of health. The sheer potential transforms adult education into the best ally currently available to boost the health of the planetary population.
1 / Study published by UNESCO-UIL (2011), in the book “Accreditation of prior learning as a lever of lifelong learning”, chapter by Henrique Lopes.
Feinstein, L.; Sabates, R.; Anderson, T. M.; Sorhaindo, A. and Hammond, C. (2006): What are the effects of education on health? In: Organisation for Economic Cooperation and Development (ed.): Measuring the Effects of Education on Health and Civic Engagement: Proceedings of the Copenhagen Symposium, 171- 354. Paris: OECD.
Howard, J.; Howard, D. and Dotson, E. (2015): A Connected History of Health and Education: Learning Together Toward a Better City. In: New Directions for Adult and Continuing Education, 145, 57-71.
Kasemsap, K. (2017): Promoting Health Literacy in Global Health Care. In: IGI Global (ed.): Public Health and Welfare. Concepts, Methodologies, Tools, and Applications, 242-263. Hershey: IGI Global.
Keikelame, M. J. and Swartz, L. (2013): Lost opportunities to improve health literacy: Observations in a chronic illness clinic providing care for patients with epilepsy in Cape Town, South Africa. In: Epilepsy and Behaviour, 26, 36-41.
Kunthia, J.; Taniru. M. and Zervos, J. (2017): Extending Care Outside of the Hospital Walls: A Case of Value Creation through Synchronous Video Communication for Knowledge Exchange in Community Health Networks. In: IGI Global (ed.): Public Health and Welfare. Concepts, Methodologies, Tools, and Applications, 603-620. Hershey: IGI Global.
Lopes, H. (2011): Family, a key variable to explain participation in NOI and lifelong learning. In: Accreditation of prior learning as a lever of lifelong learning, 263-318. Brussels: UNESCO/UIL and Menon Foundation.
Lopes, H. (2015): Report of the Project PIVS – Oral inspection of 8,000 children made by MaS NGO. Analisys of efficiency, quality and epidemiology.
Spring, B. et al. (2013): Better Population Health Through Behavior Change. In: Adults A Call to Action. American Heart Association/Circulation, 128, 2169-2176.
UNESCO (1999): Health Education for Adults. Booklet 6-b the CONFINTEA V International Conference on Adult Education. Hamburg: UNESCO.
UNESCO-UIL (2016): 3rd Global Report on Adult Learning Report. Hamburg: UNESCO-UIL.
About the author
Henrique Lopes, professor and researcher of Public Health, works in the fields of Public Health Policies, Health Quality and Health Literature. He has also worked in research on adult education. Currently he is the scientific coordinator of the European research project for Hepatitis C elimination until 2030 “Let’s End Hep C”.
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