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Community health education: an idea whose time has come

January 28, 2013

Responsibility for provision of public health is transferring to local authorities from April 2013 and this gives an opportunity to press the case for adult education as an essential part of an integrated public health strategy.

Public health is about ‘protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society’. Currently this includes a set of public health priorities around physical activity and diet; things that have a direct effect on millions of people. The impact of obesity, for example, limits the quality of life and increases vulnerability to diseases such as diabetes 2, cancer and stroke.

But these issues do not affect everyone equally. Sixty four years after the formation of the NHS, and forty-two years after the Black report on health inequality, the social gap in health and life chances remains massive.  There is a seven-year gap in life expectancy between the most and least well off areas and, perhaps more striking, a seventeen year gap in disability-free life expectancy.  Shocking really. Surely those figures alone (taken from the 2010 Marmot review, ‘Fair Society, Health Lives’) present a massive case for piling resources into public health measures to engage with and support those who are most vulnerable to life limiting conditions and shorter life expectancy.

I appreciate that the explanation for these inequalities, and hence how they can be addressed, lies deep in the class structure and material life. But the provision and encouragement of preventative measures can make a significant difference and form part of combatting inequality.

Education is a critical part of any preventative strategy. At one level the contribution of adult education to health and wellbeing is  known and accepted. It is recognised in Marmot:

‘Adult Learning improves confidence and self efficacy, increases social capital and leads to positive and substantial changes in health behaviours’ (paragraph B.2.3)

Students on WEA  classes, as well as volunteers, frequently refer to this when advocating the benefits of their programmes. Good adult education provides intellectual stimulation, companionship and a sense of community. Accounts of the support class-groups give individuals undergoing life crises, such as bereavement, are often very moving. Many adult tutors are gifted at developing group exchange and solidarity which is often commented on by students.

All the above are part of the powerful case for sustaining (indeed expanding) accessible publicly supported adult education as an irreplaceable part of civic life.

However my interest here is in arguing the case for specific and targeted health improvement education that can provide people with the skills and knowledge to manage their health in the long-term as well as providing a springboard for social action.

There is ample data on ‘health deprivation’ that enables initiatives to be designed for and with particular groups. For example I was recently looking at data on health deprivation in London; this ranked boroughs according to these criteria: infant mortality, population aged less than 65 who die each year, working age people with limiting long-standing illness, and underage pregnancies.  Additionally there is similar data on smaller geographical areas (super-output areas) that has been used to inform public health policy. There is also good data on class and occupation, gender and ethnicity.

Well targeted and planned educational activity is a valuable contribution to addressing inequality. Along with careful community consultation and involvement, this enables activities to reach those most at risk and engage them in health improvement. This targeting is necessary; universal health campaigns (whilst important and valuable) can actually increase inequality as they are taken up disproportionately by advantaged populations.

What sort of education are we talking about? Here I’m concentrating on very local provision around physical activity of the sort I’m familiar with from the West Midlands. I’ll use the term ‘community gym’ that was developed by the Primary Care Trust in Dudley, working alongside the WEA.

Firstly a community gym is very local taking place in familiar venues used by local residents: primary schools, children’s centres, community centres and other places used by local groups. A programme of the sort run by the WEA in Dudley (or Stoke or Birmingham) would take place in about thirty different venues so that participants didn’t have to travel far and found the location congenial and familiar. This approach based around local partnerships is very well-known to adult educators; it appeals to people who would never, ever, consider a conventional gym.

Yet a community gym can combine the benefits of a conventional gym and adult education. Equipment can be bought quite cheaply (say £1-2k) and stored locally when not being used so a range of activities can be done and adapted to those with particular needs, for instance chair based activities for people with limited mobility. Educational practice with initial and summative assessment  means that exercise activities can be designed for the individual and their progress monitored with them. Alongside this are the benefits of a shared experience and group support, essential in sustaining morale and commitment, making it ‘fun’ and overcoming isolation and improving wellbeing. It is remarkable incidentally how an exercise group can work with a huge range of age and fitness levels. In the WEA’s experience community gyms are very popular; they invariably have high enrolments and very few withdrawals.

Whilst physical exercise is the main driver in attracting students, there are innumerable opportunities to develop a broader understanding of health and fitness with a much longer term impact. This may be explanations of muscles and other body parts and the impact of exercise.  Short sessions on food and diet can be included.

The whole experience of a community gym can be linked to discussion and campaigns about health inequalities, the allocation of NHS resources and the comparatively meagre resources devoted to public health. Diabetes alone accounts for 10% of NHS expenditure annually; at the same time public health accounts for only 4% of health expenditure. There must be a strong financial case for devoting money to preventative education amongst those at risk of diabetes 2 (for example), let alone the benefits to the quality of life for the people concerned.

Finally. the case for community health education is not just warm words. One of its strengths  is that the outcomes for participants have been systematically recorded and reported. Blood pressure, weight, waist measurements and Body Mass Index are measured at the beginning, during and end of classes. There is a lot of  hard statistical evidence on the improvements for individuals alongside a steady stream of illustrations of improved well-being, social interaction and community involvement.

West Midlands WEA, in response to government consultation on the Public Health White paper, reported that of 2,000 health education students in 2009/10, over 90% had maintained or improved their blood pressure. The recent evaluation of the longstanding Dudley Tandrusti project, link below, provides considerable quantitative and qualitative data. Incidentally it illustrates the range of outcomes. In addition to greater fitness and mobility students general sense of wellbeing improved  (for instance overcoming social isolation) as well as their social and civic understanding and involvement.

Put together the potential savings to the NHS (and the economy more widely), the impact on health inequality and benefits to individuals and communities and there must be a compelling case. Surely community health education is an idea whose time has come?


A blog of mine 2 years ago on the same topic

Marmot Review: full report

Data on deprivation in London boroughs

Evaluation of Dudley Tandrusti project
  1. Thanks for posting this blog Pete. I think you have raised some poignant points about health improvement and the need to recognise how prescriptive approaches are becoming less and less effective. The recent health white paper recognises that to improve a community’s health is to support them to become empowered to do that for themselves. Adult education is the perfect vehicle to undertake this delicate task, as it already has several advantages such as community engagement, trust and friendship. So, I agree there is a compelling case for sure and I feel we are moving in a better position to be able to convince funders and partners of the value of a collaborative approach to health improvement…. we just need to keep pressing on!

  2. Hugh Humphrey permalink

    I thought the recent move to make Health one of our 4 themes was an excellent one because health education in this country is, I believe, poor and there is real gap which the WEA could fill. There is a real opportunity for us in this field of work. I agree that there are two aspects. One is the health and well being factor of all courses which is particularly well served by the WEA’s interactive style of learning. Secondly, there is the more direct approach which you mentioned based on physical activity. I would also include in this area the information and discussion based courses as outlined in the spiral bound Women and Health booklet which was used in the 90’s. This was very sucessful with young mums’ groups. It has probably been updated but a handbook of this sort with information handouts would provide the basis for much useful work and help promote the sense of empowerment mentioned in the previous comment.

  3. Pete Caldwell permalink

    Helpful comments; many thanks. Iram I think you say very well how adult education can engage and empower people in a positive and supportive way (rather than being hectoring or punitive).
    Hugh- various other people made similar comments via email i.e. drawing attention to other valuable strands of health education work that should be included. I agree. I concentrated on the physical activity strand for two reasons. Firsly I know the work well and could speak about it with some confidence. Secondly it involves a significant volume of learners (several thousand annually In West Midlands) so I feel we can show that it can be ‘scaled up’ and make a serious impact.
    Thanks again

  4. Rosemary Mayes permalink

    Sorry for not getting round to reading this before Pete, especially given the discussion at the strategy day on Wednesday. I’m very interested in your research in London and will, be following up this link when I get back from New Zealand.

    I am also very interested in the community gym idea which I shall be taking forward with the head of the school of which I am chair of governors in one of the most deprived and diverse boroughs in London.

    • Pete Caldwell permalink

      Thanks Rosemary; there is a great deal of information and support in the WEA that you can draw on if you wish to put forward the ‘community gym’ idea. All the best

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