Extension and Health Promotion: An Adult Learning Approach

Introduction

Over the last decade, the Canadian health system has been attempting to shift towards greater decentralization in the governance of health care services and more community involvement in decisions about health related policies, programs, and services (Canadian Public Health Association, 1996a). This shift has been prompted, in part, by a recognition that health is determined by many factors, not just health services but also socioeconomic factors such as unemployment, income, social status, education, and social supports (Evans, Morris, & Marmor, 1994).

This article examines how a university Extension department became involved in a rural, health promotion initiative in order to further learning and action around the determinants of health. Although the role of Extension education in health education is documented (Williams, 1997), little attention has been given to the role of adult learning in these initiatives. In order to strengthen community participation in health planning of three communities in rural Nova Scotia, the Extension Department of St. Francis Xavier University collaborated with the local women's association and the regional public health department, in the People Assessing Their Health (PATH) project (Gillis, 1999). This article discusses the role of adult learning strategies in this health promotion initiative and suggests ways that Extension educators in similar contexts can employ these strategies in their work.

The federally funded PATH project (Gillis, 1999) was unique in involving team members who had extensive knowledge and experience in adult education as well as health promotion. Consequently, the team, led by two adult educators who shared the project coordinating position, incorporated a strong adult learning component, resulting in PATH becoming a stellar example of how to integrate adult learning principles in community health projects.

Using a participatory process, community members from all walks of life identified factors that they considered important in making and keeping their communities healthy. The outcome was the development of community health impact assessment tools to enable citizens to become more informed participants in decisions influencing their health. Through the PATH process, community members become more aware of the broad spectrum of factors influencing their health as well as the health concerns of other communities in their region.

The Literature

The literature from health promotion and adult learning inform this research. The World Health Organization (1984) has defined health promotion as enabling people to increase control over, and to improve, their health. The Ottawa Charter for Health Promotion called for a collective and cooperative, rather than individualistic, approach to promoting health (World Health Organization, 1986). In many ways, health promotion is thought of as a social movement (Pederson, O'Neill, & Rootman, 1994). Labonte (1993) defines health promotion as "any activity or program designed to improve social and environmental living conditions such that a person's experience of well-being is increased." Among the varied dimensions of health promotion, Mittelmark (2000) emphasizes its basic component of "strengthening communities' ability to take effective action at the local level." Health promotion has been widely endorsed at various levels of government in Canada (Canadian Public Health Association, 1996a, 1996b; Epp, 1986; Nova Scotia Department of Health, 1994).

Several factors influence the need to increase public awareness and collective participation in issues affecting health. Like many governments in the Western world, the Canadian government has been using multiple public awareness campaigns to promote individual lifestyle changes to reduce risk of chronic disease. Although such health promotion initiatives encourage individuals to modify their risk behaviors, they tend to result in the near exclusion of collective initiatives. They also result in the neglect of the broader determinants of health such as education, social status, employment opportunities, geographical isolation, and social support systems, factors that are at the heart of poor health (Evans et al., 1994).

Evidence is growing linking the impact of socioeconomic conditions and health (Canadian Public Health Association, 1997). Overshadowing the Canadian health promotion movement during the last decade, has been the escalation in health care costs and consequently a substantial number of efforts to reform the health system (Bickerton, 1999). The overall result has been greater recognition of the need for more informed citizen involvement in issues that affect community health.

Community-based health initiatives are frequently premised on learning from and with the community in order to increase capacity, although the learning dimension is rarely acknowledged. Early community development initiatives, such as the Antigonish Movement, for example, integrated a strong adult learning component (see Coady, 1939). On close examination, many of the Antigonish Movement's adult learning initiatives were informal (e.g., dialoguing, study groups, mentoring). Informal learning theory points to the use of numerous other informal strategies (e.g., networking, self-directed learning) to increase individual and group learning outside of established academic structures (Watkins & Marsick, 1990; 1992). Similarly, the PATH project employed numerous strategies, especially dialoguing through storytelling (Labonte & Feather, 1996), to increase learning in the community.

The frequency of informal learning was noted early-on by adult educator Allan Tough (1979), whose seminal studies on self-directed learning projects in the 1970s indicated that adults are continuously learning and becoming independent and self-directed in their learning. A recent Canada-wide study confirmed this early research. Livingstone (1998) found that 90% of adults are involved in informal learning for work or for general interest and that the average amount of time they spend on such learning is 6 hours per week. Their extensive telephone survey revealed that 75% of adults (n=1500) have intentionally learned about their health and wellbeing in the last year, whether alone or with other people. This result begs many questions, such as: how does such learning occur?; how significant is the learning in the life of the individual and community?; and what future impact does new knowledge have on the quality of the person's life?

The Canadian Context

This project was located in eastern Nova Scotia, a province on the East Coast of Canada. Communities in this region have faced many barriers to maintaining and promoting health due to geographical isolation and socioeconomic conditions such as lack of employment, inadequate income, and limited education. Residents of three diverse communities in this region were involved in identifying what determined their health and developing community health impact assessment tools to guide decision making related health programs and policies. The three communities included a remote Atlantic fishing community; a rural community dependent of seasonal fishing, forestry, and tourism; and a multicultural urban community with a declining economic base due to the demise of the steel industry.

The Canadian health-care system provides universal access and is publicly funded. All Canadians are entitled to full medical care without discrimination on any basis. However, through the forces of corporate globalization, public concern is growing that the Canadian health care system is being eroded. A lack of both federal and provincial funding is paving the way for the privatization of health care and a two-tiered system that will see the rich receive better health care than the poor.

This creeping privatization is especially relevant for the rural people in this study, who will be detrimentally affected by privatization. In a private system it is unlikely that these citizens will be able to afford quality health care and very likely that they will lose the range of choices they currently access. The drive of privatized health care to make the greatest profit possible is likely to deprive rural dwellers, who have low population base (and hence low profit margins), of adequate health care services. As researchers Bell and Cloke (1989) note, "rural areas provide less healthy arenas for competition than their urban counterparts."

Moreover, corporate globalization threatens the role that health care facilities play in the web of rural life. Rural hospitals and health centers are prime targets for government cutbacks without any consideration for the fact that the rural health care sector may not only be concerned with health care access, but also with the economic, social, and environmental health and wellbeing of the community as a whole (Lauzon & Hagglund, 1998). This study is situated within the overall context of health care in Canada, one in which many community-based agencies have had to "rationalize" their programs and services, and in which the responsibility for many aspects of health care falls on overburdened volunteer organizations and informal caregivers.

The rural context of health is significant (Health Canada, 2001) especially as changing demographics heighten the challenges facing rural and remote areas. (Although there is no single standard of what rural means, we define rural as consisting of country living, low population, and relative isolation.) In their report on the closing of rural hospitals in the province of Ontario, Canadian researchers Lauzon and Hagglund (1998) note that rural health levels are lower than urban ones (see also Lorenz et al., 1993). Similarly, U.S. research shows that populations in rural areas generally suffer greater levels of disability, impairment, and mental and physical disorders than those in urban areas, while at the same time experiencing higher rates of poverty and less access to health and human services (Jacob et al., 1997; Wimberley, 1993).

PATH Adult Learning Strategies

This article focuses on the question: How were adult learning theory and strategies used to increase informal learning in the PATH project? The particular adult learning strategies that we have identified in the PATH project are:

1. Integration of the learning cycle and experiential learning,
2. Dialoguing and storytelling, and
3. Networking.

We examine each of these strategies in order to explicate how Extension educators can learn from the PATH project to become even more effective in community-based health initiatives.

Working with Experience

Underlying the PATH project was the firm belief that people in each of the three communities knew a considerable amount about what makes them and their communities healthy, although they are likely not to express it in the technical language of determinants of health. A selection committee, formed in each community, hired a local person to organize and facilitate a series of community meetings over a 6-month period. The basic criteria for selection of the facilitator was that the individual knew the community, its key organizations and agencies, local leaders, and both the formal and informal channels of communication and that he or she had an interest in being trained as a community facilitator.

This local person (facilitator) convened and facilitated meetings in community halls and over kitchen tables so that people could share their views on what determines their health. The facilitators received training in basic facilitation skills as well as the story-telling/structured dialogue approach, which was based on the experiential learning cycle by David Kolb (1984). The questions were:

1. What do you see happening?
2. Why do you think it happened?
3. So what have you learned from the experience?
4. Now what can you do about it?

The process enabled participants to draw out themes related to health determinants from their discussions. The themes from all the discussion groups were then further analyzed into clusters of themes related to the health determinants.

Working with their local steering committee, the facilitators used the information that had been generated by the community members to design their community health impact assessment tools. Each tool reflected the unique nature of the community and the community's understanding of what determines health.

Story-telling was a key strategy in the PATH project. Local residents met in small groups to tell their stories of successes and frustrations in trying to maintain and promote their health. For example, a single mother told of her desire for more education so she could become employed and the difficulty she faced having neither an education program close-by nor the money for a correspondence course. She also talked about needing transportation to medical services when her children were ill and about her children not being involved in after-school activities because they needed to come home on the bus. She felt isolated and depressed because she was identified as a "socially assisted" person.

From each story, a web of socioeconomic factors determining health unfolded. After each story was shared, participants examined what happened, why it happened, what they learned from it, and what could be done about it. Being aware that the community members were learners with a lifetime of experience, the PATH team encouraged them to reflect on and critique their experience in order to learn from it. The group process strengthened the adult learning possibilities, built community identity, and stimulated a desire to move towards constructive action on issues affecting their health (Schneider, 1997). As one participant reported, "I was amazed at how the community was able to look at itself and draw out the main things that affect its health" (PATHways, 1997).

These sessions were not intended to be traditional adult education experiences, yet there was intentionality in the integration of adult learning strategies. One participant reported, "The facilitator seemed comfortable and made others comfortable. She had a command of the situation and knew why she was there" (PATHways, 1997). The honoring of individual experiences was key in this learning process. By engaging participants' experiences with the broader determinants of health, such as their lack of employment or education, their interactions with the health care system, and their sense of ability or inability to manage their health, the facilitators were able to help the groups examine the stories, critically reflect on them, and learn from them. The telling of stories became an opportunity to reflect on one's experience, construct new knowledge, and plan for the future.

Although many people have experiences that they do not learn from (Jarvis, 1987), the facilitator intervention in this case assisted community members in learning from their experiences. Experiences, from individual and community perspectives, were shared with the intent of creating knowledge and generating action. As one participant stated, "It started to take on a positive tone, going from 'they don't care' to 'why can't we make it happen?'" (PATHways, 1997). Some examples of actions initiated after the PATH project that came out of these discussions included organizing well women's clinics, well men's clinics, and self-esteem workshops for adolescent women.

Using Dialogue as the Basis for Learning

The facilitators called meetings of community residents in each of the three project sites. Because the facilitators understood their communities and were respected by the residents, they were, for the most part, effective in organizing these meetings. They sought out people of different ages, cultural background, locale, gender, and occupations, attempting to reflect the make-up of the three communities. The most challenging group to involve tended to be health professionals.

People gathered in kitchens and community halls to discuss the factors that contributed to the health of their community. They identified strengths as well as gaps in resources and services, and in the capacity of the community to improve health. Engagement in a dialogical process facilitated the identification of supports and challenges to healthy living (English, 2000). To ensure that all the voices were heard, the facilitators used small group meetings to create a comfortable and respectful atmosphere where everyone present could have an opportunity to speak.

This process enabled participants to begin strategizing about how they could have a greater voice in assessing the impact of programs, policies, or services on their community's health. Their participation enabled each community to develop a community health impact assessment tool which could be used to assess the impact of existing and potential programs, policies and services on their health (Gillis, 1999).

The facilitation of meaningful dialogue was key in assisting the participants in making sense of their community experiences, such as being able to access adequate health services when distance was a barrier, finding social support when living in an isolated rural community, or affording adequate food for their children when employment opportunities were scarce. By sharing their life experiences, they saw how health determinants were closely interrelated. Through creating an image, for example a clock or a tree, participants saw the dynamic nature of health and how many socioeconomic factors were linked and essential for building a healthy community. They were able to identify what was happening to them and their communities, and why.

In one community group discussion, the dialogue centered around the escalation in unemployment due to the decline in the off-shore fishery, which made healthy living very difficult for the residents. Unemployment affected residents' ability to maintain mental health, good nutrition, effective schools, and a stable home life. For another community group, a toxic waste site was the focus of attention. The informal meeting structure engendered extensive dialogue among members and increased community awareness of the issues that were affecting their quality of life. The group safety (Vella, 1994) created by the small group meeting structure was especially important to support the potential for learning. As one participant noted, "I felt I learned a lot; it broadened my outlook and changed some of my opinions. I saw the other side, other values, why people don't want to leave here" (PATHways, 1997).

Networking

Another important informal learning strategy was the facilitation of networks within communities and among them. Although the three communities were geographically separate, community facilitators and steering committee members from each of the three sites benefited from opportunities to meet regularly and share their perspectives. Knowing that another community was experiencing similar problems helped the respective groups put their own issues in perspective and realize that, living in this region of the province, they all shared common interests and concerns. As one participant said, "The process itself did something to get people to talk together about what had to be done, first within individual communities and then between them" (PATHways, 1997).

Members of the partner agencies, including the local women's association, the university Extension department, the public health department, along with the facilitators and members of each community steering committee, were part of a regional advisory committee. They were actively involved in the planning, design, implementation, and evaluation of the project. This participatory structure encouraged networking among community members, discouraged thinking that the facilitators and project organizers were the experts, and increased community members' belief that they could take control over their own health.

By bringing residents together to share their perspective on the health of their community, the facilitators were able to connect people in their communities and build their vision of a healthy community. Community development is successful when it brings people together and enables them to be active in shaping their future. When the PATH project ended, participants in one of the project communities formed an action group to address issues (the main issue being water quality) they had identified through the PATH process. In another community, two groups collaborated to plan and implement specific health promotion programs to address the needs of women and adolescents identified through their involvement in the PATH project.

Implications for Extension Departments

A prime intention of this project was to enable learning. More specifically, the intention was to:

• Increase community awareness and understanding about the broad spectrum of factors that determine health,
• Build a strong community network of people interested in taking action on health issues, and
• Promote information sharing and a common understanding about health issues facing their region among people from three diverse and remote communities within the region.

What lessons can Extension take from the deliberate adult learning element core to this project? Can the specific teaching and learning strategies used in this PATH project be used by other communities to promote health? We believe that Extension educators can learn a great deal from the PATH project.

To begin with, the participatory design permitted a considerable amount of learning to occur, without any lectures being given or any explicitly educational activities being used. Sensitivity to the community context, the range of literacy levels of participants, and the immediate need of residents to address current concerns around their health made structured educational initiatives superfluous. The PATH team believed that the community members knew much more than they could ever be told about what it takes to make their community healthy. The purpose of PATH was to enable the community members to work together to find their own answers to their own problems, not an easy feat when one considers the economic, social, and geographic challenges of these three communities.

Extension educators can take note that the deliberate inclusion of a learning process centered on the learning cycle of Kolb (1984) is an effective means of facilitating group learning. Encouraging the group not only to tell a story, but to critically assess why it happened and what can be done to change it, was an integral part of the individual and group learning that occurred. Although these community sessions were not structured, formal educational events, they did include intentional learning that was supported by opportunities for story-telling, dialogue, and networking. This intentional use of the elements of the learning cycle increased the possibility that learning could occur.

Extension educators can benefit from working closely with adult educators to plan participatory processes for community learning and development. In this case, such collaboration resulted in the inclusion of intentional informal learning strategies such as:

• Engaging experience, which encourages participants to learn from their everyday experiences of working together;
• Promotion of dialoguing, which honors the community participants as subjects of their learning; and
• Networking, which encourages the sharing of information and the strength of a collective effort.

Extension educators can also learn that they have a head start on identifying effective health promotion strategies. Because their focus typically is participatory, they often are able to avoid the pitfalls of some traditional health education initiatives. By using a participatory process and focusing on active, collective involvement in decisions affecting community health, Extension educators can avoid the extreme individualism that places responsibility for health primarily in the hands of the individual rather than in communities.

Extension educators are in a unique position to enable people to look at the "big picture" of health, especially the factors influencing overall population health and wellbeing. This position is particularly significant at this time, when many agencies have to rationalize their programs and services to focus on one aspect of wellbeing, such as economic development or environmental sustainability. This unique role for Extension departments ought to be carefully considered.

Future Directions

The qualitative nature of this study made certain information inaccessible. Does informal learning have a lasting impact? Did participants apply or transfer their learning after the PATH project was completed? What supports or conditions need to be in place for this transfer to happen? (See Ottoson, 1997.) How might this PATH project be used to generate other teaching/learning projects, including but not limited to health, that enable people at the grassroots to empower themselves? These questions have not been answered and warrant further study. However, Extension educators can benefit from reflecting on the lessons learned from this project as a way to further the process of adult learning and community development within the context of their work.

Acknowledgements

The authors would like to acknowledge Peggy Mahon of the St. Francis Xavier University Extension Department for her work on the PATH Project. They would also like to thank Jennifer Sumner of University of Guelph for helpful comments on an early draft of this article.

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