The outcomes of community legal education: a systematic review, Justice issues paper 18 ( 2014 ) Cite this report
The following are the key findings from the literature.
Quantity and nature of the literature
Even in the health education field, in which evaluation research is more consistently undertaken, authors commonly expressed caution about their conclusions due to, for instance, the limited number of studies, their variable quality and/or methodological limitations (e.g. Gibson et al. 2009; Bryanton & Cheryl 2009), or variable/short follow-up periods (e.g. Barlow et al. 2010, p.2). This is a reminder that challenges in evaluating short education interventions are not unique to the community legal sector.
Is health education effective in changing participants’ knowledge, attitudes, skills and behaviour?
There is evidence that health education is effective in increasing knowledge (Deakin et al. 2009; Dorresteijn et al. 2010), but that it has stronger impacts on knowledge than behaviours (Yankah & Aggleton 2008, p.465; Kaminski et al. 2008).
There are very variable findings relating to the impact of education on behaviour change (as measured by the ‘proxy’ measure of health outcomes such as better pain management or fewer pregnancies), ranging from an impact on all/most outcomes (Kendrick et al. 2009; Barlow et al. 2010) to some (Young et al. 2011) or none (Gibson et al. 2009).
The variability of the findings could reflect differences in the:
• nature of the education programs (e.g. the number of hours, and nature of the education activities and educator)
• characteristics of the participants
• health issue addressed
• types of behaviour change required for the outcomes to be achieved.
However taken together, the studies suggest that health education is much more effective in producing shorter-term and ‘simpler’ behavioural changes (Deakin et al. 2009; Lopez et al. 2010) compared to longer-term more complex and fundamental behaviour changes relating to ‘higher level’, longer-term health outcomes.
Similarly, studies that use a mix of both shorter-term, more immediate behavioural measures and longer-term, more complex measures, tend to find stronger outcomes on the former. For example, education about asthma improves perceived symptoms but not asthma-related health outcomes (Gibson et. al. 2009); home safety education for parents increases most of a wide range of safety practices but not injury outcomes (Kendrick et. al. 2009, p.17); and education about diabetes improves people’s foot care knowledge and behaviours in the short term but not the occurrence of ulcers and foot amputations (Dorresteijn et al. 2010; see also Young et al. 2011, p751 and Warsi et al. 2003).
Kendrick et al.’s (2009, p.17) study confirms that health education tends to be more effective in the shorter term. The effect of home safety education reduced over time, with greater effects for most outcomes over a shorter period (three months or less) than a longer time period.
The finding that education is more effective in producing shorter-term outcomes may be because:
• education does in fact only produce shorter-term outcomes
• more complex longer-term health outcomes may be related to a range of environmental, socio-economic and other factors which education alone cannot address (see Young et al. 2011, p.776)
• it is harder to measure and capture data on longer-term outcomes, and studies tend to have shorter follow-up periods.
The above findings suggest that potentially CLE may be more effective in producing changes in knowledge and simpler behavioural changes in the short-term, rather than longer-term more complex behavioural changes.
What factors influence how effective a health education program is?
The following factors have been found to influence the effectiveness of health education programs:
• High versus lower risk target groups. Education is not necessarily any less effective for those who are most at risk of the problem. Kendrick et al. (2010) found that even for those who may generally require more intensive help (parents whose children were at greatest risk of injury) home safety education programs can be equally effective compared to those requiring less intensive assistance.
• The mode of delivery. The delivery mode can impact on the effectiveness of a program, for example:
- Structured teaching is much more effective than unstructured, ad hoc teaching (Friedman et al. 2011, p.17).
- Targeted interventions that provided patient-specific information increased patients’ knowledge, decreased anxiety and increased satisfaction (Friedman et al. 2011, p.18).
• The number of education sessions. Both shorter-term interventions (one or two sessions) or multiple-contact interventions had positive effects (Lopez et al. 2010, p.327, 331).
• Conducting education in conjunction with other activities. Providing mechanisms to reinforce the messages taught in the education session can potentially help to increase the effectiveness of the education. For example, Kendrick et al. (2010, p.17) found that home safety education for parents has stronger effect sizes in improving safety practices when it is combined with the provision of low cost, discounted or free safety equipment. On the other hand, Kaminski et al. (2008, p.578) found greater effect sizes for education programs that were standalone versus those that were embedded within a broader package of interventions.