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Health Education

School-based health education helps adolescents acquire functional health knowledge, strengthen attitudes and beliefs, and practice skills needed to adopt and maintain healthy behaviors throughout their lives.

Schools can play a critical role in reducing adolescent health risks through the delivery of effective health education. 1-3

The specific content and skills addressed in health education, including sexual health and other related topic areas (e.g., violence prevention, mental and emotional health, food and nutrition), are commonly organized into a course of study or program and often summarized in a curriculum framework.

Health education curriculum should include:

A set of intended learning outcomes or objectives that directly relate to students’ acquisition of health-related knowledge, attitudes, and skills.

A planned progression of developmentally appropriate lessons or learning experiences that lead to achieving health objectives.

Continuity between lessons or learning experiences that clearly reinforce the adoption and maintenance of specific health-enhancing behaviors.

Content or materials that correspond with the sequence of learning events and help teachers and students meet the learning objectives.

Assessment strategies to determine if students have achieved the desired learning.

Health education is effective at addressing adolescent behaviors

Youth behaviors and experiences set the stage for adult health. 1-3  In particular, health behaviors and experiences related to early sexual initiation, violence, and substance use are consistently linked to poor grades and test scores and lower educational attainment. 4-7  In turn, providing health education as early as possible can help youth to develop positive well-being, academic success, and healthy outcomes into adulthood.

Health education tends to be more effective when it is taught by qualified teachers, connects students to health services, engages parents and community partners, and fosters positive relationships between adolescents and adults who are important to them.

Research suggests that well-designed and well-implemented school health programs can influence multiple health outcomes, including reducing sexual risk behaviors related to HIV, sexually transmitted diseases (STDs) and unintended pregnancy, decreasing substance and tobacco use, and improving academic performance. 8-10

Schools can promote safe and supportive environments by improving students’ connections to schools and increasing the support they receive from parents.

See CDC’s  Characteristics of an Effective Health Education Curriculum  to learn more about research on effective curricula in school health education.

Standards for Health Education

Health education standards are designed to establish, promote, and support health-enhancing behaviors for students in all grade levels. 11 These learning standards have been updated or are currently being revised by multiple professional organizations in school health. Versions of these standards are available here  and here .

Sexual health is a critical component of health education

School-based sexual health education provides youth with the knowledge and skills they need to protect their health and become successful learners. Increasing the number of schools that provide health education on key health risks facing youth, including HIV, STDs and unintended pregnancy, is a critical health objective for improving our nation’s health. 12

National Sex Education Standards

The National Sex Education Standards outline foundational knowledge and skills students need to navigate sexual development and grow into sexually healthy adults. The standards are designed to help schools focus on what is most essential for students to learn by the end of a grade level or grade span and can be used to create lessons and curricula with aligned learning objectives. 13

Learn more about CDC's program guidance for school-based HIV/STD prevention.

Access CDC resources to support health education teaching and learning.

Develop, revise, and evaluate health education curriclua using CDC's Health Education Curriculum Analysis Tool (HECAT).

• Eisen M, Pallitto C, Bradner C, Bolshun N. Teen Risk-Taking: Promising Prevention Programs and Approaches . Washington, DC: Urban Institute; 2000.
• Lohrmann DK, Wooley SF. Comprehensive School Health Education. In: Marx E, Wooley S, Northrop D, editors. Health Is Academic: A Guide to Coordinated School Health Programs. New York: Teachers College Press; 1998:43–45.
• Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane, E, Davino K. What works: principles of effective prevention programs . American Psychologist 2003;58(6/7):449–456.
• Centers for Disease Control and Prevention. School Health Profiles 2018: Characteristics of Health Programs Among Secondary Schools . Atlanta: Centers for Disease Control and Prevention; 2019.
• Rasberry CN, Tiu GF, Kann L, et al. Health-Related Behaviors and Academic Achievement Among High School Students— United States, 2015 . MMWR Morb Mortal Wkly Rep 2017 ;66:921–927
• Basch CE. Healthier students are better learners: high-quality, strategically planned, and effectively coordinated school health programs must be a fundamental mission of schools to help close the achievement gap . J Sch Health . 2011 Oct;81(10):650-62.
• Murray NG, Low BJ, Hollis C, Cross AW, Davis SM. Coordinated school health programs and academic achievement: A systematic review of the literature . J Sch Health 2007;77:589-600.
• Kirby D, Coyle K, Alton F, Rolleri L, Robin L. Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs . Scotts Valley, CA: ETR Associates; 2011.
• U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People–An Update: A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2011: 6-22–6-45.
• Centers for Disease Control and Prevention. Youth Risk Behavior Survey: Data Summary & Trends Report: 2009-2019 . Atlanta: Centers for Disease Control and Prevention; 2020.
• Centers for Disease Control and Prevention. Health Education Curriculum Analysis Tool , 2021, Atlanta, GA: CDC; 2021.
• United States Department of Health and Human Services. HP 2020 Topics and Objectives: Early and Middle Childhood . Healthy People website. Accessed February 2021.
• Future of Sex Education Initiative. (2020). National Sexuality Education Standards: Core Content and Skills, K-12 .

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• Open access
• Published: 06 April 2020

The influence of education on health: an empirical assessment of OECD countries for the period 1995–2015

• Viju Raghupathi 1 &
• Wullianallur Raghupathi 2  

Archives of Public Health volume  78 , Article number:  20 ( 2020 ) Cite this article

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A clear understanding of the macro-level contexts in which education impacts health is integral to improving national health administration and policy. In this research, we use a visual analytic approach to explore the association between education and health over a 20-year period for countries around the world.

Using empirical data from the OECD and the World Bank for 26 OECD countries for the years 1995–2015, we identify patterns/associations between education and health indicators. By incorporating pre- and post-educational attainment indicators, we highlight the dual role of education as both a driver of opportunity as well as of inequality.

Adults with higher educational attainment have better health and lifespans compared to their less-educated peers. We highlight that tertiary education, particularly, is critical in influencing infant mortality, life expectancy, child vaccination, and enrollment rates. In addition, an economy needs to consider potential years of life lost (premature mortality) as a measure of health quality.

Conclusions

We bring to light the health disparities across countries and suggest implications for governments to target educational interventions that can reduce inequalities and improve health. Our country-level findings on NEET (Not in Employment, Education or Training) rates offer implications for economies to address a broad array of vulnerabilities ranging from unemployment, school life expectancy, and labor market discouragement. The health effects of education are at the grass roots-creating better overall self-awareness on personal health and making healthcare more accessible.

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Introduction

Is education generally associated with good health? There is a growing body of research that has been exploring the influence of education on health. Even in highly developed countries like the United States, it has been observed that adults with lower educational attainment suffer from poor health when compared to other populations [ 36 ]. This pattern is attributed to the large health inequalities brought about by education. A clear understanding of the health benefits of education can therefore serve as the key to reducing health disparities and improving the well-being of future populations. Despite the growing attention, research in the education–health area does not offer definitive answers to some critical questions. Part of the reason is the fact that the two phenomena are interlinked through life spans within and across generations of populations [ 36 ], thereby involving a larger social context within which the association is embedded. To some extent, research has also not considered the variances in the education–health relationship through the course of life or across birth cohorts [ 20 ], or if there is causality in the same. There is therefore a growing need for new directions in education–health research.

The avenues through which education affects health are complex and interwoven. For one, at the very outset, the distribution and content of education changes over time [ 20 ]. Second, the relationship between the mediators and health may change over time, as healthcare becomes more expensive and/or industries become either more, or less hazardous. Third, some research has documented that even relative changes in socioeconomic status (SES) can affect health, and thus changes in the distribution of education implies potential changes in the relationship between education and health. The relative index of inequality summarizes the magnitude of SES as a source of inequalities in health [ 11 , 21 , 27 , 29 ]. Fourth, changes in the distribution of health and mortality imply that the paths to poor health may have changed, thereby affecting the association with education.

Research has proposed that the relationship between education and health is attributable to three general classes of mediators: economic; social, psychological, and interpersonal; and behavioral health [ 31 ]. Economic variables such as income and occupation mediate the relationship between education and health by controlling and determining access to acute and preventive medical care [ 1 , 2 , 19 ]. Social, psychological, and interpersonal resources allow people with different levels of education to access coping resources and strategies [ 10 , 34 ], social support [ 5 , 22 ], and problem-solving and cognitive abilities to handle ill-health consequences such as stress [ 16 ]. Healthy behaviors enable educated individuals to recognize symptoms of ill health in a timely manner and seek appropriate medical help [ 14 , 35 ].

While the positive association between education and health has been established, the explanations for this association are not [ 31 ]. People who are well educated experience better health as reflected in the high levels of self-reported health and low levels of morbidity, mortality, and disability. By extension, low educational attainment is associated with self-reported poor health, shorter life expectancy, and shorter survival when sick. Prior research has suggested that the association between education and health is a complicated one, with a range of potential indicators that include (but are not limited to) interrelationships between demographic and family background indicators [ 8 ] - effects of poor health in childhood, greater resources associated with higher levels of education, appreciation of good health behaviors, and access to social networks. Some evidence suggests that education is strongly linked to health determinants such as preventative care [ 9 ]. Education helps promote and sustain healthy lifestyles and positive choices, nurture relationships, and enhance personal, family, and community well-being. However, there are some adverse effects of education too [ 9 ]. Education may result in increased attention to preventive care, which, though beneficial in the long term, raises healthcare costs in the short term. Some studies have found a positive association between education and some forms of illicit drug and alcohol use. Finally, although education is said to be effective for depression, it has been found to have much less substantial impact in general happiness or well-being [ 9 ].

On a universal scale, it has been accepted that several social factors outside the realm of healthcare influence the health outcomes [ 37 ]. The differences in morbidity, mortality and risk factors in research, conducted within and between countries, are impacted by the characteristics of the physical and social environment, and the structural policies that shape them [ 37 ]. Among the developed countries, the United States reflects huge disparities in educational status over the last few decades [ 15 , 24 ]. Life expectancy, while increasing for all others, has decreased among white Americans without a high school diploma - particularly women [ 25 , 26 , 32 ]. The sources of inequality in educational opportunities for American youth include the neighborhood they live in, the color of their skin, the schools they attend, and the financial resources of their families. In addition, the adverse trends in mortality and morbidity brought on by opioids resulting in suicides and overdoses (referred to as deaths of despair) exacerbated the disparities [ 21 ]. Collectively, these trends have brought about large economic and social inequalities in society such that the people with more education are likely to have more health literacy, live longer, experience better health outcomes, practice health promoting behaviors, and obtain timely health checkups [ 21 , 17 ].

Education enables people to develop a broad range of skills and traits (including cognitive and problem-solving abilities, learned effectiveness, and personal control) that predispose them towards improved health outcomes [ 23 ], ultimately contributing to human capital. Over the years, education has paved the way for a country’s financial security, stable employment, and social success [ 3 ]. Countries that adopt policies for the improvement of education also reap the benefits of healthy behavior such as reducing the population rates of smoking and obesity. Reducing health disparities and improving citizen health can be accomplished only through a thorough understanding of the health benefits conferred by education.

There is an iterative relationship between education and health. While poor education is associated with poor health due to income, resources, healthy behaviors, healthy neighborhood, and other socioeconomic factors, poor health, in turn, is associated with educational setbacks and interference with schooling through difficulties with learning disabilities, absenteeism, or cognitive disorders [ 30 ]. Education is therefore considered an important social determinant of health. The influence of national education on health works through a variety of mechanisms. Generally, education shows a relationship with self-rated health, and thus those with the highest education may have the best health [ 30 ]. Also, health-risk behaviors seem to be reduced by higher expenditure into the publicly funded education system [ 18 ], and those with good education are likely to have better knowledge of diseases [ 33 ]. In general, the education–health gradients for individuals have been growing over time [ 38 ].

To inform future education and health policies effectively, one needs to observe and analyze the opportunities that education generates during the early life span of individuals. This necessitates the adoption of some fundamental premises in research. Research must go beyond pure educational attainment and consider the associated effects preceding and succeeding such attainment. Research should consider the variations brought about by the education–health association across place and time, including the drivers that influence such variations [ 36 ].

In the current research, we analyze the association between education and health indicators for various countries using empirical data from reliable sources such as the Organization for Economic Cooperation and Development (OECD) and World Bank. While many studies explore the relationship between education and health at a conceptual level, we deploy an empirical approach in investigating the patterns and relationships between the two sets of indicators. In addition, for the educational indicators, we not only incorporate the level of educational attainment, but also look at the potential socioeconomic benefits, such as enrollment rates (in each sector of educational level) and school life expectancy (at each educational level). We investigate the influences of educational indicators on national health indicators of infant mortality, child vaccinations, life expectancy at birth, premature mortality arising from lack of educational attainment, employment and training, and the level of national health expenditure. Our research question is:

What are some key influencers/drivers in the education-health relationship at a country level?

The current study is important because policy makers have an increasing concern on national health issues and on policies that support it. The effect of education is at the root level—creating better overall self-awareness on personal health and making healthcare more accessible. The paper is organized as follows: Section 2 discusses the background for the research. Section 3 discusses the research method; Section 4 offers the analysis and results; Section 5 provides a synthesis of the results and offers an integrated discussion; Section 6 contains the scope and limitations of the research; Section 7 offers conclusions with implications and directions for future research.

Research has traditionally drawn from three broad theoretical perspectives in conceptualizing the relationship between education and health. The majority of research over the past two decades has been grounded in the Fundamental Cause Theory (FCT) [ 28 ], which posits that factors such as education are fundamental social causes of health inequalities because they determine access to resources (such as income, safe neighborhoods, or healthier lifestyles) that can assist in protecting or enhancing health [ 36 ]. Some of the key social resources that contribute to socioeconomic status include education (knowledge), money, power, prestige, and social connections. As some of these undergo change, they will be associated with differentials in the health status of the population [ 12 ].

Education has also been conceptualized using the Human Capital Theory (HCT) that views it as a return on investment in the form of increased productivity [ 4 ]. Education improves knowledge, skills, reasoning, effectiveness, and a broad range of other abilities that can be applied to improving health. The third approach - the signaling or credentialing perspective [ 6 ] - is adopted to address the large discontinuities in health at 12 and 16 years of schooling, which are typically associated with the receipt of a high school diploma and a college degree, respectively. This perspective considers the earned credentials of a person as a potential source that warrants social and economic returns. All these theoretical perspectives postulate a strong association between education and health and identify mechanisms through which education influences health. While the HCT proposes the mechanisms as embodied skills and abilities, FCT emphasizes the dynamism and flexibility of mechanisms, and the credentialing perspective proposes educational attainment through social responses. It needs to be stated, however, that all these approaches focus on education solely in terms of attainment, without emphasizing other institutional factors such as quality or type of education that may independently influence health. Additionally, while these approaches highlight the individual factors (individual attainment, attainment effects, and mechanisms), they do not give much emphasis to the social context in which education and health processes are embedded.

In the current research while we acknowledge the tenets of these theoretical perspectives, we incorporate the social mechanisms in education such as level of education, skills and abilities brought about by enrollment, school life expectancy, and the potential loss brought about by premature mortality. In this manner, we highlight the relevance of the social context in which the education and health domains are situated. We also study the dynamism of the mechanisms over countries and over time and incorporate the influences that precede and succeed educational attainment.

We analyze country level education and health data from the OECD and World Bank for a period of 21 years (1995–2015). Our variables include the education indicators of adult education level; enrollment rates at various educational levels; NEET (Not in Employment, Education or Training) rates; school life expectancy; and the health indicators of infant mortality, child vaccination rates, deaths from cancer, life expectancy at birth, potential years of life lost and smoking rates (Table 1 ). The data was processed using the tools of Tableau for visualization, and SAS for correlation and descriptive statistics. Approaches for analysis include ranking, association, and data visualization of the health and education data.

Analyses and results

In this section we identify and analyze patterns and associations between education and health indicators and discuss the results. Since countries vary in population sizes and other criteria, we use the estimated averages in all our analyses.

Comparison of health outcomes for countries by GDP per capita

We first analyzed to see if our data reflected the expectation that countries with higher GDP per capita have better health status (Fig. 1 ). We compared the average life expectancy at birth, average infant mortality, average deaths from cancer and average potential year of life lost, for different levels of GDP per capita (Fig. 1 ).

Associations between Average Life Expectancy (years) and Average Infant Mortality rate (per 1000), and between Deaths from Cancer (rates per 100,000) and Average Potential Years of Life Lost (years), by GDP per capita (for all countries for years 1995–2015)

Figure 1 depicts two charts with the estimated averages of variables for all countries in the sample. The X-axis of the first chart depicts average infant mortality rate (per 1000), while that of the second chart depicts average potential years of life lost (years). The Y-axis for both charts depicts the GDP per capita shown in intervals of 10 K ranging from 0 K–110 K (US Dollars). The analysis is shown as an average for all the countries in the sample and for all the years (1995–2015). As seen in Fig. 1 , countries with lower GDP per capita have higher infant mortality rate and increased potential year of life lost (which represents the average years a person would have lived if he or she had not died prematurely - a measure of premature mortality). Life expectancy and deaths from cancer are not affected by GDP level. When studying infant mortality and potential year lost, in order to avoid the influence of a control variable, it was necessary to group the samples by their GDP per capita level.

Association of Infant Mortality Rates with enrollment rates and education levels

We explored the association of infant mortality rates with the enrollment rates and adult educational levels for all countries (Fig. 2 ). The expectation is that with higher education and employment the infant mortality rate decreases.

Association of Adult Education Levels (ratio) and Enrollment Rates (ratio) with Infant Mortality Rate (per 1000)

Figure 2 depicts the analysis for all countries in the sample. The figure shows the years from 1995 to 2015 on the X axis. It shows two Y-axes with one axis denoting average infant mortality rate (per 1000 live births), and the other showing the rates from 0 to 120 to depict enrollment rates (primary/secondary/tertiary) and education levels (below secondary/upper secondary/tertiary). Regarding the Y axis showing rates over 100, it is worth noting that the enrollment rates denote a ratio of the total enrollment (regardless of age) at a level of education to the official population of the age group in that education level. Therefore, it is possible for the number of children enrolled at a level to exceed the official population of students in the age group for that level (due to repetition or late entry). This can lead to ratios over 100%. The figure shows that in general, all education indicators tend to rise over time, except for adult education level below secondary, which decreases over time. Infant mortality shows a steep decreasing trend over time, which is favorable. In general, countries have increasing health status and education over time, along with decreasing infant mortality rates. This suggests a negative association of education and enrollment rates with mortality rates.

Association of Education Outcomes with life expectancy at birth

We explored if the education outcomes of adult education level (tertiary), school life expectancy (tertiary), and NEET (not in employment, education, or training) rates, affected life expectancy at birth (Fig. 3 ). Our expectation is that adult education and school life expectancy, particularly tertiary, have a positive influence, while NEET has an adverse influence, on life expectancy at birth.

Association of Adult Education Level (Tertiary), NEET rate, School Life Expectancy (Tertiary), with Life Expectancy at Birth

Figure 3 show the relationships between various education indicators (adult education level-tertiary, NEET rate, school life expectancy-tertiary) and life expectancy at birth for all countries in the sample. The figure suggests that life expectancy at birth rises as adult education level (tertiary) and tertiary school life expectancy go up. Life expectancy at birth drops as the NEET rate goes up. In order to extend people’s life expectancy, governments should try to improve tertiary education, and control the number of youths dropping out of school and ending up unemployed (the NEET rate).

Association of Tertiary Enrollment and Education with potential years of life lost

We wanted to explore if the potential years of life lost rates are affected by tertiary enrollment rates and tertiary adult education levels (Fig. 4 ).

Association of Enrollment rate-tertiary (top) and Adult Education Level-Tertiary (bottom) with Potential Years of Life Lost (Y axis)

The two sets of box plots in Fig. 4 compare the enrollment rates with potential years of life lost (above set) and the education level with potential years of life lost (below set). The analysis is for all countries in the sample. As mentioned earlier, the enrollment rates are expressed as ratios and can exceed 100% if the number of children enrolled at a level (regardless of age) exceed the official population of students in the age group for that level. Potential years of life lost represents the average years a person would have lived, had he/she not died prematurely. The results show that with the rise of tertiary adult education level and tertiary enrollment rate, there is a decrease in both value and variation of the potential years of life lost. We can conclude that lower levels in tertiary education adversely affect a country’s health situation in terms of premature mortality.

Association of Tertiary Enrollment and Education with child vaccination rates

We compared the performance of tertiary education level and enrollment rates with the child vaccination rates (Fig. 5 ) to assess if there was a positive impact of education on preventive healthcare.

Association of Adult Education Level-Tertiary and Enrollment Rate-Tertiary with Child Vaccination Rates

In this analysis (Fig. 5 ), we looked for associations of child vaccination rates with tertiary enrollment and tertiary education. The analysis is for all countries in the sample. The color of the bubble represents the tertiary enrollment rate such that the darker the color, the higher the enrollment rate, and the size of the bubble represents the level of tertiary education. The labels inside the bubbles denote the child vaccination rates. The figure shows a general positive association of high child vaccination rate with tertiary enrollment and tertiary education levels. This indicates that countries that have high child vaccination rates tend to be better at tertiary enrollment and have more adults educated in tertiary institutions. Therefore, countries that focus more on tertiary education and enrollment may confer more health awareness in the population, which can be reflected in improved child vaccination rates.

Association of NEET rates (15–19; 20–24) with infant mortality rates and deaths from Cancer

In the realm of child health, we also looked at the infant mortality rates. We explored if infant mortality rates are associated with the NEET rates in different age groups (Fig. 6 ).

Association of Infant Mortality rates with NEET Rates (15–19) and NEET Rates (20–24)

Figure 6 is a scatterplot that explores the correlation between infant mortality and NEET rates in the age groups 15–19 and 20–24. The data is for all countries in the sample. Most data points are clustered in the lower infant mortality and lower NEET rate range. Infant mortality and NEET rates move in the same direction—as infant mortality increases/decrease, the NEET rate goes up/down. The NEET rate for the age group 20–24 has a slightly higher infant mortality rate than the NEET rate for the age group 15–19. This implies that when people in the age group 20–24 are uneducated or unemployed, the implications on infant mortality are higher than in other age groups. This is a reasonable association, since there is the potential to have more people with children in this age group than in the teenage group. To reduce the risk of infant mortality, governments should decrease NEET rates through promotional programs that disseminate the benefits of being educated, employed, and trained [ 7 ]. Additionally, they can offer financial aid to public schools and companies to offer more resources to raise general health awareness in people.

We looked to see if the distribution of population without employment, education, or training (NEET) in various categories of high, medium, and low impacted the rate of deaths from cancer (Fig. 7 ). Our expectation is that high rates of NEET will positively influence deaths from cancer.

Association of Deaths from Cancer and different NEET Rates

The three pie charts in Fig. 7 show the distribution of deaths from cancer in groups of countries with different NEET rates (high, medium, and low). The analysis includes all countries in the sample. The expectation was that high rates of NEET would be associated with high rates of cancer deaths. Our results, however, show that countries with medium NEET rates tend to have the highest deaths from cancer. Countries with high NEET rates have the lowest deaths from cancer among the three groups. Contrary to expectations, countries with low NEET rates do not show the lowest death rates from cancer. A possible explanation for this can be attributed to the fact that in this group, the people in the labor force may be suffering from work-related hazards including stress, that endanger their health.

Association between adult education levels and health expenditure

It is interesting to note the relationship between health expenditure and adult education levels (Fig. 8 ). We expect them to be positively associated.

Association of Health Expenditure and Adult Education Level-Tertiary & Upper Secondary

Figure 8 shows a heat map with the number of countries in different combinations of groups between tertiary and upper-secondary adult education level. We emphasize the higher levels of adult education. The color of the square shows the average of health expenditure. The plot shows that most of the countries are divided into two clusters. One cluster has a high tertiary education level as well as a high upper-secondary education level and it has high average health expenditure. The other cluster has relatively low tertiary and upper secondary education level with low average health expenditure. Overall, the figure shows a positive correlation between adult education level and compulsory health expenditure. Governments of countries with low levels of education should allocate more health expenditure, which will have an influence on the educational levels. Alternatively, to improve public health, governments can frame educational policies to improve the overall national education level, which then produces more health awareness, contributing to national healthcare.

Association of Compulsory Health Expenditure with NEET rates by country and region

Having explored the relationship between health expenditure and adult education, we then explored the relationship between health expenditure and NEET rates of different countries (Fig. 9 ). We expect compulsory health expenditure to be negatively associated with NEET rates.

Association between Compulsory Health Expenditure and NEET Rate by Country and Region

In Fig. 9 , each box represents a country or region; the size of the box indicates the extent of compulsory health expenditure such that a larger box implies that the country has greater compulsory health expenditure. The intensity of the color of the box represents the NEET rate such that the darker color implies a higher NEET rate. Turkey has the highest NEET rate with low health expenditure. Most European countries such as France, Belgium, Sweden, and Norway have low NEET rates and high health expenditure. The chart shows a general association between low compulsory health expenditure and high NEET rates. The relationship, however, is not consistent, as there are countries with high NEET and high health expenditures. Our suggestion is for most countries to improve the social education for the youth through free training programs and other means to effectively improve the public health while they attempt to raise the compulsory expenditure.

Distribution of life expectancy at birth and tertiary enrollment rate

The distribution of enrollment rate (tertiary) and life expectancy of all the countries in the sample can give an idea of the current status of both education and health (Fig. 10 ). We expect these to be positively associated.

Distribution of Life Expectancy at Birth (years) and Tertiary Enrollment Rate

Figure 10 shows two histograms with the lines representing the distribution of life expectancy at birth and the tertiary enrollment rate of all the countries. The distribution of life expectancy at birth is skewed right, which means most of the countries have quite a high life expectancy and there are few countries with a very low life expectancy. The tertiary enrollment rate has a good distribution, which is closer to a normal distribution. Governments of countries with an extremely low life expectancy should try to identify the cause of this problem and take actions in time to improve the overall national health.

Comparison of adult education levels and deaths from Cancer at various levels of GDP per capita

We wanted to see if various levels of GDP per capita influence the levels of adult education and deaths from cancer in countries (Fig. 11 ).

Comparison of Adult Education Levels and Deaths from Cancer at various levels of GDP per capita

Figure 11 shows the distribution of various adult education levels for countries by groups of GDP per capita. The plot shows that as GDP grows, the level of below-secondary adult education becomes lower, and the level of tertiary education gets higher. The upper-secondary education level is constant among all the groups. The implication is that tertiary education is the most important factor among all the education levels for a country to improve its economic power and health level. Countries should therefore focus on tertiary education as a driver of economic development. As for deaths from cancer, countries with lower GDP have higher death rates, indicating the negative association between economic development and deaths from cancer.

Distribution of infant mortality rates by continent

Infant mortality is an important indicator of a country’s health status. Figure 12 shows the distribution of infant mortality for the continents of Asia, Europe, Oceania, North and South America. We grouped the countries in each continent into high, medium, and low, based on infant mortality rates.

Distribution of Infant Mortality rates by Continent

In Fig. 12 , each bar represents a continent. All countries fall into three groups (high, medium, and low) based on infant mortality rates. South America has the highest infant mortality, followed by Asia, Europe, and Oceania. North America falls in the medium range of infant mortality. South American countries, in general, should strive to improve infant mortality. While Europe, in general, has the lowest infant mortality rates, there are some countries that have high rates as depicted.

Association between child vaccination rates and NEET rates

We looked at the association between child vaccination rates and NEET rates in various countries (Fig. 13 ). We expect countries that have high NEET rates to have low child vaccination rates.

Association between Child Vaccination Rates and NEET rates

Figure 13 displays the child vaccination rates in the first map and the NEET rates in the second map, for all countries. The darker green color shows countries with higher rates of vaccination and the darker red represents those with higher NEET rates. It can be seen that in general, the countries with lower NEET also have better vaccination rates. Examples are USA, UK, Iceland, France, and North European countries. Countries should therefore strive to reduce NEET rates by enrolling a good proportion of the youth into initiatives or programs that will help them be more productive in the future, and be able to afford preventive healthcare for the families, particularly, the children.

Average smoking rate in different continents over time

We compared the trend of average smoking rate for the years 1995–201 for the continents in the sample (Fig. 14 ).

Trend of average smoking rate in different continents from 1995 to 2015

Figure 14 depicts the line charts of average smoking rates for the continents of Asia, Europe, Oceania, North and South America. All the lines show an overall downward trend, which indicates that the average smoking rate decreases with time. The trend illustrates that people have become more health conscious and realize the harmful effects of smoking over time. However, the smoking rate in Europe (EU) is consistently higher than that in other continents, while the smoking rate in North America (NA) is consistently lower over the years. Governments in Europe should pay attention to the usage of tobacco and increase health consciousness among the public.

Association between adult education levels and deaths from Cancer

We explored if adult education levels (below-secondary, upper-secondary, and tertiary) are associated with deaths from cancer (Fig. 15 ) such that higher levels of education will mitigate the rates of deaths from cancer, due to increased awareness and proactive health behavior.

Association of deaths from cancer with adult education levels

Figure 15 shows the correlations of deaths from cancer among the three adult education levels, for all countries in the sample. It is obvious that below-secondary and tertiary adult education levels have a negative correlation with deaths from cancer, while the upper-secondary adult education level shows a positive correlation. Barring upper-secondary results, we can surmise that in general, as education level goes higher, the deaths from cancer will decrease. The rationale for this could be that education fosters more health awareness and encourages people to adopt healthy behavioral practices. Governments should therefore pay attention to frame policies that promote education. However, the counterintuitive result of the positive correlation between upper-secondary levels of adult education with the deaths from cancer warrants more investigation.

We drilled down further into the correlation between the upper-secondary education level and deaths from cancer. Figure 16 shows this correlation, along with a breakdown of the total number of records for each continent, to see if there is an explanation for the unique result.

Association between deaths from cancer and adult education level-upper secondary

Figure 16 shows a dashboard containing two graphs - a scatterplot of the correlation between deaths from cancer and education level, and a bar graph showing the breakdown of the total sample by continent. We included a breakdown by continent in order to explore variances that may clarify or explain the positive association for deaths from cancer with the upper-secondary education level. The scatterplot shows that for the European Union (EU) the points are much more scattered than for the other continents. Also, the correlation between deaths and education level for the EU is positive. The bottom bar graph depicts how the sample contains a disproportionately high number of records for the EU than for other continents. It is possible that this may have influenced the results of the correlation. The governments in the EU should investigate the reasons behind this phenomenon. Also, we defer to future research to explore this in greater detail by incorporating other socioeconomic parameters that may have to be factored into the relationship.

Association between average tertiary school life expectancy and health expenditure

We moved our focus to the trends of tertiary school life expectancy and health expenditure from 1995 to 2015 (Fig. 17 ) to check for positive associations.

Association between Average Tertiary School Life Expectancy and Health Expenditure

Figure 17 is a combination chart explaining the trends of tertiary school life expectancy and health expenditure, for all countries in the sample. The rationale is that if there is a positive association between the two, it would be worthwhile for the government to allocate more resources towards health expenditure. Both tertiary school life expectancy and health expenditure show an increase over the years from 1995 to 2015. Our additional analysis shows that they continue to increase even after 2015. Hence, governments are encouraged to increase the health expenditure in order to see gains in tertiary school life expectancy, which will have positive implications for national health. Given that the measured effects of education are large, investments in education might prove to be a cost-effective means of achieving better health.

Our results reveal how interlinked education and health can be. We show how a country can improve its health scenario by focusing on appropriate indicators of education. Countries with higher education levels are more likely to have better national health conditions. Among the adult education levels, tertiary education is the most critical indicator influencing healthcare in terms of infant mortality, life expectancy, child vaccination rates, and enrollment rates. Our results emphasize the role that education plays in the potential years of life lost, which is a measure that represents the average years a person would have lived had he/she not died prematurely. In addition to mortality rate, an economy needs to consider this indicator as a measure of health quality.

Other educational indicators that are major drivers of health include school life expectancy, particularly at the tertiary level. In order to improve the school life expectancy of the population, governments should control the number of youths ending up unemployed, dropping out of school, and without skills or training (the NEET rate). Education allows people to gain skills/abilities and knowledge on general health, enhancing their awareness of healthy behaviors and preventive care. By targeting promotions and campaigns that emphasize the importance of skills and employment, governments can reduce the NEET rates. And, by reducing the NEET rates, governments have the potential to address a broad array of vulnerabilities among youth, ranging from unemployment, early school dropouts, and labor market discouragement, which are all social issues that warrant attention in a growing economy.

We also bring to light the health disparities across countries and suggest implications for governments to target educational interventions that can reduce inequalities and improve health, at a macro level. The health effects of education are at the grass roots level - creating better overall self-awareness on personal health and making healthcare more accessible.

Scope and limitations

Our research suffers from a few limitations. For one, the number of countries is limited, and being that the data are primarily drawn from OECD, they pertain to the continent of Europe. We also considered a limited set of variables. A more extensive study can encompass a larger range of variables drawn from heterogeneous sources. With the objective of acquiring a macro perspective on the education–health association, we incorporated some dependent variables that may not traditionally be viewed as pure health parameters. For example, the variable potential years of life lost is affected by premature deaths that may be caused by non-health related factors too. Also there may be some intervening variables in the education–health relationship that need to be considered. Lastly, while our study explores associations and relationships between variables, it does not investigate causality.

Conclusions and future research

Both education and health are at the center of individual and population health and well-being. Conceptualizations of both phenomena should go beyond the individual focus to incorporate and consider the social context and structure within which the education–health relationship is embedded. Such an approach calls for a combination of interdisciplinary research, novel conceptual models, and rich data sources. As health differences are widening across the world, there is need for new directions in research and policy on health returns on education and vice versa. In developing interventions and policies, governments would do well to keep in mind the dual role played by education—as a driver of opportunity as well as a reproducer of inequality [ 36 ]. Reducing these macro-level inequalities requires interventions directed at a macro level. Researchers and policy makers have mutual responsibilities in this endeavor, with researchers investigating and communicating the insights and recommendations to policy makers, and policy makers conveying the challenges and needs of health and educational practices to researchers. Researchers can leverage national differences in the political system to study the impact of various welfare systems on the education–health association. In terms of investment in education, we make a call for governments to focus on education in the early stages of life course so as to prevent the reproduction of social inequalities and change upcoming educational trajectories; we also urge governments to make efforts to mitigate the rising dropout rate in postsecondary enrollment that often leads to detrimental health (e.g., due to stress or rising student debt). There is a need to look into the circumstances that can modify the postsecondary experience of youth so as to improve their health.

Our study offers several prospects for future research. Future research can incorporate geographic and environmental variables—such as the quality of air level or latitude—for additional analysis. Also, we can incorporate data from other sources to include more countries and more variables, especially non-European ones, so as to increase the breadth of analysis. In terms of methodology, future studies can deploy meta-regression analysis to compare the relationships between health and some macro-level socioeconomic indicators [ 13 ]. Future research should also expand beyond the individual to the social context in which education and health are situated. Such an approach will help generate findings that will inform effective educational and health policies and interventions to reduce disparities.

Availability of data and materials

The dataset analyzed during the current study is available from the corresponding author on reasonable request.

Abbreviations

Fundamental Cause Theory

Human Capital Theory

Not in Employment, Education, or Training

Organization for Economic Cooperation and Development

Socio-economic status

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Raghupathi, V., Raghupathi, W. The influence of education on health: an empirical assessment of OECD countries for the period 1995–2015. Arch Public Health 78 , 20 (2020). https://doi.org/10.1186/s13690-020-00402-5

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What you need to know about education for health and well-being

Why focus on education for health and well-being.

Children and young people who receive a good quality education are more likely to be healthy, and likewise those who are healthy are better able to learn.

Globally, learners face a range of challenges that stand in the way of their education, their schooling and their futures. A few of these are related to their health and well-being. Estimates show that some 246 million learners experience violence in and around school every year and 73 million children live in extreme poverty, food insecurity and hunger. Pregnancy related complications are the leading cause of death among girls aged 15-19, and the COVID-19 pandemic has vividly highlighted the unmet needs of learners and their mental health.

UNESCO works to promote the physical and mental health and well-being of learners. By reducing health-related barriers to learning, such as gender inequality, HIV and other sexually transmitted infections (STIs), early and unintended pregnancy, violence and discrimination, and malnutrition, UNESCO, governments and school systems can pose serious threats to the well-being of learners, and to the completion of all learners’ education.

Why is health and well-being key for learners?

The link between education to health and well-being is clear. Education develops the skills, values and attitudes that enable learners to lead healthy and fulfilled lives, make informed decisions, and engage in positive relationships with everyone around them. Poor health can have a detrimental effect on school attendance and academic performance.  Health-promoting schools  that are safe and inclusive for all children and young people are essential for learning.

Statistics  show that higher levels of education among mothers improve children’s nutrition and vaccination rates, while reducing preventable child deaths, maternal mortality and HIV infections. Maternal deaths would be reduced by two thirds, saving 98,000 lives, if all girls completed primary education. There would be two‑thirds fewer child marriages, and an increase in modern contraceptive use, if all girls completed secondary education.

At UNESCO, education for health and well-being refers to resilient, health-promoting education systems that integrate school health and well-being as a fundamental part of their daily mission. Only then will our learners be prepared to thrive, to learn and to build healthy, peaceful and sustainable futures for all.

• The relevance and contributions of education for health and well-being to the advancement of human rights, sustainable development & peace: thematic paper , UNESCO, 2022

How is UNESCO advancing learners’ health and well-being for school and life?

UNESCO has a long-standing commitment to improve health and education outcomes for learners. Guided by the  UNESCO Strategy on Education for Health and Well-Being,  UNESCO envisions a world where learners thrive and works across three priority areas to ensure all learners are empowered through:

• school systems that promote their  physical and mental health  and well-being
• quality, gender-transformative  comprehensive sexuality education  that includes HIV, life skills, family and rights
• safe and inclusive learning environments  free from all forms of violence, bullying, stigma and discrimination

Through its unique expertise, wide network and a range of strategic partnerships, UNESCO supports tailored interventions in formal educational settings at regional and country levels, with a focus on adolescents. Key areas of actions include:  technical guidance  at global levels, and targeted and holistic action at national levels such as the Our Rights, Our Lives, Our Future (O3) programme; joint efforts through the  Global Partnership Forum for comprehensive sexuality education  and the  School-related gender-based violence working group ; guidance on school health and nutrition; advocacy around the  International Day against violence and bullying at school ; capacity-building and knowledge generation such as the  Health and education resource centre .

UNESCO aims to make health education appropriate and relevant for different age groups including young learners and adolescents, thus working closely with young people and youth networks. It identifies adolescence (ages 10-19) as ‘a critical window of opportunity to invest in education, skills and competencies; with benefits for well-being now, into future adult life, and for the next generation’ and a time when schools should impart healthy habits that will empower adolescents to become healthy citizens.  Young People Today  is an initiative aiming to improve the health and well-being of young people in the Eastern and Southern Africa region.

Why is comprehensive sexuality education key for learners’ health and well-being?

Comprehensive sexuality education (CSE) is  widely recognised as a key intervention  to advance gender equality, healthy relationships and sexual and reproductive health, all of which have been shown to positively improve education and health outcomes.

At UNESCO, CSE is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It offers life-saving knowledge and develops the values, skills and behaviours young people need to make informed choices for their health and well-being while promoting respect for human rights, gender equality and diversity. CSE empowers learners to realize their health, well-being and dignity, develop respectful relationships and understand their sexual and health rights throughout their lives. Effective CSE is delivered in an age-appropriate manner.

Without correct knowledge on sexual and reproductive health, learners face risks directly impacting their education and future. For example, early and unintended pregnancy increases the risk of absenteeism, poor academic attainment and early drop-out from school for girls, while also having educational implications for young fathers.

Through its O3 flagship programme, UNESCO contributes to the health and well-being of young people in Africa with a view to reducing new HIV infections, early and unintended pregnancy, gender-based violence, and child and early marriage. The O3 programme has benefitted over 28 million learners so far and has introduced ‘O3Plus’, focusing on actions in favour of young people in tertiary education.

UNESCO’s  Foundation for Life and Love campaign  (#CSEandMe) aims to highlight the benefits of good quality CSE for all young people. Because CSE is about relationships, gender, puberty, consent, and sexual and reproductive health, for all young people.

Why is UNESCO building back healthy and resilient schools?

As the education of 1.6 billion learners came to a halt as a result of the unprecedented COVID-19 global health pandemic, the world became witness to the crucial importance of schools as lifelines for learners’ health and well-being. Schools are a social safety net providing essential health education and services including meals,   identifying signs of mistreatment or violence, establishing links to health services, fostering social connections and promoting physical activity. And without this safety net, millions of learners were at risk.

For example, early and forced marriage and unintended adolescent pregnancy rose during the pandemic and lockdown periods. This resulted in more dropouts from school, leaving learners and girls in particular out of school. The pandemic vividly illustrated the interlinkages between education and health, and the urgent need to work across sectors to advance the interests of future generations,  building back resilient  education systems to prevent, prepare for and respond to health crises. It also highlighted learners’ unmet need for support around their mental health.

Learner mental health and well-being is an integral part of UNESCO’s work on health education and the promotion of safe and inclusive learning environments. UNESCO joined with UNICEF and the WHO to launch a  Technical Advisory Group  of experts to advise educational institutions on ensuring schools respond appropriately to crises like the COVID-19 pandemic.

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• Published: 09 April 2024

National norms for the obstetric nurses’ and midwives’ health education competence, and its influencing factors: a nationwide cross-sectional study

• Jingjing Zou 1   na1 ,
• Jingling Wu 2   na1 &
• Xiumin Jiang 3  

BMC Medical Education volume  24 , Article number:  389 ( 2024 ) Cite this article

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Metrics details

Strengthening obstetric nurses’ and midwives’ health education competence is the investment and guarantee for the population’s future health. The purpose of study is to establish national norms for their health education competence, and explore possible influencing factors for providing an uniform criterion identifying levels and weaknesses.

An online questionnaire with a standard process was used to collect data. Three normative models were constructed, and multiple linear regression analysis analyzed possible influencing factors.

The sample respondents ( n  = 3027) represented obstetric nurses and midwives nationally. Three health education competency normative norms (mean, percentile and demarcation norm) were constructed separately. Locations, hospital grade, department, marital status, training times and satisfaction with health education training influenced obstetrical nurses’ and midwives’ health education competence ( P <0.05).

This study constructed the first national standard for assessing obstetric nurses’ and midwives’ health education competence, providing a scientific reference to evaluate the degree of health education competence directly. These known factors could help clinical and policy managers designate practice improvement measures. In future research, Grade I hospitals should be studied with larger sample sizes, and indicators need to improve to reflect health education’s effect better.

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The World Health Organization has long recommended [ 1 ] that pregnant women need more health education, life guidance, and follow-up visits. “Outline of the Healthy China 2030 Plan” [ 2 , 3 ] also proposed that health services would be strengthened to improve the health of women and children, and it is essential to provide health education covering the prenatal, perinatal and postnatal periods. Comprehensive and practical health education can significantly enhance maternal and infant safety, promote spontaneous delivery, and increase exclusive breastfeeding rates [ 4 ]. Authorities such as the International Confederation of Midwives [ 5 ] and the American College of Nurse-Midwives [ 6 ] emphasise the critical role of midwives and obstetric nurses in providing comprehensive care, assisting in labour and delivey, and managing complications [ 7 ]. Obstetric nurses and midwives should possess extensive health knowledge and excellent education competence to ensure women and their families can make informed decisions, and safely manage maternal health and well-being [ 8 ].

Strengthening obstetric nurses’ and midwives’ health education competence is the investment and guarantee for the population’s future health [ 9 ]. Given its importance, researchers have conducted in-depth discussions on health education quality, goals, strategy and evaluation. However, no study has built a uniform criterion for assessing the performance of obstetric nurses’ and midwives’ health education competency. A norm, a reference standard for the scores obtained using a scale, is usually the average score and standard deviation of many testers. A norm could compare the differences between different groups and assess individual performance [ 10 ]. Meanwhile, based on the normal analysis, a more scientific and reliable scale promotion strategy can be formed to popularize and promote relevant scientific theories and methods [ 11 ].

The rating scale of health education competence for nurses (RSHECN) was developed and verified its reliability and validity (Tong and Li, 2010). The scale determined that good performance in health education requires nurses to have adequate expertise, sound assessment, planning and implementation and the ability to evaluate the effectiveness of health education, which calcified the connotation of health education competence for nurses and provided a way for evaluation. Therefore, a nationwide cross-sectional survey of multi-stage stratified cluster sampling was conducted to establish norms for RSHECN and explore their influencing factors of health education competence, providing a reference for clinical and policy managers to identify weaknesses and formulate practice improvement plans.

Study design

A cross-sectional study of multi-stage stratified cluster sampling was carried out [ 12 , 13 ]. The nationwide obstetric nurses and midwives were selected as participants from April to May 2021 to establish the mean norm, percentile norm and demarcation norm of RSHEC and explore possible influencing factors of obstetric nurses’ and midwives’ health education competence.

Participants

The participants were recruited using a stratified multistage cluster sampling method with three steps: (1) Selected representative regions. Three regions (Eastern China, Central China and Western China) were selected, divided by the National Bureau of Statistics of China according to geographic location and economic level. (2) Selected provincial administrative unit (from now it was referred to as the “unit”). The convenient sampling method was used to decide the final units. Seven out of eleven in the eastern region were selected: Tianjin, Hebei, Liaoning, Jiangsu, Zhejiang, Fujian and Guangdong. Four out of eight units in the central region were selected: Shanxi, Heilongjiang, Jiangxi and Hunan. Seven out of twelve units in the western region were selected: Sichuan, Chongqing, Gansu, Qinghai, Xinjiang, Guangxi and Inner Mongolia. (3) Selected included hospitals. The selection of hospitals adopted a convenient sampling method and ensured the diversity of garde I, II and III hospitals as much as possible. After that, with the consent of the hospital nursing department, a whole-group sampling method was used to include all obstetric nurses who met the inclusion criteria in the included hospitals. All active registered obstetrical nurses or midwives who voluntarily participated were included in this study. Moreover, interns, visiting nurses, and nurses who were absent during the survey or could not attend for personal reasons were excluded. The ethical committee of the principal researcher’s hospital approved the study (No 2018 − 206). Before the survey, written consent was obtained from all nursing departments. The questionnaire does not collect the personal information of the participants, and the database can only be accessed by the members of the research group. Participants were informed consent, and the returning online questionnaire was considered consent of participation.

Data collection

An introduction letter stating the study aim and process was issued to the department of the selected hospital to obtain survey permission. Then the online training was held to conduct a unified training for the hospital responsible person for the project. The standard data collection process was introduced to the responsible person with a standard language, and the contact information of the research group was provided to communicate the problem during the survey. The standard data collection process is the following: (1) Screen potential participants according to inclusion and exclusion criteria; (2) Seek the consent of potential participants. (3) Emphasize anonymity and confidentiality and sign the informed consent; (4) Invite participants to complete the questionnaire. Considering workforce and material resources, this survey adopts electronic questionnaires by the software “Questionnaire Star”, which helps to distribute questionnaires more scientifically in such an extensive national survey. The procedure was set so that each electronic device could only fill in the questionnaire once and submit the questionnaire after completing all items within 30 min. At the end of the survey, 5% of the questionnaires were randomly selected for quality check.

Measurements

The health education competence assessment questionnaire involves two parts: (1) general information questionnaire: The questionnaire was designed by reviewing relevant literature research and discussing with obstetric nursing experts, which covered the potential factors that might affect the health education competence of obstetrical nurses and midwives, including the type of hospital, age, educational level, current work department, additional training in health education, working years and other basic social demographic information. (2) Rating Scale of Health Education Competence for Obstetric Nurses and Midwives. The scale was used to evaluate the competence of health education of nurses and midwives, which had been authorised by the developer of Tong [ 14 ]. The self-evaluation scale includes four dimensions: assessment, plan, implementation and evaluation. Thirty-eight items on a five-point Likert-type scale (1 to 5, “completely disagree” to “completely agree”) and all items are positive. The score ranges from 37 to 185, and higher scores indicate better health education competence. The psychological verification was completed among various departments, including the obstetric nurse and midwife. The scale’s Cronbach α and half-fraction reliability were 0.949 and 0.953, the content validity index was 0.90, and it was verified with good construction validity and distinguish validity [ 14 ]. In this sample, 500 questionnaires were randomly selected in proportion to the number of obstetric nurses and midwives for reliability testing, and its Cronbach α was 0.987. Moreover, to facilitate understanding and comparison, the results of this study were analysed using conversion score, and the formula is as follows: conversion score = (original score theoretical minimum score of this aspect) / (theoretical maximum score theoretical minimum score of this aspect) ×100.

Data analysis

All calculations were performed using IBM SPSS Statistics software (version 26.0). Continuous variables were reported as mean ( \(\stackrel{-}{\text{x}}\) ) ± standard (S), and categorical variables were presented as frequencies and proportions. Three types of norms were developed in this study to establish normative values for health education competence among obstetric nurses and midwives. The mean norm was determined using the results of one-way ANOVA to calculate the mean and standard deviation of conversion scores and each dimension score. Percentile norm was established using the percentile method, with 5% percentile intervals, resulting in normative values at the 5th, 25th, 50th, 75th, and 95th percentiles. The demarcation norm was established through the distribution method with different demarcation schemes calculated at a spacing of 0.5 S within the total scale score ( \(\stackrel{-}{x}\)  ± 2.5 S). After that, we performed correlation analysis and selected the scheme with the highest correlation as the demarcation constant for the study [ 15 ]. Differences in assessment, plan, implementation, evaluation and conversion scores were analysed using an independent two-sample t-test and one-way analysis of variance, with demographic characteristics as independent variables. Statistically significant variables from the ANOVA analysis were included as independent variables in a stepwise multiple linear regression analysis to evaluate their contributions to conversion scores. In this study, covariance diagnosis of independent variables is based on tolerance (TOL) and variance inflation factor (VIF), and if TOL < 0.1 or VIF ≥ 10, it means that there is serious covariance between independent variables.

Three thousand three hundred questionnaires were received, 97 were excluded due to logical self-contradiction of data and abnormal distribution of values, and 3207 questionnaires were available with an effective recovery of 97.18%. All participants were female between eighteen and sixty-four years (33.20 ± 7.51 years). They had one to forty-five working years with an average of (11.00 ± 8.15) years covering the general population for job title, education, department and health education training conditions. Detailed demographic characteristics of the sample are shown in Table  1 .

Mean norms could be established for groups with different characteristics in the tested population. Considering the different economic and medical levels, five categorical mean norms were determined, including grade III hospitals, grade II hospitals, eastern China, central China and western China (Table  2 ). There is no specification Grade I for hospitals because of the insufficient sample size of primary hospitals (only 41 nurses from Grade I hospitals). The percentile norm was calculated based on scale scores and each dimension score at an interval of 5%, as shown in Table  3 . The distribution method was used to establish the demarcation norm, and plan 4, with the highest correlation coefficient ( r  = 0.970), was selected as the final scheme, as shown in Table  4 . The final demarcation grade was extremely poor [0, 70.32), poor [70.32, 76.5), medium [76.5, 88.86), good [88.86, 95.04), and excellent [95.04, 100].

The results of one-way ANOVA showed statistically significant differences ( P  < 0.05) in the health education competency conversion scores comparing hospital type, hospital grade, department, locations, marital status, satisfaction with health education training, and training times of health education. The multiple linear regression analysis showed that hospital grade ( P  = 0.002), locations ( P  = 0.032), department ( P  = 0.001), marital status( P  = 0.003), satisfaction with health education training ( P  < 0.001), and training times of health education ( P  = 0.006) were independent influencing factors of obstetric nurses’ and midwives’ health education competency scores. In this study, the TOL values were 0.956–0.993 and VIF values were 1.007–1.046, which cannot be considered as the existence of multiple covariance between independent variables, and all independent variables can be analysed by multiple regression.

This study established the first national norms for obstetric nurses’ and midwives’ health education competency and explored possible influencing factors. The mean norm can be used to determine whether obstetric nurses’ and midwives’ health education competency is within the reference range [ 15 ]. The result showed that the health education competency was highest in Central areas, followed by Eastern areas, and the lowest in Western areas. The central and east areas have superior medical resources, attracting more medical and nursing talents, while the western region has more mountainous areas with less developed medical resources. Central region scores higher than East region, probably because Central region contains fewer cities. The sample size of this survey is smaller, which makes its average score higher. The mean norm describes the overall level, and the percentile norm was formed to compare the individual score within the corresponding percentile norm to identify individual positions in the group [ 16 , 17 ]. The higher the score, the higher the percentile norm position, which means the health education competency level is better. The result of showed that the best division scheme was extremely poor [0, 70.32), poor [70.32, 76.5), medium [76.5, 88.86), good [88.86, 95.04) and excellent [95.04, 100], which make the scores for different indicators can be compared easily, reducing the difficulty of interpreting and comparing data, while also allowing for a more intuitive and accurate assessment of individual performance.

In this study, the mean scale score was (82.68 ± 12.36), which is intermediate compared to the norm [ 18 , 19 ]. The conversion scores from highest to lowest were implementation, evaluation, assessment and planning, consistent with clinical practice. In the clinical environment, each pregnant woman has different educational needs. However, nurses, as mainly part of implementer of health education, only teach fixed content but do not individualise health education on a case-by-case basis. Although there are often many research materials, such as guidelines, to guide obstetric nurses and midwives on what to do, they often copy and use indoctrination again, lacking individualised assessment of pregnant women [ 20 ]. Thus, the result prompts us to form a practical health education model in line with national conditions, strengthing the status of evaluation, assessment and planning to provide individualised health education and play the role of health education better.

The study identified that locations, hospital grade, department, marital status, satisfaction with health education training and training times were influencing factors for obstetric nurses’ and midwives’ health education competence. Among different locations, the disparity in medical conditions may lead to managers with different perceptions on the role of nurses’ and midwives’ in health education. Within health care teams, obstetric nurses and midwives are vital health education providers throughout the pregnancy and delivery. The government could introduce more policies and supportive steps to improve the attention of hospitals in underdeveloped areas to the health education capacity of nurses.

The score of tertiary hospitals was higher than secondary, and the possible reason is that tertiary hospitals absorbs higher qualified nursing talents [ 21 , 22 ], and they have more robust medical resources, research and teaching capabilities to provide more professional training and education and are more excellent regarding professional qualifications and skills [ 23 ]. Meanwhile, the regression analysis showed that the times and satisfaction of health education training were influencing factors. Long-term participation in health education training could enhance the professional confidence, stability and self-confidence of obstetrical nurses and midwives [ 23 , 24 ]. Satisfactory training can encourage applying knowledge and skills in practical work, promoting health education competency and work continuity [ 25 ]. Each training is a process of knowledge accumulation, and the increasing knowledge reserve in reproductive health, prenatal, intrapartum and postpartum care can better guide maternal health management and improve the life quality of birthing mothers and their infants [ 26 , 27 ]. Therefore, for hospitals managers, the organization of comprehensive, professional and satisfactory health education knowledge training should be regarded as an important part of management, especially for grassroots hospitals.

Another interesting result is that the health education competence of married and fertile nurses was better, who can better feel the actual needs of pregnant women and combine their own experience to provide more detailed and thoughtful health education in dealing with various real situations [ 28 , 29 ]. Future research can explore more health education methods from the perspective of maternity, so as to help unmarried and infertile nurses and midwives. Our result also showed that midwives scored lower than obstetric nurses, which may be due to the different work nature. Generally, obstetric nurses provide health education in the ward, while midwives in the delivery room. The unique physiological conditions for childbirth can make it challenging to provide health education. And the demand for health education after delivery is more significant, as the mother and her family require more information about puerperal rehabilitation and neonatal care. When providing health education, midwives and obstetric nurses could promote strengths and avoid weaknesses. Obstetric nurses can provide comprehensive health education for mothers and their families after delivery, and midwives can try to move forward their own health education opportunities and provide health education in midwives’ outpatient clinics.

A normative standardised reference will serve as a reference to help obstetric nurses and midwives identify strengths and weaknesses in health education competence and help management establish a more reasonable nursing echelon for enhancing maternal health [ 30 , 31 ]. The nationwide cross-sectional survey could help clinical and policy managers understand the current health education situation and formulate corresponding management plans for practice improvement [ 32 , 33 ]. Although the results reported here are of interest, it is necessary to acknowledge certain limitations of the study. Firstly, due to time and human constraints, the small sample size of the Grade I hospitals in this study affected the completeness of the norm. Also, the convenience sampling method used for hospital selection might introduce bias, as it does not ensure a randomized and comprehensive representation of all hospital grades, particularly Grade I hospitals. Future studies should aim for a more extensive and diverse sample, including a better representation of all hospital grades. Secondly, the study is limited to a specific time frame, which may not adequately represent changes over time. A longitudinal approach could offer insights into how health education competence evolves over time and its long-term impact on patient care and outcomes. Thirdly, the scale is a self-assessment scale, which is subjective in evaluating health education competence and lacks objective evaluation indicators. Obstetric nurses and midwives with higher scores indicate a certain level of health education competence. However, the effect of health education is not reflected by objective indicators, which need to be improved in future studies. Finally, implementing and evaluating training interventions could provide practical insights into effective strategies for improving health education competence among obstetric nurses and midwives.

A nationwide cross-sectional study of multi-stage stratified cluster sampling was conducted to establish the first national norms for obstetric nurses’ and midwives’ health education competency. Locations, hospital grade, department, marital status, satisfaction with health education training and training times were independent influencing factors for obstetric nurses’ and midwives’ health education competence. The study provides a valid way to assess obstetric nurses’ and midwives’ health education competency comprehensively and comparatively. It helps practitioners make more informed choices when developing relevant programs or decisions. In future research, Grade I hospitals should be studied with larger sample sizes, and indicators need to improve to reflect health education’s effect better.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Thanks to all participants for their valuable contribution to this study.

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Jingjing Zou and Jingling Wu contributed equally to this work.

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School of Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian Province, China

Jingjing Zou

Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

Jingling Wu

Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, No.18 Daoshan, Fuzhou, Fujian Province, China

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JJ.Z was responsible for data analysis, data interpretation and drafted the work.JL.W was responsible for conception, design and substantively revised work.XM.J was responsible for data acquisition and project administration.

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All active registered obstetrical nurses or midwives who voluntarily participated were included in this study. The ethical committee of the principal researcher’s hospital approved the study (No 2018 − 206). Before the survey, written consent was obtained from all nursing departments. Participants were informed consent, and the returning online questionnaire was considered consent of participation.

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Zou, J., Wu, J. & Jiang, X. National norms for the obstetric nurses’ and midwives’ health education competence, and its influencing factors: a nationwide cross-sectional study. BMC Med Educ 24 , 389 (2024). https://doi.org/10.1186/s12909-024-05249-w

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The processes of health education and health promotion are linked and may overlap. Health education is the process by which messages aimed at enabling individuals to take greater control over and improve their health are defined. The first step in the process is to gain an understanding of the basic cause of the disease process under consideration. The second step is to identify the essential causative factors. Some of these will be beyond individual personal control, such as environmental factors and genetics. However, other factors may be under the control of the individual and amenable to change. The final step is that to define and communicate key messages derived from the previous stages so as to improve the health of both individuals and populations. Health promotion is the process by which these messages are taken and disseminated whether by word of mouth, in print or through one of the rapidly expanding forms of electronic media. The World Health Organisation defines health promotion as the process that extends health education beyond a focus on individual behaviour towards a wide range of social and environmental interventions.

Health education is the process by which people are given information needed to exercise a greater degree of control over their own health.

The process requires an understanding of disease aetiology, the causative factors, and socially simple and acceptable messages for beneficial behavioural change.

Oral health education should be integrated into general health education as there are common risk factors linking oral and systemic diseases.

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The BDJ Editorial Team would like to thank the authors of this chapter for granting us permission to republish their chapter within our journal. This chapter was first originally published in Ronnie Levine and Catherine Stillman-Lowe, The Scientific Basis of Oral Health Education , BDJ Clinician's Guides, https://doi.org/10.1007/978-3-319-98207-6_1 © Springer Nature Switzerland AG 2019.

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How health systems and educators can work to close the talent gap

Every patient who engages with a health system has a team of healthcare workers supporting and administering care, whether in hospitals, clinics, ambulatory surgery centers, or other settings. Attracting enough qualified employees in nursing, allied health, and many other roles has posed a meaningful challenge for the healthcare sector since before the COVID-19 pandemic.

About the authors

This article is a collaborative effort by Brandon Carrus , Connor Essick, Martha Laboissiere , Meredith Lapointe, and Mhoire Murphy , representing views from McKinsey’s Healthcare Practice.

Resignations among healthcare workers have increased steadily from about 400,000 per month in 2020 to nearly 600,000 per month in May 2023. 1 “Job openings and labor turnover—July 2023,” US Bureau of Labor Statistics, accessed August 20, 2023. The vacancy rate—the difference between the number of job openings and hires—has also increased during this period, with about 710,000 vacant positions as of May 2023 (down from a high of more than a million in December 2022). 2 “Job openings and labor turnover—July 2023,” US Bureau of Labor Statistics, accessed August 20, 2023. Other factors compound the challenge, including workforce demographic shifts and changing care needs.

Attracting enough qualified employees in nursing, allied health, and many other roles has posed a meaningful challenge for the healthcare sector since before the COVID-19 pandemic.

Health systems could take a decade or more to make the adjustments needed to address some of these pressing workforce challenges. Moreover, reskilling and upskilling can help build workforce resilience and job security (for example, by avoiding obsolescence as automation takes over roles) while ensuring that skills align with employers’ evolving needs. In the meantime, the US healthcare sector is facing multiple headwinds that threaten affordability, access, and industry economics. 3 Addie Fleron and Shubham Singhal, “ The gathering storm in US healthcare: How leaders can respond and thrive ,” McKinsey, September 8, 2022.

Health systems are actively designing and planning for workforce models that are more sustainable, including by innovating care models, increasing the use of technology, and boosting efforts to attract, recruit, and retain workers. 4 “ Care for the caretakers: Building the global public health workforce ,” McKinsey, July 26, 2022. They are also becoming more involved in efforts to expand the pool of qualified talent in nursing and allied-health professions through education. These efforts can take many forms but can be clustered broadly into three models: health systems creating or acquiring their own education entities, health systems and educational institutions creating equal partnerships to educate the workforce, and health systems partnering with education providers to develop (at least in part) the talent supply they need.

This article explores workforce shortages in healthcare, describes the three educational models, and examines five design elements that could improve the likelihood of success, regardless of the chosen model.

The challenge of securing essential healthcare talent

The workforce shortages confronting health systems executives are well documented. 5 “ Nursing in 2023: How hospitals are confronting shortages ,” McKinsey, May 5, 2023. Aside from baseline demographic shifts (even the youngest baby boomers are nearing retirement age), challenges associated with the COVID-19 pandemic prompted workers, especially women, to leave healthcare in droves. 6 Gretchen Berlin, Nicole Robinson, and Mayra Sharma, “ Women in the healthcare industry: An update ,” McKinsey, March 30, 2023. Moreover, a McKinsey survey of nurses found that more than 30 percent are thinking of leaving direct patient care, even though they find the work meaningful. 7 Gretchen Berlin, Meredith Lapointe, and Mhoire Murphy, “ Surveyed nurses consider leaving direct patient care at elevated rates ,” McKinsey, February 17, 2022. Along with higher attrition, health systems are having great difficulty finding qualified individuals to backfill those roles.

These severe labor supply constraints come at a time of accelerating demand for care because of an aging population, rising disease burden, exacerbated chronic conditions, and worsening mental health, among other factors. We project there will be one million additional nursing care jobs by 2031, primarily for certified nurse assistants, outpacing the number of individuals expected to complete degree programs based on current capacity. 8 McKinsey analysis of Lightcast data; working with 2021 Lightcast data on US labor markets, we estimated potential workforce gaps based on projected annual job openings and completed degrees across different healthcare jobs. Yet across the United States, educational institutions lack the capacity to close the gap (exhibit).

Against this backdrop, health systems are thinking more strategically about the broader healthcare workforce pipeline, including by expanding their engagement with education providers. But these efforts are frequently unproductive and fall short of achieving the desired objectives for either entity. Health systems report a shortage of graduates in multiple professions, graduates who are not sufficiently productive in their early months of employment, and an overall system that fails to attract individuals to healthcare professions. 9 “Study projects nursing shortage crisis will continue without concerted action,” American Hospital Association, April 13, 2023; “A public health crisis: Staffing shortages in health care,” University of Southern California, March 13, 2023; Rob Preston, “The shortage of US healthcare workers in 2023,” Oracle, January 2023. Education providers report a shortage of clinical-rotation seats, challenges in securing qualified faculty, challenges in identifying sufficiently qualified and interested applicants, and an unfavorable financial structure in which many programs are net negative. 10 “Fact sheet: Nursing shortage,” American Association of Colleges of Nursing, last updated October 2022; Michal Cohen Moskowitz, “Academic health center CEOs say faculty shortages major problem,” Association of Academic Health Centers, 2007.

Varied educational models based on participants’ strategic priorities

Many health systems leaders are considering three models to address the talent shortage.

Health systems creating or acquiring their own education entities

Some health systems choose to build or acquire a new entity and create their own proprietary program and curriculums. Of the three models, this one requires the largest investment and strategic focus. For example, Kaiser Permanente opened its own medical school to train future physicians and healthcare leaders using its team-based approach. 11 Eddie Rivera, “New Kaiser medical school opens in Pasadena,” Pasadena Now , July 27, 2020. Additionally, HCA Healthcare acquired a majority stake in the Galen College of Nursing in 2020. 12 Jeff Lagasse, “HCA Healthcare investing $300K to improve access to healthcare careers,” Healthcare Finance , January 26, 2023.

This model is characterized by a focus on meeting the health system’s own workforce needs. In doing so, health systems are effectively running educational institutions. Each has a chancellor or president and a separate physical space or a campus. They compete with other educational institutions for students, face the same requirements for accreditation, and are subject to rules similar to those of other education providers.

To accomplish its goals, the health system offers highly customized programs, including microcredentialing, 13 Defined as short, focused credentials designed to provide in-demand skills and experience. Microcredential courses can run from an hour to 16 weeks depending on the topic’s complexity. that align with the health system’s professional-development pathways. From a recruitment standpoint, this approach can be effective at attracting entry-level employees who can then progress in their careers to perform higher-skilled jobs. For example, a system could create an “imaging technician” program track that allows an individual with a high school degree or GED credential to complete an associate-level degree in nuclear-medicine technology, a profession that’s in high demand at many health systems. This pathway allows the employer to focus primarily on professions in which demand is great enough to justify the needed investments in curriculums and faculty while still providing the opportunity to engage in other models for low-volume demand.

Although health systems could diversify their portfolios into the education arena and train graduates for other health systems as a revenue-generating opportunity, they rarely do. Some believe this is a deviation from their core mission that dilutes their distinctive proposition and competitive advantage.

Health systems and educational institutions creating an equity partnership

Alternatively, health systems may choose to develop education programs through a joint venture with an existing postsecondary-education provider. For example, CommonSpirit Health and Global University Systems created a joint venture to provide online degrees and leadership training to clinical and nonclinical health professionals. 14 Dave Muoio, “Providence, Premier invest in CommonSpirit’s workforce development platform,” Fierce Healthcare , November 11, 2022. The joint investment in program development and operations demonstrates the commitment of both entities. This model offers the additional benefits of customization based on health system needs. The health system can make use of the education provider’s existing programs, resources, and competencies—including faculty, curriculums, assessments, enrollment protocols, and tuition and fee collection systems—while remaining focused on its core mission.

Health systems partnering with vendors to administer education

To promote educational advancement among workers without getting directly involved, a health system could pursue partnerships with education providers or education technology platforms such as Guild Education that aggregate online courses to curate specific programs. For example, Community Health Systems partnered with Western Governors University as its preferred education provider in exchange for discounted tuition rates for its employees. 15 “Tuition reimbursement benefits,” Western Governors University, accessed August 30, 2023. This model provides health systems with access to the full breadth of existing education programming and the ability to customize, particularly in cases in which the partnership is well established.

The value in partnerships for different stakeholders

Partnerships between health systems and postsecondary institutions can create substantial value beyond what each entity brings to the table, including in education quality, graduate preparedness, and the relationships that can result among students, health systems, and schools.

The value for health systems

Studies have shown that employees who use education benefits are more likely to stay with their current employer than those who do not. 16 “Evaluating employee education benefits: Tuition assistance, tuition reimbursement & more,” University of Massachusetts Global, accessed August 30, 2023. Education benefits can also help health systems more effectively compete in a tight labor market. Enrollees of corporate higher education programs are more than 80 percent more likely to recommend their employer to others. 17 “The dollar value of education benefits: 5 elements of ROI,” Guild Education, December 2020. One LinkedIn study revealed that companies can lower the cost of recruiting and retaining workers by investing in their employer brand. 18 Kaidlyne Neukam, “How to leverage companies’ employer branding to attract and retain tech talent,” LinkedIn, February 2, 2021.

Additionally, education is often connected with a more engaged and productive healthcare workforce. Workers who feel their employer is invested in their long-term success are less likely to disengage. Research shows that productivity among highly engaged teams is 14 percent higher than that of teams with the lowest engagement, and employees who are not engaged cost their company the equivalent of 18 percent of their annual salary. 19 Jake Herway, “Increase productivity at the lowest possible cost,” Gallup, October 15, 2020. Moreover, continual advances in medical technology have translated to a need for a nimbler and more advanced workforce. Boosting the skills of current employees and training them to perform new roles is more efficient and cost-effective than recruiting external talent.

The value for postsecondary-education providers

Higher education institutions derive value from a health system partnership through the following channels:

Access to clinical rotations for students. In most health professions, guaranteed, high-quality clinical rotations for students are both highly desirable and difficult to secure. Increased access to clinical rotations through a health system partnership could ease a large burden for higher education institutions and serve as a differentiator to attract potential students.

Access to a large pool of prospective students. Health systems could provide access to thousands of healthcare workers seeking educational advancement to boost their credentials or qualify them for other roles. A steady influx of students over a multiyear period could provide educational institutions with financial security in an increasingly competitive industry and help them shift their focus from recruiting to curriculum development and instruction. Moreover, students could gain access to programs that lead to careers they may not have known about.

Improved postgraduation outcomes. In general, better alignment between curriculums and workforce needs leads to better employment outcomes for students. There is a large gap between what students learn in healthcare education programs and the abilities employers are looking for in new hires. 20 Cheryle G. Levitt, “Bridging the education-practice gap: Integration of current clinical practice into education on transitions to professional practice,” Sigma Repository, July 28, 2014. Health systems can provide input to shape curriculums to meet their specific needs, thus enabling graduates to maximize their potential for employment success—more job offers, improved retention, and continued growth—and creating a virtuous cycle of upward mobility.

In 2019, INTEGRIS Health partnered with Southwestern Oklahoma State University to establish tuition support for first-year nurses. 21 Van Mitchell, “INTEGRIS Health partners with SWOSU in degree program,” Oklahoma’s Nursing Times , September 16, 2019. Licensed vocational nurses employed by INTEGRIS Health are eligible for tuition support and can work while taking classes. Upon completion of the program, participants transition to roles as registered nurses.

The value for communities

Partnerships between health systems and postsecondary-education providers could create value for individuals and communities. They could improve access to care, promote economic growth and vitality within communities, create more professional and higher-paying jobs, and pave career paths for the next generation of healthcare workers.

Educational partnerships also create opportunities for entry-level workers to gain critically needed and specialized skills so they can transition to in-demand careers in nursing and allied health—a financially advantageous career path. For example, the median salary for healthcare support occupations (such as home health and personal-care aides, occupational-therapy assistants, and medical transcriptionists) that require minimal educational requirements and credentials is approximately $30,000, compared with $48,000 for licensed practical nurses, $62,000 for respiratory therapists, and more than $77,000 for registered nurses with bachelor’s degrees. 22 “Healthcare occupations,” US Bureau of Labor Statistics, accessed August 30, 2023.

Additionally, historically marginalized people make up a disproportionate share of entry-level clinical and nonclinical workers in health systems. 23 Janette Dill and Mignon Duffy, “Structural racism and Black women’s employment in the US health care sector,” Health Affairs , February 2022, Volume 41, Number 2. Training these workers to perform higher-skilled jobs is one way to address long-standing racial inequities in healthcare pay and career trajectories. For example, many minority candidates see the licensed practical nurse (LPN) role as an entry point into clinical care because becoming an LPN is comparatively faster and cheaper than the more advanced credentialing necessary for registered-nurse (RN) licensure. Twenty-five percent of LPN positions are filled by Black women, compared with just 10 percent of RN positions. 24 Janette Dill and Mignon Duffy, “Structural racism and Black women’s employment in the US health care sector,” Health Affairs , February 2022, Volume 41, Number 2. The compensation differential between the two roles is also sizable, with LPNs earning just more than 60 percent of an RN’s annual salary on average. 25 “Healthcare occupations,” US Bureau of Labor Statistics, accessed August 30, 2023. Health systems can use education partnerships to help more LPNs train for and advance into RN roles.

Last, using partnerships to secure needed talent will likely expand healthcare access, which could disproportionately benefit underserved communities. According to the Agency for Healthcare Research and Quality, substantial disparities in access to healthcare exist throughout the United States but especially in rural states, where labor shortages are most acute. 26 2019 national healthcare quality & disparities report , US Department of Health and Human Services, December 2020. And despite gains in insurance coverage in the past few years, disparities persist: nonelderly Native American and Hispanic people have the highest uninsured rates, at 21 percent and 19 percent, respectively. 27 Samantha Artiga, Anthony Damico, and Latoya Hill, “Health coverage by race and ethnicity, 2010-2021,” KFF, December 20, 2022. With improved labor supply, severely underserved areas and populations would be more likely to receive care.

Five design elements that characterize successful partnership models

Based on our experience, reviews of partnerships, and interviews with stakeholders, we have identified five elements of effective education partnerships.

Education is designed to help students get a job and succeed in it. For health systems, ensuring that employees are ready on day one is a primary objective of any education partnership. This can be accomplished by collaborating to develop programs and course curriculums that provide the skills needed for proficiency in specific roles. Where possible, it can also be beneficial for the health system to play a direct role—for example, by offering clinical rotations, having staff serve as faculty, and participating in career days.

Job demand regularly informs education pathways. As labor markets shift, health system partners need to continually reassess their education programs. Optimal program choices typically mirror roles in highest demand within the health system in a specific geographic region. The most valuable partnerships go beyond providing a single certificate or degree: they support lifelong learning, retain a record of all learning completed, and promote career advancement.

Programs are accessible to a broad set of students. A successful partnership requires a clear path to recruiting and enrolling students as well as a differentiated value proposition compared with competitors. Moreover, the entry-level nature of many of these professions highlights the importance of a support system to help students navigate the demands of the educational system and transition to employment. This support system can be part of the education institution’s offering or available through a third-party collaborator that is equally committed to the outcomes of the program.

Education is affordable for students and financially sound for partners. Partnerships between health systems and educational institutions need to be financially sound for all stakeholders, including prospective students. To minimize the financial burden on students, educational institutions could create affordable programs and health systems could fund a substantial portion of the cost.

Partners make a long-term commitment. Partnerships require energy, commitment, and investment in resources. Partners can clarify their expectations up front to avoid disconnects that can strain relationships. For example, educators can explicitly state their expectation that the health system will support them with clinical rotations, faculty, and preceptors. Having aligned on objectives and priorities, the partners can take steps (for example, writing contracts and setting up a governance structure) to support their long-term mutual goals.

Addressing current labor challenges in healthcare and laying the foundation to collaboratively develop a more diverse and equitable workforce to meet future demand are dual imperatives. As health systems and postsecondary institutions consider partnership opportunities, they can bolster the likelihood of success by understanding workforce needs and the value at stake, choosing a partnership model that aligns with the health system’s priorities, and leveraging existing workforce development initiatives and affiliated stakeholders.

Brandon Carrus is a senior partner in McKinsey’s Cleveland office; Connor Essick is an alumnus of the Bay Area office, where Martha Laboissiere is a partner and Meredith Lapointe is an alumna; and Mhoire Murphy is a partner in the Boston office.

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Arkansas led the nation sending letters home from school about obesity. did it help.

Kavitha Cardoza

Since Arkansas started sending the obesity letters to parents, the state's childhood obesity rates rose to nearly 24% from 21%. During the pandemic, the state obesity rate hit a high of more than 26%. M. Spencer Green/AP hide caption

Since Arkansas started sending the obesity letters to parents, the state's childhood obesity rates rose to nearly 24% from 21%. During the pandemic, the state obesity rate hit a high of more than 26%.

LITTLE ROCK, Ark. — Sixth-grade boys were lining up to be measured in the Mann Arts and Science Magnet Middle School library. As they took off their shoes and emptied their pockets, they joked about being the tallest.

"It's an advantage," said one. "You can play basketball," said another. "A taller dude can get more girls!" a third student offered.

Everyone laughed. What they didn't joke about was their weight.

Anndrea Veasley, the school's registered nurse, had them stand one by one. One boy, Christopher, slumped as she measured his height. "Chin up slightly," she said. Then Veasley asked him to stand backward on a scale so he didn't see the numbers. She silently noted his height as just shy of 4 feet, 7 inches, and his weight as 115.6 pounds.

Lifesaving or stigmatizing? Parents wrestle with obesity treatment options for kids

His parents later would be among thousands to receive a letter beginning, "Many children in Arkansas have health problems caused by their weight." The letter includes each student's measurements as well as their calculated body mass index. The BMI number categorizes each child as "underweight," "normal," "overweight," or "obese." Christopher's BMI of 25.1 put him in the obese range.

In 2003, Arkansas became the first state to send home BMI reports about all students as part of a broader anti-obesity initiative. But in the 20 years since, the state's childhood obesity rates have risen to nearly 24% from 21%, reflecting a similar, albeit higher, trajectory than national rates. During the pandemic, the state obesity rate hit a high of more than 26%.

Still, at least 23 states followed Arkansas' lead and required height and weight assessments of students. Some have since scaled back their efforts after parents raised concerns.

One school district in Wyoming used to include a child's BMI score in report cards , a practice it has since stopped. Ohio allows districts to opt in, and last year just two of 611 school districts reported BMI information to the state. And Massachusetts stopped sending letters home . Even Arkansas changed its rules to allow parents to opt out.

Multiple studies have shown that these reports, or "fat letters" as they're sometimes mockingly called, have had no effect on weight loss. And some nutritionists, psychologists, and parents have criticized the letters, saying they can lead to weight stigma and eating disorders.

BMI as a tool has come under scrutiny, too, because it does not consider differences across racial and ethnic groups, sex, gender, and age. In 2023, the American Medical Association called the BMI "imperfect" and suggested it be used alongside other tools such as visceral fat measurements, body composition, and genetic factors.

All that highlights a question: What purpose do BMI school measurements and letters serve? Nearly 20% of American children were classified as obese just before the pandemic — up from only 5% some 50 years ago — and lockdowns made the problem worse. It's unclear what sorts of interventions might reverse the trend.

Joe Thompson, a pediatrician who helped create Arkansas' program and now leads the Arkansas Center for Health Improvement , said BMI letters are meant to be a screening tool, not a diagnostic test, to make parents aware if their child is at risk of developing serious health issues, such as heart disease, diabetes, and respiratory problems.

Sharing this information with them is critical, he said, given that many don't see it as a problem because obesity is so prevalent. Arkansas is also a rural state, so many families don't have easy access to pediatricians, he said.

Don't Focus On Kids' Weight Gain. Focus On Healthy Habits Instead

Thompson said he's heard from many parents who have acted on the letters. "To this day, they are still our strongest advocates," he said.

The program also led to new efforts to reduce obesity. Some school districts in Arkansas have instituted " movement breaks ," while others have added vegetable gardens , cooking classes , and walking trails . One district sought funding for bicycles . The state does not study whether these efforts are working.

Researchers say the BMI data also serves an important purpose in illuminating population-level trends , even if it isn't helpful to individuals.

Parents are generally supportive of weighing children in school, and the letters have helped increase their awareness of obesity, research shows. At the same time, few parents followed up with a health care provider or made changes to their child's diet or physical activity after getting a BMI letter, several other studies have found.

In what is considered the gold-standard study of BMI letters , published in 2020, researchers in California found that the letters home had no effect on students' weight. Hannah Thompson , a University of California-Berkeley assistant professor who co-authored the study, said most parents didn't even remember getting the letters. "It's such a tiny-touch behavioral intervention," she said.

Arkansas now measures all public school students in even grades annually — except for 12th graders because by that stage, the pediatrician Joe Thompson said, the students are "beyond the opportunities for schools to have an impact." The change also came after many boys in one school wore leg weights under their jeans as a prank, he said.

Kimberly Collins, 50, remembers being confused by the BMI letters sent to her from the Little Rock School District stating that all her children were overweight, and that one daughter was considered obese.

"It offended me as a mama," she said. "It made me feel like I wasn't doing my job."

She didn't think her children looked overweight and the family pediatrician had never brought it up as a concern.

Hannah Thompson, the researcher from California, said that's the biggest problem with BMI letters: Parents don't know what to do with the information. Without support to help change behavior, she said, the letters don't do much.

"You find out your child is asthmatic, and you can get an inhaler, right?" she said. "You find out that your child is overweight and where do you even go from there? What do you do?"

Kevin Gee , a professor at the University of California-Davis, who has studied BMI letters , said the mailings miss cultural nuances. In some communities, for example, people prefer their children to be heavier, associating it with comfort and happiness. Or some eat foods that they know aren't very nutritious but are an important way of expressing love and traditions.

"There's a lot of rich contextual pieces that we know influences rates of obesity," Gee said. "And so how do we balance that information?"

Collins' daughter, now 15, said that as she's grown older she increasingly feels uncomfortable about her weight. People stare at her and sometimes make comments. (Collins' mother asked that her daughter's name not be published because of her age and the sensitive nature of the subject.)

"On my birthday, I went to get my allergy shots and one of the nurses told me, 'You are getting chubbier,'" she said. "That didn't make me feel the best."

How Doctors Can Stop Stigmatizing — And Start Helping — Kids With Obesity

Collins said it pains her to see her soft-spoken daughter cover herself with her arms as if she's trying to hide. The teenager has also begun sneaking food and avoids the mirror by refusing to turn on the bathroom light, Collins said. The girl signed up for tennis but stopped after other children made fun of her, her mother said.

Looking back, Collins said, while she wishes she had paid more attention to the BMI letters, she also would have liked practical suggestions on what to do. Collins said she had already been following the short list of recommended healthy practices, including feeding her children fruits and vegetables and limiting screen time. She isn't sure what else she could have done.

Now everyone has an opinion on her daughter's weight, Collins said. One person told her to put a lock on the fridge. Another told her to buy vegan snacks. Her mother bought them a scale.

"It's a total uphill climb," Collins said with a sigh.

This article was produced as a part of a project for the Spencer Education Journalism Fellowship .

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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3 Rhode Island power players just launched a political nonprofit

The group’s goal is to “influence policy makers and constituents to work for progressive change in housing, education, labor, and health care, particularly women’s health care,” according to incorporation papers.

We’re still a few months away from Rhode Island’s elections taking center stage, but three of the best-known insiders in the state have just launched a new nonprofit “social welfare” organization that they believe will play a big role in local politics for years to come.

Kate Coyne-McCoy, a former executive director of the state Democratic Party, George Zainyeh, who was chief of staff to former governor Lincoln Chafee and is now one of the most influential lobbyists on Smith Hill, and Patti Doyle, a top communications pro for just about everyone, formed Better RI NOW on April 8. 

The group’s plans are still vague, but its goal is to “influence policy makers and constituents to work for progressive change in housing, education, labor, and health care, particularly women’s health care,” according to incorporation papers.

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Asked to expand on the group’s goals, Doyle said the group plans to raise money, but won’t directly endorse candidates for office. She said “we can let voters know which candidates stand for issues important to them.”

”The three of us have been active in public policy for a while, we witness the ongoing national dialogue, and just want to be additive to a local conversation on a variety of key issues,” Doyle said.

Stepping back: Coyne-McCoy, Zainyeh, Doyle aren’t necessarily household names to the average Rhode Islander, but they’re a powerful trifecta in political circles. Doyle said the group plans to focus on the congressional delegation and statewide offices.

US Senator Sheldon Whitehouse and US Representatives Seth Magaziner and Gabe Amo are all on the ballot this year, although all three are heavy favorites to be reelected (especially in a presidential election year). It’s more intriguing to think about the role Better RI NOW might play in 2026 in Rhode Island.

This story first appeared in Rhode Map, our free newsletter about Rhode Island that also contains information about local events, links to interesting stories, and more. If you’d like to receive it via e-mail Monday through Friday,  you can sign up here.

Dan McGowan can be reached at [email protected] . Follow him @danmcgowan .

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Empowering Patients: Promoting Patient Education and Health Literacy

Pradnya brijmohan bhattad.

1 Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Chan Medical School, Worcester, USA

Luigi Pacifico

Patients are generally keen to understand and obtain more information about their medical conditions. There exists a need to develop updated and thorough yet concise patient education handouts and to encourage healthcare providers (HCPs) to use uniform patient education methods.

A thorough review of literature on patient education material was performed prior to starting the study. A comparison with different resources regarding the appropriateness of patient education was done. Educating HCPs to effectively use patient educational materials incorporated into the electronic health record system, including electronic methods, such as the use of a patient portal, to help educate patients. 

Strategies were formulated to reduce the amount of processing and attending time required for fetching appropriate materials and lead to fast, efficient, and effective patient education. To improve the physical and psychosocial wellbeing of a patient, personalized patient education handouts, in addition to verbal education by the HCPs, augment the betterment of patient care via shared decision making and by improving patient satisfaction and health literacy.

Introduction

Patients are often eager to understand and know more about their medical conditions and health situation, and educating them with the most relevant, current, consistent, and updated information helps patients and their families significantly in the medical care and decision-making process [ 1 ]. 

Patients need formal education on the disease condition; they need to know their ailment, understand their symptoms, be educated on the diagnostics, appropriate medication use, and should be taught when to call for help. Several patient education handouts for various conditions are available, and there exists a need to assess which one is better suited for a particular disease/condition encountered and provides concise information. Patient education materials help educate the patients on their health conditions, improves their health literacy, and enhances and promotes informed decision-making based on the most current and updated medical and clinical evidence as well as patient preference [ 2 ].

The aim of this study was to develop updated patient education handouts and materials in addition to verbal counseling of the patients to help them understand the disease condition, diagnostic studies, proper advice on medications, and when to call for help. And to encourage healthcare providers (HCPs) to use uniform patient education materials.

The objectives of this study are 1) the implementation of quality improvement techniques of Plan-Do-Study-Act (PDSA) cycles on patient education in clinical settings; 2) to enhance the delivery of patient education and create awareness amongst the HCPs regarding the importance of patient education and improved health literacy; 3) to verify if patient education handouts have the minimum necessary information that patient should know; 4) to compare patient education handouts from databases integrated in the electronic health record (EHR) with standard patient education database websites like the Centers for Disease Control and Prevention website, and MedlinePlus® site to make sure that they have the minimum necessary information; and 5) to educate and encourage HCPs on the use of appropriate patient education articles in the EHR and utilize an electronic patient portal for patient education, help transition the patient education to an electronic form, and increase efficacy and consistent patient education.

Materials and methods

A comprehensive review of the patient education materials on the most common medical ailments in various clinical settings was performed. We compared the existing patient education database integrated in the EHR with the standard resources such as the CDC, MedlinePlus via retrospective chart study format to ensure the minimum necessary information is available. 

A comparison of existing educational material was completed by analyzing other patient education materials from resources such as UpToDate (the basics/beyond the basics), MedlinePlus, US National Library of Medicine of NIH, CDC, and the US Department of Health and Human Services to ensure that effective, most updated, current, and evidence-based information is provided to the patients from the educational materials.

Search words were incorporated to help search for the educational articles in the existing EHR by the title of the article. Educational materials studied were relevant to the common medical ailments in various clinical settings. The patient handouts were made available in such a way that these should be able to be sent either through an electronic patient portal or printed out.

HCPs were educated in a session with pre- and post-lecture survey qualitative and quantitative questionnaires. The impact of these interventions was further assessed by pre- and post-intervention surveys after educating the HCPs.

Uniform updated patient education handouts were created after comparing them with standard resources. A pre-test survey questionnaire was obtained to discuss with HCPs regarding the current knowledge and practices of the usage of patient education handouts and the understanding of EHR to utilize uniform and standardized patient education handouts. After educating the HCPs, their knowledge regarding the use of EHR to effectively use patient education handouts was tested in a post-test survey questionnaire. After completion of the pre and post-test survey questionnaire by HCPs, analysis of the data performed (Figures ​ (Figures1 1 - ​ -20 20 ).

HCPs - healthcare providers

"Do you feel that attending and processing times required for fetching appropriate educational articles will be reduced if standard materials are outlined?"

“Do you think that efficient patient education is effective in creating and improving adherence to treatment, medication compliance, and for improving overall patient health?”

Quality improvement (QI), problem-solving, and gap analysis

QI techniques, including PDSA cycles, to improve patient education implemented in various clinical settings [ 1 ].

Reasons for Action

There is a need for updated and uniform patient education materials in addition to verbal counseling of the patient to help them understand the disease condition, diagnostic studies, proper advice on medications, and when to call for help, thereby enhancing health literacy. There exists several patient education materials for various ailments, and the need to assess which one is better suited for a disease condition and contains concise information.

Initial State

We reviewed the available patient education material from the patient education database integrated in the EHR, and compared it with current standardized resources such as MedlinePlus, US National Library of Medicine of NIH, CDC, and the US Department of Health and Human Services. A thorough review of literature on patient education material was performed prior to starting the study.

We compared more than one source regarding the appropriateness of patient education, most specifically, how to use the medications and when to call for help. The quality of educational materials regarding disease education, diagnostics education, education on medication use, and education on when to call for help was assessed. The resources described above were utilized for comparison.

Gap Analysis

A graph of the gap analysis is displayed in Figure ​ Figure21 21 below.

Solution Approach

It was noticed that the educational materials were available only in printed format. Enrolling patients on the electronic patient portal helps send educational materials to the patient as a soft copy in a faster and more efficient electronic format. 

Higher attending and processing time is required for fetching appropriate materials due to the unavailability of exact materials and using non-updated educational materials. Therefore, creating an index of educational articles on commonly encountered medical situations and ensuring that these articles are current and updated might make the process more efficient. 

There is a very limited time availability to impart specific educational elements with the limited appointment times. Appropriately detailed educational materials can be sent to the patient via a patient portal even after the patient encounter has ended. For patients with limited technology/computer use, educational materials can be mailed if they're missed during the encounter. 

Inadequate educational methods were utilized; thus, incorporating educational articles from resources other than the databases in the existing EHR, and using the index of educational articles on commonly encountered medical situations were applied.

Inefficient usage of the operational capacity of EHR for patient education, using database integrated in the EHR, and lack of training were identified. As a result, HCPs were trained on using educational materials for their patients in an efficient manner, and patient education was prioritized.

Rapid Experiment: Plan-Do-Study-Act Cycle

Plan: Plan to use appropriate patient education material from several sources made available in the index of the educational articles.

Do: Counsel and verbally educate the patients, along with providing educational materials. Obtain a verbal read-back from the patients about how to use medications and when to call for help.

Study: Use the teach-back method to make patients explain back the information provided in their own words to see if they understood the disease, diagnostics, medication use, and when to call for help to improve health literacy.

Act: If a patient has questions, address them appropriately and if need be, set up a follow-up appointment. 

Actions Taken

An index of educational materials relevant to the common medical ailments in various clinical settings was created. This index of educational materials was to guide HCPs in choosing appropriate and relevant articles in an efficient, quick, and timely manner for patients in various clinical settings. Effective use of patient educational materials in the database incorporated into the EHR, including electronic methods such as the use of the patient portal to help educate patients, was promoted. Alternate resources other than those from the database in the existing EHR were utilized. Educational materials in printed format were made available for patients with limited technology access. The amount of time required for fetching appropriate materials was reduced by creating and referencing to an index for commonly encountered medical situations.

Efficient and faster patient education was imparted with reduced processing and attending time required. Prioritized health education to improve health literacy. Efficient usage of operational capacity of database integrated in the EHR was undertaken to improve health literacy. HCPs were trained to use patient education materials efficiently. 

What Helped

Fast, efficient, and effective patient education helped patients and their families significantly in medical care and shared decision-making based on the most current and updated clinical evidence and patient preference. Creating an index of educational materials relevant to the medical conditions commonly encountered thereby reduced the amount of processing and attending time required for fetching appropriate materials. Effectively using patient educational materials in the database incorporated into the EHR, including electronic methods such as the use of a patient portal to help educate patients, using soft copy (electronic-copy) reduced requirement of printed materials. Correction of misconceptions that patients may have helped improve health literacy. 

What Went Well

Helping engage, encourage, and empower the patients in participating in their own health care and treatment decisions. Enhanced patient satisfaction and better outcomes (for instance, educating a patient on osteopenia encouraged them to continue/start the vitamin D supplementation, participate in regular exercise, healthy diet preferences, and health promotion). 

What Hindered

High HCP turnover rate with changing schedules hindered consistent use of patient education materials. Insufficient number of HCPs trained for patient education.

What Could Improve

Incorporating educational materials in the video format for patients who do not wish to read or talk about their health situations. Enhanced training of all the HCPs for effective and efficient use of patient education resources to allow consistency in effective patient education.

Personalized patient education engages, encourages, and empowers patients in participating in their own health care and treatment decisions and leading to better outcomes, decreased need for excess diagnostic testing, and enhanced patient satisfaction [ 3 , 4 , 5 ]. This needs motivation on the part of the resident doctors, nurse practitioners, physician assistants, physicians, and the allied staff. 

The Advisory Committee on Training in Primary Care Medicine (ACTPCMD) recommends that Health Resources & Services Administration’s (HRSA) Title VII, Part C, Section 747 and 748 education and training programs should prepare students, faculty, and practitioners to involve patients and caretakers in shared medical decision-making which can happen well with better patient education process [ 6 ].

We as HCPs should cultivate good habits amongst ourselves to ensure patients know about their condition and treatment well. This will help increase medication and treatment compliance amongst patients and enhance the physician-patient relationship to a higher level.

Conclusions

To improve the physical and psychosocial well-being of a patient, personalized patient education materials, in addition to verbal education by the HCPs, augment the betterment of patient care via shared decision making and by improving patient satisfaction. There is a need to reiterate that HCPs understand patients' concerns and provide effective patient education and counseling for effective health care delivery.

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The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.