European Union’s Lifelong Learning Policy 

and the EMILIA Mental Health Project:

Including the Excluded



Dr. Christopher A. Griffiths, BSc, PhD
 Project development and researcher
 
 Middlesex University
Department of Mental Health and Social Work
Holborn Union Building (F Block)
Archway Campus
2-10 Highgate Hill
London
N19 5LW
Email: c.griffiths@mdx.ac.uk


Dr. James Ogunleye, BA, MSc, PhD
Researcher
Middlesex University

Dr. Tim Greacen, PhD
 Director of Research
Université de Paris

Professor Peter Ryan, DProf, MSc, DipSW
 Professor of Mental Health
Middlesex University




Citation:

 

Abstract
EMILIA (Empowerment of Mental Illness Service Users: Lifelong Learning, Integration and Action) used a five step process embedded in European lifelong learning policy to set up learning courses, developed with mental health service users. There were two strands to the research. One was an organisational strand which assessed the learning organisations based in eight European countries. The second focused on mental health service user participants. The main result and conclusion is that promoting and facilitating lifelong learning and employment opportunities for an excluded group can have a positive effect social inclusion of that group and produces benefits for organisations involved, including making them more open to mental health service user involvement.

Key words: Lifelong learning, social inclusion, mental health, service users, empowerment, and employment.

Introduction:
Lifelong learning, social inclusion and mental health have been found to be interlinked (Griffiths & Ryan, 2008). The Treaty of Lisbon (2009) refers to mental health in Articles 151-161 (Social Policy); Article 165 (Education); Articles 174-178 (Economic, Social and Territorial Cohesion), Articles 179-190 (Research) and Article 168 which states: “European Union action, which shall complement national policies, shall be directed towards improving public health, preventing physical and mental illness and diseases, and obviating sources of danger to physical and mental health. Such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education...”

The Lisbon strategy (COM, 2000) set a clear and ambitious goal: to make the European Union region the most innovative, competitive and dynamic knowledge-driven economy by 2010. An important element of the Lisbon strategy is lifelong learning (CEC, 2002) which has become a major tool for fostering community cohesion/citizenship and social inclusion. European policy on lifelong learning has five linked operational elements, corresponding to the stages involved in developing lifelong learning, all of which are key to achieving coherent and comprehensive national strategies for lifelong learning (COM, 2001a; COM, 2001b; COM, 2003). These elements are:

1)    Building up partnership or partnership working
2)    Insight into the demand for learning
3)    Adequate resourcing
4)    Facilitating access to learning opportunities/Creating a learning culture
5)    Striving for excellence

The EMILIA project sought to evaluate this policy with regard to people with serious and enduring mental illness by the implementation and evaluation of each of these five elements. The main theme of the paper is to link lifelong learning policy to the operational research strategy and results of the EMILIA project and to evaluate whether the lifelong learning process can be a mechanism for facilitating the social inclusion of socially disadvantaged groups such as mental health service users.

EMILIA was a research project which sought to facilitate social inclusion and empowerment through providing formal lifelong learning and employment opportunities for mental health service users. It commenced in September 2005 and was completed in February 2010 (54 months).

To achieve this, a radical new approach to education and training for this population was called for. The EMILIA project employed innovative pedagogical strategies beginning with a shift in emphasis away from knowledge acquisition to competence and capability development, building on expertise acquired as patients and users of health and social care systems, and necessarily implying new roles for teachers and learners. The EMILIA strategy for lifelong learning was founded on a partnership approach; EMILIA sought to encompass the learning needs of the individual learner, of organisations, communities and the labour market itself.  It also sought to increase learning opportunities, raise participation levels and stimulate demand for learning whist striving for excellence on an ongoing basis. EMILIA collaborated with a European-wide mental health network of local level partnerships of learning communities and learning organisations with the aim of organically linking education and training to the mental health workplace, so as to optimise the quality of the working environment both for service users and for the clinical and management staff of mental health services. It encouraged mental health services to maximise mental health service user involvement in the training for, and delivery of, new and innovative services, thus opening up new employment routes for mental health service users. 

A major goal of the EMILIA project was to make a contribution in the area of mental health to the European Union’s ambitious objective to become: “the most competitive and dynamic knowledge-based economy in the world, capable of sustained economic growth with more and better jobs and greater social inclusion” (COM, 2000). The EMILIA project thus set out to link European policies on both lifelong learning and social exclusion; given that people living with long term mental illness are one of European society’s most disadvantaged groups. EMILIA adopted the concept of social innovation (OECD, 2000) with its four main characteristics: social inclusion, social cohesion, cooperation, and mobilisation of resources. 

Social innovation seeks new answers to social problems by, on the one hand identifying and delivering new services that improve the quality of life of individuals and communities and, on the other, identifying and implementing new labour market integration processes, new competencies, new jobs and new forms of participation. The EMILIA project can thus be seen as part of the existing social agenda, as described in the Renewed Social Agenda: Opportunities Access and Solidarity in the 21st Century (COM, 2008), by focussing on: “empowering and enabling individuals to realise their potential while at the same time helping those who are unable to do so” (COM, 2008, p. 3). The EMILIA project links to the Social Agenda in that both were built around creating opportunities (for learning and employment), providing access (to actively participate and integrate in society) and demonstrating solidarity (fighting poverty and social exclusion and enabling adaptation to change). The main purpose of the paper is to link lifelong learning policy to the operational research strategy and to evaluate the EMILIA Project in relation to this.

Innovatory nature of the EMILIA project

-Engaged a socially excluded and multiply disadvantaged group – mental health service users. 

-Consulted with service users on lifelong learning subjects resulting in training that was more meaningful for their lives.

-Developed a series of twelve lifelong learning training programmes designed in conjunction with mental health service users and housed on a free-to-access public website.

-Developed innovatory new roles for service users such as lifelong learning trainers, personal medicine coaches and assistant researchers.

-Developed a lifelong learning organisational implementation tool which identifies obstacles and solutions so as to enable organisations to become effective deliverers of lifelong learning to disadvantaged and socially excluded groups.

-Enabled universities and health care centres to realise the value of the experience and knowledge of mental health service users and to employ mental health service users to positively contribute to health care management and education.

Methods
Design
EMILIA consisted of 8 separate case studies with a 20 month follow-up within groups research design. Data collection took place on individual (strand 1) and organisational (strand 2) levels. The data were collected in eight demonstration sites: Paris, France; Tusla, Bosnia-Herzegovina; Sjalland, Denmark; London, UK; Athens, Greece; Warsaw, Poland; Barcelona, Spain; and Bodø, Norway at baseline (T0) and 20 month (T20) follow up point. These demonstration sites delivered the EMILIA intervention to participants.

Participants
Strand 1 of the research included a total of 212 mental health service users with a history of long-term mental illness, aged 18-64. The diagnostic inclusion criterion for the EMILIA participants was a diagnosis of schizophrenia F20 (ICD-10), schizoaffective disorder F25 (ICD-10) or bipolar disorder F30-F31 (ICD-10) and at least three years of using mental health services. The EMILIA intervention did not include people with a diagnosis of learning disabilities or dementia.
The participants of strand 2 of the research were the eight EMILIA European demonstration site learning organisations.

Intervention
The EMILIA project intervention consisted primarily of participation in learning modules specifically designed for the project. In addition to these modules, participants were provided with optional opportunities to have paid or voluntary employment.

Research Measures
The five stages of the operational research strategy were directly linked to the five operational elements of EU lifelong learning policy (COM, 2001c). These were measured using information collected through the Client Social-demographic and Service Receipt Inventory (CSSRI), the quality of life instrument SF-36-v2 and self reports and interviews from participants in strand 1 and with audits of the demonstration sites in strand 2.

The SF-36-v2 (Ware & Sherbourn, 1992) is the most widely used health related quality of life measure. The SF-36-v2 is a 36 question generic self-report measure of functional health and well-being, psychometrically-based physical and mental health, and preference-based mental and physical health (Ware, 2006). The SF-36-v2 is well established and has proven reliability and validity (Jenkinson, Stewart-Brown, Petersen, & Paice, 1999; Ware et al., 2000; Ware, 2006).

The Client Social-demographic and Service Receipt Inventory – EU version (Chisholm et al., 2000), which itself is an adaptation of the CSSRI (Beecham & Knapp, 1992), was developed as an instrument for international research.

Self reports and key user interviews: both the self-report and key informant service user interviews consisted of a series of ten open-ended questions. The answers to one of these questions: ‘What do you want to achieve over the coming year?’ will be examined in the present paper.
Audit: through a series of questions the audit aimed to monitor the implementation of the five stages of the European lifelong learning strategy in the eight EMILIA demonstration sites.
The ‘problems and successes factors in implementation survey’ consisted of seven consecutive surveys addressed to researchers, users and care professsionals at all sites in different phases of implementation with the aim of discovering descriptions of obstacles encountered in the implementation process and sharing information across sites on facilitators and solutions

Procedure
Representatives from the case study demonstration sites and participants taking part in the EMILIA intervention completed the strand 1 research measures before the intervention at baseline and at the 20 month follow-up point, when the intervention was completed.

Results

Stage 1 - Partnership working across the learning spectrum approach

Across all sites there was a reported increase in the quantity of communication between European teams of mental health learning organisations (phone calls, emails, and chatroom meetings). At both baseline and follow-up, communication was generally described as useful, helpful and productive. Qualitativement statements from demonstration sites provided detail on the usefulness, helpfulness and productive nature of the various forms of communication.

Influence of project on work-based education and training:
Continuous professional development was available for staff at all demonstration sites at baseline. Course topics included mental health promotion, legal aspects relating to mental health issues and fighting stigma. At follow-up, all sites except Bosnia reported additional courses directly related to the EMILIA intervention and henceforth integrated into the continuous development training programme.

Work-based education offering open access to service users:
At baseline three demonstration sites (Spain, Norway and Bosnia) stated that they did not provide training opportunities that were accessible to people with serious mental illness. However, at follow-up, all demonstration sites except Bosnia stated that they provided training opportunities that were accessible to people with serious mental illness.

Proportion of working week spent by mental health service staff on work-based learning:
Although the training offered had changed during the time span of EMILIA, no significant changes were observed in the number of hours spent in training between baseline and follow-up.

Stage 2 - Insight into Demand for Learning

EMILIA participant self-report and key user interview data:
The qualitative data collection from participants of the lifelong learning intervention consisted of service user self reports (baseline=165, T20=86) and key user interviews (baseline=27, T20=23). The percentage who mentioned learning in answer to the open-ended question: ‘What do you want to achieve in the coming year?’ increased from 20.7% at baseline to 24.4% at 20 month follow-up. Although this difference was not statistically significant, it must be underlined that the question asked was an open question: it purposefully did not specifically ask the user if he or she wanted to take part in formal learning in the coming year. So the figures do not reflect the plans of all of those who had the ambition to take part in formal learning, but instead record freely expressed learning ambitions. The desire to achieve learning-related goals came second only to the desire to achieve employment related goals. 

The percentage of key users who mentioned learning in answer to the open-ended question: ‘What do you want to achieve in the coming year?’ was 48.3% at baseline and 39.1% at follow-up. However, there was a significant shift amongst key users towards the ambition of getting and holding employment: 27.6% at baseline to 43.5% at 20 month follow-up, raising the hypothesis that for certain users goals related to learning had been transferred to goals related to employment. This may have been because EMILIA had fulfilled some of their learning ambitions allowing them to shift their focus towards to ambitions related to obtaining work.

Innovations in occupational role task analysis:
All eight sites reported that new roles, jobs and activities had been created for mental health service users since the beginning of the EMILIA Project. See table 2 below.

Innovations in occupational role task analysis:
Five out of the eight sites (Spain, UK, Bosnia, Greece, and France) listed new roles, jobs or activities created for mental health service users outside the learning organisation during the project. For example, in France, employment in a state vocational centre and, in Greece, voluntary roles on a geriatric hospital ward, in the hospital library and in running a hospital radio station.

Stage 4 - Facilitating user access to learning and work opportunities

Problems and Success Factors in Implementation Survey:
Seven surveys were conducted recording the implementation of stage 4 and these identified problems, solutions and success factors in implementing the project. The main result of this was the development of the ‘Obstacles and Facilitators Checklist’ tool for use in project implementation.

Stage 5 - Striving for excellence through service improvement

Demonstration sites were asked to rate how the EMILIA project had changed the level of participation of service users in design and delivery of training programmes, on a scale of 1 (unsatisfactory) to 7 (satisfactory). Results ranged from 3 (Poland) through to 7 (Bosnia, Spain, UK) see Table 3.

Demonstration sites were then asked what they would suggest for the improvement of the level of participation of service users in future educational actions. Sites systematically underlined the importance of integrating users into the decision-making process but also into training delivery from the very start.

Table 4: Recommendations for improving user participation in future educational actions 

 

Service user income level before and after the EMILIA intervention:
A total of 72 participants provided data on their net income at baseline and 20 month follow-up. T-test results revealed a significant increase in income from baseline (M=€760.64, SD=509.63) to the 20 month follow-up point (M=€865.03, SD=575.82), t(71)=-2.42, p=.018 (two-tailed). The mean increase in income scores was €104.39 with a 95% confidence interval ranging from -190.43 to -18.35. The eta squared statistic (.08) indicated a moderate effect size. The average increase in net income from baseline to 20 months was 19%. The total Euro Zone inflation for the 2008-2009 period was 3.51%, indicating a real-world increase of over 15% in net income.

Self-perceived health and quality of life status:
Information was available from 97 participants at both baseline and 20 month follow-up concerning mental and physical health-related quality of life. SF-36-v2 mental health related quality of life scores rose by .65 (with a 95% confidence interval ranging from -2.74 to 1.44) from baseline (M=33.93, SD=7.39) to the 20 month follow-up point (M=34.58, SD=8.1), but this difference was not statistically significant: t(96)=-.61, p=.54 (two-tailed T-test). Concerning SF-36-v2 physical health related quality of life, T-test results revealed that there was a very small non-significant decrease from baseline (M=48.81, SD=10.82) to the 20 month follow-up point (M=48.41, SD=11.54), t(96)=-.42, p=.68 (two-tailed). The mean decrease in SF-36-v2 physical health related quality of life was .4 with a 95% confidence interval ranging from -1.49 to 2.29.

Service user employment level pre and post project intervention:
Sixty-nine participants provided data on employment status at baseline and 20 month follow-up, 6 (7.1%) reported being in competitive paid employment at baseline and 12 (14.3%) at 20 month follow-up. This increase in the numbers in competitive paid employment was not significant (p=.51) using the McNemar test.

Discussion
The results indicate possible positive effects of the project at both an individual and organisation level. At an individual level participants experienced an increase in factors related to social inclusion and at an organisational level the organisations involved demonstrated an increase in open access to training and employment, and innovations in employment roles.
An important element of the European Union’s lifelong learning strategy is concerned with the building and working of partnerships. This study’s findings show that the EMILIA project may have made a contribution to partnership working across a wide range of the project’s operational activities and, by extension, to this strategic element of the European Union’s lifelong learning policy agenda. The use of information and communication technologies involving mental health academics, practitioners and mental health service users has helped to build and develop cohesion and cross-cultural understanding, and to foster professional relationships within and outside the EMILIA consortium. This outcome has contributed to the European Union wider vision of developing social inclusion (see, for example: COM, 2008).

In connection with partnership working, results show that at baseline only three of the sites provided open access for work-based education, whilst all sites did so at the follow up point. A implication for lifelong learning policy here would be that services or institutions working with disenfranchised groups such as people with long term mental health difficulties should consider opening up their staff continuous development training programmes to their client population. 

The results also show that a contribution may have been made to the second critical bedrock for lifelong learning: Insight into the demand for learning. The EMILIA project’s lifelong learning training intervention was demand-led: it was explored, designed and developed with the active involvement of the mental health service users themselves, the primary target group. Service users were co-trainers and were involved in delivering the training modules. Such an innovative, demand-led and needs-addressed approach has brought a new set of learners to lifelong learning and has contributed to the European Union agenda on widening access and participation in education and training (see COM, 2003). This success is in all likelihood largely due to the collaborative, participatory process through which the learning needs agenda was co-developed through a partnership approach with the service users themselves. The training received by the participants has led to a demand for new learning as evidenced by a high proportion of service users who expressed a desire to achieve learning related goals at follow-up. 

The findings may also contribute to the third strategic element in the policy framework of lifelong learning – Adequate resourcing and judicious deployment, use and allocation of human and financial resources. The indicator here did not refer to the lifelong learning programmes themselves, but to the consequences of these in terms of more meaningful and socially inclusive roles and tasks for the participants. It is clear that the demonstration sites were successful in developing, either inside or outside of their own organisational systems, a variety of innovatory new roles, both paid and voluntary. For example, UK users were employed in a variety of teaching roles within a university department of Mental Health and Social Work. In both London and Paris, users participated in research projects and audits of local services. Many also undertook additional voluntary work in local user groups. 

Stage 4: Facilitating user access to learning and work opportunities, involved cross-European analysis on four levels: individual, microsocial, institutional and macrosocial and this analysis revealed problems, solutions and success factors. One of the fruitful outcomes was the development of the EMILIA Obstacles and Facilitators Checklist. This tool, initially conceived of as a simple checklist to be used by learning organisations as sites begin implementation, was considerably extended throughout implementation to include obstacles and facilitators encountered by individual sites during projects, thus allowing sharing of solutions and facilitating success across all sites. 

Stage 5: Striving for excellence, is concerned with establishing and embedding credible quality assurance mechanisms in lifelong learning provision. In the EMILIA project, measures were used to examine the quality and effectiveness of the training outcome. The results indicate, for example, greater numbers of service users in open, competitive employment; although this increase was not statistically significant. Also, the findings indicate an increase in disposable income. Although there was virtually no change in health-related quality of life this is a somewhat positive result, as health-related quality of life would be expected to decline over time in this participant group. The results provide some support for findings in early studies that demonstrate a link between recovery and lifelong learning (Lanham et al, 1997; Griffiths & Ryan, 2008). Of more strategic importance, the findings show that EMILIA may have contributed to the broader economic and social dimensions of the Lisbon strategy. 

The future social policy agenda can be further improved by taking into account the findings of the EMILIA project. There will continue to be a need for creation of opportunities for employment and social inclusion for socially excluded groups. There is also a need to ensure and facilitate potential individual progression in these opportunities and onto other opportunities – linking to individual and societal goals and competiveness. There will continue to be a need for provision of access. When individuals have gained access, consideration should to be given to the needs of these individuals in order to support them to make the most of their opportunities. 

The EMILIA project demonstrated ways to encourage access and to support disadvantaged individuals once access is gained so that they can realise their full potential through lifelong learning. In reference to the Social Agenda (COM, 2008) ‘demonstrating solidarity,’ there will continue to be a need to fight poverty and social exclusion and enable adaptation to change. EMILIA has shown that it may be possible to do this by facilitating a sense of social cohesion through developing lifelong learning collaborations and networks amongst lifelong learning students and supportive organisations. Lifelong learning programmes facilitate and encourage the development of the strengths of individuals and this can benefit the future social agenda through the application of these individual strengths within society.

The EMILIA project represented a major attempt to systematically review each of the five stages of the European lifelong learning policy (COM, 2001a). The policy as stated made no suggestions as to how its implementation might be measured, or what indicators might be particularly appropriate. The development of such indicators in the EMILIA project is in itself innovatory and represents the first attempt to monitor European lifelong learning policy using this methodology. Inevitably, some indicators worked better than others and future projects can hopefully learn from the EMILIA project experience in their improvement.

Conclusion and recommendations
The wide range of research and intervention themes covered in the EMILIA project has underlined the role of lifelong learning as a driver for the economic dimension of the Lisbon strategy, and as key to achieving its social dimension in terms of enhancing the social inclusion of disadvantaged groups such as people experiencing long term mental health illness. These findings give rise to a number of recommendations which are particularly important as the European Union devises a new strategy for sustainable growth and employment for the period beyond 2010 – known as the EU 2020 Strategy. Main recommendations from this project include:

-Promoting lifelong learning and employment opportunities for service users to facilitate social inclusion.

-Support at the European and national level the adaptation of currently existing lifelong learning policies and strategies to ensure that on a permanent basis they take on board the specific strategies necessary to engage with the variety of socially excluded groups in the EU. 

-Support the need for a universal assumption of a return, following illness, to full participation in society, defined on an individual basis, including participation in learning and employment. 

-Actively promoting the employment of mental health service users through appropriate awareness and skills training.

 
Acknowledgements
The EMILIA project was funded through the 6th EU Framework Programme for Research and Technological Development (FP6).

 
 

 

References