Applying Knowles’ Model of Andragogy to Individualized Osteoporosis Education

Applying Knowles’ Model of Andragogy to Individualized Osteoporosis Education

Chesbro, Steven B


Osteoporosis is one of many health-related conditions about which physical therapists routinely educate consumers. However, the process by which therapists provide education is variable. Malcolm Knowles introduced a model of adult education in the 1960s, called andragogy, which identified characteristics of how adults learn. While this framework for adult education has been widely used in the general education of adults, it has realized limited application in patient/client-related instruction. The purpose of this manuscript is to demonstrate how Knowles’ model of andragogy can be applied to the process of education-based intervention with older adults. An example applied to individualized osteoporosis education is given.


Patient/client-related education about the relevant condition and the treatment course of a disease is a key element of patient management and is within the scope of practice of physical therapists as described in the Guide to Physical Therapist Practice.’2 Patients of all ages are interested in learning about their health but often do not receive the desired information and teaching from their health care providers.37 Practitioners teaching an older adult about health issues should use an appropriate model of adult education that is facilitory rather than use a generic lecture-type transmission of knowledge from the teacher to the learner. This allows the adult to be in control of the learning while the therapist serves as a much-needed resource in the educational effort. There are numerous models of adult education including transformative learning, lifelong learning, and empowerment.8-16 The purpose of this article is to demonstrate how Malcolm Knowles’ assumptions about adult learners, andragogy, can be applied to individualized osteoporosis education so that therapists can facilitate the learning process. This article will help the reader answer the following question: What assumptions can be made about adult learners and how can they be applied to the education process? Knowles’ model of andragogy can serve as a template for therapists by helping them understand adult learners and the process by which adults learn.

Osteoporosis, a disease characterized by significant loss of bone density, has gained more public awareness in the past decade.17,18 According to the National Osteoporosis Foundation, there are currently 10 million people in the United States with the disease and another 18 million who have been diagnosed with decreased bone density.19 Eighty percent of those affected by Osteoporosis are female, and Caucasian women over the age of 60 are at greatest risk of the disease.19,20 Prevention of Osteoporosis often focuses on an appropriate diet of calcium and vitamin D rich foods, medication, and weight-bearing exercise.17,21,22

The responsibility of those who educate others about Osteoporosis is to make certain that the information or skills being shared is presented in a manner that is appropriate for the older adult and is as effective as possible.23-25 Understanding how older adults learn is a key factor in teaching any subject to this population. Failing to understand the process of adult learning can serve as a barrier that prevents important information about Osteoporosis from being effectively transmitted to, and fully understood by, an older adult. If the individual does not truly understand and value the information being shared, the odds of adherence to a therapeutic regimen will decrease.26,27 Therefore, using an andragogical model of adult education is appropriate in order to increase the likelihood of an effective teaching-learning transaction and a successful outcome.


In the 1960s, the field of adult education was attempting to define itself. A focus was placed on the status of the field in the professional community. Was the field of adult education in fact a profession, or was it a subset of some established profession? Malcolm Knowles began developing a model of adult education in the 1960s in response to the needs of the field at the time.28 The term he used to identify his model of adult education was andragogy.

Andragogy is defined as “the art and science of teaching adults.”29 Knowles was introduced to the term in 1967 by a Yugoslavian adult educator and used the term in an article published in 1968.28 In his first writings, Knowles contrasts the concepts of andragogy to pedagogy. Pedagogy is defined as “the science and art of how children learn.”29 Initially, the models of pedagogy and andragogy were strictly contrasted to describe assumptions that directed the teaching of children versus adults. However, Knowles and others later acknowledged that the art and science of teaching could be viewed as a continuum that was not always based upon age. Some individuals are at a point where they passively rely on teacher-directed learning but can begin to appreciate and benefit from a student-centered approach.28 Other individuals are mostly self-directed learners who only use the teacher as a sounding board. In adult education, the teacher serves as a facilitator of learning rather that the primary provider of information. Hundreds of articles and studies related to Knowles’ model of andragogy and its application to adult learning have been published since the concept was developed in the late 1960s.30


Knowles presented 6 assumptions about adult learners that he believed should be a foundation of adult education:

1. As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directed human being;

2. An adult accumulates a growing reservoir of experiences, which is a rich resource for learning;

3. The readiness of an adult to learn is closely related to the developmental tasks of his or her social role;

4. There is a change in time perspective as a person matures-from future application of knowledge to immediacy of application. Thus, an adult is more problem-centered than subject-centered.29

5. Adults are motivated to learn by internal factors rather than external ones.31

6. Adults need to know why they need to learn something before undertaking to learn it.28

Knowles introduced the first 4 assumptions in 1970. After a number of experiences using this model of adult education and discussing its use in practice with others, Knowles added the fifth assumption in 1984. By adding this to the list of andragogical assumptions, Knowles demonstrated his ability to evaluate the model and modify it based on its use in practice. This flexibility also demonstrates his dedication to the development of the concept of andragogy. As recently as 1990, Knowles reassessed and modified the model based on his observations and external feedback.28 The sixth assumption was added based on the work of Alien Tough.16

Many adults have participated in educational programs that rely on teachers to direct the learning; however, adult learning is based on the concept that participation and experience lead to self-directed learning. Adults are not dependent upon others to teach them all they need or want to know about a subject; however, they do often need a facilitator to promote and guide learning. It is important for the educator to realize that this model of adult learning is not linear or hierarchical. Therapists can maximize teaching effectiveness by being mindful of Knowles’ assumptions and addressing all 6 in a context meaningful to the patient. Individuals with similar diagnoses may require very different information in order for the educational intervention to be effective.


An individual diagnosed with decreased bone density usually learns something about the disease from a health care provider. Information is often provided in the form of a pamphlet and a verbal discussion about the condition, and this interaction usually includes recommendations for treatment.32 Since adults have at least some degree of self-directedness, an appropriate strategy of identifying information about the learner and relevant needs should be used. Knowles’ model of andragogy can be used as a guide to gather this information, but does not replace other required components of the patient education process such as identifying a preferred learning strategy, determining literacy level, and considering culture.

Assumption 1

Assuming this individual is a self-directed learner, the therapist may discover that she prefers to gather information about osteoporosis from a variety of sources. Adults may seek out health related information from family,friends, physicians, libraries, and the Internet.·1 Identifying how she prefers to get information can also be helpful for making recommendations. Asking the straightforward question,”How do you find answers to health questions?” is one of the only ways for the therapist to determine this information.”

Assumption 2

If we agree with Knowles’assumption that “an adult accumulates a growing reservoir of experiences, which is a rich resource for learning,”29 then ascertaining what this individual already knows about osteoporosis will prevent the physical therapist from teaching above or below her current level of understanding. A simple beginning to this process would be for the therapist to ask the individual, “What do you know about osteoporosis and the effect it can have on someone’s life?” Asking this type of open-ended question is a good facilitator for determining other information needed about the learner.34 Specifically, identifying the learner’s cognitive understanding of the disease, observing the performance of psychomotor components that can prevent or create problems in the future, and identifying how she affectively views the disease in her life can be helpful in facilitating learning. By these actions, the therapist can begin to determine how much the individual knows relative to the knowledge needed and if the information the person has is correct.

Assumption 3

If we agree with Knowles that “the readiness of an adult to learn is closely related to the developmental tasks of his or her social role,”29 then it is appropriate to find out about the individual’s activities and how these could influence receptivity to the topic. In this case, it is appropriate to highlight how osteoporosis can affect this person’s life by relating the disease to work, self-care, and leisure roles.2 For example, if the individual described in this case plans to plant a vegetable garden as a hobby, it may be helpful to remind her that this task can place demands on the skeletal system requiring her to carry a heavy load and that the activities required for gardening may put her at greater risk for fractures. Therefore, applying proper ergonomie techniques of lifting, carrying, stooping, and digging to gardening is appropriate for this individual so she can see the functional relevance to her life.35

Assumption 4

The educational focus should be on the individual and not the disease. According to Knowles,”there is a change in time perspective as people mature-from future application of knowledge to immediacy of application. Thus, an adult is more problem-centered than subject-centered.”29 Individuals are more likely to be receptive to the information being shared if they recognize how the disease can affect their current life activities. In order to make the information problem-centered rather than subject-centered, the focus should be on impairments, functional limitations, and disability rather than pathology. In this case, a discussion of this person’s current interest in gardening and the lifestyle changes required to safely continue the hobby is appropriate. Information should be individualized and personalized to highlight the impact of the disease. Once the individual is able to make the connection between current life roles and the negative effect of the disease, the immediacy of the problem will be more apparent.

Assumption 5

This assumption states that,”adults are motivated by internal factors rather than external ones.”31 It is important to realize that the motivation for behavioral change should come from within the individual. Family pressure and health advice will not necessarily influence an individual’s actions. The behavior changes needed to preventthe progression of bone loss and pathologic fractures require a life-long commitment. If temporary behavioral changes are made to satisfy others, the preventive effort is more likely to be short-lived, and a relapse to previous patterns is likely to occur. Therapists need to discover the factors that motivate each unique individual.26,36 Engaging individuals in a discussion about motivation to change behavior will give the therapist much needed insight about factors affecting their decisions.

Assumption 6

It is important that the individual understands the rationale underlying what the therapist is teaching. In this case, assessing and reassessing the individual’s knowledge in the cognitive, psychomotor, and affective domains during and after the education-based intervention may give the facilitator greater insight into how the adult understands and values the information provided and the extent to which the information has been applied. Asking adults if they perceive the information to be relevant and meaningful to their current life roles is a direct way to determine this information. The therapist should facilitate learning in any case where a deficit of knowledge, skills, or attitude is identified. Goals may need to be changed, or further teaching may be necessary so that individual understands the functionality of the intervention. Initial joint goal setting will help assure that activities are focused upon both the individual’s and the professional’s priorities from the onset.


Therapists can use Knowles’ assumptions about adult learning to better understand their patients and how they learn. Adults tend to be self-directed individuals who apply knowledge based on past experiences and who are problem-centered. In order for these individuals to participate in a learning activity, they prefer to know why they need to know something, and the intervention should be applicable to their current life roles. When the therapist uses this concept, the information provided is most appropriate and more likely to be valued and used, and this also shows respect for the patient as an individual.

A large amount of information about osteoporosis is directed toward older adults in the hope that the topic is of interest to them and that they will be self-directed enough to follow-up on specific health recommendations. Many older adults have at least heard about osteoporosis, its causes, and how to prevent it. However, until individuals truly realize how the disease can impact their unique life roles, the topic may not be of particular interest and may not receive an appropriate amount of attention. It is important to realize that self-directedness is a part of the process of adult learning. Focusing educational efforts toward individuals and their life situations rather than toward the disease and its manifestations will increase the likelihood that the problem and the related interventions are perceived to be relevant.


1. American Physical Therapy Association. Guide to physical therapist practice. 2nd ed. PhysTher. 2001;81:9-744.

2. Best JT. Effective teaching for the elderly: Back to basics. OrthopNurs. 2001;20:46-52.

3. Chernoff, R. Nutrition and health promotion in older adults. JGerontolA. 2001;56A:47-53.

4. Davis LA, Chesbro SB,Wilken CA. Retirement community residents’ interest and preferences in an onsite health education library. Southwest JAging. 2000;16:101 -105.

5. McLennan M, Anderson GS, Pain K. Rehabilitation learning needs: Patient and family perceptions. Patient Educ Couns. 1996;27:191-199.

6. van Veenendaal H, Grinspun DR, Adriaanse HP. Educational needs of stroke survivors and their family members as perceived by themselves and by health professionals. Patient Educ Couns. 1996;28:265-276.

7. Wiles R, Pain H, Buckland S, McLellan L. Providing appropriate information to patients and carers following a stroke. J Adv Nurs. 1998;28:794-801.

8. Adams F, Norton M. Unearthing seeds of Fire: The Idea of Highlander. Winston-Salem, NC: John F. Blair; 1975.

9. Brookfield SD. Understanding and Facilitating Adult Learning. San Francisco, Calif: Jossey-Bass; 1986.

10. Freire P. Pedagogy of the Oppressed. New York, NY: The Seabury Press; 1970.

11. Goodwin-Johansson C. Educating the adult patient. Lifelong Learning: An Omnibus of Practice and Research. 1988;11:10-13.

12. Houle CO. The Inquiring Mind. Madison, Wis: University of Wisconsin Press; 1963.

13. Kidd JR. How Adults Learn. New York, NY: Association Press; 1976.

14. Lindeman EC. The Meaning of Adult Education. Montreal. Harvest House; 1961.

15. MezirowJ. Fostering Critical Reflection in Adulthood. San Francisco, Calif: Jossey-Bass; 1990.

16. Tough A. The Adults Learning Project. Toronto: The Ontario Institute for Studies in Education; 1973.

17. Arkachaisri T, Lehman JA. Low bone mass in children: Who is at risk, and what can be done? J Musculoskeletal Med. 2001 ;18:357-362.

18. Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications. N Engl J Med. 2000;342:1645-1650.

19. National Osteoporosis Foundation. Disease Statistics. Available at: Accessed August 20,2001.

20. Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. Norwalk, Conn: Appleton and Lange; 1994:415-416.

21. Dawson-Hughes B, Harris SS, Krall EA, Dallai GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med. 1997;337:670-676.

22. Prince RL, Smith M, Dick IM, et al. Prevention of post-menopausal osteoporosis: A comparative study of exercise, calcium supplementation, and hormone-replacement therapy. N EnglJ Med. 1991 ;325:1189-1195.

23. Finkel ML, Cohen MC, Mahoney H. Treatment options for the menopausal woman. Nurse Practitioner. 2001;26:5-15.

24. Geier KA. Osteoporosis in men. Orthop Nurs. 2001,-20:49-56.

25. Lawson MT. Evaluating and managing osteoporosis in men. Nurse Practitioner. 2001;26:26-46.

26. Falvo DR. Effective Patient Education: A Guide to Increased Compliance. 2nd ed. Gaithersburg,Md:Aspen Publishers, lnc; 1994.

27. Lipkin M. Patient education and counseling in the context of modern patient-physician-family communication. Patient Educ Couns. 1996;27:5-11.

28. Knowles MS. The Adult Learner: A Neglected Species. Houston, Tex: Gulf; 1990.

29. Knowles MS. The Modern Practice of Adult Education: Andragogy versus Pedagogy. New York, NY: Association Press; 1980.

30. Carson R. Malcolm Knowles: Apostle of andragogy. Vitae Schol. 1989;8:217-233.

31. Knowles MS. Andragogy in Action. San Francisco, Calif: Jossey-Bass; 1984.

32. Tresolini CP, Gold DT, Lee LS. Working with Patients to Prevent Treat and Manage Osteoporosis: A Curricuium Guide for the Health Professions. 2nd ed. San Francisco, Calif: National Fund for Medical Education; 1998.

33. Conti GJ, Fellenz RA.Teacher actions that influence Native American learners. In: Zukas M, eds. Transatlantic Dialogue: A Research Exchange. Leeds, England: School of Continuing Education; 1988:96-101.

34. Smith RC, Marshall-Dorsey AA,Osborn GG, et al. Evidence-based guidelines for teaching patient-centered interviewing. Patient Educ Couns. 2000;39:27-36.

35. Gold DT. The non-skeletal consequences of osteoporosis fractures: Psychologic and social outcomes. In: Lane NE, ed. Rheumatic Disease Clinics of North America: Osteoporosis. Philadelphia, Pa: Saunders; 2001:255-262.

36. Lubinski R. Environmental systems approach to adult aphasia. ln:Chapey R, ed.Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders. 4th ed. Philadelphia, Pa: Lippincott, Williams and Wilkins; 2001:269-296.

Steven B. Chesbro, PT, EdD1, Lori A. Daw’s, FdD, CCC-SLP2

1 Assistant Professor, Howard University, College of Pharmacy, Nursing, and Allied Health Sciences, Department of Physical Therapy, Washington, DC

2 Assistant Professor, University of Tulsa, College of Arts and Sciences, Department of Communication Disorders

Please address all correspondence to: Steven B. Chesbro Assistant Professor, Howard University, College of Pharmacy, Nursing, and Allied Health Sciences, Department of Physical Therapy, 6th and Bryant Streets, NW, annex 1 office B-33, Washington, DC 20059 Ph: 202/806-7562, Fax: 202/462-6194 (

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