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Invited Review
Nonformal education as health promotion
method among European youth: the example
of transitional Albania
E. Tresa
1,2,
*, G. Burazeri
1,2
, S. Van den Broucke
3
, G. Qirjako
2,4
, and
K. Czabanowska
1,5
1
Department of International Health, School CAPHRI, Care and Public Health Research Institute,
Maastricht University, Maastricht, The Netherlands,
2
Department of Public Health, Faculty of Medicine,
University of Medicine Tirana, Tirana, Albania,
3
Psychological Sciences Research Institute, Universite´
Catholique de Louvain-la-Neuve, 1348 Ottignies-Louvain-la-Neuve, Belgium,
4
Department of Health
Promotions, Institute of Public Health, Tirana, Albania and
5
Institute of Public Health, Faculty of Health
Sciences, Jagiellonian University, Krakow, Poland
*Corresponding author: E-mail: eni_tresa@hotmail.com
Summary
Nonformal education methodology is promoted by the European Union as a priority. Western Balkan
countries are supported in using this methodology via access Community funds (Erasmus þ,
previously Youth in Action). Nonformal education (proven as the most effective education method for
youth) is expected to have the same impact if used in Public Health. We aimed to explore how
nonformal education methodology contributes to health promotion through elaborating the example
of transitional Albania. An Exploratory Sequential Mixed Methods design was used. We organized
two focus groups: one with students of medical sciences and another with none medical students. We
randomly selected eight participants per focus group from the Beyond Barriers association database
(Contact point for ErasmusþProgramme in Albania). We used conventional content analysis to ana-
lyze qualitative data. Exploratory group interviews were conducted previously, using a questionnaire,
which was piloted prior to administration. Of a population of 581 youth who participated in nonformal
education activities during 2007–2013, 113 youths were interviewed. Ninety percent of interviewees
declared that nonformal education activities have influenced improvement of their skills/competences
or helped to acquire new ones; 53% declared that they reflected a change into personal behavior/
actions/attitudes. Trainees learned through practice. They intended to retain the healthy behavior
even when the activity was finished. Nonformal education activities offered equal opportunities to all
youth despite their gender or field of study. Nonformal education methodology is recommended to
be used in health promotion campaigns targeting young people as a very effective tool.
Key words: non-formal education, health promotion, young people
V
CThe Author(s) 2021. Published by Oxford University Press. All rights reserved.
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Health Promotion International, 2021, 1–10
doi: 10.1093/heapro/daab005
Invited Review
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INTRODUCTION
The Europeanization process influences the Western
Balkan (WB) countries as new member states and acces-
sion countries not only through norms and rules but also
through new policies and programs (Denca, 2008). The
European Union (EU) has supported the development
of the EU youth policy and has influenced national
youth policy through programs, such as Erasmus þ
(2014–2020) and Youth in Action (2007–2013)
(Lejeune, 2015; European Commission, 2018). The for-
mulation of European policy for NFE can be understood
as a part of the ‘Europeanization process in education’
(Mikulec, 2015).
Nonformal education (NFE) is one of the methodolo-
gies promoted by the EU as a priority working area in
the Council of Europe’s youth field included in the
agenda 2020 (Council of Europe and Committee of
Ministers, 2003;Council of Europe and Youth, 2008;
Witthaus et al., 2016). NFE is defined as ‘an integral
part of a lifelong learning concept that ensures that
young people and adults acquire and maintain the skills,
abilities and dispositions needed to adapt to a continu-
ously changing environment’ (Parliamentary Assembly
and Committee on Culture and Education, 1999).
Health promotion (HP) is defined as ‘the process of
enabling people to increase control over, and to im-
prove, their health’ (World Health Organization, 2018).
HP serves the core mission of higher education by
supporting students and creating healthy learning
environments, at colleges and universities (American
College Health Association, 2020). The principles
approach in HP include (i) a broad and positive health
concept; (ii) participation and involvement; (iii) action
and action competence; (iv) a settings perspective; and
(v) equity in health (Grabowski et al., 2017). The
principles approach in HP goes in the same line with the
elements of NFE.
NFE influences in improvement of Public Health. It
focuses on the positive elements of learning. NFE is used
as well to promote health and improve psychophysical
well-being among housewives and informal care work-
ers in southern Spain. Through these activities, women
empowerment is achieved by increasing self-esteem and
self-confidence. Among NFE workshop participants
there are evident positive effects on the cognitive and
psychological dimensions (Pietila¨ , 2009). Participation
and involvement are core principles of NFE. ‘Learners
are active participants in their learning, and that they
and their families and communities are involved in
running the nonformal education programme’ (Kamala
Achu et al., 2010).
Health Literacy is defined as ‘people’s knowledge,
motivation and competences to access, understand,
appraise, and apply health information in order to make
judgments and take decisions in everyday life concerning
healthcare, disease prevention and health promotion to
maintain or improve quality of life during the life
course’ (Sørensen et al., 2012). NFE activities promote
health literacy and well-being, leading to improvement
of Public Health in the community context, where
people live. Nonformal health education helps children
and adolescents to acquire relevant information regard-
ing their own health condition, share strategies to cope
with the disease and with the physical and attitudinal
barriers they face in their daily life, and develop a criti-
cal consciousness regarding their health rights and their
role as citizens in a community (Pais et al., 2014).
NFE tries to empower the participants through build-
ing their competences and skills (Tudor, 2016). It is pur-
posive but voluntary learning (Council of Europe and
European Union, 2018). Inclusion and equity are the
main pillars of NFE education (Kamala Achu et al.,
2010). Comparing health of participants and nonpartici-
pants in NFE activities seems that participation in NFE
activities has a significant impact on relevant dimensions
of the quality of life of children and adolescents with
chronic disease. Participants do feel more satisfied with
their health condition [F(1, 160) ¼15.347, p<0.001],
more capable of making decisions regarding their own
health [F(1, 160) ¼7.501, p¼0.007] and to influence
other people regarding issues related to chronic diseases
[F(1, 160) ¼37.003, p<0.001] (Pais et al., 2014). NFE
activities give the possibility, especially to youngsters
coming from disadvantaged groups, to act free from
many of the constraints they experience in their daily
lives, to experiment with aspects of their personality
that are normally suppressed, and to a certain extent ‘re-
invent themselves’ without fearing the disapproval of
their peers (Friesenhahn et al., 2013). NFE activities
provide opportunities to persons who often are hardly
mobile in their daily lives to move to a neighboring
town for further abroad education or employment op-
portunities (Kristensen, 2013).
NFE is used to train adults in many fields including
health promotion in such countries as Australia, New
Zealand, Korea, Japan, and the USA (Singh, 2015).
Evaluation of NFE programs in Bangladesh showed they
were effective and efficient (Ministry of Primary and
Mass Education and Government of the Republic
People’s of Bangladesh, 2006). To reach a wide audi-
ence, NFE activities have been on air in national TV
talking about nutrition, population control, maternity
and childcare (Alamgir, 1999). Nonformal education is
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often seen as the most positive, efficient and attractive
counterpart to educate young people (Monika
Novosadova, Gulece Selen et al., 2006). It can be used
for health-related issues as smoking, alcohol consump-
tion, sport or gender (Singh, 2015).
In Albania, the prevalence of smoking among youth
depends on gender and group age. Men smoke more
than women. Of total, 12.3% of men 0.9% of women
15–19–year-old smoke. When age increases, the level of
smoking also increases. In total, 44.1% of men and
5.9% of women 24–29-year-old smoke. Of total 20% of
girls and 31.1% of boys 15–19 years old consume alco-
hol. Meanwhile, 35.2% of women 20–24-year-old con-
sume alcohol and 67.9% of men 25–29–year-old.
82.7% of women do not exercise and 55.2% of them
have a body mass index (BMI) over 25. Although
77.2% of men do not exercise, 59.8% of them have a
BMI over 25 (Institute of Statistics and UNWOMEN,
2019).
The EU is linking NFE with a lifelong learning strat-
egy (OECD, 2010). Even though NFE is promoted by
the EU and a lot of money is invested in this field, there
is no evidence for the use of NFE as a method for HP in
the European Region, in WB and in Albania. No other
study is available to give evidence of how NFE can be
used as an HP method. Therefore, through this study,
we aim to explore how NFE methodology contributes to
HP to raise awareness among the youth thought the ex-
ample of transitional Albania using a mixed-methods
approach.
METHODOLOGY
The study is based on Exploratory Sequential Mixed
Methods design (Creswell, 2014). This methodology
allows exploration of the topic through a qualitative
study in the first phase and then during the second phase
to test or generalize the initial findings using quantita-
tive methods (Berman, 2017). During a final phase, the
data from the two separate strands of data are integrated
and linked (Creswell and Clark, 2007).
The exploratory group interviews preceded a ques-
tionnaire study which was piloted prior to administra-
tion (Pope and Mays, 2006). Through quantitative
methods, we tried to answer to the research question:
How do participants of NFE activities perceive NFE
methodology? Through qualitative methods, we asked
their opinion on whether NFE methodology should be
used in HP activities?
Through qualitative methods, we identified and built
a theoretical background of NFE methodology whereas
quantitative methods supported our findings with other
data. All questions of both focus group discussion and
survey are available in the Appendix.
Qualitative methods
Two focus group discussions (FGD) with eight
participants each were organized. The participants were
selected randomly from the Beyond Barriers Association
(BBA) database. The inclusion criteria for the focus
group were participants had to be young people
18–25 years old who had participated in at least one
NFE activity. All interviewees were Albanian, and were
volunteers in the BBA association. One of the FGD
comprised eight students of medical sciences (three
males and five females). In the other FGD, eight students
of law, economics and engineering (four males and four
females) participated. The division in the two FGD was
based on the field of study and was conditional, to avoid
any possible bias coming from previous knowledge on
health promotion activities.
The main author of the study led the focus group
based on pre-defined questions. There were ten ques-
tions in the FGD. They were related to the experience of
the participants with NFE activities, their opinion on the
methodology and if they see it as appropriate to be used
in HP activities.
All the interviews were recorded. All data were
transcribed and analyzed verbatim. Analysis was based
on Conventional Content Analysis, ‘coding categories
are derived directly from the text data’ (Hsieh et al.,
2005) The results were compared with the same FGD
and in between the FGDs.
Quantitative methods
We conducted a cross-sectional study based on a popu-
lation of 581 volunteers of BBA. We collected data in
2013, a time when BBA was the contact point for Youth
in Action Programme launched by the European
Commission (2007–2013), now for the Erasmus þpro-
gram (2014–2020). We contacted BBA, as at the time
when the study was conducted, it was the only local
NGO that worked with NFE and had an offline
database of volunteers.
The sample was selected through systematic
sampling methods and its size was calculated with a
95% confidence interval, a level of confidence 5% and
a 10% population portion (London School of Hygiene
and Tropical Medicine, 2009). We selected each five
names in the BBA database, the first, the fifth, tenth, the
fifteenth and so on. Of 112 minimal required sample,
we interviewed 113 youngsters. The level of respond-
ence was 95%. As per operative definition, youngsters
Nonformal education as health promotion method 3
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are considered students aged between 18 and 25 years
old, volunteers of BBA. Youth in action Programme of
the European Commission supported mobility of young-
sters 13–30 years old (European Commission, 2013).
Inclusion criteria: Youngsters 18–25 years old that
had participated in at least one NFE activity and did not
participate in the FGD and in validation of the question-
naire. From the BBA volunteer database, every fifth vol-
unteer was contacted to participate in the study. We sent
the questionnaire electronically to each of the selected
candidates. Before that, we validated the questionnaire
among other 16 participants/trainees/interviewees/vol-
unteers (PTIV). Based on their feedback, some of the
questions were re-formulated and adapted for clarity.
The questionnaire contained 23 closed questions
about demographic data, such as age, gender, number of
NFE activities they had participated and other questions
about their experience with NFE activities. Questions
were organized as per the five principles of HP
(Grabowski et al., 2017). See Table 1 in the Appendix
for the full pull of questions.
All data were analyzed with the Statistical Package
for the Social Sciences) (SPSS, version 16) (IBM, 2020).
Based on our dataset we were able to perform: descrip-
tive analysis, and chi-square tests. The data we obtained
allowed us to conduct all the needed analyses and to
answer to our research objectives The chi-square test
was used to analyze the independent proportions of
categorical data (Mchugh, 2013). A value of p0.05
was considered statistically significant.
Characteristics of the participants in the
questionnaire
The median age of interviewees was 22 years old (min
18, max 25, range 7). Of the total, 38% were male and
62% were female. The majority of the subjects studied
medical sciences (25 %), social sciences (23%), econom-
ics (17 %), engineering (17%), law (9%) and other sub-
jects 12%. 21% of interviewees participated for the first
time in NFE activities from 2007 to 2010. The majority
of them (80 %) participated for the first time in NFE ac-
tivities from 2010 to 2013. The majority of interviewees
(80%) had taken part in 1–5 activities. 17% had taken
part in 6–10 activities and only 4% had taken part in
over 10 activities.
RESULTS
Based on the content analysis, the following categories
were identified: Activity methods, Participation, Learning,
Communication, Spirit, and Reflection Behavior. In some
cases, subcategories were created: Learning methods,
Communication/Learning (Fig. 1).
Activity methods
Different methods were used during the activity, in or-
der to adapt to the different learning styles of the train-
ees. The Participants/Trainees/Interviewees/Volunteers
(PTIV) thought that methods used during NFE activities
were new and not known before. They found them as
special methods of education. NFE methods were inter-
active methods of learning that keep trainees interested
and focused. The information is served in a simple and
Table 1: NFE activity methods and how knowledge is used
Statement Yes No
During the NFE activity different work-
ing methods were used
100% 0%
I did not like the working methods 3.5% 94.7%
The methods used during the activity
were repetitive
13.3% 84.1%
The working methods were in compli-
ance with my way of learning
92% 7.1%
Did you manage to memorize the infor-
mation received during the activity?
98.2% 1.8%
During the activity, I had space to reflect
on the topic
95.6% 4.4%
During the activity, I discussed with other
participants
93.8% 4.4%
After the activity, I shared experience and
information with friends/family/other
volunteers of the organization
63.4% 36.6%
After the activity, I used the information
for presentations in/at school/work
42.6% 57.4%
After the activity, I reflected on the activ-
ity in general
91.2% 8%
After the activity was finished, I wanted
to take part in another one.
97.3% 1.8%
Fig. 1:Components of NFE methodology. Source: This study.
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understandable manner. Through concrete examples,
PTIV were able to understand different situations and
put the theoretical information into practice. All were
presented in a new approach that youngsters like very
much. In schools, they would lose concentration because
of long PowerPoint presentations. In NFE activities,
however, they were active all the time. NFE activities
differ from traditional learning methods, as all activities
are organized in working groups. During group work,
they build the work based on each other ideas.
Participation
Participation in NFE activities was voluntary, not
obligatory. The NGOs use techniques as ‘mouth to
mouth’, presentations or innovative means of communi-
cation to promote NFE activities. PTIV said that they
were influenced by their older siblings/friends to
participate in NFE activities. Some of them had heard
about NFE activities during presentations or open days
at universities, NGO fairs in the city center, activities on
Europe day. Social media was also a tool that informed
PTIV about NFE activities. Through videos and photos,
they were motivated to participate. NFE activities
encourage the inclusion of people as people with
disability/different ability can take part.
Learning
The process of learning was active. PTIV learnt through
practice and there was no extended, long and boring
theoretical information. They learnt through exchanging
ideas, opinions and experiences with each other. Group
was seen as resource. In this way, PTIVs increased their
capacities and competences. PTIV described learning as
‘was easy and interesting’. NFE activities fostered
creativity and the desire to learn among participants.
During the activity, PTIV met friends from other
countries and this helped them to break down prejudices
and stereotypes about other cultures. The activity
fostered inter-culture dialogue.
Learning methods
Posters and leaflets may not be read as they require an
active learning process. Through NFE, youngsters
(PTIV) received the information passively through
exercises and educational games. NFE activities used
group work, open group discussions, reflections, role
plays, simulation exercises, drama, small quizzes, case
studies, outdoor group activities, brainstorms and videos
to enhance learning process. Through debates and
discussions, they learned to analyze different situations,
to develop critical thinking and in the same time to be
realistic and objective in the discussion. Through the
methods used, PTIV could put themselves in the shoes of
other people and see the situation with a different lens.
The learning methods are appropriate for health
education activities. The age range of participants in
NFE activities allows the facilitator to create a smooth
environment to discuss sensitive issues. Learning
methods, such as peer-to-peer education, can be used to
promote healthy behavior including sexual and
reproductive health, sports, healthy diet, and road safety.
Communication
PTIV said that during NFE activities (different from for-
mal education/school) they felt free to communicate, to
express their opinion, without being afraid of the opin-
ion of the professor. Even though the trainer/facilitator/
youth worker (TFYW) worked at the European level,
they did not feel any barrier that would lead to difficul-
ties in learning. Every idea was valid and there was no
wrong answer. This made them free to express them-
selves leading to an increase of the self-confidence
needed to take part in the discussion. Even though they
did not know each other, there were organized ‘getting
to know each other’ and ‘icebreaker’ activities that
make them feel free to communicate.
Communication/learning
NFE activities helped PTIV to develop communication
skills. They learned how to speak in public, communi-
cate in small and big groups, and make presentations.
PTIV developed their leadership skills. During youth
exchanges, some of the participants were group leaders
and this made them learn how to manage group dynam-
ics, keep balance within groups and solve possible
conflicts among group members. They learnt how to
take decisions as a group even though they had different
ideas at the beginning. Most of the PTIV developed their
skills to communicate in a foreign language as in most
of the cases, English was the main language of the
activity. During the European Voluntary Service (EVS)
volunteers could learn the local language through
courses provided to them. They could also interact with
local people, which helped them to learn how to behave,
adapt and live in a new culture.
Group spirit
PTIV liked the general atmosphere of NFE activities.
During NFE activity after ‘getting to know each other’
exercises, the entire group (including TFYW) worked
with team building activities in order to create a warm
environment for PTIV to feel safe to discuss and
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participate. The group spirit was in the same line with
group dynamic and made NFE activities very effective in
sharing the needed information to the disadvantaged
groups.
Reflection behavior
NFE activities encouraged PTIV to reflect on their be-
havior. Discussion and working in groups all week long
on health-related issues meant the PTIV intended to
keep the healthy behavior even when the activity was
finished. They tried to educate their family members and
friends about healthy behavior. Not all changed their
behavior. Some PTIV thought that they needed to take
part in other activities and to follow up after the activity
in order to use the information and to maintain their
healthy behaviors. Working on health promotion, they
intended to have healthy behavior themselves. The com-
munity benefited as well, by their increase of capacity.
Some of the PTIV created other youth organizations that
helped in the mobilization and learning of other young-
sters in other disadvantaged areas.
Results as per five principles of HP
A broad and positive health concept
Around 70% of interviewees found NFE activities to be
very interesting. None of them thought that NFE activi-
ties were somehow interesting or not interesting at all.
Table 1 shows what the participants thought about the
methods used in NFE activities and how the information
received during the NFE activity was used. NFE is
equally appreciated by both students of medical sciences
and other students. There is no significant difference
among those groups in the way they perceive NFE
(p¼0.76) (Table 1).
Participation and involvement
Of the total number of participants, 97% said that they
worked well in the group and they felt free to open up
and discuss with other participants (98%). The majority
of interviewees declared that they felt confident enough
to have discussions on different topics. 95% of inter-
viewees said that during the activity, an open environ-
ment was created to discuss sensitive health-related
issues, such as sexual and reproductive health, physical
activity, smoking, etc. Only 4% of the participants said
the relationships with other participants were rigid and
they could not discuss personal issues. After the activity,
63% shared what they learned with others like family
members, friends, and other volunteers of the organiza-
tion. No gender differences are present in this indicator
(p¼0.93).
There was shown no significant difference in be-
tween medical students and other students in the way
they participated in NFE activities (p¼0.42). In fact,
there is no significant correlation in between the number
of activities in which students participate and the per-
ception they have about NFE activities (p¼0.81). As
well as, there is no significant change in the number of
activities in which medical students and other students
have participated (p¼0.14).
Action and action competence
The majority of interviewees (90%) declared that NFE
activities had helped to improve their existing skills and
competencies or to give them new ones. The majority of
interviewees (98%) said that they achieved to memorize
the information received in NFE activities and 72% said
they used the information received (42% used for
presentations in school). Around 80% of interviewees
declared that they put into practice the information re-
ceived and 53% declared that they reflected on changing
the personal behavior/actions/attitudes. No evidence is
available about the gender differences/field of study and
influence of NFE activities in improving skills and
competences (Table 2).
A settings perspective
96% of participants declared that they themselves
decided to take part in the activity and 4% said that
they were influenced by friends. No gender influence is
present in the participation in NFE activities (p¼0.40).
56% declared that they had heard of NFE activities
before participation. Female participants significantly
had more information about NFE activities before par-
ticipation than males, 29% more (p¼0.003). Also, the
information was shared with other colleagues or family
members in 63% of the cases. There is no difference
among male and female participants in the information
they shared with family members (p¼0.936). Figure 2
shows the influence of NFE activities on participants.
98% of interviewees disagreed that the NFE activities
did not have any influence on them.
Equity in health
Nonformal education activities offer equal information
and possibility of training to both men and women,
medical sciences students (who are supposed to have
more information on public health issues) and other
students. There is no significant difference among field
of studies/gender and the valuable information they
received for their lives. The values are, respectively,
p¼0.91 for field of study and p¼0.46 for gender.
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About the relationship with the TFYW, 89% of inter-
viewees said they did not feel the presence of barriers;
meanwhile, 11% said that even though they felt a dis-
tance, they could communicate. Only 1% said that there
was a big barrier in between TFYW and participants
and therefore they could not communicate freely. There
is no significant difference of field of study/gender and
the relation they build with TFYW. The test values are,
respectively, p¼0.36 for field of study and p¼0.31 for
gender. 99% of the PTIV say they had a friendly relation
with the group of other PTIV which offered the space to
communicate freely. No significant difference among
medical students and other students/men and women is
evident for this indicator. The scores are p¼0.56 for
field of study and p¼0.20 for gender differences.
DISCUSSION
This study found that NFE activities are appropriate for
young people. The results of this study support NFE
methodology as an HP method that can be used during
health education activities and health promotion cam-
paigns. NFE activities are appropriate for all youth de-
spite their fields of study, gender, or their places of
origin. They offer equal opportunity to be informed
about health activities, reflect about health-related issues
Table 2: Disaggregation of data based on gender and Field of studies
Gender Field of study: medical/other
Pearson chi-square p-value Pearson chi-square p-value
Influence of NFE activities in improving skills and competences 1.8 0.407 0.443 0.506
Memorization of theoretical information received in NFE activity 0.105 0.746 0.679 0.410
Use the information received 4.218 0.121 1.912 0.384
Use the info for presentations in school 1.08 0.299 3.114 0.078
Reflected to change the behavior/actions/attitudes 0.563 0.453 1.029 0.310
Put into practice the theoretical information received 0.167 0.683 0.488 0.485
Appreciation of NFE 0.534 0.766
Share of information with family and friends 0.006 0.936
Participation in NFE activities 1.817 0.403 1.695 0.429
Information on NFE activities before participation 9.13 0.003
Valuable information received for life 0.546 0.460 0.013 0.911
Relation built with trainer 2.344 0.310 2.032 0.362
Relation build with the group of participants 1.582 0.208 0.336 0.562
Fig. 2:Influence of NFE activities.
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and change their health behavior. Of the total, 53% of
PTIV declared that the information and knowledge re-
ceived in NFE activities, they used to reflect on change
of personal behaviors/attitudes/actions and 63% had
shared this information with friends, family members or
other volunteers of the organization. 95% of interview-
ees said that during the activity an open environment
was created to discuss on sensitive health-related issues,
such as sexual and reproductive health, physical activity,
smoking, etc. After the activity, 63% shared what they
learned with others like family members, friends, and
other volunteers of the organization.
Both qualitative and quantitative data showed that
interviewees found NFE activities very interesting
(70%). The learning methods were very interactive and
adapted to different learning styles. Group work was
much appreciated as it made PTIV feel free to discuss
with other participants (98%). This led to confidence in
discussing sensitive health issues like sexual and repro-
ductive health or smoking. NFE activities helped PTIV
to improve their skills and competences/acquire new
ones (90%). PTIV learnt to speak in public and develop
leadership skills. PTIV learned through practice and
NFE activities presented no extended, long and boring
theoretical information.
Health promotion is a process of learning and ‘en-
abling people to increase control over, and to improve,
their health’ (World Health Organization, 2018). NFE
methodology goes in the same line with the five elements
of the principles approach in HP:
1. 1 A broad and positive health concept
2. Participation and involvement
3. Action and action competence
4. A settings perspective
5. Equity in health (Grabowski et al., 2017)
NFE activities give young people new information in
the way that they would like to listen to it, improve their
skills and competences, and reflect on their behavior
which leads to improving their health (Tudor, 2016).
NFE activities give youngsters a positive prospective in
learning process. They foster participation of youngsters
with fewer opportunities and vulnerable groups to be ac-
tive in their learning process (Kamala Achu et al., 2010).
Health literacy is offered to young people in their con-
textual setting at community level (Pais et al., 2014).
Since 90s NFE has been suggested as a method for
health education in India especially reaching people liv-
ing in slums, regarding malnutrition, infant mortality,
sanitation-related disease and common disease (Selva
et al., 1990). Nonformal education enables people to
control situations that affect their lives. It gives
equal opportunities to all youth without fearing the
disapproval of their peers (Friesenhahn et al., 2013).
The education approach in health promotion explains
the importance of receiving information and developing
skills to be able to make informed health choices.
However, the changes in health behavior are voluntary
(Qirjako et al., 2008). NFE activities allies with the
education approach in health promotion.
NFE activities are oriented to the learning cycle of
the participants. They aim to balance out the skills,
theory and attitudes. Changing the attitudes of PTIV
might lead to change of their habits. The KASH model
explains the process of receiving theoretical information,
practical skills and changes in attitudes aiming at chang-
ing habits (Neale et al., 2009). For this reason, methods
of NFE have been used in India since 1993 to train
school children 7–10 years old on health nutrition
including importance of nutrition, the major nutrients,
and their food sources. Children that participated in
these activities were compared with other children that
did not participated. It was proven as an effective, low-
cost methodology in learning (Udipi et al., 1993). NFE
is also used in training manuals for people living with
HIV (Alexandria and Bundy, 2004). NFE activities are
used in countries like Australia, New Zealand, Korea,
Japan, USA as HP methods among youngsters (Singh,
2015). As well, it was used to ‘ever HIV tested young
people among sexually active ones in Urban Chiang
Mai, Thailand. It resulted that among sexually active
youngsters, 65.4% did not consistently use condom’
(Musumari et al., 2016).
Limitations of the study: This study was conducted
in 2013, a time when the Youth in Action program had
ended and contained only Albanian participants’ data in
NFE activities. Another data collection needs to be car-
ried out in 2020 upon the completion of the Erasmus þ
program. The study will be more complete if it is con-
ducted in many European countries or in the entire WB
region. The quantitative study design did not allow us to
have causal data analysis. However, the Exploratory
Sequential Mixed Methods design gave us a broad
prospective as to why NFE methodology should be used
in HP activities.
In conclusion, NFE is a very effective tool in health
promotion campaigns targeting youngsters. NFE activi-
ties help young people to reflect on their behavior.
Youngsters like it very much as an HP method. The EU
has put a lot of money in place and WB countries should
use it to build HP activities. NFE methodology should
be promoted as a health promotion tool among organi-
zations/institution in WB countries that work in the
8E. Tresa et al.
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health field. Manuals and booklets with best practices
should be published containing step by step descriptions
of how to use NFE methodology in the health field.
ACKNOWLEDGMENTS
We acknowledge Beyond Barriers Association and its Executive
Director Ana Mullanji, for giving as access in their volunteer
database. As well, we acknowledge Andre´e Rose Catalfamo for
her contribution in proof-reading.
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