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Special Article

Emerging Pedagogies for Effective Adult Learning: From

Andragogy to Heutagogy
Thomas V. Chacko, M.B,B.S M.D
Dean Medical Education and Department of Community Medicine, Believers Church Medical College, Thiruvalla, Kerala, Director, PSG-FAIMER Regional Institute, Past
President, Academy of Health Professions Education, Past Secretary-General SEARAME (S-E Asia Regional Association of WFME), India

Abstract
Understanding the way the student learns effectively is important for teachers so that they can then more effectively design their learning
experiences. As the student in the health profession education progress across the long period and phases of learning from being an advanced
beginner in a wider range of competencies during Undergraduate (UG) to becoming proficiently competent in areas of their specialization
during their Postgraduate (PG) period and then after professional specialization while engaging in learning for expertise on-the-job during
early professional development, they transition from a low learner maturity phase to full learner autonomy where they determine what and
how to learn. Whereas pedagogy with high degree of teacher control matches low learner maturity, as the learners become more autonomous,
teachers face the dilemma about how much they need to let go of their power and control to transition from “sage-on-stage” to “guide-on-the-
side”. This article examines some of these dilemmas and attempts to suggest use of effective pedagogies (teaching methods) that match the
transition of the adult learner engaged in the art and science of healing and progressing through the professional course’s stages of competence
progression from being a novice to a competent professional and after their formal professional qualification to help them reach expertise and
improve quality of care by engaging in continuing professional development (CPD). This knowledge about learner maturity and adult learning
principles will also help diagnose and address learner’s problems and obstacles to effective learning that is happening at the institutional level.

Keywords: Andragogy, Adult learning theories, continuing professional development, e-learning, heutagogy, pedagogy, self-directed
learning, self-determined learning, web 2.0 Technology

Introduction and so teachers are in a dilemma as to whether they should

The learning during childhood is what all of us are familiar
with. Here the child in a protected environment is taught by the
teacher, where the teacher determines what the child learner
needs to learn. The child, of course, has no prior knowledge
of what is being taught, is like an empty vessel waiting to be
filled in by the prior knowledge gained by an adult teacher
and so whatever the teacher says is accepted by the child in a
nonquestioning way. We use the term “pedagogy” to describe
the methods mostly used by teachers during childhood.
We often encounter such students in the preclinical years during
their learning of basic sciences in the 1st year of medical schools
where they have to acquire new basic science knowledge, and
this is compounded by the fact that they are fresh from high
school where the teaching is also pedagogical unidirectional
transfer of knowledge from teacher to the learner. These
students are transitioning from adolescence to adulthood,
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continue with pedagogy or switch to methods directed toward
adult learning or andragogy. In the era of competency‑based
medical education (CBME); however, even in preclinical
phase since the application of basic science knowledge to its
clinical application is being introduced, using principles of
adult learning for application of this new knowledge needs to
be initiated and so teachers must become familiar with and use
adult learning principles and design learning experiences to
externally motivate the learner and initiate internal motivation
by revealing the relevance of why the basic science knowledge
needs to be acquired. During paraclinical and clinical phase,
greater scope for using adult learning theories and methods
Address for correspondence: Dr. Thomas V. Chacko,
Department of Community Medicine, Believers Church Medical College,
Thiruvalla ‑ 689 103, Kerala, India.
E‑mail: drthomasvchacko@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Chacko TV. Emerging pedagogies for effective
10.4103/amhs.amhs_141_18 adult learning: From andragogy to heutagogy. Arch Med Health Sci
2018;6:278-83.

278 © 2018 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow

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Chacko: From andragogy to heutagogy for effective adult learning
presents. It also becomes important for teachers to introduce the
students at this stage to become familiar and start using adult
self‑directed learning and reflection on their learning. In fact,
it is the habit of reflection on the learning that differentiates
and marks the transition from pedagogy to andragogy. Later,
after the students graduate and become professionals, their
learning needs and methods also change and so it becomes
a dilemma for the teachers of these adult learners who are
pursuing their postgraduate (PG) courses and some who have
completed formal higher specialization courses but are still
in the learning and growing stage of professional proficiency
toward expertise about when to use didactic methods and when
to use adult learning theory and learning methods modelled
on these principles. Educators have recognized the need for
a different approach to meet the learning needs and style of
the newly qualified professionals who are highly autonomous
and for whom pedagogical and even andragogical educational
methods are no longer an answer to preparing the professionally
qualified learners for thriving in the workplace and so a more
self‑directed and self‑determined approach is needed where
the learner reflects on what is learned and how it is learned and
where the educators teach the learners how to teach themselves,
this is termed as Heutagogy building on humanistic theory of
the 1950s.[1] Heutagogyis a form of self‑determined learning by
an autonomous learner with practices and principles rooted in
andragogy where the learner chooses what is to be learned and
even how they would like to learn it. In this learner‑centered
and learner determined learning, the “teacher” takes the role
of facilitator, guide or mentor suggesting to the autonomous
learner how the desired learning might take place and if a
formal assessment of learning is required, assist in determining
an appropriate method of assessment.
Therefore, as teaching faculty, for facilitating the learning of
students we are entrusted with, the dilemma and questions that
need to be answered are: What are the adult learning theories
and method based on them that we could use to facilitate
student learning at different phases of undergraduate (UG),
during PG and while mentoring them during early professional
development? How will knowing adult learning theories inform
us teachers to facilitate their learning more effectively? This
article examines some of these dilemmas and attempts to suggest
effective pedagogies (teaching methods) for the adult learner
learning the art and science of healing and progressing through
the professional course’s stages of competence progression from
being a novice to a competent professional and after their formal
professional qualification, at the workplace reaching the level
of professional proficiency and expertise.
An Overview of Adult Learning Theories and
Their Implications for Medical Education
Knowles[2] was the one who brought the concept of adult
learning into prominence when he stated that adults learn
in different ways from children and introduced the word
andragogy. However, his interest in this theory led him to find
Archives of Medicine and Health Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2018
out that it was first used by a Dutch adult educator Alexander
Kapp in 1833 who described it as fitting the educational
theory of the Greek philosopher Plato as the normal process
by which adults engage in continuing education. Building
on his own work, Knowles[3] reiterated that for applying
modern principles of adult learning, andragogy leverages the
assumption that adults are independent and self‑directing,
have various degrees of prior experience, integrate learning
to the demand of their everyday life, are more interested in
immediate problem‑centered approaches and are motivated
more by internal than external drives.
Taylor and Hamdy[4] citing Knowles et al. (2005) list how adult
learners differ from child learners in six respects: first, the need
to know (Why do I need to know this?); second, the learners’
self‑concept (I am responsible for my own decisions); third,
the role of the learners’ experiences (I have experiences which
I value, and you should respect); fourth, the readiness to learn
(I need to learn because my circumstances are changing); fifth,
the orientation to learning (learning will help me deal with the
situation in which I find myself) and finally the motivation
(I learn because I want to).
Abela[5] in his review on adult learning theories in the realm
of medical education stated that adult learning theories
describe ways in which adults assimilate knowledge, skills,
and attitudes and that the adult learning theories can be
grouped into five main classes of learning  (instrumental,
self‑directed, experiential, perspective transformation, and
situated cognition) and Andragogy being one of the popular
theory of adult learning under self‑directed learning. Taylor
and Hamdy[4] also give a good overview of the adult learning
theories categorizing them into instrumental learning theories,
humanistic theories, transformative learning theories, social
theories of learning, motivational models, and reflective
models.
Taylor and Hamdy [4] concluded that since instrumental
learning theories focus on individual experiences and include
behaviorist and cognitive learning theories, behavioral theories
are the basis of many competency‑based curricula where the
focus is on individual learning and explicitly states what the
graduate of a course or a learning experience must be able
to do with observable performance or professional behavior
measured as the outcome to be achieved. Experiential learning
theory has helped educators create learning experiences in
the curricula to facilitate learning through discovery. Kolb’s
experiential learning cycle helps curriculum planners and
educators make the learners plan for and later reflect on the
learning experience so that they are better prepared for the
next time they are faced with the same problem or professional
task and thereby improve the quality or effectiveness with
which the task is carried out. Maudsle and Strivens,[6] reiterate
that in experiential learning using the Kolb’s framework
helps in professional knowledge acquisition, fosters critical
thinking, problem‑solving and lifelong professional learning
by encouraging learners to test out and apply new knowledge.
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Chacko: From andragogy to heutagogy for effective adult learning
Transformative learning theories
Mezirow’s theory of transformative learning[7] encourages
critical reflection on an established frame of reference (currently
accepted as “fact’ or “truth”) to challenge the assumptions and
search for evidence. Learners are taken through experiential
learning experience or simulated scenarios, and the teacher’s
role is to facilitate the learners to question and reflect on
own and others assumptions. Critical thinking, perspective
transformation in the affective domain, leadership, and
change management competencies can be learned using
this theory. Methods that work include the use of critical
incident analysis, small group discussion to arrive at ways
to solve and formulate new ideas and engaging in reflective
practice helps in bringing about the change in perspectives.
Greenhill et al.[8] using clinical immersion models of clerkship
rotations in hospital and community over 4 years observed
that the learners gained insights in the areas of self‑awareness,
patient‑centeredness, systems thinking, self‑care, clinical
skepticism, and understanding diversity.
Social theories of learning
Bandura [9] posited that learning happens by observing
how others behave, a form of learning in context. In our
apprenticeship model of medical education, most professional
behaviors and attitudes, as well as ethics, are imbibed by
students observing their role model teachers. With the CBME
curriculum being launched with attitude, communication
and ethics modules as a pilot, success will depend on
teachers demonstrating through their everyday action and
interaction with patients– the hidden curriculum. Wenger[10]
emphasized the importance and influence of “communities of
practice” (CoP) in guiding and encouraging the learner. CoP
has three elements‑ one, members are bound together and hold
each other accountable to the joint enterprise; second, build
the community through mutual engagement building trust, and
sense of partnership; third, they produce a shared repertoire of
resources for use to gain the required competencies. Forming
groups with common purpose help the group members to
learn from and with each other. Learning within health
systems, in health teams, and in CoP helps to know each
other’s shared values and contribution to a shared common
purpose. Professionals engaged in continuing professional
development (CPD) and health professions education students
engaged in interprofessional education to foster team‑work
and better health service delivery in teams are good candidates
for this mode of social learning in context and within CoP.
Motivational Models
These, along with the reflective models help better understand
factors influencing adult learning among educational theories.
Ryan and Deci.[11] postulated three innate psychological
needs‑‑competence, autonomy, and relatedness which when
satisfied yield enhanced self‑motivation and mental health and
when thwarted lead to diminished motivation and well‑being.
These influencers need to be kept in mind by the educator
280 Archives of Medicine and Health Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2018
and the academic leadership within institutions to create
a supportive learning environment. This theory also helps
diagnose problems in adult learning where the learner seems
to be not motivated enough to learn and thereby acts as an
obstacle to improved performance as expected by the institution.
Kusurkar and Ten Cate.[12] (2013) applying this theory to
medical students found that intrinsic motivation in education
is associated with deep learning, higher academic performance,
greater creativity, higher engagement, higher persistence, lower
dropout, and more positive well‑being when compared with
extrinsic motivation. They recommend that curricular reformers
need to pay more attention to the motivational component of
learning and that teachers play an important role in determining
student motivation, and that autonomy‑supportive teaching can
be learned and is not difficult to practice.
Reflective models
Schon’s “reflection on practice” when combined with deliberate
practice and feedback for improving the performance of the
novice learner and “reflection in practice” for the proficient
or experts are helpful for improving their level of competence
and quality of outcomes, respectively.[13] They help students
become autonomous learners and later after their formal
professional training is over, they find it easy to engage in CPD.
Humanistic theories guide learning for self‑improvement that is
mostly applicable for professional development after formally
qualifying as a professional. They are learner‑centered, produce
individuals who have the potential for self‑actualization, are
self‑directed and internally motivated. We can also use this
theory for helping acquisition of competencies in the early
stage of professional development where the teacher will
have to take remedial measures to counteract the absence of
self‑motivation in the learning through role modeling with real
patient encounters in the ambulatory and inpatient settings.
Heutagogy
This approach to adult learning is most effective when directed
to adult learners who are already professionally qualified and
are self‑motivated and self‑determined to improve practice
due to the challenges and complexities at the workplace.
Heutagogy needs to be seen as a continuum of andragogical
adult learning theory in line with the transition in graduate
medical education directed toward becoming competent using
core andragogy of self‑directed learning to an autonomous,
self‑determined learner once the professional qualifies and
focus now shifts from competency to capability  (proficient
and then on to the state of expertise). Blaschke[14] presents the
features of heutagogy as a continuum of andragogy as follows:
• Andragogy  (self‑directed learning)  Heutagogy
(self‑determined)
• Single loop  (experiential) learning  Double‑loop
(reflection on experience)
• Competency development  Capability development
• Linear design and learning approach  Nonlinear design
and learning approach
• Instructor‑learner directed  Learner‑directed
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Chacko: From andragogy to heutagogy for effective adult learning

• Getting students to learn content  getting students to
understand how (process).
Heutagogical methods addressing the self‑directed learning
needs of the autonomous professional learner include distance
learning and use of Web 2.0 technologies. Designing curricula
and the learning modules used for CPD require a different set
of teaching skills as course and learning module creator and
provider of feedback that recognize the needs and styles of
these learners is different.
Andragogy and Heutagogy: A Good Fit for
Professionals as Methods for Continuing
Medical Education and Continuing Professional
Development
Scott[15] studying and using evaluative research framework
to explore theoretical models to explore the relationship
among key elements of certain theoretic models as applied to
continuing medical education (CME) program concluded that
physicians as adult learners are:
1. Self‑directed and experientially oriented (Knowles)
2. Impacted by their physical age and stage in life (Bennett)
3. Influenced by year or decade of graduation (Savatsky)
can leverage the six ways in which the adult learners differ
from child learners to improve the efficiency of learning of
our adult student learners.
Emerging Pedagogies for Effective Adult
Learning
Knowing how adults learn across different phases of
professional education during formal UG, PG, and during
early professional development helps us to identify and
choose methods that match the learner’s maturity transition
see [Figure 1] from immature learner during early UG period
to a self‑directed one during later clinical years when single
loop experiential learning takes place and during PG years
self‑directedness gets stronger but happens within the structured
curriculum of the higher education system within institutions.
Postqualification as a specialist, the autonomous professional
who is capable of determining their own learning needs on the
job, the heutagogical methodologies [Figure 2] become the
methods of choice by the proficient professional in search of
Basic Sciences  UG Clinical Phase  PG Training  Professional Practice
Pedagogy  Andragogy-----------Heutagogy  Heautagogy

4. Impacted by four dimensions of practice (Nowlen)

5. Require a force and image for change (Fox) Learner Centered Learner determined
6. Must be motivated to participate in CME (Knox). Self Directed
Teacher/peers as
Teacher driven Teacher as facilitator professional co-mentors
learner engagement
How the Adult Learning Theories Inform Single-loop Double-loop
experiential learning reflection on & in practice
Practice and Medical Education
For the educationist, knowledge of adult learning theories
helps them to serve as a lens to look at the learning problems Learner Autonomy
Learner maturity Learner determined
and diagnose the reasons for and answer why effective learning Teacher Control course preference
is not taking place in a given scenario or context. Once the & course structuring

diagnosis is made, then remedial measures in the form of

effective strategies and approaches present themselves. Let Figure 1: Spectrum of learning in medicine from Pedagogy to Andragogy
us, for example [Table 1], examine how medical educators and Heutagogy

Table 1: Leveraging adult learning principles to increase efficiency of learning by adults

# How adult learners differ from child
learners (Knowles)
1 The need to know (Why do I need to know this?)
2 The learners’ self‑concept (I am responsible for
my own decisions)
3 The role of the learners’ experiences (I have
experiences which I value, and you should respect)
4 Readiness to learn (I need to learn because my
circumstances are changing)
5 Orientation to learning (Learning will help me
deal with the situation in which I find myself)
6 Motivation (I learn because I want to)
CPD: Continuing professional development, LNA: Learning need assessment
Educator’sroleto increase efficiency of professional learning by adult learners
Do a LNA of the learner
Making learner aware or help discover and identify further learning need
Help learner become aware of the learning opportunities in context and that decisions
taken regarding them have professional consequences
Recognise and respect prior experience and help them build on their prior experience
Help them plan their own “learning contract” keeping in mind the learning opportunities
and time available
Help them with realizing the benefits of adapting to the changing environment
Prompt them to do a “gap analysis”
Make professionals aware of benefits of and avenues for engaging in CPD
Create supportive institutional environment by promoting and rewarding engaging in CPD
Explore ways to do extrinsic motivation like recognition and rewards to leverage/trigger
the internal motivation of the adult learner

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Chacko: From andragogy to heutagogy for effective adult learning

Figure 2: Learning environment and methods for learning and self-improvement

gaining further expertise in an increasingly competitive world
of knowledgeable colleagues and patients and thereby putting
pressure for quality improvement in service delivery to ensure
better patients’ outcomes and patients’ satisfaction.
The pedagogies of old– giving didactic lectures and teacher
directed courses are still useful and effective for both the
immature learner just coming out of high school and need a
good knowledge base in a short time. However, these need
to be gradually weaned off as learner maturity increases
and experiential learning methods in simulated and real‑life
situations become more interesting and triggers and boosts
internal motivation of the adult learner to learn. Over the
years, many innovative methods for engaging the learner
starting with interactive lectures have been tried and tested.
Group discussions and critical reflection on existing frames of
reference and worldview in thinking and feeling brings about
transformative learning in feeling and thinking and builds
critical thinking. Case or problem triggered learning helps the
learner understand the relevance of learning basic sciences
for future professional practice as a doctor. Problem‑based
learning makes them familiar with the process of self‑directed
learning and diagnosis of their own further learning needs.
Use of technology always creates interest in the 21st century
learners and the introduction of such technologies including
the use of social media builds on what they are already
familiar outside the classroom. Flipped classrooms where
students deliver the content and classroom time is used for
higher cognitive and deep learning make the student learning
more effective. Inter‑professional team training makes the
learner better prepared for working in teams in the healthcare
delivery systems. Early exposure to reflection on learning and
seeking feedback make them imbibe this important skill of
self‑improvement in professional practice.
Although Heutagogical methods are more suited for the
professional who by then becomes a mature autonomous
learner who is internally motivated to improve professional
skills and so determines and chooses what to learn and how
to learn and how to get self-assessed to measure improvement
in practice, exposure to these methodologies even in the early
phase of professional education makes learning interesting,
breaks the monotony of the usual didactic teacher controlled
pedagogies and prepares them for the way they would be
learning in the future.
Financial support and sponsorship
Nil.

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Chacko: From andragogy to heutagogy for effective adult learning
Conflicts of interest
There are no conflicts of interest.
References
1. Hase S, Kenyon C. From Andragogy to Heutagogy. Ulti‑BASE
In‑Site; December, 2000. Available from: http://www.pandora.nla.gov.
au/nph‑wb/20010220130000/;http://www.ultibase.rmit.edu.au/New/
newdec00.html. [Last accessed on 2018 Dec 07].
2. Knowles MS. Andragogy: Adult learning theory in perspective.
Condensed from chapter in book “The adult learner: A neglected
species”. Houston Tx: Gulf Publishing Company. Community Coll Rev
1978;5:9‑20. Available from: https://www.journals.sagepub.com/doi/
pdf/10.1177/009155217800500302. [Last accessed on 2018 Dec 07].
3. Knowles MS. Andragogy in Action: Applying Modern Principles of
Adult Learning. San Francisco: Jossey‑Bass; 1984.
4. Taylor DC, Hamdy H. Adult learning theories: Implications for learning
and teaching in medical education: AMEE guide no. 83. Med Teach
2013;35:e1561‑72.
5. Abela J. Adult learning theories and medical education: A review. Malta
Med J 2009;21:11‑8. Available from: http://www.um.edu.mt/umms/
mmj/showpdf.php?article=234. [Last accessed on 2018 Dec 07].
6. Maudsley G, Strivens J. Promoting professional knowledge,
experiential learning and critical thinking for medical students. Med
Educ 2000;34:535‑44.
Archives of Medicine and Health Sciences  ¦  Volume 6  ¦  Issue 2  ¦  July-December 2018
7. Mezirow  JE. Perspective transformation. Adult Educ  (USA)
1978;28:100‑10.
8. Greenhill J, Noreen Richards J, Mahoney S, Campbell N, Walters L.
Transformative learning in medical education: Context matters,
a South Australian longitudinal study. J Transformative Educ
2017;16:154134461771571.
9. Bandura A. Social Learning Theory. New York: General Learning Press;
1971.
10. Wenger E. Communities of practice and social learning systems.
Organization 2000;7:225‑46.
11. Ryan RM, Deci EL. Self‑determination theory and the facilitation of intrinsic
motivation, social development, and well‑being. Am Psychol 2000;55:68‑78.
12. Kusurkar R, Ten Cate O. AM last page: Education is not filling a bucket,
but lighting a fire: Self‑determination theory and motivation in medical
students. Acad Med 2013;88:904.
13. Schon  D. The Reflective Practitioner: How Professionals Think in
Action. London: Temple Smith; 1983.
14. Blaschke LM. Heutagogy and lifelong learning: A review of heutagogical
practice and self‑determined learning. Int Rev Res Open Distance Learn
2012;13:56-71. Available from: http://www.irrodl.org/index.php/irrodl/
article/viewFile/1076/2113. [Last accessed on 2018 Dec 07].
15. Scott CJ. Applied adult learning theory: Broadening traditional CME
programs with self-guided, computer-assisted learning. J Contin Educ
Health Prof 1994;14:91‑9.
283