Marcia Drew Hohn

The role of Adult Basic Education (Adult Literacy)
in developing health literacy

by Marcia Drew Hohn, Ed.D.

Adult basic education is referred to as ABE in this document and includes English for Speakers of Other Languages. The term is used inter-changeably with adult literacy.
[See Working definitions below.]

Integrating literacy and health education
– the U.S. experience

Working with health, including explicitly linking literacy and health education, is a new arena for adult basic education, which has developed primarily over the last decade. While many teachers have long incorporated health issues into their literacy and ESOL classes to spark student interest and to address life issues, the instruction was likely to be sporadic, inconsistent, and placed within a traditional teaching and learning framework.

In the last decade, adult basic education has struck out in new directions in seeing the ABE system as a critical part of addressing health literacy among limited literacy and limited English populations. These new directions have resulted from a convergence of trends that include:

• Research findings about the connections between limited literacy and poor health [Davis, Grosse & Auffrey, Perrin, Weiss, Williams, and others]
• The increasing recognition that health is central to one’s ability to attend effectively to family, school, work, and community needs
• New perspectives within adult literacy and public health about the need for a learning together approach, community empowerment, and teaching and learning contextualized in adults’ lives. [Arnold, Auerbach, Fingeret, and Freire on the literacy side. Labonte, Minkler, Rudd, and Zimmerman on the public health side].
• Passionate advocates on both the literacy and health sides having conversations and meetings

• researching health information
• teaching other students about health
• making and distributing brochures
• developing and conducting surveys
• participating in or running health fairs
• arranging for medical screening services at the program
• documenting and taking action around community health issues

Massachusetts’ adult basic education learners have been articulate about what they see as the problems with health education for limited literacy individuals and groups. They see materials written at an appropriate level as important, but only the tip of the iceberg of the communication and learning issues.

There is too much reliance on written materials, they say. What is needed are settings where health information can be connected to everyday life and a psychologically safe environment for learning is present. Having or getting health insurance is an issue in the United States but understanding both private and public health insurance programs, especially HMOs, is equally important, say students. Deeper issues are also present. One of these issues is that immigrants often have little or no experience with the concepts of prevention and early detection and their allied community health programs. So they are not conscious of health promotion messages, and extra care has to be taken to ensure these concepts are communicated. Another issue is that adult students fear discrimination in health care settings when they do not know the language and/or do not have health insurance; they are therefore less likely to engage with prevention and early detection, and may delay seeking medical care until it is too late. Research from the American Cancer Center has established that poor women die more frequently from cervical cancer – a cancer that is 100% curable if found early – as poor women often do not have the information to seek services early enough. (Health Education and Adult Literacy: Breast and Cervical Cancer, 1999)

To address these issues, Student Health Team members have developed an array of projects, interventions and materials. In the process, they have developed new knowledge, skills, awareness and vision for social action that promote new images of themselves as people who can make things change. Other adult students who benefit from these activities also report increased awareness, knowledge, skills and increased engagement with prevention and early detection practices. ABE programs and practitioners find that health topics catalyze and enhance literacy instruction in speaking and listening, reading, writing, math and critical thinking.

Selected approaches

A number of other programs and initiatives have addressed literacy and health initiatives issues in a variety of different approaches. Some of these efforts include:

• Project HEAL (Health Education and Adult Literacy) with a focus on early detection of breast and cervical cancer which grew out of a national cancer working group of health educators and educators. Now in its fourth iteration, AND HEALTH: HEAL provides curricula and lessons for ABE teachers in 16 states who want to offer in-depth health lessons, incorporating basic skill development, focused on specific health issues. Health Promotion for Adult Literacy Students and Rosalie’s Neighborhood were similar curricula projects.
• Collaborative interagency projects where multiple agencies with a common interest in developing health literacy for specific populations work together to develop a coordinated effort. e.g. Pennsylvania developed interagency programming to address the health literacy needs of seniors with diverse cultural or linguistic backgrounds and/or limited literacy (Hohn, 2002).
• Enhancing current services and leveraging resources was an approach used in Virginia to enhance their technology initiative in adult basic education The importance of health literacy was recognized and teacherstudent teams in adult basic education programs developed projects that were shared electronically across the state (Hohn, 2002).
• In Georgia, where many potential participants in adult basic education shy away from ABE programs because of the perceived stigma of illiteracy, special health programs were taught by health educators and ABE instructors together. The health programs became a venue for literacy instruction and a drawing card into other ABE programs (Hohn, 2002).
• Adult educators have worked across a number of initiatives with health care workers to simplify materials and to better understand the communication needs and learning styles of people with limited literacy-limited English skills.

All these avenues are valuable pieces of the puzzle about the role of the ABE system in developing health literacy. The next section looks at the accumulating evidence about impact and outcomes on health literacy when health is explicitly integrated with literacy instruction.