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Impacts and outcomes of integration

Yes, it sounds wonderful for health to be addressed in ABE classrooms. Yes, student health teams sound like a empowering idea. But do adult learners want and appreciate health education? Do they develop new awareness, knowledge and skill about health topics? Do they engage more with preventive health practices? How does health work with literacy instruction?

In Massachusetts, a participatory action research study with a student health team, cumulative experience, and an investigative study of 13 ABE programs engaged with literacy and health work provides beginning evidence that integrated literacy and health education has substantial impact on adult learners’ health literacy. The following were statistically significant findings among the Massachusetts programs: (Hohn, 1998; Hohn, 2004).

Learners’ Perceptions about Learning about Health

• Adult learners say learning about health is important and that the information was useful and meaningful in their lives. Health also catalyzes their literacy learning. Teachers and learners report an intense engagement in conversation, reading, and writing activities that revolve around health topics.
• Adult learners find ABE programs a good place to learn about health because the time, psychological conditions, and an understanding of their communication and learning needs are present. Many said this was the first time they understood health information.
• Adult learners appreciated being taught by “people like myself” (Student Health Team members working with health educators and ABE practitioners). Adult learners trusted peer teachers and the social space to talk about health.

On the Health Topics and Methods

• Adult learners usually choose the health topic to study. In Massachusetts ABE programs, stress and depression are the topics most frequently studied. Diet and exercise are also favorites. Other topics include violence (as a health issue), smoking, diabetes, HIV/AID, cancers, fire safety, cholesterol and heart disease, SARS, food safety, as well as community environmental issues. The emphasis is on prevention and early detection.
• Common method elements among the programs include:
  – Students choose the health topics (ensuring meaningful connection)
  - Student teams lead the learning (working with health groups and teachers)
  - Use of drama, small group discussions, posters etc. increased understanding
  - Emphasis is on developing understanding

What was learned?

• Increased understanding
  – about concepts of prevention and early detection
  – about how things are connected. e.g. diet and exercise relationship to well-being and preventing or managing illness, relationship of stress and back pain
  – about community health services for treatment and prevention services such as blood pressure, blood sugar, cholesterol checks, and immunizations
  – about rights and responsibilities in health care settings and insurance programs

• Increased Skills
  – Health vocabulary
  – Read nutrition labels
  – Talk about health
  – taking a risk to ask questions, more confident in talking about health, share health information, support others and others support me
  – Recognize symptoms from reading a health brochure e.g., brochures on diabetes
  – Find and evaluate health information
  – Question information, see different perspectives

What are students doing differently?

– Eating more fruits and vegetables
– Drinking water rather than soft drinks like coke
– Avoiding fried foods
– Reading nutrition labels
– Requesting vending machines with healthy snack food
– Reducing stress through exercise, music, stretching, etc.
– Blood pressure checks
– Blood sugar screening
– Cholesterol screening
– Taking Pap tests
– Use of condoms
– Smoking less, trying to quit
– Exercising more – especially walking
– Showing more concern about weight
– Sharing learning with family and friends
– Washing hands more
– Asking doctor more questions concerning self, children and family
– Getting excited about learning about new health areas

Some Conclusions

Collectively, all these changes contribute to critical shifts for adult learners in:

• Belief about what a person can or cannot do about their health.“I can be healthier” was a common refrain.
• Personal knowledge and skills for dealing with health issues in their lives and the lives of their families and communities – through more intense engagement with public health information and initiatives.

One group of students said that learning about health in their ABE programs and classrooms boosts learners to grab the strings of opportunity to learn health facts and information, see options, learn about resources, and get help. [See BOX, above]

Emerging questions

As we move forward to develop the role of the ABE system working with the public health and health care systems, important questions are emerging. Some of these are:

1. When literacy and health are joined, what comes first, literacy or health?
2. Which approaches work best under what circumstances, e.g. an empowerment approach that emphasizes student leadership? A disease-specific approach that concentrates health learning on one health topic separated from regular instruction or an integrated curriculum approach?
3. In what ways do the practices of literacy teachers and programs change by being involved in health work?
4. How can we produce evidence that further documents changes in health knowledge, beliefs, and attitudes – ultimately behavior – through linking literacy and health education?
5. What influence does an inter-agency approach have on partners involved?
6. What kinds of financial, resource and program and staff development support need to be in place for effective linking of literacy and health education?

Further reading:

At the time of writing (May 2003), Marcia Drew Hohn was the Director of Northeast SABES (System for Adult Basic Education Support) in Massachusetts. She has long been a researcher, practitioner and advocate for the integration of literacy and health education and is currently Director of Public Education for The Immigrant Learning Center, Inc. in Malden, Massachusetts.

Arnold, R., Burke, B., Carl. J., D’Arcy, M. & Thomas. B (1991). Educating for change. Toronto: Between the Lines Press.

Auerbach, E. (1992). Making meaning, making change. Washington, D.C.: The Center for Applied Linguistics.

Davis, T.C., Meldrum H. Tippy, P.K.P., Weiss, B.D. & Williams, M.V. (1996, Oct. 15). How poor literacy leads to poor health care. Patient Care, 94-108.

Fingeret, H.A. (1991). Meaning, experience and literacy. Journal of Adult Basic Education 1 (1).

Freire, P. (1985). The politics of education; Culture, power, and liberation. South Hadley, MA: Bergin- Garvey.

Grosse, R.N., Auffrey, B. (1989). Literacy & health status in developing countries. Annual Review of Public Health, 10, 281-297.

Health education and adult literacy: Breast and cervical cancer curriculum. Available at www.worlded.org/us/health/lincs.

Hohn, M. (2004). Health education in Massachusetts adult basic education programs: Impacts and outcomes. Available at www.sabes.org

Hohn, M. (2002). Literacy, health and health literacy: State policy considerations. In Focus on Basics 5 (C), February 2002.

Hohn, M. (1998). Empowerment health education in adult literacy. Washington, D.C: National Institute for Literacy. Available at www.nifl.gov.