This supplement of HLRP: Health Literacy Research and Practice seeks to affirm the relevance of adult basic education (ABE) to advancements in the health literacy field. The worlds of health literacy and ABE have much in common, as both are preoccupied with promoting self-efficacy. Yet, they have largely remained unconnected in their research, policy, and practice. This supplement aims to highlight ways in which the health literacy and ABE fields have intersected and influenced each other to the benefit of adult populations with inadequate literacy skills, including those with limited print literacy and numeracy skills, and those with limited English proficiency.
After several decades of research, we know that limited literacy skills are frequently linked to poor comprehension of health conditions and the management of health conditions, underuse of preventive health services, higher rates of hospitalizations for preventable conditions, and poor overall health (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). Fortunately, there has been a proliferation of health literacy interventions aimed at mitigating these disparities (Sheridan et al., 2011). At the same time, the unique and substantive contributions that ABE programs are making to these efforts tend to go unnoticed and underappreciated, largely because the health literacy work underway in classrooms and community settings is rarely presented in peer-reviewed journal articles or health conferences.
Together, the articles in this supplement demonstrate how health literacy collaborations with ABE help to refine our understanding of what exactly health literacy is and what is involved in learning to be “health literate.” We hope these articles open up new arenas for debate and innovation in the health literacy field.
This supplement affirms the critical importance of conceptualizing literacy as a dynamic learning process, an insight that reflects decades of robust theorizing and research in literacy education (Fingeret, 1991; Lesgold & Welch-Ross, 2012; Lytle, 1994; Sticht, 1988), that, as reflected in this supplement, has only recently begun to inform the design of health literacy interventions. By shifting attention to the conditions and approaches that support adult learners (what adult educators refer to as a pedagogical orientation), health literacy cannot be reduced to an individual trait scaled from low to high or conflated with our expectations for how well adults who have limited skills need to be able to read, write, and communicate in our health care system. For these shifts in thinking to gain traction in health literacy research and theory building, greater investment in interdisciplinary dialogue and collaboration among researchers and practitioners in health, public health, and adult education is essential.
This call for interdisciplinary coordination is hardly new, having been sounded with each wave of adult literacy populations assessments since the 1990s (e.g., National Assessment of Adult Literacy, National Adult Literacy Survey, International Adult Literacy Survey, Program for the International Assessment of Adult Competencies). Nutbeam (2000) provides a useful metaphor (“new oil into old lanterns”) for framing our understanding of what is both familiar and fresh in efforts to link adult education and improved health.
Health literacy is a concept that is both new and old. In essence it involves some repackaging of established ideas concerning the relationship between education and empowerment. Education for health directed toward interactive and critical health literacy is not new, and has formed part of social mobilization programs for many years. There are many contemporary examples of education being used as a powerful tool for social mobilization with disadvantaged groups in both developed and developing countries.
Nutbeam's (2000) observations that “education for health. . .is not new” is evident in this supplement as several articles highlight health literacy initiatives in ABE programs that have been around for many years, such as the Wisconsin Health Literacy (2003-present) (Erikson, 2019) and the Florida Health Literacy Initiative (2009-present) (Hohn et al., 2019). Hohn et al. (2019) provide a brief history of health literacy partnerships in the United States with references to several on-going partnerships. The authors emphasize that there is no inevitable trade-off between health literacy and basic skills instruction in funding and programming priorities. The authors also suggest that, through partnerships, health care and adult education are better poised to strategize a response to uncertain futures (e.g., changes to the Affordable Care Act ) and program funding. As the former director of a health literacy partnership (Literacy Coalition of Central Texas), Wagner (2019) describes her hopes to promote health literacy instruction in adult basic education, efforts that were dissolved after only 2 years due to loss in funding. Clearly, without more concerted documentation and dissemination of health literacy partnership efforts with ABE, the health literacy field risks losing valuable sources of knowledge regarding what has worked and not worked for adults with low basic skills. In response to the tremendous proliferation of technology in health care, readers should pay particular attention to the urgent call to action made by Harris, Jacobs, and Reeder (2019) in their Perspective article on supporting digital health literacy.
This article showcases the kind of scientific heft we can expect of health literacy partnerships with ABE, which takes two important forms: empirical evidence and professional wisdom.
Empirical evidence is the knowledge researchers develop through well-designed, rigorous studies. Professional wisdom is the knowledge practitioners develop as they work with students, and as they take research findings and apply them in their programs. Neither source of knowledge alone is sufficient to ensure effective policies and practice, but together they provide the best guidance available for programs
Although article categories seem to reflect empirical evidence (Original Research and Brief Report) and professional wisdom (Perspective and Best Practice), readers should avoid treating them as absolutes, or regarding articles authored by university researchers as a “better” source of evidence than knowledge garnered by a practitioner who has years of classroom practice. Readers are encouraged to reflect on a question posed David Rosen, a coauthor on the Best Practice article by Hohn et al. (2019):
There is limited research in the (adult literacy) field, even less experimental design research, and almost no gold standard experimental research…If adult education practitioners have so little research to base their decisions on, why isn't our field paying more attention to the profession wisdom side of this definition
In response, we would assert that interdisciplinary collaborations in health literacy represent a powerful vehicle by which the professional wisdom of adult educators is gaining greater attention as an important source of knowledge in the health sector, and thus compelling adult education practitioners to articulate how they think about literacy and its links to health. Adult education has its own vocabulary and assumptions regarding what questions about literacy are legitimate and the standards used to gauge the validity of literacy measures and learning outcomes. To what extent does the empirical research and professional wisdom in adult education synchronize with the ample research base on health literacy instrumentation development? Arguably for the health literacy field to stay relevant, adult education must be included in debates about the kind of scientific scrutiny, theory-building, and practical solutions that are defining the “problem” of health literacy.
For a closer look at what the integration of health literacy can look like in ABE programs, readers are directed to the research-based article by Sarkar, Salyards, and Riley (2019). This article provides a clear illustration of what adult educators refer to as “contextualized instruction,” a widely endorsed approach that aims to align instruction with the learners' everyday life, incorporating materials and tasks that simulate real-life applications of basic skills. ABE programs, in collaboration with health partners, can make a difference in the way learners engage with the local health care system. Champlin, Hoover, and Mackert (2019) focus attention on the capacity of ABE educators and staff to deliver health topics and provide instruction that supports adult learners in their role as family members.
Johnson et al. (2019) describe how adult ESL learners, as peer leader navigators, can play a productive part in the diffusion of health information from the classroom into the community. Hohn and Rivera (2019) also draw attention to the power of learner-driven diffusion in their article.
Articles also address important methodological questions about how to measure outcomes in ABE-based health literacy interventions, such as “What constitutes success”? Hohn and Rivera (2019) make the case for linking health literacy instruction in ABE/English as a Second Language classrooms to changes in individual self-efficacy and collective efficacy. McCaffery et al. (2019) document an approach to health literacy assessment in ABE settings that reflects a broad view on health literacy competence (functional, communicative, and critical). In a partner study, Muscat et al. (2019) focus on the importance of tracking changes in a learners' self-directing skills and capacity in health literacy interventions. No single health literacy measure can tell the story of growth from such programs. However, these studies show that, through interdisciplinary research with ABE partners, we are able to move toward a finer-grain set of learning goals and outcome measures that capture the complexity of health literacy learning.
Over the past few years, the field of health literacy appears to have shifted focus somewhat to promoting the attributes of health organizations that help ameliorate health literacy barriers (Brega et al., 2019). This is an important evolution in the field, but such organizational improvements need not forestall efforts to advance partnerships with ABE. The health and public health systems can be substantively involved in adult education for health. Indeed, the movement for social determinants of health is a call to action to impel health care organizations into the delivery of social services, such as housing, food, and education.
An important summary observation for this supplement is that we all need to continue innovating methods for effective adult education that are compelling, engaging, and empowering. Creativity will be important and we cannot yield to complacency. As Dr. Nutbeam has expressed enthusiastically during karaoke sessions in six continents, quoting the King of Rock and Roll with a full-throated baritone urging us to action: “Well, it's one for the money, Two for the show, Three to get ready, Now go, go, go!” For Dr. Nutbeam, his blue suede shoes are advancing the cause of health literacy as a public health vocation. What will it be for you?
- Affordable Care Act of 2010, Pub. L. No. 111–148, 124 Stat. 328 (2010).
- Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J. & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97–107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005 PMID:21768583
- Brega, A. G., Hamer, M. K., Albright, K., Brach, C., Saliba, D., Abbey, D. & Gritz, R. M. (2019). Organizational health literacy: Quality improvement measures with expert consensus. HLRP: Health Literacy Research and Practice. 3(2), e127–e146. doi:10.3928/24748307-20190503-01 [CrossRef].
- Champlin, S., Hoover, D. S. & Mackert, M. (2019). Family health in adult education: A missing piece of the health literacy puzzle. HLRP: Health Literacy Research and Practice. 3(Suppl.), S75–S78. doi:10.3928/24748307-20190624-03 [CrossRef]
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- Erikson, M., Smith, P. D. & Sparks, S. W. (2019). Best practices to advance health literacy in a Wisconsin adult literacy coalition. HLRP: Health Literacy Research and Practice. 3(Suppl.), S8–S14. doi:10.3928/24748307-20190405-01 [CrossRef]
- Fingeret, A. (1991). Meaning, experience, literacy. Adult Basic Education, 1, 4–11.
- Harris, K., Jacobs, G. & Reeder, J. (2019). Health systems and adult basic education: A critical partnership in supporting digital health literacy. HLRP: Health Literacy Research and Practice. 3(Suppl.), S33–S36. doi:10.3928/24748307-20190325-02 [CrossRef]
- Hohn, M. D., Lawrence, W., McKinney, J., Rosen, D. J., Santos, M. G., Sheppard, R. & Ziskind, A. (2019). Adult basic education: Community health partnerships and health disparities. HLRP: Health Literacy Research and Practice. 3(Suppl.), S1–S7. doi:10.3928/24748307-20181125-01 [CrossRef]
- Hohn, M. D. & Rivera, L. (2019). The impact and outcomes of integrating health literacy education into adult basic education programs in Boston. HLRP: Health Literacy Research and Practice. 3(Suppl.), S25–S32. doi:10.3928/24748307-20190325-01 [CrossRef]
- Johnson, R. M., Shepard, L., Van Den Berg, R., Ward-Waller, C., Smith, P. & Weiss, B. D. (2019). A novel approach to improve health literacy in immigrant communities. HLRP: Health Literacy Research and Practice. 3(Suppl.), S15–S24. doi:10.3928/24748307-20190408-01 [CrossRef]
- Lesgold, A. M. & Welch-Ross, M., eds. (2012). Improving adult literacy instruction: Options for practice and research. Retrieved from National Academies of Sciences Engineering Medicine website: https://www.nap.edu/read/13242/chapter/1
- Lytle, S. L. (1994). Living literacy: Rethinking adult learner assessment. Literacy Practitioner, 2(1).
- McCaffery, K. J., Morony, S., Muscat, D. M., Hayen, A., Shepherd, H. L., Dhillon, H. M., Smith, S. K. & Nutbeam, D. (2019). Evaluation of an Australian health literacy program delivered in adult education settings. HLRP: Health Literacy Research and Practice. 3(Suppl.), S42–S57. doi:10.3928/24748307-20190402-01 [CrossRef]
- Muscat, D. M., Suzanne, M., Trevena, L., Hayen, A., Shepherd, H. L., Smith, S. K. & McCaffery, K. J. (2019). Skills for shared decision-making: Evaluation of a health literacy program for consumers with lower literacy levels. HLRP: Health Literacy Research and Practice. 3(Suppl.), S58–S74. doi:10.3928/24748307-20190408-02 [CrossRef]
- Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267. https://doi.org/10.1093/heapro/15.3.259
- Rosen, D. J. (2012). Professional wisdom in 2013. Retrieved from LINCS (Literacy Information and Communication System) website: https://community.lincs.ed.gov/discussion/professional-wisdom-2013
- Sarkar, J., Salyards, A. & Riley, J. (2019). Health in the English language: A partnership with the Alaska literacy program. HLRP: Health Literacy Research and Practice. 3(Suppl.), S79–S87. doi:10.3928/24748307-20190624-02 [CrossRef]
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- Sticht, T. G. (1988). Adult literacy education. Review of Research in Education, 15, 59–96. https://doi.org/10.3102/0091732X015001059
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