Abstract
Objective. Incorporating health content into adult education courses is promising for increasing health literacy skills among “hard-to-reach” populations. The purpose of this study was to gain previously untapped knowledge of adult education personnel (i.e., educators, staff) about the strategies and programs that would be beneficial for helping students learn about health. Method. Personnel (N = 53) from three literacy coalitions completed an online survey that assessed interest and preferences for developing a health literacy curriculum. Results. Personnel indicated general concepts such as health services and insurance as those of greatest priority. Additionally, tools designed for general use (completion of forms) were favored. Personnel preferred programs that focused on general skills over those designed to address specific health topics, χ2(1) = 11.52, p = .001. Conclusions. Adult education personnel find greatest value in health literacy programs aimed at increasing general skills rather than disease-/topic-specific content. There were several mismatches in topics noted as a “priority” and those for which personnel felt comfortable teaching. A focus on fostering general health skills will help all students—not just those with specific health concerns such as diabetes and asthma. Teaching health literacy through general skill development could make health programs exciting, engaging, and accessible for students.
Introduction
Health literacy plays a critical role in determining health decisions and outcomes. It is commonly noted that individuals who struggle with health information are less likely to engage in preventive health behaviors (Fernandez, Larson, & Zikmund-Fisher, 2016; Kobayashi & Smith, 2016; Oldach & Katz, 2014; Scott, Gazmararian, Williams, & Baker, 2002) and often have poorer health (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004). Recent research adds that delaying medical care, struggling to find a doctor, and the absence of having a regular source of care are associated with decreased health literacy skills (Levy & Janke, 2016). Estimates suggest that one third to half of U.S. adults have “low health literacy” (Kobayashi & Smith, 2016; Nielsen-Bohlman, Panzer, & Kindig, 2004), though systematic, updated national assessments are needed. This is particularly common among racial/ethnic minorities, older adults, and those with lower education and income (Kutner, Greenberg, Jin, & Paulsen, 2006; Paasche-Orlow & Wolf, 2007).
In their model of causal pathways to health literacy, Paasche-Orlow and Wolfe (2007) suggest that a patient’s health literacy is developed through numerous cognitive and social factors. While health literacy might be a product of factors such as race/ethnicity, income, and reasoning ability, the authors argue that health literacy is “subject to change over time” (Paasche-Orlow & Wolfe, 2007). While low health literacy is prevalent in the United States, it is a skill that can be improved over time. However, much of health literacy research continues to focus on assessment and measure creation (Mackert, Champlin, Su, & Guadagno, 2015) rather than on initiatives that facilitate skill development. Calls have been made to focus attention on strategies that go beyond merely assessing individuals’ health-based knowledge to improving patient outcomes (Weiss, 2015).
With this in mind, there now exists a range of programs designed to improve individuals’ health literacy. Most of these initiatives, however, have been designed, implemented, and tested in a health care context (Duren-Winfield, Onsomu, Case, Pignone, & Miller, 2015; Jibaja-Weiss et al., 2011) and/or were created to assist health care providers (Coleman, Nguyen, Garvin, Sou, & Carney, 2016; Kripalani & Weiss, 2006; Mackert, Ball, & Lopez, 2011). Though these are important initiatives, they are limited in several critical ways.
First, the design and evaluation of health literacy programs in health care contexts captures and serves only those individuals who have successfully reached and been admitted to a health care facility. A central goal of existing programs is to design more effective education materials for those patients, such as a hospital-based computer program with visuals and narration instead of text (Duren-Winfield et al., 2015). Many individuals with low health literacy, however, may not visit health care facilities due to a lack of transportation, navigation skills (Champlin, Mackert, Glowacki, & Donovan, 2016), health insurance, or the ability to complete in-patient paperwork (Donovan-Kicken et al., 2012; Yin et al., 2009). These individuals are thus often deemed “hard-to-reach” (McCaffery et al., 2016). Piloting interventions at health care facilities is a place to start, but certainly, it does not thoroughly reach those who are most at risk for the negative effects of low health literacy. Thus, considerations for “reach[ing] people beyond the traditional patient encounter” are needed (Sentell, Zhang, Davis, Baker, & Braun, 2013).
Other health literacy programs focus on training health care providers in health literacy (Coleman et al., 2016; Kripalani & Weiss, 2006; Mackert et al., 2011). For example, students in family medical residency programs report receiving training regarding the prevalence of health literacy and how it relates to health outcomes, how to communicate using plain language in oral and written discussions, and other techniques to work with patients of low health literacy such as the teach-back method (Coleman et al., 2016). Many health care teams lack health literacy leaders/champions and, as a result, have weak or nonexistent curriculum for staff, professionals, and other personnel (Coleman et al., 2016). Still, there are many other types of “health educators,” some of whom are informal information providers (Champlin et al., 2016), including community leaders, family, friends, clergy, and others. Greater efforts are needed to expand informal health educators’ ability to assist individuals who struggle with health information. Indeed, the health literacy social ecological model pinpoints opportunities for engaging patients in their health, including organization-based programs such as workforce initiatives, and community efforts such as neighborhood messaging (McCormack, Thomas, Lewis, & Rudd, 2017).
Existing health literacy programs miss tremendous opportunities to help a diverse, at-risk population. Adult education and literacy centers are an important and relatively untapped avenue that could be leveraged. In the United States, approximately 1.5 million adults enrolled in state-administered adult education courses in 2014 (National Center for Education Statistics, 2016). Adult education organizations such as the National Center for Education Statistics have led efforts to determine the U.S. prevalence of health literacy. The National Assessment of Adult Literacy was the first national initiative to incorporate health as a facet of “general” adult literacy (Kutner et al., 2006). As such, literacy centers are a viable and strategic platform for teaching health-related skills and knowledge to an at-risk audience.
Work in this area remains limited (Black, Balatti, & Falk, 2013), especially in the United States. Resources exist to help adult educators facilitate the incorporation of health-related topics into existing general education curricula (Soricone, Rudd, Santos, & Capistrant, 2007), and several health literacy programs show promising results. These programs have been implemented in adult education centers in varying ways. For example, in one study, a health literacy program, including content on illness prevention, management, and system navigation (adapted from Study Circles; Soricone et al., 2007), was administered to three groups of adult students: general education diploma (GED), English as a second language (ESL), and adult basic education (ABE). Health literacy improved as a result of the program, such that ESL and non-ESL students experienced similar increases in health literacy, but ESL students exhibited larger increases in self-efficacy for health-related behaviors than did non-ESL students (Chervin, Clift, Woods, Krause, & Lee, 2012). In another initiative, Soto Mas, Ji, Fuentes, & Tinajero (2015) combined health literacy programming with ESL coursework to produce specific content for adults with limited English speaking skills. Compared with adults in a control group, those who received the health literacy program exhibited an increased health literacy score following the intervention, with a greater number of participants moving from “inadequate” health literacy to a higher level (Soto Mas et al., 2015). Other programs are not specialized for a specific population within adult education. A recent publication by McCaffery et al. (2016) describes the design of a program consisting of an 18-week health knowledge course available to students in a basic adult “language literacy and numeracy” course at a literacy organization. This course includes language, literacy, and numeracy content tailored to health topics such as reading prescription labels and engaging in shared decision making with a health provider (McCaffery et al., 2016). In sum, efforts are needed to strengthen health literacy proSgrams as they are often impromptu, implemented as “trials,” and rarely include sustainable practices (Black et al., 2013).
One way to strengthen protocols and enhance the implementation success is to develop curricula that fit programmatic needs. Adult educators and program staff are on the ground working with students every day and understand the needs of their students and the paths for successful learning. The voices of these critical players are necessary prior to building health literacy programs for literacy centers and should be built into the development of curricula. In some cases, adult educators are interviewed after the implementation of a health literacy program to determine program success (McCaffery et al., 2016; Morony et al., 2017). No prior studies that we know of have explored the needs of adult educators and program staff who teach or assist with these courses.
This is an important gap in existing research, yet it is essential for understanding the logistics and needs when it comes to administering these programs. Comparable to other health interventions, incorporating the stakeholder perspective (in this case, the adult educators and program staff at literacy centers) by exploring the topics they believe are a priority and the materials and tools they believe are most effective would be invaluable in the creation of robust health literacy programs. Existing health literacy programs at literacy centers have not incorporated the key knowledge and experience of educators into program design.
Moreover, a noted barrier in the development of health literacy programming courses for literacy centers is the capability of personnel to teach health topics (Rudd, 2002); yet some argue that this is waning (McCaffery et al., 2016). Rudd (2002) suggests that one avenue to reduce this is to focus on the development of skills (e.g., asking questions about health) through course content, rather than specific health topics (e.g., understanding diabetes). It is currently unknown which of these perspectives, if any, adult educators find more effective and valuable for their students.
The purpose of this exploratory study was to determine the needs and preferences of literacy coalition adult educators and staff (“adult education personnel”) for teaching health-related topics to adult learners. Adult education personnel from three literacy coalitions (Coalition A, Coalition B, Coalition C; names of the coalitions blinded to further protect the identities of study participants)—each from a different major city in Texas—participated in a survey-based study. Key objectives were to understand the following:
Which health topics and skills are key priorities for the design of health lessons?
Which health topics and skills do personnel feel most/least confident in their ability to teach and what might assist them in this endeavor?
What types of materials/tools are best for helping students learn about health topics?
Which type of health literacy program—one focused on health skills or one focused on health topics—would personnel select for use at their coalition?
Method
At the present time, there is no standard curriculum used in Texas to teach students about health at adult education organizations. Personnel at each coalition assist students with health-related issues using different approaches and to varying degrees. The leadership at all the three coalitions exhibited enthusiasm for harnessing insight from their educators and staff, as well as learning from other literacy coalitions. The research team worked with a coalition team lead (a current program director at each coalition) at each of the three coalitions who provided feedback about the design of the survey. Revisions were made based on direct feedback from coalition team leads; notably, in many cases, the use of the word teach was replaced with help students learn.
An anonymous online survey was built using the survey building platform Qualtrics. The research team sent each coalition team lead a brief summary of the project and the link to the online survey. These materials were distributed at each coalition via e-mail, to adult educators, staff, and leadership, who were invited to complete the survey. A follow-up announcement was made at 2 and 4 weeks following the initiation of the project.
On opening the survey link, participants read a consent form and advanced to the next page after providing informed consent. Participants were reminded of the purpose of the study, the anonymity of their answers, and were assured that their responses would not be used to evaluate their teaching skills or force them into teaching certain classes. Participants completed items assessing their preferences about the structure and content they believed should be included in health-related programs at their coalition. All study procedures were approved by the relevant institutional review boards.
Participants were asked if they had ever heard a student ask about a health topic (yes/no), and if so, they were asked to specify the types of topics students typically asked about. Participants were then provided with a list of topics (e.g., health insurance, strategies for information seeking, etc.) and asked to indicate how much of a priority they felt each topic was for health lessons (Objective 1; 1 = not a priority, 5 = essential) and how comfortable they would feel about teaching each topic (Objective 2; 1 = poor, 5 = excellent). The list of health topics was generated from existing health literacy curricula, suggestions from coalition team leads and volunteers, prevalent health concerns in the United States, and topics included in health education textbooks (e.g., Health Stories workbook series (Gianola, 2007) and Pacemaker Health textbooks (Fearon, 2004). These concepts also echoed the factors included in the health literacy causal pathways model developed by Paasche-Orlow and Wolf (2007), for example, health care navigation skills, patient–provider communication, and problem solving. Following the list of priority health topics, participants were also asked to list any other topics that were absent in the list provided. Similarly, after indicating their ability to teach each of the listed health topics, participants were asked, “For those topics you said ‘poor’ or ‘fair,’ what might you find helpful if you were asked to lead a class on those topics—this could be teaching materials (lesson plans, etc.), books, etc.?”
In the next section, participants were asked to indicate the types of health-related materials and tools they felt “would work best to help students learn (Objective 3).” A list of materials was created from existing curricula (Morrison, 2012) and suggestions from coalition team leads and volunteers. Participants were encouraged to select any tools they felt would “help students learn about health topics.”
Next, participants were provided with descriptions of two hypothetical health literacy programs—one focused on the development of general health skills and the other focused on specific health topics. The descriptions of each are included in Table 1. Participants were asked which of the two programs they would be more likely to select for use at their coalition and to provide justification for their selection (Objective 4). Additionally, participants were asked to choose the program they believed would be “an easier way to help students learn about health.”
Descriptions of Two Hypothetical Health Literacy Programs for Implementation in Adult Literacy Centers
NOTE: These descriptions appeared verbatim in the survey.
Participants then indicated their literacy coalition affiliation, provided basic demographic information (i.e., age, gender, race/ethnicity), and completed the Brief Health Literacy Screen, a three-item measure of self-reported health literacy (Chew, Bradley, & Boyko, 2004). The three items were summed, where higher scores reflected greater health literacy (score range: 3-15). Frequency and descriptive statistics were calculated for each of the four objectives. For Objective 4, chi-square analyses were performed.
Results
Eighty-five participants opened the survey, and 53 completed a majority of the variables of interest. Of those who responded, 18.9% were from Coalition A, 45.3% from Coalition B, and 32.1% from Coalition C. Given variations in size and resources, response rate varied by coalition. Coalition A did not provide response rate information. Coalition B distributed the survey through a newsletter, which was opened by 640 people (response rate = 3.75%). Coalition C distributed the survey to a list serve, consisting of 68 people (response rate = 25%). Two participants (3.8%) did not indicate their coalition. See Table 2 for participant demographics.
Demographic Distribution, Background, and Role of Participants by Literacy Coalition
NOTE: HL = health literacy; M = mean; SD = standard deviation; ABE = adult basic education.
Notably, most participants reported hearing a student ask about/discuss a health topic while at the coalition (Coalition A = 50%, Coalition B = 71%, Coalition C = 59%). These topics ranged but included medical terminology, communicating with physicians, health care costs, feeling intimidated or confused by prescriptions or provider recommendations, and children’s health.
Objective 1 inquired about specific health topics and skills and personnel’s perceptions regarding priorities for the design of health lessons. Table 3 reflects priority scores for each of the topics. The topic of highest priority was health services and how to access health services (M = 4.21, SD = 0.79). Overall, general health topics such as health insurance (M = 4.17, SD = 1.00) and making a doctor’s appointment (M = 4.13, SD = 1.02) were rated as higher priorities than specific health issues. Indeed, asthma was the topic that was rated of lowest importance in the list provided (M = 2.92, SD = 1.09).
Scores and Rankings for Health Topics and Skills
NOTE: Objective 1 asked personnel to indicate how much of a priority it would be to include each health topic/skill into health lessons for adult education students (1 = not a priority, 5 = essential). Objective 2 then asked personnel to report their ability to help students learn about each topic/skill (1 = poor, 5 = excellent). M = mean; SD = standard deviation.
When asked to specify if there were any priority topics that were not included in the list, participants added the following: child health (including nutrition, dental, and mental), body parts in English, modeled conversations with health care professionals (and the opportunity to practice them), ways to prep for a doctor’s visit (e.g., writing down questions and knowing how to ask for something to be repeated more simply, instructions given in writing, etc.), transportation that is available to reach medical facilities and appointments, when outbreaks of diseases occur that are reported on the news (i.e., Zika, Ebola), and others.
Objective 2 sought to shed light on which health topics and skills personnel at literacy coalitions feel most/least confident teaching. Table 3 outlines these scores and rankings. Participants reported feeling most comfortable with teaching students how to make a doctor’s appointment (M = 4.040, SD = 0.92). In contrast, they felt ill equipped to teach students about health insurance (M = 2.48, SD = 0.91) and asthma (M = 2.22, SD = 0.98).
In response to the open-ended question, which asked participants to indicate solutions that would help them teach topics they might struggle with, many participants desired refresher courses, more background information, or existing lesson plans/guides to use as teaching guidelines. Additionally, participants indicated that having health-oriented lessons planned or prepared for them could facilitate helping students. The topic of health insurance was a particular concern. To curb these challenges, participants suggested receiving a primer on health insurance, and one noted that having an expert help teach the class would be helpful.
The purpose of Objective 3 was to determine which types of teaching materials or tools would be most effective in helping students learn about health topics. Frequencies are outlined in Table 4. A majority of participants (79%, n = 42) indicated that working with real-world forms would be the best tool for students. In contrast, only two participants (4%) indicated that completing math exercises would be a helpful tool for health-related concept development. Thirteen participants (25%) selected “other”—noting tools including videos, MP3s, visiting clinics/field trips, listening exercises, using an “app” (e.g., on a mobile phone), and experiential-oriented activities to assist students.
Frequencies for Effective Teaching Tools
NOTE: Objective 3 asked participants to indicate the materials and the tools they felt would work best to help students learn about health topics.
Finally, we assessed participants’ preference for a health literacy program that focused on health skills versus one focused on specific health topics (Objective 4). Results from a chi-square analysis indicated that participants preferred a program focused on health skills (n = 37) over one designed to address more specific health topics (n = 13), χ2(1) = 11.52, p = .001. Moreover, participants reported that a health literacy course that emphasizes skills (n = 32) over specific topics (n = 17) would better help students learn about health, χ2(1) = 4.59, p < .05.
Discussion
Creating and implementing health content into adult education curricula in literacy organizations is a promising avenue for increasing health literacy among hard-to-reach, at-risk patients (Chervin et al., 2012; McCaffery et al., 2016; Muscat et al., 2016; Soto Mas et al., 2015). Per the causal pathways model, health literacy should not be thought of a consistent trait but as a dynamic skill set that can change as a result of many factors, including further education (Paasche-Orlow & Wolfe, 2007).
Based on the current findings, it seems that integrating health content into adult education curricula would be a promising path for improving health literacy in the United States. Some coalitions may have a specific need for health literacy programs. In other cases, or situations where a coalition might not have time or space for programs specifically dedicated to health literacy, health content could be infused into skills-based courses such as reading and writing activities about health topics. Moreover, student learners who complete health literacy courses themselves could become mentors or teachers for the program. This would bring additional opportunities and insights to improve the curricula over time. Before advancing further, more information is needed from the perspective of those who are on the ground, teaching these courses so that feasible, effective, and approachable content can be developed. In this study, personnel at adult education centers provided thoughts on what would best serve their students. This was a fruitful endeavor, which could similarly be replicated in the design of health literacy programs including those aimed at patients and training health care providers, so that their input becomes essential to content development.
The most important finding from the current study is that personnel preferred the development of health literacy programs focused on general skills, rather than specific health topics, when the two program structures were compared. Moreover, when asked to indicate key priorities for health literacy programs, personnel chose general concepts as the top four priorities.
These findings are promising for future health initiatives in this context, where a focus on fostering general health skills will help all students, not just those with specific health concerns such as diabetes and asthma. Teaching health literacy through general skill development could make health programs exciting, engaging, and accessible for students. It is clear that Rudd’s (2002) suggestion regarding a focus on “skills” rather than “topics” are supported through the current study by opinions from personnel. One explanation for this could be that health literacy programs relying on general skill development are perhaps seen by personnel as easier to implement and more effective in helping these at-risk students. It is suggested that future research develop and test pilot programs in this area and garner direct personnel feedback in the process.
In contrast, for several topics noted as high priority, personnel indicated a lesser ability to teach these challenging concepts. To summarize, there were several “mismatches” between topics viewed as a priority and those that personnel felt confident in teaching. This finding has crucial implications for the design of future health literacy programs.
Health practitioners and educators should collaborate with literacy coalitions to co-create health literacy courses; as indicated by one participant, “if specialists had written curriculum targeting these topics particularly, it would be helpful.” Additionally, offering opportunities to meet with health practitioners such as pediatricians, nurses, emergency room staff, and others could support personnel in their creation of exercises and lessons by having their own questions answered. Those working in health care settings have unique expertise, and we suggest that by sharing this expertise through partnerships with adult education or literacy coalitions, they might benefit by improving individuals’ understanding of health information, thus leading to better health outcomes. For example, a health care provider could visit the adult education center and engage in question/answer session with students as well as discuss an average day in their clinic. Health care providers could also collaborate with adult education teachers to create content to meet the needs of students based on common issues they see among clinic patients. Those working in academic institutions could add expertise on other, broader topics related to health such as patient-provider communication and health literacy. University researchers, teachers, and students could support initiatives in curriculum development by helping design innovative exercises that fold health content into practical skills such as reading a financial statement or nutrition label. Indeed, designing health literacy activities and content could serve as an important course project for university students enrolled in health and education classes. Finally, those working for insurance companies and non-profit groups could contribute their knowledge of terminology, systems, and involvement in the community. Generating additional partnerships within the community would not only support the center itself through content development but also increase students’ access to resources they did not know were available. We see this as a mutually beneficial opportunity for future research and applied practice.
In the current study, many participants appeared willing to teach health topics (i.e., participants did not indicate in their qualitative responses that they would be opposed to teaching health topics), yet they desired a primer in specific areas—for example, health insurance. In the development of future health literacy programs for adult education audiences, it is important to not shy away from the challenging skills related to health insurance. Existing curricula do not currently incorporate lessons attributed to health insurance (Chervin et al., 2012; McCaffery et al., 2016; Soto Mas et al., 2015), despite findings from the current study suggesting that this should be a priority topic addressed at adult education centers. Personnel were willing to admit difficulties in understanding topics such as health insurance but appeared eager to help students. Forming creative community partnerships with insurance companies, local health practitioners, nonprofits, and other gatekeepers could strengthen a center’s health insurance course content. Incorporating guest speakers (one of the top tools reported for helping students learn about health) would lessen students’ intimidation through increased exposure and interaction with practitioners. For students without health insurance, health insurance counselors and volunteers at nonprofit organizations could assist with navigating the Affordable Care Act policies, terminology, and enrollment. Local community colleges could be another fruitful resource for connecting students to health insurance options while simultaneously introducing them to university offerings.
Interestingly, in the current study, only two participants suggested that completing math exercises would be a helpful tool for increasing health-based skills among adult education students. Numeracy is believed to be a critical component of health literacy (Estrada, Martin-Hryniewicz, Peek, Collins, & Byrd, 2004; Golbeck, Ahlers-Schmidt, Paschal, & Dismuke, 2005), especially when it comes to understanding risks/outcomes, dosages, and, indeed, health insurance. Future research should specifically explore the needs of educators and patients when it comes to numeracy skills designed for health.
While this study contributes important findings regarding strategy for future program development, several limitations should be discussed. First, while we explored the needs of personnel at three leading literacy coalitions in large cities, this study was limited to the coalitions surveyed. It is likely that the demographic makeup of the surveyed coalitions differs from coalitions in other states, especially those with a lower/higher Hispanic population. In Texas, many literacy coalitions combine ESL with other life skills topics including health literacy. In addition to incorporating exercises to promote understanding of health concepts/definitions in general adult education and literacy curricula, it would be beneficial for ESL courses to specifically address common health terms presented in English. Future research should further explore the combined impact of low health literacy with ESL to design an efficient health curriculum specifically for these students. This could expand on the work of Soto Mas et al. (2015) as well as take suggestions from the current study to provide content that teaches students health terminology in English. Assessments such as that conducted in the current study should be performed with ESL centers and teachers to specifically address the needs of those students. It would also be fruitful to compare the current findings with results from needs assessments conducted with students.
Finally, understanding the needs of adult education personnel contributes a perspective regarding patient health literacy outside the traditional focus on health care workers. More work is needed in other groups such as informal community and neighborhood leaders as well as in programs designed for implementation through employers (McCormack et al., 2017).
Conclusion
The development of health literacy training programs aimed at health care providers has been an ongoing area of work in the health literacy field. This project was designed to complement this line of work by focusing on how another kind of health literacy training—specifically, building health literacy into adult education programs—can build equally important skills for patients. Results from this study shed light on opportunities for the development of programs that assist learners with health content. As such, this may be applicable not just to those working in adult education centers but also to those who design health literacy programs that train health care providers as well.
These findings suggest that adult education programs may be an ideal platform for building the health literacy skills of patients. Specifically, programs should focus on helping students learn general health literacy skills, such as navigating and accessing health services, rather than narrow health topics. Moreover, learning could be facilitated by having students practice completing medical forms, such as patient information forms or informed consent, in adult education classes. Participants reported that they would be more comfortable teaching general (vs. specific) content and would require additional supports (e.g., curriculum, further training, consultation with experts) to teach particularly complicated health skills such as dealing with health insurance. Results from this study will be used to inform the development of health literacy programming to be implemented in literacy organizations.
Footnotes
Authors’ Note:
This research was supported by the National Cancer Institute at the National Institutes of Health (P30 CA016672 to University of Texas MD Anderson Cancer Center as a Cancer Center Support Grant) and the National Institute on Drug Abuse at the National Institutes of Health (K23 DA040933 to DSH).