Lilian,
THANK YOU! How generous of you to share this with all of us! I am wondering if others on this list see health literacy as a social justice issue. If yes, do you have any thoughts that you would like to share?
I am particularly taken by Lilian's statement:
"As adult educators we express concern for the poor and underprivileged among us and many of us espouse a belief in social action; this is an arena where I believe our critical engagement is warranted."
Any thoughts on this?
Daphne

>>> "Lilian H. Hill" <lilian.hill at usm.edu> 06/05/07 3:16 PM >>>

Daphne Greenberg has asked me to share from my article in the Health Literacy issue of Adult Learning that is entitled 'Health Literacy is a Social Justice Issue that Affects Us All." This is excerpted from a published article and the citation is below::
  Hill, L. H. (2007). Health literacy is a social justice issue that affects us all. Theme editors' article for special issue on Health Literacy. Adult Learning, 15(1/2), 4-6.

Health literacy is often defined as the ability to read, understand, and act on health care information. It entails the ability to perform basic reading and numeric tasks in the health care context including comprehending prescription labels, appointment slips, insurance forms, and other health-related information distributed to patients (Andrus & Roth, 2002; Kirsch, Jungleblut, Jenkins, & Kolstad, 1993; Schillinger et al., 2003). Zarcadoolas, Pleasant, & Greer (2005) propose an expanded model of health literacy in which the concept refers to a "wide range of skills, and competencies that people develop to seek out, comprehend, evaluate and use health information and concepts to make informed choices, reduce health risks, and increase quality of life" (p. 196).  

Patients with low health literacy have difficulty with written and oral health communications that can limit their understanding and retention of the information provided to them (Davis et al., 2002; Williams et al., 1995). Patients with low literacy have more difficulty naming their medications and may hold health beliefs that can interfere with taking them correctly (Schillinger et al., 2003). Low health literacy can impair communication about the risks and benefits of treatment options (Davis et al., 2002) which is especially critical in the management of chronic diseases because patients "typically must cope with complex treatment regimens, manage visits to multiple clinicians, monitor themselves for changes in health status, and initiate positive health behaviors" (Schillinger et al., 2003, p. 84).  As our population ages, chronic diseases such as hypertension, diabetes, osteoporosis, and heart disease are becoming more prevalent.

There are several problems with definitions of health literacy that are found within the medical literature (Greenberg, 2001; Cuban, 2005). They tend to ignore cultural differences as well as health beliefs and practices that are rooted in culture. Definitions of health literacy often do not address the "receptive and oral communication skills that are necessary to navigate the health environment" (Greenberg, 2001; p. 70) which may lead to a patient not knowing what information is important to share with a physician or understanding how to adhere to medical instructions which are based on assumptions patients may not share. The needs of English Language Learners are often not recognized by medical professionals. Nor are the difficulties addressed that many patients have with medical vocabulary, no matter their education level. Patients are often reluctant to reveal their low literacy to medical providers, and few health professionals have received training in how to detect potential literacy problems. The patient education literature has historically placed the onus for understanding on patients rather than perceiving health communications as a shared responsibility; this is beginning to change. Nevertheless, patient education efforts often rely on a deficit model in which low functional health literacy is "equated with limited compliance with the heath care system, with treatment plans, and minimal lifestyle change (Cuban, 2005, p. 104). Patients are expected to learn topics and behaviors that are provider-defined rather than heath care professionals, whose time is often constrained by health insurers, taking the time to find out what patients need to know (Greenburg, 2001; Wise & Owens, 2004).  

Patients are increasingly being asked to take more responsibility for self-care in a complex health care system, and this can be a challenging prospect for even the most educated. Patient education materials are an important method of healthcare communications about medical treatment and health behaviors, but their value depends on how accessible and useful patients find them to be. Information can play an important role in fostering patients' self-care behaviors (Wilson, Baker & Brown-Syed, 2000), yet many health-related materials are written well above the average reading ability of many adults (Clerehan, Buchbinder & Moodie, 2005; Estey, Musseau & Keehn, 1991; Schillinger et al., 2003; Stephens, 1992) and contain vocabulary that renders them unapproachable for many patients. Patients' use of the health information provided to them is greatly influenced by its readability and cultural sensitivity. Rather than responsibility being taken by the health care system to clearly communicate about health issues, the burden falls on patients to interpret and act on health information that is encumbered with unfamiliar vocabulary and instructions. 

While health literacy has become an issue of concern increasingly discussed in the health professions, this is also an issue of importance for adult educators. The Virginia Adult Education Health Literacy Toolkit notes that educational endeavors for a number of adults come to a premature end due to untreated health problems because the individuals lacked knowledge of how to negotiate the complex healthcare system (Singleton, 2003). In addition to the definitions of health literacy above, the toolkit adds dimensions of understanding one's own health beliefs and practices, and the ability to make personal choices about health care options. Health literacy is an issue where I believe adult educators need to be involved because it is an issue of social justice. It is also important for us to become involved because the medical model will tend to take a deficiency approach rather than recognizing and building on the knowledge and experience that adults bring to learning and their lives. Health changes and crises are a part of being an adult and often provoke learning needs in order for the person to cope with the medical condition itself as well as with the changes in life and social conditions that a major diagnosis can cause. The highly educated will usually find their way to the knowledge they need and have the skills to navigate the healthcare system to get the answers they want. However, the health outcomes for others may be very different. As adult educators we express concern for the poor and underprivileged among us and many of us espouse a belief in social action; this is an arena where I believe our critical engagement is warranted.  

This issue of Adult Learning addresses the topic of health literacy from a number of perspectives: adult and community education and public health. Rima E. Rudd of the Harvard School of Public Health describes a collaborative approach between public health and adult education in which the health literacy team began by examining the daily health decisions adults make. Allan Quigley and Doris Gillis of St. Francis Xavier University have written companion articles. By recounting 200 years of history of literacy education, Quigley sets the stage for Gillis' article about a participatory action research health literacy study in which critical decisions were made to work in partnership with the community rather than proceed from assumptions about the community's needs. As the only Spanish speaking bilingual member of a medical missionary team, Nancy Faux describes the creation of a tool she designed to help physicians communicate medication information to patients in Bolivia who were Spanish speaking. Faux could not be available for every consultation so she designed a pictorial tool that contained pictograms for how much medication was to be taken, whether it should be taken with or without meals, when to take the medication, for how long, and what the medication was intended to treat. Using pictures can provide an alternate strategy for communicating medical information to low literate patients, however, the topic is more complex than it first appears. Ros Dowse tackles this complexity in the context of South Africa where a majority of the consultations between physicians are cross-cultural because there are 11 official languages and 8 different African ethnic groups, each with its own culture, language and customs. Pictures are not interpreted in the same way by all cultural groups, and health beliefs and practices also differ culturally. People designing visuals need to learn about the living conditions and health habits of the population they wish to reach and to work collaboratively with them. Finally, Sandy Diehl addresses teaching health literacy in the ESL classroom, but she also makes the point that health literacy is an issue that affects many people and is not restricted to ABE, ESL, or adult literacy classes. 

Clearly, health literacy is an area in which there is a lot to learn, and it can be approached from a number of perspectives. Given the complexity of health information this issue affects us all, rather than just a segment of the population, and involves adult learning and decisions about health practices, health information, and health options. The articles presented in this issue address the need for an approach in which the people's knowledge and life experience should be taken into account, and materials developed need to be written in clear language and be culturally appropriate. Any materials must also be tested with their intended audiences. Above all, a deficiency approach with an emphasis on patient compliance should be avoided. People should be treated with respect and their knowledge and life experiences taken into account. It is matter of social justices, and in more instances than we know, a matter of life and death. 

References 

 Andrus, M. R., & Roth, M. T. (2002). Health literacy: A review. Pharmacotherapy, 22(3), 282-302.

Baker, D. W., Parker, R. M., Williams, M. V., Pitkin, K., Parikh, N. S., Coates, W., & Imara, M. (1996). The health care experience of patients with low literacy. Archives of Family Medicine, 5(6), 329-334.

Clerehan, R., Buchbinder, R., & Moodie, J. (2005). A linguistic framework for assessing the quality of written patient information: Its use in assessing methotrexate information for rheumatoid arthritis. Health Education Research, 20(3), 334-344.

Cuban, S. (2005). A critique of the transmission model of functional health literacy. In R. J. Hill, & Kiely, R. (Eds.), Proceedings of the Adult Education Research Conference 2005. Athens GA: University of Georgia. 

Davis, T. C., Williams, M. V., Marin, E, Parker, R. M., & Glass, J. (2002). Health literacy and cancer communication. CA: A Cancer Journal for Clinicians, 52(3), 134-149.

Estey, A., Musseau, A., & Keehn, L. (1994). Comprehension levels of patients reading health information. Patient Education and Counseling, 24(1), 73-78.

Greenberg, D. (2001).  A critical look at health literacy. Adult Basic Education, 11(2), 67-79.

Kirsch, I., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993, 2002). Adult literacy in America: A first look at the findings of the National Adult Literacy Survey (3rd ed.). Vol. 201. Washington, DC: National Center for Education, US Department of Education.

Kutner, M., Greenberg, E., & Baer. J. (2005). A first look at the literacy of America's adults in the 21st century. Retrieved February 13, 2006, from http://nces.ed.gov/NAAL/PDF/2006470.PDF 

Raising the score: Promoting adult literacy in Canada. Retrieved March 10, 2006, from http://www.ccl-cca.ca/english/resources/lessons/280905.asp 

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B.  (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90.

Singleton, K. (2003). Virginia adult education health literacy toolkit. Retrieved February 16, 2006 from http://www.aelweb.vcu.edu/publications/healthlit/sections/toolkit.pdf

Stephens, S. T. (1992). Patient education materials: Are they readable? Oncology Nursing Forum, 19(1), 83-85.

Williams MV, Parker RM, Baker DW, Parikh, N. S., Pitkin, K. Coates, W. C., & Nurss, J. R. (1995). Inadequate functional health literacy among patients at two public hospitals. Journal of the American Medical Association, 274(21), 1677-1682.

Wilson, F. L., Baker, L. M., & Brown-Syed, C. (2000). An analysis of the reading level and cultural sensitivity of information on the National Cancer Institute's Web site: CancerNet. Oncology Nursing Forum, 27(9), 1403-1409.

Wise, M., & Owens, B. (2004). At the margins of the research enterprise: Learning from an interdisciplinary ehealth research program. In M. Wise & M. Glowacki-Dudka (Eds.). Embracing and enhancing the margins of adult education. New Directions for Adult and Continuing Education, No. 104. San Francisco: Jossey Bass. 

Zarcadoolas, C., Pleasant, A., & Greer, D. S. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20(2), 95-203





Lilian H. Hill, Ph.D.
Assistant Professor of Adult Education
Education Leadership and Research
College of Education and Psychology
University of Southern Mississippi
#5027, 118 College Drive
Hattiesburg MS 39406
601-266-4622
FAX 601-266-5141
----- Original Message ----- 
From: "Greenberg, Elizabeth" <EGreenberg at air.org>
To: "The Poverty, Race,Women and Literacy Discussion List" <povertyracewomen at nifl.gov>
Sent: Monday, June 04, 2007 2:49 PM
Subject: [PovertyRaceWomen 778] NAAL Discussion



>I want to thank everyone who participated in last week's discussion

> about the National Assessment of Adult Literacy (NAAL).  Your comments

> provided those of us who work on the project with much to think about.

> 

> If you have any additional questions about NAAL in the future, please

> feel free to contact me directly.  My e-mail address is

> egreenberg at air.org. If I can't answer your question, I'll try to

> identify someone who can.

> 

> _________________

> Elizabeth Greenberg

> American Institutes for Research

> (202) 403-5359 

> ----------------------------------------------------

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