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Focus On Basics

Volume 8, Issue A ::: November 2005

A Conversation with FOB

Learning How to Teach Health Literacy

The Health Literacy Study Circle+ Facilitator Guides is a new series being published by NCSALL. Each of the three guides provides all the materials and methods needed to facilitate a 15-hour study circle that introduces teachers to a skills-based approach to health literacy. Focus on Basics spoke with NCSALL’s Lisa Soricone, one of the Study Circle+’s authors; and New York City Literacy Assistance Center’s (LAC) Winston Lawrence, a staff development facilitator who piloted the guides. We talked about what a Study Circle+ is, what a skills-based approach to health literacy is, and why both are valuable to adult basic educators.

FOB: Let’s start at the beginning. What is a study circle?

Winston: A study circle is  a group of anywhere from eight to 12 people who come together to discuss and explore a particular topic of concern. Each person in the group may be given an assignment to investigate some aspect of the topic. Subjects can be anything, from sexuality, to Marx, to issues in the community. NCSALL has study circle guides on a variety of topics including learner persistence and accountability. Study circles have been conducted in many communities to discuss and understand conditions of social life. It’s a discussion-oriented structure that enables people to arrive at a better understanding of a topic or issue.

Lisa: Sometimes study circles culminate in a series of strategies and next steps that participants can pursue.

FOB: And the “+”?

Winston: While other study circles may end with the generation of ideas for further action, the Study Circle+ is designed to integrate action into the study circle experience. Teachers take the discussion from the group back to the classroom, where they conduct a needs assessment and try out new health literacy lessons. Teachers then return to the study circle and process these experiences with the group.

Lisa: The “+” notion is that you don’t just read and talk. You use the Study Circle+ discussions to guide new activities in your classroom and then build on that experience within the Study Circle+ sessions.

Winston: So the difference is the real practical outcome: the teacher tries out the lesson, returns to the study circle, and shares the results of the classroom experience.

FOB: How did you get involved in the pilot?

Winston: The Literacy Assistance Center, which provides professional development opportunities for ABE programs in New York City, was asked by the [New York City] Mayor’s office to assist in developing a framework to inform students in literacy classes about how they could access low-cost health insurance. We are not direct providers of literacy services. We had never had an initiative like this on health literacy. And we certainly couldn’t just go to programs and say “teach health insurance.” So we were interested in finding a model that enabled teachers to bring health literacy into the classroom in a structured and integrated way. We knew that teachers were not very comfortable teaching health content in the classroom. We said, “Let’s try to look for something else that would be more interesting and engaging.” We reviewed literature, we looked at who was doing what. In the course of investigating, we learned that Dr. Rima Rudd [of Harvard School of Public Health and NCSALL] was doing some work in this area and knew that we should talk with her.

FOB: You also needed programs to work with. How did you find them?

Winston: We looked at the literacy community [in New York City] and determined that this would be difficult to do across all five boroughs. It was going to be better to start with a few programs. We looked at context and neighborhoods, and also capacities of programs. As we looked for programs, we also thought that we could conduct a pilot with a couple of programs. Within that context we identified four programs. Thirteen teachers and 183 students participated in the project.

FOB: Did they see health as an issue for their learners? 

Winston: As we raised the question, they all said that this would be interesting for their students. In Sunset Park, where there’s a large Asian and Hispanic community, they agreed that it was an area of concern. The Queens Public Library, which serves the most ethnically diverse community in the city and is reported to have the largest ESOL program in the country, said that health has always been a part of their ESOL curriculum. We also met with the Mid-Manhattan Adult Learning Center, based in Harlem, where ESOL teachers noted that their students were interested in health. Many of them were interested in pursuing health careers. Carroll Gardens, in Brooklyn, saw this as an opportunity to work with its Arab-speaking women around health issues.

FOB: So there was an opportunity, and a need. What about the approach itself? How did the Study Circle+ approach differ from other staff development approaches you’ve used in the past?

Winston: We’ve done institutes, one-day workshops, and half-day workshops, but the Study Circle+ approach has some attractive elements that makes it different. First, it did not take teachers away all day. As you know, many adult education teachers teach part time, sometimes in several places. If a teacher is working at different institutions, it’s difficult for that person to be in a workshop all day: it creates a gap at the other places they work. So the three-hour sessions seemed a good way to organize staff development.

The five three-hour sessions were really spread out: starting in December and ending in February. Teachers had time to get back to the classroom and test out what they were learning.

The role of the staff developer was that of a facilitator: providing teachers with research-based articles from NCSALL and from the medical community. As teachers read data showing the connections between
low literacy and poor health outcomes, I could see them opening up and becoming excited. The model of professional development is useful and valuable.

Finally, the model gives teachers the opportunity to receive feedback from peers. In the evaluation, most of the teachers said that receiving feedback was one of the most important elements of the project. The sharing of experiences was another positive aspect of the Study Circle+ model.

FOB: What about the content?

Winston: In the first place, the issue of disparity in health and how the health system treats people seemed to us an attractive proposition, because it gets teachers focused on a social objective. The Study Circle+ provides an organized framework from the point of view of what was to be learned. It organizes health literacy into three areas: health care access and navigation, managing chronic illness, and disease prevention and screening. The framework allowed us to avoid engaging teachers in teaching health content such as cancer or diabetes.  Health is the context, but the teachers focus on teaching language and literacy skills. The ability to instruct therefore doesn’t depend on the teacher’s interest in or knowledge of health.

FOB: What were the challenges?

Winston: One challenge was how to get literacy programs to send several teachers to attend five sessions of professional development. Some programs have to pay substitute teachers while teachers are away. We were fortunate enough to have a grant to provide some monetary assistance to programs. Sometimes such funds are not available to literacy programs.

A related challenge is the time commitment required. The Study Circle+ takes 15 hours of professional development time. Many teachers who participated said they really benefited, but hoped the time could be shortened in future programs.

FOB: Doesn’t it take time to learn and implement fully a new practice?

Winston: Yes, but as you know, that time is not available in ABE programs. The monetary resources needed to do a 15-hour staff development program on one topic, important though it may be, is a real issue. What incentive do teachers or programs have to make this kind of investment?

FOB: The strength of the model is one reason to run a Study Circle+, but time is an important consideration. What else should staff development programmers consider?

Winston: When considering these particular Study Circles+, one important issue for program managers is their own philosophy and whether they see navigating the health care system as a legitimate activity in which their students should be engaged.

A second consideration is the notion that as students’ engage in contextualized learning, they are more likely to show educational gains. Teachers told us in the ESOL classes that students became quite engaged, they were asking questions, talking, discussing things. This can positively affect the NRS outcomes. [The National Reporting System is a student gain measurement system that programs must report on.] In fact, the preliminary evaluation showed that students who participated in health literacy classes showed early educational gains. Students become interested in these health issues, so they become engaged and motivated learners.

FOB: Let’s shift from the model of professional development to the concept of health literacy. What do you mean by a skills-based approach to health literacy?

Lisa: It’s an approach that focuses teachers’ attention on the reading, writing, math, and communication skills that adults need to carry out the wide range of skills needed to manage their health. It’s not a content focus. The skills are the driving force behind the lessons and the units. The health content is limited, although it can be expanded by having, for example, a medical partner or resource person come into the classroom. With this approach, the teacher focuses on the literacy, language, and math skills that students need to carry out health-related tasks.

This approach isn’t new; some teachers are already doing this kind of stuff. The Study Circles+ offer a way to make it more consistent, to encourage more teachers to do it, and to help teachers feel more confident doing this kind of work.

FOB: Why is a skills-based approach to health literacy important?

Lisa: There are four reasons. First, the degree to which individuals have the capacity to use their skills to make decisions and take action on their health is important. It may involve deciding what foods to eat, habits like smoking, making sense of health information, accessing health care, filling out forms, finding your way physically in the health center. These are demanding tasks for all of us but really hard for folks with low education levels and limited English. This approach helps reduce disparities in the health outcomes of people such as our ABE students.

A second reason for using a skills-based approach to health literacy, if you’re interested in health literacy, is that when teachers approach health education via content, they’re likely to feel limited. They’re not health educators, and some topics, such as cancer, are touchy areas. Teachers are comfortable teaching basic skills, however, and that’s the emphasis with this approach.

This leads to the third reason: by approaching health literacy via basic skills, it doesn’t increase demands on teachers. Instead, it fits with their goals of building basic skills.

The fourth reason is transferability. The skills we’re talking about with health literacy are also transferable to other contexts: advocating for yourself, asking questions for clarification, reading charts and tables for information, understanding instructions, and finding your way around a new environment. These are skills that people need at work, as parents, and members of their communities.

FOB: What does it involve for teachers?

Lisa: The first step is to understand the connections between health- related activities and the reading, writing, math, and communication skills that teachers already work on in their ABE and ESOL classes. Teachers may already have some sense of such connections, such as in making a doctor’s appointment, filling out forms, or reading labels, but there are many more links between health tasks and ABE/ESOL instruction. The Study Circle+ Series is designed to provide teachers with structured opportunities to explore these links with specific emphasis on the areas of health care access and navigation, chronic disease management, and disease prevention and screening. These are the three areas the health field has identified as critical for the populations served by ABE and ESOL programs.

Teachers can also continue teaching skills as they currently do but weave in examples related to health contexts. For example, GED teachers who work on reading tables and charts might use examples that relate to health, such as a health insurance eligibility table or body mass index chart.

Winston: As the teachers participated in the project and saw the connections, they became much more enthused and committed to working with students on it. It seemed to renew their commitment to helping students navigate and access the health system.

As part of the study circle, teachers ascertain students’ needs. That’s another important area. The curriculum, in a way, is governed by students’ needs. If the dominant concern in one community is asthma, learning activities can be designed to address that. Somewhere else teachers might focus on obesity. Teachers would then build language and literacy skills on the tasks students need to address these relevant issues. The framework allows for students to inform the process. Ultimately, one of the objectives is that students can advocate for themselves and their families. When they become aware of the issues in their community, they can advocate around those issues.

FOB: Study Circle+ encourages practitioners to partner with local health care providers. What should they be doing together? Why?

Winston: At the LAC, when we looked at the model, we thought that if we were going to support teachers they would need a connection with a health care agency to provide access to health facilities and personnel. They need to take students to see the physical layout of health centers and hospitals. Many students have had a bad experience at hospital. It might have been traumatic situation and students might have had some incidental learning in the process. By seeing the system firsthand, students can engage in some deliberate learning.

Another reason to create these partnerships is that while teachers are focusing on language and literacy skills, sometimes students may say, “I need to know more on this topic.” We don’t want the teacher to be saddled with the responsibility [of being the content expert]. Through the program manager, someone from the hospital will visit the class and do a presentation on the topic in question. The partnering is necessary so that health staff are not being asked on an ad hoc basis but through a continuing, dynamic relationship. We’re expecting that the literacy site can be seen as a laboratory for the health agency since the students in the literacy site are probably representative of the patients in that neighborhood. As the health provider talks to the students, he or she gains knowledge that can be taken back to the hospital setting. This includes insights into issues that affect this population and about the barriers put up by the health system. A mutual education process occurs.

In Harlem, students were invited to the Harlem Hospital, where they met with staff from various departments including Maternity and Emergency. The director of the Emergency Department, who had worked all night, was present the next morning to give students a tour of the department. The students seemed so appreciative of that, and of hearing the explanations of what goes on. In presentations in their classrooms, they were able to tell their fellow students what they saw and share their changed views of the hospital. That’s what you get in a strong partnership: a feeling of commitment on the part of the health sector to help the students know the system.

Another advantage of partnering is that when a major public health issue gets introduced, you already have this relationship to build on, allowing the health and education sectors to work together. This helps to build community capacity, with the two agencies working together and strengthening each other.

To download the Study Circle+ Facilitator Guides, go to http://www.ncsall.net/index.php?id=891

About the Participants

Lisa Soricone is a research associate and former fellow at NCSALL. She has taught adult basic education and English for speakers of other languages and did doctoral research on the labor market outcomes of Spanish GED recipients. Her current work focuses on evidence-based practice in adult education and the development of the Study Circle+ Series.

Winston Lawrence is a senior professional development associate with the Literacy Assistance Center (LAC) in New York City. He is responsible for implementing the LAC’s Health Literacy Initiative. Winston has taught with the Department of Education, City Univeristy of New York, and in community-based organizations in New York City. He has a doctorate in adult education from Northern Illinois University.

Updated 7/27/07 :: Copyright © 2005 NCSALL