Why Healthy Communities Need Adult Basic Skills Education April 2017
Open Door Collective The Open Door Collective (ODC) http://opendoorcollective.org is dedicated to reshaping U.S. society to have dramatically less poverty and economic inequality and more civic engagement and participation in all our society has to offer. ODC is made up of professionals working in adult basic skills, social services and poverty reduction, who believe that adult basic skills and lifelong learning programs can open doors of opportunity to healthier, more prosperous and more satisfying lives. ODC members have expertise in connecting adult basic skills to healthcare, employment and training, corrections and family and social services. We advocate including adult basic skills, including English language, basic literacy, numeracy, high school equivalency, college readiness and technology skills as an integral part of a larger agenda of reducing poverty and income inequality, broadening social participation, and moving us closer to the kind of society in which we all want to live.
Adult Basic Education Programs (ABE) State and federally funded adult basic education programs and adult schools in the United States comprise what is often referred to as the Adult Basic Education (ABE) system. The ABE system’s focus is basic skills for adults who have not completed high school, who have limited English Language Skills, and who are at least sixteen years old. Each year, about 1.8 million adults participate in programs funded by federal and state government under Title II, Adult and Family Literacy, of the Workforce Innovation and Opportunity Act (WIOA).[i] WIOA focuses primarily on adult learners who are ready to join programs that lead to a career pathway.
The Role of Adult Basic Education in Addressing Key Health Issues Low literacy and numeracy are associated with a reduced use of healthcare services and poor health outcomes in chronic, emergent and preventive disease care.[ii] These basic skills are social determinants of health, a category of factors influencing health that is increasingly recognized as directly relevant to patients’ clinical care.[iii] These factors influence health through the life course and are associated with mortality.[iv] Studies of informed consent, emergency department discharge instructions, cervical cancer screening, heart health knowledge and mammography use demonstrate a significant association between lower literacy and numeracy, extremely limited health knowledge, and limited use of healthcare services.[v] Adults with low literacy and numeracy are also less able to manage chronic health conditions due to their lack of understanding self-management requirements.[vi] Adults with low literacy skills are less likely to seek health information and more likely to miscommunicate with their health providers.[vii]
The ABE system works with adults to build language, reading, writing, math, and technology skills; these are needed for accessing and understanding written and oral health information and instructions. For example, increases in reading skills lead to increases in oral vocabulary, which allows adults to comprehend complex oral and written communications.[viii] Improving basic skills should reduce the cost, and increase the quality and effectiveness, of healthcare services to low-income populations.[ix]
The Relationship Between Key Health Issues and Poverty Reduction Research and practice within the fields of public health and healthcare have identified a number of critical connections between poverty and health. Nearly all of the priority health measures included in Healthy People 2020, the nation’s 10-year agenda for improving the health of all Americans, vary by income, with the poor experiencing the worst health outcomes. For instance, adults in the lowest income decile in the United States have a life expectancy nearly five years less than adults in the highest decile, and this disparity has increased since 1980.[x] Income inequality causes worse health outcomes for all members of society, whether rich or poor. A recent epidemiological review concludes that “reducing income inequality will improve population health and well-being”.[xi]
Furthermore, the relationship between poverty and health is bi-directional; living in poverty is associated with poor health, and poor health can exacerbate individual- and population-level poverty due to limited employment opportunities, job loss, and high medical costs.[xii] This cycle of poverty and poor health is perpetuated throughout the life course and across generations.[xiii] The negative effects of poverty begin even before birth, with maternal income and neighborhood deprivation contributing to adverse birth outcomes and child developmental outcomes.[xiv]
To address these health disparities, the US needs innovative social and economic policies that prioritize promoting health equity. In an analysis of estimated deaths attributable to social factors in the United States, 245,000 excess deaths were attributable to low education, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty.[xv] Policies that synergistically address education, income and inequality could, therefore, save more than 500,000 lives per year. There is a profound opportunity to achieve population health and health equity gains by investing in preventive interventions such as education-promoting and poverty-alleviating programs.
Why Health Advocacy and Health Promotion Organizations Should Advocate for Adult Basic Education Each year, over 1.8 million adults lacking basic skills and/or Limited English Proficient adults participate in programs supported by the ABE system.[xvi] This is a population that is underserved in the healthcare system. Health advocacy, promotion and direct care organizations need informed health consumers who can understand prevention and early detection messages and medical instructions, and who have enhanced capacity for patient-centered care. ABE program learners develop the reading, writing, speaking, math, and technology skills needed to comprehend and benefit from health information and services. Many adult learners have an urgent need for improved access to health information and services, but unfortunately health-contextualized basic skills learning is not currently part of federal or most states’ legislation, funding, or program implementation.
One solution might be found in partnerships between the federally qualified Community HealthCenter (CHC) and ABE systems. The CHC system is the designated provider of primary and preventive care for low-literate, low income, and underserved populations, and of increasing importance under the Affordable Care Act. The ABE and CHC systems have overlapping and intertwined responsibilities for the same population, and partnerships would have great mutually beneficial potential. ABE programs provide access to hard-to-reach adults, experience in teaching them, a sustained teaching environment, and the knowledge of how to integrate health content into basic skills development, a practice known to support motivation and engagement for many adult learners.[xvii] CHCs provide access to a broad range of health services, medical expertise, and connection to other health services. Prevention and screening services could be provided at ABE programs, and CHC representatives could regularly talk with adult learners at the ABE programs about important topics as such healthy eating, smoking cessation, and access to preventive care services. Working together, the ABE and CHC systems can provide ABE learners opportunities to improve their health and gain the literacy skills they need to be productive workers, parents and community members. Improved health and improved skills lead to better jobs and better income, thereby reducing poverty. Policy and funding that supports ABE/CHC partnerships could increase the effectiveness of health care services to low literacy populations with strong potential to reduce delivery costs. The ACA expects Americans to understand and choose between available insurance options in terms of costs and benefits and to manage their healthcare accounts more generally. Improved basic skills are essential to doing this.
Conclusion Low funding for adult basic skills education has discouraged thoughtful interchange between the adult education and healthcare fields about the role of adult basic skills educators in the health equity movement. This under-funding has consequences for the healthcare system, as an increasing number of lower-skilled adults and English language learners are not able to get the knowledge and skills they need to manage their own or their family’s healthcare needs. This in turn may result in having to use costly emergency and safety net health services, and may contribute to high healthcare costs. Increased investment in the ABE system will signal an important shift in the way we address mitigating health disparities tied to U.S. health literacy and poverty. This investment will expand the number of education and training opportunities for adults in poverty, increase the roles of adult basic education students in health leadership, and scale up successful models, with the ultimate goal of improving lower-skilled adults’ access to and engagement with the healthcare system. The healthcare cost savings of better skills could easily offset the additional funds needed to improve patients’ basic skills through innovating and expanding health-focused basic skills programs.
Adult basic skills education and healthcare fields are both concerned with people’s engagement with information; however, for the most part, the professional knowledge base in these fields has been treated as separate, unrelated domains of practice. Greater collaboration between the adult basic education and healthcare fields has the power to achieve the overlapping aims of reducing entrenched health disparities and enabling adult learners to acquire the essential literacy skills they need to care for themselves and their families.
Including adult basic skills practitioners in discussions of healthcare and public health at local, regional and national levels is an important action step to reduce health disparities. By drawing on adult educators’ adult learning and literacy development expertise, clinical research and practice will be able to move beyond narrow conceptions of literacy and learning in the healthcare context. By listening to adult learners and including learner leaders in the design of health interventions, both fields will better understand how to harness the health literacy skills already at work in the lives of adult learners, providing an important counterweight to the prevailing focus on the struggles of low-skilled adults.[xviii] Only by recognizing the interdependence of these two systems in tackling health disparities, securing funding to support health literacy in the ABE system and to sustain an active research and development agenda, can we be effective in our efforts to improve the health outcomes for a large low-income population of U.S. adults.
The authors of this paper are Ian Bennett, MD, PhD, University of Washington Seattle; Iris Feinberg, PhD, Georgia State University; Marcia Hohn, EdD, Independent Consultant; Ellen Kersten, PhD, University of California San Francisco; David J. Rosen, EdD, Independent Consultant; and Maricel G. Santos, EdD, San Francisco State University.
[i] Programs that are funded by private, local, and state funding and those that benefit from the teaching services of volunteers serve an additional 250,000 adults. An unknown number of adults are served through programs funded by charitable and corporate foundations and donations.
[ii] Nancy D. Berkman et al., “Low Health Literacy and Health Outcomes: An Updated Systematic Review,” Annals of Internal Medicine 155, no. 2 (July 19, 2011): 97–107, doi:10.7326/0003-4819-155-2-201107190-00005; Michael K. Paasche-Orlow and Michael S. Wolf, “The Causal Pathways Linking Health Literacy to Health Outcomes,” American Journal of Health Behavior 31 Suppl 1 (October 2007): S19–26, doi:10.5555/ajhb.2007.31.supp.S19; Barry D. Weiss et al., “Quick Assessment of Literacy in Primary Care: The Newest Vital Sign,” Annals of Family Medicine 3, no. 6 (December 2005): 514–22, doi:10.1370/afm.405.
[iii] American Academy of Pediatrics Council on Community Pediatrics, “Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health,” Pediatrics 131 (2012): 623–28.
[iv] David W. Baker et al., “Health Literacy and Mortality among Elderly Persons,” Archives of Internal Medicine 167, no. 14 (July 23, 2007): 1503–9, doi:10.1001/archinte.167.14.1503.
[v] David Baker, “The Associations between Health Literacy and Health Outcomes: Self Reported Health, Hospitalization, and Mortality.,” Surgeon General’s Workshop on Improving Health Literacy (Bethesda, MA: National Institutes of Health, n.d.); Berkman et al., “Low Health Literacy and Health Outcomes”; Anita Peerson and Margo Saunders, “Health Literacy Revisited: What Do We Mean and Why Does It Matter?,” Health Promotion International 24, no. 3 (September 2009): 285–96, doi:10.1093/heapro/dap014; Usha Sambamoorthi and Donna D. McAlpine, “Racial, Ethnic, Socioeconomic, and Access Disparities in the Use of Preventive Services among Women,” Preventive Medicine 37, no. 5 (November 2003): 475–84; Christian von Wagner et al., “Health Literacy and Health Actions: A Review and a Framework from Health Psychology,” Health Education & Behavior: The Official Publication of the Society for Public Health Education 36, no. 5 (October 2009): 860–77, doi:10.1177/1090198108322819.
[vi] Berkman et al., “Low Health Literacy and Health Outcomes”; “Health Literacy: A Prescription to End Confusion” (Washington, DC: National Academies Press: Institute of Medicine of the National Academies (IOM), 2004), www.iom.edu/project.asp?id=3827; Mark Kutner et al., “The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy” (Washington, DC: National Center for Education Statistics, 2006); Laurie T. Martin et al., “Developing Predictive Models of Health Literacy,” Journal of General Internal Medicine 24, no. 11 (November 2009): 1211–16, doi:10.1007/s11606-009-1105-7; Kristine Sørensen et al., “Health Literacy and Public Health: A Systematic Review and Integration of Definitions and Models,” BMC Public Health 12 (2012): 80, doi:10.1186/1471-2458-12-80; Weiss et al., “Quick Assessment of Literacy in Primary Care.”
[vii] C. Aguilera, W. Dailey, and M. Perez, “Aging and Health Education: Partners for Learning,” in Cultural Competence in Health Education and Health Promotion, ed. M.A. Perez and R.R. Luquis (San Francisco: Jossey-Bass, n.d.), 201–12; Ian M. Bennett et al., “The Contribution of Health Literacy to Disparities in Self-Rated Health Status and Preventive Health Behaviors in Older Adults,” Annals of Family Medicine 7, no. 3 (June 2009): 204–11, doi:10.1370/afm.940; Elizabeth Manafò and Sharon Wong, “Promoting eHealth Literacy in Older Adults: Key Informant Perspectives,” Canadian Journal of Dietetic Practice and Research: A Publication of Dietitians of Canada, 74, no. 1 (2013): 37–41, doi:10.3148/74.1.2013.37; Alexa T. McCray, “Promoting Health Literacy,” Journal of the American Medical Informatics Association: JAMIA 12, no. 2 (April 2005): 152–63, doi:10.1197/jamia.M1687.
[viii] Robert A. LeVine, Literacy and Mothering: How Women’s Schooling Changes the Lives of the World’s Children (London: Oxford University Press, 2012).
[ix] Regina M. Benjamin, “Medication Adherence: Helping Patients Take Their Medicines as Directed,” Public Health Reports (Washington, D.C.: 1974) 127, no. 1 (February 2012): 2–3; N. Egbert and K. Nanna, “Health Literacy: Challenges and Strategies,” OJIN: The Online Journal of Issues in Nursing 14, no. 3 (September 30, 2009); Paasche-Orlow and Wolf, “The Causal Pathways Linking Health Literacy to Health Outcomes”; Weiss et al., “Quick Assessment of Literacy in Primary Care.”
[x] Gopal K. Singh and Mohammad Siahpush, “Widening Socioeconomic Inequalities in US Life Expectancy, 1980-2000,” International Journal of Epidemiology 35, no. 4 (August 2006): 969–79, doi:10.1093/ije/dyl083.
[xi] Kate E. Pickett and Richard G. Wilkinson, “Income Inequality and Health: A Causal Review,” Social Science & Medicine (1982) 128 (March 2015): 316–26, doi:10.1016/j.socscimed.2014.12.031.
[xii] Peter Muennig, “Health Selection vs. Causation in the Income Gradient: What Can We Learn from Graphical Trends?,” Journal of Health Care for the Poor and Underserved 19, no. 2 (May 2008): 574–79, doi:10.1353/hpu.0.0018.
[xiii] Hirokazu Yoshikawa, J. Lawrence Aber, and William R. Beardslee, “The Effects of Poverty on the Mental, Emotional, and Behavioral Health of Children and Youth: Implications for Prevention,” The American Psychologist 67, no. 4 (June 2012): 272–84, doi:10.1037/a0028015.
[xiv] Anna Aizer and Janet Currie, “The Intergenerational Transmission of Inequality: Maternal Disadvantage and Health at Birth,” Science (New York, N.Y.) 344, no. 6186 (May 23, 2014): 856–61, doi:10.1126/science.1251872.
[xv] Sandro Galea et al., “Estimated Deaths Attributable to Social Factors in the United States,” American Journal of Public Health 101, no. 8 (August 2011): 1456–65, doi:10.2105/AJPH.2010.300086.
[xvi] US Department of Education, Office of Career, Technical, and Adult Education, “Adult Education -- Basic Grants to States,” Program Home Page, (March 26, 2014), http://www2.ed.gov/programs/adultedbasic/index.html?exp=0.
[xvii] Marcia Hohn, Empowerment Health Education in Adult Literacy: A Guide for Public Health and Adult Literacy Practitioners, Policy Makers, and Funders (Washington, DC: National Institute for Literacy, 1998).