Adult Basic Education and Community Health Center Partnerships

Adult Basic Education and Community Health Center Partnerships

Adult Basic Education and Community Health Center Partnerships
Improving the Health of ABE Learners
An Open Door Collective Background Paper for ABE Teachers and Directors

 March, 2017
The Open Door Collective is dedicated to reshaping U.S. society to have dramatically less poverty and economic inequality and more civic engagement.  Members have expertise in connecting adult basic skills to health care, employment and training, corrections, and family and social services.  We advocate including adult basic skills as 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. 
This is the second of two papers addressing adult basic skills and community health. The audience for the first one, Why Healthy Communities Need Adult Basic Skills Education, is community health public policy advocates. The audience for this paper is Adult Basic Education (ABE) managers and teachers, including those in ESL/ESOL, basic literacy, adult secondary education/HSE preparation, and transition to post-secondary education programs.  The term ABE used in this paper refers to all of these instructional areas.
Focus of This Paper
This paper lays out the research that links low literacy/limited English with poor health, and introduces how ABE and health care organizations have begun addressing the resulting health disparities over the last two decades.  It also introduces the impact of integrating health in ABE for learners and, in the appendix covers the wealth of curricula and materials that support contextualizing ABE instruction in health.  The benefits of emerging partnerships between ABE programs and Community Health Centers are discussed as well as robust examples of four such partnerships. These partnerships are especially timely in early 2017 as U.S. policymakers debate the future of the Affordable Care Act that directly affects large numbers of ABE learners, particularly those living in poverty, with limited education, or limited English proficiency.
Low Literacy and Poor Health are Directly Linked
In the early 1990s, research began emerging that established a direct connection between low literacy and poor health.  The term health literacy was introduced to define the array of skills needed to obtain, process and understand basic health information to take care of one’s health. Berkman et al. synthesized the research and found that low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. In addition, the research found that poor health literacy partially explains racial disparities.[i] This emerging research was coupled with literacy assessments in 2003 and 2011 that uncovered alarming rates of low literacy in the U.S, finding that the low literate population simply did not have the health literacy skills to navigate an ever-changing health care system.[ii]
History of ABE and Health Care Efforts to Address Literacy and Health Issues
ABE and health care organization practitioners began meeting to address this national social justice issue, culminating in the 2010 Health and Human Services “National Action Plan to Improve Health Literacy” and “Healthy People 2020”, which emphasizes integrated systems to improve health literacy.[iii] The ABE field began its own programming to integrate health literacy education into their ABE curricula and classrooms. Research studies about the impact and outcomes of integrating health found that ABE is a good place to learn about health, and is particularly effective when programs collaborate with local health services. Learners have been highly receptive to learning about health in ABE classrooms.[iv]
The Impact of Health Literacy Integration on ABE Learners 
Long before health literacy became a field in its own right, adult educators had been teaching adults to read, write, communicate, and do math, customizing these skills to address the learners’ real-life needs and purposes. Across program contexts, learners frequently identify health information, communication with healthcare providers, and healthcare navigation skills as high priority topics in their learning. They value the classroom for the opportunities to ask questions and clarify their understanding of health information in a safe, trusted environment: a luxury that is rarely afforded to them in clinics or hospital settings.[v]
Many ABE teachers have found health to be a motivating and engaging content area that can successfully improve both health literacy skills and the core literacy or language skills they are charged with teaching.[vi] Successful health literacy projects in ABE reveal the range of relevant and meaningful markers of change that matter to ABE programs, and most importantly, to adult learners themselves. In many cases, these projects have been shown to improve not just learners’ knowledge of basic health, but their confidence communicating with healthcare professionals, enhanced self-efficacy, and intention to make changes in health behavior, such as getting blood pressure/sugar checks or improving their nutrition.
This has not been at the expense of the development of transferable literacy and language skills.
For example, a health literacy curriculum based in El Paso, Texas, found that ESOL learners improved their document literacy skills (e.g., filling out a health form, reading a prescription label). Moreover, learners reported increased intrinsic motivation for seeking out online health information, as reflected in this learner’s comment: “I [used to] look at the computer and I did not even w to turn it on.... [but] with this program with the worksheets that they gave us, with the suggestions that the teacher gave us, it’s that now I’m getting the sweet taste of investigating... it was good because now I am interested”.[vii]
Opportunities, Challenges and Resources for Teaching Health in ABE
The success of health literacy/ABE integration has created a growing interest among ABE practitioners and program directors, but there are some challenges. Two of the barriers that teachers often voice are their lack of health knowledge and a lack of health-related curricula materials.  Teachers often worry that they will not be able to answer health-related questions. There are two easy fixes for this concern: One is to focus more on the skills needed to find and understand health information, and less on teaching health facts. Another is to partner with a Community Health Center (CHC) and invite an expert into the classroom to share health information and answer questions.
But both of these fixes require some curriculum resources to help guide teachers through the process. In order to incorporate health units and health literacy skills into curricula, teachers need specialized instructional materials and also guidance in how to address health in the classroom. In some cases, ABE programs have had success with mini-grants that allow them to create their own instructional materials, but short of that, there is a need for ready-to-use materials. There are now many resources available, which include comprehensive curricula, lesson plans, easy-to-read health books (authentic materials) and guidance in how to incorporate health into ABE instruction. There are also guides to help build partnerships between ABE programs and Community Health Centers. These resources would be useful to both teachers and program administrators who want to build a mutually beneficial relationship with local health organizations. Examples of these resources will be found in appendices A and B, including guides for teaching health in ABE programs, guides for partnering with health organizations, and ready-to-use health literacy curricula.
ABE and Community Health Center Partnerships
One promising avenue emerging from the work over the last two decades is partnerships between the ABE and CHC systems, which have overlapping and intertwined responsibilities for the same population.  Local program partnerships have shown great potential benefits for both partners, and of course for the communities they serve. The CHCs are providers of primary and preventive care for low-literate, low income, and other underserved populations. However, they struggle to connect with those most in need of their services. ABE programs are in direct contact with members of these underserved communities, and the teaching environments provide much greater learning time than health care settings. Moreover, ABE educators are skilled in teaching diverse populations such as this, and have already gained their trust. Working together, the ABE and CHC systems can provide ABE learners with opportunities to improve their health and, as a result, enhance their productivity as workers, parents and community members. In addition to improving health literacy skills, ABE learners can learn to trust and use their local primary care health services. This not only improves their health, but also reduces costs for them and the healthcare system by reducing emergency room use and unnecessary doctor visits.[viii] Partnership work is relatively new but promising models are emerging.
Examples of ABE and CHC Partnerships
(See Appendix C for greater detail about these partnerships and links to resources and program materials)
Four funded partnerships between adult basic education and community-health centers
These brief descriptions include: The Health Literacy Initiative, Partnership Goals, and Funded Activities

1) The Florida Health Literacy Initiative. A partnership between the Florida Literacy Coalition (FLC) and Florida literacy, ESOL and Family Literacy programs Funded by the Florida Blue Foundation, 2009-present

Partnership Goals:
• To teach students English language and literacy while sharing information and resources to help them to navigate the
   healthcare system and make informed choices about their health and nutrition.
•  To help local literacy providers build successful and robust health literacy projects

Funded Activities:
• Teacher professional development
• Health literacy grants
• Improving access to free, high quality instructional materials
• Project based learning
• Network-building and resource-sharing across organizations
2) The Literacy Assistance Center of New York City. 
A partnership between 75 ABE programs and 35 community health centers.
Funded by private foundations and the New York Department of Education, 2003-2010

Partnership Goal:
• To increase the health knowledge of ABE/ESOL students, promote learner involvement with health issues, and connect them to
   health services

Funded Activities:
• Health literacy curriculum development
• Network-building and resource-sharing across organizations
• Program evaluation research
• Student tours of health centers

3) The Chicago Citywide Literacy Coalition’s Empowerment-based Health Literacy Project - Improving Access to Health Care. A partnership between 8 adult literacy organizations and local federally qualified health centers (FQHCs).*
Funded by The Chicago Community Trust, 2016-2018

Partnership Goals:
• To promote adult learners’ access to the health care system and strengthen their preventative health knowledge
• To create partnerships between adult education providers and community outreach staff at FQHCs

Funded Activities:
• Student tours of FQHCs
• Collaborative ABE/ESOL curriculum development on topics such as Type 2 Diabetes, heart disease, mental health, communication
   with doctors, and navigation of health care system
• Program stipends provided to adult education teachers

4) Quincy Asian Resources (QARI).  A partnership between a Boston-area nonprofit organization, local ESOL programs and supported by the Boston Medical Center Health Net Plan
Partnership Goal:
To lay the foundation for formal integration of health literacy into the ESOL curriculum

Funded Activities:
• Funding supported ESOL programming
• Delivery of two workshops on doctor-patient relationships and health insurance
• Health literacy curriculum development for ESOL classrooms
Partnerships between ABE programs and their CHCs can be mutually beneficial. ABE provides access to hard-to-reach populations and a safe learning environment. The CHCs can provide health expertise, preventive health screening, and treatments. ABE students have consistently shown strong interest in learning about health for themselves and their families, and health content energizes ABE curriculum and instruction. Teachers do not have to be health experts and can draw on a wealth of resources for contextualizing instruction in health content. Robust examples of partnerships show how they operate and benefit ABE programs, teachers and students. They also provide guidance for program directors in setting up partnerships and securing funding.
The links between low literacy and poor health are no longer disputed. ABE programs and CHCs share a common mission and commitment to serving vulnerable populations. Thus, stronger partnerships between these systems should be viewed as a viable strategy for addressing health disparities. A coordinated effort is required to meaningfully respond to health literacy disparities as a national social issue.
Marcia Drew Hohn,EdD, Literacy & Health Consultant; Winston Lawrence, EdD, retired health literacy director, Literacy Assistance Center, New York City; Julie McKinney, MS, Health Literacy Consultant; David J. Rosen,EdD,  President, Newsome Associates; Maricel G. Santos, PhD, San Francisco State University; Rob Shepard, MA, Director, Quincy Asian Resource Center; Gregory Smith, MS, Executive Director, Florida Literacy Coalition, Inc.; Alexandra Ziskind, MSW, Program Associate, Chicago Citywide Literacy Coalition

 *A Federally Qualified Community Health Center is more commonly known as a Community Health Center (CHC) and is a primary care center that is community-based and patient-directed.


[i] 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.

[ii] U.S. Department of Education, Institute of Education Sciences/ National Center for Education Statistics (n.d.). Program for the International Assessment of Adult Competencies (PIAAC). Retrieved from

[iii] Koh, H. K., & Rudd, R. E. (2015). The Arc of Health Literacy. JAMA: Journal of the American Medical Association314(12), 1225–1226. 2015, 9978

[iv] Levy, S. R., Rasher, S. P., Carter, S. D., Harris, L. M., Berbaum, M. L., Mandernach, J. B., Martin, L. (2008). Health literacy curriculum works for adult basic education students. Focus on Basics, 9(B), 33-39.

[v] MAGI Educational Services, Inc. (2005). The Health Literacy Initiative: A Pilot Project of the Literacy Assistance Center, Evaluation Report 2003-2004. White Plains, NY: MAGI Educational Services, Inc.

[vi] Hohn, M. (1998). Empowerment health education in adult literacy: A guide for public health and adult literacy practitioners, policy makers, and funders. Lawrence, MA: National Institute for Literacy
Santos, M., Handley, M., Omark, K., & Schillinger, D. (2014). ESL Participation as a Mechanism for Advancing Health Literacy in Immigrant Communities. Journal of Health Communication19(S2), 89–105.

[vii] Soto Mas, F., Mein, E., Fuentes, B., Thatcher, B., & Balcázar, H. (2013). Integrating Health Literacy and ESL: An Interdisciplinary Curriculum for Hispanic Immigrants. Health Promotion Practice, 14(2), 263–273.

[viii] Herman, A.D., & Mayer, G.G. (2004). Reducing the Use of Emergency Medical Resources Among Head Start Families: A Pilot Study. Journal of Community Health29(3), 197–208.

Appendix A
                                                                         Ready-to-use Health Literacy Curricula
These instructional materials were created specifically for ABE programs to use in their classes. They address specific vocabulary, grammar and literacy skills, and tie them to health-related content, which is written at a low literacy level. They cover skills like finding health information, accessing healthcare and communicating with providers. They have a participatory approach that encourages learners to think critically, practice language and literacy skills, and use these skills to take action to improve their health.
Staying Healthy: An English Learner's Guide to Health Care and Healthy Living
A publication of the Florida Literacy Coalition, Inc., this easy-to-read health book is written for new immigrants and English language learners. It includes basic information about health issues and health care access. The teacher's guide includes specific lesson plans and activities to use along with the book.
HEAL – Health Education and Adult Literacy
Developed by Literacy for Life. This is a comprehensive health literacy curriculum that was created for three instructional levels: beginner, intermediate and advanced. There are 7 lessons and a field trip at the end, which introduces students to a local hospital or health center so they can feel more confident accessing services.
Expecting the Best
From Sandra Diehl and a team of multidisciplinary organizations. This is a health and wellness curriculum for English as a Second Language (ESL) students designed to improve health literacy, functional literacy, and enhance English communication skills.
Queens Library: A Health Literacy Curriculum for ESOL Learners
Written for a library-based class to improve English language skills in the context of learning about health, this curriculum includes downloadable lessons plans, student worksheets and audio files.
Picture Stories for Adult ESL Health Literacy                                                                                                This eight-lesson curriculum uses picture stories to address health literacy issues. Each lesson includes teaching points and can be adapted to any level.              
The Virginia Adult ESOL Health Literacy Toolkit
This online collection includes a variety of resources for teachers, learners and program administrators.

Appendix B
                                            Guides to Creating Partnerships and Incorporating Health in ABE programs
Improving the Health Literacy of Hospitals: A Collaborative Guide for Literacy Organizations
From Wisconsin Health Literacy, this guide describes how to create a successful partnership between a hospital and a literacy center in order to engage the community in their local healthcare options.
Family Health and Literacy
From World Education, Inc. , this is an online collection of resources for teaching about health in literacy programs. The first chapter provides guidance in how to get started using health as a content area. It covers common concerns, how to engage students, how to prepare a speaker to talk to students, and how to find and collaborate with local health organizations.
Health Literacy in Adult Basic Education: Designing Lessons, Units, and Evaluation Plans for an Integrated Curriculum
This guide is designed to help adult educators create health literacy curricula, lessons, and evaluation plans. It includes an overview of skills to address, planning templates, and links to sample lessons from the Study Circle+ Guides.

Appendix C    
                                                     Examples of Partnerships between ABE Programs and CHCs
The Florida Health Literacy Initiative is a statewide grant program administered by the Florida Literacy Coalition (FLC) and funded by the Florida Blue Foundation. It provides training, resources, and financial support to assist Florida literacy, ESOL and family literacy programs to integrate health education into their instruction. The objective is to teach students English language, literacy and math skills while sharing information and resources to help them to navigate the health care system and make informed choices regarding their health and nutrition.
The Initiative seeks to help local literacy providers build successful and robust health literacy projects.  This includes providing: 1) Grants of up to $5,000, 2) Regular professional development and technical support opportunities, 3) Access to free, high quality instructional materials, including the Initiative curricula Staying Healthy, An English Learner’s Guide to Health Care and Healthy Living, and 4) Opportunities to network and share promising practices, partnership opportunities and resources across programs.
Working with health centers and other community partners is a key component to the Initiative. Activities have included providing health care screenings, CPR courses, health provider presentations, exercise classes, health fairs, and field trips to hospitals, health centers, grocery stores, and fire stations.
Since 2009, the Initiative has served more than 15,000 students in partnership with adult education and literacy programs throughout Florida. Approximately 76% of assessed students have experienced measurable improvement in their health literacy, with a 26% average increase in performance as measured through pre and post health literacy assessments. Students report through program surveys that they are exercising more, eating healthier, and better able to communicate with their doctor.
The Literacy Assistance Center of New York City implemented a robust program between 2003 and 2010 to increase the health knowledge of ABE students, increase their involvement with health issues and connect them to health services. Partnerships were developed between approximately 75 programs and 35 health facilities that involved more than 3000 adults and 175 teachers during the seven year period.
The program was carried out using an empowerment approach where ABE students identified and named health topics and issues important to them.  Teachers contextualized these topics with oral communication lessons for ESOL students and math, science and writing lessons for higher level students.  For example, students used data from the healthcare industry to explore math concepts and practices such as percentages, decimals, fractions and data analysis as these relate to daily living.  Data sources included the cost of insurance, drugs and of visits to doctors, and charts and tables were used that contained health related data. For science, students learned medical and scientific terminology, and explored content learning on the human body’s structure, vital systems, diseases, and conditions.  Students also read medical articles and wrote opinion pieces on health topics and issues, developing an understanding of the language of health care and debating health care quality.
Initially, partnerships were funded primarily through private foundations.  Later in the initiative, there was some indirect funding from the NY State Education Department. One stream of funding was awarded to the Literacy Assistance Center, an adult education professional development agency, for general leadership development and training of teachers as part of federal WIA legislation. Another funding opportunity came to the state funded programs that were part of a NY state adult education program initiative called Literacy Zones. Some monies were allocated primarily for case managers to develop partnerships with social service agencies in the community, including health agencies, to ensure that students were able to access services while pursuing their education and training.
Funding played an important part in garnering support from program managers who were then able to provide stipends to staff to attend professional development and to pay substitute teachers. Outcomes for students included: 1) increased health-related knowledge; 2) increased understanding of the medical system; 3) being able to identify the causes, symptoms or conditions of various diseases; and 4) an increase in healthy practices in dietary habits and participating in blood pressure and other preventive screenings. Students also showed greater educational gains on standardized tests in pre/post testing than students in other classes.  Programs developed relationships that enhanced their ability to work in the community and that benefitted their students by being a partner in a project to promote health equity and reduce health disparities.
The Chicago Citywide Literacy Coalition (the Coalition) has gained firsthand knowledge about the valuable benefits that a partnership can bring to learners as well as to the ABE programs and CHCs.  The Coalition received funding from the Chicago Community Trust to focus on preventative health and create deeper engagement between ABE providers and federally qualified CHCs*. This initiative, the Empowerment-based Health Literacy Project, consists of eight community-based adult literacy organizations across Chicago who are paired with a nearby CHC to create and implement a preventative health care curriculum for their learners. Some organizations chose their CHC partner based on a pre-existing relationship with a nearby CHC; others needed help being matched with a CHC. In those cases our funder made recommendations about a potential partner, and the Coalition helped broker that relationship. The Coalition distributes a stipend to the providers for implementing this work, and with that gave them the responsibility to forge and develop what their partnership with a CHC would look like. The Coalition created a detailed list of roles and responsibilities for the CHCs so they could better understand their involvement.
The five modules that the CHC and provider are required to create in their curriculum include: how to navigate the health care system (which includes a tour of a CHC), how to talk to your doctor, diabetes, heart disease, and mental health. Both teachers and CHC partners were trained in the participatory-centered approach, which emphasizes that learning is a result of participant action. It focuses on using a wide variety of techniques to facilitate learning and aid in retention.
In the initial phase of the Coalition’s project, some teachers were concerned they could not deliver the health content effectively, because they were not medical professionals. With the support and content knowledge from the CHCs, providers felt more confident in delivering the modules. Also, a partnership with a CHC allows providers to offer more robust health services to their students. For example, one organizations in the Coalition’s project noted that they plan to continue their relationship with the CHC by offering stress management classes to their students.
After launching the Health Literacy Project, several CHC’s approached the Coalition to see if there were more potential adult education providers to partner with – this emphasizes the CHC’s need to engage patients earlier and in a more preventative way.  A project of this nature, which emphasizes strong partnership, allows CHCs and CBOs to continue engaging with each other beyond the scope of the current initiative.
Quincy Asian Resources (QARI) is an example of a program in its beginning.  QARI s a mid-sized nonprofit outside Boston with various ESOL programs serving roughly 350 students per year. Health Literacy had not been a formal, fixed component in the ESOL curriculum, and one of the barriers to doing so was limited funding. As a step toward the formal incorporation of health literacy, QARI partnered with the Boston Medical Center Health Net Plan. The health plan sponsored the ESOL program, and delivered two workshops on topics of interest to students in the program: the doctor-patient relationship in the US and health insurance in the US. The workshops were integrated into the health units in the curriculum, and designed in collaboration with the teachers in the program.