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Julie McKinney- In a small but comfortable room, 18 women and men sit at desks arranged in a circle. Among other things they are parents, factory workers, home health aides, students and patients. Most are low income and have no health insurance. Most, but not all, are new and second-generation immigrants and represent 8 different countries of origin. Their accents and shades of skin are but scant outward signs that reflect the cultural upbringing and life experience that defines each of them.

They are talking about mammograms. Many have stories to share about how cancer has affected their families. Others have questions about finding services, paying for tests, and how they can prevent cancer. Perhaps surprisingly, the men are talking as much as the women, and most women seem able to voice their concerns and experiences in front of the men.

It takes a few minutes to determine which one is the teacher. She is sitting among them and listening. The clue appears when she gently addresses a woman from Cambodia, who has been silent. “Chenda,” she asks, “what do you think about going to the clinic for screenings?” Chenda begins hesitantly, but is encouraged by her peers. Eventually, her story comes out.

It is a story born of her experience, shaped by her culture and affected by the culture of health care in the U.S. It is a story of feeling small and depersonalized in the face of a hurried and intimidating clinical system. It is a story that resulted in confusion, frustration, and eventually inaction. The inaction led to the preventable death of her mother.

Stories like Chenda’s are common, as are the concerns of her classmates. What is also common is the miraculous ability of an adult education class with an experienced teacher to engage a diverse group of adults in addressing health issues this deeply and openly.

Why is this?

Mainly it is because the culture of adult education is built on providing a safe environment in which to learn, and on engaging the student in an interactive manner.

This is why the adult education community can be immensely useful to health care providers who are looking to improve patient engagement. There are three main parts to this community that are important here:

  1. The teachers
  2. The learning environment
  3. The students.

The teachers

Quite simply, adult education teachers have skills engaging adult learners, which we can learn from to better engage patients.

Adult educators teach a range of levels centering on literacy and communicating in English. Although their main goal is teaching literacy and/or language, they are also charged with helping people to use their literacy and language in the context of all aspects of their life. Health is a popular and effective context for teaching literacy because it is vital and meaningful to people in their daily lives.

The students, or adult learners, include those who are new to English or who never learned adequately in school. Adult learners include new immigrants, U.S. born English speakers who never engaged well in their schooling, and those with a learning disability that hindered their education. Many learned enough literacy to get by, but not to thrive. (I think we all would agree that the ability and willingness to navigate our complicated health care system demands “thriving!”)

Literacy includes more than just reading, writing and comprehension

Book Chaos

It also includes numeracy, critical thinking, listening, speaking, categorizing and organizing ideas. These are all critical skills that need to be shared along with the sea of facts and information that we give to patients. In fact, these are skills that both patients and their care providers need in order to interact effectively and optimize health.

Adult educators not only address all of these skills, but also use research-based methods to convey them to students and make them actionable.

These methods include the following:

  • Use life experience
  • Validate each person’s knowledge and beliefs
  • Allow and demand participation of each student
  • Teach to different learning styles (for example, let students learn by seeing, by hearing, by doing, by using creative outlets, etc.)
  • Incorporate new knowledge and skills into real life in order to practice them and make them meaningful
  • Repeat, process, practice and teach others
  • Use stories and real examples

Here is what literacy teachers have experience and training to do. They do these things every day:

(Think about what you want for your patients, your family and your community when you read this!)

  • Communicate clearly and respectfully with diverse groups of people
  • Teach diverse groups of people how to communicate clearly with others
  • Teach diverse groups of people new information AND how to use that information to improve their daily lives
  • Help diverse groups of people feel comfortable and confident to advocate for themselves effectively

This experience makes adult education teachers perfectly suited to help train providers and also to help the health system connect with patients. By collaborating between adult education programs and health systems, we can put more teachers in a mentoring role with health care providers, health educators and patients.

The Learning Environment

As you see from the scenario above, an adult education classroom is a special place. It is a safe and comfortable environment, where people are sharing their stories and learning together. It is a place where there is a supportive peer group and a supportive teacher, whose role it is to help each person integrate new knowledge and skills into their busy lives. This environment does more than make people feel good. It opens their mind to learning new things and accepting new ideas. It helps to facilitate learning and readiness to change behavior. It strengthens their sense of self-esteem, and their ability to self-advocate.

Clearly, this environment is a luxury that cannot be used in a clinical appointment setting, but it is one that can be used as a model for extended health education. It is also a place where health literacy skills can be honed, and where people can give open feedback about their needs and preferences for health care and health information services.

The Students

In terms of demographics, the vignette above is not an exaggeration. This is what many adult education classes look like. Of course it varies by location and type of community, but chances are, the demographics at your local adult education center match rather startlingly with your underserved, or “hard-to-reach” population.

Adult learners who are in literacy or English programs represent populations most in need of accessible and understandable health information and services. They include people from diverse backgrounds, language groups and cultures, and those with major educational and economic challenges. They also represent people who have been uninsured or under-insured, and with the Health Care Reform Act will hopefully have increasing access to health insurance, and thus increasing need to interact effectively with the health care system.

Adult learners are the end users of health care services, and they represent many of those who are disengaged with the health system. Because of this, health care programs must take into account these learners’ perspectives, needs and abilities in order to design, deliver and evaluate the health services offered to the community.

Why are the end users important? How can they help the providers?

  • They are the ones whose opinions count
  • They know what they want
  • They know what they need
  • They know what the barriers are
  • They know how they can best understand the information
  • They know what supports they need to access services

But it gets better! Not only is this the perfect population to help us understand how to better serve them, but they are conveniently scheduled two or three times a week to be in a room together learning about strategies that they can use to improve their lives. They are here in an environment where they feel safe and confident, where they share information freely and listen to others, where they practice new skills and actively think about how to incorporate those skills into their life.

Even better, they have a teacher who they trust and confide in. This teacher can be a liaison to health educators, and health outreach of any type. In this environment, with the support they have and the demographics they represent, adult learners can be the best advisors a health system can find.

There has been much debate in the health literacy world about how best to deliver health information and services to patients with such varied cultures, needs and abilities. How do we present information that people can understand, but not “dumb it down” or offend people? In the end, it always comes back to universal design. Studies show that most people, regardless of their education or literacy level, prefer the simpler and more interactive, engaging approach to learning. This is also what adult learning research has shown. The adult education community can help us to adopt an effective universal design approach:

If it’s easier for adult learners, it’s easier for everyone!

I encourage all health care providers and educators to find an adult basic education program in your community and sit in on a class. I guarantee that you will learn at least one new thing about engaging patients. (…or your money back! ;-)

How can adult learners help to improve patient care?

Here are some ideas...

  • Pilot test written materials, programs and systems
  • Do a walk-through of the building to assess ease of access and navigation
  • Provide feedback and recommendations through focus groups
  • Promote health services to those in their community

How can literacy and ESOL teachers help to improve patient care?

Here are some ideas...

  • Advise and mentor health professionals and staff
  • Participate in health literacy trainings
  • Act as liaison to their students for pilot testing or focus groups
  • Work with outreach and health education departments
  • Teach onsite health literacy classes

About Julie Mckinney

Julie is the moderator of the LINCS Health Literacy Discussion List online.



ABE Adult Basic Education

ESOL English for Speakers of Other Languages

ESL English as a Second Language

ELL English Language Learners

LEP Limited English Proficiency



The Emergence of Health Literacy as a Public Policy Priority: From Research to Consensus to Action

Article by Anthony Tassi (Literacy Harvest, 2004)


Health Literacy Special Collection

This site has a variety of resources for patient education, health literacy training and partnering between health and literacy agencies.


Literacy Directories

Although geared towards learners looking for a literacy program, these can also help health agencies to find local programs with whom to partner.



The Health Literacy Discussion List

Sponsored by Literacy Information aNd Communications system (LINCS), this e-mail discussion group links health educators, medical providers, literacy practitioners, researchers, policy makers, and other interested parties as a community of practice.

To subscribe go to: http://lincs.ed.gov/mailman/listinfo/Healthliteracy