Amplifying Diffusion of Health Information in Low-Literate Populations Through Adult Education Health Literacy Classes

Abstract

Over the next decade, as literacy rates are predicted to decline, the health care sector faces increasing challenges to effective communication with low-literate groups. Considering the rising costs of health care and the forthcoming changes in the American health care system, it is imperative to find nontraditional avenues through which to impart health knowledge and functional skills. This article draws on classroom observations and qualitative interviews with 21 students and 3 teachers in an adult education health literacy class to explore the efficacy of using adult education courses to teach functional health literacy skills to low-literate populations. Data were analyzed using a combination of thematic and content analyses. Results describe the motivation of students to share information within the classroom and with friends and family outside the classroom. This article also provides several recommendations to help ensure accuracy of diffused information both within and outside of the classroom. Ultimately, this study suggests that the adult education system is in a prime position to impart functional health literacy skills to low-literate populations in the classroom. Significantly, this study demonstrates that adult education students themselves may be a powerful vehicle for health communication beyond the walls of the classroom.

“I'm learning something, and not only am I learning something, but I'm putting it in action. Not only that, but I'm sharing the information with people I run across.”

– Adult education health literacy student

Over the next decade, as literacy rates are predicted to decline, the health care sector faces increasing challenges to effective communication with low-literate populations (Kirsch, Braun, Yamamoto, & Sum, 2007; Parker, Wolf, & Kirsch, 2008). Individuals with limited literacy skills are less likely to obtain preventive services (Scott, Gazmararian, Williams, & Baker, 2002), are at greater risk for having chronic conditions (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004; Schillinger, Grumbach, et al., 2002; Schillinger, Piette, et al., 2003; Williams, Baker, Honig, Lee, & Nowlan, 1998; Williams, Baker, Parker, & Nurss, 1998), and have poorer disease self-management skills (DeWalt, Berkman, et al., 2004; Schillinger, Grumbach, et al., 2002; Schillinger, Piette, et al., 2003; Williams, Baker, Parker, et al., 1998). This population also experiences greater challenges when asking questions of health care providers (Katz, Jacobson, Veledar, & Kripalani, 2007), completing health history forms, and understanding printed directions, such as instructional brochures, preoperative instructions, and medication labels (Baker, Parker, et al., 1996; Koo, Krass, & Aslani, 2006; Schillinger, Piette, et al., 2003; Shrank & Avorn, 2007). Chronic disease prevention and management involve mastery of a complex set of skills (Clark, Becker et al., 1991). When disease management skills are taught in the health care setting, they are often taught didactically and over a short duration of time, neither of which is conducive to helping low-literate individuals learn critical skills and information (Brodenheimer, Lorig, Holman, & Grumbach, 2002). Additionally, most health care professionals are expertly trained in medical terminology; however, they are often not trained to break down complex concepts and explain them using clear language (Doak, Doak, Friedell, & Meade, 1998; Leonard, Graham, & Bonacum, 2004).

The potential social and economic impact of declining literacy rates requires the use of the most effective methods to impart functional health skills to low-literate populations. As with many public health issues, this requires looking to other disciplines for expertise (Institute of Medicine, 2004). Among other recommendations to remove low literacy as a barrier to health care, the Institute of Medicine recommends using adult education programs as a vehicle to teach functional health literacy skills (Institute of Medicine, 2004). Infusing functional health skills into adult education courses is a natural extension of the types of skills already being taught to help break the cycle of low literacy in families and to assist with employment readiness (American Medical Association Council on Scientific Affairs, 1999; Institute of Medicine, 2004; Kirsch, Braun, et al., 2007). These programs provide classes to over four million adults every year on topics related to health literacy, such as basic reading, writing, and mathematical skills (Institute of Medicine, 2004). Adult educators focus specifically on using strategies that can motivate adults to learn information and to acquire functional daily living skills (U.S. Department of Health and Human Services, 2003). The strength of these classes is that instructors place learning in the context of real-life situations, make learning immediately relevant, and empower learners to take an active role in posing questions and developing solutions (Candy, 1991; Freire, 2000; Knowles, 1973).

As Healthy People 2010 indicates, one of the main challenges in designing effective health communication programs is identifying the optimal contexts, channels, content, and reasons that motivate people to pay attention to and use health information (Healthy People 2010, 2001). Adult educators are particularly adept at knowing how to reach low-literate adults (Institute of Medicine, 2004), yet low-literate adults may be even better at knowing how to reach each other. Most intervention developers assume that the information delivered is received only by participants themselves; however, a preliminary evaluation of an adult education health literacy program found that learners shared information with family friends outside the class (Hohn, 1998; MAGI Educational Services, 2004). This evaluation did not explore what types of information were shared, for what purpose, or how sharing of information influenced those with whom information was shared.

The focus in diffusion is on the spread of new ideas throughout a group. As described by Rogers in the theory of Diffusion of Innovations, “Diffusion is the process through which an innovation is communicated through certain channels over time among members of a social system” (Rogers, 2003). Interpersonal channels (such as face-to-face communication or, potentially, classroom education) are typically more effective for helping individuals to form and change attitudes toward an innovation (Rogers, 2002). This is because most people tend to rely on the subjective evaluation of friends, family, and trusted others to make a decision, rather than using scientific evidence to form an opinion about something (Rogers, 2002). This process is especially evident in low-literate and minority communities, where individuals are more likely to seek advice from friends and family than from trained health care providers or peer-reviewed journals (Earp and Flax, 1999).

There are two aspects of adult education that provide a unique opportunity for diffusion of knowledge and skills: social support and a similarity to lay health advisor models. Social support has been demonstrated to help chronic disease patients with self-management skills (Gallant, 2003) and may serve to help students in adult education acquire knowledge and skills and motivate them to share with others. Social support involves several domains, including informational and emotional support (Brown, Nesse, Vonokur, & Smith, 2003). Informational support involves giving advice or sharing informational resources, while emotional support involves providing encouragement, reassurance, or empathy (Brown, Nesse, et al., 2003). As an extension of social support, many adult literacy centers function similarly to lay health advisors by placing emphasis on information shared among peers. Lay health advisors within a group or community are trusted individuals, known to be a source of accurate information and able to explain it in understandable terms (Earp & Flax, 1999). The teachers in adult education courses typically serve in this capacity, but other students may, as well.

This study draws on core concepts from several disciplines—communications, adult education, health education, and sociology—to explore how adult education centers function as a vehicle for communicating health information to low-literate adults in the classroom and beyond. This article also provides recommendations to increase accuracy and further diffusion of information within low-literate populations.

Methods

This qualitative case study was conducted with students from an adult literacy center in the urban South who attended a health literacy class covering preventive care, disease management, communication with health care professionals, and other health topics. Specific lessons varied, based on the needs and interests of students, although most courses covered topics such as diabetes, oral health, sexually transmitted diseases, nutrition, and physical activity. The course was based on the National Institute for Literacy's Health Literacy Curriculum and was taught by adult educators. Course materials included worksheets oriented towards teaching reading skills (with a health-content focus), news articles drawn from local media, information printed from the internet, informational health brochures, and actual forms from area hospitals and clinics. Classes met twice a week for two hours at a time over a 12-week semester.

Data collection included 20 hours of classroom observations, interviews with 21 adult literacy students and three instructors, and a final focus group with nine students to increase interpretive validity (Maxwell, 2002). Instructors and adult learners for this study were drawn from five semester-long courses. Interviews with adult learners explored the types of information shared and motivation for sharing information with friends and family outside the class. Interviews with instructors explored instructional strategies used to facilitate collaborative learning and overall perspective on teaching health literacy skills.

Student participants must have attended at least 12 hours of the health literacy classes and be sufficiently fluent in English to engage fully in the interview. Participant variation was sought in both age and gender. Twenty-one students and three educators were interviewed. All participants were given $20 for their participation. Interview transcriptions were anonymous, with a unique study ID number used to identify individual interviews. Observational data was recorded in the form of field notes during classroom sessions. The Emory University IRB approved all study procedures.

Data Analysis

Descriptive statistics were calculated on student participant gender, age, race/ethnicity, employment status, and frequency of class attendance. Transcripts and field notes were analyzed using a combination of Thematic Analysis and Content Analysis (Weber, 1990; Maxwell, 2002; Braun and Clarke, 2006). These processes resulted in themes derived from both the data and theory that explore how adult education centers function as a vehicle for diffusion of health information to those in and beyond the classroom (Yin, 1989).

Results

Demographics

The majority of students (76%) were female and all were of African or African American descent. Most students read between a 4th- and 6th-grade reading level, although most had completed school through the 10th or 11th grade. Average number of classroom contact hours varied, with a mean of 37.5 hours and a median of 32 hours. Six students had taken the class multiple times, while other students had only recently taken the class once. Table 1 summarizes demographic characteristics of student participants.

Table 1. Demographics of student participants

Student characteristics	Total (n = 21) % (N)
Gender
Female	76% (16)
Male	24% (5)
Age
20–29	19% (4)
30–39	19% (4)
40–49	24% (5)
Over 50	38% (8)
Race/Ethnicity
African	5% (1)
African-American	95% (20)
Educational Attainment
High School Diploma/GED	24% (5)
10th/11th grade	52% (11)
9th grade or below	24% (5)
Employment Status
Employed full-time	5% (1)
Employed part-time	24% (5)
Unemployed, looking for work	33% (7)
Unemployed, not looking for work	38% (8)
Classroom Contact Hours
12–20 hours	33% (7)
28–46 hours	43% (9)
64–118 hours	24% (5)

All three instructors were female. They ranged from having little formal education to prepare them for teaching adults to having an advanced degree in adult education. None of the instructors had any formal training in the health or medical fields.

Importance of Sharing Within the Class

Many health education classes focus on using didactic methods wherein the instructor imparts knowledge to the students. Conversely, central to this adult education course was a focus on empowering students to share their knowledge and experiences during class. Table 2 summarizes the importance of sharing information within the classroom environment, described in greater detail below.

Table 2. Importance of students sharing information during class

Value of sharing	Implication
Instructors and students planned course together content based on interest and need.	Students are more motivated to use information and skills acquired in class when they help select topics.
Instructors learned information from students.	Instructors continued learning throughout the class and gathered information to aid in subsequent courses.
Students are often more knowledgeable of community resources than instructors.	Students can become valuable resources for each other.
Students use similar terminology and plain language.	Students can “translate” complicated health information for each other using familiar terms.
Provides opportunities for learning new perspectives from other students.	Students are engaged and interested which motivates them to attend class and participate.
Provides opportunities for hearing personal experiences from other students (perceived to be similar to they themselves).	Students recognize their own susceptibility to health problems and are motivated to change behavior.

Collaborative Planning of Course Content

The health literacy class relied heavily on student input to the content and direction of the course. Many students discussed feeling very motivated by having the opportunity to learn about topics of their choosing. A middle-aged male student described the process of planning collaboratively:

“We discussed everything together. It wasn't all just talking to the teacher or waiting on her to bring it to the table … One person might want to bring this to the table or another one.”

Instructors Learn from Students

Information was passed among students and also from students to teachers. Teachers found this type of sharing to be both interesting and professionally useful, as explained by one of the teachers:

“It's kind of like a cycle: they teach me, I teach them and it's going around … the more I learn, the more I can teach.”

Students Share Knowledge of Community Resources

Discussions were often informal, focusing more on the students sharing personal experiences and knowledge. For example, during one class session, several students were instrumental in helping other students identify reputable and affordable dental clinics, and they gave suggestions on how to make a timely appointment. This discussion also served to raise and clarify misunderstandings about the necessary frequency of dental visits.

Students Explain Information to Each Other Using Common Terminology

Students placed great emphasis on other students as a valuable resource for trusted health information using plain language, similar to the lay health advisor model:

“[Other students] can talk to you on the level you're on … The good thing about it is that you can always ask them questions: What did you do when your husband blanked out? What did you do when you needed CPR or needed to do some? It's good because they can explain.”

Students Challenge Each Others’ Perspectives

Both students and teachers valued the input of others in the class and felt that these contributions added meaning to their experience in the class, as explained by a middle-aged female student:

“You have different people who come from different backgrounds who explain different things, or their point of view about it, and it all just fits into one decent conversation where I learned a lot from the class.”

The teacher also empowered students to become experts in content knowledge by encouraging them to do research on topics relevant to them, then presenting this information to the class. During one session, students took turns presenting information about different kinds of doctors, including descriptions of the types of conditions treated and indications for needing to see certain types of doctors.

Students Are Motivated by Hearing Stories from Others Seen as Similar

Students were often motivated to change their behaviors by hearing the stories and experiences of other students in the class. One young woman described the way she was very motivated to change her eating behavior after hearing the stories of older diabetic women in the class and realizing that she could have the same future:

“Listening to other people's problems when everybody sit around the room. And one lady … she's a diabetic, high blood pressure, heart problems … I ask a lot of questions on how often she go to the doctor to prevent me from being in her situation … So it forced me, just my way of thinking and eating … ”

Diffusion of Information Beyond Classroom Environment

Students were motivated to share information learned in class with a range of people—from specific loved ones to the community in general. The types of information varied based on the perceived need of the person with whom information was shared. Sharing of information and skills learned in class helped many students’ friends and loved ones to exercise, eat healthier foods, and engage in other healthful behaviors. Table 3 summarizes the key findings regarding sharing of information outside the classroom environment.

Table 3. Key findings on diffusion of information and skills beyond classroom

Domain of sharing	Examples
Views of Self as Lay Health Advisor	• Family Caretakers• Community Caretakers
Types of Information Shared	• Medical Knowledge• Functional health literacy skills• Nutrition-related knowledge and skills
Effects of Sharing	• Encouraged others to exercise• Helped loved ones to eat healthier foods• Loved ones shared health information and skills with other friends and family

Views of Self as “Lay Health Advisor”

Students found the information they learned in class to be highly relevant to their lives, but also to the lives of their loved ones or to their larger communities. Relevance to others was a strong motivator for students to pay attention during class, as explained by one middle-aged woman responsible for taking care of her children in addition to her aging parents:

“I learned a lot by hearing others talking in class … If it didn't relate to something I was going through, somebody in my family I've heard was going through it, so … my ears were like all over the room.”

Beyond learning information about a loved one's condition for themselves, students tended to fall into two main lay health-advisor-types with regard to what motivated them to share this information with others: they were family caretakers or community caretakers. Family caretakers felt strongly that it was their responsibility to learn information in order to improve the health of specific loved ones, such as children, parents, or grandparents:

“My family is down [south]. If anyone was to kick the bucket before I get down there, it would just eat me up. I need to know these things to share with my folks because I love them. I just want everyone to live.”

Community caretakers felt that their duty was to learn information to share with a larger community, rather than with specific individuals. Typically, women saw themselves as family caretakers, whereas men saw themselves more as community caretakers. This difference might have been because of the fact that most men in the class were not actually caretakers of specific individuals themselves, as they did not have children at home nor did they provide direct care to aging family members. Regardless, both types of caretakers saw themselves in a position of lay health advisors, feeling strongly that it was important for them to help others by sharing health information, whether it was intended for a community or for specific individuals.

Types of Information Shared

Students shared a variety of information and skills with family and friends. Information most often shared was based on an identified need, although information was also shared at times because it was interesting to the student. One type of information shared was medical knowledge, particularly regarding anatomy, physiology, or specific diseases. The quote below illustrates one student's desire to explain a family member's condition to her children:

“[My ex] is waitin’ for a kidney … He's the type that don't tell me or our children much information so all we know is daddy need a kidney. He takes dialysis, but I wanna be able to tell my kids more than just your daddy needs a kidney and he's on dialysis … like what caused this.”

Students also shared new skills with family members, such as reading medication labels and food labels. One middle-aged woman described the way she taught her mother about reading nutrition labels:

“In class we learned about reading the [nutrition] label, the fats and all the ingredients in the different items, the calories and all this. I told my mom, ‘Read it. It's on the back … We've got to see what it says.'”

Skills related to nutrition, such as healthy cooking techniques or food substitutions, were among the most commonly shared. The same woman described teaching her grandmother about eating healthier foods:

“My grandmother is 90 years old and her body is deteriorating, but she's still here. There's certain things she cannot eat now, and I would share it with her from my class … My grandma loves sweets, and I was sharing that instead of having sweets around she should have fruit instead.”

Effects of Sharing

In addition to sharing health information with loved ones, students also were able to help them make positive changes in their lives. One woman described the process of encouraging her father to exercise:

“I actually took a lot that I learned [in class] about diabetes and gave it to my dad … Two weeks ago I started him to go to the exercise room where they stay. I told him, ‘Daddy, just do what you can.’ Next day he was back and forth across the street walking … He seen a difference too and he liked it.”

Further, several students reported that the loved ones benefitting from health information went on to share that same health information with others. One woman described the way she helped her mother begin to exercise, and then her mother encouraged another family member to exercise as well:

“I shared with my mom about getting outside, doing a little walking, not just sitting … My mom started walking, and now my mom says she can sleep a whole lot better at night … My mom also shared that with my aunt and that aunt says she's going to start walking.”

In these types of situations, the sharing of information extended beyond the reach of the health literacy class to an additional tier beyond the student, making the health literacy class a very powerful vector for reaching a much larger audience than just the students alone. Students seemed to have an inherent ability to recognize the needs of others and desired to share what they knew. Seeing themselves as “lay health advisors,” even without the formal title, gave students a sense of pride that, in turn, motivated them to continue learning during class and sharing with others.

Addressing the Challenge of Lay-Health “Experts”

Despite the many benefits of health literacy students seeing themselves as lay health advisors, it can be challenging to help students recognize the limitations of their expertise and subsequently ensure the diffusion of accurate information to others. Two specific challenges in this case study were the lack of formal teacher training on health content and the mismatch of print materials to students’ reading abilities.

Challenges of Seeing Adult Educators as Health Experts

Although students considered their teachers to be health experts, the teachers recognized their lack of expertise in the field and often felt uneasy when discussing topics out of their comfort zone. One teacher explained her concern about being seen as a health expert:

“What makes me uncomfortable, more than just my lack of expertise, is that something happens when someone stands up in front of the room and they're called the teacher. You believe whatever comes out of their mouth … We have to be very careful with our students about what we're experts in and what we're just learning along with them.”

Students also expressed interest in having a medical professional visit their class to answer questions about anatomy, physiology, or certain diseases. As explained by one teacher:

“Sometimes you do wish you had a doctor in class … it would be nice to have when the students start asking questions. It would be a good learning and teaching experience for the doctors as well.”

As demonstrated by the teacher's quote above, these types of informal interactions between adult education students and health care professionals could also serve to assist health care providers in communicating more clearly with their patients.

Matching Reading Abilities of Students with Reading Level of Print Materials

This health literacy class served students of all reading levels, which made it a challenge to provide materials at an appropriate reading level for everyone simultaneously. One of the teachers explained this delicate balance:

“You have students who are at all different levels in this class … Sometimes you get students who don't know how to read at all, so you have to try to balance it out where those who can read a little bit better don't get bored and don't get impatient with those who are learning.”

Teachers reported that the curriculum provided materials at an appropriate reading level for students, but often at too basic a level regarding content. As a result, teachers often turned to the Internet to find additional course materials, yet these were often too challenging for basic readers. These students reported feeling frustrated because they did not understand the information well enough to remember it or share it with others, as explained by one older female student:

“I'm trying to read it and tell my husband about it when I get home and I'm missing so many words. I'm not saying use all kindergarten level. Just break it down so I can read it … I just want to be able to take this information somewhere else and emphasize on it myself.”

Students felt strongly that it was their responsibility to understand information thoroughly if the information were to be helpful to others. The quote below came from an older woman who attended a weekly church group immediately following her health literacy class. She described how she always enjoyed sharing what she had learned from her health literacy class with her church group, but she wanted to make sure she was explaining everything correctly:

“If I don't have my facts right, ain't no sense in me sharing it with them, because they go back and share it with someone else and it's not right.”

Students reading at lower levels still benefitted from the conversation surrounding the print material, yet felt frustrated when wanting to share the information with others because they could not read it. Students reading at higher levels did not report as many challenges with being able to read class materials or in sharing them with others.

Student Recommendations to Increase Diffusion of Accurate Health Information

Several students discussed the benefit of participating in the development of a newsletter on H1N1 (Swine Flu) and distributing it to other students. Students described that researching a topic, then working together to present information to other students in writing helped them remember information better and motivated them to ensure its accuracy. Students felt that the newsletter would be a good activity to continue in the future. One student even recommended taking time to present this information to all students at the literacy center.

Discussion

In sum, results from this study illustrate the power of the adult education health literacy classroom to reach not only students, but also the friends and families of students (and possibly the friends and family of those individuals). Although the potential reach of the health literacy class is significant, so, too, is the importance of ensuring accuracy of diffused information if it is to be considered a viable method for widespread communication with low-literate individuals.

The underlying assumption of most interventions is that at best, only those participating in the intervention acquire information and skills. This study demonstrated the high likelihood of diffusion of information and skills within the classroom and outside the classroom to friends and family of students. Within the classroom, social support was key to helping students share information and experiences with each other. This environmental openness served to facilitate greater learning from peers. Outside the classroom, students were highly motivated to share information with friends and family, essentially functioning as lay health advisors. While this diffusion of knowledge and skills makes adult education courses a powerful vehicle for health communication, it is important to find ways to maximize potential reach while simultaneously ensuring accuracy of shared information, especially when students perhaps feel over-confident in their newfound knowledge.

These results have several limitations, specifically that changes in behavior of family and friends were not observed directly and may have been exaggerated by students, given their enthusiasm for sharing health information. This study was also conducted with a primarily homogenous population in the urban South who were nearly all native English speakers. Heterogeneous cohorts, English-language learners, and those in rural parts of the country might have varying levels of comfort with regard to sharing information in class or could be motivated to share with others in different ways.

Results from this study indicate several areas on which to focus in order to help ensure accuracy of information transfer both within and outside the classroom: (a) focusing on teaching health skills over content, (b) ensuring readability of course materials, and (c) properly equipping students as would be done for lay health advisors. First, adult educators teaching health literacy classes seem to be most comfortable with and skilled in teaching functional or procedural skills (i.e., “how to”) rather than discussing higher-level medical content information (Hohn, 1998). Although basic content is perhaps necessary in order to teach functional skills, results from this study and previous studies (Brodenheimer, Lorig, et al., 2002) suggest that the curriculum might be most useful to students when it is organized around building health-related skills, rather than around content knowledge. Instructors would be able to determine and teach skills most needed and applicable to students, thus ensuring relevance of materials.

Additionally, it could be beneficial for the curriculum if a primer on anatomy, physiology, and basic disease mechanisms were included for instructors to use as a reference when questions arise. Including this type of reference in the curriculum may be more helpful than a series of links for more information online, because it would be presented briefly, and instructors could access it as needed during class, rather than waiting to follow up during a later session. Additionally instructors might also want to invite in a medical professional to answer students’ more complex health questions.

Teachers noted that although the reading level of curricular materials was generally appropriate, the information presented was often too basic. Teachers often turned to the Internet to find more detailed information, yet this material was often at too high a reading level (Echt & Burridge, 2011). Students reading at lower levels often failed to comprehend the supplemental information during class, thus making it more difficult and less likely for them to share the information with others after class. In a class with mixed reading abilities, it might be difficult to find information written at the appropriate reading level for everyone; however, there are several health literacy websites that could serve as a good resource for teachers seeking handouts for students, such as Health Literacy Missouri (www.healthliteracymissouri.org/library) and Oregon Health Sciences (www.ohsu.edu/library/patiented/links).

Students also discussed the benefit of working in a group to prepare a newsletter on a current health topic. These types of activities can serve to reinforce acquired knowledge, but can also be an excellent method of health communication, as students can write information in a way their peers can comprehend. This type of activity also empowers students to seek information independently, a skill that can easily be transferred to other aspects of their lives.

Because students often use print materials as a means to share information with others, it may be helpful to provide extra copies of materials during class for students to bring home. Teachers might even challenge students to share the information with others in order to help facilitate diffusion of health knowledge and skills. Providing additional copies of clearly written materials can help to ensure accuracy of diffused information but can also further amplify the diffusion of information to others outside the class.

While these suggestions are directly relevant to adult education courses, they are also relevant to those developing health behavior change interventions and materials, particularly for low-literate populations. Rather than assuming that information and skills provided are only for participants, sharing of information can instead become an integral part of interventions. Intervention developers can encourage participants to share information with others by providing additional materials and by providing time during the intervention for participants to practice sharing information (thus providing an opportunity to assess comprehension and accuracy). Further, sharing information can also help participants remember information and take ownership of it, thus increasing the likelihood of later use. Finally, encouraging participants to share information with friends and family is a natural way to informally access existing channels of communication via established trusting relationships, as in the lay health-advisor model. These relationships could be especially powerful communication vehicles for non-native English speakers, low-literate populations, and communities with low trust in the medical system. Future studies should assess the impact and effectiveness of sharing information in several areas with intervention participants: (a) knowledge retention, (b) intent to change behavior, (c) actual behavior, and (d) impact on health status. Additionally, it may be interesting to assess these same areas with those with whom information has been shared. To that end, social network analysis might be a useful tool for demonstrating the impact of information sharing within the networks of intervention participants.

Considering the rising costs of health care and the forthcoming changes in the American health care system, it is imperative that the medical and public health communities begin to find nontraditional avenues through which to impart health knowledge and functional skills. The significance of this study is that it demonstrates the strength of a nontraditional partner—the adult education system—as a very powerful vehicle for health communication beyond the walls of the classroom. Results demonstrate that the adult education system is in a prime position to help low-literate Americans become better prepared to manage their health, especially considering the complex sets of skills needed to navigate the health care system in order to prevent and manage disease.

Acknowledgments

The contents do not necessarily represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Notes

This research was funded by Emory University, Laney Graduate School and Rollins School of Public Health, the Department of Behavioral Sciences and Health Education, and Letz Funds. We also extend our gratitude to the students and staff of Literacy Action, Inc., for their interest and willingness to participate in this study.