Literacy and health work in Massachusetts has a long and varied history. It began formally in 1991 when representatives from the Health Promotion Council in Philadelphia came to the Adult Literacy Resource Institute (ALRI) in Boston to discuss their plans for working with limited literacy adults who had chronic health conditions such as high blood pressure and diabetes. This meeting brought together a group of adult literacy and health education practitioners who were concerned about the mismatch between health education efforts and needs of limited literacy adults. The group formalized itself into the Massachusetts Health Team in 1993. It met regularly at World Education in Boston and worked on the development of a mission and vision for the future. Drawing on the work of such thinkers as Wallerstein and Szudy (1998) in workplace health and safety, Rudd and Comings (1994) in learner-generated health materials, and empowerment advocates Roberston and Minkler (1994), they developed the following mission and vision statement:

Health Team
The Massachusetts Health Education team is a group of health educators and adult literacy practitioners in Massachusetts. Its goal is to promote the health of learners and teachers through health education activities in adult literacy programs. We understand health to include physical, emotional, and spiritual aspects, and that a healthy life is defined individually and culturally. We intend to support individuals, family, and community/environmental well-being through facilitating ways for learners and teachers to evaluate current health choices, make informed decisions, and create new options. This includes decisions concerning prevention and access to health care. We understand that our goal may also involve advocacy for policy and other social changes at the state, regional, and local levels.

Comprehensive Health Education Projects
This statement of beliefs and purposes has been the touchstone for the literacy and health work throughout the decade. It provided the foundation for the Comprehensive Health Education Projects (CHEP) that began in 1994 under tobacco tax dollars and continue today under general adult basic education funds. The CHEP projects have promoted the participatory approach to health education where the needs and interests of the participating students are paramount and student leadership of the projects is supported and facilitated. The empowerment approach also guided the development of Project HEAL (Health Education in Adult Literacy) that focused on early detection of breast and cervical cancer. HEAL continues today in New England and across the country under funding from the Centers for Disease Control and prevention.

Health Education in ABE: A Short History
Toward the middle of the decade, awareness of literacy problems for many adults in health care settings grew rapidly. Many articles began appearing in health journals about the extent of limited literacy in the United States and the lack of appropriate materials for patient education. An important research study was undertaken at Atlanta General Hospital that measured the extent to which patients understood medication instructions, discharge instructions, forms, appointment schedules, and related materials and found huge gaps in understanding that could cause serious medical consequences.

Health care professionals became increasingly interested in working with adult literacy to begin addressing these problems. The National Institute for Literacy formed the Cancer Working Group, established a national Health and Literacy listserv, and cosponsored a conference on literacy and health at Tufts University called "Ideas in Action," developed through and with World Education. Pfizer Corporation began sponsoring annual national meetings on Health Literacy -- a term that was emerging in the health care world -- and provided grants to develop innovative new approaches to developing health literacy. Public health conferences began focusing on literacy in such national and international conferences as "Culture, Cancer and Literacy" and the Canadian "Health and Literacy in the New Millennium."

Back in Massachusetts, the CHEP projects continued. Most projects formed partnerships with community health agencies but the focus and processes were primarily student identified and led. Innovative programs flourished across the state, using drama, social action theater, art, and student-generated brochures for teaching and learning on a range of health issues. These issues included immigration-related stress, child street safety, disease prevention, and wellness topics like diet and exercise. Health content promoted literacy learning, and students developed as peer teachers and program leaders. SABES/World Education developed several trainings on integrating health that increased program capacity to undertake the work.

Project HEAL continued to work in both Massachusetts and nationally through World Education, who also developed a New England-wide Women and Violence project about the effects of violence on literacy learning. This work was funded by the National Institute for Literacy (NIFL) and the Metropolitan Life Foundation. World Education simultaneously developed a compendium of low literacy materials and developed a health and literacy Web site, both of which could be accessed nationally. All the projects were promoted through conference presentations, articles, and reports. Massachusetts emerged as a national leader in health and literacy education.

Toward the end of the decade, Adult and Community Learning Services (ACLS) made a major commitment to literacy and health work by funding health projects under general adult basic education funds. This enabled programs to forge ahead with their health related curriculum work.

Looking Ahead
Many challenges face us in the literacy and health work as we begin 2001. We need to find ways to integrate health into programs via the experience of the Comprehensive Health Projects and other literacy and health ventures so that it becomes integral to program development, curriculum development, and technological capacity-building. But we need to do this using the following guidelines:

1. We need to continue with an approach that includes student input and is inclusive of student leaders;
2. We need to continue working with community health resources in meeting common goals for health education;
3. We need to expand the number of ABE programs that are working on integrating health.

To this end, ACLS has agreed to fund ten mini-grants statewide to support the development of special student-led health projects that relate to curriculum, technology, and/or community planning. These mini-grant projects will be under the joint leadership of SABES and MassAll (the state student leadership organization) who will bring together the mini-grant programs, the CHEP programs, and other student leadership ventures for a joint learning from the work. Simultaneously, the Health Curriculum Framework Team is hard at work on revising the Health Curriculum Framework, drawing on the experience and learning of the last decade. As we move into the new century, we look forward to health as an increasingly permanent presence across programs, to participatory process as the touchstone, and to the continuing development of student leaders who have taught us so well about health.

Notes
Robertson, A., and Minkler, M. (1994). "New health promotion movement: A critical examination." Health Education Quarterly, 21 (3), 296-311.

Rudd, R., and Comings, J. (1994). "Learner developed materials: An empowering product." Health Education Quarterly, 21 (3), 313-327.

Szudy, E., and Arroyo, M. (1994). The right to understand: Linking literacy to health and safety training. Berkeley: University of California Press.

Wallerstein, N., and Bernstein, E. (1998). "Empowerment education: Freire's ideas adapted to health education." Health Education Quarterly, 15 (4), 379-394.

Marcia Drew Hohn, Ed.D., is director of Northeast SABES at Northern Essex Community College. She has been a practitioner, researcher, and advocate for literacy and health work since 1990. She can be reached at mdrewhohn@aol.com