Twelve percent of people who participated in the now-famous 1992 National Adult Literacy Survey reported having physical, mental, or other health conditions that kept them from participating fully in work or other activities. Of these individuals, approximately 75 percent scored in the two lowest literacy levels (NALS, 1992). The implications of this finding are staggering. Most of the information we get about health is in written form, and it is written at the 10+ reading level. Therefore, the population that needs health education the most is least likely to benefit from the majority of health education efforts.

Even more dramatic is the increasing evidence that higher education levels lead to longer, healthier lives overall. In one study, researchers found that as less educated adults age, they are increasingly more likely to be depressed than adults with more education-perhaps because adults with lower education have more health problems (Miech and Shanahan, 2000). Another study indicates that less educated people show more signs of physiological wear and tear than those who are more educated. The results of this study suggest a direct relationship among socioeconomic status (as measured by education level), psychological factors, and health (Kubzansky, et al, 1999). Most recently, the National Policy Association and the Academy for Health Services Research and Health Policy collaborated to produce a book based on its landmark research: Income, Socioeconomic Status and Health: Exploring the Relationships. Through this newly published book, researchers intend draw scientific conclusions about the social determinants of health to the attention of U.S. public and private policymakers. The book's authors cite income inequality and socioeconomic status as the principal factors affecting health in the United States today (US Newswire, 2001).

Students in Adult Basic Education (ABE) and English for Speakers of Other Languages (ESOL) classes have limited access to understandable health information. And it's no secret that adult learners often miss school because of personal and family health problems. Adult education programs can begin to address the health information and communication gap by offering health education that is relevant, understandable, and interactive, in a comfortable and safe environment.

Students Define Problems
A participatory action research study by Hohn (1998) documented what ABE and ESOL students perceive are the problems with health education among limited literacy individuals and groups. While ABE and ESOL students agreed that easy-to-read materials are essential, they said that there is too much reliance on written materials and that difficult materials are only the tip of the iceberg. Much more important is the provision of a psychologically safe environment in which to learn about health-an environment that also helps people connect health education with everyday life. Adult learners want to know: "What does this health information mean for me as an individual, for my family, friends, neighbors, coworkers, and people in my other social networks?"

ABE and ESOL students also observed that too many community health educators do not understand how to work with limited literacy groups. Such health educators talk too fast, make too many assumptions about what people know, and retreat behind scientific jargon and statistics. Adult learners noted that limited literacy groups, especially those from other countries, cultures, and traditions, may not understand concepts of prevention and early detection, and that they may not know that access to community health services is both a right and responsibility in the United States. Such groups may also fear discrimination in accessing community prevention, screening, and health services, especially when they do not have health insurance (which is often the case) or may be limited in the English they speak.

Students Define Benefits
Students in the participatory action research study (Hohn, 1998) affirmed that health is an important topic to them and that ABE and ESOL programs are a good place to learn about health. ABE and ESOL programs, they said, provide a supportive environment to develop understanding of the information and time to relate the information to everyday life so that it is seen as useful and meaningful. Having a choice about the health areas to explore was also very important to students. Students generally perceived health broadly to include such issues as street safety, housing conditions, the stress of immigrant life, as well as diet and exercise and prevention/early detection of disease. They enjoyed a "learning together" approach with teachers and community educators, which eased the burden and oppression of reliance on "expert knowledge." Students recognized that health topics also facilitate and motivate literacy learning. One student reported that when she realized that what she said was more important than how perfectly she said it, she was "released" from the fear of speaking "not so perfect" English. Teachers reported an intense engagement in conversation about health topics that enhanced speaking, listening, reading, and writing activities. The classroom became a social "open" space to talk about health, not only for the students but for the teachers and other staff. Having peers from their program teach about health was especially important to students.

Students also took action. They shared information with families and friends, used community resources for prevention and early detection, and supported each other in accessing health care services. An evaluation study of learners' perceptions of integrated literacy and health researched by Whiton and Zahner and documented by Rudd (1994) had similar findings but found a number of other vital outcomes. This evaluation study found that students perceived that they had developed skills useful in understanding and communicating in a medical setting, which supported them in making changes in personal health behaviors that promoted a new sense of self.

Student Leadership Development
Time and again we hear the accounts of students who, before studying health, were quiet and reserved in class. But when faced with the opportunity to learn and teach about health, these same students become outspoken and eloquent, designing and presenting workshops, skits, and brochures, and leading community meetings. One woman (a Spanish-speaking GED student) said, exhilarated, after teaching her first CPR class (in English!), "I have never done anything like that in my life!"

Conclusions
Literacy and health integrated education is more than simply another content area for instruction. And health education is more than simply reaching people with a particular health message or fact. Information is only one piece of an education process that needs to include community context, participation, and support. In ABE and ESOL programs, there is time and potential for an environment conducive to participatory process. Learners and staff can work together with community health educators to design and implement health teaching and learning programs. Allied with continuing efforts within public health and health care systems, ABE and ESOL programs can broaden access to health education, promotion, and care, and reduce disparities in the health status of limited literacy groups.

Notes
Hohn, M. (1998). Empowerment health education in adult literacy. Washington DC: National Institute for Literacy.

Kubzansky, L., Kawachi, I., and Sparrow, D. (1999). "Socioeconomic status, hostility, and risk factor clustering in the Normative Aging Study: Any help from the concept of allostatoc load." Annals of Behavioral Medicine, 21:4.

Miech, R. and Shanahan, M. (2000). "Socioeconomic status and depression over the life course." Journal of Health and Social Behavior, 41:2.

Rudd, R. (1994). Learners' perceptions of the benefits of integrated health and literacy. Unpublished evaluation study for World Education, Boston.

Marcia Drew Hohn is the director of Northeast SABES. She can be reached at mdrewhohn@aol.com
Alisa Vlahakis Povenmire is associate coordinator of Northeast SABES. She can be reached at avlahakis@aol.com