the National Institute for Literacy, and the National Center for the Study of Adult Learning and Literacy (NCSALL). Thus, ABEL represents a collaborative activity that spans government, private, and volunteer activities at the federal, state, and community levels, which could have a large effect on health literacy.

In fiscal year 1998, the ABEL system provided English language services to approximately 2 million adults, high school equivalence preparation services to 800,000 adults, and basic skills services to 1,300,000 adults (U.S. Department of Education, 1999). Each year, between 3 million and 4 million adults spend some time in an ABEL program. Though the mean hours of participation is only 72, a significant percentage of students drop out within the first 30 hours, and so more than half of the students are receiving at least 100 hours of instruction. Most of these adults are in the primary target population of health literacy programs. ABEL programs are, therefore, an effective venue for health literacy activities. However, the potential demand for these services was much greater and may be affected by the fact that the ABEL system has limited resources for one-time developmental costs that produce curriculum, materials, and teacher training designs. These efforts, and effective adult education programs to improve health literacy, could be made available to more people through a cooperative effort between the health system and the ABEL system to undertake a research and development agenda that would lead to educational programs that served the needs of health literacy and the needs of English language and basic skills instruction.

Strategies and Opportunities in the Adult Education System

Adult education theory maintains that people prefer and want information that is relevant to their current situation, and they tend to learn better when the environment is open and encouraging (or facilitative) rather than narrow and passive (or restrictive) (Knowles, 1980). The complexities of the health-care system today require that information be constructed and delivered with consideration for literacy and culture, and cast within a problem-solving or behavioral context (the “how-to” approach). This how-to approach should be geared to the behavioral information needed to act. While general facts about cancer, nutrition, or care-giving are helpful, unless the health information is cast within a problem-solving context, it is often lost. In many print and oral instructions, the reader does not encounter the behavior information early enough. Most people need to have advice that makes sense to them and is logical from their own perspective (Doak et al., 1996). For example, instructions provided to an elderly man with diabetes on the importance of foot care would be more effective if the information is presented within the context of how to achieve the necessary care.



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