# Presentation: 803634

## Testing Impact of Health Literacy Research Project

- Susan R. Levy, PhD, FASHA
- University of Illinois at Chicago,
- Institute for Health Research & Policy
- National Institute for Literacy
- Health Literacy Summit
- Indianapolis, IN     March 25, 2008

## Basic Facts

**Funded By:**
**National Institute of Child Health and Human Development (NICHD)**
**U.S. Department of Education (OVAE)**
**National Institute for Literacy (NIFL)**
**Grant # 1 RO1 HD4 3761**
**Funding Term:**
**October 1, 2002 until August 31, 2008**

## Research Team

**Principal Investigator:**
**Susan R. Levy, PhD, FASHA, Professor**
**Institute for Health Research & Policy (IHRP), University of Illinois at Chicago, Chicago, IL**
**Co-Investigators:**
**Sue Rasher, M.Ed.**
**OER Associates LLC, Wilmette, IL**
**Michael Berbaum, PhD, Biostatistician**
**IHRP, University of Illinois at Chicago, Chicago, IL**
**Laura Bercovitz, MA**
**Adult Learning Resource Center, Des Plaines, IL**
**Jan Mandernach, PhD**
**OER Associates LLC, Wilmette, IL**
**Rodrigo Garretón, PhD**
**OER Associates, LLC, Wilmette, IL**
**Project Director:**
**Sarah Deardorff Carter, MPH, CHES**
**IHRP, University of Illinois at Chicago, Chicago, IL**

## Research Team (continued)

**Project Staff: UIC**
**Yingyu Chen, PhD**
**Lesley Maradik, MSW**
**Yoonsang Kim, MPH, MS**
**Project Staff:  OER**
**Rebecca Goold, MA**
**Elizabeth Johnson, PhD**
**Mary Suddarth, EdSp**
**Bonnie Hemmati, BA**
**Shari Sacks, BA**
**Project Staff:  ALRC**
**Laurie Martin, MA**

## Project Summary

**A randomized, controlled study to test the relative effectiveness of different curricula and different program structures on adult literacy.**
- Target population: Adult education programs in Illinois.

## Project Summary (cont.)

- Ultimate Goal: Health Literacy curriculum will develop general adult literacy skills as well as improve health-related knowledge, self-efficacy, and potentially, health promoting behaviors
- Project is designed to scientifically test the relative superiority of selected different approaches on adult literacy

## Health Literacy Research

- Health literacy is “the ability to read, understand, and act on health care information” (AMA, 2002).
- Correlation between low literacy and poor health well documented –
- 45% of adults cannot understand printed health information
- 26% cannot understand when their next appointment is scheduled
- 42% do not understand the instruction to “take on an empty stomach”

## Health Literacy Research (cont.)

- Adults with low health/literacy
- Experience annual healthcare costs four times higher than those with higher health literacy
- Cost the health care system as much as          $73 billion per year (AMA Foundation, 2006)

## Adult Health Literacy Curriculum

- 42-hours
- Explicit instruction
- Theoretically driven
- Researchers hypothesize that health content and its relevance will personalize student interest in the adult literacy curriculum, leading to greater increase in literacy as well as greater health knowledge and ability

**Notes:**
Explain theoretically driven

## Adult Health Literacy Curriculum (cont.)

- Content includes:
- Introduction to health care
- Health care institutions/professionals
- Health history
- Health terminology
- Physical activity
- Nutrition
- Medications

**Notes:**
Hand out curriculum objectives and make mention of it here.
Objectives prioritized by national panel of experts

## Curriculum Examples

**Parts of the Body, Part B**

**Notes:**
EB – all arrows are not included because cannot fit them all in such a small space

## Curriculum Examples (cont.)

- a.	cough
- b.	fever
- c.	chills

- Vocabulary practice – EB level

*Directions:*  Circle the correct symptom/health problem for each picture.

- runny nose
- dizzy
- diarrhea

## Curriculum Examples (cont.)

**Word Forms, Part A:  Section 17**
*Directions:*  Read each sentence out loud with your class.  With a partner, make a check (****) on the chart to show if the underlined word is a noun or a verb.

|  | Noun | Verb |
| --- | --- | --- |
| 1a.  Doctors examine you to see if you have a health problem. | ______ | _____ |
| 1b.  Before your examination, you have to fill out some health forms. | ______ | _____ |
|  |  |  |
| 2a.  The doctor prescribed a medication for Peggy. | ______ | _____ |
| 2b.  Peggy took the prescription to the pharmacy.  | ______ | _____ |

**Notes:**
AB level
Literacy is the lesson – health just used as subject matter

## Curriculum Examples (cont.)

**Patient Information Form**
*Directions: *You are the patient.  At home, fill out this form with your information.
- 1.	Last name:  ________________________
- 	First name:  ________________________	Middle initial:  ______
- 2.	Street address:  __________________________________________
- 	City:  _____________________________	State:  _____________
- 	Zip code:  _________________________
- 3.	Date of birth:  ______________________
-                                       (month, day, year)
- 4.	Social Security Number:  ___________________________________
- 5.	Marital status -- put a check mark (****) on the correct blank:
**	**Single  ____      Married  ____      Divorced  ____      Widowed  ____
- 6.	Occupation/job:  __________________________________________
- 7.	Employer’s name:  ________________________________________
- 8.	Employer’s street address:  _________________________________
- 	City:  _____________________________	State:  _____________
- 	Zip code:  _________________________

- [Page 1 of 2 - Used in various forms at all levels of instruction]

**Notes:**
Page 1 of 2 - Used in various forms at all levels of instruction
Activity appears in various ways b/c important for all to learn, but too much writing/text on one page for lower levels

## Curriculum Examples (cont.) – (All levels but beginning)

**Personal Medication Lists as of ____________________** (date)
**Over-The-Counter Medications:  **Use the chart below to record all of the over-the-counter medications you are taking.  Be sure to update the list when you start taking a new medicine (including vitamins and herbal products).

| Name | Why do you take it?  
(allergies, headache, upset stomach, etc.) | Dosage 
(medication strength or amount) | How do you take it? | Doctor’s Name 
(if recommended by a doctor) |
| --- | --- | --- | --- | --- |
| Example:  Extra Strength Tylenol | Arthritis pain | 1,000 mg (2 caplets) every 6 hours | 4 or 5 times a month | None |
|  |  |  |  |  |
|  |  |  |  |  |
|  |  |  |  |  |
|  |  |  |  |  |
|  |  |  |  |  |

**Notes:**
AI, AA, AS, EI, EA
Practice in writing skills  - refer back to curric table handout

## Curriculum Examples –Role Play (AB, EI, EA)

| 2.a.  You are a doctor.  
Ask the patient the following questions:
1.  Why are you here today?
2.  Has your appetite changed?
3.  When did this start?
4.  Do you have any pain or feel ill when you eat?  
     After you eat?
5.  Where is the pain?  
6.  Have you tried eating different kinds of foods?
7.  Have you taken any new medication before this started?
8.  How are things going in your life right now?  Have you been worried or upset about something? | 2.b.  You are a patient. 
You have come to the clinic because you have had trouble eating for the past two weeks.

Answer the doctor’s questions about your appetite problem. |
| --- | --- |

**Notes:**
AB, EI, EA
Do a couple of role plays – both ways

## Curriculum Examples (cont.)

**Expiration Dates**
*Directions:* Look at today’s date.  Look at the expiration date.  Put a check (****) on the chart to keep the medication or throw it away.

|  | Today’s Date | Expiration Date | Keep the Medication | Throw Away the Medication |
| --- | --- | --- | --- | --- |
|   1. | June 6, 2003 | May 2003 |  |  |
|   2. | February 26, 2004 | Sept. 2006 |  |  |
|   3. | 04-13-04 | 2003/05 |  |  |
|   4. | 12-02-03 | 11/2003 |  |  |
|   5. | April 10, 2004 | 05-2004 |  |  |

**Notes:**
AB level
Pretend today is... is your medication expired?  Like how it uses various forms of the date (math and literacy skills)

## Curriculum Examples (cont.)

**DIRECTIONS:**
- Do not take more than 4 doses in any 24 hour period
- Adults and children 12 years of age and older – 2 tablespoons every 6 to 8 hours
- Children under 12 years of age – ask doctor
- Stop use and ask a doctor if:  cough lasts more than 7 days, comes back, or is accompanied by fever, rash or persistent headache.  These could be signs of a serious condition.

**Maximum Strength**
**Cough Medicine**

|  | True | False |
| --- | --- | --- |
| 1.  The dosage is 2 teaspoons every 4 hours.  |  |  |
| 2.  You can take 4 doses a day.  |  |  |
| 3.  The dosage for children under 12 is the same as for adults.  |  |  |
| 4.  Adults should take 2 tablespoons every 6 to 8 hours.  |  |  |
| 5.  You can’t take this medication any longer than 8 days.  |  |  |
| 6.  A fever, rash or persistent headache could be a sign of a serious condition.  |  |  |
| 7.  If the cough comes back, you begin taking                   the medication again.  |  |  |

**Notes:**
AI, EI
Go through a couple of questions and point out where answers are on the bottle

## Curriculum Examples (cont.)

*Directions:**	** *Look at the pictures below and write a story about this emergency or you may write a story about your own 	experience.  Your teacher will tell you if you should write the story by yourself, with a partner, or in a small group.

**Notes:**
AI, EI, and AA levels
Mention about misuse  of emergency rooms
Also, different ways this is done at different levels (Same pictures are used one at a time - beginning – written in their own language, teacher writes on board, they practice saying and reviewing, etc), intermediate, work on writing own basic sentences

## Curriculum Examples (cont.)

| Situation #7
Jean, 25 years old, tripped and fell on the sidewalk outside where she works.  She got up unhurt, and then realized that one of her front teeth had been knocked out.  She found her tooth lying on the sidewalk and ran back into her office.  She was bleeding, so she began rinsing her mouth with cold water.  To make the bleeding stop, she pressed an ice cube wrapped in a towel where the tooth had been. 
What should Jean do?  Is this an emergency?  What would you do? |
| --- |

**An Emergency or Not?**
*Directions: * With a partner, choose at least three situations below and decide what action to take, if any.  If you think it’s an emergency, then an action would be to call for an ambulance (call 911) or take someone to the hospital emergency room or an immediate care center.  If it’s not an emergency, then an action might be self-care or calling the doctor’s office.  Be prepared to explain your actions.

**Notes:**
AB, AI, AA, AS, EI, EA level (all levels BUT EB)
Tooth skills –unique item that a lot of people don’t know that was tested (learned from our curric)

## Curriculum Examples (cont.)

|  | Healthy Things I Do | Unhealthy Things I Do | Changes I Want to Make | What I Need to Do |
| --- | --- | --- | --- | --- |
| physical activity | walk 15-30 minutes a day | watch TV 2-3 hours a day | exercise 30 minutes a day, and  watch less TV | make a schedule
substitute TV with exercise |
| nutrition | eat balanced meals |  |  |  |
| preventive care |  | my last checkup was 5 years ago | get a checkup | call the doctor |

**Getting Healthier Action Plan Example**

***Directions***: Mike wants to be healthier and make good health decisions.  He wants to make a few changes in his life.  Look at his plan, then fill in your own plan.  Start with just a few changes.  When you finish, talk about your action plan with a partner.

**Notes:**
EI, EA, AI, AA, AS levels
Building on literacy skills needed at different levels

## Curriculum Examples (cont.) –ASE level

**Self-Help Analysis**
*Directions:* Using the information from your Personal Physical Activity Log, the Reading Passage sections on physical activity, and the article, “Physical Activity and Health,” describe your overall habits for doing physical activity.  What days of the week or time of day do you do more physical activity?  Are your physical activities less vigorous or more vigorous?  Can you make them more vigorous?  Are you satisfied with the physical activities you are doing?  Are there any physical activity changes you would like to make?

## Map of Waves 1 - 5 sites

**N = 42**

**Notes:**
Point out Quad Cities area (Davenport), St. Louis area, Chicago as to why there are some clusters of sites.  Randomization works – we didn’t plan the way the sites fell out, but it worked well.  Different waves had different # of sites  - less at the end b/c all eligible sites used

## Participants

|  | Wave 1 | Wave 2 | Wave 3 | Wave 4 | Wave 5 | Total |
| --- | --- | --- | --- | --- | --- | --- |
| # of Sites | 11 | 11 | 10 | 7 | 3 | 42 |
| # of Classes | 26 | 34 | 33 | 18 | 9 | 120 |
| # of Adults* | 362 | 588 | 654 | 272 | 70 | 1946 |
| *Participants with Pretest TABE, BEST, CELSA, or Health Literacy Assessment |  |  |  |  |  |  |

**Notes:**
Filter 2

## Data: Waves 1-5

| Group | Frequency | Percent |
| --- | --- | --- |
| Experimental | 971 | 49.9 |
| Control | 975 | 50.1 |
| Total | 1946 | 100.0 |

**Notes:**
Filter 2
RANDOMIZATION!!! We couldn’t believe it ourselves

## Data: Waves 1-5

|  | ABE/ASE |  | ESOL |  |
| --- | --- | --- | --- | --- |
| Level of Instruction | N | %* | N | %* |
|     Literacy/Beginning | 71 | 3.7 | 624 | 32.8 |
|     Intermediate  | 348 | 18.3 | 522 | 27.5 |
|     Advanced | 89 | 4.7 | 159 | 8.4 |
|     ASE | 88 | 4.6 | -- | -- |
|  |  |  |  |  |
| Total | 596 | 31.4 | 1305 | 68.6 |

- *Percent of total sample.

**Notes:**
1901 total.  This doesn’t add up to 1946 (experimental/control total for Filter 2) because all students in that sample may not have had a literacy pre-test, which this is based off of, but this is everyone in Filter 2 who had a pre literacy BEST, CELSA, or TABE score).  1946-1901=45.  These 45 had a pretest HLA only, but not a literacy pretest.
Increase in number of students in ESOL in last few years is significant
Notice that in ABE/ASE, #s are in Intermediate (primarily) and up
ESOL – largest # in beginning

## Data: Waves 1-5:Demographics

| Characteristic | N | % |
| --- | --- | --- |
| Gender |  |  |
|         Male | 469 | 24.5 |
|         Female | 1449 | 75.5 |
| Hispanic/Non-Hispanic |  |  |
|         Hispanic | 1027 | 53.6 |
|         Non-Hispanic | 888 | 46.4 |

**Notes:**
This is using Filter 2 – ANY pre-test.  Gender has 28 missing (469+1429+28=1946).  Hispanic/Non-Hispanic has 31 missing (1027+888+31=1946).

## Data: Waves 1-5:Demographics

| Characteristic | N | % |
| --- | --- | --- |
| Ethnicity |  |  |
|       White | 1345 | 70.2 |
|       Black or African American | 311 | 16.2 |
|       Asian | 98 | 5.1 |
|       American Indian/Alaska Native | 11 | 0.6 |
|       Multi-Racial | 68 | 3.6 |
|       Native Hawaiian/Other Pacific Islander | 5 | 0.3 |
|       Other | 78 | 4.1 |

**Notes:**
Using Filter 2 
Total = 1916 + 30 missing = 1946  

## Data: Waves 1-5: Demographics

|  | Hispanic |  | Non-Hispanic |  | Total |  |
| --- | --- | --- | --- | --- | --- | --- |
| Characteristic | N | % | N | % | N | %* |
| Ethnicity |  |  |  |  |  |  |
|   White | 939 | 49.0 | 405 | 21.1 | 1344 | 70.2 |
|   Black or African American      | 4 | 0.2 | 307 | 16.0 | 311 | 16.2 |
|   Asian | 2 | 0.1 | 96 | 5.0 | 98 | 5.1 |
|   American Indian/Alaska Native | 6 | 0.3 | 5 | 0.3 | 11 | 0.6 |
|   Multi-Racial | 64 | 3.3 | 4 | 0.2 | 68 | 3.6 |
|   Native Hawaiian/
  Other Pacific Islander | 2 | 0.1 | 3 | 0.2 | 5 | 0.3 |
|  Other    | 10 | 0.5 | 68 | 3.5 | 78 | 4.1 |

***percents may not total 100 due to rounding error**

**Notes:**
Filter 2  N=1915 + 31 missing Hispanic/Non-Hispanic or Ethnicity
Federal reporting requirements – different ways of looking at demog.

## Data: Waves 1-5:Demographics

| Characteristic | N | % |
| --- | --- | --- |
| Primary Home Language |  |  |
|        English | 565 | 29.4 |
|        Spanish | 1107 | 57.6 |
|        Other | 249 | 13.0 |

**Notes:**
Total = 1921; 25 missing, so this is Filter 2
Filter 2
Other –often russian, polish, chinese, other asian languages

## Data: Waves 1-5:Demographics by Literacy Group

|  | ABE/ASE |  | ESOL |  |
| --- | --- | --- | --- | --- |
| Characteristic | N | % | N | % |
| Gender |  |  |  |  |
|      Male | 155 | 26.6 | 312 | 23.6 |
|      Female | 427 | 73.4 | 1010 | 76.4 |
| Hispanic/Non-Hispanic |  |  |  |  |
|      Hispanic | 40 | 6.9 | 975 | 73.8 |
|      Non-Hispanic | 540 | 93.1 | 346 | 26.2 |

**Notes:**
Filter 2.  Gender N=1904 + 42 missing.  Hispanic N=1901 + 45 missing=1946
Essential what you would expect

## Data: Waves 1-5:Demographics by Literacy Group

|  | ABE/ASE |  | ESOL |  |
| --- | --- | --- | --- | --- |
| Characteristic | N | % | N | % |
| Ethnicity |  |  |  |  |
|    White | 275 | 47.4 | 1056 | 79.9 |
|    Black or African American | 284 | 49.0 | 27 | 2.0 |
|    Asian | 6 | 1.0 | 92 | 7.0 |
|    American Indian/Alaska Native | 4 | 0.7 | 7 | 0.5 |
|    Multi-Racial | 5 | 0.9 | 63 | 4.8 |
|    Native Hawaiian/Other Pacific Islander | 0 | 0.0 | 5 | 0.4 |
|    Other | 6 | 1.0 | 72 | 5.5 |

**Notes:**
Filter 2:  1902 + 44 missing=1946

## Data: Waves 1-5:Demographics by Literacy Group

|  | ABE/ASE |  | ESOL |  |
| --- | --- | --- | --- | --- |
| Characteristic | N | % | N | % |
| Primary Home Language |  |  |  |  |
|      English | 552 | 94.4 | 13 | 1.0 |
|      Spanish | 26 | 4.4 | 1069 | 80.9 |
|      Other | 7 | 1.2 | 240 | 18.2 |

**Notes:**
Filter 2 N=1907 + 39 missing=1946
Reason for looking at these groups in many different ways is that we can ask different questions.  I’ll show you what I mean...

## Data: Waves 1-5: Mean Pre-Test Health Knowledge Scores

| Variable | N | Mean | S.D. | t | df | p |
| --- | --- | --- | --- | --- | --- | --- |
| Gender |  |  |  |  |  |  |
|      Male | 395 | 10.6 | 4.59 | -6.84 | 617 | < .0001 |
|      Female | 1210 | 12.38 | 4.14 | -- | -- | -- |
| English Language
Learner |  |  |  |  |  |  |
|      ESOL | 1093 | 10.66 | 3.78 | -19.16 | 910 | < .0001 |
|      ABE/ASE | 503 | 14.79 | 4.09 | -- | -- | -- |

**Notes:**
Filter 2  Gender (341 missing gender or pretest Health Knowledge).  English Language Learner (350 missing ELL or pretest Health Knowledge) highest score possible is 24.
Why knowing what the demographics are become important when we look at some data.  For example, what is health knowledge by gender?  How does basic health knowledge change?  We expect women know more than men, HA HA – but you can see that ESOL pop which is lower literacy initially scores lower (vulnerable populations)

## Data: Waves 1-5:Mean Pre-Test Health Knowledge Scores

| Variable | N | Mean | S.D. | t | df | p |
| --- | --- | --- | --- | --- | --- | --- |
| Hispanic |  |  |  |  |  |  |
|      Male | 190 | 9.1 | 3.55 | -8.82 | 846 | <.0001 |
|      Female | 658 | 11.65 | 3.50 | -- | -- | -- |
| Non-Hispanic |  |  |  |  |  |  |
|      Male | 203 | 12.02 | 5.02 | -3.14 | 752 | .0018 |
|      Female | 551 | 13.25 | 4.66 | -- | -- | -- |

**Notes:**
Filter 2 highest score possible is 24
Significant difference between men and women – even a few questions make a difference
Questions represent knowledge of a body of information with the large numbers of people – questions cover specific objectives and missing one is important – guessing gets “washed out” with such a large sample (similar to randomization)
Men are more vulnerable that women – in reality, women have more responsibility for health care and use the system more than men.  Everyone is bad, but Hispanic men are way behind the rest – we need to do something about the health knowledge of this population.

## Data: Waves 1-5: Mean Pre-Test Health Knowledge Scores

| Pre-test Literacy Level | N | Mean | SD |
| --- | --- | --- | --- |
| ABE |  |  |  |
|      Literacy/Beginning | 63 | 10.82 | 3.60 |
|      Intermediate | 284 | 14.04 | 3.54 |
|      Advanced | 75 | 16.76 | 3.49 |
| ASE | 80 | 18.56 | 2.78 |
| ESOL |  |  |  |
|      Literacy/Beginning | 494 | 9.42 | 3.37 |
|      Intermediate | 431 | 11.17 | 3.67 |
|      Advanced | 141 | 13.60 | 3.73 |
| TOTAL | 1613 | 11.94 | 3.73 |

**Notes:**
Filter 2 Highest score possible is 24; please note that scores are directly related to literacy level in both ABE/ASE and ESOL and risk is relatively greater for the lowest levels although it is clear all of the adults are a relatively vulnerable health literacy group
Susan likes to say, she could not have planned this better – as literacy increases, so does health knowledge (even at pre-test) – reinforces everything we know.  The most vulnerable are the ones with the weakest language/literacy skills.
**emphasize b/c what teachers are doing is very important – the reinforces that anything you do to increase knowledge will help with health...

## Preliminary Data: Waves 1-5Pre/Post Health Knowledge Mean Score Comparisons

| Group | Pre-Test | Post-Test | Pre/Post
Difference | N |
| --- | --- | --- | --- | --- |
| Control | 11.60 | 12.21 | 0.60 | 468 |
| Experimental | 11.60 | 14.90 | 3.29 | 347 |
| Group Difference | 0.003 | 2.69 | 2.69 | 815 |
| Significance | n.s. | p<.0001 | p<.0001 |  |

**Notes:**
Filter 4:  Had to have BOTH pre and post on one of: HLA or TABE or BEST or CELSA. Repeated measures
Repeated measures, or paired.  Equivalent to Filter 4.
Not showing all the breakdowns – who did what to whom – remember – almost 3 questions different but VERY significant change from same starting point.  Had bigger gains at intermediate level than at higher levels.  Gains at all levels.
Success still kept that step-wise order by literacy level similar to previous slide

## Waves 1-5: Effects on Health Knowledge

**The average post-test health knowledge score is significantly higher than the average pre-test health knowledge score**
**The pre/post gain is significantly greater for the experimental group whether ESOL or ABE/ASE**
**Adults increase their health knowledge when participating in classrooms using the health literacy curricula**
**Adults increase their health intentions and efficacy using the health literacy curricula**

## Preliminary Data: Waves 1-5Pre/Post Literacy Mean Score Comparisons

| Test | Pre-test | Post-test | N | P value |
| --- | --- | --- | --- | --- |
| TABE | 529.56 | 538.78 | 283 | p<.0030 |
| BEST | 42.89 | 49.17 | 633 | p<.0001 |
| CELSA | 40.85 | 43.34 | 144 | p<.0001 |

**Notes:**
Total = 1061
Filter 4:  Had to have BOTH pre and post on one of: HLA or TABE or BEST or CELSA.    Repeated measures
Repeated measures, or paired.  Equivalent to Filter 4.
Ppl increased even in ONLY 42 hours of instruction and we know that people are recommending many more hours of instruction to see increases.  Happy with the gains.

## Waves 1-5: Effects on Literacy

**Adults in experimental and control groups make gains in literacy**
**In our study, control teachers received training in literacy strategies and embedding strategies**
**Further analyses by literacy level and demographics and multi-variate analyses are continuing**

**Notes:**
Sub-bullet: therefore, we did not have a completely untreated control group and all success that we had is a relatively conservative test – showing success, but it is really conservative!

## Pre Health Knowledge Score &Attrition Between 6 & 21 Hours

| 
Level | 6hrs |  | 21hrs |  | Attrition |  |
| --- | --- | --- | --- | --- | --- | --- |
|  | Mean | N | Mean | N | N | % |
| ABE Begin | 10.06 | 46 | 9.84 | 31 | 15 | 32.6 |
| ABE Inter | 14.05 | 213 | 13.66 | 127 | 86 | 40.4 |
| ABE Adv | 16.57 | 51 | 16.21 | 28 | 23 | 45.1 |
| ASE  | 18.10 | 59 | 17.88 | 26 | 33 | 55.9 |
|  |  |  |  |  |  |  |
| ESL Begin | 9.44 | 447 | 9.63 | 331 | 116 | 25.9 |
| ESL Inter | 11.08 | 409 | 11.38 | 331 | 78 | 19.1 |
| ESL Adv | 13.51 | 128 | 13.38 | 100 | 28 | 21.9 |
| Total | F=106.08
p<.0001 | 1353 | F=52.92
p<.0001 | 974 |  |  |

**Pre Health Knowledge Score &****Attrition Between 6 & 21 Hours**

**Notes:**
Discuss attrition – different levels have different attrition levels (exact opposite).  Attrition in experimental groups proved higher. This is usual for experimental interventions and is reported in clinical trials as well. Attrition at the higher literacy levels, ASE and ABE advanced were related to the practice of studying for the GRE and reports of having health literacy information in previous adult ed classes (told by teachers).  6 hours is enrollment for adult ed in ICCB network classes; 21 hours is minimum for program attendance in even start classrooms. Reason we looked at these particular hours of attedance Filter 2
Expected 50% attrition at outset
Daryl Mellard – U of Kansas has published that at least 28% of ABE usually burdened with other learning issues – more transient, other challenges.

## Health Literacy Program Completers:Even Start vs. Non Even Start

|  | Even Start | Non Even Start |
| --- | --- | --- |
|  | % | % |
| TABE | 52.17 | 48.06 |
| BEST | 68.56 | 56.60 |
| CELSA | 80.49 | 65.65 |
| TOTAL N = 1890 |  |  |

**Notes:**
What about those that started and completed the program?
Didn’t work anything with children, haven’t done analysis of hypothesis related to even start
Given attrition we had, looking at breakdown, program completion rate much greater for ES participants
Can learn a lot about how the program is working for different people by looking at who stays and who goes (and if you can find it out, why)  i.e. GED issues
This curriculum apparently appealed to the needs of lower and intermediate level adults, based on attrition and program completers. It is interesting that Even Start participants as a whole whether ABE or ESOL tended to significantly stay in the literacy programs.

## Implications

- Data show direct and progressive association between literacy level and health knowledge, intentions, and self-efficacy (low to high)
- Study has begun to differentiate needs/uses of health information by low literate adults

**Notes:**
Bullet #1: Lower levels scored lower, scores increased as literacy levels increased
Bullet #3: We don’t show this data in this presentation

## Implications (cont.)

- Data indicate control students show greater health-related deficits at post-test than experimental students at same literacy levels; ESOL male controls remain highest risk.
- Our belief is that lower literacy levels need more than 42 instructional hours to progress to next literacy level; while health knowledge and related efficacy can be significantly improved relatively quickly, even within the “up to” 42 hours

**Notes:**
Bullet #1: Lower levels scored lower, scores increased as literacy levels increased
Bullet #3: We don’t show this data in this presentation

## Policy Implications

- Curricula need to differentiate between ABE/ASE and ESOL concerns and interests, especially at lower levels
- Greater focus on males in general and especially ESOL males in recruitment and retention may benefit adult literacy programs greatly and male health literacy in particular

**Notes:**
Males seem to be at greatest deficits
Bullet 3: distribution stayed the same 
I

## Policy Implications (cont.)

- Literacy levels and health literacy levels are proven to be correlated from low to high; thus providing further evidence that adult literacy education needs to be a national priority
- The most vulnerable adults in respect to overall health and mortality will continue to be highly populated by those adults with the lowest literacy skills.  The cost of health care will continue to escalate if literacy is not addressed.

**Notes:**
#2: also their families are also affected by the adult’s lack of literacy skills – so the health implications expand.

## Practical Lessons Learned

- Integrate 42 hour Health Literacy Curriculum with other adult literacy materials over the course of a semester to keep students involved
- Research format too focused for higher literacy level if not integrated

**Notes:**
#1: comment from the sites – would like to integrate some of this instruction with more specific items students are requesting, esp at higher levels (ie GED prep)

## Thank You!

- Currently analyzing data
- Would be glad to consider any questions you might have through data analysis process