The instructional system design process (ISD) often overlooks health literacy. This paper has two purposes. First, I will examine health literacy and its social implications by describing instructional design process and its relationship to curriculum design using instructional design models, applying adult learning and teaching principles to health literacy. Second, demonstrate how instructional system design can provide a practical method to improve the effectiveness and efficiency of adult health literacy delivery. Research question: Can the principles of adult learning coupled with technology and IDS content make change outcomes?
Many public health educators are content / subject proficient but not formally trained in ISD and its technology. Ineffective instruction or communication results in failure to understand, interpret, or ignore required action. To create efficient and cost effective health literacy programs for adults, it is essential the health practitioner distinguish and understand how educational adult theory (andragogy) and applying instructional system designs can enhance health literacy.
Introduction to Problem: Impact of Inadquate Health Literacy:
Adult literacy is alarming low. The National Assessment of Literacy Survey (NALS), conducted in 1992 and funded by the US Department of Education, provides insight of adults living in United States. Literacy is complex. NALS reported 90 million adults scored in the lowest two levels of a five level scale that assesses the proficiency of practical reading and routine numerical skills required to function in society. Forty million people read on the lowest level and another 50 million scored at a level two. NALS reported that 44% of adults age 65 years or older scored in the lowest level. Level 2 indicates a 5th grade reading level. (Berkman, 2004; Dewalt, Berkman, Sheridan, Lohr, & Pignone, 2004; Gazmararian, et al., 1999)
The NALS survey profiles English literacy of US adults using a variety of tasks and materials encountered in their daily lives. The survey of over 26,000 adults explored the connections between literacy skills, and social and economic variables such as voting, economic status, employment and income. The results have wide spread educational and social implications with practical information about the literacy skills of the US adult population and the vulnerable ‘at risk’ population. This study underscores how educational systems are inadequate or at best mediocre. It demonstrates that human capital is wasted and appropriate national action is required.
Outcomes of poor health literacy:
Inadequate health literacy is a wide spread problem. Inadequate health literacy is a public health issue. Poor health outcomes are expressed in terms of mortality, morbidity, disability, dysfunction, functional independence, and quality of life.
Low health literacy affects individuals but also can affect public health resources. Engaging in healthy lifestyles is important, but health literacy is necessary to avoid risky behaviors. Studies that regular physical activity can help prevent or manage a variety of chronic disease. Regular physical activity has beneficial effects on all cause mortality, increase longevity, heart disease, hypertension, diabetes, lipid disorders, osteoporosis, cancer, obesity, weight management, mental illness such as anxiety and depression. In terms of public health, poor lifestyle choices can reduce health status, resulting in poor health knowledge, worse health behaviors, threatened health care quality and increased health care services costs.
Individuals with poor health literacy may not present themselves for primary or secondary care, or they lack understanding on the importance of follow up care. They often do not present themselves preventive care screenings such as flu shots or STD (sexual transmitted disease) testing. They often do rely on emergency care and do not seek primary care. These behaviors results in increased emergency care, inpatient, and a higher rate of hospitalization.
Individuals with poor health literacy have a greater difficulties navigating and accessing care. Research documents that 81% of English speaking elderly patients had inadequate health literacy. Sometimes individuals are ashamed, because cultural differences influence the way individuals interpret their health problems. (cite) Individuals with Lower English Proficiency (LEP) are less likely to engage in regular health care, seek emergency care, including dental care or filling prescriptions. (cite). LEP individuals, families, lower income individuals have difficulty knowing how to navigate Medicaid or utilize state health plans. Individuals do not understand their rights, responsibilities including, including informed consent because of low health literacy.
Individuals with low health literacy skills usually have higher health costs than those health literate individuals. Lower health literacy individuals are more likely to self-treat themselves resulting in higher out of pocket expenses. Sicker individuals utilized greater resources. Contributing causes is higher number of excessive emergency care, hospitalization, medication errors and higher acuity of illness due to self-care. This results in higher Medicare, Medicaid and private insurers costs. Absorbing this extra financial burden are taxpayers.
Rising health insurance premiums may forgo insurance companies from offering because of economic conditions. Recently, many business and corporations have reduced their benefit programs to employees, retirees and their spouses. Benefit reductions has reduced wellness screenings, regular health care checkups, and medications. Cost becomes a factor; individuals may select to self-treat, taking advice from friends, family and internet. Individuals lacking adequate health literacy skills are not likely to recognize the risk involved in self- medication when professional care is warranted.
Define Health Literacy: Conceptual Requirements: (Tasks and performance skills required)
Health literacy differs from general literacy. In 2003, the National Assessment of Adult Literacy (NAAL) expanded adult literacy study to include assessing adult ability to perform health related activities or tasks. (White, 2008) Because of the rapid growth that health literacy has achieved in the last two decades, it has experienced several variations in definitions.
Agency for Healthcare Research and Quality (AHRQ) describes literacy as “an individual ability to read, write and speak in English and compute solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and to development one’s knowledge about a particular topic.” This definition comes from the 1991 National literacy act. Both the Institute of Medicine (IOM) and the American Medical Association (AMA) describes health literacy as constellation of skills, including the ability to perform basic reading and numerical tasks required to function in a health care environment.” (cite)
Because of lack of consensus, the definition continues to evolve. (cite Pleasant 2011) The multiple terms is due to lack of consensus. Criticism of AHRQ is the definition requires the individual to read and write in English. The IOM and AMA definition requires the individual to function in a health care environment and does not recognize health literacy within the context to daily life decisions. These decisions are not context driven in everyday life. In a 2004 IOM report, entitled Health Literacy: A Prescription to End Confusion explains “health literacy goes beyond the individual. It depends upon the skills and expectations of health information and care providers: our doctors, nurses, administrators, home health workers, and many others.” (Joint Commission Resources)
A similar definition to the IOM is the National Library of Medicine (NLM) definition The term is described “ as the degree to which individuals have the capacity to obtain, process and understand the basic health information and services need to make appropriate health decisions.” (Parker & Jacobson, 2000). This definition is found on the Healthy People 2010 web site. The framework for Healthy People activities and process focuses on health promotion.
The Ottawa Charter defines health promotion as “the process of enabling people to exert control over the determinants of health and thereby improve their health.” Health promotion is process that is a means to its own end and not an outcome in its own right. Health promotion represents not something done on or to people but it is done with people either as an individual or as a group. (Nutbeam- 98) Health literacy and empowerment fits within the context of health promotion.
Zarcadoolas, advances the defination and theme stating an individidual with good health litearcy evolves over an individuals lifespan. It is influenced by such factores as general state of health, culture, democraphics, pyscholosocial variables. General factors influencing health litearcy are age, education, race and ethnicity. Hearing, memory, resasonng, verbal ability and vision are phsycial facotrs influencing health literacy. Social health literacy factors include; culture, employment, income, language, occupation and social support. The defination is describeds as “the wide range of skills and competencies tghat people develop to seek out, comprehend, evalutae and use health information and concepts to make informed choices, reduce health risks, and increase quality of life.” (cite Assessing Health Literacy Needs)
Strategies to increase people’s control over their health are critical. For individuals, empowerment requires daily health decisions, in the home, the workplace, the community, the marketplace, and the political arena. (Pleasant, 20110) Health literacy empowerment requires prevention knowledge, behavioral care practices, and navigation skills. Acquiring and practicing health literacy is necessary for individuals, organizations, business and institutions.
According to the Joint Committee on National Health Education Standards, a health literate individual posse; skills and abilities for critical thinking and problem solving, a productive and responsible citizen, an effective communicator and a self-directed life long learner. (cite, p. 2)
Contributing Health Literacy Variables:
Health literacy requires more than functional interaction and interpretation skills. Social and community factors influence health literacy. Individual factors include; poor English skills, limited education, inability to communicate effectively and motivational level influence. Unfamiliar terms or medical jargon, inability to navigate a health system, including electronic technology, or have utilized health services beyond primary or public health care. Certain mental health conditions can affect an individual level. Individuals with poor mental health may not recognized common emotional or identify mental disorders. Without outside support are unable to make decisions or seek assistance. This conditions leads to delays in effective diagnosis and treatment, often leading to less effective or self-care. Health literacy has been extended into ‘maternal health literacy’. It is defined as “the cognitive and social skills that determine the motivational and ability of women to gain access to, understand, and use information in ways that promote and maintain their health and that of their children.” (cite)
Communication is crucial skill for effective health literacy. An individual is influenced by their belief system, including ethnicity, family history, religion, social status and values. Problematic is the failure to understand language. US Census 2007 reports there are four major language groups, but there is growing role of non-English language due to the US being a destination from other nations.. “This language diversity will also likely continue.”
Implementing Solutions: Theory
Integral to health practices, health promotion, and research are theories. Theories provide a framework of examining and observing reality. Theories shape knowledge collection and interpretation. From a practical and scientific viewpoint, theories inform and influence our understandings of learning and health. Basic beliefs of theories center on the production of knowledge, what counts as knowledge, and the nature and working of things. Theories provide a conceptual framework for understanding key construct that influence health behavior. (cite Anderson, BMJ,
(Nutbeam, 2000) suggests that health literacy is an outcome of health education and identifies the domains as function, interactivity, and critical literacy. Major variables in health behavior changes are knowledge, skills, beliefs, and values. Behaviors are cognitive and affective. Wolf (2009) reported earlier health literacy interventions were limited, strategies involved ‘rewriting health materials at a simpler level or following designed principles to enhance reading comprehension.” (p. S276) Latter efforts using multiple approaches, on various behaviors, knowledge, and outcomes have shown hopeful results.
Recent literacy intervention focuses on advancing the conceptual understanding the problem. Because health literacy is so broad, emphasis on reading or reading difficulties may be restrictive and not address the broader health literacy definitions previously discussed. Health knowledge, behavior and motivation is problematic. Bozekowski (2009) approaches health literacy using cultural relevant participatory strategies. These interventions, based on educator and philosophy Paulo Freire, encourage the individual to take greater responsibility for personal learning and well-being, thus reducing dependence patterns., Freire viewed education must be greater than ‘banking’ text. The ‘banking of text and facts’ kept marginalized groups political powerless. The process of education occurs through discussions, reflection and action served to liberate or empower individuals.
Recognizing the learner
Robert Gagne (1916-2002) suggests there must be conditions of learning, principles of information process and models of cognitive learning. “Instruction is a set of events embedded in purposeful activities that facilitate learning.” Analyzing and understanding the learner is critical for teaching because it allows the instructional design process to match the learner needs
Gagne recognizes that learning is a complex process influenced by many variables. Teaching tasks include selecting materials, assessing, managing, monitoring, facilitating and serving as a resource. Instruction is a process involving a range of activities to engage the learner. This process involves understanding the practice design, vision, assessment, monitoring, and evaluation. Instruction becomes a process of ‘intention’ as opposed to ‘incidental’ learning. Learning has desired and meaningful learning outcomes. These outcomes can be information learning or problem-solving skills. (Gagne 2005, p 1- 3)
Wolf(2009) believes the “that measures of literacy and health literacy are strongly correlated with specific and global tests of cognitive functions. The consideration of cognitive abilities in the act of learning about and managing one’s health may better clarify how individual skills subsequently affect health behaviors and outcomes.” (p. s276).
Shambaugh (1997) says models have three useful purposes. 1), understand and represent reality helps to explain complex systems (Cognitive). 2) Models help to communicate how the learner and designer perceive the environment (Behavioral). 3) Models reveal the hidden reality about “what our views are on learning, teaching or designing” (Constructivists).
Wolf (2009) views health literacy interventions should target the health system complexity. This requires deconstructing what is asked, how to understand the tasks and seek ways to simplified or eliminate tasks. Wolf provides a scaffold using from the fields of education, cognitive science, psychology research. This model approach involves “recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. He describes this as a “health learning capacity.” This framework explains the fundamentals required for obtaining, processing and understanding health information and making health decisions. (Model appendix.)
Conceptual model of health learning. (Wolf, 2009)
According to Duffy & Conningham, constructivism shares similarities and differences between many learning theories; however, the basic tenets are (1) learning is an active process of constructing rather than communicating knowledge, and (2) instruction is a process supporting construction rather than communicating knowledge. (p. 2)
The primary idea of constructivism is the learners make self-judgments about how and when to modify their knowledge. Learning becomes self-directed, a method of organizing teaching and learning so that the learning is within the learner’s control. The goal of the self-directed learning is to become and accept responsibility for his/her learning. Self constructive learning requires a degree of self motivation.
Adult Learning Theory-An Andragogical Process Model for Learning:
In applying the adult learning framework, Knowles (2005) originally based andragogy on the five assumptions previously described. These assumptions were changed to seven principles or guidelines sought to teach independent and self-directing learners. For the adult learner, the instructor’s role is to facilitate or process the learning experience and not teach the subject content. This process model involves seven elements. These teaching guidelines or principles include:
1. Based on Maslow Hierarchy of Needs Theory, establishing an effective and conducive learning environment is important for learners to feel safe and comfortable in expressing themselves.
2. Learners mutually plan relevant learning strategies and content. This involves self-directed learning and requires the learner to accept responsibility for his or her own learning. Successful application of self-directed learning supports Self-Efficacy theory. (REF)
3. According to Knowles, learners assess their learning needs as a critical part of self-directed learning. Self-assessment triggers internal motivational drives. Assessment influences learning.
4. Leaders formulate their own learning objectives. Adults are mature, independent, self-directing and desire to have control of their learning. According to Allen Tough’s The Adult learning Projects, “when adults learn on their own initiative, they learn more deeply and permanently than what they learn by being taught.” (Knowles, p. 265)
5. Learners identify resources and develop strategies for using them to achieve their objectives.
6. Learners carry out their plans by supporting skills that involve building relationships serving as a resource, and encouraging individual initiative.
7. Learners evaluate their own learning by providing “opportunity for and support reflection on both the content learned and the learning process.” (Knowles, p. 193)
Table #: Comparative Learner Assumptions
1. Adults are independent & self directing
2. Accumulated a large amount of experience that is a rich learning resource
3. Value learning that integrates with the demands of everyday life tasks and problem solving
4. Interested in immediate problem centered approach rather than subject centered
5. Motivated to learn by internal drives rather than external ones
1. Concept of the learner
2. Learners experience role
3. Readiness to learn
4. Orientation to learning
Instructional System Design
• Models – teaching and learning
• Basic Requirements
Application of Technology ( search literature – two example,
• Use of audio podcasts
• Blogs and other social media
• Technology emailing – text messaging,
• Interactive Multimedia
• Older adults
• Isolated –
• Lack technology
• Networking / support system
• Navigating system – legal / regulator
How do we incorporate basic learning into health literacy:
(Listening, speaking, analogies, numeracy, language, questions and answering, stories, etc….