Australian Journal of Adult Learning Volume 52, Number 1, April 2012

Diabetes literacy: health and adult literacy practitioners in partnership

Stephen BlackUniversity of Technology, Sydney

This paper describes pedagogy in a series of ‘diabetes literacy’ programs involving culturally and linguistically diverse (CALD) communities. The programs were jointly delivered in local community sites, including neighbourhood centres and public housing halls, by qualified nutritionists from a public health service and adult literacy teachers from a technical and further education (TAFE) institute. The programs were funded by the Australian Government as an adult literacy innovative project, and they were considered innovative because the concept of ‘diabetes literacy’ is relatively new, and in the Australian health literacy context, the work of health professionals in a team with adult literacy teachers and other organisational partners is undeveloped and rarely documented. The main focus of the paper is on how these two partners managed to work together effectively within an integrated literacy approach focusing on the situated health needs of selected CALD communities.

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Introduction

ThispaperreportsonaprojectfundedbytheDepartmentofEducation,EmploymentandWorkplaceRelations(DEEWR)underits2007AdultLiteracyNationalProject.Itwasaninnovativeprojectinthesensethatitfocusedon‘diabetesliteracy’,aconceptnotyetwidelyknown,anditinvolvedorganisationalpartnershipsbetweenavocationaleducationandtraining(VET)institution,apublichealthorganisation,adiabeteseducationorganisationandlocalcommunitygroups(seeBlack,Innes&Chopra2008).Atlocallevelssimilarpartnershipsmayhaveoperated‘undertheradar’,butrarelyhavetheybeendocumentedinAustralia.Acentralfeatureoftheprojectinvolvedadultliteracyteachersco-presentingwithqualifiednutritionists(alsodietitians)toprovidediabeteseducationtolocalcommunitygroups.Underpinningthedeliveryoftheprogramswasapedagogywhichviewedparticipantsasmembersofsocialnetworks(Balatti&Black2011),andfocusedontheirsituatedhealthneeds.Thispapermakesthecaseforthefurtherdevelopmentofsimilarpartnershipsandpedagogicalapproachesinhealthliteracyprojects.

Theprojectinvolvedthetriallingofsixshortdiabetesliteracyprograms(twohoursperweekforsevenweeks)whichfocusedoneducatingculturallyandlinguisticallydiverse(CALD)groupsabouttherisksandpreventionoftype2diabetes.Theseprogramscanbeseenasalocalresponsetowhathasbeentermedanationaldiabetes‘epidemic’(DiabetesAustraliaNSW2007),orinthewordsofsomeresearchers,adiabetes‘juggernaut’(Zimmet&James2006).Theprogramswereconductedoverthecourseofoneyear(fromOctober2007toSeptember2008)andeachprogramtargeteddifferentCALDgroupsintheirlocalcommunitiesontheoutskirtsofamajorAustraliancity.ThetargetgroupsincludedCALDgroupsknowntoexperienceahigherrateoftype2diabetes,includingpeopleborninChina,Armenia,IranandAfghanistan.Eachprogramwasjointlydeliveredbyanadultliteracyteacherandaqualifiednutritionist,with

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thesupportinsomecases,ofalocalcommunitymemberwhoactedasaninterpreter.Adiabetessupportorganisation(DiabetesAustralia)providedsomeresourcesandprofessionaldevelopmentforadultliteracyteacherspriortotheprograms.Thefocusofeachprogramwasonthepreventionnotthemanagementoftype2diabetes,andeachprogramfocusedoneducatingaboutthetypesandnatureofdiabetes,andtheroleofdietandexerciseinhelpingtopreventtype2diabetes.

An integrated concept of literacy

Theprogramswerebasedonan‘integrated’conceptofadultliteracy(e.g.Courtenay&Mawer1995;McKenna&Fitzpatrick2005;Wickert&McGuirk2005;Black&Yasukawa2011).Thatis,theprimeconcernintheprogramswastheeffectivedeliveryandunderstandingofimportanthealthmessages,andliteracypracticeswerehighlightedandaddressed‘asinterrelatedelementsofthesameprocess’(Courtenay&Mawer1995:2).Thus,theywerenotprogramsdesignedtoimproveliteracyskillsassuch,exceptintheprocessoffacilitatinglearningaboutdiabetesprevention.Theadultliteracyteacher’srolewasmainlytominimiseEnglishlanguageandliteracybarrierstolearning,andtohelpprovidetheapproachtolearningthatbestenabledparticipantstolearnaboutdiabetes.Qualifiednutritionistsprovidedthediabetesknowledgeandexpertise.

Diabetes literacy—a new concept

Whilehealthliteracygenerallyisacontestedconcept(e.g.Peerson&Saunders2009),wedrewonadefinitionofhealthliteracybyZarcadoolas,PleasantandGreer(2005:196–197)todefinediabetesliteracyas:‘Theskillsandcompetencestocomprehend,evaluateanduseinformationtomakeinformedchoicesabouttherisks,preventionandmanagementofdiabetes’.Specifically,themajorconcernwastype2diabetes,andtolocatediabetesliteracyasanactiveformofcommunitydecision-makingforpromotinggoodhealth.Inthe

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internationalresearchliterature,therearerelativelyfewexamplesofspecificprogramsbeingconductedasameansofpreventingtype2diabetes,thoughprogramshavebeendevelopedtoassistcommunitygroupsinmanagingthedisease(e.g.Deitrick,Paxtonetal.2010),anddiabetesmanagementinformationisavailable(asa‘toolkit’)foradultswithlowliteracyandnumeracyskills(Wolff,Cananaghetal.2009).

Literature review

Thisprojectbringstogethertheadultliteracyandhealthsectorsina‘healthliteracy’initiative.InAustralia,comparedwithsomeotherwesterncountries(outlinedbelow),therearefewhealthliteracyinitiatives,andespeciallywhereliteracyandhealthprofessionalshaveworkedtogether.Todate,healthliteracyinAustraliahasbeenaconceptdevelopedandpromotedlargelyfromwithinthehealthsector(e.g.Nutbeam,Wiseetal.1993;Nutbeam1999;Green,LoBianco&Wyn2007;Keleher&Hagger2007;Peerson&Saunders2009)withverylimitedinputfromliteracyspecialists(foranexception,seeFreebody&Freiberg1999).

ThesituationinAustraliaisincontrasttohealthliteracyintheUnitedStates(e.g.Nielsen-Bohlman,Panzar&Kindig2004),Canada(e.g.Rootman&Gordon-El-Bihbety2008,Simich2009)andinEurope(Kickbusch,Wait&Maag2005),wheretheconceptandresultingprogramsareverywelldeveloped.Inthesecountriesandregionstherearealsoexamplesofstronglinksbetweentheadultliteracyandhealthsectors.IntheUnitedStates,thishasbeenevidentsincethe1990s(e.g.Sissel&Hohn1995;Hohn1998),andadecadeagotheselinkswerereferredtoas‘amaturingpartnership’(Rudd2002).IntheUK,the‘Skilledforhealth’initiativeshavedemonstratedsimilarlyeffectivepartnershipsbetweenhealthandadultliteracypractitioners(TheTavistockInstitute2009).

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InAustralia,thefirstnationalhealthliteracysurvey(AustralianBureauofStatistics2008)basedontheAdultLiteracyandLifeSkillssurvey(ALLS,seeAustralianBureauofStatistics2007)providedapotentialcatalystforthedevelopmentofhealthliteracyinitiatives,thoughtodatetherehasbeenlittleevidenceofanyaction.Defininghealthliteracyasessentiallytheabilitytoaccessandusehealthinformation,thesurveysoughttoquantifytheextentofhealthliteracyinAustralia,withclaims,forexample,thatthosewiththepooresthealthliteracylevelsweregenerallyolder,lackingformaleducation,unemployedortheirfirstlanguagewasnotEnglish.

Cross-sectoral partnerships

Inboththehealthandadultliteracysectors,thereiscurrentlyapushforpartnershipsaspartofatrendtowards‘linked-up’or‘whole-of-government’approachestoaddressingsocialpolicyproblemsandissues.Inhealthpromotionthepushforsuchpartnershipsandallianceshasbeengoingoninternationallyformorethanadecade(e.g.Gillies1998).Thisisduelargelytothehealthsector’sshiftbeyondclinicalandcurativemeasurestothegrowingrecognitionofthebroadersocial,economicandenvironmentaldeterminantsofhealth(e.g.Wilkinson&Marmot2003;Keleher&Murphy2004),andtheneedtocrosstheboundariesofdifferentpolicysectorsandthusbreakdownprevious‘silo’approachestohealth.

TheadultliteracysectorinAustraliabycontrastisrelativelynewtothepromotionofpartnershipsbut,inrecentyears,cross-sectoralpartnerships,communitycapacitybuildingandnotionsof‘integrated’and‘socialpractice’understandingsofliteracyhavebeenpromotedstronglyinsomenationalresearchreports(e.g.Wickert&McGuirk2005;Balatti,Black&Falk2009).ResearchbyFiggis(2004)andHartleyandHorne(2006),however,indicatethepaucityofpartnershipsinvolvingadultliteracyandthehealthsector.

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The role of social capital

Linkedstronglytothepushforpartnershipsandcommunitycapacitybuildingistheconceptofsocialcapitalwhichreferstosocialnetworksandrelationsbetweenpeoplewithingroupsasaresource(seeAustralianBureauofStatistics2004).Thereisincreasingrecognitionthatthesocio-economicwell-beingofindividuals,groupsandnationsisdependantnotjustontheacquisitionoftechnicalskills(humancapital),butalsothenetworks,trustandsharedvaluesthatcomprisesocialcapital(OECD2001).

Socialcapitalisincreasinglybeingseenasplayingaroleinbothhealthandadultliteracydiscourses.Forexample,ataverybasicstatisticallevel,theAustralianhealthliteracysurvey(AustralianBureauofStatistics2008)indicatesthatthosewhoparticipateingroupsandorganisations,evenasnon-paidvolunteers,achievehigherhealthliteracylevelsthanthosewhodonotparticipate.Whiletherearesomeresearcherswhoseetheroleofsocialcapitalinhealthasbothcomplexandcontested(e.g.Campbell2001;Szreter&Woolcock2004),neverthelessitisseentoofferausefulstartingpointandthespacetoexaminethedynamicsinvolvedinthesocialdeterminantsofhealth(e.g.Brough,Hendersonetal.2007),andworldwidethisisaburgeoningareaofresearch(e.g.Kawachi,Subramanian&Kim2008).

Intheadultliteracyfieldthereisresearchindicatingthesocialcapitaloutcomesfromadultliteracycoursesandhowparticularpedagogicalstrategiescanhelpproducetheseoutcomes,suchasfosteringbondingtiesbetweenparticipants,drawingontheirlifeexperiencesand,throughbridgingandlinkingties,encouragingconnectionswithoutsidenetworks(Balatti,Black&Falk2006,2009).Muchofthisworkdrawsonsocialtheoriesoflearninginwhichlearningisunderstoodtooccurbestwhenitissituatedin‘communitiesofpractice’(Lave&Wenger1991;Wenger1998).Learnersinthesecommunitiescreateandnegotiateknowledgeandmeaningin

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dialoguewithothercommunitymembers,andthusbecomeactiveparticipantsintheirownlearning.Thismodelhasbeenproposedrecentlyforhealthlearninginvolvingadultliteracyprograms(Schecter&Lynch2011),anditunderpinstheeffectivedeliveryofthetype2diabetespreventionprogramsdescribedinthispaper.

Type 2 diabetes and CALD groups

AccordingtorecentAustralianGovernmentreports,diabetesisoneoftheleadingchronicdiseasesaffectingAustralians,withanestimated787,500people(3.8%ofthepopulation)diagnosedwithtype2diabetesin2007–8(AustralianInstituteofHealthandWelfare2011:15).Further,therateoftype2diabetesinAustraliahasincreasedsteadily,triplingfrom1995to2007–8(AustralianBureauofStatistics2011).Themajorityofcasesoftype2diabetes(upto80%)areconsideredpreventableorcanbedelayedbyhealthydietandincreasedphysicalactivity(Colagiuri,Thomas&Buckley2007:2;DiabetesAustralia2007).IndigenouspeopleinAustraliaexperiencethehighestratesofdiabetes,threetimesthenon-Indigenouspopulation,anddiabetesisalsoassociatedwithsocio-economicdisadvantage,livinginremoteareasandbeingbornoverseas.Regardingthelattergroup,theprevalencerateishigherforpeopleborninregionssuchasNorthAfrica,theMiddleEastandSouth-EastAsia(AustralianInstituteofHealthandWelfare2008).

Itismainlypeoplebornoverseasinnon-EnglishspeakingcountrieswhocomprisetheCALDgroupsthatarethefocusofthispaper,andreportshaveexaminedthecomplexityoffactorsresponsiblefortheirhigherprevalencerates(e.g.AustralianInstituteofHealth&Welfare2003;AustralianCentreforDiabetesStrategies2005;Thow&Waters2005;Colagiuri,Thomas&Buckley2007).Includedinsocio-economicriskfactorsarelevelsofspokenandwrittenEnglish,andtheAustralianHealthLiteracySurvey(AustralianBureauofStatistics2008)indicatedthatpeoplewhosefirstlanguagewasnotEnglishperformedmainlyatthelowesttwohealthliteracylevelsonthefive-pointscaleofproficiency.

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Interventionstohelppreventtype2diabetesforCALDcommunitiesoftenfocusonchanginglifestylefactorssuchasdietandphysicalexercise,andsuccessfulinterventionsareseentobethosethatare consultative,involvingthetargetcommunity;collaborative,usingarangeofpartnerships;practical,inremovinglinguisticandsocio-culturalbarriers;andculturally appropriate,takingaccountofthecharacteristicsofthetargetgroups(Colagiuri,Thomas&Buckley2007).Establishingpartnershipswithethniccommunitiesinordertoencourageculturally-competenthealthpromotionisalsoseentobesignificant(NationalHealthandMedicalResearchCouncil2006).Alloftheseelementsresonatestronglywiththediabetesliteracyprogramsoutlinedinthispaper.

Methoology and research samples

Primarily,thisprojectadoptedaqualitativeresearchapproach.Theresearchcomprisedthreecomponents:firstly,anactionresearchcomponentinvolvingtheresearcher,theadultliteracyteachersandthehealthprofessionalsineachprogram;secondly,semi-structuredinterviewswiththeparticipantsattheconclusionofeachprogram;andthirdly,afollow-uptelephoneevaluationofparticipants’viewsundertakenatleastonemonthaftertheprogramfinished.Thispaperreportsmainlyonthefirstcomponent—theactionresearch.DetailsoftheotherresearchcomponentsareavailableinBlack,InnesandChopra(2008).

Thekeyaimofthestudy,andthemain‘new’elementtoberesearchedaspartoftheactionresearch,washowadultliteracyteachersandhealthprofessionalscouldworktogethereffectivelyasteamteachers.Forbothgroups,teamteachingwasnewinthedeliveryofdiabetesliteracyprograms,thoughsomeadultliteracyteachersdidhaveexperienceteamteachingwithdifferentvocationalteachersinaVETcontext.

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Actionresearchfocusesonthepracticalissuesofimmediateconcerntosocialgroupsorcommunities(Burns1999:24).Itisusuallyundertakeninnaturallyoccurringsettingsandusesmethodscommontoqualitativeresearch.Theparticipatorynatureofactionresearchanditsemphasisonchangeandreflectiveprofessionalpracticemadeitparticularlysuitablefortheinnovative,community-basedprogramsinthisstudy.Theactionresearchinthisstudymainlycomprisedjointplanningbetweentheadultliteracyteachersandhealthprofessionalspriortoeachsession,and‘reflections’attheconclusionofmostsessionsonhowthesessionsprogressedandhowtheycouldbeimprovedinfuture.Itfollowedtheestablishedformatofmostactionresearchstudies—thespirallingprocessofplanning,action,observationandreflection(e.g.Kemmis&McTaggart1988).Thereflectionsessionscomprisedtheresearcherwhoprovidedsomefocusquestions,togetherwiththetwoco-presentersoftheprogram,andthesesessionsweretaperecordedandlatertranscribedinfull.

Inlightoftheaimofthestudy—toinvestigatehowadultliteracyteachersandhealthprofessionalscouldworktogethereffectivelyasteamteachers—thetranscriptinterviewdatawereorganisedaccordingtoseveralthemes.Theseincluded:howan‘integrated’conceptofliteracywasimplemented;howtheadultliteracyandhealthprofessionalsdeterminedtheirrespectiverolesandprofessionalboundaries;theimportanceofplanningandcommunicationforsuccessfulprograms;andthemainelementsofacollaborativepedagogywhichincludedasocialcapitalapproachtopedagogy.Thesethemescomprisethemainheadingsofthefindingsanddiscussionsectioninthispaper.

Intotal,sixlocalcommunityprogramsweredelivered,featuringAsianandMiddleEasterncommunitygroupsidentifiedintheresearchliteratureasexperiencinghigherratesoftype2diabetes.Theprogramsweredeliveredinlocalcommunitysitesconsideredtobeinareasoflowsocio-economicstatus,andwhichfeaturedahigh

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concentrationofpublichousing.Thesitesincludedneighbourhood/communitycentres,achurchhall,apublichousinghalland,inoneprogram,aTAFEcollege.Onaverage,10participantscompletedeachprogram,andpredominantlyparticipantsintheprogramswerefemale(86%).Theagesofparticipantsvaried,butprimarilytheywereolder,averaging55years,thoughintwoprogramstheagesaveraged70and72yearsrespectively.Recruitmenttotheprogramswasmainlythroughwordofmouthviaexistinglocalcommunitynetworks,includingthroughlocalChinese,ArmenianandIranianorganisations.

Program structure

Thestructureoftheprogramswasinitiallydeterminedthroughdiscussionsbetweenthenutritionistsandtheadultliteracyteachers.Whilethereweresomeslightvariations,inthemainthesixprograms(oftwo-hoursessionsforsevenweeks)adoptedthefollowingstructure:

Weeks 1 & 2: Introduction,gettingtoknowparticipantneeds,introductiontowhatisdiabetes—thedifferencesbetweenthetypesofdiabetesandhowdiabetesaffectspeople.

Weeks 3 & 4: Afocusondiet—discussionsonfoodtypes,foodlabels,nutritionandthefoodanddietoftheparticipantsinthecourse.Insomeprogramsatriptoasupermarketwasundertaken.

Weeks 5 & 6: Afocusonexercise—pedometersweresuppliedtoeveryparticipant,andinsomeprogramsthereweregroupexerciseactivities(TaiChiforexample,andashortwalkingtourinthecommunity).

Week 7: Arelaxedfinalsessionwithgeneraldiscussions,recapsontheessentialmessages,detailsprovidedof

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diabetestreatmentreferralservicesinthearea,andacommunallunchprovidedbytheparticipants.

Findings and discussion

Implementing an ‘integrated’ concept of literacy

‘Integrated’literacyisawellknownconceptinvocationaleducationandtraining,butthereareoftenmisunderstandingsoverwhatitinvolvesandhowitshouldbeimplemented(Black&Yasukawa2011).Forseveralofthepresentersinthesediabetesliteracyprograms,itwasmainlythroughtrialanderrorthattheygainedabetterunderstandingofhowitmightworkeffectivelyinpractice.Aswehaveindicated,theseprogramswerenotdesignedtoimproveliteracyskillsassuch,exceptintheprocessoffacilitatinglearningaboutdiabetesprevention,butattimesthismessagebecamealittleconfusing.Ahealthprofessionalcommentedatonestage,‘well,Idon’twanttotakeoverbecausetheaimisalsoliteracy’,whichwasnotentirelycorrect.Inherparticularprogramtherewasgreaterpotentialforconfusionbecauseitinvolvedconvertinganexistingadultliteracyclasstoadiabetespreventionclassfortheperiodoftheprogram(sevenweeks).Whiletherationalefordoingthiswassound—workingwithanexistingmainlyChinesecommunitygroupattendinganoff-campusliteracyclassinalocalneighbourhoodcentre—itwasneverthelessfoundproblematictore-labeltheclassasa‘diabetesprevention’programandtothenexpectallparticipantsandpresenterstounderstandtheprimaryfocuswasnowhealthandnotliteracy.The‘integrated’concept,however,waslessofanissueintheotherdiabetesliteracyprograms,astheliteracyteacheronaprogramdeliveringtoaChinesegroupdemonstratedinexplainingwheresheconsideredliteracyshouldfitin:

WeusealotofEnglishandtheygetthekeywords,[but]fromanEnglishteacherpointofview,it’snotgivinggrammarandeverything,it’sjustthekeywords,likecarbohydrate,Glycemic

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Index…insulin,allthesekindofkeywords…orliketheGIsymbols,[so]theyknowwhattolookfor…

Determining roles

Itwastobeexpectedthattherewouldbesomedifficultiestoovercomewithtwoprofessionals,unknowntoeachotherpriortotheprogramandfromdifferentdisciplinarybackgroundsandsectorsofwork,teamteachingonaseven-weekprogram.

Astheprogramswereessentiallyaboutdiabeteseducation,inmostprogramsthenutritionistledtheprogrambyintroducingthediabetespreventionknowledge,andtheliteracyteacherprovidedasecondary,supportingrole,tryingtoensurethatparticipantsunderstoodandwereengagedwiththeissues.However,thiswasnotnecessarilythecasewithallprograms.Inoneoftheprograms,itwasclearthatthehealthandliteracypresentersconsideredtheyhadequalthoughdifferentroles,andtheyweresufficientlyconfidentandrelaxedenoughintheirrolesto‘justjumpupandinterchange’astheneedaroseinthesessions.Asthedietitian(D)explained,theyworkedtogetherinacooperative,equalfashion:

Yes,well,Ithinkweworkedverywelltogether,becauseoftenwewouldfindoneofuswasstandinguptalkingordoingsomethingonthewhiteboardandsuddenlytheclasswouldbetryingtosayawordandIwouldn’tknowhowtoinstructthemthroughthat,soIwoulddeflecttoL[theliteracyteacher],whowouldthentakeoverorjumpupanddoadiagram…andshewoulddothesamewhenshewasrevisingsomethingwiththemandacontentquestionwouldcomeup—eithershewouldansweritandlooktomeforconfirmation,orshewouldthrowitovertome...

Theliteracyteacherintheabovepartnershipstated:

D[dietitian]putsthecontent,andthenIdoactivities,say,withD’scontent,soshe’sliketheknowledge,andIkindofstructuretheclassanddotheactivitieslikeIwouldnormallyinaneverydayclassroom.

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Issuesinvolvingtherelativestatusofthetwoteamteachers,andwhetherornotonedominates,appeartobecentralissuesinteamteachingsituationsinvolvingdisciplinaryexpertsworkingwithadultliteracyandnumeracyteachers(Black&Yasukawa2011).Inanotherofthediabetesprograms,theadultliteracyteacherknewtheparticipantsverywell,havingtaughtthemliteracyskillsforpartoftheyear,andthisteacherwasalsoquiteknowledgeableaboutdiabetes.Inthesecircumstances,shetookamoredominantroleinthedeliveryoftheprogram,whichmadethehealthprofessionalfeeluneasy,especiallyassheconsideredsomeoftheinformationprovidedtoparticipantswastooprescriptive,andfromherhealthperspective,actuallyincorrect.Asshestated,‘it’shardwhensomeone’stryingtotalkaboutyourareaofexpertise’.

Professional boundaries

Theabovesituationofahealthprofessionalfeelinguneasyabouthowhealthknowledgewasbeingdeliveredbyanon-healthprofessionalshouldhardlybesurprising,andtherewereseveralothersituationsintheprogramswherebothoreitherpresenterswereseentomovebeyondtheirareasofprofessionalexpertise.Inonecase,adietitianfeltsufficientlystronglyaboutanissueofincorrectinformationbeingdeliveredthatsheinformedherco-presentingadultliteracyteacherbyemailpriortotheirnextsession.Similarly,someadultliteracyteachersexpressedtheviewthattheirco-presentinghealthprofessionalssometimesspoketoofastanddeliveredinformationinappropriately,forexample,coveringtoomanyconceptsinonego,orbeingtoodidactic(‘youcan’tjustsitthereandtalk’).Thesewererelativelyminorissues,easilyovercome,thoughtheyneverthelessdemonstratedthatpresenterswereawaretheyweremembersofdifferentprofessionalnetworks,andtherewasanaturalsensitivityontheirparttoreflectandprotecttheirownareasofexpertise.Inanidealsituation,itwaspreciselythecombination(i.e.‘integration’)ofthetwoareasofprofessionalexpertisethatofferedthepossibility

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ofanenrichedlearningexperienceforparticipants.Thefollowingthree-waydialogueinvolvingtheresearcher(R),adietitian(D)andherco-presentingliteracyteacher(L)canbeviewedasanexampleofprofessionalsrepresentingtheirrespectiveareasofexpertiseinanintegratedway:

(R)Well,that’stheotherthing,whentheydogoandconsultadoctor…theyknowthequestionstoask,theyalreadyhaveagrounding[astheresultofthiscourse]

(D)That’swhatI’dliketo,Imean,(my)personalrolethatIhaveisthattheywillleavethiswithanincreasedawarenessoftheissuesarounddiabetes,eating,exercise,careofthefeet,andwheretogoformorehelp,andtobeabitmoreempoweredinaskingtheirdoctor

(L)Andtheyknowwhatthesewordsmean,theyknowconcepts,whatinsulinisandwhatitdoes

(D)Takemorecontrolovertheirownhealth

(L)Andthey’vealreadygotthatschemabeforetheygointhere…theyknowthewords.

Therewasalsoinevitablyacarry-overofskillsandknowledgefromoneprofessionalareatoanother.Literacyteachersgainedknowledgeaboutdiabetesandhowtopreventtype2diabetes,andhealthprofessionalsdevelopedpedagogicalstrategiesappropriateforworkingwithCALDparticipants.

Planning and communicating

Akeyelementtoeffectiveteamteachingintheseprogramswastheplanningandthecommunicationbetweentheco-presentersthatwentonbeforetheprogramstartedandbetweensessionsduringtheprogram.Inmostprogramsthetwopresenterscommunicatedviaemailpriortothesessions,andthisenabledagoodworkingrelationship.Onedietitiancommented:

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Ourresourcescomplementedeachother.IhadthesepictorialresourcesIgotfromDiabetesAustraliaonrisk,andtheyfittedperfectlywiththeworksheets.Well,Iguessthat’sbecausewehadcommunicatedaboutwhatwewanted.

However,inoneoftheprogramswheretheco-presentersdidnotcommunicateveryeffectivelyfromthebeginning,thereweresomeinitialproblems,astheliteracyteacherexplained:

Iwasabitsurprisedbecausewhensheturnedup,shesaidsortof,‘now,doyouwanttogetstartednow?’…AndIwassurprisedbecauseIpresumedthatshewasgoingtobeleadingitandgivingtheinformation.SoIactuallydidn’tquiteknowwhere…[tobegin].

Inthisprogramthesituationwasquicklyresolvedbeforethefollowingsessionandhenceforththerewasregularcommunicationbetweenbothpresentersbyphoneandemail,promptingtheliteracyteachertolaterstate,‘Itfeltmorecomfortableandshesaidthattoo…Ifeellikewe’vegotbitmoreofagame-plan’.

A collaborative pedagogy

Alltheprogramswereconductedinaninformal,relaxed,interactivemanner,encouragedbythelocalcommunitycontexts.Everyprogramexceptone(conductedinaTAFEcollege)involvedparticipantsseatedaroundonecentraltable.Teachingfacilitiesweresometimessparsewithamobilewhiteboardbeingtransportedtotwocentres,butthatwasasecondaryconcern.InoneprogramtargetingChineseresidentsinaneighbourhoodcentre,otherChinesepeoplewereinthesamecentreplayingmahjong,tabletennisanddoingChinesebrushpainting.Asanindicationofinformalityandthecommunityfeeloftheseprograms,theliteracyteachercommentedthatatmorningteatimeherstudents,‘…haveachatwiththepeopleinthereandsaywhatthey’rebeendoing,andthenwegetpeoplewanderingpastthedoorandhavinganoseinhere’.

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InoneprogramtargetingAfghanandIranianmothers,theiryoungchildrenplayedclosebyandinteractedwiththemduringtheclass.SomegroupscomprisedmainlyolderparticipantswithsomeChineseandArmeniansintheirrespectiveprogramsbeingintheir80s,thoughsomeoftheirpeersintheclasswerequiteyoung.Inoneprogram,agrandmother,daughterandgrand-daughterwereallinvolvedinsessionsforashorttime,andintergenerationalandinterfamilialfactorsofsomekindwereatplayinotherprograms.Theformaleducationlevelsofparticipantsvariedalso,withsomehavinguniversityqualificationswhileotherswereilliterateintheirownfirstlanguage.Oneelderlyparticipantwasblind.Noattemptwasmadetoscreenparticipantspriortothecourse;allwerewelcomed.AlthoughthepresentersspokeinEnglish,inseveraloftheprograms,localcommunitymembersactedasinterpreters,andthisdynamic,multi-dimensional,communicationprocess,whileappearingtoanoutsideraschaoticattimes,allowedallparticipantstocommunicateinwaystheyfeltmostcomfortableabouthealthissuestheyallfeltstronglyabout.Theselocalcommunity/networkaspectswereverysignificantinfacilitatingtheinformalpedagogicalapproachintheprograms,andtheyareindicativeofthesocialcapitalelementsdiscussedinthefollowingsection.

‘Empowerment’ and a social capital approach

Alltheprogramsinvolvedasimilarpedagogicalapproach,withtheadultliteracyteachersbeingemployedintheoneTAFEcollege,andthuslikelytosharesimilarpedagogicalperspectives.Interestingly,therewasnohintofdissonancefromthehealthprofessionalswiththepedagogicalapproachtaken.Thediscoursesofadultliteracypedagogyandpublichealthinparticularsharesomesimilarthemes,withastrongfocusoncommunityandindividualempowerment,andeventhebackgroundinfluenceofeducationalphilosopherssuchasFreire(e.g.seeLaverack2004:51).

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Recentadultliteracyresearchhasdemonstratedhowparticularteachingstrategiesresultinsocialcapitaloutcomes(Balatti,Black&Falk2006,2009),andthepresentationofdiabetesknowledgeintheprogramswasundertakeninawaythatencouragedthesocialcapitalconceptsofbonding,bridgingandlinkingties.

Bonding tiesarethestrongtiesthatbuildcohesionandcommonpurposewithinthelearninggroup.Thereweremanywaysthatbondingwasencouragedwithintheprograms,andinparticularitinvolvedbuildingtrustwhichrequires‘encouragingpeopletogettoknowoneanotherandcreatinganon-judgmentalclimateinwhichpeoplefeelsafetosharelifeexperiencesandtomakeerrorsastheyarelearning’(Balatti,Black&Falk2009:23).

Oneliteracyteachersaidsheandthedietitiandeliberatelysatdownwiththeparticipantsinthesessionsratherthanstandup,‘sowedidn’thavethattypeofusandthemkindofthing,sowewerealloneyecontact’.Activitiesinthesessionswerealsoasnon-threateningaspossible.Forexample,ratherthanaskifanyparticipantshadtype2diabetes,participantswereaskediftheyhadorknewofanyfamilymemberswiththedisease.Participantsalsodidgroupactivitiesbasedontheirdietratherthanitemisetheirpersonalfooditemsoverasetperiod,whichmighthavebeenconfrontingorembarrassingtosomeparticipants.Thecommunityinterpreterswerealsoveryhelpfulasmediatorsinreducingthesocialdistancebetweenpresentersandparticipants.

Tonurtureasenseofbelonging,sessionsincludedalotofgroupdiscussionandworkinginpairs,andparticipantswereencouragedtosharetheirviewpointsandtheirlifeexperiences.Groupcohesionwasassistedbythehealthprofessionalsaccommodatingtheexpressedneedsofindividualparticipants,evenwhentheywerenotdirectlyrelatedtodiabetesprevention.Forexample,oneelderlyparticipantwantedtoknowaboutosteoporosis,whichthedietitiansubsequentlydiscussedwiththegroup,andanotherparticipantwithdiagnosed

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type2diabetesbroughthisownglucosereadingsalongforthedietitiantoadvisehimon.

Theexercisecomponentofoneprogramalsoencouragedgroupcohesion.TheTaiChivideowhichthepresentersshowedtothegroup,whileuseful,wassoonabandonedastheolderChineseparticipantsdemonstratedtothepresenterstheirownlocalformofTaiChi.Thesessionwas,inthewordsoftheteacher,‘veryphysicalandtogether,reallyconnecting…’.Thissessioninturnseemedtoencouragethegrouptofocusonotherformsofdanceinthenextsession,furtheringbondingwithinandbetweenparticipantsandthepresenters,astheliteracyteacherindicated:

…andtheywouldalllaugh,andthentheotheronewouldgetthemtoshowthemsomekindofdance...andtheyareshowingeachotherdifferentdancemovesandthingsthisweek,I’vekindofnoticedthat,socialaspectsofthem…itwasverynice,butitwasaveryrolereversal,theywereshowinguswhattodo…Butitwasreallylovely,andtheywerelovingit,andIwasgettingmyrightandleftwrongallthetime...

EvidenceofincreasedbondingandtrustinthegroupwhichresultedfromthispedagogicalapproachwasprovidedinoneChinesegroupwithparticipantsincreasinglyadmittingtohavingtype2diabetes.Thisappearsrelevantbecausethereisevidenceintheresearchliteraturethatsomeethnicgroups,includingtheChinese,feelstigmatisedbyacknowledgingtheirdiabetescondition(Colagiuri,Thomas&Buckley2007:22).Andyet,assessionsprogressedandparticipantsfeltmoreateaseintheirgroup,theywereaskingspecificquestionsrelatingtotheirowncondition,includingbringingalongtheirownmedicalrecordstodiscusswiththedietitian.Asthedietitiannoted,‘IthinkinthefirstweekorsoIwasawarethatonepersonactuallyhadtype2diabetes.Bytheend(aftersevenweeks),therewerestillpeoplecomingoutofthewoodwork’.

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Bridging ties, whicharelinksbetweengroupsofpeoplewhoaredifferent,andlinking ties,thoselinkstoinstitutions,werealsoencouraged.Therewereinstances,forexample,ofthepresenterstryingtoencourageparticipantstojoinwalkinggroupsoralocalgymorswimmingclubordancinggroupinordertoincreaselevelsofphysicalactivity.Someparticipantswereencouragedtogetinvolvedinacommunitygardenprojectinonelocalarea,andlocalexcursions(wherepossible)wereafeatureofeachprogram.Inallprograms,linksweremadetolocalhealthinstitutionsprovidingspecialiseddiabetesservices.

Thepedagogywasthussituatedintheeverydaylivesoftheparticipantsintheirowncommunities.Whilethetwopresentersdidhaveapre-conceivedideaofthestructureoftheprogramsessions(outlinedearlier),theaimwasnottoadoptadeficitapproachandimpartknowledgetounknowingparticipants.Veryquicklysessionsfollowedthedirectionoftheparticipants’interests.SessionsondietinoneprogramforChineseresidents,forexample,ledtoheateddiscussionsaboutdifferenttypesofrice,therelevantcoststopurchase(ricewithalowerglycemicindex[GI]tendstobemoreexpensive),andculturalvaluesinconflictwithhealthiestoptions.Thisledtoacompromisehealthmessageofeatingsmallerservingsofrice,butmorevegetables.Culturalvaluesrelatingtodifferenttypesofcookingoilweresimilarlydiscussedandnegotiated,andseeminglystraightforwardconceptssuchaswhatismeantby‘apieceoffruit’werethesubjectofcontestation.Theparticipantscouldbeseentocompriselearning‘communitiesofpractice’,withlargelysharedethnicandculturalvalues,andmuchoftheirlearningintheprogramsresultedfromdiscussionswitheachother.Interestingly,theoneprogramwherethisdidnotworkquitesoeffectivelywastheonedeliveredintheTAFEcollege.Inthisprogramtheparticipants,whilecomprisinga‘student’communityofpractice,featuredgreaterdiversityintheirlanguageandculturalbackgrounds,andtheclassroomseatingarrangements(atseparatetablesandinrows)did

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notencouragethesamelevelofdialogueandself-direction.Inthisprogramtherewasgreaterfocusonteacher-developed‘worksheets’,whichgavetheprogrammoreaflavourofformallearning,incontrasttotheinformalityofprogramsdeliveredinthelocalneighbourhoodcentresorpublichousinghalls.

Conclusions

Healthprofessionalsprovidingeducationonpreventingtype2diabetestovariousCALDgroupsinlocalcommunitycontextsisnotnew(seeColagiuri,Thomas&Buckley2007).Buttherearefeaturesofthisproject,includingthevariousorganisationalpartnerships,andadultliteracyteachersandhealthprofessionalsworkingtogetherwithinasocialcapitalpedagogy,thatmakethisprojectinnovativeandpotentiallyusefulasamodelforotherhealthliteracyinitiatives.

Intheliteraturereview,Rudd(2002),awellknownhealthliteracyspecialist,refersto‘amaturingpartnership’betweentheliteracyandthehealthsectorsintheUnitedStates.Bycomparison,andadoptingtherelationshipmetaphor,thiswouldmakepartnershipsbetweenthetwosectorsinAustralia,suchasthosefeaturedinthisproject,akinto‘afirstdate’.Asindicatedintheliteraturereview,thereareveryfewdocumentedcasesinAustraliaofhealthandliteracyprofessionalsworkinginpartnership.

Thispaperindicatestoalargeextentthepotentialforadultliteracyteachersandhealthpractitionerstoworktogethereffectively.Theyappeartosharetheaimsofindividualandcommunityempowerment,andtheycanworkcollaborativelyusingpedagogicalapproachesthatencouragesuchempowerment.However,thisprojectwasessentiallyapilotstudy,aone-off,government-funded,innovativehealthliteracyproject,andtomovebeyondpilotstudiestomoresystematicinitiativesrequiresgreaterresourcecommitments.Whilethisprojectfeaturedorganisationalpartnershipsatthemicro(theteachinginterface)andmeso(middleorganisational)levels,whatAustralia

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lacksintheareaofhealthliteracyarepartnershipsatthemacrolevel—betweenpeakgovernment,healthandliteracy/educationalorganisations(seeBalatti,Black&Falk2009),whichwouldprovidesomepolicydirection,stablefundingandsustainabilitytohealthliteracyprogramsinAustralia.Thesediabetesliteracyprogramshopefullywillencourageastepinthatdirection.

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About the author

Stephen Black is a Senior Researcher in the Centre for Research in Learning and Change at the University of Technology, Sydney. Most of Stephen’s research has been in areas relating to adult literacy studies. His PhD is 2001 was entitled ‘Literacy as critical social practice’, and most of his research has been located within socio-cultural understandings of literacy, including recent work on social capital with Jo Balatti and Ian Falk, and integrated literacy and numeracy with Keiko Yasukawa.

Contact details

Centre for Research in Learning and Change, University of Technology, Sydney, Building 10, Level 5, 235 Jones Street, Broadway 2007Tel: (02) 9514 4590 Fax: (02) 9514 3939Email: Stephen.Black@uts.edu.au