OVERVIEW and - NCSALL

Skills for Health Care Access and Navigation

HEALTH LITERACY STUDY CIRCLES+

HALL/NCSALL May 2005

OVERVIEW andPREPARATIONfor SESSION ONE

NCSALLThe National Center for the Study of Adult Learning and LiteracyHarvard Graduate School of EducationNichols House, Appian WayCambridge, MA 02138(t) 617-495-4843 (f) 617-495-4811Web site: www.ncsall.net

HALLHealth and Adult Learning and Literacy InitiativeHarvard School of Public HealthDepartment of Society, Human Development and HealthHealth Literacy Studies677 Huntington Avenue, 7th FloorBoston, MA 02115(t) 617-432-1135 (f) 617-432-3123Web site: www.hsph.harvard.edu/healthliteracy

Copies of the Health Literacy Study Circle+ guide, Skills for Health Care Access and Navigation can be ordered by contacting NCSALL/World Education, 44 Farnsworth Street, Boston, MA 02210, (t) 617-482-9485, (f) 617-482-0617, (E-mail) [email protected].

Copyright © 2005 by National Center for the Study of Adult Learning and Literacy andHealth and Adult Literacy and Learning Initiative.

Skills for Health Care Access and Navigation

Rima Rudd, Sc. D.

Lisa Soricone, Ed. D.Maricel Santos, Ed. D.

Emily Zobel, Sc. M.Janet Smith, Ed. M.

Winston Lawrence, Ed. D.

OVERVIEW and PREPARATIONfor SESSION ONE

HEALTH LITERACY STUDY CIRCLES+

HALL/NCSALL May 2005

About the Authors and Contributors

The following Health and Adult Literacy and Learning (HALL) teammembers contributed to the writing, editing, and the design of theFacilitator’s Guide to the Health Literacy Skills: Health Care Access andNavigation Study Circle+.

Rima Rudd, Public Health Researcher and Educator

Lisa Soricone, Educator and NCSALL Research Associate

Maricel Santos, Educator and NCSALL Research Associate

Emily Zobel, Public Health Practitioner

Janet Smith, Educator and Coordinator of HALL

Winston Lawrence, Adult Education Teacher-Training and Development

The following individuals offered substantial contributions to the HealthLiteracy Skills: Health Care Access and Navigation Study Circle+:

In-depth Reviews: John Comings, Winston Lawrence, David Rosen,Cristine Smith, Ira Yankwitt, Sarah Oppenheimer, and Jennie Epstein Anderson

Lessons: Kenny Tamarkin, Lee Hewitt, Vinetta Charles, andCarmen Gomez Mandic

Pilot Study Facilitator: Winston Lawrence

Pilot Study Partner: The Literacy Assistance Center of New York Elyse Rudolph, Director

Photography: Jon Crispin (photographer), Catherine Pham and Sarah Oppenheimer (coordinators for photo sessions)

Overview and Preparation

Organization of the Health Literacy Study Circle+ Guides

Study Circle+ Variations

Preparation for Session One

Materials to send out to participants (loose leaf pages following

this booklet)

Session One Booklet: Introduction to Health Literacy

Notes to Facilitator

Overview

Introductory Activities

Discussion and Analysis Activities

Planning Activities

Closure Activities

Materials (DVD in front notebook pocket, all other materials in

the loose leaf pages following the booklet)

Session Two Booklet: Identifying Access and Navigation Tasks andUnderlying Skills


Overview



Planning Activities

Closure Activities

Materials (loose leaf pages following the booklet)

Overview and Preparation for Session One v

Facilitator’s Guide Contents

Health Literacy Study Circles+: Skills for Health Care Access and Navigationvi

Session Three Booklet: Integrating Health Literacy Skills into Instruction


Overview



Planning Activities

Closure Activities


Session Four Booklet: Planning Lessons, Units, and Evaluations


Overview



Planning Activities

Closure Activities


Session Five Booklet: Developing Strategies for Success


Overview



Planning Activities

Closure Activities


As a facilitator of this study circle, you are about to embark on anexciting and powerful professional development experience. This guide isdesigned to be a training manual and resource for facilitators who willconduct the Health Literacy Study Circle+ on the topic of Health CareAccess and Navigation.

We use the word “navigation” in both a literal and figurative sense.“Navigating the health care system” means “finding one’s way” throughthe hallways of health centers and the departments of hospitals. It alsorefers to one’s ability to “obtain appropriate services.” Many adults in oursociety have trouble finding their way to and within health care programsand centers. They may face literacy-related barriers as they attempt tofigure out and obtain needed services and coverage. Furthermore, theymay be daunted by the language and assumptions of various groups ofservice professionals and the myriad forms and questionnaires put beforethem. Finally, they may feel intimidated or bewildered as they attempt tounderstand and advocate for their rights.

This Health Literacy Study Circle+ is based on five sessions. Each sessionis planned for approximately three hours (1⁄2 day). This notebook containsall the information you will need to conduct each of the sessions. Eachsession has been formatted as a bound booklet so that you can easilycarry it to the session and return it to the notebook. Behind each booklet(including this one), you will find materials such as background reading,handouts for activities, and materials for work between sessions. Thesematerials are in loose leaf format so that you will be able to make copiesfor each participant.

In addition, please note that this first booklet includes two variations, onefor those who have participated in another Health Literacy Study Circle+

and one for an expanded full day session. We placed the full descriptionof the two options here, in this booklet, so that you could make advanceplans for one or both variations.

Overview and Preparation for Session One 1

About This Study Circle+ Guide

Who should use this guide?

This Health Literacy Study Circle+ guide has been developed to help youfacilitate a learning experience for adult educators. If your state educationdepartment, community organization, or adult education program is lookingfor a professional development tool on the topic of health literacy, this guideprovides you with a manual and a resource for training adult educators.

Who should attend the Study Circle+?

All of the Health Literacy Study Circles+ are designed for practicing adulteducators who are interested in learning about health literacy and waysthat they can integrate health literacy skills into their classroom teaching.We use “adult educator” to refer to practitioners working in adult basiceducation (ABE), General Educational Development (GED), and Englishfor Speakers of Other Languages (ESOL) programs.

Important activities take place between study circle sessions. Participantsare asked to try out activities with their students and share their teachingexperiences and ideas with other participants. For this reason, it isimportant that participants have easy access to a classroom (ideally, theirown) for the duration of the study circle sessions.

Adult educators who participate in this study circle are not asked tobecome health care experts. Instead, they are encouraged to use theirexpertise and help their students improve their reading, writing, math, andcommunication skills and apply these skills to health materials and tasks.

How should this guide be used?

This study circle guide was developed for facilitators. It contains notes tothe facilitator, agendas, and all the printed materials and handouts you willneed to facilitate each of the sessions. The guide presents this study circleon Health Care Access and Navigation in a recommended format, but thedesigners expect that facilitators will review the material and adjust theformat and activities to suit the needs of the participating educators.

No matter how much experience you have as a facilitator or with studycircles, we strongly recommend that you read this entire guide. It includesdirections, all needed materials, guidelines for preparing materials,suggestions for working within the existing parameters of adult educationprograms, and facilitating tips for each session.

Health Literacy Study Circles+: Skills for Health Care Access and Navigation2

Health and Adult Literacy and Learning/NCSALL

What outcomes do we anticipate from this Study Circle+?

We hope that the outcomes of the Health Care Access and NavigationStudy Circle+ will be three-fold:

1. Outcomes for adult educators: The Study Circle+ on Health CareAccess and Navigation will offer teachers a deeper understandingof health literacy, health literacy research, and health literacy skills.

The activities used in these sessions feature a range of groupdiscussion methods that teachers might want to try out in theirclasses. We hope that activities such as small group discussions, useof “triggers,” and brainstorming, will expand teachers’ repertoireof co-operative learning tools.

This study circle will serve as a “jumping off point” for adulteducators to help them develop ideas and activities to improveadult students’ ability to access and navigate health care systems.This study circle also provides an opportunity for teachers to formsupport groups and networks of colleagues so that they cancontinue to discuss and share their experiences teaching andevaluating health literacy activities.

2. Outcomes for the field of adult education: This study circle willprovide opportunities to develop links between adult education andpublic health programs and between adult education professionalsand health care providers. The health goals and objectives for thenation, delineated in Healthy People 2010, include the goal ofimproving health literacy. The health field cannot do this withoutthe important contribution of adult education experts and apartnership with the adult education field. This study circlehighlights the expertise of adult educators by focusing on criticalhealth literacy skills.

3. Outcomes for adult education students: We hope that this studycircle will lead to positive changes in adult learners’ abilities tointeract with health care systems and professionals. The variousexample lessons offer opportunities for learners to acquire healthliteracy skills and increase their confidence in navigating healthcare systems. We believe that improvements in our students’ healthliteracy skills and in their health outcomes are the most importantmeasures of success of all the Health Literacy Study Circles+.



We welcome your comments and advice on how to improve the HealthLiteracy Study Circle+ and we look forward to hearing about yourexperience using this guide. In the future, we hope to post your suggestionsand examples of the work done in your groups on our Web site.

Please feel free to contact us:

Rima E. Rudd, Sc.D.Principal Investigator for Health and Adult Literacy and Learning StudiesHarvard School of Public HealthDepartment of Society, Human Development and Health677 Huntington Avenue, 7th Floor KresgeBoston, MA 02115Tel. 617-432-1135Fax. 617-432-3123E-mail: [email protected] site: www.hsph.harvard.edu/healthliteracy



The Health Literacy Study Circles+ Guides consist of two parts. The firstis a separate book titled: Introduction: Overview, Planning, andFacilitation Tips. The second is the Facilitator’s Guide, prepared innotebook format, containing all the information needed for each of thethree Health Literacy Study Circles+. The three Health Literacy StudyCircle+ Guides in the series are: Skills for Health Care Access andNavigation, Skills for Chronic Disease Management, and Skills for DiseasePrevention and Screening.

Overview, Planning, and Facilitation Tips

Introduction: Overview, Planning, and Facilitation Tips has beenstructured for use with all three Health Literacy Study Circles+. This bookaccompanies all Study Circle+ Guides, provides background informationabout each of the three study circles, and offers important guidelines forplanning, organization, and facilitation. Please read this book first, in full.

Facilitator’s Guide: Skills for Health Care Access and Navigation

This guide, in notebook format, contains six booklets. The first of the sixis titled Overview and Preparation for Session One. This booklet offers anoverview of Skills for Health Care Access and Navigation, study circlevariations, details related to preparation for Session One, and materials tobe sent out before Session One.*

Session Booklets

Each session booklet offers a step-by-step guide for conducting the sessionactivities with needed time indicated. A copy of all of the materials neededfor each session is provided as well. These materials, in loose leaf format,


Organization of the Health Literacy Study Circle+ Guides

*You will need to send out materials for Session One at least TWO WEEKS before thesession begins. The flow of Session One is dependent on the reading assignment.

consist of mailings to participants, background readings, handouts in thesession, and information and tools needed for work between sessions. Thefollowing bulleted list offers an overview of each session.

n Session One: Introduction to Health LiteracyParticipants develop a shared definition of “health literacy,” discussdifferent types of health-related activities, and identify barriers thatmake it difficult for people to complete those activities. Participantsalso prepare to conduct a needs assessment activity with theirstudents. After Session One, participants conduct a needsassessment with their students.

n Session Two: Identifying Access and Navigation Tasks and Underlying SkillsParticipants review the results of the needs assessment activity andcompile a list of specific health tasks and underlying skills that canbe addressed with their classes. Participants also review andprepare to teach sample health literacy lessons between SessionsTwo and Three.

n Session Three: Integrating Health Literacy Skills into InstructionParticipants evaluate the experience of teaching sample lessons anddefine key health literacy skills that they will focus on in theirprograms. They also begin to create new health literacy lessons andconsider what a health literacy unit would look like. After SessionThree, participants complete and teach their own health literacylessons and develop outlines for health literacy units.

n Session Four: Planning Lessons, Units, and EvaluationsParticipants share their teaching experience and consider healthliteracy units. They also consider how to define and measure theirstudents’ health literacy skills. After Session Four, participants use aplanning template to outline the design and evaluation of healthliteracy units.

n Session Five: Developing Strategies for SuccessParticipants share and analyze their plans and consider how they will incorporate health literacy skill development into theirprograms. They identify barriers, supports, and strategies for suchwork. Study circle participants also identify ways they can stay incontact and work together in the future.



Each session in the Facilitator’s Guide follows the same general formatand contains the following sections:

n Notes to the Facilitator: Offers brief descriptions and explanationsof the activities and the discussion methods that will be usedthroughout the session. It offers a rationale for the focus andstructure of the session’s activities.

n Overview: Contains the session objectives and agenda, lists thematerials you will need, and describes the preparations required forthe session.

n Introductory Activities: Contains the objectives and agenda and setsthe stage for the session.

n Discussion & Analysis Activities: Provides directions for helpingparticipants define the health literacy skills related to the study circle topic.

n Planning Activities: Describes the activities that participants willcomplete in their own classrooms between sessions.

n Closure Activities: Provides an opportunity for participants toconsider a range of discussion methods used during the session thatmight be useful for their own teaching. The evaluation activityoffers participants an opportunity to summarize and evaluate bothcontent and methods.

n Materials: Contains copies of all the readings and handouts neededfor each session.




This section describes two variations for this study circle. You will wantto consider the first option IF the participants have already completed oneof the other Health Literacy Study Circles+. You will want to consider thesecond option IF you and the participants agree to turn one of the halfday sessions into a full day meeting.

If participants have already completed one of the Health Literacy Study Circles+ . . .

If participants have already completed one of the three Health LiteracyStudy Circles+, you might choose to modify Session One by skipping overa good deal of the introductory discussions focused on health literacy andthe development of the study circles. You may, instead, want to include anactivity using photographs of people engaged in different health-relatedactivities to generate a discussion about barriers to navigating the healthcare system.

You will find a one-page description of this activity on the next page. Youwill find the photographs for this activity included with the “AlternateAssessment Activity” in the materials for Session One.

You can use this activity with study circle participants in the same way thatparticipants might use it with their students to generate a discussion. Youcan ask participants to look at the pictures, consider the activities illustrated,and identify barriers that people may face. This activity has been verypopular in workshops given at professional adult education conferences.

If you and the participants decide in advance to expand asession . . .

You could choose to expand one of the sessions to include a structured fieldtrip to a local hospital within easy access to where the study circle meets.

This activity is designed to provide participants with an active hands-onexperience of getting to a hospital and finding their way around thehospital. The purpose of the field trip is to heighten the participants’

Study Circle+ Variations



awareness of the challenges that their students might face getting to ahospital and navigating within a hospital setting.

If you meet in the mornings, consider having a lunch break and then planfor this two-hour activity after lunch. You will find a description of thehospital field trip in the following pages.

Variation for Session OneTime: as neededDiscussion Method: Group Discussion

When participants have already completed one of the other HealthLiteracy Study Circles+ please consider this substitution.

Activity with Photographs

Consider using the photographs (found with the materials for SessionOne) to facilitate discussion about barriers to navigating the health caresystem.

Use the photographs to generate discussion of participants’ experiencesnavigating health care.

Hang three sheets of newsprint with the following titles:

n Difficulties/Barriers n Coping strategies n Needed changes

Ask participants to look at the photographs and describe what ishappening in each one. Pose the questions listed below to stimulatediscussion:

1. What do people find difficult about going to a hospital? (Difficulties/Barriers)n What is difficult for you and people you know?n What might be particularly difficult for your students?

2. What can people do to solve some of these problems? (Coping strategies)

3. What things can the hospital or clinic do to make it easier for people to get help? (Needed changes)

4. What can doctors do to make it easier for people to get help?(Needed changes)

Continue with the activities for Session One.

An Expanded Session – Field Trip to a Local Hospital (2 hours)Overview of Field Trip Activity

This activity is designed to provide participants with an active hands-onexperience getting to a hospital and finding their way in the hospital. Thepurpose of the field trip is to heighten the participants’ awareness of thechallenges that their students might face navigating a hospital setting. Thisfield trip activity consists of four steps.

1. Travel to the hospital

2. Analysis of the hospital lobby

3. A navigation assignment

4. Discussion and analysis

For each step, you will ask the participants to think about the resourcesthey use to navigate the hospital. A resource is any source of informationthe participants use to help them get to their destination, such as any use ofprinted materials (e.g., tools such as maps, signs, directories) or verbalinteractions with people. Participants are also asked to think about “keydecision points” such as taking a left instead of a right turn, checking amap, or asking someone for directions. Finally, for each step, participantsare also asked to think about the activity from their students’ perspectiveand identify the challenges that students might face in navigating a hospital.

1. Travel to the Hospital (15 minutes)

First, ask the participants to make their way, as a group, to the hospitalfrom a designated public transportation stop.

Travel from the transportation stop (10 minutes)

As you approach the hospital, ask participants to consider where someoneshould enter the hospital. As you near the hospital, raise these questions:

n Is it easy or difficult to get from the transportation stop to thehospital? Why or why not?

n What, if any, resources are available to help you figure out how toget from the stop to the hospital?

n How do you determine the main entrance of the hospital?

n What resources are available to help you figure out where to enter?



n What challenges might your students face in getting to the hospitaland locating the right entrance?

Once you have reached the main entrance, take a few minutes to discussthe groups’ reactions to the questions and their observations.

Entry and Preparation (5 minutes)

At the entrance of the hospital, before the participants enter, tell the groupthat you would like them to enter the hospital and take some time toexplore the overall “literacy environment” of the hospital lobby. Thisinvolves noting all instances of print use and any print that couldpotentially be used to navigate the hospital. For example, this may includesigns, printed notices, pamphlets, maps, or directories. In addition, ask thegroup members to note additional sources of help.

Plan a meeting place near the lobby. Ask group members to meet you in10 minutes.

2. Analysis of the Hospital Lobby (30 minutes)

Ask participants to look around the lobby to characterize the overall“literacy environment” and to identify sources of help for navigating theenvironment.

Look About (10 Minutes)

Ask participants to think about the following questions as they enter thehospital and explore the overall “literacy environment” of the lobby.

n How did you feel when you entered the lobby?

n How would you describe the overall atmosphere? (What are peopledoing? How are people dressed? Did you feel welcomed?)

n How much is the printed word used? How is it used?

n What resources do you see that might help someone navigate thehospital? (e.g., signs, maps, help desk)

n How might your students feel here? What challenges might theyface?



Meeting and Discussion (20 minutes)

After the participants have explored the lobby, ask them to come backtogether to discuss their reactions to the questions and their observations.

Next, select a meeting place for a discussion. You might want to move tothe hospital cafeteria. This same spot can serve as the meeting place afterthe small groups find their assigned location.

3. A Navigation Assignment (30 minutes)

This step in the activity focuses on actually getting from the hospital lobbyto a specific designation elsewhere in the hospital, in other words, theactual process of navigating the hospital. Some people might get lost. Besure to set a time and a meeting place (e.g., a nearby coffee shop) for thefinal discussion. Tell participants to return to the designated meeting placefor the final discussion at the specified time, whether or not they everreach their destination.

Group Work Assignments and Preparation (10 minutes)

Ask the group members to break into small groups of two or three. Assigneach group a different destination in the hospital. Here are some options:

n Medical records

n Asthma center

n MRI or CAT Scan Testing

n Blood Donation Center or Station

n Gift shop

n Chapel

n Emergency Department Registration

Ask each group to consider the following issues as they move from thelobby to their assigned destination.

n Signs or tools• Placement of signs and tools• Words in signs

n Sources of help (help desks, interactions with people)• Ready access to these sources of help• Usefulness of the information received

Encourage participants to use any sources of help they wish.



Navigation Activity (20 minutes)

As participants carry out the small-group exercise, you may wish toaccompany one of the groups so you can listen to their comments andobservations.

4. Discussion and Analysis (40 minutes)

Once everyone comes together again, ask group members to share theirexperiences. The following questions could be used to encourage discussion:

n How did you find your destination? What resources did you use tomake your way? (Did you ask other people for directions? Did youuse a map?)

n What did you notice about placement of signs and/or language onsigns?

n How did you know that you reached your destination?

n How easy or difficult would this activity be for your students?What challenges might they face?

n What skills could you teach in your classroom that might helpstudents overcome these challenges?



Handout: Field Trip to a Local Hospital

This activity is designed to provide you with a hands-on experiencegetting to a hospital and finding your way about.

The purpose of the field trip is to help us become more aware of thechallenges adult students face when they need to make their way to andwithin a hospital.

This field trip activity consists of four steps.

1. Travel from a transportation stop to the hospitalQuestions to guide your observations:

• How do you know which way to go?• How do you find the main entrance?

2. Analysis of the hospital lobbyQuestions to guide your observations:

• What is the overall atmosphere? • How is the printed word used?• What assistance is available to help you find your way about?

3. Navigation assignment Questions to guide your observations:

• What resources did you make use of as you tried to locate yourassigned destination?

• How is the printed word used?

4. Discussion and analysisQuestions to guide your observations:

• What did you learn?• How would your students do with this task?




First, note the set of handouts following this booklet. These handoutsshould be sent to participants in advance of the first session meeting.Some of the readings in this packet were included to provide a context forthe focus on Skills for Health Care Access and Navigation. Other readingswill help prepare the participants for the overall Health Literacy StudyCircle+ experience. Others will serve as the foundation for the discussionsin Session One.

Next, the information below and the accompanying checklist offerdetailed preparatory steps to help you get ready for Session One.

Preparation for Session One

About the Welcome Letter to Participants

Before you send out thesematerials, you need to customizethe Welcome Letter to Participants.This letter is designed as atemplate to help you create yourown welcome letter for study circleparticipants.

Place this letter on top of all thematerials.

n Be sure to include the dates,times, and location for eachstudy circle session.

n Tell participants that theyshould plan to attend allsessions. If anyone anticipatesproblems with the scheduleddates, he or she should let youknow before Session One so thatyou can discuss the feasibility ofthat person’s participation. Notethat attendance at all sessions isessential.

Summary Checklist

nn PLEASE CHECK

nn Have you created your ownversion of the Welcome Letterto Participants indicating thedates, times, and location foreach study circle session?

4



n Ask participants to bring to thefirst session all the materials yousent out.

Background Materials for Session One

Background materials for SessionOne should be sent out toparticipants at least TWO WEEKSbefore the session begins.

n Be sure that you have acomplete set of all materials forSession One.

n Copy all of the handouts andreadings on 3-hole paper.

n Send out the materials for Session One to all participants.

n NOTE: We do not recommendproviding participants withmaterials for all sessions at thispoint – just send out thematerial needed for Session One.

Note about Participant Expectations

We feel that it is important toprovide participants with anopportunity to convey their ownexpectations for this study circle.Although you may not be able tomake changes to accommodate allexpectations, knowing whatparticipants expect will give yousome insight into participants’thinking about the experience.

Summary Checklist

nn Do you have a complete set ofbackground materials forSession One? (See the list ofMaterials to be sent out beforeSession One.)

nn Did you make copies of thebackground materials for Session One on 3-hole paper?

nn Did you place the WelcomeLetter and the ParticipantExpectations sheet on top of thebackground materials you aresending out to participants?

nn Did you send out thebackground materials forSession One to all participantsat least TWO weeks prior toSession One?

Summary Checklist

nn Have you included a self-addressed envelope with thematerials so participants canreturn the ParticipantExpectations sheets to you?



n Ask participants to completeand return the ParticipantExpectations sheet to you beforeSession One begins so that youcan review them ahead of time.

n When you send out thematerials for Session One, besure to include a self-addressedenvelope or your address soparticipants can complete andreturn the ParticipantExpectations sheets to you.

n During Session One, you willhave time to review participants’expectations and note those thatwill be addressed during thecourse of the study circle.

Facilitator Preparation

It is important for you to review thestudy circle guide and all thehandouts for each session well inadvance. You will need to prepareall the materials for each session andfor follow-up assignments (copyhandouts and prepare newsprints).

For Session One, we recommendthat you make a few extra copiesof background materials in caseparticipants have misplaced thosethey received prior to the start ofthe study circle.

Each handout and readingincluded in this guide is a stand-alone document and can either bephotocopied or downloaded fromthe NCSALL Web site atwww.ncsall.net and the HALLWeb site at www.hsph.harvard.edu/healthliteracy

Summary Checklist

nn Have you read all the SessionOne background materials thatyou sent out to the participants?

nn Have you read all of the Session One materials?

Notes

The National Center for the Study of Adult Learning and Literacy (NCSALL) is a collaborative effort between theHarvard Graduate School of Education and World Education. The University of Tennessee, Portland StateUniversity, and Rutgers University are NCSALL’s partners. NCSALL is funded by the Educational Research andDevelopment Centers program, Award Number R309B60002, as administered by the Institute of EducationSciences (formerly Office of Educational Research and Improvement), U.S. Department of Education. The contentsof this publication do not necessarily represent the positions or policies of the Institute of Education Sciences, orthe U.S. Department of Education, and you should not assume endorsement by the Federal Government.

National Center for the Study of Adult Learning and Literacy

NCSALL at World Education44 Farnsworth Street • Boston, MA 02210

(617) 482-9485www.ncsall.net

Documents

OVERVIEW and - NCSALL