Health Literacy and Adult English Language Learners

Kate Singleton
Fairfax County (Virginia) Public Schools
February, 2002

In recent years health literacy has garnered increasing attention in the adult literacy, English as a second language (ESL), and healthcare fields. Recent research findings indicate a correlation between low literacy and poor health in adults and between poor health and difficulties in participating in educational programs (Hohn, 1998). This Q&A defines health literacy and its importance in the United States and discusses implications for adult English language learners, instructors, and programs. It also offers a few recommendations for addressing health literacy in the ESL classroom.

What is health literacy?

The American Medical Association defines health literacy as "a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment. Patients with adequate health literacy can read, understand, and act on health care information" (Bresolin, 1999, p. 553). The National Library of Medicine (NLM; 2000) defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (p. v). From the field of adult literacy, Harvard health literacy specialist Rima Rudd (2001) explains health literacy as the ability to use English to solve health-related problems at a proficiency level that enables one to achieve one's health goals, and develop health knowledge and potential.

Rudd's definition seems most appropriate to ESL literacy instruction because it addresses the significant linguistic and cultural obstacles nonnative speakers may encounter when seeking health care in the United States. Also, it refers to attaining personal health goals; people from different cultures understand health differently, and NLM's ambiguous "appropriate health decisions" may refer to decisions supported by U.S. medical culture alone.

What is the history of health literacy instruction?

Health has been included in ESL instruction since the advent of competency-based education (CBE) in the mid-1970s (Crandall & Peyton, 1993). The term health literacy was first coined in 1974 in a paper calling for minimum health education standards for all school grade levels (National Library of Medicine, 2000). The Mainstream English Language Training (MELT) program of 1983 formally recommended health as a standard in competency-based ESL curricula, resulting in its broad inclusion in commercial textbooks and individual program curricula (Grognet, 1997).

Health literacy gained visibility in 1993 with the publication of results from the National Adult Literacy Survey (NALS), which found that almost "44 million Americans are functionally illiterate, or approximately one quarter of the U.S. population, and another 50 million have marginal literacy skills" (Bresolin, 1999, p. 552). For the most part, health education materials target adults with an eighth- to tenth-grade reading level. Many adults, however, both native and nonnative speakers, read significantly below these levels and thus have great difficulty utilizing health care safely and effectively. Furthermore, adult ESL learners themselves indicate an interest in and need for studying health-related issues (Povenmire & Hohn, 2001).

How are literacy and health professionals responding to health literacy needs?

Literacy and health professionals agree that a collaborative effort is needed. Some in the medical field are assessing patients' literacy levels, revising educational materials into plain language, and providing patients with oral and video instruction in addition to written materials. Written materials are being translated into other languages, and medical professionals are receiving cultural sensitivity training. Some healthcare facilities are using certified medical interpreters for patients with limited English.

While these improvements are occurring, however, advancing medical developments demand that patients become more proactive and self-advocating than ever before. For example, many patients utilizing managed care must routinely advocate-on the telephone and in writing-for insurance coverage of procedures and treatments. As patient time with healthcare providers is often brief, it is becoming more important for patients to increase their own knowledge of health issues through research via the Internet and other sources. Additionally, as technological and pharmacological advances in the medical field create more treatment options, patients are expected to make complicated treatment decisions. These are challenges for many people and are especially daunting for those who are still learning the language.

What obstacles may ESL learners encounter?

Obstacles that adult English language learners may encounter in developing health literacy have been discussed by ESL educators (Brown, Ojeda, Wyn, & Levan, 2000; Feld & Power, 2000; Singleton, 2002):

• Lack of access to basic health care due to language barriers, lack of insurance, lack of information on available low-cost services, or fear of jeopardizing immigration status by utilizing such services.
• Lack of language skills. Learners may be unable to speak for themselves, use sophisticated vocabulary, formulate appropriate questions in a medical setting, or comprehend basic instructions without an interpreter. Many immigrants use their children as interpreters. This creates problems for the adults who fear losing status with their children, for the healthcare professionals who must deal with a child rather than an adult, and for the children who are put in situations where they are expected to function as adults and to convey intimate health information about their parents.
• Lack of educational background (for some students) in basic human physiology, which precludes comprehension of treatment information even with an interpreter's help.
• Lack of awareness of U.S. healthcare culture, including what is expected of the patient (e.g., preventive behaviors, treatment compliance, proactive questioning, provision of medical history, payment procedures) and what the patient can expect of care providers (e.g., patient's right to an interpreter, right to have questions answered and information clarified, right to a second opinion).
• Lack of identification with culture of health materials. The 1993 NALS results showed the majority of marginally literate adults to be white and native born (Bresolin, 1999); many health education materials may therefore be culturally and idiomatically directed to this population, making the content less accessible to patients from other backgrounds. Furthermore, careful thought needs to be given by teachers when using cartoons from brochures and textbooks. Illustrations, especially those of isolated body parts, may be unclear to English language learners, perhaps even incomprehensible to people with limited literacy in their native language (Hiffeldt, 1985). They also may be offensive to some groups. Teachers need to be aware of these issues and prepared to use other resources such as photographs, videos, or gestures.
• Lack of awareness of available mental health treatment. English language learners often do not know that treatments exist for managing depression, anxiety, and mental illnesses. Some learners who are aware of mental health treatment still lack information on the growing availability of culturally sensitive and linguistically appropriate care (Adkins, Sample, & Berman, 1999; Isserlis, 2000; see also Center for Multicultural Human Services [Resources]).

What are some challenges for ESL instructors?

Instructors may find the personal nature of class health discussions uncomfortable. They also may need to broaden their knowledge of the availability of health resources in their community. To address both of these issues, they can access informational support in the community by forming partnerships with health professionals. Additionally, the Internet can provide helpful information on insurance and other health care culture issues (see Resources).

Teachers may worry about being unfamiliar with their students' cultural beliefs on health issues. Learners can be resources for this. In the classroom, all views should be respected and students given the choice whether or not to share personal stories and beliefs such as traditional health practices from their native culture. Although general awareness is increasing, students need to know that the mainstream medical field may have less awareness or respect than do their instructors for health remedies and customs outside those practiced in Western medicine.

Instructors of students with minimal English literacy must select health materials carefully. If written information appropriate for students' reading level is unavailable, the teacher can orally provide clear information.

What kinds of activities develop health literacy?

As the health information needs of ESL students can be extensive, instructors must decide how much time is available to meet these and other curricular needs. LaMachia and Morrish (2001) and Povenmire and Hohn (2001) stress that class time spent on health can be particularly effective for language-skill and critical-thinking development. In a class activity leading up to speaking with a healthcare provider, students can practice a basic dialogue with the teacher, then work in groups to brainstorm other questions to ask the doctor about health-related concerns. For example, many immigrants are found to be carriers of dormant or active tuberculosis (TB) and are given the antibacterial drug Isoniazid to treat it. The following dialogue and activities can be used to prepare intermediate-level students for speaking with a doctor at a public clinic.

Dialogue Doctor:     Your skin test and x-ray show you are positive for TB. Patient:     Is it serious? Doctor:     No, the TB is not active, but you need to take medicine so it won't make you sick in the future. Patient:     What medicine should I take? Doctor:     You need to take 300 mg. of Isoniazid everyday for 6 months. Activities 1. As a whole group, students go over vocabulary and pronunciation and then recite the dialogue. 2. After this, learners work in small groups, utilizing critical thinking, teamwork, speaking, listening, and writing skills as they brainstorm questions they want to ask the doctor about taking Isoniazid, such as how to take it, what are serious side effects, what are less serious side effects, and what should they do for the serious side effects. 3. Back in the whole group, the teacher helps learners correct question formation and practice the questions. Issues about what questions are appropriate to ask the doctor are discussed. 4. The teacher provides vocabulary on side effects and precautions (see Resources). 5. A role-play activity where students act out a conversation with the doctor about taking Isoniazid provides further listening and speaking practice.

How can programs use a participatory approach to health literacy instruction?

Health competencies such as making an appointment, reporting medical problems, or asking about prescription side effects have typically been taught in ESL classes via CBE, blended with features of other approaches-such as whole language, learner-centered, or language experience-according to teaching styles and learner needs.

Participatory approaches to teaching health, often coupled with the development of a project, have received much attention recently in the adult education field. Students select health topics, such as how to find affordable, culturally sensitive health care in their area; how to prevent HIV infection; or how to determine the health problems prevalent in their ethnic or age group and how to prevent or treat them. They investigate the topic in teams and create a product (e.g., a brochure or presentation) to educate others (Hohn, 1998). Projects can improve language skills, enhance learner motivation and confidence, and ultimately empower learners. Moss and Van Duzer (1998) warn, however, that project-based learning "involves careful planning and flexibility on the part of the teacher" (p. 2), which may be difficult in some less intensive ESL classes with time constraints or for instructors with limited training. It may also be inefficient for conveying needed basic healthcare information to beginners, newcomers, or people with minimal literacy skills.

Conclusion

Adult English language learners face significant social, linguistic, and cultural obstacles to healthcare self-efficacy. Sensitive health instruction continues to help learners negotiate some of these obstacles. Ensuring that adult English language learners have the literacy skills and cultural information necessary to access the care they need means specific training and lesson preparation for instructors, collaboration with healthcare providers, and more recognition of its importance by program administrators and funders.

References

Adkins, M. A., Sample, B., & Berman, D. (1999). Mental health and the adult refugee: The role of the ESL teacher. ERIC Digest. Washington, DC: National Center for ESL Literacy Education. (EDRS No. ED439625)

Bresolin, L. (1999). Health literacy. JAMA: The Journal of the American Medical Association, 281(6), 552-557.

Brown, E. R., Ojeda, V. D., Wyn, R., & Levan, R. (2000). Racial and ethnic disparities in access to health insurance and health care. Washington, DC: UCLA Center for Health Policy Research & Kaiser Family Foundation.

Crandall, J., & Peyton, J. K., (Eds.). (1993). Approaches to adult ESL literacy instruction. Washington, DC, & McHenry, IL: Center for Applied Linguistics & Delta Systems.

Feld, P., & Power, B. (2000). Immigrants' access to health care after welfare reform: Findings from focus groups in four cities. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.

Grognet, A. G. (1997). Performance-based curricula and outcomes: The Mainstream English Language Training project (MELT) updated for the 1990s and beyond. Washington, DC: Center for Applied Linguistics. (Available from Spring Institute for International Studies, 303-863-0178, www.spring-institute.org/)

Hiffeldt, C. (1985, Winter/Spring). Picture perception and interpretation among pre-literate adults. Passage: A Journal of Refugee Education 1(1), 27-30.

Hohn, M. (1998). Empowerment health education in adult literacy: A guide for public health and adult literacy practitioners, policy makers and funders. Washington, DC: National Institute for Literacy.

Isserlis, J. (2000). Trauma and the adult English language learner. ERIC Digest. Washington, DC: National Center for ESL Literacy Education. (EDRS No. ED444397)

LaMachia, J., & Morrish, E. (2001, Spring). Teachers' concerns about incorporating health into adult education. Field Notes, 10(4).

Moss, D., & Van Duzer, C. (1998). Project-based learning for adult English language learners. ERIC Digest. Washington, DC: National Center for ESL Literacy Education. (EDRS No. ED427556)

National Library of Medicine. (2000). Current bibliographies in medicine: Health literacy. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.

Povenmire, A. V., & Hohn, M. (2001, Spring). Why teach health? Field Notes, 10(4).

Rudd, R. E. (2001). Health literacy overview. [Electronic slide presentation] Retrieved December 2001, from Harvard School of Public Health, Health Literacy Studies Web site: http://www.hsph.harvard.edu/healthliteracy/overview.html

Singleton, K. (2002). ESL teachers: Helpers in healthcare. Focus on Basics, 5(C), 26-29.

Resources

Agency for Healthcare Research and Quality. This Web site contains easy-to-read information on health conditions, health insurance, and consumer rights. www.ahrq.gov

American Pharmaceutical Association. Avoiding medication errors. www.pharmacyandyou.org/

Center for Multicultural Human Services. A culturally and linguistically sensitive mental health treatment provider. www.cmhsweb.org/

Cross Cultural Health Care Program. Provides information on health beliefs in different cultures. www.xculture.org/

Fadiman, A. (1997). The spirit catches you and you fall down. New York: Noonday Press. True account of the culture collision that occurred with tragic results in the 1980s in California, where a Hmong child was treated for a severe seizure disorder.

Federal Resources for Educational Excellence (FREE). Health and safety. Links to Web health information compiled by federal agencies. www.ed.gov/free/s-health.html

Galanti, G. (1997). Caring for patients from different cultures. Philadelphia: University of Pennsylvania Press. Relates 172 case studies of cultural conflicts that occurred in U.S. hospitals.

Levine, D. A. (2001, October). Health Literacy: Implications for Seniors Symposium Proceedings. Washington, DC: U.S. Department of Education, Office of Vocational and Adult Education, Division of Adult Education and Literacy. Includes apendices and contact information for classroom resources. (Available in 2002 online and from ERIC Document Reproduction Service.)

Medline Plus. National Library of Medicine Web site with plain English information on health and medicines. www.nlm.nih.gov/medlineplus/

McKinney, J., & Kurtz-Rossi, S. (2000). Culture, health and literacy: A guide to health education materials for adults with limited English literacy skills. Boston: World Education.

New York Online Access to Health (NOAH). A well-organized, English/Spanish directory on health topics and resources. www.noah-health.org/

System for Adult Basic Education Support (SABES) Health Page. Provides information and resources that link the fields of health and ABE/ESL. http://www.sabes.org/health/

U.S. Department of Health and Human Services. (2001). Mental health: Culture, race and ethnicity. Rockville, MD: Author. Available: http://www.mentalhealth.org/Publications/allpubs/SMA-01-3613/sma-01-3613.pdf

---

This document was produced at the Center for Applied Linguistics (4646 40th Street, NW, Washington, DC 20016 202-362-0700) with funding from the U.S. Department of Education (ED), Office of Vocational and Adult Education (OVAE), under Contract No. ED-99-CO-0008. The opinions expressed in this report do not necessarily reflect the positions or policies of ED. This document is in the public domain and may be reproduced without permission.