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ESL Resources

Picture Stories for Adult ESL Health Literacay

Created by Kate Singleton
Fairfax County (Virginia) Public Schools

The picture stories are:

Designed to help ESOL instructors address topics that affect the health and well-being of their students.
Useful for beginner and low-literacy students. Newcomers to the United States and adults with lower literacy tend to have the least awareness of and access to health care services, thereby running the risk of more serious and chronic health outcomes. Words are kept to a minimum in the stories to give just enough information to convey an idea without becoming too distracting for students with very low literacy.
Designed to be safe, impersonal prompts to allow students to discuss difficult topics, ask questions, and obtain information. As the stories are about cartoon characters, the students should not feel pressure to disclose their own experiences on the topic if they don't want to.
Adaptable for use at different levels.

What groups of students are the picture stories suitable for?

The stories "Emergency," "A Doctor's Appointment," and "Stressed Out" are suitable for most classes, as the topics are common and uncontroversial. "What Should She Do?," however, should be used with discretion, as its topic of domestic violence may evoke strong reactions and discomfort, especially if a class member has experienced domestic violence personally or knows someone who has.

How can the stories be used in class?

The Language Experience Approach (LEA) is an effective way to use the picture stories with beginners.

Benefits of LEA:

Uses the students' own language, experiences and observations to create a product, their own story.
Promotes speaking, listening, reading and writing, while letting students decide on the content.
Life skills are discussed, and the students negotiate to come up with a story on which all can agree.

Suggested LEA procedure:

The teacher can ask the students what is happening in each frame of the story. She can ask questions to elicit specific details or observations, and if students don't have a clear idea of what to say, various scenarios can be discussed until the class chooses one they like.
Once the whole story has been elicited orally, the teacher tells the students that she will write it down as they retell it. While the students retell it, the teacher writes, trying to stay close to the students' own language. She can smooth it out for clarity's sake occasionally, but the story should be the students' product, based on their ideas.
The teacher can ask questions again to make sure important information or vocabulary is included.
After the story has been written, the class can practice reading it chorally and individually.
Students can then copy it down (it's best to leave this step until the end; if students are writing as the teacher is eliciting the story, they don't participate in the creation of the story.).
If reading is a skill focus of the class, various follow-up activities like sentence or word sequencing, or cloze activities can be done in a later class. If oral skill development is the focus, retelling without reading could be practiced.

Are there any other considerations?

In using picture stories, teachers should carefully consider the images that they choose to use. Cartoons or similar drawings or illustrations that incorporate figures of isolated body parts may not be recognizable or comprehensible to all English language learners. This may be especially true for learners with limited literacy in their native languages. Drawings of people or body parts may even be offensive to some groups. Teachers need to be aware of these issues and be prepared to use alternative resources such as photographs, videos, or gestures.

Picture Story 1: Emergency

Picture Story 2: A Doctor's Appointment

Picture Story 3: Stressed Out!

Picture Story 4: What Should She Do?

Picture Story 5: Depressed

Picture Story 6: The Right Dose

Picture Story 7: What Happened to My Body?

Picture Story 8: Snack Attack

Picture Story 1: Emergency!

View the picture story.

Health literacy issues:

access to care; availability of low or no-cost health care for low-income uninsured cost of care; cost comparison of preventive care and emergency care;
negotiating a payment plan; credit records and non-payment of bills
health insurance system, availability, procedures
the culture of preventive care in the United States

The basic story:

A man feels pain symptoms in June, but ignores them because he doesn't have insurance and feels he can't afford medical care without it. A female acquaintance suggests that he see a doctor, but he repeatedly refuses to because of his concern about the cost. Six months after his pain starts, he is taken to the emergency room by ambulance because his condition has worsened. A month later, he is still in bed, faced with a large hospital bill which he doesn't know how he will pay.

Background information:

Beginning and low literacy students commonly report to ESOL teachers that they don't have insurance and don't go to the doctor in the United States because it costs too much money.
Students are often unaware of local low or no-cost clinics that they are eligible to use, or they fear that using clinics will jeopardize their immigration status. Low or no-cost clinics exist in many urban areas and some rural areas in the U.S. Low cost clinics charge fees on a sliding scale based on income. New patients may need to make a preliminary appointment for verifying eligibility before they can have a medical appointment at some clinics. Some clinics periodically close enrollment because they are overburdened, so a student might need to check back regularly to see if new patients are being accepted.
Consequently, conditions that could be treated at relatively low cost and physical discomfort to the patient can become very costly and chronic when treatment is delayed.
Such situations can derail a student's efforts to attend school or maintain employment, among other repercussions.
When students do see a U.S. health care provider, they may be confused by the expectation of self-care and prevention in our health care culture if these are not the norm in their native culture.

Suggested questions for prompting discussion while eliciting the story:

First frame: What is happening in the picture? What do you see? What is the man's name? What's the matter with him? What is he saying? What does "ouch" mean?(What do you say in your language when you are hurt?) When is it happening?
Second frame: When is it now? How is the man now? What is he saying? Who is the woman? What is she saying? (If students just say, "Doctor?," ask them for a complete question, like "Did you see a doctor?")
Third frame: What does he answer? (Again, try to elicit more words than "No doctor. Too much money." If students are confused or hesitant, you can propose "I can't go to the doctor! It costs too much money!"
Fourth frame: When is it now? How does he feel now? (A common answer is "Double ouch!") Does he go to the doctor in December? Why not?
Fifth frame: When is it now? What's happening? Where is he now? Where is he going? What room will he go to in the hospital? What will happen in the emergency room? (This can bring up vocabulary like surgery, operation, medicine, etc.)
Sixth frame: Now what month is it? Where is he now? What is he looking at? How much do you think the bill is for? How much does it cost to go to the emergency room? How much does surgery cost? How much does it cost to go in an ambulance? What is he thinking? How is he feeling? What can he do?

With the sixth frame the opportunity arises for particularly valuable discussion on students' health care options and responsibilities:

Can he do anything different in June so he will not have a big problem in January? (Some students may bring up valuable suggestions for preventive care, such as exercising, taking vitamins, reducing stress, etc. Some may have experience with clinics and volunteer information, which is great!)
Can he go somewhere to see a doctor? (Often this meets a negative response from students who are unaware of local affordable clinics. The teacher can provide the phone number, address and basic eligibility information for such clinics and explain that their use is not reported to Immigration.)
How will he pay the bill? (Some students may have had the experience of arranging a payment plan with a hospital. If not, the teacher can bring up the idea. Also, individual doctors may agree to charge less for uninsured patients.)
What happens if he doesn't pay the bill? (This can lead to discussion of credit, why it's important, what it is needed for, and how to keep in good standing.)

Additional Useful Information

The following information can be helpful for your students. Language is simplified, but you can decide how to present it, how much to present and what specific information suits the interest and needs of your students. The information may be used for teacher reference, or it may be modified for the level of your students to make an informational handout or other activity.

Paying for health care if you do not have insurance

Is there a low-cost or free clinic near your home? Find the phone number and call to see if you qualify for treatment there. Sometimes you need to wait a few weeks for your first appointment because the clinics are busy.
If you do not have insurance, sometimes (not always!) regular doctors charge less for uninsured people's treatment. You need to ask at the doctor's office or hospital. Sometimes no one tells you if you don't ask.
If you have a big bill that you cannot pay at one time, ask if you can have a payment plan. With a payment plan, you pay the same amount each month (for example, $50) until you finish paying everything off.
If you do not pay a medical bill, usually your bill will go to a collections agency. This is very serious! Collections agencies give you a bad credit rating in computer systems that banks and many other businesses can check. If you do not pay the collections agency, you will have bad credit. With bad credit, you cannot buy a house, car, or college education. You cannot rent a new apartment. You cannot get a credit card. You cannot receive a loan from a bank, and sometimes you cannot open a bank account. It is very difficult to fix bad credit.

Picture Story Two: A Doctor's Appointment

View the picture story.

Health literacy issues:

Speaking with a health care provider
The right to an interpreter
Patient self-advocacy; patient's responsibility to ask questions in brief clinical encounter
Clarification of treatment plan
Avoiding medication errors
Cultural perceptions of doctor/patient relationship

The basic story:

A man feels a pain and goes to the doctor. The doctor examines him, asks questions about the symptoms and gives him a lot of information. The man pretends he understands, but he doesn't speak much English and doesn't know what the doctor is saying. The doctor gives him a chance to ask questions, but the man doesn't ask any. He gets some new prescriptions but doesn't understand how to take them. At home one of his family members asks what the doctor said, and the man reports that he doesn't know. He is frustrated and confused.

Background information:

Students report and statistics bear out that they often don't understand what health care providers tell them in English, don't feel able to ask questions, and don't understand all the written instructions for medicines and treatment.
Fear of having to communicate in English keeps some from seeking treatment.
Federal law (Civil Rights Act of 1964) mandates that any facility receiving federal payments (medicare, medicaid) must provide interpreters for patients whose English is limited. Specifically, the law prohibits discriminatory treatment on the basis of national origin by agencies receiving federal funds. While compliance with the law is not well-monitored, the use of trained health care interpreters is increasing in the medical field. Your local health department might be able to provide an interpreter for a students' medical appointment. Doctors sometimes subscribe to call-in translation banks that can do interpretation for most languages over the phone.
Some cultures believe that a doctor is an expert and therefore should not be questioned. Students from such a background could benefit from learning the importance of the patient's asking clarifying questions in today's typically brief medical encounter, and their right to seek a second opinion.
Medication errors are a growing problem in the United States. While causes vary, evidence shows that many adults lack the literacy skills to understand medication information and instructions, which can lead to serious errors in their usage.

Suggested questions for prompting discussion while eliciting the story:

First frame: What's the matter with the man? What is his name? What should he do?
Second frame: Where is he now? Who is with him? What is the doctor doing? How is the man feeling?
Third frame: What is the doctor saying? What does the man say? Do you think the man understands the doctor? Why not? Why does he say "OK"?
Fourth frame: Now what is the doctor saying? What question does he ask the man? What does the man answer? Is that true?
Fifth frame: Now what does the doctor ask him? What does the man answer?
Sixth frame: Now the man leaves the doctor's office. What is in the picture with him? What is he thinking? What is the problem with taking the prescriptions?
Seventh frame: Now where is the man? Who is he speaking with? What does she ask him? How is the man feeling now?
Eighth frame: What does the man answer?

With the eighth frame the opportunity arises for particularly valuable discussion on language barriers in health care and what communication is expected of the patient in the U.S. health care system.

Has this ever happened to you? (Students have reported that "This is my story," or "The man is me!")
What advice can you give the man?
What can someone do if they don't speak much English and they need to see the doctor? (At this point the teacher can give information about the rights of limited English speakers and any interpreting options available in the community or through a doctor's office, e.g. the call-in interpreter banks. Other suggestions students have come up with include taking a friend or family member who speaks more English, or finding a doctor who speaks your language. There is no perfect answer, but it is important to know the law and discuss options.)
What questions can this patient ask the doctor about the prescription medicines? (The class could brainstorm a list. Some examples of possible questions follow. Questions are simplified, but some may still be difficult for lower levels and some vocabulary may need explanation. You can decide how much and what kind of information your students is suited to your students' levels and needs. You may use these as a reference, or you may modify them for your students' level to make informational handouts or other activities.)

Questions to ask the doctor about your medicine
1. What is this medicine?
2. Why am I taking it?
3. What does this medicine do?
4. How long do I need to take it?
5. When will I start feeling better?
6. What are ok side effects of the medicine?
7. What are bad side effects of the medicine?
8. What side effects do I need to call you for?
9. Is it ok to drink alcohol with this medicine/this condition?
10. Do I need to come back and have the doctor check my medicine?
  (Certain medicines require that the level of the medicine in the blood is regularly monitored.)
11. Here are the names and doses of other medicines I'm taking now. Is it ok to take the new medicine with them? (Include over-the-counter medicines, prescriptions, vitamins, and herbs, from the United States and other countries.)

Additional Information

More advice for talking with doctors about your medicines

If you cannot read the doctor's handwriting on the prescription, ask him to write it again clearly so the pharmacist can read it, too.
Tell the doctor your allergies to medicines, and bad side effects you had from medicines in the past.
Write a list to show the doctor or hospital staff what medicines you are taking and how much you take. If you cannot write it, put your medicines in a bag and take them with you to the doctor.
Check before you leave the pharmacy that you got the correct medicine and that you understand how to take it. It is ok to ask the pharmacist questions.

General advice for patients in the doctor's office/hospital
(This information refers to what is expected from the patient in U.S. health care culture. It is simplified, but still uses useful health care vocabulary which may need to be introduced to your students. Again, you can decide how much and what kind of information is suited to your students' levels and needs. You may use these as a reference, or you may modify them for your students' level to make informational handouts or other activities.)

SPEAK UP. ASK QUESTIONS! Doctors want patients to be interested in their treatment. In the US doctors expect you to make decisions together with them.
If a doctor is busy, he or she sees the patient for only 10 minutes. Think of some questions before you go to the appointment so you get the information you need.
Take a friend with you who can help you ask questions and understand the doctor. Sometimes a friend is better than someone in your family, because a family member may not be comfortable speaking about your health and body.
Make INFORMED DECISIONS. This means learn all you can about your problem and its possible treatments before you decide what treatment to have. Ask questions to doctors, nurses, and other people who had your problem. If possible, read information about it in books and on the Internet.
Be ready to tell the doctor what symptoms you have and how long you have had the symptoms.
In the US, be ready to tell the doctor your family's medical history. What big health problems did your parents, grandparents, brothers and sisters have? This helps the doctor know what to check for in you.
If you are in the hospital, talk with the doctor or nurse before you go home about what you should do and what medicines you should take when you leave the hospital. Make sure you understand everything. If you don't understand, ask more questions.
If you don't want to take a medicine or have an operation, you can ask the doctor if there is an alternative treatment. If you are not sure that surgery is the right thing for you, you can ask a different doctor for a second opinion. (You have to pay both doctors!)
If you need to go to the hospital for an operation, try to go to a hospital that does this operation a lot.
If you don't hear test results in the time the doctor tells you, call the doctor to check on the results.

Picture Story Three: Stressed Out!

View the picture story.

Health literacy issues:

stress management
self-care
prevention

Basic Story:

A woman wakes up in the middle of the night to feed her baby. Her family (her husband and 2 older children) is waiting for her to cook them breakfast at 7AM. She arrives late to work, and her supervisor is angry with her. On her way home from work, she is in a fender bender. Later that night, she looks at her bills and worries about money. After that, she feels completely stressed out from all the stressors of her day.

Background Information:

Stress is something most adult ESL students can relate to. Many juggle the demands of one or more low-paying jobs while going to school and taking care of family.
The immigration process itself generates stress as people adapt to the new culture.
Intergenerational stress occurs as children assimilate to U.S. culture and using English faster than their parents.
Unchecked stress can lead to physical illness in many people and mental illness, such as anxiety and depression, in some.

Suggested questions for prompting discussion while eliciting the story:

First frame: What time is it? Who is in the picture? What is the mother doing? What is the baby doing? How does the mother feel?
Second frame: What time is it now? Who are the people in the picture? (the woman's husband and two older children) What do they want? Who makes the breakfast for them? Where do you think the mother is now?
Third frame: What time is it now? Now where is the woman? What is the problem? Who is the man in the picture? What is he saying? Is he happy? Why not? How does the woman feel?
Fourth frame: What time is it now? Where is the woman? What happened? What is she thinking? How does she feel?
Fifth frame: What time is it now? Now where do you think the woman is? What is she holding in her hand? What is she thinking? Is she happy? Why not?
Sixth frame: What time is it now? What is the woman doing? Why?

With the sixth frame the opportunity arises for particularly valuable discussion on stress reduction and stress management.

What are the woman's problems in the story?
What can happen if she continues to have too much stress in her life? (e.g. make mistakes at home and on job, physical illnesses, anger, depression, anxiety)
What advice can you give the woman to have less stress in her life? What do you do when you feel stress? (Students can create lists of ideas in groups when finished with LEA story. They could make a poster or share ideas orally.)
What are some things that give you stress in your life?
Can you change anything to feel less stress for yourself? What can you do?

Picture Story Four: What Should She Do?

View the picture story.

Health literacy issue:

domestic violence

IMPORTANT: "What Should She Do?" should be used with discretion, as its topic of domestic violence may evoke strong reactions and discomfort, especially if a class member has experienced domestic violence personally or knows someone who has.

It is the author's experience that students who feel comfortable in a class sometimes ask their teacher for information about the rights of domestic violence victims in the U.S. as well as services that can provide refuge from abuse. Such students may indicate that they know a friend of a friend who is in an abusive situation. The picture story can be a safe catalyst for discussion of the law and dissemination of accurate information on services for victims.

The timeline: Times of events are shown in the story simply to indicate the passage of time for a learner to follow. They do not indicate a standard timeline of a domestic violence situation. Each situation in real life is different, and events should not be discounted as domestic violence because they are far apart or intense periods of violence are followed by fewer episodes.

The basic story:

A woman and man fall in love. They live peacefully together and start a family. One day, the man drinks too much. He gets angry and hits the woman. The woman has a black eye. The children see what happens and become upset. Later the man apologizes to the woman, tells her he loves her and gives her flowers. She is confused, but she hopes things will be better. The man drinks again, and he beats the woman again. Now the woman is very confused. She doesn't know if she should stay with the man, who says he loves her, but keeps getting drunk and beating her. She doesn't know what she should do to protect her children. She thinks about calling 911, but she isn't sure what will happen if she does.

Background information:

Evidence shows that "there are large numbers of immigrant women trapped and isolated in violent relationships" in the United States. (Family Violence Prevention Fund website, http://www.fvpf.org/immigration/index.html, 1999, as cited in the ERIC Digest "Trauma and the English Language Learner" by Janet Isserlis, http://cal-org.wdi.net/caela/digests/trauma2.htm.)
Immigrants are frequently unaware that victims of abuse have legal rights in the U.S. They are also often unaware of the existence of shelters. Teachers are encouraged to find phone numbers and procedural information for shelters to provide to students in conjunction with picture story activities. Victims need a realistic idea of what they will encounter if they try to leave an abuser with the assistance of public services.
Immigrant and refugee victims of abuse are threatened by abusers with loss of child custody and immigration status.
Children are strongly affected by observing domestic violence. Some may become violent themselves as a result, while others withdraw or act out in other ways. For more information on this topic, see http://www.ndvh.org/, website of the National Domestic Violence Hotline.
October has been designated domestic violence awareness month, which provides an impersonal opportunity to bring up the issue for educational purposes.

Suggested questions for prompting discussion while eliciting the story:

First frame: Who are the people in the picture? How are they feeling? What are they thinking?
Second frame: When is the picture happening? Who is in the picture now? What is new in the picture? How is the family feeling?
Third frame: Now what day is it? Who is in the picture? What is he doing?
Fourth frame: Now what day is it? Who is in the picture? What is the man doing? Why do you think he is hitting the woman? What is the woman doing? (Note: the alcohol is a prop in the story to illustrate a possible progression of events; however, you may want to clarify to students that domestic violence occurs without substance abuse as a precursor.)
Fifth frame: Now what do you see? What are the mother and children doing? Why is the mother crying? Why are the children crying?
Sixth frame: Now what day is it? What is the man doing? What do you think he is saying? What is the woman thinking?
Seventh frame: Now what day is it? What is happening in this picture?
Eighth frame: How is the woman? (upset, confused). She is thinking about many things. What is she thinking about? (calling police, effect on kids, alcohol problem, man says he loves her and won't do it again, etc.)

With the eighth frame the opportunity arises for particularly valuable discussion on the problems a victim of abuse faces and sources of help available in the community.

What happens in your country in this kind of situation? Is it the same or different from the United States?
What are the problems for the children? (trauma of seeing their mother attacked, possibility of become victims themselves, neglect by parents, etc.)
What do you think the woman will do? Why? If they answer "stay," maybe it's for reasons of loving husband, wanting to keep the family together, embarrassed that community will find out, or fear of having to support kids alone, financially and emotionally.
What do you think the woman should do? Why?
What can happen if she calls 911? (maybe positive outcome of protective order and placement in shelter; or negative outcome of police don't believe her, children removed from home, etc. Students may come up with some bleak outcomes from situations they have heard about. It is important that the teacher knows in advance what local police and social service resources are available to victims so that students know what hope and help there is for victims. Maybe a local police officer or a social worker who specializes in domestic violence cases would speak to your class.)
What can she do if she lives in your community? (This gives you the opportunity to provide accurate information for your community.)

Picture Story Five: Depressed

View the picture story.

To print picture as a handout, use the pdf version of the file.

Health literacy issues:

Mental health awareness
Different cultural views on mental health issues
Available community services for mental health care in the United States

The basic story:

In January, a woman is having an active, happy life. She is busy with work, friends, family, school, exercise and parties. In February she starts to feel sad. In March she feels worse. She cries a lot. In April she is still sad, and she doesn't want to eat. In May she feels very tired and stays in bed all day while other people are busy outside. In June she decides to ask for help.

Background information:

Depression is a very common illness worldwide, affecting an estimated 9.9 million adults in the U.S. alone annually. It is believed to be in part caused by environmental factors and in part caused by biological factors. Nearly twice as many women as men experience major depression. Depression can occur at any age to people from all ethnic, racial and socioeconomic groups. Depression is highly treatable with counseling, antidepressant medication, or a combination of the two. Many people from other countries don't know about treatment, in part because of a low presence of mental health care in many parts of the world. The World Health Organization reports that:

Over 30% of countries do not have a mental health program.
More than 25% of countries do not have access to basic psychiatric medication.
70% of the world's population has access to less than one psychiatrist per 100,000 people. (WHO, 2001)

Many people come to the United States to escape situations of war and torture, which may have left them traumatized and depressed. Others may experience socioeconomic hardship or other challenges of cultural adjustment which make them more vulnerable to depression. Often immigrants don't seek care because they are unaware of mental health care options, feel stigma around the issue of mental health, or feel they can't afford care.

Many communities in the United States provide sliding scale mental health services. These services may be found via county or municipal health departments or community service boards. Increasingly, services are being offered in languages other than English from government and other non-profit mental health care providers.

Major depression (sometimes called clinical or chronic depression) is believed to have a biological basis that can respond to triggers in life. Neurotransmitters in the brain are out of balance. The term major depression is used when a person has some of the following symptoms for more than 2 weeks and the symptoms don't get better. Possible symptoms:

You are very sad. Maybe you cry all the time.
Sleeping is a problem. Maybe you sleep too much, or maybe you sleep too little.
Eating is difficult. Maybe you don't feel like eating, or maybe you eat all the time.
Thinking, remembering and concentrating are difficult.
Your physical energy is low, or you feel like you can't sit still.
You don't like doing things that you always liked before.
You have physical problems like headaches or stomachaches, but they don't get better from normal treatments.
You think about dying or killing yourself.

Some other important things to know about depression:

An episode of major depression can be triggered by a traumatic life event, or it can happen without a triggering event.
If you have major depression, it does not mean you are "crazy." It may be important to clarify this in class.
If other people in your family have major depression, there is a stronger chance that you can get it.
Some people get depression from taking some kinds of medicine.
Some people get it if they have certain physical illnesses.
Sometimes women can get depression after they have a baby.

Suggested questions for prompting discussion while eliciting the story:

Go over the title, "Depressed," with students. Ask if anyone knows what depression means. Ask if they know what symptoms a person has if they are depressed. Ask what a person can do if they are depressed.

Preteach vocabulary as needed: symptoms (problems you have when you are not healthy, like sneezing and a runny nose for a cold), treatment (something to help you get better, like medicine; you go to the doctor for treatment), energy (pantomime the difference between having energy and having no energy).

First frame: What do you see in the picture? What is the woman's name? What month is it in the picture? How is she? (busy) Why is she busy? What does she do? (You can emphasize that she is busy and happy in her life. She does many different things and she has friends and family in her life.)

Second frame: When is it now? How is the woman now? Is she very depressed, or just a little depressed? Do you know why she is sad? (Tell students that we don't know why she is sad. Sometimes people get depressed because something bad happened in their life. Sometimes people get depressed without something bad happening in their life.)

Third frame: Now what month is it? How is she in March? Is one month a long time to be sad, or a little time?

Fourth frame: When is it now? How does she feel now? Does she want to eat the food? Why not? (Explain that being sad for a long time and having no appetite are symptoms of depression.)

Fifth frame: When is it now? Where is she now? How is she feeling? (You might want to elicit words like very depressed, no energy, very tired. You can explain that having no energy and being tired all the time are symptoms of depression.) What's happening outside? (It's sunny. People are busy/playing/walking, etc.) What time do you think it is? Do you think she feels lonely? (Explain that feeling lonely and not wanting to do activities that you liked before are symptoms of depression.)

Sixth frame: Now what month is it? Where is she now? What is she doing? Who do you think she is calling? (Maybe a friend, family member, person from her church, counselor, or doctor.) Why do you think the woman waited until June to get help? (e.g., stigma, no information about help, thought she might get better on her own.)

With the sixth frame the opportunity arises to talk with students about cultural differences and options for treating depression in the United States. You can ask if there is treatment available for depression in their native countries.

Do many people talk about depression in your native countries?
Is it OK to talk about?
What do depressed people do for help in your native country?
Do many people talk about it in the United States? (You can point out that some people don't like to talk about it and others think it's ok. It is ok to talk about with social workers and doctors because they can help you get the treatment you need to get better. Medicine and counseling are very common for treating depression in the United States.)
What do depressed people do for help in the United States?
Where can you get help for depression in this community? (Before class, check local listings of mental health service providers. Possible sources of mental health help, or referrals for help, in your community: community service board, public health clinics, the local department of health and human services, doctors' offices.)

Reference:

World Health Organization (WHO). (2001). Mental health policy project policy and service guidance package. Executive summary. Geneva: WHO.

Resources:

National Alliance for the Mentally Ill website at http://www.nami.org. Click on "Education."

National Mental Health Association at http://www.nmha.org. Click on "Mental Health Information."

Picture Story Six: The Right Dose

View the picture story.

To print picture as a handout, use the pdf version of the file.

Health literacy issues:

Understanding medication directions
Avoiding medication mistakes
Child and Adult dosages

The basic story:

One medicine label says that children should take 2 teaspoons of the medicine every 2 hours. A mother gives the medicine to her son. She confuses the teaspoon and tablespoon. She gives her son 2 tablespoons of the medicine at 7 AM. It is too much medicine. At 11:30 her son is very sleepy. The mother shouts, "WAKE UP!!!" She is worried.

Another medicine label has one dose for adults and one dose for children. A father reads the label wrong. At 7:00 AM, he gives his little daughter the adult dose by accident. He should give her 2 pills, but he gives her 4. At 12:00 PM his daughter is very sleepy. The father shouts, "WAKE UP!!!" He is worried

Background information:

Medication errors are a big problem in the United States. It is important to understand all the information on the medicine label, and to ask your health care provider questions about medication for yourself and your children. If reading skills are limited, asking questions about medication directions is essential. Mistakes can include taking the wrong dose, taking the wrong medicine, or taking a medicine you are allergic to. Adult ESL learners often report to their teachers that they have difficulty understanding medication labels to decide the correct dose to take themselves or to give their children. People make medication mistakes in their homes and hospitals also make mistakes. An estimated 7,000 people die each year in the United States from medication errors.

Common suggestions for medication safety:

Make sure you know the name of your medicine and what it does.

Make sure your doctor knows all the medications you are taking, even vitamins.

Make sure your doctor knows your allergies.

Make sure you understand the doctor's instructions. Ask questions to the doctor or pharmacist. Examples:

What is this medicine?
What is it for?
How much do I take at one time?
How many times do I take it in one day?
How often do I take it?
Are there foods and drinks I should not have with this medication?
Can I drink alcohol with this medication?
Are there activities I cannot do when I am taking this medication?
What are side effects of the medication?
What should I do if I have side effects?
I'm taking (medication name) and (medication name). Is it ok to take the new medication with them?
If I forget to take it one time, what should I do?
If I take too much by accident, what should I do?

If you cannot read your doctor's writing on a prescription, ask him or her to write it more clearly. It might be difficult for the pharmacist to read, also.

Suggested questions for prompting discussion while eliciting the story:

Go over the title, "The Right Dose." What does "dose" mean? (How much medicine to take at one time.) What does "the right dose" mean? (Taking the correct dose, not too much, not too little.)

Preteach vocabulary, as needed: Dose (How much medicine to take at one time.), label (the writing on the medicine that tells you the medicine's name and dose), teaspoon (the small sized spoon; bring in example), tablespoon (the large sized spoon; bring in example), directions/instructions (the words that say how much medicine and when to take the medicine), adults (older people, not children; like mother, father, etc.), children (young people, like babies, kids, etc.), every (as in every 4 hours; give examples), too much (make sure students understand that "too much" does not equal "a lot." Too much means you have a problem, like "Too much ice cream can make you sick.")

First frame: What do you see in the picture? What are the directions on the medicine label? What is the name of the little spoon? What is the name of the big spoon? What spoon do you use for this medicine?

Second frame: What do you see in the picture? What time is it? What spoon is the mother using for the child, a teaspoon or a tablespoon? Is that correct? What will happen to the child?

Third frame: What time is it now? What happened to the boy? (He fell asleep/He is sleepy, etc.) Why? (He had too much medicine.) What is the mother saying? How does she feel? (She feels nervous, worried, etc. You might want to clarify that if she cannot wake the boy up, she should call 911.)

Fourth frame: Now here is a different medicine. What are the directions for adults for the medicine? How many pills can an adult take at one time? (You might want to ask students some questions, like "If I take 4 pills at 6 pm, what time do I take the next 4 pills?, etc.") What are the directions for children? How many pills can a child take at one time? (Again, you might want to quiz students on what times they can take the pills.)

Fifth frame: What's happening in this picture? What time is it? How many pills is the father giving his daughter? (4, the adult dose) Is that correct? What will happen to the child?

Sixth frame: What time is it now? What happened to the girl? (She fell asleep/She is sleepy, etc.) Why? (She had too much medicine.) What is the father saying? How does he feel? (He feels nervous, worried, etc. You might want to explain that if he cannot wake the girl up, he should call 911.)

Resources:

Agency for Healthcare Research and Quality, "Your Medicine: Play it Safe." at http://www.ahrq.gov/consumer/safemeds/safemeds.htm.

American Pharmacists Association Web site at http://www.pharmacyandyou.org/ . Click on "About your Medicine" for extensive information on medication safety.

U.S. Food and Drug Administration, "FDA's Tips for Taking Medicine" at http://www.fda.gov/fdac/reprints/medtips.html.

Picture Story Seven: What Happened to My Body?

View the picture story.

To print picture as a handout, use the pdf version of the file.

Health literacy issues:

Nutritional values of different foods and diets
Nutritional and exercise awareness
Need for stress management and self-care when changing lifestyle and adjusting to a new culture.
Awareness of diseases for which poor nutrition increases risk, such as heart disease and diabetes

The basic story:

In his native country, the man was very active and ate fresh, nutritious food every day. When he came to the United States he got a job as a taxi driver. He didn't get much exercise. He ate a lot of fast food. For breakfast, he ate at McDonalds (note golden arches behind taxi cab in the second frame). For lunch he ate pizza. For dinner he ate food he could microwave quickly. After dinner he ate snacks of ice cream and potato chips while watching TV. After one year, he had gained a lot of weight. He couldn't breathe while going up some stairs. His body had changed a lot in one year! He was not healthy!

Background information:

Learners from different countries often report to their teachers that they have gained weight since they came to the United States, or that they have less energy. Often their diets in their native countries were lower in fat and sugar than the food they eat here, and their daily routine contained more physical activity. They may not have had much education in nutrition or preventive health practices in the past to help them make better food and exercise choices in their new home.

Being overweight increases health risks like type 2 diabetes (also known as adult onset diabetes) and heart disease (cardiovascular disease, high blood pressure, coronary heart disease). Risk for both diabetes and heart disease can usually be decreased with:

weight loss
change in diet
stress reduction
increased exercise

Some ethnic groups are at greater risk for diabetes and cardiovascular disease than others. Type 2 diabetes is especially common among certain ethnic groups, including Hispanics, some Asian and Pacific Islander groups, African Americans and Native Americans.
Symptoms of diabetes may include:

frequent urination
excessive thirst
extreme hunger
unusual weight loss
increased fatigue
irritability
blurry vision

heart disease
high blood pressure
blindness
kidney failure
foot or leg amputations due to circulatory or nerve damage

controlling carbohydrates
limiting fat intake (especially saturated fat)
limiting calories

Suggested questions for prompting discussion while eliciting the story:

Go over the title, "What Happened to My Body?" Ask what students think it means. What will the story be about?

Pre-teach vocabulary as needed. Vocabulary might include: nutrition/ nutritious (knowing what food that is good for your body, like foods that don't have too much fat, sugar, and salt, or foods that have a lot of vitamins), fresh (new food, not old), healthy (good for your body), fast food (food that you can buy quickly, like McDonalds, Wendy's, KFC; many times it has a lot of fat, salt and sugar.), junk food (food that is not nutritious, like chips, soda, and french fries; it has a lot of fat, salt, or sugar), microwave (a machine for cooking food fast), exercise (moving your body to make your body strong and healthy; e.g., running, swimming, walking, playing sports), fat (bring in examples of high fat foods like butter and oil, or pictures of cakes, ice cream, etc. Pantomime your stomach getting bigger as you are eating them) and gain weight or get fat (the latter might be easier for lower level learners to remember; pantomime for students to understand), and breathe (pantomime).

First frame: Where is the man? What is his name? What do you see in the picture? What do you think the man eats every day in his native country? Is the food good for him/ nutritious/ healthy? (You can draw attention, if necessary, to the fact that the food is fresh and nutritious.)

Second frame: Now where is the man? (Point out the arches if necessary.) What do you think he eats for breakfast in the U.S.A.? What is his job? Do you think he gets much exercise in his job?

Third frame: Now where is the man? What does he eat for lunch every day? What does he drink? Are pizza and soda nutritious?

Fourth frame: What does the man eat for dinner every day? Is it nutritious? (You can point out that some foods that you buy for microwaving are healthy, but others have a lot of fat and salt. It's important to look at what is in the foods. You can bring in boxes and talk about ingredients if your learners are up to it.)

Fifth frame: Now what is the man doing? What is he eating? (ice cream cone and chips.) Are ice cream and chips nutritious? Is he doing any exercise? (Only the finger on the remote exercise!). Does he get much exercise in the day?

Sixth frame: When is this picture? Is the man different? What is happening? What's the problem? Why is it difficult for the man to go up the stairs? What can the man do to be more healthy? (Your students will probably be able to come up with specific examples, but in general solutions include weight loss, change in diet [if your students are up to handling the details, this includes controlling carbohydrates, and reducing fat and calories in the diet], stress reduction, and increased exercise).

With the sixth frame the opportunity arises to talk with students about the health risks that increase with weight gain and inactivity and possible solutions.

What are some health problems you can get if you don't exercise and you gain weight/get fat? (e.g. heart disease, diabetes)
Do a lot of people have these problems? Are they a problem for people from your country?
What kinds of foods do people eat in your native country?
What kinds of foods do you eat in the United States? Do you eat healthy food in the United States?
Did you get exercise in your country?
Do you get exercise in the United States?
What are different kinds of exercise? Do you need to go to the gym or play sports to get exercise? What other things can you do for exercise? (Point out that things like walking instead of driving or taking the bus and taking the stairs instead of the elevator can give you exercise. Exercise doesn't have to cost money or have special equipment. You can also get exercise playing with your kids.)
Do you ever ask a doctor to check for diabetes or high blood pressure?

Resources:

American Diabetes Association Web site at http://www.diabetes.org. Information on types of diabetes, prevention, and management.

American Heart Association Web site at http://www.americanheart.org. Information on heart-related diseases, their prevention and treatment.

U.S. Food and Nutrition Information Center Web site at http://www.nal.usda.gov/fnic/Fpyr/pyramid.html. Has a variety of Food Guide Pyramids which print out clearly, including ethnic and culturally-based pyramids.

Picture Story Eight: Snack Attack

View the picture story.

To print picture as a handout, use the pdf version of the file.

Health literacy issues:

Childhood obesity epidemic in the United States
Halth risks crated by childhood obesity
Health education and modeling by parents for their children on nutrition and exercise

The basic story:

In summer, the boy in the story is active and healthy. He plays soccer, basketball, and baseball, and goes swimming, so he has a lot of exercise. In September he does not exercise much. He eats snacks of chips and soda after school while he sits in front of the T.V. In October, he eats ice cream while he sits at the computer. In November, he eats cookies while he watches T.V. He weighs a little more. In December, he eats French fries while he sits at the computer again. He has gained a lot of weight. He is not healthy anymore like in the summer.

Background information:

Childhood obesity is considered to be a major health problem in the United States today. The rate of childhood obesity in this country is believed to have tripled in the past 15 years. There is debate over the causes. Too much TV, Nintendo, and computer time? Working parents not around to monitor kids' eating and activity level after school? Too much access to junk and fast food? However, the basic facts that many children are not getting enough physical activity and they are eating too much fat and sugar to be healthy are widely accepted. More children are showing signs of high blood pressure and type 2 diabetes (also called adult onset diabetes), conditions that usually show up much later in life. (For more information on heart disease and diabetes, see Background Information for the story "What Happened to My Body?")

Suggested questions for prompting discussion while eliciting the story:

Go over the title, "Snack Attack." What is a snack? (eating food between meals.) What does "attack" mean? (something hurts you or hits you strongly.) Ask what students think the title means.

Pre-teach vocabulary as needed. Vocabulary might include: nutrition/ nutritious (knowing what food that is good for your body, like foods that don't have too much fat, sugar, and salt, or foods that have a lot of vitamins), healthy (good for your body), fast food (food that you can buy quickly, like McDonalds, Wendy's, KFC; many times it has a lot of fat, salt and sugar.), junk food (food that is not nutritious, like chips, soda, and french fries; it has a lot of fat, salt, or sugar), exercise (moving your body to make your body strong and healthy; e.g., running, swimming, walking, playing sports), fat (bring in examples of high fat foods like butter and oil, or pictures of cakes, ice cream, etc. Pantomime your stomach getting bigger as you are eating them) and gain weight or get fat( the latter might be easier for lower level learners to remember; pantomime for students to understand).

First frame: What is the boy's name? When is it? What does the boy do in summer? How is the boy? Is he healthy?

Second frame: Now when is it? What is the boy doing? What is he eating? Are chips and soda healthy (or nutritious)?

Third frame: Now when is it? What is he doing? (He's using the computer.) What is he eating? (An ice cream cone.) Is an ice cream cone healthy (or nutritious)?

Fourth frame,: Now when is it? What is he doing? What is he eating? (Cookies.) Are cookies healthy (or nutritious)?

Fifth frame: Now when is it? What is he doing? (He's using the computer.) What is he eating? (French fries.) Are French fries healthy (or nutritious)?

Sixth frame: With the sixth frame arises the opportunity to talk about health problems related with being overweight, and possible solutions for the child and his parents. What happened to the boy? (He gained weight/got fat.). Is he very healthy now? (No.) What can he do to be more healthy? (Exercise more, eat healthy foods, not junk food or fast food.) What can his parents do to help him?

See what suggestions for parents your students can come up with. Here are some ideas:

Teach children about eating healthy foods. Teach them to be careful about fat, sugar, and salt.
Talk about being healthy, not about how your child's body looks.
Provide healthy food choices for children to eat. Reduce the amount of fast food, junk food and soda kids get.
Show children what a healthy serving size is. Don't supersize! Give smaller servings.
Don't give food as a prize or reward ("If you are good, I will get you an ice cream.").
Give kids time limits for TV, Nintendo and computer use.
Model healthy behaviors for children. If parents try to teach kids healthy eating and exercise habits, but don't do what they teach, the kids won't either. Parents have to show good examples to kids.
Try to make opportunities to get exercise with your children by going to a park, playing a sport together, etc.
Help your children find an afterschool activity to sign up for which will give them regular exercise. The American Heart Association says that children should get at least 30 minutes of moderate physical activity every day.
Help children talk about things that give them stress so they don't turn to food or zoning out in front of the TV or computer to relieve stress.

What are some health problems you can get if you don't exercise and you gain weight/get fat? (e.g., heart disease, diabetes)
Do a lot of children have these problems? (Not a lot, but many more have them now than 10 or 15 years ago. In the past we called these adult health problems.)
If a child gets these problems, how will their health be in 20 years? What do you think? How can we help make the problem better?

Resources:

American Diabetes Association Web site at http://www.diabetes.org. Information on types of diabetes, prevention, and management.

American Heart Association Web site at http://www.americanheart.org . Information on heart-related diseases, their prevention and treatment.

KidsHealth Web site at http://kidshealth.org/ . Has 3 sections, one for parents about their kids, one for teens, and one for younger kids. Each section has articles with important nutrition and fitness information for that group to know.

U.S. Food and Nutrition Information Center Web site at http://www.nal.usda.gov/fnic/Fpyr/pyramid.html. Has a variety of Food Guide Pyramids which print out clearly, including ethnic and culturally-based pyramids and a pyramid for young children.

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