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AUTHOR Singleton, Kate . TITLE Health Literacy and Adult English Language Learners. ERIC Q & A. INSTI TUTION National Center for ESL Literacy Education, Washington, DC.; Center for Applied Linguistics, Washington, DC. SPONS AGENCY Office of Vocational and Adult Education (ED), Washington, DC. Adult Learning and Literacy Clearinghouse. PUB DATE 2002-02-00
NOTE 6P * CONTRACT ED-99-CO-0008 AVAILABLE FROM NCLE, 4646 40th Street, N.W., Washington, DC 20016-1859. Tel: 202-362-0700,ext. 200; e-mail: [email protected]. For full text: http://www.cal.org/ncle. PUB TYPE ERIC Publications (071) -- Reports - Evaluative-(l42) EDRS PRICE MFO~/PCO~Plus Postage. DESCRIPTORS *Adult Education; *Basic Skills; *English (Second Language); Health Promotion; *Language Skills; *Literacy Education; *Second Language Learning; Student Participation IDENTIFIERS Health Information; *Language Barriers
ABSTRACT This question-and-answersheet defines health literacy and its importance in the United States, discussing implications for adult English-as-a-Second-Language(ESL) learners, instructors, and programs. It also offers recommendations for addressing health literacy in the ESL classroom. It focuses on what health literacy is (a constellation of skills, including the ability to perform basic reading and numeric tasks required to function in the health care environment); how literacy and health professionals are responding to health literacy needs; obstacles that ESL learners may encounter (e.g., lack of access to basic health care due to language barriers and lack of information, lack of language skills, and lack of awareness of the U.S. health care culture); challenges for ESL instructors (e.g., lack of knowledge about health issues and unfamiliarity with students' cultural beliefs on health issues); types of activities to develop health literacy (e.g., practice dialogues); and how programs can use a part.icipatory approach to health literacy instruction. A list of relevant resources is included. (Contains 15 references.) Adjunct ERIC Clearinghouse for ESL Literacy Education) (SM)
Reproductions supplied by EDRS are the best that can be made from the original document. HEALTHLITERACY AND ADULTENGLISH LANGUAGELEARNERS Kate Singleton, Fairfax County (Virginia) Public Schools
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HEALTHLITERACY AND ADULTENGLISH LANGUAGE LEARNERS Kate Singleton, Fairfax County (Virginia) Public Schools
E~CQ~A February 2002
n recent years health literacy has garnered ing for minimum health education standards for all increasing attention in the adult literacy, English school grade levels (National Library of Medicine, I as a second language (ESL), and healthcare fields. 2000). The Mainstream English Language Training Recent research findings indicate a correlation between (MELT) program of 1983 formally recommended health low literacy and poor health in adults and between poor as a standard in competency-based ESL curricula, re- health and difficulties in participating in educational sulting in its broad inclusion in commercial textbooks programs (Hohn, 1998). This Q&A defines health and individual program curricula (Grognet, 1997). literacy and its importance in the United States and Health literacy gained visibility in 1993 with the discusses implications for adult English language publication of results from the National Adult Literacy learners, instructors, and programs. It also offers a few Survey (NALS), which found that almost “44 million recommendations for addressing health literacy in the Americans are functionally illiterate, or approximately ESL classroom. one quarter of the U.S. population, and another 50 mil- What is health literacy? lion have marginal literacy skills” (Bresolin, 1999, p. 552). For the most part, health education materials The American Medical Association defines health lit- target adults with an eighth- to tenth-grade reading eracy as “a constellation of skills, including the ability level. Many adults, however, both native and nonna- to perform basic reading and numerical tasks required tive speakers, read significantly below these levels and to function in the health care environment. Patients thus have great difficulty utilizing health care safely with adequate health literacy can read, understand, and and effectively. Furthermore, adult ESL learners them- act on health care information” (Bresolin, 1999, p. 553). selves indicate an interest in and need for studying The National Library of Medicine (NLM; 2000) defines health-related issues (Povenmire & Hohn, 2001). health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic How are literacy and health professionals health information and services needed to make ap- responding to health literacy needs? propriate health decisions” (p. v). From the field of Literacy and health professionals agree that a col- adult literacy, Harvard health literacy specialist Rima laborative effort is needed. Some in the medical field Rudd (2001) explains health literacy as the ability to are assessing patients’ literacy levels, revising educa- use English to solve health-related problems at a profi- tional materials into plain language, and providing ciency level that enables one to achieve one’s health patients with oral and video instruction in addition to goals, and develop health knowledge and potential. written materials. Written materials are being translated Rudd’s definition seems most appropriate to ESL lit- into other languages, and medical professionals are re- eracy instruction because it addresses the significant ceiving cultural sensitivity training. Some healthcare linguistic and cultural obstacles nonnative speakers facilities are using certified medical interpreters for pa- may encounter when seeking health care in the United tients with limited English. States. Also, it refers to attaining personal health goals;, While these improvements are occurring, however, people from different cultures understand health dif- advancing medical developments demand that patients ferently, and NLM’s ambiguous “appropriate health become more proactive and self-advocating than ever decisions” may refer to decisions supported by U.S. before. For example, many patients utilizing managed medical culture alone. care must routinely advocate-on the telephone and What is the history of health literacy instruction? in writing-for insurance coverage of procedures and treatments. As patient time with healthcare providers Health has been included in ESL instruction since is often brief, it is becoming more important for pa- the advent of competency-based education (CBE) in tients to increase their own knowledge of health issues the mid-1970s (Crandall & Peyton, 1993). The term through research via the Internet and other sources. health literacy was first coined in 1974 in a paper call- Additionally, as technological and pharmacological ad-
National Center for ESL literacy Education Center for Applied Linguistics 4646 40th Street NW Washington, DC 20016 202-362-0700 3 vances in the medical field create more treatment op- may be offensive to some groups. Teachers need to tions, patients are expected to make complicated treat- be aware of these issues and prepared to use other ment decisions. These are challenges for many people resources such as photographs, videos, or gestures. and are especially daunting for those who are still learn- + Lack of awareness of available mental health treat- ing the language. ment. English language learners often do not know What obstacles may ESL learners encounter? that treatments exist for managing depression, anxi- ety, and mental illnesses. Some learners who are Obstacles that adult English language learners may aware of mental health treatment still lack informa- encounter in developing health literacy have been dis- tion on the growing availability of culturally sensi- cussed by ESL educators (Brown, Ojeda, Wyn, & Levan, tive and linguistically appropriate care (Adkins, 2000; Feld & Power, 2000; Singleton, 2002): Sample, & Berman, 1999; Isserlis, 2000; see also Cen- Lack of access to basic health care due to language ter for Multicultural Human Services [Resources]). barriers, lack of insurance, lack of information on available low-cost services, or fear of jeopardizing What are some challenges for ESL instructors? immigration status by utilizing such services. Instructors may find the personal nature of class Lack of language skills. Learners may be unable to health discussions uncomfortable. They also may need speak for themselves, use sophisticated vocabulary, to broaden their knowledge of the availability of health formulate appropriate questions in a medical set- resources in their community. To address both of these ting, or comprehend basic instructions without an issues, they can access informational support in the interpreter. Many immigrants use their children as community by forming partnerships with health pro- interpreters. This creates problems for the adults who fessionals. Additionally, the Internet can provide help- fear losing status with their children, for the ful information on insurance and other health care healthcare professionals who must deal with a child culture issues (see Resources). rather than an adult, and for the children who are Teachers may worry about being unfamiliar with put in situations where they are expected to func- their students’ cultural beliefs on health issues. Learn- tion as adults and to -convey intimate health infor- ers can be resources for this. In the classroom, all views mation about their parents. should be respected and students given the choice Lack of educational background (for some students) whether or not to share personal stories and beliefs in basic human physiology, which precludes com- such as traditional health practices from their native prehension of treatment information even with an culture. Although general awareness is increasing, stu- interpreter’s help. dents need to know that the mainstream medical field Lack of awareness of U.S. healthcare culture, includ- may have less awareness or respect than do their in- ing what is expected of the patient (e.g., preventive structors for health remedies and customs outside those behaviors, treatment compliance, proactive ques- practiced in Western medicine. tioning, provision of medical history, payment pro- Instructors of students with minimal English literacy cedures) and what the patient can expect of care must select health materials carefully. If written infor- providers (e.g., patient’s right to an interpreter, right mation appropriate for students’ reading level is un- to have questions answered and information clari- available, the teacher can orally provide clear information. fied, right to a second opinion). What kinds of activities develop health literacy? Lack of identification with culture of health materi- As the health information needs of ESL students can als. The 1993 NALS results showed the majority of be extensive, instructors must decide how much time marginally literate adults to be white and native born is available to meet these and other curricular needs. (Bresolin, 1999); many health education materials LaMachia and Morrish (2001) and Povenmire and may therefore be culturally and idiomatically di- Hohn (2001) stress that class time spent on health can rected to this population, mahing the content less be particularly effective for language-skill and critical- accessible to patients from other backgrounds. Fur- thinking development. In a class activity leading up to thermore, careful thought needs to be given by teach- speaking with a healthcare provider, students can prac- ers when using cartoons from brochures and textbooks. tice a basic dialogue with the teacher, then work in Illustrations, especially those of isolated body parts, groups to brainstorm other questions to ask the doctor may be unclear to English language learners, perhaps about health-related concerns. For example, many im- even incomprehensible to people with limited literacy migrants are found to be carriers of dormant or active in their native language (Hiffeldt, 1985). They also tuberculosis (TB) and are given the antibacterial drug # Isoniazid to treat it. The following dialogue and activi- field. Students select health topics, such as how to find ties can be used to prepare intermediate-level students affordable, culturally sensitive health care in their area; for speaking with a doctor at a public clinic. 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 investi- Dialogue gate the topic in teams and create a product (e.g., a Doctor: Your skin test and x-ray show you are brochure or presentation) to educate others (Hohn, positive for TB. 1998). Projects can improve language skills, enhance Patient: Is it serious? learner motivation and confidence, and ultimately Doctor: No, the TB is not active, but you need to empower learners. Moss and Van Duzer (1998) warn, take medicine so it won’t make you sick however, that project-based learning “involves careful in the future. planning and flexibility on the part of the teacher” (p. Patient: What medicine should I take? 2), which may be difficult in some less intensive ESL Doctor: You need to take 300 mg. oflsoniazid every classes with time constraints or for instructors with lim- day for 6 months. ited training. It may also be inefficient for conveying Activities needed basic healthcare information to beginners, new- 1. As a whole group, students go over vocabu- comers, or people with minimal literacy skills. lary and pronunciation and then recite the dialogue. Conclusion 2. After this, learners work in small groups, uti- Adult English language learners face significant so- lizing critical thinking, teamwork, speaking, cial, linguistic, and cultural obstacles to healthcare self- listening, and writing skills as they brain- efficacy. Sensitive health instruction continues to help storm questions they want to ask the doctor learners negotiate some of these obstacles. Ensuring about taking Isoniazid, such as how to take that adult English language learners have the literacy it, what are serious side effects, what are less skills and cultural information necessary to access the serious side effects, and what should they do care they need means specific training and lesson prepa- for the serious side effects. ration for instructors, collaboration with healthcare 3. Back in the whole group, the teacher helps providers, and more recognition of its importance by learners correct question formation and prac- program administrators and funders. tice the questions. Issues about what ques- References tions are appropriate to ask the doctor are Adkins, M. A., Sample, B., & Berman, D. (1999). Mental discussed. health and the adult refugee: The role of the ESL teacher. 4. The teacher provides vocabulary on side ef- ERIC Digest. Washington, DC: National Center for fects and precautions (see Resources). ESL Literacy Education. (EDRS No. ED439625) 5. A role-play activity where students act out a Bresolin, L. (1999). Health literacy. JAMA: The Journal conversation with the doctor about taking of the American Medical Association, 281 (6),552-557. Isoniazid provides further listening and Brown, E. R., Ojeda, V. D., Wyn, R., &Levan, R. (2000). speaking practice. Racial and ethnic disparities in access to health insurance and health care. Washington, DC: UCLA Center for Health Policy Research & Kaiser Family Foundation. How can programs use a participatory approach Crandall, J., & Peyton, J. K., (Eds.). (1993). Approaches to health literacy instruction? to adult ESL literacy instruction. Washington, DC, & Health competencies such as making an appoint- McHenry, IL: Center for Applied Linguistics & Delta ment, reporting medical problems, or asking about pre- Systems. scription side effects have typically been taught in ESL Feld, P., &-Power,B. (2000). Immigrants‘access to health classes via CBE, blended with features of other ap- care after welfare reform: Findings from focus groups in proaches-such as whole language, learner-centered, four cities. Washington, DC: Kaiser Commission on or language experience-according to teaching styles Medicaid and the Uninsured. and learner needs. Grognet, A. G. (1997). Performance-based curricula and Participatory approaches to teaching health, often outcomes: The Mainstream English Language Training coupled with the development of a project, have re- project (MELT) updated for the 1990s and beyond. Wash- ceived much attention recently in the adult education ington, DC: Center for Applied Linguistics. (Avail- -
able from Spring Institute for International Studies, Fadiman, A. (1997). The spirit catches you and you fall 303-863-0178, http://www.springinstitute.com) down. New York: Noonday Press. True account of Hiffeldt, C. (1985, Winter/Spring). Picture perception the culture collision that occurred with tragic re- and interpretation among pre-literate adults. Pas- sults in the 1980s in California, where a Hmong sage: A Journal of Refugee Education 1(1), 27-30. child was treated for a severe seizure disorder. Hohn, M. (1998). Empowerment health education in adult Federal Resources for Educational Excellence (FREE). literacy: A guide forpublic health and adult literacyprac- Health and safety. Links to Web health information titioners, policy makers and funders. Washington, DC: compiled by federal agencies. http://www.ed.gov/ National Institute for Literacy. free/s-health. html Isserlis, J. (2000). Trauma and the adult English language Galanti, G. (1997). Caring forpatients tiom direrent cul- learner. ERIC Digest. Washington, DC: National Cen- tures. Philadelphia: University of Pennsylvania Press. ter for ESL Literacy Education. (EDRS No. ED444397) Relates 172 case studies of cultural conflicts that oc- LaMachia, J., & Morrish, E. (2001, Spring). Teachers' curred in U.S. hospitals. concerns about incorporating health into adult edu- Health Literacy. U.S. Department of Education Web site cation. Field Notes, lO(4). offers up-to-date information on health literacy and Moss, D., &Van Duzer, C. (1998). Project-based learning resources . h t t p :/ / w w w. e d .g ov/o f f i c e s / 0VA E/ for adult English language learners. ERIC Digest. Wash- AdultEd/health 1.html ington, DC: National Center for ESL Literacy Edu- Joint Commission on Accreditation of Healthcare Or- cation. (EDRS No. ED427556) ganizations. Provides easy-to-read information on National Library of Medicine. (2000). Current bibliogra- making healthcare choices. http://www.jcaho.org/ phies in medicine: Health literacy. Bethesda, MD: Na- trkgen-frm. html tional Institutes of Health, U.S. Department of Levine, D. A. (2001, October). Health Literacy: Zmplica- Health and Human Services. tions for Seniors Symposium Proceedings. Washington, Povenmire, A. V., & Hohn, M. (2001, Spring). Why DC: U.S. Department of Education, Office of Voca- teach health? Field Notes, lO(4). tional and Adult Education, Division of Adult Edu- Rudd, R. E. (2001). Health literacy overview. [Electronic cation and Literacy. Includes apendices and contact slide presentation] Retrieved December 2001, from information for classroom resources. (Available in Harvard School of Public Health, Health Literacy 2002 online and from ERIC Document Reproduc- Studies Web site: http://www.hsph.harvard.edu/ tion Service.) healthliteracy/overview.html Medline Plus. National Library of Medicine Web site Singleton, K. (2002). ESL teachers: Helpers in with plain English information on health and medi- healthcare. Focus on Basics, 5(C), 26-29. cines. http://www.nlm.nih.gov/medlineplus/ Resources McKinney, J., & Kurtz-Rossi, S. (2000). Culture, health and literacy: A guide to health education materials for Agency for Healthcare Research and Quality. This Web adults with limited English literacy skills. Boston: World site contains easy-to-read information on health Education. conditions, health insurance, and consumer rights. New York Online Access to Health (NOAH). A well-or- http://www.ahrq.gov ganized, English/Spanish directory on health top- American Pharmaceutical Association. Avoiding medi- ics and resources. http://www.noah-health.org/ cation errors. http://www.pharmacyandyou.org/ System for Adult Basic Education Support (SABES) aboutmedicine/med. html Health Page. Provides information and resources Center for Multicultural Human Services. A culturally that link the fields of health and ABE/ESL. http:// and linguistically sensitive mental health treatment www.sabes.org/health/ provider. http://www.cmhsweb.org/ U.S. Department of Health and Human Services. (2001). Cross Cultural Health Care Program. Provides infor- Mental health: Culture, race and ethnicity. Rockville, mation on health beliefs in different cultures. http:/ MD: Author. Available: http://.www.mentalhealth.org/ /www.xculture.org/ P~1blications/allpubs/SMA-Ol-3613/sma-Ol-3613.pdf
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