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For Instructors

Health Literacy

Note: Read an interview with Kate Singleton, healthcare social worker and former adult ESL instructor below.

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.

Obstacles that adult English language learners may encounter in developing health literacy include the following:

  • 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; 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. 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

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. 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. Some learners may come from cultures where there is a stigma attached to accessing mental health services.


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.


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 to take to avoid and minimize the side effects.

5. A role-play activity where students act out a conversation with the doctor about taking Isoniazid provides further listening and speaking practice.

            Adapted from Health Literacy for Adult English Language Learners.

Kate Singleton, author of  the digest Health Literacy for Adult English Language Learners, ”Picture Stories for Adult ESL Health Literacy” and the Virginia Adult Education Health Literacy Toolkit is  a healthcare social worker at  Inova Fairfax Hospital, Falls Church, Virginia.

Previously-- when Kate was an adult ESL instructor and coordinator in Arlington and Fairfax counties in Virginia—she  became concerned about the intersection between health, healthcare, and  literacy-level learners in her classes. Because of this  concern, Kate investigated the topic, developed, then shared her materials online.  Below, Kate responds to questions about effective and appropriate ways for instructors to help adult English language learners acquire the language and skills they need to navigate the American healthcare system. 

CAELA: Hi, Kate,  in your digest <excerpted above>, you list obstacles that adult English language learners may face in developing health literacy.  Do you have a short list of strategies or techniques teachers might keep in mind as they develop health lessons?

Kate: Using healthcare today is fraught with roadblocks for patients and their families.  It raises frustration levels very quickly.  Miscommunication is common in healthcare settings.  Problem-solving activities and dialogue development for difficult healthcare situations learners might find themselves in can be very helpful and can generate a lot of good language learning for many situations in life.

Don’t try to be the expert.  Elicit learner experience. Keep lessons learner-focused, relevant to their situations and needs.  Approaches that work well for these purposes are life-skills/ content-based (drawing in realia, role-play, dialogue development), Language Experience Approach, problem-solving, participatory or project-based approaches, narrative approach.

Make use of the many Internet resources there are on health and health care.  There are heaps more useful sites now than when I wrote the Toolkit.  Quality of information and cultural and linguistic appropriateness are definitely still concerns, but there has been some improvement.  Remember, websites are primarily useful as a reference for the ESL teacher.  Many sites still tend to be visually or linguistically overwhelming for many levels of ESL learners.

Use community resources.  Healthcare providers (especially ones that receive a lot of government. funds like many hospitals or free clinics) are definitely increasing interest in making their services more usable to those with low health literacy.  Check with organizations like the American Medical Association (AMA) to see what practitioners are working on (e.g., studying, giving trainings to other practitioners) health literacy issues in your region.

CAELA: Now that you are working in healthcare setting, do you also have some tips for health educators and providers? For example, do you see differences in the health literacy needs of native speakers of English and adult English language learners? If yes, what do providers need to know about the differences?

Kate: Well, the AMA and public health definitely deserve credit for trying to increase cultural sensitivity and health literacy awareness among their workforces, but there is still a way to go.  I would encourage providers and health educators not to make assumptions about their patients or audience such as  that because a person is a limited English speaker he or she has a low educational level, or because a person is a Spanish speaker they will “get it” if things are interpreted into Spanish for them.  Also, U.S. mainstream medicine is built around the concept of “one size fits most” solutions, which does not work in trying to address health literacy.  (e.g., not all people with low health literacy are going to benefit from interactive computer tutorials on health topics).  In terms of differences between native speakers of English and adult English language learners, both groups have many of the same problems related to  the locating and navigating of health care and understanding conditions and treatments.  Often people with limited English encounter additional difficulty because they lack important cultural awareness relating to U.S. health care.  They often don’t know their rights, such as the right to an interpreter provided by the healthcare provider (rather than relying on a family member), the right to question a doctor, the right to get a second opinion, the right to use some public clinics, etc.  If they haven’t received much basic education on health or human physiology in their native language, then they are at the mercy of the health care provider --- they have no idea what their condition is or how proposed treatments will affect them.  And of course, there are still plenty of limited English speakers in the US who are afraid to seek health care, or put it off because of lack of health insurance, fear, or other reasons.


Beginning- and Literacy-Level Adult ESL Learners

Health Literacy Resources & Programs For Adult ESL

Digests, and Q&As

Cross-Cultural Issues in Adult ESL Literacy

Health Literacy for Adult English Language Learners

Mental Health and the Adult Refugee: The Role of the ESL Teacher

Refugees as English Language Learners: Issues and Concerns

Trauma and the Adult English Language Learner

Other CAELA Resources

Picture Stories for Adult ESL Health Literacy (by Kate Singleton)

Other Resources for Teachers and Administrators

Arlington Education and Employment Program (REEP). (2003). REEP ESL Curriculum for Adults: Health Lesson Plans. Arlington, VA: Author.

Arlington Education and Employment Program (REEP). REEPworld for Students Website: English for Health.

California Health Literacy Initiative. Health Literacy Resource Center (including sections such as Plain Language health Resources for Literacy and ESL Students and Multicultural and Multilingual Health Information).

Diversity Rx " Promoting language and cultural competence to improve the quality of health care for minority, immigrant, and ethnically diverse communities." (homepage)

Harvard University School of Public Health and National Center for the Study of Adult Learning and Literacy. NCSALL. Health Literacy Studies Retrieved December 14, 2006 from

The Joint Commission. Speak Up Initiatives. "In March 2002, The Joint Commission, together with the Centers for Medicare and Medicaid Services, launched a national campaign to urge patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team." (Facts abut Speak Up Initiatives). Materials available in English and Spanish at

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006) The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: US Department of Education, National Center for Education Statistics. Available at

Massachusetts Department of Education Adult and Community Learning Services. (October 2001). Massachusetts Adult Basic Education Curriculum Framework for Health. Malden, MA: Author.

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. (ERIC No. ED 465 311)

McKinney, J., & Kurtz-Rossi, S. (2006). Family Health & Literacy: A Guide to Easy-to-Read Health Education Materials and Web Sites for Families. Boston: World Education.

National Institute for Literacy electronic discussion on Health and Literacy. (To subscribe, go to

Singleton, K. (2002, February). ESOL Teachers: Helper in Health Care. Focus on Basics Vol. 5(c). (Note: This entire issue of Focus on Basics is focused on literacy and health at

Virginia Adult Learning Resource Center (2003). Virginia Adult Education Health Literacy Toolkit

World Education. (2003-2004). Health and Literacy Special Collection. (While this Web site--supported by the LINCS project of the National Institute for Literacy--is no longer being updated, there are many live links to resources of interest to adult ESL teachers and administrators at