• What is health literacy?
• How extensive is the problem of low literacy in non-native speakers of English?
• What general relationships exist between illiteracy and poor health?
• In general, what is the financial impact of health illiteracy?
• Why is health an important issue for ESL literacy programs?
• What needs does IHA's HELP Curriculum meet?
• Who were the curriculum writers who developed this project?
• How were topics for this project selected?
• How are the topics used instructionally?
• What materials are available in each unit?
• Why are materials numbered the way they are rather than numbered sequentially?
• Do the units need to be used in any special order?
• What other materials are available?
• How can I obtain these materials?
• What makes these materials unique?
• There are a lot of activities. How would I ever use them all?
• What would a typical hour session look like?

What is health literacy?

• The ability of individuals to obtain, interpret, and understand basic health information and to use such information and services in ways that enhance health. (Source: American Cancer Society, National Health Education Standards)
• The ability to read and comprehend basic concepts and tasks needed to function sufficiently in the health care system (Source: U.S. Department of Adult Education, Fact Sheet 20)

Thus, health literacy is not just reading health information but also understanding and properly acting on this information. Health literacy contributes to civics education by helping non-native speakers of English navigate the American institution of healthcare in order to make effective health decisions for their children. This project provides a functionally contextual assessment and curriculum based on common childhood medical problems that will help ESL learners develop listening, speaking, reading, and writing skills needed to solve healthcare issues for their children.
 

How extensive is the problem of low literacy in non-native speakers of English?

• Of the 28.4 million people with a non-English background, 22% said that they could only read and write in their own language and 35% were identified as functionally illiterate. This includes those who are literate in their native language but are unable to take tests in English. (Source: 1992 National Adult Literacy Survey)
• Nationally, 27.8% of individuals with Hispanic origins who are 25 years of age or older have less than a 9th grade education, and another 16.1% have not finished high school (a total of 43.9% for Hispanics), whereas only a total of 12.3% of white, non-Hispanics 25 years of age or older have less than a 9th grade education or failed to complete high school. (Source: March 1999 Census Data)
• Minority populations, and especially those for whom English is a second language, are more likely to be functionally or marginally illiterate. (Source: 1992 National Adult Literacy Survey)
• Adults who are functionally or marginally illiterate are more likely than those performing at higher levels to be economically disadvantaged. (1992 National Adult Literacy Survey) According to March 1999 census data, 22.7% of families with Hispanic origins are below the poverty level, compared to 6.1% of families of a non-Hispanic, white origin.

Although illiteracy is a national problem with implications for many areas of life, illiteracy mostly affects non-native speakers of English who are unable to use the listening and speaking skills possessed by native speakers of English. The reading level of the target material in this project, What To Do When Your Child Gets Sick, is between 2nd and 4th grade. The low readability level of this material, in conjunction with the development of a communication assessment tool specific to medical terminology and problems, a visual dictionary of difficult medical terms specific to this book, and companion teaching resources focusing on reading comprehension and critical thinking, will provide ESL functionally and marginally illiterate learners with a viable means of learning health concepts.
 

What general relationships exist between illiteracy and poor health?

• Economically disadvantaged people, who are more likely to be illiterate, are also more likely to 1) be exposed to environmental and occupational hazards which impact health; 2) have limited or substandard educational, housing, and employment opportunities which affect health; and 3) have limited access to health promotion, disease prevention, and curative programs which ensure health. Many of these people face triple jeopardy because of a combination of minority status, poverty, and communication barriers. (Source: Healthy People 2000)
• One-third of Medicare beneficiaries surveyed were unable to adequately understand basic health-related materials. (Source: 1997 Prudential Health Literacy Study)
• Patients with low literacy levels are more likely to report poor health conditions. (Source: National Center for the Study of Adult Learning and Literacy Report #14)
• Poor literacy may lead to the improper use of medication, rehospitalization, incurable cancer that may have been detected earlier if the patient had the ability to understand its seriousness and implications, birth defects, and other illnesses. (Source: U.S. Department of Adult Education, Fact Sheet 20)
• The use of assessments to measure health literacy can target individuals who are at a greater risk of developing medical problems due to low literacy skills. (Source: U.S. Department of Adult Education, Fact Sheet 20)
• The relationship between illiteracy and poor health is so strong, that improving reading skills is a way to improve health. (Source: Weiss, Journal of Health Care for the Poor and Underserved)

Illiteracy in general, and low health literacy specifically, affects an individual's ability to access health services and make effective decisions about their healthcare and that of their children. The authors of What To Do When Your Child Gets Sick, Gloria Mayer, Ed.D., R.N., and Ann Kuklierus, R.N., have written a text (available in either Spanish or English versions) that focuses on health literacy in terms of common childhood problems. The Spanish-language version helps make this information accessible to individuals who are already literate in Spanish. Utilization of both versions promotes the transfer of concepts from Spanish to English. What To Do When Your Child Gets Sick, published by the Institute for Healthcare Advancement, features a low-readability level, easy-to-read large print, easy-to-understand writing, practical application, and a focus on what parents need to know when making decisions about their children's healthcare needs. The Institute for Healthcare Advancement is a nonprofit 501 (c)(3) private operating foundation whose mission is to advance healthcare delivery through education and demonstration of innovative healthcare practices.
 

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In general, what is the financial impact of health illiteracy?

• Low-literacy patients seeking emergency treatment for non-life-threatening conditions are twice as likely to be hospitalized as are those patients with adequate skills. (Source: National Center for the Study of Adult Learning and Literacy Report #14)
• An estimated $73 billion per year for longer hospital stays or rehospitalization can be attributed to low health literacy. (Source: National Academy on an Aging Society).
• A 2-year outcome study found the use of a self-help handbook resulted in a 12.2% reduction in primary care visits, a 17.1% reduction in urgent care visits, and a 15.4% reduction in emergency room visits. (Source: Kaiser Foundation)

Although specific statistics are not available by race/ethnicity, individuals who are economically disadvantaged are more likely to be low-literate and also more likely to rely on public health clinics and charity hospitals for healthcare and medical attention. Thus, taxpayers face a greater tax burden as a result of rising healthcare costs for patients with inadequate literacy skills. Self-help educational materials in health literacy topics have a significant impact on reducing healthcare costs.
 

Why is health an important issue for ESL literacy programs?

• In a National Survey of State Directors of Adult Education, priority ratings were given to health within the context of adult learning. (Source: National Center for the Study of Adult Learning and Literacy Report #9)
• Participants in ESL literacy classes are members of families and communities who can act as effective channels for health promotion among people in low income and minority populations. (Source: National Center for the Study of Adult Learning and Literacy Report #9)
• As parents, health issues are of vital importance to adults and may help provide motivation for learning basic literacy and communication skills. (Source: National Center for the Study of Adult Learning and Literacy Report #9)

Health issues create attendance problems as well as academic performance problems in adult education programs. In many cases, adult learners miss classes due to sick children or other family members. Thus, better health contributes to the retention of ESL learners in adult education programs.
 

What needs does IHA's HELP Curriculum meet?

• Need for a functionally contextual curriculum that enhances the learning of health and language by ESL learners through meaningful content. In a National Survey of State Directors of Adult Education (Source: National Center for the Study of Adult Learning and Literacy Report #9), one of the two most frequently listed barriers to inclusion of health within the context of adult learning was lack of curriculum materials. Specifically, respondents indicated that teachers lack resources to teach appropriate health issues and need a curriculum that also teaches basic education skills, especially one that is multicultural in its approach and meets the needs of ESL learners.
• Need for a better match between reading level of students and readability level of health-related materials. Studies found large discrepancies between the readability levels of patient education materials and reading levels of the audience for which they are intended. (Source: National Center for the Study of Adult Learning and Literacy Report #14) Most health education print materials are written at or above the 10th grade level. (Source: Northeast SABES January 2000 Conference) However, the average reading level among all U.S. adults is no higher than an 8th-grade level - and only a 5th-grade level for Medicaid enrollees. (Source: Journal of American Geriatric Society)
• Need for a functionally contextual screening inventory that assesses different aspects of communication and health knowledge. Limited literacy affects listening and speaking abilities as well as reading ability. Decontextualized medical language may be difficult for those who are poorly educated and those for whom English is a second language. (Source: National Center for the Study of Adult Learning and Literacy Report #14)
• Need for the development of a visual dictionary of medical terms for ESL populations. Researchers recommend the use of illustrations to increase patient comprehension, especially among low-literate populations. (Source: National Center for the Study of Adult Learning and Literacy Report #14) This is especially important for non-native speakers who may have a wealth of background knowledge but lack the verbal language to express themselves or make sense of information.
• Need for a focus on children's health. Children's health in the U.S. is cited as a priority issue. (Source: Children's Defense Fund 1997 Report) Parents' literacy affects their ability to follow prescribed therapy for their children. (Source: National Center for the Study of Adult Learning and Literacy Report #14)
• Need for the inclusion of health education in adult education programs. In a national survey of adult basic educators, 93% of the respondents indicated that the adult learning setting was an appropriate setting for teaching and learning about health. Teachers indicated that health lessons increased skills in dialogue and discussion, vocabulary building, reading, language development, and critical thinking-all skills needed by ESL learners. They suggested that health was more advantageous than other topics in terms of contributing to learner interest, participation, and motivation. (Source: National Center for the Study of Adult Learning and Literacy Report #8)

This curriculum addresses the development of literacy and communications skills in ESL adults by using the health and well being of their children as a motivator. Thus, the increased ability to navigate the intricacies of the healthcare system provides a powerful driving force for the ESL learner to remain in the adult education program because the content of this curriculum is personally meaningful and relevant. The readability level of What To Do When Your Child Gets Sick more closely parallels the reading abilities of ESL learners. What To Do When Your Child Gets Sick is also available in Spanish, which makes it usable by bi-literate learners and learners who are literate in Spanish but not literate in English. The screening inventory developed in this project helps ensure that teachers are more able to meet the communication needs of individual non-native speakers of English by specifically assessing their health literacy in terms of listening, speaking, reading, and writing in English. The visual and text glossaries of medical terms in the book will help make concepts within the book accessible to those individuals whose reading levels in English are below 2nd grade and to beginning, limited English speakers. Simple, easy-to-use teacher directions accompany each exercise. This allows paraprofessionals and volunteers as well as teachers to effectively use the materials to assist ESL learners.
 

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Who were the curriculum writers who developed this project?
Rhonda Atkinson, Ph.D., has written numerous textbooks on reading and study strategies for developmental students. She has also developed curricula for low-literate readers in the areas of corrections education, environmental literacy, construction trades, commercial driver's licensure, and health/safety for childcare providers.

Catherine Frazier, MSE, has over 20 years of experience in teaching English overseas and is an internationally known expert in the area of ESL instruction. The instructional series she authored is widely used in Asia and other parts of the world. She currently teaches ESL students at both the post-secondary and elementary school levels.

Tom Atkinson, Ph.D., has developed software for nearly 25 years. His projects include database applications, information kiosks, and multimedia Web-based instruction. He currently teaches graduate courses in Educational Technology at Central Missouri State University.
 

How were topics for this project selected?
Twenty topics from What To Do When Your Child Gets Sick were selected for use in the project. The topics that were selected were identified as those which were most basic (e.g., safety; what to do when your child has a fever) or most applicable to school-age children (e.g., head lice, impetigo).
 

How are the topics used instructionally?
Each topic forms a single, stand-alone unit that can be used in any order. In addition, each unit is developmentally graded so that every unit is usable and functional for learners at all levels. A teacher or facilitator might choose topics based on knowledge of what learners need or learners might assist in selecting topics they want to know more about.
 

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What materials are available in each unit?
Each unit includes the vocabulary for the unit in a word bank. Words are classified as:

Each unit also includes 3 listening exercises, 2 speaking exercises, 7 reading exercises, 5 writing exercises, and 4 thinking exercises. Each type of exercise provides for Level 1, Level 2, or Level 3 instruction.
 

Why are materials numbered the way they are rather than numbered sequentially?
Each scenario or activity is numbered separately to facilitate usage with learners at multiple levels. For example, one student might be a Level 1 reader, a Level 3 listener, a Level 2 speaker, and a Level 1 writer. No single sequential page numbering order could fit everyone.
 

Do the units need to be used in any special order?
No. Each unit is complete within itself and does not assume that the learner has any prior content knowledge. Thus, some terms and concepts (e.g., fever) appear in multiple units.
 

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What other materials are available?
An easy-to-administer informal screening inventory is available to help determine each learner's listening, speaking, reading, and writing level. A visual glossary of approximately 250 terms from the book is cross-referenced by topic, book chapter, page number, and difficulty level. A textual glossary of approximately 350 words from the book is cross-referenced by topic, book chapter, page number, and difficulty level.
 

How can I obtain these materials?
"Teaching Reading and Health Together: IHA's Health Literacy Curriculum" was written to be used in conjunction with the book, What To Do When Your Child Gets Sick. The curriculum is available at no charge through any of the following:

1. At the Institute for Healthcare Advancement Web site, www.iha4health.org (Download .pdf files)
2. At the State of Louisiana Department of Education Web site, www.leeric.lsu.edu/slrc (Download .pdf files)
3. By contacting the Institute for Healthcare Advancement, 501 S. Idaho Street, Suite 300, La Habra, CA  90631, (800) 434-4633; fax (562) 690-8988; or email info@iha4health.org (Request a free CD-ROM be mailed)

What makes these materials unique?
The design of the materials allows for flexibility of instruction that is unparalleled in ESL education. For example, some learners may have listening comprehension skills that exceed their abilities to read, write, or speak English. Or, you could have a learner that speaks and understands spoken English, but does not read or write English. Thus, you could have a learner who gets the Level 1 scenario and reading and thinking activities, the Level 2 listening and speaking activities, and the Level 2 writing activities. This curriculum enables you to provide parallel instruction to learners at different levels of English understanding and expression. In addition, as learners become more proficient, they can easily move from level to level in subsequent units.
 

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There are a lot of activities. How would I ever use them all?
Think about instruction in terms of a single unit. You would provide each learner with a word bank for that unit. You could give copies of the visual and textual glossaries to each learner or you could keep copies in the classroom for student use. Each learner would receive a unit scenario appropriate to his or her reading level. Each learner would get activities based on his/her level in that area.
 

What would a typical hour session look like?
Open the session with an introduction or review of words in the word bank (10-15 minutes). Begin with informal brainstorming (e.g., How many of you have heard the word "colic"? How do you know this word? What do you know about it? Where have you seen or heard it?) Show learners the lists from the word bank. Read them aloud and ask learners to repeat words together. Ask students to elaborate on what they already know about colic. (Which words do you already know? Where have you seen or heard them? What do you know about them?). This forms an immediate evaluation of how well a specific group understands the concept. If learners know 50% or more of the words, then you can proceed with the lesson and expect 50% understanding. If they know less than 50%, you may want to spend more time in the first lesson looking up the words and practicing vocabulary.