Welcome to our Guest Discussion: Introduction to Health Literacy in ABE and ESOL

Hi Everyone!

This discussion series started in October, 2013. There are 4 parts to the series, and they continue to grow even after the advertised dates. We have laid down the basics of each topic, and here's what I hope will happen now: You will explore the ideas, resources and examples that we have talked about and then weigh in with your comments, questions and ideas. It doesn't matter if it's months or years after the discussion began. I hope that this discussion series will keep growing and evolving into something that will continue to be more useful as time goes by!

Please read and add to whichever part you like:



This is the beginning of Part 1:


Welcome to our discussion!

I am so pleased to welcome Kate Singleton as our guest speaker. Kate has been a sturdy bridge between the ESOL and health literacy worlds for many years. She wrote the Picture Stories for Adult ESL Health Literacy, which is one of the earliest, most well-known and best-loved teaching resources for health literacy in adult education. She has been a teacher, trainer and curricula developer, a vocal advocate for health literacy, and more recently a social worker. She now works a clinical social worker in a hopsital, so she sees how health literacy affects people and systems fromt the adult education classroom to the emergency ward.

Kate recently developed the Virginia Adult ESOL Health Literacy Toolkit: a large collection of resources to help the ABE and ESOL fields to understand and address health literacy in our programs.

This discussion has four parts. (See the Schedule, pasted below.) This week is an introduction to health literacy in ABE and ESOL. 

See the whole description of this week's discussion at this link:


We will start by discussing the preparation readings. The main one iss this article:

What is ESOL Health Literacy and Why Do I Need To Know About It?


This article is about ESOL specifically, but as you read it, you'll see that it relates just as well to adult basic education settings.

So, Welome, Kate! Let's get going!


~ Julie



Schedule of discussions:

November 11-15: Introduction to Health Literacy in Adult Basic Education (ABE)

We will discuss this article with its author, Kate Singleton: What is ESOL Health Literacy and Why Do I Need To Know About It? This topic will help frame the series of discussions and set the stage for why health literacy is an important topic for ABE programs. 

November 18-22: Resources for Addressing Health Literacy in ABE Programs

We will share and discuss curricula and other practical resources, including those from the LINCS Resource Collection.

November 25-December 3: Integrating Health Literacy into Basic Skills Instruction

We will discuss how using health as a context for teaching basic skills can strengthen what teachers already do in the classroom. We will use the resources discussed in Week 2 to showcase examples of their use integrated into literacy/language instruction.

December 4-10: Health Literacy in ABE: What Are People Doing? Examples of Successful Projects

We will hear from ABE teachers and administrators about how their programs have successfully incorporated health literacy into their curricula and activities.




Hello, everyone, and thank you, Julie, for the very kind introduction.  

I am honored to be part of this important discussion focusing on health literacy and adult education!  In the years that I have been working on health literacy issues in adult education and clinical settings, I have heard from many adult educators and health care providers as well who have shared that they see the potential for adult education to play a larger role in improving adult health literacy skills in the US.  At the same time, many have expressed puzzlement over how best to address this complex issue --- how to provide health literacy instruction in adult education that:

  • Is learner-centered and best meets learner “real world” needs for our complex health care system;
  • Best utilizes the strengths and resources of adult educators and doesn’t have them trying to fill roles outside of their expertise;
  • Is manageable and sustainable with all the other demands on adult ed programs;
  • And effectively leverages community and health care resources to support health literacy instruction. 

I am hoping that discussion here in the coming weeks will get some great ideas flowing around these issues! 

As Julie mentioned, we are going to start off with discussion of the introductory article from the Virginia Adult ESOL Health Literacy Toolkit (published in 9/2013), What is ESOL Health Literacy and Why Do I Need to Know About It?.  I wrote this article to begin to clarify some of the complex issues around understanding health literacy for adult ESOL educators. As Julie stated, much of what is included in it can apply to some degree to all ABE learners.  For those who haven’t had a chance to read it yet, the article looks at defining health literacy for ESOL learners’ realities, the skills needed by English language learners for health literacy in the US, relevant research findings, recommended content and directions for ESOL health literacy instruction, and relevant federal and health care policies and practices.

I suggest we start our discussion by looking at Question 1 from the recommended discussion questions Julie posted last week:

1.       What are the different kinds of skills needed by ELLs, and to varying degrees by all ABE learners, to be health literate for the US health care system?  Which do you currently address in your instruction?

As you'll see, the list of skills I propose is quite broad.  I am curious to hear which of these types of skills educators feel they are already touching on in their health-related instruction, or feel they could incorporate without too much difficulty.

That said, if any of you have other questions or comments you are eager to post about this article or the other resources Julie has posted, please go right ahead!  We are eager to see them and respond!


Hi, Kate and others,

I've been looking forward to this discussion. Thanks, Kate, for the cogent overview (in the article) of issues related to adult English language learners and health literacy.  On a first read, I am particularly interested in the chart that gives examples of health literacy skills learners may need to acquire.  Also, I  strongly second the notions that 1) many traditional textbook style practice in a health unit may not be enough to give adults the tools they need in the real world and that  2) literacy- and beginning-level adult English language learners need and can understand complex issues, tasks, and language related to health.

I'm looking forward to the coming discussion.

Best wishes,

Lynda Terrill

Adult ESOL Consultant

Charlottesville, Virginia






Hi Lynda,

Great to hear from you here!  And thank you for posting Picture Stories for Adult ESL Health Literacy to the CAL website all those years ago to make them widely available to educators! :-)

I’m glad you find the skills chart helpful.  It sure is a LOT of skills that we all need to have to try to communicate effectively and get our needs met in US health care, but they are an especially heavy load for people with low literacy and people coming from different cultural and/or language backgrounds.  I’m curious --- from your extensive ESOL experience, which types of skills listed there would you say ESOL classes are especially suited to address in basic ways?

Thanks for your comments on traditional ESOL health content vs. learner realities. When I first started practicing social work in hospital and clinic settings, the disconnect between the health lessons in beginning level ESOL textbooks and the truly complicated, difficult communication situations that LEP patients and families experience in those health care settings was really striking to me. 

I remember in my early years as an ESOL teacher I had encouraged ESOL learners to try to speak English with the doctor.  Boy, was I naive!  As I heard more learner stories about their healthcare encounters (all emergencies resulting from delayed access to care for problems that started out small and potentially manageable), and later as I worked in clinical settings myself, I realized I had been doing my earliest learners a disservice (granted, there were far fewer medical interpreters available back then).  People with limited English proficiency are very vulnerable to health care miscommunication, medication errors, repeat hospitalizations, higher healthcare costs, and poor health outcomes.  This is all well-supported in health literacy and health disparity literature.  Probably the most important health content that we can teach beginning level ESOL learners is how to ask for a medical interpreter to help them understand complex medical information as best as they can.  And thankfully that’s pretty simple English to teach :-): “I need an interpreter, please.  I speak ____.”


Hi, Kate,

Right now, I am wishing I had spent more time working with the learners on how to ask for to ask for a medical interpreter. 

As to your question about what skills (from the chart in your article) I think are suited to literacy-level classes: we spent a great deal of time working on speaking and listening.  We spent time working on expressing needs and preferences and being assertive, which I think directly connects with cultural contexts.  In addition, I generally added vocabulary (e.g., unconscious, tumor) to the small word/picture lists sometimes found in beginning level texts. The learners seemed to want more precise vocabulary.  For example, I usually spent time distinguishing "chest" from 'breast." 

One more comment: what we worked on in class was related to the learners' self-identified short-term goals related to health.  It did, take some time to work together on identifying goals (e.g. talk with the doctor, find exercise opportunities), but that was a good opportunity for bringing up relevant vocabulary and language patterns.

I have a question for you, now.  By law or convention, can individuals with limited English proficiency ask (and expect to receive) medical interpretation services at a doctor's office or just at a hospital or clinic?





Good morning, Lynda,

Thanks for your reply.  Your comment about learner-identified short-term goals brings up an interesting conundrum re: health literacy instruction for ABE and ESOL learners.  While adult educators wisely aim to be as learner-centered as possible and avoid being too prescriptive in our instructional approaches, with health and health care literacy there is most definitely a "you don't know what you don't know" aspect to be considered. If people haven't had many healthcare system experiences to draw upon in the US and have limited knowledge of health disparities impacting their racial and ethnic communities (this goes for native speakers as well as ELLs), they might have difficulty identifying some important things to ask for in the way of health lit instruction.  As a field, adult education can perhaps help learners with this by collaborating with the public health and health literacy fields and representatives of learner population groups to pinpoint health care and health information topics that are likely to be of high relevance to learner populations.  Ideally we would then develop simple materials and lessons on identified topics so that we can offer more for learners to choose from, especially for lower levels where learners might have bigger challenges identifying and articulating these needs and interests in class.  Of course, funding needs to be available to make this happen.

Your question about interpreters is an excellent one.  Unfortunately as with many healthcare-related questions the answer is a little murky (and I welcome anyone out there with any clarifying info on the issue to chime in!).  According to federal law, specifically Title VI of the U.S. Civil Rights Act of 1964 and Executive Order 13166 which provides additional explanation of that law, any healthcare provider (or other organization) that receives funding from the federal government is mandated to provide "meaningful access" to services for limited English proficient people (note: not just lawfully present LEP people).  This meaningful access has been explained by the Dept. of Justice as providing interpretation in person or via telephone, at no cost to the patient or family members.  A key piece here is that the healthcare providers who must comply with this are those receiving federal funding.  In the majority of private practices this would most likely occur in the form of Medicare payments.  So yes, the majority of private practices SHOULD comply with this law.  The reality is that many do not yet, and I think a couple of things are at work here.  1) Hospitals are better "policed" than private practices around providing interpreters.  They are more closely watched by the Joint Commission (accreditation org. for hospitals) and federal agencies, and are generally pretty responsive to lawsuits relating to healthcare communication barriers which lead to medical errors. 2) I suspect that many private practices do not offer interpreters to LEP--- they wait for patients to request them, and patients are not well-educated about their right to request them.  I think many LEP patients just assume they need to take a family member or friend with them to interpret at English-speaking private practices, and that works fine for the practices who would otherwise have to foot the bill for interpreter services.  

As tends happen in health care, when more lawsuits and/or medical errors occur in private practices in relation to communication breakdowns with LEP patients and family, use of interpreters will likely increase.  Hopefully more people requesting interpreters in private practice (and expressing knowledge of their legal right to an interpreter) will nudge things along for the better.  It will be interesting to see how the projected increase of LEP patients to private practices under Obamacare impacts this situation as well.

FYI, the entities which investigate complaints of violations of the "interpreter law" as it's often called are regional Offices for Civil Rights.  Here is the link for them: http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html

An ESOL teacher take-away from my lengthy response is that it IS important to educate learners about their right to an interpreter, to teach them how to ask, and to ask in private practices as well as in clinics and hospitals.   




Hi, Kate,

I understand your perspective about the complexities of learner goal-setting related to what they really do need to know and and be able to do.  As you indicate, successfully navigating the healthcare system is challenging for  both native speakers (including me) and English language learners, and we need all the information we can get.

Thanks for the information (including citations) on the laws and practice of providing medical interpreration in private practice. 




I think Lynda brought up a really important aspect of the skills we teach: "expressing needs and preferences and being assertive".

All the skills we teach that will help our students with their health depend on their being comfortable and confident enough to put these skills into practice. If you look at any skill on the chart in the article and think about how it is used in a real-life health-related situation, you can see that the person will need to be confident enough to use that skill to get what they need from a website or a doctor. This is why adult education classrooms are such a good place to teach health literacy skills. In the trusting, safe environment of an ABE or ESOL classrom, people are more open to learning this assertiveness and confidence. I believe that this will help them to use all the skills way more effectively.

So, how do we do that? Would love to hear how you all approach this!

What do others think?  

These are great questions!!  Thanks, Julie and Lynda for focusing on assertiveness and confidence in relation to health literacy.  There are many ways that adult educators can and do address assertiveness skills and confidence with their learners.  I'll put some of my thoughts below, but I hope others will still chime in on this important topic.

Our assertiveness and confidence in different life situations are in part culturally driven, so in adult ed we can teach about these as culturally based communication and problem-solving skills useful  for US health care, employment, and other life skill areas.  Toolkit Item 1.8, Aspects of US Health Care Culture, can give teachers some ideas of health care culture topics to present/discuss with learners.  As  I often remind patient, provider, and educator audiences, we don't get any formal education or informal training around the kitchen table on how to understand and use US healthcare, but it is a unique system with its own confusing, ever-changing culture.  We expect people to "get" it in intuitively and feel competent using it.  That's just not a reasonable expectation!  

Additionally, as a healthcare social worker I have been asked to assist with communication between patients, families, and health care providers many times and am constantly struck by how difficult assertiveness and having confidence in one's beliefs/values/preferences can be for people from all kinds of cultures, educational backgrounds, and socioeconomic status in healthcare scenarios.  I think many things drive this, including "white coat syndrome," the fast pace of healthcare settings and brevity of appointments, values within families around assertiveness, stress levels of patients/family relating to illness or other pressing life events, side effects of medications affecting cognition, and patient/family low health literacy for the particular health scenario they find themselves in.

It is so easy for people with limited English and/or low literacy to blame themselves for confusion in healthcare communication and lack of understanding of health information.  Normalizing to them that just about everybody is struggling to communicate effectively now in US healthcare can go a long way to calming the anxiety level of those who are especially vulnerable to low health literacy.  They are not alone and not the cause of the problem!  We can follow up the normalizing with teaching strategies for how to communicate questions/concerns in healthcare effectively. Some tools in the Toolkit that can be helpful for this are:

Here are some of the ideas presented in those tipsheets:

Asking questions is OK and important! - One tool I like to use for this with ESOL learners is the picture story A Doctor's Appointment .  This story allows for discussion of the importance and acceptableness of asking questions of healthcare providers in the US.  I share with learners that many people, even highly educated native English speakers, fear asking questions of their doctors, or feel confused and can't think of questions to ask.  I share that questions are very important because there is a high rate of medication errors and other medical errors in the US.  I tell them that doctors want this to improve, and a very important way to help improve this is for people  to ask questions. Yes, some doctors may be busy and seem frustrated with questions, but it is still important for your safety that you ask your questions.  Once learners get the baasic concepts here they can brainstorm ideas for how to make this easier and the teacher can fill in gaps with ideas like those below.

It's OK to bring an advocate - I point out to learners that we usually don't feel good when we are sick and talking with a doctor, and that when we don't feel good we are not so great at thinking of questions or asserting ourselves.  I emphasize that bringing a trusted friend or family member along to be "an extra brain" can be very helpful and is perfectly acceptable.  They can help you think of questions that you might not be able to think of yourself.

Use planning and other strategies to communicate better in health care - Some tips I try to convey are that if you know your condition before your appt. and have the skills to do so, look it up on a reliable web source like medlineplus.gov first so you will know a little more about it before your appointment.  Write down questions before hand and take them with you to your appt. so you won't have to think of them on the spot. Take notes or audiorecord your communication with the healthcare provider if you think you will not be able to remember important information.  If things are too rushed in the appointment, it is ok and sometimes necessary to say that you have more questions or need more information.  

Unfortunately, another issue that can impact people's ability to assert themselves in health care is the perception or experience of discrimination or stigma in health care.  These are reasonable concerns for some ABE/ESOL populations based on history and care disparity data.  This is something educators need to be mindful and respectful of in discussions of using health care.

Lastly, people who have had few US healthcare experiences (i.e., limited access to care in the past, or access to care in a very different healthcare system) are at a big health literacy disadvantage.  A pretty simple thing that can help start to build their confidence for healthcare a little is a field trip to a healthcare facility.  In the Toolkit there is a report of one project in Charlottesville, VA, in which learners do just that.  Also in the Toolkit are reports on service learning projects which bring medical and nursing students to ABE and ESOL programs, giving adult ed learners and healthcare learners the learning benefits of interaction with each other.  See REEP project and Hawthorne Center project.




Thanks, Kate. A few things to add:

I agree that a good strategy when addressing health literacy in the classroom is to reassure students that they are not the only ones who get confused by the health care system and what doctors are telling them! One thing that sets health literacy apart from literacy in a teaching situation is that we have all been there ourselves. We can honestly say that we've been in their shoes and understand. This lets us be parteners instead of just teachers, and find ways to work it out together. 

Some resources for teaching the skills of being assertive and asking questions:

Questions Are the Answer

This is from The Agency for Healthcare Research and Quality (AHRC). One highlight of this site is a collection of short videos that could be built into a cool classroom activity. They show patients telling stories of how asking questions really helped them, and one of a doctor who talks about how she herself needs to use some strategies to ask questions when she sees her own doctor!

  • http://www.ahrq.gov/legacy/questions/ 

There are also some funny tv ads that can get people thinking:

  • http://www.youtube.com/watch?v=jfylYtyb8tE
  • http://www.youtube.com/watch?v=DTo_KS88D1I
  • Or, for a silly approach, the "Singing Doctor Video": http://www.youtube.com/watch?v=0PudB0uYnFU 

Communicating When Naked: My Perspective as a Patient

This article by a well educated occupational therapist and health Literacy consultant tells of her experience as a patient


Building Bridges: A Health Literacy Partnership

Kate mentioned in her last ¶ how little experience some learners have in using the healthcare system. Here is a video of an activity they did in NYC to address this.

  • http://www.youtube.com/watch?v=uPM3kSb2Cfw 

Hello Kate and others,

Kate, you asked, “What are the different kinds of skills needed by ELLs, and to varying degrees by all ABE learners, to be health literate for the US health care system?”

The list of ELL Health Literacy Skills in the Health Literacy Toolkit document is sensible and wide-ranging. However, there are a few elements, most having to do with a digital environment, that are missing, or perhaps that are implicit where I would like to see them made explicit.

Some background

The Pew Internet and American Life project earlier this year reported that the two groups in the U.S. with the most remarkable increase in their use of Internet-accessible smart phones, were African Americans and immigrants. Also, many immigrant families, even low-income families, have made it a priority to get access to the Internet for their children and themselves through a home computer.

Missing skills

While the Reading in English skills list does include reading health information on a web site, there is an equally important set of technology and problem-solving skills involved in finding and judging the quality of health-related information on the Internet. As you mention later in the article, there are now a number of good web sites geared to providing health information in plain language in English, and in immigrants’ first languages. Important digital literacy skills I think we need to teach ELLs include how to find these web sites, how to navigate in them, and how to know if or why the information they provide is accurate.

In the Writing in English skills list, many of the forms you list are now available, perhaps soon only available, in digital formats. That means that ELLs need to learn how to complete computer-based health related forms in English. That involves not only learning how to write in English, but also  keyboarding (typing) skills, understanding what information is being asked of them on these forms, and learning how to organize that information and to have it accessible.

Part of the Cultural Awareness skills is an understanding of online culture regarding health and disease prevention. Especially important is how to discriminate between healthcare scam emails and web sites and real health insurance, how to judge health care related information in social media and other informal online environments, and how not to get overwhelmed in a health information information search, especially if the context of the search is a family emergency or health crisis.

The Numeracy  skills section needs to include how to read a numerical scale, and other math that may be needed in order to take the right dosage of medicine,  or to self administer an injection. Unfortunately, when a diabetic needs to administer insulin there may be no one available to teach the math they need; as I am sure you are aware, diabetes is a major health problem among low-income communities in the United States, including among low-income immigrants.

Under System Access and Navigation, there is a new set of skills that is beginning to emerge in some places in the U.S., and this phenomenon could accelerate. If so, many adult learners may need to be aware of these and may need to use them in the next few years. The skills include using smart phones to communicate with their physician or other health care team member. This communication could be by text (already many community health centers rely on text messaging patients reminders of their appointments) but also is likely to include requiring them as patients to send data to their health practitioner, data such as blood pressure (using a cuff connected to a smartphone), daily weight (a cable connected from a digital scale to a smart phone) and  their blood sugar level. To some, this may sound “futuristic” or unlikely to be needed by low-income ELLs, but I think it is the near future, and that as ELL and ABE educators we need to prepare to teach adult learners these skills.

I have another objective in bringing up this last set of issues now. Adult ELL and adult basic skills practitioners need to raise with our health practitioner colleagues, and with health care funders, that unless adult educators have training in how to teach these applications, and unless they are paid for the time to do so, for economically poor and low-literate populations in the U.S. having these technologically advanced, perhaps improved, perhaps cost-saving ways of communicating with patients may not be possible. We may have a new health literacy digital divide in the making.

These considerations aside, I think the Virginia Adult ESOL Health Literacy Toolkit is a great introduction to ELL health literacy, and I thank you for letting us know about it.

David  J. Rosen




Thank you, David, for your thoughtful and detailed response regarding technology skills needed for today's US health care.  I absolutely agree that electronic media is becoming a major feature in healthcare communication and is something that learners will need skills to work with.   You've cited some terrific examples for teachers to address with learners.  In some ways I think health literacy and technology is such a complex and rapidly-changing topic that it warrants its own (frequently updated) toolkit!  And yes, as for all aspects of health literacy for ABE and ESOL, funding, training, and effective interdisciplinary collaboration are needed to get the job done well.

It is good news that, as you have cited, many more African American and immigrant learners are likely to have regular access to the web these days, and as educators we can certainly help these learners to improve skills for getting accurate information from the web and communicating with healthcare providers better online.  We do need to be mindful that roughly 1/3 of US adults in low income households are not yet online.  

Interestingly, a couple years back I did a health literacy intervention with ESOL learners in northern VA.  As part of the project I introduced ESOL classes to MedlinePlus.gov and HealthyRoadsMedia.org, two reliable health info sites that have materials in many languages.  Learners were very excited about the sites in class and I was very excited about introducing them to the learners.  About 6 weeks after the intervention I interviewed learners (admittedly a very small sample) and asked if they had used the sites since their presentation.  All learners reported that, while they thought the sites looked really useful, they didn't have time to look at them at home because of their work and school schedules and/or they didn't have computer access. Some stated that they had computers in their home but didn't have time or energy to look at them --- they considered the computers to be their kids' domain.

Educators may find the Toolkit tipsheet from the Links for Educators section useful: 5.1 Using Online Resources in ESOL Health Literacy Instruction. I've listed many web resources on a wide variety of health literacy-related topics in the Links for Educators section, many of which I've annotated as to how they might be used with learners or what they might be useful for.  There is also a Links for Learners section which presents tipsheets and resource lists for learners in a simple format for easy access.



Thanks to Kate for keeping a valuable conversation about the significance of health literacy work in ABE classrooms alive and kicking!

I appreciate Lynda and Kate’s comments about the need to think about the kinds of generative skills that we should be teaching in the ABE classrooms – and the need to get beyond the assumption that the language of navigation is, by default, English in order to be construed as sufficiently “health literate”.  Although Kate’s article underscores the importance of being able to communicate and comprehend “in the predominant language of the available health care system” (Section 1.1.3), the emphasis on empowering our learners with the language tools and self-efficacy to request a medical interpreter suggests that health literacy for our adult ESL learners is more accurately viewed as a multilingual achievement.

The prevailing definition of health literacy in the U.S. is a functional one (what reading, writing, listening, speaking enables us to do in the health care system).  Although the field of literacy studies engages in a rich debate about literacy as “skill” versus “practice”, the health literacy research world has, for the most part, clung to its functional definitions.  What will it take to broaden the thinking in the U.S.?

I also wanted to respond to David Rosen’s call for greater attention to the digital realm of health literacy.  Data from the NAAL, PIACC, and other consumer-oriented studies suggest that (1) individuals scoring at lower levels of literacy tend to place little trust in print sources (whether in print or digital), but also that (2) members of at-risk groups tend to trust information from health care professionals and television, over the Internet.  As David points out, the health care system is inevitably going digital, so we’ll need to think carefully about what we can do in our classrooms to ensure that our learners don’t continue to be outpaced by an information-driven society. 

I’d like to think of the classroom as a place where important trust-building has to happen so that we can increase our learners’ capacity to direct their own health outcomes. NAAL/PIACC use one question to measure sense of trust in information, but I imagine we in adult education can do a better job of measuring and validating increased trust as an important HL outcome.

I look forward to reading more this week, Maricel

Maricel, thanks so much for your insightful comments.

For those who aren't familiar with Maricel's work, she is an associate professor of English at San Francisco State Universty and one of a small handful of researchers that I am aware of who specializes in research specifically on health literacy and ESOL.  She graciously agreed to be interviewed about her work for the Virginia Adult ESOL Health Literacy Toolkit.  You can find that interview here.


Thanks, Julia, for your follow-up -- an apologies for not catching this posting sooner.

One alternative view to the functional approach is a social practice approach to health literacy. We can see health literacy as practice at work by observing health literacy events (e.g., an encounter at the pharmacy encounter); the practices approach compels us to look for patterns in behavior that are shaped by health care institutions (what information am I expected to know when I approach a pharmacy counter?) and power relationships (What kinds of questions do I want to ask of my doctor, versus what questions am I given an opportunity to ask in an 11-minute appointment?)

The functional approach emphasizes patient comprehension in health care, of text or health care interactions.  Practice approaches emphasizes what people DO with their literacy/lanuguage and numeracy skills, and with whom, where, and how.  We focus on the social/cultura practices within which words and numbers are given meaning. 

For example, let’s consider the case of a young mother who is a beginning-level learner of English.  The functional approach might emphasize limitations in her ability to comprehend and act on health care information (e.g., vaccination schedule, OTC labels, nurse’s recommendations about fever treatment). The practices approach, however, would emphasize the following:

  • Her resource-seeking behaviors, including her reliance on old (print) and new (digital) media
  • Her independent comprehension of printed sources, as well as her verbal interactions with health care professionals, relatives, or peers about the printed information – interactions which enable her to clarify her own comprehension.  As literacy researcher David Olson comments, text is important, but so is talk about text.
  • Her ability to analyze texts critically – Do I believe this information? Does it apply to me? If I have questions about a document, who should I ask?
  • Her ability to participate in health-literate systems. This idea recognizes the value of Donald Nutbeam’s views on ‘public health literacy’.  An individual will struggle to look health-literate if the health care system is dysfunctional. Similarly, an individual with limited English proficiency may be able to very effective at navigating the health care systems if there are support systems along the way that boost her health literacy practices.

It would be misguided to view the functional vs social approach are at complete odds: in fact, both contribute to a fuller picture of what becoming health literate entails.  However, the prevailing focus on the functional approach has left us with an impoverished view of what people actually do on an everyday basis to live healthy and stay healthy.

Happy Thanksgiving to all, Maricel   

I agree, David, that we need to keep addressing learners' digital skills as we go. And yes, this is important in teaching health literacy. Even if it is years before that last 1/3 of people have internet at home, and even if it is years before it becomes essential for people to interact with doctors and hospitals online, it will most likely happen eventually, and we have to start preparing people earlier rather than later.

But as Kate recounts from the small follow-up sample, it will be hard, in the short term at least, for a lot of learners to practice and use these skills on their own. So I see another skill that we need to teach: how to interact with services that are available to help. What comes first to mind are local public libraries and family resource centers at hosptials and health centers. Just as we need to teach folks how to ask for services (like interpreters) in a hospital encounter, we also need to address how to use some of the ongoing community services that are available.

Here are some resources that relate to this:

An article about a project that helped connect the libraries to rural community members who were enrolled in literacy programs.

Health Information Literacy Outreach: Improving Health Literacy and Access to Reliable Health Information Online in Rural Oxford County Maine


And here is the sourcebook they developed: 

Who Can You Trust? Health Information and the Internet: Curriculum Sourcebook



Another point we should keep in mind... A lot of the skills we think to teach center on the encounter with doctors and other providers, or navigating hospitals,etc. But so much information has recently come out that reminds us that most of people's health care practices happen outside of the health system.

They happen at home, at the grocery store, at school and work, and during the precious free moments when people decide to (or are too tired to) do something for themselves. They happen when no one is sick, no medicine needs to be given, and no there is no urgency. But these are the moments that may have the most impact on our health. We decide to eat differently, to exercise, to find a way to get to a better weight, to teach our kids healthy habits.

Again, this is another area where perhaps the best thing we can teach in our unique environment is how to self-advocate. It is also an area where we can use a classroom community to help each other. By giving our students the opportunity to discuss these issues together and support each other, we can find ways to motivate them to make real changes. And this kind of "we're-in-it-together" activity can be a very compelling topic for written reflection, vocabulary building, speaking and listening skills, and other literacy/language competencies that we are required to address.


Hi Everyone,

Kate has loaded us with very relevant information, useful resources, and some pretty big things to think about! So I just want to check in with you all:

  • What would you like to ask?
  • What questions/concerns do you have about teaching health literacy in your setting?'
  • What do you want to address in this discussion that hasn't come up yet?

We'd really like to hear from you!


I just want to second Julie's statement that we'd really like to hear from you!  We can see by the 350+ views for this discussion that people are definitely interested in the topic.  We want to encourage you not to be timid about asking questions or sharing experiences, concerns, or ideas.  ABE and ESOL have so much to offer to help improve health literacy among adults in the US.  Let's get more voices and perspectives in the discussion!


Hi All,

Congratulations on such a rich discussion about a crucial problem in the U.S.  Working closely with Kate on the development of the toolkit, every week I marveled at the depth and breadth of the content that she was including.  The toolkit will help ESOL practitioners focus their health lessons on what the learners actually need to improve their health and make the system work for them.  Just teaching vocabulary and phrases will not be useful to immigrants that don’t know how, when, or where to use them.

Anila’s story in Article 1.1 of the toolkit is a perfect illustration of the situation of many immigrants.  All too often they resort to the emergency room for health care.  In textbook driven classrooms, we teach the learners to make a doctor’s appointment by phone.  This concept is so foreign to many learners, especially those from Latin America.  I can only speak for Mexico (lived there for 25 years and practiced medicine for a few), where no-one makes a doctor’s appointment.  You just show up.  If the doctor is busy, you can wait, come back later, or go to another doctor. (Done that myself, in fact.) And when you show up, you have with you half your immediate family.  And, at least, one other person goes in with you to the consulting room. The doctor may take up to an hour talking with you, while charging a fee according to your economic status.  If you need to take any medications, these are purchased (no insurance) at a local pharmacy for a minimum cost.

The point is that our very different system seems impersonal, complicated, expensive, and frightening.  Anything that a teacher can do to alleviate these characteristics is a boon to the learners.  Visiting a health clinic is a wonderful idea. Helping your learners fill out and use the forms that Kate has included in Section 3 (3.15, 3.16. and 3.17) should be at the top of the list for an ESOL class.  While working at the University of Virginia, we helped migrant workers fill out a form similar to 3.15.  It was a form that they could take with them as they moved around the country from job to job.  On a medical mission trip to Bolivia, I created a form similar to 3.16 for patients that we saw in the clinics. The doctors would fill them out and include them in the little baggies of pills that were given to the patients.  That way, they could remember what they were for and when to take them. The doctors felt that there would be better compliance to medication regimens while the patients left feeling more confident with special instructions that they could understand.

Again, thank you for the discussion around this critical topic and for getting the word out that more needs to be done in the classroom regarding health literacy.


Best wishes,

Nancy Faux

ESOL Specialist

Virginia Adult Learning Resource Center



Nancy, thanks so much for your comments.  Your description of Mexican health care from your patient and care provider experiences show quite a contrast with how health care functions in the US.  

Reading your comment that "our very different system seems impersonal, complicated, expensive, and frightening" reminds me of many learners and patients I’ve worked with.  I want to share a story of one, a high level ESOL learner, with higher health literacy skills than most ELLs, who was at a presentation for learners on using US health care. I’m sharing her story because it shows that there is no shortage of cultural information for educators to impart to ESOL and ABE learners on healthcare communication, even for higher level learners; and it shows that ESOL/ABE settings can be effective places for sharing scenarios and problem-solving around healthcare challenges. The story is also about primary care rather than emergency care.  Hopefully many more ABE and ESOL learners will be entering primary care under the ACA, so the types of healthcare communication challenges they face may shift to more in primary care settings. This story also revisits our earlier assertiveness and self-advocacy themes.  


Here goes.  This student was a highly educated woman from Eastern Europe and possibly one of the most acculturated learners in her ESOL program.  We had just gone through the picture story "A Doctor's Appointment" and were having a discussion about communicating with doctors in the US.  She asked if she could get feedback on a US healthcare experience that had clearly shaken her confidence.  She was fortunate enough to have insurance and got an appointment with a primary care provider.  She told the doctor as best as she could about a chronic health problem she needed treatment for.  She said the doctor was very rushed and didn't take time to listen to her history completely or let her ask questions (sadly all too common in the US).  She said she knew the treatment that the doctor was proposing wouldn't work and that her condition would get worse.  As she was leaving the appointment, in the lobby she burst into tears and voiced with frustration that she hadn't gotten the help she needed.  She said that then an office manager and a nurse met with her privately and helped her get the care she needed.  The student shared with us that she felt terrible that she had broken down and cried and raised her voice in the doctor's office.  She said she felt like her visibly emotional behavior made immigrants look bad.  She shared that as an immigrant she tries to be polite and calm, to never request special treatment, and to learn the culture as best as she can so she can do her part to help immigrants have a better image in the US. She seemed pretty mortified at her own reaction to the poor healthcare communication.  I shared with her and the rest of the learners that, unfortunately, the way that our healthcare system works, sometimes speaking firmly and showing a little emotion is what's required to get the care you need.  I assured her that in my healthcare work I've seen plenty of reasonable people behave the same way she did to get their needs met when other approaches hadn’t worked, which relieved her (and probably many others in the audience) greatly. We agreed that it doesn’t always feel good, but sometimes it’s necessary. We also talked about different strategies to prepare for those fast-paced appointment conversations so they go as well as possible. Then I taught the audience the idiom "The squeaky wheel gets the grease."  :)  



Here's a very concrete, practical question to continue our discussion:

Of the 8 recommendations for improving ESOL health literacy instruction listed in What is ESOL Health Literacy and Why Do I Need to Know About It?, which are you already doing?  Which others appear doable?  What additional supports might programs need to take them on?  ABE programs can select from the listed recommendations that are relevant to the populations you serve.

Looking forward to hearing your responses!



ESOL and ABE Teaching colleagues,

Kate has asked for your help. She has asked you to look at "the 8 recommendations listed in What is ESOL Health Literacy and Why Do I Need to Know About It?," and to tell us which ones you are already doing?  Which others appear doable?  What additional supports might programs need to take them on? 

I know that is not often that in a CoP that you are asked to reply. But now you are. You may be thinking:

  • "I've never written a reply in a CoP before." If so, now is a good time to do it. 
  • "I am not an ESOL teacher." ESOL and ESL and ELL are just different ways to describe those who teach immigrants English. Also, as Kate mentioned, she wants to hear from ABE teachers too.
  • "I don't have time to reply." Really? After all you do have time to read this far in my post. How about a quick reply?
  • "I am shy. I don't usually or ever respond to these posts." Often the posts don't require responses. They are just information out. This one is different. Kate is asking for your help. So am I. I want to hear from teachers.

Whatever you are thinking, please take a moment to reply. I hope we are "swamped" by teachers' replies. After all, this is a community of practice, not just a discussion list. This is the time to tell us what you are doing, or perhaps which of the eight recommendations you are thinking about doing and why.

I eagerly await your reply. By the way, I have never met Kate (although I am impressed with her work and her contributions to this discussion.) Neither Kate nor Julie asked me to post this. This is my idea because I want to know what adult ed teachers are doing with health literacy. I hope I won't be disappointed.

David J. Rosen


Hello everyone ....

Here are a couple questions I'd like to learn your answers to:

- What are the main barriers to taking up health literacy within ABE and ESOL programs?

- What could the field of health literacy do to help increase the uptake of health literacy within your educational programs?

- What best practices (evidence-based) are you aware of that address health literacy within ABE and ESOL contexts?


Just a couple quick obversations, if you don't mind.

Tis generally expected that there will be an emphasis on skill acquisistion and which skills are needed as has occurred in the conversation to date, but we've found it is as, if not more, important to focus on what people actually do with the skills they do have or can gain. That is really the central focus of the Calgary Charter on Health Literacy's definition which presents health literacy as a path to informed behavior change.

Given the evidence on the relationship between health literacy and health outcomes - which can produce gains in satisfaction, enjoyment, productivity, self-efficacy, social support, and civic engagement across the life span - I remain puzzled by the relatively low level of uptake of health literacy efforts in not only ABE and ESOL programs but also in public health efforts at large. Certainly, there are great individual examples of successful programs, but those efforts - I think it fair to say (but happy to be proven wrong on that!) - are far from systematized, universally adopted, or sustainable. Thus, the questions above hope to illuminate how that can be addressed.

Finally, I would like to briefly point out the opportunity to address health literacy within jail and prison populations - does anyone have any examples of successful programs in these contexts they may care to share?

Appreciate your thoughts and best wishes,

Andrew Pleasant

Thank you Kate for leading this important discussion - I apologize for late participation due to travel this week but wanted to address # 7 of your 8 reccomendations from the article. "7. At a program level, partner with other fields and organizations." In Madison, WI one of our member literacy agencies, Literacy Network, offers an English for Health Class that is a fantastic model for teaching health literacy in ESOL instruction.  This model was presented at the recent ProLiteracy - USCAL Conference in DC and currently the staff is working with other Wisconsin Literacy member agencies to help them replicate it in their communities.  Please see this link for a description of the "English for Health Class" offered in local hospital settings through a parntership with local health care providers.    http://www.litnetwork.org/programs/index.php?category_id=4496  To answer your 3rd question, Andrew, I think this is a best-practice with outcome data on improved health understanding and improved health behaviors by the participants in the program.  While this takes funding to implement, it is a collaborative program that both hospitals and literacy agencies and learners stand to gain a lot from.  The mock clinic at the end of the 3 units allows for real life practice with real health practitioners, including doctors, nurses and pharmacists. If for some reason the link doesn't work, go to www.litnetwork.org and click on custom programs and then Health Literacy. 

Hi Michele,

No worries at all on chiming in late --- we are delighted to have your information!  Thanks so much for sharing about Literacy Network's English for Health Class.  I absolutely love the mock clinic idea to help learners conquer anxieties and get a real-life feel for the communication.  I have talked to different state-funded adult ed program administrators (not privately funded literacy orgs.) about offering a similar class on communication for health care settings and have met with the same concern a few times: how can we be sure to attract enough learners to make developing and running the class pay off?  I think the assumption is that learners have limited time and money to pay for classes, and they will prioritize more general ESOL classes or employment-focused ESOL classes over classes focusing on health and health care. It's a reasonable concern, knowing that it is often human nature to deny health issues and the need to seek care until symptoms can no longer be ignored, especially when many other life stressors are competing for attention.  I wonder if this was a concern that you ran into in the planning stages in Wisconsin.  Do you have any advice to other adult ed administrators about this?  

Also, I am sure that other adult educators would love to learn more on outcome specifics and how gains were assessed on health understanding and health behaviors in this project.  Is this info written up yet in a form that Literacy Network can share with others?


Hi Andrew,

I'm going to have a go at answering the first question you put forth last week. I'll answer the others a little later.  After working to raise awareness of health literacy needs of adult learners for over 10 years, I, too, am sometimes mystified as to why we haven't made more progress on health literacy in adult ed, but at the same time, I get it.  I'll try to articulate some of the challenges I see, and some that have been shared with me by adult ed program administrators and teachers over the years.

Question 1: What are the main barriers to taking up health literacy within ABE and ESOL programs?
  • Health literacy doesn't clearly match overtly stated priorities of  funders and learners   In my observation at this point many adult educators are aware that health literacy is important for learners and that they would like to be able to support learners more around health literacy.  However, federal, state, and private foundation funders do not typically list health literacy as a priority area for grantmaking for public adult ed programs, and there is no state or federal mandate for adult ed programs to cover health literacy. Non-profit literacy organizations in my observation have much more flexibility in applying for health literacy-related funding than adult ed programs run through public schools and community colleges.  By my observation many health literacy funders exclude public education programs from competing for their grants.  

As one program administrator for a public school adult ed program told me recently, "I just don't see any RFP's come across my desk that mention the words 'health literacy.'  When we are applying for funding we have to do our best to match funders' listed priority areas and if we don't see health literacy spelled out, we are going to go with a less risky proposal topic area that is a more clear match with the RFP." In view of the considerable cuts to adult ed funding in recent years, that caution is extremely wise.  Typical areas of funding priority for public programs tend to involve getting learners ready to work, helping them keep or improve their employment, helping them transition to other educational settings or pass the GED, and increasing their civic participation.  


In ESOL, English Literacy - Civics (EL-Civics) http://www2.ed.gov/about/offices/list/ovae/pi/AdultEd/elctopic.html money has been a steady funding source for years.  Some programs around the country have used it to address health literacy --- in fact Virginia EL-Civics money funded the Virginia Adult ESOL Health Literacy Toolkit --- but nowhere that I have seen is it overtly spelled out that health literacy is an accepted or desired area for EL-Civics funding to be used.  In the Toolkit I make the case for health literacy instruction to be seen as civics education http://www.valrc.org/toolkit/docs/1-5Civics.pdf, but programs that choose to apply for EL Civics funding on a strongly health literacy-focused proposal are still taking a pretty big risk.  And of course, how EL-Civics money should be spent is no doubt viewed differently from state to state.  

When educators ask adult learners about their learning priorities (e.g. in in-class needs assessments), their top responses are often employment-related.  In my experience health often comes in second in front of many other life skill areas, but what learners articulate about employment readiness seems to match what funders are asking for.  As you know, many people don't prioritize health until they are in a crisis.  Many adult learners have a present-time focus out of necessity, so it makes sense that they are prioritizing work over health.

  • Overloaded plates --- At the risk of sounding cliche, adult education programs and teachers are swamped with work and under-resourced.  Yes, health care is also swamped, but it has many more resources to work on health literacy, plain and simple.  In adult ed hourly pay is not great, and benefits and full time work are rare.  Teachers work very hard, combining multiple part-time jobs to make full-time schedules. Planning time and paperwork time aren't always compensated.  Time spent with learners varies --- classes might be 4 hours a week, or 15.  Intensity of classes has a great impact on how much content can be covered.  A lot of teachers feel health instruction is important and would like to do more, but it is hard to know how to fit more in while meeting learner-expressed needs, program curriculum requirements, and funder requirements.
  • Confidence of adult educators for HL instruction/Narrowing down scope of HL instruction --- These 2 may appear different, but I see them as overlapping. I have heard many times from adult educators that they want to do more health literacy instruction for learners but they are overwhelmed by the US health care system themselves.  They see the range of possible health literacy content as vast and don't know where to start.  They worry about stepping outside of their expertise. A couple things stand out to me here: 1) educators want and need professional development opportunities around health literacy instruction (again, we need to consider competition for limited PD funding and time here), and 2) we need a discussion in the field --- or rather between the adult ed and health literacy fields --- about what are the most efficient/effective ways to use adult ed teacher expertise and class time in health literacy instruction.  Of the vast ocean of things people need to know to be empowered for health and health care, which are the best to be conveyed in adult ed classrooms by adult ed teachers, and which will help support other adult ed learning goals best?  What topics are best covered by partnering organizations, and what would those partnerships look like? 

I've gotten very positive feedback from the list I include in the Toolkit about the basics English language learners need to know for health care http://www.valrc.org/toolkit/docs/3-1NeedtoKnow.pdf because it gives educators a limited, doable list to focus on of things that they know, from learners' own accounts of healthcare challenges, will be immediately valuable to learners.   I'm not saying that list is the answer, by any stretch, but it is an example of narrowing things down in a way that educators can view as manageable and practical.

I hope these observations are helpful.  (Apologies for the wonky formatting!  I seem to be having trouble with that on LINCS lately.) I look forward to tackling your other questions in the not too distant future.Kate



Hi Andrew,

Sorry for the delay --- below is my response to your 2nd question: “What could the field of health literacy do to help increase the uptake of health literacy within your educational programs?”

Thanks for asking this great question.  Here are some thoughts:

1. Reach out to adult ed programs for health literacy research and partnerships. Health literacy researchers can reach out to adult literacy and ESOL programs --- publicly funded as well as private ones --- to include adult ed programs and learners in health literacy research and interventions.  As you no doubt picked up from my response to your first question, these programs are under-resourced and are hard-pressed to initiate health literacy research partnerships themselves.  There is no shortage of health literacy research questions that could be explored within adult ed programs and their large pools of learners from vulnerable populations. 

It is important that research involving adult ed has factored into its design the challenges inherent in adult ed --- limited funding, limited time available for health instruction in consideration of other curricular requirements and learner needs, limited professional development resources, irregular learner attendance patterns, etc.

2.Help make the case to education policy makers for sustained, learner-centered health literacy instruction in ABE and ESOL. Adult educators would welcome any support from the health literacy field that helps convey to adult education policy makers at the federal and state levels that sustained, learner-centered health literacy instruction in adult education is important for both learners and US health care, and supports multiple adult education goals (e.g., empowers learners to engage and participate in one of the most complex and challenging systems in the US;  provides a highly engaging way for learners to strengthen and apply basic skills; helps support learners’ health so they can continue with their education, job-seeking, or employment).  We need better cross-pollination of info on health literacy and adult literacy between the health literacy, public health, and adult education fields, be it through interdisciplinary meetings and workshops, webinars, conferences, journal articles, white papers, social media, or other means I haven’t thought of.

3.Help funders understand the potential value of working with adult education on health literacy solutions.  For those of you who have the ear of (or publish papers read by) any funders who prioritize improving health literacy and health communication for vulnerable populations, please help funders to understand that adult education programs can be a great place for research and interventions to occur in support of these priorities.  It is important that funding criteria be written in such a way as to allow (or even invite) public adult ed programs to participate as well as privately funded literacy organizations. (To clarify some differences, public programs tend to have access to larger groups of students, and also tend to have paid teachers with more in-depth instructional training than volunteer-based, privately funded community organizations.  While both are great places for research and interventions to occur, there are these differences and some others to consider.)  It would, of course, be terrific if funders and state and federal adult ed policy makers would meet and discuss this potential, so if you have access and ability to encourage that in any way, please do!

4.Consider starting an affordable e-journal or website for sharing about interdisciplinary health literacy work.  One thing I have heard repeatedly from people in adult education, and from people in social work and library science as well, is that there is really nowhere that people from those fields can write up and share about their contributions to interdisciplinary health literacy efforts. They do good work which very few hear about, and potentially effective, replicable ideas get lost.   I think everyone agrees at this point that the solutions to health literacy challenges have to be interdisciplinary, yet we lack a publication that is affordable to less-resourced fields like those I’ve just mentioned to publish articles on what it really takes to make such interdisciplinary work happen.  Getting ourselves out of our professional siloes to work effectively and sustainably on health literacy issues is extremely challenging but important for the work we are all committed to doing.  We need more formal ways to share about it that are accessible to the less-resourced fields as well, and not intimidating to those fields.  So if anyone out there has the resources, time, and creativity to start such a resource it could be very helpful for encouraging adult educators and others to take on more with health literacy, and to be less intimidated about interdisciplinary partnering.  :)

Those are the recommendations that come to my mind, Andrew.  I hope they make sense and that I’ve worded them in a way that people in the field can relate to their work and interests.  I’m happy to answer questions on any of the above.

I also want to comment briefly on your remark about health literacy instruction for incarcerated learners.  I have heard from several teachers over the years who very much wanted to provide health literacy instruction to incarcerated learners. The teachers saw an urgent need and learners asked a lot of questions and asked for help getting access to care.   To put it mildly, the educators encountered a lot of frustrations in their efforts to get information on procedures for obtaining health care for the learners.  To make this kind of health literacy instruction work there needs to be buy-in from prison/jail administration and and the managed care provider companies that serve prisons and jails, which can sometimes be hard to come by.  I’m sure the ease of getting this buy-in varies greatly from jurisdiction to jurisdiction.  I included a brief info sheet on health literacy significance for incarcerated learners in the Virginia Adult ESOL Health Literacy Toolkit, fyi, at http://www.valrc.org/toolkit/docs/1-9Incarcerated.pdf.




Hi Everyone,

Thanks so much to those who participated in this discussion, and to those of you who read the posts. I really hope that  this has given you some new ideas to work with, and some impteus to to address health literacy in your settings. This is the first of a 4-part series, so there is more to come!

And a special thanks to Kate, who shared so much of her time and passion by writing such thoughtful and comprehensive answers to everyone's comments. Thank you, Kate!

We will continue this discussion, so please stay tuned! I would really like to hear some thoughts about Andrew's questions. They are good ones, and it will be very helpful to hear your responses!

As we continue next week, we will share some more specific resources that we hope will make it easier for you to address health literacy in your programs. Two things I would like you all to think about:

  • What kinds of resources would help you to include some health literacy in your classrooms or programs?
  • What resources have you used for this, and what did you think of them?

Have a great weekend!


Hi everyone,

I want to thank everyone who shared comments here this week and the many people who viewed the discussion.  The over 500 views confirm for me that health literacy is indeed a topic adult educators care about and want to learn more about.  Thank you also to Julie McKinney --- it's been a pleasure working with you all week.

I would like to mention a few more things to close my week here.  

1) Health literacy instruction doesn't need to be an overwhelming endeavor.  I truly get that teachers' and programs are all under-resourced and overloaded right now, moreso than at any time I can remember.  I want to emphasize that incorporating the things we've talked about this week, and the ideas that will continue to come forth in this discussion in the coming weeks, is not meant to entail starting from scratch.  We are talking about infusing health content into skills work you are already doing, or updating current ways of presenting health to make them most relevant for learners' lives. Various ABE/ESOL programs and literacy organizations are already working on this around the US, with positive results. (I hope we will hear from some of these programs in the weeks to come!) Remember, learners, educators, and a growing body of research indicate that:

  • Health content in ABE and ESOL lessons and curricula is highly relevant and engaging for adult learners.
  • Integrating health into adult education curricula has the potential to produce beneficial health, language learning, critical thinking, problem-solving, skill synthesis, and learner empowerment outcomes. At least one research project (Levy et al, 2008) has already demonstrated concurrent health knowlege and literacy gains.
  • Health literacy partnerships between adult education and health care can create mutually beneficial learning situations [taking some of the resource load off adult ed]                                                      
Source: What is ESOL Health Literacy and Why Do I Need to Know About It?  

Bottom line: Health-related instruction is an engaging, productive way to teach learners the many kinds of skills we are charged with teaching them in ABE and ESOL, while empowering them for functioning in one of the most complex and challenging systems in US society, the health care system.


​2)  We have an important opportunity before us regarding health literacy. Julie and I were recently at the Health Literacy Annual Research Conference (HARC) at the Institute of Medicine in Washington, DC, where we attended a panel discussion focused on the recent PIAAC results and what they mean to health literacy of US adults and health literacy research.  The panel included representatives from the Centers for Disease Control and Prevention, the National Center for Education Statistics, and the Office of Adult and Vocational Education.  One important thing that came out of that discussion is consensus that adult education and the health literacy research world need to work together more closely to better understand what will help especially vulnerable adults to improve their health literacy.  While we don't know what form(s) this collaboration will take yet, I find it very encouraging that the experts are having initial conversations about it.  It would be great if people can share any ideas or experiences they have relating to collaboration between adult ed and health care in the discussions here in the next few weeks.


3) Our field has expertise to offer, and we shouldn't be shy about it!  I have been told by some in adult ed that they are a bit intimidated at the thought of collaborating with health care on health literacy.  Perhaps this is due to "white coat syndrome," or discomfort over being in a vastly under-resourced field compared to health care, or maybe other reasons.  Adult educators do amazing work on a daily basis, in spite of their lack of resources. Health care very much needs more input on how to address health literacy and more partners for doing so. Please don't hesitate to share what strengths you or your program can bring to work on health literacy.  For suggestions on how to articulate what you bring to interdisciplinary partnerships and how to initiate a partnership, check out the ESOL Health Literacy Partnerships section of the Virginia Adult ESOL Health LIteracy Toolkit.  


4) A Health Literacy Wish List. ABE and ESOL could frankly use a lot of support to work on health literacy in a sustainable, effective way.  The Toolkit contains a wishlist, a brainstorming of things that would make the job easier for ESOL specifically,but there's plenty of overlap with ABE.  I encourage you to take a look and see if there's anything you would add, or if you have any ideas as to how to make any of the wishes reality.  


Thank you all.  Have a great weekend.




Kate Singleton, MSW, LCSW

Health Literacy Consultant to Adult Education, Health Care, and Social Work


ESOL Health Literacy page on Facebook: https://www.facebook.com/esolhealthliteracy

Twitter: @healthlitkate



Hi Everyone,

Please join us for Part 2 of the Health Literacy Discussion series:

Resources for Addressing Health Literacy in ABE Programs


We will share and discuss curricula and other practical resources, including those from the LINCS Resource Collection.

We started a new thread for part 2 (see above.) but please add to this thread as much as you want! 


All the best,