Promoting Health Literacy Among Adult ELLs Virtually During COVID-19

Abstract

The adult English language learner (ELL) population is often overlooked in health literacy discussions, which can result in perpetuating low health literacy and unfamiliarity with and low access to community resources. Health literacy interventions can reduce the impacts of social determinants of health. We examine the experience of a virtual health literacy educational course, Health in the English Language, for ELLs at Alaska Literacy Program (ALP), an Anchorage nonprofit. Our class was designed to help students navigate interactions with health care services, including medical care, pharmacy, health insurance, and nutrition resources. After 2 years of in-person teaching by university undergraduates, COVID-19 required a pivot to virtual instruction in Zoom in the summer of 2020. Instructors describe lessons learned and adjusting to student needs, community-building and personal connections, and the complexities of the topic of health literacy. ALP collaboration with university students continues to be a successful partnership to build health literacy capacity. Adoption of virtual instruction during COVID demonstrated the role that partnerships between nonprofits and university students can play to benefit all partners in the collaboration.

Health literacy, the ability to understand and use health information, can influence the relationship between poor socioeconomic conditions and poor health outcomes (Nutbeam & Lloyd, 2021). The adult English language learner (ELL) population is often unfamiliar with community resources and faces challenges shaped by social contexts, including language barriers and cultural differences (Johnson et al., 2019). Although the adult ELL population is growing, their health literacy needs are often not addressed.

The health care experience is intimidating to many. Adult ELL patients are particularly hesitant to ask for clarification of unfamiliar terms, making them vulnerable to negative health impacts (Johnson et al., 2019). Prior knowledge of or exposure to health care terminology plays a pivotal role in the utilization of preventive services (Han et al., 2019).

Health education interventions can help improve health literacy among underserved populations, serving as “midstream” strategies to reduce the impacts of social determinants of health (Nutbeam & Lloyd, 2021). Students in health literacy ELL programs have reported sharing newly learned preventive health content with their social networks, demonstrating that social interactions can promote health literacy in communities (Santos et al., 2014).

Health Literacy Intervention

Anchorage, Alaska, has a large ethnically and culturally diverse immigrant and refugee population, the majority of whom have limited English proficiency (Johnson et al., 2019). The Alaska Literacy Program (ALP) nonprofit organization helps ELLs utilize community resources and strengthen English proficiency through volunteer-led classes. ALP has offered Health in the English Language as a course to improve health literacy through a partnership with Georgetown University for 3 years. ALP leadership has described the many benefits of university–student partnerships, including diverse points of views and interactions, a tailored curriculum that prioritizes ALP needs, and instructors who are motivated and ready to impart their contextual knowledge.

Our course aimed to introduce ALP students to health topics and encourage meaningful social interactions within the community. Lessons focused on social health literacy encourage and support ELLs in advocating for themselves and contributing toward community decision-making and change, and emphasize applying social and community relationships to develop health literacy and communication skills (Santos et al., 2014). This work is especially vital during the COVID-19 pandemic, when individuals are often overwhelmed by health information and are responsible for prioritizing and utilizing public health communications at both individual and community levels (Abel & McQueen, 2020). This work was institutional review board (IRB) exempt, meeting all the criteria as educational research.

Health in the English Language

Our summer 2020, Health in the English Language course enrolled 10 student participants with a mean age of 35.8 years. Their English as a second language (ESL) score ranged from 54 (Level 3) to 76 (Level 6) with a mean ESL level of 5, which indicates that individuals can function independently in most face-to-face basic interactions with some assistance but have limited ability to understand conversations through the telephone. High English proficiency is ESL Levels 7 to 10. ESL levels were determined by adult English proficiency assessments created by the Center for Applied Linguistics, called BEST Literacy (measures speaking and listening skills) and BEST Plus 2.0 (measures reading and writing abilities). Both assessments are aligned to the ESL descriptors of the National Reporting System and the Student Performance Level (Center for Applied Linguistics, 2019a, 2019b). Participants identified as Asian (n = 5), Hispanic (n = 3), Black (n = 1), and White (n = 1).

Two undergraduate students delivered the health literacy course to ALP ELL students in two 4-week summer terms. Class convened twice a week on Zoom. Within each 60-min session, students reviewed previous topics, learned new material and practiced using interactive discussions, games, and collaborative activities that engaged students and reinforced material. Throughout the 8-week course, the shifting landscape of the COVID-19 pandemic and changing public health guidelines was a repeated theme. During most sessions, students asked questions about what they were reading and seeing on the news.

Each lesson broadened knowledge and understanding of health and health-related language and fostered a social support system within the online learning environment (Table 1: Lessons and Learning Activities). To help participants translate class learning to their community and practice health behaviors, various clinics and services in Anchorage and online were introduced to students. Services such as pharmacy, urgent care, community clinics, grocery stores, and recreational opportunities, with pictures of the facility, and contact names with email or phone numbers, were described. Role-playing contacting the service was done in class with participants particularly enjoying this by the second term.

Table 1.

Lessons and Learning Activities

Day	Topics	Learning activities
Session I
1	Understanding Health Information ● Foundational health care vocabulary ● Seeking health care: Primary, urgent, emergency	● Student introductions: Name, language(s) spoken at home, fun fact ● Share learning preferences: Do you learn best by speaking? reading? hearing? or all of these? What do you want to know? ● Planning to schedule an appointment: Describing care you seek, with whom, when (have calendar)
2	Medical Conditions ● Reporting symptoms: Headaches, sore throats, fever, shortness of breath, injury, urinary track infections (UTI), STDs, and so on.	● Distinguish between types of health care ● Role-play: How to make a doctor’s appointment ● Matching review game: Match the term with the picture of its physical presentation
3	Symptoms and Feelings (continued) ● Vocabulary: Wheezing, fever, congestion, fatigue, nausea, vomit, numbness, tingle, ache, and so on.	● Discussion: Words to describe how you feel; Symptoms that need attention by a health care provider ● Examine clinical intake form about recent medical symptoms ● Games: Vocabulary crossword puzzle using terms on intake form; Symptom vocabulary Jeopardy
4	Symptom Review ● Anchorage Neighborhood Health Center Health History Form ● Coronavirus ● Vocabulary: Quarantine, social distancing, underlying health risks, asymptomatic ● Changing guidelines from CDC	● Vocabulary recall from pictures on slides ● Analyze health forms utilized in local clinics ● Discuss the importance of health precautions during the pandemic; hand hygiene, social distancing, and using masks to protect yourself ● Identify presentations of COVID-19 symptoms vs. being asymptomatic ● Share personal quarantine hobbies and empathize with feelings about lockdown ● Symptom and Coronavirus vocabulary Jeopardy
5	Health Insurance: Introduction ● Overview of key health insurance vocabulary ● Scenarios of insurance at work	● Discussion: Why have car insurance? What does car insurance protect you from? ● Differentiate between deductibles, out-of-pocket costs, premiums, copay ● Describe when insurance is utilized and who provides insurance
6	Health Insurance: Sources ● Understand payer networks ● Medicare, Medicaid, Children’s Health Insurance Program (CHIP) ● Care for children: Alaska Denali KidCare	● Distinguish between preferred provider organization (PPO), health maintenance organization (HMO), point of service (POS), and health reimbursement arrangement (HRA) ● Discuss eligibility and benefits of Medicare, Medicaid, and CHIP ● Resources for Medicaid enrollment assistance in Anchorage ● Fill in the blank: Apply newly learned knowledge and vocabulary
7	Health Insurance: Accessing ● Learn how to navigate HealthCare.gov to enroll ● Preventive care without cost sharing	● Using an insurance card; Examine components of an insurance card ● Discuss FAQs about health insurance; Small group solving multiple-choice questions and discussion ● Insurance vocabulary Jeopardy
8	Health Insurance: Navigating ● Sliding scale clinics in Anchorage ● Major health systems in Anchorage ● Planned Parenthood	● Health insurance review video: “Health Insurance Coverage 101—The Basics Explained” ● Role-play: Asking for care when uninsured, sliding scales, available clinics ● Practice insurance “math” problem: Amount patient pays and amount insurance pays ● Patient cases analysis: Navigating and paying for care in each scenario
Session II
9	Welcome Session II new students ● Nutrition ● Food groups ● Servings/portions ● Vocabulary: Low-fat, fat-free, calories, organic, and so on.	● Student Introductions: Name, language(s) spoken at home, fun fact about you ● Share learning preferences: Do you learn best by speaking? reading? hearing? or all of these? What do you want to know? ● Discussion of healthy vs unhealthy food: What is your favorite healthy food? What is your favorite unhealthy food? What makes them healthy vs. unhealthy? ● Explore the different food groups and recommended intake of each group using MyPlate ● Drag and drop: Categorize specific foods into food groups
10	Nutrition ● Nutrition labels; Nutrition Percent Daily Value ● Recipes for healthy eating ● Physical Health Vocabulary/picture association ● FITT Principle: Frequency, Intensity, Time, Type Intensity according to Rate of Perceived Exertion (RPE) Scale	● Analyze components of a nutrition label ● Identify the significance of Nutrition Percent Daily Value ● Create a short story about physical health using comic strips: What is happening, add captions ● Discussion: Why is physical activity important? What are short-term and long-term benefits? What are types of physical activity that can be done in the winter and in the summer? ● Share personal experiences and preferences of physical activity ● Explore various hiking trails through Municipal of Anchorage website ● Writing activity: Brainstorm three goals for healthy eating and physical activity ● Matching review game: Match names and images of physical activities
11	Mental Health ● Vocabulary: Stigma, mental health, psychologist, general anxiety, ADHD, anorexia nervosa, bipolar disorder, and so on.	● Discussion: Share personal experiences of learning about mental health in respective origin countries ● Discussion: How do you promote your mental health? ● Mindfulness practices and coping with stress; Practice mindful breathing and discuss experience ● Familiarize with mental health resources in Anchorage
12	First Aid ● Eye problems, fainting, nosebleed, bruises, cuts, wounds, burns, sprain, inflammation	● Discussion: What do you do when you have a cut? ● Fill-in-the-blank activities about scenarios requiring first aid: What would you do? ● Drag and drop: Identify tools that belong in a first aid kit
13	Dentistry ● Vocabulary: Plaque, cavity, tooth decay, gingivitis, fluoride, root canal, and so on.	● Discuss dental hygiene, purpose of dentist appointments, and preventive dental care ● Identify factors that contribute to getting a cavity, gingivitis, tooth decay, and plaque ● Role-play: Talking with a dental hygienist
14	Vaccinations ● Vocabulary: Vaccines, prevention, protection, herd immunity, immunization record, and so on. ● Immunization resources in Anchorage	● Identify vaccine-preventable diseases and the importance of vaccines for prevention; Why vaccinate? ● With health insurance, recommended adult and child vaccines are provided without cost sharing ● Immunization vocabulary Hangman
15	Medications ● over the counter (OTC) vs. prescription medicine ● Acquiring and filling a prescription ● Vocabulary: Capsule, dose, syrup, side effects, expiration date, infection, allergy, and so on.	● Acquiring a prescription, questions for the doctor about medications, and calling for a refill ● Distinguish between OTC and prescription medications ● Role-play: Retrieving a prescription at a pharmacy ● Examine components of drug labels: Instructions, pill description, number of pills/refills, and so on. ● Analyze OTC drug label components: Effects, uses, dosage, warnings, and so on.
16	Final Review and Games ● Overview of lessons learned in Session II	● Games and discussion on key takeaways from Session II lessons  ○ Matching vocabulary words and health behaviors with images  ○ Analyze nutrition labels  ○ Should you take this medication?  ○ Vocabulary Jeopardy

Note. Class lesson schedule for the summer 2020 Health in the English Language course at Alaska Literacy Program. CDC = Centers for Disease Control and Prevention; ADHD = attention-deficit hyperactivity disorder.

Lessons Learned

Anticipated obstacles to applying a social context to the Health in the English Language course, such as loss of social connection, trust, and application of learning during the pandemic, were not encountered as barriers. ALP, ELL students, and instructors found the structured social learning environment conducive to communicating health information.

The camaraderie between instructors set the tone for the class, creating a welcoming learning environment and applying the social view of health literacy. Role modeling conversation and inviting students into discussions created a personal and engaging learning experience. Instructors offered each other support, setting the stage for openness and asking questions through teaching styles that allowed for engagement.

Lessons fostered teams and pairs of students, further building confidence. Encouraging students to share with family and friends helped apply health literacy and develop their comfort speaking. Visiting the local pharmacy, reading grocery labels, and asking store staff questions were outside class activities. Practicing lessons about nutritious meals, daily exercise, reviewing handouts, and discussing healthy living with family and friends were emphasized.

Helping students express their feelings and health inquiries in their own words developed their skills and built confidence in effectively communicating about their health. Connecting to the lived experiences of each student allowed integration that personalized the learning. Virtually being in students’ homes brought family members, pets, hobbies, and interests into the learning. Empathy, compassion, and student-centric practices helped ELLs navigate the course in Zoom. Instructors were flexible and invited suggestions, which participants shared freely. Incorporating ongoing student feedback in the course was essential for student engagement.

Often the gains in accessing and using health information were made by students understanding resources and how to use them. Bringing a family member to health care appointments, planning meals as a family, walking daily with a friend, and asking pharmacists for assistance are means of using existing networks to improve health. Empowering ELLs to tap into their community resources promotes skill development, builds confidence, and prompts action to address personal health goals.

Recommendations

Virtual instruction offers an effective health literacy intervention for ELLs who need to provide childcare, lack transportation, are geographically isolated from in-person programs, or struggle with other barriers to community engagement. While this course was offered during COVID-19, the virtual format and instruction delivery can help overcome barriers to learning, not only during a pandemic. This program serves as a model of the potential of university–student partnerships, allowing nonprofits to effectively and economically harness the efforts of higher education students outside their immediate geographic regions. Intentional design, opportunities for application, and integration of social networks can all allow for positive connection facilitating learning between adult ELLs and college students.