Opinions from ESL Instructors and Students about Curricula on Hepatitis B for Use in Immigrant Communities

Abstract

Background

Chinese immigrants in Canada have a disproportionately high risk for hepatitis B compared with non-Hispanic whites. Hepatitis B is the leading cause of hepatocellular carcinoma among Asian immigrants to North America. English as a Second Language (ESL) classes are an effective way of reaching newly immigrated individuals and are a potential channel for delivering health messages.

Methods

Using data from six focus groups among ESL instructors and students, we characterized perceptions about activities that are successfully used in ESL classrooms and strategies for delivering hepatitis B information.

Results

Instructors and students generally reported that activities which focused on speaking and listening skills and that addressed content relevant to students' daily lives were successful in the classroom. Instructors generally avoided material that was irrelevant or too difficult to understand. Focus group participants offered strategies for delivering hepatitis B information in ESL classrooms; these strategies included addressing symptoms and prevention, and not singling out a specific population subgroup in order to avoid stigmatization.

Conclusions

These findings might assist efforts to develop ESL curricula that target immigrant populations.

Introduction

Many adults in North America are thought to have difficulty understanding and using health information. A 2004 report published by the Institutes of Medicine (IOM) notes that one in two U.S. adults have difficulty obtaining, processing, and understanding basic information needed to make appropriate decisions regarding their health (1). These individuals with low levels of health literacy may be unable to comply with medical recommendations, or engage in behaviors to prevent the onset of illness. Moreover, a greater number of hospitalizations and more frequent use of emergency room services are observed among individuals with low levels of health literacy, compared to those with average or high health literacy levels (1).

One strategy for improving health literacy is through English-as-a-Second Language (ESL) classes. English education classes provide ready access to populations with limited English language literacy (these populations are often not reached by English language health education materials or media-based health education campaigns) (2, 3). The ESL environment is considered to be an ideal avenue for reaching immigrants since people in such classes are generally motivated to improve their knowledge (4).

Previous investigations on health-based ESL curricula are scarce (4). No studies known to these authors have reported on the specific activities in the classroom that may be particularly useful in teaching health issues or sensitive health topics in this venue.

One health topic that is particularly relevant for immigrants to North America is hepatitis B prevention. Asian immigrants, in particular, have a disproportionately high prevalence of hepatitis B infection (HBV) compared to native-born individuals (6, 7). HBV, a preventable disease by vaccination, is a blood-borne infection that is spread from person to person though sexual contact, direct contact with blood (though use of injection needles, tattooing, piercing, or acupuncture needles), and household contact (such as sharing toothbrushes or razors). Vertical transmission of HBV from mother to child is a common infection route. Hepatitis B infection is the leading cause of hepatocellular carcinoma among Asian immigrants to North America (8, 9).

Using data from focus groups among ESL instructors and students, we examined the perceptions of successful ESL activities and suggestions for the development of a curriculum on HBV. These findings add to the existing literature by providing qualitative information that can assist in the development of ESL curricula addressing health topics for immigrant populations.

Methods

Setting

The Chinese community in British Columbia is concentrated in the greater Vancouver area, where 2001 Statistics Canada census data estimates the number of Chinese-speaking individuals at 293,065 (15 percent of the total Vancouver population) (10). Vancouver is an urban center with many community-based organizations offering on-going ESL classes for newly immigrated individuals.

ESL classes for adult newcomers to Canada are taught in accordance with the English Language Services for Adults (ELSA), an English program paid for by the Canadian government. There are three levels of ELSA and all reflect a basic level of English proficiency. These classes are offered without charge through a variety of immigrant and community organizations and schools. A typical full-time ELSA program offers 25 hours of instruction per week and a part-time program offers 9.0 to 12.5 hours.

Data Gathering

For this project, we conducted six focus groups, three among ELSA instructors and three among Chinese Canadian adult ELSA students. We recruited instructors and students at three community-based organizations: United Chinese Community Enrichment Services Society (S.U.C.C.E.S.S.), the Immigrant Services Society of British Columbia (ISS), and the Richmond School District (RSD). The students were Cantonese or Mandarin speakers in ELSA levels 2 and 3. Students at these levels can generally follow simple instruction that is given in a predictable context and can copy words and phrases. All focus group participants were recruited by representatives of the three participating organizations.

Focus groups were held in classrooms provided by each of the participating organizations. Instructor focus groups were conducted in English and were led by a project investigator (G.C.) with extensive experience in focus group facilitation. Focus groups among Chinese Canadian students were led by one of two bi-lingual project staff (Cantonese-English and Mandarin-English), also with previous experience facilitating focus groups. All focus groups employed general principles of group facilitation, such as active listening, being flexible when necessary, accepting all ideas and opinions as valid, being non-judgmental, and being sensitive to individuals who do not want to reveal information. These qualities are thought to maximize trust of participants. Each focus group also had a note-taker to record observations as field notes.

The Research Ethics Board at the British Columbia Cancer Agency reviewed and approved the interview questions and research protocol. At the beginning of each focus group, the facilitators explained to the participants that the focus group discussions would be audio-recorded and the information collected would be used for research purposes only. Participants were assured that their names would not be recorded on the tape. Written consent was obtained from all participants. Audio-tapes were shared only with the project staff and were erased after transcription to maintain confidentiality.

An open topic schedule was used to guide the focus groups, leaving the facilitators considerable freedom to explore issues that emerged in the discussion. Questions asked about teaching strategies, teaching material, and important considerations in developing a curriculum to motivate students to get hepatitis B testing, among others. Focus groups were conducted in English for instructors, and Cantonese and Mandarin for students.

Data Analysis

Information was gathered from the audio-tapes and field notes taken by the note-taker and facilitator. After the focus groups, transcriptions were made of the tapes and field notes. Student transcriptions were translated into English and were reviewed by the staff present at the focus group. Analysis of this information was made following principles of qualitative research suggested by Morgan and Krueger (11, 12). In each transcript, four individuals independently identified and coded key words and common themes that appeared throughout the interviews. They then met to review all identified themes and key words. In cases of disagreement about a theme or key word, the item was discussed until consensus was reached. Where consensus could not be attained, the opinion of the focus group facilitator prevailed.

Results

A total of 29 instructors and 27 students participated in the focus groups, group sizes ranging between nine and ten individuals. Instructors were generally female, with an average age of 50 years and having taught ESL for 11 years at various class levels. Students were generally female with an average age of 42 years. The majority were born in mainland China, having immigrated to Canada, on average, three years prior. The majority was also currently married, had an average of 14 years of education, and was unemployed. After independent analysis, the four staff members agreed on the following themes.

Effective teaching strategies/activities

Instructors identified several overarching goals to guide the selection and development of classroom activities. One goal is to engage students in interactions with other students to build skills in speaking and listening. Several instructors also noted the importance of improving the functional language skills of students which improves one's ability to operate in society. Learning words that allow one to take a bus or to explain one's health symptoms to a doctor are examples of functional language. Several examples were given for ways to achieve these goals through the development, selection, and delivery of curricula.

Student interactions through incomplete stories

Instructors mentioned that student-to-student interactions are encouraged through a number of classroom activities (Table 1). One such activity is a mingle, where students are given a list of characteristics and they need to find another student who matches one of these characteristics (e.g. has brown hair).

Table 1.

Focus group comments

Subject	Comments
A. Student interactions through incomplete stories	“Well we do a lot of mingles, like where we've got a question page and they have to ask each other, do you like cantaloupe? Do you like… that kind of stuff.”
	“… maybe Jill has half the information, and I have the other half of the information and we ask, we quiz each other to get that information…”
B. Student interactions through games	“… so they roll the dice and whatever square they land on it would be a question there. So it could be ‘what is a good thing to eat when you have this particular problem?’ It could be a diet question or ‘what is the best way to avoid or to take care of yourself when…” … they roll the dice and they go along the board game until they get to the end.”
	“I write a topic and then I have people come to write on the board things about that topic and they're into different teams and the person that writes the correct answer to what I just asked them about the topic gets a point, so it's like a competition game.”
	“Some teachers like to have us play games in the class. But, I feel that is the way to teach children, not the adult. It would be better if we could use the time to learn more stuff.”
	“…teacher's body language was very important. If the vocabulary word was running and jogging, s/he would show us what running and jogging is.”
C. Speaking and listening skills	“The exchange through conversation is more important [than grammar] and it is exactly what we need.”
	“…Chinese who live in Vancouver can still live pretty well without knowing how to speak English. So we treasure very much the amount of time we have in the class where we are encouraged to speak English.”
D. Functional language	“One student went to the post office to mail a package and encountered some difficulties… The teacher would teach us everything related to the post office. There are benefits using this strategy. First, we feel a bit more relaxed when we are learning English… and the things that we learn can be used in our daily life right away.”
	“When my tire was flat, I didn't know how to tell the repair shop about it. Also, when I need to have my car fixed, I'm not trying to learn too specialized jargons, but my car… seems like there is some noise coming from it… but how do I tell the person?”
	“What I like best is the field trip… the impression is very lasting… if it is just talk and you haven't seen it, then it may not get so deep in your head.”
	“When s/he [the instructor] talks about bus-stop, s/he would take you to the bus-stop. And on your way walking there, s/he would describe in English what we came across. This method gives you a very lasting impression.”
	“…going on field trip is not bad, but too many people… one teacher leads 20 students.”
E. Teaching material	“…if I'm doing a story or whatever, you want to have something that is a picture… that matches that story, that goes along with that story that you can elicit ideas from the beginning and just grab their attention with that.”
	“The teacher displays diagrams or pictures, while covering up the words or sentence below. So, when you see the picture you can try to guess what it is about.”
	“…with a video, you can cut it into short episode [to match the level of the student], it's very helpful.”
	“… use the VCR to show us some conversation… the best part of this is, at the end, the teacher will give us the answers of the questions related to the conversation to see if our understandings of the conversation are correct.”
F. Development of a curriculum on hepatitis B	“…so could there be examples like stories, or real live people, movie stars, cultures and different situations where this happened [getting hepatitis]. And then, statistically we can indicate that in certain groups, this happens more, but it happens across a broad range.”
	“… it's necessary to let people feel that hepatitis has the personal relations with them.”
	“People will look at the illness seriously only when they feel scared.”
	“…we should teach about the consequences of hepatitis B, if you get hepatitis B. If everyone thinks that the consequences are very serious, then s/he will think that ‘ah, this issue is very important to me’.”
	“We have been told that the Chinese has higher rate of hepatitis B infection and the Caucasian has lower rate of getting it. Now I am living in Caucasian [sic]. I should not be infected.”
	“… actually, most of us people from China actually know that it's a very serious problem in China, but we think that we are safe after we came to Canada.”

In addition to mingles, instructors noted common exercises that encourage student interactions. One specific activity is a jigsaw reading, wherein students form groups (generally of four students), and each group is given text to a single part of a larger essay or story. The groups meet to review their part, then the students form new groups consisting of a single member from each of the original groups. Each student then explains his/her part and the larger story is created. A list of true-false or matching questions may also be given to the final group to test comprehension.

Another group activity is called an information gap. For this activity, students get into pairs and one student is given text where a word or group of words is omitted. The second student is given the same text where a different word or group of words is omitted. The students then quiz each other to complete their text.

Student interactions through games

The use of games is another example of activities that instructors mentioned was effective in encouraging student-to-student interactions. Several instructors stated that using games in the classroom is well-received. It is a common practice for instructors to adapt commonly used games, such as Bingo and Concentration to reinforce key vocabulary, and Go Fish to match components of a topic, such as a given disease with its remedy. Some instructors adapt the television game Jeopardy, where students are presented with the answer to a question and they must invent the question. Other games allow groups of students to compete with each other and receive points or fake money for stating or writing the correct answer.

Students, however, were not uniformly pleased with the use of games in the classroom. Most students stated that they enjoyed the games, however some students believe that games are for children only. Students noted, however, that instructors who use body language, facial expression, and are lively are considered more effective and interesting, than other instructors.

Speaking and listening skills

Both instructors and students underscored the importance of instruction that focuses on speaking rather than on writing. Moreover, students stated that they prefer instruction that is taught solely in English, without the aid of native language dictionaries.

Functional language

Several instructors noted the importance of teaching language that allows students to improve their functioning in society. To that end, instructors usually select curricula on topics that are considered relevant to students. The importance of building students' functional abilities in English was echoed by students. Students, for example, noted that they pay attention to instruction that addresses relevant topics, such as going to the post office, finding an apartment, dealing with immigration or legal issues, or ordering food at a restaurant. In contrast, instruction about holidays is not considered relevant, especially if the holiday is not celebrated in their home country.

Instructors noted that field trips were useful means of developing functional language skills. Field trips were commonly mentioned by both instructors and students as an activity that made a lasting impression.

Teaching material

Instructors mentioned that they supplemented their teaching strategies with visual aids and props. Students also stated that diagrams and pictures aid in learning. Instructors and students both noted that videos are commonly used and effective in reinforcing content.

Some instructors and students mentioned activities that accompany a video, such a pre-teaching vocabulary using matching or other activities, providing students with a list of words that they check off as they hear them on the video, or providing students a copy of the entire dialog for the video with key words blanked out (students then listen for the words to complete the dialog).

Development of a curriculum on hepatitis B

As the purpose of our project was to develop a curriculum on hepatitis B, we gathered instructor and student input relevant to hepatitis B content and activities. Some instructors suggested inviting a guest speaker with hepatitis B to talk about his/her personal experience with the disease. Other instructors stated that the curriculum must address key content areas, such as routes of transmission, symptoms, how to prevent becoming infected, and the logistical aspects of getting a blood test (i.e. where to go, what the results mean, and who will see the results, etc.).

Instructors also expressed the concern that hepatitis B may be a sensitive topic and many offered suggestions for desensitizing the instruction. They noted the importance of being clear and honest about the routes of transmission, and none thought that transmission through blood and body fluids would be difficult to teach. Instructors thought that it is important not to single out a given racial or ethnic group as being at particular high risk of disease, but instead to present examples of real people, even movie stars who have had hepatitis B.

When students were asked about ways to develop a curriculum on hepatitis B, several common themes emerged. Students were very interested in learning about ways to prevent getting hepatitis if one is uninfected, and what hepatitis B carriers ought to do to improve their health and prevent the spread of disease to others. Students commonly mentioned that the curriculum must address the severity of the disease. Some students noted that the curriculum should address symptoms of the disease. One student offered that persons will pay attention only when they feel scared.

Students were also interested in knowing why certain groups have higher rates of hepatitis B than others. Some students believe that a person's risk of hepatitis B decreases once that person comes to Canada. As also mentioned by the instructors, students expressed interest in learning about the logistical aspects of receiving a blood test, such as how to arrange a doctor's visit, how to make an appointment, how to explain one's symptoms, and how to pick up medicine from the pharmacy. Students noted that while many physicians serving Chinese Canadians in Vancouver speak Chinese, lab personnel rarely do. Finally, students raised concerns about cultural taboos around being infected with hepatitis B. Students mentioned that it was important not to associate hepatitis B with a given racial or ethnic group.

Discussion

We identified key activities for an ESL curriculum to be considered effective for learning English. Our findings also identified important principles for guiding curricula development and selection, those that encourage student-to-student interactions that build students' ability to participate in society and that focus on speaking and listening skills. This information can provide important insight to researchers and public health educators for the development of health promotion material aimed at individuals with low levels of English literacy.

The findings from our focus groups suggest that instructors prefer activities that allow student-to-student interaction and that both instructors and students prefer activities that develop skills in speaking, rather than in writing. Focusing on speaking and listening also develops the functional use of the language, since renting an apartment, seeing a doctor or getting your car fixed generally require speaking and listening skills.

The language experience approach is a method of teaching that relies on language that the students themselves generate. According to the method, learning takes place through experiences, either real or created, that activate the use of the words or phrases. A ride on the local bus, for example, may effectively teach students words such as “seat”, “driver”, “bus stop”. Our finding that students enjoyed and learned from organized field trips provides support for the use of this type of teaching strategy in curriculum development. Both instructors and students stated that material learned in the classroom must be relevant to the daily lives of students so that relevant information can be used and practiced immediately. Focusing on relevant topics also builds a student's functional language, by introducing them to words and phrases that improve their day-to-day interactions.

Comments from instructors and students may also relate to other theories of curriculum development. For example, task-based learning focuses on the acquisition of language to complete a given task. Students often stated that they desired to learn tasks, such as talking to a mechanic about how to fix one's car or ordering food at a restaurant.

The desire to learn listening skills may explain why students and instructors believed that videos are effectively used in the classroom. Videos typically demonstrate social interactions, thereby teaching students cultural norms and expectations and preparing them for greater social participation. Videos also expose students to communication styles and accents that are different from their regular teacher. Videos were also thought to be effective in addressing sensitive topics because other activities that model student interaction, such as role-plays, may be uncomfortable for some students when a sensitive topic is presented.

Instructors and students also identified useful strategies for addressing hepatitis B. Notably, neither group expressed concern about presenting information about sexual intercourse and injection drug use as routes of transmission. However, both groups were concerned about providing information that singled out a given racial or ethnic group as at particular risk of disease. Instructors, for example, prefer to state that immigrants from various countries have high rates of hepatitis B, rather than that Asian immigrants have high rates.

Students also expressed the belief that once an individual comes to Canada, his/her risk of hepatitis B decreases. Risk for hepatitis B may lessen somewhat because the likelihood of exposure through injection drug, tattooing, or piercing may be lower in Canada than in Asia. However, the major sources of transmission are from mother-to-child during childbirth, sexual intercourse, and household contact with infected individuals (sharing toothbrushes and razors) and these risk factors do not change with immigration. There remains a continued need for testing and vaccination among susceptible individuals.

Apart from actual classroom activities, students noted that an instructor's enthusiasm also lends itself to the creative use of activities that are fun and engaging. Students also noted that instructors who used facial gesture and “cared” about their students' education were most effective.

Limitations

Focus groups for our study were restricted to Vancouver, Canada, where training of ESL instructors and the structure of ESL programs may differ from other geographical regions. Thus, care must be exercised in generalizing these findings to other areas. Moreover, these results are preliminary and validation of these findings using quantitative techniques is needed. Nevertheless, focus group participants identified overall teaching and learning strategies and practical approaches to curriculum development that may be useful elsewhere.

Conclusion

The findings suggest that ESL strategies and activities that engage students in interactive communication, that focus on developing skills in listening and speaking, and that address content that is relevant to students' daily lives are most effective in the classroom. A curriculum on hepatitis B ought to address prevention and logistical aspects of obtaining a blood test, and should avoid focusing on a single racial or ethnic group. Further research is needed to examine the effectiveness of a hepatitis B curriculum on improving knowledge and promoting testing for hepatitis B.