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Focus On Basics

Volume 5, Issue C ::: February 2002

ESOL Teachers: Helpers in Health Care

Singleton developed methods to help students navigate the health care system

by Kate Singleton
Luz, a 36-year-old mother of seven from El Salvador, was in my adult English for speakers of other languages (ESOL) class in Arlington, VA. After three 3-month terms, she was beginning to sight-read when she started experiencing severe abdominal pains. Her attendance dwindled. At school, her pain distracted her. One day she reported that she had been to the emergency room; her children had been told that their uninsured mother needed an operation very soon. As the operation date approached, Luz said she was very nervous.

Never having studied in her native country, Luz knew nothing of internal organs.  She did not know what her diagnosis of uterine fibroid meant. I tried to calm her, saying the surgery was done all the time with no problems. But in her case there were problems; a surgeon slipped and accidentally cut into her bladder. The surgery and recovery suddenly became longer, more traumatic, and more costly to Luz and her family. As she recuperated at home she received piles of medical bills in the mail. Her literate children understood little on the bills, but the whole family understood the large numbers of dollars printed at the bottom. Luz, who had been making long-sought gains in her struggle for literacy, dropped out of school.

Jose, a Bolivian man in his early 30s, stayed after class one night so I could help him understand a hospital bill. He had been having bad headaches for some time.  Thinking it was his only option for care, he had gone to the emergency room to get treatment. There he was told the headaches would clear up if he got glasses. He was charged $300 for this diagnosis.

Maria, a Salvadorean woman in her early 40s, came into class pale and panicking. She had gone to the emergency room over the weekend and had had an operation. When asked about the procedure she said hysterically, "Me don't know. They cut me. What they take me don't know!" She had had a hospital interpreter, but she, like Luz, did not have the basic anatomical knowledge to understand what was explained. Unlike Luz, she had no family in the area to intercede for her.  I called a social worker, who helped Maria find out that she had had a gallstone removed, and that she needed to follow a specific diet and receive follow-up care. The social worker also helped her negotiate a payment plan for her hospital bills.

I taught these three students and many other beginners like them during my nine years in Arlington County. They are hard working and hungry for education. Most often uninsured, they do not seek preventive care. A health problem arises, or a lingering one worsens, and they are in crisis, immersed in a health care system they do not know how to navigate. They have weak support systems in this country, little English to speak, and no idea how to access helpful services. With poor health and the urgent need to pay large medical bills, their attendance in school suffers and they often drop out to work harder and raise money when they should probably be working less.

Curriculum vs. Life

Based on these experiences, I felt a gap between what I have been teaching  (my program's health curriculum) and the health-related situations my students actually encounter. I do not dislike the curriculum: I have taught most of my beginner classes for the Arlington Education and Employment Program (REEP), and know how hard the teachers have worked to make the curriculum practical, needs-based, and learner-centered. The content is simple, it presents basic, important vocabulary on body parts and describing symptoms to the doctor. The simplicity of the language structures and the basic life skills are level-appropriate and necessary for beginner students, designed to be pertinent but not overwhelming. In my experience, however, it is precisely the uninsured beginners who find themselves overwhelmed in the most catastrophic, complicated health situations. Beginning-level students need and want to be able to describe basic symptoms (more often than not it was their first or second choice in class needs assessments) but they also need to understand the comparative financial and health costs of opting for emergency care over preventive care. They can similarly benefit from understanding how to advocate for themselves when or if they suddenly find themselves having to navigate the complexities of the US health care system.

Certainly many people, fluent English speakers among them, are overwhelmed when seeking health care in the United States. Language and cultural barriers present additional difficulty. It seems that the less language and cultural skill one has, the less the likelihood of having health insurance, access to preventive care, and an understanding of the US health care system. Research indicates that uninsured people who do not get care tend to have more chronic, difficult to treat conditions (Ayanian et al., 2000). Beginning-level ESOL students need the complex health-related material and concepts that often are only taught in higher level classes. These observations led me to explore the following question: What else can ESOL teachers do to prepare our beginning-level students for encounters with the US health care system, especially those who are uninsured?


I started by exploring the question informally, talking with other teachers in my program and finding that many had made the same observations. Many students who had been here for years, I learned, some with high levels of English competency, were unaware of the availability of low-cost clinics for the uninsured. I educated myself more about community services available to immigrants in the community and read about physical and mental health problems common among low-income immigrants (see Blackboard for recommended resources). I began reading about health beliefs and practices in other cultures, and how those beliefs blend or clash with mainstream US practices.

I also began a Masters degree in social work. My work in ESOL had made me curious about what immigrants go through when they settle in a new country, and social work has allowed me to explore that in more depth.  The coursework has helped me understand how truly difficult it is for care providers with the best intentions to suppress their own cultural beliefs when working with clients or patients from other cultures. If we can introduce ESOL students to just a little of the mainstream US medical culture, then they might have more understanding of what is expected of them as patients. With this awareness, they might be able to be more active in their treatment and better advocate for their own needs.

When I started reading on the subject of health literacy as viewed by literacy professionals within the medical field, I detected a general disregard for contributions of adult educators to the discussion and a preoccupation with semantic issues. While the issues deserve some place in discussion, I saw little analysis of the effects of culture on comprehension, or the effect of the context in which a person was being given information. As a literacy instructor, I know that when people are feeling stress, their comprehension decreases. Imagine the stress an immigrant like Maria feels, with scant English and low literacy, having just had emergency surgery, sedatives still blurring the senses, as follow-up care instructions are presented to her. 

One person who helped recharge my optimism was Maria Meuse, RN, a community health nurse in Bailey's Health Center, a county-run, low-cost clinic in Falls Church, VA. She recognized the cultural variation among the clinic's immigrant patients, and the stresses that illness and seeing a US health care provider create for them. In the box below is a listing of several cultural expectations of the US medical system that are problematic for many immigrants, as described by Maria.

With Maria's clarification, I decided to design materials that would help teachers convey to students concepts such as preventive care and the need to ask questions of the doctor. The materials needed to enable but not require both students and teachers to discuss difficult, potentially personal topics. I would identify questions that are culturally appropriate to ask a doctor about medicines, surgery, and general treatment. In addition, I planned to collect and share information on the low-cost health services available and how to access them. And last, I would develop suggestions on how to pay for emergency medical procedures if the patient is uninsured. The suggestions would not eliminate the financial burden, but they could give the student more control.

Suggestions for low-income students 
who do not have health insurance

  • Find out if there is a low-cost clinic in your area.

  • If you must see a regular doctor, say you are uninsured and ask if you can pay a lower rate.

  • If you have a big bill, ask for a payment plan so you can pay a little every month.

  • Don't wait until the problem is an emergency. If you go to the doctor early, you will probably pay much less.

  • See if your children qualify for free health insurance. Ask at their school or at the health department.

Tips for handling sensitive subjects

Many teachers might be uncomfortable taking on health topics in class that have the potential to bring up very personal experiences for students. They might feel that they don't have enough specific knowledge of US health care practices (or the time to acquire it) to be able to handle students' questions. These concerns and others are addressed in a useful chart by J. LaMachia and E. Morrish entitled "Teachers Concerns about Incorporating Health into Adult Education" in the Spring 2001 edition of Field Notes, available on-line at http://www.sabes.org/resources/fieldnotes/vol10/f04conc.htm

Handling language problems at the doctor

  • Bring a friend with you who speaks more English than you do. Sometimes it is not comfortable for children to translate their parents' health problems.

  • Write down some questions to take with you. This will help you remember to get all the important information.

  • Ask someone who speaks English to call the doctor's office before your appointment to say that you will need an interpreter. The doctor may know someone who can interpret for you.

  • If you can pay, see if there is a doctor near you who speaks your language.

  • Always ask questions! You are the customer and your health is important. In the United States, it is OK to ask the doctor questions until you understand.

Cultural expectations of the US medical system

  • Preventive care is seen as the patient's responsibility. US medical culture emphasizes self-care.

  • Patients have the responsibility to ask questions in a fast-paced doctor's office or clinic.

  • Patients must be clear with their health care provider about any medications they take, even herbs or traditional medicines from another country, to avoid dangerous interactions.

  • Patients are expected to find out which side effects of medications are dangerous and which are benign before leaving the doctor's office, clinic, or pharmacy.

  • Sometimes payment plans or financial assistance are available in hospitals for uninsured patients, but the patient must ask about them specifically.

  • By law (the federal Civil Rights Act of 1964), patients whose first language is not English should be provided with an interpreter. If one is locally unavailable, 24-hour telephonic interpretation services exist for doctors to use (at the doctor's expense). This is not popular among doctors, but it does exist for emergencies.

Testing Materials

The materials that evolved included picture stories about preventive care, asking for clarification from the doctor, handling stress, and domestic violence. I also wrote problem-solving stories, for readers at a high beginner level or above, about anxiety and depression. I compiled lists of simple questions to ask the doctor, and a brief list of options for payment after an emergency.

I piloted the picture stories in the Arlington County Community Outreach Program classes held in apartment buildings and community centers around the county: drop-in, multilevel classes that tend toward beginner level but have some higher-level students as well. I started each session with a picture story about a man who ignores pain symptoms until he has to be taken to the emergency room for emergency surgery. In the last frame he is still in bed a month after surgery, looking in terror at a big bill. (See below.) We analyzed the situation, then wrote a story about it, with the students dictating and me writing. We discussed alternatives the man might have pursued at the beginning to avoid the catastrophic outcome, and talked about preventive practices, low-cost clinics, requesting payment plans, and what happens if you do not pay the medical bills. 

person delaying going to doctor because of expense

The materials that evolved included picture stories about preventative care, asking for clarification from the doctor, handling stress, and domestic violence.

In every group, people had a lot to say or ask. After the first pilot lesson, a young man came up to me and said, "This is my story!"  Excited to learn about the clinic, he had thought the emergency room was his only option for treating gastritis, and now was paying the bills. Another man said he had had emergency surgery and had ignored a collection agency's attempts to reach him. That admission led to discussion about the importance of credit records in the United States and what effect nonpayment of bills can have.

In the first pilot class, after developing the story I talked about asking the doctor questions. I thought that the more advanced students might be able to brainstorm some suggestions that other students could practice. The activity needed more clarification: some students were suggesting questions the doctor would ask a patient rather than the opposite. Others had an idea in their own language of an appropriate question, but could not find the right English words. 

I therefore created a second picture story, in which a man tells the doctor that he understands everything, but in fact understands nothing. When he gets home, he is thoroughly confused as to how to treat his problem. At another center, I did the same story writing with the first picture story, then presented the second picture story as a conversation topic. As the students looked at the story for the first time, I heard laughter and admissions of "This is me!" Discussion brought out many questions from students: "The doctor knows more. Why should I ask questions?" "The doctor speaks too fast. What can I do?" "All my friends are at work. Who can interpret for me?" The topic is hard, but we did generate some worthwhile suggestions and comparisons between health care here and in the students' native cultures.

man thinking No English, saying I don't know.

I consider the pilot lessons to have been generally successful. Most students, although a little puzzled by the approach to health in the United States, have been inquisitive and enthusiastic. Students occasionally complained that clinics have income restrictions and may charge a small amount to higher-income patients, but the complaints were easily handled by asking the class to compare the cost of the emergency room with the inconvenience of the clinic qualification requirements. The questions for the doctor are the hardest part with every group, and much more difficult for the very beginners. I usually try to dissuade translation among students during class, but in these lessons I sometimes encouraged it because I thought that the information was so important. I urged participants to share the information with their families and read the list of questions at home with someone who could explain it in their language.

I was able to share what I had learned from my research and pilot lessons at the Virginia Institute for Lifelong Learning ESOL Conference in Arlington in July, 2001. Comments from participants indicated that the session was "much needed" and that "curiosity has been sparked." I hope that ESOL instructors will continue to explore ways to empower the neediest students for inevitable encounters with the complexity of the US health care system.


Ayanian, J., Weissman, J., Schneider, E., Ginsburg, J., & Zaslavsky, A. (2000). "Unmet health needs of uninsured adults in the United States." Journal of the American Medical Association, 284, 2061-2078.

About the Author

Kate Singleton is an ESOL teacher and curriculum writer for the Fairfax County Adult and Community Education program in Virginia. She has been teaching adult ESOL for 14 years, during which her special interests have been literacy instruction, working with students perceived to have learning disabilities, and health education.  She is also pursuing a Masters in Clinical Social Work at Virginia Commonwealth University, for which she works as a case manager of HIV-positive clients at Whitman Walker Clinic of Northern Virginia. 


Updated 7/27/07 :: Copyright © 2005 NCSALL