Additional Information about the SHINE ESL Health units

Why were the SHINE Health Literacy Units designed?
The ability to achieve effective communication with a health provider is an essential component of health literacy.  Insufficient language skills create serious difficulties for elderly immigrants as they attempt to communicate their problems and needs to health care professionals.  For example, interactions with office staff before the elder even sees a physician often lead to miscommunication and misunderstanding that can adversely affect future care.  Even seemingly simple and formulaic exchanges such as making an appointment, completing a patient history, consent or HIPPA form can present extremely challenging and intimidating communication contexts for the non-native speaker.  Although large ethnic groups with an established history and/or available resources often have access to health care providers who speak their native language, groups with much smaller populations or with limited resources do not necessarily have access to physicians who speak their language.  Moreover, most elderly immigrants encounter on-going communication challenges in settings outside primary care, such as a specialist’s office or in hospitals where doctors who speak their native language are not readily available.

What health literacy issues are seniors most concerned about?
In Project SHINE’s investigation of the elderly immigrant population’s perception of their challenges and needs when communicating with healthcare professionals, nearly half the respondents indicated that “understanding medical instructions” is a topic they would like to learn about in a health literacy curriculum.  Among different categories for possible health literacy lessons, many of their interests were concentrated on communication tasks, such as understanding a doctor’s explanation of the signs and treatment options for diseases such as high blood pressure, heart disease and diabetes, communicating their own traditional medical practices to health care workers discussing concerns about medications, and giving personal or family medical histories.

How do the units attempt to meet these needs?
The units are designed around a communication framework that is based on the work of Canale and Swain (1980).  Based on their work with non-native speakers of English, they devised a list of four components that are necessary for effective communication.   Below is an adapted version of their framework which includes the elements necessary to achieve effective communication in a healthcare encounter:

Each of these four competence areas - language, culture, strategic and discourse - provides one piece of the communication puzzle. When any of these four pieces is missing, miscommunication, or even communication breakdown, will occur. Let’s move clockwise around the four quadrants in the figure above, in order to explore how each contributes to effective communication.

Of course, the development of linguistic competence - vocabulary, grammar and pronunciation training - is central in the design of the health literacy units including instructional targets ranging from basic vocabulary sets, such as names of conditions and body parts, to more complex skills such as precisely describing degrees of pain and symptoms. However, for language instruction to be truly effective, the units are designed to approach the language use of elderly immigrants in context. Therefore, in addition to teaching basic language skills and structures, it is important to develop the discourse, sociolinguistic and strategic competencies they will need to communicate effectively in a healthcare setting.

What is discourse competence?
Discourse competence refers to a speaker’s knowledge of and ability to interpret the context, or discourse, that frames any given language event (for example the common structure of a conversation – how it begins, develops and ends, or the way we organize a business letter). By discourse we are referring to both of these micro-level contexts of communication as well as macro-level or institutionalized/cultural structures and ways of thinking in which the texts or conversations are embedded (for example, the common structure of a voicemail system, or the way insurance providers work).

The following summary of an interview illustrates an elder’s lack of discourse competence that has led to communication breakdown between herself and her healthcare provider. With her limited English skills, at the micro-level she does not understand the meaning of the letters she has received regarding payment, nor does she seem to understand the institutional structure of her insurance benefits:

“When (she) first (arrived) in the US she tried to make a medical appointment. A social worker at self-help told her that she could get free check-up. Soon after the appointment, bills came then collection notice. She was very afraid since she did not understand what it meant. So she had to borrow money from her son. Now she will not go back to the doctor. …Social worker had said it would be free. Had she known ahead of time she would not have gone (to the doctor).” Chinese, San Jose

From Project SHINE’s investigation it is evident that many elderly immigrants are similarly confused by topics such as “patient’s rights,” “insurance forms” and “reading prescription labels.” The development of the discourse competence required for these non-native speakers to be able to understand and react to these critical medical contexts is, for this reason, an essential component of each unit.


What is sociolinguistic competence?
Sociolinguistic competence is the ability of the speaker to understand and produce language that is appropriate to any given situation by effectively interpreting and reacting to factors such as the status of participants and cultural norms and conventions influencing communicative interactions.

Cultural beliefs regarding status and doctor-patient relationships significantly influence what a patient considers appropriate within a healthcare encounter. A Philadelphia healthcare provider who works mainly with Chinese elders commented that in traditional Chinese culture, “the doctor is a god never to be questioned.” This stance differs markedly from the prevalent attitude within American healthcare that patients should be informed health consumers, who take an active role in their care by asking questions and obtaining second opinions. This cultural difference, intensified by a lack of grammatical competence, is reflected in immigrant elders’ inability to appropriately ask direct questions, express their opinions, refute charges or demand a second opinion. With this in mind it is no wonder that many immigrant elders expressed greater comfort with a provider who spoke their native languages, precisely because they were more comfortable with the discourse context and the sociolinguistic norms that define these kinds of conversations in their culture. Providing learners with information and practice activities that help them to bridge this divide is another important instructional target of each unit.


What is strategic competence?
Strategic competence is the ability to use verbal and non-verbal communication strategies that enable a non-native speaker to manage communicative interactions in which they may have difficulty understanding healthcare providers. The information collected by Project SHINE indicates that immigrants’ strategic competence is as crucial as any of the competencies described above for improving communication in medical settings. Immigrant patients often do not know how to ask for clarification (for example they do not effectively use common clarification phrases like: “I’m sorry, could you say that more slowly? I didn’t understand.”) when they are confused or when they require more information. They also may not feel comfortable interrupting their health care provider, or taking the lead in a group discussion to ask their questions. For this reason each unit aims to provide information and activities that will help alleviate some of this uneasiness and build more effective strategies for appropriately intervening in conversations to gain clarification, ask for explanations, and/or negotiate medically-related matters in English.