Health Literacy Program for Connect2Health

Significance
The purpose of this paper is to request grant funding for a program that seeks to
address low health literacy (LHL) as it impacts community members’ ability to access and use
resources that can benefit their health. Health literacy is defined as skills that a person needs in
order to navigate healthcare systems and conversations related to health, including the ability to
understand health information that is written or spoken (Hersh et al., 2015).
Connect2Health (C2H) is a non-profit organization in Salt Lake City, Utah. C2H’s
mission is to “mobilize student volunteers to link underserved populations with social services
and to prepare students to be empathetic future health professionals who understand the
importance of social determinants of health” (Holliday, 2021, p. 4). Social determinants of health
are circumstances in a person’s neighborhood, school, or workplace that impact their health
(CDC, 2021). The volunteers provide information about resources, including, but not limited to,
medical supplies and services, food, shelter, and clothing, to clients at eight sites throughout the
Wasatch Front. Each of the sites where C2H volunteers serve provides a service that addresses
health in some way.
Data show that people who live in the areas served by C2H are more likely to
experience poverty, have low levels of education, be an ethnic minority, and/or have a first
language other than English (U.S. Census Bureau, 2020). Additionally, people who live in the
areas served by C2H have higher rates of homelessness, a lack of healthcare, and/or chronic
health conditions (United States Interagency Council on Homelessness, n.d.; Utah Department
of Health, 2020). Research and data show that people with these characteristics and Utah
residents in areas served by C2H are predicted to have LHL (Christy et al., 2017; Farrell et al.,
2019; Knighton et al., 2017; Kutner, 2006; Odoh et al., 2019; Olives et al., 2011; Rothman et al.,
2004; Schillinger, 2020; University of North Carolina at Chapel Hill [UNC-Chapel Hill], 2014; see
Appendix A).
Gaps in Services
Health literacy is a major emphasis of Healthy People 2030, the United States’ 10-year-
plan to address the most critical public health priorities and challenges. (Office of Disease
Prevention and Health Promotion [ODPHP], 2021; ODPHP, n.d.). Health literacy is directly
related to C2H’s mission because it is a social determinant of health (Centers for Disease
Control and Prevention [CDC], 2021). LHL is associated with several negative outcomes which
include decreased compliance with medication and medical advice, higher risk for
hospitalization and emergency department visits, and reduced participation in preventative care
(Griffey et al., 2016; Kutner et al., 2006). Other negative outcomes include a worse overall
health status and lower quality of life (Griffey et al., 2016; Kutner et al., 2006). C2H volunteers
currently do not receive training for how to address the LHL of clients who visit sites.
Large healthcare organizations, including the National Work Group on Cancer and
Health, American Medical Association, and National Institutes of Health, recommend that
patient information material be no higher than a sixth-grade level (Cotugna et al., 2005; U.S.
Department of Health and Human Services, n.d.; Weiss & Schwartzberg, 2003). Based on their
research, Albright et al. (1996) created general guidelines that should be considered when
patient information material is being written, including: having an adequate number of
illustrations; using a font size between 12 to 15 points; and avoiding use of all capital letters,
italics, nontraditional fonts, and sans-serif fonts. Presently, the written information that C2H
volunteers give to clients does not follow these guidelines, and staff do not have resources on
health literacy to refer to when making written materials. Without written information that is
health literate and volunteers who are trained to address the LHL of clients, the clients will not
fully benefit from the valuable resource information that is available.
Currently Existing Programs
In order to address the priority of LHL, the Centers for Medicare & Medicaid Services
(CMS) created a free toolkit for making written material understandable and effective (McGee &
McGee & Evers Consulting, Inc., 2010). This valuable resource is a useful guide but focuses
exclusively on health information. It does not specifically address how to make written resource
information that relates to social determinants of health more health literate. Not having a toolkit
specific to making written information related to resources clear and understandable limits the
ability of C2H volunteers to address social determinants of health.
Programs exist that have trained volunteers and community health workers to address
LHL as it relates directly to the client’s health including: increasing organ donation, promoting a
healthy lifestyle, reducing obesity, reducing chronic conditions, mental health promotion, and
encouraging health screenings (Adams et al., 2021). The “Just What the Doctor Ordered?”
program trains volunteers to help people with LHL understand pamphlets given out by doctors,
and to teach them how to fill out medical forms (Relias Media, 2009). Another program found
that the combination of having an educational pamphlet and receiving verbal education from a
community health worker was more effective in increasing patient knowledge about breast
cancer than distribution of the pamphlet alone (Payán et al., 2020; Stormacq et al., 2020). While
research shows that various programs with volunteers or community health workers can
effectively improve knowledge of health issues, no programs were found that train volunteers
who provide resource information. A program is needed that has a combined approach of
creating written materials that are health literate and implementing a volunteer training to
address LHL.
Program Introduction
The health literacy program for C2H will consist of a training module for volunteers that
will introduce strategies, such as the teach-back method, that they can use when interacting
with clients with LHL. C2H will also receive a customized health literacy toolkit that specifically
offers guidance for making written resource information more clear and effective. By addressing
LHL, volunteers will be better able to help clients access resources that address their social
determinants of health.
Theory
The primary theory that informs the need for the implementation of a volunteer training
program to address LHL within the C2H organization is the Social Cognitive Theory. This theory
focuses on prevention and health promotion by improving the interaction between personal
factors, environmental influences, and behavior (Bandura,1986). The training module will
introduce volunteers to strategies to use when working with individuals with LHL and will
ultimately impact their perception of and belief in their ability to overcome the obstacle of LHL.
The training will also improve volunteer behavior by increasing their self-efficacy and
competence as they address LHL skills in C2H clients while providing them with information
about resources. The Social Cognitive Theory states that indirect behavior changes can occur
via social modeling, which new volunteers can experience by observing veteran volunteers
implement training strategies and effectively interact with C2H clients.
Innovation
This program is innovative because it outlines a method of addressing LHL in the
context of volunteers providing resource information to community members receiving
health services, rather than medical professionals providing health information. Doctors and
community health workers have used a variety of effective strategies to address LHL
(Adams et al., 2021; Juckett, 2013; Lor & Bowers, 2014; Sudore & Schillinger, 2009). This
program uniquely applies the same strategies used by health professionals and tailors them
to fit the role of volunteers providing resource information. The training module for
volunteers will consist of a PowerPoint and video presentation about health literacy and
how strategies can be modified to fit with their role of providing resource information to
clients with LHL. The program also includes a toolkit for C2H that outlines foundational
health literacy principles to refer to so that the resource information is more health literate.
The toolkit, as well as additional resources for health literacy, will be provided so that C2H
can refer to them as needed when revising future written materials. This will uniquely
address LHL as it relates to written resource information, specifically for clients served by
C2H volunteers.
Novel Aspects of the Program
Current training for the C2H volunteers is approximately five hours and is completed in-
person before each semester starts (D. Holliday, personal communication, November 5, 2021).
Volunteers will participate in the proposed training asynchronously before the in-person training
by viewing a video module wherever they can use a device that has capabilities to connect to
the internet. The training will be given over one of two online platforms, depending on what is
most accessible to the volunteers. This allows the volunteers to prepare for the in-person
training, with an understanding of how they can be more effective in their role of providing
resources to clients with LHL. Another new aspect will be the creation of a short quiz that the
volunteers will take at the end of the video module. The quiz will assess their understanding and
retention of the information. The quiz results for each volunteer will automatically be recorded
and will be accessible to the C2H director for review.
Approach
Summary of the Needs Assessment
In order to assess the needs of C2H, volunteers were informally observed and
interviewed during their shifts at three sites where they serve: Primary Children’s Hospital
Diabetes Clinic, The Wellness Bus, and the Fourth Street Clinic. Volunteers at The Wellness
Bus ask clients what their needs are and select relevant resource information to create a
“resource prescription.” Then the volunteers distribute it to clients via email or print. Volunteers
at the Fourth Street Clinic approach clients in the waiting area, ask if they need resources, and
give the Premade Resource Prescription packet, if warranted. Volunteers at the Primary
Children’s Hospital Diabetes Clinic call families of patients and email requested resource
information to them. C2H volunteers were observed to hand out or email resource prescriptions
to clients, and then told them that they could go to one of the places listed for help. Printed
materials were noted to have small fonts, long paragraphs, and to be poorly photocopied (see
Appendix B). This observation indicated a need to improve the readability of resource
prescriptions, and a need to further consider how health literacy principles can be implemented
within C2H. During informal interviews, some volunteers reported feeling like they were not
effective and questioned how often clients were accessing the resources they provided.
Volunteers reported that they were not trained on how to help clients understand and use the
resources that are offered. The interviews with volunteers and observations showed that they
would benefit from training in order to be and feel more effective. The observations also showed
a need to revise the resource prescriptions so that they are more readable.
In order to learn more about how clients understand and use resource prescriptions
provided by volunteers, information was collected from clients using a four-item demographic
questionnaire (see Appendix C) and brief interviews based on the “Toolkit for Making Written
Material Clear and Effective” produced by CMS (McGee & McGee & Evers Consulting, Inc.,
2010). Participants were found through convenience sampling at The Wellness Bus and at the
Fourth Street Clinic. As recommended in the Toolkit, clients were shown an example of a
printed resource prescription during the interview. Interviews were done in English or Spanish,
as appropriate. Of note, two clients declined to participate in the interviews, citing limited
proficiency in English or Spanish.
Questions from the interview addressed the readability of the sites’ resource
prescriptions, clients’ preferred method for receiving resource information, and the likelihood of
using the resource prescription. Data collection also included observation of the client using the
resource prescription to find a resource and to locate specific information (i.e., phone number,
address). The majority of the clients interviewed required cueing or additional time to find
resource information or could not find it at all. Results from the interviews showed that clients
generally felt that the resource prescriptions were difficult to read and use (see Table 1). This
indicated that LHL can impede clients’ ability to access resources. The majority of clients
reported that they preferred receiving resource information by a volunteer talking to them about
the information. The second most preferred method was receiving handouts with resource
information.
Program Details
C2H recruits students who are pursuing a career in healthcare. After being accepted
as a volunteer, students participate in C2H training. Therefore, no additional recruitment is
necessary for participation in the proposed health literacy training module. The C2H director
will designate volunteers who will revise the Premade Resource Prescription packet. These
volunteers will implement the changes to the resource packet, referring to the C2H health
literacy toolkit and with guidance and approval from relevant C2H administration.
In the training module, volunteers will learn about health literacy by viewing an
informational PowerPoint and watching instructional videos of the importance of health
literacy and will be introduced to strategies that can be used when providing resource
prescriptions to clients with LHL. Strategies that will be taught include the teach-back
method, the show-me method, using plain language, and using visuals to facilitate
understanding. These strategies will be clearly explained and taught in the training module.
In order to evaluate the effectiveness of the program, the C2H director will conduct
mid-semester check-ins to assess volunteers’ carryover of the health literacy training. The
C2H director will utilize a feedback form to facilitate this conversation.
The rate that clients are accessing resources will also be evaluated to see if the
program increases resource access. Pre-program and post-program semesters will be
compared by site leaders, utilizing the C2H database where volunteers document whether
clients accessed resources that were provided to them. The semester before the program is
in place and the semester after will be compared.
Goals
● Goal 1: C2H volunteers will have improved skills for addressing LHL during interactions
with clients.
Objectives:
○ All C2H volunteers will participate in an online training module about strategies to
use with clients with LHL within their first week of volunteer training.
○ All C2H volunteers will receive at least a 75% pass rate on the health literacy
training quiz.
● Goal 2: C2H volunteers/staff will have resources to refer to in order to increase the
readability of written materials.
Objectives:
○ Within 6 months, a meeting will be held that includes the C2H director, the
Information Chair, Associate Director of C2H, Faculty Advisor for C2H, and the
Staff Development Educator with University of Utah Health Care to assess the
Fourth Street Clinic Premade Resource Prescription packet and to consider the
need for revision based on health literacy principles.
○ Within 3 months of assessing the Fourth Street Clinic Premade Resource
Prescription packet, a C2H Fourth Street Volunteer or AmeriCorps member will
implement at least 3 changes to the packet.
● Goal 3: Increase the rate that C2H clients access resources.
○ At the mid-semester check-in, data pulled from the C2H database will show a 5%
increase in clients accessing resources provided by volunteers as compared to
the beginning of the first semester that the program is in place.
○ At the end of the first semester that the program is implemented, data pulled from
the C2H database will show a 10% increase in clients accessing resources
provided by volunteers as compared to the beginning of the semester.
Potential Problems and Solutions
One problem that may arise following the roll-out of the program is having a lack
of volunteer follow through on implementing strategies from the training module during
their interactions with clients. Another potential problem involves ensuring that there is a
reliable way to track if volunteers feel effective in their role of using strategies to provide
information about resources to clients with LHL. In order to address these potential
problems, questions related to the health literacy training module will be included on a
feedback form that will be completed by volunteers at a mid-semester reflection
meeting. On this form, volunteers will report if and how strategies are being used at the
sites. Volunteers can also provide feedback on whether or not participating in the
training module has helped them to feel more effective in their role. Information gathered
from the form will also allow C2H to measure whether the program objectives are being
met.
Another problem that may arise is that making changes to the Fourth Street Clinic
Premade Resource Prescription packet may seem to be an overwhelming project. To minimize
this issue, C2H will be provided with a health literacy toolkit specific to its needs and mission. It
will contain information about foundational principles of health literacy that can be referred to in
order to improve the readability of the resource prescriptions. Having a summary of health
literacy principles and access to more sources for addressing LHL will make revising printed
materials feel more do-able.
Another potential problem that may arise is if volunteers do not own an electronic device
that can access the internet. If this is the case, volunteers can check out a device from the
university library or go to the local public library to participate in the online training.
Personnel, Resources, and Sustainability of the Program
In order to successfully implement this program, it will be important to involve relevant
stakeholders and multiple sources of health literacy information and strategies. The C2H
director should attend all meetings and be involved in evaluating the effectiveness of the
program. Relevant parties will work collaboratively to assess the readability of the Premade
Resource Prescription packet and to revise it. People who should attend meetings related to
revising the resource packet include the Information Chair of C2H, Associate Director of C2H,
Faculty Advisor for C2H, and Staff Development Educator with University of Utah Health Care.
Veteran C2H volunteers and AmeriCorps volunteers working with C2H will assist in the
sustainability and implementation of the program. New volunteers will also assist as they apply
the strategies taught.
To sustain the program, the two platforms where the video training module will be
uploaded will need to be maintained. These platforms are the online Canvas course and the
C2H YouTube channel. A meeting room in the C2H shared office building will be required for
C2H administrators and others to meet and collaborate regarding the implementation of the
training and revisions to the Premade Resource Prescription packet. These individuals will also
meet annually to address health literacy in C2H approaches and resource prescriptions. A
printer will be necessary to print the packet and access to a copier will be required to have
enough packets for dissemination to clients. Volunteers will need access to an electronic device
that accesses the internet in order to participate in the online training module. Software will be
necessary in order to create a revised Premade Resource Prescription packet.
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 Budget

Budget Item Cost

Space (e.g., rent or reservation fees)
Canvas, YouTube No cost
Meeting Space No cost
Supplies (e.g., materials, printing costs)
Printer In-kind
($250)
Printed materials/year (5 pages in a resource $350
handout x 1000 copies/ x7 cents per copy)
Equipment (e.g., tablets, computers)
Electronic device that can access the internet In-kind
($120)
Software capable of revising printed materials In-kind
($48)
Marketing (e.g., flyers, advertising)
Recruitment of volunteers N/A
Personnel (e.g., salary with % time/effort, hourly wage,
benefits, consultant fees)
C2H Program Director 20 hours/semester x $1,800
$30/hr x 3 semesters

Total $2,568
In-kind donations -$418
Total Requested $2,150
 Budget Justification

Budget Item Cost Rationale

Space (e.g., rent or reservation fees)
Canvas, YouTube
Meeting Space
Supplies (e.g., materials, printing costs)
Printer
Printed materials/year (5 pages in a resource
handout x 1000 copies/ x7 cents per copy)
Equipment (e.g., tablets, computers)
Electronic device that can access the internet
Software capable of revising printed materials
Marketing (e.g., flyers, advertising)
Recruitment of volunteers
Personnel (e.g., salary with % time/effort, hourly wage, benefits, consultant fees)
C2H Program Director 20 hours/semester x
$30/hr x 3 semesters
Total
In-kind donations
Total Requested
No cost Training is completed online. No paid
subscription required.
No cost Provided at no charge by the clinic when
needed.
In-kind Newly designed and/or revised resource
($250) handouts will be printed for volunteers to
$350 provide clients with.
In-kind The C2H director needs an electronic
($120) device that can access the internet in
order to send the training to volunteers.
The volunteers who make revisions to
the resource prescriptions also need an
electronic device that can access the
internet.
In-kind Software is needed for designing and
($48) revising the resource handouts given to
clients.
N/A Not an essential component because
training is provided for volunteers who
have already been recruited.
$1,800 C2H Program Director will spend time in
meetings with the College of Health
Graphic Designer and Information Chair,
and in reflection meetings with site
leaders. They will also spend time
sending training module information to
site leaders/volunteers.
$2,568
-$418
$2,150
Table 1:

Coded Responses to Questions Asked to Clients at the Fourth Street Clinic and The Wellness
Bus

What do you think of this pamphlet/email? You said this pamphlet/email is ____. Would
you show me which parts are ____?

Frequency of Response
Response

4 “Very difficult to read”

5 “I can’t even see everything”; need glasses

8 Small letters

3 Sloppy

3 Crammed

2 Blurry

2 Too many paragraphs

3 Poor photocopy, “background letters are distracting”

3 Confusing

1 Unable to read font due to dyslexia

If we were looking for a (clothing/food/etc.) resource, can you tell me where we could
find it in the pamphlet and where we could find the address/phone
number/website/hours of operation?

Frequency of Response
Response

7 Able to find information with ease

10 Able to find information with increased time and/or cueing

5 Unable to find information

If someone handed this to you, how likely would you be to look at it and use it when
you leave?

Frequency of Response
Response

3 Not likely

2 Maybe

8 Likely
 What do you think is an effective way of giving resources to people like you who come
here?

Frequency of Response
Response

4 Paper

7 Talking

1 Hyperlink

1 QR Code

1 Text

1 Email

2 Illustrations/photos/graphics x2

2 2-1-1 phone number

3 Bigger font

2 Make headings more noticeable

2 More bullet points instead of paragraphs

4 Change to a smaller packet (pamphlet/small book)

2 Brief

1 Highlight what resources need appointments vs. walk-ins, and

which ones require an ID

Note. Clients’ responses to interview questions regarding the Fourth Street Clinic and The
Wellness Bus resource prescriptions were coded based on themes related to readability of the
resource prescription, clients’ preferred method for receiving resource information, and the
likelihood of using the resource prescription after leaving the site.
 Appendix A

Health Literacy Data Maps

Figure 1

Figure A1. Health literacy scores from health-literacy specific assessments administered by the
National Assessment of Adult Literacy (NAAL). Below basic health literacy is defined as “no
more than the most simple and concrete literacy skills.” These skills range from having no
literacy in English to being able to perform simple tasks. Examples of simple tasks include being
able to locate information in brief paragraphs but not reading or understanding the information
(Kutner et al., 2006). The Health Literacy Data Maps were created by the University of North
Carolina at Chapel Hill (UNC-Chapel Hill, 2014).
Figure 2

Figure A2. Scores from the health literacy assessments administered by the NAAL throughout
the United States were divided into quartiles in order to draw comparisons in health literacy
between populations in the United States (UNC-Chapel Hill, 2014).
 Appendix B

Figure 1
Figure B1. Sample Resource Prescription, in English and in Spanish.
Figure 2
Figure B2. Premade Resource Prescription packet at the Fourth Street Clinic.
 Appendix C

Demographic Data of Connect2Health Clients at The Wellness Bus and Fourth Street Clinic

Figure C. Clients utilizing The Wellness Bus or the Fourth Street Clinic services completed a
four-item demographic questionnaire.
*=a single respondent appeared to be confused while filling out demographic questions; this
respondent was >12-17 years old, appearing to be between 45 and 64 years old.
**=a single respondent appeared to be confused while filling out demographic questions; this
respondent did not speak English as a first language.