Promoting Health Literacy and Cultural Humility: CBOs and Wraparound Services

Abstract

The COVID-19 pandemic placed demands on community-based organizations (CBOs) to address human needs to promote the health and well-being of diverse communities experiencing high rates of disparities. To enhance the capacity of CBOs in engaging with their communities, we developed webinars on health literacy and cultural humility. The concept that drove the training was wraparound services, with the objective to increase CBOs' skills and knowledge for addressing the needs of the whole person.

The COVID-19 pandemic was harmful and overwhelming for all populations, but it was especially devastating to communities that already experience systemic health disparities.¹ These communities are medically and socially underserved and economically disadvantaged. The infection and death rates were three to six times higher in predominately African American counties compared with predominately White counties.¹ For example, in Louisiana (2020–2022), African American residents made up 72% of the COVID-19 deaths, even though they made up only 32% of the population.¹ The Hispanic populations suffered tremendously because they represent a large share of service and essential workers (employed in industries such as agriculture, construction, and food service) which increased their exposure, thus putting them and their families at an increased risk for contracting COVID-19.¹

Since the start of the COVID-19 pandemic, community-based organizations (CBOs) in underserved communities experienced increased demands to address the health disparities that were exacerbated by the pandemic. These communities had a high representation of ethnic/racial minority groups.² Low health literacy and lack of trust in the system are believed to be some of the many root causes of poor health status and outcomes.³ To reduce racial disparities and improve health outcomes, CBO staff and social service providers must enhance their knowledge and skills in health literacy and cultural humility.³

Background

The Office of the Assistant Secretary for Health/Office of Minority Health: Advancing Health to Enhance Equitable Community Responses to COVID-19 grant is an initiative aiming to improve health literacy and positively affect health outcomes in communities of color. This grant program, which ran from 2021 to 2024, began with a call to action from The Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services (HHS). There were several different organizations with unique roles working on this grant initiative. These entities and organizations included the University of Illinois Chicago, College of Medicine, Office of Health Literacy (UIC-OHL), College of Medicine Rockford Division of Health Research and Evaluation (UI-COMR-HRE), CURA Strategies, and the Health and Human Services Department of the City of Rockford.

The UIC-OHL was established to advance the scientific base of health literacy and workforce development. This office collaborates with county, state, and federal entities to reduce health disparities, promote equitable health outcomes, and prevent chronic illnesses in socioeconomically diverse communities. In response to the challenges posed by the pandemic, the UIC-OHL provided training to health care providers. While training residents and other primary health care providers, the UIC-OHL saw the critical role of CBOs.

CURA Strategies is a bipartisan strategic communications and public affairs agency that aims to transform health care. On this grant, they assisted partner organizations with program design, project management, integrated communications, material development, and graphic design.

The Health and Human Services Department of the City of Rockford is committed to improving the health and well-being of its community. The OMH grant has facilitated the development of community partnerships focused on health literacy and cultural humility, assisting agencies in developing action plans to address health disparities, as well as providing critical training on health literacy to a variety of health care providers.

Low health literacy is a major public health concern.^4–5 The U.S. Department of Education estimates about 130 million people lack proficient literacy and nearly nine out of 10 adults have difficulty using everyday health information found in clinics and retail outlets.^6–7 Low health literacy can lead to adverse health-related outcomes, including low knowledge on how to manage chronic illness and cost—bringing about return visits to clinics and hospitals.

The definition of health literacy was updated in August 2020 with the release the U.S. government's Healthy People 2030 initiative. The update addresses personal health literacy and organizational health literacy and provides the following definitions:

• • Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

• • Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

These definitions are a change from the health literacy definition used in Healthy People 2010 and Healthy People 2020: "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

The new definitions:

• • Emphasize people's ability to use health information rather than just understand it

• • Focus on the ability to make well-informed decisions rather than "appropriate" ones

• • Acknowledge that organizations have a responsibility to address health literacy

• • Incorporate a public health perspective

From a public health perspective, the organizational definition acknowledges that health literacy is connected to health equity. Health equity is the attainment of the highest level of health for all people. We will achieve health equity when everyone has the opportunity to be as healthy as possible.⁸

Cultural humility is also critical to developing strong relationships with disadvantaged communities and building trust. Cultural humility is the practice of self-reflection, one's ability to understand others who are different from us, ability to set aside judgment and engage in active listening and be willing to learn about others.^9–10 Evidence has indicated that health literacy and cultural humility (and cultural competence) need to be considered when working with diverse communities.^11–12

Adverse social factors found in one's community can contribute to poor health outcomes, particularly for individuals/families living in poverty and/or geographic areas isolated from the mainstream.¹³ CBOs are not-for-profit entities designed to promote the health, well-being, and overall functioning of individuals and communities.¹⁴ Health-related CBOs are concerned about the health needs of the community and/or a particular segment of the community (e.g., Hispanic and African American communities, church groups, food pantries, homeless shelters, mental health clinics, well-baby clinics, youth organizations, senior programs, recreational centers, childcare providers, and vaccination clinics). They must be armed with health literacy and cultural humility strategies to effectively engage clients and communities.

During the COVID-19 pandemic, CBOs provided services on many fronts and in various venues. Health care providers were widely discussed and praised in the news media for their actions in response to this public health crisis. Not mentioned as often were the roles CBOs played in the U.S. and even around the globe – addressing insecurity in the provision of vaccine education, sheltering, and in many cases, food due to the negative economic ramifications of the pandemic for the economy and labor market.¹⁵

One of the primary goals of the grant was to offer training to CBOs and increase awareness of the importance of health literacy and cultural humility among primary care providers serving and interacting with predominantly African American and Hispanic residents living in the City of Rockford, a community with over 145,000 residents. In terms of health and well-being, nearly 55% of the city's residents, or 79,605 people, are living in census tracks with the highest social vulnerability index (CDC SVI >75).^16–17 Nearly half of these residents, or more than 38,000, live in areas with a CDC SVI >90.^16–17 At the time the grant was launched in 2022, the county at large had experienced 28,719 cases of COVID-19; however, the distribution among different ethnicities was disproportionate. As of October 1, 2021, Hispanic persons constitute 27% of all COVID-19 cases, approximately 10% higher than their proportion in the general population. However, African Americans were 12% of all cases, which is more in line with the proportion of African Americans in the general population at 12.5%.¹⁸

This article details the training and results of webinars provided to CBOs aimed at increasing knowledge of and the strategies for applying health literacy and cultural humility in their daily work with diverse populations. The concept applied to rationalize the inclusion of CBOs was wraparound services. Wraparound services are a novel approach to health care that offers comprehensive care to individuals by focusing on the patients' needs in various aspects of their lives.¹⁸ Training on using a wraparound service delivery model allows one to have a larger impact on the health and well-being of the patients and community members one serves.^19–23 The purpose of this article is to describe the training of CBOs leaders on health literacy and cultural humility.

Methods

Training of CBOs

Wraparound services were initially developed to address children and families experiencing trauma, instability, and behavioral health challenges. It is important to note that this approach is currently being used to address inequalities in health care.^19,23 Driven by the concept of wraparound services for this intervention, the investigators offered a series of webinar trainings on social determinants of health (SDOH), health equity, health literacy, and cultural humility. The webinars were led by two health scholars and health care practitioners committed to improving health literacy and positively affecting health outcomes in communities of color. These webinars were held virtually and synchronously through the online platform Zoom. Box 1 shows in great detail the outline of the three-hour webinar with the various sections. Additionally, more detail on the topics covered during the training including using frameworks of significant learning are shown in Box 2²⁴.

One implementation webinar was offered, that lasted two hours, in which we reviewed health literacy and cultural humility strategies as well as techniques to optimize adoption and sustainability. We introduced participants to SMARTIE goals to promote the implementation of health literacy strategies. SMARTIE goals are specific, measurable, action-oriented, relevant, time-bound, inclusive, and equitable (SMARTIE).²⁵ Discussion centered around how new ideas and innovations at the organizations one represented were or could be implemented. Community engagement strategies were discussed as well as the importance of building trust (e.g., door-to-door canvassing, sponsoring events in the community such as at local parks and schools). In other words, how does one create a health-literate organization in the agency that addresses the human needs of the clients/consumers? There was additional time set aside by the webinar

Box 1. OUTLINE AND DETAILS OF ROCKFORD READY'S HEALTH LITERACY WEBINAR FOR CBOS

leaders to provide consultation and advice to those who wanted to discuss challenges and opportunities. These were unstructured opportunities to brainstorm opportunities and potential solutions. Those who participated in the 3-hour webinar were invited back to discuss their efforts in implementing their new knowledge and skills during a consultation session.

Participants and Recruitment

Forty-four leaders from various local CBOs were recruited to attend the three-hour interactive online training on health literacy and cultural humility. The team developed materials indicating the topic of the webinar, registration link, and eligibility criteria. The leaders eligible for participation were those working in CBOs within communities of color that were targeted under the grant project. Recruitment materials and announcements were distributed through the grant project's website, email newsletters, mass text campaigns, Facebook communications, and flyers available at CBOs and community health centers in the specific zip codes targeted for the project.

The grant created a task force composed of community leaders and CBO administrators from the targeted zip codes, who aided in recruitment. The grant projects' partnerships and task force members were also responsible for sending out announcements and recruitment materials to their members, specifically targeting CBOs. We also recruited participants from CBOs targeting housing, food insecurity, mental health, health promotion, and overall well-being in the target communities. Lastly, the project partners reached out to local CBOs supporting the health and wellness of residents through phone calls.

Training evaluation methods

A mixed methods approach (quantitative and qualitative) was used to examine the impact of the training and collect data on specific health literacy and cultural humility strategies participants thought they could implement. We

Box 2. TRAINING ON HEALTH LITERACY AND CULTURAL HUMILITY

used a pre-post evaluation design to measure changes in confidence in defining health literacy, SDOH, and ability to identify cultural humility and health literacy strategies. The team identified four survey questions informed by existing validated questionnaires, in addition to other questions.^26–28 Furthermore, participants were asked to complete a pre- and post-knowledge survey, using a Likert-type scale, with questions related to perceived confidence in defining SDOH and health literacy and confidence in identifying health literacy best practices and applying cultural humility strategies. The survey also included open-ended questions asking participants to share the strategies they plan to apply in their daily work and recommendations for improving the webinars.

A Cohen's D value was calculated and reported.²⁷

Results

Forty-four leaders from various local CBOs attended the three-hour interactive synchronous online training on health literacy and cultural humility. Although many CBO leaders registered for the webinars, a much smaller number of staff participated. We believe this attrition was due to work schedule conflicts, workload, and circumstances related to COVID-19. The attendance and survey completion rate for these participants are shown in Table 1. The pre-knowledge survey was sent to all those who registered. 100% of participants completed the pre-knowledge survey for webinar 1, but only 50% completed this survey for webinar 2. Unfortunately, there was also a lower response rate for the post-survey, as indicated in Table 1. For webinar 1, only 43% of attendees completed the survey and 38% for webinar 2. The satisfaction survey also lacked a high survey completion rate with only 46% of attendees completing it for webinar 1 and 31% for webinar 2.

Changes in pre and post knowledge

As indicated by the results outlined in Table 2, the Cohen D value indicates a meaningful change in knowledge from pre to post. The Cohen D values for questions 1–4 (1.30, 1.67, 1.92, and 0.73, respectively) (Table 2) demonstrate that webinar participants gained valuable knowledge and insight because of their attendance. Participants who completed the post-knowledge survey indicated higher confidence in defining SDOH and health literacy and in identifying health literacy strategies and skills to practice cultural humility (see Table 2). When looking at all webinar attendees, the mean response for questions 1–4 were 4.56, 4.89, 4.78, and 4.67 respectively, indicating high confidence in the material that was taught during the webinar. The largest meaningful increase was seen in the participants' confidence in identifying health literacy best practices, which was one of the webinars' main goals—for participants to learn about health literacy best strategies they could apply in their daily work with diverse communities.

Table 1.

ROCKFORD READY HEALTH LITERACY TRAINING CBO WEBINAR DATA^a

Table 2.

ROCKFORD READY HEALTH LITERACY TRAINING WEBINAR DATA COLLECTED FROM PRE- AND POST-KNOWLEDGE SURVEYS FOR THE CBO WEBINARS^a

Satisfaction with the webinars

As Table 3 indicates, participants who completed the satisfaction survey were very satisfied with all aspects of the training. All satisfaction dimensions indicated high rating on a five-point Likert Scale.

Action steps participants identified

Importantly, CBO leaders and staff identified health literacy and cultural humility action steps and strategies to implement in their daily work. Some of the participants identified using the teach-back technique (they had been unaware of such a strategy); breaking information down for participants; being sensitive and mindful of the abilities, culture, and values of the clients they serve; working on putting aside their own biases when working with diverse clients; helping individuals advocate for themselves; and connecting with organizations in the area that serve similar populations. Participants also identified strategies such as revising handouts and materials into plain language and having these handouts available in Spanish.

Participants learned a variety of valuable skills to inform their practice to be more inclusive of those with differential experiences in terms of health literacy. Those strategies include avoiding acronyms, using visual aids, drawing pictures, and using simplified instructions. In addition, CBOs were encouraged to identify measures to assess organizational health literacy attributes. The training emphasized the importance

Table 3.

SATISFACTION SURVEY DATA FROM ROCKFORD READY HEALTH LITERACY WEBINAR FOR CBOS^a

of conveying information orally and in writing using plain language at a 5th-grade reading level. This ensures the information is not overly technical, making it easier to understand. These are examples but not an exhaustive list of the strategies discussed. Participants also expressed that they were not aware of the need to keep language at the 5th-grade level.

Regarding cultural humility, participants identified strategies such as being more mindful of developing trust with clients, refraining from judging clients, practicing active listening, being more empathetic with clients, and understanding their background and the SDOH they experience. Additional cultural humility strategies included valuing the customer, addressing power dynamics, creating consumer advisory councils and boards, and engaging in self-reflection. CBO leaders also identified the need to provide ongoing training on cultural humility and health literacy to all CBO staff and to integrate a culture of learning within the dynamics of their organization. This included having ongoing conversations with staff on health literacy and assessing how to best develop trust with the diverse community residents they serve. Furthermore, participants (100% of whom completed the survey) thought they had acquired important new knowledge and skills and enjoyed the webinar. One participant commented that because of the training, they would "talk more about health and make healthy options available to staff (for example, food, exercise, and breaks)". Another participant spoke about how they would "revise practices to minimize the barriers to accessing our services for clients (e.g., mobile delivery of services, translated/simple materials)."

Table 4.

SATISFACTION SURVEY DATA FROM ROCKFORD READY HEALTH LITERACY IMPLEMENTATION WEBINAR FOR CBOS^a

As stated previously, we offered a two-hour health literacy implementation webinar toward the end of the project. All who attended any of the three-hour introductory health literacy webinars were invited to attend. Those who completed the survey at the end of the implementation webinar indicated high satisfaction levels as shown in Table 4. Overall, participants were highly satisfied with the preparedness and effectiveness of the instructors, the learning objectives, and overall format. In addition to the six quantitative questions asked, participants were asked two qualitative questions: If you intend to adopt a new or change an existing strategy for interacting with community residents or accomplishing the work that you do, what do you intend to do differently? The second question asked was what features of today's webinar did you like best and why? Participants responded with a variety of answers including implementing SMARTIE goals; increasing access to information and events; identifying and combating barriers to being health literate; making health materials easy to understand and accessible; improving task force communication; and "attempt to locate how to disseminate information more to CBO's and community members." For the second question regarding what aspects of the implementation webinar did participants like best and why, few participants answered the question asked, but the two that responded commented on "ways to reach our communities" and "how to keep information flowing about resources."

Discussion

As stated, Covid-19 elevated health disparities and inequities within certain populations, particularly racial and ethnic minority groups. The outcome data demonstrate that participating CBOs greatly benefited from the webinars and post-webinar consultations on cultural humility and health literacy (Tables 1, 2, 3, and 4). The webinars covered new concepts, skills, strategies, and case vignettes to reinforce content.²⁹ In accordance with the literature on CBOs, we find that it is urgent that staff be provided state-of-the-art knowledge and training to improve competencies and outcomes to better serve their clients. The health care enterprise cannot achieve its objectives without assistance from family, social networks, and CBOs. Collaborations between CBOs and the health care enterprise are increasingly common in efforts to address the needs of at-risk populations.³⁰ This approach yields a wraparound, holistic, client-centered approach.³¹

The purpose of this article was to describe the importance of training CBOs. This article indicates that CBOs learned important skills that contribute to addressing health disparities and engaging with communities of color. The training webinars on health literacy, health equity, and cultural humility were effective in helping attendees gain knowledge about strategies they can implement in their daily work with diverse populations. We recognized though that a three-hour webinar and consultancy to continue to address health disparities and promote health equity is insufficient to create long-term impact and/or to create sustainable change. These webinars provided participants with an introduction to foundational concepts and strategies, and thus a deeper discussion and follow-up is needed. This team of webinar leaders was not assigned the task of following up to ascertain whether or not webinar attendees implemented next steps.

Based on the results, health literacy and cultural humility training and consultations created awareness. Engaging in health literacy and cultural humility practices is an ongoing and developmental process and everyone's responsibility. Culturally-prepared training programs are thought to improve knowledge and attitudes.³²

There are numerous benefits in training CBOs. Although our training effort has ended, webinar participants could develop personal health literacy development plans to implement lessons learned. They could work with their organizational leadership to develop strategies to create a health-literate CBO, and they could create and improve agency messaging/signage to improve communications with consumers of their services. In other words, they could become agents of change.³³ Future training could consider advanced discussion about how to overcome challenges participants may experience in implementing action. As indicated by evidence, addressing health literacy, and providing culturally relevant services is one way to help address disparities and promote equity, yet not enough. Policy and system changes are needed. Promoting health literacy starts with all of us.

Limitations

There were limitations of this project. One was that these results are not generalizable given that the number of webinar participants was small and the recruitment process consisted of CBOs who volunteered to participate. Another limitation was the low response rate of CBOs to various surveys. Additionally, the trainers did not have the opportunity to follow-up with webinar participants to ascertain if proposed next steps, in terms of health literacy and cultural humility strategies, were implemented.

Conclusion and future directions

To conclude, more advanced training on topics mentioned in the discussion section and evaluations are needed to discern long-term impact. One time exposure to these strategies may be insufficient. Training health care professionals in these strategies is urgent and an invaluable resource to achieve a comprehensive, holistic approach to care that wraps around the patient/client. Often, CBOs are located at the nexus of the health care enterprise and the community. CBOs are a part of the ecosystem in which the patient functions and offer pivotal resources and services to promote health and well-being.

Given that low health literacy is a major public health problem, there is a need for a comprehensive approach to reduce health disparities by promoting health literacy and cultural humility to achieve health equity. Health care providers cannot do this alone and neither can CBOs. To achieve improved health literacy with cultural humility, providers beyond health care providers must wrap their assets around patients and clients to address human needs.