Health Literacy On Wheels: Using Formative Evaluation to Guide Implementation

Background:  Interpersonal communication with providers yields more credible and actionable information for patients than any other source, yet it is too rarely addressed in health literacy improvement programs.  Poor interactive health literacy results in low utilization of health services, lack of satisfaction with providers, low rates of compliance with medical orders, and low self-efficacy for health.  Elderly individuals, many of whom suffer chronic illness, and for whom the linkage between health literacy and health status is especially strong, are particularly at risk for several of these negative outcomes. 

Program background:  Health Literacy on Wheels is a project that takes a novel approach to reaching older adults and advancing their health literacy.  By partnering with several community-based organizations across the state, this study seeks to examine a model of health literacy coaching wherein Meals on Wheels (MOW) volunteers work with older adults to improve their ability to interact with health care providers. 

Evaluation Methods and Results:  A team of researchers from the University of Georgia’s Center for Health and Risk Communication conducted formative research with several Georgia MOW programs, volunteers, and clients to assess their suitability for a health literacy training intervention.  Lessons learned from key-informant interviews and ride-along observations, as well as experience to-date with training coaches and recruiting clients, provides program planners with a deeper understanding of MOW programs, volunteers, and clients and provides an evidence base for implementation. Results from key-informant interviews suggest  the MOW population is unstable due to demise, transfers to assisted living, and program funding challenges.  In addition, many clients suffer from moderate to severe hearing, vision, and cognitive impairment that reduces capacity to engage with project materials or to interact with their providers.  Observations during ride-alongs on MOW routes reveal a need to encourage deeper engagement from volunteers who too often drop meals off quickly with only intermittent interaction with their elderly recipients.  One challenge emerging from early stages of program implementation is older adults’ high levels of fear and insecurity that make access by telephone difficult.  Another implementation challenge is the unstable MOW volunteer force for delivering the intervention and the consequent reliance on part-time staff.

Conclusions:  In light of this study, we recommend that community-based programs working with vulnerable elderly adults develop techniques for maintaining contact with those clients; they should not be excluded from health communication programs only because they are harder to reach.  In addition, when health promotion interventions will be delivered by community-based volunteers, it is necessary to evolve train-the-trainer modules that can accommodate rapid turn-over.  

Implications for research and/or practice:  The lessons learned from this research should be of interest to practitioners partnering with various community-based organizations and working with volunteers or other colloborators. The formative evaluation methods employed in this study may differ from the methods typically thought of in health communication research (i.e. focus groups, intercept interviews).  However, the results of direct observation during ride-alongs, and interviews with key program personnel, afford program planners with a better understanding of how MOW programs operate in reality and ultimately increase the chance of success during implementation.