Activities should be simple, enjoyable, and normalize positive behaviors. Audience-centered communication initiatives use the concept of fun, easy, and popular to develop initiatives (Smith, 2007). Fun refers to whether the target audience perceives a positive benefit to the behavior, as well as a lack of negative emotions, such as shame, frustration, and fear. Easy refers to whether the intended audience has the knowledge and skills to perform the behavior successfully. Popular refers to the need for participants to believe that the new behavior is normal and common among other individuals. Health literacy initiatives incorporate this concept into campaigns and information, developing activities that are easy to engage in and understand and acknowledging challenges that occur. One example of this type of initiative is the People Reducing Risk and Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD) intervention to improve diet, exercise, and medication adherence in a senior housing community (Resnick, Shaughnessy, Galik, Scheve, Fitten et al., 2009). The initiative held one-hour sessions over 12 weeks, and included exercise, motivation, and ongoing education, and then reported participants diet, exercise, and medication adherence in logs. The program was successful in getting participants to engage in education and exercise three times per week, and participants demonstrated improved outcomes in blood pressure.
One example of this approach to in financial literacy is making it easier to save for retirement through savings bonds. Starting next year, Americans have the option of using their refunds to purchase U.S. Savings Bonds by simply checking a box on their tax returns, even if the taxpayers do not have bank accounts (Retirement security for American families, n.d.). Another example of could be developing an initiative around obtaining a checking and savings account for new immigrants. The initiative could focus on positive benefits, such as having a central place for your money, checks to use for payments, and (potentially) automatic deposits from the employer, as well as potential gains in savings accounts. In addition, the initiative could reduce negative emotions, such as fear of banks and fear of loss of money, by describing what banking is, the ease of getting a bank account, the types of available bank accounts, and the rules for keeping money safe. To popularize the use of checking and savings accounts, videos of other immigrants similar to the target population could show the video participants indicating the benefits of using the banks. To emphasize the ease of using banks, the video could describe a typical banking process, acknowledging the discomfort the person might have about setting up an account.
Education assists in managing present difficulties and to prevent future problems. Both chronic care education and financial education consist of managing long-term issues or conditions, preventing potential problems, managing problems should they arise, and conducting regular checkups or check-ins about specific health or financial issues. In both cases, lack of knowledge and ability to maintain consistent positive behavior over time leads to poor outcomes, such as poor quality of life exemplified by emergency room visits, days spent at home, problems with credit, and lack of money. Where the chronic care education and the financial education initiatives differ are the outcomes when individuals manage their conditions or finances well. In chronic care, the positive outcome of managing their condition is the lack of deterioration and lack of problems, such as emergency room visits, surgery, or loss of eyesight. In financial education initiatives, the positive outcome is not only a lack of financial deterioration but, potentially, financial progress, such as increasing savings, owning a home, or improving credit.
Two studies examining chronic care self-management found that participants in the treatment group were more likely to do a better job of managing their health care, although the results on quality of life were mixed. In one study on asthma self-management in which the treatment group received four group sessions and six home visits by community health workers, compared with the control groups receipt of educational pamphlets, the treatment group was more likely to have asthma action plans at 3 months, and at 6 months. The treatment group had improved quality of life and improved asthma coping skills, compared with the control group (Martin, et al., 2009). Hostetter (2008) found that patients with coronary failure trained by health care providers about self-management were more likely than those in the control group to check their weight daily and watch for signs and symptoms that indicated worsening of heart failure. However, there were no significant differences in quality of life between the two groups. Finally, in a study implemented in underserved communities, patients in the intervention group, who received tailored and planned education from their clinicians, had significantly lowered blood sugar levels, improvements in non-high-density lipoprotein also known as non-HDL cholesterol levels, and higher frequency of self-monitoring, compared with the control group (Piatt et al., 2006).
Similar results were found in financial literacy evaluations that discussed skill building, including planning (Lyons, Chang, & Scherpf, 2006; Grinstein-Weiss et al., 2007). For example, Lyons, Chang, and Scherpf studied individuals who took part in an eight-session financial education program to train individuals on making spending choices, managing personal finances (e.g., bank accounts), managing credit problems, and planning expenditures. After the counseling sessions, 85% of participants reported improving financial management.
The concept of chronic care is so significant in health education that a field of study dedicated to the Chronic Care Model has emerged. First developed by Wagner in 1999, this model seeks to improve clinician interactions with patients, thereby encouraging patients to be informed, engaged, and active. Clinicians plan, educate, and provide decision making support. The model starts with changing the behavior of the health care team to tailor information for patients and train patients to take care and manage their own condition or conditions. In turn, patients have the necessary information and skills to make decisions and have confidence in making health care decisions later. In a study using the Chronic Care Model in the community, the researchers reported decreases in blood glucose levels, decreases in non-HDL cholesterol, and improvements in diabetes knowledge (Piatt, et al., 2006). One challenge to applying this model to the financial education field is that most individuals do not regularly interact with a trusted and credible financial educator, as people may with a health care provider.
Low health literacy and education levels and barriers to information predict the degree of information seeking. One way that individuals can increase their health literacy is through accessing information pertinent to their health condition, a critical step toward health
decision making and health management. Shieh, McDaniel, and Ke (2009) examined the information-seeking behaviors of pregnant women and found that information needs and information barriers predict womens degree of information seeking. Barriers to information were categorized as psychological (e.g., avoiding health decision making), demographic (e.g., minority status or low health literacy), interpersonal (e.g., lack of a support network), environmental (e.g., lack of libraries or internet services), and information source barriers (e.g., a providers disregard for prenatal health education). Even when controlling for first pregnancy, low-income level, and additional health issues, barriers to information were the most significant predictor of womens information-seeking behavior, not information needs. In a similar study conducted by Shieh, Mays, McDaniel, and Yu (2009), findings suggest that varying health literacy levels may contribute indirectly to health outcomes by affecting other information-seeking behaviors. The authors reported that only 14% of pregnant women with low levels of health literacy frequently used the internet as an information source, compared with 47% of those with high levels of health literacy. As the internet can be a significant source of information, this presents a huge gap for low-income pregnant women in terms of their information-seeking capabilities. At the same time, it is unclear whether individuals become more literate because of the internet or information-seeking individuals are more likely to use the internet.
Two studies found that the barrier of low health literacy was a more relevant predictor of health outcomes than was lower education, although it was still significant. Inadequate health literacy had a strong, independent association with mortality even after adjusting for sociodemographic characteristics, chronic conditions, and physical and mental health (Baker, et al., 2007). In addition, the extent of the association between inadequate health literacy and mortality was similar to the association between low annual income and mortality. Wolf, Gazmararian, and Baker (2005) also reported that individuals with inadequate health literacy had worse physical function and mental health than those with adequate health literacy levels.
At the same time, one study found a strong correlation between lower levels of education and less information seeking (Wiltshire, Roberts, Brown, & Sarto, 2009). Using the 20002001 Household Component of the Community Tracking Study, the authors observed that, compared with individuals with college or higher level education, respondents with less than a high school education were 74% less likely to seek information; high school graduates were 51% less likely, and those with some college were 29% less likely. When adjusting for variables, poverty is significantly associated with information seeking; the poor (those at less than 99% of the federal poverty level) were 13% less likely to seek health information, and the near poor (those at 100 to 199% of the federal poverty level) were 15% less likely, when compared with the non-poor (at 300% or more of the federal poverty level). This study did not examine health literacy, and thus it is unknown whether education level or the health literacy would be a greater barrier to information seeking.
Peer mentoring has been shown to improve outcomes. Peer mentoring may support behavioral change. Examples in the health field include the American Cancer Societys mentor program and Weight Watchers. These peer-mentoring programs are long term, with the expectation that individuals will participate although with the understanding that participation is voluntary. Some dieting behaviors are similar to financial management, such as reducing spending and financial planning, and have been found to be effective in one study. A randomized trial evaluating multiple diet plans, including Weight Watchers, which includes a peer-mentoring component to the program, found statistically significant reductions in weight and cardiovascular risk factors (Dansinger, Gleason, Griffith, Selker, & Schaefer, 2005).
In financial literacy, three studies of IDA programs report that IDA enrollees who participated in peer-mentoring programs had an average monthly net deposit of between $8.19 and $16.53 higher than IDA enrollees who did not participate in peer-mentoring programs or who participated in programs without peer mentoring (Curley, Ssewamala, & Sherraden, 2009; Grinstein-Weiss et al., 2007; Grinstein-Weiss, Yeo, Despard, Casalotti, & Zhan, 2010; Han, 2007). In contrast, the gains in individuals average monthly net deposit based on financial education were quite modest, although still statistically significant (Curley, et al., 2009; Grinstein-Weiss et al., 2007; Grinstein-Weiss, et al., 2010; Han, 2007). Han and Hong (2006) also found positive correlations between the access to peer mentoring and savings, but did not describe the effect on the average monthly net deposit. This finding suggests that peer mentoring, which provides informal support, encouragement, and sharing related to saving in IDAs, may be a valuable method of increasing financial literacy. Of course, one of the limitations of these findings is that they are from studies of IDA programs alone and thus are hindered by self-selection bias.
Communities have trusted sources of health education but often lack a trusted source of financial education. Eighty-five percent of individuals have reported that they have a usual place to go for medical care (HHS, CDC, NCHS, 2010). Almost 70% of participants in the Health Information National Trends Survey stated that they trusted the information from their doctors a lot (HHS, National Cancer Institute [NCI], 2009). Individuals may go to a doctor, nurse, pharmacist, or a public health department. In contrast, communities do not necessarily have trusted sources of financial information, even if the potential exists. Over 60% of banks provide education in the form of pamphlets to unbanked and/or underbanked individuals, although less than 40% perform outreach efforts to engage with the unbanked and/or underbanked and only 25% target marketing to reach unbanked and/or underbanked individuals. Most important, although most banks are aware of significant unbanked or underbanked populations in their area, less than 20% seek to actively market to this population (FDIC, 2009). While banks exist in most but not all communities, common reasons reported for the unbanked to avoid them are a lack of comfort with banks and a lack of trust of banks (FDIC, 2009). Ease and comfort with using a bank may be further hampered by constraints imposed by the bank: Approximately 40% of banks offer limited extended hours and foreign language capabilities. In addition, 25% reject new account applications by those with poor credit histories (FDIC, 2009).
The amount of education participants receive positively correlates with the outcomes. Research on IDA programs has found that the more an individual participated in financial education, the more the individual saved, as defined by individuals average monthly net deposit. Specifically, three studies showed that each additional hour of financial education corresponded to an increase of $0.45 to $1.76 in average monthly net deposit (Curley et al., 2009; Grinstein-Weiss et al., 2007; Han, 2007). Han and Hong (2006) also found positive correlations between the amount of education and savings, but did not describe the effect on the average monthly net deposit. Seeking to identify the specific amount of financial education that led to the best outcomes, Curley et al. found that each additional hour of financial education led to a $1.23 increase in an individuals average monthly net deposit. Each hour between 7 and 12 hours of education led to an increase of $1.76 in individuals average monthly net deposit, but that having more than 12 hours of financial education did not correlate with an additional significant increase. One explanation for increased savings is because financial education may help IDA program participants make better financial decisions and identify opportunities and possible consequences related to saving and asset building (Grinstein-Weiss et al., 2007).
In a similar manner, in health literacy, Counsell et al. (2007) found that ongoing visits over a two-year period between a nurse and individuals 65 and older improved self-management and health outcomes. The visits, which encouraged goal setting and self-care, taught problem-solving skills, and provided education using low-health-literacy materials, led to improved self-management of chronic conditions and fewer emergency room visits. The findings of Ell et al. (2009) did not support these findings, although this may be due the nature of the study and the shorter length of visits. The investigators found that the use of patient navigation (decision support and emotional support provided by a nurse) had no effect on drug adherence, compared with the control group, which received standard written information and information from their clinical providers. This result might reflect that patients with cancer already have significant motivation to adhere to medication regimens, that the written information was sufficient, or it might reflect the similar finding from the IDA research that there is a limit to the amount of education or information a patient needs before there is no impact.