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Service Delivery Innovation Profile

Health Literacy Tutoring Program Enhances Access to Culturally AppropriateĀ Education, Increases Knowledge and Skills Among Health Profession Students and Elder Immigrants

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The Project SHINE (Students Helping in Naturalization of Elders)-MetLife Foundation Health Literacy Initiative builds partnerships between universities and community-based organizations to address the health literacy needs of elder immigrants and refugees. By using health profession students to deliver a culturally appropriate health literacy curriculum in the community, the program aims to increase the ability of elder immigrants to communicate with health care providers and access health care while also increasing the cultural competency of future health care professionals. The program has enhanced access to culturally appropriate health education and increased knowledge and skills among participating students and elders.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on program usage, comparisons of pre- and post-implementation survey results from student participants, and anecdotal feedback from elders and students.
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Developing Organizations

MetLife Foundation; Temple University Center for Intergenerational Learning
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Date First Implemented

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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Immigrants; Age > Senior adult (65-79 years)end pp

Problem Addressed

The many elder immigrants who live in the United States face a number of challenges in accessing health care, including cultural and linguistic barriers for those with limited English proficiency. Cross-cultural education for current and future providers can help to alleviate these barriers, but such education is seldom available.
  • A large, growing population of elder immigrants: Between 1990 and 2000, the foreign-born population in the United States increased by 57 percent, from 19 million to 31 million. Of the current 37.7 million foreign-born individuals, 23 percent are older than 55 years.1 By 2050, the ethnic minority population is projected to comprise more than 35 percent of the elderly population.2
  • Many linguistic and cultural barriers to care: More than 75 percent of immigrants are from Latin America and Asia,1 and the majority of elder immigrants do not speak English as their first language. Limited English proficiency makes it difficult to communicate with health care providers, understand and engage in prevention-related activities, and comply with treatment regimens. Furthermore, elder immigrants may find it difficult to understand the American health system and may wish to continue the cultural practices and health beliefs of their native countries.2,3
  • Need for provider education: Providers often lack knowledge about the health care practices and beliefs of immigrant groups, thus resulting in a perceived disregard for their traditions and preferences. Research suggests that cross-cultural education and experiences can be an important tool in improving current and future providers' understanding of the cultural aspects of health care and in reducing health disparities.4 Yet, such education and experiences are often not available.

What They Did

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Description of the Innovative Activity

The Health Literacy Initiative builds partnerships between universities and community-based organizations to address the health literacy needs of elder immigrants and refugees. The program uses health profession students to deliver a culturally appropriate health literacy curriculum in the community, aiming to increase the ability of elder immigrants to access health care while also increasing the cultural competency of future health care professionals. Key elements of the program include the following:
  • University/community partnerships: Currently, academic institutions in four cities partner with community-based organizations that serve elder immigrants and refugees. Examples of these organizations include senior centers, churches, temples, clinics, ethnic-specific senior housing, and English as a Second Language (ESL) classrooms. Each college or university recruits health profession students (including students enrolled in nursing, physical therapy, occupational therapy, gerontology, pharmacology, therapeutic recreation, and medical interpretation programs) to provide health literacy tutoring to elder immigrants at a partnering community-based organization.
  • Training for student tutors: Student tutors participate in a preservice orientation that introduces them to the experiences of elder immigrants in the health care system.
  • Onsite tutoring for elder immigrants: Students provide onsite health literacy tutoring to elder immigrants at community-based organizations. The nature of the tutoring relationship varies from site to site. For example, at one participating refugee center, students first observe ESL classes before assisting existing ESL teachers with implementing health literacy lessons into the classroom. At another site, students meet individually with elders to interview them about their experiences navigating the health care system.
  • Health literacy curriculum: When working with elders, students use a comprehensive ESL health literacy curriculum developed specifically for the program. The curriculum is culturally appropriate, using narratives and images that are drawn from and reflect the shared experience of elder immigrants. (For example, a lesson on stress management includes the story of an immigrant from China who struggles with isolation and loneliness after an injury.) The curriculum consists of five units, each offering health-related content as well as listening, discussion, reading, and writing activities. Student tutors pick and choose from among the lessons, tailoring them to meet the needs and interests of the elder learners. The five units include the following:
    • The doctor's office: This unit helps patients learn to make appointments, describe symptoms, and understand and communicate their health history.
    • The hospital: These lessons cover the emergency department and operating room and review how to take charge while receiving care in the hospital.
    • Managing illness: This unit provides information on managing several chronic conditions, including diabetes, high blood pressure, and heart attack/stroke.
    • Healthy aging: These lessons cover proper nutrition, exercise, and stress management.
    • Taking medications: This unit covers managing and taking medications safely, as well as alternative medicine.
  • Other health literacy activities: Participating students also serve as representatives of the Health Literacy Initiative at health fairs, health education workshops, and community health screenings, providing ESL support and health literacy information to attendees.

Context of the Innovation

Founded in 1985, Project SHINE is a national service learning program that supports a broad and diverse group of college students in building relationships with elderly immigrants and refugees through language, literacy, and citizenship tutoring. The program is run through Temple University's Center for Intergenerational Learning, a national resource for intergenerational programs dedicated to strengthening communities by bringing generations together to address the needs of individuals and families. Project SHINE's Health Literacy Initiative emerged as a result of an overall needs assessment (see Planning and Developing Process below) conducted through the national Project SHINE consortium, a group of 18 higher-education institutions in 14 cities that are replicating the Project SHINE model. The needs assessment revealed a significant concern among elder immigrants about their inability to access and navigate the health care system due to language and cultural barriers. The Health Literacy Initiative launched in 2003 to further research and address this concern.

Did It Work?

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The program has enhanced access to culturally appropriate health education and increased knowledge and skills among participating students and elders.
  • Many students trained, elders served: From 2005 to 2007, the program trained 1,025 health profession students on how to provide ESL health education and services to elder immigrants and refugees. Approximately 460 elders participated in health literacy tutoring sessions during this time period. In the absence of this program, it is unlikely that these students or elders would have been able to access such services.
  • Increased knowledge among students: Surveys of student tutors before and after participating (321 surveys before, 221 afterward) suggest that the program increased knowledge on how to more effectively communicate with elder immigrants. Mean ratings of health communication knowledge were 0.44 points higher after completing the program (scores represent the mean rating across seven items, each ranked on a four-point scale). The largest improvements in knowledge occurred in the following areas: how to work with an interpreter, cultural competence, and health communication issues facing older immigrants. In addition, anecdotal feedback from participating students suggest that they have become more aware of how to effectively communicate with non–English-speaking patients.
  • Increased knowledge among elders: Anecdotal feedback from participating elders suggest that the program made them more aware of how to navigate the American health care system. Some also report increased knowledge of their rights and responsibilities as a patient.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on program usage, comparisons of pre- and post-implementation survey results from student participants, and anecdotal feedback from elders and students.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Conducting consortium-wide needs assessment: Each of the 18 colleges and universities in the Project SHINE consortium held a focus group of immigrant elders to identify their core motivations for learning English. The focus groups revealed that older immigrants wanted to access and navigate the health care system with self-efficacy and independence but believed they could not due to language barriers.
  • Obtaining funding: Project SHINE sought and received a grant from the MetLife Foundation to further research and address disparities in health literacy among elder immigrants.
  • Conducting targeted needs assessment: Project SHINE conducted a health literacy needs assessment of elder immigrants in Philadelphia, PA, and San Jose, CA. The program held 10 focus groups with 84 participants who were asked to take part in a discussion and complete a checklist identifying health topics of interest to be addressed in an ESL class. In addition, the program conducted 17 individual interviews to further probe the concerns expressed in the focus groups and to garner immigrants' personal stories and experiences.
  • Developing curriculum: Using the information gathered during the needs assessment, project developers collaborated with professional ESL teachers to develop a health literacy curriculum. The curriculum incorporates the personal narratives and issues raised by focus group participants. For instance, the curriculum includes a lesson on making medical appointments, as focus group participants commented that communicating with receptionists and navigating complicated automated phone menus is difficult for those with limited English proficiency.
  • Piloting and revising curriculum: In the Health Literacy Initiative's second year, the project piloted the curriculum at multiple Project SHINE consortium sites around the country. Feedback from participants led developers to simplify the content to make it more user-friendly.

Resources Used and Skills Needed

  • Staffing: Project SHINE employs one project manager who coordinates the Health Literacy Initiative across all participating sites. Each local site has one or more health profession faculty members and one staff representative from a partnering community-based organization who implement the program. The majority of direct services are provided by students, who receive service-learning credits for their participation.
  • Costs: The project operates on an annual budget of $150,000.
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Funding Sources

MetLife Foundation
The MetLife Foundation provides annual grant funding to support program operations.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Build relationships early: Establish connections with a network of interested stakeholders early on in the development process. Bringing together institutions and organizations with differing areas of expertise can help to more thoroughly address the needs of the target community.
  • Value expertise of community-based organizations: Community-based organizations have a deep knowledge of the community’s needs and strengths; value and learn from their experience as experts in the field.
  • Emphasize strong campus–community partnerships: Ensure that all partnerships between universities and community-based organizations are mutually beneficial and grounded in a shared vision of service.

Sustaining This Innovation

  • Always think broadly: To diversify funding options, identify multiple approaches and objectives for each program. Project SHINE designed the Health Literacy Initiative to serve as both a health literacy tutoring program for elder immigrants and a service learning program for health profession students.
  • Remember the bigger picture: Most elder immigrants seek the ability to take part in American society as full, self-sufficient participants. Keep this core principle in mind when implementing interventions for the community.

More Information

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Contact the Innovator

Patience Lehrman
National Director, Project SHINE
Intergenerational Center
Temple University
1700 N. Broad Street, 4th Floor
Philadelphia, PA 19122
Phone: (215) 204-3212
Fax: (215) 204-3195

Innovator Disclosures

Ms. Lehrman has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

More information on the Health Literacy Initiative, including the health literacy ESL curriculum, can be found on the Project SHINE Web site, at


1 United States Census Bureau. 2006-2008 American community survey 3-year estimates. Available at:
2 Gordon D, Yoshida H, Hikoyeda N, et al. Patient listening: health communication needs of older immigrants. Temple University Center for Intergenerational Learning. 2004. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Plawecki HM. The elderly immigrant: an isolated experience. J Gerontol Nurs. 2000;26(2):6-7. [PubMed]
4 Institute of Medicine: Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Health Care. 2002. Available at:
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 11, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 12, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.