Promoting Community Health and Understanding of Science Topics by Reading Graphic-Style Stories Aloud Together

Abstract

Limited health literacy and access to engaging, relevant, understandable health promotion and disease prevention materials are barriers to achieving and maintaining health. The We-Engage-4-Health program co-created the graphic-style story “Foamy Soap Fun” with community members to reinforce the importance of the primary preventive strategy—handwashing—in limiting spread of COVID-19. Pre/postsurveys were administered, and a modified focus group was conducted to learn community participants’ preferences for reading stories (aloud together and/or silently to themselves), versus reading typical health promotion information sheets. Three themes were identified related to reading the story aloud: increased enthusiasm, increased attentiveness, and improved interpretation skills, vocabulary, and information processing skills. Educational constructs included: empathy with the story’s characters, engagement with previous health experiences, enthusiasm with sharing health information, and explanation of complex health topics. This study supports the value of graphic-style stories in helping communities to better understand the science behind health topics.

Introduction

During the COVD-19 pandemic, public health officials were working diligently to keep people healthy by encouraging social distancing, mask wearing and vaccination. Handwashing resurfaced as a health promotion target as a simple, primary strategy to limit spread of viruses and other “germs.” Unfortunately, public health officials more than often tell people “what” to do and fail to explain “why” these measures are useful. Messaging that clearly communicates “why” is invaluable to engage and empower individuals and communities to choose healthier lifestyles and make positive behavior changes (Alzyood et al., 2020). Important to understanding “why,” is one’s ability to meaningfully discuss and safely clarify confusing scientific information (aka critical skills in health literacy).

To overcome these barriers, We-Engage-4-Health (WE4H) uses graphic-style stories as a foundation for their experiential learning programs targeting middle school aged children through adults living within local urban underserved communities. The program initiates meaningful discussion by inviting attendees to read their stories aloud together as story characters. This offers community members of all backgrounds and abilities a low-stakes way to enter an active learning and questioning process. Importantly, reading graphic-style stories does not depend on prior knowledge of science or health topics. As the characters and storylines were co-designed with representatives of local communities, the story is also expected to be engaging and culturally relevant. While WE4H program attendees often indicated they enjoyed the WE4H story-sharing approach, the team sought to better understand why our adult program participants specifically appreciated WE4H stories over learning the same information in traditional ways (Day, 2009). Using the handwashing-focused Foamy Soap Fun story, three different formats for story sharing were compared: reading the story aloud (vs silently) compared to reading silently a typical information sheet with text and accompanying images.

Research Design

The Story:

The Foamy Soap Fun graphic-style story was co-created by members of an urban community center in Cincinnati’s West End neighborhood and their academic partners (collectively called the WE4H team) through an iterative process starting with story inception through evaluation of the story graphics developed using Comic Life software (plasq, 2005). The reading level of the final story was Grade level 2 (Figure 1; see also We Engage 4 Health, 2021).

Figure 1.

Panel 3 of the Foamy Soap Fun story shared with study participants.

Surveys and Modified Focus Group (MFG):

Both quantitative and qualitative methods were used to answer the research question:

Research Question 1 (RQ1): What is community participants’ preferences for reading graphic-style health promotion stories (aloud together and/or silently to themselves), versus reading typical health promotion information sheets?

One trained community facilitator (both a WE4H team member and a community member) purposefully selected other community members to participate in the study held at a local community center. Before reading the Foamy Soap Fun story aloud together, participants were given a presurvey. The presurvey included four self-constructed knowledge-based questions, two self-efficacy questions and demographic questions. After reading the story, the postsurvey was given. The postsurvey included the same knowledge and self-efficacy questions as the presurvey as well as one open-ended question asking participants to reflect on the story and one question about participants’ interest in future WE4H materials.

After completing the surveys and reading the Foamy Soap Fun story aloud together as the story’s characters, participants discussed their experiences in a MFG (Denzin & Lincoln, 2018). Unlike typical focus groups, the MFG did not follow traditional focus group methodology; rather it was used as both a teaching and data collection tool. The MFG script was designed to better understand participants’ experiences with reading the story aloud together compared to reading it silently or reading the information as instructional text with and without graphics. MFG participants were given all materials, read the story aloud together, and gave feedback about the story. Then, participants were asked to read the story silently to themselves as well as read an information sheet covering the same information silently themselves. A discussion followed to understand material preferences.

Analysis:

MFG data were analyzed using thematic analysis (Denzin & Lincoln, 2018). The digital recording of the MFG was transcribed and a codebook was developed after dwelling with the data recording and notes. The data and codebook were entered into MAXQDA (VERBI Software, 2019) and coded again to inductively generate themes emerging from the data. Three major themes emerged, and educational constructs were identified by two qualified WE4H team members. The qualitative findings were triangulated with the survey data from giving additional meaning and summary to the findings. Findings were confirmed by the community members who serve as WE4H team members, one of which (JH) is also an author on this paper.

Results

Participants completing the presurvey included 12 female and 2 male African American adults. One participant was between the age of 35 and 44 years, 2 were between the ages of 45 and 54 years, 3 were between the ages of 55 and 64 years, and 8 participants were over the age of 65 years. Overall, participants were knowledgeable on the topic of handwashing prior to reading the story with 64% of responses correct on the presurvey. After reading the story, 89% of knowledge question responses were correct (an increase of 25%). Based on the two self-efficacy questions postsurvey, all participants reported that they were confident that they would use soap, water, and apply a rubbing technique to wash their hands and felt that they could explain why washing their hands with soap was important to one’s health. Qualitative data from the postsurvey revealed that all participants enjoyed reading the Foamy Soap Fun story more than the instructional sheet with images. Participants also indicated that they looked forward to reading other information shared in the same format in the future.

Thereafter, 15 female and 2 male African American adults participated in the MFG. At the MFG, a count was conducted, and 13 participants preferred reading the story aloud, 3 participants preferred reading it silently, and 1 participant preferred the information sheet. The following themes emerged from the data:

Theme 1:

Participants used key concepts of the story to empathize with the characters and relate the story to their own life experiences resulting in an increased enthusiasm to read more stories aloud with their own children, family, and/or friends.

Participants said they related to the story’s characters and their personal experiences. One participant said, “I like the shape of their faces because even though it’s kind of a little orange-ish, obviously they’re people of color. So it seems like they’re one of us.” Many participants remarked that they were reminded of their childhood when reading the Foamy Soap Fun story. Participants shared that, as a child, they also had conversations like Jazzy (an approximately 12-year-old girl) and her mom had in the story. They share that their parents or teachers would tell them to wash their hands and brush their teeth; however, they would not always explain “why” they needed to do it. This story was beneficial to them in learning the scientific basis of handwashing which was supported by the increase in knowledge reported in the postsurvey.

After reading the story aloud together, participants also recognized that they were beginning to improve upon their scientific knowledge and were eager to share their new learning with family and friends supporting the self-efficacy responses from the postsurvey. Although the room where the MFG was held was small and the environment was loud, participants were engaged and eager to discuss the stories and share their own stories of their youth. Participants expressed their enjoyment with reading because they liked the characters, colors, and clothes. One participant noted that “It’s fun because the people look different.”

Theme 2:

Participants were more likely to read stories with graphics that reflect their own health experiences.

Both after reading the story aloud together and then silently to themselves, participants were anxious to talk about their handwashing experiences with friends and family. Participants expressed interest in partaking in the hands-on shaving cream activity that was offered to them after the MFG discussion just as the characters had done in the story.

The relatable characters encouraged discussion within the group. Participants saw themselves in the characters having conversations about hygiene with their parents or children. They were excited to talk about similar prior experiences or other health relevant topics. Furthermore, participants reported that they wanted to share this information with their families and friends because they now understood the science behind it. They reported that this story helps them better understand the scientific basis for handwashing so they can teach others about the importance of good handwashing techniques. A participant shared. “You know, we tell our kids to wash their hands with soap and stuff, but we don’t tell our kids why. So, this helps us get the science of it and then we can explain why.”

Theme 3:

Participants learned that reading the story aloud together helps them improve their interpretation skills, vocabulary, and information processing skills so they can better understand challenging health topics.

Although many participants were knowledgeable on the topic of handwashing prior to reading the story, additional understanding of the scientific basis was developed while reading the story aloud together. The graphics in the story helped participants learn difficult science topics while enhancing their empathy. Participants mentioned that although they knew the importance of soap and water, the graphics helped them further their learning about the water loving and oil loving components in handwashing. A participant shared:

I like this illustration where it talks about the water loving part of the shaving cream. Like color versus the oil level are part of the shaving cream and that’s where you get that friction part, so that’s the part that that’s the science that I get [in] these stories.

From these themes, four educational constructs were identified: (a) empathy with the story characters, (b) engagement with previous health experiences, (c) enthusiasm with sharing health information, and (d) the explanation of complex health topics.

Discussion

This study provides support for the value of using graphic-style stories to help people understand important, but confusing, health science topics when participating in community-focused health programming. Our results indicate that reading Foamy Soap Fun aloud as a group was an effective approach for adults to learn and embrace the value of handwashing.

The increase in knowledge scores after reading the story aloud is consistent with a large body of evidence indicating that reading aloud results in better retention of content than reading silently (Hendricks, 2018; MacLeod, 2011). This finding is labeled the production effect because the reader is “producing” the words using active cognitive processes that differ from the process of silent reading (MacLeod et al., 2010; University of Iowa (n.d.)). Studies of the production effect have shown that memory improvement is greatest when the reader reads aloud to him or herself, but the effect does extend (although with less impact) to taking turns reading with someone else so that each person reads part of the content (MacLeod, 2011).

Our results also indicate that reading aloud was a non-threatening and engaging approach to create opportunity for meaningful discussion and personal story sharing among community participants. Participants’ comments indicated that reading the character commentary aloud as a group created a feeling of ownership of the characters’ worries, questions, and experiences which built a sense of empathy. By increasing ownership, reading the story supported the transition to a higher-stakes process of participants sharing their own similar questions, concerns, and experiences in the group interactions that follow the story. An important strength of group story-reading is providing a low-stakes entry into a health science learning experience. Low stakes, meaning that prior knowledge is not required and the story content itself creates a level playing field for discussion. Furthermore, rather than expecting participants to voice questions or concerns about their own health that might seem intrusive or intimidating, the characters take on the burden of having health dilemmas, being unsure about what to do, needing to seek health and science information, and coming up with action plans. A successful story format instills empathy in the participant through its content, demonstrates engagement and generates enthusiasm about the topic, and explains complexities in the health care topic. Creating stories that build these constructs into the foundation are necessary for the understanding of content.

In addition to the Foam Soap story, MFG participants stated there were many other uses of graphic-style stories and specifically suggested additional public health based stories on the topics of dental hygiene and first aid. Once created, stories can be altered to cater to diverse populations who may have different accessibility to resources. For example, they suggested that for people who do not have access to a clean toothbrush and toothpaste, a story could be used to suggest other resources that people could use to maintain proper dental hygiene.

Conclusion

This study offers significant implications for health promotion programming seeking to increase the health knowledge and health literacy of culturally diverse groups of adult participants who might otherwise not want to engage. Indeed, when read aloud together, graphic-style stories are effective in encouraging empathy, promoting engagement among participants, creating enthusiasm for learning and sharing health knowledge in communities and explaining complex health information. Just as important, participants further develop their cognitive skills as they both think deeply about the content and relate it to their own lives.