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The Health Fluency Project

How two Harvard students are increasing the health literacy and communication skills of non-native English speakers to improve health outcomes

By Beier Nelson Student, Harvard College and Aditya Tummala Student, Harvard College 

public health staff discussing cultural and language barriers


More than 25 million people in the United States, or 8 percent of the nation’s population, have limited English proficiency (LEP), meaning that they do not speak English as their primary language and have a limited ability to read, write, speak, and understand English. Individuals with such language barriers suffer substantially worse health outcomes than their fluent counterparts, including higher rates of misdiagnosis, lower treatment adherence, and longer hospital admissions, resulting in overall lower confidence and satisfaction in the healthcare system.

For patients and providers to understand and communicate with each other more effectively, we must teach healthcare providers how to be better communicators and empower LEP communities with the skills they need to confidently navigate the healthcare system.

The latter, precisely, is our goal with the Health Fluency Project.

The Stories Behind the Health Fluency Project

We are undergraduates at Harvard College and cofounders of this student-led initiative. Our relationship as cofounders is not limited by academic formalities. We are classmates, roommates, and the closest of friends, and it was through our chats over hurried meals in the dining hall, conversations at the pool table, and deep late-night discussions in our rooms that the core of this project developed.

Personal stories provided inspiration for action. We asked each other: What are you passionate about? How do you want to make an impact on something you would like to change?

Here are our personal perspectives.

Aditya: Growing up in small-town Brookings, S.D., I was familiar with health disparities throughout my community. In such a homogenous population, linguistic and cultural differences of those in the minority tend to be overlooked. Access to healthcare infrastructure is sparse, so the focus of care often lies in efficiency: how to serve the majority rather than adapt treatment options to minority populations. 

From pervasive substance abuse among classmates to disparities on the Rosebud and Pine Ridge reservations to my own household’s experiences with miscommunication and frustrations during appointments, I saw the consequences of these barriers firsthand in my own community. Whether due to linguistic or cultural barriers, navigating the healthcare system and effectively communicating with doctors in a rural community were a challenge for my family and countless others like mine. These experiences and stories have shaped me, fueling my dedication to making any difference I can in healthcare access and outcomes — especially for those in LEP communities and communities at the margins of society. 

 

Beier: My mother and I immigrated to the U.S from China when I was 4 years old. I remember my mother’s experiences with healthcare vividly, how she would come home from appointments frustrated, saying things along the lines of, “I don’t feel like my doctor understands me.”

One time, my mother came home with a bleeding ear. She explained that her doctor was being too rough in her exam, but she was uncomfortable alerting the doctor to her discomfort. The continual frustrations built up over time, and my mother eventually told me that she was switching her primary care provider (PCP) to someone who speaks Mandarin—and she has been going to a Mandarin-speaking PCP ever since. These stories inspired me to address health inequities in LEP communities.

Our Project’s Goals

When we launched the Health Fluency Project in late spring 2023, we knew it would not be about implementing what we believed was important, but what the true needs of the community were. It was only through thoroughly understanding our local community and its needs that we would make a difference. So, we listened to the stories of our LEP neighbors. We held meetings with community organizations and healthcare providers. We dove deep into peer-reviewed articles on language barriers in healthcare. We prioritized partnerships and established a strong advisory board to ensure we stay aligned with the needs of our community.
 

This groundwork enabled us to identify some key bottlenecks in the field of health literacy and communication in our area. Our approach was thus segmented into three major campaigns:

  • Enhancing patient-provider communication
  • Disseminating key information
  • Advocating for policy

Enhancing patient-provider communication

Clear communication between patients and healthcare providers is crucial for successful health outcomes. At the heart of our project are free educational workshops, offered in collaboration with local communities and community organizations, for LEP individuals to strengthen their English to better communicate with providers. We have found that one of the largest factors contributing to health outcomes in LEP communities is what happens at the first patient visit. So, rather than offering a broad health literacy workshop, we focus on that first appointment. 
 
Currently, we partner closely with numerous local libraries and ESOL (English for Speakers of Other Languages) centers — Boston Public Library, Cambridge Public Library, and the Rian Immigrant Center are a few examples — in hosting these workshops. We started these workshops in fall 2023, and since then we have offered 10 sessions and have served more than 115 attendees.

Disseminating key information

Workshops can impact only those who are able to access them. Further, planning workshops takes time — time to meet with the partner organizations and, most critically, time to build trust with and understand the unique needs of each community we work with. 
 
Therefore, another core component of the Health Fluency Project is creating, translating, and disseminating pamphlets on key health concepts. Specifically, our pamphlets focus on topics that native English speakers or those well acquainted with the healthcare system may take for granted, such as different types of pain, what to bring to your first appointment, over-the-counter medications, navigating pregnancy care, etc. 
 
These pamphlets are reviewed by members of our physician team and then translated into different languages. Currently, our pamphlets have been translated to Spanish, Mandarin, Haitian, Creole, and Ukrainian, which are the primary languages spoken by the communities we serve, and have reached more than 1,700 individuals across 39 countries.
 

Advocating for policy

Lastly, we believe policy changes are needed to address systemic language inequities in healthcare in the long term. We have worked with local advocacy groups such as MassSpeaks to raise awareness and promote legislation that seeks to improve LEP health outcomes. In October 2023, we became a formal endorsing organization of Massachusetts Bill H.3084, also known as the Language Access and Inclusion Act, which mandates state agencies to “provide timely, culturally competent oral language services” to all LEP individuals who need them.

Receiving Feedback and Learning

Engaging at a deep level with the community you serve is the critical first step when creating an initiative like the Health Fluency Project. In addition, it’s vital to allow the ongoing project to be guided by the needs of the community. This is why we continuously seek feedback and evaluations from everyone involved. 
 
For example, at the end of each workshop, we hold a quick debriefing that lets participants respond to the workshop and ask them to fill out a feedback form. We are also in constant communication with the librarians and ESOL instructors we collaborate with, seeking input on topics to teach as well as advice on teaching style. We seek to improve based on critiques we receive. Similarly, we measure success by positive feedback from the community, including participants. If a participant leaves a workshop having learned skills to communicate with a provider and is feeling more confident in their healthcare journey, that’s a win.

Plans for the Future

We are excited about the future of the Health Fluency Project. We have recently begun to explore opportunities to engage with artificial intelligence (AI) in our work. We are collaborating with a Harvard Medical School startup, Auxhealth, to integrate and evaluate AI tools to improve health communication. For example, in our workshops, we have introduced Auxhealth’s MD&ME, a conversational symptoms checker that enables patients to practice their speaking skills in a medical setting. In a world of technological advances, we are continuously seeking opportunities to utilize technology to improve language equity.
We are also looking to expand our project to other cities and locations around the world. We hope to recruit other passionate students and engage in conversations with a variety of community stakeholders to systematically improve health communication in LEP communities. 

Tips for Aspiring Initiatives

Thinking of starting your own health literacy initiative? Here are some tips we’ve developed from our own experiences.

  • A core pillar of any successful initiative is its community-facing orientation. The needs of the community should drive the initiative’s efforts — not the other way around.
  • It is also important to engage in conversations with a variety of stakeholders. For our initiative, we have had countless conversations with libraries, ESOL centers, community centers, refugee and immigrant assistance centers, physicians, researchers, advocacy groups, government officials, and more.
  • Lastly, for those seeking ideas to start an initiative, we encourage you to ask yourself this question: What are you passionate about, and how do you want to make a difference?

About the Authors

Beier Nelson

Beier Nelson is a student at Harvard College working toward a dual major in molecular and cellular biology and government. Beier is cofounder and executive director of the Health Fluency Project.


Beier Nelson


Aditya Tummala is a student at Harvard College working toward a bachelor’s degree in biomedical engineering and a concurrent master’s degree in bioengineering. Aditya is cofounder and executive director of the Health Fluency Project. 
 
Learn more about the Health Fluency Project at https://www.healthfluencyproject.org/


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