Using Formative Research to Tailor a Complex Health Literacy Program


Canyon Ranch Institute Life Enhancement Program is an evidence-based, integrative health and health literacy program that demonstrates significant and healthy outcomes across diverse cultures. This session will illustrate how formative research is used to tailor the program to local communities. Tailoring program materials to each community is a health literacy best practice. Canyon Ranch Institute Life Enhancement Program employs extensive formative research in the training of health care professionals and revision of program materials with our partner healthcare provider organizations. Participant guides are tailored through a series of narratives describing people reflective of the local population experiencing healthy changes.


Andrew Pleasant, Ph.D
Senior Director for Health Literacy and Research, Canyon Ranch Institute

Jennifer Cabe, M.A.
Executive Director and Board Member, Canyon Ranch Institute

Ana Lucero-Liu, Ph.D
Program and Evaluation Manager, Canyon Ranch Institute

Canyon Ranch Institute Life Enhancement Program

Canyon Ranch has an integrative approach to health to understand the personal and emotional connections.

They always have a local partner in every community where they work.

For any program: Engage people early and often. You will get to know them. Include their whole lives (integrative health). That will take you upstream from health care to prevention.

Finding Partners for the LEP program: You need an established health care organization to deliver the program to their people.


  1. Match program design and materials to realities of people’s lives
  2. Not a one-size-fits-all approach
  3. Tailered interventions are more likely to create change than non-tailored programs.
  4. Must be evidence-based. That’s why you need formative research.

Food desert example:

Sometimes they have to go into the community. E.g., they convinced a vendor to start selling fruits and vegetables, and said they would buy whatever wasn’t sold in the day. They had to buy back for about a week and a half. Now there are plenty of places to buy produce in that community.

In a community with a lot of unemployment: They partnered with Project HOPE to work on work skills with teens.

Canyon Ranch Institute Life Enhancement Program Process:

  1. They take the core team to Canyon Ranch for a week.
  2. They have individual interviews with audience.
  3. They determine the key concepts and messages: eg. Access to food, recreation, behavioural therapy etc.
  4. They focus on the causes of the problems for each individual.
  5. Then they recruit actual participants. And they engage with the core team weekly to check progress.

Evaluations: post, +3 months, +1 year

Find info, understand, evaluate, communicate, re-assess.

The LEP program takes a 2-sided approach by addressing challenges in both the health system AND the public.

Rather than always using the Plain Language standard of putting the most important message first, they recognize that sometimes people aren’t ready to hear the most important message. Sometimes they need to find a path to their true goal.

Rather than removing complexity, LEP works to make complexity understandable and actionable.

Use narratives: opening situation, a changing situation, a closing situation.

Stories are culture.

A good story:

  • Is understandable
  • Has context and cohesion (story holds together)
  • Has relevance to the listener’s life

So each LEP has a program guide (among other materials) that incorporates a number of unique narratives.

They test the stories with the community.

The core team comes from the participating health organization. Participants are recruited from the patient population.

Research Process

  1. Research to find issues
  2. Find a local person to represent the population
  3. Have one-on-one with members of the core team
  4. Team members report back to one another
  5. Evaluation of the “hand-off” happens onsite and through written feedback and video of the session.

A lot of information is given that is not directly related to the expertise or question of the specific person they’re meeting, but that is relevant to another person on the team.

The research process takes about 3 months.

Core team of 20. Each participant group is 100.




Building Health Literate Organizations: A Guidebook to Achieving Organizational Change

Abrams2_smPresenter: Mary Ann Abrams

Dr. Mary Ann Abrams hosted an informational and engaging session that encouraged organizational change.  She began her discussion with a brief overview of the health literacy field and the immediate need of implementing health literacy principles into organizational structure.  She then moved into describing the 10 Attributes of Health Literate Health Care Organizations; a guide with 9 chapters dedicated to help organizations implement and spread health literacy related improvements.  Dr. Abrams began the discussion of this guide by providing the 3 questions that are asked in every chapter:  1) Why do you need to address health literacy issues in this area? 2) What would success in this area look like? 3) How could one accomplish these successes?

When using the guide, Mary Ann encourages individuals to start with the chapter that would achieve the most organizational support.  She suggests that the guide does not need to be used in chronological order and each chapter can be used as a standalone.  After this description, Mary Ann moved into group activities.  She divided the room into groups to discuss chapters 3-7 and gave specific questions to each group to report on.  Once the groups reconvened, each group reported their responses to their assigned questions.  This interactive discussion led participants to collaborate on shared experiences and resources.

Standards for Equity in Healthcare: An Organizational Self-Assessment Tool


The Task Force on Migrant-friendly and Culturally Competent Healthcare has developed a set of standards aimed at monitoring and measuring equity in health care for immigrants and other vulnerable groups. The Standards for Equity in Healthcare provide opportunity for staff and services to question what they do, why they do it, and whether it can be done better. The Standards is a free self-assessment tool which produces valuable data on your organization’s practices, its strengths as well as its gaps, enabling effective quality improvement. Data is rolled up by country. Your organization’s results are confidential.


Elizabeth Abraham, Vice President, Critical Link International

How do we make sure Health Care is accessible, effectively utilized, that health care staff have the skills and knowledge to deliver care equitably?

We have CLAS standards, but they are only recommendations. Elizabeth’s team developed a tool that organizations can use to measure these factors.

The tool was developed in Europe and uses European terms. Such as “migrant” where in the U.S. we would say “immigrant.”

It was started by the Migrant-Friendly Hospital project involving hospitals in 12 countries in Europe.

Outcomes for the Task Force hospitals:

  1. Whole organizational development
  2. Interpreting/mediation services
  3. Patient education and information
  4. Staff training

The MFH task force was charged to create a framework for measuring and monitoring for continuity.

What constitutes a vulnerable population? Examples:

  1. Migrants/immigrants
  2. Elderly
  3. Homeless
  4. LGBTQ
  5. Disabled
  6. Orphans
  7. Mentally ill
  8. Indigent
  9. Victims of domestic violence
  10. Low-literacy
  11. Low education
  12. Children
  13. Ethnic minorities
  14. People living with AIDS (PLA)
  15. Chronically ill
  16. Sex professionals
  17. People living with addiction
  18. Runaways
  19. Low-income
  20. Veterans
  21. Uninsured
  22. Indigenous people, etc.

The tool was revised after the first pilot test. The second-generation tool is now available for download.

It’s a Free tool: If you submit results to the Task Force, they will show how you compare with other organizations in your country and compared to Canada and some other countries.

Standards for Equity that the tool is designed to measure:

  • Equity in policy
  • Equitable access and utilization
  • Equitalble Quality of Care
  • Equitable Participation
  • Promoting Equity

In 2012, 45 orgs participated in the pilot test. They gave feedback on the tool.

The second pilot was carried out in 16 countries and 54 organizations.

It takes 2-3 meetings to get through the 7 phases of the assessment.

  1. General information
  2. Identify and describe areas of improvement.
  3. Describe an action plan.

This self-assesment tool has not been used in the U.S. You are invited to download the tool and use it. If you think you can get your organization to use and report from the tool, or if you would like more information, contact Elizabeth Abraham at or

See also the handouts for this presentation, which include the Self-Assessment Tool.