Addressing Literacy as a SDOH in One Rural Florida County

Highlands is a rural Florida county in the central part of the state known as the Heartland.  Adjacent to Polk, Hardee, Okeechobee, and DeSoto Counties, Highlands is considered a medium-sized county with a population of approximately 105,000 full-time residents, according to the 2020 U.S. Census.  This count does not include seasonal residents, such as winter visitors or migrant labor groups, who significantly increase the population at certain times of the year. 

Highlands County demographic data for 2020, according to FLHealthCharts, show that 79.3% of the population is White, 9.5% Black or African American, with categories for Other Races and Two or More Races totaling 9.6%.  Hispanic or Latino ethnicities comprise 20.4% of the population.  The population is closely divided between men, at 48.5%, and women, at 51.5%. The largest age groups represented in Highlands County are seniors from 65 to 74, at 17%, and those aged 75 to 84, at 13.7%.  Median household income is $43,708 and high school graduation/GED attainment is 37.2%. The main cities in Highlands County are Avon Park to the north, Sebring in the center, and Lake Placid to the south.  Sebring also serves as the county seat. 

The Florida Department of Health in Highlands County (DOH-Highlands) provides all essential public health services to residents and visitors, including primary care, in this designated health professional shortage area. Using 3 locations and a staff of about 55 people, DOH-Highlands offers clinical, WIC, Environmental Health, Immunizations, Epidemiology, and Vital Statistics services.  We also provide school health nurses and a comprehensive dental sealant program in the schools. The website for DOH-Highlands is https://highlands.floridahealth.gov. 

Being able to read is crucial to health. Health literacy is essential for everyone to advocate for and make informed decisions about health care for themselves and their families.  Data from the Florida Department of Education shows that the average 3rd-grade reading level for Highlands County elementary-aged children is 44%.  This practice was designed to improve the reading level of elementary-aged children in Highlands County, thereby building a foundation for future health literacy.  It is hoped that this practice will also encourage adults with reading challenges to improve skills by reading with their children. 

The Florida Department of Health in Highlands County (DOH-Highlands) has been awarded $14,207 in Maternal Child Health and Healthy Babies (MCH) grant funding annually for several years. The Health Education team decided that a new approach to improving health was needed, and so designed a project to address reading as a social determinant of health, adding a health equity lens to this practice.  Since foundational reading skills are built in elementary schools and through programs that encourage reading, it was decided that this practice would purchase and provide books to all children in Highlands County through partnerships with Highlands County schools, the public libraries, Boys and Girls Clubs, Big Brothers Big Sisters, and the Redlands Christian Migrant Association (RCMA) program. Other organizations and schools will be added as this practice develops over time, given continued funding.  

For FY 2021/2022, this practice provided over 5,890 books free to organizations and one elementary school in Highlands County, as listed above.  Unlike books borrowed from the library or school, each child is given a book to take home and keep. It becomes their personal property, thereby fostering a sense of ownership and pride.  As they read and share this book, it is hoped that each child, and the adults around them, will discover the adventure and excitement of reading while building literacy skills that will improve health for a lifetime.  

Objectives for this practice will be realized long-term, but measured annually by monitoring reading level data provided by the Florida Department of Education.  With the benchmark of 44% of elementary students at a 3rd-grade reading level, as measured in 2022, we can continue watching trends for the duration of this practice to gauge outcomes. While it is anticipated that the results from this practice will result in gradual improvement over time, we must be prepared for any negative outcomes and adapt accordingly.  DOH-Highlands' practice coordinator will provide periodic reports to CHD Administration to allow oversight and input from senior leaders.  Grant funds will be monitored quarterly for proper and timely expenditure. Health equity will be a constant consideration during this practice.  As more organizations are added to the list of participants, analysis of the ability of this practice to impact children who speak languages other than English will be documented and included in ongoing analysis. 

This practice has resulted in building new relationships with community partners who might not otherwise have engaged with DOH-Highlands.  It has opened doors to further collaborations and shown us to be an innovative and committed partner.  This practice will also build trust and open communication channels with other county agencies and the public. The broad scope of this practice will allow it to reach children and families from all socioeconomic levels and cultural groups, thereby fostering health equity.

The target population for this practice is the estimated 5,442 elementary-aged children in Highlands County.  Reaching the majority of this population requires building a partnership with the Highlands County school system and local agencies or organizations that serve the needs of these children. In the first year of this practice, books were distributed as follows: 346 to the public libraries; 554 within the DOH-Highlands primary care clinic and dental sealant program; 234 to the WIC program; 1176 to Big Brothers Big Sisters of Sebring; 1201 to the Boys and Girls Clubs of Sebring; 615 to RCMA Highlands; 629 to Avon Elementary; and, 1135 through various outreach events.  Since we are not able not track how many children each agency reaches, and assuming there are duplicates, we decided to use the number of elementary students as our goal.  With that objective in mind, we have reached at least 13% of our target population in the first year.  With the anticipated increase of 4 more participating schools for FY 2022/2023, we expect to increase that reach to at least 50% or higher during the second year of the practice. We will also implement better tracking processes to definitively measure the reach of each agency and incorporate that into our data for more accurate analysis going forward.

This practice is driven by the need to increase health literacy in Highlands County.  Currently, only 44% of elementary-aged students in Highlands County read at a 3rd-grade level, which may be directly related to the low rate of adult literacy in the county.  Data from the National Center for Education Statistics PIACC show that only 34% of adults in Highlands County read at level 3, indicating the ability to process more complex text and materials.  If parents are challenged in reading, they will not be able to help their children learn. Reading is only part of the standard school curriculum, so additional efforts must be made to improve this skill.  In the past, tutoring and intensive reading classes have been offered, but some parents may not be able to take advantage of these services, especially if they involve cost or after-school attendance.

Highlands County has a large Hispanic population, including that of migrant labor families who come each year to work in our agricultural industry.  Because of this, language barriers may hinder the ability to read and understand English-language materials.  In some families, parents speak only Spanish and the children become interpreters.  Some of these children are still learning English and struggle to assimilate in school.  For this reason, our practice has incorporated as many Spanish-language and bilingual books as possible.  In fact, when teachers at the local elementary school were asked to choose books for their students, some of the books were available in both languages, so they were able to provide Spanish versions for those students who needed them.  Books for the other agencies were purchased in bilingual versions, as well, such as a bilingual version of The Cat in the Hat. Should any group express interest in books in other languages, the practice coordinator will search for vendors to fill that request.   

In the first fiscal year of this practice (FY 2021/2022), we were able to partner with Avon Elementary in Avon Park as a pilot project. This project was vetted and approved by school administration. Teachers in all grades were then asked to pick books from the First Book Marketplace website to give to their students, keeping cost as a consideration.  First Book Marketplace is a non-profit organization that receives book donations from major publishers, like Disney, and sells books at a reduced price. Often, cartons of books are free if you pay the shipping cost.  For example, fifth grade teachers chose the Percy Jackson Demigod Collection, a book containing 3 stories by author Rick Riordan. On First Book Marketplace, the books were available free in cartons of 12 at a shipping cost of $7.20 per carton, making the cost per book $0.60.  Suggested retail price for this book is $19.99 each.  The 190 fifth graders were each given a very nice book for a total cost to the practice of $108.00. 

Currently, there are 9 elementary schools in Highlands County with a total of 5,442 students for an average of 605 students per school.  Third-grade reading levels for these schools range from a low of 36% at Fred Wild Elementary to 63% at Sun 'n' Lake Elementary.  This practice will focus on those schools with the lowest reading level scores first and then move through the list, as funding allows. We will repeat the project at Avon Elementary to include that 13%. 

While we cannot say if it is new to public health, this practice represents an innovative way to encourage reading and promote literacy. Healthy People 2030 has a focus area of Health Equity: Out-of-School-Time Academic Programs - Reading Focused.  This was recommended by the Community Preventive Services Task Force as a way to improve reading achievement, focused on students from kindergarten through 3rd grade who are either low-achieving or at-risk of low achievement in reading.  While this CPSTF program involves tutoring or remedial classes, our practice allows parents and children to work on reading skills at home, as time allows, with books that belong only to them and with subject matter that may encourage interest in reading for pleasure.  If children read for pleasure, their skills will develop accordingly, with resulting improvement in future performance. 

The ultimate goal of this practice is to improve health literacy in Highlands County.  To gauge the impact of this practice, we have chosen the benchmark of 44% of elementary-aged students at a 3rd-grade reading level, as measured by the Florida Department of Education for 2022. It is expected that consistent annual improvement in this statistic should result in higher overall literacy in Highlands County over time.  To implement this change, DOH-Highlands has initiated this book give-away to local children, with the objective to instill a lifelong love of reading and resultant improved literacy so more residents can make informed health care decisions for themselves and their families in the future. 

Implementation of this practice involved reviewing current grant-funded health improvement projects for effectiveness and redirecting some of those monies to this project.  Once we established funding, a cost-effective vendor was needed to make purchasing appropriate books practical.  First Book Marketplace is a non-profit organization that offers books and other resources at low cost. In fact, some books only require payment of shipping costs for each multiple-book carton.  This dramatically increases the buying power of our grant monies. Once we had a place to purchase books, a list of organizations that would be interested in taking books to give out to their clients was developed through outreach and practice promotion.  All books are labeled with information about the purpose of the practice and the grant source. 

This practice was initiated in September 2021 with $14,207 in Maternal and Child Health (MCH) grant funding and will continue with level funding for FY 2022/2023.  There were no start-up costs, but the practice coordinator made an initial book order during December 2021 in the amount of $1,309.60 to initiate the practice. A second book order was processed in May 2022, with distribution to Avon Elementary and other partners, as enumerated above. Should DOH-Highlands be fortunate enough to receive this grant funding past FY 2022/2023, we expect to continue building partnerships and connections to increase book distribution to local elementary schools and interested organizations. With one elementary school already part of this practice, from the 9 in Highlands County, we hope to add at least 4 schools each of the next 2 grant cycles until all students have received at least 1 book.  Stakeholders for this practice include Highlands County elementary schools, Boys and Girls Clubs, Big Brothers Big Sisters, RCMA, and the three public libraries in Avon Park, Sebring, and Lake Placid.   

DOH-Highlands Community Programs Division designed and implemented this practice.  It is now a welcome addition to those organizations who accepted books, with many expressing thanks for the gift to children in their programs. Personal delivery of the books to each partner organization offered a chance for interaction between the practice coordinator and agency leads, establishing connections that will enhance other CHD programs and initiatives in the future.  Building goodwill is one way to enlist reciprocal participation from community partners and will provide a pathway for communication that was not previously open.

Practice participants are from all areas of the community and serve children from all socioeconomic levels.  It is hoped that using this broad approach will allow all children to benefit from this practice, especially those with socioeconomic challenges and barriers to reading.  Additionally, being able to provide Spanish-language versions of many books allows those children who cannot yet read English to participate in this practice and engage with other children in class or with family members. 

Objectives for this practice will be realized long-term, but measured annually by monitoring reading level data provided by the Florida Department of Education.  Additionally, demographic and socioeconomic data will be gathered from FLHealthCharts and the U.S. Census, and other relevant data from national-level research organizations, such as the National Association for Education Statistics.  With the benchmark of 44% of elementary students at a 3rd-grade reading level, as measured in 2022, we can continue watching trends for the duration of this practice to gauge outcomes.

While it is anticipated that outcomes from this practice will result in gradual improvement in reading levels, we must be prepared for any negative outcomes and adapt accordingly.  DOH-Highlands' practice coordinator will provide periodic reports to CHD Administration to allow oversight and input from senior leaders.  Grant funds will be monitored quarterly for proper and timely expenditure. Health equity will be a constant consideration during this practice.  As more organizations are added to the list of participants, analysis of the ability of this practice to impact children who speak languages other than English will be documented and included in ongoing analysis. 

This practice is sustainable through various funding sources within the CHD.  Currently, we are using the MCH381/382 grant funding and anticipate that this source will be ongoing, if the past is any predictor of future awards.  However, should that not prove true, we are prepared to use Health Equity funding from REDCH to continue this practice, as that source remains available. The fact that this practice uses such a relatively small amount of money ($14,207) makes it easier to find ways to fund it if current grants are not renewed.  Given that we were able to provide over 5,890 books to Highlands County children at an average cost of $1.82 each and with an estimated total suggested retail value of $57,350 makes this practice extremely cost effective. While outcomes for this project remain to be seen in the long-term analysis of reading levels, it is anticipated that future improvement will be statistically relevant and prove this practice to be sound. 

As we developed this practice over the past year, there were lessons learned that have proven helpful.  First, allowing teachers to select books for their students assures that the books would be related to curriculum and appropriate for each class.  Having books vetted through each school administration ensures that there are no issues with prohibited or controversial subject matter or content.  Asking teachers to choose books for their Spanish-speaking students allows all children to get a book that they can really read and extends the discovery of reading to all, making this an equitable practice.

We found that talking to the libraries gave us an understanding of how their Story Time reading program works, so we were able to choose books that covered appropriate topics.  This year, the librarians will be asked to select books from the Marketplace website that they feel are best for reading sessions.  We also provided]appropriate books for older children in the families who come to the library for Story Time, so they have a book to take home and keep, as well. 

Some partners will need to be consulted as to the number of books they can accept and distribute, but many are using the second order of books we gave out this September for Christmas presents to the children they serve.  We will continue to interact with partners to adapt this practice as needed and to ensure it is practical for each partner going forward.