Mobile Fotonovelas within a Text Message Outreach to Build Health Literacy and Influence Behaviors in Response to the COVID-19 Pandemic

Originally developed for Latin American audiences, fotonovelas are similar to a comic book in format. They typically tell a story using a dramatic or soap-opera-style plot with illustrations or photographs and dialogue bubbles to capture the user's attention. They have been used, in particular, to help low-literacy or underserved populations understand the value of preventive care and screenings and improve self-management of chronic conditions. Fotonovelas are often passed on to family or friends through social networks, thereby increasing their reach beyond the individual.

In light of the fact that SMS is a channel for rapid deployment that has a high rate of adoption, mPulse Mobile, Inc. adapted the traditional print format by creating a series of mobile (digital) fotonovelas that could be used to improve health literacy around COVID-19, to fill knowledge gaps around perceived severity and susceptibility, and to help health plan members build new healthy habits to avoid exposure to the virus. Delivered to health plan members and patients as a link within SMS text messages, the two mobile fotonovelas (in both English and Spanish) were designed to be educational, with lighthearted content, and to reduce cultural and linguistic barriers. The readability of all content is at or below a sixth grade reading level, and the characters in the visuals are culturally diverse, vary in age and gender, and communicate in English or Spanish. They included:

1. The messages in Fotonovela 1 were created as an early response to the COVID-19 threat. Recipients received an SMS text message telling them that their health plan had put together "COVID-19 simple steps" to help them stay safe and healthy, and they were asked to click on a link to see more. Upon clicking, they viewed the mobile fotonovela, which consists of 8 frames in story format showing different settings and how to stay safe around people in those settings. The various scenes in the story model good behaviour concerning interacting with high-risk individuals, washing hands, sneezing into the elbow, greeting people by bumping elbows, using only trusted information sources on the internet, and avoiding crowds. These messages address the various determinants of behaviour or constructs that are outlined in the Health Belief Model (HBM): perceived severity, perceived benefits, perceived barriers to action, and exposure to factors that prompt action. mPulse Mobile, Inc. also relied on social cognitive theory (SCT), which posits that understanding health risks and benefits will influence changes in health habits and behaviours if an individual believes that these new health behaviours can positively impact their health.
2. To address the effects of limited social contact over several weeks and the impact of these restrictions on personal well-being and perceived loneliness, Fotonovela 2 depicts 4 houses and introduces the user to the people in these homes. As the user scrolls down, a story unfolds behind closed doors and shares how people in the neighbourhood are staying at home, coping with change, and finding ways to stay emotionally connected and positive. At the end of each story, there are specific suggestions to encourage users to explore new ways to stay actively engaged and develop a sense of routine. This fotonovela features photographs instead of illustrations and presents the stories within each vignette with elements of humour and lightheartedness (a dog that speaks or a toddler who has a design plan). The fotonovela is also grounded in theory: optimism bias (where people underestimate risks when considering potential harm in the form of disease or catastrophe and also (erroneously) tend to believe that others are more likely to be impacted than themselves) and present bias (which tends to overvalue immediate rewards in the present (seeing friends at a get-together in two days) at the expense of long-term benefits (delaying the gathering until it is safe in order to prevent COVID-19).

mPulse Mobile, Inc. also built a natural language understanding (NLU) system, which can recognise and address member questions and concerns relating to COVID-19, and created a series of check-ins via SMS text messages with advice, suggestions, and support on a range of topics (e.g., suggestions to manage stress and increase mindfulness, and to avoid monitoring news reports throughout the day - with links to resources).

Health Literacy

Health literacy may be defined as the degree to which individuals can obtain, process, and understand basic health information needed to make appropriate health decisions. Approximately 80 million people in the United States (US) have low health literacy, which is associated with problematic outcomes, including lower adoption of protective behaviours such as vaccinations and hand hygiene.