What Structural Features Make Porous 
Carbons Work for Redox-Enhanced 
Electrochemical Capacitors? A Fundamental 
Investigation
Clarann Weinert, Elizabeth Nichols, Jean Shreffler-Grant
Weinert, C., Nichols, E., & Shreffler-Grant, J. (2021). Be Wise: A complementary and alternative 
medicine health literacy skill-building programme. Health education journal, 80(3), 327-336. https://
doi.org/10.1177/0017896920974060
This document is the Author’s version that was accepted for publication.
Made available through Montana State University’s ScholarWorks 
scholarworks.montana.edu 
Published in final edited form as:
Health Educ J. 2021 April ; 80(3): 327–336. doi:10.1177/0017896920974060.
Be Wise: A complementary and alternative medicine health 
literacy skill-building programme
Clarann Weinert, Elizabeth Nichols, Jean Shreffler-Grant
College of Nursing, Montana State University, Bozeman, MT, USA
Abstract
Background: Health literacy has been found to be the strongest predictor of health status; and 
without adequate health literacy, consumers may not understand/adequately evaluate the myriad of 
choices available. Older rural residents tend to use self-prescribed complementary and alternative 
medicine (CAM) therapies and glean information about these therapies primarily by word of 
mouth/media.
Objectives: The purpose of this article is to describe the Be Wise health literacy skill building 
programme and the participants’ evaluation of the programme.
Design: The programme involved four sessions delivered over 7 weeks at seniors’ centres in rural 
communities.
Method: Data were collected initially (N = 127), at the end of the sessions (N = 67) and after 5 
months (N = 52).
Setting: Participants were primarily rural Caucasian women, mean age 76 years, and most had an 
associate/baccalaureate degree.
Results: Questions were worded to ascertain satisfaction with the programme, usefulness of the 
information provided, willingness to recommend the programme, and the likelihood of using the 
programme. All scores were most favourable ranging from 3.35 to 4.41 on a 5-point scale. A 
question regarding the usefulness of the Be Wise programme in managing health received at mean 
score of 3.55 on a 5-point scale. Written comments on the questionnaires were overwhelmingly 
favourable.
Conclusion: Delivering programmes to older adults in small rural communities has special 
challenges and rewards. Participants were enthusiastic about learning more about making 
informed health care choices. There is a compelling need for continued programme development 
and long-term outcomes evaluation.
Keywords
Complementary and alternative medicine; health literacy; health literacy skill-building; older rural 
adults
Article reuse guidelines: sagepub.com/journals-permissions
Corresponding author: Clarann Weinert, College of Nursing, Montana State University, Sherrick Hall, Bozeman, MT 59717, USA. 
cweinert@montana.edu. 
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Weinert et al. Page 2
A rancher is driving 20 miles back to the ranch after helping with a blood drive in 
the local town. She ponders the conversation that the volunteers had about the use 
of herbal products and thinks she should probably use them. She is taking several 
prescription medicines but decides not to talk with her health provider about it 
because he may not approve of her using alternative therapies. Another rancher is 
heading home after a farm bureau meeting. Over coffee, there was a discussion of 
various dietary supplements. He decides he should take supplements but does not 
know which are right for him or how to get accurate information about them.
Both of these events raised relevant and critical health literacy questions or more specifically 
questions about complementary and alternative medicine (CAM) health literacy.
Introduction
Health literacy has been defined as ‘the degree to which individuals have the capacity to 
obtain, communicate, process and understand basic health information and services needed 
to make appropriate health decisions’ (US Patient Protection and Affordable Care Act, 
2010). It has been found to be the strongest predictor of an individual’s health status, more 
so than age, income, employment status, education or race/ethnicity (Berkman et al., 2004; 
Seminole County Patient Safety Initiative, 2006). The degree of health literacy influences 
the ability of individuals to monitor their health and productively engage with the health care 
system and has been a major public health priority that was included in the US 2010 and 
2020 Healthy People priorities (US Department of Health and Human Services, 2000, 2013).
Complementary or alternative medicine (CAM) therapies are health care approaches that are 
not typically part of conventional health care or that may have origins outside usual Western 
practice. They include natural products such as herbs, vitamins and other dietary 
supplements and mind/body practices such as yoga, meditation and acupuncture (National 
Center for Complementary and Integrative Health, 2020). Individuals use CAM for a variety 
of reasons including perceived cost, dissatisfaction with regular health providers, perceived 
preventive or restorative properties and ease of purchase (Altizer et al., 2013; Arcury et al., 
2015).
Natural products and dietary supplements are the most commonly used types of CAM and 
are readily available for purchase over-the-counter. While some of these products may have 
significant therapeutic value, others may present untoward health consequences if the dose, 
expected effects/side effects and potential interactions with food and/or other medications 
are not adequately understood. Individuals with low health literacy may not adequately 
understand and evaluate the myriad of choices that confront them.
In a series of studies exploring the use of CAM by elderly rural dwellers, we found that use 
of CAM was approximately the same rate as of their more urban counterparts. Consistent 
with the characteristics of rural populations, participants who used CAM tend to use self-
directed modalities rather than therapies provided by alternative practitioners, tend to glean 
information about these therapies primarily by word of mouth or from the media and used 
CAM inconsistently. Some did not seek information about the effects or risks of CAM, and 
when they did, the information sources they used were informal and those that the Institute 
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of Medicine (2005) expressed concern about as not being reliable (Nichols et al., 2005; 
Shreffler-Grant et al., 2007).
Rural dwellers are self-sufficient, rely on social systems for information, are ageing, and are 
among those identified as suffering from health disparities (Holmes and Levy, 2015). Rural 
communities have fewer health-related resources, poorer Internet access, lower income 
levels, lower educational levels and less health insurance coverage. Rural populations are 
ageing, and with that are more likely to suffer from poor health literacy and chronic illnesses 
(National Center for Chronic Disease Prevention and Health Promotion, 2011). Sudore et al. 
(2006) linked limited literacy in older people to disparities in health and health care access. 
Yamashita et al. (2018) suggested that lifelong learning activities may help mediate the 
impact of educational levels on health status for older individuals. The programme described 
here provides an example of such a programme.
The Be Wise programme
The intent of the programme titled Health Care Choice: Be Wise was to deliver and evaluate 
a skill-building intervention to enhance literacy about complementary and alternative 
therapies, specifically natural products. The development of the Be Wise programme was 
approved by the Montana State University Institutional Review Board for the Protection of 
Human Subjects. The programme was implemented with older adults in eight rural 
communities in two northwestern states in the USA and consisted of four skill-building 
sessions held over a 7-week period in centres and living facilities for the elderly in each 
community.
The sessions were developed based on the team’s prior research, evidence from the relevant 
literature and a conceptual model developed to guide the team’s exploration of CAM health 
literacy The key components of the model that guided content selection for the four skill-
building sessions were: information needed to assess a product or treatment; how to find and 
assess information about a product; and how to take an active role in health decision-making 
(Shreffler-Grant et al., 2013). Although the programme focused on dietary supplements and 
natural products, the skills acquired can be used with other types of self-prescribed health 
care such as over-the-counter medicines. A PowerPoint presentation and script outline were 
used to enhance the session information and to ensure consistency of the programme 
delivery across sites. Copies of the PowerPoint slides were provided as handouts. Only two 
of the investigators (JS-G and EN) served as presenters, again to promote consistency of the 
programme.
Site selection
The Be Wise programme was designed to be provided face to face to older adults in small 
rural towns (less than 8,000 population). Several potential rural towns in a northwestern state 
in the USA were identified and local contacts made. Centre directors and the directors of 
seniors’ living facilities, natural social gathering places for older individuals in small towns, 
were conducted. Two of the team members travelled to visit each potential site to identify 
the expectations of centre directors and participants. An important part of the discussion was 
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the willingness of the director to support the programme by hosting the sessions and helping 
recruit participants. Recruitment strategies included the distribution of flyers around town, 
an article in the local newspaper and announcements at seniors’ centre and seniors’ living 
centre meetings.
Be Wise programme delivery
The Be Wise programme was open to any adult in the community, not just members of the 
seniors’ centre or living centre. While the intent was for participants to attend all four 
sessions, the reality was that some people dropped in only for a session or two. Thus, the 
team designed each session to be self-contained with each session covering related, but 
different, material.
First session
The first session included information on health literacy, an overview of the programme, the 
responsibilities of participants and completion of the first questionnaire. Those who chose to 
participate agreed to attend four skill building sessions and complete a series of 
questionnaires. The session content included an overview of health literacy, its meaning, and 
importance to health, as well as a brief overview of dietary supplements and natural 
products. After the programme overview and introductory information had been presented, 
those interested in participating in the programme completed the first questionnaire that 
included basic demographics and several scales to assess general and CAM health literacy. 
A total of 127 participants completed the first questionnaire (see Table 1 Demographics). 
The same general and CAM health literacy scales were also included in the second and third 
questionnaire with results reported elsewhere (Shreffler-Grant et al., 2020).
Second session
The focus of the second session was on how to be safe in terms of what an individual needs 
to know about using dietary supplements, natural products and other self-prescribed over-
the-counter health products. While many dietary supplements pose a relatively low risk, the 
skill-building content included red flags to look out for when considering the use of a 
supplement or other self-prescribed remedy. Examples of red flags included: overly 
impressive language making claims that sound too good to be true. Additional red flags were 
the inclusion of words such as cure-all, totally safe, all natural, scientific breakthrough, or 
contains a secret ingredient and promises of no-risk money-back guarantees.
Other important considerations when taking a natural product or any over-the-counter 
medication were the amount (dose), the anticipated effect, possible interaction with other 
medications and the availability and cost of the product. The importance of talking with 
one’s health care provider about using dietary supplements was included in each session. It 
was reiterated that the intent was not to discourage or encourage the use of dietary 
supplements. The programme was designed to help participants be better informed if they 
choose to use dietary supplements or other over-the-counter medicines or products.
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Third session
The focus of the third skill-building session was on how to seek out and evaluate general 
health information as well as information on natural products and dietary supplements. A 
variety of sources of information were detailed including family, friends, health care 
providers, media and the Internet. The content included considering the source and purpose 
of the publication or person providing information; who the sponsor of the information was; 
who wrote the information; clues to the accuracy; who reviewed the information; currency 
(up-to-date) and how to contact the source for further information. A portion of the content 
was focused on searching for and evaluating information on the Internet. The importance of 
discussing herbal products with a health care provider or other professional such as a 
pharmacist was reinforced. In anticipation of the content in the fourth session, participants 
were given the booklet ‘A Guide for Older People: Talking with Your Doctor’, a US 
National Institute on Aging (2016) publication designed to help enhance individuals’ ability 
to work as a team along with nurses, doctors, pharmacists and other health care providers to 
solve health problems and to maintain health.
Fourth session
The focus of the fourth session was on forming partnerships with health care providers, 
tracking health information and communicating with health care providers. The importance 
of active engagement with one’s provider and personal health care was emphasised. Tools to 
facilitate partnerships with the health care provider were also distributed and discussed 
including the booklet provided during Session 3 and My Health Companion (MHC).
MHC provides a structure for tracking and maintaining health information and enhancing 
health literacy. Such a health information management tool can facilitate more informed 
decision-making and foster productive interactions with the health care system (Weinert and 
Cudney, 2012; Weinert et al., 2010). Participants were asked to use the MHC for the next 5 
months and to share their opinion of the usefulness of this health information tracking device 
on the third questionnaire.
At the conclusion of the fourth session, participants completed the second questionnaire that 
contained programme evaluation questions and questions related to their anticipation of 
using the information provided in the Be Wise programme. A total of 67 participants 
completed the second questionnaire.
Following in-person sessions
After a 5-month interval, the third questionnaire was mailed to those who had completed the 
second questionnaire. The intent was to assess retention of the skill-building information 
provided by the Be Wise programme and to gather programme evaluation information from 
the participants’ perspectives. A total of 52 participants returned the completed third 
questionnaires.
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Participant evaluation of the Be Wise programme
In the second questionnaire, completed at the end of the fourth programme session, three 5-
point programme evaluation questions were asked. Participants rated their satisfaction with 
the programme: mean of 4.13 (SD = 1.07). On the question ‘How useful will the information 
in the Be Wise programme be in making informed health decisions’, the mean was 4.16 (SD 
= .739). They were also asked if they would recommend the programme to others, which 
generated mean score of 4.41 (SD = .894).
Included in the second questionnaire were five less-direct programme evaluation questions 
about how likely participants were to use the skill-building information provided in the 
programme. The questions were phrased as to how likely they were to use the information 
on: health literacy for decisions about their own health (mean 4.09, SD = .803); seeking/
evaluating health information (mean 4.04, SD = .729); information on safe use of natural 
products (mean 4.04, SD = .903); and communicating with their health care provider (mean 
4.58, SD = .543). The question on the likelihood of using the Internet to access health 
information received the lowest mean score (3.35, SD = .153; see Table 2).
In the third questionnaire, the same five questions were asked to assess actual use of the 
information on: health literacy for decisions about health (mean 2.96, SD =1.27); seeking/
evaluating health information (mean 3.24, SD = 1.25); the safe use of natural products 
(mean 3.18, SD = 1.25) and communicating with health care providers (mean 3.29, SD = 
1.44). The question on the use of the Internet to access health information again received the 
lowest score (mean 2.79, SD = 1.49). Based on a paired t-test, all the scores were 
statistically significantly lower in the third questionnaire than in the second. (see Table 2)
Included in the third questionnaire was an overall evaluation question ‘How useful was 
participating in the Be Wise programme to managing your health?’ (mean 3.55, SD = 1.06). 
Additional evaluation questions were included to assess the perceived impact of 
participating in the Be Wise programme. As seen in Table 3, all the 5-point questions had a 
mean score of 3 except for the question regarding the use of the computer to seek health 
information, which had a mean score of 2.79 and SD = 1.49. (see Table 3)
The use of MHC was also evaluated in the third questionnaire, which included six questions 
with 6-point response options. Those who used MHC indicated they would strongly 
recommend it to others (5.13, SD = 1.09). The MHC was rated most useful in better 
preparing for visits to health care providers (4.20, SD = 1.13) and helping to better organise/
track personal health information (4.47, SD = 1.20; see Table 4).
Discussion
Delivering a programme such as Be Wise to older rural residents posed some challenges and 
the need for careful planning. Financial and other time constraints dictated that the 
programme be delivered at two sites on two consecutive days on each trip. Thus, the towns 
needed to be geographically close to each other. For example, one combination was a site in 
a town with a population of 4,134 that was 138 miles from the second site, which was a 
town with a population of 4,594. This was an ideal combination for delivery of the 
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programme over two days although the most direct route between the two towns involved 
crossing a very high mountain pass. At times, snow covered the ground and icy roads made 
this a long slow white-knuckle drive.
Another consideration was the time of year to present the programmes. Favourable seasons 
for driving such as the summer months were not ideal for participants as this is a time for 
visitors and for travel, as well as a very busy farming/ranch season. Avoiding the holidays 
was also a consideration and thus the only 7-week stretch of time to present the programme 
was February/March and September/October. Despite some inclement weather, the team was 
successful in safely delivering the programme without cancelling or changing the schedule 
at any site. To deliver the programme, and to involve a sufficient number of participants, 
required over 9,200 miles on the road.
Participants provided data on questionnaires at the beginning of the programme, at the end 
of the fourth session and 5 months after the fourth session. There were 127 useable first 
questionnaires, 67 second questionnaires and 52 third questionnaires. While the intent had 
been to have 80 useable questionnaires by the third and final questionnaire, the attrition rate 
was higher than expected. However, by adding additional sites for the presentation of the 
programme, an adequate number of participants was recruited in order to provide 
meaningful results. Retention of participants was a challenge during project implementation. 
As noted above, quite a few more (N = 127) participated in the initial session than at the 
fourth session (n = 67), and 5 months later when the third questionnaire was sent, 52 people 
participated. The demographic characteristics of those who were retained were not 
significantly different than those who were not. No consistent causes of attrition were 
identified, although inclement weather, doctors’ appointments, illness, local funerals, the 
arrival of unexpected guests and so on accounted for at least some of the attrition.
In the second questionnaire three questions were worded to directly ascertain participants’ 
satisfaction with the programme (4.13, SD = 1.07), the usefulness of the information 
provided (4.16, SD = .739) and whether they would recommend the programme to others 
(4.41, SD = .894). The high mean scores indicated overall satisfaction with the Be Wise 
programme. Questions were also included to assess their likelihood of using the information 
provided in the programme. The scores on four of the five questions were most favourable 
(mean of 4.04–4.58 on 5-point questions) and provided a clear demonstration of the 
usefulness of the skill-building information provided in the programme sessions. The scores 
for the fifth question on using the Internet to access health information was not as high 
(mean of 3.35 on 5-point questions). Although most participants had access to a computer 
with Internet connections at the seniors’ centre, seniors’ living centre and/or at home, some 
participants indicated that they did not use computers at all. Even though a portion of the 
third programme session described the use of the Internet to access health information, the 
participants who did not use computers were not intending to use it as a source of health 
information.
To gain an idea as to the actual use of the skill-building information, the questions in the 
second questionnaire involving willingness to use were re-worded as ‘How much have you 
used’ in the third questionnaire. All scores were statistically significantly lower on the third 
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questionnaire indicating that, while the participants anticipated using the programme 
information, they did not actually do so over the intervening 5-month period. In one sense, 
this was disappointing but given that all but one of the mean scores in the third questionnaire 
were at or above 3, this indicates that patici-pants used the information to a modest degree. 
Again, the scores on the question regarding the use of the computer to access health 
information were low (mean score of 2.80) and not a surprise.
In the third questionnaire, eight questions were included to assess the overall usefulness and 
impact of participating in the Be Wise programme. The mean scores were all favourable 
(mean scores of 3.09–3.55) except again for the use of the computer to access health 
information (mean score of 2.80).
The use of MHC was also evaluated in the third questionnaire. Unfortunately, there was not 
a high use of the MHC but as can be seen in Table 4, those participants who did use it 
indicated that they would strongly recommend it to others. It was rated most useful in better 
preparing for visits to their health care provider and helping to better organise/track their 
personal health information.
Written comments on the questionnaires were transcribed and majority of them were very 
favourable. A few examples are: ‘very informative and applicable programme’; ‘a very good 
and informative programme’; ‘would highly recommend it’; ‘I was pleased with the way it 
was presented and was able to ask questions’; ‘get the word out to more people’, 
‘programme gave me more confidence in making wise choices’.
Conclusion
While the quantitative evaluation scores for the Be Wise programme provided useful 
information, they do not fully capture the usefulness and impact of the programme. Without 
more detailed long-term exploration, it is not possible to know how exposure to the skill-
building content might play a critical factor in participants’ actual health care decisions. A 
longer time for the use of MHC may demonstrate more clearly its usefulness in helping to 
take a more active role in health care decisions.
Prior to developing the Be Wise programme, a pilot study of parts of the programme had 
been conducted. This helped with the development of the session content and affected the 
logistics of delivery. One factor that was clear from the pilot and the investigators’ years of 
rural health research experience was that face-to-face interaction is critical. With this, 
however, came the challenges of getting financial support to recruit an adequate number of 
participants from sparsely populated areas, retaining older individuals in the project, having 
adequate financial resources for transport to present the programme and dealing with 
seasonal scheduling issues. Perhaps providing the programme on a weekly basis rather than 
every other week would have helped with retention. The other work demands of those who 
conducted the programme, however, precluded travelling 4 weeks in a row. A weekly more 
compressed schedule would also not allow time for the participants to reflect on the content.
Overall, Be Wise programme content and take-home materials were favourably evaluated 
and this skill-building intervention resulted in enhanced CAM and general health literacy 
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among older rural adults (Shreffler-Grant et al., 2020). With these outcomes, it can be 
concluded that participating in the Be Wise project provided important skills for making 
more informed health care choices and thus enhanced engagement in the participants’ 
personal health and health care.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of 
this article. National Institutes of Health, National Center for Complementary and Integrative Health, 
1R15AT009097-01.
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Table 1.
Demographic characteristics of participants.
Variable 1st questionnaire, N = 127 2nd questionnaire, N = 67 3rd questionnaire, N = 52
Frequency (%) Frequency (%) Frequency (%)
Gender Men = 36 (28.3) Men = 15 (22.4) Men = 11 (21.2)
Women = 91 (71.7) Women = 52 (77.6) Women = 41 (78.8)
Age Mean 76.15 SD = 10.66 Mean 76.52 SD = 0.41 Mean 76.98 SD = 9.73
Mode 79 Mode 78 Mode 81
Education High school/less = 43 (36.8) High school/less = 25 (39.1) High school/less = 17 (34.7)
Assoc/Bach = 54 (46.2) Assoc/Bach = 32 (50.0) Assoc/Bach = 25 (51)
Post Bachelors = 20 (17.1) Post Bachelors = 7 (10.9) Post Bachelors = 7 (l4.3)
Marital Not coupled = 79 (67.5) Not coupled = 46 (71.9) Not coupled = 36 (73.5)
Coupled = 38 (32.5) Coupled = 18 (28.l) Coupled = 13 (26.5)
Race White = 115 (97.5) White = 63 (98.4) White = 48 (98.0)
American Indian = 3 (2.5) American Indian = 1 (1.6) American Indian = 1 (2.0)
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Table 2.
Be Wise programme evaluation based on responses to the second and third questionnaires.
Question Range 2nd questionnaire Mean (SD) 3rd questionnaire Mean (SD)
How likely to use information provided on health 1 Not at all likely 4.09 (.803) 2.96 (1.27)
literacy?
5 Extremely likely N = 47 N 47
How likely to use skill building on seeking/ 1 Not at all likely 4.04 (.729) 3.24 (1.25)
evaluating health information?
5 Extremely likely N = 46 N = 46
How likely to use internet to access health 1 Not at all likely 3.35 (153) 2.79 (1.49)
information?
5 Extremely likely N = 43 N = 43
How likely to use information about safe use? 1 Not at all likely 4.04 (.903) 3.18 (1.25)
5 Extremely likely N = 45 N = 45
How likely to use information on communicating 1 Not at all likely 4.58 (.543) 3.29 (1.44)
with health care provider?
5 Extremely likely N = 45 N = 45
Included those who completed both the second and third questionnaires.
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Table 3.
Impact of the Be Wise programme – responses to the third questionnaire.
Question Range Mean (SD)
How useful was the Be Wise programme in managing your health? 1 Not useful 3.55 (1.06)
5 Extremely useful N = 40
How much impact did the Be Wise programme have on: 1 Very little impact 3.37 (1.11)
Ability to interact with health care providers 5 Great deal of impact N = 49
How much impact did the Be Wise programme have on: 1 Very little impact 3.26 (1.11)
Better manage your health? 5 Great deal of impact N = 47
How much impact did the Be Wise programme have on: 1 Very little impact 2.80 (1.47)
Use computer to seek health information 5 Great deal of impact N = 46
How much impact did the Be Wise programme have on: 1 Very little impact 3.31 (1.19)
Understand safe use of natural products 5 Great deal of impact N = 48
How much impact did the Be Wise programme have on: 1 Very little impact 3.42 (1.33)
Seek health information from a variety of sources 5 Great deal of impact N = 48
How much impact did the Be Wise programme have on: 1 Very little impact 3.51 (1.27)
Know what questions to ask health care providers 5 Great deal of impact N = 47
How much impact did the Be Wise programme have on: 1 Very little impact 3.09 (1.47)
Evaluate health information 5 Great deal of impact N = 47
Health Educ J. Author manuscript; available in PMC 2021 August 08.
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Weinert et al. Page 14
Table 4.
Evaluation of My Health Companion – responses on third questionnaire.
Question Range Mean (SD)
How much did you use My Health Companion”? 1 Never used it at all 2.93 (1.47)
6 Used it a lot N = 45
Would you recommend the My Health Companion” to others? 1 Would not recommend 5.13 (1.09)
6 Would highly recommend N = 31
How useful was My Health Companion in: 1 Not at all useful 3.71 (1.05)
Helping to better manage your health? 6 Extremely useful N = 28
How useful was My Health Companion in: 1 Not at all useful 4.20 (1.13)
Better prepare for visits to your health care provider? 6 Extremely useful N = 30
How useful was My Health Companion in: 1 Not at all useful 3.97 (1.27)
Strengthening your partnership with your health care provider? 6 Extremely useful N = 30
How useful was My Health Companion in: 1 Not at all useful 4.47 (1.20)
Helping to better organise/track your personal health information? 6 Extremely useful N = 30
Only including those who reported having used My Health Companion.
Health Educ J. Author manuscript; available in PMC 2021 August 08.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript