Creating Understandable and Actionable COVID-19 Health Messaging for Refugee, Immigrant, and Migrant Communities

The paper addresses how to create understandable and actionable COVID-19 health messages for refugee, immigrant, and migrant (RIM) communities facing high risk of misinformation, mistrust, and barriers to accessing health information. The context is the rapidly changing COVID-19 pandemic, with extensive misinformation and limited culturally and linguistically responsive messaging. The purpose is to present a case study from Clarkston, Georgia, demonstrating a systematic, community-centered approach grounded in CBPR, CLAS standards, and health literacy guidelines to improve message clarity, usability, and trust, ultimately supporting mitigation behaviors, testing, and vaccine uptake among RIM populations.

The authors describe a substantial health literacy gap during COVID-19, noting that RIM populations face compounded challenges due to mistrust of institutions, language barriers, and the spread of misinformation and disinformation via traditional and social media. They reference the national CLAS standards, the health literacy universal precautions approach, and demographic shifts in the U.S. increasing the need for culturally and linguistically responsive health information. Prior work indicates that translated materials alone are insufficient without plain language, readability, and cultural relevance, and that trusted local sources are often more effective messengers than governmental entities.

Design: Case study using a community-based participatory research (CBPR) approach integrating CLAS standards and health literacy universal precautions. Setting: Clarkston, Georgia—a highly diverse community where more than 60 languages are spoken, served by volunteer-led clinics, a sliding scale clinic, and nearby public health resources. A CDC-funded Prevention Research Center (PRC) at Georgia State University (GSU) and a Community Advisory Board (CAB) formed a Clarkston Community COVID-19 Task Force with clinicians, local government, community leaders, and organizations to coordinate efforts. Organizing frameworks: (1) CBPR principles to engage community members as equal partners; (2) CLAS standards to ensure cultural and linguistic appropriateness; (3) health literacy universal precautions to use plain language, clear design, and actionable guidance for every message. Four health communication principles guided work: identify target behaviors, use trusted sources, develop exposure strategies, and comprehensive dissemination. Materials development process: Topics, audiences, and dissemination modes were identified with the Task Force. Drafts used CDC guidance as a baseline and were reviewed by clinical providers for scientific accuracy. Plain language principles from CDC’s "Simply Put" were applied: prioritize key information, limit messages, state clear actions, and use common words. Design elements included large, simple fonts (12–14 pt), dark-on-light contrast, ample white space, and culturally relevant visuals. The Patient Education Materials Assessment Tool (PEMAT) was used to assess understandability and actionability. Cultural and linguistic adaptation: Student assistants with lived migration experience reviewed content for literacy level and cultural appropriateness (“Would your mother/father/aunt/uncle understand this?”). Materials were translated by community members or professional translators depending on script needs (e.g., Amharic requires appropriate character set). Translations were reviewed by bilingual community members to ensure accuracy, cultural fit, and correct text placement for languages with specific line requirements. Dissemination: Modalities included printed flyers/brochures, booklets, lawn signs, bus shelter posters, social media (Instagram, Facebook), WhatsApp lists, websites, listservs, and mass media. Distribution points for print included clinics, childcare centers, apartment complexes, and van-share routes to workplaces. Products: (1) Answers to Coronavirus booklet in English and seven languages (Arabic, Amharic, Burmese, Nepali, Spanish, Swahili, Tigrinya), reframing “myths” as “This is what I heard” followed by a corrective statement; (2) Information cards included in >20,000 PPE kits instructing on mask use and testing locations; (3) Protect Clarkston and Vaccinate Clarkston lawn signs (250 signs in six languages) emphasizing collective responsibility; (4) 60-second animated vaccine encouragement videos in 20 languages; (5) Vaccine Ambassador (VA) program targeting Arabic, Swahili, Dari/Pashto, Somali, and Burmese speakers, supported by tailored fact sheets and flyers (including 12 community- and topic-specific flyers) to address misinformation, including messages circulating from overseas; (6) MARTA bus shelter poster campaign featuring seven trusted community leaders with translated quotes and QR codes linking to mobile vaccination schedules.

• Implementation outputs: Hundreds of multilingual booklets distributed at clinics, testing sites, childcare centers, and van-share routes; >20,000 PPE kits distributed with instructional information cards; 250 multilingual lawn signs posted along high-traffic pedestrian routes; animated vaccine videos produced in 20 languages; at least 12 community- and topic-specific flyers created for Vaccine Ambassador use; bus shelter campaign featuring seven trusted leaders.
• Reach/engagement indicators: Bus shelter posters had over 530,000 views in four weeks; the QR code on posters was accessed 26 times during the same period.
• Outcome observations: As part of a broader, multi-pronged, community-wide effort incorporating these materials and strategies, vaccination rates in Clarkston outpaced similar areas in the county and state.
• Process insights: Iterative co-development with community members improved buy-in, clarity, and cultural/linguistic responsiveness; print materials were particularly effective due to digital access and literacy barriers; trusted local sources (healthcare providers, faith leaders, community leaders) enhanced message uptake.

The case study demonstrates that a systematic, community-engaged approach integrating CBPR, CLAS standards, and health literacy universal precautions can produce health messages that RIM communities understand and act upon. By prioritizing clear, concise, and culturally concordant content delivered by trusted messengers and through accessible channels (especially print), the intervention addressed key barriers such as mistrust, low literacy, language diversity, and the digital divide. Tailoring messages to community concerns and countering misinformation—including messages from overseas—improved relevance and trust. These strategies likely contributed to higher vaccination uptake in Clarkston relative to comparable areas, illustrating the importance of cultural and linguistic responsiveness and local partnerships in public health communication during rapidly evolving crises.

Grounded in best practices of community engagement and health literacy, this case study outlines a replicable, centralized process to create scientifically accurate, trustworthy, and actionable health information for diverse RIM communities. The integration of CBPR, CLAS, and universal health literacy precautions, coupled with comprehensive, culturally informed dissemination, supported community health workers and organizations and was associated with improved vaccination rates. Future efforts should maintain community-centered design, invest in culturally and linguistically tailored print and digital materials, and develop stronger evaluation frameworks to quantify impacts. Listening to communities, leveraging trusted messengers, and applying health-literate design should be universal standards for crisis and routine public health communication.

• Highly dynamic information environment with frequently changing guidance created challenges for timely updates and consistency.
• Extreme linguistic diversity (60+ languages) and varying literacy levels complicated translation, layout, and messaging; translation alone did not ensure understandability.
• Digital divide limited the effectiveness of web-based and social media dissemination; reliance on print was necessary but resource-intensive.
• Professional/formal language common in public health materials was often not comprehensible; extensive community review was needed to ensure colloquial clarity.
• Evaluation relied largely on process metrics and ecological comparisons (e.g., poster views, QR scans, distribution counts, and observed higher vaccination rates) rather than controlled, quantitative outcome analyses, limiting causal inference.
• Approach was time-consuming and potentially expensive to sustain at scale.