Award Date

May 2018

Degree Type


Degree Name

Doctor of Philosophy (PhD)



First Committee Member

Du Feng

Second Committee Member

Catherine Dingley

Third Committee Member

Michael Johnson

Fourth Committee Member

Howard Gordon

Number of Pages



Low- and middle-income countries (LMICs) are often disproportionately faced with environmental hazards, which can cause adverse health outcomes. Although humanitarian engineering projects have been created to mitigate these hazards, LMICs are also frequently impacted by literacy deficits, creating a barrier in training low-literacy individuals to construct these projects. The purpose of this dissertation was to develop, refine, and test the usability of pictorial action instructions (PAI) in training low-literacy individuals to construct a humanitarian engineering project. A concept analysis was completed, including the creation of an operational definition, for “lay worker health literacy.” This analysis and definition set a foundation for equipping non-health professionals with methods for applying basic health interventions to promote health at individual and community levels. Next, PAI were developed using best practice guidelines and expert review. A feasibility study was conducted with five low-literacy adults to assess how the instructions were interpreted and could be improved; revisions were then made accordingly. The final PAI were used in a 60-participant randomized control trial in rural Guatemala, which compared the PAI-based training to demonstration-only training for constructing a solar bottle bulb. Both methods were evaluated for construction effectiveness and efficiency, as well as user satisfaction and self-efficacy levels. Significantly better results were noted for effectiveness and self-efficacy in the intervention group. Efficiency was not significantly different between the two groups, and a ceiling effect was noted for user satisfaction. Overall, the process used to develop and refine the PAI resulted in training instructions that increased construction effectiveness and self-efficacy among low-literacy individuals. Further studies are needed to test these PAI among low-literacy individuals in different contexts, as well as to develop and test PAI for other humanitarian engineering projects.


Environmental Health; Humanitarian Engineering; Literacy; Pictorial Action Instructions; Sustainability; Usability


Bilingual, Multilingual, and Multicultural Education | Nursing

File Format


Degree Grantor

University of Nevada, Las Vegas




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