Educating Low Literacy Clients About the Professions Using E-Health Technology

1. Educating Low Literacy Clients About the Professions Using E-Health Technology Silvia Martinez, Ed. D., CCC-SLP, PI Tara Smith, M.A., CCC-SLP, Doctoral Student Martine Ellie, M. S., CCC-SLP, Doctoral Student Howard University

2. Collaborators • Janice Trent, M. A. CCC-A, Howard University Speech and Hearing Clinic • Margarita Bautista-Vigas, M. A. CCC-S, Scottish Rite Center for Childhood Language Disorders

3. Learner Outcomes • Describe different health barriers among minorities as described by Healthy People 2000/2010 and impact to the professions • Summarize literacy issues as they relate to patient education and methods to address them

4. Learner Outcomes • Describe how to develop and use web-based materials to educate patients regarding nature of communication, communication disorders and treatment approaches

5. Healthy People 2000/2010 http://www.healthypeople.gov/Document/html/uih/uih_2.htm#deter

6. Access to Health Care • Leading Health Indicators • Health insurance • Higher income levels • Regular primary care provider or other source of ongoing health care

7. Health Disparities

8. Barriers to Access • Financial Barriers • Structural Barriers • Personal Barriers http://www.health.gov/healthypeople/ or call 1-800-367-4725.

9. Structural Barriers Lack of Service Providers to meet the needs of clients • Only 2.5% of Speech-Language Pathologists and 1.8% of Audiologists identify their ethnicity as Hispanic • Not all Hispanic professionals are Spanish proficient

10. Structural Barriers • Time demands of service providers, and particularly of those serving bilingual populations preclude them from entirely meeting all of their clients’ individual needs

11. Personal Barriers • Language barriers • Lack of knowledge about health procedures

12. Language Barriers • Barriers caused by low literacy rates in immigrant Hispanics and African Americans because of inadequate education attainment in Spanish and/or English • Barriers faced with Hispanics because of their limited oral English proficiencies or limited Spanish proficiencies in service providers

13. Literacy and Patient Education

14. An exercise

15. Literacy Issues • The Center for Health Care Strategies has estimated that minorities and immigrants (50% Hispanics and 40% Blacks) have disproportionate literacy problems, which increase their health risks. • In Washington, D. C., adult education levels in the site communities are the second lowest with only 68.4% reporting having a High School education.

16. Literacy Issues • As reported by the National Library of Medicine (NLM), studies state that “one-third of English-speaking patients at two public hospitals were unable to read basic health materials.” • NLM also reports a Medicare finding that “34% of the English speaking and 54% of the Spanish speaking patients had inadequate or marginal health literacy”

17. Literacy Issues • The Institute for Healthcare Advancement summarized from research that written health materials: • usually appear at the 10th grade level or higher (above average abilities), • that they include too much information and no explanation of uncommon words, • and that treatments are accompanied by complex instructions

18. Internet and Literacy Berland, et. Al (2001) Journal of American Medical Association • 18 English-language health Web sites (6 general health, 12 condition-specific) and 7 Spanish-language Web sites (3 general health, 4 condition-specific). • Most Web-based health information will be difficult for the average consumer to understand: • Half of the English-language materials are written at the college level, and all were at least a tenth-grade reading level. • Forty percent of the Spanish-language materials are written at the college level, almost all were written at least a ninth-grade reading level Health Information on the Internet: Accessibility, Quality, and Readability in English and Spanish, Journal of the American Medical Association, Vol. 285, No. 20, May 23 2001, pp. 2612-2621

19. Health Literacy • The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Definition of Health LiteracyHealthy People 2010

20. Health Literacy Measures • Rapid Estimate of Adult Literacy in Medicine (REALM) – Screener to assess ability to read common medical words of body parts and illnesses (2-3 mins. to assess). Participants read words (different numbers of syllables) in columns • Test of Functional Health Literacy in Adults (TOFHLA) (also in Spanish) (22 mins)– tests numerical abilities and comprehension using Cloze procedures

21. Readability Measures Readability Formulas – more than 40 formulas • SMOG – counts words with 3 or more syllables in 30 sentences • Flesch-Kincaid Grade Level Index – found with your Microsoft Word software, grammar check • Flesch-Kincaid Formula – average number of syllables/word and average number of words/sentences • Fry Readability – 3 samples of 100 words and count number of sentences and words (Spanish also) • Lexile Measures – average sentences length and word familiarity (software) (Spanish also)

22. Problems with Readability Measures http://csep.psyc.memphis.edu.cometrix.readabilityresearch.htm • Surface Characteristics – scores rely on surface characteristics, but comprehension and learning depend on more in the text • Reader’s cognitive aptitudes – scores do not consider knowledge, language skills and other cognitive aptitudes (interaction of reader and text) • Cohesion and coherences – readability scores do not necessarily correlate with text cohesion.

23. Alternatives http://cdc.gove/od/ads/smog.htm Replacement words • Allowing – letting • By telephone – by phone • Commonly – most often • Convenient – handy • Decision – ? • Several – ? • Evidence – ? • Receive - ? • Understand - ? • In addition - ?

24. Resources • Guidelines for Patient Education Written Materials: An author’s guide http://www.med.utah.edu/pated.authors • Health and Literacy Compendium http://easternlincs.worlded.org/heatlh/comp/index.htm • Health Information Handouts Used at UCSF Homeless Clinic http://itsa.ucsf.edu/~hclinic/handouts.dir/handouts.html • Information from Your Family Doctor http://familydoctor.org • Harvard School of Public Health, Health Literacy Studies http://www.hsph.harvard.edu/healthliteracy.html • National Cancer Institute, Making Health Comm. Progs Work www.cancer.gove

25. Resources • Lister Hill Library Internet MEDLINE Training Site http://www.uab.edu/lister/medtrain/consumerinfo.html • Literacy: Working through Literacy Barriers http:www.nurseweek.com/features/98-01/literate.html • Michigan Adult Learning &Technology Center: Health Literacy http://www.malt.cmich.edu/healthlit.htm • Patient Education Resources for Clinicians, OHSU Libraries http//www.ohsu.edu/library/patiented • Nationl Network of Libraries of Medicine, Consumer Health http:www.nnlm.gov/scr.conhlth/read.htm

26. Fotonovelas • Use stories to convey a message similar to comic books. • Relate a story using photographs and dialogue boxes or bubbles containing simple language. • Format takes advantage of the strong oral traditions of both African Americans and Hispanics

27. Fotonovelas and Education • Have been used successfully internationally and in the United States for health education. • In this project, the photographs will also be accompanied by voice-overs in English and in Spanish separately. • Will be produced using PowerPoint software since it is a program that is readily available and does not impose memory, speed and storage demands on computers. • Furthermore, hardcopies may be printed for clients.

28. The Typical Fotonovela RURAL WOMEN’S HEALTH PROJECT STD Prevention http://www.rwhp.org/nov_ed/fotonov.html

29. The Typical Fotonovela RURAL WOMEN’S HEALTH PROJECT Condom Use http://www.rwhp.org/nov_ed/fotonov.html

30. Howard University Project • Project HealthStories: Talking Fotonovelas for Low Literacy Culturally and Linguistically Diverse Populations • Funding: • ASHA Multicultural Projects Grant

31. Goals This project will reduce structural and language barriers by developing culturally and linguistically appropriate web-based materials to: • Increase the knowledge of African Americans and Hispanic populations about professional issues and services. • Meet the needs of health providers with materials to complement and enhance their services. • Research the effectiveness of web-based materials • Knowledge increase • Knowledge retention

32. Process

33. Focus Groups Speech and Language Pathologists • Parent language stimulation activities for ages 0-3 (7) • Services available at school (7) • How to read a book (6) • How speech and language problems impact education (6) • Stages of speech and language development (5) • Relaxation exercises (5) • Importance of keeping native language (5) • Enhancing fluency in the preschool population (4) • How children learn a second language (4) • How is my child going to learn English (3) • What to expect (Diagnostic Procress) (3) • Play (3)

34. Focus Groups Audiologists (conversation) • Importance of Screening/Follow-up for Babies • OAE • ABR • Tymps • Basic Audio Instructions • What is a Hearing Aid? • Hearing Aid Use • Sings of Hearing Loss in Children • Hearing Aid Evaluation • Hearing Loss and Noise • Signs and Symptoms of Hearing Loss • Communicative Strategies

35. Production

36. Production Worksheet

37. Story Board Worksheet

38. Script Worksheet

39. Research • Summative and formative evaluation purposes • Service providers and participants will be asked questions regarding facility of use and satisfaction • Health knowledge attained using pre & post test • Retention of knowledge- After 30 days, participants will be interviewed

40. Our Website Project: HealthStories

41. Questions and Comments??