Educating Low Literacy Clients About the Professions Using E-

Health TechnologySilvia Martinez, Ed. D., CCC-SLP, PISilvia Martinez, Ed. D., CCC-SLP, PI

Tara Smith, M.A., CCC-SLP, Doctoral StudentTara Smith, M.A., CCC-SLP, Doctoral StudentMartine Ellie, M. S., CCC-SLP, Doctoral StudentMartine Ellie, M. S., CCC-SLP, Doctoral Student

Howard UniversityHoward University

Collaborators

• Janice Trent, M. A. CCC-A, Janice Trent, M. A. CCC-A,

Howard University Speech and Hearing Howard University Speech and Hearing ClinicClinic

• Margarita Bautista-Vigas, M. A. CCC-S, Margarita Bautista-Vigas, M. A. CCC-S, Scottish Rite Center for Childhood Language Scottish Rite Center for Childhood Language DisordersDisorders

Learner Outcomes

• Describe different health barriers among Describe different health barriers among minorities as described by Healthy minorities as described by Healthy People 2000/2010 and impact to the People 2000/2010 and impact to the professionsprofessions

• Summarize literacy issues as they Summarize literacy issues as they relate to patient education and methods relate to patient education and methods to address themto address them

Learner Outcomes

• Describe how to develop and use web-Describe how to develop and use web-based materials to educate patients based materials to educate patients regarding nature of communication, regarding nature of communication, communication disorders and treatment communication disorders and treatment approachesapproaches

Healthy People 2000/2010

http://www.healthypeople.gov/Document/html/uih/uih_2.htm#deter

Access to Health Care

• Leading Health IndicatorsLeading Health Indicators• Health insuranceHealth insurance• Higher income levelsHigher income levels• Regular primary care provider or other Regular primary care provider or other

source of ongoing health caresource of ongoing health care

Health Disparities

Barriers to Access

• Financial BarriersFinancial Barriers• Structural BarriersStructural Barriers• Personal BarriersPersonal Barriers

http://www.health.gov/healthypeople/ or call 1-800-367-4725.

Structural Barriers

Lack of Service Providers to meet the Lack of Service Providers to meet the needs of clientsneeds of clients

• Only 2.5% of Speech-Language Only 2.5% of Speech-Language Pathologists and 1.8% of Audiologists Pathologists and 1.8% of Audiologists identify their ethnicity as Hispanicidentify their ethnicity as Hispanic

• Not all Hispanic professionals are Not all Hispanic professionals are Spanish proficientSpanish proficient

Structural Barriers

• Time demands of service providers, and Time demands of service providers, and particularly of those serving bilingual particularly of those serving bilingual populations preclude them from entirely populations preclude them from entirely meeting all of their clients’ individual meeting all of their clients’ individual needsneeds

Personal Barriers

• Language barriersLanguage barriers• Lack of knowledge about health Lack of knowledge about health

proceduresprocedures

Language Barriers

• Barriers caused by low literacy rates in Barriers caused by low literacy rates in immigrant Hispanics and African Americans immigrant Hispanics and African Americans because of inadequate education attainment because of inadequate education attainment in Spanish and/or Englishin Spanish and/or English

• Barriers faced with Hispanics because of their Barriers faced with Hispanics because of their limited oral English proficiencies or limited limited oral English proficiencies or limited Spanish proficiencies in service providersSpanish proficiencies in service providers

Literacy and Patient Education

An exercise

Literacy Issues• The Center for Health Care Strategies has The Center for Health Care Strategies has

estimated that minorities and immigrants estimated that minorities and immigrants (50% Hispanics and 40% Blacks) have (50% Hispanics and 40% Blacks) have disproportionate literacy problems, which disproportionate literacy problems, which increase their health risks.increase their health risks.

• In Washington, D. C., adult education In Washington, D. C., adult education levels in the site communities are the levels in the site communities are the second lowest with only 68.4% reporting second lowest with only 68.4% reporting having a High School education.having a High School education.

Literacy Issues• As reported by the National Library of As reported by the National Library of

Medicine (NLM), studies state that “one-Medicine (NLM), studies state that “one-third of English-speaking patients at two third of English-speaking patients at two public hospitals were unable to read public hospitals were unable to read basic health materials.” basic health materials.”

• NLM also reports a Medicare finding NLM also reports a Medicare finding that “34% of the English speaking and that “34% of the English speaking and 54% of the Spanish speaking patients 54% of the Spanish speaking patients had inadequate or marginal health had inadequate or marginal health literacy” literacy”

Literacy Issues• The Institute for Healthcare The Institute for Healthcare

Advancement summarized from Advancement summarized from research that written health materials: research that written health materials: • usually appear at the 10th grade level or usually appear at the 10th grade level or

higher (above average abilities), higher (above average abilities), • that they include too much information and that they include too much information and

no explanation of uncommon words, no explanation of uncommon words, • and that treatments are accompanied by and that treatments are accompanied by

complex instructions complex instructions

Internet and Literacy

Berland, et. Al (2001) Journal of American Medical AssociationBerland, et. Al (2001) Journal of American Medical Association

• 18 English-language health Web sites (6 general health, 12 18 English-language health Web sites (6 general health, 12 condition-specific) and 7 Spanish-language Web sites (3 condition-specific) and 7 Spanish-language Web sites (3 general health, 4 condition-specific). general health, 4 condition-specific).

• Most Web-based health information will be difficult for the Most Web-based health information will be difficult for the average consumer to understand: average consumer to understand: • Half of the English-language materials are written at the college Half of the English-language materials are written at the college

level, and all were at least a tenth-grade reading level. level, and all were at least a tenth-grade reading level. • Forty percent of the Spanish-language materials are written at the Forty percent of the Spanish-language materials are written at the

college level, almost all were written at least a ninth-grade reading college level, almost all were written at least a ninth-grade reading level 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

Health Literacy

• The degree to which individuals have The degree to which individuals have the capacity to obtain, process, and the capacity to obtain, process, and understand basic health information and understand basic health information and services needed to make appropriate services needed to make appropriate health decisions.health decisions.

Definition of Health LiteracyDefinition of Health LiteracyHealthy People 2010Healthy People 2010

Health Literacy Measures

• Rapid Estimate of Adult Literacy in Medicine Rapid Estimate of Adult Literacy in Medicine (REALM) – Screener to assess ability to read (REALM) – Screener to assess ability to read common medical words of body parts and common medical words of body parts and illnesses (2-3 mins. to assess). Participants illnesses (2-3 mins. to assess). Participants read words (different numbers of syllables) in read words (different numbers of syllables) in columns columns

• Test of Functional Health Literacy in Adults Test of Functional Health Literacy in Adults (TOFHLA) (also in Spanish) (22 mins)– tests (TOFHLA) (also in Spanish) (22 mins)– tests numerical abilities and comprehension using numerical abilities and comprehension using Cloze proceduresCloze procedures

Readability Measures

Readability FormulasReadability Formulas – more than 40 formulas – more than 40 formulas• SMOG – counts words with 3 or more syllables in 30 SMOG – counts words with 3 or more syllables in 30

sentencessentences• Flesch-Kincaid Grade Level Index – found with your Flesch-Kincaid Grade Level Index – found with your

Microsoft Word software, grammar checkMicrosoft Word software, grammar check• Flesch-Kincaid Formula – average number of Flesch-Kincaid Formula – average number of

syllables/word and average number of syllables/word and average number of words/sentenceswords/sentences

• Fry Readability – 3 samples of 100 words and count Fry Readability – 3 samples of 100 words and count number of sentences and words (Spanish also)number of sentences and words (Spanish also)

• Lexile Measures – average sentences length and Lexile Measures – average sentences length and word familiarity (software) (Spanish also)word familiarity (software) (Spanish also)

Problems with Readability Measures

• Surface Characteristics – scores rely on Surface Characteristics – scores rely on surface characteristics, but comprehension surface characteristics, but comprehension and learning depend on more in the textand learning depend on more in the text

• Reader’s cognitive aptitudes – scores do not Reader’s cognitive aptitudes – scores do not consider knowledge, language skills and consider knowledge, language skills and other cognitive aptitudes (interaction of other cognitive aptitudes (interaction of reader and text)reader and text)

• Cohesion and coherences – readability Cohesion and coherences – readability scores do not necessarily correlate with text scores do not necessarily correlate with text cohesion.cohesion.

http://csep.psyc.memphis.edu.cometrix.readabilityresearch.htm

Alternatives

Replacement wordsReplacement words• Allowing – lettingAllowing – letting• By telephone – by phoneBy telephone – by phone• Commonly – most oftenCommonly – most often• Convenient – handyConvenient – handy• Decision – ?Decision – ?• Several – ?Several – ?• Evidence – ? Evidence – ? • Receive - ?Receive - ?• Understand - ?Understand - ?• In addition - ?In addition - ?

http://cdc.gove/od/ads/smog.htm

Resources

• Guidelines for Patient Education Written Materials: An author’s Guidelines for Patient Education Written Materials: An author’s guideguidehttp://www.med.utah.edu/pated.authorshttp://www.med.utah.edu/pated.authors

• Health and Literacy CompendiumHealth and Literacy Compendiumhttp://easternlincs.worlded.org/heatlh/comp/index.htmhttp://easternlincs.worlded.org/heatlh/comp/index.htm

• Health Information Handouts Used at UCSF Homeless ClinicHealth Information Handouts Used at UCSF Homeless Clinichttp://itsa.ucsf.edu/~hclinic/handouts.dir/handouts.htmlhttp://itsa.ucsf.edu/~hclinic/handouts.dir/handouts.html

• Information from Your Family DoctorInformation from Your Family Doctorhttp://familydoctor.orghttp://familydoctor.org

• Harvard School of Public Health, Health Literacy StudiesHarvard School of Public Health, Health Literacy Studieshttp://www.hsph.harvard.edu/healthliteracy.htmlhttp://www.hsph.harvard.edu/healthliteracy.html

• National Cancer Institute, Making Health Comm. Progs WorkNational Cancer Institute, Making Health Comm. Progs Workwww.cancer.govewww.cancer.gove

Resources

• Lister Hill Library Internet MEDLINE Training SiteLister Hill Library Internet MEDLINE Training Sitehttp://www.uab.edu/lister/medtrain/consumerinfo.htmlhttp://www.uab.edu/lister/medtrain/consumerinfo.html

• Literacy: Working through Literacy BarriersLiteracy: Working through Literacy Barriers http:www.nurseweek.com/features/98-01/literate.htmlhttp:www.nurseweek.com/features/98-01/literate.html• Michigan Adult Learning &Technology Center: Health LiteracyMichigan Adult Learning &Technology Center: Health Literacy

http://www.malt.cmich.edu/healthlit.htmhttp://www.malt.cmich.edu/healthlit.htm• Patient Education Resources for Clinicians, OHSU LibrariesPatient Education Resources for Clinicians, OHSU Libraries

http//www.ohsu.edu/library/patientedhttp//www.ohsu.edu/library/patiented• Nationl Network of Libraries of Medicine, Consumer HealthNationl Network of Libraries of Medicine, Consumer Health

http:www.nnlm.gov/scr.conhlth/read.htmhttp:www.nnlm.gov/scr.conhlth/read.htm

Fotonovelas

• Use stories to convey a message Use stories to convey a message similar to comic books. similar to comic books.

• Relate a story using photographs and Relate a story using photographs and dialogue boxes or bubbles containing dialogue boxes or bubbles containing simple language. simple language.

• Format takes advantage of the strong Format takes advantage of the strong oral traditions of both African Americans oral traditions of both African Americans and Hispanics and Hispanics

Fotonovelas and Education

• Have been used successfully internationally Have been used successfully internationally and in the United States for health education.and in the United States for health education.

• In this project, the photographs will also be In this project, the photographs will also be accompanied by voice-overs in English and in accompanied by voice-overs in English and in Spanish separately. Spanish separately.

• Will be produced using PowerPoint software Will be produced using PowerPoint software since it is a program that is readily available since it is a program that is readily available and does not impose memory, speed and and does not impose memory, speed and storage demands on computers.storage demands on computers.

• Furthermore, hardcopies may be printed for Furthermore, hardcopies may be printed for clients. clients.

The Typical Fotonovela

http://www.rwhp.org/nov_ed/fotonov.html

RURAL WOMEN’S HEALTH PROJECT

STD Prevention

The Typical Fotonovela

http://www.rwhp.org/nov_ed/fotonov.html

RURAL WOMEN’S HEALTH PROJECT

Condom Use

Howard University Project

• Project HealthStories: Talking Project HealthStories: Talking Fotonovelas for Low Literacy Culturally Fotonovelas for Low Literacy Culturally and Linguistically Diverse Populationsand Linguistically Diverse Populations

• Funding:Funding:• ASHA Multicultural Projects GrantASHA Multicultural Projects Grant

Goals

This project will reduce structural and language barriers This project will reduce structural and language barriers by developing culturally and linguistically appropriate by developing culturally and linguistically appropriate web-based materials to:web-based materials to:

• Increase the knowledge of African Americans and Increase the knowledge of African Americans and Hispanic populations about professional issues and Hispanic populations about professional issues and services.services.

• Meet the needs of health providers with materials to Meet the needs of health providers with materials to complement and enhance their services.complement and enhance their services.

• Research the effectiveness of web-based materialsResearch the effectiveness of web-based materials• Knowledge increaseKnowledge increase• Knowledge retentionKnowledge retention

Process

Focus Groups

Speech and Language PathologistsSpeech and Language Pathologists1.1. Parent language stimulation activities for ages 0-3 (7)Parent language stimulation activities for ages 0-3 (7)

2.2. Services available at school (7)Services available at school (7)

3.3. How to read a book (6)How to read a book (6)

4.4. How speech and language problems impact education (6)How speech and language problems impact education (6)

5.5. Stages of speech and language development (5)Stages of speech and language development (5)

6.6. Relaxation exercises (5)Relaxation exercises (5)

7.7. Importance of keeping native language (5)Importance of keeping native language (5)

8.8. Enhancing fluency in the preschool population (4)Enhancing fluency in the preschool population (4)

9.9. How children learn a second language (4)How children learn a second language (4)

10.10. How is my child going to learn English (3)How is my child going to learn English (3)

11.11. What to expect (Diagnostic Procress) (3)What to expect (Diagnostic Procress) (3)

12.12. Play (3)Play (3)

Focus GroupsAudiologists (conversation)Audiologists (conversation)

1.1. Importance of Screening/Follow-up for BabiesImportance of Screening/Follow-up for Babies• OAEOAE• ABRABR• TympsTymps

2.2. Basic Audio InstructionsBasic Audio Instructions3.3. What is a Hearing Aid?What is a Hearing Aid?4.4. Hearing Aid UseHearing Aid Use5.5. Sings of Hearing Loss in ChildrenSings of Hearing Loss in Children6.6. Hearing Aid EvaluationHearing Aid Evaluation7.7. Hearing Loss and NoiseHearing Loss and Noise8.8. Signs and Symptoms of Hearing LossSigns and Symptoms of Hearing Loss9.9. Communicative StrategiesCommunicative Strategies

Production

Production Worksheet

Story Board Worksheet

Script Worksheet

Research

• Summative and formative evaluation Summative and formative evaluation purposes purposes

• Service providers and participants will be Service providers and participants will be asked questions regarding facility of use and asked questions regarding facility of use and satisfactionsatisfaction

• Health knowledge attained using pre & post Health knowledge attained using pre & post testtest

• Retention of knowledge- After 30 days, Retention of knowledge- After 30 days, participants will be interviewedparticipants will be interviewed

Our Website

Project: HealthStoriesProject: HealthStories

Questions and Comments??