Low-literacy Audiences Research Articles

P099 Collaboration Yields Evidence-Based and Stakeholder-Reviewed Online Nutrition Content for Patient Activated Learning System

<h3>Background</h3> The Patient Activated Learning System (PALS) is a free web-based patient application platform designed for low literacy audiences. Evidence-based information is presented in single-objective webpages, with content ranging from pharmacological treatment to behavioral approaches to disease prevention and management. Multidisciplinary collaboration that includes nutrition education program stakeholders may benefit PALS nutrition content development. <h3>Objective</h3> Pilot methods to develop and evaluate acceptability of PALS nutrition pages with a team of physicians, nutrition researchers, and Expanded Food and Nutrition Education Program (EFNEP) educators and participants. <h3>Study Design, Setting, Participants</h3> We conducted a feasibility and acceptability study with convenience samples of geographically dispersed EFNEP educators and participants in New York. We identified commonly asked cardiovascular disease (CVD) related nutrition questions using two online surveys of educators (n = 12, n = 45), then used a rapid systematic review of relevant scientific evidence and practice guidelines to generate PALS pages. We assessed page acceptability in focus groups with educators (n = 10) and interviews with participants (n = 12). <h3>Measurable Outcome/Analysis</h3> Educator-generated questions were grouped thematically, condensed, and rated based on perceived relevance. Researchers iteratively coded focus group and interview transcripts, independently summarized feedback, and met to discuss acceptability-related findings. <h3>Results</h3> Educators identified 33 common CVD-related nutrition questions; highest rated questions informed development of 4 PALS pages about coconut oil, saturated and unsaturated fat, and fiber. Educators reported the pages were clear, concise, and acceptable for educators and participants. The combination of text and figures addressed a range of learning needs, and educators appreciated the behaviorally focused content. Most EFNEP participants found the content relevant, easily digestible, and helpful. Incorporating practical information in colorful figures was particularly appealing. Participants demonstrated an understanding of the content. Most would return to PALS, citing clarity and trustworthiness of information provided. <h3>Conclusions</h3> The multidisciplinary team successfully engaged EFNEP stakeholders in the development and review of evidence-based nutrition online information, which helped generate relevant, clear, appealing, and trustworthy content. Lessons learned can inform development of PALS content and may apply to other eHealth platforms. <h3>Funding</h3> Cornell Center for Health Equity

Development and Field-Testing of Proposed Food-Based Dietary Guideline Messages and Images amongst Consumers in Tanzania.

In this paper we report on the development and field-testing of proposed food-based dietary guideline (FBDG) messages among Tanzanian consumers. The messages were tested for cultural appropriateness, consumer understanding, acceptability, and feasibility. In addition, comprehension of the messages was assessed using culturally representative images for low literacy audiences. Focus group discussions were used as method for data collection. Results indicate that the core meaning of the proposed FBDG messages and images were understood and acceptable to the general population. However, participants felt that nutrition education would be required for improved comprehension. Feasibility was affected by some cultural differences, lack of nutrition knowledge, time constraints, and poverty. Suggestions were made for some rewording of certain messages and editing of certain images. It is recommended that the field-tested messages and images, incorporating the suggested changes, should be adopted. Once adopted, the FBDGs can be used to inform and engage various stakeholders, including parents, caregivers, healthcare providers and educators on appropriate nutritional practices for children and adults. They can also be used to guide implementation of relevant policies and programmes to contribute towards the achievement of sustainable healthy diets and healthy dietary patterns.

Attendance to Eye Screening from The Eye of Healthcare Professionals: A Qualitative Finding

Background: Diabetes Mellitus (DM) is on a rising trend globally. In the third National and Health Morbidity Survey 2012, the number of patients who underwent proper eye screening is still far from satisfactory and the study regarding this aspect in the Malaysian setting is secluded. This study explored the current management of eye screening for diabetic patients within the Ministry of Health (MOH) setting and how it influences the attendance of patients for routine eye screening. Method: This descriptive qualitative study used in-depth semi-structured with ten health care provider who involved in diabetic eye screening and document analysis process. The interviews were audio-taped, transcribed and analyzed using Atlas-Ti. An iterative process of thematic analysis was used. Results: The factors that influence the attendance to eye screening were health care providers confidence in performing eye screening, the effectiveness of the green card system, interactive health educational session and continuous support from family members. Lack of information received by the patients on the importance of eye screening and communication issues seems to be prominent and become the reasons for patients’ poor attendance to eye screening. Having a structured programme which emphasises on the importance of eye screening could be able to empower the patients and facilitate better communication strategy between patients and healthcare professionals. This simultaneously would increase the interest of the patient to follow the schedule of eye screening to achieve better health outcomes. Conclusion: The establishment of diabetic retinopathy–focused education materials that target multiracial and low literacy audiences, observation during data collection through more natural methods and inclusion of comorbidity aspects in future research should be considered.

MANTRA: development and localization of a mobile educational health game targeting low literacy players in low and middle income countries

BackgroundMobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal.MethodsThe serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment.ResultsThe MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game.ConclusionsThis MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development.Trial registrationThis project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.

MANTRA: a serious game improving knowledge of maternal and neonatal health and geohazards in Nepal

Abstract Background Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. Specifically, we assess impact of the serious game to improve knowledge gain in our target audience. Methods Co-creation with the MANTRA team and local stakeholders in Nepal identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot game to the local cultural context. Through picture matching with immediate audio and visual feedback, the game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards. To assess the game, 35 participants were recruited in Kathmandu and villages in Kavre district. Sessions consisted of pre-test assessment, playing the game, post-test assessment, and a focus group to elicit qualitative feedback. Results The knowledge assessment quantified knowledge gain. Overall, the group averaged a normalized 6.8 point improvement (p = 0.000022). Change in the geohazard module was 9.5 points (p = 0.001), followed by maternal health (7.4 points, p = 0.007), and neonatal health (4.3 points, p = 0.83). Four learning objectives had statistically significant change (p &amp;lt; 0.05). Feedback demonstrated high engagement, motivation, and usability of the game. Conclusions This MANTRA study is a unique mhealth intervention of a serious game to teach core health and hazards messages to low-literacy audiences in rural Nepal. The pilot intervention demonstrated statistically significant knowledge improvement among participants. Key messages The pilot MANTRA mobile serious game intervention is a novel idea, to bring public health knowledge to difficult to reach vulnerable populations, including often ignored illiterate audiences. The pilot MANTRA mobile serious game intervention demonstrated a statistically significant knowledge improvement of geohazard, maternal, and neonatal health learning objectives among participants.

Producing and using community health education films in low- and middle-income countries

Objective: To analyse the production and use of health education films in Kenya, Tanzania and Zambia. Design: Review of community health education films and their use by three partner organisations. Methods: A focused content analysis of 18 community health education films was conducted, and three exemplar films were selected for more detailed review. Interviews were carried out with four film production personnel and seven project workers using the films in health education projects in Kenya, Tanzania and Zambia. Concepts drawn from the Ottawa Charter for Health Promotion and Anchored Instruction informed the study. Findings: The films, produced primarily for use across sub-Saharan Africa, mostly conveyed biological information and addressed behavioural issues related to maternal and child health topics. The predominantly low-literacy audiences reached by the projects may further benefit from localised content highlighting the social determinants of health through engaging narrative formats. While the health education projects provided some opportunities to discuss the films after screening, linked problem-solving activities could raise awareness of the multiple factors influencing health and help community members formulate holistic action plans. Conclusion: The film production company responded to emerging findings, noting that more context-specific films should be produced, with community members being more fully involved in planning, production and evaluation. Such an approach could generate more relevant content and engage audiences more effectively in problem-solving related to health and wellbeing.

Savvy Survey #10: In-Person-Administered Surveys

In-person-administered surveys are a type of face-to-face interview that collects mainly quantitative data from a number of individuals and can be useful for collecting information from low-literacy audiences or obtaining very detailed information from agricultural producers or business owners about needs or program outcomes. As part of the Savvy Survey Series, this 7-page fact sheet presents the construction, development, and implementation of in-person surveys, as well as how to prepare an introductory script, train interviewers, and manage the survey process. Written by Glenn D. Israel and Jessica L. Gouldthorpe, and published by the Agricultural Education and Communication Department, December 2015. AEC404/PD074: The Savvy Survey #10: In-Person-Administered Surveys (ufl.edu)

Tailored DVDs: A novel strategy for educating racially and ethnically diverse older adults about their medicines

IntroductionThe availability of comprehensive and accurate medication history information in electronic medical records and through electronic prescribing provides the opportunity to create tailored interventions based on individuals’ particular medication information needs. To meet the challenges of providing medication information to low-literate English and Spanish speaking older adults, we sought to create individualized, culturally and linguistically inclusive medication education materials for older adults from diverse backgrounds. MethodsWe used a mixed-method design including a systematic review, analysis of existing data, a telephone survey (n=326), and exploratory focus groups stratified by race/ethnicity and language spoken (11 focus groups; n=106) to identify what information about medications older adults need, want to learn, and in what format. We evaluated reactions to three DVDs at low-income senior community centers (2 focus groups; n=16). ResultsExploratory focus groups provided insights on areas for improvement in patient–provider communication, and suggested use of vignettes and testimonials. Upon viewing, participants could relate to the testimonials in which actors portrayed people who have problems with their medications and were interested in the medication advice presented, especially when it was presented by a healthcare professional. DiscussionTailored medication education materials in English and Spanish DVD and print material format are suitable for low-literate audiences, acceptable to older adults, and feasible to implement using health IT. Virtually all households in the United States have a television, with most having a DVD player. DVD segments can be used in Internet links, physician office-based television, and consumer health IT applications.

“Teach to Goal”: Theory and Design Principles of an Intervention to Improve Heart Failure Self-Management Skills of Patients with Low Health Literacy

Self-management is vital for achieving optimal health outcomes for patients with heart failure (HF). We sought to develop an intervention to improve self-management skills and behaviors for patients with HF, especially those with low health literacy. Individuals with low health literacy have difficulty reading and understanding written information and comprehending numerical information and performing calculations, and they tend to have worse baseline knowledge, short-term memory, and working memory compared with individuals with higher health literacy. This paper describes theoretical models that suggest methods to improve the design of educational curricula and programs for low literate audiences, including cognitive load theory and learning mastery theory. We also outline the practical guiding principles for designing our intervention, which includes a multisession educational strategy that teaches patients self-care skills until they reach behavioral goals (“Teach to Goal”). Our intervention strategy is being tested in a randomized controlled trial to determine if it is superior to a single-session brief educational intervention for reducing hospitalization and death. If this trial shows that the “Teach to Goal” approach is superior, it would support the value of incorporating these design principles into educational interventions for other diseases.

Using Qualitative Methods to Improve Questionnaires for Spanish Speakers: Assessing Face Validity of a Food Behavior Checklist

Development of outcome measures relevant to health nutrition behaviors requires a rigorous process of testing and revision. Whereas researchers often report performance of quantitative data collection to assess questionnaire validity and reliability, qualitative testing procedures are often overlooked. This report outlines a procedure for assessing face validity of a Spanish-language dietary assessment tool. Reviewing the literature produced no rigorously validated Spanish-language food behavior assessment tools for the US Department of Agriculture's food assistance and education programs. In response to this need, this study evaluated the face validity of a Spanish-language food behavior checklist adapted from a 16-item English version of a food behavior checklist shown to be valid and reliable for limited-resource English speakers. The English version was translated using rigorous methods involving initial translation by one party and creation of five possible versions. Photos were modified based on client input and new photos were taken as necessary. A sample of low-income, Spanish-speaking women completed cognitive interviews (n=20). Spanish translation experts (n=7) fluent in both languages and familiar with both cultures made minor modifications but essentially approved client preferences. The resulting checklist generated a readability score of 93, indicating low reading difficulty. The Spanish-language checklist has adequate face validity in the target population and is ready for further validation using convergent measures. At the conclusion of testing, this instrument may be used to evaluate nutrition education interventions in California. These qualitative procedures provide a framework for designing evaluation tools for low-literate audiences participating in the US Department of Agriculture food assistance and education programs.

Designing e-Health Interventions for Low-Health-Literate Culturally Diverse Parents: Addressing the Obesity Epidemic

Child and adolescent obesity is a significant problem contributing to long-term trends in adult obesity. Educating parents about strategies for raising healthy children is complicated by the problem of low health literacy. E-health provides new opportunities to educate lowhealth-literate audiences, and this project was intended as formative research to guide design of interventions for low-health-literate parents. Focus groups were conducted with African American, Hispanic, and white parents (n = 43), 18 years of age or older, and at or below median income for the region. Each focus group included the following: a discussion of parents' general use of the Internet for health information, the demonstration of a Web site designed specifically for low-health-literate users, and asking participants about ideas under consideration for future interventions. Participants use search engines to look for health information and use heuristics, such as position in search results, to evaluate Web site quality. Some participants avoid information from .edu and .gov domains due to perceived complexity, and there was an almost-universal lack of trust in the government for health information. University researchers, by contrast, were trusted sources as information providers. Content and usability that meet the needs of extremely low-literate audiences may be perceived as slow and lacking depth by more literate and Internet-savvy users. E-health can be used to educate low-health-literate audiences, but interventions designed for these users must be layered in terms of content and usability to meet varying levels of functional and media literacy.

Abstract B28: Effects of low- versus high-literacy materials on knowledge and risk perceptions regarding cervical dysplasia

Abstract B28 Background Health literacy is an important determinant of health status. Developing and evaluating health education materials for low-literate audiences is a priority and critical to helping individuals participate in health care decisions and self-management. However, questions remain as to whether low-literacy materials are appropriate for all audiences. We sought to determine if low-literacy materials would be appropriate and effective in educating individuals at wide ranges of health literacy, or if materials should be tailored to a patient’s health literacy level. Methods Eighty patients returning for follow-up colposcopy appointments were randomized to read a brochure about cervical dysplasia that was written at either a high (8th grade) or low (4th grade) reading level. Before reading the brochure, patients completed assessments of health literacy (Short Test of Functional Health Literacy in Adults, STOFHLA; Rapid Assessment of Adult Literacy in Medicine, REALM), knowledge, and perceived risk. After reading, knowledge, perceived risk, and brochure evaluation assessments were completed. Results Overall, patients had a high level of health literacy (STOFHLA M=70.1, SD=2.3; REALM, 4 patients 7-8th grade level, 76 patients 9th grade level and above). Average knowledge score before reading was 12.9 (SD=2.4) on a 17-point scale. Patients receiving either high- or low-reading level brochures improved their knowledge scores after reading (Mpst = 14.4, SDpst=1.7, p&amp;lt;0.001). Change in knowledge score did not differ between the two groups (p=0.664). Groups did not differ significantly in their ratings of brochure quality (e.g., completeness, clarity and organization, interest, credibility, relevance). Conclusions Brochures written at low reading levels can improve knowledge about cervical dysplasia, even for patients with high health literacy, and are judged by patients to be similar in quality. Citation Information: Cancer Prev Res 2008;1(7 Suppl):B28.

Understanding visuals in HIV/AIDS education in South Africa: differences between literate and low-literate audiences

This article reports on a research project aimed at determining the scope and nature of differences in picture comprehension between literate and low-literate audiences in the context of HIV and AIDS. Structured interviews were held with 30 low-literate and 24 literate adult speakers of African languages. The responses were coded and analysed both qualitatively and quantitatively. Consistent with previous research, we found that purely analogical visuals pose relatively few interpretation problems across the literacy spectrum. Literate and low-literate respondents recognised human beings and familiar analogous objects equally successfully. The interpretation of abstract items was problematic for respondents at both literacy levels, but relatively more so for low-literate respondents. Purely symbolic or conventional abstract elements, such as speech and thought balloons, and purely mathematical symbols are difficult for low-literate individuals since they do not have any analogical residue that will trigger relevant meaning aspects of the visual. Metaphors are difficult when they require culture-specific knowledge. The results strongly suggest that designers should exploit the expressive power of the human body in constructing (abstract) meaning. All humans have comparable experiences with associated basic actions and bodily expressions. Therefore, facial expressions and body postures and positions are powerful in transferring complex messages. We advise that pictorial metaphors, art styles that distort objects, complex pictures with partially symbolic content, as well as abstract symbols borrowed from written language should be omitted where possible.

Abortion and Sex Determination: Conflicting Messages in Information Materials in a District of Rajasthan, India

Public information campaigns are an integral component of reproductive health programmes, including on abortion. In India, where sex selective abortion is increasing, public information is being disseminated on the illegality of sex determination. This paper presents findings from a study undertaken in 2003 in one district in Rajasthan to analyse the content of information materials on abortion and sex determination and people's perceptions of them. Most of the informational material about abortion was produced by one abortion service provider, but none by the public or private sector. The public sector had produced materials on the illegality of sex determination, some of which failed to distinguish between sex selection and other reasons for abortion. In the absence of knowledge of the legal status of abortion, the negative messages and strong language of these materials may have contributed to the perception that abortion is illegal in India. Future materials should address abortion and sex determination, including the legal status of abortion, availability of providers and social norms that shape decision-making. Married and unmarried women should be addressed and the participation of family members acknowledged, while supporting independent decisions by women. Sex determination should also be addressed, and the conditions under which a woman can and cannot seek an abortion clarified, using media and materials accessible to low-literate audiences. Based on what we learned in this research, a pictorial booklet and educator's manual were produced, covering both abortion and sex determination, and are being distributed in India.

Developing an Illustrated Version of the Consumer Assessment of Health Plans (CAHPS®)

The most commonly used tool for assessing member satisfaction with health plans in the United States is the Consumer Assessment of Health Plans (CAHPS). Yet its complexity exceeds the abilities of many patient populations. An illustrated version of the CAHPS instrument was designed for low-literacy audiences; the illustrations were tested and were then revised toreflect respondents' feedback. Ilustrattions were developed to support the central themes in each of 63 CAHPS text items. The cognitive testing approach was used to create a systematic method to analyze key features of an item and develop the corresponding interview procedure. Following cognitive interviews on subsets of illustrations and items with more than 900 patients, all but 7 (11%) of the 63 items met the criterion that no more than 25% of the sample who saw the illustration could be rated as having "limited/no understanding." By the final pilot, a median of 66% had "full understanding," 20% had "partial understanding," and 14% had "limited/no understanding" of the 43 illustrations needing revision. The protocol helped improve the respondents' understanding of the illustrations. The experiences and lessons learned can guide design of illustration-enhanced materials for low-literacy populations.

Tailoring print materials to match literacy levels:A challenge for document designers and practitioners in adult literacy

One in three South Africans aged 20 and older has not completed primary school, or has no schooling at all. Communication specialists who are in the business of writing public information documents need to take cognisance of this fact if they are committed to producing documents that meet the needs and skill levels of their different audiences. They also need a basic understanding of the reading strategies of both highly skilled and less-skilled readers, an awareness of the differences in processing and acceptance of visuals by skilled and unskilled viewers, and the ability to translate the relevant user variables into textual variables. This article is aimed at giving an overview of the most important theories that describe and/or explain how low-literate audiences process and react to printed information, and to match these theories with research-based principles and best practices for designing readercentred public information documents. The outcome of the article is a comprehensive set of design heuristics for low-literacy public information materials, based on relevant information-processing features that have been derived from the literature on reading comprehension and visual literacy.

Development of a Color-Coded Bilingual Food Label for Low-Literacy Latino Caretakers

The purpose of this study was to develop a bilingual, user-friendly food label (UFFL) for low-literacy audiences. The UFFL developed was based on (a) a quantitative and qualitative needs assessment of Food and Drug Administration (FDA) food label understanding and use, (b) the development of a UFFL, and (c) a qualitative evaluation of the UFFL. Subjects consisted of a convenience sample (N = 150) of low-income Latino caretakers living in Hartford with children under 6 years of age, who were recruited from local community agencies.The primary outcomes measured in this study were food label use, knowledge, and understanding. Chi-square analyses were conducted to determine relationships between subjects’ socioeconomic status and demographic characteristics with food label use, knowledge, and understanding. Although 96% of respondents were familiar with the FDA food label, only 30% used it routinely when grocery shopping. FDA food label knowledge was positively associated (p ≤ .05) with younger age, level of education, and being an English speaker. A UFFL was developed that included color coding, bilingual text, and a shaded Food Guide Pyramid. Results indicated that participants found the UFFL easy to understand. The UFFL can be used as a nutrition education tool and the methodology developed may help food policy makers to improve the nutrition education value of the FDA food label.

Overview of reading and literacy research and applications in nutrition education

Literacy requires information processing skills in addition to the ability to read and write. Estimates of the prevalence of illiteracy in the United States vary according to the criteria used. Economic, social and cultural factors contribute to higher rates of illiteracy in some population subgroups. Tools for quantitative and qualitative measures of literacy skills have been developed. Nutrition education materials are often written at levels that are too difficult for low-literate readers. Educational materials are more effective when they are tailored to the cognitive abilities and learning styles of the intended audience. The readability of a given text can be crudely estimated by several formulas that use sentence length and multi-syllable words to indicate complex syntax and difficult vocabulary. Techniques such as Cloze and signaled stopping provide more direct measures of readability. The Language Experience Approach has been adapted to aid in developing materials for specific low-literate target groups. Examples of existing low-literacy materials and guides for educators interested in developing materials for low-literate audiences are cited. Practical techniques are needed for measuring literacy skills of target clientele and readability of nutrition education materials.

Developing materials for low-income low-literacy audiences

Developing materials for low-income low-literacy audiences