Optim timizing Health lth Lit iteracy Pro rograms: : In - - PowerPoint PPT Presentation

Optim timizing Health lth Lit iteracy Pro rograms: : In Innovativ tive St Stra rategies Fro rom th the Fie ield (P (Part rt 2)

Ap April il 9, 9, 201 2019

The importance of health literacy

1 Kutner, Greenburg, Jin, & Paulsen, 2006

Prevalence of low health literacy

In 2003, only 12% of American adults had proficient health literacy.1 Rates were lower for racial and ethnic minorities, nonnative English speakers, and those with a low socio-economic status.

The importance of health literacy

2 Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004; Paasche-Orlow & Wolf, 2007 3 Chaudhry et. al, 2011; Howard, Sentell, & Gazmararian, 2006; Osborn et.al, 2011; Osborn, Paasche-Orlow, Davis, & Wolf, 2007

• Low health literacy is linked to variety of

poor health outcomes, including higher morbidity rates.2

• Low health literacy contributes to racial

and ethnic health disparities.3

Impact of low health literacy

PRESENTERS FOR TODAY’S WEBINAR

Neissly Tapia, Outreach Worker, North Carolina Farmworkers Project. Ms. Tapia uses the Popular Education Insurance Utilization Training Program, which helps seasonal farmworkers learn about how to access needed health care and stay healthy. The program delivers procedures and protocols via song- and video-based activities. Everly Macario, Public Health Research and Communications Consultant. Dr. Macario is a behavioral scientist with expertise in health communications and social marketing. Dr. Macario developed a series of English/Spanish fototabloids that were published in community newspapers, reaching predominantly Hispanic/Latino populations with varying levels of English proficiency and health literacy about diabetes prevention in rural New Mexico. Oscar J. Espinosa, Senior Associate at Community Science. He has led multiple projects in underserved communities around the country that assessed the effectiveness of outreach and education strategies designed to improve access to health care services for difficult-to-reach populations.

USING SONGS AND GAMES TO REACH RURAL FARM WORKERS

North Carolina Farmworkers Project

• Ms. Neissly Tapia

NORTH CAROLINA FARMWORKERS PROJECT

• Founded in 1994 to promote the organization of farmworkers, help them find

solutions to their problems and give them the tools to better their work conditions, living conditions, and health.

• Located in Benson, NC
• Current programs:
• Health education
• Promotores
• Project of healthy foods for

diabetics

• Research partnership with

Wake Forest University

• Affordable Care Act outreach

and enrollment

OUR PURPOSE

• Identify problems
• Find solutions
• Empower

CHALLENGES

• Schedule flexibility
• Low education levels/reading

proficiency

• Engage audience in dynamic and

culturally competent way:

• “De Colores” song
• “El Repollo” game
• Gain audience’s trust and engage them in a conversation

about their health

DEVELOPING THE INNOVATION

• Popular Education trainings
• Team Work
• Brainstorming process
• Cultural and linguistic

competence

• El tabaco (The Tobacco) song

(music of De Colores)

• El Repollo (the cabbage) game
• Knowledge gain in an

interactive way

• Meetings (outreach visits)
• Impact (behavior change)

EL TABACO “THE TOBACCO” SONG

The tobacco, the tobacco has nicotine That comes through your pores. The Tobacco, the tobacco is very bad, very bad Even for the bulls. If it gets wet, if it gets wet you can have nauseas And also throw up. //And that’s why you should cover With long sleeves and your boots

• too. //

English version Versión en español

El tabaco, el tabaco tiene nicotina que entra por los poros. El tabaco, el tabaco es muy malo, muy malo, hasta para los toros. Si se moja, si se moja les puede dar náuseas Y también vomitar. // Y es por eso debes cubrirte con las mangas largas y botas también. //

EL REPOLLO (THE CABBAGE) GAME

• Q & A Game
• Audience participation
• Learn from each other
• Changes in behavior
• Increase in use of preventive practices
• Reduction of allergies and tobacco related

illness

TIPS/ LESSONS LEARNED

• Flexibility
• Schedules
• Needs
• Environment
• Resources
• Empathy
• Cultural and linguistic competence
• Social and economic issues
• Making information useful

and accessible

• Creativity
• Use existing material in a dynamic

way

• Teamwork
• Brainstorm process
• Community Connection
• Partnerships with local clinics and transportation services
• Relationships with Farmworkers

CONTACT INFORMATION

Neissly Tapia CAC O&E Program neissly@ncfwp.org 919-820-7381 Ana Beltran CAC O&E Program anab@ncfwp.org 910-891-8254 Janeth Tapia Outreach coordinator Janeth@ncfwp.org 919-915-2220 Anna Jensen Executive Director annaj@ncfwp.org 919-915-9990

BILINGUAL FOTO-TABLOIDS IN COMMUNITY NEWSPAPERS

• Dr. Everly Macario

Public Health Research and Communications Consultant

MINI-HISTORY OF FOTONOVELAS

• “Fotonovela:” Story using posed photographs (not illustrations), text

bubbles with simple text, dramatic narrative with characters in common everyday situations.

• Fotonovelas started post-WWII—photo-booklets 1st produced in Italy as a

by-product of film industry—pictorial summaries of Hollywood films; evolved into their own/unique mediums.

• 1979: Mexico publishing 70 million copies PER MONTH of fotonovelas /

“historietas” (graphic novels with illustrations).

• 1970s-1980s—fotonovelas became a popular cultural communication /

entertainment medium within U.S. Latino communities.

• Fotonovelas served as a cultural bridge between an often impersonal,

unfamiliar, and often alienating environment and the more familiar heritage of readers.

SAMPLE 1986 FOTONOVELA

SAMPLE 1986 FOTONOVELA

FOTONOVELAS TODAY

• Today, fotonovelas read/discussed/loaned/rented/resold among family

members and neighbors.

• This is important because: 7 in 10 Latinos report obtaining health

information through their social networks (family, friends, churches, community groups).

• Public Health uses fotonovelas as an educational tool—educational

messages are incorporated into popular entertainment narratives (consciousness raising, dramatic relief) (“edutainment”).

• Motivation to learn increases when education content relates to personal

beliefs and experiences through open-ended stories, socio-dramas, and pictures depicting typical health-related situations.

SAMPLE BILINGUAL FOTONOVELA (2013—DATE)

LATINOS IN THE UNITED STATES

• Latino population in the U.S.: 56.6 million.
• 17.6% of total U.S. population.
• CHALLENGE: Latinos suffer disproportionately from diabetes and

pre-diabetes.

• 17% of adult Latinos in the U.S. have diagnosed diabetes, compared

with 8% of non-Hispanic white adults.

• For Mexican Americans, who comprise 63.3% of the U.S. Latino

population, the rate of diagnosed diabetes is 18.3%.

HISPANICS/LATINOS & HEALTH LITERACY: CHALLENGES

• Latinos are more likely than non-Hispanic whites to experience

difficulty communicating with their physicians.

• Spanish-speaking Latinos have more difficulty than whites and African

Americans understanding prescription bottle instructions and written health information obtained from a doctor’s office.

• Health literacy is an issue for the general population, but for Latinos,

the issue is magnified because:

• Lack of English language proficiency.
• Inadequately translated materials that go from high literacy English to even

higher literacy Spanish.

• Trouble accessing health care.
• Other socio-cultural barriers.

HISPANICS/LATINOS & RURAL U.S.

• Latinos are one of the fastest growing RURAL populations in the U.S.
• 3.2 million Latinos live in rural areas, comprising 6.3% of the nation’s

non-metro inhabitants.

• New Mexico is in top 7 states in U.S. with highest concentration of

Latinos living in non-metro areas.

• CHALLENGE: Meeting rural Latinos’ health information and health

care needs.

PRINT VS. ONLINE HEALTH INFORMATION: CHALLENGES

• A majority of seniors prefer information in PRINT form to learn about

health.

• A 2016 study found that only 5%-8% of thousands of Medicare

patients were going online to fill prescriptions, deal with health insurance, or communicate with their doctors.

• Only 16% were searching for health information online.

HEALTH LITERACY INNOVATION: FOTOTABLOIDS

• CHALLENGE: How to address Latino diabetes health disparities in rural

areas?

• KEY

DECISIONS: We combined 3 proven, popular, and credible communication vehicles for addressing Latino diabetes health disparities in rural areas: Bilingual--

• Community newspapers
• Health-related fotonovelas in fototabloid format.
• Community health promoters/workers (“promotores”).

FOTOTABLOID CONTENT

• Fototabloid content was based on CDC National Diabetes Prevention

Program (NDPP)—a program proven to prevent or delay type 2 diabetes.

• Goal of fototabloids: To motivate Latinos with prediabetes to call for

more information on diabetes prevention or enroll in local NDPP class (sponsored by New Mexico Department of Health).

• We

tested this intervention in Albuquerque (intervention-plus: fototabloids+promotores), Española (intervention: fototabloids only/no promotores), and Sunland Park in New Mexico (control: posters/pamphlets only [no foto-tabloids/no promotores]).

FOTOTABLOID PRODUCTION PROCESS

1. Secure SBIR funding. 2. Partner with The Fotonovela Production Company & New Mexico Department of Health. 3. Conceive the idea/plot for each fototabloid, based on CDC DPP content. 4. Write a script for each fototabloid. 5. Cast actors for photographs. 6. Take the photographs. 7. Lay-out the photographs and talking bubbles. 8. Fine-tune the final copy and photographs for a seamless story and layout. 9. Publish foto-tabloids in Dandy Dime/Thrifty Nickel (deposited at locations like truck stops) and The Albuquerque Journal (11”x17” color), one-week apart.

FOTOTABLOID TOPICS

• What is Prediabetes? / ¿Qué es la prediabetes?
• Know Your Prediabetes Score / Conozca su riesgo de prediabetes
• Move Your Body / ¡A moverse!
• Why Lose Weight? / ¿Por qué perder peso?
• What’s All This Talk about My Plate? / ¿Qué es esto de mi plato?
• Breaking A Habit / A cambiar los habitos

CALL-TO-ACTION

Project Toll-Free Number

• In all fototabloids, we included a dedicated bilingual program

telephone number for readers to contact if interested in more information and registering for a local NDPP class.

National Diabetes Prevention Program (NDPP) Classes

• We offered 2 NDPP classes, facilitated by 2 Certified NDPP Health

Coaches (trained by New Mexico Department of Health and CDC) at Rio Arriba County Health Commons (Española) and Bernalillo County Extension Office (rural South Valley, Albuquerque).

FOTOTABLOID EXAMPLES

Know Your Prediabetes Score English Move Your Body English

CHALLENGES

• Community

newspapers have limited reach (re: days paper is circulated / number of papers it circulates & drop-off locations) and because of low funding, are subject to shutting down unexpectedly.

• Community newspapers have their own formatting requirements so 1 layout

may not fit all requirements; tailoring artwork to fit different newspapers’ needs adds costs.

• Partners that commit early on may “drop-out” once the project is:

funded or ready to go in the field.

• Transportation / time of day (at night, when it is dark) to/from NDPP

classes can be a barrier to potential participants participating.

• The NDPP program is intensive—1x/week, 1 hour each meeting, for 6-12

months (inclusive of labor-intensive daily food log): it is challenging for participants to sustain this level of participation. (Participants who maintain the most meticulous food logs lose the most weight.) Physical activity expectations are also challenging for participants to achieve.

TIPS / LESSONS LEARNED

• Use culturally appropriate elements.
• Develop fototabloids in English and Spanish.
• Consider specific target audience elements.
• Use attention-grabbing elements.

TIPS / LESSONS LEARNED

• Focus on one topic at a time.
• Keep audience engaged over time.
• Include interactive activities.
• Include clear action steps.
• Action or service offered should try to remove barriers / not be overwhelming.
• Use local expertise.
• Develop Memoranda of Understanding with partner(s) before project launch.
• Disseminate via existing community-trusted vehicles.

CONTACT INFORMATION

• Dr. Everly Macario, Sc.D., M.S., Ed.M.

Consultant Public Health Research and Communications English & Spanish 773-752-7732 everly.macario@gmail.com

EMERGING DESIGN PRINCIPLES FOR OPTIMIZING HEALTH INTERVENTIONS FOR UNDERSERVED POPULATIONS

Oscar Espinosa Senior Associate Community Science

ILLUSTRATIVE IMPLEMENTATION CHALLENGES

Domai ain Implement mplementat ation ion Challen enge ge Ac Access cess

Lack of trust in program staff Isolated/hard-to-reach populations Participants’ limited access to transportation to access services Limited access to the internet

Compreh prehen ension sion

Need to tailor materials to be culturally relevant Age-appropriate content and information delivery methods

Commu mmuni nicat cation ion

Limited computer literacy skills Limited English proficiency

Up Uptake

Opportunity to apply information learned Lack of familiarity with the U.S. health care system Note: Domains adapted from Shum, J., Poureslami, I., Doyle-Waters, M. M., & FitzGerald, J. M. (2016).

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES

Challen enge ge Strategy Age-appr pprop

• pria

iate conten ent t and deliver ery

Pilot test the content using cognitive interviewing with participants from same age group. Align the delivery method to the age group: coloring books for kids, card games for adults, video games for teens.

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES (2)

Challen enge ge Strategy Cultu tural al compe mpetence nce Divers erse service ice populat ation

• n

Hire intervention support staff from within the community so they reflect the culture of the target population. Think beyond language; incorporate cultural symbols, philosophies, and history into the health message and how it is delivered. Get to know the community during the design phase, not during implementation. Respect local expertise by recruiting subject matter experts from within or in close proximity to the target community.

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES (3)

Challen enge ge Strategy egy Isol

• lat

ated/h ed/har ard-to to-rea each ch populat ations

• ns

Geogr grap aphica ically y dispe persed sed populat ation

• n

Transpor sporta tatio tion n constr straints aints

Meet people where they congregate rather than spend funds for recruitment and rent (schools, churches, post office, etc.). Use local newspapers, radio, and/ or online resources to disseminate information. Train those who have ready access to your target population so that information reaches the right people (e.g. students to get to low literacy adults). Partner with local service providers who might provide transportation for your target population.

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES (4)

Language age barrier er Divers erse levels els of formal mal educat ation ion Strategy egy

Use plain language in your verbal and written communication. Keep written materials short (one page); use contextually relevant pictures and examples. Deliver health messages using song, theatre, animations, games, and using on-line media (e.g., YouTube, Facebook, etc.). Use knowledge-reinforcement techniques like “teach back” and “need to know, need to do” to reinforce information.

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES (5)

Challen enge ge Strategy egy Lack of fa fami miliar iarit ity y with h the U. U.S.

• S. health

th care system em

Make resources from the U.S. health system accessible; this may include translating the information, rewriting in plain language, incorporating it into a game, etc. Break down the process of accessing health services using theatre- based skits that demonstrate procedures and protocols.

STRATEGIES THAT ADDRESS IMPLEMENTATION CHALLENGES (6)

Challenge Strategy La Lack of comput puter er literacy acy skills Limited ed access cess to interne net

Partner with libraries and schools to provide computer and internet access. Teach computer and health literacy simultaneously by providing health resources via the internet. Build skills that help participants assess the validity of on-line health information. Teach young adults to train adults on basic health information search techniques.

INTERVENTION DESIGN PRINCIPLE 1

Get t to know w th the communit unity

• Know where community members:
• Congregate
• Feel comfortable
• Who they trust
• Learn about community health concerns
• Learn about previous efforts to address specific health issues

INTERVENTION DESIGN PRINCIPLE 2

Make th the deliv iver ery y of information

• rmation fun and engag

gagin ing

• Keep participants engaged
• Can make complex terms and concepts easier to understand and apply
• Reinforces information
• Improves long-term recall
• Fun/engaging activities:
• Watching or participating in theater
• Singing songs
• Playing games

INTERVENTION DESIGN PRINCIPLE 3

Thin ink k beyond

• nd lang

nguage age in cultural tural competence ence

• Translating material into multiple languages is necessary but not sufficient
• Things to consider when creating culturally competent forms:
• Authenticity
• Format of communication vehicle
• Values of target group

INTERVENTION DESIGN PRINCIPLE 4

Focus s on th the endg dgam ame e early ly—di disseminat semination ion

• Be creative in disseminating information, esp. with hard-to-reach

populations

• When disseminating key health messages, creative solutions should

consider:

• Technology
• Social media
• Word of mouth
• Common gathering places

INTERVENTION DESIGN PRINCIPLE 5

Think ink of long-term erm impacts cts beyond

• nd th

the inter erven enti tion

• n period

iod

• Think of ways to incorporate core parts of the intervention into the
• rganizations’ current practices
• Create resources that can remain with participants after the intervention

QUESTIONS

CONTACT INFORMATION

Brandon W. Coffee-Borden, Managing Associate Community Science (240) 813-9240 bcoffeeborden@communityscience.com Neissly Tapia CAC O&E Program North Carolina Farmworkers Project 919-820-7381 neissly@ncfwp.org Lindsay R. Bynum Senior Analyst Community Science 240-813-9266 lbynum@communityscience.com Everly Macario Consultant Public Health Research and Communications English & Spanish 773-752-7732 everly.macario@gmail.com Maria F. Mata Analyst Community Science 240-813-9262 mmata@communityscience.com Oscar J. Espinosa Senior Associate Community Science 240-813-9280

• espinosa@communityscience.com

THANK YOU!