Initial Project Plan
This project is aimed
at increasing health literacy in the areas of Speech and Language Pathology, and
Audiology of Hispanics and African Americans who have low literacy levels in
English and/or Spanish.
Washington, DC is
comprised of 63% Blacks and 7% Hispanics.
Even though communities such as Ward 1 include 45.7% Blacks and 24.7%
some clinics do attract a larger percentage of minority clients. For example, the
profile of minorities served at the Scottish Rite Child Language Development Center comprises 70% Hispanics
and 25% Blacks (from a total of 600 clients).
Similarly, the population seen at the Howard University Speech and Hearing
Clinic comprises 95%
Blacks and 5% Hispanics (from a total of 225 clients).
The Center for Health
Care Strategies has estimated that minorities and immigrants have
disproportionate literacy problems (50% Hispanics and 40% Blacks) which increase
their health risks.
In D. C., adult education levels in the communities where the sites are located
are the second lowest. Only 68.4% report having a High School education.
Nevertheless, based on the numbers reported in the previous paragraph, it would
be assumed that the percentage of clients with only High School education or
less is higher. Most Hispanics served are Central American immigrants who do
not have English literacy competencies necessary to successfully navigate
English literature. Furthermore, because they come from poor rural sectors,
Spanish language literacy skills are also low. Filling out simple clinical case
history and insurance forms in either language requires individual attention
from clinical staff. This experience runs in concert with a report of the
Council of Scientific Affairs of the American Medical Association (1999) on
functional health literacy. As reported by the National Library of Medicine (NLM),
this study states 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.”
Description of health programs
This program proposes to establish a web-based site containing “talking
brochures” to be accessed by different service delivery sites. The “talking
brochures” will be designed to complement Speech and Language Pathology, and
Audiology services. These web-based culturally and linguistically appropriate
materials will offer low literacy clients the opportunity to receive clinical
instructions and health information in a format that will increase their
understanding of: a) procedures of services, b) the nature of speech and
language pathologies and hearing problems, and c) clinical recommendations.
Offering alternative methods of communication to English and/or Spanish low
literacy Hispanics and African Americans will address the Healthy People 2010
overarching goal of eliminating health disparities. One of the leading health
indicators is Access to Health Care.
For minorities, financial, structural and personal barriers prevent access.
This project will address the latter two barriers. A structural barrier
includes the lack of service providers to meet the needs of clients. The
American-Speech-Language and Hearing Association (ASHA) has identified the lack
of professionals as a problem, particularly with respect to limited English
proficient speaking clients. Only 2.5% of Speech-Language Pathologists and 1.8%
of Audiologists identify their ethnicity as Hispanic, and not all Hispanic
professionals are Spanish proficient.
Furthermore, the time demands of service providers, and particularly of those
servicing bilingual populations preclude them from entirely meeting all of their
clients’ individual needs. Personal barriers include among others, language
barriers and lack of knowledge about health procedures.
Two language barriers are of interest to this project. First, language barriers
caused by low literacy rates in immigrant Hispanics and African Americans
because of inadequate education attainment in their Spanish and/or English.
Second, language barriers faced by Hispanics because of insufficient oral
English proficiencies in the clients or insufficient Spanish proficiencies in
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 to much information and no
explanation of uncommon words, and that treatments are accompanied by complex
They recommend that appropriate materials be developed. The materials that
will be developed in this project will be culturally and linguistically
appropriate by presenting material that is printed in appropriate educational
levels, that is accompanied by voice and pictures. A “photonovela” format will
be utilized, which has proven to be effective with low-literate immigrant
Specific Aims. 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 speech and language pathology, and audiology issues and services.
Meet the needs of health providers by offering materials to complement
and enhance their services.
Carry out research activities to probe on the effectiveness of using
web-based materials with low literacy and limited English proficient clients.
Plan for the Program.
A. Needs Assessment. A needs assessment will be carried out to gather
information about what materials are needed by the service providers in both
sites. Service providers will be asked to name and prioritize the subject
matter of the “talking brochures” and to brainstorm different methods for their
utilization. Information gathered will be used when developing materials and
training service providers in their use. Service providers will be asked to
select topics regarding to speech and language pathologies, hearing problems,
normal speech and language development and use and normal hearing development
and use. They will also be asked to specify if the materials will be used: a)
for prevention (i.e. normal language development in children, proper care of
voice, protection from noise), b) for service delivery (i.e. hearing screening
instructions and demonstrations, steps of an articulation evaluation), or c) for
remediation (i.e. proper care of the hearing aid, caring for a family member
with swallowing problems).
B. Materials Production. Once the topics and purposes of the “talking
brochures” have been identified, teams will use research-based information to
develop the information content. While video-streaming would seem the
preferred mode, the “talking brochures” will be produced using PowerPoint
software since it is a program that is readily available in most computers and
does not place memory, speed and storage demands. Furthermore, they may be
downloaded and printed offering clients hardcopies.
The brochures will be produced using a “photonovela” format, which takes
advantage of the strong oral traditions of both African American and Hispanic
populations. Both “photonovela” formats and stories have been used successfully
internationally and in the United States for health education
The “photonovela” uses stories to convey a message similar to comic books. They
relate a story using photographs and dialogue boxes or bubbles containing simple
language. Appendix A presents a sample of a hard copy by the Farm Worker Eye
Network addressing eye care and eye injury prevention.
In this project, the photographs will also be accompanied by voice-overs in
English and in Spanish separately.
C. Implementation. The “talking brochures” will be produced and linked
to a web site. Service providers will be trained in the use of the brochures.
Service providers will be able to use the materials at any moment of service
delivery. For example, a photonovela giving instructions in Spanish about an
audiological evaluation may be made available to the client while they are
waiting for services, or simultaneously when the audiologist is giving the
instructions. These materials may also by parents while they are waiting for a
child being evaluated so they better understand the procedures. Since the
materials can be reproduced, clients may also take hard-copies home.
D. Evaluation. This project will carry out a research program that
will be used for evaluation purposes. First, service providers and clients
will be surveyed to obtain formative and summative information. They will be
asked questions regarding facility of use and satisfaction. Second, health
knowledge retention will be gauged by offering one set of clients traditional
brochures, a second set of clients traditional brochures and asking them to read
and respond to questions and a third set of clients “talking brochures”
web-based materials and asking them to respond to questions. After 30 days,
all clients will be interviewed and their recall will be compared to their
previous performance and to that of other clients.
Project Impact and
This program will be an interdisciplinary effort between speech and
language pathologists, and an audiologist. This program’s activities will
address, first, immigrant Hispanics who are limited English proficient and who
have low literacy levels in English and/or Spanish, and second, African
Americans with low literacy levels. It is expected that presenting culturally
and linguistically appropriate materials will help clients to better understand
and retain information that will enhance prevention, procedural and treatment
goals and activities.
The dissemination plan will include presenting papers in professional
organizations of both professions. These may include ASHA, American Academy of
Audiologists, the National Black Association of Speech, Language and Hearing,
and the Council for Exceptional Children. Furthermore, papers may also be
presented before professional organizations addressing health literacy in
minority populations. Because this program will have materials that are
web-based, professionals in other states and countries may readily access them.
Links to the web-site may be made through the websites of professional
organizations such as ASHA.
As more clinics acquire technology with more capacities, these “talking
brochures” may be delivered using video streaming and touchscreen