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[1].  Even though  communities such as Ward 1 include 45.7% Blacks and 24.7% Hispanics[2], 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)[3].  Similarly, the population seen at the Howard University Speech and Hearing Clinic comprises 95% Blacks and 5% Hispanics (from a total of 225 clients)[4].

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[5].  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.[6]  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.”[7]

Description of health programs

Overview.  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[8].  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.[9]  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[10].   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 service providers.

The Institute for Healthcare Advancement summarized from research that written health materials usually appear at the 10^th 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 instructions.[11]  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 populations.

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

a.                   Increase the knowledge of African Americans and Hispanic populations about speech and language pathology, and audiology issues and services.

b.                  Meet the needs of health providers by offering materials to complement and enhance their services.

c.                   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. [12]  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 [13]^{,[14],[15],[16]}.  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[17].  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 Dissemination

Impact.  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. 

Dissemination.  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.