 We're getting into a little bit more information and specifics about connecting with clients as well as health care information providers with regard to literacy and health related information. I'm really grateful that she'll be able to introduce Catherine Anderson. And she is with Sage Works, Accessible Health Communications from Austin, Texas. She is a member of our Sally community and was very, very helpful in helping us put this program together and our input from putting the program together. So she works, her organization works with increasing the ability of all audiences, especially those with limited literacy to be able to read, to comprehend and act on health information. So, thank you very much. Thank you. I'm so glad to be here and glad to see everyone here. It's nice to have a great audience like this. And nice to be following up on such a wonderful, wonderful introduction or continuation of Health Literacy from Terry Davis, who's, as always, inspiring and wonderful. And I'm so glad I was able to be there for that. And so we are going to talk at the sort of nitty-gritty level of health literacy today. How do you get down there in that interaction between the provider or the resource person, many of you from health agencies are not providers, but are the people who provide access or go out into the community and talk to people about health care? So how do you get right there in that interaction and pass on what you know about health literacy? So what I'm going to talk about today is mostly the low-tech, high-touch area of the spectrum. And I'll be talking about something called collaborative composing. So let's go right in to just quick review some of those recommended strategies that Terry Davis is talking about this morning for improving communication between a user and a user and a provider or a community worker or a social worker who is working with someone who's coming in and is at risk for HIV-AIDS. So what are those strategies look like? They are explaining things, clearly focusing on key messages and repeating those key messages using teach back. This is all reviewed. Terry just said all this a few minutes ago. Effectively soliciting questions and this is where we come in. Focus on using patient-friendly educational materials to enhance that interaction, not just to send them home with that great diabetes material, as Terry was saying, but using those patient-friendly materials as a tool in that interaction. So that's what we focus on at SageWords. But we were lucky enough to come down to San Antonio to start working with the health collaborative and with Sally. And so we got involved in a project to create some materials, some prevention messages for women, Latinas who are at high risk for contracting HIV-AIDS. So quick review some of those strategies again that Terry talked about for patient-friendly educational materials. Cultural awareness is one I don't know that she actually mentioned, but it's key for us understanding who the end user is. Okay, graphics, we talked about those. We'll be talking a lot about those later on. Using plain language, fonts and font size, we talked about that a little bit. This is annoying. Let me see if I can... Let me actually see if I can speak up a little bit. Can you hear me now? Okay, let's try it without the microphone for the time being. Okay, a little bit better. You can still hear me, but don't speak back. Font size, we talked about that. Fifth grade reading level. Everybody knows about this, but I want to stress that that is the very first condition, but certainly not the following condition that you need to have. In fact, we have done testing where we have used two different materials, both at the fifth grade reading level. Both of them are materials that people could understand, but the one that used other strategies in addition to that were the ones that were successful. Just being able to read is not enough. It's a necessary but not a sufficient condition. Plenty of white space and user input into the content. We boiled these down to three key strategies. All the others you need to have and you need to be aware of. But these are the ones we believe make the most difference to the kind of graphics that you use having that end user input into the content and being culturally attentive. Terry, this morning, talked a little bit about the providers not knowing what it is that their patients don't know. And having user input into the content is the only way you can find out what the patients don't know. You need to know what they know as well as what they don't know in order to be able to give them materials that are going to be really useful to them. A little bit of meaningful and useful at the same time. So what was the process for this project that we embarked upon with the Health Collaborative and with Sally? The first part of the process was the getting together, the gathering of an expert panel. And that happened. I'll talk a little bit more about this through the offices of the Health Collaborative who, as you have heard, has its many, many pieces, many parts in this community. And so they were in fact able to do this for us. They brought to the table some key players to discuss, first of all, what is going to be the message of this material that we were going to construct? Prevention, HIV-AIDS, Latinas, what actually was the message going to be? So we sat around a table with groups and all identified them in a minute to talk about what the message would be. Protection was the primary message. This is for women who are at risk of HIV-AIDS. And so that included condom use and testing. While it's important to do those two things, use condoms and get tested, offering help and encouragement to do it, that's the action part of it. You can tell them it's a good thing to do, or as Terry said, you can tell me I need to exercise five times a week, but that's like telling me that I need to go to the moon. So why do it as a key piece? And then key to this was where resources for testing could be found. So that was what we agreed upon. But we really focused on in the user panel the idea that we really needed to know the end user. We needed to have cultural awareness of who that person was. And so in the expert panel in that room were many people who serve the San Antonio community. There were HIV-AIDS providers in Bear County who many of them themselves were Latinas. And one of the very important things that came out of that discussion was the importance of the different ages of the Latina women. The recognition that the message about prevention and testing would need to be very different if you were 19 as opposed to if you were 65. So that was absolutely key to how we started to develop the message. And what we decided was that we would develop three materials. One for the Hovencithus, the 18 to 29 year olds, one for the Damas, the 30, 45 year olds, and then for the Donias, the 45 and older. So that was our key piece, yes. Because that's where I'm following up. I don't see that age group there. 45 and older. 45 and older. Sorry. I think we have our faces covered. And of course those age groups are, they're numerical but flexible of course. In the Hovencithus group are many young women who are much younger than 18 who need access to this kind of information as well. But this is our general grouping. So the second thing we did in the expert panel was we worked on choosing the form. What were we going to provide in the way of patient education materials? Were we just going to give out a flyer or brochure? Was it going to be a booklet? And the idea of photo novellas was really key again at the beginning of this project. So how many of you are familiar with photo novellas? How many of you are not familiar with photo novellas? Okay. So a photo novella is basically a booklet. It's really a comic book format except it uses photographs, not drawings. And it's not about comedy at all in any way shape or form. And you can see here is a standard page from a very traditional photo novella which uses primarily dialogue to get the message across. So it's a little story. You all know tele novellas, right? And so this is photo novellas which were in fact they were developed as synopses of movies in the 1950s in Latin and Central America. And they were very, very popular. So they started out in this kind of context of summarizing these 1950s movies which were often about sex and so on and so forth and action and adventure. And they became subsequently a tool to educate about sexual risk and action and adventure. In the 1970s they became very popular and there's an astounding number of these that were produced in the 1970s in the millions of copies in Mexico and other countries. So they were a very popular way of delivering health information and especially popular with middle-aged Latino women who were at least a third of our target audience. And there's evidence that shows that it's a successful medium for delivering health education in this particular way. More reasons why photo novellas, they are inherently health literate. They relied primarily on graphics and dialogue and dialogue is very little text. So you don't have a big paragraph of information that tells you all kinds of things. You have a conversation between people. And in our case we realized that the conversations in our little photo novellas actually modeled what we hoped that the end user would be able to say. So we can use them as models. You can actually read one of these. I think I can say that to my boyfriend and actually use those words as models. They're narratives and of course storytelling is a most compelling way of getting information across. It's really effective. You remember that Terry talked about the automated telephone calls and she said that they began with stories. So those automated telephone calls are their way of engaging people, drawing them in right from the very beginning. And then the other thing, the final thing is that if you do a photo novella well then you see yourself in those characters. They are who you are. And that becomes a really effective motivator. So let's talk for a few minutes about graphics in general. This is the graphics I think all but one maybe from a brochure. And what I'm going to ask you to do is tell me what do you think the topic of this brochure is? Any guesses, any clues? Education. Education? Any other guesses? Health. Health? What makes you think it's health related? The stethoscope. The stethoscope, yes. Okay we've got a little cue in the graphic there. Okay. And there's a doctor who's got a piece of paper and describing something or talking about something to a patient. Any other ideas? Family. Family? It could be about family, yes. Because you've got the family down there at the bottom. Yeah? The guy in the right is really throwing me out. What is he doing at least? He looks nice. He looks nice? He's very closet? What emotion, yes. Sorry? Health education for all ages? Right. Well, we've got all those ages down there at the bottom. Okay. This is a brochure about bipolar disorder. Yup. A story of bipolar disorder. There he is. Happy as a clam, right? He says, I knew there was something wrong with him. So the point about this is of course that graphics are great and they're important and in fact even we've done a little bit of research that says even if you just put pictures into it, no matter what the pictures are, people respond better to it. They'll be more likely to read it. You might be more likely to, we want to find out about this guy because of the graphics, but you have no idea really what the content is at all. And so our goal is to use the graphics closely linked to the text so that the graphics tell the story as well. This is actually a really well done brochure in other ways, in other help literate ways. You can see it has lots of white space, great big font, nice chunking of information, etc., etc. But the graphics are not working for it. I admit it's hard to imagine what graphics would work for bipolar disorder. But here is what we are doing in terms of graphics with a photo novella with the form itself really directing us into how the graphics can be affected. We also chose, the users helped us choose formats that reflected the reader. So for our younger age group, the Hoven Seekers, we built a very small flyer. And I'll show you these in just a minute, because one of the main concerns of this age group is confidentiality. They don't want to be carrying around a big piece of paper or leaving it on the desk for their parents to find, etc., etc. So having it small was really key. For the middle age group, this was an interesting thing that arose out of the expert panel primarily. They decided that perhaps that middle group, and I'm going to try really hard not to call them middle aged, even though that's where they are, that middle group, they thought would be more interested in a magazine format or a revista format rather than a typical photo novella. So we started out with that, and we took that concept to the end users, and they really liked it. So for the donias, for the older women, the traditional photo novellas seemed like it was going to work the best. So that's what we started out in terms of with the format. At this point is when we took it, let me actually back up and say, this is really the high touch piece of this project was twofold. That first step of going to the expert panel and gathering many of you, some of you in the room here, together at a table to talk about what it was we actually wanted to have. And these people are experts not from the user sense, but from the provider sense. They know the clients. They know the people that they're working with. They know what kinds of barriers there are for those clients, both in feeling comfortable with getting tested and using protection, but also in getting access to information and resources. They have lots of great insights into their clients. They also had access to clients, which helped us later on when we wanted to actually have the users create the materials. And they had expertise and experience. And so that crucial high touch piece was really at the bottom, at the foundation of this project that we couldn't have done without. So the second piece of high touch was on the user end rather than on the provider end. And we did that in two ways. We engaged in this process called collaborative composing, which we're going to do some of in a minute. And then from our point of view, very, very crucial is using what's called usability testing so that when we actually completed a draft of our material, we took it back to the client and said, what do you think? So then they gave us feedback at that point. We'll talk a little bit more about that as well. Does anybody know what, are you familiar with usability testing? Is this something you've heard of before? Some people, yes. Most people, it sounds like no. Not familiar with usability testing. Okay. We'll be sure to talk about that at length in a few minutes. Okay. Questions so far? Okay. Okay. So let's talk for a minute about collaborative composing. The longest piece of my somewhat scattered background as a career person is in teaching and mostly in adult education and as a teacher of writing. And so we took this concept really from writing classes where you focus on the generation of as many points of view as possible. You have a group writing activity. And the key for this project and for health literacy projects is that the end user actually writes the text. Not us. Not the health literacy expert, not the provider. And so in Terry Davis' words, the text is organized from the user's perspective. It's them telling us what needs to be said. And the end user also had input in this case into the actual design. So it's much, I think it's much, it's very clear to me that if it's somebody you're aiming at, they can tell you what's important. What they do and what they don't know. We can guess at it. We know what's important for us. We know what the message is. We want to convey. But what does it mean to them? Okay. So, and I'm just going to stop here for a minute and look at the Davis' version of our photo novella and talk a little bit about the process that we used. And then we're actually going to go in and do some of it yourself. We had some, we had a number of different exercises. We gathered together groups, thanks to the organizations whose names you saw before, of typical users from those three age groups. In each group, we did it a little bit differently. For the Davis' group, because it was a magazine article or a magazine, we had several different exercises. So one of them, for example, was colors. We just said, okay, here's colors. Let's describe those colors and describe them in terms that have to do with how you feel about yourself and getting tested for AIDS. That's kind of a complicated activity. But they were great at it. They were really great at it. We gave them a prompt that said, here's an article. It's like, you know, like interviewing Angelina and Brad, okay, except in this case it's a couple who just gotten back together after the young, the husband has been in prison for 10 months. Okay, and he's learned while he's in prison that he's HIV positive. How would you write this up? Write it for us. Write it right here and now. And they did. They did. We borrowed from those many, many, many magazine articles where there are five ways to do X, Y, or Z. You know, five ways to lose weight, five ways to stretch your, your, the items in your closet, five ways to fill up your handbag, you know, so on and so forth. So we had five ways to stay safe and we had a similar one for condom use. So we gave them prompts and they wrote them. Okay, I'll show you a little bit more about that process right now. Because what I'm going to do is, this was one of the prompts that we did not use for the donus. Okay, so Felix has come home after 10, well maybe this was a different one, about after 10 months in prison and his wife and children are very happy and so is his mother. She's very happy, but she's a little worried. So then the group of donus then had to take this exercise with the donus, the two women and the blank cartoon bubbles and fill them in. Any questions so far? So let's do a little bit of it. I have three exercises and we have nice table groups right here. So we have donus, donus and holding seat to exercises. So let's pass them out and at your table take a stab at following the instructions on the exercise. Now I have to say that a conference in a workshop like this is not a great context. For doing this in a classroom setting where it's a little more intimate and you have a facilitator who can work with the group it makes it a little bit easier but let's give it a try and you'll see what it feels like. So in your groups, in each of your groups, you can just choose to fill out one, you just have one scribe, one person who writes. But look at the prompts, talk amongst yourselves and then see if you can't actually come up with a dialogue in the case here. A dialogue about post-aphenone hands. You might have that one. You may have the advice column. I don't know who has the advice column. Or you may have the third one which is the donus one. So talk amongst yourselves. Oh you don't have one. Which would you like? Talk amongst yourselves, see what you've come up with and I'll drift around from table to table. We're going to take about 15 minutes to do this exercise. We're going to go back there and reflect on the space. In relation to how it was valued as a model. In relation to that knowledge you have at whatever age that's an apple. So how do I talk? Do you have any advice? Or do you have any advice? Do you have any advice? Do you have any advice on how I talk to myself? Sex and dating or sex and marriage? The way you talk to yourself and your friends. I don't think the relationship that they've been in is going to be the same. I don't think the relationship that they've been in is going to be the same. I'll look back and have a good night guys. Bye now. I'm going to hold the freedom. I'm going to hold the freedom. I'm going to hold the freedom. I'm going to hold the freedom as I walk in. And talk just a little bit, just remember that it's a point back about a new project. Now, one of the reasons I'm doing this here is if you want to go back to your group And you kind of get a feel of what it's like to ask somebody to do this, or how to finish something, and what you might need to do. But let's just hear in general how did it go? Let's start with you guys. How did it go? What happened? I think it went very well. Except for we are all in the doughnut and doughnut category, and we had the moment see this. So we had to reflect back to when we were younger and really didn't have this type of conversation. So we brought in the peer pressure type, you know, what are you going to do first thing? The first thing is what are you going to do? Yeah. The decision that you're going to work from there, to find a conclusion to get tested, or I ask you. That's right. That's a very realistic piece of dialogue. You know, I can imagine, well, what are you going to do exactly that? And I'm not your interviewer session to be represented. But you're doing it that you want to reach, because they are the experts in themselves. How about the group that they have that table, and we have those who do want to reach? Yeah, we had the same one. It was very interesting in ours, because when they selected the message, the first one was talking to their son about sex, number one, because we didn't know the age of the son. And the second one, we started out with relationships. And then the dialogue said, no, it says in here that he's seen several different women, and the consensus of the group became that's not developing relationships, that's dating, or that's casual sex. So when you drill down, is the point, sexual health and relationships? Or is it sexual health and then being saved in casual relationships? Or is it sexual health and dating? And so just in the dialogue and going around the thing, how do you begin to find clarity? What's your point? What's your message? What's your main goal? Exactly. So does the mother want to talk to you, that don't need to want to talk to each other about how to go about talking to your son? Or do they want to talk to each other about how to talk to your son and maintain a relationship with your son? You know, in an adult act, the Dallas table where you were doing, tell them what you were doing. They were trying to figure out how to reach the subject. And they were trying to, not solve it, they were trying to talk to each other that was the focus of our friends that they could talk to each other and that was the focus of our work. Sex again. In a few minutes that we have left, let's talk a little bit about usability testing. What is it? It's a kind of field testing along the same set of arguments. Some people say you should do this way, some people say you should do it that way. You take it to the user and that's what you listen to. And it's a way of seeing your material through the eyes of the thought. What you do when you do usability testing is you actually hand them the brochure that happened on the phone on vanilla. You watch them use it, you watch them and you watch them think aloud about it and then maybe ask them some, ask them a task with ours. And they tell you that you can watch them read it. It's done one-on-one, just about opinions because you're getting that information what the test is. So it's not just, I like the brackets, I don't like the overdress, I don't like the brochures. It's not just that we did because we created drafts of our photo envelopes and it's not user-created, it's user-individual. That gets lots of information and color is not great. But that's an initial processing. We asked them to do a task. This one was for the open seat. What we were really looking for was whether or not they would do this. But they pretty much always were able to initiate that and that was really helpful. We asked them where one place they could go to get tested and asked them some more in-line questions. This is the first page of our daughter's photo novella. Other things, I'm out there, we handed it off. Our job is done. Could have done that. Make that conversation in the she would say on 14 or I could get tested. Oh, maybe yes. Actually, there's something else. That's great. That conversation goes in before anyone that's seen in the story. I don't know if you were getting into the story. It was a novella on paper. Yeah. It was a soap opera. That's right. One minute. Oh, one minute. Okay. So you can see how we did it. That's not fair. We'd better go back and do it almost exactly like we said using bubbles. For the damas, lots of the four of the five said the main message was to use protection. But we were also pleased to find it. We said, take care of yourself, respect yourself, and educate your men across. They really responded strongly to the cover. In particular, we as a group, beforehand, had some real indecision about the color of it. First of all, I said, who uses black lips? Well, actually, it's mine. But, it's kind of really strongly the idea of a shadow side which was languished from them. And that's how they describe it. So that was really, really interesting. Maybe you really like this a lot. And the other things inside are a couple we met and reunited after 10 months. What is your most important accessory? The answer? Condoms. Five ways to stay safe and then finally, where to get tested. But again, nobody went to the testing. Nobody found that we didn't have to prompt them. So, here's the album. Seen someone, again, said on this research page, most of them got the ideas testing as the main message. But the more interesting in this one was that five clients said they would pick it up because they needed the information. That was really important. And the other four said they would pick it up because it was interesting. Yay! That's what we're looking for. Okay? So, just quickly on the high tech. We're now on the revision stage. We have to revise all three of them so I'm a little bit more so to pop out without putting them on the front page where we don't want them to not be on the front page. And I'm going to develop the first films that got translated to paper, especially the one that's each one. This size, i.e. if it were an app, this is how it would function. So, here is the hall holding to the app. I'll do it slowly so you can have a little part of it The women and the girls had never seen a female so they were just taking a break and the male, a lot of responses, they weren't aware that they had expiration dates. These are college kids. Yes. Wow. Because you're not supposed to talk about this. That's right. Yeah, but I noticed that they were all embarrassed to pick them up but they just passed by saying, this is not getting dark. And then they were just laughing. Great. Well, I just have one final thing to say before I hear all jargony said, open to people right there. So, is that piece, actually did that beforehand. In other words, she took the message first and used these kind of high-touch elements to get the message right before she got the delivery over after she got that. That's really key in all that you're doing. The last point I'd like to make is that the Health Collaborative submitted this project to the National All Parts meeting for the Health Resources and Services Administration that we held in Washington, D.C. in November. It was a collaboration between my party project, Ryan White and my party project, and we've been accepted. So, this will go national and be shown at a workshop in the Washington, D.C. in November. The second announcement I'd like to make, as many of you are from our HIE Services providers, and for those of you who are not, I'm really speaking to you. We're going through the last phase of doing the tweaks as Cap said and the shortly after the first of the year. If you would like to be a dissemination point for the Pueblo Novelas, please send an email to the Health Collaborative on this Pueblo Pueblas because we're looking for at least five sites, some of them not HIV sites, some of them boys and girls, whatever you can use to do these over the second ones, for the older ones. They're 18 years or not because as you know the age of 17-18. So that's where they're going to go. If you'd like to be a demonstration site, we're going to try and follow up with a small evaluation asking you who did you submit them to, how did they receive, and then did you do any follow up to see when the actually took action. So that's all part of the process of this project. So this is a real life thing that's going to happen in San Antonio and you could be a part of it. So thanks Kat. So much. The objectives for this particular session, again, jot down a couple of takeaways that are significant. It is a process in putting something together in order to achieve success. And one of the biggest things that she's emphasized is that we have a script, we have the expertise in developing the material, we have the input, but you use with the knowledge.