A process evaluation of a health literacy intervention targeting pediatric providers' communication skills at the Texas Children's Health Plan

Background. Health literacy is an important determinant for quality health care, and affects communication between patients and physicians. Poor communication may result in negative effects in health. Improved communication between patients and physicians could positively affect health outcomes. Communication skills are teachable.^ Objectives. (1) to evaluate the process involved in the design and implementation of a health literacy intervention targeting pediatric providers’ communication skills at the Texas Children’s Health Plan in Houston, Texas; and (2) to describe lessons learned from this process that may be used in future attempts to address the issue of health literacy and health communication. ^ Design/methods. The process evaluation of the implementation of a health literacy strategy at the Texas Children’s Health Plan (TCHP) consisted of a critical analysis of all documents and minutes from meetings of the team of investigators. It also involved a secondary analysis of data collected between December 2006 and June 2007. Descriptive statistics, paired t-test and Wilcoxon-signed-rank test were employed in analyzing the data. This information was complemented with a limited review of existing literature on communication skills training programs. ^ Results. The design of the educational intervention followed recommendations from experts in the field of health literacy. The delivery of the intervention was possible and benefited from existing resources and logistics within the TCHP. Very few targeted providers participated in two offerings of the workshop (6.6% and 1.7% respectively). After the educational intervention, providers showed increased knowledge of health literacy facts and its effects in health (p=0.001); increased awareness of the low health literacy problem (p=0.003); increased expectations for change in practice (p=0.002), and intent to use health literacy strategies for communication immediately following the intervention (p=0.001). Low participation indicated the need for further investigation of barriers to, and means for successful implementation of programs aimed to improving health communication. ^ Conclusions. A short, focused intervention utilizing health literacy strategies for communication appeared effective in increasing knowledge and intentions for change in a small group of pediatric providers. ^

The physician's perception of medical error and its application to the development of an educational training tool.

It is becoming clear that if we are to impact the rate of medical errors it will have to be done at the practicing physician level. The purpose of this project was to survey the attitude of physicians in Alabama concerning their perception of medical error, and to obtain their thoughts and desires for medical education in the area of medical errors. The information will be used in the development of a physician education program.

Camp For All Connection: a community health information outreach project

Purpose: The purpose of the Camp For All Connection project is to facilitate access to electronic health information resources at the Camp For All facility. Setting/Participants/Resources: Camp For All is a barrier-free camp working in partnership with organizations to enrich the lives of children and adults with chronic illnesses and disabilities and their families by providing camping and retreat experiences. The camp facility is located on 206 acres in Burton, Texas. The project partners are Texas Woman's University, Houston Academy of Medicine-Texas Medical Center Library, and Camp For All. Brief Description: The Camp For All Connection project placed Internet-connected workstations at the camp's health center in the main lodge and provided training in the use of electronic health information resources. A train-the-trainer approach was used to provide training to Camp For All staff. Results/Outcome: Project workstations are being used by health care providers and camp staff for communication purposes and to make better informed health care decisions for Camp For All campers. Evaluation Method: A post-training evaluation was administered at the end of the train-the-trainer session. In addition, a series of site visits and interviews was conducted with camp staff members involved in the project. The site visits and interviews allowed for ongoing dialog between project staff and project participants.

A MANAGEMENT INFORMATION SYSTEM AND EVALUATION SCHEME FOR THE UNIVERSITY OF TEXAS EMPLOYEE ASSISTANCE PROGRAMS

Early Employee Assistance Programs (EAPs) had their origin in humanitarian motives, and there was little concern for their cost/benefit ratios; however, as some programs began accumulating data and analyzing it over time, even with single variables such as absenteeism, it became apparent that the humanitarian reasons for a program could be reinforced by cost savings particularly when the existence of the program was subject to justification.^ Today there is general agreement that cost/benefit analyses of EAPs are desirable, but the specific models for such analyses, particularly those making use of sophisticated but simple computer based data management systems, are few.^ The purpose of this research and development project was to develop a method, a design, and a prototype for gathering managing and presenting information about EAPS. This scheme provides information retrieval and analyses relevant to such aspects of EAP operations as: (1) EAP personnel activities, (2) Supervisory training effectiveness, (3) Client population demographics, (4) Assessment and Referral Effectiveness, (5) Treatment network efficacy, (6) Economic worth of the EAP.^ This scheme has been implemented and made operational at The University of Texas Employee Assistance Programs for more than three years.^ Application of the scheme in the various programs has defined certain variables which remained necessary in all programs. Depending on the degree of aggressiveness for data acquisition maintained by program personnel, other program specific variables are also defined. ^

A project to improve the information seeking skills and increase the use of evidence-based research in public health practice

The ability of public health practitioners (PHPs) to work efficiently and effectively is negatively impacted by their lack of knowledge of the broad range of evidence-based practice information resources and tools that can be utilized to guide them in their development of health policies and programs. This project, a three-hour continuing education hands-on workshop with supporting resources, was designed to increase knowledge and skills of these resources. The workshop was presented as a pre-conference continuing education program for the Texas Public Health Association (TPHA) 2008 Annual Conference. Topics included: identification of evidence-based practice resources to aid in the development of policies and programs; identification of sources of publicly available data; utilization of data for community assessments; and accessing and searching the literature through a collection of databases available to all citizens of Texas. Supplemental resources included a blog that served as a gateway to the resources explored during the presentation, a community assessment workbook that incorporates both Healthy People 2010 objectives and links to reliable sources of data, and handouts providing additional instruction on the use of the resources covered during the workshop.^ Before- and after-workshop surveys based on Kirkpatrick's 4-level model of evaluation and the Theory of Planned Behavior were administered. Of the questions related to the trainer, the workshop, and the usefulness of the workshop, participants gave "Good" to "Excellent" responses to all one question. Confidence levels overall increased a statistically significant amount; measurements of attitude, social norms, and control showed no significant differences before and after the workshop. Lastly, participants indicated they were likely to use resources shown during the workshop within a one to three month time period on average. ^ The workshop and creation of supplemental resources served as a pilot for a funded project that will be continued with the development and delivery of four 4-week long webinar-based training sessions to be completed by December 2008. ^

The information bottleneck method for genome-wide association studies

In population studies, most current methods focus on identifying one outcome-related SNP at a time by testing for differences of genotype frequencies between disease and healthy groups or among different population groups. However, testing a great number of SNPs simultaneously has a problem of multiple testing and will give false-positive results. Although, this problem can be effectively dealt with through several approaches such as Bonferroni correction, permutation testing and false discovery rates, patterns of the joint effects by several genes, each with weak effect, might not be able to be determined. With the availability of high-throughput genotyping technology, searching for multiple scattered SNPs over the whole genome and modeling their joint effect on the target variable has become possible. Exhaustive search of all SNP subsets is computationally infeasible for millions of SNPs in a genome-wide study. Several effective feature selection methods combined with classification functions have been proposed to search for an optimal SNP subset among big data sets where the number of feature SNPs far exceeds the number of observations. ^ In this study, we take two steps to achieve the goal. First we selected 1000 SNPs through an effective filter method and then we performed a feature selection wrapped around a classifier to identify an optimal SNP subset for predicting disease. And also we developed a novel classification method-sequential information bottleneck method wrapped inside different search algorithms to identify an optimal subset of SNPs for classifying the outcome variable. This new method was compared with the classical linear discriminant analysis in terms of classification performance. Finally, we performed chi-square test to look at the relationship between each SNP and disease from another point of view. ^ In general, our results show that filtering features using harmononic mean of sensitivity and specificity(HMSS) through linear discriminant analysis (LDA) is better than using LDA training accuracy or mutual information in our study. Our results also demonstrate that exhaustive search of a small subset with one SNP, two SNPs or 3 SNP subset based on best 100 composite 2-SNPs can find an optimal subset and further inclusion of more SNPs through heuristic algorithm doesn't always increase the performance of SNP subsets. Although sequential forward floating selection can be applied to prevent from the nesting effect of forward selection, it does not always out-perform the latter due to overfitting from observing more complex subset states. ^ Our results also indicate that HMSS as a criterion to evaluate the classification ability of a function can be used in imbalanced data without modifying the original dataset as against classification accuracy. Our four studies suggest that Sequential Information Bottleneck(sIB), a new unsupervised technique, can be adopted to predict the outcome and its ability to detect the target status is superior to the traditional LDA in the study. ^ From our results we can see that the best test probability-HMSS for predicting CVD, stroke,CAD and psoriasis through sIB is 0.59406, 0.641815, 0.645315 and 0.678658, respectively. In terms of group prediction accuracy, the highest test accuracy of sIB for diagnosing a normal status among controls can reach 0.708999, 0.863216, 0.639918 and 0.850275 respectively in the four studies if the test accuracy among cases is required to be not less than 0.4. On the other hand, the highest test accuracy of sIB for diagnosing a disease among cases can reach 0.748644, 0.789916, 0.705701 and 0.749436 respectively in the four studies if the test accuracy among controls is required to be at least 0.4. ^ A further genome-wide association study through Chi square test shows that there are no significant SNPs detected at the cut-off level 9.09451E-08 in the Framingham heart study of CVD. Study results in WTCCC can only detect two significant SNPs that are associated with CAD. In the genome-wide study of psoriasis most of top 20 SNP markers with impressive classification accuracy are also significantly associated with the disease through chi-square test at the cut-off value 1.11E-07. ^ Although our classification methods can achieve high accuracy in the study, complete descriptions of those classification results(95% confidence interval or statistical test of differences) require more cost-effective methods or efficient computing system, both of which can't be accomplished currently in our genome-wide study. We should also note that the purpose of this study is to identify subsets of SNPs with high prediction ability and those SNPs with good discriminant power are not necessary to be causal markers for the disease.^

Assessment of markers of medication literacy in a US-Mexico border community

Each year an estimated 180,000 people in the United States (U.S.) die as a result of medication errors, now considered a major public health problem. If a patient cannot correctly act on information related to medication use or "Medication Literacy" there is an increased potential for error. Medication use issues are unique on the US-Mexico border because they include high rates of herbal products and medication products from Mexico as well as issues related to the preferred language (English or Spanish) of the patient. To evaluate the medication literacy in a US-Mexico border community, this retrospective study evaluates 180 subjects representing four diverse economic segments of a metropolitan US-Mexico Border community who have taken a Medication Literacy Assessment. The assessment tool has been created to understand how patients interpret medication information for prescription, over-the-counter, herbal, and Mexican medication product use, and how they problem-solve medication questions. The Medication Literacy Assessment tool specifically assesses document literacy (e.g., prescription labels), prose literacy (e.g., patient leaflets), numeracy (e.g., calculations and measurements) as well as qualitative data related to medication use practices. The main hypothesis of this study is that the ability to interpret and use medications will vary based on education, language (Spanish or English), and recruitment sites (economically diverse communities). The results will provide information to better characterize medication use in a primarily Hispanic population on the US-Mexico border and may be used to influence policy decisions regarding prescription and over-the-counter product information.^

Revisiting health literacy and its impact on patient-physician communication

Objective. To review professional literature on health literacy and its impact on patient-physician communication, to describe significant literature on this issue, and to summarize implications of the findings from this literature. Design. Update of a review of literature. Data sources: MEDLINE. Review Methods. Articles dealing with the impact of health literacy on patient-physician communication were selected. The articles addressed at least one of four criteria on the subject: prevalence of the problem; effect of health literacy on patient-physician communication; association of health literacy to health outcomes; and interventions to enhance communication with patients exhibiting limited health literacy. Results. Approximately 623 articles were selected for review; 87 were fully reviewed and found to be relevant to the issue; and 25 articles were cited. Conclusion. Limited health literacy is extremely widespread throughout the U.S., particularly among specific populations. Providers must be aware that patients often process health care decision making differently from their own familiar procedures and that by taking the steps to make medical language and health information simpler and the time to confirm patient understanding, health outcomes of limited health literacy populations will improve. ^

A summative evaluation of a HIV/AIDS Early Childhood Care, Education and Development Teacher Training Workshop in Mongu, Zambia

Objective. To conduct a summative evaluation of an Early Childhood Care, Education and Development (ECCED) Teacher Training Workshop in Mongu, Zambia by assessing changes in knowledge, attitudes and intent to use the information. ^ Study design. A matched cohort survey design was used with additional qualitative data collected by structured observation of workshop sessions, daily facilitator and participant debriefs and participant interviews. ^ Results. Matching pre and post tests were completed by 27 individuals in addition to daily debriefs, structured workshop observation and participant interviews with 22% of the group. The participant population was predominantly female individuals aged 15-44 years old that had completed high school and additional post-secondary training, been teaching children aged 0 – 8 years for 2-5 years in the Western Province and received other HIV/AIDS and ECCED education. Pre-tests indicated a strong understanding of ECCED principles and misconceptions regarding HIV transmission, prevention and the disease's impact on early childhood development. The workshop was found to significantly increase the participants' knowledge of topics covered by the curriculum (paired t-test, N=27, p = 0.004, 95% CI 1.8, 8.6). Participants began with a more limited understanding of HIV/AIDS than ECCED, but the mean gain was much greater at 7.4 +/- 12.3 points. Significantly more participants believed at post-test that HIV/AIDS education should increase for future educators. The 77.8% of participants that increased their knowledge scores at post-test expressed significantly less fear of having a child with HIV/AIDS in the classroom (Independent Samples t-test, N= 27, p = 0.011). Overall participant fear decreased 15.5%. 92.6% and 88.9% of participants planned at post-test to respectively use and share the taught information in their daily professional lives and reported on innovative strategies to communicate with the community. ^ Conclusions. Teacher training workshops can significantly increase HIV/AIDS awareness and promote positive attitudes in educators working with children affected by HIV/AIDS. Using participant suggested teaching techniques such as poems and songs and translating the materials to the local language could assist future facilitators to both culturally and professionally relate to the workshop audience as well as increase participant capacity to share the information with the local community. ^

Use of tabletop exercises for disaster preparedness training

Background. In public health preparedness, disaster preparedness refers to the strategic planning of responses to all types of disasters. Preparation and training for disaster response can be conducted using different teaching modalities, ranging from discussion-based programs such as seminars, drills and tabletop exercises to more complex operation-based programs such as functional exercises and full-scale exercises. Each method of instruction has its advantages and disadvantages. Tabletop exercises are facilitated discussions designed to evaluate programs, policies, and procedures; they are usually conducted in a classroom, often with tabletop props (e.g. models, maps or diagrams). ^ Objective. The overall goal of this project was to determine whether tabletop exercises are effective teaching modalities for disaster preparedness, with an emphasis on intentional chemical exposure. ^ Method. The target audience for the exercise was the Medical Reserve Brigade of the Texas State Guard, a group of volunteer healthcare providers and first responders who prepare for response to local disasters. A new tabletop exercise was designed to provide information on the complex, interrelated organizations within the national disaster preparedness program that this group would interact with in the event of a local disaster. This educational intervention consisted of a four hour multipart program that included a pretest of knowledge, lecture series, an interactive group discussion using a mock disaster scenario, a posttest of knowledge, and a course evaluation. ^ Results. Approximately 40 volunteers attended the intervention session; roughly half (n=21) had previously participated in a full scale drill. There was an 11% improvement in fund of knowledge between the pre- and post-test scores (p=0.002). Overall, the tabletop exercise was well received by those with and without prior training, with no significant differences found between these two groups in terms of relevance and appropriateness of content. However, the separate components of the tabletop exercise were variably effective, as gauged by written text comments on the questionnaire. ^ Conclusions. Tabletop exercises can be a useful training modality in disaster preparedness, as evidenced by improvement in knowledge and qualitative feedback on its value. Future offerings could incorporate recordings of participant responses during the drill, so that better feedback can be provided to them. Additional research should be conducted, using the same or similar design, in different populations that are stakeholders in disaster preparedness, so that the generalizability of these findings can be determined.^

The assessment of standardized training programs in public health preparedness

The Texas Bioterrorism Continuing Education Consortium (BCE) provided National Disaster Life Support (NDLS) training courses throughout the state of Texas in 2005, to help improve knowledge and skills pertaining to bioterrorism and other public health emergencies. The NDLS training courses include curriculum in Basic Disaster Life Support (BDLS) and Core Disaster Life Support (CDLS). A course evaluation which included items assessing ability and willingness of training participants, role of responders, and other variables was mailed to all NDLS participants who provided contact information. An analysis was conducted to determine whether the survey respondents participated in the Hurricanes Katrina and/or Rita relief efforts, as well as to evaluate the impact of the NDLS training courses on the participant's ability and willingness to respond during a disaster. The study population (n = 2150) consisted mostly of nurses (50%) (n=1074). A chi-square test of analysis indicated the following results. Among the survey respondents who took the CDLS course, there was no statically significant difference by occupation pertaining to ability or willingness to respond (x2 [df = 5] = 4.02, p= 0.546); (x2 [df = 5] = 2.45, p = .783). However, there was a statistically significant difference among those respondents who took the BDLS course with respect to ability, and a slightly significant difference with respect to willingness (x2 [df = 5] = 13.35, p = .020 and (x2 = [df = 5] = 10.299, p = .067). These findings are similar to previous studies assessing willingness to respond to a disaster.^ A second analysis was conducted with these survey data to evaluate the implications for disaster response training for the NDLS courses. Results indicated that the majority of disaster responders served in the role for which they were professionally trained (Physicians=68%; Nurses = 50.4%). Nurses, EMT, and Fire professionals served in multiple roles. These results suggest the importance of developing training programs that will prepare professionals to serve in multiple roles. The development of standardized evaluation methods would fill an important gap in assessing impact of national training programs. ^

The use of social media to communicate child health information to low-income parents: A formative study

The Internet, and specifically web 2.0 social media applications, offers an innovative method for communicating child health information to low-income parents. The main objective of this study was to use qualitative data to determine the value of using social media to reach low-income parents with child health information. A qualitative formative evaluation employing focus groups was used to determine the value of using social media for dissemination of child health information. Inclusion criteria included: (1) a parent with a child that attends a school in a designated Central Texas school district; and (2) English-speaking. The students who attend these schools are generally economically disadvantaged and are predominately Hispanic. The classic analysis strategy was used for data analysis. Focus group participants (n=19) were female (95%); White (53%), Hispanic (42%) or African American (5%); and received government assistance (63%). Most had access to the Internet (74%) and were likely to have low health literacy (53%). The most preferred source of child health information was the family pediatrician or general practitioner. Many participants were familiar with social media applications and had profiles on popular social networking sites, but used them infrequently. Objections to social media sites as sources of child health information included lack of credibility and parent time. Social media has excellent potential for reaching low-income parents when used as part of a multi-channel communication campaign. Further research should focus on the most effective type and format of messages that can promote behavior change in this population, such as story-telling. ^

Adherence to HIV /AIDS therapies among low -literacy populations: The ALP project

Adherence to HIV/AIDS therapies has been an important health problem since the early 1980s when AZT was first prescribed as a therapy for HIV/AIDS. It became particularly important between 1995 and 1997 with the advent of protease inhibitors (Chesney, Ickovics, Hecht, Sikipa, & Rabkin J., 1999) and became even more significant as persons with HIV/AIDS began to develop resistance to medications. Low-literacy populations have poorer health (Brez & Taylor, 1997) and higher AIDS rates (Simon, Hu, Diaz, & Kerndt, 1995), than their higher literacy counterparts due to delayed treatment (Baker, Parker, Williams, Clark, & Nurss, 1997), shame of literacy skills (Parikh, 1996), and poor access to care (Williams, et al., 1995). Poorer health and higher AIDS rates can also be attributed to poor patient-provider relationships (Crespo-Fierro, 1997; Eldred, Wu, Chaisson, & Moore, 1998) to a poorer understanding of medical protocols (Murphy, 1997), and inadequate patient education (Ungvarski, 1997; Davis, Michielutte, Askov, Williams, & Weiss, 1998, Doak, Doak, & Root, 1996). ^ The ALP intervention was developed for HIV positive low-literacy populations of African American women in Houston, Texas. The intervention was based on a needs assessment, using the PRECEDE model, an innovative process referred to as Intervention Mapping, and validated using formative evaluation methods with 54 individuals. The needs assessment resulted in a list of behavioral, environmental, predisposing, enabling, and reinforcing determinants of adherence. The Intervention Mapping framework was used to refine these determinants and develop a list of objectives describing what must be learned or changed to for the target population to adhere to HIV/AIDS therapies. Methods and strategies, were developed using theoretical constructs from the Health Belief Model (Rosenstock, 1974) and Social Cognitive Theory (Bandura, 1986). These theories, empirical evidence, and information from the target population indicated that perceived susceptibility, perceived severity, outcome expectations, and self-efficacy were important and changeable determinants of adherence to HIV/AIDS therapies for this population. ^ These components were brought together in the form of a theory-based color cartoon book and 10-minute cassette tape. The book was developed for people with 2.9 years of U.S. education as measured with the Flesch-Kincaid Grade Level method and the script was recorded onto a cassette tape to make it suitable for populations with even lower-literacy skills. A formative evaluation was conducted to ensure that the content and structure were accurate, clear, realistic, readable, appropriate, and likely to be used as intended. ^