Using Health Literacy Principlesfor Virtual World Exhibits:A Case StudySusan Toth-Cohen, PhD, OTR/LHarpreet Kaur, OTSAlexandra Harkins, OTSFifth Annual Faculty DaysThomas Jefferson UniversityPhiladelphia, PA, USAJune 7, 2013
Purpose of Presentation• To discuss development of a checklist for avirtual world exhibit on health and wellness,to ensure adherence to principles of healthliteracy• To discuss the development of a virtualworld exhibit over time, as informed by ateam of graduate students and the facultyproject director
ObjectivesAfter attending this presentation, you will be able to:• Discuss key principles of health literacy and the “translation”of these principles to consumer health education in virtualworlds• Identify methods for evaluating the fit of educationalmaterials with principles of health literacy• Describe ways in which virtual worlds can be used to deliverquality health information that meets consumers’ needs• Discuss the role of graduate research assistants incontributing to programs on consumer health education
What is Health Literacy? What doesit include?We first asked our audience. Their contributions:“Communication” and” Self-directedness.” Then, we showed the aboveselection of key words and discussed as a group.
How does health literacy apply to your current work?What are some examples of media you use as healthcare educators?sHandouts & brochures Simulations Video (Self-producedand YouTube)Learning managementsystems Organization websitesWikis
Why Virtual Worlds?• Convenience and relatively low cost (similar to “traditional” web media)• Unique opportunities for immersion, networking and collaboration, andexploratory learning and training (Boulos, Ramloll, Jones, & Toth-Cohen, 2008).• Implementation is complex and many criteria must be met, such as:• Ensuring use of reliable sources of information (National Library ofMedicine, 2012)• Using the unique features of virtual worlds to full advantage, suchas interactivity, 3D displays, and social networking.• Virtual exhibits for health information created in a consumer-friendly, interactive style.(Boulos, Ramloll, Jones, & Toth-Cohen, 2008).however…
Why Care about Health Literacy inVirtual Worlds (VW’s)?• Participation in VWs continues to expand in all age groups,with a projected increase in adults engaging in VW from 11.5million in 2009 to 32.5 million in 2015 (Cohen, 2009).• Unique venue for reaching a diverse group of individualsworldwide, to provide consumer health information andpotential to improve individuals’ health literacy skills.• Low health literacy has been strongly linked to poor healthoutcomes in many areas, such as increase in chronic illness,less use of preventative health services, increasedhospitalization, and mortality(Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; DeWalt, Berkman,Institute of Medicine, 2009; Sheridan, Lohr, & Pignone, 2004).
Garden of Healthy Aging Project:Second Life®A comprehensive exhibit onhealthy aging for residents ofSecond Life® consisting ofinteractive media, focused onstrategies for maintaining andimproving health as one growsolder.The GHA is based on Rowe & Kahn’s (1999) seminal work,Successful Aging and consists of 10 exhibits. All are based onresearch evidence and interactive design principles for virtualenvironments.
Conceptand Links toComponentsof Successful/HealthyAgingFigurederived from:Rowe & Kahn, 1999,p. 39Maintain HighCognitive andPhysical FunctionSuccessful/healthyagingEngage/Participatein lifeAvoid diseaseAvoid worseningof chronic disease Living with diabetes Heart healthManaging stress Care for the caregiver Healthy activity Social support Spirituality &religious practices Healthy activity Future of healthyagingHealthy BrainEach green bulletbelow is a stationin the garden
Background and Timeline of The Garden of HealthyAging Project by Project Team (GA’s and ProjectDirector)EvidenceBasedExhibitDevelop-ment& Review2008-2009ProgramEvaluationof Exhibit2010FurtherDevelop-mentBased onVisitorInput2010-2011Focus onHealthLiteracy2011-presentDevelop-ment ofHLChecklistandRevisionof Exhibits2012-presentGA’s developedexhibits basedon currentevidence inhealthy agingTeam conductedprogramevaluationwith 18 residentsvia surveys andsemi-structuredinterviewsTeam revisedexhibits toincludemore informationon caregiving &change thespirituality exhibitto broader focusTeam conductedextensiveliterature reviewon healthliteracy; realizedneed for changeto existingexhibitsTeam developedchecklist forpromotinghealth literacy invirtual worldsand isconducting pilotanalysis
Development of checklist:Promoting Health Literacy in Social VirtualWorlds Conducted literature review (health care, public health, healthliteracy) Created outline of key concepts applicable to virtual worlds Piloted preliminary version of PHLSVW with exhibits in theGarden of Healthy Aging 2 graduate students identified specific exhibit componentsrequiring change 2 additional graduate students and project director thenreviewed each exhibit to come to consensus on changesneeded Re-formatted original version to improve ease of use
Health Literacy Principles and DomainsApplied to Virtual Worlds• Readability: Reading grade level (CDC, 2009;Ridpath, Greene, & Wiese, 2007; Osborne, 2013; Ridpath, et. al.2007 )• Plain language: Jargon-free, active voice,shorter words, use of lists, single main idea,definitions(Osborne, 2013; Ridpath, Greene, & Wiese, 2007; US Dept. HHS,2009, 2010)• Format & layout: Font size and style, balance ofwhite space, paragraph length, use of headings(Osborne, 2013)
Health Literacy Principles and DomainsApplied to Virtual Worlds• Graphics: Simple, easily identifiable, culturallyrelevant, shown in context• Credibility: Reliable sources, access to referencelist, “about us” info (Abu-Zahara, 2012; Osborne, 2013)• Navigation/Accessibility: Multi-sensory access,interaction, intuitive use, single main idea(Osborne, 2013)(Abu-Zahara, 2012; Osborne, 2013;The Tech Virtual, n.d.)
Excerpt from Original Version Same Excerpt – First RevisionWord file that included ratings forexhibits, notecards, and wiki allon one pageExcel with separate worksheets for evaluatingeach venue: Exhibits, notecards, and wiki(quicker and easier than original)Promoting Health Literacy in Social Virtual Worlds (PHLSVW)
Documentation of changes after evaluation withthe PHLSVW (Excerpt from our Google Docs Spreadsheet)
Evaluation of The Garden of Healthy Aging Using thePHLVW (examples from the Diabetes Exhibit)Issues with original exhibitInfo on glycemic index included on table display but notincluded in BBQ grill that shows calorie and fat contextNo labels onpressure soredisplay (foot model)Shoe with insertnot easilyrecognizable
Evaluation of The Garden of Healthy Aging Using thePHLVW (examples from the Diabetes Exhibit)Sample changesGrill and table displays are bettercoordinated (both include Gly. Index)Easy to recognize shoe and pop-upexplanationLabels onpressure soredisplay (footmodel)
Sample change tonotecardNotecards are a commonway to provide textinformation in virtual worldssuch as Second Life
Proposed Next Steps• Expert review of PHLSVW Checklist• Testing with other health andwellness sites in Second Life andpossibly other virtual worlds• Revise PHLSVW based on testing;make recommendations for use
Role of Graduate Research Assistants inVirtual World Project DevelopmentRoles Translators of health literature to consumer information Researchers-finding up to date evidence Writers/developers/builders of wikis, interactive displays, notecards Evaluators of project componentsContributions Used HL checklist to critically analyze project components Implement changes based on checklist findings Refine HL checklist to make more user-friendly Document all changes to exhibit components, including rationale,HL domains/principles, and results
What we got out of the process Learning how to interact with clients/patients todevelop rapport, which promotes patient involvementin care (example: using plain language in patientcommunications) Empowering clients to ask for more info when in needof clarification through the use of education andadvocacy Opportunity to learn based on highly interactive,collaborative work with colleagues Using health literacy principles to dissect healthliterature for ourselves in order to drive evidence-based practice.Role of Graduate Research Assistants in Virtual World Project Development
Overall, it is our responsibility as health providersto provide information to clients that is accessible andhelping clients to feel comfortable in asking questions.What we got out of the process Identifying resources that can prove useful to clients How to implement health literacy within theframework of Universal Design, in effect makinginformation more accessible by consumers. Using virtual worlds as a way for health professionalsto meet “the triple aim” of health care reform:improving care, improving health, and reducing costs(IHI, 2013).
References1. Abou-Zahra, S. (2012). How people with disabilities use the web. (2012).Retrieved from http://www.w3.org/WAI/intro/people-use-web/Overview2. Berkman, N.D., Sheridan, S.L., Donahue, K.E., Halpern, D.J. & Crotty, K. (2011).Low health literacy and health outcomes: An updated systematic review. Annals ofInternal Medicine, 155, 97-107.3. Bloomfield, P. R., & Livingstone, D. (2009). Immersive learning and assessment withquizHUD. Computing and Information Systems Journal, 13(1), 20-26.Retrieved from http://cis.uws.ac.uk/ research/journal/vol13.htm4. Charnock, D. (1998). The discern handbook: Quality criteria for consumer healthinformation and treatment choices. Oxon: Radcliffe Medical Press.Retrieved from http://www.discern.org.uk/discern.pdf5. Cohen, H. (2009). Virtual worlds forecast to grow at 23% through 2015. Retrieved from:http://www.strategyanalytics.com/default.aspx?mod=PressReleaseViewer&a 0=47456. Institute for Healthcare Improvement (2013). IHI triple aim initiative. Retrieved from:http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx7. Institute of Medicine (2009). Toward health equity and patient-centeredness: Integratinghealth literacy, disparities reduction, and quality improvement. Washington, D.C.
References8. Kamel Boulos, M. N., Ramloll, R., Jones, R., & Toth-Cohen, S. (2008). Web 3D forpublic, environmental and occupational health: Early examples from second life.International Journal of Environmental Research & Public Health [ElectronicResource], 5(4), 290-317.9. Osborne, H. (2013). Health literacy from A to Z: Practical ways to communicateyour health message (2nd ed.). Burlington, MA: Jones & Bartlett Learning.10. Ridpath, J. R., Greene, S. M., Wiese, C. J. (2007). PRISM readability toolkit(3rd ed.). Retrieved from Group Health Research Institute website:http://www.grouphealthresearch.org/capabilities/readability/ghchs_readability_toolkit.pdf11. Rowe, J. & Kahn, J. (1999). Successful aging. New York: Basic Books.12. Rudd, R. (n.d.). Guidelines for creating materials: Resources for developing andassessing materials. Retrieved fromhttp://www.hsph.harvard.edu/healthliteracy/files/resources_for_creating_materials.pdf13. Sarkar, U., & Schillinger, D. (2011). Literacy and patient care. S. W. Fletcher, ed.Retrieved from http://www.uptodate.com/contents/literacy-and-patient-care14. The TechVirtual Museum (n.d). Exhibit design tutorial. [Virtual World Resource]http://slurl.com/secondlife/The%20Tech/197/159/38