Development of a Low-Literacy "Rx for Physical Activity" for ...

Development of a Low-Literacy Rx for Physical Activity for a Rural Community Health Center Linda S. Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes Prevention & Control Program Delaware Division of Public Health Presented at the 2009 Diabetes Translation Conference Long Beach, CA, April 24, 2009 Setting: Rural county in DE Served by La Red Health Center (FQHC) Seaford Georgetown (La Red FQHC)

Millsboro Site: 3 towns hi % Hispanic many illiterate much obesity, prediabetes Partners University of Delaware, School of Education Delaware Diabetes Prevention & Control Program (DCPC) Federally Qualified Health Center (FQHC)La Red La Red Health Center Serves most rural county (Sussex) FQHC since 2004 Patient population

80% minority (mostly Hispanic) 50% live at or below 200% of Federal Poverty Level 250 active patients with diabetes Aim Develop simple physical activity tools For clinic staff to use, To aid patients with pre-diabetes or diabetes, And accessible to patients with low literacy (low literacy = poor reading, learning, reasoning skills) 2 projects Rx for physical activity Rx for walking with pedometer Rx for Physical Activity: Four Guiding Questions 1. What activity resources are available?

Safe Low/no cost Close & accessible 2. What resources will patients actually use? Rx is comprehensible with low literacy (simple maps with icons) Activities fit into family/cultural life (soccer games)enhance, not burden Activities provided/reinforced by community organizations (churches, major employers) 3. What tools will staff actually use? Supports Chronic Care Model (Self-Management)

Fast (90 seconds) Easy (scripts for staff, materials to give patients) 4. How well did Rx work? Record of Rx given Follow-up of patients Exemplar Activity: Walking routes on main UD campus Miles: 1.0 1.25 1.5 3.0 Great idea but has really big problem

The Literacy Challenge 1. Patient must perform task using map 2. Using a map is inherently complex Highly abstract depiction of space Orientation is top-down Many patients cant read in any language Literacy Demands of Sample Daily Tasks (Tasks from NALS adult functional literacy test) Level <1 1 2

3 4 5 White 3 9 26 40 21 2

Black 12 22 41 22 3 * 22 5 * 16

3 * Hispanic 30 (half Over age 65 foreign-born) 19 F 15 27

29 U 33 Interpret phrase from long news article = mean F = foreign born U = US born Find shipping costs too State argument in long news article Total items on order form Find intersection on map Identify country in short article Sign name HALS LEVELS:

Below Level 1 175 HALS SCORES: % adults Level 1 7 Level 2 225 12 Level 3 275 27

Level 4 325 36 Level 5 375 17 500 1 Be mindful thateven simplest tasks can be difficult for some people ProcessEnvironmental Scan 3 locales scanned for: Safe, accessible walking routes In-town facilities (ball fields, YMCA, )

More distant sites (beach, state parks, ) Info gathered by: KS & LG interviewed local social service agencies met with La Red staff on patient needs/preferences/barriers toured locales, identified large employers located mapping resources :UD Applied Demography Center, Delaware DataMIL (states internet mapping service at datamil.delaware.gov) UD student assistant telephone, internet searches physically inspected 3 locales assessed walkability of streets

Info recorded in spreadsheets Type, location, hours, costs, clientele, disability access, parking, contacts Intended products Rx Lists of resources for patients, with maps Results of Environmental Scan None YMCA, YWCA indoor malls (mall walking) public use of school athletic fields walking to school (too far, not walkable, bussed)

Rare 1 city park 1 soccer field (Saturday use) walkable sidewalks (not even for half mile) Obstructions on sidewalks Sidewalks Rare Conclusion: Shockingly few activity resources No resources to list for an Rx Plan BRx for Pedometer Walking Guiding questions 1. What kind pedometer available & appropriate ? 2. How many steps to prescribe: at start, increments, end-goal? 3. Who prescribe & explain Rx (MD, other)? 4. How should Rx be explained (scripts for staff)? 5. How should Rx be followed up and reinforced?

Considerations with free/donated pedometers Cover keeps coming off Extra features: Bulky 2-sec. reset 5 steps before count recorded Hard to open Easy to see Slim the count, but Requires mental calculation Hard to rewind All have belt clips, some have tethers Variability in recording

Conclusion: Probably all good enough, but get to know the one you prescribe 200 steps, TM Total-Day 1 Treadmill Total-Day 2 Street walk A (UD) 93 B (ours) 180 C 162 D

220 E 149 .7 .7 1.0 .9 1.0 (5681) 1.0 (4236) 1.0 (2975) 1.0 (2557) 1.2 1.2 1.4 1.1 1.3

1.2 1.4 1.1 1.0 1.1 failed failed Rx for Pedometer Walking English What regimen is reasonable to prescribe? Hard to find guidance Made prudent guess Spanish Keep form simple Limit content to the essentials

Keep Regimen Simple Front Back Extra Steps MON TUES WED THUR FRI SAT SUN

Week 1 Week 2 Week 3 Week 4 Must increase dose over time but: Changed only one element of regimen Provide record-keeping form with Rx Support clinic staff with scripts when they 1. Give the Rx (MD, CDE, other) 2. Explain how to use the pedometer with Rx 3. Follow-up patient use of pedometer Why?

Hidden complexities for patients in adhering to Rx Hidden complexities for staff in explaining Rx Script 1: Key Ideas to convey to patient when staff give Rx for Walking If MD, have only 90 seconds Key ideas = Implicit training for the teacher Pedagogical principles be concrete, personalize, use meaningful metaphors, etc. Sample statements = Curriculum for teacher Not all content would be obvious, how to handle contingencies, etc. Script 2: Key Ideas to Convey When Staff Explain Rx for Walking Cant assume anything: That patient will know: What a pedometer is

Understand regimen on the Rx That the staff will know: your aim (e.g., extra steps) how to explain & adjust regimen Script 2: cont. Quite challenging to design clear, concise explanations that simultaneously anticipate common errors and attempt to motivate Script 3: Follow-up on Patients Use of Pedometer During First Month Degree of adherence Reasons for nonadherence (barriers) Lessons Learned

Scarcity of activity resources No malls, YM/WCA, parks Competing demands Clinic staff Patients EMR introduction: absorbing energies Thank you Linda S. Gottfredson Kathy Stroh School of Education Diabetes Prevention & Control University of Delaware Division of Public Health Newark, DE 19716 540 S. DuPont Highway, Suite 10 [email protected] Dover, DE 19901 [email protected]

Slides are available at: http://www.udel.edu/educ/gottfredson/reprints/2009CDC_Rx.ppsx or http://www.udel.edu/educ/gottfredson/reprints/2009CDC_Rx.ppt