#3607 An Edutainment Tool for Increased Compliance with DR ...€¦ · An Edutainment Tool for...
1
An Edutainment Tool for Increased Compliance with DR Screening and Management: A KAP study An Edutainment Tool for Increased Compliance with DR Screening and Management: A KAP study Anne M. Edwards 1 , Gilberto Zamora 1 , Heidi Becker 2 , Joan Smith 2 , Ana Matiella 3 , Peter Soliz 1 . 1 VisionQuest Biomedical LLC, Albuquerque, NM; 2 University of Texas Health Science Center - San Antonio, San Antonio, TX; 3 The Fotonovela Production Company, Santa Fe, NM. Anne M. Edwards 1 , Gilberto Zamora 1 , Heidi Becker 2 , Joan Smith 2 , Ana Matiella 3 , Peter Soliz 1 . 1 VisionQuest Biomedical LLC, Albuquerque, NM; 2 University of Texas Health Science Center - San Antonio, San Antonio, TX; 3 The Fotonovela Production Company, Santa Fe, NM. Women had significantly greater improvement on Practices questions, indicating greater sensitivity than men to the health education messages and greater potential for self-care and compliance (Table 4). Diabetics scored significantly better (p < .001) on Knowledge and Attitude questions but failed to improve on Practices questions (p> .4), suggesting persistant resistance to compliance despite their familiarity with Diabetes issues (Table 3). Contact: Ana Edwards, M.A. (505) 508-1994 [email protected] VisionQuest Biomedical LLC 2501 Yale Blvd. SE Ste. 301 Albuquerque, NM 87106 1 Danaei, Goodarz, Friedman, Ari B, Oza, Shefali, Murray, Chris topher JL, Ezzati, Majid,” Diabetes prevalenc e and diagnos is in U S s tates : analys is of health s ur veys ,” Population H ealth Metric s 2009, 7:16. 2 Varma R, Macias GL, Torres M, Klein R, Peña FY, Azen SP; Los Angeles Latino Eye Study Group, “Biologic ris k factors as s ociated with diabetic retinopathy: the Los Angeles Latino Eye Study,” Ophthalmology, July;114(7):1332- 40, 2007. 3 Convers e, Jean ,Pres s er, Stanley, Sur vey Ques tions : H andc rafting the Standardiz ed Ques tionnaire (Quantitative Applic ations in the Soc ial Sc ienc es ) Sage Public ations , Thous and Oaks , California, 1986. Results Acknowledgements To study the knowledge, attitudes and practices (KAP) of Hispanics with Type II Diabetes before and after an education intervention using a culturally competent graphical edutainment fotonovela To ascertain the barriers to compliance with eye exams through focus group discussions with health care professionals and with Hispanic individuals at risk for Type II Diabetes. To design and implement a visually compelling, edutainment tool, a bilingual fotonovela, based on responses collected from the focus groups. To design and implement a KAP survey instrument to field-test changes in subjects exposed to two versions of the fotonovela. Hispanics in the United States, especially those who are Mexican American, suffer from high rates of eye disease and visual impairment [1, 2]. A tool to increase compliance (Fig. 1) with annual eye exams and health life-style will yield significant cost-saving to the national health-care system. Fotonovelas are a low-tech, graphic, inexpensive, immediate method for increasing awareness and intention to improve diabetes self-care management and compliance (Fig. 2). Data 55 individuals were used for focus groups in Albuquerque, New Mexico and San Antonio, Texas. Of these, 20 were health professionals and 35 were Hispanics with Diabetes. Pre-tests of the surveys to refine the KAP questions were conducted on 70 individuals using a condensed 4 page version “fotonota.” For field testing the fotonovela, two cohorts were recruited by local promotores (community health-care workers). In Albuquerque, N = 139. In San Antonio, N =124. Figure 1 -- Triad Model of the Fotonovela for Type II Diabetes / Diabetic Retinopathy, and the relationship between three factors that contribute to personal health management. 5 Focus group discussions were held: 2 in New Mexico (Health Care providers) and 3 in Texas (Hispanic individuals at risk). Twenty-five open questions were asked to the focus group partici- pants on Type II Diabetes, Diabetic Retinopathy, fotonovelas and storytelling. (Table 1). Resonant, repeating themes and cultural issues uncovered in the participant responses were used to develop the fotonovela script and to develop the KAP survey. Among both the health-care providers and the Hispanic individuals at risk, there was strong agreement, demonstrated by the frequency of similar individual responses and by show-of-hands. Key responses included: — Information about Diabetes and Diabetic Retinopathy should be communicated in Spanish. — Fotonovela, with its graphic visual methods was an ideal tool for Diabetic Retinopathy and other chronic diseases associated with Diabetes. — Strong, older male character was preferred as the protagonist — A doctor should be the character to deliver the most potent messages regarding compliance — Two story lines were needed: a redemptive story for the protagonist and a tragedy for a female character in a subplot. Misinformation was uncovered in all groups. There was confusion regarding familial associations vs. heredity in Type II Diabetes, as well as cultural fatalism and the myth of the “susto” or fright as the cause of Type II Diabetes. 1) Focus Group Discussions 2) Fotonovela 2) KAP Survey Field Tests (pre- and post- exposure) 1) Focus Groups 2) KAP Survey Field Tests A variety of KAP questions on Diabetes knowledge, DR knowledge, attitudes and practices were pre-tested on 2 small preliminary groups for comprehension, clarity of meaning and investigator bias [3]. From the results of the pre-tests, 9 final questions were developed for the field-tests of the 16 page fotonovela and the 2 page fotonota. All surveys were anonymous. Demographic data was also collected: age-range, gender, preferred language (English, Spanish, or Bilingual) and presence of Type II Diabetes or Pre-Diabetes. TM Support: This work was supported by Grant EY021092 from NEI and NIDDK . The authors would like to thank The Fotonovela Production Company of Santa Fe for providing production support; Dr. Winston Crandall, Ph.D., for his statistical analysis; promotores Ramon Crespo, Guadalupe Campos, Maria Castillo, Maria Santiago; and facilities Encuentro, Partnership for Community and the Billa Learning Center. Commercial Relationships: Edwards, Zamora, Soliz, VisionQuest Biomedical E; Becker, Smith, UTHSC-SA C; Matiella, The Fotonovela Company, E. ©2011, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to www.iovs.org to access the version of record. For permission to reproduce any abstract, contact the ARVO Office at [email protected]. Table 1-- A Sample of Focus Group Questions (health provider group questions in bottom section) Barriers Motivators Personal Health Self-Care Provider-Care Compliance normal vision lack of funds lack of time laziness stubbornness family members low or no cost positive health outcome fear less doctor visits or ER care save money improved quality of life Improved KAP Improved communication Domain Question Diabetes How many of you have your diabetes under control? DR & Vision How many of you have heard about Diabetic Retinopathy? DR & Vision How ofter should you have your eyes checked? Fotonovela Would a fotonovela be a good tool to educate you about Diabetics Retinopathy? Fotonovela Should the story be a tragedy, or one of redemption? Diabetes What is the best way to inform patients? DR & Vision How often does the ADA recommend eye exams for people with Diabetes? DR & Vision Does speaking Spanish help compliance? Fotonovela Would a fotonovela motivate your patients? Based on the focus group responses (Results, Focus Groups) a script and storyboard were developed for a 32 page (16 Spanish, 16 English) bilingual fotonovela booklet (Fig. 2). Responses to 8 KAP survey questions showed significant improvement in correct response from pre-test to post-test after exposure to fotonovela or fotonota, with positive increases of between .25 and 1 categories per question (p < 0.01 to p< 0.001) (Table 2). Total number of subjects, N = 263, with 186 females (71%) vs. 77 males (29%). Total Diabetics, N = 73 (28%). 1t (one sample), 2t (two sample) or ANOVA statistical tests were performed to analyze changes between pre- and post-test responses. Location (NM and Texas) did not demonstrate any statistical significance except on Practices questions in the San Antonio population due to promotora health care management within the local community (p < 0.05, Table 2). Preferred language (Spanish, English or Bilingual) demonstrated no statistical significance in score improvement (Table 2). Signficant improvement demonstrated for Practices questions (p < .001) indicates that participants are capable of changing their their self-care management when they understand the stakes (Table 2). Three survey questions, #s 7, 10 and 12, specific to three important teaching points in the fotonovela presented statistically significant improvement in all subjects (p < 0.01) in the post-test scores. (Table 3). Fotonovela for Type II Diabetes- Diabetic Retinopathy Fotonovela for Type II Diabetes- Diabetic Retinopathy Table 4 Comparison of KAP scores for all Diabetics, and Women v. Men. Question All Women v. Knowledge < .001 NSD* Attitude < .001 NSD* Practices NSD* < .01 Type Diabetics (2t) Men (2t) p p #3607 #3607 Table 2— Comparison of KAP scores for all subjects (N=263), Location (NM v TX), and Preferred Language (1t, 2t or Anova (A) tests were used). Question Preferred Knowledge .924 < .001 NSD NSD* Attitude .817 < .001 NSD NSD* Practices .916 < .001 < .01 NSD* Language (A) Mean p p p Type All Subjects (1t) Location (2t) Post - Pre *NSD p>.05. The use of field testing for measuring fotonovela impact lead to the inclusion of 3 additional points in the booklet to emphasize the risk of vision loss even among those Type II Diabetics who practice rigorous self-care. Statistically significant score improvement (p< .001) suggests that the fotonovela is a robust, low-cost tool for health education in underserved populations. Question Answer 7. Diabetes affects: Retina of the Eye 10. If you have Diabetes, how often should you have your eyes checked? Once a Year 12. Retinal damage can cause a black spot in your vision. Strongly Agree Table 3 Survey questions 7, 10 and 12 and their correct answers. No m‛ijo. I‛m not. Who told you that? I heard grandma tell auntie that if you and she didn‛t watch it, you would both go blind. No, Betito. Auntie and I learned our lessons. From now on both of us are going to have our eyes checked every year. Grandpa, ? What is it, mijo? Will you read to me? Of course, m‛ijo. Let‛s see what that old troll is up to now. I love you, grandpa. I love you too, my boy. 16 Figure 2 -- Fotonovela pages (L) Cover , Spanish; (R) Page 16, English. ¡Qué! ¡Ay, Dios! Estudio de VisionQuest Biomedical financiado por NEI y NIDDK, © 2011 VisionQuest Biomedical LLC Biomedical Biomedical ¿Ves una mancha negra con el ojo izquierdo? Cálmate, Lourdes. ¡Enseguida voy! ¡Te dije que no te comieras todo ese pastel! En la clínica. . . Temo que las noticias no sean buenas, Lourdes. Tenía tanta sangre en su ojo que no pude tratar todas las zonas dañadas. Su otro ojo tiene las señales tempranas del mismo tipo de daño. Así es como Lourdes ve cuando mira a su hermano y al médico. . . ¿Qué pierde Lourdes ? Independencia Calidad de vida Ver a sus seres queridos SIGA LEYENDO para saber toda la historia ¿Ves una mancha negra con el ojo izquierdo? Cálmate, Lourdes. ¡Qué!
Transcript of #3607 An Edutainment Tool for Increased Compliance with DR ...€¦ · An Edutainment Tool for...
An Edutainment Tool for Increased Compliance with DR Screening and Management: A KAP study
An Edutainment Tool for Increased Compliance with DR Screening and Management: A KAP study
Anne M. Edwards1, Gilberto Zamora1, Heidi Becker2, Joan Smith2, Ana Matiella3, Peter Soliz1.1VisionQuest Biomedical LLC, Albuquerque, NM; 2University of Texas Health Science Center - San Antonio, San Antonio, TX; 3The Fotonovela Production Company, Santa Fe, NM.
Anne M. Edwards1, Gilberto Zamora1, Heidi Becker2, Joan Smith2, Ana Matiella3, Peter Soliz1.1VisionQuest Biomedical LLC, Albuquerque, NM; 2University of Texas Health Science Center - San Antonio, San Antonio, TX; 3The Fotonovela Production Company, Santa Fe, NM.
Women had significantly greater improvement on Practices questions, indicating greater sensitivity than men to the health education messages and greater potential for self-care and compliance (Table 4).
Diabetics scored significantly better (p < .001) on Knowledge and Attitude questions but failed to improve on Practices questions (p> .4), suggesting persistant resistance to compliance despite their familiarity with Diabetes issues (Table 3).
Contact:Ana Edwards, M.A.(505) 508-1994 [email protected] Biomedical LLC2501 Yale Blvd. SE Ste. 301Albuquerque, NM 87106
1 Danaei, Goodarz, Friedman, Ari B, Oza, Shefali, Murray, Christopher JL, Ezzati, Majid,” Diabetes prevalence and diagnosis in U S states: analysis of health
sur veys,” Population Health Metrics 2009, 7:16.2 Varma R, Macias GL, Torres M, Klein R, Peña FY, Azen SP; Los Angeles Latino Eye Study Group, “Biologic risk factors associated with diabetic retinopathy: the Los Angeles Latino Eye Study,” Ophthalmology, July;114(7):1332- 40, 2007.3 Converse, Jean ,Presser, Stanley, Sur vey Questions: H andcrafting the Standardized Questionnaire (Quantitative Applications in the Social Sciences) Sage Publications, Thousand Oaks, California, 1986.
Results
Acknowledgements
To study the knowledge, attitudes and practices (KAP) of Hispanics with Type II Diabetes before and after an education intervention using a culturally competent graphical edutainment fotonovela
To ascertain the barriers to compliance with eye exams through focus group discussions with health care professionals and with Hispanic individuals at risk for Type II Diabetes.
To design and implement a visually compelling, edutainment tool, a bilingual fotonovela, based on responses collected from the focus groups.
To design and implement a KAP survey instrument to field-test changes in subjects exposed to two versions of the fotonovela.
Hispanics in the United States, especially those who are Mexican American, suffer from high rates of eye disease and visual impairment [1, 2].
A tool to increase compliance (Fig. 1) with annual eye exams and health life-style will yield significant cost-saving to the national health-care system.
Fotonovelas are a low-tech, graphic, inexpensive, immediate method for increasing awareness and intention to improve diabetes self-care management and compliance (Fig. 2).
Data55 individuals were used for focus groups in Albuquerque, New Mexico and San Antonio, Texas. Of these, 20 were health professionals and 35 were Hispanics with Diabetes.
Pre-tests of the surveys to refine the KAP questions were conducted on 70 individuals using a condensed 4 page version “fotonota.”
For field testing the fotonovela, two cohorts were recruited by local promotores (community health-care workers). In Albuquerque, N = 139. In San Antonio, N =124.
Figure 1 -- Triad Model of the Fotonovela for Type II Diabetes / Diabetic Retinopathy, and the relationship between three factors that contribute to personal health management.
5 Focus group discussions were held: 2 in New Mexico (Health Care providers) and 3 in Texas (Hispanic individuals at risk).
Twenty-five open questions were asked to the focus group partici-pants on Type II Diabetes, Diabetic Retinopathy, fotonovelas and storytelling. (Table 1).
Resonant, repeating themes and cultural issues uncovered in the participant responses were used to develop the fotonovela script and to develop the KAP survey.
Among both the health-care providers and the Hispanic individuals at risk, there was strong agreement, demonstrated by the frequency of similar individual responses and by show-of-hands. Key responses included:
— Information about Diabetes and Diabetic Retinopathy should be communicated in Spanish.
— Fotonovela, with its graphic visual methods was an ideal tool for Diabetic Retinopathy and other chronic diseases associated with Diabetes.
— Strong, older male character was preferred as the protagonist
— A doctor should be the character to deliver the most potent messages regarding compliance
— Two story lines were needed: a redemptive story for the protagonist and a tragedy for a female character in a subplot.
Misinformation was uncovered in all groups. There was confusion regarding familial associations vs. heredity in Type II Diabetes, as well as cultural fatalism and the myth of the “susto” or fright as thecause of Type II Diabetes.
1) Focus Group Discussions
2) Fotonovela
2) KAP Survey Field Tests (pre- and post- exposure)
1) Focus Groups
2) KAP Survey Field Tests
A variety of KAP questions on Diabetes knowledge, DR knowledge, attitudes and practices were pre-tested on 2 small preliminary groups for comprehension, clarity of meaning and investigator bias [3].
From the results of the pre-tests, 9 final questions were developed for the field-tests of the 16 page fotonovela and the 2 page fotonota. All surveys were anonymous. Demographic data was also collected: age-range, gender, preferred language (English, Spanish, or Bilingual) and presence of Type II Diabetes or Pre-Diabetes.
TM
Support: This work was supported by Grant EY021092 from NEI and NIDDK . The authors would like to thank The Fotonovela ProductionCompany of Santa Fe for providing production support; Dr. Winston Crandall, Ph.D., for his statistical analysis; promotores Ramon Crespo, Guadalupe Campos, Maria Castillo, Maria Santiago; and facilities Encuentro, Partnership for Community and the Billa Learning Center.
Commercial Relationships: Edwards, Zamora, Soliz, VisionQuest Biomedical E; Becker, Smith, UTHSC-SA C; Matiella, The FotonovelaCompany, E.
©2011, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to www.iovs.org to access the version of record. For permission to reproduce any abstract, contact the ARVO O�ce at [email protected].
Table 1-- A Sample of Focus Group Questions (health provider group questions in bottom section)
Barriers
Motivators
Personal HealthSelf-Care Provider-Care
Compliance
normal visionlack of fundslack of timelazinessstubbornness
family memberslow or no costpositive health outcomefearless doctor visits or ER caresave moneyimproved quality of life
Impr
oved
KAP
Improved com
munication
Domain Question
Diabetes How many of you have your diabetes under control?
DR & Vision How many of you have heard about Diabetic Retinopathy?
DR & Vision How ofter should you have your eyes checked?
Fotonovela Would a fotonovela be a good tool to educate you about Diabetics Retinopathy?
Fotonovela Should the story be a tragedy, or one of redemption?
Diabetes What is the best way to inform patients?
DR & Vision How often does the ADA recommend eye exams for people with Diabetes?
DR & Vision Does speaking Spanish help compliance?
Fotonovela Would a fotonovela motivate your patients?
Based on the focus group responses (Results, Focus Groups) a script and storyboard were developed for a 32 page (16 Spanish, 16 English) bilingual fotonovela booklet (Fig. 2).
Responses to 8 KAP survey questions showed significant improvement in correct response from pre-test to post-test after exposure to fotonovela or fotonota, with positive increases of between .25 and 1 categories per question (p < 0.01 to p< 0.001) (Table 2).
Total number of subjects, N = 263, with 186 females (71%) vs. 77 males (29%). Total Diabetics, N = 73 (28%). 1t (one sample), 2t (two sample) or ANOVA statistical tests were performed to analyze changes between pre- and post-test responses.
Location (NM and Texas) did not demonstrate any statistical significance except on Practices questions in the San Antonio population due to promotora health care management within the local community (p < 0.05, Table 2).
Preferred language (Spanish, English or Bilingual) demonstrated no statistical significance in score improvement (Table 2).
Signficant improvement demonstrated for Practices questions (p < .001) indicates that participants are capable of changing their their self-care management when they understand the stakes (Table 2).
Three survey questions, #s 7, 10 and 12, specific to three important teaching points in the fotonovela presented statistically significant improvement in all subjects (p < 0.01) in the post-test scores. (Table 3).
Fotonovela forType II Diabetes-
Diabetic Retinopathy
Fotonovela forType II Diabetes-
Diabetic Retinopathy
Table 4 Comparison of KAP scores for all Diabetics, and Women v. Men.
Question All Women v.
Knowledge < .001 NSD* Attitude < .001 NSD*
Practices NSD* < .01
Type Diabetics (2t) Men (2t)
p p
#3607#3607
Table 2— Comparison of KAP scores for all subjects (N=263), Location (NM v TX), and Preferred Language (1t, 2t or Anova (A) tests were used).
Question Preferred
Knowledge .924 < .001 NSD NSD* Attitude .817 < .001 NSD NSD*
Practices .916 < .001 < .01 NSD*
Language (A)
Mean p p p
Type All Subjects (1t) Location (2t)
Post - Pre
*NSD p>.05.
The use of field testing for measuring fotonovela impact lead to the inclusion of 3 additional points in the booklet to emphasize the risk of vision loss even among those Type II Diabetics who practice rigorous self-care.
Statistically significant score improvement (p< .001) suggests that the fotonovela is a robust, low-cost tool for health education in underserved populations.
Question Answer7. Diabetes a�ects: Retina of the Eye10. If you have Diabetes, how often should you have your eyes checked? Once a Year12. Retinal damage can cause a black spot in your vision. Strongly Agree
Table 3 Survey questions 7, 10 and 12 and their correct answers.
No m‛ijo. I‛m not. Who told you that?
I heard grandma tell auntie that if you and she didn‛t watch it, you would both go blind.
Grandpa, are you going blind?
Back at home. . .
No, Betito. Auntie and I learned our lessons. From now on both of us are going to have our eyes checked every year.
Grandpa, ?
What is it, mijo?
Will you readto me?
Of course, m‛ijo. Let‛s see what that old troll is up to now.
I love you,grandpa.
I love you too,my boy.
16
Figure 2 -- Fotonovela pages (L) Cover , Spanish; (R) Page 16, English.
¡Qué!
¡Ay, Dios!
Estudio de VisionQuest Biomedical �nanciado por NEI y NIDDK, © 2011 VisionQuest Biomedical LLC BiomedicalBiomedical
¿Ves una mancha negra con el ojo izquierdo? Cálmate, Lourdes.
¡Enseguida voy!
¡Te dije que no te comierastodo ese pastel!
En la clínica. . .Temo que las noticias no sean buenas, Lourdes. Tenía tanta
sangre en su ojo que no pude tratar todas las
zonas dañadas.
Su otro ojo tiene las señales tempranas del mismo tipo de daño.
Así es como Lourdes ve cuando mira a su hermano y al médico. . .
¿Qué pierde Lourdes ?
Independencia
Calidad de vida
Ver a sus seres queridos
SIGA LEYENDO para saber toda la historia
¿Ves una mancha negra con el ojo izquierdo? Cálmate, Lourdes.
¡Qué!
