Using Animation to Enhance Diabetes
Health Literacy in Vulnerable Populations
José Luís Calderón, MD
Associate Professor
Center for Health Services Research
Research Centers in Minority Institutions
Charles Drew University of Medicine and Science
Los Angeles, CA
Literacy and Health
Literacy is independently associated with health status

Non-industrialized nations
UNESCO. Statistical Yearbook 1988 Paris

United States
Weiss BD, et al J Am Board Fam Pract 1992:5
Literacy
• Ability to decipher and comprehend written information
• Reading, writing and arithmetical skills
• Relation to educational attainment
National Adult Literacy Survey
40-44 million adults
functionally illiterate
Cannot perform basic reading tasks required to function in society
50 million adults
marginally literate
Can only perform basic reading tasks
Reading skills are deficient in 46%- 51% of adult US Citizens
African Americans and Latinos are over represented
Kirsh, et al NCHS, US Dept. of Ed. 1993
Functional Health Literacy
•Ability to comprehend written health information
•Ability to act on this information
•Negotiate health care delivery systems
•Chronic disease self-management
•Perceived self-efficacy
The majority of persons have some degree of
limited functional health literacy
Vulnerable populations
Tend to have limited literacy skills





Racial/ethnic minorities
The Aging
Immigrants and other marginalized groups
Persons with chronic diseases
Populations living in poverty
Aging and chronic disease leads to cognitive decline
Cognitive decline leads to diminished literacy skills
Diabetes Epidemic
Estimated 21 million people in the U.S. with Diabetes
15 million are diagnosed
 about 6 million unaware
Diabetes Type II accounts for 90% of cases
Prevalence of Obesity and DM Type II is on the rise
Young adults and adolescents
Risk Factors
•Genetic predisposition
•Family History
•Obesity
•Sedentary lifestyle
•Dietary indiscretion
Diabetes Incidence Age <20
Source: SEARCH for Diabetes in Youth Study.
NHW=Non-Hispanic whites; AA=African Americans; H=Hispanics; API=Asians/Pacific Islanders; AI=American Indians
A Survey of Kidney Disease and Risk Factor Information on the World Wide Web
RELATIOINSHIP OF FLESCH-KINCAID SCORES
ACROSS INFORMATION TYPE AND SOURCE
14
12
Reading Grade Level
10
KIDNEYS
KD
8
DM
KD & DM
6
HTN
KD & HTN
4
2
K
Fo
Ki
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dn
da
ey
tio
Fo
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un
W
of
or
C
ld
an
Ki
ad
dn
a
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Fu
nd
-S
in
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es
Au
s
R
Ki
dn
ey
Fu
nd
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-U
K
Fe
d
N
at
K
id
ne
y
Fo
un
id
ne
y
at
K
N
Al
ab
am
a
Fo
un
Ki
dn
ey
Am
er
-U
S
Ki
dn
ey
&
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ro
AK
KP
AA
KF
N
F
-U
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-U
K
D
ID
N
S
0
Calderón JL; Zadshir A ; Norris K. MedScape General Medicine 2004;6(4):3 Available at:
http://www.medscape.com/viewarticle/489230
Health Literacy
Knowledge, perceptions and beliefs about disease, risk factors,
treatment and management
•Enhancing health literacy does not require reading
•Visual media may communicate health information more readily than
written materials alone
Calderón JL, Smith Sandra. ‘Health Literacy’, Sahler OJZ, Carr JE (eds. ) The Behavioral Sciences
and Health Care (2nd edition). Cambridge, MA: Hogrefe & Huber
Animation
Accessible format across a spectrum of age, culture and
literacy
Presents potentially sensitive and fearful information in a
non-threatening way
Avoids visual cues that may be cultural or psychological
barriers to learning, or that otherwise may alienate
patients and inhibit behavioral change
Visual Cues
Animation Health Education
• Since the 1960s, UNICEF has used animation as an educational
intervention to address health care issues such as oral rehydration
therapy, nutrition, teenage pregnancy, clean water and sanitation,
and HIV/AIDS.
•
“The Three Amigos” is a series of 20 short,
animated PSAs designed to encourage the
use of condoms to stop the spread of HIV/AIDS. Made
available by the United Nations for free distribution, the
effort is touted as the world’s largest behavior modification
program.
• Walt Disney’s “VD Attack Plan” and “The Story of Menstruation”
• Starlight Starbright Children’s Foundation, in association with
The Leukemia and Lymphoma Society – “Coping with Chemo”
• HopeLab’s “Re-Mission” demonstrated in clinical trials that
patients’ knowledge about cancer, adherence to therapy regimens,
self-efficacy and quality of life increased because of their interactive play of a specially produced animated video game.
Diabetes Health Literacy Augmentation in Minority Populations
(Diabetes Health LAMP)
Purpose:
• Script and produce and animated video on diabetes
• Test face validity using qualitative methods
• Test the efficacy of the animated video at enhancing
diabetes knowledge in a randomized controlled trial
• Community-based participatory research project
Animation Pipeline
The entire process for producing animation can be understood as occurring in three phases:
• Pre-production
script
visual design
voice recording
storyboard
animatic
• Production
animation
inking and painting
backgrounds
rendering
• Post-production
sound design
music
output to media
Project Health LAMP: Qualitative Study
8 Focused Discussion Groups: 4 Latino 4 African Americans
•Consensus agreement across all groups that:
•Lotta Hart & Corazon Quelate were appropriate icons
•Content was comprehensible in English and Spanish
•Compared to diabetes information from NIDDK video preferred
•Participants knew more about diabetes after participating in the FDG
then previously
Calderón JL. The Evolution of the Focused Discussion Group: From non-participant to one of the crew.
The Weekly Qualitative Report 2009;2(22):135-138. Retrieved from
http://www.nova.edu/ssss/QR/WQR/calderon.pdf
Project Health LAMP: RCT Inclusion
•Spanish as primary language
•Diagnosed with diabetes
•Receiving care at the South Central Family Health Center
•Never had formal diabetes education/training
Project Health LAMP: Surveys




Drew Demographic Survey
Diabetes Health Literacy Survey
 Modified Starr County Diabetes Knowledge Questionnaire
Short Test of Functional Health Literacy in Adults
 STOFHLA
SF-12
 General quality of life survey
Interviewer administered except STOFHLA
TOFHLA Scoring
TOFHLA scores are classified into 3 functional health literacy categories:
Inadequate Score
0-16
•unable to read and interpret health information
Marginal Score
17-21
•has difficulty reading and interpreting health information
Adequate Score
>22
•can read and interpret most health information
DHLS Scoring
DHLS scores are calculated as the proportion of 30 items answered
correctly and classified into 3 categories:
Inadequate Score
0-15 (<50%)
•unable to read and interpret health information
Marginal Score
16-22 (51%-74%)
•has difficulty reading and interpreting health information
Adequate Score
>23
(75%)
•can read and interpret most health information
Diabetes Health LAMP: RCT
Control Group
Intervention Group
Baseline:
Surveys completed
NIDDK diabetes information
Baseline:
Surveys completed
Video ‘What is Diabetes?’
Posttest 1
Immediately after reading
Take home information
Posttest 1
Immediately after viewing video
Received copy of video
Posttest 2
2 weeks after
Referral to diabetes nurse
Received copy of video
Posttest 2
2 weeks after
Referral to diabetes nurse
Results: Population Characteristics
Intervention Group
Number (%)
Control Group
Number (%)
Total
Number (%)
Male
25 (21.2)
19 (15.6)
44 (18.3)
Female
93 (78.8)
103 (84.4)
196 (81.7)
18-39 Years
23 (19.8)
26 (21.5)
49 (20.7)
40-60 Years
70 (60.3)
69 (57.0)
139 (88.6)
>60 Years
23 (19.8)
26 (21.5)
49 (20.7)
< High School
84 (87.5)
85 (85.9)
169 (86.7)
=> High School
12 (12.5)
14 (14.1)
26 (13.3)
<10,000
83 (76.9)
81 (74.3)
164 (75.6)
=>10,000
25 (22.2)
28 (25.7)
53 (24.4)
Insured
41 (35.7)
31 (27.0)
72 (31.3)
Not insured
74 (64.3)
84 (73.0)
158 (68.7)
Gender
Age group (years)
Education level
Income level ($)
Insurance Status
Results: Perceived Health Status and Health Literacy
Perceived health status
Intervention
Control
Total
Excellent
6 (5.4)
0 (0)
6 (2.6)
Very good
3 (2.7)
3 (2.5)
6 (2.6)
Good
17 (15.2)
19 (16.1)
36 (15.7)
Fair
56 (50.0)
78 (66.1)
134 (58.3)
Poor
30 (26.8)
18 (15.3)
48 (20.9)
64 (62.1)
61 (53.5)
125 (57.6)
Marginal
8 (7.8)
10 (8.8)
18 (8.3)
Adequate
31 (30.1)
43 (37.7)
74 (34.1)
Health Literacy
Inadequate
Results: Diabetes Knowledge Scores
No significant between group difference in baseline, posttest1, and posttest2 (p>0.05)
N
Baseline score
Posttest 1
score
Posttest2 score
Mean
Std.
Deviation
Std.
Error
Minimum Maximum
INT
118
.5030
.08740
.00805
.17
.72
CONT
122
.5026
.09861
.00893
.14
.72
Total
240
.5028
.09307
.00601
.14
.72
INT
118
.5493
.08248
.00759
.33
.73
CONT
117
.5289
.08657
.00800
.30
.72
Total
235
.5392
.08498
.00554
.30
.73
INT
113
.5858
.09647
.00908
.25
.90
CONT
109
.6003
.08051
.00771
.39
.75
Total
222
.5929
.08909
.00598
.25
.90
Results: Diabetes Knowledge Scores
There was significant within group differences baseline, posttest1, and posttest2 (p<0.05)
Table 3. Paired Samples Statistics for the study groups (intervention and
control)
Control Group
Mean
Pair 1
Pair 2
Pair 3
Std. Deviation
Intervention Group
Mean
Std. Deviation
mean_score_2
.5289
.08657
.5493
.08248
mean_score_1
.5050
.09720
.5030
.08740
mean_score_3
.6003
.08051
.5858
.09647
mean_score_1
.5065
.09784
.5045
.08879
mean_score_3
.6011
.08021
.5858
.09647
mean_score_2
.5302
.08695
.5503
.08226
Results: Within Group Differences in Knowledge Scores
Using the paired t-test, there was a significant increase in the diabetes
knowledge score in posttest1 and posttest2 relative to the baseline score
Control group:
•2.4% increase in knowledge in post1 relative to the baseline
•9.4% increase in knowledge in post2 relative to the baseline
Intervention group:
•4.6% increase in knowledge in post1 relative to the baseline
•8.1% increase in knowledge in post2 relative to the baseline
Results: Diabetes Knowledge Scores



There was a positive association between diabetes knowledge
score and income (p<0.05) at baseline with lesser income
brackets associated with poorer diabetes knowledge levels.
Participants with inadequate health literacy in the intervention
group had significantly higher knowledge scores than those with
inadequate health literacy in the control group in posttest1
(54% and 49%, respectively, p<0.05).
This was not observed in scores between the groups among
participants with adequate health literacy (p>0.05) in post
test1.
Conclusions




This pilot study demonstrated that animation has the potential
to serve as a culturally appropriate health information source
that may improve health literacy among persons with
inadequate health literacy
Animation may be the preferred venue for enhancing health
literacy among persons with limited reading skills.
The study did not prove conclusively that animation is better
than NIDDK very easy to read information at enhancing
diabetes health literacy as measured by the DHLS
A larger multi-lingual and multi-cultural RCT that screens for a
study population with inadequate health literacy is needed.
Limitations



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Participants were clinic based
Participants had varied health literacy which diluted sample
The animated video may not have been viewed at home as
requested
For both the control and the intervention group mean
diabetes knowledge scores remained marginal at 2 weeks
post test
Animation
•
Animation has universal application and a long shelf-life, so
that it can provide useful, life-saving information for years
after its creation.
•
Through “edu-tainment,” friends, family and significant
others also benefit from watching animated media, thereby
increasing social support for patients and motivating them
to adopt positive health behaviors.
ACKNOWLEDGEMENTS

MRISP Grant 1R24-HS014022-01A1 from the Agency for Healthcare
Research Quality to the Charles Drew University

Drs. Richard Baker, Magda Shaheen, Nisa Sangasubana

Dr. Keith C. Norris, interim President, CDU

Martha Navarro: Research Associate/Promotora

Richard Veloz, JD (CEO) and Genevieve Filmadorrosian
“You cannot teach what you do not know,
You cannot lead where you do not go”.
-Martin Luther King, Sr