Hi everyone-
Lorena - I appreciate you chiming in! 
 
If our goal is to promote positive, meaningful, sustained change inherent in
health literacy objectives, then I agree with Lorena about a participatory
approach to health education efforts. And more broadly, if we are committed
to transforming our systems of care to a patient or cultured-centered model,
which also requires sharing power, then a participatory or collaborative
approach seems only logical too. However, this makes me think about Mark's
post earlier this week about how decisions are often not rational and making
changes typically involve complex dynamics that are difficult to make
explicit.
 
One challenge we face in the transformation process that Laura brought up
regarding Freire and her work in the community is recognizing and naming the
factors and dynamics of the different paradigms. If we can do that, then we
are in a better position to make conscious choices on individual and
organizational levels, in policy and practice. 
 
I find that it's not an easy task because it's so pervasive and
institutionalized in our culture. For example, 'either/or,' 'win/lose'
thinking is characteristic of a 'power over' way of relating whether we are
relating as individuals, groups, or even with the environment. This is
expressed in obvious ways such as, 'It's my way or the highway,'  'Either
you are with us or against us.'  It can also come up in more subtle ways.
For example, in cultural competency trainings when we  talk about the use of
sharing power in patient-practitioner communication. Someone usually asks,
Does this mean that a doctor or nurse must give up their power and stop
being directive? What about my legal responsibilities and obligations, I
can't let others do or say whatever they want. 
 
Or it can also be expressed by patients who want or expect an 'expert' not a
'facilitator,' e.g., 'don't ask me what I want or think I should do, that's
what you went to school for and why you got all that training.' A great
example is in the AMA health literacy video, 'Helping Patients Understand,'
a female patient says something to the effect, 'I do whatever the doctor
tells me, I trust him with my life.'  She either directly or indirectly says
she doesn't really ask questions or need to understand.  Embedded in these
questions is a sense of 'either/or,'  power over- someone is on top, someone
is on bottom...so if I'm not in a dominant position, then I'm in a
submissive one. I am excited about the health literacy movement because it's
helping make explicit the dangers and hidden costs of simply focusing on
'compliance' at the expense of critical thinking and fostering a sense of
mutuality and ownership of one's health and well-being.
 
So Lorena, your analogy of a participatory approach as 'a dance where no
person leads and everyone is a leader' is an elegant one. It helps answer
the questions posed by those health professionals. Supporting others in
claiming and expressing their voice and power does not mean we lose our
power personally or professionally (it's not either/or), we use our power
and authority differently. As Jean Baker Miller and others suggest in
relational-cultural theory, we view and understand relationships in a
holistic and interdependent context. 'And' is the operative principle. Power
sharing is 'power with' others, side by side, while we each build our own
'power-from-within' (however you define it, e.g., self-efficacy or perhaps
in a spiritual way). Are there situations that require a directive approach
or an intervention, e.g., a parent abusing a child, suicidal tendencies, an
emergency or diminished capacity of some sort). Absolutely- there is a
continuum of responses available. And as Lorena, and the others who have
shared this week have pointed out, when we work in a collaborative way, with
a better understanding of the whole picture (individual, family, community),
we have a better sense and range of options, we make better, more informed
choices and decisions, we can be more effective in promoting change and
health, not just those we serve.
 
Since it's Friday, I figured it would be alright to write a little longer
post :)
Susan
 
Auger Communications, Inc.
PO Box 51392
Durham, North Carolina 27717
tel:  919.361.1857
fax: 919.361.2284
email:  <mailto:auger at augercommunications.com> auger at augercommunications.com
 

  _____  

From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Lorena Sprager
Sent: Thursday, November 20, 2008 12:24 PM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 2492] Re:
Teach-With-Storiesmethodforusingphotonovellas


Dear Susan and Colleagues,
 
I have been a quiet participant on this list serve for years.  I have been
learning from the discussions and information sharing, then applying it to
my work.  Like you, Susan, Teaching Patients with Low Literacy Skills has
been my bible.
 
It is my passionate belief that the participatory, or collaborative,
approach is the way to share health information and promote positive changes
in individuals and communities.  I have had the privilege and honor to work
with Promotores de Salud, or Health Promoters (also known as Community
Health Workers) for over a decade. 
 
In a nutshell, this model brings in respected members of the target
community to work hand in hand with the health care system.  They then share
health information with their community members in a culturally and language
appropriate way.  The Promotores are an ongoing health resource in their
community.  Also, they are a bridge to their community members accessing and
maneuvering within the health care system.
 
To answer Susan's question, as a facilitator, the impact of working in this
participatory approach has been:

*	Making positive inroads with the target population, 

*	Sharing health information and services effectively in a respectful
and appropriate way, 

*	Seeing positive health outcomes as a result of working hand in hand
with the target population, 

*	Recognizing we are all learners and teachers, and 

*	Feeling humbled, awed and great joy

The best analogy I can offer for this participatory approach is a dance
where no one person leads and we are all leaders.  We all bring our
strengths and wisdom to make a positive difference.
 
Lorena Sprager
Consultant
lsprager at gorge.net
541-386-4113

----- Original Message ----- 
From: Susan  <mailto:sauger at mindspring.com> Auger 
To: 'The Health and Literacy Discussion  <mailto:healthliteracy at nifl.gov>
List' 
Sent: Thursday, November 20, 2008 5:24 AM
Subject: [HealthLiteracy 2488] Re: Teach-With-Stories
methodforusingphotonovellas

Hi Bobbie-
I agree - I think there's lots of potential for photonovellas related to
diabetes since it involves lifestyle management and behavior change issues
(which are multi-dimensional). With the disparities and rising rates of
diabetes among children- the cultural and developmental issues are important
to consider and address in educational efforts too. I was having a bit of
trouble visualizing an end product based on your description though. It
might be easier to brainstorm details on the phone or off-line which I would
be more than willing to do.
 

>From a broad perspective, I don't know that there is a right or wrong way or

even a best way to develop photonovellas. I think it comes down to making
choices about what works and doesn't work according to your principles and
what you want to acheive. I encourage anyone interested in the photonovella
concept to think critically about the nature of the relationship that they
want to have with the people that they serve and also the type of outcomes
that they want to acheive. The paradigm a person chooses will make a
difference.
 
My passion is in creating photonovellas that are developed through some type
of participatory process- whether it's supporting a learner-centered
approach or facilitating a collaborative one. It fits with our company
mission and values. It's fun. I am always learning, and ultimately, I feel
humbled and awed by the creativity, insights, gifts, and feeling of
connection that emerge during the process. 
 
We've mentioned some benefits for the participants.  What are other people'e
experiences re: the impact of a participatory approach as a facilitator? Do
others agree or disagree that the paradigm makes a difference? If so, in
what ways?
 
Susan

  _____  

From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Bobbie Randall
Sent: Wednesday, November 19, 2008 2:22 PM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 2483] Re: Teach-With-Stories method
forusingphotonovellas



I have been reading with great interest the discussion on photonovellas.  I
see a great use for them with my diabetic clients.

 

Question:  If I have a class of people with diabetes for only a few days or
a week is it possible for me to put together a photonovella for them?

 

            I guess I could have a prototype already put together on my
computer and just add the photos.  I love the personalization of the
project.  I think that my clients would really identify with a book
featuring them.  

 

            Last year I heard a lecture by Andrew Pleasant from Rutgers on
Health Literacy and he reminded the diabetic educators that for our clients:
Diabetes is a new lifetime contract with their health.  Seeing their photo
with a caption or dialogue bubble stating that they are willing to consider
to make lifestyle changes could make an impressive impact.  The finished
product will either end up on the refrigerator or the trashcan. 

 

            Thank you for all of this info.  I may be contacting a few of
you experienced photonovella-ers for guidance.

 

 

Bobbie Randall, MEd, RD, LD

Dietitian

Dunlap Community Hospital

832 South Main Street

Orrville, OH  44667

330-684-4776

 


  _____  


From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Susan Auger
Sent: Wednesday, November 19, 2008 1:27 PM
To: 'The Health and Literacy Discussion List'
Subject: [HealthLiteracy 2482] Re: Teach-With-Stories method for
usingphotonovellas

 

I wanted to share some background info to help clarify how I came to develop
and use photonovellas differently...

In the early 1990's I 'discovered' photonovellas while conducting a national
search for culturally appropriate bilingual educational materials for NC
health departments.  As the State Training Coordinator for women's health at
the time, I was responsible for conducting statewide training needs
assessments, as well as developing and coordinating training for health
professionals in maternity and family planning.

Serving the growing Hispanic population posed many challenges, e.g., lack of
bilingual, bicultural staff, interpreters, and bilingual materials. It was
common for women to come into prenatal care late or just show up in the
emergency room at the time of delivery. Issues voiced by providers included
problems with no-shows, 'non-compliance,' and perceptions that Latinos were
'difficult to reach,' and 'didn't like groups.' The more I learned about
literacy and cultural competency, I realized that this probably had more to
do with our lack of cultural competency (individually and organizationally)
and ineffective service delivery strategies, than simply a lack of
appropriate written materials and problem patients. 

Similar to John and Laura, Paolo Friere, along with Malcom Knowles' work
(adult learning theory), were also inspirational to me.  From a systems
perspective, I saw the need to transform how we were teaching mandated
prenatal education- from a teacher or clinician-centered model to a learner,
patient or cultured-centered model.  To me, the photonovella was a perfect
tool to assist providers and educators who wanted to adopt a participatory,
empowerment-based approach. 

Using a collaborative development process, we wove together key content
taught in traditional prenatal education curricula, actual experiences of
Latino families and providers who serve them to create the De Madre A Madre
photonovellas.  Embedded in the stories are discussion 'sparks' related to
common issues and concerns (mental, emotional, social, spiritual)
experienced by women during and after pregnancy.  

As Julie and Mary mentioned, the women read the novella out loud like a play
(so those who can't read can still participate). While key health messages
are automatically addressed while reading the story, the dialog focuses on
the priorities, experiences, and questions of the group members.  So they in
effect tailor the session to their unique needs and interests. This
structure shifts the dynamics from a passive, lecture style to an active,
participatory one where everyone truly is a teacher and a learner. 

The group process, what we now call the Teach-With-Stories(TWS) method,
fosters critical thinking, behavior change, and social support- all key
elements of health literacy.  Julie touched on its simplicity and
flexibility. It takes no more time than a traditional class and you can
weave in other activities or use it to supplement an exisiting curriculum.
And as Julie also mentioned, the photonovellas can still be used for
information dissemination and in one-on-one education.

As Mark suggests, the dynamics in making change in one' life or one's family
are complex and can be complicated to explain. We need to create 'space ' in
our systems of care to address these types of needs and realities.  It is at
the heart of true health literacy. I think using photonovellas with a
participatory, group approach, like our TWS method, gives providers and
educators a practical and easy way to do this.

Susan

 

Auger Communications, Inc.

PO Box 51392

Durham, North Carolina 27717

tel:  919.361.1857

fax: 919.361.2284

email:  <mailto:auger at augercommunications.com> auger at augercommunications.com

 

 


  _____  


From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of MarkH38514 at aol.com
Sent: Wednesday, November 19, 2008 10:55 AM
To: healthliteracy at nifl.gov
Subject: [HealthLiteracy 2481] Re: Treatment refusal and verbal abilitiesand
phot...

Susan: 

 

This sounds promising. >From my own experiences as a Psychologist and a
patient...

 

Because so much information about medical treatments and research is focused
on the patient,  health care providers don't always realize that every
disease is a family disease. 

 

Physicians are often frustrated by "non-compliant" patients (a description I
despise) who don't do what they're told--losing weight, for example. But
losing weight means you have to change what you eat and that decision alone
can create profound spousal, family, cultural and religious conflicts. 

 

Plus, successful weight loss can be psychologically threatening to other
family members who can't or don't want to lose weight, or feel that their
spouse's weight loss will threaten the marriage because the spouse may now
be more attractive to the opposite sex. Sometimes family members can
sabotage one's best efforts to lose weight and keep it off. Obviously
there's more to weight loss than telling patients to lose weight and giving
them nutritional handouts. 

 

If you can find patients willing to talk honestly about these issues, you
may be able to identify possible barriers to healthy behavior and provide
some possible solutions in a format that's more meaningful than just another
medical handout. 

 

Mark

 

Mark Hochhauser, Ph.D.

Readability Consultant

3344 Scott Avenue North

Golden Valley, MN  55422

Phone: 763-521-4672

Fax: 763-521-5069    

Cell: 612-281-1517

email: MarkH38514 at aol.com

 

 






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