Product Details

Author Information

Corresponding Author
Dr. Dodi Meyer
Columbia University Medical Center
622 West 168th Street, VC412
New York, NY 10032
United States
p: 212-305-6227
ddm11@columbia.edu

Authors (listed in order of authorship):
Dr. Dodi Meyer
Columbia University Medical Center

Emelin Martinez
NewYork-Presbyterian Hospital

Rica Mauricio
Americorps VISTA Community Health Corps

Melissa Ip
Teacher's College, Columbia University

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Medicine, Public Health, Health Information Management

What specific topics does your product address?

Community-based clinical care , Access to health care, Community engagement, Community health , Community-based education, Cultural competency , Education, Health care quality, Health education , Interdisciplinary collaboration, Maternal/child health, Minority health, Primary care, Race & health, Social determinants of health, Low Income Health

Does your product focus on a specific population(s)?

Children, Immigrant, Latino/Hispanic, Urban

What methodological approaches were used in the development of your product, or are discussed in your product?

Community needs assessment, Community-academic partnership, Community-based participatory research , Focus group , Qualitative research

What resource type(s) best describe(s) your product?

Best practice , Curriculum, Handout, Manual/how to guide, Training material

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

This product is a health literacy toolkit that focuses on medication management in order to reduce medication errors in an immigrant pediatric urban community. The toolkit consists of a curriculum aimed at empowering patients to understand medication management, and a volunteer handbook that guides volunteer-health-educators, CHWs (Community Health Workers) and medical providers in the use of this curriculum. The curriculum is aimed at caregivers of pediatric patients, ages 1-18 years old. It can be implemented in different venues such as waiting rooms of pediatric practices, head starts or during home visits.
The curriculum consists of seven bilingual educational units with the majority using pictorials with content written at a fifth grade reading level. The first component helps caregivers prepare for a doctor’s visit. The second one focuses on upper respiratory infections, which aims at distinguishing between the cold and flu, and how to treat and prevent such viruses. The third unit helps caregivers understand the proper use of antibiotics and how to avoid antibiotic resistance. The fourth unit informs patients how to apply the instructions found on prescribed medication labels. The fifth unit is centered on over-the-counter (OTC) medication, highlighting their appropriate usage for specific age ranges. The sixth unit focuses on medication management by teaching the various dosing forms, intervals, and measurements tools used to administer medication. The seventh unit covers home remedies, which encourages caregivers to disclose the use of home remedies in order to avoid known side effects and contraindications.
The volunteer handbook focuses on using effective conversational skills, while identifying signs of illiteracy among patients, and tactfully approaching patients regarding each topic addressed in the curriculum.

2. What are the goals of the product?

The goals of the HEAL toolkit is to enable health care providers, CHWs and volunteers to effectively communicate with caregivers while following the basic tenets of health literacy in order to enhance caregivers’ understanding of common health topics that may influence their child’s well being. Ultimately the goal is that caregivers will acquire knowledge about medication use, increase their involvement in planning care, and improve their adherence to medical instructions. In order to fulfill the primary goal, it is vital to bridge the communication gap that currently exists between patients and health care providers. This is accomplished by the development of a train the trainer manual that guides such health care providers in the application of the basic tenets of health literacy and practice of effective communication skills. Healthcare Providers are trained on issues of dr/pt communication and health literacy and asked to use this curriculum while seeing patients. Volunteers are trained with the volunteer handbook to deliver this curriculum to parents and caregivers in waiting rooms of community health care practices. Community Health Workers are trained to use this curriculum when interacting with caregivers in their community programs such as head start and home visiting programs using the same volunteer handbook as a guide.

3. Who are the intended audiences or expected users of the product?

The toolkit is targeted for frontline health care providers that deliver services to children in both clinical and community settings. These frontline healthcare providers include pediatricians, community health workers (CHWs), and volunteer health educators. Toolkit contains a curriculum designed to be taught in settings where caregivers attend to care for their children. Examples include: waiting rooms of clinical settings such as primary care practices, homes of children visited by CHW and Head Start programs where parental education sessions take place. This curriculum has been developed for caregivers of Latino Urban Immigrant Community, predominantly Dominican and Mexican origin. It is our intent that the process used to develop this curriculum could inform other curricula targeted to different populations, regardless of language, health beliefs or particular home remedy used.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

Key to the successful implementation of this product is the training given to pediatric providers, volunteers, CHWs. Training is delivered using the project-based learning strategy in which participants learn to address realistic scenarios that are relevant to the issues patients face due to poor health literacy. Training should provide opportunities to role play, allowing trainees to demonstrate what they learned prior to engaging caregivers. It also includes the principles of health literacy, effective communication skills, cultural competency, and the curriculum’s content. Since the product is shared with patients in a non-didactical manner, it is crucial for the trainees to have extensive content knowledge.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

The role of low health literacy in mediating health disparities is well documented and it is a prevalent issue in the United States, particularly in low income and immigrant communities as defined by Nielsen-Bohlman and colleagues (5). Low health literacy worsens health outcomes, increases healthcare costs and impairs quality of care. Families with low health literacy are at particular risk for medication administration errors, with dosing error rates of home administration of medicines to children reported to be as high as 50% (11). Educational interventions can improve health knowledge, behaviors, and the use of healthcare resources among patients with low health literacy. Interventions as these are rarely described in sufficient detail to be adapted and replicated in other settings (3). In order to be successful, these interventions must integrate health literacy with cultural and linguistic competency, which can be achieved when members of the target population are invited to be directly involved in the development, design, and testing of materials implemented (7), narrowing the communication gap between providers, patients, and their caregivers. While there is a vast amount of literature describing the extent of the problems faced by populations with limited health literacy, there are few examples of replicable, sustainable programs that work within primary care and community-based settings to improve the health literacy of the population served (1).

Since educational interventions can improve health knowledge and behaviors among patients with low health literacy, the Health Education and Adult Literacy (HEAL) program was developed with the goal of improving health literacy with emphasis on medication management among pediatric patients in an urban New York City community.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse populations. American Journal of Health Behavior, 31(Suppl 1), S122-133.

2. Centers for Disease Control and Prevention. The Interagency Task Force on Antimicrobial Resistance and A Public Health Action Plan to Combat Antimicrobial Resistance; available at http://www.cdc.gov/drugresistance/actionplan/. Accessed February 20, 2009.


3. Cooper, L. A., Hill, M. N., & Powe, N. R. (2002). Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med, 17, 477-86.


4. DeWalt D.A., Callahan L.F., Hawk V.H., Broucksou K.A., Hink A., Rudd R., & Brach C. (2010) Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality.


5. Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.) (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press.


6. Makoul, G., et al. (2001). Essential elements of communication in medical encounters: The Kalamazoo Consensus Statement. Academic Medicine, 76(4), 390-393.

7. Rima R. (2011) Instant Access & Old Faulty Assumptions. Retrieved from Engaging the Patient website: http://engagingthepatient.com/2011/10/19/instant-access-old-faulty-assumptions/

8. Sobo, E. J., Seid, M., & Gelhard, L. R. (2006). Parent-identified barriers to pediatric health care: a process-oriented model. Health Serv Res, 41(1), 148–172.


9. Stockwell M.S., Catallozzi M., Meyer D., Rodriguez C., Martinez E., & Larson E. (2010) Improving Care of Upper Respiratory Infections Among Latino Early Head Start Parents. Journal of Immigrant and Minority Health, 12(6), 925-31.


10. Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med, 162(9), 814-822


11. Yin, H. S., Forbis, S. G., & Dreyer, B. P. (2007). Health literacy and pediatric health. Current Problems in Pediatric and Adolescent Health Care, 37(7), 258-286

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The HEAL Program partnered with Alianza Dominicana, the largest social service community-based organization (CBO) serving Washington Heights at the time, to inform the design of the program and enable its implementation in community settings. HEAL was initiated in 2007 at which time it was integrated into Alianza Dominicana’s Best Beginnings Program, a home-based service for high-risk families that employs Family Support Workers (FSWs) to promote child health and enhance parental self-sufficiency. During the initial years of the program, Best Beginnings played an instrumental role in recruiting members of the community to participate in three focus groups, which sole purpose was to help determine the needs of the community in order to address additional health-related issues identified by parents as critical when visiting a doctor.

These focus groups—two in Spanish and one in English—were conducted with twenty-two parents of children under the age of eighteen. Initially, the goal of the HEAL program was to concentrate on the known relationship between medicine administration errors and health literacy. However, focus groups revealed the need to address additional health-related issues identified by parents as critical when visiting a doctor. The most commonly coded domains in the focus groups were: provider-patient communication, approaches to communication about medication usage, use of home remedies, parent expectations of the clinical encounter and physician and clinic qualities. Thus, a curriculum was developed with these important themes in mind.

In addition, clinical observations of provider-patient interaction in the ACN sites were also conducted to better understand the needs of the population and inform the development of the curriculum. Two randomly selected community based hospital affiliated pediatric outpatient clinics at New York Presbyterian Ambulatory Care Network. Sixteen pediatric residents and 4 attending physicians were randomly selected for observation. During the patient visit, the observer completed a communications checklist form based on the Kalamazoo Consensus Statement on essential elements in communication in medical encounters (6). At the end of the visit, the observer conducted exit interviews with patients and providers separately in Spanish or English. Both caregivers and providers were interviewed on: the diagnosis/assessment of the visit, medications, amount of technical language used, use of written materials or visual models, use of the teach-back method and overall communication. The clinical observations and exit interviews revealed that caregivers demonstrated basic understanding of the assessment of the patient’s health problem(s). Observed physicians showed most skill at: building relationships with patients and their caregivers; using caring body language, tone, eye contact, and pace; avoiding medical and technical jargon and relating to caregivers’ illness frameworks; and providing written materials. Physicians did not perform as well in the following areas: allowing caregivers to explain the presenting problem(s) in their own words; not interrupting caregivers; using visual methods; identifying additional resources; asking caregivers if they had questions during the visit other than the end; and asking about caregivers' ability to follow treatment plans. None of the physicians used the teach-back method. Based on the results of the clinical observations, the observer recommended that the HEAL program curriculum for pediatric providers to focus on improving physicians' skill and performance in the following areas:
• Allowing the caregiver to describe the problem uninterrupted
• Asking if the caregiver has questions before the end of the visit
• Using visual methods
• Using the teach-back method, particularly when giving instructions on medication provision
• Using the translator phone as needed
These recommendations are consistent with current guidelines for clear provider-patient communication described in the AHRQ Health Literacy toolkit(4).

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

Integral to the development of the curriculum is the collaboration of the members of the community, which consists of medical providers, patients’ caregivers, and members of established community based organizations. Each member of the community provided expertise to create a curriculum that is conducive to the urban immigrant of community of Northern Manhattan. Some members were part of the HEAL Advisory Board Committee, who reviewed product and recommended revisions prior to implementing the curriculum among the target population. Below are some of the CBOs and key health care professionals, and their role in the development of the product.

Alianza Dominicana was our community partner for this project and has been involved in the design and implementation of this program. We have worked with Best Beginnings, one of Alianza’s signature programs. Best Beginnings is a home-based service for high-risk families that employs community health workers (CHWs) to promote child health and enhance parental self-sufficiency. During the initial years of the program the Best Beginning director served as the Community Coordinator, she coordinated the recruitment of participants for the focus groups held prior to the development of the product. In addition to establishing an understanding of the common health beliefs and practices of the population served, focus groups also helped develop a culturally responsive health literacy curriculum. While the initial goal of the HEAL Program was to reduce medication errors, focus groups revealed that other health-related issues needed to be addressed in order for the curriculum to be fully responsive to community needs. These needs included helping patients to prepare for a medical visit and improving provider-patient communication around the issue of home remedies. The director also organized the training sessions regarding the health literacy curriculum for the CHWs. These workers reached out to participants during their home visits in an effort to improve the communication gap, increase medication adherence, and reduce dosage errors.


The Literacy Assistance Center is a nonprofit organization dedicated to supporting and promoting the expansion of quality literacy services in New York. A literacy specialist from the center is a member of the advisory board, assisted in the revision and editing efforts of the written materials for HEAL.

Northern Manhattan Improvement Corporation, a community organization in Upper Manhattan, has over 1,000 students a year at the 33 literacy classes it offers to community members. Parents identified as having low literacy in our program’s waiting room can be referred to ESL classes offered by the organization. The HEAL advisory board member of Northern Manhattan helped make revisions to the curriculums to ensure that the content designed in a culturally sensitive manner, while providing expertise regarding strategies that are helpful for the adult learner.

Columbia University’s Clerkship Program at the College of Physicians and Surgeons gives first year medical students a chance to participate in a clinical experience based in a primary care setting. In this program medical students learn how to interview and communicate effectively with patients. Every semester one to two 1st year medical students are placed in our HEAL program in a neighborhood ambulatory care clinic, specifically the Washington Heights Family Health Center in which they engage patients in the waiting to discuss the components of the health literacy curriculum, in addition to shadowing a medical provider’s skills in patient interviews.

The medical director of the program, an associate clinical professor of pediatrics, has expertise in building and sustaining community- academic partnerships for the purpose of training, service and research. Her knowledge in cultural competency and health literacy was instrumental to ensuring that content was aligned with sound medical knowledge and that it was culturally responsive to the population served.

The program coordinator is an educator and has extensive experience in teaching methodologies. She manages the Reach Out and Read and HEAL Programs. She promotes emergent and health literacy by training community volunteers, medical residents within the Ambulatory Care Network Setting at NewYork-Presbyterian Hospital, and community health workers in the implementation of the program model as it relates to the needs of the patients and their caregivers.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

The HEAL intervention has been successfully used in different group settings in the community and in the university.
1) The curriculum development process proposed in this report was used to develop an intervention focusing on the common cold, appropriate care of upper respiratory infection and antibiotic resistance in a Head Start setting. During the 2010 H1N1 outbreak, information was included on H1N1 to educate about the emerging public health threat using an approach tailored to the culture, language, and health literacy level of patients served. The process of curriculum development was the same as used for the HEAL curriculum described above. Community input was sought once general drafts were created. The final product represented modules that were culturally and linguistically sensitive to the population served. The use of separate modules allowed greater flexibility to meet each family’s needs and allowed the team to rapidly include new topics. In a pilot of this intervention, caregivers mean composite knowledge/attitude score increased from 4.1 (total: 10) to 6.6 (p < .05), and parents reported improved care practices in treating the common cold (9).


2) During the latter half of 2011, the HEAL curriculum was used by a multidisciplinary team to design and implement Multimedia Educational Modules on Fever Assessment and Medication Administration Project. The goal of this projects was to the assess effectiveness of multimedia education about (1) fever assessment and (2) medication administration on knowledge and care practices among parents in a pediatric emergency department (PED)



The 55 parents who participated (27 fever, 28 medication administration) were primarily mothers, Latino, immigrants, publicly insured, and at high risk of low health literacy as measured by the Newest Vital Sign. Subscale scores were calculated as number of correct answers out of 5 questions. There were no significant differences between groups in pre-test mean scores for fever (2.7 fever, 2.4 medication administration, p=.18) or medication subscales (4.1 fever, 4.2 medication administration, p=.7). On the fever subscale, both in the post-test (3.9 vs. 2.4, p<.001) and telephone test (2.1 vs. 1.6, p=.03) parents in the fever group had higher knowledge than those in the medication administration group. Parents in the fever group improved more than those in the medication administration group (p=.0002). On the medication subscale, both groups performed the same at post and telephone tests and improvement over time was the same (p=.95).
In these two examples we can see that the fluid health literacy curriculum, capable of further development and adaptation, is instrumental in addressing the health concerns of the community Embedding the curriculum into the patient education component of both community and clinical interventions can ensure program sustainability.

3) The Community Engagement Core Resource (CECR) of the Irving institute for Clinical and Translational Research partnered with the HEAL team to create consent forms that meet the health literacy levels of research participants. Using a round robin method of reviewing material to assess health literacy levels and idiomatic expressions, a template for minimal risk informed consent is now posted at the university IRB.

10. Please describe why you chose the presentation format you did.

The curriculum was purposely created in stand-alone units as to allow patients to drive the content of the teaching. This format also allows for new units to be added as new issues arise that require attention. The key of this curriculum is to always allow for the process of its development to be informed by recipients of the teachings in order to ensure that material taught is culturally and linguistically relevant and sensitive. Based on the needs-assessment, the curriculum was initially divided into five units: preparing for a doctor’s visit, over-the-counter medications, prescription medications, home remedies, and medication management. The format utilized pictorials and educational materials written at a fifth grade reading level. The Spanish translation was developed with the input of native speakers from multiple countries that represent the communities in WHI in order to address the diversity of patients’ origin and address issues of colloquialisms. Two years after the original HEAL curriculum was implemented two additional units were incorporated in direct response to the growing need for education on upper respiratory infections, specifically the H1N1 influenza epidemic. Emphasis was placed on the unnecessary use of antibiotics for these illnesses and the antibiotic resistance that emerges with this common practice (9).

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The key to the program’s sustainability is its integration into ongoing residency and faculty training programs and into ongoing existing partnerships and programs in community agencies and settings. A strong community partnership is critical to the success and sustainability of the HEAL program. The partnership has been crucial in the recruitment and facilitation of community focus groups as well as in ensuring that the language used in modules was both appropriate and culturally sensitive. Focus groups and clinical observations offered qualitative data that was essential for gaining insight into parental perceptions and experiences of medical visits; such information was instrumental in the development of patient-centered interventions that functioned to minimize barriers to care (8).
There were a number of limitations to the HEAL program. Recruitment and training of long-term volunteers was found to be challenging and time-consuming, but training providers, medical students and CHWs ensured greater sustainability of the program. Secondly, long-term behavioral changes in both patients and providers were not measured. Because the intervention was developed as a service-learning program and not a research study and because health literacy universal precautions were used, as suggested by AHRQ (4), validated health literacy assessment tools were not used. Instead, health care providers informally assessed the health literacy of patients during patient encounters. Further work is needed to assess the impact of this program on improved patient-provider communication and long-term knowledge and impact of care practices in the population served.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

The community partner was key in setting up the focus groups that informed the curriculum These focus groups were held at the community site, and participant were recruited by the community agency. Once the curriculum was developed, translation and accuracy of terms used were reviewed by the community partner. This occurred in a relationship based on mutual trust and a significant history of past collaborations and credit sharing. For the past 15 years, Best Beginnings and the department of pediatrics at CUMC have been working together in a partnership devoted to service, training and research. The curriculum was implemented and embraced by one of the community’s agency core programs, Best Beginnings a home visiting program that utilizes CHW to optimize child’s health, well being, and parental bonding. As in many other examples, university and community partners shared authorship on an abstract and a webinar describing the HEAL product. . This project was approved by the Columbia university IRB board

Over this past year, Alianza has been undergoing major restructuring. Although Best Beginnings is still in existence, all the people involved in this project are no longer there. We are unable to contact original program leaders so authorship for this particular publication will not be shared