As per the 2006 World Health Report from the WHO at least 1.3 billion people worldwide do not have access to the most basic healthcare. Key reasons include economic status and a serious shortage of health care workers in many parts of the world. One solution is to find ways to provide basic training in health care, i.e., to promote health literacy, amongst individuals, families and communities in marginalized populations.
The aim of the Living Document program is to develop a multimedia tool designed to overcome health literacy barriers by facilitating access to meaningful, customized health information. A prototype has been developed that takes an educational health text and adds various features to make it more accessible to an individual user’s culture, literacy level, and language.
The principles guiding development of the Living Document program are, one, that the tools being developed should be functional within diverse populations, especially within traditionally underserved populations; and, two, that the “open content model” should be followed. The open content model is a licensing extension to copyright which gives end users the rights to modify and distribute the licensed information (Liang, 2007, p. 19). One specification of our open content principle is the use of open source software whenever possible in the development of the tool so that the final product can be provided to users with minimal hurdles. In a more general sense, an open content model may be employed by the program as a whole so that community-created content and regional perspectives may be inserted by users.
An XML-based model is being explored to customize the presentation of health information for a variety of audiences and for multiple communication mediums. XML makes it possible to create a “logical” document spine to which varying document components may be attached. More specifically, XML allows documents to be enriched with metadata and to be defined independently of layout; as a result, a single XML document can be transformed into several output formats through the use of multiple distinct stylesheets. Variations in the format and content of the documents can thus be molded to fit the needs of diverse audiences. Designing for extensibility of this nature leads to a “living document”. We describe a prototype that has been created and future plans for continued development of the tool.
The Living Document model is being developed in the context of a book called “Where there is No Doctor” (Werner et al., 2007). The book, which has been used for close to three decades, is in its ninth revised edition and is freely available for download in both English and Spanish from the Hesperian Foundation website.[1] Additionally, owing to the Hesperian Foundation’s open content policies, non-profit groups throughout the world have translated the book into more than 80 languages. A report by global health researchers states “a community health worker may find a single copy of Where there is No Doctor, adapted and written in the local language more useful than access to thousands of international journals” (Godlee et al., 2004, p. 297). According to the Hesperian Foundation, individuals in over 100 countries have used the book since its publication in 1977.
When a single document is used on a global scale, the challenge of reaching diverse populations becomes acute; cultural learning styles, expectations, life-styles, food preferences etc. must be considered. In preliminary work we transformed two chapters (English and Spanish versions) of the book into XML (using the DocBook standard) and added metadata to identify information that can be localized. We also began adding audio content to better serve low-literacy users and began exploring the use of alternate images to develop particular cultural contexts. In Figure 1, below, a sample of the book in XML format is shown; you can see the corresponding section of the book by mousing over Figure 1. Figure 2 shows an example of how images can be customized for a particular cultural context.
XML extract
Figure 1: An Extract from the XML Version of a chapter. Visible in the XML code is a reference to an audio version of the section that is specifically for mothers. By mousing over the picture you can see the corresponding section of the book in PDF format.
Alternative cultural contexts of images--Latina and Anglo
Figure 3: Same Image in Latino Context (left) and Anglo Context (right)
The next step is to complete the markup of the book “Where there is No Doctor” using the DocBook XML standard. Additionally, an interface accessible to low-literate users will be developed. In order to inform future development, we intend to study user reactions and outcomes to the “living” versions of the book versus the original. The long-term plan is to extend the tool by adding other books and materials which were developed for low literacy populations.
References
Godlee, F., Pakenham-Walsh, N., Ncayiyana, D., Cohen, B., Packer, A. (2004). Can we achieve health information for all by 2015? Lancet, 364, 295–300. Retrieved January 5, 2008, from http://image.thelancet.com/extras/04art6112web.pdf
Liang, L. (2007). Free/open source software: open content. Retrieved January 29,, 2008, from http://www.iosn.net/open-content/foss-open-content-primer/foss-opencontent.pdf
Werner, D., Thuman, C., Maxwell, J. (2007). Where there is no doctor (9th rev. ed.). Berkeley: The Hesperian Foundation. Retrieved January 5, 2008, from http://www.hesperian.org/ publications_download_wtnd.php
World Health Organization. (2006). The world health report 2006 - working together for health. Geneva, Switzerland: WHO Press. Retrieved January 29, 2008, from http://www.who.int/ whr/2006/en/
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