Authors: Toth-Cohen, Kaur, & Harkins, 2013

1. Using Health Literacy Principles
for Virtual World Exhibits:
A Case Study
Susan Toth-Cohen, PhD, OTR/L
Harpreet Kaur, OTS
Alexandra Harkins, OTS
Fifth Annual Faculty Days
Thomas Jefferson University
Philadelphia, PA, USA
June 7, 2013

2. Purpose of Presentation
• To discuss development of a checklist for a
virtual world exhibit on health and wellness,
to ensure adherence to principles of health
literacy
• To discuss the development of a virtual
world exhibit over time, as informed by a
team of graduate students and the faculty
project director

3. Objectives
After attending this presentation, you will be able to:
• Discuss key principles of health literacy and the “translation”
of these principles to consumer health education in virtual
worlds
• Identify methods for evaluating the fit of educational
materials with principles of health literacy
• Describe ways in which virtual worlds can be used to deliver
quality health information that meets consumers’ needs
• Discuss the role of graduate research assistants in
contributing to programs on consumer health education

4. What is Health Literacy? What does
it include?
We first asked our audience. Their contributions:
“Communication” and” Self-directedness.” Then, we showed the above
selection of key words and discussed as a group.

5. How does health literacy apply to your current work?
What are some examples of media you use as health
care educators?
s
Handouts & brochures Simulations Video (Self-produced
and YouTube)
Learning management
systems Organization websites
Wikis

6. Why Virtual Worlds?
• Convenience and relatively low cost (similar to “traditional” web media)
• Unique opportunities for immersion, networking and collaboration, and
exploratory learning and training (Boulos, Ramloll, Jones, & Toth-Cohen, 2008).
• Implementation is complex and many criteria must be met, such as:
• Ensuring use of reliable sources of information (National Library of
Medicine, 2012)
• Using the unique features of virtual worlds to full advantage, such
as interactivity, 3D displays, and social networking.
• Virtual exhibits for health information created in a consumer-
friendly, interactive style.
(Boulos, Ramloll, Jones, & Toth-Cohen, 2008).
however…

7. Why Care about Health Literacy in
Virtual Worlds (VW’s)?
• Participation in VWs continues to expand in all age groups,
with a projected increase in adults engaging in VW from 11.5
million in 2009 to 32.5 million in 2015 (Cohen, 2009).
• Unique venue for reaching a diverse group of individuals
worldwide, to provide consumer health information and
potential to improve individuals’ health literacy skills.
• Low health literacy has been strongly linked to poor health
outcomes in many areas, such as increase in chronic illness,
less use of preventative health services, increased
hospitalization, and mortality
(Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; DeWalt, Berkman,
Institute of Medicine, 2009; Sheridan, Lohr, & Pignone, 2004).

8. Garden of Healthy Aging Project:
Second Life®
A comprehensive exhibit on
healthy aging for residents of
Second Life® consisting of
interactive media, focused on
strategies for maintaining and
improving health as one grows
older.
The GHA is based on Rowe & Kahn’s (1999) seminal work,
Successful Aging and consists of 10 exhibits. All are based on
research evidence and interactive design principles for virtual
environments.

9. Concept
and Links to
Components
of Successful/
Healthy
Aging
Figure
derived from:
Rowe & Kahn, 1999,
p. 39
Maintain High
Cognitive and
Physical Function
Successful/
healthy
agingEngage/Participate
in life
Avoid disease
Avoid worsening
of chronic disease
 Living with diabetes
 Heart health
Managing stress
 Care for the caregiver
 Healthy activity
 Social support
 Spirituality &
religious practices
 Healthy activity
 Future of healthy
aging
Healthy Brain
Each green bullet
below is a station
in the garden

10. Background and Timeline of The Garden of Healthy
Aging Project by Project Team (GA’s and Project
Director)
Evidence
Based
Exhibit
Develop-
ment
& Review
2008-2009
Program
Evaluation
of Exhibit
2010
Further
Develop-
ment
Based on
Visitor
Input
2010-2011
Focus on
Health
Literacy
2011-present
Develop-
ment of
HL
Checklist
and
Revision
of Exhibits
2012-present
GA’s developed
exhibits based
on current
evidence in
healthy aging
Team conducted
program
evaluation
with 18 residents
via surveys and
semi-structured
interviews
Team revised
exhibits to
include
more information
on caregiving &
change the
spirituality exhibit
to broader focus
Team conducted
extensive
literature review
on health
literacy; realized
need for change
to existing
exhibits
Team developed
checklist for
promoting
health literacy in
virtual worlds
and is
conducting pilot
analysis

11. Development of checklist:
Promoting Health Literacy in Social Virtual
Worlds
 Conducted literature review (health care, public health, health
literacy)
 Created outline of key concepts applicable to virtual worlds
 Piloted preliminary version of PHLSVW with exhibits in the
Garden of Healthy Aging
 2 graduate students identified specific exhibit components
requiring change
 2 additional graduate students and project director then
reviewed each exhibit to come to consensus on changes
needed
 Re-formatted original version to improve ease of use

12. Health Literacy Principles and Domains
Applied to Virtual Worlds
• Readability: Reading grade level (CDC, 2009;
Ridpath, Greene, & Wiese, 2007; Osborne, 2013; Ridpath, et. al.
2007 )
• Plain language: Jargon-free, active voice,
shorter words, use of lists, single main idea,
definitions
(Osborne, 2013; Ridpath, Greene, & Wiese, 2007; US Dept. HHS,
2009, 2010)
• Format & layout: Font size and style, balance of
white space, paragraph length, use of headings
(Osborne, 2013)

13. Health Literacy Principles and Domains
Applied to Virtual Worlds
• Graphics: Simple, easily identifiable, culturally
relevant, shown in context
• Credibility: Reliable sources, access to reference
list, “about us” info (Abu-Zahara, 2012; Osborne, 2013)
• Navigation/Accessibility: Multi-sensory access,
interaction, intuitive use, single main idea
(Osborne, 2013)
(Abu-Zahara, 2012; Osborne, 2013;
The Tech Virtual, n.d.)

14. Excerpt from Original Version Same Excerpt – First Revision
Word file that included ratings for
exhibits, notecards, and wiki all
on one page
Excel with separate worksheets for evaluating
each venue: Exhibits, notecards, and wiki
(quicker and easier than original)
Promoting Health Literacy in Social Virtual Worlds (PHLSVW)

15. Documentation of changes after evaluation with
the PHLSVW (Excerpt from our Google Docs Spreadsheet)

16. Evaluation of The Garden of Healthy Aging Using the
PHLVW (examples from the Diabetes Exhibit)
Issues with original exhibit
Info on glycemic index included on table display but not
included in BBQ grill that shows calorie and fat context
No labels on
pressure sore
display (foot model)
Shoe with insert
not easily
recognizable

17. Evaluation of The Garden of Healthy Aging Using the
PHLVW (examples from the Diabetes Exhibit)
Sample changes
Grill and table displays are better
coordinated (both include Gly. Index)
Easy to recognize shoe and pop-up
explanation
Labels on
pressure sore
display (foot
model)

18. Sample change to
notecard
Notecards are a common
way to provide text
information in virtual worlds
such as Second Life

19. Proposed Next Steps
• Expert review of PHLSVW Checklist
• Testing with other health and
wellness sites in Second Life and
possibly other virtual worlds
• Revise PHLSVW based on testing;
make recommendations for use

20. Role of Graduate Research Assistants in
Virtual World Project Development
Roles
 Translators of health literature to consumer information
 Researchers-finding up to date evidence
 Writers/developers/builders of wikis, interactive displays, notecards
 Evaluators of project components
Contributions
 Used HL checklist to critically analyze project components
 Implement changes based on checklist findings
 Refine HL checklist to make more user-friendly
 Document all changes to exhibit components, including rationale,
HL domains/principles, and results

21. What we got out of the process
 Learning how to interact with clients/patients to
develop rapport, which promotes patient involvement
in care (example: using plain language in patient
communications)
 Empowering clients to ask for more info when in need
of clarification through the use of education and
advocacy
 Opportunity to learn based on highly interactive,
collaborative work with colleagues
 Using health literacy principles to dissect health
literature for ourselves in order to drive evidence-
based practice.
Role of Graduate Research Assistants in Virtual World Project Development

22. Overall, it is our responsibility as health providers
to provide information to clients that is accessible and
helping clients to feel comfortable in asking questions.
What we got out of the process
 Identifying resources that can prove useful to clients
 How to implement health literacy within the
framework of Universal Design, in effect making
information more accessible by consumers.
 Using virtual worlds as a way for health professionals
to meet “the triple aim” of health care reform:
improving care, improving health, and reducing costs
(IHI, 2013).

23. Closing thoughts and take-home
messages

24. References
1. Abou-Zahra, S. (2012). How people with disabilities use the web. (2012).
Retrieved from http://www.w3.org/WAI/intro/people-use-web/Overview
2. Berkman, N.D., Sheridan, S.L., Donahue, K.E., Halpern, D.J. & Crotty, K. (2011).
Low health literacy and health outcomes: An updated systematic review. Annals of
Internal Medicine, 155, 97-107.
3. Bloomfield, P. R., & Livingstone, D. (2009). Immersive learning and assessment with
quizHUD. Computing and Information Systems Journal, 13(1), 20-26.
Retrieved from http://cis.uws.ac.uk/ research/journal/vol13.htm
4. Charnock, D. (1998). The discern handbook: Quality criteria for consumer health
information and treatment choices. Oxon: Radcliffe Medical Press.
Retrieved from http://www.discern.org.uk/discern.pdf
5. Cohen, H. (2009). Virtual worlds forecast to grow at 23% through 2015. Retrieved from:
http://www.strategyanalytics.com/default.aspx?mod=PressReleaseViewer&a 0=4745
6. Institute for Healthcare Improvement (2013). IHI triple aim initiative. Retrieved from:
http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
7. Institute of Medicine (2009). Toward health equity and patient-centeredness: Integrating
health literacy, disparities reduction, and quality improvement. Washington, D.C.

25. References
8. Kamel Boulos, M. N., Ramloll, R., Jones, R., & Toth-Cohen, S. (2008). Web 3D for
public, environmental and occupational health: Early examples from second life.
International Journal of Environmental Research & Public Health [Electronic
Resource], 5(4), 290-317.
9. Osborne, H. (2013). Health literacy from A to Z: Practical ways to communicate
your health message (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
10. Ridpath, J. R., Greene, S. M., Wiese, C. J. (2007). PRISM readability toolkit
(3rd ed.). Retrieved from Group Health Research Institute website:
http://www.grouphealthresearch.org/capabilities/readability/ghchs_readability_toolkit.pdf
11. Rowe, J. & Kahn, J. (1999). Successful aging. New York: Basic Books.
12. Rudd, R. (n.d.). Guidelines for creating materials: Resources for developing and
assessing materials. Retrieved from
http://www.hsph.harvard.edu/healthliteracy/files/resources_for_creating_materials.pdf
13. Sarkar, U., & Schillinger, D. (2011). Literacy and patient care. S. W. Fletcher, ed.
Retrieved from http://www.uptodate.com/contents/literacy-and-patient-care
14. The TechVirtual Museum (n.d). Exhibit design tutorial. [Virtual World Resource]
http://slurl.com/secondlife/The%20Tech/197/159/38