Unravelling digital health literacy

When I come across the phrase ‘Digital health literacy’, I feel uneasy. There seems to be ambiguity here and I often wonder if I’m the only one who senses it.

Finally, I have decided to explore whether there is a distinction between the potentially three meanings of the phrase:

  1. Is it about ‘digital information literacy’ in the world of health?
  2. Or perhaps we are talking about health literacy in the digital age (digital ‘health literacy’)
  3. Or is it about people’s ability to engage with digital health (‘digital health’ literacy)?

Or are they the same phenomena? To understand the knot I’ve created for myself, I’ll begin by disentangling these terms.

What is Literacy?

Literacy word cloud
Image source: http://dpcdsb-literacy.wikispaces.com/

‘Literacy’ is a widely-used term, especially amongst educators. From nurseries to universities, literacy looms as a set of skills and competencies that need mastering.

UNESCO recognises the complexity of meanings the word represents. At a basic level, literacy is about simply being able to read and write. But it is also about being educated and knowledgeable, including knowing how to access, engage with, and share knowledge. Amongst academics, the main buzzword is ‘information literacy’. In this context, people develop the skills to interpret information sources, making ‘informed judgments’. They also learn how to produce information in their own right. Armed with these skills, people are empowered to make critical decisions about key aspects of their lives, including their own health.

Temporarily discarding the ‘digital’ label, this seems a good point at which to consider ‘health literacy’. According to the World Health Organisation (2015), health literacy refers to ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.’ This definition of health literacy is very close to the idea of information literacy (as defined above), applied to health domain.

And so, to digital ‘health literacy’. The European Commission’s definition of ‘digital health literacy’ looks very much like a ‘digital’ extension of ‘health literacy’: ‘the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem’. A scan of publically available literature on digital health literacy reveals a common, almost exclusive, focus on using the internet to search for health-related information. This observation is unnerving because it seems to be side-stepping the elephant in my room, which is the one obsessed with digital health.

Image of elephant in roomm labelled with 'digital health'

Digital health involves the application of digital tools (e.g. smartphones, wireless sensors, apps, and social networking) to monitor and help to maintain health. It draws on advances in genomics and mobile technologies to individualise healthcare interventions as well as to understand population health. Self-monitoring becomes a central feature of digital health tools.

In this world of digital health, consumers have access to raw data about their own bodies and they need to develop a new set of literacies around reading and interpreting this information. I was encouraged to see that a summary of ‘digital ambitions’ for healthcare in Wales included developing capability in both staff and patients to engage with smartphones and wearable devices, as well as online records. Engaging with digital health helps to meet the ambitions of providing increasingly personalised care.

This wider application of the term ‘digital health literacy’ can encompass a diverse range of electronic information sources. Greater use of technology-based health tools would open the way for the Internet of Things, as well as the pre-digested information found on the internet. The burgeoning of digital health technologies is no less a challenge for healthcare staff as it is for the general public.

Returning to the puzzle I set for myself, it seems that the first two meanings are practically the same. Most common understandings of ‘digital health literacy’ are about digital ‘health information literacy’, where the focus is mainly on the ability to engage with health-related texts on the internet. This is different to the third meaning, in which the focus is on ‘digital health’ interventions. I would like to see ‘digital health literacy’ represent the broadest range of digital tools, data and information, to keep pace with advances in technology.

 

Dickens’s ‘A Christmas Carol’ and mentorship

Image representing 'A Christmas Carol'

Turn on the television this time of year, and you can guarantee that it won’t be long before Ebenezer Scrooge appears on the screen. He is cold natured and miserly, with no charitable bones in his body. He shuns Christmas celebrations and prefers his own company. In the story ‘A Christmas Carol’, his intransigence seems absolute – he is thoroughly mean. It becomes clear at an early stage that if Scrooge is to learn a different approach to life, it will take much effort and he will not do it alone.

As the respective ghosts visit him, they operate as catalysts for change. In many respects, they act like mentors. One exception to this is that a mentoring relationship is usually a mutual one, where both parties agree to work together in a climate of trust and respect. However, by the time the Ghost of Christmas Future arrives, Scrooge is much more willing to engage and accept guidance from his ‘mentor’.

Change is an outcome of learning. For Scrooge, nothing would change if his ‘mentors’ do not engage his emotions first of all. The Ghost of Christmas Past begins by reminding Scrooge of deep-seated, repressed emotions linked to his childhood and earlier adulthood. Scrooge tries to fight against re-connecting with the painful memories. But this re-connection seems to be essential for Scrooge to see the need for change.

Mentoring is frequently portrayed as a role most people can do, with a little help and training. The benefits of being a mentor usually outweigh any drawbacks, but there can be risks, especially when deep-seated beliefs and feelings are involved. Mentees may not always want to adapt in a certain way, or address difficult emotional issues, to make real progress. Mentors have to respect this of course, but it can get messy without clear boundaries. Mentors also can be confronted with their own difficult feelings about their past when helping someone.

If we accept that digging up the past was an essential first step in Scrooge’s learning journey, the next stage is where Scrooge learns to ‘see’ what is happening around him. He can no longer shut himself off from others, and is suddenly painfully aware of the misery for which he is partly responsible. Learning to view the present through a new lens is another step towards change. When training for professional roles, this lens can take the form of principles of practice (e.g. client confidentiality) or theoretical frameworks (e.g. social construction of ageing, or materials science). A mentor can support their mentee to understand how these lenses relate to their own situation.

At this point, Scrooge recognises the need for change and starts to find new ways of seeing the world. Now, he needs a mentor more than ever to help him overcome his inertia. The Ghost of Christmas Future achieves this by showing him what a sad, lonely death Scrooge would have if he didn’t change. Seeing into this dark future is the tipping point. With the help of the three ghosts, Scrooge is able to work out what he needs to do. In any mentoring relationship, the mentee must be able to take the guidance and decide on their own path.

Scrooge’s dramatic transformation is symbolic of the kind of outcomes mentoring can achieve. Few would be so extreme, but nevertheless A Christmas Carol provides us with a vehicle for understanding a little more about how a timely intervention can make all the difference.

 

Buzzwords galore, but what about the learning?

I’ve always had a problem with the term ‘e-learning’. Learning doesn’t take place electronically, but in people and communities of practice.

Cartoon of an e-learning course

There are many different words and phrases bandied about these days to describe 21st Century modes of teaching and learning. Here are some: e-learning, blended learning, technology enhanced learning, flipped classroom, social learning, mobile learning, gamification, cloud based learning, synchronous classroom, distance learning, agile learning, rhizomatic learning.

Experts attempt to differentiate between and define these various terms, which overlap considerably.  I can’t help thinking they all sound very clever, very technical, and slightly mysterious. Certainly, they have their proponents and trailblazers who desperately want others to ‘get it’, adopt the approach and join in the conversation about how it can benefit and transform learning. This all helps to build communities of practice and gather evidence of effectiveness.

Underneath all the buzzwords, there is the tricky concept of LEARNING. Learning is very difficult to pin down. On my bookshelf I have a book edited by Knud Illeris, a Danish professor of lifelong learning, who has gathered contemporary accounts of 16 influential learning theorists. It is a fascinating and inspirational read. But having read it, I still sense that learning itself remains mysterious. Learning is not a spectator sport – you cannot ‘see’ learning happen, although you can witness what emerges the other side of the ‘learning black box’. And you can study the learning context in order to understand how to help people learn.

Learn-small

Behind the inventive terminology and fascinating theories, I can identify five common threads for a successful learning context.

  1. Provide access to information
  2. Promote interaction between the source of information and the learner
  3. Create space for personal reflection and discussion with other learners
  4. Allow learners to test out their newly acquired knowledge/skills and to obtain feedback
  5. Provide learners with means of sensing progress and achievement

Here are some ways these five threads are woven into contemporary education.

  1. Provide access to information

  • Get people into a physical or online (synchronous or asynchronous) classroom and a teacher talks. The talking could be augmented by demonstrating a skill, technique, or practice situation. In an online or face-to-face classroom, the demonstration could be delivered as a pre-recorded video.
  • Supply reading material or a reading list. Formats for reading materials can be print or to suit a range of electronic devices. Some devices are more portable than others. Electronic delivery allows flexibility in meeting the needs of some learners with sensory impairment and learning disabilities – e.g. changing font size and colour, allowing audio conversion.
  • Help learners gain the skills to find appropriate information – e.g. in libraries and on the World Wide Web.
  • In a workplace, allow learners to immerse themselves in the community of practice, observe others, supply them with a buddy or mentor, provide access to libraries and internal documents.
  1. Promote interaction between the source of information and the learner

  • Help learners to make notes, actively interrogate content, organise their thoughts and responses in light of the information. They are not ‘just reading’, or ‘just listening’, or ‘just watching’ – engagement with the information has to be active. Gamification is a very engaging technique for promoting such interaction. In classroom situations, learners commonly achieve active interrogation and organising their thoughts by asking the teacher questions.
  • Help learners to question their information sources. Teach them the skills to judge the provenance, trustworthiness, and so on, of sources.
  • In a workplace, cultivate a climate of trust. Train mentors and buddies to adopt a facilitative, non-judgemental attitude to questions.
  1. Create space for personal reflection and discussion with other learners

  • Create break-out groups in lectures – either virtual or face-to-face. Online classrooms also have the facility for messaging, emoticons and voting buttons – and voting buttons are also available in some lecture halls. Online forums are widespread, a very useful tool for running discussions. Blogging is also becoming increasingly popular for reflection and discussion.
  • Provide prompt questions for reflection. Online, questions can be made interactive so that a learner’s response influences the next question posed.
  • A flipped classroom involves learners accessing the information they need before entering the classroom. This frees up the classroom time for extensive group work and reflection. This is a common model used in distance learning with tutor support.
  • In a workplace, a useful approach is to facilitate learners to form networks or learning sets for reflection, discussion and peer support – ‘social learning‘ springs to mind here.
  1. Allow learners to test out their newly acquired knowledge/skills and to obtain feedback

  • In academic learning, this testing out commonly occurs in formal or informal written assignments.
  • Peer feedback can also be solicited in group work and discussions via a range of electronic media as well as old-fashioned face-to-face.
  • In practice situations, trying things out and obtaining feedback could be almost continuous. If mentors and supervisors accept mistakes as part of the learning process rather than a source of shame, discussion opens up and learning is more likely.
  1. Provide learners with means of sensing progress and achievement

  • Set meaningful and tangible learning outcomes and objectives.
  • Design assessment tasks carefully.
  • Regular quizzes (in any format) can be fun and motivating.
  • Ensure any feedback is carefully formulated to encourage.
  • Emphasise the value of any qualifications to be gained.

I may have missed something out. Can anyone add anything?

5 indispensable tips for giving feedback to struggling learners

Five tips

One of the most persistent challenges that tutors and workplace mentors face, is how to get learners to respond appropriately to feedback. So often, it seems that the student hasn’t been paying sufficient attention. Repeated enough times, this experience can lead to desperation in which tutors start to sound like a broken record, relaying the same message over and over again, and mentors begin to doubt whether the student is really up to the task. This can easily lead to exasperation and disillusionment for learning facilitators.

Want to hear2
But before you give up on any learner or beat yourself up as a failure, consider whether there are any alternative approaches. Always remember that feedback has to be given AND received.

1. Tell them something they want to hear

No, it’s not a cop-out! But if you want someone to hear you, they need to be receptive. It’s easy if your learner is a real star who you can’t praise enough. Praise for performance can soon feel hollow if it doesn’t fit the situation. Here are some alternative openings your learner might want to hear:

  • You clearly have a passion for [the subject/work]
  • Your personal experience and insights about [the subject/work] really shine through
  • I’m really pleased you managed to submit this work by the deadline, as this shows good time management skills.
  • Just think how far you have come since [the first essay/you first arrived]!
  • I always look forward to [receiving your work/working with you]
  • I was very relieved when your assignment appeared, as I know how difficult things have been for you
  • It is rewarding for me to see the journey you are on.
  • I’m amazed at how resourceful you are.
  • Your resilience/perseverance is impressive!

In other words, the learner may be struggling but you still appreciate them as a person.

2. Focus on observable behaviours

Focusing on observable behaviours avoids falling into the trap of making unwelcome personal comments. You might be thinking that that your student is not really interested in helping the clients. If you tell them this, the defences go up, and any further communication will be hampered. Instead, share exactly what you have seen and heard. The learner stood or sat with folded arms. They missed an opportunity to intervene when a more experienced member of staff would have dived in without thinking. These are then opportunities to talk about body language or to teach ‘helping’ techniques.

Feedback

When students repeatedly make the same mistakes in their written work, it is easy to believe that they are ignoring your feedback. But writing well is hard. Try unpicking the issue. Is it grammar, style, structure, showing understanding, using the appropriate content, using evidence? You might think that correcting grammar is simple, but it can be the hardest thing to do. And grammar mistakes often originate from a poor grasp of the topic or the message. Students who struggle with sentence construction are also struggling to express themselves at all as they grapple with new ideas.

Look for clues in the writing and find alternative ways of helping. Such as:

You used a lot of colloquial/informal language, which made your essay seem less persuasive and less objective

It was sometimes difficult for me to follow your discussion, as you were trying to say too many things at once.

Writing

3. Don’t accuse your learner of not putting the time in

Your learner’s work might appear scrappy, rushed and sloppy. But the chances are, this person has sacrificed their family and social life to study or develop a new career. You will instantly alienate your protégé by suggesting they are not doing enough work (even if this is true).

4. Make clear suggestions for moving forward

This may be obvious, but it’s difficult to do well. The learner who is holding back in the workplace may be lacking confidence and/or skills. Find out which it is and help them to address the issue. Draw on the observable behaviours in your discussions and invite the learner to impart the less observable. How are they feeling? Perhaps there is a clash of values or attitudes that needs unpacking. Whatever it is, make sure you can make concrete suggestions – small things like ‘try smiling more’, or bigger things such as shadowing a more experienced colleague or practising one skill until it is mastered.

Moving forward with written work, again try matching your suggestions with your observations:

Try to adopt a more formal writing style, by bringing in more of the specialist language and the concepts discussed in the course

At the planning stage, have a go at writing one phrase that sums up what each paragraph is about. Does the order of your main points seem about right? If not, change it.

5. Listen. Listen. Listen.

I’ve left this most important one until last. Remind yourself that feedback communication is a two-way process. Find out what your learner is thinking and feeling. Check their understanding of the topics or skills they are learning, as well as the feedback they have received. Ask them for their own ideas of how you can help them learn.

Want to hear

Time, pace, rewards, and obstacles in a distance learner’s journey

A family travel in Rajkot, India
A family travel in Rajkot, India

Here, I consider some of the strategies employed by students on a daily and weekly basis to maximise the value and impact of their limited study time. I discuss the manageability of distance study for these students. Above all, their resourcefulness and sheer determination were most impressive.

Engaging with the learners

Recently, over a two-month period, I enlisted the help of a small sample of distance-learning students studying an introductory health and social care module. I wanted to assess their experiences of studying. How do they engage with the materials, how do they manage their time, and what strategies do they resort to when time is short?

Most research asking these types of questions of distance learners tends to collect the data at the end of a study period, and I was interested in developing methods that would allow educators to gather useful data during study. This immediately throws up issues of time shortage. It is difficult to defend asking time-poor students to devote even more time in relation to their studies.

I anticipated that few of our entry-level students of health and social care would find the time or energy to maintain a study diary. Many of them were combining their studies with child-care responsibilities and full or part-time work. And as it turned out, only a very small proportion of the student cohort actually replied to my request for volunteers.

Diary keeping

I invited my volunteers to choose from a menu of methods for recording their study experiences and behaviours as often as required, but once a week minimum.

  • Receive a regular call from me, in an agreed time slot
  • Call an automated phone line to record a message
  • Make a short voice or video recording on a smartphone, tablet or pc and upload it to a secure website
  • Keep a written log of study experiences and send it to me

Of the seven volunteers, five chose to send weekly written diaries by email, and two elected for a weekly phone call. To my surprise, none chose to make audio or video diaries. I had previously believed that recording their voices would offer welcome relief from writing. But in fact they decided, probably rightly, that messing around with the technology would consume much more time than writing things down or simply speaking to me at a pre-arranged time.

Time and pace

Time and pace were fundamental concerns. The participants all found it a challenge to make time for study. This was a standard approach to time management: ‘I have been trying to do an hour of study every night when I have finished work and doing as much as I possibly can at the weekend.’ These good intentions could easily melt away, however, when other priorities crowded in.

Guilt commonly cropped up: ‘I’ve had some annual leave and have been trying to enjoy time off and do those annoying bits around flat which I’ve been putting off. Felt a bit guilty about putting the essay off.’ When one of the participants did use his holiday for study, he still came up against competing demands on time after his return: ‘Found it harder this week as I’m back at work and need to study other things for my work too’.

By contrast, experiencing a sense of speed could be invigorating – for example, one student triumphantly ‘flew through the last unit’ after consistently worrying about falling behind. Rewards were important, and for this student the reward was the ‘fun’ of speeding through number skills activities after grappling with copious reading and writing. The thrill and relief of receiving a good assignment mark also energised these students.

More often, the students tried to find active strategies to increase their pace through the module. This would sometimes backfire: ‘I have skimmed Block 3 in bed over the past fortnight, just concentrating on pages which I think are relevant to the essay. But I sat down last night to write the essay and soon realised I simply don’t understand the material well enough to do it. I’m having to go back through it in a linear way today so I can make another attempt.’

Those with dyslexia found the large amount of reading to be the greatest challenge. Alternative visual and audio stimuli could help to maintain momentum and motivation:

‘I’ve started using sticky labels to mark the case studies for future reference. When I make notes, I draw different shapes around each bit. I use highlighters in three different colours: one for the positives or general info; another for challenges or difficulties; the third for the references. I write notes to myself in the margins, which helps to keep me focused. I fall asleep at night listening to the audio book.’

Life events

The diarists experienced many life events and study situations that presented obstacles to study. For example, one explained that ‘there was so much going on, it felt everybody wanted a piece of me.’ Furthermore, serious health and personal issues could be real obstacles to successful study: ‘I’m literally hanging on by a thread due to personal circumstances, work, social factors, physical and mental health problems, computer breaking down…’

One participant reflected the experience of many of our students when she described family responsibilities that demanded flexibility in order to maintain study progress: ‘It was half term. I have three young children – we had family trips and attended two weddings, so we did a lot of travelling. I did the DVD activities in the car.’

Maintaining motivation

Motivators for continuing with their studies fitted under three headings: being kind to yourself and finding a balance, seeing the relevance of the new knowledge, and personal strength and determination.

Being kind to yourself:

‘I’ve found myself adopting a ‘that’ll do attitude’ just to get through everything – sometimes you just haven’t got the time to do yourself justice’
‘I’m feeling motivated and tell myself not to be too hard on myself. I’m so tired but getting a good mark in the last assignment refreshed me.’
‘I struggle to get started without doing anything first so on Sunday I went out for the morning and spent the afternoon doing the bulk of the essay’

Seeing the relevance of knowledge gained:

‘The stuff I have learnt has actually came up in topic while chatting with family’
‘I can make personal links with the social model – it helps me to look at things in a different way.’

Personal strength and determination:

‘I’m not the sort of person who would let go – I keep the pressure on.’
‘I keep going because I chose to do this and I want my degree in 3 years. This week I’m going to prove to myself I can rise to the challenge’
‘What has kept me going this week has been sheer determination not to give up.’

What did I learn?

In some ways, I learnt nothing new – I have supported distance learners for well over a decade. But by thinking hard about some of these recurring themes of time, pace, rewards, and obstacles, I am developing new insights. Perhaps we can design in more quick-and-easy quizzes that provide a sense of speed and achievement. We should design formal continuous assessment so that it reflects progress more sensitively than it currently does, saddled as we are with the blunt instrument of learning outcomes. Most of all, we can surely apply our creativity in steering time-poor students along a journey that can fit alongside their often chaotic, busy, and unpredictable lives.