Examining Health Literacy and Appropriateness of Commercially Developed Patient Education Materials for Adults Living With Diabetes on the U.S./Mexico Border

Abstract

Effective patient education is critical to an individual’s treatment plan when living with diabetes, a debilitating disease requiring extensive knowledge and skills to effectively manage and prevent future morbidity. This descriptive, cross-sectional study assessed the appropriateness of commercially developed patient education materials for rural adults with diabetes. Using electronic health record data from patients (n = 132) with documented health literacy levels (HLL), their HLL scores were reviewed for suitability of educational materials provided by a single rural-border hospital. HLL was measured using the Newest Vital Sign, while educational materials were assessed by two independent reviewers using the Patient Education Materials Assessment Tool for Printable Materials to measure understandability and actionability, and the Simple Measure of Gobbledygook to measure the readability level of documents in both English and Spanish. The mean HLL for Spanish speakers (n = 77) was 2.01 (±1.56), while the mean HLL for English speakers (n = 55) was 2.09 (±1.46), indicating a high likelihood of low health literacy. The materials were evaluated with the English materials achieving an understandability score of 83.33% and an actionability score of 60.00%. By contrast, the Spanish materials scored lower, 61.54% and 20.00%, respectively. In addition, the readability of the materials measured a 9.0 grade level for English materials and a slightly higher 10.8 for Spanish materials. These findings highlight a significant discrepancy between the HLL and the appropriateness of educational materials for the sample population. Although commercially available educational products may provide a budget-concise solution to patient education, particularly in low-resourced organizations, they fail to address the health education needs of the individuals who receive them. Despite the project’s limited sample size and single geographical location, it underscores the importance for healthcare organizations to address the health education needs of their communities.

Introduction

Diabetes mellitus is a complex, debilitating disease that requires an individual to have extensive knowledge and skills to manage their condition successfully. Gaining this knowledge and skill can be a complex process, requiring an individual to rely not only on their healthcare team for access to information but also on an array of commercially available and mass-produced educational products (Protheroe et al., 2015).

Educational products produced commercially are typically designed with a broad audience in mind, which can unintentionally neglect the unique needs or subtleties of individuals from diverse backgrounds or cultures. If individuals living with diabetes mellitus lack the necessary knowledge and skills to manage their condition effectively, they may struggle with disease management. This could potentially lead to future health complications and poor outcomes.

An individual’s health literacy abilities play an important role in actively engaging with health information. Health literacy is the ability of an individual to access, comprehend, and utilize basic health information to make meaningful decisions about their health and healthcare (Ingram & Kautz, 2018). Within this context, access refers to sources of information, including members of their healthcare team, online educational videos or websites, and written educational materials printed on paper or digitally posted online. Written educational materials present an even greater challenge, as the individual has to possess basic reading skills to uptake the information and adequate comprehension skills to understand the information being read (Ingram & Kautz, 2018).

Low health literacy (LHL) occurs when the individual does not possess adequate comprehension abilities and/or struggles to perform basic functional skills such as reading or arithmetic (Williams et al., 2024). LHL tends to be more common in rural and racially and ethnically diverse communities where educational levels are lower and limited English proficiency or English as a second language (ESL) and social and economic disparities are prevalent (Golboni et al., 2018; Soto Mas & Jacobson, 2019).

In smaller, less resourced healthcare organizations, such as those in rural communities, educational material development is often un- or underfunded, with many organizations opting to use readily available, commercially produced educational products. While these products may be easily accessible to patients and providers, they often do not address the localized needs and nuances of the organization’s diverse patient population. They also tend to be written at a much higher reading level than needed by populations who suffer from LHL (Khorasani et al., 2020).

Leading organizations, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Agency for Healthcare Research and Quality (AHRQ), have issued evidence-based guidelines for creating patient educational materials (Agency for Healthcare Research and Quality, 2024; Centers for Disease Control and Prevention, 2024; National Institutes of Health, 2025). These guidelines recommend that materials should not exceed a sixth-grade reading level and should be culturally and linguistically relevant to the intended patient population (O’Reilly et al., 2024). However, these nuances can pose a challenge for companies that produce commercially available health education materials. These companies must strive to balance the diverse needs of various populations while creating a product that appeals to a broad audience. This balancing act often results in materials that provide general knowledge but lack cultural or linguistic relevance for specific subsets of the target population. For individuals suffering from diabetes mellitus, this could lead to an inability to effectively manage their disease within the context of their unique lifestyle or cultural context.

Purpose of the Study

The study aimed to assess the appropriateness of commercially developed patient education materials for adults with diabetes living in a rural community on the U.S./Mexico border by comparing their assessed health literacy scores with the suitability of materials provided by a single rural-border hospital.

Significance of the Study

Diabetes mellitus management requires individuals to have not only a deep understanding of the disease but also the practical skills to implement lifestyle changes and adhere to complex treatment regimens. However, commercially available educational materials—often designed for a broad, general audience—may fail to meet the specific cultural, linguistic, and literacy needs of individuals living in these underserved communities. This study seeks to evaluate the appropriateness and effectiveness of such materials in a rural U.S./Mexico border community, where challenges such as LHL, language barriers, and socio-economic disparities are common (Golboni et al., 2018; Soto Mas & Jacobson, 2019). By assessing the understandability, actionability, and readability of these materials, the study aims to highlight whether current resources are sufficient or require modification to improve disease self-management. The findings will contribute to the broader conversation on health literacy and underscore the importance of creating culturally and linguistically tailored educational tools that empower individuals to manage chronic conditions like diabetes more effectively. In addition, this research contributes to a significant gap in the research exploring the use of commercially available educational products and their appropriateness for use in diverse, low-resourced communities. Finally, this research holds the potential to inform policy and practice in rural healthcare settings and offer insights into improving patient outcomes through more accessible, relevant educational materials.

Methods

This descriptive, cross-sectional study was conducted within a single healthcare organization in a rural, largely agricultural community along the U.S./Mexico border. The organization comprises an acute care hospital and several outpatient primary and specialty care clinics throughout the region. This project was determined to be exempt by the university’s human research protection program. A convenience sample of 132 unique patients that met the study criteria was collected from the organization’s electronic health record (EHR) with visit dates between January 2023 and June 2023. Participant data were included in the study if they were over the age of 18 years, noted to have a documented diagnosis of type 1 or type 2 diabetes mellitus, and had at least one health literacy score recorded in the EHR. Participant data were excluded if they were under the age of 18 years, did not have a diagnosis of type 1 or type 2 diabetes mellitus, or were missing a documented health literacy level (HLL) score. Data collected included the patient’s HLL as measured by the Newest Vital Sign (NVS), demographic information (age, gender, ethnicity, language, and highest level of school completed), and location of admission or visit. A documented diagnosis of type 1 or type 2 diabetes mellitus was confirmed using ICD-10-coded data.

Assessment of Participant HLL

HLL was measured using the NVS, a 6-item screening tool designed to elicit individual responses to six questions involving reading, numeracy, and comprehension skills to decipher information printed on a simplified ice cream nutrition label (Chan, 2014). The NVS has a rapid administration time, which makes it ideal to use when assessing health literacy abilities in busy clinical environments (Ylitalo et al., 2018). The screening tool is administered orally with individuals viewing a printed copy of the nutrition label (Weiss, 2018). For every question answered correctly, a point is awarded, with a possible score of zero (0), indicating no questions were answered correctly, up to six (6), indicating all questions were answered correctly. Based on the number of correct answers given, the individual is determined to likely have adequate health literacy (score of 4–6 points), possibility of limited health literacy (score of 2–3 points), or likely has LHL (score of 2 or less) (Welch et al., 2011). The NVS has been validated in a wide range of clinical settings with both English- and Spanish-speaking individuals and is recognized as having similar predictive abilities as the Test of Functional Health Literacy, a recognized gold standard in health literacy assessment (Chan, 2014; Ylitalo et al., 2018).

Evaluation of Patient Education Materials

The healthcare organization provided standard diabetes education materials in both English and Spanish. These materials, which were commercially produced, are written documents accessible to the healthcare team via the organization’s EHRs. Typically, these documents are printed by the healthcare team and given to patients in their preferred language during their healthcare visit. Two bilingual reviewers were trained to evaluate these educational materials for understandability, actionability, and readability. One reviewer was a registered nurse, while the other was a lay-person with no formal clinical or healthcare training or experience. The assessments were carried out independently, with any discrepancies in scores discussed to reach a consensus after the assessment.

Understandability and actionability were scored using the AHRQ’s Patient Education Materials Assessment Tool (PEMAT) for Printable Materials (PEMAT-P). The PEMAT-P is a validated instrument (α = .71; Kappa inter-rater reliability .40 to .84 for understandability and .35 to .76 for actionability) designed to assess understandability and actionability of written educational materials (Shoemaker et al., 2013). Understandability and actionability are measured by evaluating the materials against distinct criteria. If the material meets a criterion, it is assigned a score of 1. If it does not, it receives a zero (0) score. If a criterion does not apply to the document, such as assessing the understandability of a visual image in a document that does not contain one, the score assigned is “Not Applicable” or “N/A.”

Understandability is the ability of participants from diverse backgrounds and varying HLLs to understand the information as it is written and explain key messages in the educational text (Shoemaker et al., 2013; Zuzelo, 2019). Understandability is measured by reviewing the document’s style and word choice, content, organization, use of numbers, overall layout and design, and visual aids, and comparing it to 17 distinct criteria (Abdul Rahman et al., 2020; Johnson et al., 2019; Shoemaker et al., 2013). A point is awarded for each criterion that is met, resulting in a possible total of 17 points being awarded for each document.

Actionability is the ability of people from diverse backgrounds and varying HLLs to identify a course of action based on the written information provided (Abdul Rahman et al., 2020; Shoemaker et al., 2013). Actionability is measured by evaluating the materials against seven distinct criteria, including the inclusion of a tangible tool, clearly defined and actionable steps, or a visual aid to support the individual’s ability to act upon the information being presented. A point is awarded for each criterion met, resulting in a maximum score of 7 points.

Scores for understandability and actionability are calculated by summing the total points in each section. Each score is then divided by the total number of possible points, and the result is multiplied by 100 to convert it into a percentage. The higher the percentage, the more understandable or actionable the material is deemed to be (Shoemaker et al., 2013). The raw understandability and actionability scores from both reviewers were collected for each document, along with the final adjudicated score.

The readability of the documents was evaluated using the Simple Measure of Gobbledygook (SMOG), a validated tool that assesses the reading grade level of written materials. Excerpts from the beginning, middle, and end of the document are analyzed by counting the number of words containing 3 or more syllables within each 10-sentence excerpt. The total number of polysyllabic words is then compared to the tool’s scoring rubric, with a larger number of polysyllabic words indicating a higher reading level for the document (Grabeel et al., 2018; Johnson et al., 2019). The SMOG has been widely used in studies focusing on patient education materials, and its manual scoring system is considered more reliable than computerized scoring (Grabeel et al., 2018; McLaughlin, 1969). However, one drawback to using SMOG to determine reading level is that SMOG was developed for English texts, requiring further score adaptation for Spanish documents using the Spanish Oral language (SOL) formula. The SOL formula is a validated tool specifically tailored to address the complexities of the Spanish language, allowing for better accuracy in assessing the readability of Spanish language documents (Contreras et al., 1999).

The SMOG score was determined by counting the number of polysyllabic words in the text extracted from a document and applying the SMOG scoring formula to ascertain the document’s reading grade level (Grabeel et al., 2018). For documents in Spanish, the SMOG score was calculated and then adjusted by applying the SOL formula. Both raw SMOG scores and the final adjudicated score were collected for documents written in Spanish.

Results

Participant Demographics and Health Literacy Score

Of the 132 participants in the final analysis, 116 were inpatients admitted to the healthcare organization’s acute care hospital, and 16 (12.1%) were outpatients seen for routine care in one of the healthcare organization’s primary or specialty care clinics (Table 1). The mean age of the sample was 59.54 years (±14.13), with the majority (57.5%) of participants between 60 and 79 years of age. There were a total of 72 males (53.8%) and 61 females (46.2%), with an overwhelming majority (97%) identifying as Hispanic or Latino. Regarding language, 77 (58.3%) reported being Spanish speaking, and 55 (41.7%) reported being English speaking. Of those who reported their highest level of education completed (n = 128), 36 (27.3%) reported achieving a college education, 47 (35.6%) reported they graduated from high school or obtained a graduate equivalency degree, and 45 (34.1%) had completed grade school or elementary school, defined as kindergarten through eighth grade. HLL was collected on all 132 participants, with 22 (16.7%) determined to have adequate health literacy, and 110 participants (83.3%) having inadequate health literacy, scoring either as “limited literacy likely” (n = 54, 40.9%) or “limited literacy possible” (n = 56, 42.4%).

Table 1.

Participant Demographics and Health Literacy Score (N = 132).

Variable	n (%)
Admission status
Inpatient	116 (87.9)
Outpatient	16 (12.1)
Age (years)
18–39	15 (11.4)
40–59	36 (27.3)
60–79	76 (57.5)
80+	5 (3.8)
Sex
Male	71 (53.8)
Female	61 (46.2)
Ethnicity
Hispanic or Latino	128 (97.0)
Non-Hispanic	4 (3.0)
Language
English	55 (41.7)
Spanish	77 (58.3)
Highest level of school completeda
Grade school/Elementary	45 (34.1)
High school/ GED	47 (35.6)
College (Ass, Bach, Grad, etc.)	36 (27.3)
Health literacy level (NVS score)
Limited literacy likely (0–1)	54 (40.9)
Limited literacy possible (2–3)	56 (42.4)
Adequate literacy (4–6)	22 (16.7)

Note. GED = Graduate Equivalency Degree; NVS = Newest Vital Sign.

^aAbout 0.03% (n = 4) of participants did not report the highest level of school completed.

Patient Education Materials Assessment Using PEMAT-P

Understandability and Actionability:

Materials were independently assessed by two bilingual reviewers for understandability and actionability using the PEMAT-P. After assessment and adjudication, the English version of the materials scored 83.33% for understandability and 60.00% for actionability, whereas the Spanish materials scored 61.54% for understandability and 20.00% for actionability (Table 2).

Table 2.

Understandability, Actionability, and Readability Scores of Educational Materials.

Material Language	Understandability score (%)a	Actionability score (%)a	Readability scoreb	Readability levelb	SOL formulac
English	83.3	60.0	42	9.0
Spanish	61.5	20.0	227	18.0	10.8

Note. PEMAT-P = Patient Education Materials Assessment Tool for Printable Materials; SMOG = Simple Measure of Gobbledygook; SOL = Spanish Oral language.

^aAs determined by PEMAT-P.

^bAs determined by SMOG.

^cAfter the SOL Formula was applied to the SMOG score.

The agreement between the two raters on PEMAT-P items was evaluated, and the raw percentage agreement was reported for both the English and Spanish versions of the educational materials. An agreement was defined as both raters providing the same raw score (1, 0, or N/A) for the same item on the same patient education material. Any other combination of responses was classified as a disagreement.

Interrater Reliability of the PEMAT-P

Furthermore, the interrater reliability of PEMAT, as assessed by two consistent raters (both bilingual speakers), was calculated for each language using the Kappa statistic (Cohen, 1960) (Table 3). All analyses were performed using Stata 16.1 (StataCorp, 2019).

Table 3.

Raw Percent Agreement and Kappa Between Two Raters for Education Material in Each Respective Language.

Material Language	Raw percent agreement (%)	Kappa	Standard error	p
English	70.8	.552	0.1445	<.01
Spanish	91.7	.872	0.1459	<.01

For the English materials, the two raters agreed 70.8% of the time. After adjusting for chance agreement, the computed kappa value was .55, indicating moderate agreement between the raters (Landis & Koch, 1977a, 1977b). This level of agreement suggests we can reject the null hypothesis that the raters evaluated the items randomly (p < .01).

Regarding the Spanish materials, the raters agreed 91.7% of the time. After accounting for chance agreement, the kappa value was .87, demonstrating a very strong level of agreement between the raters. This level of agreement also suggests rejecting the null hypothesis that the raters evaluated the items randomly (p < .01).

Readability

The readability of both sets of materials was evaluated using the SMOG assessment tool. Excerpts of 10 sentences were selected from the beginning, middle, and end of each set of materials. Two bilingual reviewers assessed these excerpts and identified the number of words containing three or more syllables within each excerpt. After the initial assessment, the reviewers discussed their scores and reached an agreement, resulting in a final adjudicated score of 42 for the English materials and 227 for the Spanish materials. The SMOG readability formula was then applied to these adjudicated scores to determine the materials’ readability level. The English materials were found to have a readability level equivalent to the ninth grade (Table 2). The initial SMOG readability level for the Spanish document was equivalent to the 18th grade. However, this was adjusted using the SOL Formula, which accounts for the complexities of the Spanish language. This adjustment resulted in a final readability level equivalent to the 10th grade (Table 3).

Appropriateness of Materials

The mean health literacy score for the English-speaking sample population was 2.09, indicating that this group is likely to have LHL. The English materials were assessed at a 9.0-grade reading level, which is significantly higher than the recommended 6th-grade level. This disparity presents a substantial challenge for English-speaking patients who rely on these documents to learn more about their chronic illness. A similar predicament exists for Spanish-speaking patients. They have an average health literacy score of 2.01, and the materials intended for them were assessed at a 10.8-grade reading level (Table 4). This discrepancy puts the Spanish-speaking population at a higher risk of misunderstanding the materials provided, as evidenced by their lower understandability and actionability scores.

Table 4.

Appropriateness of Materials by Language (N = 132).

Material Language	Health literacy score (mean ± SD)	Readability	Understandability (%)	Actionability (%)
English	2.09 ± 1.46 (n = 55)	9.0	83.33	60.00
Spanish	2.01 ± 1.56 (n = 77)	10.8a	61.54	20.00

Note. SOL = Spanish Oral language.

^aGrade level after applying the SOL formula.

Discussion

Summary of Findings

Findings from this study underscore the difficulties of using commercially available educational resources for patients with LHL, especially in racially and culturally diverse groups. The English materials scored relatively well in terms of understandability, indicating they were easy to comprehend, used common language, defined medical terms, and used informative headers to create natural breaks. However, the material was written above the recommended 6th-grade reading level. It lacked crucial elements like a comprehensive summary of key information, which would increase the likelihood of a reader understanding the critical information conveyed.

Similarly, the Spanish materials scored moderately well for understandability but lacked important elements such as the use of active voice and a concluding summary. Regarding actionability, both materials struggled to communicate tangible actions or “next steps” for the reader. They failed to outline actions into manageable steps, provide a helpful tool (e.g., menu planner, checklist), or use visual aids to facilitate the reader’s ability to act upon instructions.

Both sets of materials were too complex to meet the literacy needs of the target population, compared to the average HLL of the population by language. This project’s findings also contribute to the discussion on the use of commercially produced educational materials in low-resource or financially challenged organizations and communities.

Implications of Using Commercially Available Educational Materials in Diverse Populations

Developing patient education materials that align with the community’s needs can be expensive and time-consuming. In organizations where resources, manpower, and expertise in material development are limited or nonexistent, creating patient education materials may not be feasible. Healthcare organizations often must provide patient education as part of their licensure or accreditation requirements, forcing them to create expensive materials or rely on commercially produced educational programming.

These materials are often sold as an educational system or embedded in tools like the organization’s electronic health record (EHRs), with finances often serving as the driving factor in organizational decision-making. This approach is concerning for several reasons. First, the commercially produced materials may not be culturally or linguistically appropriate for the intended population, presenting a challenge when used in populations with unique needs or following cultural customs or norms not generally observed in mainstream culture.

The materials may be neither understandable nor actionable if they do not consider the unique circumstances and characteristics of the individual reading them. In addition, unique dialects within common languages may present additional challenges when already-generalized information is translated into a variety of languages (Brelsford et al., 2018; Lambert et al., 2021). Such was the case in this project, as the document reviewers noted nuances in the language dialect used to translate information into Spanish. They identified that the language used to translate the information contained within the English materials to the information contained within the Spanish materials was a very technical version of the Spanish language, often spoken in European countries rather than the Spanish dialect spoken along the U.S./Mexico international border. These nuances in language made it difficult to decipher the meaning of critical information presented in the materials. Both reviewers identified areas within the Spanish text that would have benefited from using the local dialect to address both material understandability and actionability.

Second, the materials may refer to treatment options and/or resources that are not present within a low-resourced community. A representative example from the project included the mention of a continuous glucose monitor (CGM) as a part of standard diabetes treatment. The availability of CGMs within the community where this project took place is limited and significant barriers to CGM use are present, including limited healthcare professional knowledge and comfort with the device and the presence of a digital divide which would have a negative effect on device performance (Eiland & Drincic, 2022; Robertson et al., 2022). The inclusion of this treatment option in the materials, but the lack of access to the device, may erode patient-provider trust and reduce the patient’s ability to trust the materials their healthcare team is giving them. It also poses significant legal and ethical implications if the commercial materials recommend treatments not aligned with the patient’s established treatment plan.

Lastly, findings from this project contribute to a wider understanding of reported barriers concerning health education materials in general. While current evidence has highlighted the significant challenges associated with the quality and readability of electronic patient education materials being accessed by patients and families through search engine queries via the internet, there tends to be a lesser focus on educational materials available through educational platforms or accessed as a component of the EHR purchased by healthcare institutions. This gap may reflect an inherent trust between healthcare organizations and commercial producers of health education or perhaps a lack of ability to assess the health literacy needs of the population and find a suitable solution to address those needs.

Finally, healthcare professionals’ awareness of their population’s health literacy needs is important to ensure patients can participate in their plan of care to the fullest extent possible. When health literacy challenges are present, healthcare professionals may need to deploy additional health education measures to ensure patients comprehend their disease process, treatment plan, and are equipped with the knowledge and skills needed to effectively manage their disease. Future research opportunities should focus on expanding the current model to other healthcare settings and topics and further exploring the impact of commercial educational products on patient health outcomes.

Study Strengths

This study contributes to a growing concern related to the unique health education needs of rural and diverse populations, particularly when factors such as low educational attainment or ESL are present. Furthermore, this study contributes to the ongoing conversation about the challenges of integrating health literacy principles into commercial educational tools and highlights the need for a more rigorous assessment of these resources before their widespread adoption in healthcare settings. Moving forward, healthcare organizations must prioritize developing or sourcing education materials that better meet the unique needs of their diverse patient populations, ensuring that both the content and delivery methods are accessible, culturally relevant, and actionable.

Study Limitations

This study contains some limitations, including using a single organization, which contributed to the small sample size. The use of a single organization also limited the number of educational materials assessed, as the organization indicated they only provide a single document to patients who are either newly diagnosed or present with complications related to their diabetes. The organization does not employ an in-hospital diabetes educator but utilizes its outpatient/clinic-based diabetes education program to educate its patient population. Despite these limitations, this study highlights the importance of healthcare organizations’ understanding of their population’s health literacy and patient education needs, ensuring their educational programming is commiserate with their patient population’s abilities.

Conclusion

In conclusion, this study highlights critical challenges in the use of commercially available patient education materials, particularly for populations with LHL and diverse cultural and linguistic backgrounds. While the English and Spanish materials assessed were generally comprehensible, they fell short in key areas, such as readability, actionability, and cultural relevance. The materials’ failure to align with the literacy and language preferences of the target population underscores the need for a more tailored approach to health education. Specifically, these findings point to the limitations of relying on commercially produced resources, particularly in low-resource settings, where the cost of developing customized materials may not be feasible. In addition, the lack of consideration for local dialects, culturally appropriate content, and the availability of recommended treatments poses a significant barrier to effective patient education. These issues not only compromise the understandability and actionability of the materials but also risk undermining patient trust in healthcare providers.

Biographies

Dr. Shiloh A. Williams, PhD, RN, NPD-BC, CNE is an Assistant Professor at San Diego State University’s School of Nursing in Imperial County, California, and co-directs the SDSU IV Research, Innovation & Student Engagement (RISE) Center. Her research focuses on health equity and the impact of health literacy in rural and border communities, aiming to promote patient-centered care through community-academic partnerships. With over a decade of experience as a registered nurse and healthcare leader, Dr. Williams integrates clinical practice, research, and education to advance health outcomes for underserved populations.

Dr. Shih-Fan Lin, DrPH, is Co-Leader of the Health Data Analytic and Measurement Methods Groups at the SDSU HealthLINK Center and an Adjunct Associate Professor at SDSU’s School of Public Health. He offers training and consultation in data management, biostatistics, measurement, and electronic data capture systems. His research focuses on health disparities, childhood obesity, disability, and fall prevention among older adults.

Dr. Stephen Jaime PhD, RN, CNS, CCRN, is a nurse with over 18 years of experience and a passion for diabetes education and community health. He leads the only recognized diabetes education program at for the community at El Centro Regional Medical Center and serves as an assistant professor at San Diego State University – Imperial Valley for the nursing program.

Beverly Carlson is an Emeritus associate professor in Nursing at San Diego State University and Co-Director of the SDSU-IV Research, Innovation, and Student Engagement (RISE) Center. Using a community-based participatory research approach, Dr. Carlson’s work focuses on chronic disease management strategies and workforce development in rural and Hispanic populations.

Maria Keckler, Ph.D., is a behavioral researcher at San Diego State University and co-founder of the Healthcare EmpathyRx Lab. Her research focuses on addressing the decline of empathy in healthcare education and practice.