Sustainable collaboration for community outreach: lessons from the Spanish Access to Literature/Uso Directo (SALUD) project

INTRODUCTION AND BACKGROUND

Health sciences librarians have an active interest in community health information outreach projects [1–8]. Successful community partnerships are guided by each partner clearly defining goals. Accomplishing these goals requires time and personal contact to develop trust, active engagement of all partners, and careful planning [9, 10]. The investment required to develop partnerships makes project sustainability a desired outcome. The academic health sciences library exists to support the educational mission of the institution. By collaborating with other academic units, the library can meet its educational goals while building the sustainable relationships necessary for successful outreach projects.

At the University of Illinois at Chicago (UIC), the Library of the Health Sciences (LHS) and College of Nursing (CON) developed an outreach project that directly supports the mission of the university while strengthening relationships between the library, CON, and surrounding community [11]. As part of a core course in the undergraduate nursing curriculum, CON faculty supervise students in clinical rotations at two Chicago Department of Public Health (CDPH) clinics in nearby neighborhoods, engaging them in the challenges and rewards of community practice. In the fall of 2005, CON and LHS faculty saw an opportunity for outreach. The resulting Spanish Access to Literature/ Uso Directo (SALUD) Public Health Information Pilot Project provided education on evaluating and using online health education materials by leveraging community health nursing students and existing relationships between these organizations. This paper describes the project's core activities with an emphasis on the project's techniques for sustainability.

THE SPANISH ACCESS TO LITERATURE/USO DIRECTO (SALUD) PROJECT

The core project team responsible for implementing the SALUD project included health sciences librarians and a nurse clinical consultant. Members of the project planning group met with CDPH clinic staff, administrators, and members of the community advisory board to identify challenges and develop an outreach plan to address health information needs of Latino patients at these clinics. Based on quarterly chart audits and patient questionnaires from the year preceding the SALUD project, administrators were interested in exploring ways to make improvements to their health education activities. Staff expressed a need for information that is up-to-date, at a low reading level, and in languages other than English. Both clinics serve a majority Latino population, many of whom speak Spanish as their primary language.

Librarians were familiar with many websites, such as MedlinePlus, that offer health education materials written at a lower reading level and written in Spanish or other languages [12]. These online materials are convenient, inexpensive, and easily distributed to patients. However, health care providers continue to face barriers to their use: lack of technology to access the Internet, lack of awareness or skills to locate materials, and dispersed selection of materials relevant to clinic population.

Librarians had learned from previous outreach that the time necessary to develop and implement an outreach program is often underestimated [3]. With this in mind, the goals and implementation plan for the project were designed to not only meet community needs, but also closely align with institutional objectives (Table 1). This approach would allow for continuation of successful project activities and improvements on unsuccessful activities.

Table 1 Spanish Access to Literature/Uso Directo (SALUD) Public Health Information Pilot Project objectives

Team members were cognizant of building on the strengths of project partners, distributing the resource burden across organizations, and leveraging collaboration as features that appeal to funding agencies. Librarians agreed to develop resources, conduct training, and provide administrative support for the project. The consultant, a CON faculty member supervising students in clinics, agreed to act as an essential liaison to clinic staff and provide a “reality check” on feasibility of activities. Clinic resources were limited, but administrators offered support to the SALUD liaison and were helpful in organizing training sessions. The SALUD project was approved by the UIC Institutional Review Board.

PROJECT IMPLEMENTATION

Several preliminary steps were necessary to launch the project. Because clinic administrators expressed concern over the relatively low computer literacy of some staff, librarians created a web portal designed for clinic staff use [13]. The web portal included links to health education websites and direct links to handouts in English and Spanish addressing topics commonly seen in the clinics, such as diabetes, domestic violence, and obesity. The SALUD website was designed to prevent staff with lower computer literacy from being overwhelmed by a large number of sites with vastly different interfaces and search systems. One mobile computer-printer station was placed in each clinical cluster (adult, pediatric, and women's health) at clinic I, and, due to wiring constraints, a single station was installed at clinic II. Lastly, librarians provided one-on-one, hands-on, online health education resource training for staff at both clinics.

With improvements made to clinic infrastructure, the SALUD project team was ready to implement the heart of the project—a train-the-trainer model. Librarians trained community health nursing students, as part of their clinical orientation process, to access and evaluate health education materials that are reading-level and language appropriate for community health patients. Students then applied their knowledge during their clinical rotations in the target clinics. Students, working in pairs, also gave a graded presentation about health education resources to staff at another community health clinic in the city selected from a list of approximately thirty clinics with whom CON has established a relationship.

EVALUATION AND OUTCOMES

Evaluation activities were ongoing throughout the SALUD project to track progress and assess outcomes. Measures were both quantitative (e.g., numbers of participants) and qualitative. The two key methods used were written evaluations and focus groups (two student groups with a total of thirteen participants, two staff groups with a total of fifteen participants).

During the SALUD project, librarians taught six sessions to sixty-nine nursing students. In two focus groups at the close of the funded project year, students (n=13) all indicated that they had learned about health education resources online and were able to describe trustworthy resources. Students identified several barriers to putting their knowledge into practice, including computer location and lack of time. However, they believed health education to be an important activity and hoped to have more time to use online health education resources in their private practice.

Approximately 128 clinic staff from across the city learned about online resources providing access to materials in languages other than English. Clinic staff were invited to provide oral and written feedback throughout, and a focus group was convened at each of the 2 CDPH clinic sites at the conclusion of the SALUD project (n=15). Focus group participants described continued barriers to effective resource use. Good computer placement led to use of online resources at clinic I; poor placement at clinic II meant that resources were rarely used by staff. Staff at clinic II in particular noted that material on the SALUD website was at reading levels that were too high for their patients. Their comments were not entirely surprising, as during the project, librarians had expressed difficulty in finding language and reading-level appropriate materials on the topics staff had identified. Web usage statistics available for the first months of the project— March, April, and May 2005—showed that the average number of visits per month was 121. It is unclear what percentage of these visits were made by nursing students versus clinic staff. Staff in focus groups indicated that one-on-one training was valuable, especially when tailored to different levels of knowledge and experience. Anecdotally, librarians noted that medical assistants in particular had appreciated the training, as they have few opportunities for professional development but may have a role to play in patient education.

DISCUSSION

SALUD project staff and students continue to face challenges reported in library outreach literature: computer skill level and access, need for comprehensive yet audience-specific resources, staffing, and time demands [1–8, 14]. These barriers limit Latino patients' access to quality reading-level and language-appropriate health education materials. The library continues to maintain the SALUD web portal for the two clinics and will periodically reevaluate its use. Usage statistics in March through May of 2007—almost a year following the end of the project funding period— show an average of 375 visits per month, which is more than double the number of visits during the project year itself.

The component deemed most successful by all parties is the sustainable collaboration. The CDPH has devoted additional resources to continuing elements of the SALUD project. Students are highly motivated trainees and trainers because participation is a mandatory and graded portion of their curriculum. Because a new group of nursing students begins approximately every five to eight weeks during the academic semester, CDPH clinic staff throughout the city receive education about a broad number of topics, and their knowledgebase is refreshed as changes are made to materials, websites, and modes of access.

CDPH administrators have embraced this continuing education model that helps them meet their goal of improved health education. A portion of the CDPH clinics' budget has been allocated to place a computer station to be used for health education activities in the clinics. Staff at clinic II have expressed increased interest in online health education since two new computers from CDPH were planned to be installed in more convenient locations. This additional support from CDPH will improve access and training regarding health education activities.

A valuable outcome of this project is the strengthened relationship between library and nursing faculty. Even after completion of the pilot project and in spite of turnover in original staff, the project has been fully integrated into the UIC curriculum for community health nursing. In the year following the contract period, the number of librarian sessions on health education resources increased from six to ten. Librarians developed a tutorial that is available via the university's online course management system. Integrating instruction into an established curriculum is an activity that librarians can sustain practically. Relationships developed through the SALUD pilot project have also enabled librarians to provide additional instruction throughout the nursing curriculum. Through better integration, they can now provide a richer educational experience for students. The librarian-led curriculum prepares future nursing students to deliver patient health information in the CDPH clinics and later in their own practice. It would be valuable to investigate in the future the extent to which students use these resources following graduation.

Perhaps most importantly, because the collaboration between the library, CON, and clinics continues, there is an opportunity to explore new means of improving health education in the community and to develop interventions with more rigorous outcome measures. In planning for a project, it is important not only to include evaluation activities, but also seek out assessment expertise in partner organizations. CON has both clinical and research expertise that could be utilized in future projects. For instance, the SALUD project team is curious about whether patient satisfaction improves when patients are provided with information in their preferred language and at an appropriate reading level. Future research could systematically investigate what health education materials staff would use in a clinic and how many appropriate materials are available for those topics.

Librarians at UIC focused on the library's educational mission and their own strengths as teachers in the institution. By fitting these strengths with the talent and existing relationships of the CON faculty, the SALUD project team was able to form an effective academic-community partnership. The relationship formed between the library, CON, and CDPH clinics during the project has built a foundation that will give a positive edge to future efforts to address the health education needs of Latino patients. In light of increasing demands and decreasing resources, academic health sciences librarians could consider the SALUD model in seeking opportunities to build sustainable collaborations that will serve as a foundation for outreach initiatives. Interdisciplinary, collaborative relationships diffuse the resource burden, appeal to funders, leverage diverse skills of partners, and, over time, build expertise and systems for successful outreach. Sustainable collaboration between the library and other academic units is a model for a new generation of outreach programs that can meet both educational goals and community service needs.