A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Objective: Effective physician‐patient communication is critical to the clinical decision making process. The informed consent process for any intervention can be one of the most important moments for effective physician‐patient communication in regards to outcome and liability. We studied parental recall of information provided during an informed consent discussion process prior to performance of emergency medical procedures in a pediatric emergency department of an inner city hospital with a large bi‐lingual population. Methods: Parent/child dyads undergoing emergency medical procedures were surveyed prospectively in English/Spanish, post‐procedure for recall of informed consent information. Logistic regression analysis was used; outcome variables were the ability to name a risk, a benefit, and an alternative to the procedure and predictors were language, education, and acculturation. Results: Fifty‐five parent/child dyads completed the survey. Logistic regression analysis showed that respondents with less than high school education were approximately 80% less likely to be able to name a risk or a benefit, while respondents with a high school education were approximately 24 times more likely to be able to name an alternative procedure. Conclusion: A gap in communication exists between physicians and patients during the consent taking; it is significantly impacted by socio‐demographic factors like education level, language and acculturation.

Each day in the United States, millions of adult consumers possessing traditional literacy skills below an eighth grade reading level enter a marketplace packed with written messages. This research offers the first in-depth, systematic investigation exploring the impact of low literacy skills within the marketplace and the methods consumers utilize to cope with literacy deficits. Based on the body of literature on stigma theory (Goffman 1963), previous work suggested coping strategies to result as a mechanism to protect the consumers' feelings of self-worth. This research identifies seven categories of coping strategies. The data collected show that coping strategies are not only used to protect the consumers' self-esteem but also to facilitate problem-solving tasks within the marketplace. In several cases, informants reveal their successes in getting marketplace needs met. Thus, a new conceptualization of the consumer literacy construct is offered to consist of traditional literacy skills, coping strategies or surrogate literacy skills, and specialized knowledge of the marketplace environment. Applying Link and Phelan's (2001) reconceptualization of the stigma concept to the data yields a richer understanding of the stigmatization process and consequences within the marketplace. Rather than passively accept the role of low literate, this research offers a perspective of the low literate consumer as an active challenger to the stereotypes that lead to negative evaluations and stigmatization. Implications of these findings for public policymakers, academicians, and members of the business community, as well as future researcher opportunities are discussed. The Association for Consumer Research (http://www.acrweb.org), the Society for Consumer Psychology (http://fisher.osu.edu/mkt/scp/), and the Sheth Foundation provided financial support for this research in the form of dissertation grants. / Ph. D.

This study aimed to determine the feasibility of three distinct self-monitoring modalities employed as part of a weight-loss intervention among Spanish- and Mixtec-speaking women with low-no literacy who were overweight or obese (body mass index, BMI> 25). Primary outcomes assessed include self-monitoring adherence, weight, body composition, and diet quality. Participants (n=18) were recruited from the Cal Poly Women and Infants Mobile Health Unit, and contacted if they had a BMI> 25 and did not attend school beyond elementary level (6th grade). Upon enrollment, participants were asked to attend a weekly meeting at which the lifestyle intervention was delivered by a trained research assistant. In addition, all participants were randomized to one of three self-monitoring modalities (written-diary, photographs, audio-recordings), which they were prescribed to adhere to throughout the study. Adherence was evaluated weekly and participants were provided tailored feedback the day following the group meetings. Body composition and dietary habits were assessed at pre- and post-intervention visits. Participants (N=18; aged 41.3 ± 7.3 years; 100% female; BMI 34.6 ± 4.0) in all three groups were assessed on four different measures of adherence to self-monitoring (% total adherence, ≥3 submissions, ≥2 submissions, ≥1 submission). Percent total adherence ± standard deviation (SD) was on average 44.1 ± 34.4% with 48.8% in the written-diary group, 46.4% in the photos group and 37.1% in the audio-recording group (p=0.878). In accordance with previous studies supporting the efficacy of self-monitoring in weight loss, adherence was also assessed on 75% of days weekly. Upon examining ≥2 and ≥3 submissions daily for 75% of days weekly, adherence was highest in the written-diary group (54.4% and 49.1%, respectively), followed by the photos (15.1% and 38%, respectively) and audio-recording groups (20.7% vs 30.6%). Body composition and weight were assessed using an electronic scale and Tanita Bioelectrical Impedance Scale (BIA) scale at baseline and post-intervention. Weight loss observed was 6.4 ± 3.5 lbs (mean ± SD or 3.7% body weight (BW). Weight loss was greatest in the photos group with 7.6 ± 4.7 lbs, followed by the audio-recording group with 6.8 ± 3.9 lbs, and the written-diary group with 4.8 ± 4.2 lbs (p=0.588). Change in percent body fat was not significantly different across the three groups with an average of 2.1 ± 1.6% body fat lost. Mean attendance at weekly intervention meetings was 76.4% and was similar across groups. Finally, diet quality was significantly improved during the intervention with a reported 20.8% increase in consumption of servings of fruit daily, a 54.5% increase in servings of vegetables consumed daily, and overall 82.4% more participants using measuring cups while preparing food, and 58% less participants consuming fast food in the past 7 days. The application of written-diaries, photographs and audio recordings are all feasible and acceptable modalities of self-monitoring for promoting self-regulation in a population of Hispanic women with BMI>25 and low-literacy. Future research efforts should continue to explore the application of existing and novel self-monitoring methods in order to determine the most optimal way to engage with this subpopulation.

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[pt] Dados do Ibope e do Indicador de Analfabetismo Funcional (Inaf) de 2012 revelam que, no Brasil, existem aproximadamente 14 milhões de analfabetos absolutos e um pouco mais de 35 milhões de analfabetos funcionais. Segundo estatísticas, o Brasil é o terceiro país do mundo em tempo gasto na internet, sendo mais da metade em mídias sociais. Nesse contexto, as atividades diárias se direcionam a comunicações baseadas em texto, e a falta de capacidade de leitura e escrita torna-se obstáculo ainda mais significativo para os adultos que apresentam nenhum ou baixos níveis de letramento. Dessa forma, esta pesquisa procurou responder à seguinte indagação: como se configura a experiência de uso e consumo das redes sociais e comunicadores instantâneos por indivíduos com baixo letramento? Para tal, realizou-se um estudo qualitativo exploratório, baseado em entrevistas pessoais com 22 adultos com Ensino Fundamental incompleto. Por meio dos resultados obtidos, foi possível perceber a estigmatização sofrida por esses indivíduos devido às suas limitações, assim como as estratégias de combate adotadas por eles, como a preferência por postagem de fotos e mensagens de voz. Pode-se sugerir que as novas formas de comunicação instantânea promovem uma certa liberdade para se cometer erros de gramática ou de pontuação que, muitas vezes, são atribuídos ao corretor automático dos dispositivos móveis. Outra evidência do baixo letramento é a preguiça de ler e escrever nas redes e nos comunicadores; o que os usuários chamam de textos grandes são, na verdade, considerados curtos segundo estudiosos de analfabetismo funcional no Brasil. / [en] Data from IBOPE and INAF 2012 reveals that, in Brazil, there are approximately 14 million full illiterate adults and a little more than 35 million functional illiterate individuals. According to statistics, Brazil is the third country in the world where users spend the most time online, which more than half of this time is spent on social media. Within this framework, as more daily functions move toward text-based electronic communication, reading literacy becomes even more important for adults who are illiterate or for those with low-literacy levels. Therefore, this research sought out to answer the following question: What kind of experience low-literacy individuals have with the social media and instant messengers usage and consumption? To this end, a qualitative exploratory study was created based on individual interviews with 22 adults with incomplete elementary education. Among the results, it was possible to notice the stigmatization suffered by these individuals due to their reading limitations as well as to some of their strategies to overcome the issue, such as sending audio instead of written messages or posting photos instead of texts on social media. It can be suggested that the new forms of instant communication promote freedom to make mistakes in grammar or punctuation that are often attributed to auto correctors of mobile devices. Another evidence of low-literacy is the laziness to read and write on social media and communicators - what users believe to be big reading are actually considered short reading according to specialists on Functional Illiteracy in Brazil.

[pt] O Brasil possui aproximadamente 54 milhões de pessoas consideradas analfabetas funcionais, segundo o Índice Nacional de Alfabetismo Funcional (INSTITUTO PAULO MONTENEGRO, 2016). Com base na premissa de que os consumidores só estão aptos a interagir no mercado se são capazes de responder adequadamente aos elementos da sua comunicação, é necessário analisar como os indivíduos com baixo letramento deveriam ser abordados para acessar bens e serviços de forma transparente. Neste contexto, o presente estudo objetiva explorar como os consumidores analfabetos funcionais interpretam a comunicação de marketing feita no Brasil. Para tal, foram realizadas dezessete entrevistas em profundidade com sujeitos com baixo letramento e os dados gerados foram analisados utilizando técnicas de análise do conteúdo. Os resultados indicam que uma parte dos entrevistados não diferencia o que é atividade de merchandising (product placement) do que normalmente é difundido como notícias e entretenimento por meio de programas de TV. Outra questão relevante foi o desafio frente à dificuldade de abstração dos sujeitos de pesquisa. Nesse sentido o estudo corrobora uma evidência presente na literatura estrangeira sobre o tema, que relata a maior facilidade de processamento e memorização por parte destes sujeitos de elementos que guardam correspondência de 1 para 1 com a realidade. Por fim, a pesquisa aponta características da interação dos sujeitos com o mercado, abordando pontos como a dependência de uma pessoa de referência; a preferência por compra em varejo de autosserviço; e o afastamento do comércio online quando não há assistência de outras pessoas. / [en] Brazil has approximately 54 million functionally illiterate individuals, according to the National Index of Functional Literacy (INSTITUTO PAULO MONTENEGRO, 2016). Based on the premise that consumers are only able to interact if they respond adequately to the elements of communication in the market, it is necessary to analyze how individuals with this type of limitation should be approached so that they can have a fair chance to access to goods and services. In this context, the present study aims to explore how functional illiterate consumers interpret a marketing communication made in Brazil. Thus, seventeen in-depth interviews with low-literate subjects were performed and the data generated was analyzed using content analysis techniques. The results indicate that some of the respondents do not differentiate between product placement and what is usually broadcast as news and entertainment through TV programs. Another relevant finding challenged the difficulty of abstraction of the subjects. In this sense the study corroborates evidence presented in the foreign literature on this subject, which reports the greater ease of processing and memorization by these subjects of elements that keep 1 to 1 correspondence with reality. Finally, the research points out characteristics of the interaction of the subjects with the market, addressing points such as the dependence of a reference person, the preference for retail self-service purchases and the removal of online commerce when there is no assistance from other people.

Introduction: Fish is an affordable animal source food that provides nutrition and serves as a source of income for many people especially women in Nigeria. Smoking and sun drying are the processing methods in practice that expose the fish products to possible contaminants which may consequentially negate their nutritive value. Aim: To improve the knowledge of fish processors on nutrition and safe fish handling. Methodology: A 3-day participatory training was organized to train 122 fish processors, 95 women, and 25 men. The training was conducted in the three senatorial districts in Delta State, Nigeria. Knowledge was assessed using the pre and post quizzes and assessed self-evaluated knowledge using a 5 points-Likert scale survey. The training material was validated using the content validity index (CVI) and modified kappa index (k*). Comprehensibility was determined using the cloze procedure. Minimum dietary diversity survey (MDDW) was used to determine the dietary diversity of women at baseline and 12 weeks after the training. Low literacy tools and the overall training were evaluated on Likert scales. Results: The developed seven-module nutrition and food safety flipbook were validated at a content validity index value of 0.983 and kappa index value ≥ 0.67., and the cloze score of 72.1%. There was a significant improvement in knowledge (p ≤.05) in the 7 modules taught. Wristbands and hand fans were rated useful and served as a reminder of nutrition values. There was no significant difference (p > .05) between the dietary diversity at the baseline; 5.8 ±.22 and end-line; 6.4 ±.20 at 95% CI. However, the number of women that consumed ≥ 6 of 10 food groups increased by 9.8% after 12 weeks of training intervention. Conclusion: The developed and validated training material was considered culturally suitable and appropriate. There was an increase in knowledge acquired in all modules taught on nutrition and food safety. Consumption of animal source food increased post-training. However, there is a need for additional training to address food contamination and dietary diversification.