Learning from the field and its listserv: Issues that concern health literacy practitioners

1.Introduction

This study assesses the content of email messages posted to the Health Literacy Discussion List (HLDL) during a two-year period. The study identifies issues of concern to list subscribers, describes the purposes the list serves for health professionals, and contributes to the health literacy literature by providing an email listserv as a research corpus.

Listservs are computer-mediated discussion groups by which subscribers can send and receive electronic mail (email) messages. Listservs provide professionals with similar interests the opportunity to ask questions and make requests, share resources and information, and discuss issues of common concern. Subscribers send and receive messages (posts) to all members of the list. Members can either respond to the email messages they receive from the list or simply read the posts and not respond. A key question is what purposes do lists serve for professional communities of practice.

To understand how the HLDL serves the health literacy community of practice, the authors identified categories for types and topics of posts made to the list. We sorted emails into types of posts categories to better understand the utility of the list for members. We sorted emails into topical categories to assess the substantive areas of concern to listserv members.

This paper reviews studies of lists serving professionals and presents background information on the evolution of Health Literacy Discussion List (HLDL). The authors detail the inductive methodology used to identifying types and topics of posts made to the list. We report common themes discussed and suggest the ways in which the list supports subscribers and the health literacy field of research and practice. Finally, we discuss how this work may serve as a model for future research.

2.Background

Electronic discussion lists, also known as Listservs, are used within many professional disciplines to facilitate communication. Professionals with similar interests use listservs to exchange email messages, share information, ask questions, learn from others, and discuss relevant issues.

Professional organizations and associations often maintain listservs as a service to their field. For example, the American Evaluation Association maintains a listserv for members to exchange information and ideas related to evaluation. As new professionals enter the field, the list serves as a forum for offering feedback and soliciting advice [2].

Some discussion lists are unmoderated and allow all messages to go automatically to all list members. Other lists are moderated, meaning all email messages are read by a moderator, before they are allowed through to the group. A moderated format screens for inappropriate posts and may help promote and facilitate interaction.

Listservs are increasingly valued as a setting for investigation. There is a growing body of research looking at how and why groups of professionals such as teachers, nurses, and librarians use listservs and the topics they discuss [1,2,6,11,13,17]. Investigators have developed methodologies for content analysis of emails posted from listservs and demonstrated these methods as reliable and valid ways of conducting research.

In one example, investigators conducted content analysis of emails posted to a discussion list for councilor educators and practitioners [11]. Neukrug and colleagues examined 9,197 emails posted to the list over a three-year period [11]. They identified 20 superordinate and 17 subordinate categories using an inductive approach. The majority of posts represented resource requests (29%) and personal communication (21%). Fifteen percent were categorized as program development, and 7% were jobs related.

Another study identified types of posts and types of knowledge shared by nurses through an online community of practice discussion list [6]. Ten types of posts were identified with 56% categorized as knowledge sharing and 33% as solicitation. The next most common type of post was job postings (6%). Through interviews with list members, Hara, Noriko Hew, Khe Foon [6] found that the moderator was pivotal to facilitating knowledge sharing.

3.Methods

The authors analyzed 2,036 email posts to the Health Literacy Discussion List (HLDL) during a period of two years (October 2013–October 2015). Subscribers to the listserv agree to have their posts viewed by other subscribers and stored as a body of knowledge that can be searched and referenced for research. We applied a mixed methodological approach of inductive naturalistic inquiry and heuristic decision making to identify thematic codes that emerged from the data [5,9,16]. As such, this research is a descriptive evaluation of text and limited to the specific topics subscribers raise as well as the broader categories of subscriber posts. The authors developed descriptive categories for the types and topics of posts through an iterative process. Types of posts categories provided insight into the function of the listserv for members. Topics of posts categories highlighted the substantive areas of interest to listserv members.

The first (SKR) and third (JM) authors reviewed the subject lines of all 2,036 emails posts as the first step in the iterative process. Following that review we independently developed lists for the types and topics of posts. We combined the lists and placed them on a white board to review and discussion. The second author (RVR) facilitated a collaborative discussion to agree on a common understanding of the types and topics categories. Note: the third author (JM) was the HLDL moderator during the assessed time period, and the first (SKR) and second (RVR) authors were subscribers to the list during the assessed period. Figure 1 displays the preliminary list of eight types of posts categories and Fig. 2 displays the preliminary list of 95 topics of posts categories.

Fig. 1.

Preliminary list of post types.

Fig. 2.

Preliminary list of post topics.

The second iterative step involved creating a “tally sheet” to categorize a random sample of 200 listserv posts into the initial types and topics categories. The 200 posts were selected without replacement to the total 2,036 posts (i.e., 1,836 remaining posts). Each post received a unique post number (P) for identification purposes. SKR and JM independently read each of the 200 posts and categorized posts by type and topical area of interest. The tally sheets were returned to RVR to calculate intercoder reliability. Cohen’s kappa reliability coefficient [3,4] estimates the level of intercoder reliability between raters analyzing qualitative data. Kappa values for the types of posts ranged from 0.42 (a “moderate” level of agreement) to 1.00 (an “almost perfect” level of agreement) [8]. Kappa values for the topical areas ranged from 0.09 (a “slight” level of agreement) to 1.00. The preliminary analyses suggested the need for further refinement as part of the heuristic decision making process [3]. During a weekly research meeting, SKR and JM each described their decision-making process to categorize posts by types and topical areas. RVR facilitated discussions and resolved disagreements on type and topics categorizing through consensus. Discussions lead to the development of a codebook containing the final list of six types of posts in Table 1 and 48 post topics in Table 2. The agreed upon list of types and topics guided the next iterative step.

A second random sample of 200 email posts were selected from the 1,836 remaining listserv posts. Using a revised “tally sheet” of type and topical areas, SKR and JM independently read and categorized the second sample of posts. The tally sheets were returned to RVR to calculate intercoder reliability. The kappa values for types of posts improved and ranged from 0.90 to 1.00 (an “almost perfect” level of agreement) [15] and kappa values for the topical categories ranged from 0.89 to 1.00 (a “substantial” to “almost perfect” level). To ensure and further validate the reliability for the topical categories of interest, RVR independently categorized the second random sample of 200 posts using the key word search function in Atlis.ti 7 [15]. Atlis.ti 7 key word search function includes the option to search and systematically analyze text using Boolean logic operators (e.g., AND, NOT, OR). Including the key word search results slightly increased the estimated kappa values for topical areas and ranged from 0.91 to 1.00 (an “almost perfect” level). The authors also identified clusters of “hot topics” most frequently discussed by listserv members from the total 2,036 posts. We elaborate further on the identified “hot topics” within the Results section.

4.Results

The authors extracted contributors’ signature lines to examine the characteristics (i.e., location, degree(s) earned, and position title) of listserv members and identified 322. Of the 322 unique contributors to the list during the two-year period, 289 included a physical address within the signature. Nine countries were represented including Australia, Canada, Israel, Italy, New Zealand, Pakistan, The Netherlands, United Kingdom, and the United States. The majority (89%) of addresses were located within the United States. We did not observe contributions to the listserv from South America and Africa. In terms of formal training, 22% of members listed a degree in Public Health, 17% in Nursing/Allied Health Science, and 11% in Library Sciences. In addition, 20 members listed a health literacy specific title in their signature line. Examples include, Health Literacy: Manger, Consultant, Director, Specialist and Coordinator.

5.Discussion

This study describes how subscribers to the Health Literacy Discussion List (HLDL) use the service and what topics of discussion are of interest. The findings add to a growing body of literature that uses electronic discussion lists as a setting and corpus for research.

Among the study’s limitations, the study’s findings reflect only the assessed two-year time frame – from October 2013 to October 2015. The findings are limited to the activities of involved HLDL subscribers. The findings may or may not apply to subscribers who receive but do not interact with the listserv. The authors acknowledge a potential for selection bias since we are health literacy practitioners and were involved in HLDL activities during the study’s assessed time period. Conversely, the authors’ knowledge, experience, and involvement in HLDL and health literacy practice may have helped detect patterns in subscriber use.

In terms of basic use, the results suggest HLDL supports health literacy professionals by raising diverse topics and providing peer-generated feedback. Among its peer services, the HLDL: asks and answers questions; shares information and resources; provides technical assistance; and is a platform for professional discourse. The authors found subscribers use the list for: announcements; asking and answering questions; sharing resources; and discussion.

The majority of announcements are to promote professional development opportunities including conferences and online trainings. Subscribers also seek feedback, such as technical assistance regarding intervention approaches as well as sharing professional and consumer resources. Subscribers who are most inclined to use the list as a feedback resource, seem to be students or practitioners who are in the nascent stage of a health literacy job or career. These findings are consistent with other studies of how health and non-health professionals use a peer, subscriber listserv [1,2,6,7,10,11,13,17].

In terms of subscriber background, while some email lists serve subscribers with similar professional training, HLDL’s members are professionally diverse. Nurses, librarians, and public health professionals all subscribe and use the HLDL.

By analyzing the listserv’s signature lines, the authors found subscribers also represent an array of 20 job titles that include the words ‘health literacy,’ including Health Literacy Manager and Health Literacy Coordinator.

Interestingly, some subscribers described that professional isolation is an operant challenge for some health literacy practitioners around the world. For example, one subscriber posted: “I’m the only one in my workplace who is advocating for health literacy.” Apparently for these and other subscribers, the HLDL is a place where health literacy practitioners create a sense of community and peer support. Some other specific health literacy issues discussed within the HLDL include: health literacy research and assessment; how the U.S. Affordable Care Act and health insurance impact health literacy; health literacy interventions in healthcare settings; peer coalition building; providing or finding plain language health information; and the training of health literacy and other health professionals [2].

In contrast, with one exception there was little interaction among HLDL subscribers regarding contemporary health information technological (HIT) issues, such as the use of social media to improve public access to health information and services as well as HIT interventions to improve health outcomes. Yet, HLDL subscribers discussed their experiences with electronic medical records (EMRs). Subscribers asked questions, shared resources, and discussed the implications of integrating a health literacy measure within patient EMRs.

In addition, some subscribers used the HLDL for what the authors term ‘service to the field.’ In these cases, subscribers would ask peers to take action in some way, or formally share their expertise in a survey. In one case, subscribers were asked to review the new design of a U.S. government website and provide feedback. In another case, subscribers were asked to advocate for the inclusion of health literacy questions in the U.S. Behavioral Risk Factor Surveillance System (BRFSS) survey and to give feedback on a set of draft questions. Another small, but noteworthy, use of the list is to post health literacy job announcements.

The findings additionally suggest subscribers appreciated the role and presence of HLDL’s moderator. The study suggests subscribers value the ability of a moderator to facilitate peer discussion. The positive influence of the list moderator to generate discussion and engage subscribers is consistent with previous research [17].

The current research contributes to the growing literature on electronic discussion lists (listservs) as a setting for research. The study’s methods include the use of an independent coding tool to assess the face validity of researcher-derived findings.

Finally, the study suggests electronic data can be a data corpus for researchers who wish to assess the content of electronic mediated communication. The current research describes the specific listserv use of some health literacy practitioners and suggests the importance of online discussions about research and practice within a professional community.

6.Implications

The authors suggest three broader implications of the HLDL for health literacy knowledge and practice: as an information repository, as a site for professional development, and as a forum for identifying needs and solutions prior to discourse at professional meetings and in publications.

First, the HLDL serves as an information repository for the field of health literacy. As pointed out, listserv members did not use the web-based version of the list for approximately two years. The change from an email listserv to a web-based system from 2011 to early 2013 resulted in a loss of professional discourse. To develop and maintain a corpus of professional thought, it is critical to have a communication system such as the HLDL the health literacy community of practice will use.

Second, the list serves the field as a site for peer to peer professional development and support. Similar to other professional listservs, the HLDL serves as a means to request information and share best practices. The HLDL is especially important to the development and socialization of new professionals and students. Long term subscribers share institutional knowledge of the field, while new subscribers ask for insights about ideas and practices.

Third, the HLDL is a forum where new topics and challenges (such as the adoption of electronic medical records) are discussed before they appear at conferences or in professional papers. During the early iterations of analysis, the authors also identified information communication technologies (ICTs) such as mobile app, webinars, chat, and social media as topics of discussion. The proliferation of ICTs highlight a need and opportunity not fully realized to utilize new technologies and ICTs to leverage and enhance health literacy practice.

7.Conclusions

Electronic discussion lists are a valuable mechanism for professional discourse and development. Content analysis of the HLDL suggests that a diverse group of professionals interested in health literacy use the list to make announcements, ask and answer questions, share information and resources, and discuss practical and conceptual issues.

Topics of discussion largely mirror those reflective of the time period and include “hot topics” such as assessment and measurement, the U.S. Affordable Care Act, and creating health literate organizations. List members also addressed topics that are not yet being addressed in research or publications but warrant more immediate outlets for discussion because they are already confronted in practice. Examples include electronic medical records and a growing interest in exploring the relationship between health literacy, equity, and social justice. The list and its members serve as a source for expertise and input on issues that affect the field as a whole, and a corpus for research and tracking emerging concepts that will shape development of health literacy study and practice.