Speaking Books
The South African Depressionand Anxiety Group

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
According to the IFAD Rural Poverty Report (2011), 67% of the population in Sub-Saharan Africa live in rural areas, and rural poverty is deepening. Social services, like health and education, can be up to 10 times more difficult and more costly for rural people to access compared to urban populations. Illiteracy, particularly in rural areas, is high - over 785 million adults are illiterate and Africa has a literacy rate lower than 60%). Two-thirds of these are women. Low literacy deprives people access to life-saving information and reduces health care literature efficacy - however good written material is; if people cannot read, the messages are ineffective. Research shows that health care is at its lowest where literacy is poor. Illiteracy is a potentially life-threatening issue. In developing countries, illiteracy affects up to 80% of the population; in countries with relatively high levels of literacy, there are still serious gaps in health literacy. Poverty and burden of disease correlate directly with low levels of literacy. Life expectancy is lowest where people cannot read. People with low literacy are less likely to understand directions by doctors, read and understand prescriptions, or be able to navigate the health system. “Literacy is a bridge from misery to hope. It is a tool for daily life in modern society. It is a bulwark against poverty and a building block of development…” (Kofi Annan) Many diseases like HIV and AIDS, TB, Malaria, and Pneumococcal disease respond to prevention and early intervention, but illiteracy threatened the ability of health care messages being effective. The need was to create an innovative tool that simply and effectively engages patients regardless of literacy levels or geographical location. Women and children continue to be the most highly effected group – and with illiteracy among women, comes a decrease in family health, nutrition and support, as well as higher rates of infant illness and mortality. Women are most affected by illiteracy; are unaware of their rights, and unaware that domestic violence is a crime. Appropriate healthcare communication that reaches all people, regardless of area or reading ability, is critical to the health of all people. Often the lack of capacity and absence of trained health care workers prohibits the provision of health and patient care education to prevent the spread of HIV and AIDS, TB, Malaria, and other life threatening diseases. The South African Depression and Anxiety Group (SADAG) has created an innovative patient education tool – the Speaking Book – which makes critical information available to all people regardless of literacy level, gender, area or socio-economic group. The Speaking Book addresses a major inequality - illiteracy - which deprives people access to life-saving information. The Speaking Book is an interactive education tool for communities with low levels of literacy which is effective over a long period of time. And the Books are distributed free to the communities that need them.

B. Strategic Approach

 2. What was the solution?
SADAG has created a world first technology for rural and disadvantaged Africans, Indians, and Chinese living in rural areas. SADAG has used a simple technology in an innovative way to empower communities and clinics. Used traditionally as a children’s book for learning nursery rhymes or numbers , this simple technology of interactive children’s books has become a powerful communication, education, and empowerment tool for rural and vulnerable communities. Speaking Books are hard-backed books with colourful illustrations with 16 sound buttons that read the exact text on the pages at the push of a button for up to 60 seconds per page so that people who can’t read still understand the messages. While illiteracy is not a daily issue for the majority and many people are able to function , poor and illiterate communities are often overlooked and given health brochures they cannot read. The Speaking Books goal is to effectively impart critical health information to patients in hard-to-reach areas, with low levels of literacy, who may be unable to read information brochures due to illiteracy, illness or age. This initiative allows all people, regardless of area, reading ability, or age to gain information that will empower them and enable them to achieve health and wellness. The Speaking Book was initially developed in partnership with the South African Directorate of Mental Health with a book on Teen Suicide Prevention. This was so successful that relationships have been forged with other government departments for Books on HIV and AIDS, TB, and Malaria. The concept is such a powerful one that it has now diversified to include such topics as getting government grants, Child-Headed Households and self-care for caregivers, as well as road safety, vaccinations and clinical trials. The South African Government’s Centre for Public Service Innovation said: “The Speaking Book exists because of technology that allows a recorded voice in any language to follow the written text, page by page, at the press of a button. Each button talks to the patient for approximately 30/60 seconds, the length of a radio advert. There are 16 messages in each book. The Speaking Books has over 52 titles created in over 28 languages. Each is its own success story – with the time volunteered by local celebrities from TV and Radio, and musicians and soccer stars, It has support of the media, and impact on each community especially Health Workers. Speaking Books positively changed the lives of individuals , family members , neighbours, and churches. Over 400, 000 Speaking Books have been delivered, in over 28 languages, across the world with over 50 clients, including Unicef, Pfizer, WMA, USAID, Rotary International and Governments in several countries. Research indicates that each book is shown to a minimum of 27 people. Unicef research in Ethiopia reported an average of 180 people listened to each Speaking Book. The Speaking Book offers an innovative, effective and far-reaching solution to the issue of patient education in low literacy communities. Solutions exist for patients needing information about complex health issues but who lack the ability to read them and have no electricity. The African continent is poised for innovation and change. SADAG and the Speaking Books can give new thought and direction to that path.

 3. How did the initiative solve the problem and improve people’s lives?
The Speaking Books meet the challenges of Africa’s health care system by reducing the enormous costs involved in getting access to a clinic, and giving immediate, free access to critical life-saving information. Through this project, poor, vulnerable and illiterate people can benefit whilst sitting in waiting rooms in clinics can listen to the book. . This original approach provides a way of disseminating information in a non-threatening, user-friendly way. Through a hard-covered, 16-page book with an accompanying 30/60-second-per-page audio track, the Speaking Book talks to the reader, in their own language. Soundtracks can be played in any order and repeated again and again. Knowing the Celebrities helps identify with them. The books are not dependent on electricity. When information is presented in both visual and audio form, retention is increased by over 50%. The Books answer questions and can even provide critical information even in the absence of trainers or nurses. SADAG has developed an existing medium and by using it in a unique way, that engages healthcare professionals, patients, Governments , NGO’s , caregivers, and the pharmaceutical industry, makes a powerful impact. The first of its kind, this is an African solution for vulnerable communities worldwide.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The objective is to allow all people, regardless of their geographical location, level of education, literacy, gender, age, or acute poverty to access relevant information about their health and treatment. The fundamental obstacle was finding a way to educate people with low levels of literacy – finding appropriate and effective ways to leave information behind that was economical and sustainable. The Speaking Book was created 7 years ago. Quotes were obtained from around the world, and suppliers sourced. The first book was on Teen suicide with De Beers and S A Government and researched in a school with low literacy. This was to ascertain to what extent the books compared with trainers on site. They are colourful and interactive and Speaking Books can be seen, read, heard, and understood regardless of reading ability. Soundtracks can be played in any order, so the Book can be listened to repeatedly until the message is absorbed. They’re also battery operated. The technology consists of a hardbound laminated book equipped with a sound box (IC recorded chip, circuit board, speaker, batteries) that produces the recorded spoken text identical to the printed words. The first Speaking Book, on Teen Suicide Prevention, was developed in partnership with the South African Directorate of Mental Health. SADAG’s teen suicide prevention programme, run in schools, showed the need for an interactive, safe tool to get the message to children and teens that depression exists and suicide can be prevented. This book was such a success that more topics were created and the concept was applied to rural home-based care workers to use with their patients and communities. The content and illustrations of each individual Speaking Book series are copyrighted and most are in the public domain. SADAG works with other NGO’s, government departments, pharmaceuticals, and communities to develop the content for the Books. The Speaking Book has been recorded in a variety of languages and have been supplied to a number of African and non-African countries. The Books are distributed during training and education workshops in communities with local stakeholders, clinics, home-based caregivers, and schools. They’re delivered free of charge and communities are trained to use them. The Speaking Book literally talks to the ‘reader’ in his own language, and answers questions that may not be able to be answered - or asked - elsewhere. Many patients who use the Speaking Books feel like their doctor is always with them, answering their questions, and reinforcing healthy treatment compliance. The Book is a powerful aid for health personnel, NGO staff and government workers and a training tool for community workers and volunteers. The traditional model of patient education has become outdated, boring, and selective in its target. The world is changing. Illiteracy and poverty are on the increase, and the healthcare industry can ill afford sophisticated but misguided training techniques. Poverty and burden of disease correlate directly with low levels of literacy. Life expectancy is lowest where people cannot read. Appropriate healthcare communication has indeed become critical to the health of all people, and the need has arisen for a new form of communication and instruction that can instill knowledge in all people, literate or not. The Speaking Book offers – and delivers – an innovative, interactive, and influential alternative to patient awareness and learning. 5. Who were the stakeholders involved in the implementation?

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Initially the Speaking Book was developed in partnership with the South African Directorate of Mental Health with a book on Teen Suicide Prevention. The book was co-funded by the Department and privately and a local South African copywriter and illustrator were used. The Speaking Books works with all interested parties and stakeholders – from government to other NGOs, pharmaceutical companies to business. The Books are also endorsed by various national and international organisations like the WMA, SAMA, The Steve Biko Centre for Bioethics, Johns Hopkins, Rotary International, USAID, and Pepfar. The Speaking Book works because the people involved are dedicated to patient education. Whether it’s the copywriters, researchers, illustrators or the company funding the book, each Speaking Book is created with passion and inspiration. Without volunteers, community caregivers and community stakeholders on the ground in the communities, we would not be able to distribute the books or train people how to use them as an education tool. The Speaking Books are accountable to the government of South Africa, NGOs, clients and patients to ensure that the messages are clear and understandable, and the Books are effective. The Speaking Book has over 52 titles created in over 28 languages. Each is its own success story – from the time volunteered by local celebrities, to the support of the media, to the impact on each community the book touches, every Speaking Book has positively changed the lives of individuals and communities.
 6. How was the strategy implemented and what resources were mobilized?
The Books were initially funded in conjunction with SADAG and each time with a new donor. De Beers funded the teen suicide book at R460,000. To date we have been able to maintain the cost at around R500,000 for a complete project. We have also been able to develop longer sound tracks, at a slightly higher cost from R95.00 per book, and up to R125.00 per book, for dual language dual track Speaking Books allowing clients to provide multiple languages in one book. Speaking Book orders are only undertaken when a donor has been found, or as is often the case, a donor approaching us. As an NGO we were not able to spend our own internal funding . Human Resources costs were no extra to the NGO as the Founder and the CEO took additional fund raising for the sales of the books and sourcing of donors. Other external cost have all been negotiated at great discounts, ie the artists whose names are promoted in the cover of the book , and follow specific briefs from client. Celebrities at nominal costs as the publicity gained is beneficial to them. Print and layout staff who work with the charity on our other work and do this work at a discount. Shipping is a cost which must also be taken into consideration. Typically Speaking Book orders are delivered to one venue in South Africa or other countries, unless client has other needs which can then increase the cost. There has been a diversity of clients with unique needs who require specific briefs, like the Swaziland government in a landlocked country. Most clients have specific needs for unique donors logos and graphics and very clear copy. One of our biggest problems is making sure the copy is appropriate in terms of words used that are comprehensive and understandable to the users. Frequently this copy is tested in a rural community prior to printing . Very often the language is too mature and needs altering with the client.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Following the launch of the first Speaking Book in 2005 “Suicide Shouldn’t Be a Secret” to educate South African rural teens on suicide prevention, acceptance and demand for the books has increased dramatically to over 52 titles, in 28 different languages and distributed internationally throughout Africa, China, India, Pakistan, Haiti, USA and South America and funded by all the major pharmaceutical companies, major NGO's and many Governments. Being able to adapt and be suitable for adults and children alike. Introducing stigmatising topics such as sexual behaviour, substance abuse, HIV and AIDS, and safe use of medicine in a non threatening or embarrassing environment. Being used as a teaching tool that can also be left behind for distribution and further discussion amongst the community who can play the messages over and over again as necessary Numerous International Awards for Sustainable Innovation by UN, UNESCO, Pepfar, Saatchi, Pan African Health, Commonwealth Association, etc

 8. What were the most successful outputs and why was the initiative effective?
The research indicated its success in a variety of topics. We looked at participants in communities, hospitals, clinical drug trials, and Schools. The initial one was North of Kimberley for children, comparing trainers in the schools on suicide prevention with free standing books. Results showed, a very positive improvement using the speaking books. Clinical drug trials is a key topic to ensure patients fully understand the Informed consent process. Initially it was tested through Wits University with non Educated teams of cleaners and lay staff. Then it was compared to research with over 90 in Uganda University and Hospital for comprehension and Knowledge of Clinical trials. Prof Roberson showed that participants who had instruction in the Speaking Books had a statistically significantly larger increase in knowledge assessment score. One of the areas in Africa using Speaking books is Home Based Care workers, tested in the Free State Province. 210 participants participants were requested of which 63% participated. 92% indicated that the book was easy to understand and they shared their book and over 6000 members of the community were exposed to it by the care workers. Ie 38 people per book. Unicef book on Maternal Child Health completed a major study and showed they were an extremely useful guide in the hands of health care workers to listen to books at home in Amharic. Each health care worker met with 30 groups of women approx 6 per group. Conclusions indicated that women all understood the messages. They believed content to be very accurate and truthful. Comparatively readers did not have the same level of confidence in the health workers. This research was accepted and printed by world medical journal. A very emotive book Comparing for your Child Headed Household was tested with 23 Home Based Care Workers so that we could return and assess their comments. 99% reported that the books were easy to understand and 96% indicated they had learnt new facts. Of key importance the HBCW indicated that Home Based Caregivers should have their own book in their home. Communities that have been exposed to the Speaking Book are more aware that help and support exists, are more likely to access that help, and talk more openly and freely about previously ‘taboo’ subjects. There is other research available that has equally positive responses. In a study in the Limpopo Province, 88% of home-based caregivers reported the Book made it easier to talk to patients about depression (an average of 35 people were shown each Book). The Speaking Books are accountable to the government of South Africa, NGOs, clients and patients to ensure that the messages are clear and understandable, and the Books are effective.. From abused and vulnerable children, to HIV positive patients, from pregnant women to pensioners needing to access government grant, the Speaking Book is touching and impacting the lives of all communities and people. 5000 copies of a Speaking Book are likely to impact 30,000 to 100,000 people. Communities that have been exposed to the Speaking Book are more aware that help and support exists, are more likely to access that help, and talk more openly and freely about previously ‘taboo’ subjects. They’re empowered to be responsible for their wellbeing. The Speaking Book has demonstrated success in communities, and organisations, and contributed to a better understanding of health care issues. The Speaking Book educates and empowers low literacy communities. The Book is a powerful aid for health personnel, NGO staff and government workers and a training tool for community workers and volunteers.

 9. What were the main obstacles encountered and how were they overcome?
Once the batteries die, the book may be thrown away even though the trainers and health care workers are trained in advance to explain how to replace them. The use of solar power has been investigated and can be made available, however at a significantly higher cost. Profit margins are minimal to ensure we can offer books at the lowest unit cost. This means that we do not have significant funds to market the Speaking Books internationally or support a sales staff, so we rely on referrals and, awards and press reports on the impact and cost effectiveness of our books. Similarly as much as we would like to exhibit at more international conferences on health care and public health, the cost is prohibitive and we look to invitations as guest speaker and allowed to display Speaking Books for free. The only suppliers for the Speaking Book sound boxes are in China where we are required to meet their minimum order quantities, so we cannot do small quantity orders. Speaking Books are perceived as items of value that empowers the holder as being more knowledgeable on the particular topic. As such they are often reluctant to give up or pass on the book, even though Speaking Books are always provided free of charge to the community. There has been limited reported cases of attempts to sell some sample books for personal gain. These are quickly halted.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
It is often thought that people living in developing countries such as South Africa do not suffer from mental disorders to the same extent as people in more developed countries. Not true, but very few sufferers seek help because of the stigma, shortage of mental health personnel, and formidable barriers of language and culture. In every city, in every country, there are those who are unable to access or understand basic healthcare. The Speaking Books provide access to critical information to people who are usually side-lined on the road to health. The Speaking Book empowers the user, whether a low literacy adult, or school child to look, listen and learn, so that the message is clearly understood and retained. Whilst the focus of the Speaking Book is primarily to benefit disadvantaged communities, health providers benefit enormously from a portable teaching tool that ensures the health care messages they are conveying are correct and stay on track. From abused and vulnerable children, to HIV positive patients, from pregnant women to pensioners needing to access government grant, the Speaking Book is touching and impacting the lives of all communities and people. To date research is available on 9 different Books. Keeping up to date with the research helps us continuously develop content and voices. Almost 300 000 adults in Gauteng have no schooling, and for every South African with a higher degree, there are three people who have no schooling at all (Census 2011). Low levels of education and literacy mean that people are less likely to understand health issues or follow treatment. Many governments have little access to health care and a reduced number of nurses and limit patients. By making the books available patients will learn on their own and limited time with nurses and health care workers will still have strong tangible results. Being able to use any language helps patients become very understanding. Even people who are blind can benefit from the Books. Due to a shortage of social workers, Teachers and life skills staff, government needs more help in schools for psycho social care and support, which is why Dept of Education and Health have looked at different topics , namely, Bullying, Substance Abuse, Suicide Prevention and Depression. . Communities that have been exposed to the Speaking Book are more aware that help and support exists, are more likely to access that help, and talk more openly and freely about previously ‘taboo’ subjects such as AIDS or Drugs or Sexual behavior. They’re empowered to be responsible for their wellbeing. Improving health care is a top priority for Africa and through the Speaking Books access to essential information for low literacy, rural, and vulnerable Africans is improved. The Speaking Books meet the challenges of Africa’s health care system, reduce the enormous costs involved in getting to a clinic, and give immediate, free access to life-saving information. No reception, no network, no pre-paid airtime – just simple, effective information distribution.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Yes the Speaking Books have frequently been replicated following the successful launch of a particular Speaking Book on a critical topic for one country and then produced for other countries, eg Clinical Trials in South Africa, followed by the same subject being covered in India, the Gambia, and Kenya, Pediatric Immunization in South Africa, Kenya, The DRC, Pakistan and Ethiopia, Safe Use of Medicine being produced for both South Africa and Kenya, Malaria Speaking Books for South Africa, Kenya, The Comoros and Liberia Unicef after their initial impact and positive results supported books in Pakistan, Ethiopia, Kenya and Nigeria all with the governments full support particularly for distribution. Speaking books for Substance Abuse were initially used only in two languages and then their success encouraged the Dept of Social Development to extend to all 11 official languages having seen the results. The books on children and AIDS originally completed in South Africa, have now been developed in Swaziland where there is a high rate of HIV in youth and a shortage of teachers and counsellors. It was supported by the Dept of Education and UNESCO. The government of Kenya wanted support for hand washing and Pneumococcal immunization. The hand washing was part of a children’s programme and Vaccines focusing on mothers to prevent Pneumonia. A government hospital in New York had the need for a Speaking book and the management of High Blood Pressure for Asian immigrant families who were changing their eating habits on arrival in America. These were specifically to take home to their families It’s not only healthcare that is being addressed. SADAG has created books on Teen Suicide Prevention, How to get a Government Grant, Caring for your Child-Headed Household, and Substance Abuse. People with low levels of literacy and children need an effective way to gain and retain information on a number of critical issues. The Speaking Book does just that. Nearly every title produced has been replicated - new print runs have been ordered in the same first language, or in one or several new languages. The concept can be applied to innumerable issues and each time we pitch to potential clients, they come up with uses which we have not thought of. Sustainability is the ability to continue and expand the project into new countries and markets. Each topic or Book is funded by a corporate sponsor with an interest in that area – for example, Pfizer has worked with us to produce Books on Pneumococcal disease vaccination – and distributed free of charge. The Books are also endorsed by various national and international organisations like the WMA, SAMA, The Steve Biko Centre for Bioethics, Johns Hopkins, Unicef, Rotary, CDC, USAID, Pepfar. We go where the need is – and where there are forward-thinking companies, government agencies and NGOs that want to develop a Speaking Book for their community, region or country. We’re a world first and the only product to address information dissemination, lack of access to care facilities and personnel as well as the issue of literacy. While other organisations work with training nurses, caregivers and lay people in rural communities, they do not address the need of low literacy patients in poor areas. We work together with other organisations for the betterment of the community. Initially the Speaking Book was developed in partnership with the South African Directorate of Mental Health with a book on Teen Suicide Prevention. Relationships have been forged with other government departments for Books on HIV and AIDS, TB, and Malaria, and the concept has been diversified to include such topics as getting government grants, Child-Headed Households and self-care for caregivers, as well as road safety, vaccinations, clinical trials and property acquisition. It’s not only healthcare that is being addressed. SADAG has created books on Teen Suicide Prevention, How to get a Government Grant, Caring for your Child-Headed Household, and Substance Abuse. People with low levels of literacy and children need an effective way to gain and retain information on a number of critical issues. The Speaking Book does just that. Nearly every title produced has been replicated - new print runs have been ordered in the same first language, or in one or several new languages. The Speaking Book has been recorded in a variety of languages and have been supplied to a number of African and non-African countries. The world over, immigrants, rural uneducated people are ignored or by-passed on the road to health. In every city, in every country, there are those who are unable to access or understand basic healthcare. It is for those people the Speaking Book was created. Illiteracy is a potentially life-threatening health issue. SADAG knows it is time we start communicating with all patients regardless of race, socio-economic position, geographic location, or reading ability about real health issues. Our Books have reached markets from Sub-Saharan Africa, to Asia, the USA and South America, empowering communities to look after and be responsible for their own health.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Started in March 2005, the Speaking Books project was created to give all people, regardless of their education levels, literacy or location, access to health information. SADAG has negotiated with a wide range of topics not just Mental Health which is our field. The diversity has expanded our knowledge. We need to work one to two years in advance to allow clients time to plan their budgets well in advance. We are developing new ideas with government and donors to teach very young children the shape, sound and use of the letters of the alphabet, with a 26 button sound box, one for each letter of the alphabet. The use of the speaking books in support groups is very effective. It is a tool for the support leaders to use and one they can spread around their groups. The selection of the voice overs in each book is key and the more well known they are the more popular and are shared with more status. Frequently books are shown in big church groups, using the microphone if the church has one and even taken to Shebeens (informal bars) or Hairdressers. We are still identifying venues for distribution usually neglected, ie Taxi Ranks for bulk passengers. Male speakers and presenters get them together with non alcoholic drinks and snacks. Men generally stay away from education. Shopping malls are very popular and we use them to support special countrywide health care days by donating free Speaking Books ICT coverage reaches further than roads, further than electricity, further than sanitation and further than clean water. So does SADAG and the Speaking Books. The simple technology of an interactive children’s book has been harnessed as a powerful communication, education, and empowerment tool for rural and vulnerable communities. The African continent is indeed poised for innovation and change. SADAG and the Speaking Books can give new thought and direction to that path with an NGO spearheading the initiative.

Contact Information

Institution Name:   The South African Depressionand Anxiety Group
Institution Type:   Non-Governmental Organization  
Contact Person:   Zane Wilson
Title:   miss  
Telephone/ Fax:   +2711-262-6396
Institution's / Project's Website:  
E-mail:   zane1@hargray.com  
Address:   PO Box 652548, Benmore
Postal Code:   2010
City:   Benmore
State/Province:   Gauteng
Country:  

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