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On Plain Language & Improving Health Literacy
9 out of 10 adults lack the skills to manage their health. Really?
Health Literacy Researchers, let’s move on!
Paid parental leave - finally
February is Teen Dating Abuse Awareness Month

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Center for Health Literacy Promotion Blog

On Plain Language & Improving Health Literacy

Information producers should be less concerned about healthcare consumers’ lack of literacy skills and more concerned that we are all “limited-capacity information processors” [1].
 
"In any situation, a person decides what to do based on under-
standing of facts, issues, options for action, and consequences.
 
This  statement from an article titled “Improving Health Literacy” at PlainLanguage.gov is bound to set information providers and health literacy promoters down a dead end. It describes health decisions that fit the process for effective decision making taught in graduate classes Dartmouth  [http://www.umassd.edu/fycm/decisionmaking/process/] and multiple models of how health decisions ought to be made. We hope and trust that healthcare professionals use this conscious, deliberative, analytical, linear, reasoned process for treatment decisions. Consumers do not.
 
Healthcare decisions are based on emotion
We consumers are much more likely to use what experts in decision-making processes call an “experimental” approach that is intuitive, automatic, associative and driven by emotions.  It is feelings that make meaning from information and motivate actions. Because we can only use a limited amount of information, we consumers automatically search for info that warrants our attention and info we can disregard. Health decisions typically are complex and require complex information on unfamiliar topics,  using unfamiliar terms and concepts.  More info requires more time and energy and often yields more uncertainty and competing messages. Even otherwise information-hungry consumers may limit information seeking and almost certainly disregard available information that is hard to use when physically, mentally, spiritually and financial stressed by illness. The value of plain language information in a simple form is that it makes information easier to use so that consumers do not have to use short cuts.
 
Plain language information is necessary but insufficient to improve health literacy. It needs to be formulated to make decision-making, rather than reading less cognitively and emotionally demanding. It needs to come with direct support to help people process the info based on their specific needs and the everyday home context in which they are expected transform decisions into actions and outcomes.
 
References
Consumers in Healthcare: The burden of choice. (2005). Shaller, D.  California Healthcare Foundation, Oakland. Online at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ConsumersInHealthCareBurdenChoice.pdf
 
The Adaptive Decision Maker. John W. Payne, James R. Bettman and Eric J. Johnson, Cambridge: Cambridge University Press, 1993,307 pp. ISBN 0 521 41505 5 (hc), ISBN 0 521 42526 3 (pb)
 
 
 

 

9 out of 10 adults lack the skills to manage their health. Really?

I just saw it again:  In fact, 9 out of 10 US adults do not have the skills to manage their health (from a newsletter whose author shall remain unnamed)
 
Last week, I saw that figure, stated as a related but different known fact, on the NYU student health website:  Nearly 9 of 10 adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media, and communities (not sure who our refers to). That same quote is found in the CDC report titled The State of Aging and Health in America 2013  

Here’s another version made somewhat more accurate by qualifiers: Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy. In other words, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease.
 
The source of this oft quoted and variously interpreted statement is data from the 2003 National Assessment of Adult Literacy. That was a lengthy pencil and paper literacy test taken by 19,000 US adults 12 years ago. It included “health tasks”, hypothetical situations thought to represent common literacy activities related to health.
 
 Use your critical literacy skills
•   The statement is not a fact.
It is a national-level estimate extrapolated from a population sample. Research, and especially literacy testing, does not produce fact, only likelihood; in this case, at the national level. The statement is meaningless in discussion of individuals.

•   The test has been used once. Its validity is unknown.

•   “Health literacy tasks” in the test are common only to insured, experienced patients.

For example: A Proficient rating means the person can use a table to calculate an employee’s share of health insurance costs for a year. This is nonsense to a person who has never qualified for employer-based coverage.
 
Below Basic means a person cannot read a short set of instructions and identify what is permissible to drink before a medical test.  More nonsense for a person who has never had a medical test.
 
•   The information was produced to publicize a problem, spur action and advocate for research funding. That may explain why reports refer to “only 12 % are Proficient” and then round down to 10% and delete nearly to state that 9 out of 10 are not proficient; and suggest that individuals need to score at the Proficient level to manage their health, or use everyday health information, or prevent disease.  A more accurate, but less motivating report might have said,  “Only 14% of US adults scored Below Basic in heath literacy. They are primarily impoverished, socially disadvantaged adults who attended low quality schools and are excluded from the healthcare system.”   
 
•   It is rarely reported that “the majority of US adults” (53%) scored at the Intermediate level, and another 22% (“[nearly] 1 in 4”) demonstrated Basic health literacy.   If it is true, as suggested, that a Proficient heath literacy score translates to proficient management of health, disease prevention, and “understanding basic heath information to make appropriate decisions”; and if it’s also true an Intermediate or Basic score translates to incompetence, that’s an incrimination of a healthcare system that benefits only 1 out 10 it intends to serve.
 
•   It’s rarely reported that 30% of college graduates scored at the Proficient level, compared to 3% of high school graduates and 1% of non-graduates. That figure suggests making higher education accessible to all adults as a matter of health policy and healthcare cost containment. It also suggests you need a college degree to benefit from “the best healthcare system in the world”
 
It is imperative to move away from this questionable, disempowering, self-defeating, system-centric oft-repeated extrapolation that 9 out of 10 US adults do not have the skills to manage their health. Healthcare would benefit by using theories of health literacy as an asset and a pragmatic intervention to design health services that benefit people with the skills they have instead of lamenting that people just are not smart enough to use health information and services. As long as we contend that what we need in order to have quality, equitable, affordable healthcare is a smarter patient; we’re spinning our wheels.

 

Health Literacy Researchers, let’s move on!


My grandson was up to bat in his first little league game. I shouted enthusiastically from the stands, “Eye on the ball, Rhett. Eye on the ball!”  He stepped out of the box, lowered the bat, and replied in a low bored voice with all the power of a stage whisper,  “ I already know that. You don’t need to tell me.”  Now I know how he felt.
 
A headline flashed on my screen this morning “Information materials… too complex for patients". We know that. For sure. For certain. No doubt. No question.    A PubMed search on “readability of patient information”  brings up 2149 published articles; 45 already in  2015, one every work day.
 
The continued focus on patients’ inability to understand information from healthcare providers and insurers is not just wasteful, it’s harmful in several ways.
 
Readability is the low hanging fruit of health literacy research. It’s picked. There are so many urgent unanswered questions to investigate.  Funders and editors, please require more forward thinking, and more actionable results.
 
Readability studies are about patients and their deficits.  On average, Americans spend about 1 hour per year as a patient in a clinical setting. The near exclusive focus on patients’ in health literacy research excludes most of us, most of the time. It defines individuals as their disease. It suggests a person only needs health literacy when seeking or obtaining medical care. If research refocused on what promotes a person’s or community’s ability to use information and services for health, risk would less often progress to need, and fewer of us would be patients. We would discover interventions to complement information-improvement initiatives.
 
Focus on “low literate patients’”  deficits  is disempowering, disrespectful, and self-defeating.  It positions patients as incapable of doing what is required to recover and cope. It breeds unnecessary dependence on professionals. It positions patients as victims of disease, and providers as their rescuers — both untenable positions in a system that strives to be patient centered and prevention focused and wants patients to self-manage disease and be partners in treatment.
 
We need no  more studies to document the problem. We need to remove barriers, and develop skills, particularly interactive and reflective skills which are typically categorized as advanced health literacy skills and not included in health literacy studies.  We need to understand the contexts in which people strive to act on information to keep healthy, live well with disease, and raise heathy competent children.  We need recognize and research health literacy beyond the clinical encounter in everyday life where information is understood and acted on - or not.
 
Let’s stop analyzing how bad health-related information is, put into practice what we know about making it clear and actionable,  and move on to figure out what, besides plain language, empowers people translate information into health promoting actions and outcomes.

Paid parental leave - finally

I’m proud of my city. We are catching up with the rest of the world.
 
Yesterday Mayor Ed Murray announced Seattle will provide paid parental leave for City employees.  All parents — foster parents, adoptive parents, mothers and fathers— will have the option to take four weeks off —with pay— to bond with a new child.  The mayor is encouraging other employers in the state to offer similar benefits.
 
This should not be the surprise, the bold move, the breakthrough that it is.
The US is the only developed country on the planet that does not give new parents paid time off to support attachment and bonding and infant brain development, and to put their newborns on a positive health trajectory. President Obama announced a similar new  policy to provide six weeks paid parental leave to federal workers in his State of the Union address.
 
A step toward gender equity in the workplace
I’m especially glad the paid leave policy will apply to fathers as well as mothers. That presents child care as a shared responsibility. It puts to rest arguments and  unfair choices that have plagued so many women’s career…You are on the mommy track, so you can’t be on the partnership track. The paid leave policy protects mothers’ earning potential, avoids unfair expectations and burdens and removes that awful choice between career and family.
 
Most of all, this investment in parents shows we are a society that values its children, including adopted children and those in foster care. It shows respect for the role of fathers in raising children, and the role of mothers in the workforce.  It acknowledges the contributions  of foster parents — special people who can love other people’s children as their own, and encourages foster parenting. Thank you Mr Mayor and Mr President for leadership toward a stronger city, region and society.

February is Teen Dating Abuse Awareness Month

February is teen dating abuse awareness month.  Throughout the month of February, teens and organizations across the country have been working together to raise awareness about teen dating violence.  As a dating abuse prevention educator February is my busiest month (which is why it has taken me so long to write this blog). Every week I visit the schools in my community to discuss dating violence, healthy relationships and how to recognize warning signs. I speak with students from 7 grade all the way through college about their experiences. I am proud of what I do and I am grateful to work in a community that considers these issues important enough to discuss with our children all throughout they year. I wish I could say the same for the community I live in.  Not every district or county recognizes the importance of discussing healthy relationships with adolescence, which is shocking considering the statistics (see below). I have tried on more than one occasion to bring presentations similar to the ones I do in other communities to my son’s school to no avail.  The question is why aren’t some schools or some communities talking about dating violence?
 
The simple answer is, it is not an easy subject to talk about. We are taught to ignore or to stay quiet when we see signs of abuse. We are not encouraged to talk about abusive behaviors in relationships. If you are parents, it's even more challenging to open a conversation with your child about relationships. Where do you begin, and at what age?
 
It is important to recognize that dating abuse affects everyone. It knows no boundaries and crosses all barriers. It can and does happen to anyone, at any time at any age all around the world. The repercussions are far-reaching and impossible to ignore.  According to loveisrespect.org violent relationships in adolescence can have serious ramifications by putting the victims at higher risk for substance abuse, eating disorders, risky sexual behavior and further domestic violence.  It affects children, their families, their schools and their communities.
 
It can be difficult to talk to your children or a young person in your life about relationships, dating and especially sex but if you don’t, who will? We must talk to our youth about how to recognize warning signs, what a healthy relationship looks like and where to get help.  Talk to them and listen to what they have to say. If you don’t know where to begin, I have listed resources for you below as well as some statistics.
 
Everyone deserves a healthy relationship. Not everyone knows what that looks like (especially when they are looking to the media and culture for examples but that is an entirely separate future blog post) so it is up to us to begin the conversation. Reach out to your local agencies; see if they can bring someone in to the schools to reinforce what you are teaching them at home. We can raise awareness, we can prevent violence in relationships and we can do that one talk at a time.
 
 
Did you know:
 
·       1 in 3 teens in the U.S. is the victim of physical, sexual, emotional, or verbal abuse by a dating partner, a figure that far exceeds other types of youth violence.
 
·       Girls and young women between the ages of 16 and 24 experience the highest rate of intimate partner violence (almost triple the national average).
 
·       Violent relationships in adolescence can have serious ramifications by putting victims at higher risk for substance abuse, eating disorders, risky sexual behaviors, and further domestic violence.
 
·       Eighty one percent of parents believe teen-dating violence is not an issue or admit they don’t know if it’s an issue.
 
·       One in three adolescents in the U.S. is a victim of physical, sexual, emotional or verbal abuse from a dating partner, a figure that far exceeds rates of other types of youth violence.

·       One in 10 high school students has been purposefully hit, slapped or physically hurt by a boyfriend or girlfriend.
 
·       One quarter of high school girls have been victims of physical or sexual abuse.
 
·       Approximately 70% of college students say they have been sexually coerced.
 
There are many organizations doing incredible work focusing on relationship violence awareness and prevention. These are a few of my favorites.
 
 
 
Reference:
 
www.loveisrespect.org

 

CLAMs for diverse populations can overcome language barriers Culturally & Linguistically Appropriate Materials

US residents speak at least 329 languages. In some US cities less than 60% of the population speaks English. About 32 million of us speak a language other than English at home. If your service population is not diverse now, it will be soon.  Pew Research projects the US Spanish speaking population will triple by 2050, and the Asian population will double. Success in improving the health of ethnic populations will substantially influence the future health of America as a whole.
 
Healthcare organizations have been working to develop their capacity to address language barriers and cultural differences, but it’s hard to make progress when the challenge is increasing along with the complexity of treatments and healthcare delivery and financing systems. Non- English speakers still face substantial communication barriers at almost every level of the health care system.
 
Studies show that communication barriers have a negative impact on health, discourage use of preventive services, and increase costs of treatment through unnecessary testing, delayed diagnosis, extended treatment times, and misinterpreted instructions. Without information that they can understand and use in their everyday lives, patients cannot engage in self-care or self-management. In short, they cannot take responsibility for their health and be partners in treatment, as effective care now requires.
 
In most cases, provider organizations and insurers have the means to overcome language barriers. But current practice in most communities still reflects an assumption that it is the patients' obligation to make themselves understood, to ask appropriate questions and to correctly interpret and comply with instructions. In most instances, this assumption is wrong as a matter of law. Federal and state civil rights laws and Medicaid regulations require access to linguistically appropriate care. These laws are the basis for accreditation standards that require providers and insurers to position themselves for our multicultural future.  

Studies show that print materials, particularly in combination with brief counseling, can increase recall, compliance, and behavior changes; and reduce consultations regarding discomforts that could be self-managed. Health information is increasingly available and accessed online, through mobile devices and virtual patient educators. Still a clear message from research participants is that written information should always be available, even in the presence of multiple other media.

While they are not a total solution, CLAMs remain the necessary foundation for a comprehensive communication effort, and an obvious starting place to promote health literacy. Organizations serving diverse populations will need to hone a process to develop and test English language materials, and to adapt essential proven materials for non-English speakers.  More on that next time. Stay tuned.
 
 
 
 
 

 

Critical Health Literacy: The mind’s strongest glue?


Previously in this space, we talked about the identified consequences of health literacy. I argued that the documented presence of those consequences in a mother’s (or other’s) life would be evidence that she  possesses and used health literacy skills to produce those consequences.  Now we look specifically at critical health literacy and its consequences.
 
Nutbeam (2000, 2008) followed literacy scholars Freebody and Luke (1990) to name levels, or, more accurately, categories of health literacy: functional/technical skills (ability to read and use numbers); interactive/social skills (listening, speaking) and critical health literacy, critical thinking skills that enable a person to apply information in new circumstances (Nutbeam 2000) in one’s own life (Kickbush 2001).
 
While critical skills are commonly considered advanced or higher level skills, some literacy scholars (Charner-Laird, Fiarman, Park, Soderber & Nunes, 2003) have argued that critical  thinking, especially reflection, is so essential to making meaning from information and using it in context, that it should be considered a basic skill. They describe reflection as the “mind’s strongest glue” for making connections essential to understanding any subject.  Maternal health literacy includes all three categories of health literacy skills, which mothers use in various combinations according to the task and the context. Strong skills in one category (say listening and remembering) can compensate for lesser skill in another category (like reading).
 
Is Critical Health Literacy different from Health Literacy?
Sykes and colleagues (2013) wanted to know if critical health literacy is really different from associated concepts like health literacy and empowerment. So they analyzed the literature on critical health literacy and interviewed UK health literacy experts. They concluded that critical health literacy is indeed a unique concept differentiated from related concepts by its consequences: confidence or self-efficacy,  improved quality of life,  increased social capital, and improved health outcomes.  The unique consequences of critical heath literacy suggest that critical thinking is the active ingredient in health literacy that leads to action and outcomes. This adds weight to our operating theory at Beginnings Guides and the Center for Health Literacy Promotion that reflection is a key lifeskill for mothers taking responsibility for family health.
 
The Active Ingredient in Health Literacy: critical thinking skills
My friend and colleague, home visiting expert Linda Wollesenhas been saying for decades that mothers make progress when home visitors, parent educators (I’ll add patient educators and health educators) stop giving answers and instead ask questions that make mothers think. In the process of working out answers to reflective questions mothers learn to look objectively, critically at a situation to make sense of it and choose a purposeful response, to formulate their own questions for information seeking, to interpret information and use it for practical purposes in their everyday lives. 
 
Basic health literacy, described as reading and numeracy skills used to understand basic information needed to make appropriate health decisions (Monday I will quit smoking)  is insufficient to affect outcomes. Action is required for outcomes, often sustained and difficult action. And critical thinking skills are required to plan action, progress in the face of barriers, and produce desired outcomes. So to be health literate, mothers and others need skills in all three categories: functional, interactive and critical health literacy. And the greatest of these is critical health literacy — thinking skills to respond intentionally to the health challenges and opportunities of everyday life.
 
 
References
Nutbeam D. (2000)Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st Century. Health Promotion International, 15, 259267.
 
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67, 2072-2078.
 
Kickbush,IS. (2001).Health Literacy: addressing the health and education divide.Health Promotion International 16 (3), 289-297.
 
Sykes S, Willis J, Rowlands G & Popple K. (2013). Understanding critical literacy: a concept analysis. Biomed Central Public Health:13:150. http:www.biomedcentral.com1471

Measuring Health Literacy by its Consequences

Let’s welcome the new year with some new thinking about measuring health literacy.
 
It’s hard to say exactly what electricity is, but if the lights are on, we know we’ve got it. And we measure electricity by the light it produces. So it is with health literacy. It is hard to say just what health literacy is, but we know it by its consequences, and we can measure those consequences.
 
Services utilization, behaviors, self-care
Two recent systematic reviews and concept analyses (Sykes 2013, Sorenson 2012) identified the consequences of health literacy.  Both studies found the most frequently reported consequences of health literacy are improved use of services, behaviors, and self-care. These consequences reflect how people use their health literacy skills in everyday life and what they   actually do for health with the information and support available to them.  Although these consequences are supposed or anticipated rather than evidence-based (Sykes 2013), the documented presence of these consequences would indicate that the person possesses and has used health literacy skills to produce them. Studies using the Life Skills Progression instrument to assess maternal heath literacy are building the evidence base.
 
The LSP Maternal Health Literacy Scales rate mothers health literacy by their health and healthcare-related actions practices and behaviors. Sequential measures show change —improvement or regression.  The LSP Healthcare Literacy Scale uses 9 items to rate mothers’ use of information, emergency services, medical and dental care and preventive services for herself and her child. The Selfcare Literacy Scale uses five items to assess risk behaviors and selfcare practices.  Three  published studies using LSP data on three different cohorts of mother-child dyads  provide evidence that mothers supported by home visitors trained to promote maternal heath literacy produced the consequences of health literacy at increasing levels over 12-18 months.  So the recent analyses of the consequences of health literacy confirm earlier findings that the LSP can be used as meaningful measure of MHL.
 
Next: the recently identified unique consequences of critical health literacy add weight to our theory that critical thinking skill, particularly reflection, is the active ingredient in health literacy  that enables mothers (and others) to transform their decisions into health promoting actions and outcomes. Stay tuned
 
 
References
Sorenson K. Van den  Broucke S, Fullam J, Doyle G, Pelikan J, et. al. (2012). Health Literacy and Public Health: A systematic review and integration of definitions and models. BMC Public Health12:80. http://www.biomedcentral.com/1471-2458/12/80.
 

Sykes S, Willis J, Rowlands G & Popple K. (2013). Understanding critical literacy: a concept analysis. Biomed Central Public Health:13:150. http:www.biomedcentral.com1471-2458/13/150

Smith, S. A., & Moore, E. J. (2012). Health literacy and depression in the context of home visitation. Maternal and Child Health Journal16, 1500-1508. 

Carroll LN, Smith SA & Thomson NR. (2014). The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice pii: 1524839914538968. [Epub ahead of print]. Available on Internet at: http://hpp.sagepub.com/content/early/2014/06/23/1524839914538968.abstract

Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014) Maternal Health Literacy Progression Among Rural Perinatal Women. Maternal Child Health J 18: 1881-1892. 
Sandra Smith, PhD, MPH sandras@u.washington.edu

Reflections on 2014

Beginnings Pregnancy Guide 9th Edition Sold Out  
The second printing of the 2014 is underway. The scan code that instantly links Beginningsreaders to additional prescreened information via the Internet on a mobile device has proved popular. In a survey of pregnant women in SC, we found that respondents rarely use toll free numbers; while nearly all reported finding health information online.  The entire website is available on your mobile device. 
 
Websites Continue to Grow
Beginnings Guides had 155,00 visitors in 2014.  The Center for Health Literacy Promotion had 55,000 visitors. The blogs were read by 100,00 including 6900 reads in the last 30 days.  And we have 1310 Twitter followers. Kudos to Beginnings Webmother, Simone Snyder. 
 
Most read blogs 
On Healthliteracypromotion.com
      (this one was on the most-read list for 2013, too)
 
On BeginningsGuides.com:
 
Promoting Maternal Health Literacy Nationally & Internationally 
Free Health Literacy Training Videos
We produced a series of training videos in collaboration with the National Network of Libraries of Medicine Pacific Northwest Region. This from the National Libraries Website:
 
Center for Health Literacy Promotion offers free training
Together with the National Network of Libraries of Medicine, the Center for Health Literacy Promotion has put together three short training sessions on understanding and promoting health literacy designed for social and health services providers and programs. Each session includes a short video, a pre- and post-test (with answer key), a handout, and a facilitator's guide. All three sessions and their resources are available to download or view for free online.
To view these resources, visit the Center for Health Literacy Promotion:

Published Article:  Parents As Teachers Health Literacy Demonstration Project 
Carroll LN, Smith SA & Thomson N (2014). Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice pii: 1524839914538968. [Epub ahead of print] Read the article
 
Guest editor, Curationis Special Edition: 
This turned out to be a monumental work and an inspiring labor of love. It was a joy and a challenge to work with a dozen authors whose work is at the foundation of efforts in southern and eastern African countries to develop professional education curricula and build a workforce of nurses dedicated to care of children. With health systems only about 20 years old, this work is underway to differentiate care of children from care of adults. Therefore, the articles focus on issues in professional education and practice. There are many lessons we in the US can learn from their work to build a healthcare system grounded in child rights, and to effect systems change in the face of racism and limited resources.  Curationis, a South African nursing journal has published the special edition online with free access for all. It will appear in print in 2015. 
  
HARC VI Washington DC Nov 4-5
Family transitions precluded my travel to DC this year. But I was not totally absent. Linda Wollesen, developer of the LSP presented in my stead results of a study conducted in collaboration with Anne Turner and colleagues at University of Washington Northwest Center for Public Health Practice. Conclusion: parents can and do manage child oral health, even in the face of poverty, low education and limited English proficiency where service and supports to use them are in place. This is on the list to publish in 2015.
 
New & Contintuing in 2015
Worldwide Universities Health Literacy Network
Last year in Sydney I worked with an awesome group scholars/practitioners/patient representatives to instigate an international collaboration on promoting health literacy as a personal and community asset. The group has joined with others who began similar talks in 2012 at the first Worldwide Universities Health Literacy Network meeting in Southampton, and expanded to include representatives of countries in Europe, Asia, Africa , South America (and me). The collaborators have been holding monthly meetings via Skype and are developing funding proposals to address maternal health literacy globally.
 
CenteringPregnacy Health Literacy Trial
This project continues. I got to visit the site of the comparison group, Greenville Health System, Greenville, SC.  We're searching for a second site. Want to be an intervention site? Contact me!
 
Maternal Health Literacy: Untangling the "Web of Interaction"
The research project for 2015 is funded by the National Library of Medicine. The study addresses an urgent need to determine what promotes maternal health literacy, especially in historically underserved poverty populations. We are identifying factors in the home and family context that influence mothers'health literacy, and how those factors interact. Understanding the context in which mothers use information and services for personal and child health can guide intervention design, tailoring and evaluation. We are looking for ways to visualize data to suggest points of intervention and help home visitors to answer the ever-vexing question: where to begin?
 

Toward an Integrated Approach to Promoting Health Literacy

Previously in this Space,
I suggested that efforts to promote health literacy are better guided by a salutogenic model that asks, What enables a person to move toward health? or what enables a person to take action for health? That’s true in health promotion. But a person uses the health literacy skill set in various combinations to accomplish different health task in multiple health contexts. No single approach will get us to our envisioned health literate society.
 
Need for an integrated Approach
A new salutogenic perspective and approach to health literacy needs to complement rather than replace the dominant pathogenic approach.  Nearly everyone will at some time find themselves in need of care that only hospitals and healthcare organizations can provide. The pathogenic approach is appropriate and necessary in healthcare contexts.

In addition, with chronic disease/disability steadily increasing and accounting for nearly half of all health loss (Lytton, 2013), and nearly 80% of all health costs in the US (Budenheimer 2009) continuing attention to risk factors and preventive practices is necessary and will remain so. 
 
Still, the number and variety of risks, and the number and variety of conditions that constrain health choices, are so vast that achieving health literacy as defined in the pathogenic model is nearly implausible (Lytton 2013). A salutogenic approach is needed to clarify where, when, and how mothers, and others, can take effective action to achieve, maintain and enhance good health.
 
Domains of Health Literacy
Sorenson et al (2012) integrated the pathogenic and salutogenic approaches represented in 17 definitions and 12 models of health literacy. The authors described three domains of health literacy focused on disease treatment, disease prevention (both pathogenic) and health promotion (salutogenic).
 
Maternal Health Literacy Crosses Domains
A mother uses health literacy skills to function in each of these domains. She functions in the healthcare system when she is an out-patient in prenatal care or oral healthcare, when she is an in-patient in obstetric care, and when she obtains health services for her child. She functions in the prevention domain when she engages  in preventive parenting practices (e.g. using a car seat) and avoids risky behaviors (e.g. smoking). In the health promotion domain, a health literate mother engages in self-care practices (e.g. exercise) and actively supports healthy child development (e.g. reads to the child).  This integrated model is potentially a giant leap for health literacy research. Stay tuned.
 
References
Budenheimer T, Chen E & Bennett H. (2009). Confronting the Growing Burden of Chronic Disease: Can the US Health Care Workforce Do the Job? Health Affairs 28 (1). 65-74. Available online:
 
Sorenson K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, et. al. (2012). Health Literacy and Public Health: A systematic review and integration of definitions and models. BMC Public Health12:80. Available online: www.biomedcentral.com/1471-2458/12/80.
 
Lytton M. (2013). Health Literacy: An Opinionated Perspective. American Journal of Preventive Medicine 45,e35-e40.
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