Since 2004, I have been training Maternal Child Health home visitors to promote maternal health literacy, defined as the cognitive and social skills and motivations that enable a mother to obtain understand and use information [and services] in ways that maintain or enhance her health and that of her child (Renkert & Nutbeam 2000). This is the WHO definition made specific to mothers. It is broader than the US clinical definition in several important ways: it includes social skills (interactive skills) acknowledging that reading and numeracy are insufficient to function in the Information economy, especially in the high tech healthcare arena. It includes motivation, indicating that factors other than communication skills determine a persons health literacy. Perhaps most important, this broader conceptualization includes use of information. Understanding is an essential first step , but still a long way from health promoting action. Finally, it specifies using info in ways that promote health, going beyond decision making. In order to involve community health workers as Farmer and Winston and Bonnie suggest, we need to broaden our thinking.
I chose home visitors as a channel to promote health literacy for a long list of reasons, chief among them: home visitors' unique access and long-term trusting relationships enable them to observe and to influence the interactions of multiple factors that determine a mothers' health literacy.These factors are not readily visible or modifiable in a community setting.
We trained visitors to build parents' interactive and reflective skills while providing direct assistance to make meaning from selected health education materials (Beginnings Guides) and information from healthcare providers and to apply it in vivid real life circumstances. The primary teaching and learning strategy in the intervention is reflective questioning. This does not imply that practitioners forget what they know, but rather that they use their expertise to formulate reflective questions and lead reflective conversations that facilitate self-discovery and action planning. This approach addresses the social determinants of health and the empowerment aspect of health literacy. Health literacy is empowering because, and to the degree that it enables a person to increase control over their health and its determinants.
A critical element is the routine use of data by practitioners to tailor interventions to particular families and circumstances. Many home visitation programs use the Life Skills Progression instrument (LSP) approved to demonstrate progress to federal benchmarks of effectiveness in home visitation (Maternal Infant Early Childhood Home Visitation -MIECHV under the Affordable Care Act). Using the LSP, home visitors routinely monitor parents' use of health information and services as well as self-care, support of child development and health behaviors important to both parent and child health (smoking, alcohol, drugs). Among these are indicators of maternal health literacy, situated in surrounding family conditions. Two health literacy scales derived from the LSP enable home visitors to monitor "healthcare literacy" - use of info and services and "self-care literacy" management of personal and child health at home. Intimate knowledge and data on surrounding family conditions suggest approaches to improving health literacy for a particularly mother. The routine use of data - especially where it is currently collected- enables visitors and partner researchers to consider the context in which we expect people to use health information, not as background noise, but as the primary determinant of the health literacy task, a persons capacity to accomplish the task, and the support needed.
Four studies funded by AHRQ/NICHD, National Library of Medicine and Missouri Foundation for Health indicate the intervention is effective in increasing health literacy regardless of reading ability and in spite of depression. Low maternal health literacy is associated with child developmental delays and reduced participation in early intervention.
The average American spends 1 hour per year in a clinical setting. We need more community health workers trained to promote health and health literacy in the community in the course of their usual activities, along with routine use of data by practitioners and their supervisors to continuously increase effectiveness and sustain funding. One action step would be to review existing data sets in search of indicators of health literacy and influential surrounding conditions (eg social support, living conditions). Repeated measures would show progress/regression. This is to suggest a paradigm shift from health education, anticipatory guidance, information giving that aims to increase knowledge and compliance to an empowerment approach that aims to increase autonomy and engagement.