Center for Health Literacy Promotion - Action research for effective use of health info & services
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Critical Health Literacy: The mind’s strongest glue?
Measuring Health Literacy by its Consequences
Reflections on 2014
Toward an Integrated Approach to Promoting Health Literacy
Health Literacy: Time for a new question


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Center for Health Literacy Promotion Blog

Health Literacy on the Street: Too many words make signage unreadable

If you are hit by a car going 20 miles an hour, you have 95% chance of survival. If the car is going 30MPH, your chances drop to 55%, says Harborview Injury Prevention & Research Center in Seattle. That is why signs in school zones say “Speed Limit 20”.  It’s a national public health effort to reduce accidents and injuries. A health literate driver would comply.
The Seattle Times reports a local driver had his $189 ticket for speeding through a school zone dismissed. The judge agreed with his argument that too many words on the sign made it hard-to-impossible for drivers to read in time to slow down. The driver cited the federal Manual on Uniform Traffic Control Devices, which specifies fewer words.  The City vows new signs will adhere to the manual.

CenteringPregnancy Health Literacy Trial Underway

It was Wednesday, May 21 at 10AM, the start of the 217th CenteringPregnancy group at Greenville Health Systems OB-Gyn Clinic in Greenville, SC. As participants arrived, one with a friend, one with her cousin and her mother, one with her husband, others on their own, Nora, an assistant facilitator,  greeted them and gave them supplies to make their name tags. She showed  each mom the routine for the first 30 minutes of each  Centering session: Take your blood pressure like this; record it here. This is what the numbers mean…  Weigh yourself; record it here. When she calls you,  have a private visit  and  brief exam with Vicki, the nurse practitioner.  Have a snack, visit with other participants, or ask the midwife a private question. Then for the next 90 minutes the group of 9 expectant, mostly first-time mothers sat in circle  with their supporters and three facilitators, and me, the visitor there to learn about Centering. The initial awkwardness faded quickly.
After self-introductions and a lively, laughter-punctuated discussion of current issues from morning sickness to cravings to farting; a basket of plastic food items was passed around and we took turns talking about the items we chose. “So will you eat that during your pregnancy?”, Nora asked the group gesturing to the chocolate dipped ice cream cone.  Yes, the group decided —after all  it is summer in SC. But not every day; as a special treat because it’s loaded with sugar and fat. At closing we each said one thing we were going to do to stay or get healthy during this pregnancy… walk, drink water instead of sweet tea, try eating vegetables.
Does CenteringPregnancy promote maternal health literacy?
This opening session was also the kickoff of the CenteringPregnancy Health Literacy Trial, although the group will not hear about until their next session.  The trial aims to assess the capacity of CenteringPregnancy to promote maternal health literacy and empowerment. A secondary aim to is validate the Maternal Health Literacy Self Assessment designed for the project.  We anticipate that the Centering model promotes mothers’ health literacy and health empowerment by supporting knowledge gain and changes in health behaviors and healthcare utilization practices. Previous studies have shown that social support from home visitors is a catalyst for improved health literacy. In those studies, visitors were trained to “Teach by Asking”, that is to ask reflect questions instead of delivering health education. In Centering, rather than teaching and informing, facilitators ask questions to elicit the group wisdom. The group provides social support. 
By luck of the draw, about 120 pregnant women participating in CenteringPregnancy at this Greenville clinic will comprise the comparison group in the trial; other than completing the Self-Assessment, they will receive “usual care” in the CenteringPregnancy model. An equal number of participants at a second site will incorporate Beginnings Pregnancy Guide into the program along with the Self-Assessments. We will see if providing additional information promotes health literacy more than “usual care”.
Read the project overview. Learn more about CenteringPregnancy
Stay tuned for more on the Maternal Health Literacy Self-Assessment.

Sunday is Mothers’ Day.

It’s not a day for breakfast in bed, bon bons  and roses.  It is a day for peace. 
Julia Ward Howe started Mothers Day as a call for the women of the world to come together to  protest war and create ways to do away with war as an acceptable way to solve problems. This year we can celebrate not only our own mothers and our fellow mothers. We can celebrate that America is not at war.
And we can celebrate that with the Affordable Care Act, America is supporting mothers in their role of teaching children charity, mercy and patience and keeping families healthy and productive.
Learn the deeper meaning of Mothers Day here:

Review of Beginnings Pregnancy Guide 9th Edition 2014 using PEMAT-P

26-member panel conducts independent reviews
In March 2014,  32 health and social services providers, program directors, trainers and supervisors volunteered to assess the understandability and actionability of Beginnings Pregnancy Guideusing the PEMAT-P — Patient Education Materials Assessment Tool for Printable Materials from the Agency for Healthcare Research and Quality. Twenty-six completed the assessment. The secondary purpose of the review was to implement the new PEMAT-P and get a sense of its utility. Each of the six booklets comprising the Beginnings Pregnancy Guide was reviewed separately by four or five individuals working independently.

Beginnings Pregnancy Guide Earns High Marks                           Understandability: 96.5%       Actionability: 98%

I am particularly pleased with the nearly perfect actionability score. Goethe said it centuries ago, “Understanding is not enough, we must act.”
Understandability: (a multisyllabic bit of Latinized jargon that is questionable in the context of health literacy) is the quality of information that enables users comprehend its meaning. The PEMAT-P asks reviewers to rate printable materials on 17 factors in six categories known to affect understandability.  A score of 1 indicates the factor is present; 0 indicates it is not; NA indicates the factor is not applicable. Factor scores are expressed as the percent of possible scores of 1. The final score is  calculated as the average of reviewers’ combined scores in each category. Here are the category scores:
Content: 94%    Word Choice/Style:  96%   Use of Numbers: 100%
Organization: 97%   Layout/Design: 96%   Visual Aids: 96%
     "Overall the book looks and reads very clearly and will be very      
      understandable for a low level reader.

Actionability (more jargon) is the quality of information that enables users to take action. Reviewers score seven contributing factors. The final score is calculated as the average of the factor scores. The Pregnancy Guide earned 100% on five of the actionability factors.
     “An additional plus is the links to other resources for specific topics.
Detailed results are displayed in Tables 1 and 2.  Table 3 shows reviewers’ unsolicited comments on the materials.

PEMAT-P shows good reliability
Testing during development of the tool showed acceptable validity. Results of this project suggest the tool has good inter-rater reliability, meaning that multiple reviewers of the same materials rate the factors similarly.

Technical difficulties
About one third of the reviewers struggled with the PEMAT web page. Technical difficulties may have discouraged some of the six who did not submit a competed form. SeeTable 4.

Personally, I recommend relabeling the buttons in the top menu. I expected the PRINT button to print something; it brings up the Printed Materials form. The bottom menu buttons are inactive on my machine. Those buttons and the frame around the form take up space and require printing on two pages in too-small type. I, and some others, found the numbering on the Printable Materials form confusing; it skips items related only to audio-visual materials.

Overall, the PEMAT-P is a useful at-your-desk review that can improve materials in the development process and weed out complex, fact heavy, concept-dense materials. It cannot replace testing by intended users - both teachers and learners.

Kudos to the developers of the PEMAT: Michael Wolf and Cindy Brach
Thanks to the reviewers: Betsy Rubin, Lori Lake, Pamela Cho, Michelle Breuer, Dora McKean,, Kath Anderson, Joanne Martin, Tennessa Dallas-Theus, Hudelaine Deus, Oscar Flores, Cheryl Underwood, Marisela Rosales, Kobe Rives, Alli McClennen, Eva Perez, Lina Rooney, Elizabeth Burleson, Cynthia Smith, Denise Powell, Katie Burnett, Leslie Munson, Mary Rosecky, Jeffrey Wynnyk, Linda Wollesen, Margarita Franco, Maryellen Miller

How to use print materials to promote maternal health literacy

Adults learn in order to solve a problem they have now. Pregnancy and early parenting present many new problems, along with new motivation to seek information. That makes the prenatal to preschool period the most effective time to promote maternal health literacy.
Promoting maternal health literacy means empowering mothers to better manage personal and child health and healthcare.  Print information is a useful tool to do that. But not just any information. And not just handing it to her.
The first step toward health literacy is learning to obtain information that is reliable, understandable and actionable. Information that get’s read and shared and saved is also brief, attractive, encouraging and conversational. Progress toward health literacy can start with skillfully crafted materials.
Give no info until it is requested.
A rule of health literacy promotion is that the learner must be in charge of the learning. The corollary is, give no information until it is requested.  Then give the just essentials. Select content that is easy to read and brief. Too much information, or info that exceeds the learner’s skills, is disempowering. It leaves the recipient feeling discouraged and overwhelmed, and still uninformed.
Providing information that is not requested - delivering the curriculum- makes you the expert in charge of the learning; it makes you the problem solver; it positions the mother as incapable and unreliable.  In contrast,  responding to requests for information makes you a trusted partner to the self-directed learner and problem solver.
Information that builds health literacy, not only increases knowledge. It also develops a gourmet taste for learning, builds confidence and presents opportunities for reflection, self-discovery and small, doable steps toward better self-care and healthcare. Health literacy promoting materials increase capacity to independently obtain more information from reliable sources.
For example, Beginnings Guides present free national 800 numbers to anonymously get information and assistance with topics from domestic violence to food safety to quit-smoking. The Pregnancy Guideenables  a mother to differentiate common discomforts of pregnancy from warning signs that warrant a call to her healthcare provider, and prepares her to make the call.  The new 2014 editions include a scan code to link to pre-screened online resources from a mobile device.
Beginnings Pregnancy Guide scores a Superior rating on 26 factors known to affect reading and comprehension.   See the SAM (Suitability Assessment of Materials) Review of the Guides.  Also, watch for the results of the ongoing review by 30 experts and practitioners using the new Patient Education Materials Assessment Tool (PEMAT-P) from the Agency for Healthcare Research and Quality. It rates “understandability and actionability” of information. (I’m try not to think about puppies…)
You can previewand order or reorderBeginnings Guides at

The Making of Beginnings Guides

It started as liability protection for prenatal care providers
I started developing the Pregnancy Guide in 1988. At the time over a third of obstetricians had been sued for malpractice before they finished residency. Many family physicians had stopped delivering babies as the cost of malpractice insurance became prohibitive. Around this time the Million Dollar Baby was introduced in the literature - that was the baby whose medical bills approached a million dollars before she left the hospital. One “bad baby” could wipe out an employer’s entire health insurance program.
The thinking at the time was to tell pregnant women everything there is to know about pregnancy, especially things that could go wrong, in order to avoid lawsuits. If mothers were given information, they would be informed, or uninformed by choice and therefore liable for untoward outcomes. And the research indicated that families who felt informed were more satisfied with their care and less likely to sue.
Mountains of printed material, little actionable, understandable information
I gave up on my long search for materials that I could recommend to prenatal care providers trying to respond to mandates from their professional societies and malpractice insurers to inform mothers on a long list of topics related to birth outcomes. I had found and reviewed mountains  of pregnancy information. There were thick books that seemed intent on giving mothers facts and scaring them into compliance. There were mounds of brochures, all on single topics. These answered a specific question, and so were useful only to those who knew what to ask and had sufficient reading skill to make meaning from the jargon and medical facts.
Research defines key health behavior messages
In 1989 the landmark document Caring for Our Future: The Content of Prenatal Care was published. It presented the first comprehensive guidelines for what defines a minimal quality prenatal care service. It called for more visits in early pregnancy to deliver the health promotion content of prenatal care. It detailed health behavior messages to be discussed at each visit. Subsequently, research demonstrated direct links between the recommended health behavior messages and outcomes, particularly low birth weight.
Health promotion content of prenatal care rarely delivered
 But providers said it is just not feasible to keep track of each woman’s knowledge and address their health behaviors and still meet production requirements. They were -are- not trained to support behavior change. The typical prenatal visit included about 7 minutes with the doctor and focused on screening and intervention. The health promotion content of care was addressed by recommendations to attend childbirth classes, which occurred too late in pregnancy to have any impact on outcomes and were attended primarily by college-educated women.
Beginnings Pregnancy Guide introduces staged learning, conversations for health
And so in late 1989 I published Beginnings: A Practical Guide through Your Pregnancy. It was designed to protect obstetricians from liability, and at the same time to serve mothers by providing easy-to-read, plain language actionable information on what women across cultures want to know about pregnancy. It put the health promotion content of prenatal care into text that reads like the encouraging conversations a caring, articulate, culturally competent obstetrician who was up on the research would have with each pregnant woman and her partner, if time and economics allowed. I followed Pulitzer’s mandate to provide information that is “brief so they will read it, clear so they will appreciate it, picturesque so they will remember it, and accurate so they will be guided by its light.”
Information alone is rarely enough to influence health behavior
I soon learned that simple information giving is rarely enough to influence behavior. People need assistance to make personal meaning from information and act on it in context. Information-givers need training -and time- to use materials effectively for teaching and learning. The OBs said, rightly, I think, that health education is not their job. And so the health promotion content of prenatal care fell to home visitors serving Medicaid populations, and health plans providing online and print information to the privately insured. (About 2-4% of mothers were attended by midwives who embrace pregnancy as a high state of health and focus on the health promotion aspects of pregnancy.)
Designed for mothers, and health literacy promotion
From 1990 on, Beginnings Pregnancy Guide has been designed for mothers, rather than providers. Since 1993 when the first article on health literacy appeared in the medical literature, it has been a laboratory for materials that promote health literacy.
Who uses Beginnings Guides
Beginnings Pregnancy Guide is now most frequently used by home visitors, parent educators, family support workers and case managers to promote maternal child health and maternal health literacy. There is training, a users manual, and an evidence base. It is earns high satisfaction ratings from both college educated and under educated mothers and their families.
The new updated 9th! edition is just off the press. In English and Spanish. Take a look.

The 7th Attribute - Navigation Assistance

“Health literate health care organizations design health care facilities with features that help people find their way.”
My Dad  -he’s 86 - was admitted to the hospital last Thursday with chest pains. My mother and sister sat with him that night. He woke often, agitated and not knowing where he was,  determined to get out of bed. Friday morning, mom was exhausted, so I took over the vigil. Dad had another difficult night that he will not remember, but I will. On one of his many awakenings, he had removed his gown and ripped off all the electrodes in the seconds it took me to get to his side. It was a total role reversal with me telling my father he had to stay in bed.
About 4AM, he finally settled into a sound sleep. At 5AM, I let the nurses know i was going to get some air and would be back shortly.  I exited the main entrance, breathed deeply, walked across the icy parking lot and back to the door. It was locked.
Seeking the Emergency entrance
A sign board visible only from outside read “Exit Only - Enter at Emergency Department”.  But there was no indication where the Emergency entrance is located. I walked more than a block in one direction until I reached what looked like the the maintenance buildings, thinking, “It can’t be this far; there must be lights.”  I retraced my steps back to the main entrance starting to feel the below-freezing temperature and to worry about my safety. I  proceeded in the other direction.  I found another entrance, with the same sign.  I kept going and found a third entrance, with the same sign. This one had an arrow, but it pointed into a dark space between buildings - no ER in sight.
The locked doors seemed an obvious and important security measure.
But my security was at risk wandering around in the dark and cold. I could easily read and understand the sign. But it was not an aid to navigation.  I decided to wait it out in my car, but the keys were in the building.
 Lucky for me, before long, I  encountered two nurses coming in for early morning surgeries. They had a card key and let me in the third door. when I promised not to tell.  They said, “The ER is waaaay down that way”. One of them started to lead me there. It took a bit to explain I did not want to go there, I only needed to get in the building. 
Easy to be more health literate
This hospital would easily become a more health literate organization by improving its signage to include ‘navigation assistance”. And by making the Exit only”  signs visible from inside so they can be seen on the way out.  Then the nurses would not have had to take surgery-prep time to help me.  And there would be less risk of incidents that no one wants to happen. As a former hospital public relations officer, I know all sorts of untoward events might have occurred out there in the parking lot.
This hospital would score well on most of the Ten Attributes.  Perhaps this is a case of assuming that “everyone knows” where the Emergency entrance is, and that  all other doors are locked during certain hours.  But everyone does not know. And the ED needs to be easy to find. I checked again in daylight and still saw no signs for the ED, except from the road.
Pretend you are from Mars, and go look at your signage. Can you see it where  you might need it.  Does it tell you how to get where you need to be?
 PS Dad is home, recovering well. I am grateful for good care. Nurses rock.

CORRECTION: The discussion paper posted here yesterday-

CORRECTION: The discussion paper posted here yesterday- Health Literacy as an Essential Component to Achieving Excellent Patient Outcomes -  was not commissioned by the IOM as I stated.. It was announced in the IOM newsletter. As indicated in the note accompanying the paper “The views expressed in discussion papers are those of the authors and not necessarily of the authors’ organizations or of the IOM. Discussion papers are intended to help inform and stimulate discussion. They have not been subjected to the review procedures of the IOM and are not reports of the IOM or of the National Research Council.”

New IOM Discussion Paper on Health Literacy

This discussion paper commissioned by the IOM Roundtable on Health Literacy was released yesterday. I always watch for these papers by thought leaders in the field to see the evolution of health literacy concept, measurement and intervention. 
I am quite disappointed this time.  
One statement of fact jumped out at me right away. The  paper lists an increase in the fertility rate among demographic trends behind the increasing size and diversity of the population. But, according to the CDC the US fertility rate is at an all time low. Births declined by 10% last year and the Census Bureau reports population growth has slowed to its lowest rate in decades.  The authors are correct that diversity continues to increase. Pew reports the number of immigrants in the country doubled to 46 million between 1990 and 2013. (But the Pew Hispanic Center announced in April 2012 that immigration from Mexico has stopped and perhaps even reversed.) Diversity of cultures and language is indeed a challenge for the healthcare system that adds urgency to health literacy issues.
The concept of health literacy presented in the paper seems confused. First health literacy is presented as a cognitive deficit that leaves patients  “unable to understand and act on health information”, placing the problem in patients and assuming it is intractable, therefore requiring clinicians to over come or manage the problem. The approach is necessarily information-centered and provider-centered, not patient-centered.  
The authors also note that WHO considers health literacy a personal and community asset, but seem not to notice this is contrary to their discussion focused on low health literacy as a risk to patients and the system.  Recommended universal precautions are not  sufficiently “on the ground” to change practice and represent long held heath education principles (e.g. educate using plain language, do a learning needs assessment).There is an implied assumption that universal precautions, overseen by a new office in healthcare organizations, is the whole solution. These precautions are common sense, but they are insufficient to address true cognitive impairment in the elderly population, or to overcome what Doak Doak and Root described as gaps in logic, language and experience, the origin of provider/patient communication problems with both native and foreign-born patients.
The authors suggest that efforts to develop an organization’s employees' health literacy skills  (knowledge of negative impacts of low health literacy in patients, employee-employee communication) can "empower communities to be active partners in their care.”  This is faulty thinking.  Establishing the attitude that  patients are incapable of understanding and acting on information, and so unable to learn and do what is needed to cope, recover, and improve health, disempowers patients and providers alike, makes patients unnecessarily dependent on professionals, and perpetuates the problem. The authors close with a call for "trusted partnerships” between providers and patients; that requires providers to trust patients.   As long as we say that what we need to make the healthcare system work is a smarter patient, we are stuck. 
One more thing: Americans spend about one hour per year in a clinical setting. What about health literacy in the other 8764 hours?

MLK Day of Service

Today volunteers are out all over Seattle and King County. It's MLK Day, a national Day of Service in memory of Dr King and his teaching that “Life's most persistent and urgent question is, 'What are you doing for others?”
My friend and co-author Liz Moore (aka the data whisperer) and I worked with folks fromCityFruit. Since 2008 this group has been promoting cultivation of urban fruit to nourish people, build comity and protect the climate. Last year they tended, harvested and distributed 6500 pounds of fruit grown on trees in Seattle city parks.  Liz and I worked on a hillside up behind the Amy Yee Tennis Center is south Seattle. It turns out there are 30 some  very mature long neglected apple and pear trees there, perhaps a former orchard.  City Fruit's 5 year plan includes rescuing the trees from ivy, blackberry and underbrush, restoring them to productivity, and sharing the harvest with neighbors and local food banks, and selling some to Seattle restaurants to sustain the operation.  Liz and I rescued three apple trees nearly strangled by ivy and blackberry. And we learned something about our city, met some of our fellow citizens and left the world a little better place. Thanks, Dr. King,  for the inspiration and leadership. Thanks to  UW and United Way of King Countyfor organizing the day of service. Thanks to all who serve, and all who accept service. ss

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