Center for Health Literacy Promotion Blog
is a literacy skill that is used to personalize information. We interact
with the information and with others (family, friends, professionals) to make
meaning from it and decide how it applies to us in our situation, with our
resources and our challenges.
also is a parenting skill used to engage a child and stimulate learning.
physically changes brain chemistry
Brain imaging shows how interacting
with information stimulates learning. It produces a measurable chemical change
in the brain that takes the information into long term memory. No interaction,
no long term memory. No recall. No ability to use the information for health
questions, spark thinking and action
You can work interaction into print
materials, face-to-face teaching and any media format. By now you may not be
surprised to read here that the way to facilitate interaction for learning is
to ask a reflective question that requires the learner to think. In
printed matter, our subject here, interaction usually looks like blanks to fill
in, boxes to check, pictures or words to circle, choices to make, alternatives
example, In the Beginnings Parents
Guide, running text about lead testing for infants is replaced by a set of
five short personal statements and check boxes to choose [ ] Yes or [ ] No. This follows guidelines we’ve discussed previously in this
space: no more than 5 items are “chunked”
under one subhead; a 10% cyan
(blue) screen behind the text draws the reader’s attentionto the
information. The key information
is placed at the upper left where reading starts, using the principles of reading
gravityto further ensure the reader does not miss it. The headline engages
the reader with a reflective question that requires thinking: Does your baby need a lead test?
Thinking through each question and
physically checking the box is the interaction
that stimulates the chemical change that fosters long term memory and converts
information to knowledge that can be used again later.
text is easy to read, understand and forget. Read the next sentence now;
when you finish reading the rest of this post, see what you recall.
Your baby needs a lead test if you live in a home built before 1960 or
your home has lead pipes. Also, If you live near a highway, lead smelter or
recycling plant, or you live with someone who works with lead, your child needs
a lead test.
A question-answer format is more
engaging than straight text, but it is passive, rather than interactive.
can build interaction into audio and video taped information by including a
question for each important point. Ask listeners a direct question and include
a pause. After the pause, give the answer. In face-to-face teaching, use the
“teach back method”. Ask the learner to tell you in their own words what they
are going to do at home, and what
problems they might encounter. Use their words in this conversation.
the Suitability Assessment of Materials - says that Superior health
education materials present problems or questions for reader response.
Information that does not offer interaction does not stimulate learning and is
not suitable for health education. Information that improves health literacy is
Now, close you eyes and say out loud
the ways you know that does a baby needs a lead test.
Did you ever play the party game where
multiple items are displayed on a tray; everyone gets to look at the tray for
one minute, then the tray is removed and you write down as many items as you
one remembers more than seven items
That is because of the way the brain
processes information. Earlier in this series we said the purpose of the cover,
is to attract the readers’ attention. When it does, the reader’s mind very
rapidly decides to activate memory and process the information. Or not.
Assuming the reader decides to pay
attention - the information goes to short term memory. If you’ve played the
“What’s-on- the- tray?” game, you probably noticed that short-term memory has
very limited capacity and short storage time. In a bright mind on a good day,
short term memory holds seven items. It lasts less than 1 minute. For many,
especially those with low literacy and high stress, it holds less. And here’s
the thing: the more items on the tray, the less you remember. When short-term
memory hits capacity, it dumps everything.
prevents over-taxing short term memory
The parlor game is easier when the
items on the tray are organized -- ”chunked” into groups of related items.
Chunking helps the mind associate the items with something it already knows.
Association gives the brain a place in to put the information in long-term
memory, so you can recall it.
Maybe the tray contained kitchen utensils (spoon, can opener, peeler),
bathroom items (toothbrush, comb, soap) and writing implements (pencil, pen,
marker). These chunks are easier to think about than a bunch of stuff.
It’s the same with printed
information: use subheads to chunk a list of items into logical groups that
link the information to something the reader already knows.
says that in Superior health education materials, lists are grouped under
descriptive subheadings with no group having more than five items.
Beginnings Parent’s Guide’s
Home Safety Checklist for infants up to 12 weeks old in the is a
good example. It’s on page 25; take a look. The instruction is divided into four chunks: fire safety,
sleep safety, burn safety and air safety. Each chunk covers one to three items.
In addition to increasing comprehension, this chunking makes the checklist look
and feel do-able.
The Center for Health Literacy
Promotion uses the World Health Organization (1998) definition of health literacy, adapted to be specific to
maternal health literacy by Renkert and Nutbeam (2000): the cognitive and social skills which determine a mother’s motivation
and ability to gain access to, understand, and use information in ways that
promote or maintain her health and that of her child. This definition implies that
empowerment is an aspect of health literacy since it includes using information in ways that promote health, which requires motivation
and planned action to gain control over family health. According to the W.H.O.,
health empowerment means gaining control of one’s health and its determinants
I’ve been saying and writing that the
clinical definition of health literacy dominant in the US leaves out the
empowerment aspects of health literacy because it is purely cognitive and omits
action ... ability to obtain, process and understand information needed to make
appropriate health decisions. In
this view,It is generally assumed
that understanding leads to action; that “knowledge is power”.
is power only for the empowered
This assumption that knowledge equates
to power makes health literacy and empowerment conjoined twins. In a new, must-read article from Patient Education and Counseling, Schultz
and Nakamoto make clear the importance of separating the two concepts, although
their effects are deeply intertwined.
The authors point out that ability to obtain, process and understand
health information is not necessarily empowering. And, just as a literate
person may not understand health information, an empowered person also may not
Health literacy without empowerment
makes people unnecessarily dependent on health professionals. Conversely, empowerment without health
literacy can lead to uninformed or misinformed potentially dangerous health
decisions. The authors conclude
that heath communications programs need to simultaneously address both health
literacy and health empowerment - as the Beginnings
Guides curriculum and training do.
Schultz PJ &
Nakamoto K. Health literacy and patient empowerment in health communication:
The importance of separating conjoined twins. Patient
Education and Counseling; 2013; 90:4-11.
In this Part 10 of our series using
the SAM - Suitability Assessment of Materials - to evaluate Beginnings Guides, we address layout,
the architecture of the page. Like the architecture of a building, layout makes
a page inviting or intimidating, easy or physically demanding to navigate,
memorable or nondescript. SAM
names eight factors that substantially influence the suitability of health
education materials by making the process of reading painless or not. We will
take them in order. But first, I will add one essential item that SAM leaves
out and that all page design should respect
gravity rules layout
Reading demands physical skill,
concentration and time, all of which may be in short supply. The information
architect must ensure that none of the reader’s effort and time are wasted, or
worse, sacrificed to design.
We read from the top left corner of
the page and work our way across and down; left to right and back again to the
bottom right corner. Page design
should facilitate this efficient pattern and avoid disturbing reading
rhythm. In testing, on average 67
percent of readers showed good comprehension of information that complied with
reading gravity compared to 32 percent of readers of the same information on
pages that required them to work against reading gravity. Learn more and see an
Reading gravity explains many of the
suitability factors for layout.
illustrations adjacent to related text.
SAM says photos or other graphics
should be placed adjacent to the text that they explain. Ideally the text is to
the left of the graphic (so you read it, then see the explanatory graphic) and a caption is immediately
below the graphic. Otherwise, the illustration becomes a distraction and
it easy to predict the flow of information
That means the content follows a
logical sequence and is presented consistently. For example, Beginnings Pregnancy Guide content is sequenced by
gestational age and the usual progress of pregnancy. Each of the six booklets uses
the same section heads and text addresses similar subjects in consistent order
(e.g. Your Baby’s Growth and Development). Warning Signs are always located on
the back cover; they change by stage of pregnancy; no searching is required.
visual cues to direct attention to key content
For example, Beginnings Guides highlight key messages by displaying them in bold
type in a box with 10% cyan( light blue) screen. Research suggests the light
screen attracts the eye without interfering with comprehension. A cell phone
icon alerts the reader to a condition that warrants a call to the doctor.
the page clean
Simple design works best for readers.
A cluttered page looks hard to read, and most likely is. Testers may say the over-designed page
is more attractive, but their comprehension will
color in a supporting role
Color attracts the eye. Use it to lead
the reader to key content. Or to lure the eye up to the “fallow corner” at the
upper right. Check to make sure the color does not pull the eye against reading
gravity like it does below.
lines short - 30 to 50 characters and spaces
Remember the reading eye moves from
left to right and back again. At the end of the line, the eye returns to its
starting place and drops down to the next line.
Unless something is in the way.
Then it has to search for what is next, and be lost to the distraction.
high contrast between type and paper.
contrast is low, reading is difficult. For comprehension, black type on
white paper is far and away the best. More on colored type.
says use non-gloss (matte) finish. Glossy paper carries a reflection which
can be distracting. However, other testing showed no difference in
comprehension. A coated stock repels fingerprints and is more durable.
Beginnings Guides get a Superior rating for
complying with all these factors most of the time. Look through the
Pregnancy Guide. SAM requires
at least 5 to be present. Material with fewer than three factors present or
that just looks uninviting or hard to read is Inadequate.
We continue our
series using SAM - Suitability Assessment for Materials
- to evaluate the Beginnings Guides to pregnancy and early
Today’s topic is typography, the arrangement of text on the page.
Typography has been called the art of making language visible. It can
message across or get in the way.
To read the entire document please click here.
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.
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
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.
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.
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
can facilitate learning if they engage the reader to interact with the
information, make choices, and take action. To meet this goal, the purpose of the list must be made
immediately clear through a headline or subhead (see Road Signs) and
brief instructions, as needed.
Example: Beginnings Pregnancy Guide (Page 65) includes a list of what to
take to the hospital or birthing center for childbirth. This is important
content to increase confidence and reduce anxiety, especially for the many women for whom childbirth is their
first hospital experience. “Pack you bag” is a clear simple
headline that clarifies the purpose of the list. Two short introductory
sentences tell when to pack and indicate the list includes “all you will
need.” Check boxes are included to
encourage interaction. The list is
broken up with a subhead: “Pack for
baby”, indicating the next
Explanations and directions are
essential. When presenting how-to
information, a bulleted list is easier and quicker to read and use than a
paragraph. An example clarifies
the instruction and instills confidence. When preparing instructions, think
through who will use the information and how will they use it. Where are they
likely to be when the want and need the information. What might they be doing?
Who might be with them?What might get in the way? What might be confusing? What format will be most accessible?
Focus on what-to-do. Be specific. Omit all reference to what not to do (it is equivalent to static).
Example: Every pregnant woman
wonders how she will know she is in labor and what to do when labor begins. Beginnings Pregnancy
Guide (page 72-73 ) presents step-by-step instructions under the headline “Are you in labor? Walk to find out.” Steps are numbered and presented in
logical order: 1.Notice contractions. 2. Walk 3. Time your contractions. 4. Call your doctor. Key
information is highlighted: “True labor
contractions get longer, stronger and closer together” . Instructions for
calling include who to call, when to call, what questions to anticipate, what
to say, what if you get an answering service, what if you cannot call; and
finally, what to expect at the hospital.
A photo shows a woman walking with hands on pregnant belly, noticing her
essential instructions with a few representative learners with no prior
experience and little knowledge of your topic. Invite them to read your
instructions and tell, or better show you what they would do. You will find out quickly if the
directions are too brief to use the graphic or follow the directions
independently in likely circumstances. For Beginnings,our standard is that the learner can find and follow the
necessary instructions in the middle of the night while throwing up.
gets a Superior rating on the SAM for providing step-by-step directions
with examples that build self-efficacy. Graphics--lists, charts, tables,
forms-- presented without explanations are not suitable in health education
NEXT: Typography: type sizes, fonts,
How do we advance toward the national
vision of a health literate society in which everyone gets actionable
health information along with the support needed to use it in context for
first requirement is actionable information that fits the learner. We know
that info that is meaningful and useful to me may not be suitable for you. We are using the Suitability
Assessment of Materials - SAM to check the
fit of Beginnings Guides for
promoting health literacy in mothers of children aged 0 (pregnancy) to three
years. Part 6began our consideration of graphic elements. This Part 7
addresses the type and relevance
of illustrations and captions.
key messages. The purpose of an image on the page is to present the key
content visually, to “say” the important point another way. Avoid using images to fill space
or carry the design; that is like introducing background noise.
image needs a caption to tell the reader where to focus and what to think
about. An image without a caption is a missed teaching and learning
opportunity. An intended learner
should be able to look at the images and read only the captions and still get
the key points.
Your baby has strong feelings.
SAM recommends simple line drawings
that promote realism without distracting details. The line drawings part may be out of date; learners have
become much more sophisticated viewers of images in the 20 years since Len and
Cici Doak wrote and tested the SAM.
However, the part about keeping illustrations simple, omitting
distracting detail, has become more important as the competition for attention
and memory has increased.
Non-essential details distract from the key point. For example, in info for pregnant women
and parents, wedding rings can distract readers into all sorts of tangents and
emotional issues unrelated to the topic.
I prefer photos to clip art, as long as they look “real” and there
is not too much detail. Black and white photos are less expensive to print than
color and can help focus readers on the important content.
Pregnancy is not a time to lose weight.
Do not go on a diet. Eat well and eat often.
images that are familiar to the learners; people who look like them in
settings they have experienced. We have learned from testing Beginnings Guides that abstract
symbols are often not recognized. Anatomical drawings break the rules about
simplicity and familiarity - we just are not accustomed to seeing the inside of
the body. Sometimes they are
appropriate but must be carefully labeled, and require direct assistance to
make meaning out of them. Illustrations of detached body parts made our testers
the learners know for sure which images aid their understanding and lead
them into action. Test the images along with the text. If you need to change
them, you need to retest to be sure you solved the problem and did not create a
Breastfeed your baby for as long as possible.
BeginningsGuides get three Superior ratings in
this section: for consistent use of simple, familiar images; for presenting key
messages so the learner can “get” the main ideas from the images alone; for
using a caption on nearly all illustrations.
Next: Lists, tables, charts, forms.
Here we continue our review of what makes health information
actionable.In other words, what about information facilitates or inhibits a
reader’s or listener’s decision-making and action steps?
begins a consideration of graphic elements: the
cover image, illustrations,
lists and charts, and captions. We start with the cover.
People do judge a book by the cover
Information is like medication. Before it can have any effect on
the learner, she has to hold it in her and swallow it.
We take medication to solve a problem we have now. Same with
Adults learn in order to solve a problem they have now. The purpose of
the cover is to attract the intended readers’ attention, compel her to pick up the material, and
lead her into the learning. That requires a graphic that,in a few seconds,
convinces the intended learner that “this information is about me and my
First, the cover graphic
must be friendly. Not
necessarily to the writer and designer, but specifically to the reader. When
she identifies with the graphic and feels an emotional response, she will
consider the text; you have led her into the learning. If the graphic does not speak to her,
or if it goes against the grain of what she knows and believes, she can only conclude that the information is not for her.
If the image is friendly,
it might catch her attention. Capturing your readers’ eye is becoming increasingly
competitive. Today’s readers are visually sophisticated with high expectations
and millions of images per day vying their glance. Your cover graphic may be
realistic, like a photo, or artistic like the graphics on Beginnings Guides.
When selecting a cover image, start by reviewing what you know about your audience; end by
testing three images. Make the
final selection based on the responses of representative learners. For Beginnings Guides, we chose Laurel
Burch drawings for their compelling colors,
and simple, spiritually and emotionally rich portrayals of the mother-baby
relationship. The art avoided issues like the presence or absence of wedding
bands, and dating elements like dress styles, and ethnic issues like hair
styles (I always remember the tester who asked “When
will health education
materials stop showing all black people with hair like
broccoli?”) In testing we noted that mothers saw in
the art what mattered to them. And what they saw was often surprising, and
surprisingly different from what others saw. That is the mark of a strong
Most important the graphic
must portray the purpose of the materials.
If the purpose is unclear, so is
the reason to read it.
gets SAM’s Superior rating for cover graphics since they are friendly, attractive and clearly portray the
purpose of the materials. We know because we
Beginnings Pregnancy Guide cover
art by Laurel Burch conveys that mothering begins in pregnancy and that this
information is for pregnant women. In testing we learned that pregnant women of
all ethnicities have similar questions and concerns. Pregnancy makes them more alike than different.
Laurel Burch designed these
mini-masterpieces especially for the Beginnings
Parent’s Guide. A single
mother of mixed race babies, she was sensitive to ethnic and cultural issues.
A message from the artist
As a young mother-to-be at age 18, my
own personal circumstance was
one of loneliness, without a family or spouse
supporting me in this most
profound event of my entire life. I found comfort in
knowing that I was
not alone. Mothers all over the world would be giving birth
at the very
same moment as I would.
My drawings for Beginnings came from
the challenges as much as from
the joy of finding my path as a mother. My first
born, daughter Aarin,
is 39 now. And I am still learning the art of motherhood!
If I can share
just a fragment of my support in these heartfelt drawings my
mission will be accomplished.
We need not figure out the pearls of
wisdom that have sustained mothers
through the centuries on our own. That is
what Beginnings is all about.
Comfort and support. Knowledge and belonging. It
is my joy and privilege
to be part of your new journey to motherhood. It is my
hope that these
simple lines on paper inspire your own rainbow spectrum of
color as each
day unfolds with the miracles and blessings of being a mother.
|The Nation & World section of
my morning newspaper reports, right next to the story re civil war in
Syria, on a doll that is making TV
conservatives squeamish. The Breast Milk Baby makes suckling sounds when it
touches sensors sewn into a halter top that comes with the doll. A Fox news
commentator thinks we “don’t need
this kind of stuff”. It’s hard to
say what “stuff” he’s worried about. A father says it’s “creepy”; maybe his daughter
could play with the doll at home, but not on a play date or in public.
Somehow these men think breastfeeding
has something to do with sex. So
the doll’s suckling sounds are
“too mature” for little girls who want to grow up to be mommies.
Apparently, dressing up the buxom Barbie doll in a cocktail dress and heels for a date
with hunky Ken is a better way for “kids to be kids” and for little girls to
envision their future and understand the purpose of breasts.
a health literacy standpoint
Critics of Breast Milk Baby are
showing a very limited ability to
understand and use information for health. Breastfeeding, exclusively in the
baby’s first six months, is recommended by virtually every health authority on the planet as the
healthiest way to feed a baby with benefits to both mother and child over their
Breastfeeding is only X-rated in the
minds of some adults. Let’s think about what we want to teach our daughters and
what we want to protect them from. What is it we want to protect ourselves from
by banning a breastfeeding baby doll.
If you are not ‘creeped out’ by the
thought of little girls learning that breastfeeding is normal, healthy and
health-promoting; if you believe breasts are engineered primarily for feeding
babies, and if the sound of suckling does not distract you beyond rational
thought, you can order Breast Feeding Baby online at half-price. She is more culturally competent than some of
her critics; choose a doll with one of eight names, skin tones and facial
milk is made for your baby. It contains the right amount of all the nutrients
Baby needs. As the baby’s needs
change, your milk changes, too. Mother’s milk is easy to digest. It is always
ready, clean and just warm enough. Breastfeeding creates a special bond between
mother and baby. Breast fed babies have fewer infections and allergies than
bottle-fed babies. And their brains develop faster.
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012