Center for Health Literacy Promotion - Action research for effective use of health info & services
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Health Literacy Researchers, let’s move on!
Paid parental leave - finally
February is Teen Dating Abuse Awareness Month
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Critical Health Literacy: The mind’s strongest glue?


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Center for Health Literacy Promotion Blog

Health Literacy & Maternal Health Literacy: What’s the difference?

Start with measurement
What we measure and how we measure it matters because it determines what we find out about what works and what’s worth doing and who should do it.* Measurement remains the most crucial issue for health literacy research; because we need to find out what works for whom,  and what’s worth doing and who should do it. 

Im especially interested in what works for mothers in the prenatal to preschool period. Because they are the foundation of personal and public health. Healthy mother… healthy baby… healthy population. What mothers learn about health and healthcare during pregnancy and early parenting can benefit entire families across their lifespans, and extend benefits to the healthcare, education and justice systems, and to the economy.

Health literacy focuses on patients understanding healthcare information Health literacy research assesses patients health literacy by their scores on a single administration of a reading test using medical terms. Patients are marked poor, marginal or adequate. An adequate score means you will probably not need assistance to make meaning from information  about your diagnosis or to follow treatment instructions.  If you cannot pronounce most of the words,  you are assumed to have poor health literacy and to be unable to “obtain, process and understand basic information needed to make appropriate health decisions”. 

What we find out from health literacy-reading test scores is that almost everybody has limited medical vocabulary and difficulty making sense of information from the healthcaresystem. We find out that information needs to be simplified and its delivery needs to beimproved. We find that patients score better when we give them better information andconclude that what’s worth doing is improving information and its delivery.  Since most studies originate in academic medical centers, it is not surprising that studies position health professionals as the keepers and dispensers of health and medical knowledge and so it falls to them to reduce the risk and mitigate the negative impacts of low [health] literacy on patients and the system.

Maternal health literacy focuses on parents using information for health Maternal health literacy research assesses periodically what parents do with information, how they integrate it into their lives and households. Changes in parent’s health- and healthcare-related actions, practices and behaviors provide evidence of progress (or regression) in developing the knowledge and social and cognitive skills needed to participate in healthcare and preventive practices. This approach captures effects of systems efforts to improve information as well as public health efforts to directly assist parents to make meaning from the information and apply it in real life.

By monitoring what parents actually do for health with the information available to them, wefind out that direct assistance to use information and services for health is most beneficial to lower functioning parents, while also benefitting higher functioning parents. We find that social workers, parent educators, health educators, and trained paraprofessionals working in homes and communities can enable parents to better manage family health and healthcare, even with the added challenges of poverty, limited education and limited English proficiency. 

Both approaches are needed    
The dominant clinical approach to patient’s health literacy and the public health approach to maternal health literacy are complementary rather than exclusive. Patients and parents need quality information, accessible services, and assistance to use them effectively.

*    lisabeth schorr Common Purpose: Strengthening Families and Neighborhoods to Rebuild America.   Read this book!

Health Literacy Month: Time to think about your furnace

The morning was chilly, definitely fall in the air.  I turned on the furnace.  It seemed to take a while but the house warmed up.  Just as I noticed my nose was no longer cold, a  contractor doing repairs on the exterior reported with some alarm the smell of gas around the furnace exhaust. I turned off the heat. Two days later the scene repeated itself. The previous residents could not recall any problem with the furnace,  or ever having it checked.
I called a local heating company.
The tech walked in the door, sniffed the air, and immediately pulled out his hand-held CO - carbon monoxide - monitor.  His eyebrows went up. He ordered all the windows and doors opened.  Then he went outside to get a reading at the exhaust vent. He left the area when the reading got to 260 - more than 10x the standard.
What you dont know can hurt you
Would this explain my headache that won’t go away, I asked. Yes. And dizziness, drowsiness or a lightheaded sort of flu-like feeling - early signs of carbon monoxide poisoning. That’s what kills a person who sits too long in a car in the garage with the motor running.
Turns out the furnace heat exchangers - whatever those are - had cracked, probably years earlier causing the furnace to leak moisture and over heat. It had been deteriorating, gradually producing less and less heat with more and more gas.
I’d never thought about the furnace beyond the thermostat. I took for granted that it protected my health by providing  heat in the winter. It never occurred to me that it could be health hazard.
Use information and services in ways that enhance health.
That’s the definition of health literacy. With many households switching to affordable gas heating and appliances, keeping healthy requires new awareness. Here’s information I learned about maintaining gas appliances that you, and families you serve, can use to protect and enhance health this winter.
1.    Get a CO monitor. If you have any gas appliances get a monitor. Building codes now squire them in new construction. If you have a gas furnace put one in each bedroom.  I got a model that’s guaranteed for 10 years for $23 at WallMart. It plugs in to any outlet. The alarm sounds if the CO level reaches 70 ppm -parts per million - the point when most people start to feel symptoms.  For a little more money you can get a monitor that shows the ppm . For a bit less, there are battery powered monitors, but you have to monitor the battery.
      If the alarm sounds, get to fresh air and call 911.
2.    Have the furnace checked annually- a great way to mark Health Literacy Month each October. The local heating company charges $109 to check the system including the ducts. The new furnace I bought cost $4500. If the furnace had been checked annually for the last 20 year that would have cost a total of $2180.
3.    Change the filter every six months. My local heating company provides free filters and will change them at no charge 2x a year. Does yours?
4.    If you smell gas,  do not ignore it. Turn off the appliance. Open doors and windows. Call for service to the appliance. Do not wait for the alarm to sound.
5.    Useful numbers. CO level at the furnace’s exterior exhaust should be < 24ppm (parts per million).  The level in front of a gas fireplace should be <  9ppm. My fireplace tested at 30ppm. It is off. It will be serviced tomorrow.


Discipline or abuse?

Discipline or abuse?
Social media and the NFL are enabling us to reflect together on what level of aggression and violence in family relationships is acceptable in our society. It's a fitting although inadvertent role for the NFL, whose players are de facto role models for American males, and whose recruiters, coaches and fans place high value on aggression and violence on the field. (Here is Seattle, we love the defense in Beast Mode - on the field.) The NFL's position on aggression at home is, well, evolving. Thanks to the inventors and users of social media.

There seems to be consensus that child abuse is unacceptable, and discipline is necessary. But the line between discipline and abuse is defined by a complex and dynamic web of personal beliefs, local culture, and state laws.

What is abuse?
It depends who you ask and where you are.  State law is largely focused on protecting parents' rights, and keeping the family free of government or social interference. Social workers focus on protecting the child from parental excess. The courts aim to balance parents' rights with children's welfare. There's controversy regarding how much weight should be given to potential effects on children's social and emotional wellbeing and healthy development, on what is "normal" in the child's community, on potential future harm, on how well the punishment fits the infraction, on a pattern of parental behavior.

State laws are intentionally vague about what constitutes abuse, so that cases can be decided on an individual basis.  The laws and their approaches to defining abuse vary widely. Interpretation on the ground varies by agencies and individuals. This can result in a "I know it when I see it" understanding of child abuse.  Judging by the Twitter traffic around Adrian Peterson, people who view the same video evidence interpret it very differently.

How to decide?
Ultimately, parents must decide whether, when and how to discipline their child. To me there are two important things to bring to mind when discipline is in order. First, every young child wants to be, tries to be like his or her parents. And every parental action teaches the child some lesson, by default or by design.

A clear distinction for me is that disciple is teaching by design.  It intends to teach the child appropriate behavior and right action. Abuse is teaching by default, it aims to punish inappropriate behavior. As a parent, the question to ask when provoked by a preschooler, or any child, is what do I want to teach now?

Adrian Peterson said he wanted to teach his son to be respectful and not curse at playmates. But his preschooler did not make up those swear words. He learned them from someone he is trying to be like. And hitting a person with a stick is about as disrespectful as one can get.  Peterson left a scar on his 4-year-old's head, which he said the child could have avoided by not trying to get away.  Would you try to get away from a brawny footballer coming after you with a stick? I sure would. Would you think he was abusing you or that he was teaching you appropriate social behavior?

Consider what that boy is going to say to himself as he grows up looking in the mirror at his scar? "I want to be respectful and polite like my dad". Probably not.

This from Beginnings Parents Guide
Doriane Lambelet Coleman et al., Where and How to Draw the Line Between Reasonable Corporal Punishment and Abuse, 73 Law and Contemporary Problems 107-166 (Spring 2010)
Available at:


Research guides practice; practice guides research. Health professional education for resource -constrained practice

Translating research into practice is a challenge for all practitioners. We could call it “research literacy” - ability to obtain, understand, evaluate and use research to make treatment and policy decisions. How can clinician/educators of healthcare professionals enable new clinicians to use research to challenge current practice and provide evidence-based care? How do you implement changes to long standing curricula, evaluation procedures, and teaching methods? How do you capture the richness of diversity and overcome its challenges? Those are questions faculty, staff and students of University of Cape Town School of Nursing have been actively wrestling with in recent years. The questions guide their research which is “relevant to and directly transferable to local and resource-constrained practice settings”.
Learnings to be published soon
I know this because I am guest-editing a special edition the African nursing journal Curationis.This work, like the special edition itself,  is an outgrowth of one of my all-time favorite gigs - keynoting the first, totally awesome and inspiring, conference on Building Childrens Nursing for Africa held April,2013. (Consider participating in the second conference April 22-24, 2015.)  So I get to read all the articles and shepherd them through the publication process. What an education i am getting!  The issue is shaping up nicely. I think it is going to valuable to all nursing and medical educators working with diverse student bodies or training professionals to serve low-resource populations.  Stay tuned.

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.
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