Center for Health Literacy Promotion Blog
AHRQ and the journal Demography
report research finding that the more education a mother has, the more time she
spends caring for and playing with her child. This seems to suggest that
education makes the difference, or that less educated mothers are less invested
in their child’s health and development.
More likely it is the advantage that afforded educated mothers
opportunity to go to college and the further advantage that accumulates from
higher education....more money, more resources, more skill, better jobs, more discretionary time and energy.
All these things create more options and opportunities to obtain, understand
and use information and services in ways that enhance personal and child health
- maternal health literacy.
The other side of the coin
is that mothers who have less education come from less advantaged
backgrounds, start with fewer resources and opportunities, are relegated to low
paying jobs, and work more and to earn less.
I was a single
mother with a high school education and few marketable skills. I worked three part time jobs - one to
pay childcare so I could work the other two to pay the rent and take a course
here and there. It took 12 years
to get my BA while working full time. I was in my 50s by the time I could
afford a PhD. My daughter got less attention than I wanted to give her. So the reports are right -- until they
say that educated mothers “invest
more time” in their children than
less educated mothers.
If you don’t have money, you have to invest more time for your child than with your child. Less educated mothers are no less invested in
their children. Lack of income and education prevents parents from making the
kinds of investments they want to make in their children. I hope economist James Heckman is right
when he argues that it is the quality of parenting, more than the number of
parents, their income or education that determines outcomes for children. But
that, too, is an over simplified argument.
AHRQ Research Reports Sept 2013
Kahil A, Ryhan R, & Corey M
(2012) Demography 49 pp 1361-1383
Heckman, James J. (2013) Giving Kids a Fair Chance (A Strategy That Works) MIT Press,
Cambridge, Mass. ISBN
beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in life
across cultures. They are skills that empower people to be what they want to be, to make
choices and transform those choices into desired actions and outcomes.
These life skills develop most easily
in early childhood given a stable supportive family environment. Disparity in
brain development in children growing in disadvantaged vs enriched environments
becomes apparent in the first year.
Quality of family life matters more than the number of parents, their
income or education. But poverty and accumulated disadvantage prevent parents
from doing their best to sustain the stimulating home environments that support
optimal development, especially when they themselves lack skills, resources and
role models. Early intervention --- early childhood education, parenting
training, family support and home visitation programs--- can produce positive
and lasting effects on children in disadvantaged families.
Nobel Laureate and economics
professor James Heckman, makes the business case for shifting public policy to
support programs that offer parents information, choices and assistance. Promoting health literacy means
providing direct supplemental assistance that specifically and intentionally
enables parents to develop and hone the range of life skills used to
participate in healthcare and manage personal and family health at home.
Must read: Heckman, James J. (2013) Giving Kids a Fair Chance (A Strategy That Works) MIT Press,
Cambridge, Mass. ISBN
In addition to Heckman’s monograph,
the book includes illuminating commentary by 10 experts from multiple
My favorite feature of the upcoming 9th edition of the Pregnancy Guide recognizes it is a
digital world. You told us that you and your families need print materials
since few in your caseloads have computer access or devices to use digital
information. Other surveys confirm you’re right.
Poverty and the
In December 2010, 40% of US households, did not have a broadband connection in the
home. Lack of access is a marker
of poverty. Mississippi is the poorest state and has the highest proportion of
households without access, 65%. Similar rates of poverty and no-access are
found in AR, TN, WV and OK.
Compare to wealthy states led by HI with 74% connected, only 26% with
no-access. In cities, there is
commonly low access in the urban core suffering poverty while the wealthy
suburbs are fully wired.
Still, people find a
way to get online
In a survey of over 2000 Mississippi households, 79% said someone in the home had used
the Internet. Outside locations included school, workplaces and the local
library. In some libraries, free
internet service is the biggest draw into the building.
reasons for having no access at home were cost and lack of equipment, but the
key reason seemed to be lack of understanding of the value of the Internet. an
aspect of low health literacy. Of
those without access, 46% said they didn’t need it or were not interested. Others, especially younger, less
educated, low income adults said they mostly go online using their smartphones.
Access in steadily
A February 2011 survey found 68% of households with a
connection, suggesting significant growth in just a few months. Some of the most rural areas seem to be
improving quickly; but the South has shown only modest improvement. The Obama
administration has directed billions of economic stimulus dollars to increase
Internet access. And some companies have just begun offering low-cost broadband
connection to families with a child who qualifies for free school lunch.
information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide is
intentionally focused on essential health behavior topics directly linked to
pregnancy outcomes. Some parents want to know more.
New Resources for
Mothers coming to www.BeginningsGuides.comFor those who do have Internet access, and to motivate those
who don’t to find a way, the new 2014 edition of Beginnings Pregnancy Guide
includes this icon to encourage readers to visit the new Resources for
Mothers pages of www.BeginningsGuides.com. The new section provides links to
information and resources from reliable sources that Beginnings Guides staff have reviewed and found easy to use. This reduces the need for advanced searching and evaluation
skills. We envision the new Resources for Mothers as an easy entry into online
self-directed learning about health and an opportunity for parents to improve
their health literacy.
1. Health Literacy is a key determinant of
•Limited health literacy, measured as ability to read
medical terms and documents, is linked to riskier health choices, less
participation in preventive activities, more accidents, poor adherence to
medication, more hospitalization, increased morbidity and premature death.
• Studies using more comprehensive measures
demonstrate that health literacy has a specific direct and independent effect
on self-assessed health.
• Limited health literacy in mothers is linked to
increased risk of developmental
delays and reduced participation in Early Intervention when delays occur.
literacy means empowerment: the capacity
to make choices and transform those choices into desired actions and
• Mothers cannot achieve their fullest health
potential and nurture a healthy competent child unless they are able to take
control of those things which determine their health. (Ottowa Charter for Health Promotion)
3. Efforts are highly leveraged in
pregnancy and early parenting
• Pregnant women exhibit readiness to learn and change
well above national norms. They are becoming healthcare decision-makers for
themselves and their families. Developing their health literacy in pregnancy
can benefit entire families across their lifetime with short and long term
benefits extending to the healthcare system, the justice and to the schools; to
the public health and the economy.
4. Mothers’ health literacy is an
important factor in prevention
of noncommunicable diseases that are now the leading causes of death in the US
• Both limited health literacy and noncommunicable
disease disproportionately affect poor, under-educated, and minority
• Limited health literacy reinforces inequities.
• Promoting maternal health literacy and empowering
mothers are recognized global health strategies for reducing the burden of
noncommunicable disease with origins in early development, and associated
disparities. (WHO, United
The American Medical Association House
of Delegates declared obesity a disease
last month. Is this good for maternal
and child health? For public
In 1995 the National Heart Lung and
Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten
years earlier, almost 30 years ago now,
NIH called prevention and treatment of
obesity a national medical priority.
With 90 million Americans now officially
obese, it seems few clinicians got the
prevention not a priority in maternity care
Guide, I found that weighing is still the only procedure in
care that has shown any impact on outcomes. And yet it has
become uncommon for
a pregnant woman to be weighed at prenatal visits or
when being admitted to a
hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation
will interfere with their patient/provider relationship. Others said they do not know how to calculate BMI. They also must not
know about the many BMI calculatorsthat will do it for them. One can
only hope that calling obesity a disease will change these attitudes.
mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a
mother with an excess of fat cells produces a baby
with an excess of fat cells. So we are building obesity
and the attendant health issues into the next generation.
ACEs -Adverse childhood
experiences - witnessing or experiencing interpersonal violence is closely
related to obesity. A woman fearing abuse may hide in obesity, intentionally making herself unattractive to protect herself. Is that a disease? With medical
treatment, many such women have lost weight, and gained it right back. That’s
how the lifelong effects of ACEs were discovered.
Other mothers have said it doesn’t
matter if they gain too much in pregnancy since they are just going to get
pregnant again; the weight can come off after that. Only it rarely does.
people into patients
Google “obesity disease”. The first
thing that pops up is ad ad for weight loss surgery. This may be more telling
than official statements.
Especially when we consider the Forbes
June 28 report that the AMA’s Council on Science and Public Health, the group
appointed to address the question, advised against declaring obesity a disease.
But the delegates chose ignore their own advisors.
We have to ask, what was so
Perhaps it is the implementation of
the Affordable Care Act that will bring healthcare coverage to millions of
Americans previously excluded from the healthcare system. At least a third of
them are obese. Now they can be patients.
According to CDC 35.7% of Americans
are obese, 49.5% of African Americans, 40% of Mexican Americans. Rates vary
widely by state. Find your state rate at
in need of medical treatment.
Calling obesity a disease, again,
could draw attention to related health issues, but it hasn’t in 20 years. It could result in better maternity
care, but the declaration is unlikely to improve clinicians communication and
counseling skills. It could spark
a Kennedy-style physical fitness craze, but that entails behavior change, and
the same communication issues. It
could increase research on obesity, but NIH already has a Strategic Plan for
Obesity Research and funds nearly a billion
dollars worth of studies annually. Grants.nih.gov lists 49 obesity-related
research solicitations currently open for submission of grant
Only one thing seems certain, making
obesity a disease will increase medical treatments and costs, and revenue to
2D, 3D or 4D. In-studio or at your
baby shower. Announce your pregnancy with a “viewing party”. Get a video at the
mall. Post it on Facebook. Select the premium package offered by a Miami
OB-GYN’s office and get a weekend discount.
American Institute of Ultrasound Medicine, American College of Obstetricians
and Gynecologists, American Academy of Family Physicians, March of Dimes, US
Food and Drug Administration, England’s National Institute for Health and Clinical Excellence, the UK’s
National Collaborating Centre for Women's and Children's Health, and other
national and international experts all have published strong recommendations
against non-medical use of fetal ultrasound. The Society of Obstetricians and Gynaecolgists of Canada
calls for a complete ban on non-medical use of fetal ultrasound. The state of
Connecticut legislated a ban in 2009. The FDA says that creating fetal
keepsake ultrasound images is “an unapproved use of a medical device,” and
those who perform ultrasonography scans “without a physician’s order may be in
violation of state or local laws or regulations.”
don’t need an excuse to be happy.”
Still internet ads for non-medical
ultrasounds abound, complete with slogans like this, implying you don’t need a
medical reason for the “painless, relaxing procedure”. The growing popularity
of “keepsake ultrasounds” is not due to cost or access issues. Most insurance
companies pay for one or two doctor-ordered ultrasounds as part of routine
prenatal care, and commercial ultrasound is not cheap.
start at $175 for the 3D in-studio option. $500 for an “ultrasound party” at
the location of your choice. The cheapest rate I saw was $75 for a basic
“gender determination” scan; it’s discounted to $55 on Saturdays one OB-GYN’s office. These commercial
services are not regulated or standardized.
sonographers say that ultrasound is safe. I found unclear statements like: “All research provided has been proven to
be safe for expectant mothers and baby, as long as the procedure is done by a
trained professional, and no longer that one hour intervals.” First, we have to ask, research provided by
whom? and What about the research that was not provided? Second, remember that no research ever proves anything. It can only
offer statistical evidence. Then, a more accurate statement is that repeated
ultrasounds have not been proven harmful. Still the evidence has convinced all the advisory and regulatory
agencies that entertainment ultrasounds are worrisome.
uses sound waves, not xrays. So radiation is not the issue. But the procedure
targets the fetus with heat and
pressure, especially prolonged, 4-D studies. New York state legislators
proposed a ban on ultrasonography for entertainment purposes, citing data
showing that 4Dl ultrasound equipment can emit eight times more energy than the
machines commonly used in medical settings. The risk of effects on fetal development has been
demonstrated in both human and animal models, and remains, at least
theoretically, so that the FDA
concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
concerns about non-medical ultrasonography include the possibility that
non-medical ultrasonography will fail to identify a problem with the baby,
falsely reassuring the patient and her family; or that a false-positive result
could create unnecessary anxiety and follow-up testing. Machines are
unregulated so may not be properly calibrated or maintained. Technicians may
not be well-trained or proficient. “gender determination” had never been an
accepted use of of ultrasound technology and raises thorny ethical issues.
are for doctors
Here’s the problem: In medical settings, the sonographer is commonly prohibited
from explaining ultrasound results to the patient, who must then wait for days
or weeks to get the results from the physician who ordered the scan. Family
members may be barred from attending the ultrasound appointment to avoid
congestion in the radiology department. Parents may not receive still pictures
or video to take home. If they do, they still cannot send it to a friend or
post it online. Until these
disempowering practices change, parents and sonographers
will continue to seek a more informative, convenient, family friendly experience.
Check Technician’s Credentials
Pregnancy Guides says, “Ultrasound is
safe for you and Baby.” [p8] That
remains true. The 2014 edition will add this statement: Many healthy pregnancies do not need
ultrasound. Extra “keepsake"
ultrasounds may be harmful. The Registry of credentialed sonographers will be
posted on the new Mothers’
Resources page at www.BeginningsGuides.com More
on that later.
iPhone helps too much; so we
inadvertently retweeted this, and then the retweet was favorited: Health Illiteracy-- a disease that also
afflicts doctors... I would not intentionally repeat this
phrase. I hope you won’t either. Here’s six reasons why:
1. The term “health illiteracy” focuses on patients’
deficits and places patients in a position of failure and incompetence. This
approach generates anxiety and resistance in patients and calls up their
defenses. It disempowers patients while requiring that they be active
decision-makers and participants in their care.
2. The term “health illiteracy” equates lack of
medical and healthcare vocabulary -jargon- and disease knowledge with illiteracy and all the stigma
that goes with it. It situates in the patient systemic problems in
healthcare (indecipherable &
conflicting information, inefficiency, high costs, poor outcomes); so that when
treatment is successful doctors get credit, and when it’s not, patients get the
3. “Health illiteracy” is neither a disease nor an
affliction. This metaphor further
tips the power imbalance. it implies health illiteracy is a problem that
patients have and doctors need to treat or manage. It cements the notion that
patients cannot grasp doctors’ specialized knowledge or use it for their
personal benefit; so that an “appropriate health decision” is equated to
compliance. And non-compliance is framed as cognitive deficit or
4. Here is the first definition of “disease” produced
by a Google search: “a
disordered or incorrectly functioning organ, part, structure, or system of the
from the effect of genetic or developmental errors.... The metaphor adds stigma to stigma
implying cognitive deficits and disabilities, rather than underdeveloped
skills, poor quality education, inexperience with the healthcare system, or
poor communication and complex, concept dense, jargon laden, overly technical
5. An “affliction” is defined as a condition of pain, suffering, or
distress. Most adults who scored in the Basic or Below
Basic levels on the 2003 National Assessment of Adult
Literacy reported that they read well. They are not “afflicted”until the enter
the healthcare system.
tweeted blog is titled “Screening-illiterate physicians may do more harm than
good”, which a tweeter translated to
the comment that health illiteracy afflicts doctors as well as patients.
blog bemoans that many doctors are “functionally
concepts” This language conflates functional literacy
with knowledge. Functional literacy
(the 3Rs) refers to skills used to
knowledge. Lack of a particular
set of knowledge,
does not indicate inability
or to learn.
“functionally illiterate” means having reading
and writing skills insufficient for ordinary practical
needs. Any one who got into medical school can
read and write. If they do not
concepts, that says more about their educators
than about their cognitive ability.
lack of knowledge as functional illiteracy -inability
to gain knowledge - is as disempowering
as it is to patients.
I agree with the
blog authors’ conclusion that more attention needs to be paid to improving
physicians knowledge (not their literacy) about screening tests in order to
reduce use of ineffective tests that expose patients to potential harm --
especially health literacy tests.
More attention also
needs to be paid to increasing understanding of literacy and health literacy.
Here’s the blog:
Of the 10 most frequently performed
in-patient procedures, 5 are
related to maternity and newborn
care (2010 figures - latest available).
Bad news: the cesarean section
(surgical delivery) rate continues to rise; it is up 41% since 2004, despite
global evidence that rates over 15% do more harm than good. This is a place to
cut the cost of maternity care. A cesarean section costs on average $9956 more than vaginal delivery.
Good news: Fetal monitoring,
circumcision and stripping of membranes are performed less frequently now than
in 1997. The reduction in procedures returns to mothers some control over their
most significant life event, and begins to recognize that over-management is
Frequency Number Performed Increase in
in 2010 frequency
Repair of obstetric 1,292,000 No change
Cesarean section 1,278,000 41%
Circumcision 1,164,000 -31%
Artificial rupture of 917,000 -5%
Fetal monitoring 875,000 -23%
greatest opportunity to make healthcare more affordable and improve
status of the population is to improve the way we deliver and pay
care. Investigations of the cost of maternity and newborn care
usually report charges made by providers. But charges are routinely discounted
varying rates, so the figures are not very informative re actual cost.
A new report shows actual payments made in 2010 (latest
figures) by employer
-based commercial insurers, Medicaid and parents.
delivery payments vary by state, by regions within states, by hospitals
regions, and by providers within
hospitals, so vaginal birth and cesarean
(surgical) delivery are reported
separately. A summary of findings in the table
below suggests where to focus
Item Employer Insurance + Public Insurance
Out of pocket Medicaid
Cesarean 57,125 50,374
Vaginal 18,329 + 2244 9,131
Cesarean 27,860 + 2669 13,590
Vaginal 3,180 (25%) 2,405 (39%)
Cesarean 3,580 (21%) 2,859 (36%)
Vaginal 9,048 (72%) 3,347 (55%)
Cesarean 12,739 (76%) 4655 (58%)
in hospital +
Vaginal 5,809 + 558 3,014
Cesarean 11,193 + 721 5,607
Vaginal 30,875 + 1241 13,875
Cesarean 45,496 + 1351 19,971
delivery costs are 50% greater than vaginal birth for all payers.
And cesarean delivery payments by commercial insurers
between 2004 and 2010. In addition, parents’ out-of-pocket costs
The best outcomes for women and babies
appear to occur with cesarean
section rates of 5% to 10%. Rates above 15% seem
to do more harm than
good (Althabe and Belizan 2006) Despite the evidence and the costs, the
cesarean rate for 2010 was 32.8%.
table suggests one explanation for the high cesarean rate is that surgical
birth is more lucrative than “the regular way”. Commercial payers paid
clinicians an extra $1464, and paid
hospitals an extra $7518 for cesarean
vs vaginal birth. Those incentives are
hard to ignore.
the table shows that 70-84% of all maternity payments went to
But the vast majority of mothers and newborns are healthy
have been shown to reduce preterm birth, failure to thrive, and other
land babies in Neonatal Intensive Care Units where costs were 3.7
to 5.6 times
those for other babies. More investment in prenatal care and support
reduce the need for cesarean, and
could help re-align financial incentives.
Truven Health Analytics (2013) The Cost of Having a Baby in the United States.
Connection, Catalyst for Payment Reform,Center for Healthcare Quality
Belizan JF. Caesarean section: The paradox. The Lancet 2006;368:1472-3.
term functional literacy
traditionally refers to basic literacy skills, the
3Rs: reading, ‘riting, and ‘rithmatic. These autonomous skills for gaining
knowledge were said to be functional, implying that they enabled a person to
function in society. The idea was, if you can read and use numbers, you can
learn what you need to know and do to function in any context.
was true in 1852 when MA passed the first compulsory school laws. It was still
true in 1918 when all American children were required to attend elementary
that time, the Sisters of Providence were arriving in Seattle on mule back from
the Oregon Territory to establish the city’s first hospitals. The Sisters
rode a circuit of the logging camps selling the first health insurance
policies. For $10 a year a logger
was promised full care in case of
any injury or illness. The care consisted primarily of bandaging and
amputations with handholding and whiskey for pain. The 3Rs were sufficient to
understand the policy and to obtain the full benefits of care.
have changed, but thinking lags.
The term functional health literacy came into the healthcare discourse in
1993. Starting with the
traditional understanding of functional literacy, functional health
literacy, came to be understood
as basic literacy skills applied in a clinical setting, in other words, a
patient’s ability to read and use numbers to understand medical, healthcare,
and insurance related information. This conceptualization relies on the
assumption that basic reading and ‘rithmatic skills still enable a person to
function in society, and specifically in healthcare settings that were
unimaginable even 50 years ago.
the thinking goes, a patient who can read will be able to function in the
healthcare arena. Reading will enable a person to recognize a medical problem,
understand the difference and appropriate uses of primary and tertiary care,
find an appropriate provider or collection of specialists, make appointments,
manage transportation and child care, articulate symptoms, understand the
diagnosis and treatment options, follow the medication regimen, change
behaviors to prevent repeating or exacerbating the problem, file insurance claims
and get reimbursed for costs that are unknown until the bill arrives. All this in a complex, high
tech, fragmented, rapidly changing environment with its own language and
in the health arena takes more than reading.
literacy scholars say that the meaning of literacy is constantly changing to
reflect society, so that what it means to be literate is context-specific. It’s
different at different times and places for different ages and genders and
cultures. Operationalizing health literacy simply as ability to read medical
terms and documents surely oversimplifies the literacy tasks involved in
managing personal and family health and healthcare. Time to update the way we
think and talking about health literacy, and how it enables a person to
function in the health arena.
Lucia, E.(1978). Seattle’s Sisters of Providence: The
Story of Providence Medical Center~Seattle’s First Hospital. Providence Medical