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Center for Health Literacy Promotion Blog

Maternal Child Health

Maternal Health Literacy: Foundation of personal and public health

Part 1 Maternal health literacy as skills

A life skill is a collection of skills necessary for full participation in everyday life. Maternal health literacy is a life skill that mothers use to manage personal and child health and healthcare.  It has been defined as the cognitive & social skills that determine a mother’s motivation and ability to act on information in ways that improve health (Renkert and Nutbeam, 2000).
Cognitive skills are used to understand information; they include basic literacy skills, reading and numeracy (ability to use numbers). A mother might use these basic skills to learn about ear aches, and make an appointment to take her child to see a clinician. So basic literacy skills are the essential foundation for health literacy.
Social skills are used to make personal meaning from information, including speaking and listening. The mother whose child has an ear ache uses these skills when she discusses with the clinician the information on ear aches to understand why her child has them and how she might prevent them.
Reflective skills combine cognitive and social skills to think critically, make choices, formulate plans, and take action.  The mother in our example uses reflective skills when she mulls over what the doctor said, what she read, her experience of her child’s ear ache, her actions and parenting practices, and her discussion with her mother about treatment options and possible preventive measures. Some literacy scholars say that reflective skills are so essential to applying information in context that it should be classified as a basic skill. So we could say there are 4Rs: reading, ‘riting, ‘rithmatic, and reflection.
Health literacy means empowerment (WHO 2013)
A health literate mother combines all these skills to make health related choices and transform those choice into desired action and outcomes. That is the World Bank’s definition of empowerment.  Say the mother chooses to stop putting her baby to bed with a bottle. She takes that step, and she enjoys her desired outcome, a happy ear-ache free baby. We say this mother is empowered for health. 
Her health literacy skills enable her to minimize risk, maximize protective factors, and optimize health promotion. In this way, a mother’s health literacy forms the foundation for her health and her child’s health throughout their lives.
Many factors, in addition to skills, interact to determine a woman’s maternal health literacy. More on that next time.

Notes from the Field CenteringPregnancy, Promoting Maternal Health Literacy

I’ve been in Washington DC where I co-presented a workshop at CenteringHealthcare Institute’s fourth national conference. I was drawn to this organization the first time I read their motto: Transforming care through disruptive design.
CenteringPregnancy (CP) is a rapidly spreading model of group prenatal care. Eight to 12 women with similar due dates have their prenatal visits together. Each has the usual individual health assessment with an obstetrician or midwife in the group space. Meanwhile the rest of the group engages in “self-care”; they weigh themselves, take their own blood pressures and chart the data.  They can read their own lab results and ultrasound reports. The rest of their 1.5 -2 hour appointment is dedicated to  education and support through facilitated group discussion and activities.
Reimbursement levels and processes are the same as for conventional individual prenatal care. The schedule of visits and core content follow ACOG* guidelines. 
Process trumps content
CenteringPregnancy’s founder and CEO, midwife Sharon Rising, emphasizes, “Content should not get in the way of process.” The women talk about what they want to talk about. There are games, activities and multiple ways of learning. Women test out what they've heard; they explore their cultural beliefs and share sensitive issues like violence that are only rarely discussed in traditional prenatal care. They build community and function as a support group. 
March of Dimes wants all mothers to get prenatal care in CenteringPregnancy,” says Judy Gooding, MOD’s Vice President for Signature Programs. No wonder.
She describes CP as an evidence-based program to prevent preterm birth and disparities in infant health outcomes. MOD’s  2012 Preterm Birth Report card shows the US rate at 11.7% of all births. Among women in CP the rate is 5.5%. The national low-birth-weight rate is 8.1% compared to CP’s 6.3%
CP meets the Institute of Medicine’s goals to make healthcare services safe, patient centered, equitable, timely and efficient.  Participating mothers seem to agree. There is no waiting time, no need to retell their story to strangers. They build a relationship with the provider. What they like best is being with other women.
Sharon Rising says, “Facilitation is the secret sauce.” Clinician facilitators are trained not to answer questions or instruct the group, but rather to elicit the group wisdom and listen to what drives behavior. They come to understand and appreciate the needs, beliefs, and struggles of the women and the complexity of their live. Throughout the conference there were reports of clinicians coming out of CP sessions where they completed the equivalent of 10-12 prenatal visits in 2 hours  beaming and talking in superlatives about their experience.
All this makes group prenatal care the ultimate environment for promoting maternal health literacy. I’ve been working for a year with WellPoint, the health insurance giant,  to design a pilot to test the hypothesis that CP promotes MHL as a side effect, and with facilitator awareness, tools and strategies it can be very effective.More on that next time. Meanwhile, visit
Stay tuned. ss

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills 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 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary by 10 experts from multiple disciplines.

Top 4 Reasons to Promote Maternal Health Literacy

1. Health Literacy is a key determinant of health. 

•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.

2.  Health literacy means empowerment: the capacity to make choices and transform those choices into desired actions and outcomes.(World Bank)

• 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 and globally.

• Both limited health literacy and noncommunicable disease disproportionately affect poor, under-educated, and minority populations.

• 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 Nations)

With few exception, childbirth is normal % healthy, but...

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 not beneficial.
Procedure Frequency       Number Performed          Increase in
Rank                                  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%

Mandy’s Story Part 3: Lessons

Recently in this space I told Mandy’s Story,  and then we saw how the story reflects the science on separation of mother and child due to the child’s hospitalization. There are many lessons in this story.
A young child’s healing power and reason to live reside in the mother.
Children need their mothers not only present, but interacting with them. When interaction with mother is absent, even for short periods under pleasant circumstances like Mandy’s mom’s vacation, children and mothers suffer. Although a surrogate mom like me in this story can ease the pain.
A child can become stuck in a state of anxiety
When the interaction is removed under unpleasant, unplanned, unexpected and extended circumstances, like a hospital stay, research shows development is arrested with lifelong consequences for the child, especially negativity and aggression. A hospitalized child is at risk of getting stuck in a state of anxiety.
Less interaction, more hospitalization
A recent study found that children of responsive, interactive mothers were half as likely to be hospitalized. That means children who are hospitalized are twice as likely to have mothers like Mandy. That’s the bad news.
Here’s the good news: Role models needed
I learned this lesson a little later from Mandy’s mother.  Seeing what mothering looks like, seeing ways to relate to her child, seeing how her child responds is all that Mandy’s mom needed to transform herself into a mother who actively promotes her child’s health and development.
Mandy’s mom did what we all do; she mothered as she was mothered. In this case, not at all. The fact that Mandy was failing to thrive and her mom clearly had not mothered her well was not evidence that the mother was incapable or unfit, or uncaring or lazy. Rather the facts indicated lack of a role model.
Mothers who were not well mothered themselves need a role model to see what is possible, to develop confidence in themselves and find the courage to engage in mothering and caregiving.  How can you use your position, skills, knowledge, and compassion to be that model for a mother who wants to be what her child needs but does not know how? 

Insights from the first conference on Building Children’s Nursing For Africa, Cape Town 4/17-19, 2013

I conducted a pre-conference workshop  on engaging and  empowering mothers whose children are hospitalized with 15 nurse trainers and a whole class of nephrology students, we talked about the importance of basic literacy skills as the foundation for health literacy.  We reviewed screening questions that can be used to identify individuals who might benefit from adult literacy training.  One nurse said, “But using these questions, I would have to refer everyone who comes to my clinic.” Another said, “Yes,  that’s how it is.”
That’s how it is in some disadvantaged US communities, too.
This discussion, and others during my whirlwind week at Cape Town University and the Red Cross Children’s Hospital,  led to insights about the undeniable links between basic literacy skills (the 3Rs - reading, ‘riting, and ‘rithmatic), health and health literacy.
The 3Rs are  fundamental skills for acquiring knowledge. So it is not surprising that any way “health”  and “literacy” are defined, any way they are measured, they are inextricably linked. More literacy translates, directly and indirectly, to more health and more options and opportunities to regain, maintain and improve health, accomplish one’s goals and fulfill one’s potential. Basic literacy is the foundation for health literacy, computer literacy, science literacy, financial literacies and other “types” of literacy used to function in different social contexts. 
In addition, we now have hundreds of health literacy studies that show most people in most developed nations have difficulty understanding and using information to manage their health and illness and healthcare. 
Since health and literacy are so closely linked, healthcare organizations, especially hospitals and health plans, should consider their ethical duty and the compelling financial and practical benefits of taking the lead to improve adult literacy in their service areas. As primary prevention. As a way to increase the effectiveness of all other efforts. As the foundation for a healthy population, a pathway out of poverty and the key to the advancement of women and society.
Simple, inexpensive steps include collaborating with literacy enhancing services, and in their absence, establishing programs,  providing space for on-site classes, providing health content for literacy training, advocating for adequate funding, training personnel to understand and talk to patients about the role of literacy in their health, expanding Reach Out and Read.
Yes we rely on the schools to teach literacy. And yes, many, perhaps most schools need to do a better job. But we in Healthcare cannot reform Education; and we cannot wait for Education to reform.  To reduce the burden on healthcare systems, to improve outcomes, to increase people’s capacity to obtain the benefits of healthcare, address basic literacy in your service population.

Hamza, age 11, speaking to the conference about living with a "trachy". With him is his mother Farahna, and his nurse,  Jane Booth.

Maternal Health Literacy and Home Visitors

Since 2004, I have been training Maternal Child Health home visitors to promote maternal health literacy, defined as the cognitive and social skills and motivations that enable a mother to obtain understand and use information [and services] in ways that maintain or enhance her health and that of her child  (Renkert & Nutbeam 2000). This is the WHO definition made specific to mothers. It is broader than the US clinical definition in several important ways: it includes social skills (interactive skills) acknowledging that reading and numeracy are insufficient to function in the Information economy, especially in the high tech healthcare arena. It includes motivation, indicating that factors other than communication skills determine a persons health literacy. Perhaps most important, this broader conceptualization includes use of information. Understanding is an essential first step , but still a long way from health promoting action. Finally, it specifies using info in ways that promote health, going beyond decision making. In order to involve community health workers as Farmer and Winston and Bonnie suggest, we need to broaden our thinking.

I chose home visitors as a channel to promote health literacy for a long list of reasons, chief among them: home visitors' unique access and long-term trusting relationships enable them to observe and to influence the interactions of multiple factors that determine a mothers' health literacy.These factors are not readily visible or modifiable in a community setting.

We trained visitors to build parents'  interactive and reflective skills while providing direct assistance to make meaning from selected health education materials (Beginnings Guides) and information from healthcare providers and to apply it in vivid real life circumstances. The primary teaching and learning strategy in the intervention is reflective questioning. This does not imply that practitioners forget what they know, but rather that they use their expertise to formulate reflective questions and lead reflective conversations that facilitate self-discovery and action planning. This approach addresses the social determinants of health and the empowerment aspect of health literacy. Health literacy is empowering because, and to the degree that it enables a person to increase control over their health and its determinants.

A critical element is the routine use of data by practitioners to tailor interventions to particular families and circumstances. Many home visitation programs use the Life Skills Progression instrument (LSP) approved to demonstrate progress to federal benchmarks of effectiveness in home visitation (Maternal Infant Early Childhood Home Visitation -MIECHV under the Affordable Care Act). Using the LSP,  home visitors routinely  monitor parents' use of health information and services as well as self-care, support of child development and health behaviors important to both parent and child health (smoking, alcohol, drugs). Among these are indicators of maternal health literacy, situated in surrounding family conditions. Two health literacy scales derived from the LSP enable home visitors to monitor "healthcare literacy" - use of info and services and "self-care literacy" management of personal and child health at home. Intimate knowledge and data on  surrounding family conditions suggest approaches to improving health literacy for a particularly mother.  The routine use of data - especially where it is currently collected- enables visitors and partner researchers to consider the context in which we expect people to use health information, not as background noise, but as the primary determinant of the health literacy task, a persons capacity to accomplish the task, and the support needed.

Four studies funded by AHRQ/NICHD, National Library of Medicine and Missouri Foundation for Health indicate the intervention is effective in increasing health literacy regardless of reading ability and in spite of depression. Low maternal health literacy is associated with child developmental delays and reduced participation in early intervention.

The average American spends 1 hour per year in a clinical setting.  We need more community health workers trained to promote health and health literacy in the community in the course of their usual activities, along with routine use of data by practitioners and their supervisors to continuously increase effectiveness and sustain funding. One action step would be to review existing data sets in search of indicators of health literacy and influential surrounding conditions (eg social support, living conditions). Repeated measures would show progress/regression.   This is to suggest a paradigm shift from health education, anticipatory guidance, information giving that aims to increase knowledge and compliance to an empowerment approach that aims to increase autonomy and engagement.

Breast Milk Baby reveals nation’s low health literacy

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.
From 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 lifetimes.  
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.
Good News
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 features.

Breastfeeding is best.
Your 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  

Health Education Week: Focus on Adolescent Health Teen mom’s improve their health literacy

This is Health Education Week sponsored by Society for Public Health Education. The theme is Adolescent Health. We take this opportunity to applaud the teens in our studies on maternal health literacy.
A study from the Center for Health Literacy Promotion and University of Washington reported in the September 2012 edition ofMaternal Child Health Journal found that pregnant and parenting teens participating in home visitation programs started at a significant disadvantage on almost every indicator of maternal health literacy, that is,  ability to use information and services in ways that maintain or enhance health. And  the teens made gains in the first six months of home visiting to nearly catch up with their more experienced counterparts. With support and education they became empowered as managers of personal and child health and healthcare. In so doing, they planted the seeds for a healthy adulthood for themselves and their babies.
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