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Zika and Health Literacy. Advice ignores context
Parents’ “Health Learning Capacity” Are we moving beyond reading difficulties?
Health Empowerment: the act-ive ingredient health literacy
Time to Acknowledge our Biggest Barrier to Health & Health Literacy
Improve Health Literacy in Poor Communities: Start a literacy program

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Zika and Health Literacy. Advice ignores context

Don’t get pregnant until 2018.
That is the current public health message from El Salvador’s health minister. Colombian women are warned to postpone pregnancy for 6 to 8 months. Jamaica just released similar advice. The intent is to prevent mother-to-baby transmission of Zika.

The mosquito-borne virus known since 1947 as a rare mild disease limited to central Africa, is spreading rapidly across dozens of countries in Latin America and the Caribbean. No one knows why. The World Health Organization (WHO) warns Zika is likely to reach every country in the Americas, except Canada and Chili. There is no treatment or vaccine, largely because only about 20 percent of infected adults have any symptoms. They might have a headache, body aches, a fever and red eyes for a few days.

Here is the public health concern: in Brazil, since an outbreak of Zika started there last May, more than 3800 babies have been born with microcephaly, 30 times the expected rate, according to WHO. Microcephaly is a rare birth defect characterized by a very small head and incomplete brain development leading to death or lifelong disability. There is little scientific evidence, but the apparent association between Zika and microcephaly warrants public health warnings, and delaying pregnancy seems wise. However…

The advice to women to avoid pregnancy ignores the context in which they are expected to comply. In El Salvador and Colombia there is little access to contraception, especially for poor rural women. Abortion is illegal in all cases in El Salvador, where the teen pregnancy rate is among the highest in Latin America accounting for a third of all births.  Abortion is illegal in 99% of cases in Colombia. In Jamaica, abortion is legal in some cases with the approval of the father and two medical specialists. There is little or no sex education in the schools. Sexual violence is prevalent. So women lack the knowledge, services and power to heed the advice.
 
Good risk communication?
Colombia’s health minister explained that his message to women is a good way to communicate risk. The minister seems to forget that women do not become pregnant by themselves. No similar messages have been directed to men. For sure, women who hear the warning will fear pregnancy and birth defects more than they already do, but left to protect themselves, this amounts to a “Just say No” campaign. It leaves women vulnerable to blame for unplanned pregnancy and birth defects in their babies, and to charges of non-compliance that could be misinterpreted as evidence of low health literacy.

Don’t get bit
A better message, free of gender bias, understandable and actionable, is to avoid mosquito bites. CDC has issued Level 2 travel advisories  (for all, not just pregnant women) for the Caribbean, South and Central America, Puerto Rico, Cape Verde, Samoa and Mexico.  Travelers are advised to “practice enhanced precautions”. In this case,

•       see your doctor before and after travel to areas where Zika is active
•       Use insect repellant (safe and effective for pregnant women)
•       Wear clothing to cover as much of your body as possible
•       Sleep under a mosquito net
•       Keep doors and windows closed or screened
•       Avoid standing water 
 
Important Notes:
The offending mosquitos bite in the morning, not just late afternoon and evening like other skeeters. 
 
The infection lasts only a week or less. The danger is only to a current pregnancy.  There is no danger to future pregnancies.
 
 
Resources:

US Centers for Disease Control and Prevention www.cdc.gov/zika. Information is being updated regularly

Parents’ “Health Learning Capacity” Are we moving beyond reading difficulties?

Seeking effective intervention to improve health literacy in parents, in 2009 leading US health literacy authors recognized the need to expand medical academia’s focus beyond reading difficulties. Clearly, intervention to improve health literacy requires a broadened perspective. Because when the problem is perceived as reading difficulties, intervention can only aim to make information easier to read (been there, done that, for decades now),  or increase parents’ reading ability (still no pill for that).

Drawing on research from education, cognitive science and psychology, Michael Wolf, Terry Davis, Rima Rudd and colleagues proposed a research agenda to address what they call parents’ “health learning capacity”.  In the seven years since its introduction this added conceptual layer, along with repeated calls for the field to move beyond documenting patients’ and parents’ low literacy, have not changed the direction of research.

Thought leaders described health learning capacity, as “the constellation of cognitive and psychosocial skills from which families must draw to effectively promote, protect and mange health”. In particular, learning capacity includes self-efficacy,  listening and speaking, motivation and questioning. This sounds a lot like the World Health Organization’s 1998 definition which Renkert and Nutbeam (2001) adapted to describe maternal health literacy as “the cognitive and social skills which determine the motivation and ability of mothers (parents) to gain access to, understand, and use information in ways that promote and maintain their health and that of their children”.   

This health promotion perspective on health literacy was roundly rejected by health literacy researchers in US academic medical centers as too broad, messy and unmeasurable; it “diffuses thinking on the matter”.  This may be why the authors presented “health learning capacity” as a new concept related to reading ability in a medical setting, rather than suggest adoption of the established broader health promotion definition.

“Health learning capacity” recognizes reading skill (functional literacy) is insufficient to promote, protect and manage personal and child health. Proponents call for interventions to improve parents’ psychosocial skills (social and communication skills), which Nutbeam called interactive skills.  Still, proponents reject the few reported interventions as too broad and continue seeking a single reproducible strategy to remedy the “true cause” of health literacy’s effects on clinical outcomes. But a massively multifactorial capacity like health literacy has no one true cause, and no one true remedy. Rather, to promote parents’ health literacy we need to find the right combination of factors that address a particular family’s complex and dynamic “real life”, not just their ability to communicate with doctors. Further, the randomized controlled trial is still considered the “true path” to the discovering the “true cause”. However, the RCT aims to isolate the effects of a single factor.  Where the true cause is a dynamic combination of personal, social and environmental factors, an RTC is likely to prove that no single factor works.

Proponents hoped that the idea of health learning capacity would refocus research on how parents actually obtain process and understand information. Findings would  better guide continued simplification of information and services. But reducing barriers for people with low literacy does not improve their health literacy, it only reduces the need for health literacy.

The still missing  research question is how parents use information for health. What enables a parent to transform their understanding and decisions into desired actions and outcomes? Part of the answer is what WHO and Nutbeam describe as critical health literacy, the critical thinking used along with functional and social skills to ask questions, set goals, make plans, marshall resources, assess progress toward health and quality of life. The range of health literacy skills: are used together and all are required to protect, promote and manage health. The health learning capacity concept expands thinking from purely functional literacy skills (reading,math) to include interactive (psychosocial) skills, but leaves out the empowering critical skills. 

Long term, the proposed research agenda calls for education reforms to train more health literate future generations. This suggestion is at once troubling and easy. Its troubling because it assumes adults’ reading and other cognitive abilities are not modifiable in a clinical setting, which means health literacy cannot be improved — so the only course is to reduce literacy demands in the system, and hope the children grow up to be more skilled. This underestimates and disempowers patients and parents. It implies what is needed for the healthcare system to work is a smarter patient.
The goal of better health education in the schools is easy.  All that is needed is the political will. The work is done. Health literacy standards and curricula are already defined. They have been and remain de-funded. 

Health literacy as a field is moving away from describing the problem of low health literacy, toward removing barriers to understanding health information and services.  Intervention to improve parents’ health literacy and child health outcomes is still hamstrung by focus on parents’ cognitive deficits and the perception that improvement is not possible.   

Reference
Wolf MS, Wilson EAH, Rapp DN, Waite KR, Bocchini MV, Davis, TC, & Rudd, RE. (2009). Literacy and Learning in Health Care. Pediatrics124 S3; s275-281. 

Further reading on maternal health literacy improvement

Health Literacy and Depression in the Context of Home VisitationSmith, S. A., & Moore, E. J. (2012).Maternal and Child Health Journal 16, 1500-1508.

The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education.Carroll LN, Smith SA & Thomson NR. (2015)Health Promot Pract. 2015 Mar;16(2):282-90. doi: 10.1177/1524839914538968. Epub 2014 Jun 23 www.ncbi.nlm.nih.gov/pubmed/24957219

Maternal Health Literacy Progression Among Rural Perinatal Women Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014). Maternal Child Health Journal 18: 1881-1892.

Comparing Child and Family Outcomes Between Two Home Visitation Programs

Haynes G, Neuman D, Hook C, Haynes D, Steeley J, Kelly M,Gatterdam A, Neilson C, Paine M. (2015). Family and Consumer Sciences Research Journal 43 (3):209-228.

Health Empowerment: the act-ive ingredient health literacy

Health literacy refers to a person’s ability to use information and services for health. (More definitions) 

Using information for health implies three steps: 
1) Understanding, that is, decoding the words
2) Making personal meaning, that is, reflecting on the question: What does this mean for me in my situation with my resources, my family, my beliefs, my values?
3) Acting, that is, making choices and turning those choices into desired actions and health outcomes.

These steps coincide with three steps in problem solving, 
which I’ve described previously as The Three-Step Dance

1) What do you want?  For example, a woman decodes information in Beginnings Pregnancy Guide. She understands smoking can harm an unborn baby.

2) What have you got?  She acknowledges that she has a pregnancy, and a smoking habit that she enjoys and that relieves stress. She has a husband who smokes and a mother-in-law who smoked through her pregnancy and has a son who turned out fine. She has a budget already stretched, a friend who’s been after her to quit, and a doctor who’s offered some aids.  Through self-reflection and discussion with family, friends, experts she makes personal meaning from the information.

3) What’s Next? She makes a choice (decision) not to act  or to take action — some small step that she is willing and able to do now to move toward her chosen outcome — a healthy baby, which she understands requires a smoke-free womb. 

It is the action (or inaction) that affects the outcome. 
The first two steps in using information for health, and in addressing a health problem, are “all in your head”, a purely cognitive exercise with no health effects. 

What’s empowerment got to do with it?
Take another look at Step 3 in using information for health:  making choices and turning those choices into desired actions and health outcomes.  This is the World Bank’s definition of empowerment.  And the “Three-Step Dance” is the process of empowerment described by David Emerald in his book The Power of TED* The Empowerment Dynamic.

Empowerment is the act-ive ingredient in health literacy.  Without it, it’s all in your head. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” ~Goethe    


Note the Goethe quote is typically featured in the front matter of reports from the Academy of Medicine (formerly the Institute of Medicine). It is often attributed to Bruce Lee, but  Goethe said it first)

Further Reading 
Alsop, R. & Heinsohn, N. (2005) Measuring Empowerment in Practice : Structuring Analysis and Framing Indicators. World Bank. Free online: https://openknowledge.worldbank.org/handle/10986/8856


The Power of TED by David Emerald - YouTube  https://www.youtube.com/watch?v=t5hSa16FX94

Time to Acknowledge our Biggest Barrier to Health & Health Literacy

Can you name it?
It doubles+ the risk of eight of the ten leading causes of death, which account for about 75% of the $3Trillion Americans spend on healthcare annually. It explains half of learning and behavior problems in children. It is prevalent in all sectors of society, at home and around the world. It meets the criteria for a public health crisis. Can you name it? 
 
It is ACEs — Adverse Childhood Experiences. I’ve written here before about ACEs. I’ve said that anyone working in maternal-child health, or early childhood education, K-12 education, child care, chronic disease, or health literacy needs to know about the lasting destructive power of ACEs. 
 
But, after participating in the 30th Zero To Three national conference held last week here in Seattle, I understand ACEs are not just another related issue we should be  tracking. It is time to acknowledge and address ACEs as the biggest barrier to personal and public health, and to improving heath literacy. As keynote speaker, pediatrician Nadine Burke Harris says, “ We — all of us — are the solution.”
 
Work in all the many fields that aim to build a strong foundation for healthy child development is futile where ACEs cause that foundation to crumble and leave children physically, mentally, and emotionally predisposed to impaired cognitive and emotional development, and to adulthood defined by diabetes, obesity, heart and lung diseases, cancers. In the context of health literacy, unacknowledged ACEs must be viewed as a looming barrier to health across the lifecourse, to literacy, and to effective participation in healthcare and society. It is a multigenerational problem. A mother with unaddressed ACEs cannot buffer her child from ACEs. 
 
Early years last a lifetime, for better or worse, by default or by design. ACEs are the worse-by-default part that Zero To Three mantra.  By definition an Adverse Childhood Experience occurs in childhood (< age 18) and the person remembers it as an adult.  Here are the nine types of ACEs:
* physical abuse
* sexual abuse
* emotional abuse
* mental illness of a household member
* problematic drinking or alcoholism of a household member
* illegal street or prescription drug use by a household member
* divorce or separation of a parent
* domestic violence towards a parent
* incarceration of a household member
 
Why ACEs matter so much for so long 
These are more than unhappy memories. A baby’s brain is only partially (about 25%) developed at birth so that it can be wired to enable the baby to survive in the environment into which s/he is born.  Babies absorb everything they see, hear, feel and otherwise experience. Those experiences tell the brain what to expect and how to be ready for it. By Baby’s first birthday, brain wiring is 70% complete, by age 3, it’s 85% wired. So the earlier the experience, the greater and more lasting it’s impact.

With repeated ACEs, four or more of the listed experiences, or the same experience repeated frequently, the brain and all the body systems get stuck on high alert; living in a crouch, always expecting something bad to happen. The Fight, Flee or Freeze mechanism is designed as an emergency response system. When danger is past, it is supposed to switch off so the body returns to a normal relaxed state. When it is stuck in the On position, little energy and attention are available for learning and cognitive development. Self-regulation becomes a strident challenge; behavioral problems ensue. Eventually, the wear and tear of constant stress on the body’s systems manifest as non-communicable adult disease.  The leading causes of adult deaths worldwide have their origins in early development. In ACEs.
 
Resources & Reference:
 
This from Beginnings Guides Tools for Serving Families  http://www.beginningsguides.com/Tools-for-Serving-Families.html

Find your ACE Score: See how ACEs have affected you.  Use the questions to generate a reflective conversation with a mother about her ACEs and their impacts on her life and parenting.  Testing shows the questions do not spur trauma or need for professional help.  Download the questionnaire 
Read the research: www.acestudy.org
  
View Dr. Burke Harris’ TED Talk “How  childhood trauma affects health across a lifetime”

Next: How we can use information about Adverse Childhood Experiences

Improve Health Literacy in Poor Communities: Start a literacy program

Health Literacy: An economic issue
In the US, literacy has long  been addressed as an economic issue, a pre-requisite for a productive workforce in a competitive global economy.  Some scholars argue that political campaigns to address adult low literacy have been undertaken repeatedly in the US and elsewhere to explain or distract from economic downturns, most recently in 1991 by  GH Bush.[1], That campaign produced the the 1992 National Adult Literacy Survey. Results led academic medical researchers to discover a glacier in their backyard — the fact that few Americans understand information from doctors or  insurers.  The first health literacy studies in the medical literature came out in 1993. 

Workers' low literacy as an explanation for national economic woes extended to patients' low literacy as an explanation for low quality, high costs and inequities in healthcare.  Health literacy was understood as low functional literacy (reading and numeracy) in a clinical setting. The thinking went like this: if patients could read better, they would better understand their disease and treatment instructions, and so comply. Outcomes would improve and we would avoid unnecessary expenses like ED visits,  re-testing and re-admissions. That thinking led to much needed information-improvement initiatives.
 
High demands of complex systems increase negative impact of low skills
Recent policy documents acknowledge patient's ability to understand and use information for health is determined not only by their personal skills (or lack of them) but also by the demands and complexities of healthcare systems [2] . That recognition is leading to initiatives to redesign services and remove barriers to access and participation.
 
Literacy: A health issue
In a new leap forward in thinking about HL, the National Academy of Medicine (formerly IOM) has released a discussion paper suggesting that a person's HL is also determined by the demands and complexities of their home and social context. [3] This makes HL a public health issue, a pre-requisite for an equitable health system, and  key to reducing health disparities.
 
Healthcare organizations should lead adult  & family literacy efforts
It is becoming clear that literacy is not just an economic issue, but a matter of personal and public health. There is no getting around the fact that health and literacy are inextricably linked. More literacy —  more health, and more health literacy.  In communities where low literacy is the norm, where high school graduation rates are low and schools are poorly funded —these are the same communities with high incidence of asthma, diabetes, cancers—, healthcare organizations should establish, house and and actively support adult literacy and family literacy programs. High returns can be expected from a relatively low investment. Such a program can make good use of facilities that typically are vacant in the evenings and on weekends; and provide good marketing opportunities while building the community's capacity for health and making participants more prudent healthcare consumers. A healthcare-based  literacy program  that incorporates health education and health literacy improvement can make everything easier and more efficient for the participants and for the organization that provides their healthcare.

The Gift of a Reflective Question

Reflective questioning is an alternative approach to educating and informing mothers. While the goal of 
educating and informing is to increase knowledge; the goal of reflective questioning is to empower mothers
to use knowledge for their personal benefit.  

The World Bank defines empowerment as the ability to make choices and transform those choices into desired 
actions and outcomes.  A good reflective question begins a conversation that leads the  mother through a process 
of getting from information to action to outcome. A reflective conversation opens opportunity for the mother to 
think about and articulate:

1)    What she wants (If this pregnancy turned out perfectly, what would it look like?);

2)    What she's got (What have you tried?  How have you been able to cope? How is  that working for you? What's 
       missing? Who can help? Since you've been pregnant, how are you stronger?)

3)   What's next (You say you're at 3 now, what will it take to get to 4? What might be a first step? How will you 
      know you're ready?)                                    

As one parent educator explained, "Parents have their own answers. We just need to ask questions to get them 
thinking."

(c) Practice Development Inc  All rights reserved.

Improve Health Literacy in Poor Communities: Start a literacy program

 
Health Literacy: An economic issue
In the US, literacy has long  been addressed as an economic issue, a pre-requisite for a productive workforce in a competitive global economy.  Some scholars argue that political campaigns to address adult low literacy have been undertaken repeatedly in the US and elsewhere to explain or distract attention from economic downturns, most recently in 1991 by  GH Bush[1], That campaign produced the the 1992 National Adult Literacy Survey. Results led academic medical researchers to discover a glacier in their backyard — the fact that few Americans understand information from  healthcare organizations, doctors, pharmacists, and health insurers. The first health literacy studies in the medical literature came out in 1993. 

Workers' low literacy as an explanation for national economic woes extended to patients' low literacy as an explanation for low quality, high costs and inequities in healthcare.  Health literacy was understood as low functional literacy (reading and numeracy) in a clinical setting. The thinking went like this: if patients could read better, they would better understand their disease and treatment instructions, and so comply. Outcomes would improve and we would avoid unnecessary expenses like ED visits,  re-testing and re-admissions. That thinking led to much needed information-improvement initiatives.
 
High demands of complex systems increase negative impact of low skills
Recent policy documents acknowledge patients' ability to understand and use information for health is determined not only by their personal skills (or lack of them) but also by the demands and complexities of the healthcare system [2] . That recognition is leading to initiatives to redesign services and remove barriers to access and participation.
 
Health Literacy: A health issue linked to individual & community context
In a new leap forward in thinking about HL, the National Academy of Medicine (formerly IOM) has released a discussion paper suggesting that a person's HL is intrinsically linked to an individual’s and a community’s socio- economic context, and is a powerful mediator of the social determinants of health [3].  This suggests health literacy is  strongly influenced  by the demands and complexities of the home and social context. It makes HL a public health issue, a pre-requisite for an equitable health system, and  key to achieving health equities. At a recent IOM workshop, experts discussed the role of the social determinants of health in health literacy and the need to move health literacy intervention into the community [4]. (Can you hear me applauding?)
 
Healthcare organizations should lead adult  & family literacy efforts
It is becoming clear that literacy is not just an economic issue, but a matter of personal and public health. There is no getting around the fact that health and literacy are inextricably linked. More literacy —  more health, and more health literacy.  In communities where low literacy is the norm, where high school graduation rates are low and schools are poorly funded —these are the same communities with high incidence of asthma, diabetes, cancers—, healthcare organizations should establish, house and  and actively support adult literacy and family literacy programs. High returns can be expected from a relatively low investment. Such a program can make good use of facilities that typically are vacant in the evenings and on weekends; and provide good marketing opportunities while building the community's capacity for health and making participants more prudent healthcare consumers. A healthcare-based  literacy program  that incorporates health education and health literacy improvement can make everything easier and more efficient for the participants and for the organization that provides their healthcare.
 
References
1.     Hourigan, M.M. (1994). Literacy as social exchange: Intersections of class, gender, and c Albany, NY: State University of NY Press.
2.     Logan, R. (2015). Health literacy research’s growth, challenges and frontiers in C. Arnott-Smith and A. Keselman (Eds.). Crucial conversations: Meeting health information needs outside of healthcare. New York: Chandos, In Press.
3.     Health Literacy: A Necessary Element for Achieving Health Equity. Robert A. Logan, Winston F. Wong, Michael Villaire; Gem Daus,Terri Ann Parnell, Earnestine Willis & Michael K. Paasche-Orlow, Full text at: http://nam.edu/perspectives-2015-health-literacy-a-necessary-element-for-achieving-health-equity/   
4.     Health Literacy: Past, Present, and Future: Workshop Summary. Joe Alper, Rapporteur .
This PDF is available from The National Academies Press at http://www.nap.edu/catalog.php?record_id=21714

Quick easy cheap health literacy aid

My Dad was in the hospital this week.  I found this laminated sheet on the counter at the nurses station. 
Patients, family and visitors with LEP —limited English proficiency—  or a problem speaking could just point
 to a picture to indicate  what they need.  A great simple idea that could save time and stress for all, including 
nurses who get to answer all those questions and requests.  I’m disappointed that in this rural community 
with a large Spanish-speaking population all the people pictured are white, well and handsome. The well-coifed 
woman eating is wearing a dress and pearls; she is clearly not from around here. And all the words are in English. 
If the clip art more closely reflected the community and the text was bilingual you could hear me applauding. 


What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?

This question was raised by Winston Wong, Director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, during the Institute of Medicine's recent workshop, Health Literacy: Past, Present and Future.
The workshop marked 10 years since  IOM released the landmark report Health Literacy: A Prescription to End 
Confusion.  A summary of the workshop proceedings was released this month. Download a summary of the 
workshop free from National Academy of Sciences. Definitely worth the read.

Here's the part that made me stop and applaud

In a discussion about health literacy and its role in achieving equity, Wong  recounted a conversation among
health plan leaders on patients' non-medical needs (social determinants of health), that led to the question: 
What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year? 
“One interesting proposition is that we should start the discussion with every person we come in contact with 
by asking 'what does a good day mean to you,’" Wong said,  "because that’s really a much more important 
question than ‘what hurts’ or ‘have you been taking your medicine today.’”

Why is this question more important than typical problem-focused inquiries?

It's empowering.
Wong said it reflects the fact that medicine can help with some problems, but what ultimately makes for a 
good day for someone is determined by a constellation of actors that foster good health. The question 
recognizes that on average Americans spend about one hour per year in a clinical setting; the healthcare 
professional is just one actors; s/he marshals resources that account for about 10% of health.  The other 
actors are the people the individual is with the other 8764.81 hours per year. The power to create health, 
and to live well with disease, is with the patient.

What is a good day like for you? addresses the person and his/her "real life",  instead of focusing narrowly
 on the patients' disease and treatment. It suggests the patient's selfcare is achieving some good days, rather 
than reducing the person to a medical problem and assuming that s/he has failed to comply with the medication
 regimen. 

What is a good day like for you? is a good reflective question.

> It cannot be answered yes or no. It requires the respondent to think critically about what matters to them,
 to reflect on what they want from medical care and how they will know they got it. It leads to conversation 
about what the person is able and willing to do now to achieve more good days.

> The response serves the patient, rather than simply informing the clinician.

> The response enables the clinician to hear and adopt the patient's words, so the patient is not expected 
to learn medical terminology, and the clinician is not expected to check a glossary of simplified terms.

>  The question allows the patient to figure out and articulate what they want and need, making it easier
 for the provider to achieve patient satisfaction.

> It shifts thinking and conversation from what patient and clinician do not want — disease and suffering— 
and how to get rid of it,  to what they do want —good days— and how to get more of them.

The hard part is waiting for the response

Patients are not accustomed to being asked reflective questions, especially by clinicians. Many, especially 
those who live in poverty and face daily discrimination, are rarely asked questions and may be trained not 
to think.  The reflexive first response is likely to be "I don't know".  They need a way to think about it. Try 
again; Can you remember a good day or a good moment?  Then the hard part: wait.  Let them be the one to
fill the silence.  Ask follow up questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good days. An effective
conversation will end with the patient articulating the action s/he will take and the clinician offering 
supportive information and services.

More on reflective questioning

Reference & further reading:
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active Policy Attention
To Health Promotion Health Affairs, 21, no.2 (2002):78-93 doi: 10.1377/hlthaff.21.2.78   Full text online at http://content.healthaffairs.org/content/21/2/78.full.pdf
 

 

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