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Research guides practice; practice guides research. Health professional education for resource -constrained practice
Evidence to Practice: Induction of Labor Rate Falling
New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.
CenteringPregnancy Health Literacy Trial Underway
Sunday is Mothers’ Day.

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Beginnings Guides Blog

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. 
 
 
 

Evidence to Practice: Induction of Labor Rate Falling


My mother was expecting her first child. She was due in late July. Her OB was due to be on vacation. So he induced labor July 9.
 
That was 65 years ago.  But the story, and the disconnect between the body’s wisdom and medical practice is not out of date.
 
Induction of labor became more and more common, despite increasing evidence of the risks of preterm birth; 23 years later, my labor was induced. The doctor said it was time.  Over the last 20 years, the induction rate increased every year to 23.8% in 2010.
 
Finally, practice is beginning to follow the evidence. New data show the national rate of inductions began inching down in 2011 to 23.5% in 2012, the latest available figure.
 
"Pregnancy lasts 40 weeks...Labor should not be induced before 40 weeks except for medical reasons." 

"If your doctor talks to you about inducing labor, ask if you can wait until week 40."

Beginnings Pregnancy Guide


The good news is in induction rates for “late preterm” (34-36 weeks gestation) and “early term” births (37-38 weeks). Those rates started downward in 2006, with the greatest improvement (decrease)  at 38 weeks. In 36 states and DC, inductions at 38 weeks have been reduced by 5% to 48%.
 
The national  rate is down 12%. The number births at >39 weeks gestation is up 9%.
 
The bad news is disparities continue. Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only 3% for blacks.

Questions for research: How did the state that reduced its rate by  nearly half do that?  What is different about the states that reduced their rate by 30% or more —UT, ND, SD and NE— and  states where the rate continues to increase—AK, NY and NC?
 
Source: Osterman MJK, Martin JA. Recent declines in induction of labor by gestational age. NCHS data brief, no 155. Hyattsville, MD: National Center for Health Statistics. 2014.
 

New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.


 
In a reversal of its recommendations that have for years cautioned against children and pregnant or breastfeeding women eating fish, the Food and Drug Administration’s new guidelines reflect recognition that fish is a great source of protein and other essential nutrients. For the first time, the FDA has specified a minimum intake of fish and other seafood.
 
8 to 12 ounces per week— 2 or 3 servings
That’s the new minimum recommendation for a healthy diet. Beginnings Pregnancy Guide (2014) recommends 1 or 2 servings per week, the previous maximum recommendation, now considered overly cautious.
 
The warning to avoid large, long-lived fish like swordfish, mackerel and tile fish remains. Those big fish live long enough to build up organic mercury in their flesh. According to MedlinePlus, medical evidence suggests that being exposed to large amounts of the organic mercury called methylmercury while pregnant can permanently damage the baby’s developing brain. Small exposures are unlikely to cause any problems.
 
Choose canned light tuna
Salmon, shrimp. and other seafood that Beginnings lists as safe and healthy, are still safe and healthy.  It is important to caution mothers against canned white albacore tuna since it has three times the mercury of the recommended canned light tuna. The FDA suggests limiting tuna to 6 ounces a week.
 

Beginnings Pregnancy Guide (2014) pg. 13

Use the Fish Safety Hotline
Call 1-888-SAFEFOOD That’s 1-888-723-3366 to check the safety of fish in your area. This free 24 hour resource is listed on the Pregnancy Guide’s Key Messages Poster and on page 42.

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 Guide using 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 2Table 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.

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

        

Example from the field: Medication instructions show lots of room for improvement

My dad, age 86,  was hospitalized with arrhythmia. Hospital medical staff said his heart muscle looked strong and undamaged, but later another doctor said he had a minor heart attack. Dad was sent home with several medications with instructions to stop all his usual meds - including the multivitamin, and the stool softener prescribed by his internist. The hospital  nurses could not answer why those should be stopped…  Three days later Dad quit taking the new meds. He said they made him sleep 20 hours a day, and made him stupid when he was awake.  Worried, Mom set an appointment with his personal physician who adjusted the meds, lectured him about the danger of stopping them, and gave him this summary of new instructions.

 New Medications

 Medications to Continue Taking That Have Changed

     Other Medications
     START: amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) Oral, every day. Refills: 0
     STOP:  amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) 2 times a day. Refills: 0
 
 Medications to Continue with No Changes
     Other Medications

     aspirin (Aspirin Enteric Coated 325 mg oral delayed release tablet) 1 tab(s) Oral, every day, Refills: 0
    
     dufoxetine (Cynbalta 60 mg oral delayed release tablet) 1 cap(s) Oral, every day. (do not crush or chew). Refills:0

 No Longer Take the Following Medications

     digoxin 125 mcg (0.125mg) oral tablet) 1 tab(s) Oral, every day. Refills: 0

     metoprolol (Metoprolol Tartrate 25 mg oral tablet) 1 tab(s), Oral, 2 times a day. Refills: 0

 Contact your Physician Prior to Taking the Following Medications

     None

 Problem List
 No problem found

 Upcoming Appointments
 No appointment


While the summary shows good intent to inform the patient, it could be much easier to read, understand and act on.

1.     Delete the static 
Too many irrelevant words interfere with efforts to find the important information. The first heading  New Medications is meaningless. It amounts to static interference.  The information about meds to start and stop fits under the third heading:  Medications to Continue Taking That Have Changed; but an indented  subhead - Other Medications- is inserted between - more static. It’s another empty field on the form. These headings should automatically delete when the field is left empty.
 
2. Use upper and lower case. All the headings are in title case - all the words are capitalized. A capital letter signals the brain to stop and start something new. We recognize words by their shape. The cap changes the shape, and so slows reading and reduces comprehension.  It is odd that the proper names of the medications are not capitalized, but then in parentheses they are.
 
3. Use active voice and a verb in instructions. Medications to Continue with No Changes is a label.  A call to action is more understandable and actionable:   Keep taking these medications with no changes:
 
4. Make the changes clear. The information under START and STOP is very similar. It requires careful examination of every word and symbol to discern that the instruction is to take one a day instead of two. Few understand mg. Many do not understand oral, or tab(s), or the difference between cap(s) and tab(s),  or the meaning of delayed release.
 
5. Explain when to take the medication. What does 2 times a day mean? Before breakfast and after breakfast would comply with the instruction, but that might not be what the prescriber intends.
 
6.Use the Problem List (it’s a nice table on the form with cells for Onset and Comments). This would be a good place to give the patient and caregiver information about what these drugs are for.  The entry No problems found could leave one wondering why they are taking all this medication, and whether they should have seen the doctor.
 
7. Use the Upcoming Appointments form (another nice table with cells for date, time, location, appointment type(??) and provider.  The entry is No Appointment; but Mom has written in April 10, 1pm.
 
This form reflects an effort to be patient centered and improve compliance. But it is designed for ease and speed of entry by the provider, rather than for ease of understanding and right action by the patient and caregiver.  

 

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.

The 7th Attribute - Navigation Assistance

“Health literate health care organizations design health care facilities with
features that help people find their way.”
 
So says the Institute of Medicine’s Ten Attributes of Health Literate Health
 
My Dad  -he’s 86 - was admitted to the hospital last Thursday with chest
pains. My mother and sister sat with him that night. He woke often, agitated
and not knowing where he was,  determined to get out of bed. Friday morning,
mom was exhausted, so I took over the vigil. Dad had another difficult night
that he will not remember, but I will. On one of his many awakenings, he had
removed his gown and ripped off all the electrodes in the seconds it took me
to get to his side. It was a total role reversal with me telling my father he had
to stay in bed.
 
About 4AM, he finally settled into a sound sleep. At 5AM, I let the nurses know
I was going to get some air and would be back shortly.  I exited the main entrance,
breathed deeply, walked across the icy parking lot and back to the door. It was locked.
 
Seeking the Emergency entrance
A sign board visible only from outside read “Exit Only - Enter at Emergency Department”.
But there was no indication where the Emergency entrance is located. I walked more than
a block in one direction until I reached what looked like the the maintenance buildings,
thinking, “It can’t be this far; there must be lights.”  I retraced my steps back to the main
entrance starting to feel the below-freezing temperature and to worry about my safety. I
proceeded in the other direction.  I found another entrance, with the same sign.  I kept
going and found a third entrance, with the same sign. This one had an arrow, but it pointed
into a dark space between buildings - no ER in sight.
 
The locked doors seemed an obvious and important security measure.
But my security was at risk wandering around in the dark and cold. I could easily read and
understand the sign. But it was not an aid to navigation.  I decided to wait it out in my car,
but the keys were in the building.
 
 Lucky for me, before long, I  encountered two nurses coming in for early morning surgeries.
They had a card key and let me in the third door. when I promised not to tell.  They said,
“The ER is waaaay down that way”. One of them started to lead me there. It took a bit to
explain I did not want to go there, I only needed to get in the building. 
 
Easy to be more health literate
This hospital would easily become a more health literate organization by improving its signage
to include ‘navigation assistance”. And by making the Exit only”  signs visible from inside so
they can be seen on the way out.  Then the nurses would not have had to take surgery-prep
time to help me.  And there would be less risk of incidents that no one wants to happen. As
a former hospital public relations officer, I know all sorts of untoward events might have
occurred out there in the parking lot.
 
This hospital would score well on most of the Ten Attributes.  Perhaps this is a case of assuming
that “everyone knows” where the Emergency entrance is, and that  all other doors are locked
during certain hours.  But everyone does not know. And the ED needs to be easy to find. I checked
again in daylight and still saw no signs for the ED, except from the road.
 
Pretend you are from Mars, and go look at your signage. Can you see it where  you might need it.
Does it tell you how to get where you need to be?
 
 PS Dad is home, recovering well. I am grateful for good care. Nurses rock.
 

CORRECTION: The discussion paper posted here yesterday

CORRECTION: The discussion paper posted here yesterday- Health Literacy as an Essential Component to Achieving Excellent Patient Outcomes -  was not commissioned by the IOM as I stated.. It was announced in the IOM newsletter. As indicated in the note accompanying the paper “The views expressed in discussion papers are those of the authors and not necessarily of the authors’ organizations or of the IOM. Discussion papers are intended to help inform and stimulate discussion. They have not been subjected to the review procedures of the IOM and are not reports of the IOM or of the National Research Council.”
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