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Health Literacy: Time for a new question
Stay strong, Mothers
Health Literacy for the Third Era
Health Literacy & Maternal Health Literacy: What’s the difference?
Health Literacy Month: Time to think about your furnace

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Health Literacy: Time for a new question

What causes disease?
For 200 years,  Western medicine has worked from the idea that health is the absence of disease. 
The overarching question for medicine and healthcare has been What causes disease?  And despite
the name, healthcare has always been about treating disease. Early on, care and research focused 
on germs and infectious disease; later , following the research, focus shifted to genes and risk factors 
for chronic disease. Although it is now widely accepted that health is more than the absence of 
disease,  Public Health, and even the relatively new field of Health Promotion, still maintain a steady 
focus on reducing disease risk factors. It’s time for a new question.
 
  Prerequisite for Health:
  • Peace
  • Shelter
  • Education
  • Food 
  • Income
  • Stable eco-system
  • Sustainable resources
  • Social justice
  • Equity
                      Ottawa Charter
Research has answered, in broad terms, the centuries old question. 
The roots of disease grow deeper and earlier than germs or genes and 
risky lifestyles. It is well-established that health and disease originate in early development, in the “zero to three”, prenatal to preschool period. The 
combination of Nature (genes & germs) and nurture (early parenting and environment) in the earliest months and years of life establish the foundation
for all that follows:  how susceptible we are to disease, how resilient we are,  
and further, how we learn, make friends, cope with challenges, and get
what we want. 
 
Research breakthroughs have  given health a new broader meaning that is
 expressed and accepted more internationally than in the US.  See the
Ottawa Charter  and the World Health Organization’s Health Promotion Glossary (1998)
 
It is now clear that health and disease originate in early development; and that health, like disease,
develops over time and its trajectory can be influenced, especially during fetal and early child 
development and other critical periods of development. That understanding demands that we flip 
the overarching question to ask, What causes health? And to flip the concentration of resources from
end of life care to maternal and child health promotion.
 
What causes health literacy?
Most health literacy research has taken place in US academic medical centers under the old overarching 
question asking, What is the role of low literacy in disease? It is important to note  that this research
also uses an outdated understanding of literacy as reading ability. This line of research has established
that few Americans understand medical terminology and nearly all of us have difficulty following complex
medication regimens and navigating the complexities of healthcare and insurance. 
 
If we start with the new overarching question: What causes health?, then a more actionable  question for 
health  literacy promotion is What will empower this person to use information and services for health?  
The answer, that which empowers a person to use information and services for health, is health literacy.   
Better information is necessary, but rarely sufficient. Look to the Prerequisites for Health (above) to see 
other factors necessary to develop  health and health literacy.
 
 
References
 
Antonovsky A. (1996). The salutogenic model as a theory to guide health promotion Health Promotion
International 11 (1);11-18
 
Halfon N, Larson K, Lu M, Tullis E & Russ S. (2014). Lifecourse Health Development: Past, Present and Future.
Maternal Child Health Journal 18:344-365.
 
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67, 2072-2078.
Shonkoff, J. P., & Phillips, D. (2000). From neurons to neighbourhoods. The Science of Early Childhood 
Development,: National Academy Press: Washington DC.
 
 
 
 

 

Stay strong, Mothers

Today I am sending love and light and courage to all mothers of black sons; their hearts must be in their throats. Every day. All day. But especially today.  Because racism in America is so not not a thing of the past.
 
The American justice system has again declared that its okay for an adult white man with a gun to kill an unarmed black teenager because the adult is afraid.  It is one highly questionable shocking thing for an untrained, self-appointed vigilante alone in the dark to claim a level of fear that justifies killing - and have the courts uphold that claim. The Ferguson incident is something  different, more frightening, dangerous and depressing.
 
I don’t know what happened in Ferguson.  But one must question how a trained police officer, pledged to protect citizens, inside his vehicle with a gun and backup on the way,  facing a teenager with only cigarillos in his hand,  whose crimes are lifting a handful of tobacco products from a convenience store and walking in the street —  how can that officer be so afraid and so without options that he must shoot to kill. Multiple times. Before backup arrives.
 
We have to ask, why are the Ferguson police so afraid of those it is their duty to protect?  Do they receive no training in race relations, or conflict resolution, in take down and control, in any form of self-defense that does not rely on lethal weapons?
 
Racism is fear of someone who does not look like you.  Fear as a legal justification for police shooting down citizens in the streets institutionalizes racism. Fear as justification for transforming a grand jury into a secret trial for the killer further institutionalizes the racial divide.
 
Divided we fall. A people living in fear of each other cannot achieve optimum health, or high productivity, or spiritual advancement, and certainly not liberty and justice for all. 
 
My hope lies with the mothers and fathers and spiritual leaders in Ferguson and across America who call upon themselves, their sons  and their neighbors —yet again— to be the ones to demonstrate restraint under pressure, to practice non-reaction when provoked,  to keep thinking in the face of fear,  to live up to being an American.  Stay strong, Mothers.

 

Health Literacy for the Third Era


The third era of healthcare
It started in the 1980s. Epidemiologists —they study how disease is distributed and controlled— 
realized that events and experiences we have in the womb —before we are even born—influence 
our health in middle age.  Discovery of the “Developmental Origins of Health and Disease (DOHAD) 
is what they mean by landmark research; it marks a turn that requires a new way of defining 
and measuring health, and a second transformation of healthcare services.
 
Halfon and colleagues trace the evolution of healthcare from the first era —1900-1950— 
when medical and health systems focused on germ theory and acute care of infectious disease. 
Around 1950,  gene theory and social research led to bio-behavioral theories that said disease 
results from the interaction of genetic make-up and adult health behaviors.  So the second 
era of healthcare refocused thinking and resources on chronic disease. Health promotion 
tried in vain to change adults’ risky behaviors.  Later researchers recognized that gene 
networks interact with each other and the environment in complex and dynamic ways that 
influence how our bodies and minds are engineered and re-engineered to function in our 
environments. This is when we started talking about the social determinants of health. 
 
Developing Health
By 2000, the synthesis of biological, behavioural and social sciences led to the slowly emerging
third era of healthcare where your doctor will focus less on chronic disease diagnosis and treatment 
and more on lifecourse health development.  The goal of Medicine will be to optimize your health
trajectory — the way your health plays out across your lifecourse, from preconception through infancy, 
childhood and on to old age.
 
Redefining Health
Thought leaders now are talking about health as a capacity—an ability or power to understand, experience 
of do something.  Health is used to achieve one’s potential and accomplish one’s goals.
 
Clarifying the Health-Literacy Link
The evolved concept of health is strikingly similar to current descriptions of literacy as an ability used
to achieve ones potential and accomplish one’s goals, to function in some social context. In other 
words, you’re healthy and literate when you function — interact successfully— with your environment. 
We could say further, you are health literate when you interact with your environment in ways that 
optimize your health.
 
Context Matters. Embrace Complexity
Transition to the third era of health care requires refocusing heath literacy research and practice on 
the environment in which health and disease develop, that is, on the context in which people make 
meaning from  information and use it for health and healthcare decision making and action. The  
goal of health literacy promotion for the third-era is to optimize a person’s or a community’s health 
trajectory. That means we need to be promoting maternal health literacy earlier —preconception. 
 
Repositioning Maternal-child Heath
Further, the rapidly increasing understanding of DOHAD —the developmental origins of health and 
disease— positions maternal-child health at the foundation of personal and public health and at the
center of an evolved third-era healthcare system. It makes maternal health literacy the foundation
 
That’s why I am working on ways to use data to understand the contexts in which maternal-infant
health and maternal health literacy develop.  Successful efforts to untangle the web of interactions 
that influence the health trajectories of a mother and her child may answer the health literacy 
promoter’s essential question: Where to begin?  Stay tuned.
 

Halfon N, Larson K, Lu M, Tullis E & Russ S. (2014). Lifecourse Health Development: Past, Present 
and Future. Maternal Child Health Journal 18:344-365.

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

Start with measurement
What we measure and how we measure it matters because it determines what we
find out about what works and what’s worth doing and who should do it.* Measurement
remains the most crucial issue for health literacy research; because we need to find 
out what works for whom,  and what’s worth doing and who should do it.
 
Im especially interested in what works for mothers in the prenatal to preschool 
period. Because they are the foundation of personal and public health. Healthy mother… 
healthy baby… healthy population. What mothers learn about health and healthcare
during pregnancy and early parenting can benefit entire families across their lifespans, 
and extend benefits to the healthcare, education and justice systems, and to the economy.

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

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

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

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

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

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

Health Literacy Month: Time to think about your furnace

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

 

Discipline or abuse?

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

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

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

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

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

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

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

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

This from Beginnings Parents Guide
 
Reference:
Doriane Lambelet Coleman et al., Where and How to Draw the Line Between Reasonable Corporal Punishment and Abuse, 73 Law and Contemporary Problems 107-166 (Spring 2010)
Available at: http://scholarship.law.duke.edu/lcp/vol73/iss2/6

 

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.
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