Beginnings Guides Blog
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
A summary of the workshop
proceedings was released this month. Download a summary
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:
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
than ‘what hurts’ or ‘have you been
taking your medicine today.’”
Why is this
question more important than typical problem-focused inquiries?
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
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,
than reducing the person to a medical problem and assuming that s/he has
failed to comply with the medication
What is a
good day like for you? is a good
> 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
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
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
provider to achieve patient satisfaction.
> It shifts
thinking and conversation from what patient and clinician do not want — disease
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
who live in poverty and face daily discrimination, are rarely asked questions
and may be trained not
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
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
More on reflective
McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active
disparities, low health literacy begin in poverty
Despite some encouraging news in the just-released annual
state rankings for child well-being, Annie E Casey Foundation reports large
numbers of children of all racial and ethnic groups are facing economic
conditions that can impede long-term success. In 2013 (latest figures) in the world's richest country, 22%
of all children
live below the poverty line —$24,250 annual
income for a family of 4. According to the Economic Policy Institute it takes
at least twice that amount to provide basic essentials. It's worse than the
average suggests. Here is where
health disparities begin: 39% of African American children, 37% of Native American children, 33% of Hispanic children
live in poverty. Compared to 14% of white children.
"When very young children experience poverty, particularly if that poverty is deep and persistent, they are at high risk of encountering difficulties later in life - having poorer adolescent health, becoming teen mothers, dropping out of school and facing poor employment outcomes."
Implications for health literacy improvement
These figures jumped out at me since preliminary findings
from my current research suggest that basic essentials —-
safe housing, adequate food, transportation, health insurance, and child care — are
prerequisites for developing maternal health literacy, mothers' ability to use
information and services to keep healthy and raise and healthy competent child.
It makes sense that no amount of reading skill, understanding of healthcare, or
knowledge of preventive practices can make those practices possible when
feeding the children necessarily takes priority. National and international
policy documents call for improving health literacy in parents to reduce health
disparities. Progress in unlikely until we provide health insurance and
economic supports to parents of very young children.
Cheers for the
Affordable Care Act
Thanks to Obamacare, the rate of insured kids improved 30%
leaving 7% or 5.2 million uninsured, most in states that declined to expand
Cheers for Alaska
Applause for Alaska governor Bill Walker. He announced last
week that he will use executive authority to expand Medicaid. That means nearly
30,000 Alaskans will soon be able obtain insurance. The annual Kids Count Datebook ranks Alaska 31 among the
states for child health. The governor's action bodes well for a higher ranking
in coming years.
Cheers for Minnesota
They're Number 1 overall in the Kids Count ratings, 2nd in
health behind Iowa.
Oh Mississippi! Worst place for kids. Still.
Mississippi ranked 50th overall as it has every year since
the rankings were first published in 1990. The state was last in economic
well-being, health, and family & community. It ranked 48th in education
ahead of New Mexico and Nevada.
See your state rankings here.
"In any situation, a person decides what to do
based on an understanding of facts, issues, options for action, and
." So says PlainLanguage.gov
. Oh, would that it were so! This
premise that individuals needing medical care are rational consumers is, in
in healthcare is not like buying a car.
When it comes to healthcare decisions, understanding the
medical facts and treatment options and consequences often requires an advanced
degree, specialized vocabulary, internet access and research skills. The
"facts" — like the
definition of health literacy — are likely to
differ by who you ask. Well-established medical facts change along with rapidly
developing knowledge and technology.
The price of treatments, and whether and how much insurance will cover,
is usually unknown by both service provider and consumer until after the
fact. The medical, personal and
social consequences of a disease or treatment option are in most cases
predictable only by what seems to have happened to other people in other
families and circumstances. So if
it were true that we humans base our health and medical decisions and actions
on objective rational logic, few such decisions could be made.
healthcare, where issues and consequences are intensely personal, often
embarrassing, frightening, financially devastating, and far reaching,
decision-making and behaviors are more often based on a mix of emotions,
insurance status, immigration status, cultural or religious beliefs, trust or mistrust of providers or
government, practical considerations like availability of transportation…the
list could go on and on.
Knowing is not enough; we must apply. Willing is not
enough; we must do. ~Goethe
This flawed view of individuals as rational consumers of
health services separate from the context of their everyday lives supports
another convenient but equally flawed notion: If people just had more or better
information, they would make appropriate decisions and adopt health promoting
presents this as
the theoretical foundation for the Ask Me Three
[questions] campaign. That may be a good conversation starter.
Still, seeing patients as rational consumers who ought to
lead discussions about their care places the "health literacy
problem" (high costs, disparate outcomes, inefficiencies and inequities)
squarely on the patient. If we are to achieve the national vision
of a health literate society, rather
than expecting individuals in need of healthcare services to learn medical
terminology and disease information, healthcare professionals must learn to
communicate effectively with people who have not gone to medical school. Rather
than insisting that patients re-arrange their lives, become researchers and
care managers, and endure all manner of inconvenience to comply with overly
complex treatment regimens, healthcare delivery professionals must adapt
treatments to the realities of everyday life.
Howard K. Koh, Donald M. Berwick, Carolyn M. Clancy,
Cynthia Baur, Cindy Brach, Linda M. Harris and Eileen G. Zerhusen. New Federal
Policy Initiatives To Boost Health Literacy Can Help The Nation Move Beyond The
Cycle Of Costly 'Crisis Care' Health Affairs 31, no.2
(2012):434-443(published online January 18, 2012; 10.1377/hlthaff.2011.1169)
I share this
story with the permission of it’s
author, Michael Joe Harrison. Michael was on my
first date with Larry, now my
husband of 37 years. Larry was Michael’s volunteer big brother
through Big Brothers Big Sisters
of Virginia. He was 15, a long-haired foul-mouthed certified
Delinquent. Long story short, we all got out of VA; Larry & I, my daughter Lisa and
Michael became a family
Seattle. Michael quickly adopted the role of loyal protective big
brother. At 18 he went back East, reunited with
his sister, finished school, married, established
a business, raised a family,
and became the one his relatives turned to when their kids got into
When Lisa got married, we offered her any gift she could imagine - she wanted
in her wedding. Now a grandfather, musician, business owner in Georgia,
and still very much part
of our family,
Michael reflects on fatherhood in this from his Facebook page.
Just like my
Roughly 14 years
ago, most all the trees in the front yard I planted. Each one planted
a loved one. Specifically today, would like to talk about the ones
planted for my children, Jennifer
Manor, Chris Bradley and Kim Harrison.
When I planted
these trees, they were young. I feed and watered them, pampered them hoping
they would grow tall and strong. Just like my children.
started to grow, there roots grew deep to provide a strong foundation to stand
took a little time but slowly they anchored themselves and could hold
their own. Just like my children.
spread, helped provide shade on hot days. Their branches provided shelter and
families grew from their branches. Just like my children.
branches broke. I would worry that if too many broke, I would lose them. New
grew and the trees were more resilient, wiser if you will. Just like
Each tree is
different. None are the same. This means they grew and matured at different
Their leafs and blooms grew and fell at different time. Each one is
unique. Just like my children.
These trees have
weathered many seasons. They would grow new leaves every spring. Survived the
bitter cold and survived life’s stormy weather. Just like my children.
We all moved
away. I could no longer pamper them. They had to stand on their own and they
They are strong, healthy and their leaves provide air which breath life to
all. Just like my children.
Which one is my
favorite? Well I can’t answer that. Each one has their history. Each one was
with love equally. Along the journey, each one has special memories and
stories. Just like my children.
To say I am proud
of these trees, I am. Actually I love these trees. Love comes in many forms. It’s
been a wonderful experience to watch these trees to grow and mature. So yes I
do love them.
Just like my children.
In a recent meeting to discuss online searching for health
information, Rachel was introduced as a
UX writer for Google. Mystified, I
googled her job title. Turns out UX is short for User Experience. A
is first an advocate for the user of information. Rachel does not think
readers who need to process and understand information
and gain knowledge. Rather, she
useful, meaningful text that helps users complete the task
Imagine how information from health care organizations would be
different if producers and reviewers
aimed not to educate patients with low
literacy, but rather to "simplify and beautify the user experience"
of obtaining treatment, using medications, or navigating facilities. Imagine if we wrote not for "low
patients", but for an information user assumed to be competent, although
unfamiliar with the
content and context.
What if we regularly used empathy along with logic and hard data to
choices? What if we worked closely with teammates from a variety
Rachel writes about Google software products. Elsewhere, her
position might be titled technical writer.
What differentiates her from technical writers, and most
health information producers, is her intent to
improve the users experience,
instead of intent to improve the information. Another essential differentiating
factor is that Rachel the
UX writer assumes users of the info she produces will have different levels of
proficiency, background knowledge, and experience. She does not require them to
learn a new vocabulary.
She does not demand reforms to public education to
increase computer literacy so that people can benefit
from her products and
services. Rather she enables them
to use her information with the skills they have.
A UX mindset would transform health information and the process
of health education.
A UX Writer's job
description would be a good starting place to describe a health literacy
specialist or health
educator position. Find one here.
producers should be less concerned about healthcare consumers’ lack of literacy
skills and more
concerned that we are all “limited-capacity
"In any situation, a person decides
what to do based on under-
standing of facts, issues, options
for action, and consequences.”
This statement from an article titled “Improving
Health Literacy” at
bound to set information providers and health literacy
promoters down a dead end. It describes
decisions ought to be made. We hope and
trust that healthcare professionals use this conscious,
analytical, linear, reasoned process for treatment decisions. Consumers do not.
decisions are based on emotion
are much more likely to use what experts in decision-making processes call an
“experimental” approach that is intuitive,
automatic, associative and driven by emotions. It is
feelings that make meaning from information and
motivate actions. Because we can only use a
limited amount of information, we
consumers automatically search for info that warrants our
attention and info we
can disregard. Health decisions typically are complex and require complex
information on unfamiliar topics,
using unfamiliar terms and concepts. More info requires more
time and energy and often yields
more uncertainty and competing messages. Even otherwise
consumers may limit information seeking and almost certainly disregard available
information that is hard to use when physically, mentally, spiritually and
financial stressed by illness.
The value of plain language information in a
simple form is that it makes information easier to use so
that consumers do not
have to use short cuts.
Plain language information is necessary
but insufficient to improve health literacy. It needs to be
make decision-making, rather than reading less cognitively and emotionally
It needs to come with direct support to help people process the info
based on their specific needs and
the everyday home context in which they are
expected transform decisions into actions and outcomes.
Healthcare: The burden of choice. (2005). Shaller,
D. California Healthcare
Oakland. Online at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ConsumersInHealthCareBurdenChoice.pdf
The Adaptive Decision
Maker. John W. Payne, James R. Bettman and Eric J. Johnson, Cambridge:
University Press, 1993,307 pp. ISBN 0 521 41505 5 (hc), ISBN 0 521
42526 3 (pb)
In Florida, if someone scares you
to death you can legally shoot them to death with your BLEEP. But your
family doctor or
pediatrician or health worker cannot legally ask you if a BLEEP is kept in your
house or how
it is stored.
Apparently even thinking about the
risk of unsecured BLEEPs to their children’s and
right to keep BLEEPs anywhere and any way
they want. This BLEEP has been
since 2011. (The part that made asking about BLEEPs a felony with
jail time and a $5 Million fine did not pass).
Physicians groups challenged the
law. It was upheld as constitutional in Florida since BLEEP ownership and
is a private matter unrelated to medical care.
BLEEPs and tobacco are the only
products on the market that when used correctly kill people; BLEEPS kill lots
of people, often children, in a seconds.
So BLEEPS can’t be a private matter.
Safety Checklist for a Crawler:
BLEEPS are unrelated to medical
care until a child -or some one
else- or the owner- is injured by the patients’ BLEEPs. Then
taxpayers fund emergency response and
medical care for totally
preventable horrific injury or death, and related
increased insurance premiums, and lost contributions to
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP.
Texas legislature entertained a similar gag rule this month.
Death in the United States:
A Call to Action From 8 Health Professional Organizations and the American Bar Association.
Ann Intern Med. 2015 Feb 24. doi:
10.7326/M15-0337. [Epub ahead of print]
Ferrris S. Children’s Defense Fund report on Childs’ BLEEP deaths, new BLEEP laws Data analysis: More
preschool kids dead from BLEEPfire than
police. May 19, 2014
Walters, E. Bill Would Prohibit
Doctors From Asking About BLEEPs. The Texas Tribune March 18, 2015
Pitts, L. Republican list of things you cannot say.
Seattle Times March 19, 2015
I’m proud of my city. We are catching up
with the rest of the world.
Yesterday Mayor Ed Murray announced Seattle will provide paid
parental leave for City employees.
All parents — foster parents, adoptive parents,
mothers and fathers— will have the option to take four
weeks off —with pay— to bond with a new child. The mayor is encouraging other
employers in the state to offer similar benefits.
This should not be the surprise, the bold move, the
breakthrough that it is.
The US is the only developed country on the planet that does not
give new parents paid time off to support attachment and bonding and infant
brain development, and to put their newborns on a positive health trajectory.
President Obama announced a similar new
policy to provide six weeks paid parental leave to federal workers in
his State of the Union address.
A step toward gender equity in the workplace
I’m especially glad the paid leave
policy will apply to fathers as well as mothers. That presents child care as a
shared responsibility. It puts to rest arguments and unfair choices that have plagued so many women’s
career…You are on the mommy track, so you can’t
be on the partnership track. The paid leave policy protects mothers’ earning
potential, avoids unfair expectations and burdens and removes that awful choice
between career and family.
Most of all, this investment in parents shows we are a society
that values its children, including adopted children and those in foster care.
It shows respect for the role of fathers in raising children, and the role of
mothers in the workforce. It
acknowledges the contributions of
foster parents — special people who can love other
people’s children as their own, and encourages
foster parenting. Thank you Mr Mayor and Mr President for leadership toward a
stronger city, region and society.
is teen dating abuse awareness month.
Throughout the month of February, teens
and organizations across the country have been working together to raise
awareness about teen dating violence.
As a dating abuse prevention educator February is my busiest month
(which is why it has taken me so long to write this blog). Every week I visit
the schools in my community to discuss dating violence, healthy relationships
and how to recognize warning signs. I speak with students from 7th grade all the way through college about their experiences. I am proud of what I
do and I am grateful to work in a community that considers these issues
important enough to discuss with our children all throughout they year. I wish
I could say the same for the community I live in. Not every district or county recognizes the importance of
discussing healthy relationships, which is shocking
considering the statistics (see below). I have tried on more than one occasion
to bring presentations similar to the ones I do in other communities to my
son’s school to no avail. The
question is why aren’t some schools or some communities talking about dating
The simple answer is, it is not an easy
subject to talk about. We are taught to ignore or to stay quiet when we see
signs of abuse. We are not encouraged to talk about abusive behaviors in
relationships. If you are parents, it's even more challenging to open a
conversation with your child about relationships. Where do you begin, and at
It is important to recognize that dating abuse affects
everyone. It knows no boundaries and crosses all barriers. It can and does
happen to anyone, at any time at any age all around the world. The repercussions
are far-reaching and impossible to ignore. According to loveisrespect.org violent relationships in
adolescence can have serious ramifications by putting the victims at higher
risk for substance abuse, eating disorders, risky sexual behavior and further
domestic violence. It affects
children, their families, their schools and their communities.
It can be difficult to talk to your children or a young
person in your life about relationships, dating and especially sex but if you
don’t, who will? We must talk to our youth about how to recognize warning
signs, what a healthy relationship looks like and where to get help. Talk to them and listen to what they
have to say. If you don’t know where to begin, I have listed resources for you
below as well as some statistics.
deserves a healthy relationship. Not everyone knows what that looks like
(especially when they are looking to the media and culture for examples but
that is an entirely separate future blog post) so it is up to us to begin the
conversation. Reach out to your local agencies; see if they can bring someone
in to the schools to reinforce what you are teaching them at home. We can raise
awareness, we can prevent violence in relationships and we can do that one talk
at a time.
Did you know:
1 in 3 teens in the U.S. is the victim of physical, sexual, emotional,
or verbal abuse by a dating partner, a figure that far exceeds other types of
Girls and young women between the ages of 16 and 24 experience the
highest rate of intimate partner violence (almost triple the national average).
Violent relationships in adolescence can have serious ramifications by
putting victims at higher risk for substance abuse, eating disorders, risky
sexual behaviors, and further domestic violence.
Eighty one percent of parents believe teen-dating violence is not an
issue or admit they don’t know if it’s an issue.
One in three adolescents in the U.S. is a victim of physical, sexual,
emotional or verbal abuse from a dating partner, a figure that far exceeds
rates of other types of youth violence.
One in 10 high school students has been purposefully hit, slapped or
physically hurt by a boyfriend or girlfriend.
One quarter of high school girls have been victims of physical or
Approximately 70% of college students say they have been sexually coerced.
There are many organizations doing incredible work focusing
on relationship violence awareness and prevention. These are a few of my