Beginnings Guides Blog
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
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
Translating research into practice is a challenge for all practitioners. We could call
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 Children’s Nursing for Africa
April,2013. (Consider participating in the second conference April 22-24,
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.
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.
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
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%.
national rate is down 12%. The
number births at >39 weeks gestation is up 9%.
bad news is disparities continue.
Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only
3% for blacks.
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—
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.
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
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
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.
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.
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
CenteringPregnancy promote maternal health literacy?
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
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”.
tuned for more on the Maternal Health Literacy Self-Assessment.
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
Learn the deeper meaning of
Mothers Day here:
panel conducts independent reviews
In March 2014,
32 health and social services providers, program directors,
supervisors volunteered to assess the understandability and
Education Materials Assessment Tool for Printable Materials from the Agency
Healthcare Research and Quality. Twenty-six completed the assessment.
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
Beginnings Pregnancy Guide Earns High Marks
I am particularly pleased with the
nearly perfect actionability score.
Goethe said it centuries ago, “Understanding is not
enough, we must act.”
multisyllabic bit of Latinized jargon that is questionable
in the context of
health literacy) is the quality of information that enables users
its meaning. The PEMAT-P asks reviewers to rate printable materials
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
Factor scores are expressed as the percent of possible scores of 1. The
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
Organization: 97% Layout/Design: 96% Visual Aids: 96%
“Overall the book looks and reads very clearly and will be
for a low level reader.”
(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.
additional plus is the links to other resources for specific topics.”
comments on the materials.PEMAT-P shows good reliability
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
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
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
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.
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
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,
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
them, and gave him this summary of new instructions.
Medications to Continue Taking That Have Changed
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
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
No problem found
the summary shows good intent to inform the patient, it could be much easier to
read, understand and act on.
Delete the static
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.
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.
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:
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.
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.
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
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
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.
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
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
a million dollars before she left the hospital. One “bad
baby” could wipe out an
employer’s entire health
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
Mountains of printed material, little actionable,
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
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
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
promotion content of prenatal care. It detailed health behavior messages to be
discussed at each visit. Subsequently, research demonstrated direct links
recommended health behavior messages and outcomes, particularly low
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
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
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
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
I soon learned that simple information giving is rarely enough to
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
promotion content of prenatal care fell to home visitors serving Medicaid
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
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
satisfaction ratings from both college educated and under educated mothers and
The new updated 9th! edition is just off the press. In English
and Spanish. Take a look.
“Health literate health care organizations design health care
features that help people find their way.”
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
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
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
there in the parking lot.
This hospital would score well on
most of the Ten Attributes. Perhaps
this is a case of assuming
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
again in daylight and still saw no signs for the ED, except from the
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.