Beginnings Guides Blog
This discussion paper commissioned by the IOM Roundtable on Health Literacy
yesterday. I always watch for these papers by thought leaders in
the field to see the evolution
of health literacy concept, measurement and
am quite disappointed this time.
One statement of fact jumped
out at me right away. The paper
lists an increase in the
fertility rate among demographic trends behind the
increasing size and diversity of the
population. But, according to the CDC the
US fertility rate is at an all time low. Births
declined by 10% last year and
the Census Bureau reports population growth has slowed
to its lowest rate in
decades. The authors are correct
that diversity continues to increase.
Pew reports the number of immigrants in
the country doubled to 46 million between 1990
and 2013. (But the Pew Hispanic
Center announced in April 2012 that immigration from
Mexico has stopped and
perhaps even reversed.) Diversity of cultures and language is
challenge for the healthcare system that adds urgency to health literacy
The concept of health literacy
presented in the paper seems confused. First health literacy
is presented as a
cognitive deficit that leaves patients “unable
to understand and act on
placing the problem in patients and assuming it is intractable,
requiring clinicians to over come or manage the problem. The approach is
necessarily information-centered and provider-centered, not patient-centered.
The authors also note that WHO considers health literacy a personal and
but seem not to notice this is contrary to their discussion
focused on low health literacy as
a risk to patients and the system. Recommended universal
precautions are not sufficiently
“on the ground” to
change practice and represent long held heath education principles
educate using plain language, do a learning needs assessment).There is an
assumption that universal precautions, overseen by a new office in
is the whole solution. These precautions are common sense, but they are insufficient to
address true cognitive impairment in the elderly population, or to overcome what
provider/patient communication problems
with both native and foreign-born patients.
The authors suggest that
efforts to develop an organization’s employees' health
(knowledge of negative
impacts of low health literacy in patients, employee-employee
can "empower communities to be active partners in their care.” This is
faulty thinking. Establishing the attitude that patients are incapable
of understanding and
information, and so unable to learn and do what is needed to cope,
improve health, disempowers patients and providers alike, makes
dependent on professionals, and perpetuates the
The authors close with a call for
"trusted partnerships” between
providers and patients; that requires
providers to trust patients.
As long as we say that
what we need to make the healthcare system work is a smarter patient,
One more thing: Americans spend
about one hour per year in a clinical setting. What about
health literacy in
the other 8764 hours?
Today volunteers are out all
over Seattle and King County. It's MLK Day, a
national Day of Service in memory
of Dr King and his teaching that “Life's
most persistent and urgent question is, 'What
are you doing for others?
Since 2008 this group has been promoting cultivation
of urban fruit to
nourish people, build comity and protect the climate. Last year they tended,
harvested and distributed 6500 pounds of fruit grown on trees in Seattle city
and I worked on a hillside up behind the Amy Yee Tennis Center
Seattle. It turns out there are 30 some very mature long neglected
apple and pear trees there,
perhaps a former orchard. City Fruit's 5 year plan
includes rescuing the trees
from ivy, blackberry and underbrush, restoring
them to productivity, and
sharing the harvest with neighbors and local food
banks, and selling some to Seattle
restaurants to sustain the operation. Liz
and I rescued three apple trees nearly strangled
by ivy and blackberry. And
we learned something about our city, met some of our
fellow citizens and
left the world a little better place. Thanks, Dr. King, for the inspiration
the day of service. Thanks to all who
serve, and all who accept service. ss
If you have not see the
new Beginnings Pregnancy Guide, and the new Beginnings Guia
and the new Beginnings Parents Guide, take a look!
Great new photos.
All content checked and updated. A scan code instantly links your mobile device to new
Resources and Parents Resources that we have investigated
and found to be reliable,
easy to use and free of advertising. You service
providers will find lots of useful tools in
now all our printing, inventory management and fulfillment are
in one place, at ColorGraphics
Seattle. If you distribute Beginnings by mail,
we can print your envelopes, address, stuff
and mail them and manage returns.
What a Special Edition with program specific content
and your program name on
it? We can do that, too.
had 50,000 visitors. 2000-4000 of you read the blogs
each month. And we have
900 Twitter followers.
blogsNotes from the Field CenteringPregnancy, Promoting Maternal Health
Literacy“Health Illiteracy” is Not a Disease
Promoting Health Literacy Nationally &
Cape Town, South Africa April 17-19, 2013
got to keynote the first conference on Building Children’s
Nursing for Africa organized
by Univeristy of Cape Town School of Nursing and
Red Cross Children’s Hospital. My theme:
empowering mothers for health. Now I am delighted to be serving as a guest
Prof. Minette Cootzee for a special edition of South Africa’s national
featuring 12 articles from the conference.
Vancouver, BC, Canada May 1-4, 2013
I participated in an invitational international workshop that
initiated a new “knowledge hub”
University of British Columbia. The consensus was that health literacy involves
provider and system. I argued that this formula includes the provider
and the providers’
context (the system) but
omits the patient’s social context. View
participants’ brief videos
Bozeman, MT, USA August
I got to keynote the Montana State Early Childhood
first Family Support Summit.
Theme: promoting maternal health literacy through
home visiting. In
March 2014 I will return to MT to work with all staff of Ravelli Head Start in
Hamilton, MT whose director Kristin
Segall recognized at the Summit that “Health
Washington DC, October 26-28, 2013
This was a whirlwind as I
presented on the
and presented a workshop with colleague April Thayer of WellPoint
on the upcoming
pilot project to integrate health literacy promotion into CenteringPregnancy
and field test the new
Sydney, Australia November 26-29.
I was awarded a travel scholarship
to attend University of
Sydney’s conference on health
literacy and participate in the second meeting of the Worldwide
representatives to plan an international collaboration on
developing health literacy as a community
asset. That is just getting underway.
Health Literacy Training Videos Take 2
from our reviewers and we are revising accordingly. Stay tuned.
On to 2014. I so appreciate your partnership in serving mothers,
foundation of a healthy society. SS
It was my great good fortune to attend two International
meetings of Health literacy researchers, practitioners
and policy makers
sponsored by the Worldwide Universities Network. I
have previously reported
on the May 2012 meeting at University of
Southampton, England. That
meeting was dominated by Europeans and
characterized by lively debate that
fleshed out themes and urgent
The second meeting took place in late November 2013 at University of
The location attracted the Australian experts and was notably
the routine participation of consumer representatives in
policy making, and fittingly in this meeting. I
was glad to reconnect with a
number of researchers I met in Southampton.
Our purpose in Sydney was to formulate international collaborative
The group of about 25 divided itself by interest area using
themes that emerged
from the first meeting. Noting that project groups
were forming around research
questions related to measurement, medical
education, and disease-specific questions,
I proposed "health promotion
approach" as an alternative. That attracted four
academics and three
consumer reps from Australia and the Netherlands who work with
populations (e.g. Lebanese, Vietnamese, Dutch, Aboriginal). We want to
who are the "gatekeepers" of health in families and communities;
how have they been
identified; and how have they been or how could they
be engaged to determine what
supports individual and collective health
literacy. We will necessarily start with a lit
Stay tuned. And
put Bondi Beach, a suburb of Sydney, on your bucket list.
Part 1 Maternal health
literacy as skills
A life skill
is a collection of skills necessary for full participation in everyday life.
Maternal health literacy is a life skill that mothers use to manage personal
child health and healthcare.
It has been defined as the
cognitive & social skills
that determine a mother’s motivation and ability
to act on information in ways
that improve health (Renkert and Nutbeam, 2001).
Cognitive skills are used to
understand information; they include basic literacy skills,
numeracy (ability to use numbers). A mother might use these basic skills
learn about ear aches, and make an appointment to take her child to see a clinician.
So basic literacy skills are the essential foundation for health literacy.
Social skills are used to make
personal meaning from information, including speaking
and listening. The mother
whose child has an ear ache uses these skills when she discusses
clinician the information on ear aches to understand why her child has them and
how she might prevent them.
Reflective skills combine
cognitive and social skills to think critically, make choices,
and take action. The mother in our
example uses reflective skills when
she mulls over what the doctor said, what
she read, her experience of her child’s ear ache,
her actions and parenting
practices, and her discussion with her mother about treatment
possible preventive measures. Some literacy scholars say that reflective skills
are so essential to applying information in context that it should be
classified as a basic skill.
So we could say there are 4Rs: reading, ‘riting,
‘rithmatic, and reflection.
Health literacy means
empowerment (WHO 2013)
A health literate mother
combines all these skills to make health related choices and transform
choice into desired action and outcomes. That is the World Bank’s definition of
empowerment. Say the mother
chooses to stop putting her baby to bed with a bottle. She takes
that step, and
she enjoys her desired outcome, a happy ear-ache free baby. We say this mother
is empowered for health.
Her health literacy skills
enable her to minimize risk, maximize protective factors, and optimize
promotion. In this way, a mother’s health literacy forms the foundation for her
her child’s health throughout their lives.
Many factors, in addition to
skills, interact to determine a woman’s maternal health literacy.
More on that
I’ve been in Washington
DC where I co-presented a workshop at CenteringHealthcare
national conference. I was drawn to this organization the first time
their motto: Transforming care through
(CP) is a rapidly spreading model of group prenatal care.
12 women with similar due dates have their prenatal visits together.
Each has the usual
individual health assessment with an obstetrician or midwife
in the group space. Meanwhile
the rest of the group engages in “self-care”;
they weigh themselves, take their own blood
pressures and chart the data. They can read their own lab results and
The rest of their 1.5 -2 hour appointment is dedicated
to education and support through
facilitated group discussion and activities.
and processes are the same as for conventional individual prenatal
schedule of visits and core content follow ACOG* guidelines.
founder and CEO, midwife Sharon Rising, emphasizes, “Content
should not get in
the way of process.” The women talk about what they want to talk about.
are games, activities and multiple ways of learning. Women test out what
heard; they explore their cultural beliefs and share sensitive issues
like violence that are
only rarely discussed in traditional prenatal care. They
build community and function as a
“March of Dimes wants all mothers to get prenatal care in
Judy Gooding, MOD’s Vice
President for Signature Programs. No wonder.
She describes CP as an
evidence-based program to prevent preterm birth and disparities
health outcomes. MOD’s 2012
Preterm Birth Report card shows the US rate at
11.7% of all births. Among women
in CP the rate is 5.5%. The national low-birth-weight
rate is 8.1% compared to
CP meets the Institute
of Medicine’s goals to make healthcare services safe, patient
equitable, timely and efficient.
Participating mothers seem to agree. There is
no waiting time, no need
to retell their story to strangers. They build a relationship with
provider. What they like best is being with other women.
Rising says, “Facilitation is the secret sauce.” Clinician
facilitators are trained
not to answer questions or instruct the group, but
rather to elicit the group wisdom and
listen to what drives behavior. They come
to understand and appreciate the needs, beliefs,
and struggles of the women and
the complexity of their live. Throughout the conference
there were reports of
clinicians coming out of CP sessions where they completed the
10-12 prenatal visits in 2 hours
beaming and talking in superlatives about
All this makes group
prenatal care the ultimate environment for promoting maternal health
I’ve been working for a year with WellPoint, the health insurance giant, to design
a pilot to test the
hypothesis that CP promotes MHL as a side effect, and with facilitator
awareness, tools and strategies it can be very effective.More on that next
Stay tuned. ss
FUD: Fear Uncertainty & Doubt. That is the foundation of the
Republican’ position on the Patient Protection and Affordable
Care Act of 2010.
That’s why they
call it Obamacare- in order not to say “protection” or “affordable”;
and to hide the fact that the law was
enacted 3 years ago, before the President
was soundly re-elected running
against an opponent who vowed to repeal it.
FUD, initially an IBM strategy to eliminate market competitors by
uncertainty and disinformation about their products, seems to be
working for the
House Republicans. At least to some degree, for now. Polls and
analyses of social
media suggest that some people favor the Affordable Care Act
while opposing Obamacare.
Home visitors: “Obama
snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper
tantrum until I saw
the Fox “news report” about the Affordable Care Act’s
expansion of home visitation.
a preventive strategy in which public health nurses, social workers or
paraprofessionals connect families to healthcare and community
resources and offer
health education and social support. It’s origins date back to the 1800s.
are run by county health departments, school districts, foundations,
partnerships. Home visiting programs are open to poor
parents who request assistance.
It’s worth noting that in many countries, home visiting has long
been standard for all
parents, because they acknowledge that parenting is a
challenge and everyone can
use assistance. And because research shows it
improves child developmental outcomes
and has immediate and long-term benefits
that extend to entire families and to the
healthcare, education and justice
systems. My research
shows that parents in home
improve their health literacy, capacity to manage personal and
child health and
A Fox announcer and a “business expert” called home visitors
They said in this “brand new federal program”,
“government home inspectors”
make random, unannounced “forced home visits” to snoop on parents. This is not
news. This is pure FUD -
disinformation (lies) that specifically intends to instill fear,
and doubt about the Affordable Care Act, to prevent people from learning
can afford good healthcare coverage.
I have worked for decades with home visitors and know them to be
among the most
respectful people on the planet, unlike the FUDders on Fox and in
FUD won’t work for long.
Yesterday, the heart of the Affordable Care Act started
(keep saying the real
name), opening access to healthcare for millions of poor and
citizens. Almost 3 million people visited www.heathcare.gov
similarly overwhelmed. People are
about to find out that the Affordable Care Act
makes good healthcare coverage
affordable -for them. That will help them see through
the FUD. Insurance companies are helping too.
They are enrolling people they previously
rejected because, with the ACA, it’s
good for business. Healthcare executives are calling
for more doctors, nurses
and allied health professionals - doesn’t really sound like a
On the other hand, the House Republicans just put hundreds of
thousands of people out of
work in hopes they can FUD us citizens of the
richest country in the world into continuing
denying healthcare to poor people
and sick people in order to preserve the freedom of
the rich to get richer.
beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
across cultures. They are skills that empower people to be what
they want to be, to make
choices and transform those choices into desired
actions and outcomes.
These life skills develop most easily
in early childhood given a stable
supportive family environment. Disparity in
brain development in children
growing in disadvantaged vs enriched environments
becomes apparent in
the first year.
Quality of family life matters more than the number of
income or education. But poverty and accumulated disadvantage
from doing their best to sustain the stimulating home
environments that support
optimal development, especially when they
themselves lack skills, resources and
role models. Early intervention ---
early childhood education, parenting
training, family support and home
visitation programs--- can produce positive
and lasting effects on children
in disadvantaged families.
Nobel Laureate and economics
professor James Heckman, makes the business
case for shifting public policy to
support programs that offer parents information,
choices and assistance. Promoting health literacy means
supplemental assistance that specifically and intentionally
enables parents to
develop and hone the range of life skills used to
participate in healthcare and
manage personal and family health at home.
Must read: Heckman, James J. (2013) Giving Kids a Fair Chance (A Strategy
That Works) MIT Press,
Cambridge, Mass. ISBN
In addition to Heckman’s monograph,
the book includes illuminating commentary
by 10 experts from multiple
My favorite feature of the upcoming 9th edition of the Pregnancy Guide recognizes
it is a
digital world. You told us that you and your families need print materials
few in your caseloads have computer access or devices to use digital
Other surveys confirm you’re right.
Poverty and the
In December 2010, 40% of US households, did not have a broadband connection in
home. Lack of access is a marker
of poverty. Mississippi is the poorest state
and has the highest proportion of
households without access, 65%. Similar rates of
poverty and no-access are
found in AR, TN, WV and OK.
Compare to wealthy
states led by HI with 74% connected, only 26% with
no-access. In cities, there is
commonly low access in the urban core suffering poverty while the wealthy
are fully wired.
Still, people find a
way to get online
In a survey of over 2000 Mississippi households, 79% said someone in the home had
the Internet. Outside locations included school, workplaces and the local
library. In some libraries, free
internet service is the biggest draw into the building.
reasons for having no access at home were cost and lack of equipment,
key reason seemed to be lack of understanding of the value of the Internet,
aspect of low health literacy. Of
those without access, 46% said they didn’t need
it or were not interested. Others, especially younger, less
educated, low income
adults said they mostly go online using their smartphones.
Access in steadily
A February 2011 survey found 68% of households with a
significant growth in just a few months. Some of the most rural areas seem to be
improving quickly; but the South has shown only modest improvement. The Obama
administration has directed billions of economic stimulus dollars to increase
access. And some companies have just begun offering low-cost broadband
to families with a child who qualifies for free school lunch.
information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide
intentionally focused on essential health behavior topics directly linked to
outcomes. Some parents want to know more.
New Resources for
Mothers coming to www.BeginningsGuides.com
For those who do have Internet access, and to motivate those
who don’t to find a way,
the new 2014 edition of Beginnings Pregnancy Guide
includes this icon to encourage
The new section provides links to
information and resources from reliable sources that
Beginnings Guides staff have reviewed and found easy to use. This reduces the need for
advanced searching and evaluation
skills. We envision the new Resources for Mothers
as an easy entry into online
self-directed learning about health and an opportunity for
parents to improve
their health literacy.
Dunbar, J. (2012) Poverty Stretches the Digital Divide, the Center for Public Integrity.
The 2014 9th! edition of Beginnings
Pregnancy Guide, in English and the 4th
Spanish edition are in production. Here
are some of the changes to look for.
A subtle but important revision is in who to call for information
Previous editions have said, “... call your doctor.” Since
physicians are not
always prepared or inclined to lead discussion of topics
that are sensitive or
not strictly medical, I added home visitors and sometimes doulas on topics
including breast feeding, smoking, abuse, weight gain, depressive symptoms,
conflicting advice, relationship issues, car seats, and labor pain management.
On these and similar subjects the new Beginnings
says, “Talk with your doctor,
home visitor or doula.” This supports a shift in parents’ thinking from “the
doctor takes care of my health” to ‘the doctor helps me take care of my
to a Healthy Baby, the health behavior messages that research links
to birth outcomes are modified slightly.“Do eat well” is expanded to “Do it
often” since a pregnant body easily and
quickly slips into starvation mode. Frequent
small meals best support fetal
“Do gain weight” is expanded to “Do
gain weight slowly” In response to concerns
over obesity and the trend to gaining in excess of guidelines. The latest
recommend an 11 pound gain for a woman who starts pregnancy
“Do take vitamins” is expanded to “Do
take vitamins everyday” to emphasize
the need for consistency to maintain a healthful level of nutrients in the
Early term inductions of labor for
vaginal birth more than doubled between
1990 and 2006 from 7.5 to 17.3%. And
the percentage of later preterm C-section
deliveries increased by 46% from 23.5
to 34.3%. A 2010 study found 44%
had their labor induced, often for convenience of the parent or the
Those women were twice as likely to have a C-section as women who waited
natural labor.( Ehrnethal et
al. July 2010 Ob&Gyn). In light
of that trend, the
updated Pregnancy Guide’s discussion of the course of
pregnancy (p46) includes a
statement that “Labor should not be induced before
week 40, except for medical
reasons. The section titled Baby’s Growth and Development, 9th
encourages readers to exercise their health literacy skills and
speak up about this
concern. “If your doctor talks to you about inducing labor,
ask if you wait until
Nuchal lucency test is added to the discussion
of prenatal testing.
Juice is de-emphasized in favor of
water. Juice was considered a
alternative. However, with the increase in obesity, extra
calories and sugars
in juice are
My favorite change.
Reference: National Center for Health
Statistics Data Brief 24, Nov 2009.