Beginnings Guides Blog
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.
US residents speak at least 329 languages. In some US cities less
than 60% of the population speaks English. About 32 million of us speak a
language other than English at home. If your service population is not diverse
now, it will be soon. Pew Research
projects the US Spanish speaking population will triple by 2050, and the Asian population will double. Success
in improving the health of ethnic populations will substantially influence the
future health of America as a whole.
Healthcare organizations have been working to develop their
capacity to address language barriers and cultural differences, but it’s
hard to make progress when the challenge is increasing along with the
complexity of treatments and healthcare delivery and financing systems. Non-English speakers still face substantial communication barriers at almost every
level of the health care system.
show that communication barriers have a negative impact on health, discourage
use of preventive services, and increase costs of treatment through unnecessary
testing, delayed diagnosis, extended treatment times, and misinterpreted
instructions. Without information that they can understand and use in their
everyday lives, patients cannot engage in self-care or self-management. In
short, they cannot take responsibility for their health and be partners in treatment,
as effective care now requires.
In most cases, provider
organizations and insurers have the means to overcome language barriers. But
current practice in most communities still reflects an assumption that it is
the patients' obligation to make themselves understood, to ask appropriate
questions and to correctly interpret and comply with instructions. In most
instances, this assumption is wrong as a matter of law. Federal and state civil
rights laws and Medicaid regulations require access to linguistically
appropriate care. These laws are the basis for accreditation standards that
require providers and insurers to position themselves for our multicultural future.
Studies show that print
materials, particularly in combination with brief counseling, can increase
recall, compliance, and behavior changes; and reduce consultations regarding discomforts
that could be self-managed. Health information is increasingly available and
accessed online, through mobile devices and virtual patient educators. Still a
clear message from research participants
is that written information should always be available, even in the
presence of multiple other media.
While they are not a total
solution, CLAMs remain the necessary foundation for a comprehensive
communication effort, and an obvious starting place to promote health literacy.
Organizations serving diverse populations will need to hone a process to
develop and test English language materials, and to adapt essential proven
materials for non-English speakers.
More on that next time. Stay tuned.
Let’s welcome the new year with some new
thinking about measuring health literacy.
It’s hard to say exactly what electricity
is, but if the lights are on, we know we’ve got it. And we
measure electricity by the light it produces. So it is with health literacy. It
is hard to say just what health literacy is, but we know it by its
consequences, and we can measure those consequences.
Services utilization, behaviors, self-care
Two recent systematic reviews and concept analyses (Sykes 2013,
Sorenson 2012) identified the consequences of health literacy. Both studies found the most frequently
reported consequences of health literacy are improved use of services,
behaviors, and self-care. These consequences reflect how people use their
health literacy skills in everyday life and what they actually do for health with the information and
support available to them.
Although these consequences are supposed or anticipated rather than
evidence-based (Sykes 2013), the documented presence of these consequences
would indicate that the person possesses and has used health literacy skills to
produce them. Studies using the Life Skills Progression instrument to assess
maternal heath literacy are building the evidence base.
The LSP Maternal
Health Literacy Scales rate mothers health literacy by their health and
healthcare-related actions practices and behaviors. Sequential measures show
change —improvement or regression. The LSP Healthcare Literacy Scale uses 9 items to rate
mothers’ use of information, emergency services, medical and dental
care and preventive services for herself and her child. The Selfcare Literacy
Scale uses five items to assess risk behaviors and selfcare practices. Three published studies using LSP data on three different cohorts
of mother-child dyads provide
evidence that mothers supported by home visitors trained to promote maternal
heath literacy produced the consequences of health literacy at increasing levels
over 12-18 months. So the recent
analyses of the consequences of health literacy confirm earlier findings that
the LSP can be used as meaningful
measure of MHL.
Next: the recently identified unique consequences of critical
health literacy add weight to our theory that critical thinking skill,
particularly reflection, is the active ingredient in health literacy that enables mothers (and others) to
transform their decisions into health promoting actions and outcomes. Stay
K. Van den Broucke S, Fullam J,
Doyle G, Pelikan J, et. al. (2012). Health Literacy and Public Health: A
systematic review and integration of definitions and models. BMC Public
S, Willis J, Rowlands G & Popple K. (2013). Understanding critical
literacy: a concept analysis. Biomed Central Public Health:13:150.
Smith, S. A., & Moore, E. J. (2012). Health literacy and depression in the context of home visitation. Maternal and Child Health Journal, 16, 1500-1508.
Carroll LN, Smith SA & Thomson NR. (2014). The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice
pii: 1524839914538968. [Epub ahead of print]. Available on Internet at: http://hpp.sagepub.com/content/early/2014/06/23/1524839914538968.abstract
Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014) Maternal Health Literacy Progression Among Rural Perinatal Women. Maternal Child Health J 18: 1881-1892.
Beginnings Pregnancy Guide 9th Edition Sold Out
The second printing of the 2014 is underway. The scan code that instantly links Beginnings
readers to additional prescreened information via the Internet on a mobile device has proved popular. In a survey of pregnant women in SC, we found that respondents rarely use toll free numbers; while nearly all reported finding health information online. The entire website
is available on your mobile device.
Websites Continue to Grow
Beginnings Guides had 155,00 visitors in 2014. The Center for Health Literacy Promotion had 55,000 visitors. The blogs were read by 100,00 including 6900 reads in the last 30 days. And we have 1310 Twitter followers. Kudos to Beginnings Webmother, Simone Snyder.
Most read blogs
(this one was on the most-read list for 2013, too)
Promoting Maternal Health Literacy Nationally & Internationally
Free Health Literacy Training Videos
We produced a series of training videos in collaboration with the National Network of Libraries of Medicine Pacific Northwest Region. This from the National Libraries Website:
Center for Health Literacy Promotion offers free training
Together with the National Network of Libraries of Medicine, the Center for Health Literacy Promotion has put together three short training sessions on understanding and promoting health literacy designed for social and health services providers and programs. Each session includes a short video, a pre- and post-test (with answer key), a handout, and a facilitator's guide. All three sessions and their resources are available to download or view for free online.
To view these resources, visit the Center for Health Literacy Promotion:
Published Article: Parents As Teachers Health Literacy Demonstration Project
Carroll LN, Smith SA & Thomson N (2014). Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education. Health Promotion Practice
pii: 1524839914538968. [Epub ahead of print] Read the article
Guest editor, Curationis Special Edition:
This turned out to be a monumental work and an inspiring labor of love. It was a joy and a challenge to work with a dozen authors whose work is at the foundation of efforts in southern and eastern African countries to develop professional education curricula and build a workforce of nurses dedicated to care of children. With health systems only about 20 years old, this work is underway to differentiate care of children from care of adults. Therefore, the articles focus on issues in professional education and practice. There are many lessons we in the US can learn from their work to build a healthcare system grounded in child rights, and to effect systems change in the face of racism and limited resources. Curationis, a South African nursing journal has published the special edition online with free access for all. It will appear in print in 2015.
HARC VI Washington DC Nov 4-5
Family transitions precluded my travel to DC this year. But I was not totally absent. Linda Wollesen, developer of the LSP presented in my stead results of a study conducted in collaboration with Anne Turner and colleagues at University of Washington Northwest Center for Public Health Practice. Conclusion: parents can and do manage child oral health, even in the face of poverty, low education and limited English proficiency where service and supports to use them are in place. This is on the list to publish in 2015.
New & Contintuing in 2015
Worldwide Universities Health Literacy Network
in Sydney I worked with an awesome group scholars/practitioners/patient representatives to instigate an international collaboration on promoting health literacy as a personal and community asset. The group has joined with others who began similar talks in 2012 at the first Worldwide Universities Health Literacy Network meeting in Southampton, and expanded to include representatives of countries in Europe, Asia, Africa , South America (and me). The collaborators have been holding monthly meetings via Skype and are developing funding proposals to address maternal health literacy globally.
CenteringPregnacy Health Literacy Trial
This project continues. I got to visit the site of the comparison group, Greenville Health System, Greenville, SC. We're searching for a second site. Want to be an intervention site? Contact me!
Maternal Health Literacy: Untangling the "Web of Interaction"
The research project for 2015 is funded by the National Library of Medicine. The study addresses an urgent need to determine what promotes maternal health literacy, especially in historically underserved poverty populations. We are identifying factors in the home and family context that influence mothers'health literacy, and how those factors interact. Understanding the context in which mothers use information and services for personal and child health can guide intervention design, tailoring and evaluation. We are looking for ways to visualize data to suggest points of intervention and help home visitors to answer the ever-vexing question: where to begin?
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.
especially interested in what works for mothers in
the prenatal to preschool
healthy population. What mothers learn about health and
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
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
information about your diagnosis
or to follow treatment instructions.
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
What we find out from health
literacy-reading test scores is that almost everybody has
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
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
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
literacy and the public health approach to
maternal health literacy are
complementary rather than exclusive. Patients and parents need
information, accessible services, and assistance to use them effectively.
schorr Common Purpose: Strengthening Families and Neighborhoods to Rebuild
Read this book!
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
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 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.