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Health Literacy & Maternal Health Literacy: What’s the difference?
Health Literacy Month: Time to think about your furnace
Discipline or abuse?
Research guides practice; practice guides research. Health professional education for resource -constrained practice
Evidence to Practice: Induction of Labor Rate Falling

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

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

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

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

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

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

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

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

Discipline or abuse?

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

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

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

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

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

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

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

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

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

 

Evidence to Practice: Induction of Labor Rate Falling


My mother was expecting her first child. She was due in late July. Her OB was due to be on vacation. So he induced labor July 9.
 
That was 65 years ago.  But the story, and the disconnect between the body’s wisdom and medical practice is not out of date.
 
Induction of labor became more and more common, despite increasing evidence of the risks of preterm birth; 23 years later, my labor was induced. The doctor said it was time.  Over the last 20 years, the induction rate increased every year to 23.8% in 2010.
 
Finally, practice is beginning to follow the evidence. New data show the national rate of inductions began inching down in 2011 to 23.5% in 2012, the latest available figure.
 
"Pregnancy lasts 40 weeks...Labor should not be induced before 40 weeks except for medical reasons." 

"If your doctor talks to you about inducing labor, ask if you can wait until week 40."

Beginnings Pregnancy Guide


The good news is in induction rates for “late preterm” (34-36 weeks gestation) and “early term” births (37-38 weeks). Those rates started downward in 2006, with the greatest improvement (decrease)  at 38 weeks. In 36 states and DC, inductions at 38 weeks have been reduced by 5% to 48%.
 
The national  rate is down 12%. The number births at >39 weeks gestation is up 9%.
 
The bad news is disparities continue. Induction rates at 38 weeks are down 19% for whites, 7% for Hispanics, and only 3% for blacks.

Questions for research: How did the state that reduced its rate by  nearly half do that?  What is different about the states that reduced their rate by 30% or more —UT, ND, SD and NE— and  states where the rate continues to increase—AK, NY and NC?
 
Source: Osterman MJK, Martin JA. Recent declines in induction of labor by gestational age. NCHS data brief, no 155. Hyattsville, MD: National Center for Health Statistics. 2014.
 

New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.


 
In a reversal of its recommendations that have for years cautioned against children and pregnant or breastfeeding women eating fish, the Food and Drug Administration’s new guidelines reflect recognition that fish is a great source of protein and other essential nutrients. For the first time, the FDA has specified a minimum intake of fish and other seafood.
 
8 to 12 ounces per week— 2 or 3 servings
That’s the new minimum recommendation for a healthy diet. Beginnings Pregnancy Guide (2014) recommends 1 or 2 servings per week, the previous maximum recommendation, now considered overly cautious.
 
The warning to avoid large, long-lived fish like swordfish, mackerel and tile fish remains. Those big fish live long enough to build up organic mercury in their flesh. According to MedlinePlus, medical evidence suggests that being exposed to large amounts of the organic mercury called methylmercury while pregnant can permanently damage the baby’s developing brain. Small exposures are unlikely to cause any problems.
 
Choose canned light tuna
Salmon, shrimp. and other seafood that Beginnings lists as safe and healthy, are still safe and healthy.  It is important to caution mothers against canned white albacore tuna since it has three times the mercury of the recommended canned light tuna. The FDA suggests limiting tuna to 6 ounces a week.
 

Beginnings Pregnancy Guide (2014) pg. 13

Use the Fish Safety Hotline
Call 1-888-SAFEFOOD That’s 1-888-723-3366 to check the safety of fish in your area. This free 24 hour resource is listed on the Pregnancy Guide’s Key Messages Poster and on page 42.

CenteringPregnancy Health Literacy Trial Underway

 
It was Wednesday, May 21 at 10AM, the start of the 217th CenteringPregnancy group at Greenville Health Systems OB-Gyn Clinic in Greenville, SC. As participants arrived, one with a friend, one with her cousin and her mother, one with her husband, others on their own, Nora, an assistant facilitator,  greeted them and gave them supplies to make their name tags. She showed  each mom the routine for the first 30 minutes of each  Centering session: Take your blood pressure like this; record it here. This is what the numbers mean…  Weigh yourself; record it here. When she calls you,  have a private visit  and  brief exam with Vicki, the nurse practitioner.  Have a snack, visit with other participants, or ask the midwife a private question. Then for the next 90 minutes the group of 9 expectant, mostly first-time mothers sat in circle  with their supporters and three facilitators, and me, the visitor there to learn about Centering. The initial awkwardness faded quickly.
 
After self-introductions and a lively, laughter-punctuated discussion of current issues from morning sickness to cravings to farting; a basket of plastic food items was passed around and we took turns talking about the items we chose. “So will you eat that during your pregnancy?”, Nora asked the group gesturing to the chocolate dipped ice cream cone.  Yes, the group decided —after all  it is summer in SC. But not every day; as a special treat because it’s loaded with sugar and fat. At closing we each said one thing we were going to do to stay or get healthy during this pregnancy… walk, drink water instead of sweet tea, try eating vegetables.
 
Does CenteringPregnancy promote maternal health literacy?
This opening session was also the kickoff of the CenteringPregnancy Health Literacy Trial, although the group will not hear about until their next session.  The trial aims to assess the capacity of CenteringPregnancy to promote maternal health literacy and empowerment. A secondary aim to is validate the Maternal Health Literacy Self Assessment designed for the project.  We anticipate that the Centering model promotes mothers’ health literacy and health empowerment by supporting knowledge gain and changes in health behaviors and healthcare utilization practices. Previous studies have shown that social support from home visitors is a catalyst for improved health literacy. In those studies, visitors were trained to “Teach by Asking”, that is to ask reflect questions instead of delivering health education. In Centering, rather than teaching and informing, facilitators ask questions to elicit the group wisdom. The group provides social support. 
 
By luck of the draw, about 120 pregnant women participating in CenteringPregnancy at this Greenville clinic will comprise the comparison group in the trial; other than completing the Self-Assessment, they will receive “usual care” in the CenteringPregnancy model. An equal number of participants at a second site will incorporate Beginnings Pregnancy Guide into the program along with the Self-Assessments. We will see if providing additional information promotes health literacy more than “usual care”.
 
Read the project overview. Learn more about CenteringPregnancy
 
Stay tuned for more on the Maternal Health Literacy Self-Assessment.

The Making of Beginnings Guides


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 finished residency.
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 bills approached
a million dollars before she left the hospital. One “bad baby” could wipe out an
employer’s entire health insurance program.
 
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
to sue.
 
Mountains of printed material, little actionable, understandable information
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
and reviewed 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
the 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
health promotion content of prenatal care. It detailed health behavior messages to be
discussed at each visit. Subsequently, research demonstrated direct links between the
recommended health behavior messages and outcomes, particularly low birth weight.
 
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 were -are-
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
primarily by college-educated women.
 
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 woman
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 behavior
I soon learned that simple information giving is rarely enough to influence behavior.
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
health promotion content of prenatal care fell to home visitors serving Medicaid populations,
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 of pregnancy.)
 
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
health literacy. There is training, a users manual, and an evidence base. It is earns high
satisfaction ratings from both college educated and under educated mothers and their families.
 
The new updated 9th! edition is just off the press. In English and Spanish. Take a look.

Reflection on 2013: Health Literacy Promotion Goes Global, Beginnings Guides Renewed

New  2014 Editions
If you have not see the new Beginnings Pregnancy Guide, and the new Beginnings Guia
para Embarrazo, 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
sections of  BeginningsGuides.com direct from the Guides.  For parents there are Pregnancy
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
the Resources for Beginnings Users section.  Also in 2013, we closed the warehouse so
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.
 
Speaking of the websites
BeginningsGuides.com had 125,000 visitors in 2013. HealthLiteracyPromotion.com 
had 50,000 visitors.  2000-4000 of you read the blogs each month. And we have
900 Twitter followers.
 
Most read blogs
Notes from the Field CenteringPregnancy, Promoting Maternal Health Literacy“Health Illiteracy” is Not a Disease
 
Promoting Health Literacy Nationally & Internationally
Cape Town, South Africa April 17-19, 2013
I 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 editor with
Prof. Minette Cootzee for a special edition of South Africa’s national nursing journal
Curationis 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”
at University of British Columbia. The consensus was that health literacy involves patient,
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
on health literacy here.
 
Bozeman, MT, USA  August 19-20, 2013
I got to keynote the Montana State Early Childhood
Council’s 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 literacy is
everybody’s job.”
 
Washington DC, October 26-28, 2013
This was a whirlwind as I presented on the
Conference, 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
Universities Health Literacy Network.  I participated with a group of academics and patient
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
We planned to have the free training videos produced with the National Network of Libraries
of Medicine Pacific Northwest Region up on the websites in August. But we got good criticism
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

Notes from the Field CenteringPregnancy, Promoting Maternal Health Literacy

I’ve been in Washington DC where I co-presented a workshop at CenteringHealthcare
Institute’s fourth national conference. I was drawn to this organization the first time
I read their motto: Transforming care through disruptive design.
 
CenteringPregnancy (CP) is a rapidly spreading model of group prenatal care. Eight to
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 ultrasound reports.
The rest of their 1.5 -2 hour appointment is dedicated to  education and support through
facilitated group discussion and activities.
 
Reimbursement levels and processes are the same as for conventional individual prenatal
care. The schedule of visits and core content follow ACOG* guidelines. 
 
Process trumps content
CenteringPregnancy’s 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.
There are games, activities and multiple ways of learning. Women test out what they've
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
support group. 
 
March of Dimes wants all mothers to get prenatal care in CenteringPregnancy,” says
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
in infant 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’s 6.3%
 
CP meets the Institute of Medicine’s goals to make healthcare services safe, patient
centered, 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
the provider. What they like best is being with other women.
 
Sharon 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
equivalent of 10-12 prenatal visits in 2 hours  beaming and talking in superlatives about
their experience.
 
All this makes group prenatal care the ultimate environment for promoting maternal health
literacy. 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 time. Meanwhile,
 
Stay tuned. ss
 
 
 

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
life 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
parents, their income or education. But poverty and accumulated disadvantage
prevent parents 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 providing direct
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 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary
by 10 experts from multiple disciplines.

Promoting Health Literacy with Beginnings Pregnancy Guide New Online: Resources for Mothers

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 since
few in your caseloads have computer access or devices to use digital information.
Other surveys confirm you’re right.
 
Poverty and the Digital Divide
In December 2010, 40% of  US households, did not have a broadband connection in
the 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 suburbs
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
used the Internet. Outside locations included school, workplaces and the local
library.  In some libraries, free internet service is the biggest draw into the building.
 
Among the reasons for having no access at home were cost and lack of equipment,
but the key reason seemed to be lack of understanding of the value of the Internet,
an 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 increasing
A February 2011 survey found 68% of households with a connection, suggesting
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 Internet
access. And some companies have just begun offering low-cost broadband connection
to families with a child who qualifies for free school lunch.
 
Finding reliable information is part of health literacy
Any family expecting a baby has a need for information. Beginnings Pregnancy Guide
is intentionally focused on essential health behavior topics directly linked to pregnancy
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
readers to visit the new Resources for Mothers pages of www.BeginningsGuides.com 
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.
 
 
 





Reference
Dunbar, J. (2012) Poverty Stretches the Digital Divide,  the Center for Public Integrity.
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