Beginnings Guides Blog
This continues our discussion of what makes materials easier or
harder to read,
We are using the instrument to assess the suitability ofBeginnings
Road signs reduce anxiety,
Working through information on a tough subject is like driving a
rental car in unfamiliar
territory. You need road signs to know where you are
now, and what’s ahead. Without
them, it’s easy to feel anxious, get confused
and go a long way in the wrong direction.
Road signs enable drivers and readers
to more easily find what they are looking for, and
arrive there focused and
Road signs in information -- on paper or on screen -- are
headlines and subheads. They
alert the reader to expect what’s coming next and
prepare her to think about (process
and understand) the announced topic.
Without good subheads, the reader is likely to
bypass the information or
miss the point.
Subheads break up a sea of
A text-heavy page
can be intimidating and discouraging to anyone, and especially those
unaccustomed to reading by learning. Judicious use of subheads, in bold type,
more readable, an essential first step toward being read.
A good easy-to-read sentences contain one thought. An easy to
read paragraph contains
two or three thoughts about the same topic. A subhead
announces what is coming in
the next one to three paragraphs.
Put a verb in it. A
good subhead is more than a label. It should be a short basic sentence.
You can tell your subheads are useful
if, when the reader takes in only
and subheads on a page, she gets the most important points.
Sometimes you will need
levels of heads and subheads. Note that this section
starts with a subhead, in bold type,
on its own line, with no punctuation. Then
this paragraph starts with a secondary subhead.
The topic is still subheads, but now we are talking about a different aspect of
The second-level subhead
is in bold type, but inline with the text and using a period to
from the text.
Be consistent. On the
road, drivers expect freeway signs to look different from state
and local street signs. If
they were inconsistent they would be distracting,
less informative, harder to
learn from. Navigating through a page is equally aided by
SAM says at least half of
topics must have a road sign
rating since nearly all topics are announced just before the reader
gets to them.
Starting on p 86, the text leads the parent/reader through an exploration of
new baby’s body. The
previous paragraphs’ subheads are “Get to know your baby” and
“Do not give Baby
your cold”. So now the reader understands why she would explore the
and, we hope, she has washed her hands, and is ready for the next section:
“Explore Baby’s body”.
Then, uh-oh, a label for a subhead. In this case the label
functions on its own to tell
parents where they are in the exploration. Body
parts are labeled consistently and
the discussion moves logically from head to toe. Second level subheads
that highlight things to notice. Under “Eyes”, the second level subheads are “Baby
have blood spots”, “Baby might look cross-eyed”, “Baby may cry without tears”
and “Yellowish discharge from the corner of the eyes is normal”. Each of these
information about something that mothers said they worry or wonder
To make information easier to read, lead your reader through the
text with good
Next: A new section on
graphics starts with the Cover
Today we are continuing with our Suitability Assessment of Materials using the SAM
in US mothers, including those with limited resources and limited literacy.
We’ve already discussed factors related to content. Now we are considering factors
that determine literacy demand, that is the number and difficulty of literacy tasks
required to make meaning from the information. The literacy demand of any health
related information is unavoidably high; the health communications challenge is to
reduce the literacy demand and facilitate meaning making and application in real
So far in the category of literacy demand, we have considered readability,
writing style and sentence construction. Today’s topic is vocabulary.
Choose common, explicit words
Almost always, the need for health information emerges due to something painful,
scary, “weird” or otherwise stressful, so that learning capacity is reduced. Health
information should not be a vocabulary test. Parents and patients cannot be
expected to know the specialized vocabulary of medicine. Health professionals must
be expected to use plain ordinary short words in conversation with the rest of us.
Plain talk is empowering to patients, and may be challenging to those whose power
comes from status.
What’s clear to you is clear to you
To check that you are using plain language, note the mental picture your words
create. Watch out for categories like poultry (chicken, turkey, goose, duck,
pigeon, dove, pheasant...). One mother told me, “I eat chicken; the doctor said
to stay away from poultry.”
Watch out for concepts that require a judgement.
Two men had heart surgery. On discharge, the surgeon told each of them to
“take it easy”. But the doctor’s mental picture of taking it easy was not the same
as the images his words created in the patients’ minds. Two weeks later both men
arrived at the ER by ambulance and were readmitted. The first man was a runner;
he ran two miles instead of five. The other man was a couch-potato; he had not
been vertical in weeks, his systems were shutting down. What question (s) could
you have asked these men to learn how to frame take it easy’ in way that would
facilitate their making meaning and taking recovery-promoting action?
My favorite: familiar words that mean something else
In a medical context, common familiar words often take on a new meaning. Stool
is one that often baffles new mothers. While the nurse is talking about what’s in
Baby’s diaper, the mother is wondering what a 3-legged thing to sit on has to do
He is complying to the letter. And he is
about to overdose. “Cap”
brings to his mind his hat; experience
tells him he can drink out of it in a pinch.
But in the writer’s mind, a “cap” goes
on a medicine bottle and measures a dose.
Photo Credit: "Life According to Carp"
From Smith S. (2000) Patient Education and Literacy in Laubus and Lauber (Eds)
Preventive Medicine and Patient Education. Philadelphia, Saunders, 266-290
When you cannot avoid a technical or judgement term...
Instead of excess mucus, which requires a judgement of what is excess and
interpretation of medical jargon (mucus), say it the regular way: runny nose.
Sometimes there is no plain term. In those cases explanation, example and
illustration reduce literacy demand and facilitate meaning-making.
Culture matters In testing the Beginnings Pregnancy Guide, we asked mothers
how to talk about urination, since no one actually says urinate. English speaking
moms wanted to say “go to the bathroom”. Spanish speakers seemed surprised
by the question; they said, “We know what orino means.”
Final note: no one says healthcare provider. Mothers said a provider is one who
puts a roof over your head. While they know there are physicians and nurses and
therapists and receptionists, most used the term doctor to refer to anyone they met
in the medical encounter.
Bottom line: Short plain words that create an unambiguous mental picture
Next: Road Signs
Guides to promote maternal health literacy. So the Guides need to
fit the audience, US pregnant women including those
with low resources and
limited literacy, and to facilitate use of health
information and services. In Part
3 addresses two
additional factors that determine the literacy demand of information,
style and sentence construction.
Style is Conversational
Easy-to-use health information uses a
conversational tone. Read aloud the information
you are reviewing It should sound like something you
would actually say to a person
sitting with you. Some clinicians may pan a
conversational style as “unscientific” or
“unprofessional”, a reflection of professional
training that rewards multisyllabic latinized
terms in long complex sentences like this one as
demonstration of deep knowledge.
But that is not the point here.
The point is to make the information
easy to understand, personalize, and apply in
real life. Conversational tone is familiar and expected, so quickly grasped
intimidating. Rather it invites reflection and interaction.
Conversation nearly always uses the
active voice: “ Jason hit the ball” is active. I can see
the action in my
mind’s eye. “The ball was hit” is
passive; it creates an incomplete mental
picture. It does not engage the
Conversation uses short simple
sentences, and sometimes incomplete sentences. No
embedded information. In the
first paragraph above, the third sentence intentionally
phases and embeds mostly irrelevant information about professional
demonstrating that long involved sentences and extraneous facts slow reading
and reduce comprehension. So instead of
“Patients are advised to take vitamins daily”;
say it the regular way:
“Take your vitamins every day”.
Guides get a Superior rating for using conversational style and simple
Construction: Context first
The way the sentence is built makes a
big difference in comprehension. Readers recall
the last thing they read, that
is, the end of the sentence. Starting with what the reader
provides context and increases understanding.
Start with the context - the part the
reader already knows: “While you are pregnant....”;
end with new information:
“...your uterus is big enough to hold the baby. Right after
birth, it shrinks
to the size of a grapefruit.” (Beginnings Pregnancy Guide Book 6 page
If I state the new information first, the reader is likely to miss
or forget it.
SAM gives an Adequate rating to
materials that present the context first half the time.
Beginnings Guides get a
Superior rating for consistently providing context before new
Vocabulary & Road Signs
Guides to pregnancy and parenting translate the science of prenatal
and early child development into practical guidance for parents.
The Pregnancy Guide, first published in 1989 as Beginnings: A practical guide
through your pregnancy, is now in its
8th edition (2011). It has been distributed
by home visitation programs,
prenatal care providers and health insurance plans
to more than 310,000
families. In surveys, mothers report sharing Beginnings with
their partners, friends and relatives, and their
doctors. Six months after close
service, nearly all mothers who participated in New Mexico’s Families First
program were able to report where their copy of the Pregnancy Guide would be
found. For example, one mother said,
“They are stored with the newborn clothes
for my next pregnancy.” Another said,
“I gave it to my cousin who is pregnant.”
Pregnancy Guide is not your usual pregnancy book. Let me count
1) Conversational tone is easy,
encouraging. It sounds like something you would
actually say to a mother
sitting next to you. The text reflects the conversations
a caring, articulate,
“patient-centered” practitioner who is up-to-date on the
research would have
with each mother at each visit if time allowed. Readability
Flesch documented that conversational tone using personal
pronouns and common
words increases readability and comprehension.
learning keeps info immediately applicable. Information is like
is easier to take and more effective is small doses. Adults learn
in order to
solve problems they have now. Information that is not immediately
likely to be ignored or discarded and may be overwhelming. So
the Beginnings Guides present essential information in a series of six booklets
referenced by gestational age and the usual course of prenatal care.
cover the content of each booklet in one or more visits depending
on the family’s
interests and needs and your frequency of visits.
3) It’s short. Short words in short sentences in
short paragraphs in short booklets
increase readability, comprehension and
recall. This “commitment to short” means
focus is on the essentials. Even
experienced mothers and educated first-timers
who read everything about
pregnancy welcome Beginnings’ focus
on what really
matters at a particular point in pregnancy. We converted to
the 8.5 x 5.5” booklets
mothers told us that format is easy to carry and store and “they don’t look or
feel like homework”.
4) It’s designed to promote maternal
More on that next time. ss
We’ve gone social! We started Tweeting
2011. We’re also on
parenting and health literacy is on Twitter. Social media
allows us to
monitor and contribute to related online discourse and resources.
Beginnings WebMother Simone Snyder
follows 1490 tweeters to keep
us up to the minute on the latest developments in
have a combined following of over
100,000. An additional 190+ follow
posts directly by phone or email. You can also just
check in at your
I am happily surprised by the range of
interest. Beginnings followers
include individual parents and grandparents,
physicians, nurses, nutritionists,
SIDS specialists, injury prevention experts,
health coaches, child advocates,
nine March of Dimes programs around the
country, several United Ways and
Head Starts, literacy groups in the US and
Canada, child care organizations
and women’s clinics. Major organizations tuned in to our work include the
Maternal Child Health Bureau, CityMatCH, American Association of Maternal
Health Programs, Early Intervention Family Alliance, Child Health USA,
MCH, HelpMeGrow, Text4baby.
to follow us and participate in the conversation
You can expect 10-15 quality posts a week on topics ranging from Health
Literacy, Maternal Child Health, to tips for home visitors and expecting parents.
To follow Beginnings Guides click here
or search for @BeginningsGuide.
To follow The Center for Health Literacy Promotion click here
or search for
To Like Beginnings Guides click here
or search for Beginnings Guides.
To Like The Center for Health Literacy Promotion click here
for Center for Health Literacy Promotion.
To set up an account click here
To connect with Sandra Smith, PhD on LinkedIn click here
Spanking, slapping, shoving are common
punishments for children in the
US and Canada. Hitting a child is socially
acceptable by many parents as
a form of discipline or to protect children by
teaching them to respect
A large new Canadian study documents that these punishments
are associated with
lifelong mental and emotional problems.
ACEs - Adverse Childhood
Experiences- are a frequent topic in this space.
ACEs include experiencing or witnessing physical or sexual
violence or abuse.
ACEs are closely linked to a surprisingly long list of
physical and mental
problems in adulthood. But that is not what we’re talking
Here’s the main survey question put to
over 20,500 adults: “As a child
how often were you ever pushed, grabbed,
shoved, slapped or hit by
your parents or any adult living in your house?"
often, Very often
If you answered Sometimes or more
often, these researchers would say
you experienced harsh physical punishment
and you would be among the
6% of study participants whose experience is
similar. Those who also
reported ACEs were excluded from the analysis.
Adults who were punished as children,
but not to the point of full-scale
maltreatment, were at increased risk for
depression, mood swings,
anxiety, alcohol and drug abuse, and personality
This from Beginnings Parents
What do you want to teach?
your child that hitting is not OK. It hurts
here that hitting is OK if you are the biggest and strongest
your child to keep the rules out of respect for herself and other
her to keep the rules so you will not hit her
your child she is a good person who learns from mistakes and practice
her she is bad; she does not learn well; she deserves to be hurt
your child to think for herself and do the right thing
her not to think for herself, and to do what keeps her from getting hit
you and your child feeling OK about yourselves and each other
your child in pain, feeling bad about herself and you.
Resource: Parents can talk
anonymously with a counselor, 24-7,
free in 150
languages by calling Childhelp USA National Hotline
All physicians should screen all adults for obesity. So say new guidelines published
this week by he US Preventive Services Task Force. The guidelines recommend
measuring each persons height and weight to calculate their body mass index or
BMI. Everyone with BMI of 30+ should be referred to counseling and behavior
change support programs.
It’s a good plan. Screening for obesity and managing weight is particularly
important during pregnancy. Extra weight contributes to complications and is
rarely lost after birth. Fat bodies produce fat babies building obesity and its
attending health risks into the next generation. Weighing is the only prenatal
care procedure shown to affect outcomes.
If your doctor does not discuss weight, that does not mean it doesn’t matter.
Although weight management has long been part of a minimum quality prenatal
care service, providers infrequently weigh mothers. They say weight is a touchy
subject and they don’t want to embarrass or alienate patients, so they don’t
talk about it. Others say they do not know how to calculate BMI. (Calculate it
yourself with this handy gadget
from the Beginnings Guides resources collection.)
The guidelines emphasize traditional approaches that frame weight management
as a battle involving diet diaries, calorie counting, exercising and tracking activity
levels. An approach unlikely to be engaging or popular. One of the authors said,
“We also need to help people understand why they’re not eating more healthfully
or being more active, and help them address those issues.” He is right, partly.
What’s missing from the guidelines is recognition of the links between obesity
and sexual abuse. Research demonstrates that obesity is not just about an
individual’s lousy eating habits or laziness. It is shockingly often about a history
Fat is protective.
Counseling and support services will need to do more than “get people to eat right”;
they will have to recognize and address underlying social issues, starting with
Virginia A. Moyer, on behalf of the U.S. Preventive Services Task Force. Screening for and Management
of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal
Medicine. 2012 Jun 26. Available free online at
U. S. Department of Health & Human Services, Public Health Service (1989) Caring for our future: The
content of prenatal care. A report of the Public Health Service Expert Panel on the Content of Prenatal
Care. NIH Publication No. 90-3182 Washington, DC: National Institutes of Health.
Kogan, M.D., Alexander, G.R., Kotelchuck, M., Nagey, D.A. (1994). Relation of the content of prenatal
care to the risk of low birth weight. Journal of the American Medical Association, 271(17), 1340-1345.
The Adverse Childhood Experiences Study http://www.acestudy.org/
parents anytime you are
outdoors or riding in a car. But not for babies.
reasons: Babies skin is very thin; so it absorbs chemicals more easily than
And babies have a lot of skin for their weight so the chemicals have
That means sunscreen on a baby is likely to cause an allergic
reaction or swelling or both.
Shade, long sleeves and long pants, and a hat
with a wide brim are the answer.
Especially the hat. Make sure it shades Baby’s whole
face, ears, and the extra-sensitive
For toddlers, and for Baby when you
really cannot keep him out of the sun, test a dab
of sunscreen on his inner wrist. Use SPF* of 15-30.
Higher than 30 means more chemicals,
but only a tiny bit more protection. If
you see no reaction, apply to small areas that
you cannot cover, like cheeks,
hands, and bare feet.
Remember, too,that small bodies need
in hot weather. Keep water (not soda
or juice) handy and keep them
and Drug Administration.
Download it free to handout or post.
*SPF Sun Protection Factor. It’s a confusing rating.
pretty good explanation of how SPF ratings
are set and why that new SPF 100
protect much better than 30, see Jeffries, Melissa.
"What do SPF numbers mean?" 16 August 2007.
Action research identifies best
practices for promoting
maternal health literacy
Following is a brief summary of
findings from our program
of action research* with home visitation programs
Visiting (MECHV) is an effective channel to promote
maternal health literacy,
Overall mothers (N=2572 including 23
men and a few grandparents)
who participated in enhanced home visitation for
achieved significant improvement in their use of information and
Maternal Health Literacy reduces disparities
Additional findings suggest the
intervention reduced disparities
related to literacy and age:
Lower skilled readers made greater gains than
Teen mothers started at a major disadvantage but
impressive gains in the first six months of service to nearly
with their more experienced counterparts.
and Maternal Health Literacy closely linked
Both depressed and not-depressed mothers
management of personal and child health and healthcare.
Depressed mothers made greater gains
mothers, again reducing disparities.
does not interfere with health literacy promotion efforts
Depression improved slightly but significantly
over the service
period. Home visitors were successful in supporting mothers to
overcome multiple barriers to obtain depression treatment,
increased understanding and utilization of health
services -- that’s health
literacy. Major improvements in health
literacy occurred even when changes in
depression were minor,
suggesting the effect on health literacy is separate
from the effect
(full text free online).
Health Literacy may predict child developmental outcomes
findings from our current study on the same database as
the above studies
suggests maternal health literacy is closely related
to child development, so
that efforts to promote health literacy also
promote child development. Stay tuned.
it feasible and effective to integrate health literacy promotion
This question is being addressed over
the next two years with
Anthem/WellPoint as it pilots the intervention in 12
managed care organizations. WI is up. TX is next.
health literacy promotion into Parents As Teachers
curriculum is feasible and effective
That is the preliminary finding from the Parents As Teachers Health
Demonstration Project that winds up this summer. The
Educators and other stakeholders will review
and interpret the results at a
Reflection Conference May 11.
* Action research, sometimes called “practitioner
is a reflective process in which practitioners undertake research
improve their own practice by learning from experience.
identifies ineffective practices to drop; promising
practices to hone and
finally best practices to
See Forest, M.E. & McNiff, J. (2007). Learning and
teaching in action.
Health Information and Libraries Journal, 24, 222-226.
Reports have been circulating on the
find that the recommendation to exclusively breastfeed
for six months is just too hard for modern women and is making
feel bad. The study author suggests the advice is fine
for the developing
world, but should be changed to “breastfeed
as long as you can and introduce
solids as close to six months as
There are several health literacy
lessons to be learned from this
questionable reporting on questionable
evidence is exceptionally clear and strong
First, we should note that the
recommendation to feed infants
only breast milk for at least six months is not
just a suggestion
from some guy in a diner. It is the evidence-based consensus
the U.S. Centers for Disease Control, American Academy of
Pediatrics, the World Health Organization, and
virtually all health
agencies on the planet. This level of consensus is rare
an extremely strong evidence base.
the recommendation unhelpful for mothers?
and child that last a lifetime and save
in healthcare costs.
The study’s author says the recommendation is
“unhelpful” as an
individual goal and calls for balance between
these “theoretical” longterm
benefits and immediate family well
being.Fair enough. But that can be done at the individual level
without undoing worldwide policy making and without concluding
that women are incapable of (or just too busy) for this womanly skill.
perfect food is free
The big problem for breastfeeding is
this: it’s free. This study
feeds a broadly-held perception that breastfeeding
is for poor
people in backward countries that cannot afford or reliably use
With this twisted thinking we are
willing to disregard all the
science behind the global breastfeeding
favor of the belief that in 30 years scientists have made a
formula than what Mother Nature developed over millennia.
Literacy means the cognitive and social skills which determine
the motivation and
ability of mothers to gain access to, understand,
and use information in ways
that promote and maintain their
health and that of their children.
Part of health literacy for mothers,
health promoters and
clinicians alike, is reading critically, asking where is
coming from and how reliable is it? What does it mean to me in
my situation? How can Iuse it
Read it for yourself.
The study is published in BMJ Open-
British Medical Journal Open, an open access journal.
BMJ ought to be a reliable source. But
here’s the detail that matters
(it’s in the abstract): 541 pregnant women in
Scotland were invited
to participate in monthly interviews; 72 volunteered to
Of these, 36 were interviewed along with some of their partners
is not a representative sample. People who volunteer to
surveys typically feel very strongly one way or the
other. We need to ask, how
are these 36 women different from
the 505 who declined? Further, the sample is too small to draw
any conclusions beyond the individuals involved.
them what to do does not work
Breastfeeding advocates, health
educators, parent educators,
home visitors, clinicians can learn an important
lesson re: promoting
maternal health literacy from this article. When education
is perceived as “unrealistic, overly technical and rule based”, it is
to motivate anyone to take action for health. But you
already knew that...The problem here is not the breastfeeding
policy; it’ s the
delivery of information.
Stay tuned for a model reflective conversation to
To balance the oft quoted Scottish
mothers who were not well served by
their lactation consultants and who
struggled with breastfeeding, see our
for comments from
our volunteer sample of mothers who
work in women’s health. We asked: Do you think recommending
a minimum of 6 months is unrealistic or unattainable?
No one said Yes.