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Review of Beginnings Pregnancy Guide 9th Edition 2014 using PEMAT-P
Example from the field: Medication instructions show lots of room for improvement
The Making of Beginnings Guides
The 7th Attribute - Navigation Assistance
CORRECTION: The discussion paper posted here yesterday


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Beginnings Guides

Honoring Mothers & Nurses

One of my favorite duties at the first conference on Building Children’s Nursing for Africa 
last month was interviewing a panel of three mothers of children with special needs who
are cared for at the Red Cross Children’s Hospital in Cape Town.  They talked like nurses
with full understanding of complex conditions, procedures, and medical jargon. I asked
them, “Thinking back on your experiences in the hospital, what do you want nurses to
Farahna is mother of Hamza*, now 11, who relied on a tracheostomy  for 10 years and
whose remarks closed the conference. She responded simply in a deep, quiet, powerful
voice, “ I am the mother.” 
And all  the mothers  together said, “I could not have done it without you.” 
In this National Nurses Week  leading up to Mothers’ Day. I am deeply appreciative of
the everyday huge and small sacrifices and loving kindnesses that mothers make for
their children, most of which go unnoticed and unrecognized. And I am ever more
appreciative of the expertise, heroics, gentle touches and encouraging words that
nurses bring to the mothers and their children to restore and maintain the well-being
of both.  You inspire me.
*Hamza and I won the award for Best Dancers at the conference dinner!

Heartwork: Reflective Drawings and Coloring Conversations

Coloring is meditative. With crayon in hand one is able to access a different
part of the brain, a non-thinking part that is intuitive and reflective.
Beginnings Guides Heartwork was designed to tap in to this powerful place.
The drawings were created by Laurel Burch. They invite reflection on one of
the key concepts found in the Beginnings Guides curriculum the concepts are
related to managing personal and family health. Each drawing is linked to a
booklet and key concept. The client is able to learn the concept the drawing
illustrates while encouraging her to visualize her future as a mother,to dream
ahead, to imagine and plan. Perhaps she may even reflect on her own
childhood, things she would like to carry over in to her own experience, things
she would like to do differently.
Beginnings Guides Heartwork encourages
reflection, which is key to understanding
health information, affects the ability to
make healthy decisions and therefore
improves outcomes. A simple, powerful
method to promote maternal health literacy.
Using the coloring pages can help to set up
thinking and sharing quality to a visit, it is
hands on, and will encourage the client to
find deeper meaning and to speak from the
heart. She may uncover new information or
a previously unrecognized need. Therefore
the home visitors handbook includes a chapter
on how to use the coloring pages safely and
effectively to color a conversation.  There are some key factors to keep in mind.
Client safety is very important when working with the coloring pages. Because
the exercise has the potential to bring up deep emotions and/or repressed
feelings it is important to have program protocols in place to assist the home
visitor. A client may bring up depression, domestic violence, child abuse or
substance abuse.Heartwork can be deeply powerful therefore if you do not
have a protocol set up through your organization avoid using this exercise until
something can be implemented.
Be sure to organize your visit effectively.
Heartwork requites trust and a certain
level of comfort. They were not designed
to be used on the first or second visit. It
is also suggested that you wait until the
end of a booklet to do the coloring pages.
If needed you can introduce the page and
leave it with them to complete on their
own time. They could also be encouraged
to journal or write about their experience
on the back of the page. Be sure to provide
crayons or makers and encourage
your client to find a quite place to do the work where she won’t be interrupted. Be sure
to listen, respond, follow their lead and listen to your instinct.
Do you use Heartwork in your practice? Would you like to share your experiences and
clients drawings? We would love to hear from you.

Promoting Health Literacy with Beginnings Guides Part 14 Cultural Appropriateness

This is the last in our series using the SAM Suitability Assessment
of Materials to assess the suitability of Beginnings Guides to
pregnancy and parenting for low skilled readers who may be new
to the healthcare system.

For a good cultural fit match readers’  LLE
Leonard and Cici Doak, authors of the SAM,
concluded that most communication errors
in healthcare are caused by cultural gaps
between patients and providers,particularly
gaps in Logic, Language & Experience - LLE. 
For anyone in health communications
-that’s everyone in healthcare, it’s an acronym
worth remembering. 

Logic refers to a way of thinking about health, illness, treatment. 
Because of their specialized training, healthcare professionals have
a special way of thinking. For example, to a clinician who sees 30
sick people per day, illness is normal, another day at work, the usual
routine.  But to those 30 sick people, their illness  is exceptional, a
major source of physical, emotional, spiritual and financial stress for
a whole family, a reason to miss work and suspend the usual routine.
The clinician’s routine challenge may be the patient’s life changing
event. Consider, too differences between Western and Eastern medicine,
between medical specialties,  between medicine and public health,
between medicine and health promotion. A challenge for all health
communicators is to understand and match the learner’s logic about
your topic.

Language refers to a way of talking
about health, illness, treatment
Of course, logic and language overlap.
To a professional the problem
may be hypertension exacerbated by
obesity; to the patient the problem is
bad blood making it hard to walk up the
stairs. In the West, we describe epilepsy
as a disease - abnormalities in brain cells that cause seizures. Elsewhere,
epilepsy is described as  blessing - a sign that the person may be a shaman;
“the spirit catches you and you fall down”. Other language issues are less
English is the language of the healthcare system.
If you are not proficient in English, you will struggle
at every level. And even if you are, you may still
struggle when simple English terms like stool and screen,
minor and routine take on a whole new medical meaning.
Or when simple concepts like walking  and pus or go home
take on a whole new vocabulary like ambulation and
Latin and Greek are the language of medicine.
Terms are long and technical, so a natural short hand
emerges. As public relations director for a hospital that
specializes in heart surgery, I encountered more than
one family who objected to hearing staff refer their loved one as “the cabbage
in 206”. They were using shorthand for coronary artery bypass, thinking and
talking about the patient as his procedure and location.
Experience refers to participation in events as a basis of knowledge
A clinician lives in the hospital or clinic. S/he is intimately familiar with
the technology. S/he is in charge and in control. Everything is organized
for his or her convenience and efficiency. His or her status comes from
specialized knowledge.  In many cases, the patient has no experience
and very limited knowledge. That means no basis on which to judge
quality, weigh options, or interpret instructions. At that same hospital,
two patients who had open heart surgery by the same surgeon on the
same day were re-admitted two weeks later. Their doctor had told 
them to “take it easy.”  Both complied. One ran 3 miles instead of
his usual 5. The other never got off the couch.

Who is responsible for bridging the gap?
Federal, state and local laws, Medicare and Medicaid regulations,
and accrediting bodies clearly state it is the healthcare providers’
duty to communicate in a way the patient and family can understand.
SAM says Superior health education materials match the readers LLE
and present images and examples that are realistic and and positive.

Beginnings Guides are intended for a broad
national audience. It’s intent is to be as
culture-neutral as possible. We chose cover
art by Laurel Burch in which our testers saw
whatever was important to them. 

Last words on SAM: Only readers know for sure
SAM is an at-your-desk review. It cannot tell you that your information
is easy to understand and use.  Only the intended learners can tell you
that they learn easily from your document. SAM helps you get your
materials to the point where they are ready for Reader Verification
Interviews. More on that next time.

Promoting Health Literacy with Beginnings Guides Part 13 Motivation to Learn

Adults learn to solve a problem they have now
Motivation to learn depends in part on the person’s skills, and more on the
information. Adults learn in order to solve a problem they have now. Another
way to say it: literacy skills always are used for a practical purpose. 
Health literacy...
the cognitive and social skills that determine a person’s motivation and ability to access, understand and use information is ways that maintain or enhance health.

I’ll never forget a brochure titled How to Care for Your Son’s Penis,  a topic
many a new mom has wondered about and few have been willing to ask about. 
So intended readers will be motivated to open the brochure. So far so good.
Facts do not motivate
The brochure would fail a SAM review on many counts discussed earlier in
this series, each of which puts a damper on readers’ motivation to read and
learn and take action.  But here’s the big sin: the six-panel brochure uses
five and a half panels to describe and illustrate the details of the penis,
it structure, functions and properly named parts.
None of it tells the mom what she wants to know.
None of the dense narrative of facts motivates her to adopt the desired behavior
-which is yet to be mentioned. In fact, this information is discouraging and
disempowering.  It overwhelms the reader with the author’s knowledge, leaving
her feeling like she can never learn what she needs to know to take care of her
child. It makes her unnecessarily dependent on The One Who Knows. It takes up
her time and leaves her with nothing she can use, no action she can decide to
take or not.
How to... motivates
The last sentence on the back panel  of the brochure says, “The best course is
to leave it alone.” 
There is no need for the rest of the brochure. That’s all she needs to know. 
A clinician could tell her that in less time than it takes to hand her the brochure,
and a lot less time than it would take her to wade through the irrelevant
We are motivated to read and learn from information that is clearly and immediately
relevant; AND that describes in specific familiar concrete terms the actions that will
solve the problem that motivated us to seek information in the first place.
As long as the desired behavior feels doable. On this point, the offending brochure
gets a high score. “Leave it alone” is specific and doable.
SAM - the Suitability Assessment of Materials, gives a Superior rating to materials
that describe and show specific behaviors and skills and that subdivide complex
topics so readers feel confident and ready to take action step by step. 


Editorial Conventions in Health Education Materials What to do about dads and pronouns

She or he read our February newsletter. And unsubscribed.  She or he wrote
that the posting and the included excerpt from Beginnings Parents Guide is
sexist because the text does not address fathers and it does not use the
gender neurtral “he or she” in referring to the baby.
These are two sticky issues for editors  and  reviewers of health education
materials.  Decisions need to be driven by consideration of the intended
readers and ease of reading and comprehension.
At Beginnings Guides and the Center for Health Literacy Promotion we
continuously debate to what degree to include fathers in parent education
and programs that intend to support child development.  My decision as
editor is based on data from home visitation and parent eduction programs
that have participated in our research. 
We have two databases now, totaling 2675 parent child dyads. The data are
reported by the practitioners on the families in their case loads (we have
no access to identifying information). In each database, fathers /male
caregivers make up less than 1% of the parents. That does not indicate
fathers are not active and important in the children’s lives. But the data
do show clearly that it is still mothers who are the primary caregivers. 
And so Beginnings Guidesare addressed to mothers.
I can understand our unhappy reader’s objection about the excerpt that
refers to the baby using the male pronoun he. If she or he were more
familiar with Beginnings, she or he would see that the convention is to
alternate the use of he and she in logical ‘chunks’ of text.  This avoids
cluttering up the page, slowing reading, and interfering with comprehension
by repeating the awkward and unfamiliar he or she or s/he, as I have done
here for illustration.  Another way around the pronouns is to use Baby
with a capital B as you would use a name.
I’m sad to loose a reader, and I appreciate his or her passion for equality,
and that she or he brought these issues to the forefront for reconsideration. ss

Promoting Health Literacy with Beginnings Guides Part 12: Interaction stimulates learning

Interaction is a literacy skill that is used to personalize information. We
interact with the information and with others (family, friends, professionals)
to make meaning from it and decide how it applies to us in our situation,
with our resources and our challenges.
Interaction also is a parenting skill used to engage a child and stimulate
Interaction physically changes brain chemistry
Brain imaging shows how interacting with information stimulates learning.
It produces a measurable chemical change in the brain that takes the
information into long term memory. No interaction, no long term memory.
No recall. No ability to use the information for health (health literacy).
Ask questions, spark thinking and action
You can work interaction into print materials, face-to-face teaching and
any media format. By now you may not be surprised to read here that
the way to facilitate interaction for learning is to ask a reflective question
that requires the learner to think. In printed matter, our subject here,
interaction usually looks like blanks to fill in, boxes to check, pictures or
words to circle, choices to make, alternatives to consider.
For example, In the Beginnings Parents Guide, running text about lead
testing for infants is replaced by a set of five short personal statements
and check boxes to choose [ ] Yes or  [ ] No.  This follows guidelines we’ve
discussed previously in this space:  no more than 5 items are “chunked
under one subhead;  a 10% cyan (blue) screen behind the text draws the
reader’s attention to the information.  The key information is placed at
the upper left where reading starts, using the principles of reading gravity
to further ensure the reader does not miss it. The headline engages the
reader with a reflective question that requires thinking:  Does your baby
need a lead test?
Thinking through each question and physically checking the box is the
interaction that stimulates the chemical change that fosters long term
memory and converts information to knowledge that can be used again later.
Running text is easy to read, understand and forget. Read the next sentence
now; when you finish reading the rest of this post, see what you recall.
Your baby needs a lead test if you live in a home built before 1960 or your
home has lead pipes. Also, If you live near a highway, lead smelter or recycling
plant, or you live with someone who works with lead, your child needs a lead test.
A question-answer format is more engaging than straight text, but it is passive,
rather than interactive.
You can build interaction into audio and video taped information by including
a question for each important point. Ask listeners a direct question and include
a pause. After the pause, give the answer. In face-to-face teaching, use the
“teach back method”. Ask the learner to tell you in their own words what they
are going to do at home, and what problems they might encounter. Use their
words in this conversation.
SAM- theSuitability Assessment of Materials - says that Superior health
education materials present problems or questions for reader response.
Information that does not offer interaction does not stimulate learning and
is not suitable for health education. Information that improves health literacy
is interactive.
Now, close you eyes and say out loud the ways you know that does a baby
needs a lead test.
To see how you did and check out the example, take a look at  the lead
Next: Motivation

Promoting Health Literacy with Beginnings Guides Part 11: Chunking information for Easier Recall

Did you ever play the party game where multiple items are displayed on a tray;
everyone gets to look at the tray for one minute, then the tray is removed and
you write down as many items as you can remember?
No one remembers more than seven items
That is because of the way the brain processes information. Earlier in this series
we said the purpose of the cover, is to attract the readers’ attention. When it
does, the reader’s mind very rapidly decides to activate memory and process
the information. Or not.
Assuming the reader decides to pay attention - the information goes to short
term memory. If you’ve played the “What’s-on- the- tray?” game, you probably
noticed that short-term memory has very limited capacity and short storage time.
In a bright mind on a good day, short term memory holds seven items. It lasts
less than 1 minute. For many, especially those with low literacy and high stress,
it holds less. And here’s the thing: the more items on the tray, the less you
remember. When short-term memory hits capacity, it dumps everything.
Chunking prevents over-taxing short term memory
The parlor game is easier when the items on the tray are organized -- ”chunked”
into groups of related items. Chunking helps the mind associate the items with
something it already knows. Association gives the brain a place in to put the
information in long-term memory, so you can recall it.  Maybe the tray contained
kitchen utensils (spoon, can opener, peeler), bathroom items (toothbrush, comb,
soap) and writing implements (pencil, pen, marker). These chunks are easier to
think about than a bunch of stuff.
It’s the same with printed information: use subheads to chunk a list of items into
logical groups that link the information to something the reader already knows.
SAM says that in Superior health education materials, lists are grouped under
descriptive subheadings with no group having more than five items.
The Beginnings Parent’s Guide’s  Home Safety Checklist for infants up to 12
weeks old in the is a good example. It’s on page 25; take a look.  The instruction
is divided into four chunks: fire safety, sleep safety, burn safety and air safety.
Each chunk covers one to three items. In addition to increasing comprehension,
this chunking makes the checklist look and feel do-able.
Next: Learning Stimulation
Resources: Doak C, Doak L & Root J. (1996).Teaching Patients with Low Literacy
Skills. 2nd edition. Philadelphia, Lippincott.  NB: Find it free online thanks to
Harvard School of Public Health

Promoting Health Literacy with Beginnings Guides Part 10: Layout

In this Part 10 of our series using the SAM - Suitability Assessment of Materials
- to evaluate Beginnings Guides, we address layout, the architecture of the page.
Like the architecture of a building, layout makes a page inviting or intimidating,
easy or physically demanding to navigate, memorable or nondescript.  SAM names
eight factors that substantially influence the suitability of health education
materials by making the process of reading painless or not. We will take them in
order. But first, I will add one essential item that SAM leaves out and that all page
design should respect

Reading gravity rules layout
Reading demands physical skill, concentration and time, all of which may be in
short supply. The information architect must ensure that none of the reader’s
effort and time are wasted, or worse, sacrificed to design.
We read from the top left corner of the page and work our way across and down;
left to right and back again to the bottom right corner.  Page design should facilitate
this efficient pattern and avoid disturbing reading rhythm.  In testing, on average
67 percent of readers showed good comprehension of information that complied
with reading gravity compared to 32 percent of readers of the same information
on pages that required them to work against reading gravity. Learn more and see
an illustration here.
Reading gravity explains many of the suitability factors for layout.
Position illustrations adjacent to related text.
SAM says photos or other graphics should be placed adjacent to the text that they
explain. Ideally the text is to the left of the graphic (so you read it, then see the
explanatory graphic)  and a caption is immediately below the graphic. Otherwise,
the illustration becomes a distraction and interrupts reading.
Make it easy to predict the flow of information
That means the content follows a logical sequence and is presented consistently.
For example, Beginnings Pregnancy Guide content is sequenced by gestational age
and the usual progress of pregnancy. Each of the six booklets uses the same section
heads and text addresses similar subjects in consistent order (e.g. Your Baby’s
Growth and Development). Warning Signs are always located on the back cover;
they change by stage of pregnancy; no searching is required.
Use visual cues to direct attention to key content        
For example, Beginnings Guides highlight key messages by displaying them in bold type 
in a box with 10% cyan( light blue) screen. Research suggests the light screen attracts the eye
without interfering with comprehension. A cell phone icon alerts the reader to a condition that
warrants a call to the doctor.

Keep the page clean
Simple design works best for readers. A cluttered page looks hard to read, and
most likely is.  Testers may say the over-designed page is more attractive, but
their comprehension will suffer.
Keep color in a supporting role
Color attracts the eye. Use it to lead the reader to key content. Or to lure the
eye up to the “fallow corner” at the upper right. Check to make sure the color
does not pull the eye against reading gravity like it does below.

Keep lines short - 30 to 50 characters and spaces
Remember the reading eye moves from left to right
and back again. At the end of the line, the eye returns
to its starting place and drops down to the next line.

Unless something is in the way. Then it has to search
for what is next,and be lost to the distraction.

Keep high contrast between type and paper.
When contrast is low, reading is difficult. For comprehension, black type on
white paper is far and away the best. More on colored type.

SAM says use non-gloss (matte) finish. Glossy paper carries a reflection which
can be distracting. However, other testing showed no difference in comprehension.
A coated stock repels fingerprints and is more durable.
Beginnings Guides get a Superior rating for complying with all these factors most
of the time.Look through the Pregnancy Guide.  SAM requires at least 5 to be present.
Material with fewer than three factors present or that just looks uninviting or hard to
read is Inadequate.

Promoting Health Literacy with Beginnings Guides Part 8 Lists & Charts

This segment continues our Suitability Assessment of Beginnings Guides using
the SAM instrument. It will complete the review of graphic elements begun in
Part 6 looking at cover graphicsand continued in Part 7 on illustrations and
captions. Today we consider lists, tables, charts and forms.
Lists can facilitate learning if they engage the reader to interact with the
information, make choices, and take action.  To meet this goal, the purpose
of the list must be made immediately clear through a headline or subhead
(see Road Signs) and brief instructions, as needed.
Example: Beginnings Pregnancy Guide (Page 65) includes a list of what to
take to the hospital or birthing center for childbirth. This is important
content to increase confidence and reduce anxiety,  especially for the
many women for whom childbirth is their first hospital experience.  
“Pack you bag” is a clear simple headline that clarifies the purpose of the
list. Two short introductory sentences tell when to pack and indicate the
list includes “all you will need.”  Check boxes are included to encourage
interaction.  The list is broken up with a subhead: “Pack for baby”, 
indicating the next appropriate action.
Provide instructions step-by-step
Explanations and directions are essential.  When presenting how-to
information, a bulleted list is easier and quicker to read and use than
a paragraph.  An example clarifies the instruction and instills confidence.
When preparing instructions, think through who will use the information
and how will they use it. Where are they likely to be when the want and
need the information. What might they be doing? Who might be with
them? What might get in the way? What might be confusing?  What format
will be most accessible? Focus on what-to-do. Be specific. Omit all
reference to what not to do (it is equivalent to static).
Example: Every pregnant woman wonders how she will know she is in labor
and  what to do when labor begins.  Beginnings Pregnancy Guide (page 72-73 )
presents step-by-step instructions under the headline “Are you in labor? Walk
to find out.”  Steps are numbered and presented in logical order: 1.Notice
contractions. 2. Walk  3. Time your contractions. 4. Call your doctor. Key
information is highlighted: “True labor contractions get longer, stronger
and closer together” . Instructions for calling include who to call, when to
call, what questions to anticipate, what to say, what if you get an answering
service, what if you cannot call; and finally, what to expect at the hospital. 
A photo shows a woman walking with hands on pregnant belly, noticing her
Test essential instructions with a few representative learners with no prior
experience and little knowledge of your topic. Invite them to read your
instructions and tell, or better show you what they would do.  You will find
out quickly if the directions are too brief to use the graphic or follow  the
directions independently in likely circumstances. For Beginnings,our standard
is that the learner can find and follow the necessary instructions in the middle
of the night while throwing up.
Beginnings gets a Superior rating on the SAM for providing step-by-step
directions with examples that build self-efficacy. Graphics--lists, charts,
tables, forms-- presented without explanations are not suitable in health
education materials.
NEXT: Typography: type sizes, fonts, caps, color

Breast Milk Baby reveals nation’s low health literacy

The Nation & World section of my morning newspaper reports, right next
he story re civil war in Syria,  on a doll that is making TV conservatives squeamish.
The Breast Milk Baby makes suckling sounds when it touches sensors sewn into a
halter top that comes with the doll. A Fox news commentator thinks we  “don’t
need this kind of stuff”.  It’s hard to say what “stuff” he’s worried about. A father
says it’s “creepy”; maybe his daughter could play with the doll at home, but not
on a play date or in public.
Somehow these men think breastfeeding has something to do with sex.  So the
doll’s suckling sounds are  “too mature” for little girls who want to grow up to
be mommies. Apparently, dressing up the buxom Barbie doll in a cocktail dress
and heels for a date with hunky Ken is a better way for “kids to be kids” and for
little girls to envision their future and understand the purpose of breasts.
From a health literacy standpoint                      
Critics of Breast Milk Baby are showing a  very limited ability to understand and
use information for health. Breastfeeding, exclusively in the baby’s first six months,
is recommended by virtually every health authority  on the planet as the healthiest
way to feed a baby with benefits to both mother and child over their lifetimes.  
Breastfeeding is only X-rated in the minds of some adults. Let’s think about what
we want to teach our daughters and what we want to protect them from. What is
it we want to protect ourselves from by banning a breastfeeding baby doll.

Breastfeeding is best.
Your milk is made for your baby. It contains the right amount of all the nutrients
Baby needs.  As the baby’s needs change, your milk changes, too. Mother’s milk is
easy to digest. It is always ready, clean and just warm enough. Breastfeeding creates
a special bond between mother and baby. Breast fed babies have fewer infections
and allergies than bottle-fed babies. And their brains develop faster.
Beginnings Pregnancy Guide p 62

Good News
If you are not ‘creeped out’ by the thought of little girls learning that breastfeeding
is normal, healthy and health-promoting; if you believe breasts are engineered
primarily for feeding babies, and if the sound of suckling does not distract you beyond
rational thought, you can order Breast Feeding Baby online at half-price. She is  more
culturally competent than some of her critics; choose a doll with one of eight names,
skin tones and facial features.
Italie, Leanne, Associated Press, Breastfeeding baby doll: creepy or groundbreaking? 11.8.2012  
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