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Pregnancy Guide Update: Obesity a disease?

The American Medical Association House of Delegates declared obesity a disease
last month. Is this good for maternal and child health?  For public health? 
 
It’s not new
In 1995 the National Heart Lung and Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten years earlier, almost 30 years ago now,
NIH called prevention and treatment of obesity a national medical priority.
With 90 million Americans now officially obese, it seems few clinicians got the
memo.
 
Obesity prevention not a priority in maternity care
In researching issues of weight gain in pregnancy for  the update of the
Beginnings Pregnancy Guide, I found that weighing is still the only procedure in
early prenatal care that has shown any impact on outcomes. And yet it has
become uncommon for a pregnant woman to be weighed at prenatal visits or
when being admitted to a hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation will
interfere with their patient/provider relationship. Others said they do not know how
to calculate BMI. They also must not know about the many BMI calculators that will
do it for them. One can only hope that calling obesity a disease will change these
attitudes. 
 
Healthy mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a mother with an excess of fat cells produces a baby
with an excess of  fat cells. So we are building obesity and the attendant health issues
into the next generation.
 
ACEs -Adverse childhood experiences - witnessing or experiencing interpersonal violence
is closely related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical treatment,
many such women have lost weight, and gained it right back. That’s how the lifelong
effects of ACEs were discovered.
 
Other mothers have said it doesn’t matter if they gain too much in pregnancy since
they are just going to get pregnant again; the weight can come off after that.
Only it rarelydoes.
 
Turning people into patients
Google “obesity disease”. The first thing that pops up is ad ad for weight loss surgery.
This may be more telling than official statements.
 
Especially when we consider the Forbes June 28 report that the AMA’s Council on Science
and Public Health, the group appointed to address the question, advised against declaring
obesity a disease. But the delegates chose ignore their own advisors.
 
We have to ask, what was so compelling?
Perhaps it is the implementation of the Affordable Care Act that will bring healthcare
coverage to millions of Americans previously excluded from the healthcare system.
At least a third of them are obese. Now they can be patients.
 
According to CDC 35.7% of Americans are obese, 49.5% of African Americans, 40% of
Mexican Americans. Rates vary widely by state. Find your state rate at
http://www.cdc.gov/obesity/data/adult.html.  Now all those people are diseased
and in need of medical treatment.
 
Calling obesity a disease, again, could draw attention to related health issues, but it
hasn’t in 20 years.  It could result in better maternity care, but the declaration is
unlikely to improve clinicians communication and counseling skills.  It could spark a
Kennedy-style physical fitness craze, but that entails behavior change, and the same
communication issues.  It could increase research on obesity, but NIH already has a
Strategic Plan for Obesity Research and funds nearly a billion dollars worth of studies
annually. Grants.nih.gov lists 49 obesity-related research solicitations currently open
for submission of grant applications. 
 
Only one thing seems certain, making obesity a disease will increase medical treatments
and costs, and revenue to AMA constituents.
 
 
 
 
 
 
 

Beginnings Pregnancy Guide Update: “Entertainment Ultrasound” Warning

Choose 2D, 3D or 4D.  In-studio or at your baby shower. Announce your pregnancy
with a “viewing party”. Get a video at the mall. Post it on Facebook. Select the
premium package offered by a Miami OB-GYN’s office and get a weekend discount.
 
The American Institute of Ultrasound Medicine, American College of Obstetrician
s and Gynecologists, American Academy of Family Physicians, March of Dimes,
US Food and Drug Administration, England’s National Institute for Health and
Clinical Excellence, the UK’s National Collaborating Centre for Women's and
Children's Health, and other national and international experts all have published
strong recommendations against non-medical use of fetal ultrasound.  The Society
of Obstetricians and Gynaecolgists of Canada calls for a complete ban on non-
medical use of fetal ultrasound. The state of Connecticut legislated a ban in 2009. 
The FDA says that creating fetal keepsake ultrasound images is “an unapproved
use of a medical device,” and those who perform ultrasonography scans “without
a physician’s order may be in violation of state or local laws or regulations.”
 
“You don’t need an excuse to be happy.”
Still internet ads for non-medical ultrasounds abound, complete with slogans like
this, implying you don’t need a medical reason for the “painless, relaxing procedure”.
The growing popularity of “keepsake ultrasounds” is not due to cost or access issues.
Most insurance companies pay for one or two doctor-ordered ultrasounds as part of
routine prenatal care, and commercial ultrasound is not cheap.
 
Prices start at $175 for the 3D in-studio option. $500 for an “ultrasound party”
at the location of your choice. The cheapest rate I saw was $75 for a basic “gender
determination” scan; it’s discounted to  $55 on Saturdays one OB-GYN’s office. These
commercial services are not regulated or standardized.
 
Safety Concerns
Commercial sonographers say that ultrasound is safe. I found unclear statements like:
“All research provided has been proven to be safe for expectant mothers and baby,
as long as the procedure is done by a trained professional, and no longer that one
hour intervals.”   First, we have to ask, research provided by whom? and What about
the research that was not provided?  Second, remember that no research ever proves
anything. It can only offer statistical evidence. Then, a more accurate statement is
that repeated ultrasounds have not been proven harmful. Still  the evidence has
convinced all the advisory and regulatory agencies that entertainment ultrasounds
are worrisome.
 
Ultrasound uses sound waves, not xrays. So radiation is not the issue. But the procedure
targets the fetus with heat and  pressure, especially prolonged, 4-D studies. New York
state legislators proposed a ban on ultrasonography for entertainment purposes, citing
data showing that 4Dl ultrasound equipment can emit eight times more energy than the
machines commonly used in medical settings. The risk of  effects on fetal development
has been demonstrated in both human and animal models, and remains, at least theoretically,
so that  the FDA concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
 
Additional concerns about non-medical ultrasonography include the possibility that non-
medical ultrasonography will fail to identify a problem with the baby, falsely reassuring
the patient and her family; or that a false-positive result could create unnecessary anxiety
and follow-up testing. Machines are unregulated so may not be properly calibrated or
maintained. Technicians may not be well-trained or proficient. “gender determination”
had never been an accepted use of of ultrasound technology and raises thorny ethical issues.
 
Medical ultrasounds are for doctors         
Here’s the problem:  In medical settings, the sonographer is commonly prohibited from
explaining ultrasound results to the patient, who must then wait for days or weeks to get the
results from the physician who ordered the scan. Family members may be barred from attending
the ultrasound appointment to avoid congestion in the radiology department. Parents may not
receive still pictures or video to take home. If they do, they still cannot send it to a friend or post
it online.  Until these disempowering practices change, parents and  sonographers  will continue
to seek a more informative,  convenient, family friendly experience. 

Check  Technician’s Credentials                      
Qualified sonographers are trained and certified. Find one, or check a technician’s credentials,

Beginnings Pregnancy Guides says, “Ultrasound is safe for you and Baby.”  [p8] That remains true.
The 2014 edition will add this statement: Many healthy pregnancies do not need ultrasound.
Extra  “keepsake" ultrasounds may be harmful.  The Registry of credentialed sonographers
will be posted on the new Mothers’  Resources page at www.BeginningsGuides.com  More on that later.

Don't Order Fetal Ultrasound Videos As Souvenirs: FDA

References:  http://www.aafp.org/afp/2005/1201/p2362.html#afp20051201p2362-b6
http://www.ct.gov/governorrell/cwp/view.asp?A=3675&Q=442298
 
www.guideline.gov/content.aspx?id=14306&search=ultrasound+pregnancy#Section427

The Power of Choosing


Preverbal infants show preference for others in distress
At 10 months of age, babies differentiate attackers from victims and neutral parties.
They literally reach out to victims. Their second choice is a neutral party. They avoid attackers.
 
In scientific experiments by Japanese researchers, the players were shapes on a screen, something
like the early Pac-man games. The researchers suggest the infants’ preference for the victim is the
foundation for sympathy.
 
The findings seem to confirm other research that says witnessing violence  has nearly the same
negative impact as experiencing it directly. This seems to be so even on an infant. The study
certainly confirms that babies observe and are shaped by what is happening around them.
 
The power of choosing
This experiment further suggests a very early start for what David Emerald (The Empowerment
Dynamic) describes as humans’ default way of looking at the world. It’s a survival mechanism. In
order to keep us alive, our brains are pre-set to keep us focused on problems and threats. Anything
unfamiliar or unexpected (including an aggressive square) is considered a threat, even as early as
10 months. Brain imaging shows that upon detecting a threat, real or imagined, the brain floods the
body with chemicals to produce anxiety. It gives us just three choices of how to react: fight, flee
or freeze. No thinking is involved. Anxiety is the prime motivator,  and our default state.
 
Emerald writes that It takes intention and attention to notice when we are reacting automatically
to anxiety, and to instead choose a purposeful response to the source of the anxiety.  A habit of
observing and choosing is the key.  The process of choosing takes us out of survival mode and
activates critical thinking.
 
Give Baby choices
Taken together, these works make clear the importance of allowing  very young children to make
choices.  Even before they begin to talk or to understand.  Hold up two shirts. Ask, red shirt or
green? Let Baby point. When out for a walk, ask Baby which way he wants to go. He can point.
Maybe not the first time. But probably sooner than you think.
   
“Making choices and translating those choices into desired actions and outcomes” - that is the
definition of empowerment.
 
 
References
Kanakogi Y, Okumura Y, Inoue Y, Kitazaki M et al. (2013) Rudimentary Sympathy in Preverbal Infants: Preference for Others
in Distress.PLoSONE 8(6): e65292, doi: 10.1371/journal.pone.0065292
 
 
Emerald, D. (2006). The power of TED: The Empowerment Dynamic. Bainbridge Island, WA: Polaris Press.

World Bank. (2005). "What is empowerment?"  http://go.worldbank.org/V45HD4P100.
 
 
 
 

Mandy’s Story Part 3: Lessons

Recently in this space I told Mandy’s Story,  and then we saw how the story reflects
the science on separation of mother and child due to the child’s hospitalization.
There are many lessons in this story.
 
A young child’s healing power and reason to live reside in the mother.
 
Children need their mothers not only present, but interacting with them.
When interaction with mother is absent, even for short periods under
pleasant circumstances like Mandy’s mom’s vacation, children and mothers
suffer. Although a surrogate mom like me in this story can ease the pain.
 
A child can become stuck in a state of anxiety
When the interaction is removed under unpleasant, unplanned, unexpected
and extended circumstances, like a hospital stay, research shows development
is arrested with lifelong consequences for the child, especially negativity and
aggression. A hospitalized child is at risk of getting stuck in a state of anxiety.
 
Less interaction, more hospitalization
A recent study found that children of responsive, interactive mothers were
half as likely to be hospitalized. That means children who are hospitalized
are twice as likely to have mothers like Mandy. That’s the bad news.
 
Here’s the good news: Role models needed
I learned this lesson a little later from Mandy’s mother.  Seeing what mothering
looks like, seeing ways to relate to her child, seeing how her child responds is all
that Mandy’s mom needed to transform herself into a mother who actively
promotes her child’s health and development.
 
Mandy’s mom did what we all do; she mothered as she was mothered. In this
case, not at all. The fact that Mandy was failing to thrive and her mom clearly
had not mothered her well was not evidence that the mother was incapable or
unfit, or uncaring or lazy. Rather the facts indicated lack of a role model.
 
Mothers who were not well mothered themselves need a role model to see what
is possible, to develop confidence in themselves and find the courage to engage
in mothering and caregiving.  How can you use your position, skills, knowledge,
and compassion to be that model for a mother who wants to be what her child
needs but does not know how? 

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
know?”
 
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
subtle.
 
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
discharge.
 
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
gobbledygook. 
 
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
learning.
 
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.
 
Interact!
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
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