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Research guides practice; practice guides research. Health professional education for resource -constrained practice
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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.

Example from the field: Medication instructions show lots of room for improvement

My dad, age 86,  was hospitalized with arrhythmia. Hospital medical staff said his heart muscle looked strong and undamaged, but later another doctor said he had a minor heart attack. Dad was sent home with several medications with instructions to stop all his usual meds - including the multivitamin, and the stool softener prescribed by his internist. The hospital  nurses could not answer why those should be stopped…  Three days later Dad quit taking the new meds. He said they made him sleep 20 hours a day, and made him stupid when he was awake.  Worried, Mom set an appointment with his personal physician who adjusted the meds, lectured him about the danger of stopping them, and gave him this summary of new instructions.

 New Medications

 Medications to Continue Taking That Have Changed

     Other Medications
     START: amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) Oral, every day. Refills: 0
     STOP:  amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) 2 times a day. Refills: 0
 
 Medications to Continue with No Changes
     Other Medications

     aspirin (Aspirin Enteric Coated 325 mg oral delayed release tablet) 1 tab(s) Oral, every day, Refills: 0
    
     dufoxetine (Cynbalta 60 mg oral delayed release tablet) 1 cap(s) Oral, every day. (do not crush or chew). Refills:0

 No Longer Take the Following Medications

     digoxin 125 mcg (0.125mg) oral tablet) 1 tab(s) Oral, every day. Refills: 0

     metoprolol (Metoprolol Tartrate 25 mg oral tablet) 1 tab(s), Oral, 2 times a day. Refills: 0

 Contact your Physician Prior to Taking the Following Medications

     None

 Problem List
 No problem found

 Upcoming Appointments
 No appointment


While the summary shows good intent to inform the patient, it could be much easier to read, understand and act on.

1.     Delete the static 
Too many irrelevant words interfere with efforts to find the important information. The first heading  New Medications is meaningless. It amounts to static interference.  The information about meds to start and stop fits under the third heading:  Medications to Continue Taking That Have Changed; but an indented  subhead - Other Medications- is inserted between - more static. It’s another empty field on the form. These headings should automatically delete when the field is left empty.
 
2. Use upper and lower case. All the headings are in title case - all the words are capitalized. A capital letter signals the brain to stop and start something new. We recognize words by their shape. The cap changes the shape, and so slows reading and reduces comprehension.  It is odd that the proper names of the medications are not capitalized, but then in parentheses they are.
 
3. Use active voice and a verb in instructions. Medications to Continue with No Changes is a label.  A call to action is more understandable and actionable:   Keep taking these medications with no changes:
 
4. Make the changes clear. The information under START and STOP is very similar. It requires careful examination of every word and symbol to discern that the instruction is to take one a day instead of two. Few understand mg. Many do not understand oral, or tab(s), or the difference between cap(s) and tab(s),  or the meaning of delayed release.
 
5. Explain when to take the medication. What does 2 times a day mean? Before breakfast and after breakfast would comply with the instruction, but that might not be what the prescriber intends.
 
6.Use the Problem List (it’s a nice table on the form with cells for Onset and Comments). This would be a good place to give the patient and caregiver information about what these drugs are for.  The entry No problems found could leave one wondering why they are taking all this medication, and whether they should have seen the doctor.
 
7. Use the Upcoming Appointments form (another nice table with cells for date, time, location, appointment type(??) and provider.  The entry is No Appointment; but Mom has written in April 10, 1pm.
 
This form reflects an effort to be patient centered and improve compliance. But it is designed for ease and speed of entry by the provider, rather than for ease of understanding and right action by the patient and caregiver.  

 

Government shutdown is all FUD

FUD: Fear Uncertainty & Doubt. That is the foundation of the extreme House
Republican’ position on the Patient Protection and Affordable Care Act of 2010.
That’s why they call it Obamacare- in order not to say “protection” or “affordable”;
and  to hide the fact that the law was enacted 3 years ago, before the President
was soundly re-elected running against an opponent who vowed to repeal it.
 
FUD, initially an IBM strategy to eliminate market competitors by spreading fear
uncertainty and disinformation about their products, seems to be working for the
House Republicans. At least to some degree, for now. Polls and analyses of social
media suggest that some people favor the Affordable Care Act while opposing Obamacare.
 
Home visitors: “Obama snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper tantrum until I saw
the Fox “news report” about the Affordable Care Act’s expansion of home visitation.
That’s  a preventive strategy in which public health nurses, social workers or trained
paraprofessionals connect families to healthcare and community resources and offer
health education and social support.  It’s origins date back to the 1800s. Programs
are run by county health departments, school districts, foundations, and private-public
partnerships. Home visiting programs are open to poor parents who request assistance.
 
It’s worth noting that in many countries, home visiting has long been standard for all
parents, because they acknowledge that parenting is a challenge and everyone can
use assistance. And because research shows it improves child developmental outcomes
and has immediate and long-term benefits that extend to entire families and to the
healthcare, education and justice systems. My researchshows that parents in home
visitation significantly improve their health literacy, capacity to manage personal and
child health and healthcare.
 
Pure FUD
A Fox announcer and a “business expert” called home visitors “Obama snoopers". 
They said  in this “brand new federal program”, “government home inspectors”
make random, unannounced  “forced home visits” to snoop on parents.  This is not
news. This is pure FUD - disinformation (lies) that specifically intends to instill fear,
uncertainty and doubt about the Affordable Care Act, to prevent people from learning
they can afford good healthcare coverage.
 
I have worked for decades with home visitors and know them to be among the most
caring, dedicated, respectful people on the planet, unlike the FUDders on Fox and in
the House.
 
FUD won’t work for long. Yesterday, the heart of the Affordable Care Act started
(keep saying the real name), opening access to healthcare for millions of poor and
uninsured citizens. Almost 3 million people visited www.heathcare.gov State exchanges
were similarly overwhelmed.  People are about to find out that the Affordable Care Act
makes good healthcare coverage affordable -for them. That will help them see through
the FUD.  Insurance companies are helping too. They are enrolling people they previously
rejected because, with the ACA, it’s good for business. Healthcare executives are calling
for more doctors, nurses and allied health professionals - doesn’t really sound like a
“job-killer” does it?
 
On the other hand, the House Republicans just put hundreds of thousands of people out of
work in hopes they can FUD us citizens of the richest country in the world into continuing
denying healthcare to poor people and sick people in order to preserve the freedom of
the rich to get richer.
 
 
 
 

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.

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

With few exception, childbirth is normal % healthy, but...

Of the 10 most frequently performed in-patient procedures,  5 are related to maternity 
and newborn care (2010 figures - latest available).
 
Bad news: the cesarean section (surgical delivery) rate continues to rise; it is up 41%
since 2004, despite global evidence that rates over 15% do more harm than good. This
is a place to cut the cost of maternity care. A cesarean section costs on average $9956
more than vaginal delivery.
 
Good news: Fetal monitoring, circumcision and stripping of membranes are performed
less frequently now than in 1997. The reduction in procedures returns to mothers some
control over their most significant life event, and begins to recognize that over-management
is not beneficial.
 
Procedure Frequency Rank       Number Performed in 2010           Increase in Frequency

Repair of obstetric                   1,292,000                                    No change
laceration      

Cesarean section                      1,278,000                                    41%

Circumcision                            1,164,000                                    -31%

Artificial rupture of                  917,000                                      -5%
membranes

Fetal monitoring                      875,000                                      -23%

Mandy’s Story Part 2 A true teaching story about infant depression

Last time in this space I told Mandy’s Story about the depressed 8-month old
who transformed over the course of one week of simple everyday interactions.
 
The story illustrates the scientific work of Bowlby and Robertson on the stages
children move through when separated from their mothers due to hospitalization.
 
Mandy was well beyond the first stage in a child’s response to separation: Protest.
This stage is marked by wailing and sobbing in confusion, fear, grief at being
abandoned.
 
She was also beyond Stage 2: Despair. The child becomes more hopeless and
apathetic. She withdraws. Like Mandy. This going quiet is not settling in.
It is giving up and shutting down.
 
Mandy was well into Stage 3: Detachment (or Denial). She had suppressed all
emotion, including - maybe especially, feelings for her mother. She hardly
noticed when her mother left. She was so withdrawn that she sought no
mothering at all.  Now, i would recognize that as a sign of major psychological trauma.
 
There are many lessons in Mandy’s story. More on that next time. s
 
Reference
For a history of attachment theory and the stages of separation, plus a good
bibliography,  see Van Der Horst, FCP & Van Der Veer, R. (2009). Separation and Divergence:
The untold story of James Robertson’s and John Bowlby’s Theoretical Dispute on Mother-Child
Separation. Journal of the History of the Behavioral Sciences, Vol. 45(3), 236–252. Published
online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20380 © 2009
Wiley Periodicals, Inc.
 
 
 
 

Plain Language - Are we there yet?

I twisted my knee. Before long it is too sore to ignore, so I check with a
physical therapist at the gym. He says he can fix it and that he is a
preferred provider on my insurance; his services will be fully covered.
So I visit him nine times over two months. My knee is better.
 
But my mind is boggled.
 
A week after the final scheduled PT session, I  get  a nine page so-called
“Explanation of Benefits”  from my health plan.  For each visit, there is
a not-a-bill on which I’m not-billed separately for Exercise Therapy,
Body Movement Therapy, and Muscle or Nerve Trai.
 
I’m not sure what that third item is, or if I had it, or why  the provider
billed $50, the plan allows $33.46, so I owe $33.46.  The Note says
“3024”.  So I hunt through the pages and find  a section labeled NOTES.
Here is Note 3024 (their caps): SEE THE “REHABILITATION SERVICES”
SECTION IN THE ALLOWANCE SCHEDULE OF YOUR CERTIFICATE OF
COVERAGE.” 
 
What?
 
Looking further, I see on the back of each page that if I disagree
with the payment decision, I can “submit a request for appeal
within 180 days of this notice”.  It should be in writing and include
copies of my medical records.
 
Who has their medical records? 
 
I can’t object to the decision since I can’t determine what the
procedure is. I don’t have a clue what the price should be. 
 
I give up and take the stack of papers to my husband; he’s a lawyer.
After a 15 minutes pouring over the pile,  we conclude that this
not-a-bill says the services, including the mystery procedure “Nerve Trai”,
are covered, at least partly,  but the insurer is not going to pay;
perhaps because while the individual deductible has been satisfied, 
the family deductible has not.  But the the employer says there is no
deductible on our plan... It seems the take home message is, “You might
get a bill.”  Hardly and EOB. More like a “Not-an- Explanation of No-Benefits.
 
This story would suggest that, despite the PhD and 30 years in health
services,  I have low health literacy. That is, I do not have the capacity
to process and understand information necessary to make appropriate
health decisions. Likewise for my husband the trial lawyer.
 
I’ve been impatient with the Plain Language crowd, thinking that surely
we all know about readability and jargon and all that by now. 
I am wrong. Really wrong.
 
 Keep at it Plain Language advocates!
 
 

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.
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