Beginnings Guides Blog
pregnant until 2018.
That is the
current public health message from El Salvador’s health minister. Colombian
women are warned to postpone pregnancy for 6 to 8 months. Jamaica just released
similar advice. The intent is to prevent mother-to-baby transmission of Zika.
known since 1947 as a rare mild disease limited to central Africa, is spreading
rapidly across dozens of countries in Latin America and the Caribbean. No one
knows why. The World Health Organization (WHO) warns Zika is likely to reach
every country in the Americas, except Canada and Chili. There is no treatment
or vaccine, largely because only about 20 percent of infected adults have any
symptoms. They might have a headache, body aches, a fever and red eyes for a
Here is the public health concern: in Brazil, since an outbreak of Zika
started there last May, more than 3800 babies have been born with microcephaly,
30 times the expected rate, according to WHO. Microcephaly is a rare birth
defect characterized by a very small head and incomplete brain development
leading to death or lifelong disability. There is little scientific evidence,
but the apparent association between Zika and microcephaly warrants public
health warnings, and delaying pregnancy seems wise. However…
The advice to women to avoid
pregnancy ignores the context in which they are expected to comply. In El Salvador and
Colombia there is little access to contraception, especially for poor rural
women. Abortion is illegal in all cases in El Salvador, where the teen
pregnancy rate is among the highest in Latin America accounting for a third of
all births. Abortion is illegal in
99% of cases in Colombia. In Jamaica, abortion is legal in some cases with the
approval of the father and two medical specialists. There is little or no sex
education in the schools. Sexual violence is prevalent. So women lack the
knowledge, services and power to heed the advice.
Colombia’s health minister explained that
his message to women is a good way to communicate risk. The minister seems to
forget that women do not become pregnant by themselves. No similar messages
have been directed to men. For sure, women who hear the warning will fear
pregnancy and birth defects more than they already do, but left to protect
themselves, this amounts to a “Just say No” campaign. It leaves women
vulnerable to blame for unplanned pregnancy and birth defects in their babies,
and to charges of non-compliance that could be misinterpreted as evidence of
low health literacy.
better message, free of gender bias, understandable and actionable, is to avoid
mosquito bites. CDC has issued Level 2 travel advisories (for all, not just pregnant women) for
the Caribbean, South and Central America, Puerto Rico, Cape Verde, Samoa and
Mexico. Travelers are advised to “practice enhanced precautions”.
In this case,
your doctor before and after travel to areas where Zika is active
insect repellant (safe and effective for pregnant women)
clothing to cover as much of your body as possible
under a mosquito net
doors and windows closed or screened
mosquitos bite in the morning, not just late afternoon and evening like other
lasts only a week or less. The danger is only to a current pregnancy. There is no danger to future
US Centers for
Disease Control and Prevention www.cdc.gov/zika
. Information is being updated
Health literacy refers to a person’s ability to use information and services for health. (More definitions)
Using information for health implies three steps:
1) Understanding, that is, decoding the words
2) Making personal meaning, that is, reflecting on the question: What does this mean for me in my situation with my resources, my family, my beliefs, my values?
3) Acting, that is, making choices and turning those choices into desired actions and health outcomes.
These steps coincide with three steps in problem solving,
1) What do you want? For example, a woman decodes information in Beginnings Pregnancy Guide. She understands smoking can harm an unborn baby.
2) What have you got? She acknowledges that she has a pregnancy, and a smoking habit that she enjoys and that relieves stress. She has a husband who smokes and a mother-in-law who smoked through her pregnancy and has a son who turned out fine. She has a budget already stretched, a friend who’s been after her to quit, and a doctor who’s offered some aids. Through self-reflection and discussion with family, friends, experts she makes personal meaning from the information.
3) What’s Next? She makes a choice (decision) not to act or to take action — some small step that she is willing and able to do now to move toward her chosen outcome — a healthy baby, which she understands requires a smoke-free womb.
It is the action (or inaction) that affects the outcome.
The first two steps in using information for health, and in addressing a health problem, are “all in your head”, a purely cognitive exercise with no health effects.
What’s empowerment got to do with it?
Take another look at Step 3 in using information for health: making choices and turning those choices into desired actions and health outcomes. This is the World Bank’s definition of empowerment. And the “Three-Step Dance” is the process of empowerment described by David Emerald in his book The Power of TED* The Empowerment Dynamic.
Empowerment is the act-ive ingredient in health literacy. Without it, it’s all in your head.
“Knowing is not enough; we must apply. Willing is not enough; we must do.” ~Goethe
Note the Goethe quote is typically featured in the front matter of reports from the Academy of Medicine (formerly the Institute of Medicine). It is often attributed to Bruce Lee, but Goethe said it first)
Alsop, R. & Heinsohn, N. (2005) Measuring Empowerment in Practice : Structuring Analysis and Framing Indicators. World Bank. Free online: https://openknowledge.worldbank.org/handle/10986/8856
Can you name
It doubles+ the risk of eight of the ten leading causes of death,
which account for about 75% of the $3Trillion Americans spend on healthcare
annually. It explains half of learning and behavior problems in children. It is
prevalent in all sectors of society, at home and around the world. It meets the
criteria for a public health crisis. Can you name it?
It is ACEs — Adverse
I’ve written here
before about ACEs. I’ve said that anyone
working in maternal-child health, or early childhood education, K-12 education,
child care, chronic disease, or health literacy needs to know about the lasting
destructive power of ACEs.
participating in the 30th Zero To Three national conference held last week here
in Seattle, I understand ACEs are not just another related issue we should
be tracking. It is time to
acknowledge and address ACEs as the biggest barrier to personal and public
health, and to improving heath literacy. As keynote speaker, pediatrician
Nadine Burke Harris says, “ We — all of us — are the solution.”
Work in all
the many fields that aim to build a strong foundation for healthy child
development is futile where ACEs cause that foundation to crumble and leave
children physically, mentally, and emotionally predisposed to impaired
cognitive and emotional development, and to adulthood defined by diabetes,
obesity, heart and lung diseases, cancers. In the context of health literacy, unacknowledged
ACEs must be viewed as a looming barrier to health across the lifecourse, to
literacy, and to effective participation in healthcare and society. It is a
multigenerational problem. A mother with unaddressed ACEs cannot buffer her
child from ACEs.
last a lifetime, for
better or worse, by default or by design. ACEs are the worse-by-default
part that Zero To Three
mantra. By definition an Adverse
Childhood Experience occurs in childhood (< age 18) and the person remembers
it as an adult. Here are the nine
types of ACEs:
* physical abuse
* sexual abuse
* emotional abuse
* mental illness of a household member
* problematic drinking or alcoholism of a
* illegal street or prescription drug use by a
* divorce or separation of a parent
* domestic violence towards a parent
* incarceration of a household member
Why ACEs matter so much for so long
These are more
than unhappy memories. A baby’s brain is only partially (about 25%) developed
at birth so that it can be wired to enable the baby to survive in the
environment into which s/he is born.
Babies absorb everything they see, hear, feel and otherwise experience.
Those experiences tell the brain what to expect and how to be ready for it. By
Baby’s first birthday, brain wiring is 70% complete, by age 3, it’s 85% wired.
So the earlier the experience, the greater and more lasting it’s impact.
repeated ACEs, four or more of the listed experiences, or the same experience
repeated frequently, the brain and all the body systems get stuck on high
alert; living in a crouch, always expecting something bad to happen. The Fight,
Flee or Freeze mechanism is designed as an emergency response system. When danger is past, it is supposed
to switch off so the body returns to a normal relaxed state. When it is stuck
in the On position, little energy and attention are available for learning and
cognitive development. Self-regulation becomes a strident challenge; behavioral
problems ensue. Eventually, the wear and tear of constant stress on the body’s
systems manifest as non-communicable adult disease. The leading causes of adult deaths worldwide have their
origins in early development. In ACEs.
Find your ACE Score:
See how ACEs have affected
you. Use the questions to generate
a reflective conversation with a mother about her ACEs and their impacts on her
life and parenting. Testing shows
the questions do not spur trauma or need for professional help. Download the questionnaire
View Dr. Burke
Harris’ TED Talk
childhood trauma affects health across a lifetime”
Next: How we can
use information about Adverse Childhood Experiences
This question was
raised by Winston Wong, Director of Disparities Improvement and
Quality Initiatives at Kaiser
Permanente, during the Institute of Medicine's recent workshop,
Health Literacy: Past, Present and Future.
The workshop marked 10 years
since IOM released the landmark
report Health Literacy: A Prescription to End
A summary of the workshop
proceedings was released this month. Download a summary
free from National Academy of Sciences. Definitely
worth the read.
Here's the part
that made me stop and applaud
In a discussion about health literacy
and its role in achieving equity, Wong
recounted a conversation among
health plan leaders on patients'
non-medical needs (social determinants of health), that led to the question:
should be the core conversation between a doctor and an individual s/he sees
for 15 minutes per year?
“One interesting proposition is that we should start the
discussion with every person we come in contact with
by asking 'what does a
good day mean to you,’"
Wong said, "because that’s really a much more important
than ‘what hurts’ or ‘have you been
taking your medicine today.’”
Why is this
question more important than typical problem-focused inquiries?
Wong said it
reflects the fact that medicine can help with some problems, but what ultimately
makes for a
good day for someone is determined by a constellation of actors
that foster good health. The question
recognizes that on average Americans
spend about one hour per year in a clinical setting; the healthcare
professional is just one actors; s/he marshals resources that account for about
10% of health. The other
are the people the individual is with the other 8764.81 hours per year. The
power to create health,
and to live well with disease, is with the patient.
What is a good day
like for you? addresses the person and
his/her "real life",
instead of focusing narrowly
on the patients' disease and
treatment. It suggests the patient's selfcare is achieving some good days,
than reducing the person to a medical problem and assuming that s/he has
failed to comply with the medication
What is a
good day like for you? is a good
> It cannot be
answered yes or no. It requires the respondent to think
critically about what matters to them,
to reflect on what they want from
medical care and how they will know they got it. It leads to conversation
what the person is able and willing to do now to achieve more good days.
> The response
serves the patient, rather than simply informing the clinician.
> The response
enables the clinician to hear and adopt the patient's words, so the patient is
to learn medical terminology, and the clinician is not expected to
check a glossary of simplified terms.
> The question allows the patient to
figure out and articulate what they want and need, making it easier
provider to achieve patient satisfaction.
> It shifts
thinking and conversation from what patient and clinician do not want — disease
how to get rid of it, to what they
do want —good days— and how to get more of them.
The hard part is
waiting for the response
Patients are not accustomed to being
asked reflective questions, especially by clinicians. Many, especially
who live in poverty and face daily discrimination, are rarely asked questions
and may be trained not
The reflexive first response is likely to be "I don't
know". They need a way to
think about it. Try
again; Can you remember a good day or a good
moment? Then the hard part:
wait. Let them be the one to
the silence. Ask follow up
questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good
days. An effective
conversation will end with the patient articulating the
action s/he will take and the clinician offering
supportive information and
More on reflective
McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active
In Florida, if someone scares you
to death you can legally shoot them to death with your BLEEP. But your
family doctor or
pediatrician or health worker cannot legally ask you if a BLEEP is kept in your
house or how
it is stored.
Apparently even thinking about the
risk of unsecured BLEEPs to their children’s and
right to keep BLEEPs anywhere and any way
they want. This BLEEP has been
since 2011. (The part that made asking about BLEEPs a felony with
jail time and a $5 Million fine did not pass).
Physicians groups challenged the
law. It was upheld as constitutional in Florida since BLEEP ownership and
is a private matter unrelated to medical care.
BLEEPs and tobacco are the only
products on the market that when used correctly kill people; BLEEPS kill lots
of people, often children, in a seconds.
So BLEEPS can’t be a private matter.
Safety Checklist for a Crawler:
BLEEPS are unrelated to medical
care until a child -or some one
else- or the owner- is injured by the patients’ BLEEPs. Then
taxpayers fund emergency response and
medical care for totally
preventable horrific injury or death, and related
increased insurance premiums, and lost contributions to
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP.
Texas legislature entertained a similar gag rule this month.
Death in the United States:
A Call to Action From 8 Health Professional Organizations and the American Bar Association.
Ann Intern Med. 2015 Feb 24. doi:
10.7326/M15-0337. [Epub ahead of print]
Ferrris S. Children’s Defense Fund report on Childs’ BLEEP deaths, new BLEEP laws Data analysis: More
preschool kids dead from BLEEPfire than
police. May 19, 2014
Walters, E. Bill Would Prohibit
Doctors From Asking About BLEEPs. The Texas Tribune March 18, 2015
Pitts, L. Republican list of things you cannot say.
Seattle Times March 19, 2015
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
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
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.
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
them, and gave him this summary of new instructions.
Medications to Continue Taking That Have Changed
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
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
No problem found
the summary shows good intent to inform the patient, it could be much easier to
read, understand and act on.
Delete the static
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.
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.
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:
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.
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.
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
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
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.
FUD: Fear Uncertainty & Doubt. That is the foundation of the
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
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.
a preventive strategy in which public health nurses, social workers or
paraprofessionals connect families to healthcare and community
resources and offer
health education and social support. It’s origins date back to the 1800s.
are run by county health departments, school districts, foundations,
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 research
shows that parents in home
improve their health literacy, capacity to manage personal and
child health and
A Fox announcer and a “business expert” called home visitors
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,
and doubt about the Affordable Care Act, to prevent people from learning
can afford good healthcare coverage.
I have worked for decades with home visitors and know them to be
among the most
respectful people on the planet, unlike the FUDders on Fox and in
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
citizens. Almost 3 million people visited www.heathcare.gov
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
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.
beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
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
income or education. But poverty and accumulated disadvantage
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
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
In addition to Heckman’s monograph,
the book includes illuminating commentary
by 10 experts from multiple
The American Medical Association House
of Delegates declared obesity a disease
last month. Is this good for maternal
and child health? For public
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
prevention not a priority in maternity care
, I found that weighing is still the only procedure in
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
interfere with their patient/provider relationship. Others said they do not know how
do it for them. One can
only hope that calling obesity a disease will change these
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.
experiences - witnessing or experiencing interpersonal violence
related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical
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.
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
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
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
Kennedy-style physical fitness craze, but that entails behavior change, and
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
Only one thing seems certain, making
obesity a disease will increase medical treatments
and costs, and revenue to