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Maternal Health Literacy and Home Visitors

Since 2004, I have been training Maternal Child Health home visitors
to promote maternal health literacy, defined as the cognitive and
social skills and motivations that enable a mother to obtain understand
and use information [and services] in ways that maintain or enhance
her health and that of her child  (Renkert & Nutbeam 2000). This is
the WHO definition made specific to mothers. It is broader than the
US clinical definition in several important ways: it includes social
skills (interactive skills) acknowledging that reading and numeracy
are insufficient to function in the Information economy, especially
in the high tech healthcare arena. It includes motivation, indicating
that factors other than communication skills determine a persons
health literacy. Perhaps most important, this broader conceptualization
includes use of information. Understanding is an essential first step,
but still a long way from health promoting action. Finally, it specifies
using info in ways that promote health, going beyond decision making.
In order to involve community health workers as Farmer and Winston
and Bonnie suggest, we need to broaden our thinking.

I chose home visitors as a channel to promote health literacy for a
long list of reasons, chief among them: home visitors' unique access
and long-term trusting relationships enable them to observe and to
influence the interactions of multiple factors that determine a
mothers' health literacy.These factors are not readily visible or
modifiable in a community setting.

We trained visitors to build parents'  interactive and reflective skills
while providing direct assistance to make meaning from selected
health education materials (Beginnings Guides) and information from
healthcare providers and to apply it in vivid real life circumstances.
The primary teaching and learning strategy in the intervention is
reflective questioning. This does not imply that practitioners forget
what they know, but rather that they use their expertise to formulate
reflective questions and lead reflective conversations that facilitate
self-discovery and action planning. This approach addresses the social
determinants of health and the empowerment aspect of health literacy.
Health literacy is empowering because, and to the degree that it enables
a person to increase control over their health and its determinants.

A critical element is the routine use of data by practitioners to tailor
interventions to particular families and circumstances. Many home
visitation programs use the Life Skills Progression instrument (LSP)
approved to demonstrate progress to federal benchmarks of effectiveness
in home visitation (Maternal Infant Early Childhood Home Visitation
-MIECHV under the Affordable Care Act). Using the LSP,  home visitors
routinely  monitor parents' use of health information and services as well
as self-care, support of child development and health behaviors important
to both parent and child health (smoking, alcohol, drugs). Among these
are indicators of maternal health literacy, situated in surrounding family
conditions. Two health literacy scales derived from the LSP enable home
visitors to monitor "healthcare literacy" - use of info and services and
"self-care literacy" management of personal and child health at home.
Intimate knowledge and data on  surrounding family conditions suggest
approaches to improving health literacy for a particularly mother. 
The routine use of data - especially where it is currently collected-
enables visitors and partner researchers to consider the context in which
we expect people to use health information, not as background noise,
but as the primary determinant of the health literacy task, a persons
capacity to accomplish the task, and the support needed.

Four studies funded by AHRQ/NICHD, National Library of Medicine
and Missouri Foundation for Health indicate the intervention is effective
in increasing health literacy regardless of reading ability and in spite of
depression. Low maternal health literacy is associated with child
developmental delays and reduced participation in early intervention.

The average American spends 1 hour per year in a clinical setting.  We
need more community health workers trained to promote health and
health literacy in the community in the course of their usual activities,
 along with routine use of data by practitioners and their supervisors
to continuously increase effectiveness and sustain funding. One action
 step would be to review existing data sets in search of indicators of
health literacy and influential surrounding conditions (eg social support,
 living conditions). Repeated measures would show progress/regression.
  This is to suggest a paradigm shift from health education, anticipatory
 guidance, information giving that aims to increase knowledge and
compliance to an empowerment approach that aims to increase autonomy
 and engagement.
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