Reflections on health literacy and bridging the gap from healthcare to home

In honor of Health Literacy Month, SurroundHealth took time to learn more about Sandra Smith’s Beginnings Guides Life Skills Development Curriculum that integrates health literacy promotion into maternal child health home visits. 

Sandra Smith, PhD, MPH, University of Washington, Seattle

The Beginnings Guides program has been recognized by the AHRQ/NCQA Innovations Exchange as a Quality Innovation. The Beginnings Guides are designed to complement counseling during office and home visits for prenatal and parent education. The Guides are both teaching and learning materials for promoting health literacy, reflective function, and other essential life skills  for parents.

What drew you into health literacy?  My work with the Beginnings Guides

Beginnings Guides (art by Laurel Burch)

Since the first Guide was published in 1989, I have been living in health literacy questions.  I wanted to know: 

  • Is my material effective and what makes it that way?
  • What would make a woman pick it up and start reading it?
  • What would make her keep it, share it and talk about the content with her family or her doctor?
  • What would make her find the materials when she had a problem?
  • Do mothers do anything differently from having been exposed to the content?

My work with the Beginnings Guides has really been a health literacy laboratory.  When we do our annual update and reprinting, we apply the latest findings of health literacy research.

What have been aha words which have surfaced through this real-life laboratory?  There have been many.  Several are related to medical jargon.  A good one is “healthcare provider.”  None of the moms use that word.  They typically say “doctor” and by that word they mean anyone they see on a healthcare visit.  There are also words such as “jaundice” or “ambulate” that a woman wouldn’t know if she hadn’t had a baby.  People develop health vocabulary as they experience it in life.  And, there are very common words that people do know but have very different meanings in health such as stool, screen, and cap.

As you reflect on the progress being made in health literacy, are there any misconceptions that you feel have emerged?  I wouldn’t say misconception but too narrow a conception of health literacy as the… “ability to understand health information in order to make appropriate health decisions.”  I say that because it makes (low) health literacy a cognitive deficit and focuses efforts on improving information and its delivery. Better reading and better information alone cannot fix the systemic problems within healthcare that are attributed to low health literacy — high cost, low quality care, and health disparities. Improved health information is an essential first step, but it is insufficient to achieve the goals of health literate society. 

Where does additional focus need to be made?  We need to focus on the supports people need to personalize and act on the information that they understand. In other words, we want people to say themselves, “Here’s what this means to me…in my situation…in my family…and this is how I can use this information to cope, recover, and maintain my health.

What are the supports that will enable people to use health information in real life?  I am really interested in the empowerment aspect of health literacy that Don Nutbeam articulates. He defines three categories of health literacy skills.  Most of the time, we talk about basic literacy skills – reading and numeracy skills. In addition, there are interactive skills and critical, or reflective health literacy skills.  Health literacy is empowering to the degree that it enables a person to gain control over their health. The empowerment aspect of health literacy promotion involves using reflective questions…teaching by asking…instead of telling people what to do. 

This story of Dora Nateen, a home visitor, and a mom really shows how reflective skills work.

How do you think Home Visitors can help bridge the health literacy gap?  Most health decisions are not made in a clinical setting. What affects people’s health most is the everyday decisions they make.  Right now, the connection between home visiting and healthcare settings is not there; yet maternal child health home visitors see families frequently over a long period of time.  Their unique access and long term trusting relationships position them  to observe and to influence the complex interaction of the many factors that determine a person’s health literacy. These factors are not readily visible or modifiable in a clinical setting.

This sounds promising.  What do you envision in the near future? There is already an established infrastructure of home visiting programs all around the country.  With health reform legislation, those programs are now being expanded throughout 50 states.  We can use that existing infrastructure to promote health literacy in growing families…and families would then use the skills that they learn throughout their lifetime. So, you would have short- and long-term benefits that extend to the healthcare system, to the schools, and to the justice system.

I am excited to say that the Beginnings Guides Life Skills Development Program will be implemented by Wellpoint, the nation’s largest health benefits company, in selected states’ Medicaid managed care plans.   I think the cutting edge of health reform is the primary medical home model that integrates home visiting as that bridge between healthcare and home.

What inspires you and the work you do within health literacy? The home visitors and parents that I get to work with keep me inspired…I see them work together in very difficult, chaotic life situations…And my research shows that when they have appropriate support, parents improve the management of their health despite reading ability, and despite depression. They are the ones that are doing the heroic things and make it worthwhile to me.

Interview and blog by SurroundHealth blogger, Susan Eno Collins, MS, CHES, RD.  Susan is a Community Leader of SurroundHealth  — a social network where health professionals from different backgrounds come together to learn from one another’s expertise and to share knowledge and resources.  Membership is free. Members of SurroundHealth share a passion for improving the health and well-being of communities and individuals.  We focus on a wide range of health issues such as health literacy, cultural humility, and behavior change strategies.


About Susan Collins, MS, CHES, RD, SurroundHealth Blogger

I am Community Leader for SurroundHealth (, a social network where health professionals from different backgrounds come together to learn from one another's expertise and to share knowledge and resources. We share a passion for improving the health and well-being of communities and individuals. I am also a registered dietitian and certified health education specialist.
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6 Responses to Reflections on health literacy and bridging the gap from healthcare to home

  1. Laura Wilson says:

    Thank you for sharing this. It was a great pleasure to see you refer to the work of Don Nutbeam – and a good reminder to me to keep my perspective as broad as possible. While I recognize the value of addressing the “basic” HL skills such as reading and numeracy, I realize now that most of my focus is in these areas. Good to be reminded to stretch my perspective a little bit more.

  2. Thanks Laura. I agree it helped open my eyes as well.

  3. What a wonderful interview. Thank you! Kristina

  4. Pingback: It’s Health Literacy Month…how much do you know? | SurroundHealth Blog

  5. Home health care nurses routinely make visits directly to the homes of patients, where they do things like change wound dressings, bathe immobile patients, clean wounds and so forth. They are different from home health aids, which are more like babysitters for the elderly than an actual skilled RN.

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