Home Visits Using Reflective Approach Improve Functional Health Literacy Among Low-Income Pregnant Women and New Parents

Problem Addressed

• Lack of functional health literacy among at-risk populations: Functional health literacy—which enables parents to provide appropriate health care to family members—is extremely low among at-risk populations, including those with a high school education or less.   The concept of functional health literacy expands on the Institute of Medicine definition¹ by focusing on functional abilities related to health management and use of services.
• Leading to substandard care, poor outcomes: Low functional health literacy can have a negative impact on care and health outcomes, and lead to higher use of emergency and inpatient services.¹ 
• Untapped potential to teach new mothers: Pregnancy is the entry point into the health care system for many women, most of whom demonstrate a high readiness to learn about health care during their pregnancy and when their children are very young. Yet few programs are available to improve new mothers’ functional health literacy, even though such programs could enhance health and reduce hospitalizations, emergency department (ED) visits, and related health care spending.¹
• Untapped potential of home health visitation programs: Home health visitors can potentially be effective in educating at-risk, pregnant women and new mothers. Yet few visitation programs integrate functional health literacy into their service offerings.

Description of the Innovative Activity

• Integration into existing programs: The program is integrated into established home visitation programs that promote parent and child wellness and school readiness in at-risk, low-income families. These programs typically serve pregnant women and new parents with children up to age 3.
• Weekly to monthly visits: Home visits typically last 1.5 to 2 hours and occur on a weekly, biweekly, or monthly basis as needed. The goal of the early visits is to establish a relationship with the parent; to facilitate this process, the home visitor (who may be a nurse, social worker, health educator, or paraprofessional) speaks the family's primary language and is culturally and ethnically matched to the family whenever possible. Key activities during these visits include the following:
  • Assessing functional health literacy: Home visitors use the Life Skills Progression tool to assess multiple aspects of family functioning. The tool includes the Functional Healthcare Literacy Scale, which monitors the use of the health care system, and the Functional Selfcare Literacy Scale, which assesses how well participants maintain personal and child health at home. Home visitors complete the full tool for each family at intake and once every 6 months. The process takes roughly 10 minutes. The parents' functional health literacy scores are calculated by averaging their scores on the scale items. Scores in the target range indicate adequate to optimal functioning. At entry into home visitation services, only 42 percent of participants scored in the target range for functional health care literacy and 57 percent scored in the target range for functional self care literacy.
    • Functional health care literacy scale: This tool measures the adult’s use of health care information from the home visitor and other reliable sources, use of prenatal care, whether the parent has a medical home and seeks care when needed, use of family planning, adequacy of the child’s dental care, whether well-child checkups and immunizations are up-to-date, and the level of the family’s health insurance coverage.
    • Functional selfcare literacy scale: This tool measures attitude toward pregnancy, support of the child’s development, level of home safety including use of car seats, use of community resources, and use of illegal substances and tobacco.
• Empowering participants through reflective model: Trained home visitation staff, working with the Beginnings Guides and other parent education materials, use reflective questions and other reflective teaching methods to engage, educate, and empower participants to access essential health care services and self manage family health. Home visitors can also integrate curriculum materials and reflective practices into other program components, such as prevention of child abuse. The curriculum emphasizes the need to avoid “rescuing” or “fixing” participating families. Rather, the model encourages participants to think about what they are doing and relate it to prior life experiences. For example, a home visitor might make observations, ask questions, and then brainstorm strategies with a participant to address the identified problems. By contrast, in the traditional model, a home visitor might tell the participant what is wrong and attempt to fix the problem on the participant's behalf (e.g., by calling a health care provider).
• Educating participants using reader-friendly guides: The program uses two guides, one on pregnancy and one on parenting and child development. Each guide has six to eight booklets that address specific time periods during pregnancy and infancy, detailing what to expect, what constitutes normal conditions, and when medical intervention is needed. The guides are brightly illustrated, easy-to-read, with the English version written at a fourth grade level and the Spanish version written at a third grade level.
• Developing intervention plan: The life skills assessment scores show the parents’ needs, strengths, and progress in achieving functional health literacy over time. They can be used by home visitors, case managers, and other support agencies to determine a family’s needs for additional resources and to help them exert greater control over their health and health practices. Intervention plans can include education, information, social support, and practical assistance to support parents so they can apply for health insurance, find a family doctor, keep doctor's appointments, obtain additional services to address substance abuse or domestic violence or aid smoking cessation, and enhance parent's support of child development.

References/Related Articles

Contact the Innovator

Results

• Improved functional health care literacy: The average functional health care literacy score among a sample of 486 parents who received 18 months of service rose from 3.95 (below target range–inadequate functioning) at enrollment to 4.04 (in the target range after 6 months in the program). Scores increased to 4.06 at 18 months after enrollment. A score greater than 4 on a scale of 1 to 5 indicates adequate to optimal functioning 
• Improved functional self care literacy: The average functional self care literacy score among a sample of 519 parents who were followed for 18 months rose from 4.09 at enrollment to 4.2 after 6 months, and to 4.25 after 18 months.
• Gains across ethnic/racial groups: All ethnic/racial groups demonstrated statistically significant improvements in functional health literacy but in different patterns, with Hispanic/Latino parents improving the most with overall average scores from 4.24 at baseline to 4.5 after 18 months on the personal/maternal health literacy score. African-American parents improved from 4.16 to 4.29 over the same time period, while white parents showed the lowest levels of improvement, from 3.94 to 4.1.

Evidence Rating (What is this?)

Context of the Innovation

• Healthy Families Indiana MOM Project in Indianapolis, which provides home visitations to improve the health of new and expectant families. This program is funded by the Indiana State Department of Child Services.
• Healthy Families of Grant County in Marion, IN, is a home-based counseling and case management service providing support and education to all expecting and new parents.
• Child Health Investment Partnership of Roanoke, VA, which serves families in Roanoke and Salem and the counties of Roanoke, Botetourt, and Craig by providing home visitation services to disadvantaged pregnant women and new families. 
• Enterprise Community Healthy Start in Augusta, GA, which works to reduce low birth weight, preterm delivery, and infant mortality through home visits before, during, and after pregnancy.  
• Partnership for Strengthening Families in Bozeman, MT, an interagency effort to prevent child abuse in families with children from birth to age six in 19 high-risk communities. 
• Early Head Start Monterey County, Office of Education, based in Salinas, CA, which serves pregnant women, infants, and toddlers by providing support services through home visits to promote child and family development.

Planning and Development Process

Key steps in the planning and development process included the following:

• Training staff on curriculum: Staff received one day of training on the reflective teaching strategies, Beginnings Guide material and one day of training on how to use the Life Skills Progression tool and the Functional Health Literacy Measure. The training used role-playing, educational materials, and other methods to teach promotion of health literacy. The training also teaches how to use the literacy assessment tools, coach participants (including use of reflective questions, drawings, and conversations), and develop intervention plans. This training was in addition to each program's unique home visitation training program, which promoted each organization's core mission.
• Training staff on educational guides: The home visitors received training on how to encourage parents to use the guides to manage family health and to distinguish between normal occurrences and a situation that requires medical intervention. To that end, home visitors were taught to use documentation logs, available in English and Spanish, that list all the guides’ content in the order it appears in the materials, along with spaces to date, initial, and check off topics discussed during each visit. Training sites received a CD that contained the log masters.
• Setting up monitoring system: Developers set up a database software program that tracks health literacy assessment scores over time, thus allowing analysis and reporting on the program's impact at the individual, family, home visitor, and agency level. Evaluation was based on the combined data of the six programs.

Resources Used and Skills Needed

• Staffing: As noted, home health visitors at the participating sites included nurses, health educators, and paraprofessionals. Each home visitor’s caseload ranged from 10 to 42. Typically, home visitors conduct 18 visits a year (ranging from 6 to 36), spending between 1.5 to 2 hours with a family at each visit. 
• Costs: The cost of a one-day, onsite Beginnings Guide training for home health visiting staff and case managers is $2,500 per trainer, plus $250 that includes a CD of Reflective Drawings, documentation, and a training manual. A 1-day training course on the Life Skills Progression tool runs $2,500 per trainer. The Life Skills Progression tool has software to transfer assessment results into a database, which costs $1,500 to $3,000. These costs exclude booklets distributed to parents.
• Operating costs: The cost of the existing home visitation programs vary by site. This curriculum is incorporated into the existing program, with a one-time expense for training and the database, and should not add to the operating costs.

Funding Sources

Agency for Healthcare Research and Quality; National Institute of Child Health and Human Development; National Institutes of Health, Office of Behavioral and Social Sciences Research

Tools and Other Resources

Getting Started with This Innovation

• Integrate into existing programs serving disadvantaged families: The program can be integrated into any home visitation program that works to strengthen parenting skills, early childhood literacy, family health, and access to community resources and health care services.
• Provide adequate training to staff and case managers: Train home visitors and supervisory staff in the health literacy curriculum, including how to use the educational guides and how to ask reflective questions and have reflective conversations with parents. Provide additional training on how to use the assessment instruments to chart a family’s progress and develop an intervention plan. Finally, consider dedicating one training session to analyzing traditional "victim" and "rescuer" roles so as to encourage home visitors to adopt more of a coaching mentality, and participants to view themselves as "creators" rather than victims.  
• Use a database to monitor progress: Integrate the assessments into a database that allows for regular evaluation of the program's success in enhancing health literacy, thus allowing for the timely identification of problems and implementation of modifications as needed.

Sustaining This Innovation

• Consider integrating reflective model across organization: To fully embrace and practice the reflective model, would-be adopters should consider expanding use of reflective questions and other aspects of the model to internal management practices, such as during weekly clinical supervising sessions.
• Keep case loads as small as possible: Data suggest that more frequent visits and lower case loads may be associated with higher rates of improvement.