Empowering Parents, Benefiting Children,
Creating Strong Foundations for Healthy Families
CHSA, Health Institute
May 21st, 2013
Ariella Herman, Ph.D.
Research Director
UCLA/Johnson & Johnson Health Care Institute
Harold and Pauline Price Center for Entrepreneurial Studies
UCLA Anderson School of Management
A. Herman, Copyright 2013
All rights reserved
Outline of Talk:
Health Literacy Matters
I.
Family Health Literacy: Life Course Perspective
II. NCH/Health Care Institute (HCI):
a.
HCI makes “improving health literacy in Head Start” a
priority
b.
Improving health literacy is a door leading Staff and
Families to engagement
III. Conclusions
What is Health Literacy?
“The degree to which individuals have the capacity to
obtain, process, and understand basic information and
services needed to make appropriate decisions regarding
their health.” Institute of Medicine. 2004.
Improving health literacy is the key to the success of our
national health agenda. “It is the currency for everything
we do.”
Dr. Koh, National Action Plan to Improve Health Literacy, Forward. 2010.
Why must we do something about
health literacy in America?*
 Low health literacy is “a stronger predictor of a person's health than age, income, employment
status, education level, and race”

poor health literacy Costs the American economy $73 billion annually

90 million people cannot understand and use health information appropriately

People are more likely to use emergency services, not preventive services

People are more likely to be hospitalized, not be compliant with medication

Annual health care costs are 4 times higher

Populations most at-risk for low health literacy include:
People with low SES, low level of education, from racial and ethnic minorities,
and Persons with Chronic Health Conditions & Disabilities
*Quote and data provided by the AMA, Report on the Council of Scientific Affairs, Ad Hoc Committee on Health
Literacy for the Council on Scientific Affairs. Health Literacy: A Prescription to the End Confusion, the Institute of
Medicine (IOM 2003)
Improving Health Literacy in Head start is
Critical for Child Health
Parental
Health Literacy
Families as
learners
Parental
Child
Health
SES
Culture
Community
Family
Wellbeing
Poor health literacy impacts child health:
Children of low-literacy adults are at greatest risk for low
health care quality, as measured by health care utilization
data, health behaviors, and other health outcomes
Child Health is CRITICAL for School Readiness
A FEW EXAMPLES
•Early identification of developmental,
behavioral, social, environmental and
biological conditions that affect
children’s ability to learn.
Parents:
Health
Literacy
Child
Health
SES
Culture
Community
Enhanced
School
Readiness
&
Academic
Outcomes
•Children absent from school for chronic
health conditions risk falling behind in
their schoolwork.
•Children with untreated vision
problems cannot track printed letters
and words across a page and learn to
read.
•Oral disease in children is responsible
for more than 51 million lost school
hours each year.
Potential Impacts:
Your average daily attendance,
Your school readiness goals,
Your ability for early intervention…
Life Course Perspective:
Health Literacy for Parents has Lasting Outcomes
Parents:
Health Literacy
Child
Health
SES
Culture
Community
Prenatal
Enhanced
School
Readiness
&
Performance
Infant
Child
Improved
Health
Literacy
For
Children
and Youth
Adolescent
Second
Generation:
Improved
Health
Literacy as
Parents
Children
Become
Adults/Parents
Adapted from N. Halfon, Hochstein, M. Milbank Quarterly, 2002 & L.Martin, 2009
Child Health and School Readiness: The Significance of Health Literacy
Health Literacy is Cross Cutting for the National Center on Health:
Health Promotion, Disease Prevention & Early Intervention
Addressing Health literacy aligns with Head Start
Performance Standards
HSPS: 1304.40/1304.20
• Encourage parents to become active partners in their
children’s healthcare process
• Collaborative partnership building with parents
• Access to materials and services and activities to develop
family literacy
• Respect for each family’s diversity, cultural and ethnic
background
• Medical, dental and nutrition education programs for staff
and families
• Pre natal and breastfeeding education for pregnant and
nursing mothers
• Principles of preventive medical and dental health,
emergency first aid , environmental hazards and safety
practices for use in the classroom and in the home
The work of the HCI and now the National Center on
Health is aligned with Head Start & the Urgent
National Need to Improve Health Literacy
Head Start
Performance
Standards
Head Start Parent ,
Family &
Community
Engagement(PFCE)
School Readiness!
Brief History of HCI
 UCLA’s J&J Head Start Management Fellows program trained
nearly 1400 Head Start directors and managers since 1991.
 Survey of directors identified poor health literacy and poor
attendance as obstacles to better health outcomes for these
families.*
 In response, HCI was created as a research center in 2001 and
provides an evidence base for health literacy.
 Head Start is the primary research platform:
– Vision integrates education and comprehensive health
and family services.
– Serves over a million children a year, dealing with
multiple challenges such as cultural beliefs, poverty,
language differences and literacy challenges.
*“The Status of Health Care in Head Start: A Descriptive Study”, Sept 2000, UCLA/Anderson, A. Herman
HCI Mission
Strengthen managerial capacity of agencies, so they can provide
more effective health education and prevention programs to the
children and families they serve.
HCI Strategy
Train the Trainers in Agencies to:
 Develop strategic management tools to assure successful
implementation of health education programs.
 Provide culturally sensitive, low literacy materials that engage and
empower agency staff & families to participate actively in health
decisions.
The Road to “L.O.V.E.“
2011-2015
2008-2011
2002-2007
2001
Pilot Study
Missouri
UCLA/J&J
HCI
National
Center on
Health
Health Care Institute
Strategic Implementation Phases
Train the Trainers
Who is training :
UCLA Faculty & Head Start
Leaders
Who is Trained:
Teams of 5-6 from each
agency
How long:
2 days
Parents Training
Who is training:
Head Start trainers
Who is Trained:
Head Start families
How long:
3-4 hours
Baseline Assessment
Follow up &
Reinforcement
3 Home visits to
reinforce the learning
process and track
data
Tracking data
Graduation
Celebration!
Post Assessment
Health Care Institute
Strategic Implementation
Train the Trainers
Parents Training
Follow up &
Reinforcement
Graduation
•Share data for continuo
improvement
•Apply to other trainings
•Sustain the program
over time
National Implementation
Reach:
65,000 Families Trained
1,150 Trainers Trained
All ACF Regions
45 States
Multiple Community Types
7 Languages
10 Ethnicities
Corporate & Public Funders:
•J&J
•Pfizer
•Kansas Head Start
•State of Washington
•UCLA
•OHS (I.I.P./I CAN)
•Fidelity Charitable Fund
•Los Angeles County Office of Education
•National Center on Health(HHS)
Publications:
• Journal of Community Health
• Journal of Emergency Medicine
• Journal of Health Communication
• American Journal of Health Promotion
Health Care Institute
Health Promotion
*Adapts to literacy, language
and culture
* Offers a portfolio of health topics
* Teaches health skills to
vulnerable populations
*Improves health decision making
Effective Implementation
*Builds capacity
*Develops leadership
*Provides tools for strategic
project management and replication
* Enhances community outreach
A comprehensive approach to health empowerment for Head Start agencies serving
parents, children and staff with a portfolio of programs targeting prevention
Validated by a decade of outcomes data
Portfolio of Health Topics
Treatment
of
Common
Childhood
illnesses
Oral Health
Prevention
Diabetes
Obesity
Prevention
Prenatal
OTC Medication
Health
Vaccinations
Education
Asthma/Second
Hand Smoking
Home Safety
Key Findings
Treatment
of
Common
Childhood
illnesses
PRE TRAINING
WHEN YOUR CHILD IS SICK, HOW DO YOU FEEL?
86%
90%
80%
60%
50%
20%
10%
46%
42%
47%
KNOWLEDGE
30%
57%
WORRIED
40%
CONFIDENT
70%
0%
ALL THE
TIME
SOMETIME
NEVER
BUT... ALMOST 3/4 OF PARENTS
DO NOT HAVE ANY HEALTH BOOKS AT HOME
Do you have a health book?
NO
69%
YES
31%
Note: Of the 31% that claimed they had a book, 52% DID NOT remember the name
WHERE DO YOU GET INFORMATION ABOUT
YOUR CHILD’S HEALTH?
I just know how to
take care of m y
child.
10%
Doctor or
Clinic
69%
Health Book
5%
TV and Friends
16%
WHEN YOUR CHILD IS SICK WHERE DO YOU
FIRST GO FOR HELP?
EMERGENCY
ROOM
4%
DOCTOR
69%
HEALTH BOOK
5%
What Would You Do If Your Child Had A Temperature of 99.5°F?
100%
4%
90%
45%
80%
70%
Look in a Health Book
60%
Do Nothing and Wait
Ask family/friends
50%
Take child to clinic or doctor
40%
30%
Call 911 or take child to ER
37%
20%
10%
10%
5%
0%
PRE
1%
POST
IF YOUR CHILD HAD A COUGH, WHAT WOULD YOU DO?
100%
9%
90%
44%
80%
70%
Look in a Health Book
Ask Family / Friends
60%
Do Nothing and Wait
50%
40%
30%
Take child to Clinic or Doctor
41%
Call 911 or go to Emergency
Room
20%
10%
4%
0%
PRE
14%
1%
POST
WHEN YOUR CHILD IS SICK, WHERE DO YOU
FIRST GO FOR HELP?
100%
4.70%
BO
90%
O
K
80%
47.55%
70%
60%
50%
68.79%
40%
DO
CTO
R
30%
32.64%
20%
10%
4.39%
ER
1.21%
0%
Pre
Post
“Reducing use of Emergency Medical Resources Among Head Start Families”, Journal of Community Health, June 2004, A. Herman.
DOCTOR VISITS
FIVE MAIN CHILDHOOD ILLNESSES
120
100
80
60
40
20
0
COLD COUGH EAR FEVER FLU
PRE
POST
EMERGENCY ROOM VISITS
FIVE MAIN CHILDHOOD ILLNESSES
200
180
160
140
120
Pre
100
80
60
40
20
0
Cold
Fever
Cough
Ear infection
Flu
Post
Examples of the Impacts of UCLA/J&J Health Care Institute
“What To Do When Your Child Gets Sick”
N=9240,P<0.001
*Herman A, Jackson P.“Empowering low-income parents with skills to reduce excess pediatric emergency room and
clinic visits through a tailored low literacy training intervention”, Journal of Health Communications December, 2010
“What To Do When Your Child Gets Sick”
N=9240,P<0.001
*Herman A, Jackson P.“Empowering low-income parents with skills to reduce excess pediatric emergency room and
clinic visits through a tailored low literacy training intervention”, Journal of Health Communications December, 2010
Projected Cost/Benefit Analysis
$ 554
$600.00
$500.00
$400.00
$300.00
$50-$80
$200.00
$100.00
$0.00
Total Savings Per Family Per year( Due
to decrease in ER and Doctor Visits)
Total Cost per Family Trained
+ Improved School Readiness
+Increased Productivity
Qualitative Outcomes for Families & Staff
 Increased parental awareness of health warning signs
 Prompt parental response to early signs of illness
 Appropriate use of health reference materials for first




line help
Better understanding of common childhood illnesses
Development of skills & leadership for agency and
staff
Improved staff relationships with parents
Engaged parents and staff and increased parental
participation
31
TRAINING IN 2 LANGUAGES!
TRAINING IN 4 LANGUAGES!
Family Engagement
TRAINING IN 7 LANGUAGES!
Physician and Translator at Parent Training
PHYSICIAN
HOME VISITOR/
TRANSLATOR
Physician and Translator at Parent Training
HOME VISITOR/
TRANSLATOR
PHYSICIAN
Testimonials from Head Start Communities
• “This process supports our thinking as a Head Start program, which is
that one of the most powerful things we can do is not only to make a
difference in the lives of our children, but also to effect changes for our
families as a whole…”
• “..the J&J Health Care Institute has not only enriched their abilities as
parents, it has strengthened the parents’ self esteem and the parentchild bond within the family….”
• “..the result is a family that has a brighter future and children that are
ready to learn…”
• “As we continue to fight for the future fate of Head Start, it is
passionate individuals like who you are invaluable to our Head Start
community …”
• “It is people like you that change the world…one family at a time…”
“Yes we have the data to show you the
impact, but more importantly we have seen
the impact of the health literacy training for
our families and in our communities - lives
have been changed …children are healthier ,
parents have new knowledge…..self-esteem
in families is evident and staff have found a
renewed commitment in working with
people! We are connected, indebted and
engaged “ H.S. Director
• Parents care deeply about their child’s health!
• Parents are key advocates for the health and well-being
of their families.
We need to:
• Provide families with knowledge, tools, and resources so
they can actively participate in health decisions.
• Engagement of families is essential to achieve
sustainable adoption of healthy lifestyles choices.
Health literacy is a door leading
Families to engagement!
Diabetes
Obesity
Prevention
Eat Healthy, Stay Active!
Improving Nutrition and Physical Activity among Head start Parents,
Staff and Children
(*)Herman A, Nelson B, Teutsch C, Chung P. Eat Healthy, Stay Active: A coordinated intervention to improve nutrition
and physical activity among Head Start parents, staff and children. American Journal of Health Promotion. September
2012 Open access e-publication
EAT HEALTHY, STAY ACTIVE!
Tri-level obesity prevention in school setting
 Recognized the national pediatric obesity epidemic and the paucity of
research with preschool age children and families in underserved
communities
 32% of Head Start children are overweight or obese(Faces,2013)
 Head Start parents and staff are also at high risk for overweight and
obesity
 Designed a culturally sensitive, low literacy health education program
for school staff, parents, and preschool children to create awareness of
important factors in the prevention of obesity and diabetes and actions to reduce
personal risk.
 Build knowledge
 Engage the whole community
 Empower participants to change behavior and adopt healthier lifestyles, especially around
nutrition and physical activity
Eat Healthy, Stay Active! Logic Model
Inputs
Short-Term Outcomes
Multi-Level Curriculum
STAFF
Children
NUTRITION
Increased knowledge of:
•Healthy food choices
•Consequences of poor nutrition
•Selection of affordable & healthy food
NUTRITION
Adoption of:
•Healthy eating behaviors
•Limited budget& available resources balance
-Improved attitude regarding healthy eating
-Awareness of appropriate body weight
-Adult-Child synergy leads to behavior
change
-Attain appropriate body weight
Parents
Classroom
Education
CHILDREN
Mid-Term Outcomes
Centered
Education
Family
Centered
Education
PARENTS
EXERCISE
Increased knowledge of:
•Importance of physical activity
•Health consequences of inadequate physical
activity
•Identifying appropriate level & types of
physical activity
EXERCISE
Adoption of:
•Appropriate level of routine physical activity
•Practice of balancing diet & exercise
•Increase in family physical activity
-Improved attitudes regarding physical
activity
-Awareness of appropriate body weight
-Adult-Child synergy leads to behavior
change
-Attain appropriate body weight
Long-Term Outcomes
•Decreased risk
factors for
nutrition-related
health problems &
chronic diseases
•Decreased
development of
chronic diseases
•Maintained
healthy body
weight
•Decreased health
care costs
Intervention Timeline
Curriculum






Diabetes/Obesity Awareness
Nutrition Education
Shopping Education
Physical Activity
How to stretch your food $ dollars
How to use your environment to
exercise
Sample Parent & Staff Training Presentations
Sample and Measurements
• National pilot: enrolled 6 Head Start agencies in 5 states,
intervention period of 6 months during 2009-2010 school
year.
• Staff and parents (total N = 497) completed baseline and
follow-up surveys to measure changes in:
– Knowledge of food groups and healthy food choices;
– Eating behavior, shopping behavior and physical activity.
• 417 adults (staff and parents) had baseline and follow-up
height and weight measurements.
• Subsample of 172 children, matched to parents, had height
and weight measurements at baseline and follow-up.
Pre/Post Survey Results: Knowledge and Behavior
(*)
N = 897 adults
(*)
(*) p<0.001
Obesity Definitions
• For adults, obesity defined as BMI ≥ 30.
• For children, exact age at time of height and
weight measurement was unknown, but all
children enrolled were 3-5 years old, with
majority 4 years old.
• Childhood obesity defined as BMI ≥ 95th
percentile for age and gender; in this study
defined as ≥ 18 for boys and girls.
Obesity Results (**)
Adults
% Obese
Baseline
% Obese
Follow-up
P-value (*)
45.1%
39.8%
< 0.001
41.4%
36.8%
< 0.001
51.7%
45%
< 0.001
30.4%
20.5%
< 0.001
(n = 417)
Staff
(n = 266)
Parents
(n = 151)
Children
(n = 178)
(*) Statistical significance tested using Fisher’s exact test.
(**) Regression analysis shows when parents were paired with their children, significant association
between child and adult weight change.
Children’s Healthy Living Adventure
(*) Eat Healthy , Stay Active !, 2010.N=178,p<0.001
Staff Training Photos
Parents Training Photos
Parents Training Photos
Inside & Outside the Classroom
Diabetes/Obesity Prevention
56
Children’s Activities
Farmers Market
Classroom Activities
From Classroom to the Families
Parents, Children and Staff Preparing Healthy Meals
Graduation
Graduation
Quotes from Parents:
• “I try to eat more fruits and vegetables. I drink water instead of
soda. I go outside to walk whenever I have a moment.” Mom
• “Comer mas frutas y vegetales, comer menos pocio de comida,
menos tortilla, menos carnes rojas, tomar mas aqua y hacer una
actividad fuera de casas.” Mama
• “Since the “Eat Healthy”, I have made many changes in our
family’s life. When I go to the supermarket, I am not fighting to
get the parking closest to the entrance, I started to use coupons, I
asked my grandma if I could use a piece of her yard to plant
vegetables, I take my daughter to the supermarket and let her
pick up the fruits. This program really opened my eyes on the
benefits of a healthy living.” Mom
Anecdotes of Activation
• Community garden was initiated.
• Discussions with farmers about CSA produce boxes.
• Parent volunteered and organized a coupon class to
learn how to save money.
• Teachers created new lessons and coordinated across
classrooms, including tasting new foods—Paint me
Healthy! Fruit kabobs!
• Teachers had kids run around the field once each
morning. Now incorporated permanently into
curriculum!
• Staff and parents visited grocery stores and talked with
vendors about food needs.
The work of the HCI and now the National Center on
Health is aligned with Head Start Priorities
Head Start Performance
Standards
Head Start Parent , Family &
Community Engagement(PFCE)
School Readiness!
Engagement begins with ….. L.O.V.E.™
Listening
Observing
Valuing
Encouraging
Remember to L.O.V.E. Your Staff
• Listen and understand their emotions. (i.e. fear, anxiety, anger,
loss, etc.)
• Observe to see what the staff members are interested in. (what
drives them)
• Value each employees contribution and let them know OFTEN
how their contributions lead to achieving your mission.
• Empower staff as much as possible. (include them in the decision
making process and encourage them to offer solutions)
THE LEADER IS THE KEY TO A MOTIVATED STAFF - the staff are the
necessary ingredient to assure parents/families are full engaged.
MOTIVATED STAFF = ENGAGED PARENTS
Translating Motivation . . .
. . . From Staff to
Families
Motivate families to feel excited about
playing a role in their child’s
development and health!
When programs are infused with
L.O.V.E.™ families’ power is celebrated
Powerful families are more likely to exhibit:






Ability to access resources in the
community
Decision-making abilities
Assertiveness
Feeling of hope
A belief in the family unit
A feeling of being part of a group
Building Partnerships for Health
Families bring an array of
information, feelings & beliefs
Staff bring their own needs,
knowledge & beliefs
•
Personal health needs
•
Training and experience
•
Position
•
Own health beliefs
•
Own biases and prejudices
•
Expectations, fears & hopes
•
Personal experiences in health
settings
•
Personal experiences with health
professionals
•
Health knowledge & comfort
level
Family Partnership
•
•
•
•
•
•
Listening to every family member
Demonstrate respect and empathy for every
family member
Recognize the family expertise & critical role
in their child health
Establish a clear goal of partnering with the
family
Validating the participatory role of the
family
Provide the family with low literacy and
culturally sensitive health information
“A parent who has the tools to make appropriate decisions
about the healthcare of their child has been given selfesteem……when a person has self-esteem they can move a
mountain. Mountains have been moved in the lives of the
families that I work with…….through health education with
L.O.VE.™ That is the ANSWER!”
EHS Health Manager
Empowered families can make a difference, can change
communities and will lead to a healthier nation!
National Center on Health
Contact Information
Toll-Free: 888-227-5125
Email: nchinfo@aap.org
Website:
http://eclkc.ohs.acf.hhs.gov/hslc/ttasystem/health/center
Presenter: Ariella Herman, Ph.D.
UCLA/Johnson & Johnson Health Care Institute
ariella.herman@anderson.ucla.edu
http://www.anderson.ucla.edu/x682.xml