Elena Carbone Health LIteracy Conference: Making LIfe Better Belfast 2018

1. Improving Maternal Health
Literacy and Empowerment in
the United States and Ghana:
Results of a Scoping Review
Elena Carbone, DrPH, RD, LDN, FAND
ecarbone@nutrition.umass.edu
University of Massachusetts
Department of Nutrition
Data from this slide presentation may not be quoted or used without permission.

2. Statement of the problem
• Literature on maternal health literacy (MHL) and
empowerment is lacking.
• Providing an overview of the literature is needed to determine
next steps in the generation of information to inform research,
practice, intervention development and health policies.
Purpose of the study
• To complete a scoping review to determine what is known
about improving maternal health literacy and empowerment
among socio-economically disadvantaged mothers of
children aged 0-3 years in the U.S. and Ghana.
Data from this slide presentation may not be quoted or used without permission.

3. Scoping Review – Primary Questions
1. How much research has been generated on MHL and
its improvement?
2. In what settings?
3. What interventions have been reported?
4. What experiences/situations have been documented?
Adapted from: Arksey H and O’Malley L. (2005); Levac, Colquhoun and O’Brien (2010); Colquhoun et al. (2014); and the Joanna
Briggs Institute Reviewers Manual: Scoping Reviews (2015).
Data from this slide presentation may not be quoted or used without permission.

4. Scoping Review – Secondary Questions
5. How is MHL related to empowerment?
6. How do MHL and empowerment develop?
7. What supports or impedes improvement of MHL and
empowerment?
8. How have improvement of MHL and empowerment
been measured?
9. How are MHL and empowerment related to health
disparities?
Data from this slide presentation may not be quoted or used without permission.

5. Methods
Databases:
• Medline/PubMed
• Google Scholar
Dates: Ended Dec 2017
Search terms:
• Individual concepts (stages of pregnancy) searched by keywords
(health literacy, maternal health literacy) and MeSH
• Limited by “United States” and “Ghana” filters
Inclusion criteria:
• Abstract
• Full text
• English language
• Human studies
Data from this slide presentation may not be quoted or used without permission.

6. Exclusion Criteria
• MHL operationalized as reading proficiency
• Specific health conditions (asthma, HIV, oral health, etc.)
• Specific health issues (immunizations, smoking, pregnancy
complications)
• Special populations (mothers exposed to toxins, older
mothers, women with disabilities, etc.)
• Preconception/pregnancy planning
Data from this slide presentation may not be quoted or used without permission.

7. 1. How much research has been generated?
Records identified through
database searching
(n = 245,382)
ScreeningIncludedEligibilityIdentification
Records after categories collapsed,
duplicates removed (n = 3,854)
Records screened
(n = 580)
Records excluded
based on filters
(n = 3,274)
Full-text articles
assessed for eligibility
(n = 67)
Full-text articles
excluded, based on RQ
(n = 58)
Studies included in
systematic review
(n = 9)
Records excluded based
on exclusion criteria
(n = 513)
Data from this slide presentation may not be quoted or used without permission.

8. 2. In what settings has research been conducted?
• Home-based in diverse locations throughout the
U.S. (n=5)1,3,6,8,9
• Urban hospital antenatal care units(n=4)
o Two U.S. studies 2,7
o Two Ghanian studies 4,5
Data from this slide presentation may not be quoted or used without permission.

9. 3. What interventions have been reported?
Seven studies reported on interventions to improve MHL and
empower women.1,3,5-9
• RCT found computer-based program empowered communication
and verbal engagement in 83 women with limited literacy skills.7
• Mixed methods study (n=6 Ghanian midwives), survey data showed
no change in communication skills following use of a curriculum to
build interactive skills at an antenatal care program; qualitative
data revealed three positive themes:
1) improved communications
2) enhanced information sharing and peer support
3) improved understanding of patient concerns.5
Data from this slide presentation may not be quoted or used without permission.

10. 3. What interventions have been reported?
Five quantitative studies used a common measure to evaluate
home visitation programs in different regions of the U.S. 1,3,6,8,9
• The Life Skills Progression (LSP) instrument was a part of the
intervention and primary data collection tool to monitor change
in degree to which mothers produced identified consequences of
increased health literacy, improvement in:
o health services utilization
o risk behaviors
o self-care
• Significant improvements in MHL scores were found in all 5 studies.
Data from this slide presentation may not be quoted or used without permission.

11. 4. What experiences/situations have been documented?
QUALITATIVE STUDIES (n=2)
U.S.
o Focus groups with 25 depressed or overweight postpartum women
o Knowledge enabled women to recognize depression symptoms
but did not help them overcome fears related to child protective
policies and prior negative encounters, which inhibited care
seeking.2
Ghana
o Focus groups with 68 Ghanaian mothers
o Standard antenatal education did not translate into behavior
change or utilization of services.4
Data from this slide presentation may not be quoted or used without permission.

12. 4. What experiences/situations have been documented?
MIXED METHODS STUDIES (n=2)
Ghana:
o Curriculum-based intervention to increase interactive skills of (6) Ghanian midwives.
o Survey data showed no change in levels of participation or engagement.
o FG data showed improved patient-provider communication, increased information
sharing, and peer support.5
U.S.
o Proceedings of 8 parent educators' monthly case calls documented experiences
integrating reflective practices into usual activities, and shifting focus from
education empowerment.
o Educators felt comfortable with empowerment approach after ~10 home visits.
o Educators felt empowered, viewed reflective questioning as more effective and less
stressful than delivering curriculum and needing to “know everything.”1
Data from this slide presentation may not be quoted or used without permission.

13. 5. How is MHL related to empowerment?
Two studies directly addressed the relationship of MHL and empowerment
o Service providers - recognize importance of promoting/enhancing mother’s
ability to meet her own needs, solve problems, and mobilize resources.1
o Mothers - empowering women to address intermediate risk and protective
factors through improved MHL positively impacts birth outcomes and infant
survival.6
Two studies indirectly addressed empowerment
o One US study inferred empowerment from mothers’ active participation in
prenatal care communications.7
o One Ghanian study inferred “self-determination” from improved patient-
midwife communication, increased information sharing, and peer support
among women in antenatal care.5
Data from this slide presentation may not be quoted or used without permission.

14. 6. How do MHL and empowerment develop?
Five LSP-MHL intervention studies empowered mothers by:
o Redirecting service providers’ expertise to formulate reflective questions
o Facilitating reflective conversations leading to self-discovery, learning,
and growth.1,3,6,8,9
Two studies demonstrated that:
o Support of home visitors empowered depressed mothers to seek care
and take action to manage symptoms.6,8
Two studies developed interactive skills
o Through a computer program7
o Using a curriculum to increase patient-patient sharing and improve
communication in group antenatal care.5
Data from this slide presentation may not be quoted or used without permission.

15. 7. What supports/impedes improvement of MHL
and empowerment?
Supporting factors:
o Using an approach focused on developing interactive and critical
health literacy skills 1,3,6,8,9
o Reflective questioning1
o Expressive language capacity building7
o Collaboration (social workers and public health nurses working together
to address social and health issues)3
o Group care to increase social support 5
o Sustained and trusting relationship with providers 2,6
Data from this slide presentation may not be quoted or used without permission.

16. 7. What supports/impedes improvement of MHL
and empowerment?
Impeding factors:
o Fear-generating child protective policies, limited access to care.2
o Low quality care, lack of information when to initiate care, prior
negative encounters, lack of support to translate knowledge to
action.4
o Expert advice giving, reliance on a set curriculum.1
o Negative social support, lack of transportation, other Social
Determinants of Health.6
Data from this slide presentation may not be quoted or used without permission.

17. 8. How have MHL and empowerment been
measured?
o No studies measured MHL and empowerment separately.
o Some studies used indicators embedded in descriptions and
definitions of health empowerment as indictors of MHL.1,6
o Conversely, some interpreted participation in prenatal visits as an
indicator of empowerment.5,7
o Studies using LSP used changes in actions, practices and
behaviors as indicators of progress/regression in developing
interactive and critical skills and empowerment.1,3,6,8,9
Data from this slide presentation may not be quoted or used without permission.

18. 9. How are MHL and empowerment related to
health disparities?
Findings from this review suggest that:
o Interventions reduced disparities due to mental health6,8 and
literacy 1,7, which impact birth outcomes and infant survival.
o Depressed mothers made greater gains in MHL scores than
their matched comparisons.8
o Women who are unsure when to seek care for problems in
themselves and their children often delay care or experience
poorer health outcomes.4
Data from this slide presentation may not be quoted or used without permission.

19. Limitations
• This review included only publications
o from the U.S. and Ghana
o published in English
o indexed in Medline/PubMed or Google Scholar
o accessible on line.
• To reduce the sheer volume of sources, items that did not
mention health literacy in the abstract were excluded.
• Relevant articles may have been missed.
Data from this slide presentation may not be quoted or used without permission.

20. General Themes
• Research on MHL is scant in the U.S. and nearly non-existent in
Ghana.
• Most research has focused on:
o low health-related literacy in mothers
o efforts to simplify information or improve its delivery
o clinical settings.
Data from this slide presentation may not be quoted or used without permission.

21. Summary
Findings support Nutbeam’s (2008) theory that MHL and empowerment can
be promoted through usual health promotion efforts and include:
o collaborative, problem-focused empowerment approach
o focus on improving interactive and critical health literacy skills
o address mother-defined health priorities and their social determinants.
Measurement issues continue to plague health literacy research.
o No measure of HL found suitable for use in Ghana or low-resource countries.4
o Only one measure – the LSP (Life Skills Progression instrument) – was used to
capture progress of MHL skills. 1,3,6,8,9
o Separate measure of empowerment may be unnecessary.
Data from this slide presentation may not be quoted or used without permission.

22. Next Steps
• A global systematic literature review is planned to assemble and
evaluate evidence relevant to improving MHL and empowerment in
both clinical and community settings.
• Evaluation of the evidence will clarify implications for practice and future
research.
• Standards for reporting health literacy studies would increase rigor in
research, aid learning, and speed design, evaluation and dissemination
of interventions.
Data from this slide presentation may not be quoted or used without permission.

23. Acknowledgements
The following people and organizations contributed to this
literature review:
• Sandra Smith, University of Washington
• Robert Akparibo, University of Sheffield
• Amos Laar, University of Ghana
• Janet Harris, University of Sheffield
• Members of the WUN Health Literacy Network
This work was completed as part of a Research Development Grant
funded by the Worldwide Universities Network (WUN).
Data from this slide presentation may not be quoted or used without permission.

24. References
1. Carroll L. N., Smith S. A., & Thomson N. R. (2014). Parents as teachers health literacy demonstration project: Integrating an
empowerment model of health literacy promotion into home-based parent education. Health Promotion Practice,16(2),
282–290.
2. Guy S., Sterling B. S., Walker L. O. & Harrison T. C. (2014). Mental health literacy and postpartum depression: a qualitative
description of views of low-income women. Archives of Psychiatric Nursing, 28(4), 256-62.
3. Haynes G. W., Neuman, D., Hook, C., Haynes, D. C., Steeley, J. M., Kelley, M. . . . Paine, M. (2015). Comparing child and
family outcomes between two home visitation programs. Family and Consumer Sciences Research Journal, 43(3). 209–
228.
4. Lori, J. R., Dahlem, C., Ackah, J., & Adanu, R. (2014). Examining antenatal health literacy in Ghana. Journal of Nursing
Scholarship 46(6), 432-440.
5. Lori, J. R., Munro, M. L., & Chuey, M. R. (2016). Use of a facilitated discussion model for antenatal care to improve
communications. International Journal of Nursing Studies 54, 84-94.
6. Mobley, S., Thomas, S., Sutherland, D., Hudgins, J., Ange, B. L., & Johnson, M. H.. (2014). Maternal health literacy
progression among rural perinatal women. Maternal and Child Health Journal. 18(8), 1881–1892.
7. Roter, D. L., Erby, L. H., Rimal, R. N., Smith, K. C., Larson, S., Bennett, I. M. . . . Bienstock, J. (2015). Empowering women’s
prenatal communication: does literacy matter? Journal of Health Communication, 20(2), 60-68.
8. Smith, S. A, & Moore, E. J. (2012). Health literacy and depression in the context of home visitation. Maternal and Child
Health Journal, 16(7), 1500–1508.
9. Smith, S., & Carroll, L. (2017) Data-driven maternal health literacy promotion and a postscript on its implications. In Robert
A. Logan and Elliot Siegel (Eds.) Health literacy: New directions in research, theory, and practice. Amsterdam, The
Netherlands, IOS Press.