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Objectives Parental low oral health literacy is thought to contribute to child oral health disparities. Few large-scale interventions can improve oral health literacy for diverse, high-risk populations. We sought to determine whether an oral health literacy intervention aimed at parents of children attending Head Start programs improved oral health literacy and behaviors. Methods Staff from 29 Head Start agencies across the country were trained to deliver a parent oral health literacy intervention. Parent surveys were conducted at baseline and approximately 6 months later, following intervention completion. Surveys measured parent and child demographics, oral health knowledge, behaviors, information sources, and health care utilization. Paired t tests and mixed-effects regression models controlling for agency, child age, and race/ethnicity evaluated whether measures improved after the intervention. In addition, at follow-up, agency staff were asked to complete an open-ended survey reporting how the intervention impacted their site. Responses were coded using a grounded theory approach. Results A total of 2,011 (87%) parents completed both the baseline and follow-up surveys. All oral health knowledge and behaviors improved significantly from baseline to follow-up. In addition, parents reported using more oral health information sources, using more preventative oral health care, and less emergency room (ER) use for child dental problems. Head Start staff perceived that the intervention increased parental oral health literacy, enhanced parental oral health engagement, improved child oral health behaviors, and facilitated health communication with parents. Conclusions Findings suggest that this intervention successfully improved oral health literacy for diverse parents of children at high risk for dental caries.

Background. Chronic stress and depression disproportionately affect families experiencing poverty, and likely contribute to disparities in early childhood developmental outcomes. Developing strategies to address chronic stress and depression may help mitigate these disparities. Early Head Start (EHS) and Head Start (HS) programs provide an important platform to address the disproportionate burden of stress and mental health issues experienced by EHS/HS families. However, few low-literacy, broad, scalable interventions improve parents’ knowledge and attitudes around these topics. Objectives. We examined parents’ knowledge and attitudes regarding stress and depression before and after a train-the-trainer (TTT) intervention delivered to 28 EHS/HS agencies across the United States. Methods. Following a TTT workshop, 18 agencies chose to deliver the stress training to 1,089 parents and 5 chose to deliver the depression training to 670 parents. Participating parents completed paper assessments at baseline and 3 months following the training. Paired T-tests and chi-square analyses tested whether responses significantly improved over time. Results. At baseline, 37.2% of parents reported feeling stressed most of the time and 13.4% reported feeling depressed most of the time. Following the trainings and reinforcement activities, parents’ knowledge, attitudes and self-reported behaviors significantly improved, including willingness to seek help for depression, avoidance of negative health-risk behaviors and utilization of healthy stress management practices. At follow up, 18.6% of parents reported feeling stressed most of the time and 11% reported feeling depressed. Conclusion. Findings suggest this low-literacy TTT approach is potentially a promising health promotion intervention with broad dissemination potential.

Background Medical schools need to teach future physicians about health literacy and patient-doctor communication, especially when working with vulnerable communities, but many fall short. In this article, we present a community-based, service learning experience over one academic year during the pre-clerkship portion of medical school as an innovative and successful model for medical students to learn about health literacy and practice effective communication strategies. “Eat Healthy, Stay Active!” (EHSA) is a 5-month pediatric obesity intervention designed for Head Start children, their parent (s), and staff. We hypothesized students’ attitudes, knowledge, and skills confidence regarding healthy literacy and patient communication would improve from baseline after receiving training and serving as family mentors in the EHSA intervention. Methods First- and second-year medical students were trained through a series of didactics and then partnered with Head Start children, parents, and staff to help educate and set goals with families during the EHSA intervention. Medical students were given a pre- and post-intervention survey designed to measure their attitudes, knowledge, and skills confidence regarding health literacy. The pre-survey was administered before the first didactic session and the post-survey was administered after the conclusion of the EHSA intervention. We compared students’ pre- and post-intervention responses using paired t-tests. Throughout the project, the medical students were asked to complete a set of open-ended journal questions about their experiences. These responses were examined using qualitative, thematic analyses. Additionally, the Head Start parents and staff were asked to complete a survey about their experience working with the medical students. Results Participant (n=12) pre- and post-surveys revealed that medical students’ attitudes about the importance of health literacy were ranked highly both pre- and post- intervention. However, knowledge and skills confidence regarding health literacy showed statistically significant improvement from baseline. Journal entries were categorized qualitatively to demonstrate medical students’ insight about their growth and development throughout the project. Survey results from Head Start parents showed medical student participation to be highly valued. Conclusion Providing medical students with a service learning opportunity to work with individuals with low health literacy in their pre-clerkship years increased students’ knowledge and skills confidence regarding health literacy and communication.

Good health is a life-long process. Many of the most critical behaviors are established in early childhood and need reinforcing at each life stage. To encourage physical activity, for example, young children should engage in fun, active play daily; schools should ensure that physical activity is a normal part of daily life; parents should participate in physical activity at work, home, or both and include their children; and elders should be encouraged to stretch, move, and improve their strength. Children who understand and demonstrate healthful behaviors will bring those messages home to parents. They can advocate for healthful food (and perhaps not pester parents for unhealthful foods!), encourage parents to stop smoking for their children’s sake, and seek fun active activities rather than more screen time. Thus, the family unit with young children can become an important force for sustaining more healthful living. Amplifying the positive impacts of parents as a child’s first teacher can set a child on a healthful trajectory for life. The health of Americans sadly lags that of most other developed countries (1) and is beset by large disparities among racial/ethnic groups and the socially disadvantaged. Recognition that this problem cannot be solved by better and more accessible medical care alone has led to the resurgence of interest in population health (2) and its underlying determinants: behaviors and social and environmental conditions. The ecologic model of health recognizes the biological determinants of health and emphasizes the importance of family, community, institutions, laws, policies, and customs as well as the built and natural environments. Intrinsically it means that improving health and even disease outcomes requires intervention at multiple levels. According to the Guide to Community Preventive Services, effective interventions almost invariably require multiple components (3). To continue with the physical activity example, an effective strategy might include physician counseling, physical education programs in school, easy access to parks and recreation facilities, safe neighborhoods, complete streets (4), active transportation, education about the importance of physical activity, and encouraging families to participate in activities together. Implementing such multipronged interventions in the community can be challenging. Yet multicomponent and multigenerational approaches have the potential not only to improve the health of children but also can use parents’ and grandparents’ motivation to raise healthy children to improve their own health behaviors and thereby accelerate changes in social norms. Health literacy, the ability of people to understand health and disease that empowers them to take action, is important, but by itself is insufficient. It can provide individuals and families with needed health information, motivate them, enhance communication with providers, and facilitate peer-to-peer communication. Although awareness is growing that health literacy is integral to health, it needs to be embedded in a more comprehensive set of policies, programs, and conditions that promote health and enable individuals to make healthful choices the easy choices. Vulnerable low-income families in the United States have a disproportionate share of unhealthful determinants and poor health outcomes. While lack of access to medical care is one barrier, health literacy, access to culturally relevant programs, ability to satisfy basic needs, and financial insecurity are other typical barriers this population faces. Head Start and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), along with many other agencies, foundations, and community-based organizations, provide health and education services to low-income families. Nurse Family Partnership provides public health nursing and health education services to low-income women. United Way provides workforce development, financial literacy, and health education across the country. First 5 California provides resources and tools to parents to help them navigate health and education for their children aged less than 5 years. But Head Start is one of the longest-standing programs providing health and education services to low-income families. It serves approximately 1 million children aged 0 to 5 years and requires its grantees to coordinate health-related services such as basic screenings, health education, and referrals to health care providers as well as coordinating support for routine home visits and parent education workshops to understand the needs of families and children and promote preventive health services. A 2001 survey of Head Start directors in the Johnson & Johnson Head Start Fellows program found that although grantees had access to health education materials and resources to conduct health education trainings, these sessions were often poorly attended and the materials were not well understood (5). In response, the University of California, Los Angeles/Johnson & Johnson Health Care Institute (HCI) was formed to rectify these limitations and improve health literacy among Head Start families. HCI is now working in partnership with the American Academy of Pediatrics’ National Center on Early Childhood Health and Wellness. It uses the structured framework it developed for health promotion that builds staff leadership capacity and trains Head Start staff to implement health promotion programs for their families using culturally adapted, low-literacy materials on topics such as management of common childhood illnesses, effective use of the clinical care system, obesity prevention, home safety, mental health, and oral health. Family trainings capitalize on families’ innate motivation to care for their children. The trainings include experiential group learning activities, hands-on skill-building, and creation of social networks. This approach helps not only parents and children but also Head Start staff, who gain knowledge to care for their own children. The staff also see themselves as stronger role models for healthful living for their families, which also motivates family participation and engagement (6). The health literacy components are complemented by environmental changes, such as providing more healthful foods and more physical activity at schools, visiting community grocers to learn about how to buy and prepare healthful, affordable foods, and working with grocers to sell more healthful products (7). Since 2001, HCI trained staff from 300 grantees, who reached more than 120,000 vulnerable families across the United States. Results of the health promotion program among more than 9,000 families at 55 sites were impressive: emergency department visits declined by 58% and school days missed were reduced by 29%, enhancing school readiness (8). Parents’ work-loss days decreased by 42% (8); such decreases are critical for low-wage workers at high risk of losing those jobs if they miss work, thus enhancing job security and incomes. Since income is itself a determinant of health and loss of a job a major life stressor, these indirect benefits of the program are also critical to a family’s well-being. Over the longer term, life-long improvements in health behaviors, higher graduation rates, and better job opportunities in healthier, more supportive communities should pay off in reduced rates of major chronic diseases as well. Partially in response to these successes, Head Start has incorporated health literacy into its proposed revised performance standards. A comprehensive health literacy program coupled with population health interventions can reduce short-term and long-term disparities between the general population and Head Start children, families, and staff. Short-term benefits include fewer unnecessary emergency department visits, greater self-confidence for parents, better relationships and engagement with Head Start staff, and better health decision making. In the longer term, more healthful behaviors will contribute to reduced rates of cardiovascular disease and obesity. Because the social capital for implementing these programs resides in each Head Start agency, the programs are scalable and sustainable. As this multidimensional health literacy and population health intervention illustrates, once parents have the knowledge, tools, and motivation to protect the health of their children, and barriers are removed, meaningful change can occur. When provided with simple health information in a low-literacy format, thermometers, and tips on how to improve health behaviors on a limited budget, along with changes in their school and community environments, parents were able to take positive action. Their empowerment and knowledge also better enables them to more appropriately access the clinical care system, ask appropriate questions, and understand and adhere to clinical recommendations. We can help set entire families and communities on a better health trajectory. A life-course approach and improved health literacy coupled with healthful programs and policies can reduce health disparities and make a real difference in people’s lives.

Bisphosphonates such as alendronate are widely used for postmenopausal osteoporosis. Supplemental calcium is also generally recommended. This trial directly compares alendronate to supplemental calcium and examines the effect of calcium supplementation on alendronate treatment.This 2-year, randomized, double-blind, multicenter trial enrolled healthy, postmenopausal women with low bone mineral density (BMD). Patients with a dietary calcium intakeor = 800 mg/day received daily vitamin D 400 IU and alendronate 10 mg/calcium-placebo, alendronate 10 mg/elemental calcium 1000 mg, or alendronate-placebo/calcium 1000 mg (2:2:1). Endpoints included BMD, bone turnover markers (BTMs), and adverse events.Randomized patients (N = 701) were an average of 20.4 years postmenopausal. After 24 months, increases in lumbar spine BMD differed significantly between patients receiving calcium alone (0.8%) and either alendronate alone (5.6%) or alendronate + calcium (6.0%) (p0.001). Significant differences were also seen at the trochanter and femoral neck (p0.001). BTMs were significantly lower with alendronate-containing treatments than calcium alone (p0.001). Addition of calcium supplementation to alendronate did not significantly increase BMD compared to alendronate alone (p = 0.29 to 0.97), but did result in a statistically significant, though small, additional reduction in urinary NTx. Adverse events were similar among treatment groups. Limitations include no assessment of vitamin D levels and a discontinuation rate of approximately 30%, although discontinuation rates were similar among treatment groups.In postmenopausal women with a daily intake ofor =800 mg calcium and 400 IU vitamin D, 24-month treatment with alendronate 10 mg daily with or without calcium 1000 mg resulted in significantly greater increases in BMD and reduction of bone turnover than supplemental calcium alone. Addition of supplemental calcium to alendronate treatment had no effect on BMD and resulted in a small, though statistically significant, additional reduction in NTx.

Communication is an important component of patient care. Traditionally, communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, but without a specific or intense focus on skills of communicating per se. The reliability and consistency of this teaching method left gaps, which are currently getting increased attention from medical schools and accreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specific clinical skill. In 1999, the Accreditation of Council for Graduate Medical Education implemented a requirement for accreditation for residency programs that focuses on "interpersonal and communications skills that result in effective information exchange and teaming with patients, their families, and other health professionals." The National Board of Medical Examiners, Federation of State Medical Boards. and the Educational Commission for Foreign Medical Graduates have proposed an examination between the. third and fourth year of medical school that "requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues" using standardized patients. One's efficiency and effectiveness in communication can be improved through training, but it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. The published literature also expresses belief in the essential role of communication. "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes". A systematic review of randomized clinical trials and analytic studies of physician-patient communication confirmed a positive influence of quality communication on health outcomes. Continuing research in this arena is important. For a successful and humanistic encounter at an office visit, one needs to be sure that the patient's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness. Patient concerns can be wide ranging, including fear of death, mutilation, disability; ominous attribution to pain symptoms; distrust of the medical profession; concern about loss of wholeness, role, status, or independence; denial of reality of medical problems; grief; fear of leaving home; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues are verbalized openly is fundamental to effective patient-doctor communication. The clinician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring clinician. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required. Counseling around unhealthy or risky behaviors is an important communication skill that should be part of health care visits. Understanding the psychology of behavioral change and establishing a systematic framework for such interventions, which includes the five As of patient counseling (assess, advise, agree, assist, and arrange) are steps toward ensuring effective patient-doctor communication. Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient: the physician knew best and the patient accepted the recommendation without question. This era is ending, being replaced with consumerism and the movement toward shared decision-making. Patients are advising each other to "educate yourself and ask questions". Patient satisfaction with their care, rests heavily on how successfully this transition is accomplished. Ready access to quality information and thoughtful patient-doctor discussions is at the fulcrum of this revolution.

Sustained implementation of health education interventions is important to optimize the impact of initial investments in program development and training. From 2002-2012, the Health Care Institute (HCI) at UCLA trained 192 Head Start grantees, serving low-income preschool children and families in the U.S., on how to implement lowliteracy health education programs, using a train-the-trainer (TTT) model. The purpose of this study was to investigate what key factors of implementation are associated with sustainability of HCI programs, based on an online survey of Head Start grantees who have participated in the HCI TTT. A 51% response rate was achieved, with 96 surveys returned from the 188 sent to agencies that are still open. Of the grantees responding to the survey, 84% reported that they continue to implement HCI programs and 71% continue to implement them annually. Key predictors of annual implementation included: engagement of stakeholders at all levels; continuing to provide incentives for families; putting HCI into the annual training and technical assistance budget; sending additional staff to the TTT; seeing an improvement in overall program performance; and adapting HCI topics to meet local Head Start grantee needs. Qualitative responses described these same factors in additional detail. These results are consistent with previous research on program sustainability and suggest which elements of implementation may be most important as initial and ongoing investments, if sustainability is a program goal.

Improving the health and health literacy of low-income families is a national public health priority in the United States. The federal Head Start program provides a national infrastructure for implementation of health promotion interventions for young children and their families. The Health Care Institute (HCI) at the Anderson School of Management at the University of California, Los Angeles, developed a structured approach to health promotion training for Head Start grantees using business management principles. This article describes the HCI approach and provides examples of implemented programs and selected outcomes, including knowledge and behavior changes among Head Start staff and families. This prevention-focused training platform has reached 60,000 Head Start families in the United States since its inception in 2001. HCI has demonstrated consistent outcomes in diverse settings and cultures, suggesting both scalability and sustainability.

Purpose. Examine the effectiveness of the “Eat Healthy, Stay Active!” pilot program, a multisite, 6-month educational intervention to promote healthy nutrition and physical activity among Head Start staff, parents, and children. Design. Comparison of within-group preintervention and postintervention knowledge and behavior, along with anthropomorphic measurements. Setting. The study was conducted in a convenience sample of six large Head Start agencies in five states. Subjects. Participants included 496 staff, 438 parents, and 112 preschool children. Intervention. The 6-month intervention consisted of core trainings and reinforcing activities for staff and parents that aligned with children's curricula. Measures. Pre-post questionnaires and anthropometric measurements examined changes in body mass index (BMI), knowledge, and behaviors related to nutrition and physical activity. Analysis. Paired t-tests to compare preintervention and postintervention weights and BMI; multiple regression analyses to examine associations between weight changes and other covariates, including knowledge and behavior changes, controlling for sociodemographic variables. Results. Each group of participants demonstrated significant reductions in BMI (mean = 30.1 to 29.2; p < .001 in adults and 17.0 to 16.6; p < 0.001 in children) and in the proportion of obese children (30% to 21%; p < .001) and adults (45% to 40%; p < .001). Child weight changes correlated with parent weight changes. Conclusion. This intervention showed promising initial results, with potential effectiveness as an intervention to promote healthier behaviors among adults and children in Head Start settings.

The incidence of Amanita mushroom poisoning seems to be increasing in the United States. Its neurological aspects contribute importantly to morbidity and mortality. In reported series, mortality has ranged from 50 to 90%, and survival following the appearance of coma was exceptional. The cause of nervous system involvement was uncertain. In the patient presented here, clinical and electroencephalographic observations were consistent with severe hepatic encephalopathy and correlated closely with liver function abnormalities. Despite the development of coma, full recovery followed the use of thioctic acid, an experimental therapeutic agent.