AriellaHerman,Ph.D.ResearchDirector

July19,2017

Implemen?ngandEvalua?ngaHealthLiteracyPrograminHeadStart

Agenda

I.   HealthCareIns?tute(HCI)–Whatmakesusdis?nc?ve?

II.   Innova?veImplementa?onStrategies

III.  Evalua?ons&Outcomes

IV. WheredoesHCIgoandgrowfromhere?

BriefHistoryofHealthCareIns?tute(HCI)•  HCIcreatedasaresearchcenterin2001

v  Asurveyof600HeadStartdirectorsiden:fiedpoorhealthliteracyandpoora>endanceasobstaclestobe>erhealthoutcomesforthesefamilies.

v  HeadStartdirectorssurveyedweregraduatesoftheUCLA/Johnson&JohnsonHeadStartManagementFellowsProgramØ  LeadershipandManagementDevelopmentProgram

establishedin1991Ø  Trainedcloseto1,600HeadStartdirectorstodate

•  HCIhasbeencommi>edtoprovidingacommunitybasedmodeltoimprovehealthliteracyusingbusinessmanagementprinciplesforimplementa:on.

•  HeadStart(H.S.)istheplaRormweusetodevelop,implementand

evaluatethehealthliteracyinterven:onv  Federallyfundedearlychildhoodeduca:onprogramestablishedin

1965v  Servesover1Mchildrenandpregnantwomendailyv  Comprehensiveservices

HCIMission

StrengthenmanagerialcapacityofHeadStartagencies,sotheycanprovidemoreeffec:vehealtheduca?onandpreven?on

programstothechildrenandfamiliestheyserve.

HCIStrategy

TraintheTrainersinHeadStartagenciesto:

Developandusestrategicmanagementtoolstoassuresuccessfulimplementa:onofhealthpromo:onprograms.

Provideculturallysensi:ve,lowliteracymaterialsthatengageandempoweragencystaff&familiestopar:cipateac:velyinhealth

decisions.

Reach140,000FamiliesTrained2,350TrainersTrained

AllACFRegions50States

Mul?pleCommunityTypes7Languages10Ethnici?es

EarlyHeadStart&HeadStartChildcarePartners3SchoolDistricts

Corporate&PublicFunders•  Johnson&Johnson2001-2017•  OHSHealthliteracyinnova?ongrant

2008-2010•  Na?onalCenterforEarlychildhood

Healthandwellness(HHS)2011-2020•  FidelityCharitableFund•  StateofWashingtonLegislature•  KansasHeadStartAssocia?on•  Pfizer,Inc.

HCI’sReach

WhatWeLearnedThatMakesCommunity-BasedHealthLiteracyMoreEffec?ve

UseofBusinessManagementToolsiskeytosuccess:•  Inten:onalPlanning(Goals,Objec:ves,Ac:onPlan)•  Commitmentofleadership(HeadStartgrantees)•  Staff,parent&communityengagementtools•  Lowhealthliteracy,culturallysensi:vecurriculum•  Flexibilityforlocaladapta:on•  Applicabilitytomul:plehealthtopics•  Dataforcon:nuousqualityimprovement•  Establishinganorganiza:onalculturebasedonL.O.V.E.®

MeaningfulChangeTakesTime,BuildingPartnershipsAnd

Inten?onalStrategicImplementa?on!

L.O.V.E.®

Listening Observing

Valuing Encouraging

Pre Train- the-Trainers

Pre Parents Training

Design key steps for community engagement• Logistic planning

for implementation of parents training

• Customize training to population needs: culture, beliefs and priority health issues

Who is training: Head Start trainersWho is Trained: Head Start familiesHow long: 3-4 hours

Follow Up andReinforcement

Monthly home visits/workshops to reinforce learning and impact behaviorKeep the momentum going!

Heal th Improvement P ro ject (H .I .P. )

• Acceptance notification

• Assemble team• Start planning

for success!• Submit a draft

H.I.P

Parents Training Event

Present health promotion & prevention topics• Adult learning

principles

• Diverse training tools

• Hands on group learning

BASELINE ASSESSMENT

Graduation

POST ASSESSMENT

• Share data & success stories

• Sustain the program over time

• Continuous quality improvement from each project

Who is training: UCLA Faculty & Head Start LeadersWho is Trained: Teams of 5-6 from each agencyHow long: 2 days

Develop strategic implementation• Create buy in for

program• Build leadership in

agency• Develop skills for: - Project

management - Marketing - Motivation of

staff & parents• Mock training

Train-the TrainersEvent

Figure 1 – Health Care Institute (HCI) Strategic Implementation

HermanA,NelsonB,TeutschC,Chung,P.AStructuredManagementApproachtoImplementa?onofHealthPromo?onInterven?onsinHeadStart.CDCJournalPreven.ngChronicDisease.September12,2013.

HealthCareIns?tuteStrategicImplementa?onPhases

II.Staff,Parents&CommunityEngagement

I.AgencyGoal&Objec?vesSefng

HealthImprovement

Plan

III.Iden?fyingResources

StartProcessUnderstandHCI

IV.ProgramImplementa?on,

Ac?onPlan&Budget

V.DataCollec?on/Evalua?on

Trainingin2Languages

TheStoryOfCrea?ve

Implementa?on

Trainingin4Languages

Somali

Oromo

Tigrinya

EnglishVietnamese

Cantonese

Spanish

Trainingin7Languages

ThereisNoPlaceLikeHome! Na?veAmericanHeadStart

TheHCITeam!HandsOn

Level5PolicyChange

Level4Organiza?onal

Change&Sustainability

Level3Par?cipantBehavior

Level2:Par?cipantLearning

Level1:Par?cipantReac?on

TheFiveLevelsofEvalua?onforHCI(*)

(*)Adaptedfrom:Guskey,T.R.(2000a).Evalua:ngprofessionaldevelopment.ThousandOaks,CA:Corwin.h>p://www.ascd.org/publica:ons/educa:onal-leadership/mar02/vol59/num06/Does-It-Make-a-Difference%C2%A2-Evalua:ng-Professional-Development.aspx:

Level3Par?cipantBehavior

Level2:Par?cipantLearning

ExamplesofOutcomes(Levels2&3)

HowWasItMeasured?

Pre/PostSurveysToMeasureBehaviorChange

Pre/PostTrackingOfHealthServicesUse

SuccessStories&LessonsLearned

HowWasItMeasured?

SurveysAtTheEndOfTTT(Staff)

Surveys&FocusGroupsAtTheEndOfHealthLiteracyTrainings(Parents)

Pre/PostSurveysToMeasureKnowledgeChange(Staff&Families)

4.39%

68.79%

4.70%

1.21%

32.64%

47.55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

BOOK

DOCTOR

ER

WHEN YOUR CHILD IS SICK, WHERE DO YOU FIRST GO FOR HELP?

4.39%

68.79%

4.70%

1.21%

32.64%

47.55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

BOOK

DOCTOR

ER

WHEN YOUR CHILD IS SICK, WHERE DO YOU FIRST GO FOR HELP?

HeadStartParentPRE/POSTResponsesTo:WhenYourChildIsSick,WhereDoYouFirstGoForHelp?

Herman A, Jackson P. (2010) “Empowering Low-Income Parents with Skills to Reduce Excess Pediatric Emergency Room and Clinic Visits Through a Tailored Low Literacy Training Intervention”. J Health Commun.15(8): 895-910.

N=9800

“WhatToDoWhenYourChildGetsSickTrainings2001-2008”

5%

37%

4%

1%10%

45%

0%10%20%30%40%50%60%70%80%90%100%

PRE POST

LookinaHealthBookDoNothingandWaitAskfamily/friendsTakechildtoclinicordoctorCall911ortakechildtoER

N=9800

HeadStartParentPRE/POSTResponsesTo:WhatWouldYouDoIfYourChildHadATemperatureof99.5°F?

“WhatToDoWhenYourChildGetsSickTrainings2001-2008”

Reduc?onsinSchoolandWorkDaysMissed(2001-2008)

N=9800

HermanA,JacksonP.(2010)“EmpoweringLow-IncomeParentswithSkillstoReduceExcessPediatricEmergencyRoomandClinicVisitsThroughaTailoredLowLiteracyTrainingInterven:on”.JHealthCommun.15(8):895-910.

“WhatToDoWhenYourChildGetsSickTrainings2001-2008”

N=9800

Reduc?onsinDoctorandERVisits(2001-2008)

“WhatToDoWhenYourChildGetsSickTrainings2001-2008”

HermanA,JacksonP.(2010)“EmpoweringLow-IncomeParentswithSkillstoReduceExcessPediatricEmergencyRoomandClinicVisitsThroughaTailoredLowLiteracyTrainingInterven:on”.JHealthCommun.15(8):895-910.

•  Increasedparentalawarenessofhealthwarningsigns•  Promptparentalresponsetoearlysignsofillness

•  Appropriateuseofhealthreferencematerialsforfirstlinehelp

•  Be>erunderstandingofcommonchildhoodillnesses

•  Be>ercommunica:onwithhealthcareproviders

•  Moreeffec:veuseofhealthservices

•  Increasedengagementofparentsandstaffinhealthdecisions

Qualita?veOutcomesforFamilies&Staff

“Aparentwhohasthetoolstomakeappropriatedecisionsaboutthehealthcareoftheirchildhasbeen

givenself-esteem……whenapersonhasself-esteemtheycanmoveamountain.MountainshavebeenmovedinthelivesofthefamiliesthatIworkwith…….throughhealtheduca.onwithL.O.VE.™ThatistheANSWER!”

~EHSHealthManager

Level4Organiza?onalChange&

Sustainability

ExamplesofOutcomes(Level4)

HowWasItMeasured?Implementa?onofHealthImprovementPlansbyCohorts(H.I.P.)

SurveysofLeadershiponPrac?ceChange

LongTermImpactSurveys(5-10Years)CrossSectorCollabora?onsintheCommunityAdaptabilitytoOtherHealthTopics

WrirenReportsFromAgenciesWithPictures,Qualita?veFeedback&Quotes

KeySustainabilityFactors

TheSustainabilityImpactStudy:•  Method:

Ø  Sampled203HeadStartagenciesfrom50states,alltrainedbefore2010.Responserate51%

•  Results:Ø  84%sustainedHCIac?vi?esbeyondtheini?alyearoftrainingØ  71%con?nuetoprovidetheHCItrainingannually

•  Keypredictorsofannualimplementa?on:Ø  EngagementofstakeholdersatalllevelsØ  Con?nuingtoprovideincen?vesforfamiliesØ  IncludingHCIintheannualtraining/TAbudgetØ  Sendingaddi?onalstafftotheTTTtomi?gatestaffturnover

NelsonBB,TeutschC,ChungPJ,HermanA(2014)PredictorsofSustainedImplementa:onofLow-LiteracyHealthEduca:onPrograms.JCommunityMedHealthEduc4:314.DOI:10.4172/2161-0711.1000314

Sustaining&Adap?ngHCIinCommuni?es

0% 20% 40% 60% 80% 100%

HaveyoubeenabletoADAPTtheHCItrainingtotheneedsanddesignofyourlocalprogram?

Wereyouabletosustainprovidingincen?vestoPARENTSasapartofyourHCItrainingprogram?

DidyouleveragecommunityresourcestosustainHCItrainings?

89%

72%

69%

YES NON=203Grantees

StaffandLeadershipEngagement

0% 20% 40% 60% 80% 100%

Haveyoubeenabletoengageandmo?vateyourSTAFFtocon?nuetheHCI

trainings?

Haveyoubeenabletoengageandmo?vateyourLEADERSHIPTEAMto

con?nuetheHCItrainings?

80%

82%

YES NON=203Grantees

Sustainability&FamilyEngagement

•  2017,newonlinesurvey,senttoleadershipandfamiliesthathavebeenpartofpasttrainings.

•  Goal:toiden:fythecri:calelementsthatfosterstrongimpacRulhealtheduca:onandfamilyengagement.

LeadershipSurvey

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

ProvidingTransporta?on

Havingstaffarendandmixsociallywithfamilies

Rewardingparentpar?cipa?on(intheinterac?veparts)withprizes

LowLiteracyHealthmessaging

ProvidingMealsattheTraining

34.6%

73.1%

76.9%

77.8%

80.8%

Whataspectsofthetraininghelpedyouengagemoreeffec?velywithfamilies?

LeadershipSurvey

0% 20% 40% 60% 80% 100%

StaffMo?va?on

ParentsMo?va?on

CommunityEngagement

HealthImprovementProject(HIP)

L.O.V.E.

100%

88.89%

75%

85.18%

74%

DidyouuseanyofthestrategicelementsoftheHCImodelinorganizingyourparenttrainings? YES NO

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Wastheinforma?onpresentedduringthetrainingeasytounderstand?

Didthetrainingprovideyouwithhealthinforma?onorotherhelpthatyouneededforyour

child?

Didthestaffrecommendotherhealthservicesinyourcommunitythatyouareplanningtouse?

Wouldyourecommendthistrainingtoafamilymember,friendoryourneighbor?

99.67%

98.69%

99.90%

100%

ParentSurvey(N=652)YES NO

AdaptabilitytoOtherHealthTopics

Oncethemethodisunderstoodandimplemented:Ø Minimalinvestmentallowsexpansiontoavarietyof

otherhealthpreven:ontopics

Ø  Familya>endanceisgenerallyaround75-85%na:onallyusingthismethod

Ø Oncefamiliesa>endoneHCIevent,marke:ngisminimaltogetpar:cipa:onatotherHCItrainingsandschoolevents

HermanA,NelsonB,TeutschC,Chung,P.AStructuredManagementApproachtoImplementa:onofHealthPromo:onInterven:onsinHeadStart.CDCJournalPreven.ngChronicDisease.September12,2013.

HealthEmpowermentModel

EatHealthy,StayAc?ve!StrategicImplementa.onModel

HermanA,NelsonB,TeutschC,ChungP.(2012)“EatHealthy,StayAc?ve:Acoordinatedinterven?ontoimprovenutri?onandphysicalac?vityamongHeadStartparents,staffandchildren”.AmJHealthPromot.27(1):e27–36.DOI:10.4278/ajhp.110412-QUAN-157.

EatHealthy,StayAc?ve!SampleOutcomesforAdults

(*)EatHealthy,StayAc?ve!,SantaClara,2010.N=178

ChangeinBMI:Children(9monthsaUerbaseline)

FarmersMarket

Level5PolicyChange

ExamplesofOutcomes(Level5)

HowWasItMeasured?

ChangesatASystemLevelforHeadStartGrantees(OverSeveralYears)

ChangesinOHSNa?onalCentersPolicies

ChangesInNa?onalHeadStartPerformanceStandards

PolicyChange

Governmentalandins?tu?onalpoliciesarecri?caltocreateandsustaindemandandsupportforhealthliteracyac?vi?es:

•  HealthliteracywasincludedasacrossculngconceptfortheOfficeofHeadStartNa:onalCenterforEarlyChildhoodHealthandWellnessin2016.

•  HHShasincludedhealthliteracy(forthefirst:me!)intheNewHeadStartProgramPerformanceStandards(HSPPS).

ManyElementsoftheHCIApproachareIntegratedintotheNewHSPPS

ü  HCImodelstrengthensmanagementcapacityto:

§  Be>erplanandimplementhealthtrainings§  Measureimpactoftrainingonparents§  Meetmul:plePerformanceStandards§  Implementcon:nuousqualityimprovementwiththeuseofdata§  Buildaninternalcultureofhealthandwellness§  Enhancesjobsa:sfac:on

ü  Strengthencommunitypartnershipstocollaborateinbuildingacultureofhealthinthebroadercommunityü  Provideready-to-usetoolkitstoequipcommuni?estofosterhealthandprac?cepreven?onü  Improvethehealthliteracyofstaffandfamiliesü  Increasestaff,parent,andcommunityengagement

WhatHaveBeenOurGreatestSuccesses?

WhatAreOurGreatestChallenges?

•  Fundingforimplementa:on•  Explaininghowalltheelementsofthemethodare

integrated,essen:alandcontributetothesuccess•  Learningfromourtes:ngthatshorteningthetraining,

expec:nglessfromtrainees,notprovidingmaterials,orprovidingmaterialswithouttrainingdoesn’tworkaswell

•  Howimportantbuildingateamandleadershipisto

success

HealthliteracyisatthecoreofHCIandthebenefitsareamplifiedwithstrategicimplementa.on.

WhatAreOurFutureChallenges?

•  Howdoweembedthisprogramintootherselngs(e.g.,childcare,publicschools…)thatareheterogeneousanddifferentlyresourced?

•  Howdowetakethenextsteptobuildhealthadvocacyintheparentsintheirowncommuni:es?

•  HowdoweassurethattheknowledgeandexperiencewehaveaccumulatedatHCIcanbetransferredtoanen:tythatcancarrytheworkbroadlyandcon:nuetoevolveit?

•  Howcanwelinkthisworkwithmedicalstudentsand

providersinprac:ceandmedicalcenters?

PolicyChange

Governmentalandins:tu:onalpoliciesarecri:caltocreateandsustaindemandandsupportforhealthliteracyac:vi:es:Examples:

Ø  Providinginsurancecoverage(suchasinthebasichealthcarepackage)

Ø Qualitymeasurementstandardsandtracking(suchasNQForNCQA)

Ø  Incorpora:onintoprofessionaleduca:onalstandardsØ  Clinicalcareprovisionstandards(e.g.,In

pharmaceu:calcare)Ø  Requiredtrainingandcer:fica:onØ  Programfundingrequirements,e.g.,intoWIC,Head

Start,ACOs,ACH's

Onceparentshavetheknowledge,tools,andmo.va.ontoprotectthehealthoftheirchildren,andbarriersareremoved,

meaningfulchangecanoccur.

Withasystema.capproachtocommunity-basedhealthliteracyinterven.ons,wecanmakeadifference!

Wecanhelpseten.refamiliesandcommuni.es

onabeZerhealthtrajectory!

FamilyEngagementisFosteredThroughHealthLiteracyandaManagementSystemApproach

PeerReviewedPublica?ons

1.   Sivanand,B.,A.Herman,C.Teutsch,andS.Teutsch.(2017)BuildingHealthLiteracyandFamilyEngagementinHeadStartCommuni?es:ACaseStudy.DiscussionPaper,Na?onalAcademyofMedicine,Washington,DC.hrps://nam.edu/building-health-literacy-and-family-engagement-in-head-start-communi?es-a-case-study

2.   MilfordE,MorrisonK,TeutschC,NelsonBB,HermanA,KingM,BeuckeN.(2016)“OutoftheClassroomandIntotheCommunity:MedicalStudentsConsolidateLearningAboutHealthLiteracyThroughCollabora?onwithHeadStart”.BMCMedicalEduca?on.16:121.DOI:10.1186/s12909-016-0635-z

3.   TeutschSM,HermanA,TeutschCB.(2016)“HowaPopula?onHealthApproachImprovesHealthandReducesDispari?es:TheCaseofHeadStart”.PrevChronicDis.13:150565.hrp://dx.doi.org/10.5888/pcd13.150565

4.   NelsonBB,TeutschC,ChungPJ,HermanA.(2014)“PredictorsofSustainedImplementa?onofLow-LiteracyHealthEduca?onPrograms”.JCommunityMedHealthEduc.4:314.DOI:10.4172/2161-0711.1000314

5.   HermanA,NelsonBB,TeutschC,ChungPJ.(2013)“AStructuredManagementApproachtoImplementa?onofHealthPromo?onInterven?onsinHeadStart”.PrevChronicDis.10:130015.DOI:hrp://dx.doi.org/10.5888/pcd10.130015

6.   HermanA,NelsonB,TeutschC,ChungP.(2012)“EatHealthy,StayAc?ve:Acoordinatedinterven?ontoimprovenutri?onandphysicalac?vityamongHeadStartparents,staffandchildren”.AmJHealthPromot.27(1):e27–36.DOI:10.4278/ajhp.110412-QUAN-157.

7.   HermanA,JacksonP.(2010)“EmpoweringLow-IncomeParentswithSkillstoReduceExcessPediatricEmergencyRoomandClinicVisitsThroughaTailoredLowLiteracyTrainingInterven?on”.JHealthCommun.15(8):895-910.DOI:10.1080/10810730.2010.522228.

8.   HermanA,YoungK,EspizitaD,FuN,FarshidiA.(2009)“ImpactofAHealthLiteracyInterven?ononPediatricEmergencyDepartmentUse”.PediatrEmergCare.25(7):434-438.DOI:10.1097/PEC.0b013e3181ab78c7.

9.   HermanA,MayerG.(2004)“ReducingtheUseofEmergencyMedicalResourcesAmongHeadStartFamilies:APilotStudy”.JournalofCommunityHealth.29(3):197-208.DOI:10.1023/B:JOHE.0000022026.20770.f4

10.  MestmanS,HermanA.(2004).WhattoDoforHealthyTeeth.California:Ins?tuteforHealthcareAdvancement.