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TWS FAQs

 Teach-With-Stories (TWS) Frequently Asked Questions

  1. Why incorporate the TWS Method™ for group prenatal education in our clinic or practice?
  2. How can an empowerment-based group approach improve prenatal care outcomes?
  3. Why is the TWS Method a particularly effective approach for women as learners?
  4. How is the TWS Method culturally appropriate for Latinos?
  5. What is a typical session like in the De Madre A Madre Prenatal Program?
  6. We don't have a bilingual person on staff to facilitate a prenatal education group. What are our options?
  7. Why is there such a pressing need to develop the healthcare system's capacity to provide quality prenatal education and care for Latinas?

 

 Q1.  Why incorporate the TWS Method™ for group prenatal education in our clinic or practice?

A1.  While a traditional 15 minute prenatal visit may be sufficient to screen for potential medical problems, there is no time for in-depth education and counseling or opportunity to meet social support or health literacy needs (Massey, Schindler Rising, & Ickovics, 2006).
 
Also, traditional didactic educational approaches and clinician-centered models of care can be ineffective, or worse, can disempower and further marginalize women and ethnic minority groups, especially those who are poor and have low literacy skills (Airhihenbuwa, 1995; Institute of Medicine, 2003, 2004).

The shortage of bilingual, bicultural health professionals and interpreters creates additional barriers to accessing and providing quality care for Latinas (Agency for Healthcare Research and Quality, 2005; National Research Council, 2006; Regenstein, Cummings, & Huang, 2005). 

An empowerment-based group approach can help your Spanish-speaking staff use their time more effectively, while providing more comprehensive education in a culturally appropriate way. You can provide social support during the group and an opportunity for them to build relationships with other women for greater support in their community.

References:
     Agency for Healthcare Research and Quality. (2005, May). Women's healthcare in the United States: Selected findings from the 2004 national healthcare quality and disparities report. (AHRQ Pub. No. 05-PO21)
            Retrieved December 12, 2006, from: http://www.ahrq.gov/QUAL/nhqrwomen/nhqrwomen.htm
     Airhihenbuwa, C. O. (1995). Health and culture: Beyond the western paradigm. Thousand Oaks, CA: Sage Publications, Inc.
     Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, D.C.: National Academies Press.
     Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, D.C.: National Academies Press.
     Massey, Z., Schindler Rising, S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: Promoting relationship-centered care. Journal of Gynecology, Obstetrics and Neonatology, 35(2), 286-294.
     National Research Council. (2006). Multiple Origins, Uncertain Destinies: Hispanics and the American Future. Washington, DC: National Academies Press. [Electronic version]
     Regenstein, M., Cummings, L., & Huang, J. (2005). Barriers to prenatal care: Findings from a survey of low-income and uninsured women who deliver in safety net hospitals. Washington, D.C.: National Public Health and Hospital Institute.

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 Q2.    How can an empowerment-based group approach improve prenatal care outcomes?

A2.   Multiple studies link prenatal social support and less stress with improved patient satisfaction and prenatal attendance, fewer pregnancy complications, less postpartum depression, and improved birth outcomes (Massey, Schindler Rising, & Ickovics, 2006).
      
Studies also show that when women receive support services, knowledge and skills development in an environment that facilitates mutual support, patient satisfaction and attendance to prenatal appointments improve, and adverse perinatal outcomes can be reduced (Massey, Schindler Rising, & Ickovics, 2006; United States Public Health Service, 1989).

Although further research is needed, structural and functional social support provided through community-based interventions has shown to be beneficial in overcoming limitations related to low health literacy of individuals and for improving the health status of the community (Lee, Arozullah, & Cho, 2004).

References:
      Lee. D.S., Arozullah, A.M., & Cho Y.I. (2004). Health Literacy, social support and health: a research agenda. Social Science & Medicine, 58, 1309-1321.
      Massey, Z., Schindler Rising, S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: Promoting relationship-centered care. Journal of Gynecology, Obstetrics and Neonatology, 35(2), 286-294.
      United States Public Health Service. (1989) Caring for our future: The content of prenatal care. Washington, DC: DHHS.

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 Q3.  Why is the TWS Method a particularly effective approach for women as learners?

A3.   The use of techniques to help women identify their own concerns and develop their own strategies, using their personal experience, are recommended. (Fishback, n.d.; Collard & Stalker, 1991).

    Collaborative, non-confrontational learning, like sharing stories, is important for women in general, as well as being culturally appropriate for Latinos (Fishback, n.d.).

    Women also benefit from the chance to explore their identities in relationship with others and in their societal roles (Fishback, n.d.).

    Linking information to emotional content by acknowledging feelings in the classroom, through self-disclosure, storytelling, role-playing, and literature, may be beneficial to the learning process too (Fishback, n.d., p.2). These more nurturing, 'feminine' ways of knowing and learning, typically devalued or absent in traditional pedagogy, help validate and empower women learners (Collard & Stalker, 1991).

References:
    Collard S., & Stalker, J. (1991). Women's trouble: Women, gender, and the learning environment. In R. Hiemstra (Ed.), New Directions for Adult and Continuing Education (pp.71-80). San Francisco: Jossey-Bass.
    Fishback, S.J. (n.d.). Professional tips for adult and continuing educators: Tips on teaching women. Retrieved on December 20, 2005 from http://home.twcny.rr.com/hiemstra/tips.html

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 Q4.    How is the TWS Method culturally appropriate for Latinos?

A4.   The six steps occur in a way that honors and builds on primary Latino cultural values and norms.  As illustrated in Overview Diagram (see 'Cultural Context'), the TWS Method incorporates these values and norms as members move through a session. 

Respeto: The group is founded on respect. 
             
Personalismo & simpatía:
  The TWS Method emphasizes and facilitates personal connections, in the spirit of simpatía. The steps make the learning process feel 'personal' easily and naturally. Kindness is the cornerstone of how the group listens, shares, challenges and learns from each other as they read the photonovels and tell their stories. 

Tiempo presente: The participatory process helps keep the focus on group members' present realities, immediate needs, and priorities. Learning that is relevant and that can be applied immediately to one's life, is important not just from a Latino cultural perspective but also for women as adult learners and for those who live in a culture of poverty.

Diferencias orales/no-orales:
The facilitator training, room set-up, and TWS Method are designed to help ensure that different verbal and nonverbal communication styles and norms are accommodated. 

Familismo:
The TWS Method invites inclusion of family members in the learning process whenever possible. 

Confianza:
By following the six steps each session, trust builds among the facilitators and participants over time and is supported by respect, caring and kindness. The bonds that develop often extend outside of the groups and last after the sessions are over.

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 Q5.  What is a typical session like in the De Madre A Madre Prenatal Program?

A5.  One story is read each session. Group members volunteer to read the characters' parts, creating a play. Those that can't read, listen and participate in the discussion.

  • The facilitator uses the teaching points and health issues embedded in the story to spark group dialog.
  • The characters' and participants' life experiences and beliefs are vital to the critical thinking and reflection process.
  • The process is flexible and makes it easy to tailor the discussion to the unique needs of each group.
  • You can easily incorporate other educational resources and activities as needed.

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 Q6.   We don't have a bilingual person on staff to facilitate a prenatal education group. What are our options?

A6.  With proper training and assistance, lay health educators, also known as promotoras, can be an effective alternative. In fact, the facilitators in the Center for Health Care Strategies' demonstration project at the Neighborhood Health Plan of Rhode Island (NHPRI) were bilingual lay educators. A nurse supervisor who spoke only English coordinated the project. The NHPRI study showed that the 90% of the participants received optimal prenatal care who were in the prenatal program using the De Madre A Madre photonovels and the TWS  Method™ (compared to 65% of women who received traditional prenatal services).

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 Q7.  Why is there such a pressing need to develop the healthcare system's capacity to provide quality prenatal education and care for Latinas?

A7.  Quality prenatal care is designed to promote health and reduce risks for women, infants, and families before, during, and after pregnancy (United States Public Health Service, 1989). Unfortunately, Hispanic women are twice as likely to receive late or no prenatal care as non-Hispanic white women (Children's Defense Fund, 2006). 

Currently at 11 million, over the next several decades the proportion of Latinas in their childbearing years is projected to increase 92% (MOD, 2005).

This major demographic shift will magnify the health care challenges and adverse economic, social and health impact of disparities experienced by Hispanics (Centers for Disease Control, 2004). The central role women have in Hispanic culture with respect to the health of their families, along with their high fertility rates, make reaching and engaging Hispanic women a critical strategy in efforts to reduce disparities and improve health outcomes for adults and children in these communities (March of Dimes [MOD], 2005).

If we are already struggling to provide access to quality prenatal care and education for Latinas, then we must begin to reexamine our current approaches and thinking about service delivery strategies now in order to be able to respond more effectively.

References:
    Centers for Disease Control. (2004, October). Health disparities experienced by Hispanics --- United States. MMWR Weekly, 53(40); 935-937. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5340a1.htm
    Children's Defense Fund. (2006). Improving children's health: Understanding children's health disparities and promising approaches to address them. Washington, DC: Author.
            Retrieved from: http://www.childrensdefense.org/site/DocServer/CDF_Improving_Children_s_Health_FINAL.pdf?docID=1781
    March of Dimes. (2005, November). Born too soon: Prematurity in the U.S. Hispanic population. White Plains, NY: Author. Available at: http://www.modimes.org/Peristats/pdfdocs/Hispanicptb05.pdf

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