The health literacy of parents in the United States: a nationally representative study

Health Literacy: Implications for Child Health

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Assessment of American Cleft Palate-Craniofacial Association-Approved Teams' Websites for Patient-Oriented Content and Readability

OBJECTIVE

Informed decision-making relies on available information, including online resources. We evaluated the content and readability of websites published by American Cleft Palate-Craniofacial Association (ACPA)-approved cleft lip and/or palate (CLP) teams in the United States.

DESIGN

Team websites were reviewed, and teams with no accessible website or <30 sentences of content were excluded. Website content was scored by presence/absence of 20 variables derived from ACPA approval standards. Readability was evaluated with 8 scales. Readability was then compared to American Medical Association (AMA) recommendations. The relationship between website content and readability was assessed.

MAIN OUTCOME MEASURE(S)

Content and readability of team websites.

RESULTS

From 167 reviewed teams, 47 (28.1%) had nonfunctional links, 17 (10.2%) had no accessible website, and 39 (23.4%) had <30 sentences. The average content score for all 111 team websites included was 14.5 (2.6) of 20. The combined average reading level across all scales (10.7 [1.9]) exceeded the AMA-recommended sixth-grade reading level; this finding held true for each individual website. Children's Hospital-affiliated teams (n = 86) had a significantly higher content score (14.8 vs 13.5; P = .03) and better readability as evidenced by lower reading grade level (10.5 vs 11.4; P = .04). On linear regression, a higher content score significantly predicted better readability (β = -0.226; P < .001).

CONCLUSIONS

Websites published by ACPA-approved CLP teams vary in accessibility and content and exceed the recommended reading level. These findings could inform future efforts to improve patient-oriented resources.

Knowledge, Awareness, and Prevention of Hepatitis B Virus Infection Among Korean American Parents

Hepatitis B (HB) affects 240 million people around the world, and children and young adults make up a large proportion of the infected population. Approximately 1 million people die from HB each year. Despite the seriousness of HB and its complications, many are poorly linked to clinical care. A lack of health literacy may be a critical barrier hindering access to HB care for adults as well as children in these populations. We, therefore, performed a survey to assess the level of knowledge of HB among Korean American parents. The survey was conducted on 521 Korean American adults who attended community-based HB awareness campaigns held at various locations throughout the metropolitan New York area between January 2015 and November 2016. Of these, 296 parents, who had children between ages 1 and 30, were identified. All participants were asked a series of questions regarding various aspects of HB and were evaluated on the basis of their awareness on each subject. A separate questionnaire was also employed to obtain demographic characteristics of the participants. The study revealed a significant deficit of knowledge of HB in most aspects the survey evaluated. Although the majority of the participants knew that HB is a liver disease, and many of them had been screened for HB, they had a poor understanding of vaccination, screening, their own HB status, modes of HBV transmission, and the consequences and treatment of HB. The participants also had a low level of awareness of their own children’s HB status. This study demonstrates a low level of knowledge of HB among Korean American parents electing to attend a hepatitis education program. In addition, many parents are not aware of their children’s screening and immune (or non-immune) status. The lack of health literacy may contribute to poor health access in HB care, not only in adults but also in children. This suggests an urgent need for education on HB in Korean American parents as well as in young children.

Impact of food allergy on food insecurity and health literacy in a tertiary care pediatric allergy population

BACKGROUND

Food insecurity (FI), limited availability of or access to nutritional foods, is linked to poor child/caregiver health. We examined FI in food-allergic and non-food-allergic children to determine whether dietary limitations associated with food allergy increases risk of FI.

METHODS

Food-allergic and non-food-allergic children (1-17 years) were recruited from Arkansas Children's Hospital allergy/asthma clinics. The USDA Food Security Survey, the Newest Vital Sign Health Literacy (HL) questionnaire, and the Food Allergy Impact Scale QOL survey were administered. Logistic regression and analysis of covariance models were utilized for data analysis.

RESULTS

Subjects (n = 650) included 325 food-allergic and 325 non-food-allergic children. Overall rate of FI was 21.5% (food allergic 22.2% and non-food allergic 20.9%) with no significant difference in the prevalence of FI between groups (OR = 1.30; 95% CI 0.86-1.96; P = 0.21). FI was increased in households of children with both milk and egg allergy when compared to those without food allergy and those with single food allergy (OR = 2.5; 95% CI 1.4-4.6; P = 0.003). Mean HL rates were higher in the food-secure vs food-insecure groups (mean diff = 0.31; 95% CI 0.03-0.59; P = 0.03). Among food-allergic children, QOL was better in the food-secure vs food-insecure group (mean diff = 0.61; 95% CI 0.002-1.23; P = 0.049).

CONCLUSION

Food allergy to milk and egg was associated with increased risk of household FI. Food-insecure participants had lower HL than their food-secure counterparts. Further work is needed to define risks associated with FI among food-allergic children to improve screening and management strategies.

Impact of Parents' Comprehensive Health Literacy on BMI in Children: A Multicenter Cross-Sectional Study in Japan

BACKGROUND

Low-functional health literacy (HL) of parents influences poor child health outcomes. This study aimed to assess the relationship between comprehensive HL of parents and body mass index (BMI) of their children.

METHODS

We enrolled 3- to 6-year-old preschool-aged children and their parents in this multicenter cross-sectional cohort study. We evaluated parents' comprehensive HL with the 14-item HL scale. Children's BMI categories were defined using International Obesity Task Force cutoffs according to age and sex. We analyzed differences in data between the high-HL group and the low-HL group and investigated the association between HL of parents and their children's BMI by multivariate logistic regression analysis.

RESULTS

The high-HL group comprised 208 (75.1%) children and the low-HL group comprised 69 (24.9%) children of whom 23 (8.3%) were overweight and 35 (12.6%) were thin. The low-HL group had more children with poor BMI than the high-HL group. Multivariate analysis showed an association between the low HL of parents and the poor BMI of their children after adjustment for all other confounding factors.

CONCLUSIONS

Comprehensive HL of parents appears to affect the BMI of their children independently, suggesting that interventions to improve HL in parents are necessary.

Health literacy and health-related quality of life in patients with anorectal malformations: A comparison between a charity hospital in Honduras and a tertiary care center in the United States

BACKGROUND/PURPOSE

We conduct an annual medical mission to Hospital Ruth Paz para Niños Quemados y Cirugía Pediátrica in Honduras to operate on cases of anorectal malformations (ARM). To improve our knowledge of these patients, we compared their health-related quality of life (HRQoL), and the health literacy of their caregivers from this hospital and ours in the United States.

METHODS

The BRIEF Health Literacy Screen (BHLS) and Pediatric Quality of Life Inventory 4.0 (PedsQL) were used, respectively, to assess the health literacy and HRQoL of their guardians. All patients scheduled for an ARM-related operation in October 2016 were eligible for inclusion, and a matched population was selected in Nationwide Children's Hospital, Columbus, Ohio.

RESULTS

The sample comprised 127 patients, with 22 from Honduras and 105, the US. About 13.6% and 80% of Honduran and American caregivers, respectively, had adequate literacy. Honduran and American caregivers of patients aged 12 months and below rated the HRQoL of their children at 87 and 82, respectively; aged between two and four years, at 84 and 77; aged between two and four years, at 85 and 79; and of teens, at 59 and 66. For adults, the rate was 71 and 77 in Honduras and the US, respectively.

CONCLUSION

Although health literacy is extremely low in the Honduran group, its HRQoL was comparable to that of its American counterpart. Improving health literacy by educating caregivers could be an additional goal for medical missions in the future.

LEVEL OF EVIDENCE

Level III.

Health Literacy in Adult Education Centers: Exploring Educator and Staff Needs

Objective. Incorporating health content into adult education courses is promising for increasing health literacy skills among "hard-to-reach" populations. The purpose of this study was to gain previously untapped knowledge of adult education personnel (i.e., educators, staff) about the strategies and programs that would be beneficial for helping students learn about health. Method. Personnel (N = 53) from three literacy coalitions completed an online survey that assessed interest and preferences for developing a health literacy curriculum. Results. Personnel indicated general concepts such as health services and insurance as those of greatest priority. Additionally, tools designed for general use (completion of forms) were favored. Personnel preferred programs that focused on general skills over those designed to address specific health topics, χ²(1) = 11.52, p = .001. Conclusions. Adult education personnel find greatest value in health literacy programs aimed at increasing general skills rather than disease-/topic-specific content. There were several mismatches in topics noted as a "priority" and those for which personnel felt comfortable teaching. A focus on fostering general health skills will help all students-not just those with specific health concerns such as diabetes and asthma. Teaching health literacy through general skill development could make health programs exciting, engaging, and accessible for students.

Benefits of Medical Home Care Reaching Beyond Chronically Ill Teens: Exploring Parent Health-Related Quality of Life

BACKGROUND

Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care-related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL).

METHODS

The study sample included parents or caregivers of teens with special health care needs aged 15 to 18 recruited from a pediatric Medicaid accountable care organization who participated in a survey (response rate, 40.5%). The primary outcome was parent HRQOL scores (0-100 points) measured using the Pediatric Quality of Life Inventory Family Impact Module. Medical home status was based on parent report of teen's health care meeting medical home criteria. Linear regression models were used to estimate HRQOL scores, adjusted for demographic characteristics, health literacy, and teen functional limitation.

RESULTS

Among 488 parents, 27% reported their teen received care consistent with a medical home. Adjusted parent HRQOL scores were significantly higher among those whose teens had a medical home (74.40; 95% confidence interval, 71.31-77.48), relative to those whose teens did not (65.78; 95% confidence interval, 63.92-67.65). Medical home subscale analyses showed HRQOL scores had significant positive associations with family-centered care and coordinated care, but not other subscales.

CONCLUSIONS

Teen medical home status was positively associated with caregiver HRQOL, suggesting that the medical home may benefit overall caregiver well-being. In particular, receiving care that was family centered and coordinated appeared to be the most beneficial.

Is parental oral health literacy a predictor of children's oral health outcomes? Systematic review of the literature

BACKGROUND

The scientific evidence regarding the association between parental oral health literacy (OHL) and children's oral health is unclear.

AIM

To evaluate the scientific evidence concerning the association between parental OHL and children's oral health outcomes.

DESIGN

Eight databases were searched. Studies that evaluated oral health outcomes among children and measured parental OHL through a validated tool were included. Two independent reviewers selected studies, extracted data and analysed the risk of bias.

RESULTS

Eleven studies were included. Most (n = 6) had a high risk of bias. Most studies evaluating dental caries found association between lower parental OHL and higher prevalence/experience of dental caries. Poor oral health-related quality of life was associated with decreased parental OHL (P < 0.05). Studies diverged on the association between OHL and the number of filled, extracted teeth, and dental visits. There was no association between children's tooth brushing frequency, use of toothpaste, oral health claim, oral health expenditures and parental OHL. The literature was inconclusive regarding the association between night bottle feeding, negative parental perception of the child's oral health and OHL.

CONCLUSION

Low parental OHL was associated with dental caries among their children. It is too soon to assume an association between OHL and the remaining outcomes.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Understanding of Information about Medicines Use among Parents of Pre-School Children in Serbia: Parental Pharmacotherapy Literacy Questionnaire (PTHL-SR)

Parental health literacy plays an important role in children&rsquo;s health, Experiences from pharmacy practice show that is necessary to check if parents understand instructions about use of medicines for children. This study aimed to assess pharmacotherapy literacy of parents of pre-school children and to examine association of parental pharmacotherapy literacy level with parent&rsquo;s socio-demographic characteristics. The study was cross-sectional, conducted among parents of pre-school children (1⁻7 years of age), in kindergartens in several municipalities of Belgrade, Serbia, during regular parents meetings, from May to October 2016. Functional health literacy was measured by the Serbian version of the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Parental pharmacotherapy literacy was assessed with newly constructed PTHL-SR questionnaire with good psychometric characteristics (Parental pharmacotherapy literacy questionnaire&mdash;Serbian). Overall, 813 parents participated in the study, mostly females (81.30%), between 30 to 40 years of age (70.85%) with two children (56.70%). Almost all of our study participants (99%) had adequate health literacy as assessed by S-TOFHLA. Mean score on PTHL-SR was 72.83% (standard deviation was 13.37), with better results among females than males (72% of women were in the group of highest PTHL-SR results). Our study showed that many parents (76.5%) knew the appropriate usage of non-prescription medicine for children, 57.2% parents were able to correctly calculate the dose of oral syrup for a child, and only 43.3% were able to interpret non-prescription dosage information written on the package. The majority of parents (61.3%) would make a dosage to child based on age and not on their weight. Every fifth parent with adequate functional health literacy measured by S-TOFHLA test, achieved the lowest results measured by PTHL-SR. Higher performance of the PTHL-SR was significantly correlated with education (p < 0.001), female sex (p < 0.001), married parents and those living in common-law (p < 0.001), older parents (p < 0.05) and parents who have more children (p < 0.05), and are non-smokers (p < 0.05). These results provide evidence that limitations in understanding common information about use of medicines are widespread among parents of pre-school children and encourage efforts for further investigation. PTHL-SR questionnaire may be a useful tool for identification of parents who need more instructions and assistance from healthcare providers, above all in providing better communication, written or spoken at community pharmacy settings.

Parents' pain medication underdosing is associated with more emergency department visits in sickle cell disease

OBJECTIVE

To determine the association between health literacy, medication knowledge, and pain treatment skills with emergency department (ED) use of parents of children with sickle cell disease (SCD).

METHODS

Parents of children 1- to 12-years-old with SCD were enrolled. Health literacy was assessed using the Newest Vital Sign. Parents completed a structured interview assessing knowledge of the dosage and frequency of home pain medications and an applied skills task requiring them to dose a prescribed pain medication. Underdosage was defined by too small a dose (dosage error) or too infrequent a dose (frequency error). The association between medication knowledge and applied skills with ED visits for pain over the past year was evaluated using Poisson regression adjusting for genotype.

RESULTS

One hundred parent/child pairs were included; 50% of parents had low health literacy. Low health literacy was associated with more underdose frequency errors (38% vs. 19%, P = 0.02) on the skills task. On medication knowledge, underdose dosage errors (adjusted incidence rate ratio [aIRR] 2.0, 95% confidence interval [CI] 1.3-3.0) and underdose frequency errors (aIRR, 1.7, 95% CI 1.2-2.6) were associated with a higher rate of ED visits for pain. On the skills task, underdose dosage errors (aIRR 1.6, 95% CI 1.1-2-.4) and underdose frequency errors were associated with more ED visits (aIRR 1.5, 95% CI 1.1-2.1).

CONCLUSIONS

For medication knowledge and skills tasks, children of parents who underdosed pain medication had a higher rate of ED visits for pain. Health literate strategies to improve parents' medication skills may improve pain treatment at home and decrease healthcare utilization.

Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective

BACKGROUND AND OBJECTIVES

Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective.

METHODS

A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review.

RESULTS

Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV.

CONCLUSIONS

Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.

Collecting wrappers, labels, and packages to enhance accuracy of food records among children 2-8 years in the Pacific region: Children's Healthy Living Program (CHL)

The aim was to describe differences in dietary outcomes based on the provision of food wrappers, labels or packages (WLP) to complement data from dietary records (DR) among children from the US Affiliated Pacific. The WLP were intended to aid food coding. Since WLP can be associated with ultra-processed foods, one might expect differences in sodium, sugar, and other added ingredients to emerge. Dietary intakes of children (2-8 y) in Alaska, Hawai'i, Commonwealth of the Northern Mariana Islands, and Guam were collected using parent/caregiver completed 2-day DR. Parents were encouraged to collect WLP associated with the child's intake. Trained staff entered data from the DRs including the WLP when available using PacTrac3, a web application. Of the 1,868 DRs collected and entered at the time of this report, 498 (27%) included WLP. After adjusting for confounders (sex, age, location, education, food assistance), the DRs with WLP had significantly higher amounts of energy (kcal), total fat, saturated fat, added sugar, and sodium. These results suggest the inclusion of WLP enhanced the dietary intake data. The intake of energy, fat, added sugar and sodium derived from processed foods and foods consumed outside the home was better captured in children who had WLP.

Evaluation of two health education interventions to improve the varicella vaccination: a randomized controlled trial from a province in the east China

Background

We evaluated the effect of two Elaboration Likelihood Model (ELM)-based health educational interventions on varicella vaccine (VarV) vaccination among pregnant women in a province in the east China.

Methods

A prospective randomized controlled trial was conducted among 200 pregnant women with ≥12 gestation weeks to test two interventions, including a messaging video and a messaging booklet. The participants were randomly assigned into the control group, the video group or the booklet group. The VarV coverage at 12 and 24 months old was compared among the children of the three groups and relative risks (RRs) were calculated, by using the coverage of the control group as reference. The timeliness of VarV was also assessed. Furthermore, differences in the effects on the knowledge and attitude of VarV vaccination between the two interventions was evaluated.

Results

The VarV coverage of their children by 24 months of age was 86.4%, 76.1% and 56.7% for the video group, the booklet group and the control group, respectively. The relative risks (RRs) for the coverage of VarV at 24 months of age were 4.8 (95% CI: 2.06–11.3) for the video group and 2.4 (95% CI: 1.2–5.1) for the booklet group. The means of delays were 57.3 days in the video group, 76.9 days in the booklet group, and 100.6 days in the control group. The proportion of women who intended to vaccinate their children with VarV was higher in the video group than the booklet group (93.9% vs. 82.1%, p < 0.05).

Conclusions

Our findings indicated that perinatal health education through booklet or video could improve the coverage and schedule adherence for children’s VarV vaccination.

A Survey of Return Visits to the Pediatric Emergency Department: The Caretakers' Perspective

OBJECTIVE

Approximately 5% of children return to the emergency department within 72 hours of a first evaluation. Previous literature has focused on healthcare utilization and the use of return visits as a quality metric. The goal of this study was to quantify reasons for return visits from the caretaker perspective.

METHODS

Caretaker surveys were developed based on previously identified themes from focus groups. When considering reasons for return, multiple answers were allowed. Surveys were administered to a convenience sample of eligible caretakers who returned to the emergency department within 72 hours between June and August 2013. Caretakers were excluded if the return was scheduled or for an unrelated complaint.

RESULTS

Of the 306 eligible caretakers, 83 (27%) participated. A majority returned because of continued (92%) or worsening symptoms (70%). More than half returned because they did not know how to help their child at home (60%), they did not understand their child's illness (59%), and/or they did not expect the persistence of symptoms (58%). Overall, caretakers felt more testing (55%), treatments (45%), medications (41%), and information (28%) should have been provided at the initial visit. Caretakers of children admitted at the second visit were significantly more dissatisfied with care at the first visit (P = 0.05).

CONCLUSIONS

The most commonly reported reasons for pediatric return visits were continued symptoms and lack of illness understanding. We plan to use these data to develop targeted interventions to decrease the perceived need for return visits.

Exploring the Use of Theory in a National Text Message Campaign: Addressing Problem Recognition and Constraint Recognition for Publics of Pregnant Women

Infant mortality is associated with access to healthcare, knowledge, and health literacy. Text4baby, the largest national texting health initiative, seeks to address these factors. However, no research has examined the program's theoretical framework, an aspect that may impact its success. To address this gap, Text4baby's use of theory was evaluated through a content analysis of Text4baby messages and interviews with Text4baby content developers. We compared the main variables of health behavior theories framing Text4baby messages with the situational theory of publics and its factors of problem recognition and constraint recognition. The situational theory of publics provides an understanding of the types of publics that might emerge from Text4baby's audiences of pregnant women. Aware, latent, and active publics are defined by the situational theory and are created out of problem recognition and constraint recognition along with a level of personal involvement in the issue of prenatal health. We used content analysis and interviewing to explore how Text4baby prenatal messages were constructed using theory and to offer lessons learned for prenatal health campaigns. The multi-methodological approach to understanding meaning construction in the production of these text messages and how meaning played out in the messages is a useful framework for text message campaigns.

Health IT Usability Focus Section: Adapting EHR-Based Medication Instructions to Comply with Plain Language Guidance-A Randomized Experiment

Objective Patient instructions are generally written by clinicians. However, clinician-centered language is challenging for patients to understand; in the case of pediatric medication instructions, consequences can be serious. Using examples of clinician-written medication instructions from an electronic health record, we conducted an experiment to determine whether parental misinterpretations would be reduced by instructions that followed best practices for plain language. Methods We selected examples of dosing instructions from after-visit summaries in a commercial electronic health record. A demographically diverse sample of parents and adult caregivers was recruited from an online panel to participate in an English-language experiment, in which they received a comprehension questionnaire with either original after-visit summary instructions or instructions revised to comply with federal and other sources of plain-language guidance. Results Nine-hundred and fifty-one respondents completed the experiment; 50% were women, the mean age was 36 years, and 38% had less than a 4-year college education. The revisions were associated with an 8 percentage point increase in correct answers overall (from 55% to 63%, p < 0.001), although revisions were not equally effective for all instructions. Health literacy and health numeracy were strong and independent predictors of comprehension. Overall, mistakes on comprehension questions were common, with respondents missing an average of 41% (6.1 of 15) of questions. Conclusion In this experimental study, a relatively simple intervention of revising text was associated with a modest reduction in frequency of misinterpretations of medication instructions. As a supplement to more intensive high-touch interventions, revising electronic health record output to replace complex language with patient-centered language in an automated fashion is a potentially scalable solution that could reduce medication administration errors by parents.

Sociodemographic Characteristics, Health Literacy, and Care Compliance in Families With Spina Bifida

Children with spina bifida experience varying rates of disease complications and health system overutilization. Data on sociodemographics, urinary tract infection, clean intermittent catheterization, and health system utilization were collected from caregiver-patient dyads. Newest Vital Sign (NVS) and Brief Health Literacy Screen (BRIEF) were administered to evaluate health literacy (HL). In total, 105 dyads completed enrolment with 24.8% versus 12.4% of caregivers scoring poor/marginal on the NVS and BRIEF, respectively. Nearly half on clean intermittent catheterization missed a catheterization over the previous week. Medicaid insurance, parental education, and household income predicted HL (P < .01). Over the preceding 5 years, 68.5% visited our hospital's emergency department. Eighteen (25%) visited the emergency department >6 times and 12 incurred charges over $50 000. Caregivers of children who missed ≥4 catheterizations per week had lower NVS scores (P = .03). Children with spina bifida represent high utilizers, and consideration of sociodemographic and HL differences is necessary when tailoring care plans.

Does clinic visit education within a multidisciplinary center improve health literacy scores in caregivers of children with complex colorectal conditions?

INTRODUCTION

Health literacy is low in an estimated one-third of the US population. Little is known about the health literacy of caregivers of children with colorectal conditions. The objective of this study was to investigate whether a timed health literacy intervention could improve health literacy in this population.

METHODS

We used the BRIEF Health Literacy screening (BHLS) tool on caregivers of children who came to our colorectal clinic. Health literacy was categorized as inadequate, marginal, or adequate. The number of caregivers with adequate health literacy was compared to the number of clinic visits and socioeconomic status.

RESULTS

We included 233 caregivers. The average number of clinic visits was 3.5 over 1.2years. At the first clinic visit, 70% (n=98) of caregivers had "adequate" health literacy. Scores improved to 88% (p=0.024) after the fourth visit. Socioeconomic factors were not associated with health literacy. Patients of caregivers with "adequate" health literacy visited our clinic 3.8 times, compared to 2.7 times for those with lower literacy (p=0.006).

CONCLUSION

Emphasis on providing an education-based approach at each visit increased health literacy significantly. As expected, health literacy was lowest during the first visit, which we believe is the optimal time to implement educational interventions.

TYPE OF STUDY

Case Control/Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Randomized Trial of a Children's Book Versus Brochures for Safe Sleep Knowledge and Adherence in a High-Risk Population

OBJECTIVE

Sleep-related infant deaths have plateaued in the past decade, disproportionately affecting low socioeconomic status (SES) families. Printed materials are widely used for anticipatory guidance, yet none for safe sleep has been studied. We tested the efficacy of a specially designed children's book compared to brochures for safe sleep knowledge and adherence, which we hypothesized would be greater due to superior readability and engagement.

METHODS

This randomized controlled trial involved low-SES mothers (n = 282) enrolled in a home visiting program. Home visitors (n = 56) were randomly assigned to perform safe sleep teaching and assessments during 3 visits: third trimester, 1 week old, and 2 months old, exclusively utilizing a specially designed children's book or brochures, and surveys incorporating the American Academy of Pediatrics' safe sleep recommendations. Outcomes were safe sleep knowledge, adherence, and usefulness of materials, controlling for maternal health literacy.

RESULTS

Safe sleep knowledge increased across all time points with no overall group difference, though gains for sleep-evocative and general health items varied. Odds of bed sharing were higher and exclusive crib use lower for the brochure group (P < .05). Mothers and home visitors reported similar usefulness, though home visitors reported greater dialogue via the book and mothers in the book group reported more book sharing with their baby.

CONCLUSIONS

While a specially designed children's book and brochures were equally effective conveying aggregate safe sleep knowledge in low-SES mothers, adherence to exclusive crib use and avoiding bed sharing were greater in the book group, attributable to enhanced dialogue, readability and emotional engagement. Children's books are a promising mode of anticipatory guidance, warranting further investigation.

Talking with young children about concussions: an exploratory study

BACKGROUND

Concussion education for children early in their participation in organized sport may help shape lasting attitudes about concussion safety. However, existing programming and research focus on older ages.

METHODS

Qualitative interviews about concussions were conducted with twenty children between the ages of six and eight. Structural, descriptive and pattern coding were used to organize the transcribed interviews and identify emergent themes.

RESULTS

Eighteen of the participants indicated that they had heard of the word concussion, with 12 describing the injury as related to the brain or head. The most frequently described mechanisms of injury were impacts to the head or falls, and symptoms tended to be somatic, such as generalized pain. The most frequently endorsed strategy to avoid sustaining a concussion was to 'follow the rules.' Multiple participants referenced parents as an informal source of information about concussions.

CONCLUSIONS

While most participants demonstrated some awareness about concussions, there were clear knowledge gaps that can be addressed with developmentally appropriate concussion education programming. Consistent with their developmental stage, interventions targeted at children in this age range may be most successful if they use basic logic, concrete ideas, provide rules to be followed and engage parents in dissemination.

A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Low parental awareness about energy (calorie) recommendations for children's restaurant meals: findings from a national survey in the USA

OBJECTIVE

To assess parental awareness of per-meal energy (calorie) recommendations for children's restaurant meals and to explore whether calorie awareness was associated with parental sociodemographic characteristics and frequency of eating restaurant food.

DESIGN

Cross-sectional online survey administered in July 2014. Parents estimated calories (i.e. kilocalories; 1 kcal=4·184 kJ) recommended for a child's lunch/dinner restaurant meal (range: 0-2000 kcal). Responses were categorized as 'underestimate' (600 kcal). Confidence in response was measured on a 4-point scale from 'very unsure' to 'very sure'. Logistic regressions estimated the odds of an 'accurate' response and confident response ('somewhat' or 'very sure') by parental sociodemographic characteristics and frequency of eating from restaurants. Sampling weights based on demographics were incorporated in all analyses.

SETTING

USA.

SUBJECTS

Parents (n 1207) of 5-12-year-old children.

RESULTS

On average, parents estimated 631 (se 19·4) kcal as the appropriate amount for a 5-12-year-old child's meal. Thirty-five per cent answered in the accurate range, while 33·3 and 31·8 % underestimated and overestimated, respectively. Frequent dining at restaurants, lower income and urban geography were associated with lower odds of answering accurately. Parents' confidence in their estimates was low across the sample (26·0 % confident) and only 10·1 % were both accurate and confident.

CONCLUSIONS

Parent education about calorie recommendations for children could improve understanding and use of menu labelling information in restaurants. Targeted strategies are recommended to ensure that such efforts address, rather than exacerbate, health disparities.

Association between Awareness of Nutrition Labels and Menstrual Cycle Irregularity in Korean Women: The Fifth Korea National Health and Nutrition Examination Survey (2010~2012)

PURPOSE

The aim of this study was to identify the relationship between awareness of nutrition labeling and menstrual cycle irregularity in women from a nationally representative sample of the Korean population.

METHODS

A cross-sectional analysis was performed using hierarchical multivariable logistic regression analysis models. A total of 4,324 women aged 19~54 years from the 2010~2012 Korean National Health and Nutrition Examination Survey participated in the study. The participants were classified into three groups based on self-report responses to a questionnaire about their awareness of nutrition labels: Reading, Not-Reading, and Not-Knowing Groups.

RESULTS

The Reading, Not-Reading, and Not-Knowing Groups comprised 46.4%, 44.9%, and 8.7% of the participants, respectively, and 53.6% of the participants had never used nutrition labels. In the Not-Knowing Group, irregular menstrual cycles for more than 3 months were significantly more common than women with irregular menstrual cycles for up to 3 months and women with regular menstrual cycles. Women in the Not-Knowing Group were more likely to exhibit menstrual cycle irregularity (adjusted odds ratio: 1.63, 95% confidence interval: 1.10~2.41) compared to women in the Reading Group after adjusting for age, body mass index, smoking status, alcohol intake, exercise regularity, stress, depression, suicidal ideation, metabolic syndrome, age at menarche, parity, and use of oral contraceptives.

CONCLUSION

No awareness of nutrition labeling appears to be associated with a higher prevalence of menstrual cycle irregularity in a nationally representative group of Korean women.

Emphasizing the child in child health literacy research

Child health literacy is a 'hot topic' of late, as researchers and practitioners work to attain an equitable and healthy future. Health literacy emphasizes the wide range of skills that people need to access, understand, evaluate and use health information to promote good health. In light of the recognition that health literacy is an important determinant of health for adults, addressing child health literacy early on is essential to maximize future health outcomes. Meeting children's specific needs arguably includes the delivery of information that can be easily accessed and understood by younger age groups. While much academic discourse pertains to the importance of building parental health literacy, there is less literature that explicitly focuses on child-centred health literacy. On the premise that health literacy is an asset, this paper provides an argument for investing in children's health literacy by working with children to encourage meaningful contributions in research and practice.

Parental Health Literacy and Outcomes of Childhood Nephrotic Syndrome

OBJECTIVE

Determine the association of parental health literacy with treatment response among children with nephrotic syndrome.

METHODS

This was a cohort study of children aged 1-18 with nephrotic syndrome and their parent. Health literacy was measured using the validated Short Test of Functional Health Literacy in Adults assessing reading comprehension and numeracy. Outcomes included initial relapse-free period, frequently relapsing disease, relapse rate, second-line medication use, and complete remission after therapy.

RESULTS

Of 190 parents, 80% had adequate health literacy (score >67 of 100), and higher scores were not correlated with higher education. Almost all achieved perfect numeracy scores (>86%); numeracy was not associated with outcomes. After adjusting for immigration, education, and income, higher reading comprehension scores (tertile 3) compared with lower scores (tertile 1) were significantly associated with lower risk of first relapse (hazard ratio 0.67, 95% confidence interval [CI] 0.48-0.94, P trend = .02), lower odds of frequently relapsing disease (odds ratio [OR] 0.38, 95% CI 0.21-0.70, P trend = .002), lower relapse rate (rate ratio 0.77, 95% CI 0.73-0.80, P trend < .001), and higher odds of complete remission after both initial steroids and cyclophosphamide (OR 2.07, 95% CI 1.36-3.16, P trend = .003; OR 5.97, 95% CI 2.42-14.7, P trend < .001).

CONCLUSIONS

Lower parental health literacy, specifically reading comprehension, is associated with higher relapse rates among children with nephrotic syndrome and fewer achieving complete remission. This underscores the importance of assessing and targeting health literacy for chronic management of childhood-onset diseases.

Understanding online health information: Evaluation, tools, and strategies

OBJECTIVE

Considering the status of the Internet as a prominent source of health information, assessing online health material has become a central issue in patient education. We describe the strategies available to evaluate the characteristics of online health information, including readability, emotional content, understandability, usability.

METHODS

Popular tools used in assessment of readability, emotional content and comprehensibility of online health information were reviewed. Tools designed to evaluate both printed and online material were considered.

RESULTS

Readability tools are widely used in online health material evaluation and are highly covariant. Assessment of emotional content of online health-related communications via sentiment analysis tools is becoming more popular. Understandability and usability tools have been developed specifically for health-related material, but each tool has important limitations and has been tested on a limited number of health issues.

CONCLUSION

Despite the availability of numerous assessment tools, their overall reliability differs between readability (high) and understandability (low). Approaches combining multiple assessment tools and involving both quantitative and qualitative observations would optimize assessment strategies.

PRACTICE IMPLICATIONS

Effective assessment of online health information should rely on mixed strategies combining quantitative and qualitative evaluations. Assessment tools should be selected according to their functional properties and compatibility with target material.

Readability and Content Characteristics of Powdered Infant Formula Instructions in the United States

OBJECTIVES

This study aimed to assess readability characteristics and layout features, including reading grade level, text point size, dimensions (length and width), diagrams, key directions (warnings, proper hygiene, preparation and use, and storage), and compliance to International Code provisions of English-language instructions affixed to a representative sample of brand-name and generic powdered, infant formula containers currently available for purchase in the US.

METHODS

During June 2014, comprehensive Internet searches were conducted to identify brand-name powdered infant formulas currently available for purchase in the US (n = 10). The English-language instruction section affixed to each formula container was evaluated for readability characteristics and layout features, including reading grade level, text point size, dimensions (length and width), diagrams, key directions (warnings, proper hygiene, preparation and use, and storage), and compliance to International Code.

RESULTS

Overall, containers were similar in circumference (50.8 ± 7.3 cm) and height (14.0 ± 0.0 cm) and held an average of 656.0 ± 12.3 g (range 629-663 g) of powdered infant formula. Both Directions for Preparation and Use and Storage Instructions sections had average reading difficulty scores at the college level. Step-by-Step Preparation Directions and Warnings and Safe Handling sections had reading difficulty between the 8th and 9th grade level. All container labels contained three diagrams depicting step-by-step preparation instructions and a feeding chart. Overall, infant formula containers reviewed in our study adhered to compliance to International Code provisions.

CONCLUSIONS

As negative health outcomes are associated with inappropriately prepared infant formula feedings, healthcare providers should routinely query infant caregivers regarding their formula preparation and administration practices.

Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency

OBJECTIVE

Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents.

METHODS

Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ≤8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well").

RESULTS

A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]).

CONCLUSIONS

Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

The Impact of Health Literacy Status on the Comparative Validity and Sensitivity of an Interactive Multimedia Beverage Intake Questionnaire

Self-reported dietary assessment methods can be challenging to validate, and reporting errors for those with lower health literacy (HL) may be augmented. Interactive multimedia (IMM) based questionnaires could help overcome these limitations. The objectives of this investigation are to assess the comparative validity and sensitivity to change of an IMM beverage intake questionnaire (IMM-BEVQ) as compared to dietary recalls and determine the impact of HL. Adults completed three 24-h dietary recalls and the IMM-BEVQ at baseline and after a six-month intervention targeting either sugar-sweetened beverages (SSB) or physical activity. Correlations and paired-samples t-tests are presented. For validity (n = 273), intake of SSB (mean difference = 10.6 fl oz) and total beverage consumption (mean difference = 16.0 fl oz) were significantly different (p ≤ 0.001) at baseline between the IMM-BEVQ and dietary recalls for all participants. However, the differences in intake were generally greater in low HL participants than in adequate HL participants. For sensitivity (n = 162), change in SSB intake (mean difference = 7.2 fl oz) was significantly different (p ≤ 0.01) between pre-/post-IMM-BEVQ and pre-/post-dietary recalls, but not total beverage intake (mean difference = 7.6 fl oz) for all participants. Changes in SSB and total beverage intake were not significantly different for those with adequate HL. The IMM-BEVQ is a valid dietary assessment tool that is as responsive to detecting changes in beverage intake as dietary recalls. However, adults with lower HL may need additional guidance when completing the IMM-BEVQ.

Examining health literacy among urban African-American adolescents with asthma

OBJECTIVE

This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma.

METHODS

We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006-2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization.

RESULTS

Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44-0.84), not on Medicaid (OR 0.36; 95% CI 0.17-0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07-1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59-0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25-0.94), have one or more emergency visits (OR 1.21 95% CI 1.02-1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01-1.41), respectively.

CONCLUSIONS

The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.

Sociocultural Factors and Parent-Therapist Agreement on Explanatory Etiologies for Youth Mental Health Problems

Sociocultural factors were examined in relationship to parent-therapist agreement on beliefs about the etiology of mental health problems in a sample of youth receiving outpatient mental health services (n = 277 parents). When examined individually, racial/ethnic match was unrelated, but higher parental affinity to mainstream American culture, higher parent education level, and greater similarity in parent and therapist scores on affinity to mainstream American culture were all significantly associated with greater parent-therapist co-endorsement of etiological explanations, while higher parental affinity to an alternative/indigenous culture was significantly associated with lower co-endorsement. When examined simultaneously in one model, only parent education level remained significantly associated. Findings suggest a complex relationship between sociocultural factors and that attention to parent cultural affinity and parent education level may facilitate parent-therapist agreement on beliefs about child problem causes.

Health Literacy and Preferences for Sources of Child Health Information of Mothers With Infants in the Neonatal Intensive Care Unit

BACKGROUND

Parents of infants hospitalized in the neonatal intensive care unit (NICU) frequently need guidance to prepare them for the care and health promotion of their child after hospital discharge. The health literacy of the parents should be considered so that education can be tailored to meet their needs. It is also important to understand the parents' preferences for how, and from whom, they receive education.

PURPOSE

The purpose of this study was to identify health literacy levels of parents of infants in an NICU and preferences for who they want to provide them with education.

METHODS

An exploratory, descriptive design was used to assess participant health literacy and preferences for obtaining child health information. Only mothers (no fathers) with babies in the NICU were available to complete the survey. Mean participant age was 26.4 years (SD = 6.7).

RESULTS

Participants had a mean Rapid Estimate of Adult Literacy in Medicine, Revised, score of 5.64 (SD = 2.4), indicating a low level of health literacy. Questions regarding when to administer medication were correctly answered by 69% of participants. Proper medication dosage was understood by 92% of participants; however, only 30% were able to correctly convert measurements. One-on-one discussions with a physician were the preferred source of health information for 80% of participants.

IMPLICATIONS FOR PRACTICE/RESEARCH

The current exploratory study provides new information that will help inform the development of future studies and increase awareness of nurses regarding health literacy and the specific types of skills for which parents need the most help.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

The Patient Passport Program: An Intervention to Improve Patient-Provider Communication for Hospitalized Minority Children and Their Families

OBJECTIVE

Effective patient-provider communication is essential to improve health care delivery and satisfaction and to minimize disparities in care for minorities. The objective of our study was to evaluate the impact of a patient-provider communication program, the Patient Passport Program, to improve communication and satisfaction for hospitalized minority children.

METHODS

This was a qualitative evaluation of a communication project for families with hospitalized children. Families were assigned to either the Patient Passport Program or to usual care. The Passport Program consisted of a personalized Passport book and additional medical rounds with medical providers. Semistructured interviews at the time of patient discharge were conducted with all participants to measure communication quality and patient/family satisfaction. Inductive qualitative methods were used to identify common themes.

RESULTS

Of the 40 children enrolled in the Passport Program, 60% were boys; the mean age was 9.7 years (range, 0.16-19 years). The most common themes in the qualitative analysis of the interviews were: 1) organization of medical care; 2) emotional expressions about the hospitalization experience; and 3) overall understanding of the process of care. Spanish- and English-speaking families had similar patient satisfaction experiences, but the Passport families reported improved quality of communication with the medical care team.

CONCLUSIONS

The Patient Passport Program enhanced the quality of communication among minority families of hospitalized children with some common themes around the medical care expressed in the Passport book.

Parent Health Literacy, Depression, and Risk for Pediatric Injury

BACKGROUND

Population-wide research on the impact of parent health literacy to children's health outcomes is limited. We assessed the relationship of low parent health literacy to a range of pediatric health risks within a large cohort of primary care patients.

METHODS

Data were from 17 845 English- and Spanish-speaking parents of children aged ≤7 years presenting for well-child care. We used a 3-item screener to measure health literacy. Outcomes included secondhand smoke exposure, asthma treatment nonadherence, parent depression, child-rearing practices, injury prevention, and parent first-aid knowledge. We summarized study variables with descriptive statistics and then performed multivariable logistic regression to identify associations between low parent literacy and our dependent measures.

RESULTS

Mean child age was 4.8 years (SD 3.7); 36.5% of parent respondents had low health literacy. In models adjusted for child gender, race/ethnicity, insurance, age, and parent language preference, low parent health literacy was related to a range of pediatric health risks, including parent depression (adjusted odds ratio [AOR] 1.32; 95% confidence interval 1.18-1.48), firearm access (AOR 1.68; 1.49-1.89), not having a working smoke detector (AOR 3.54; 2.74-4.58), and lack of first-aid knowledge about choking (AOR 1.67; 1.44-1.93) and burns (AOR 1.45; 1.29-1.63). Children of parents with low health literacy were also more likely to watch >2 hours of television per day (AOR 1.27; 1.17-1.36).

CONCLUSIONS

Low parent health literacy is independently and significantly related to parent depression, child television viewing, and at-risk family behaviors associated with child injury. Use of low-literacy approaches to health-behavior interventions may be essential to address common child morbidities.

Assessing the Nutrition Literacy of Parents and Its Relationship With Child Diet Quality

OBJECTIVE

To estimate the reliability and validity of the Nutrition Literacy Assessment Instrument for Parents (NLit-P) and to investigate relationships among parental nutrition literacy, parental and child body mass index, and child diet quality (Healthy Eating Index).

METHODS

Cross-sectional study of 101 parent-child dyads that collected measures of socioeconomic status, nutrition literacy, 2 24-hour child diet recalls, and body mass index. Reliability of NLit-P was assessed by confirmatory factor analysis. Pearson correlation and multiple linear regression were used.

RESULTS

Fair to substantial reliability was seen across 5 NLit-P domains, whereas Pearson correlations support concurrent validity for the NLit-P related to child diet quality and parental income, age, and educational attainment (P < .001). For every 1% increase in NLit-P, there was a 0.51 increase in child Healthy Eating Index (multivariate coefficient, 0.174; P < .001).

CONCLUSIONS AND IMPLICATIONS

The NLit-P demonstrates potential for measuring parental nutrition literacy, which may be an important educational target for improving child diet quality.

Pediatric injury information seeking for mothers with young children: The role of health literacy and ehealth literacy

BACKGROUND

An understanding of preferred sources of injury information among parents is needed to develop best practices for information dissemination. Yet, almost no research examines injury information seeking for a national sample of mothers.

METHODS

A cross-sectional online survey was conducted in 2013 with 1081 mothers in the United States (U.S.) with at least one child <6 years. We measured self-report health literacy with the Morris Single-Item Screener (18% low), and eHealth literacy using the eHEALS (28% low).

RESULTS

The internet was the most preferred source for injury information (76%), followed by health providers (44%), and family/friends (35%). Most mothers selected the internet as the first choice for information about bicycle helmets (65%) and car seats (63%). For poison prevention, preferences were mixed; 48% internet compared with 41% health providers. Mothers with low health literacy were more likely to have discussed injury prevention with their doctors (P = 0.022) and searched for injury information (P = 0.001), but less likely to report the internet as a top source (P < .0001). Mothers with low eHealth literacy were less likely to search for injury information (P < 0.0001) and report the internet as a top source (P < 0.0001), and slightly more likely to rely on health providers for information (P = 0.028).

CONCLUSIONS

Findings suggest the internet is a common source of injury prevention information, but health providers remain a valuable resource for mothers, especially those with lower literacy skills. Despite widespread internet use, health providers should be sure to communicate injury prevention information to mothers, especially those at risk for low health literacy and eHealth literacy.

Socioeconomic Gradient in Childhood Obesity and Hypertension: A Multilevel Population-Based Study in a Chinese Community

BACKGROUND

This study aims to assess evidence for any socioeconomic gradients in childhood obesity and hypertension in a population-representative sample in Hong Kong, China.

METHODS

The data of a stratified random sampled growth survey collected in 2005-2006 was matched with a population by-census. Obesity was defined using the International Obesity Task Force standard and hypertension was defined using the Hong Kong norm table. Family socioeconomic status (SES) was measured by maternal education level. Neighbourhood SES was measured by median household income of the neighbourhood. Multilevel Poisson regression models with robust standard error were used to test the association. Body mass indices of children's parents were included as potential confounders. Intra-school/neighbourhood correlations were adjusted using random factors.

RESULTS

Totally 14842 children (age 6-19 years) included in the analysis, in which 16.6% of them were overweight or obese. Children whose mother only completed secondary school or below had higher risk of childhood obesity (RR 1.41, 95% CI 1.13-1.76, p = 0.003) and hypertension (RR 1.18, 95% CI 1.01-1.36, p = 0.03). Meanwhile, children in the lowest neighbourhood SES group had higher risk of childhood underweight (RR 1.61, 95% CI 1.04-2.49, p = 0.03), overweight (RR 1.35, 95% CI 1.05-1.72, p = 0.02), and obesity (RR 2.07, 95% CI 1.11-3.88, p = 0.02).

CONCLUSIONS

Socioeconomic gradient in childhood obesity and hypertension existed in Hong Kong, one of the most developed cities in China. These results have implications for policymakers and public health experts and highlight the need to monitor trends in other parts of China.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin

OBJECTIVE

To study reconstitution and preparation dosing errors of liquid oral medications given by caregivers to children.

METHODS

A prospective observational study was carried out in the departments of general paediatrics and emergency paediatrics at the Robert-Debré Children's University Hospital. An interview with caregivers involved (1) practical reconstitution and preparation of an oral liquid medication from a prescription drawn at random (amoxicillin (Clamoxyl, dosing spoon) or josamycin (Josacine, dose-weight pipette)) and (2) a questionnaire about their use.

RESULTS

One hundred caregivers were included. Clamoxyl and Josacine were incorrectly reconstituted in 46% (23/50) and 56% (28/50) of cases, respectively, with a risk of underdosing of Clamoxyl (16/23) and overdosing of Josacine (23/28). Dose preparation with the dosing spoon was incorrect in 56% of cases, and in 10% of cases with the dose-weight pipette. Female sex, native French speaker, and age were significantly associated with correct reconstitution. Male sex and medication were significantly associated with correct preparation.

CONCLUSIONS

This study highlights the high incidence of errors made by caregivers in reconstituting and preparing doses of these liquid oral medicines, which are associated with considerable risks of over- and underdosing. Factors associated with these errors have been identified which could help health professionals to optimise their strategy for educating families about the use of liquid oral medications and the need to check that they understand these instructions.

Health literacy and the determinants of obesity: a population-based survey of sixth grade school children in Taiwan

BACKGROUND

Health literacy has become an important health policy and health promotion agenda item in recent years. It had been seen as a means to reduce health disparities and a critical empowerment strategy to increase people's control over their health. So far, most of health literacy studies mainly focus on adults with few studies investigating associations between child health literacy and health status. This study aimed to investigate the association between health literacy and body weight in Taiwan's sixth grade school children.

METHODS

Using a population-based survey, 162,209 sixth grade (11-12 years old) school children were assessed. The response rate at school level was 83%, with 70% of all students completing the survey. The Taiwan child health literacy assessment tool was applied and information on sex, ethnicity, self-reported health, and health behaviors were also collected. BMI was used to classify the children as underweight, normal, overweight, or obese. A multinomial logit model with robust estimation was used to explore associations between health literacy and the body weight with an adjustment for covariates.

RESULTS

The sample consisted of 48.9% girls, 3.8% were indigenous and the mean BMI was 19.55 (SD = 3.93). About 6% of children self-reported bad or very bad health. The mean child health literacy score was 24.03 (SD = 6.12, scale range from 0 to 32). The overall proportion of obese children was 15.2%. Children in the highest health literacy quartile were less likely to be obese (12.4%) compared with the lowest quartile (17.4%). After controlling for gender, ethnicity, self-rated health, and health behaviors, children with higher health literacy were less likely to be obese (Relative Risk Ratio (RRR) = 0.94, p < 0.001) and underweight (RRR = 0.83, p < 0.001). Those who did not have regular physical activity, or had sugar-sweetened beverage intake (RRR > 1.10, p < 0.0001) were more likely to report being overweight or obese.

CONCLUSIONS

This study demonstrates strong links between health literacy and obesity, even after adjusting for key potential confounders, and provides new insights into potential intervention points in school education for obesity prevention. Systematic approaches to integrating a health literacy curriculum into schools may mitigate the growing burden of disease due to obesity.

Promoting Health Literacy Is A Necessary Action on the Outskirts Based on the Real Condition There

Introduction

Health literacy refers to the degree to which individuals have the capacity to obtain, process, and understand the basic health information needed to make appropriate health decisions. The aim of this study was to determine the health literacy level in regions on the outskirts of Mashhad, Iran.

Methods

This cross-sectional study was undertaken in December 2014 on residents in the outskirts of Mashhad. We used a multistage sampling method, and data were collected via a questionnaire, conducted by trained interviewers. The data were analyzed using the t-test, the Mann-Whitney test, and the chi-squared test.

Results

We had 502 participants in this study. The mean age was 35.0 ± 11.06 years. Sixty percent of participants (301) were female, and 86.3% (425) had high school diplomas or lower educational levels; the rest had higher educational levels. Television/radio and the Internet were the most and least frequently accessed and used media, respectively. There were significant correlations between the level of knowledge and response to questions in specific domains, such as weight, fasting blood sugar, and blood pressure (p < 0.001). The participants had no difficulty reading booklets (63%), physicians’ prescriptions (59%), medical forms (56%), and guidance boards in hospitals (71%). People had no problems understanding most health/disease materials obtained via various routes (37%), but the health/disease materials published on the Internet/electronic resources (37%) and textbooks (64%) were difficult for them to understand.

Conclusion

Health literacy is a complicated construct, and more comprehensive studies are needed to develop health-related information that can be understood by more of the general public.