Health literacy and child health promotion: implications for research, clinical care, and public policy

Health literacy, alcohol expectancies, and alcohol use behaviors in teens

OBJECTIVE

Alcohol expectancies are developed, in part, through exposure to health messages, the understanding of which may be influenced by health literacy. This study explores the relationships among health literacy, alcohol expectancies, and alcohol use behaviors in teens.

METHODS

We studied alcohol use behaviors in the past six months in youths aged 14-19 recruited from two adolescent medicine clinics. We assessed covariate-adjusted bivariate relationships between HL, expectancies, and four measures of alcohol use and tested health literacy as a moderator of the relationship between expectancies and use.

RESULTS

Of the 293 study teens, 45 percent reported use of alcohol in the past six months. Use behaviors were positively associated with higher health literacy and positive expectancies. Our moderation model suggested that health literacy moderates the relationship between expectancies and use, with the expectancy/use relationship being significantly stronger in higher literacy teens.

CONCLUSION

Findings suggest that health literacy can influence alcohol expectancies and behaviors.

PRACTICE IMPLICATIONS

Health literacy should be explicitly considered in the design of alcohol prevention messages.

Early childhood nutrition concerns, resources and services for Aboriginal families in Victoria

OBJECTIVE

To investigate the child nutrition concerns of Aboriginal families with young children attending Aboriginal health and early childhood services in Victoria; training needs of early childhood practitioners; and sources of nutrition and child health information and advice for Aboriginal families with young children.

METHOD

Qualitative needs assessment involving consultation with Aboriginal parents of young children aged 0-8 years attending Aboriginal health and early childhood services, and early childhood practitioners from Aboriginal health and early childhood services in urban and regional Victoria. Focus groups were conducted with 35 Aboriginal parents and interviews conducted with 45 health and early childhood practitioners. Thematic analysis was used to generate and then refine distinct, internally consistent common themes from the data.

RESULTS

The most frequent issues identified were low levels of breastfeeding, inappropriate introduction of solids, reliance on bottles, sweet drinks, and energy-dense foods, poor oral health and overweight. Concerns about staff training and capacity, and access to maternal and child health services were also common.

CONCLUSION AND IMPLICATION

This study identifies major gaps in service delivery for Aboriginal families with young children and points to the need for a coordinated, culturally responsive systems approach to providing support for breastfeeding and child nutrition advice and support for Aboriginal families, including capacity building for staff, and supportive systems and policy.

Is health literacy related to health behaviors and cell phone usage patterns among the text4baby target population?

BACKGROUND

Text4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.

METHODS

Pregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.

RESULTS

Four hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).

CONCLUSIONS

Text4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.

Brief approaches to developmental-behavioral promotion in primary care: updates on methods and technology

Well-child visits are a critical opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, enhance the development and well-being of children and their families, identify problems not amenable to brief in-office counseling, and refer for services when needed. This article outlines the communication skills, instructional methods, and resource options that enable clinicians to best assist families. Also covered is how to monitor progress and outcomes. A total of 239 articles and 52 Web sites on parent/patient education were reviewed for this study. Providers require a veritable armamentarium of instructional methods. Skills in nonverbal and verbal communication are needed to elicit the parent/patient agenda, winnow topics to a manageable subset, and create the "teachable moment." Verbal suggestions, with or without standardized spoken instructions, are useful for conveying simple messages. However, for complex issues, such as discipline, it is necessary to use a combination of verbal advice, written information, and "teach-back," aided by role-playing/modeling or multimedia approaches. Selecting the approaches most likely to be effective depends on the topic and family characteristics (eg, parental literacy and language skills, family psychosocial risk and resilience factors, children's developmental-behavioral status). When providers collaborate well (with parents, patients, and other service providers) and select appropriate educational methods, families are better able to act on advice, leading to improvements in children's well-being, health, and developmental-behavioral outcomes. Provided are descriptions of methods, links to parenting resources such as cell phone applications, Web sites (in multiple languages), interactive technology, and parent training courses.

Leveraging public health nurses for disaster risk communication in Fukushima City: a qualitative analysis of nurses' written records of parenting counseling and peer discussions

BACKGROUND

Local public health nurses (PHNs) have been recognized as the main health service providers in communities in Japan. The Fukushima nuclear disaster in 2011 has, however, created a major challenge for them in responding to mothers' concerns. This was in part due to difficulties in assessing, understanding and communicating health risks on low-dose radiation exposure. In order to guide the development of risk communication plans, this study sought to investigate mothers' primary concerns and possible solutions perceived by a core healthcare profession like the PHNs.

METHODS

A total of 150 records from parenting counseling sessions conducted between PHNs and mothers who have attended mandatory 18-month health checkups for their children at the Fukushima City Health and Welfare Center in 2010, 2011 (year of disaster) and 2012 were examined. Discussion notes of three peer discussions among PHNs organized in response to the nuclear disaster in 2012 and 2013 were also analyzed. All transcribed data were first subjected to text mining to list the words according to their frequencies and inter-relationships. The Steps Coding and Theorization method was then undertaken as a framework for qualitative analysis.

RESULTS

PHNs noted mothers to have considerable needs for information on radiation risks as they impact on decisions related to relocations, concerns for child safety, and experiences with interpersonal conflicts within the family owing to differing risk perceptions. PHNs identified themselves as the information channels in the community, recommended the building of their risk communication capacities to support residents in making well-informed decisions, and advocated for self-measurement of radiation levels to increase residents' sense of control. PHNs also suggested a more standardized form of information dissemination and an expansion of community-based counseling services.

CONCLUSIONS

Inadequate risk communication on radiation in the Fukushima nuclear incident has resulted in multiple repercussions for mothers in the community. Empowerment of local residents to assume more active roles in the understanding of their environment, increasing PHNs' capacity in communication, and an expansion of health services such as counseling will together better address risk communication challenges in post-disaster recovery efforts.

Using the "Newest Vital Sign" to assess health literacy in children

INTRODUCTION

The purpose of this study was to explore the feasibility, utility, and validity of using the Newest Vital Sign (NVS) tool to assess health literacy in children.

METHOD

Forty-seven parent-child dyads individually completed the NVS and a Home Literacy Environment single-item screening question (No. of children's books in the home).

RESULTS

The majority (72%; n = 34) of parent-child dyads had adequate health literacy (NVS scores ≥4), with no significant differences (p = .95) between children's NVS scores (M = 4.8, SD = 1.5) and parents (M = 4.8, SD = 1.6). A moderate, positive correlation was found between children's and parents' NVS scores (rs = .35, p = .017). Of note was that all of the parents (n = 4) and children (n = 6) who reported having only 10 or fewer children's books in their homes had NVS scores less than 4, indicating inadequate health literacy.

DISCUSSION

The NVS is a quick screening mechanism for identifying households that have adequate health literacy levels. Asking children the Home Literacy Environment single-question screening item (No. of children's books) provided additional insight that confirmed and extended findings from the NVS.

Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness

OBJECTIVE

To examine the association between caregiver health literacy and the likelihood of a nonurgent emergency department (ED) visit in children presenting for fever.

METHODS

This cross-sectional study used the Newest Vital Sign to assess the health literacy of caregivers accompanying children with fever to the ED. Visit urgency was determined by resources utilized during the ED visit. Findings were stratified by race and child age. Chi-square and logistic regression analysis controlling for race were conducted to determine the association between low health literacy and ED visit urgency.

RESULTS

A total of 299 caregivers completed study materials. Thirty-nine percent of ED visits for fever were nonurgent, and 63% of caregivers had low health literacy. Low health literacy was associated with a higher proportion of nonurgent ED visits for fever (44% vs 31%, odds ratio 1.8, 95% confidence interval [CI] 1.1, 2.9). Low health literacy was associated with higher odds of a nonurgent visit in white and Hispanic caregivers but not in black caregivers. In regression analysis, children ≥ 2 years old had higher odds of a nonurgent visit if caregivers had low health literacy (adjusted odds ratio 2.0; 95% CI 1.1, 4.1); this relationship did not hold for children <2 years old (adjusted odds ratio 0.8; 95% CI 0.4, 1.8).

CONCLUSIONS

Nearly two-thirds of caregivers with their child in the ED for fever have low health literacy. Caregiver low health literacy is associated with nonurgent ED utilization for fever in children over 2 years of age. Future interventions could target health literacy skills regarding fever in caregivers of children ≥ 2 years.

Caregivers' health literacy and their young children's oral-health-related expenditures

Caregivers' health literacy has emerged as an important determinant of young children's health care and outcomes. We examined the hypothesis that caregivers' health literacy influences children's oral-health-care-related expenditures. This was a prospective cohort study of 1,132 child/caregiver dyads (children's mean age = 19 months), participating in the Carolina Oral Health Literacy Project. Health literacy was measured by the REALD-30 (word recognition based) and NVS (comprehension based) instruments. Follow-up data included child Medicaid claims for CY2008-10. We quantified expenditures using annualized 2010 fee-adjusted Medicaid-paid dollars for oral-health-related visits involving preventive, restorative, and emergency care. We used descriptive, bivariate, and multivariate statistical methods based on generalized gamma models. Mean oral-health-related annual expenditures totaled $203: preventive--$81, restorative--$99, and emergency care--$22. Among children who received services, mean expenditures were: emergency hospital-based--$1282, preventive--$106, and restorative care--$343. Caregivers' low literacy in the oral health context was associated with a statistically non-significant increase in total expenditures (average annual difference = $40; 95% confidence interval, -32, 111). Nevertheless, with both instruments, emergency dental care expenditures were consistently elevated among children of low-literacy caregivers. These findings provide initial support for health literacy as an important determinant of the meaningful use and cost of oral health care.

Factors associated with developmental concern and intent to access therapy following discharge from the NICU

PURPOSE

To determine factors associated with mothers' concern about infant development and intent to access therapy services following neonatal intensive care unit (NICU) discharge.

METHODS

Infant medical factors, magnetic resonance imaging results, neurobehavior at term, maternal factors, and maternal perceptions about developmental concern and intent to access therapy at NICU discharge were prospectively collected in 84 infants born premature (<30 weeks gestation). Regression was used to determine factors associated with developmental concern and intent to access therapy at NICU discharge.

RESULTS

Decreased developmental concern was reported by mothers with more children (P = .007). Infant stress signs (P = .038), higher maternal education (P = .047), reading books (P = .030), and maternal depression (P = .018) were associated with increased developmental concern. More maternal education was associated with more intent to access services (P = .040).

CONCLUSION

Maternal factors, rather than infant factors, had important associations with caregiver concern. In contrast, abnormal term neurobehavior and/or the presence of cerebral injury were not associated with caregiver concern about development.

Health literacy and depression in the context of home visitation

We explored health literacy in parents as an underlying construct that develops through social interaction and reflection and involves an array of skills that enable a parent to manage personal and child health and healthcare. We hypothesized that depression impairs health literacy and impedes efforts to promote health literacy through home visitation. We analyzed an AHRQ/NIH database of 2,572 parent/child dyads compiled in a 2006–2008 quasi-experimental six-site nationwide study using multiple waves of measurement and a matched comparison group. Cohort families participated in home visitation programs augmented to develop parents’ reflective skills. Visitors monitored depression, health- and healthcare-related practices, and surrounding family conditions at baseline and 6-month intervals for up to 36 months using the Life Skills Progression instrument. We examined differences in initial depression ratings for demographic subgroups and explored patterns of change in health literacy among depressed versus not-depressed parents. Correlation analysis showed that at each of four assessments better depression scores were consistently and positively correlated with use of information and services (r = 21–22, P < .001) and with self-management of personal and child health (r = 42–49, P < .001). Overall, parents made significant improvements in health literacy (P < .001). As expected, depressed parents demonstrated lower baseline health literacy scores than not-depressed parents; however, they achieved greater gains (P < .001). While depression is linked with lower parental health literacy, after 1 year of enhanced home visitation, vulnerable parents were better able to manage personal and family health and healthcare, especially if depressed. Enhanced home visitation could be an effective channel to develop health literacy as a life skill, and to improve depression.

Early life opportunities for prevention of diabetes in low and middle income countries

BACKGROUND

The global burden of diabetes and other non-communicable diseases is rising dramatically worldwide and is causing a double poor health burden in low- and middle-income countries. Early life influences play an important part in this scenario because maternal lifestyle and conditions such as gestational diabetes and obesity affect the risk of diabetes in the next generation. This indicates important periods during the lifecourse when interventions could have powerful affects in reducing incidence of non-communicable diseases. However, interventions to promote diet and lifestyle in prospective parents before conception have not received sufficient attention, especially in low- and middle-income countries undergoing socio-economic transition.

DISCUSSION

Interventions to produce weight loss in adults or to reduce weight gain in pregnancy have had limited success and might be too late to produce the largest effects on the health of the child and his/her later risk of non-communicable diseases. A very important factor in the prevention of the developmental component of diabetes risk is the physiological state in which the parents enter pregnancy. We argue that the most promising strategy to improve prospective parents' body composition and lifestyle is the promotion of health literacy in adolescents. Multiple but integrated forms of community-based interventions that focus on nutrition, physical activity, family planning, breastfeeding and infant feeding practices are needed. They need to address the wider social economic context in which adolescents live and to be linked with existing public health programmes in sexual and reproductive health and maternal and child health initiatives.

SUMMARY

Interventions aimed at ensuring a healthy body composition, diet and lifestyle before pregnancy offer a most effective solution in many settings, especially in low- and middle-income countries undergoing socio-economic transition. Preparing a mother, her partner and her future child for "the 1000 days", whether from planned or unplanned conception would break the cycle of risk and demonstrate benefit in the shortest possible time. Such interventions will be particularly important in adolescents and young women in disadvantaged groups and can improve the physiological status of the fetus as well as reduce the prevalence of pregnancy conditions such as gestational diabetes mellitus which both predispose to non-communicables diseases in both the mother and her child. Pre-conception interventions require equipping prospective parents with the necessary knowledge and skills to make healthy lifestyle choices for themselves and their children. Addressing the promotion of such health literacy in parents-to-be in low- and middle-income countries requires a wider social perspective. It requires a range of multisectoral agencies to work together and could be linked to the issues of women's empowerment, to reproductive health, to communicable disease prevention and to the Millennium Development Goals 4 and 5.

Hospital charges of potentially preventable pediatric hospitalizations

OBJECTIVES

Reducing the number of preventable hospitalizations represents a possible source of health care savings. However, the current literature lacks a description of the extent of potentially preventable pediatric hospitalizations. The study objectives are to (1) identify the charges and (2) demographic characteristics associated with potentially preventable pediatric hospitalizations.

METHODS

Secondary analysis of the 2006 Kids' Inpatient Database (weighted N = 7,558,812). International Classification of Diseases, Ninth Revision, Clinical Modification codes for 16 previously validated pediatric ambulatory care-sensitive (ACS) conditions identified potentially preventable hospitalizations; seven additional conditions reflected updated care guidelines. Outcome variables included number of admissions, hospitalization days, and hospital charges. Demographic and diagnostic variables associated with an ACS condition were compared with regression analyses by the use of appropriate person-level weights.

RESULTS

Pediatric ACS hospitalizations totaled $4.05B in charges and 1,087,570 hospitalization days in 2006. Two respiratory conditions-asthma and bacterial pneumonia-comprised 48.4% of ACS hospital charges and 46.7% of ACS hospitalization days. In multivariate analysis, variables associated with an ACS condition included: male gender (odds ratio [OR] 1.10; 95% confidence interval [95% CI] 1.07-1.13); race/ethnicity of black (OR 1.22; 95% CI 1.16-1.27) or Hispanic (OR 1.12; 95% CI 1.06-1.18); and emergency department as admission source (OR 1.37; 95% CI 1.27-1.48).

CONCLUSIONS

Respiratory conditions comprised the largest proportion of potentially preventable pediatric hospitalizations, totaling as much as $1.96B in hospital charges. Children hospitalized with an ACS condition tend to be male, non-white, and admitted through the emergency department. Future research to prevent pediatric hospitalizations should examine targeted interventions in the primary care setting, specifically around respiratory conditions and minority populations.

The influence of task environment and health literacy on the quality of parent-reported ADHD data

OBJECTIVES

To determine 1) the extent to which paper-based and computer-based environments influence the sufficiency of parents' report of child behaviors and the accuracy of data on current medications, and 2) the impact of parents' health literacy on the quality of information produced.

METHODS

We completed a randomized controlled trial of data entry tasks with parents of children with Attention Deficit Hyperactivity Disorder (ADHD). Parents completed the NICHQ Vanderbilt ADHD screen and a report of current ADHD medications on paper or using a computer application designed to facilitate data entry. Literacy was assessed by the Test of Functional Health Literacy in Adults (TOFHLA). Primary outcomes included sufficient data to screen for ADHD subtypes and accurate report of total daily dose of prescribed ADHD medications.

RESULTS

Of 271 parents screened, 194/271 were eligible and 182 were randomized. Data from 180 parents were analyzed. 5.6% parents had inadequate/marginal TOFHLA scores. Using the computer, parents provided more sufficient and accurate data compared to paper (sufficiency for ADHD screening, paper vs. computer: 87.8% vs. 93.3%, P = 0.20; accuracy of medication report: 14.3% vs. 69.4%; p<0.0001). Parents with adequate literacy had increased odds of reporting sufficient and accurate data (sufficiency for ADHD screening: OR 8.0, 95% CI 2.0-32.1; accuracy of medication report: OR 4.4, 95% CI 0.5-37.4). In adjusted models, the computer task environment remained a significant predictor of accurate medication report (OR 18.7, 95% CI 7.5-46.9).

CONCLUSIONS

Structured, computer-based data entry by parents may improve the quality of specific types of information needed for ADHD care. Health literacy affects parents' ability to share valid information.

Dentist-patient communication techniques used in the United States: the results of a national survey

BACKGROUND

The authors conducted a national survey to determine the communication techniques that dentists use routinely and variations in their use.

METHODS

American Dental Association Survey Center staff members mailed an 86-item questionnaire to a random sample of 6,300 U.S. dentists in private practice. Participants reported routine use ("most of the time" or "always") during a typical week of 18 communication techniques, of which seven are basic techniques. The authors used analysis of variance and ordinary least squares regression models to test the association of communication, provider and practice characteristics with the number of techniques.

RESULTS

Dentists routinely use an average of 7.1 of the 18 techniques and 3.1 of the seven basic techniques. Two-thirds or more of dentists used four of the techniques (hand out printed materials, speak slowly, use models or radiographs to explain, use simple language). Less than one-fourth of dentists used any of the techniques in the teach-back method or patient-friendly practice domains. A dentist's age, race/ethnicity, education outside the United States and area of dentistry affected use. Health literacy variables (awareness, education in communication, practice-level change, outcome expectancy) and lack of time were associated with the number of techniques used.

CONCLUSIONS

Routine use of all of the communication techniques is low among dentists, including some techniques thought to be most effective with patients with low literacy skills.

PRACTICE IMPLICATIONS

Professional education is needed to improve knowledge about communication techniques and to ensure that they are used effectively. A firm foundation for these efforts requires the development, evaluation and dissemination of communication guidelines for dental care professionals.

What makes teens start using and keep using health information web sites? A mixed model analysis of teens with chronic illnesses

OBJECTIVE

Publically available health Web sites may be able to provide support for teens with chronic disease in their transition to autonomy. This study examines teen use of health Web sites and identifies barriers and promoters of use.

MATERIALS AND METHODS

One hundred eighty (n=180) teens, aged 13-18, were recruited from asthma and diabetes specialty clinics and given a resource sheet listing selected publically available Web sites. Web sites were categorized as general health, teen health, disease specific (asthma or diabetes), and disease management. One hundred twenty-nine (n=129) participants completed a 3-month follow-up semistructured telephone interview that assessed subsequent use of resource sheet Web sites and collected verbatim comments regarding use.

RESULTS

Sixty percent visited at least one Web site from the resource sheet. General health (38.8%) and teen health Web sites (38.0%) were most likely to be visited. Reasons for not visiting any site were categorized as lack of time, lack of interest, lack of Internet access, and lack of medical need. Teen health sites had the highest intention for continued use. Comments associated with willingness to continue use were categorized into the following themes: usefulness, ease, medical need, teen-specific features, and frequency of updates. Neither health literacy nor demographic factors were significantly associated with use.

CONCLUSIONS

Making a first Web site visit generally leads to a desire for continued use, but teens will not make the first effort of visiting a Web site unless they are engaged and interested in their own health management. Teens are most willing to become regular users of Web sites that they perceive to be useful and to be targeted toward them.

The development of building wellness™, a youth health literacy program

Health literacy research has concentrated on adults; there has been inadequate research on youth health literacy and the effect it may have on health outcomes. Low-income, minority populations have low levels of health literacy and are at higher risk of illness and disease. Building Wellness™ is a youth health literacy curriculum targeting low-income youth from 3rd grade to 8th grade in order to prepare the youth to be active, educated participants in their healthcare. Lessons focus on asthma, obesity and overweight, accidental injury, and drug and alcohol use. Curriculum development was based on qualitative and quantitative assessment of the target population. The preliminary findings from the pilot project show an increase in knowledge, improved healthy behaviors, and enthusiasm from participants and facilitators. The development of the pilot project is described, with a suggestion for future development of youth health literacy assessment tools.

Oral health literacy among female caregivers: impact on oral health outcomes in early childhood

The aim of this study was to investigate the association of female caregivers' oral health literacy with their knowledge, behaviors, and the reported oral health status of their young children. Data on caregivers' literacy, knowledge, behaviors, and children's oral health status were used from structured interviews with 1158 caregiver/child dyads from a low-income population. Literacy was measured with REALD-30. Caregivers' and children's median ages were 25 yrs (range = 17-65) and 15 mos (range = 1-59), respectively. The mean literacy score was 15.8 (SD = 5.3; range = 1-30). Adjusted for age, education, and number of children, low literacy scores (< 13 REALD-30) were associated with decreased knowledge (OR = 1.86; 95% CI = 1.41, 2.45) and poorer reported oral health status (OR = 1.44; 95% CI = 1.02, 2.05). Lower caregiver literacy was associated with deleterious oral health behaviors, including nighttime bottle use and no daily brushing/cleaning. Caregiver oral health literacy has a multidimensional impact on reported oral health outcomes in infants and young children.