Health literacy and pediatric health

Patient-Reported Outcome Measures for Hearing Aid Benefit and Satisfaction: Content Validity and Readability

PURPOSE

Numerous patient-reported outcome measures (PROMs) are available to measure hearing aid benefit and satisfaction. It is unclear to what extent currently available PROMs on hearing aid outcomes, often developed decades ago, meet current guidelines for good content validity and readability. This study evaluated the content validity and readability of PROMs that focus on perceived hearing aid benefit and/or satisfaction.

METHOD

A literature review was conducted to identify eligible instruments. Content validity evaluation included mapping extracted questionnaire items to the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework. In addition, study design in content validity methodology was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments study design checklist for PROM instruments. Readability was estimated using the Simple Measure of Gobbledygook measure.

RESULTS

Thirteen questionnaires were identified and evaluated. Item content focused primarily on the components of environmental factors as well as activity limitations and participation restrictions with less emphasis on body functions and personal factors. The content validity methodology analysis revealed an underuse or lack of reporting of a qualitative methodology in assessing patient and professional perspectives. All the included questionnaires exceeded the recommended sixth-grade reading level.

CONCLUSIONS

The categories covered by hearing aid PROMs vary considerably, with no single instrument comprehensively covering all the key ICF components. Future development of hearing aid outcome measures should consider a mixed methodology approach for improved content validity and ensure an appropriate reading level.

Health literacy and its association with adherence in pediatric liver transplant recipients and their parents

OBJECTIVE

Non-adherence to pediatric regimens is a common concern. Low health literacy is correlated with poor outcomes in adults but is understudied in pediatrics. The current project aimed to determine the relationship between health literacy, adherence, and outcomes in pediatric liver transplant recipients. Hypotheses included a) parent and patient health literacy would be positively correlated; and b) low patient and/or parent health literacy would be negatively correlated with adherence and health outcomes.

PATIENTS AND METHODS

Eligible participants were recruited during routine follow-up visits in a pediatric liver transplant clinic. Parents and patients (>13 years old) completed 2 measures of health literacy. Patients ≥18 years completed health literacy measures without corresponding parent surveys. Adherence variables and health outcomes were obtained from medical records.

RESULTS

Seventy-nine patients across two sites completed the study. Variance in classification of health literacy between measures was observed; however, most parents (82%-100%) scored within an "adequate literacy" range. More adolescents scored in lower health literacy ranges relative to the parents. Markers of SES were positively correlated with health literacy. Parent health literacy was negatively associated with biopsy-proven rejection episodes and the number of hospitalizations; however, it was not associated with measures of tacrolimus adherence. There were no relationships observed between parent and adolescent health literacy.

CONCLUSIONS

Health literacy is an important consideration in managing patient care; however, available measures demonstrate variability in capturing the skills of patients. Effective communication strategies may ameliorate admittedly small, but negative, impacts of limited health literacy on outcomes.

Integrating Health Literacy Into Core Curriculum: A Teacher-Driven Pilot Initiative for Second Graders

BACKGROUND

Limited research has addressed the effects of health literacy interventions in elementary schools. However, school-aged children's health literacy is critical because children make decisions about their health every day. The purpose of the pilot project was to explore the feasibility of integrated health literacy lesson plans for second graders.

METHODS

A pretest-posttest evaluation was conducted with second grade students following implementation of health literacy lessons that were integrated into core curriculum (language arts, science, and social studies).

RESULTS

Health educators, a hospital/health care system, and a school district developed a partnership. A research team of teachers, administrators, health literacy experts and health care organizations designed and implemented health literacy lesson plans. A developmentally appropriate measure of health literacy was adapted from the Newest Vital Sign. Data showed that students' health literacy scores significantly increased after implementation of 4 lesson plans.

CONCLUSIONS

This was an exploratory, pilot project that provided a useful starting point for discussing how to integrate health literacy into elementary school curriculum. An interdisciplinary team developed integrated health literacy materials that acknowledged the needs of teachers, the resources available, and the developmental stages of children. This intervention serves as a model for future health literacy initiatives in schools.

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.

Association Between Health Literacy and Parental Self-Efficacy among Parents of Newborn Children

OBJECTIVE

To determine whether health literacy was associated with parental self-efficacy in a diverse sample of parents of newborns. We hypothesized that parents with lower health literacy would have lower parental self-efficacy.

STUDY DESIGN

We conducted a cross-sectional analysis of baseline surveys from 253 English and Spanish speaking parents >18 years old with newborns <28 days old enrolled in a trial testing a multisite primary care-based parenting intervention. Surveys assessed parental, child, and environmental characteristics, and used validated instruments to measure health literacy and parental self-efficacy (total and 4 subtypes). Bivariate analyses identified parental, child, and environmental characteristics associated with parental self-efficacy. Multivariable linear regression models examined the associations between health literacy and parental self-efficacy, adjusting for covariates.

RESULTS

Parents (median age, 29 years) were 92.1% female, 54.5% black/African American, and 29.6% Hispanic/Latino. More than one-half (58.9%) had completed some college education or more, 49.0% spoke mostly English, and 16.2% had low health literacy. In bivariate analyses, parental self-efficacy was significantly lower in parents with fewer household residents. In multivariable analyses, parents with low compared with high health literacy had significantly lower parental self-efficacy scores (total and 4 subtypes including caretaking procedures, evoking behaviors, reading behaviors and signaling, and situational beliefs).

CONCLUSIONS

Lower health literacy was associated with lower parental self-efficacy in parents of newborns. To maximize impact on positive parenting behaviors and child outcomes, interventions assisting parents with low parental self-efficacy should consider strategies to address low health literacy.

Assessing the Understanding of Pediatric-Oriented Medication Education Materials Versus Standard Available Education Materials

OBJECTIVES

The objective of this study was to determine if education material targeting children would improve understanding of medication indication, administration, and common side effects in pediatric subjects.

METHODS

This cross-sectional pilot study included students 7 to 11 years old from a suburban elementary school. Study participants were read either the US Food and Drug Administration-approved adult medication leaflet or a pediatric medication leaflet created at a first-grade reading level for levetiracetam (Keppra, UCB, Inc, Atlanta, GA). Students were asked a set of standardized survey questions to evaluate comprehension of side effects, medication indication, dosing frequency, administration, and overall impression of the leaflet.

RESULTS

Fifty-eight children were included. Fifty percent of the children were male, 79% were Caucasian, and the average age was 9 years. There was no statistical difference for demographics in the adult leaflet versus the pediatric leaflet group. Children correctly stated the indication for the medication in 30% of participants (9/30) in the adult leaflet group and 79% of participants (22/28) in the pediatric leaflet group, p = 0.002. The administration frequency question was answered correctly in 93% of the pediatric leaflet group (26/28) as compared to 73% in the adult leaflet group (22/30), p = 0.05. For questions about side effects and how to administer the medication, there was no difference between the groups. The responses regarding readability and understanding of the leaflets were significantly different in the pediatric leaflet group compared to the adult leaflet group, p = 0.001 and p = 0.001, respectively.

CONCLUSIONS

Leaflets designed for pediatric patients resulted in an improvement in the understanding of the indication for levetiracetam.

Readability of Patient-Reported Outcome Measures in Adult Audiologic Rehabilitation

PURPOSE

The purpose of this study was to examine the readability of published patient-reported outcome measures (PROMs) designed for use in adult audiologic rehabilitation. The readability results were compared with the readability levels recommended for health information by health literacy experts.

METHOD

Reading grade levels were calculated using the Flesch-Kincaid Grade Level Formula (Flesch, 1948), Gunning Fog Index (Gunning, 1952), Simple Measure of Gobbledygook (McLaughlin, 1969), and FORCAST (Caylor, Sticht, Fox, & Ford, 1973) readability formulas for 10 published PROMs. Descriptive statistics were computed across the different PROM sections: instructions, items, response scale, and overall contents of the measure directed toward respondents.

RESULTS

The majority of the PROM sections exceeded the 6th grade reading level recommended by health literacy experts, regardless of the formula applied. All PROM sections exceeded the 6th grade reading level when calculated according to the FORCAST formula, the most appropriate readability formula for use with a nonnarrative text format, such as PROMs.

CONCLUSIONS

When developing or reevaluating PROMs designed for use in adult audiologic rehabilitation, researchers should consider ways to improve the readability of their measure, as poor readability may affect the validity of the empirical data collected using the PROM. Additionally, the adequate readability of audiologic PROMs is required if patient/family-centered care values are to be adhered to within the field of adult audiologic rehabilitation.

Dental caries in schoolchildren: influence of inattention, hyperactivity and executive functions

Attention-deficit/hyperactivity disorder (ADHD) is characterized by inappropriate levels of hyperactivity, impulsivity, and/or inattention. Individuals with ADHD may present limitations with regard to executive functions and performing activities that involve planning and/or attention/concentration. The aim of the study was to investigate the association between dental caries and signs of ADHD in a representative sample of schoolchildren. A representative sample of 851 schoolchildren aged seven to 12 years was randomly selected from public and private schools. Data acquisition involved a clinical dental examination for cavitated permanent and deciduous teeth using the DMFT/dmft indices. Neuropsychological evaluations, including the assessment of intelligence (Raven's Colored Progressive Matrix Test) and executive functions (Corsi Tapping Blocks tests and Digit Span test) were also performed. Parents/caregivers and teachers answered the SNAP-IV Questionnaire for the investigation of signs of inattention and hyperactivity in the family and school environment. Parents/caregivers also answered questionnaires addressing socioeconomic and socio-demographic characteristics. Descriptive analysis of the variables and Poisson regression with robust variance were performed. Parental reports of signs of inattention (PR: 1.28; p < 0.05) and hyperactivity (PR: 1.15; p < 0.05) were associated with a greater occurrence of caries. A better performance on the backward order of the Corsi Tapping Blocks tests (PR: 0.94; p < 0.05) and higher level of mother's schooling were associated with a lower frequency of caries. A better performance on executive function tasks was a protective factor against dental caries, whereas children considered inattentive and/or hyperactive by their parents had a higher prevalence rate of dental caries.

Associations between Parents' Health Literacy and Sleeping Hours in Children: A Cross-Sectional Study

Background: Sleep in preschool children is an important factor for their health and active lives. The lack of adequate sleep in preschool children is a serious public problem in Japan. The relationship between health literacy (HL) and health status is well recognized. The purpose of this study was to investigate the association between the sleep duration of preschool children and the HL of their parents. Methods: In the present study, participants were preschool children (3–6 years) and their parents. We assessed the HL of the parents with the 14-item Health Literacy Scale (HLS-14) questionnaire. Sleep duration of the children was reported by their parents. We divided parents into two groups according to HLS-14 score and analyzed children’s sleeping time separately. Results: Data from 279 parents and their children were ultimately analyzed. The high HL group comprised 210 families (75.3%) and the low HL group comprised 69 families (24.7%). Average children’s sleep duration was significantly longer in the high HL group (9.5 ± 0.9 h) than in the low HL group (9.1 ± 1.1 h) (p = 0.013). A positive correlation was found in the low HL group between parents’ HL and their children’s sleeping times (p < 0.01, r = 0.32) but the difference was not significant in the high HL group (p = 0.98, r = −0.0009). Conclusion: The HL of parents appears to affect their children’s sleep duration, suggesting that parental HL may be an appropriate target for interventions aiming to lengthen children’s sleeping time.

Does the use of the Informed Healthcare Choices (IHC) primary school resources improve the ability of grade-5 children in Uganda to assess the trustworthiness of claims about the effects of treatments: protocol for a cluster-randomised trial

BACKGROUND

The ability to appraise claims about the benefits and harms of treatments is crucial for informed health care decision-making. This research aims to enable children in East African primary schools (the clusters) to acquire and retain skills that can help them make informed health care choices by improving their ability to obtain, process and understand health information. The trial will evaluate (at the individual participant level) whether specially designed learning resources can teach children some of the key concepts relevant to appraising claims about the benefits and harms of health care interventions (treatments).

METHODS

This is a two-arm, cluster-randomised trial with stratified random allocation. We will recruit 120 primary schools (the clusters) between April and May 2016 in the central region of Uganda. We will stratify participating schools by geographical setting (rural, semi-urban, or urban) and ownership (public or private). The Informed Healthcare Choices (IHC) primary school resources consist of a textbook and a teachers' guide. Each of the students in the intervention arm will receive a textbook and attend nine lessons delivered by their teachers during a school term, with each lesson lasting 80 min. The lessons cover 12 key concepts that are relevant to assessing claims about treatments and making informed health care choices. The second arm will carry on with the current primary school curriculum. We have designed the Claim Evaluation Tools to measure people's ability to apply key concepts related to assessing claims about the effects of treatments and making informed health care choices. The Claim Evaluation Tools use multiple choice questions addressing each of the 12 concepts covered by the IHC school resources. Using the Claim Evaluation Tools we will measure two primary outcomes: (1) the proportion of children who 'pass', based on an absolute standard and (2) their average scores.

DISCUSSION

As far as we are aware this is the first randomised trial to assess whether key concepts needed to judge claims about the effects of treatment can be taught to primary school children. Whatever the results, they will be relevant to learning how to promote critical thinking about treatment claims. Trial status: the recruitment of study participants was ongoing at the time of manuscript submission.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, trial identifier: PACTR201606001679337 . Registered on 13 June 2016.

Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment

BACKGROUND AND OBJECTIVES

Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language.

METHODS

Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose).

RESULTS

A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4).

CONCLUSIONS

Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

Adolescents with Hearing Loss and the International Classification of Functioning, Health, and Disability: Children & Youth Version

In 2007, the World Health Organization published a set of International Classification of Functioning, Disability and Health (ICF) codes designed for children and youth (ICF-CY version). The ICF-CY considers typical developmental changes associated with childhood while describing health status and the effects of intervention. In this article we will describe how a specific intervention (transition planning for adolescents) can be documented with the ICF-CY. Transition planning in health care prepares adolescents and their families for the transfer from pediatric to adult health services and has been demonstrated to be an effective practice for adolescents with many types of chronic health conditions (e.g., cystic fibrosis, epilepsy, diabetes). Audiology has not yet addressed transition planning for adolescents with hearing loss; therefore, we propose using the ICF-CY to design a pathway of care. The ICF-CY can standardize transition planning to the benefit of both teen patients and audiologists: teens and their families would gradually acquire necessary knowledge and skills, and audiologists would develop a meaningful data set to help further inform our pediatric practices, as well as give more structure, depth, and accountability to our role in rehabilitation.

Pediatric Audiology Report: Assessment and Revision of an Audiology Report Written to Parents of Children With Hearing Impairment

OBJECTIVE

The purpose of this study was twofold: first, to evaluate a typical pediatric diagnostic audiology report to establish its readability and comprehensibility for parents and, second, to revise the report to improve its readability, as well as the comprehension, sense of self-efficacy, and positive opinions of parent readers.

METHOD

In Experiment 1, a mock audiology report was evaluated via a readability analysis and semistructured interviews with 5 parents. In Experiment 2, the report was revised using best practice guidelines and parental recommendations from Experiment 1. The revision was verified by randomly assigning 32 new parent participants to read either the revised or unrevised report before their comprehension, self-efficacy, and opinions were assessed.

RESULTS

In Experiment 1, results confirmed that the report was difficult to read and understand. In Experiment 2, parents who read the revised report had significantly greater comprehension, self-efficacy, and opinion ratings than those who read the unrevised report. In addition, the readability of the revised report was markedly improved compared with the unrevised report.

CONCLUSIONS

This study shows that pediatric diagnostic audiology reports can be revised to adhere to best practice guidelines and yield improved readability, in addition to improving the comprehension, sense of self-efficacy, and positive opinions of parents of children with hearing impairment.

Parent health literacy and adherence-related outcomes in children with epilepsy

BACKGROUND

The relationship between parent health literacy and adherence to treatment in children with epilepsy has not been fully explored. The purpose of this study was to determine whether parent health literacy and other variables predicted factors associated with adherence, such as missed medication doses, missed medical appointments, and seizure frequency, in children with epilepsy between 1 and 12 years old.

METHODS

It was hypothesized that parents with adequate parent health literacy would report fewer missed doses, missed appointments, and seizure occurrences. Using a nonexperimental, cross-sectional study design, interviews were conducted with 146 parents and guardians of children with epilepsy who resided in rural communities. Univariate analyses, including ANOVA, and multiple linear regressions were conducted.

RESULTS

Results indicated that parent health literacy was the strongest predictor of two of the adherence-related factors. Higher health literacy scores were associated with fewer missed medication doses and seizure occurrences. However, health literacy was not associated with missed medical appointments. Among other study variables, higher household income was also predictive of fewer missed doses.

CONCLUSION

The study findings suggest that inadequate health literacy among parents may serve as an independent risk factor for adherence-related outcomes among children with epilepsy. Further research, as well as effective, targeted parent health literacy strategies used to improve epilepsy management and care in children, is recommended.

Teaching children in low-income countries to assess claims about treatment effects: prioritization of key concepts

BACKGROUND

Health-related knowledge and behaviours developed during childhood are increasingly being recognized as foundational, deeply rooted and resistant to change as children mature into adulthood. The aim of this study was to engage stakeholders in prioritizing key concepts that children need to understand when assessing claims about treatment effects.

METHODS

A list of 30 concepts developed prior was categorized into six groups considered important for children to understand in order to assess claims about the effects of "treatments" (any type of healthcare intervention). A teachers' network was established comprising of primary school teachers, who attended a three-day meeting where the concepts were presented, discussed and prioritized using a pre-set criteria thus: (i) relevance of concepts for children, (ii) ease of comprehension of concepts for children, (iii) potential for developing resources to teach the children and (iv) whether the resources once developed would have an impact on children's ability to assess claims. Using a modified Delphi technique, participants ranked each group of concepts using the four criteria on a Likert scale of one to six (1 = lowest, 6 = highest). The rankings were analysed using STATA statistical software.

RESULTS

Twenty-two of the 24 participants reported having understood the concepts well; with self-assessments of their own understanding above 75 on a scale of (1 to 100). All six groups of concepts were considered relevant.

CONCLUSION

It is important to teach children how to assess claims about benefits and harms of treatments. Resources will be developed to teach children these concepts.

Asthma management self-efficacy in parents of primary school-age children

The aim of this study was to investigate asthma management self-efficacy in parents of primary school-age children with asthma and to explore possible associations between parent asthma management self-efficacy, parent and child characteristics, asthma task difficulty and asthma management responsibility. A cross-sectional descriptive survey of 113 parents was conducted to assess the level of parent asthma management self-efficacy, asthma task difficulty and confidence, asthma responsibility and socio-demographic characteristics. The findings indicate that parents had higher self-efficacy for attack prevention than attack management. Parents had higher self-efficacy for asthma management tasks that are simple, skills based and performed frequently such as medication administration and less confidence and greater difficulty with tasks associated with judgement and decision-making. Multivariate linear regression analysis identified English language, child asthma responsibility and parent education as predictors of higher asthma management self-efficacy, while an older child was associated with lower parent asthma management self-efficacy. The implications of these results for planning and targeting health education and self-management interventions for parents and children are discussed.

Seven practical principles for improving patient education: Evidence-based ideas from cognition science

An important role of the paediatrician is that of a teacher - every clinician is an educator to patients and their families. This education, however, often occurs under difficult or time-pressured learning conditions. The authors present principles derived from three basic theories of human cognition that may help to guide clinicians' instruction of parents and patients. Cognitive load theory holds that an individual's capacity to process information is finite. By controlling information flow rate, decreasing reliance on working memory and removing extraneous cognitive load, learning is improved. Dual code theory suggests that humans have separate cognitive 'channels' for text/audio information versus visual information. By constructing educational messages that take advantage of both channels simultaneously, information uptake may be improved. Multimedia theory is based on the notion that there is an optimal blend of media to accomplish a given learning objective. The authors suggest seven practical strategies that clinicians may use to improve patient education.

The relationship between parent health literacy and pediatric emergency department utilization: a systematic review

BACKGROUND

Low health literacy in parents can potentially impact understanding of a child's diagnosis and treatment course. No reviews have addressed parent health literacy in the emergency department (ED), the relationship between parent health literacy and child ED utilization, or the impact of low literacy interventions on child ED utilization.

OBJECTIVE

To systematically evaluate the peer-reviewed literature pertaining to parental health literacy and ED utilization. The following key questions were addressed: question (Q) 1) What is the prevalence of low health literacy, as estimated by validated health literacy measures, of parents in the ED? Q2) Is parent low health literacy related to ED use for children? Q3) Do low literacy interventions targeting parents likely to have low health literacy affect ED use for children?

DATA SOURCES

The authors reviewed 483 unduplicated titles and abstracts published between 1980 and May 2012 using PubMed and CINAHL, with 117 retained for full review and 17 included in the final analytic review.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

All included articles had a valid measure of parent health literacy and a Q1) descriptive measurement of the population, Q2) ED utilization, or Q3) utilized a low literacy educational intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author extracted data verified by a second author. Studies were rated for quality by both authors.

RESULTS

Q1) A median of 30% (interquartile range 22-36%) of parents in the ED possesses low health literacy. Q2) Studies investigating the relationship between health literacy and ED yielded mixed results. Q3) Seven of 8 low literacy interventions were associated with a reduction in ED use. Random effects pooled odds ratios from 6 studies showed intervention effectiveness (odds ratio 0.35; 95% CI 0.15-0.81).

LIMITATIONS

No intervention studies measured health literacy, limiting the ability to determine whether the low literacy intervention targeted health literacy.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Roughly 1 in 3 parents of children presenting to the ED have low health literacy. Importantly, interventions targeting parents likely to have low health literacy have an impact in reducing ED utilization.

Evaluation, modification and validation of a set of asthma illustrations in children with chronic asthma in the emergency department

OBJECTIVES

To test, modify and validate a set of illustrations depicting different levels of asthma control and common asthma triggers in pediatric patients (and⁄or their parents) with chronic asthma who presented to the emergency department at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

METHODS

Semistructured interviews using guessability and translucency questionnaires tested the comprehensibility of 15 illustrations depicting different levels of asthma control and common asthma triggers in children 10 to 17 years of age, and parents of children one to nine years of age who presented to the emergency department. Illustrations with an overall guessability score <80% and⁄or translucency median score <6, were reviewed by the study team and modified by the study's graphic designer. Modifications were made based on key concepts identified by study participants.

RESULTS

A total of 80 patients were interviewed. Seven of the original 15 illustrations (47%) required modifications to obtain the prespecified guessability and translucency goals.

CONCLUSION

The authors successfully developed, modified and validated a set of 15 illustrations representing different levels of asthma control and common asthma triggers.

PRACTICE IMPLICATIONS

These illustrations will be incorporated into a child-friendly asthma action plan that enables the child to be involved in his or her asthma self-management care.

Contextualizing an expanded definition of health literacy among adolescents in the health care setting

The current emphasis on preventive health care and wellness services suggests that measures of skills and competencies needed to effectively navigate the health care system need to be better defined. We take an expanded perspective of health literacy and define it as a set of skills used to organize and apply health knowledge, attitudes and practices relevant when managing one's health environment. It is an emerging area of inquiry especially among adults and those with chronic conditions; however, it has been less studied among adolescent populations. To begin operationalizing this concept in a manner appropriate for teens in a health systems context, we explored knowledge, attitudes and practices related to health and preventive health care in 12 focus groups with publicly insured adolescents (N = 137), aged 13-17 years, as well as eight key informant interviews with physicians who serve publicly insured teens. Five dimensions emerged that provide a preliminary framework for an expanded definition of health literacy among adolescents. These include: (i) navigating the system, (ii) rights and responsibilities, (iii) preventive care, (iv) information seeking and (v) patient-provider relationship. This robust definition of health literacy contextualizes the concept in a health environment where individuals must be informed and skilled health care consumers.

Predictors of antiretroviral medication adherence among a diverse cohort of adolescents with HIV

PURPOSE

To compare prevalence and describe predictors of antiretroviral treatment adherence among adolescents with HIV acquired perinatally (PIY) or through risk behaviors (BIY).

METHODS

Data were obtained from the baseline assessment of Adolescent Impact, an intervention for HIV-infected adolescents receiving care in three U.S. cities. Patients self-reported missed medication doses as well as medication factors, HIV knowledge, disclosure, substance use, mental health, and social support through face-to-face or computer-assisted interviews.

RESULTS

Of 104 participants, 68 (65.4%) reported full adherence. Compared with BIY, PIY were younger, had greater HIV disease severity, and had more structural supports. Adjusting for transmission mode (PIY vs. BIY), nonadherence by self-report was associated with higher viral load (VL) (adjusted odds ratio [AOR] = 1.5, confidence interval [CI] = 1.03, 2.18). Nonadherent adolescents were significantly likely to have had AIDS, discussed HIV disease with providers, reported difficulty with medication routine, experienced internalizing behavior problems, and used drugs. In multivariate analyses, independent predictors of nonadherence included acquiring HIV behaviorally (AOR = 4.378, CI = 1.055, 18.165), ever having AIDS (AOR = 4.78, CI = 1.31, 17.49), perceiving difficult medication routine (AOR = 1.84, CI = 1.07, 3.16), discussing disease indicators with provider (AOR = 4.57, CI = 1.74, 11.98), and missing doses because of forgetting (AOR = 2.53, CI = 1.29, 4.96). Adjusting for transmission mode, detectable VL was associated with lower recent CD4(+) lymphocyte counts, discussing disease indicators with providers, and missing doses because of forgetting or being depressed. Low recent CD4(+) lymphocyte counts (AOR = .988, p = .024) but fewer HIV symptoms (AOR = .466, p = .032) and missing doses because of forgetting (AOR = 1.76, p = .05) were independently associated with detectable VL in multivariate analysis.

CONCLUSIONS

Despite differences between groups, nonadherence was associated with severity of illness, difficult medication routine, and forgetfulness. Beyond individual needs, both groups of adolescents had suboptimal adherence and would benefit from simplified medication routines and organizational skills.

Perceived barriers to care and attitudes towards shared decision-making among low socioeconomic status parents: role of health literacy

OBJECTIVE

Although low parent health literacy (HL) has been linked to poor child health outcomes, it is not known whether differences in perceptions related to access to care and provider-parent partnership in care are potential contributing factors. We sought to assess whether parent HL is associated with differences in perceived barriers to care and attitudes regarding participatory decision-making with the provider.

METHODS

This was a cross-sectional analysis of data collected from parents presenting with their child to an urban public hospital pediatric clinic in New York City. Dependent variables were caregiver-reported barriers to care (ability to reach provider at night/on weekends, difficult travel to clinic) and attitudes towards participatory decision-making (feeling like a partner, relying on doctor's knowledge, leaving decisions up to the doctor, being given choices/asked opinion). The primary independent variable was caregiver HL (Short Test of Functional Health Literacy in Adults [S-TOHFLA]).

RESULTS

A total of 823 parents were assessed; 1 in 4 (27.0%) categorized as having low HL. Parents with low HL were more likely to report barriers to care than those with adequate HL: trouble reaching provider nights/weekends, 64.9% vs. 49.6%, (p < 0.001, adjusted odds ratio [AOR] 1.7, 95% confidence interval [95% CI] 1.2-2.4); difficult travel, 15.3% vs. 8.0%, (p = 0.004, AOR 1.8, 95% CI 1.1-3.0). Low HL was also associated with not feeling like a partner (28.8% vs. 17.1%; AOR 2.0; 95% CI 1.4-3.0), preference for relying on the doctor's knowledge (68.9% vs. 52.2%; AOR 1.7; 95% CI 1.2-2.4), and preference for leaving decisions up to the doctor (57.7% vs. 33.3%; AOR 2.2; 95% CI 1.6-3.1).

CONCLUSIONS

Addressing issues of parent HL may be helpful in ameliorating barriers to care and promoting provider-parent partnership in care.

Health-related behaviour, knowledge, attitudes, communication and social status in school children in Eastern Germany

Enhancing health literacy is a keystone in health promotion. Yet, most studies on health literacy are limited to functional literacy levels. Furthermore, little evidence is available from children. Based on Nutbeam's outcome model for health promotion, this study aims (i) to elaborate a set of short scales to measure important health literacy domains in children and (ii) to analyse their associations among each other, with health behaviour as an intermediate health outcome, subjective health, social status and gender. The sample comprised 852 school children in fifth grade, aged 9-13 years, in Western Pomerania, Germany. Items were taken from the child's questionnaire to form short scales for health-related knowledge, attitudes, communication and behaviour. The internal consistencies of the communication and attitude scales were 0.73 and 0.57, respectively. Unidimensional scalability of the knowledge and behaviour scales was supported by item response models. Associations between health scales were modest. In regression analyses, social status and gender predicted only health knowledge and communication but not health behaviours, attitudes and self-efficacy. Health knowledge was not associated with any other scale. Our results suggest that targeting one specific component of health literacy in children is likely to exert only small effects on health status and health behaviour.

Impact of caregiver literacy on children's oral health outcomes

OBJECTIVE

The objective of this study was to examine the relationship of primary caregivers' literacy with children's oral health outcomes.

METHODS

We performed a cross-sectional study of children who were aged < or =6 years and presented for an initial dental appointment in the teaching clinics at the University of North Carolina at Chapel Hill School of Dentistry. Caregiver literacy was measured using the Rapid Estimate of Adult Literacy in Dentistry (REALD-30). The outcome measures included oral health knowledge, oral health behaviors, primary caregiver's reports of their child's oral health status, and the clinical oral health status of the child as determined by a clinical examination completed by trained, calibrated examiners.

RESULTS

Among the 106 caregiver-child dyads enrolled, 59% of the children were male, 52% were white, and 86% of caregivers were the biological mothers. The bivariate results showed no significant relationships between literacy and oral health knowledge (P = .16) and behaviors (P = .24); however, there was an association between literacy and oral health status (P < .05). The multivariate analysis controlled for race and income; this analysis revealed a significant relationship between caregiver literacy scores and clinical oral health status as determined by using a standardized clinical examination. Caregivers of children with mild to moderate treatment needs were more likely to have higher REALD-30 scores than those with severe treatment needs (odds ratio: 1.14 [95% confidence interval: 1.05-1.25]; P = .003).

CONCLUSIONS

Caregiver literacy is significantly associated with children's dental disease status.

Vitamin D deficiency, eosinophilic esophagitis, and health literacy

PURPOSE OF REVIEW

To review the recent literature on three topics that are important in pediatric office practice: vitamin D deficiency, eosinophilic esophagitis, and health literacy. Review of current literature will help pediatricians understand the prevalence of vitamin D deficiency, its potential negative health effects, and vitamin D supplementation guidelines. This article also provides practitioners with current knowledge of the evaluation and treatment of eosinophilic esophagitis. The article concludes with a summary of recent literature on health literacy and available techniques to improve patient education.

RECENT FINDINGS

Vitamin D deficiency in pediatric and adolescent patients is extremely common and has potential negative skeletal and extra-skeletal effects. Eosinophilic esophagitis is an increasingly recognized problem. Pediatric patients benefit from early recognition and treatment of the disease. There are effective techniques that improve patient health literacy.

SUMMARY

Vitamin D deficiency, eosinophilic esophagitis, and poor health literacy are three important problems that potentially negatively impact the lives of children and adolescents. Pediatricians should regularly counsel their patients regarding appropriate vitamin D intake. Practitioners should be aware of the clinical presentation of eosinophilic esophagitis. Pediatricians should utilize strategies to improve patient education with the goal of improving health outcomes.

Health literacy and child health outcomes: a systematic review of the literature

OBJECTIVES

To review the relationship between parent and child literacy and child health outcomes and interventions designed to improve child health outcomes for children or parents with low literacy skills.

METHODS

We searched Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for articles published from 1980 through 2008 and included studies that reported original data, measured literacy and >or=1 health outcome, and assessed the relationship between literacy and health outcomes. Health outcomes included health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity. Two abstractors reviewed each study for inclusion. Included studies were abstracted into evidence tables and were assessed by using an 11-item quality scale.

RESULTS

We reviewed 4182 new titles and abstracts published since 2003. Fifty-eight articles were retained for full review, and 13 met the inclusion criteria. Eleven articles from the systematic review from 1980 to 2003 met the inclusion criteria, giving us a total of 24 articles. Children with low literacy generally had worse health behaviors. Parents with low literacy had less health knowledge and had behaviors that were less advantageous for their children's health compared with parents with higher literacy. Children whose parents had low literacy often had worse health outcomes, but we found mixed results for the relationship of literacy to the use of health care services. Interventions found that improving written materials can increase health knowledge, and combining good written materials with brief counseling can improve behaviors including adherence. The average quality of the studies was fair to good.

CONCLUSIONS

Child and parent literacy seems associated with important health outcomes. Future research can help us understand under what circumstances this relationship is causal, how literacy and health outcomes are related in noncausal pathways, the relative importance of parent and child literacy, and what interventions effectively reduce health literacy-related disparities.

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

OBJECTIVE

To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.

METHODS

A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.

RESULTS

More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.

CONCLUSIONS

A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

Maternal literacy and associations between education and the cognitive home environment in low-income families

OBJECTIVE

To determine whether maternal literacy level accounts for associations between educational level and the cognitive home environment in low-income families.

DESIGN

Analysis of 369 mother-infant dyads participating in a long-term study related to early child development.

SETTING

Urban public hospital.

PARTICIPANTS

Low-income mothers of 6-month-old infants.

MAIN EXPOSURE

Maternal literacy level was assessed using the Woodcock-Johnson III/Bateria III Woodcock-Munoz Tests of Achievement, Letter-Word Identification Test. Maternal educational level was assessed by determining the last grade that had been completed by the mother.

MAIN OUTCOME MEASURE

The cognitive home environment (provision of learning materials, verbal responsivity, teaching, and shared reading) was assessed using StimQ, an office-based interview measure.

RESULTS

In unadjusted analyses, a maternal literacy level of ninth grade or higher was associated with increases in scores for the overall StimQ and each of 4 subscales, whereas a maternal educational level of ninth grade or higher was associated with increases in scores for the overall StimQ and 3 of 4 subscales. In simultaneous multiple linear regression models including both literacy and educational levels, literacy continued to be associated with scores for the overall StimQ (adjusted mean difference, 3.7; 95% confidence interval, 1.7-5.7) and all subscales except teaching, whereas maternal educational level was no longer significantly associated with scores for the StimQ (1.8; 0.5-4.0) or any of its subscales.

CONCLUSIONS

Literacy level may be a more specific indicator of risk than educational level in low-income families. Studies of low-income families should include direct measures of literacy. Pediatricians should develop strategies to identify mothers with low literacy levels and promote parenting behaviors to foster cognitive development in these at-risk families.

The role of parent health literacy among urban children with persistent asthma

Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.

OBJECTIVE

To examine associations between parent HL and measures related to child asthma.

METHODS

Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews.

MEASURES

the Rapid Estimate of Adult Literacy in Medicine (REALM) for parent HL; National Heart Lung and Blood Institute (NHLBI) criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences.

ANALYSES

bivariate and multivariate analyses of associations between parent HL measures related to child asthma.

RESULTS

Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry, parent perception of greater asthma burden, and lower parent-reported quality of life. MEASURES of health care use (e.g., emergency care and preventive medicines) were not associated with parent HL.

CONCLUSIONS

Parents with limited HL worried more and perceived greater overall burden from the child's asthma, even though reported health care use did not vary.

PRACTICE IMPLICATIONS

Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.

Patient education on mobile devices: an e-health intervention for low health literate audiences

Providing health information to low health literate audiences remains a challenge. Beyond message design, realistic delivery models are needed for delivering information to a traditionally hard-to-reach audience. This study investigated two e-health interventions to provide health information on mobile devices — one providing diabetes information and one offering childcare information. Both were well-received, and most of the subjects' usability issues related to the translation of these interventions to the mobile device's smaller screen. The diabetes website was effective in providing information to study participants (as measured by pre- and post-tests of knowledge), while the childcare website was not. Continued work in this area could explore improved design strategies for mobile devices — a delivery model that could be used in doctors' offices, for example. Effective delivery of health information to low health literate audiences is an important issue, and this research highlights a critical element by targeting another potential delivery model.