Alan L. Mendelsohn

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.

Readability, suitability, and characteristics of asthma action plans: examination of factors that may impair understanding.

OBJECTIVE: Recognition of the complexity of asthma management has led to the development of asthma treatment guidelines that include the recommendation that all pediatric asthma patients receive a written asthma action plan. We assessed the readability, suitability, and characteristics of asthma action plans, elements that contribute to the effectiveness of action plan use, particularly for those with limited literacy. METHODS: This was a descriptive study of 30 asthma action plans (27 state Department of Health (DOH)–endorsed, 3 national action plans endorsed by 6 states). Outcome measures: (1) readability (as assessed by Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Forcast), (2) suitability (Suitability Assessment of Materials [SAM], adequate: ≥0.4; unsuitable: <0.4), (3) action plan characteristics (peak flow vs symptom-based, symptoms, recommended actions). RESULTS: Mean (SD) overall readability grade level was 7.2 (1.1) (range = 5.7–9.8); 70.0% were above a sixth-grade level. Mean (SD) suitability score was 0.74 (0.14). Overall, all action plans were found to be adequate, although 40.0% had an unsuitable score in at least 1 factor. The highest percent of unsuitable scores were found in the categories of layout/typography (30.0%), learning stimulation/motivation (26.7%), and graphics (13.3%). There were no statistically significant differences between the average grade level or SAM score of state DOH developed action plans and those from or adapted from national organizations. Plans varied with respect to terms used, symptoms included, and recommended actions. CONCLUSIONS: Specific improvements in asthma action plans could maximize patient and parent understanding of appropriate asthma management and could particularly benefit individuals with limited literacy skills.

Low-Level Lead Exposure and Behavior in Early Childhood

Objective. To assess whether small elevations in blood lead level were associated with measurable behavioral changes in a group of poor children between 1 and 3 years old. Methods. The study population consisted of children presenting for routine well-child care to the pediatric clinic at Bellevue Hospital Center, a large urban public hospital. The following inclusion criteria were used for entry into the study: age 12 to 36 months; capillary lead screening result <1.21 μmol/L (25 μg/dL); no known prior history either of blood lead level >1.21 μmol/L (25 μg/dL) or lead exposure requiring chelation therapy; Latino or African-American; English or Spanish spoken in the home; biological mother as primary caretaker; child not presently attending day care; full-term, singleton gestation; birth weight at least 2500 g; no known neurologic or developmental disorder; and no severe chronic disease, including human immunodeficiency virus infection. Study enrollment was simultaneously stratified by capillary lead level and age. All children between 12 and 36 months attending the pediatric clinic during the study period received screening capillary blood measures of lead level following the recommendations of the Centers for Disease Control and Prevention and the American Academy of Pediatrics as part of routine primary care. During periods of enrollment, consecutive lead measurements performed in the pediatric clinic were reviewed by one of the researchers. For those children meeting entry criteria based on lead level and age, further eligibility based on the remainder of the inclusion criteria was determined through parental interview and review of the medical record. Lead exposure was assessed with a single capillary blood specimen, using atomic absorption spectrophotometry. Subjects were considered to be lead-exposed if their lead level was between 0.48 and 1.20 μmol/L (10 and 24.9 μg/dL) and nonexposed if their lead level was between 0 and 0.48 μmol/L (0 and 9.9 μg/dL). Behavior was assessed using the Behavior Rating Scale (BRS) of theBayley Scales of Infant Development, second edition. The BRS in this age group consists of three components: an Emotional Regulation Factor that measures hyperactive/distractible/easy-frustration behaviors; an Orientation-Engagement Factor that measures fear/withdrawal/disinterest behaviors; and a Motor Quality Factor that assesses the appropriateness of movement and tone. The BRS is scored as a percentile; lower scores reflect more problematic behaviors. Researchers performing the BRS were blinded to capillary lead results. Information was collected concerning factors that might confound the relationship between lead and behavior. Demographic factors were collected, including: childs age, gender, and country of origin; mothers age, marital status, parity, country of origin, and primary language spoken; parental education, and occupation and receipt of public assistance. Socioeconomic status was determined using theHollingshead Two-Factor Index of Social Position. Maternal verbal IQ was assessed using the Peabody Picture Vocabulary Test-Revised. Maternal depression was assessed using the Center for Epidemiologic Studies-Depression Scale. Cognitive stimulation provided in the home was assessed using a new office-based instrument, the StimQ, which measures the quantity and quality of play materials and parent-toddler activities in the childs home. To assess the child for iron deficiency, we performed a hematocrit and mean corpuscular volume at the time of the capillary lead evaluation. A presumptive diagnosis of iron deficiency was made if the child was either anemic (defined as a hematocrit <32) or had a mean corpuscular volume <72. Results. The study sample consisted of 72 children. Children in the lead-exposed group (n = 41) had a mean BRS behavior score that was 15.8 points lower than that of children in the nonexposed group (n = 31), which was significant by the Studentst test. For the emotional regulation factor measuring hyperactive/impulsive/easy-frustration behaviors, children in the exposed group had a mean score that was 14.6 points lower than that of the nonexposed group, which was significant by the Studentst test. For the orientation-engagement factor measuring fear/withdrawal/disinterest behaviors, children in the exposed group had a mean score that was 14.1 points lower, significant by the Students t test. Multiple linear regression analyses were used to examine the independent relationship between BRS (total and factor scores) and lead group, after adjusting for potential confounders. Six variables were related to either lead group or BRS behavior score in unadjusted analysis and were, therefore, included as potential confounders in each of the multiple regressions: childs age and gender, and mothers age, verbal IQ, depression score, and provision of cognitive stimulation. In the analysis of the relationship between the BRS total score and lead group, the adjusted mean BRS behavior score in the exposed group was 17.3 points (95% confidence [CI]: 3.3, 31.3) lower than that of children in the nonexposed group (sr = -0.27). In the analysis of the relationship between the emotional regulation factor and lead group, the adjusted mean factor score in the exposed group was 16.6 points (95% CI: 2.1, 31.2) lower than that for the nonexposed group (sr = -0.25). In the analysis of the relationship between the orientation-engagement factor and lead group, the exposed group had an adjusted mean score that was 14.2 points (95% CI: −2.1, 30.5) lower than that for the nonexposed group (sr = -0.20). In these multiple regression analyses, mothers depression score was significantly associated with a lower total BRS score (sr = -0.25) and with lower emotional regulation factor (sr = -0.23). Older children had higher BRS scores (sr = 0.20), and had significantly higher emotional regulation factor scores (sr = 0.22). A relationship was observed between male gender and lower emotional regulation scores that did not reach significance (sr = -0.21). Iron deficiency, cognitive stimulation provided in the home and mothers verbal IQ were not related to any measures of behavior. Conclusions. Low-level lead exposure is associated with adverse behavioral changes in very young preschool children. This association may be particularly important for poor children, who are also at risk for behavior problems on the basis of other environmental factors such as maternal depression. Clinicians should consider screening for behavioral problems in very young children with low-level lead exposure.

Effectiveness of a Primary Care Intervention to Support Reading Aloud: A Multicenter Evaluation

OBJECTIVE Failure to read at grade level predicts life-long economic and social disability. Early exposure to reading aloud may prevent reading problems. This study seeks to determine whether institution of Reach Out and Read (ROR) programs is associated with increased reading aloud in a national sample. DESIGN Before-after intervention study: separate convenience samples were studied before and after institution of ROR programs at multiple sites. PARTICIPANTS AND SETTING A convenience sample of parents of children age 6-72 months seeking routine health care at 19 clinical sites in 10 states. INTERVENTIONS The ROR model incorporates anticipatory guidance about reading aloud and distribution of free picture books at health supervision visits from 6 months through 5 years as well as reading aloud in the waiting room. MAIN OUTCOME MEASURES Parents were interviewed about their attitudes and practices related to reading aloud, using questions drawn from validated instruments. RESULTS The sample included 1647 subjects (730 intervention, 917 comparison). After controlling for multiple potential confounding factors, significant associations were found between exposure to ROR and reading aloud as a favorite parenting activity (Adjusted Odds Ratio [AOR] 1.6, P < .001); reading aloud at bedtime (Adjusted Odds Ratio [AOR*rsqb; 1.5, P < .001); reading aloud 3 or more days per week (AOR 1.8, P < .001); and ownership of > or = 10 picture books (AOR 1.6, P < .001). CONCLUSIONS In a national sample, implementation of ROR programs was associated with increased parental support for reading aloud. This study provides evidence of the effectiveness of a primary care intervention strategy to promote reading aloud to young children.

Use of videotaped interactions during pediatric well-child care: impact at 33 months on parenting and on child development.

Objective: We performed a randomized, controlled trial to assess the impact of the Video Interaction Project (VIP), a program based in pediatric primary care in which videotaped interactions are used by child development specialists to promote early child development. Method: Ninety-nine Latino children (52 VIP, 47 controls) at risk of developmental delay based on poverty and low maternal education were assessed at age 33 months. VIP was associated with improved parenting practices including increased teaching behaviors. Results: VIP was associated with lower levels of parenting stress. VIP children were more likely to have normal cognitive development and less likely to have developmental delays. Conclusion: This study provides evidence that a pediatric primary care–based intervention program can have an impact on the developmental trajectories of at-risk young preschool children.

Infant Media Exposure and Toddler Development

OBJECTIVE To determine whether duration and content of media exposure in 6-month-old infants are associated with development at age 14 months. DESIGN Longitudinal analysis of 259 mother-infant dyads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008. SETTING An urban public hospital. PARTICIPANTS Mothers with low socioeconomic status and their infants. MAIN EXPOSURE Duration and content of media exposure at age 6 months. MAIN OUTCOME MEASURES Cognitive and language development at age 14 months. RESULTS Of 259 infants, 249 (96.1%) were exposed to media at age 6 months, with mean (SD) total exposure of 152.7 (124.5) min/d. In unadjusted and adjusted analyses, duration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (unadjusted: r = -0.17, P < .01; adjusted: β = -0.15, P = .02) and lower language development (r = -0.16, P < .01; β = -0.16, P < .01). Of 3 types of content assessed, only 1 (older child/adult-oriented) was associated with lower cognitive and language development at age 14 months. No significant associations were seen with exposure to young child-oriented educational or noneducational content. CONCLUSIONS This study is the first, to our knowledge, to have longitudinally assessed associations between media exposure in infancy and subsequent developmental outcomes in children from families with low socioeconomic status in the United States. Findings provide strong evidence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years, although further research is needed.

Primary Care Strategies for Promoting Parent-Child Interactions and School Readiness in At-Risk Families: The Bellevue Project for Early Language, Literacy, and Education Success

OBJECTIVE To determine the effects of pediatric primary care interventions on parent-child interactions in families with low socioeconomic status. DESIGN In this randomized controlled trial, participants were randomized to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks [BB]) or the control group. SETTING Urban public hospital pediatric primary care clinic. PARTICIPANTS Mother-newborn dyads enrolled post partum from November 1, 2005, through October 31, 2008. INTERVENTIONS In the VIP group, mothers and newborns participated in 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading by reviewing videos made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. In the BB group, parenting materials, including age-specific newsletters suggesting interactive activities, learning materials, and parent-completed developmental questionnaires, were mailed to the mothers. MAIN OUTCOME MEASURES Parent-child interactions were assessed at 6 months with the StimQ-Infant and a 24-hour shared reading recall diary. RESULTS A total of 410 families were assessed. The VIP group had a higher increased StimQ score (mean difference, 3.6 points; 95% confidence interval, 1.5 to 5.6 points; Cohen d, 0.51; 0.22 to 0.81) and more reading activities compared to the control group. The BB group also had an increased overall StimQ score compared with the control group (Cohen d, 0.31; 95% confidence interval, 0.03 to 0.60). The greatest effects for the VIP group were found for mothers with a ninth-grade or higher reading level (Cohen d, 0.68; 95% confidence interval, 0.33 to 1.03). CONCLUSIONS The VIP and BB groups each led to increased parent-child interactions. Pediatric primary care represents a significant opportunity for enhancing developmental trajectories in at-risk children. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00212576.

Literacy promotion: An essential component of primary care pediatric practice

Reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by (1) advising all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills; (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word; (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children; (4) using a robust spectrum of options to support and promote these efforts; and (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences. The AAP supports federal and state funding for children’s books to be provided at pediatric health supervision visits to children at high risk living at or near the poverty threshold and the integration of literacy promotion, an essential component of pediatric primary care, into pediatric resident education. This policy statement is supported by the AAP technical report “School Readiness” and supports the AAP policy statement “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.”

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 doctors 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 doctors 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.

Infant Television and Video Exposure Associated With Limited Parent-Child Verbal Interactions in Low Socioeconomic Status Households

OBJECTIVE To assess verbal interactions related to television and other electronic media exposure among mothers and 6 month-old-infants. DESIGN Cross-sectional analysis of 154 mother-infant dyads participating in a long-term study related to early child development. SETTING Urban public hospital. PARTICIPANTS Low socioeconomic status mothers of 6-month-old infants. Main Exposure Media exposure and content. MAIN OUTCOME MEASURES Mother-infant verbal interaction associated with media exposure and maternal coviewing. RESULTS Of 154 low socioeconomic status mothers, 149 (96.8%) reported daily media exposure in their infants, with median exposure of 120 (interquartile range, 60-210) minutes in a 24-hour period. Among 426 program exposures, mother-infant interactions were reported during 101 (23.7%). Interactions were reported most frequently with educational young child-oriented media (42.8% of programs), compared with 21.3% of noneducational young child-oriented programs (adjusted odds ratio, 0.4; 95% confidence interval, 0.1-0.98) and 14.7% of school-age/teenage/adult-oriented programs (adjusted odds ratio, 0.2; 95% confidence interval, 0.1-0.3). Among coviewed programs with educational content, mothers reported interactions during 62.7% of exposures. Coviewing was not reported more frequently for educational young child-oriented programs. CONCLUSIONS We found limited verbal interactions during television exposure in infancy, with interactions reported for less than one-quarter of exposures. Although interactions were most commonly reported among programs with educational content that had been coviewed, programs with educational content were not more likely to be coviewed than were other programs. Our findings do not support development of infant-directed educational programming in the absence of strategies to increase coviewing and interactions.