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Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization
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Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization

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Rosemary Frasso's presentation from the …

Rosemary Frasso's presentation from the

Penn Urban Doctoral Symposium

May 13, 2011

Co-sponsored with Penn’s Urban Studies program, this symposium celebrates the work of graduating urban-focused doctoral candidates. Graduates present and discuss their dissertation findings. Luncheon attended by the students, their families and their committees follows.

Published in: Education, Health & Medicine
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  • IOM, health people 2010, AMA Not just reading
  • Temporary assistance for needy families
  • Linking the records: Mothers ~ birth certificate ~ children’s SSN ~ Medicaid claims Is maternal HL associated pediatric healthcare use? If and to what extent does maternal HL mediate or moderate relationships between the predisposing and enabling factors and the dependent variables understudy?
  • We  employed a HEDIS measure, appropriate to our age group of interest, which explicitly described which Current Procedural Terminology (CPT) and International Classification of Diseases 9thRevision, Clinical Modification (ICD-9-CM) procedures and diagnostic codes indicate well-child preventive visits (National Committee for Quality Assurance, 2011; Zuckerman, et al., 2004). Sick –child visits are non-routine visits to a provider (for illness or injury) ED visits are any visit to an emergency department for care (for illness or injury) There is a precedent in the literature for setting this bench-mark at 4 for year 1 and 2 for year 2 of life, slightly lower than the AAP recommendations
  • This participant’s learning disability, in this context was a negative predisposing (denoted by circle A in diagram 4.5) factor and her decision not to disclose her reading disability to the clinician or ask her daughter to help her interpret the written education material can be categorized as a negative enabling factor (denoted by circle B in diagram 4.5) as well as factors that compromised her ability to assess the health care needs of her daughter (denoted by circle C in diagram 4.5). Ultimately these factors diminished the quality of the healthcare experience.
  • Not just about reading but there are a set of well validated measure that are used to screen for low health literacy REALM and STOFHLA consistent – so we focuses on the REALM
  • In statistics, the Kruskal–Wallis one-way analysis of variance by ranks (named after William Kruskal and W. Allen Wallis) is a non-parametric method for testing equality of population medians among groups. It is identical to a one-way analysis of variance with the data replaced by their ranks. It is an extension of the Mann–Whitney U test to 3 or more groups
  • Some 84% of our sample self identified as non-Hispanic Black, 5% White, 8% Latina and 4% (or one participant) did not identify with any of these racial/ethnic groups. Of the 185 women in our sample only 20 (11%) were born outside of the United States, and English was the first language for all but 18 (10%) participants. Age was captured at enrollment in the parent study, which was during the first prenatal visit. The majority of our participants (45%) were between 20 and 24 years of age, 28% were under age 20 and 27% were 25 and older. All participants reported having housing at the time of enrollment but the housing arrangements varied as did the level and type of financial assistance received for housing (both formal and informal). In our sample 135 (73%) women rented an apartment or house with no financial assistance, 26 (14%) women reported owning their own home, the remaining 13% lived with family and friends and had a variety of informal financial arrangements with the home-mates. Most of the women in our sample were unmarried at the time of enrollment in the study (83%) and 106 women (57%) were pregnant for the first time or with the first child they ultimately delivered (Table 4.1).
  • A variable functions as a mediator when it meets the followingconditions: (a) variations in levels of the independent variablesignificantly account for variations in the presumed mediator(i.e., Path a), (b) variations in the mediator significantly accountfor variations in the dependent variable (i.e., Path b), and(c) when Paths a and b are controlled, a previously significantrelation between the independent and dependent variables is nolonger significant, with the strongest demonstration of mediationoccurring when Path c is zero.
  • Controlled for REALM even though there was not sig association between REALM and the DV Or, instead of adding each of these chi2 values and the p-values, you can out a foot note that the likelihood ratio test was used to evaluate the additional predictive power of the reading score in the regression models. None of the p-values were significant and hence adding the reading score did not increase the strength of fit of any of the models.
  • impact of the noise intensity as a predictor (Path a), the impactof controllability as a moderator (Path b), and the interactionor product of these two (Path c). The moderator hypothesis issupported if the interaction (Path c) is significant. There mayalso be significant main effects for the predictor and the moderator(Paths a and b), but these are not directly relevant conceptuallyto testing the moderator hypothesis.In addition to these basic considerations, it is desirable thatthe moderator variable be uncorrelated with both the predictorand the criterion (the dependent variable) to provide a clearlyinterpretable interaction term. Another property of the moderatorvariable apparent from Figure 1 is that, unlike the mediator-predictor relation (where the predictor is causally antecedentto the mediator), moderators and predictors are at the samelevel in regard to their role as causal variables antecedent orexogenous to certain criterion effects. That is, moderator variablesalways function as independent variables, whereas mediatingevents shift roles from effects to causes, depending on thefocus oftbe analysis.
  • General Educational Development Test (GED).
  • This participant’s learning disability, in this context was a negative predisposing (denoted by circle A in diagram 4.5) factor and her decision not to disclose her reading disability to the clinician or ask her daughter to help her interpret the written education material can be categorized as a negative enabling factor (denoted by circle B in diagram 4.5) as well as factors that compromised her ability to assess the health care needs of her daughter (denoted by circle C in diagram 4.5). Ultimately these factors diminished the quality of the healthcare experience.
  • This participant’s learning disability, in this context was a negative predisposing (denoted by circle A in diagram 4.5) factor and her decision not to disclose her reading disability to the clinician or ask her daughter to help her interpret the written education material can be categorized as a negative enabling factor (denoted by circle B in diagram 4.5) as well as factors that compromised her ability to assess the health care needs of her daughter (denoted by circle C in diagram 4.5). Ultimately these factors diminished the quality of the healthcare experience.
  • This participant’s learning disability, in this context was a negative predisposing (denoted by circle A in diagram 4.5) factor and her decision not to disclose her reading disability to the clinician or ask her daughter to help her interpret the written education material can be categorized as a negative enabling factor (denoted by circle B in diagram 4.5) as well as factors that compromised her ability to assess the health care needs of her daughter (denoted by circle C in diagram 4.5). Ultimately these factors diminished the quality of the healthcare experience.
  • This participant’s learning disability, in this context was a negative predisposing (denoted by circle A in diagram 4.5) factor and her decision not to disclose her reading disability to the clinician or ask her daughter to help her interpret the written education material can be categorized as a negative enabling factor (denoted by circle B in diagram 4.5) as well as factors that compromised her ability to assess the health care needs of her daughter (denoted by circle C in diagram 4.5). Ultimately these factors diminished the quality of the healthcare experience.
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    • 1.  Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization:Is Low Health Literacy a Barrier of Concern?
      Rosemary Frasso
      Dissertation Committee
      Chair ~ Phyllis Solomon, PhD
      Steve Marcus PhD
      Ian Bennett, MD, PhD
      Agency for Healthcare Research and Quality
      Dissertation Grant
      1 R36 HS017471-01
    • 2. Agenda
      Background and Significance
      Methods
      Results
      Discussion
      Limitations and Lessons Learned
      Next Steps
      2
    • 3. Background
      Health Literacy (HL)
      “the degree to which individuals have
      the capacity to obtain, process,
      and understand basic health
      information and services needed to make appropriate health decisions”
      DHHS, 2000
      3
    • 4. Background
       We know
      Women with low health literacy have poor health outcomes and underutilize preventive care
      4
    • 5. Background
       We know
      Appropriate use of pediatric preventive care is associated with significant reductions in morbidity and mortality and has been shown to reduce healthcare costs and decrease hospital admissions
      5
    • 6. Significance
      We don’t know
      Are children of mothers with low health literacy at a disadvantage similar to that of their mothers?
      Conflicting evidence about the impact of maternal HL on pediatric social and health outcomes
      Pati et al (2011) -TANF/Vaccination compliance
      6
    • 7. Methods
      Mix methods
      Quantitative (secondary data analysis)
      Qualitative
      14 semi-structured interviews
      11 different mothers with varied HL
      1 critical case exploration
      MOTHERS FROM
      THE PARENT
      STUDY
      (REALM)
      CHILDREN FROM
      THE MEDICAID
      CLAIM DATA
      185 DYADS
      7
    • 8. Parent Study
      Community based prospective cohort study of mothers and infants in Philadelphia
      Investigating the contextual, social, behavioral, and family context of maternal child health (extensive surveys)
      Followed from prenatal period to 24 months post partum
      >5000 participants
      1034 had health literacy assessments
      REALM / STOFHLA
      Funded by the CDC and National Institute of Child Health and Development
      8
      CDC (TS 312 15/15; Culhane) and NICHD (1R01 D36462 01A; Elo and Culhane)
    • 9. Operationalized Independent Variables
      Predisposing
      Enabling
      Need
      9
      Demographic characteristics, such as race, age, and maternal education have been shown to impact parent driven pediatric health service use
      Here Andersen grouped personal and family factors including social supports, income, insurance & physical access to providers
      Need, the strongest predictor of health service use based on how people view their own functional capacity, symptoms, & general state of health
      (and that of the children they care for)
    • 10. Dependent Variables Operationalized
      10
      The primary outcome measure of preventive care utilization is the overall number of documented well-child visits in the first two years of life
      The AAP recommends 7 WCV in year 1 of life and 3 in year 2 of life
      ED. SCV, % Compliance
      CPT and ICD-9 Codes were used to identify these visits in the Medicaid claims files
      Well- Child Visits Year 1 /Year 2
      (WCV)
      Sick - Child Visits Year 1 /Year 2
      (SCV)
      ED Visits
      Year 1 /Year 2
      (EDV)
      % Compliant
      Year 1 /Year 2 (WCV)
      AAP, 2011
    • 11. Andersen’s Model Modified
      3
      1
      2
      4
      11
    • 12. Maternal Health Literacy and Outcomes of Interest Year 1 of Life
      12
    • 13. Quantitative Analysis Revealed
      HL was not associated with the number of well-child visits, sick-child visits, ED visits or % compliance with a minimum number of visits in year 1 and year 2 of life
      HL did not prove to mediate or moderate the relationships between any of predisposing and enabling factors under study and our outcomes of interest
      Higher health literacy was not protective in this population
      13
    • 14. Frequency Distribution Well-Child Visits Year 1
      14
      AAP Recommends 7
      82% of US children in this age group are meeting this guideline
    • 15. Frequency Distribution Well-Child Visits Year 2
      15
      AAP Recommends
      3 WCV
    • 16. Qualitative Analysis Revealed
      Women with low HL and women higher HL encountered an overlapping set of challenges when navigating the healthcare system 
      Several themes emerged and were used to elaborate on Andersen’s Model and shed light on the quantitative findings and a critical case emerged
      16
    • 17. Need Factors
      Views & evaluation of the child’s functional capacity, symptoms, & general state of health
       
      Informed by health beliefs, values about health and illness & attitudes towards about health services (trust, respect†) and knowledge about health (literacy, access to information in order to appreciate need††).
       
      † Feeling respected by the provider and healthcare staff
      † Your opinion about your child’s health matters
      †† e.g. knowing when and what vaccinations a child needs
      Sources of information
      (lay, pseudo experts, experts)
       
      Compromises Ability to Assess Need
      Low Literacy
      Low Health Literacy
      Competing demands
      Lack of trust for the health care system or individual providers
      Demographics
      Race/Ethnicity
      Nativity *
      Age
      Education *
      Literacy
      • Health literacy
      • 18. Ability to function w/o reading
      Language
      Housing
      Social Structure 
      Marital Status
      Parity*
      Few competing demands
      Compromising Factors
       Low literacy
       Low health literacy
       Learning disabilities
      • Dyslexia
       No coping strategy for dealing with literacy barriers
      Parity high – too many competing demands
       Mental Illness
      Personal /Family Resources
      Income
      People @ home
      Financial Support
      Employment *†
      Insurance
      Community Resources
      • Physical access to care
      • 19. Availability/Convenience
      • 20. Time in community /strength of ties
       Social support
       
      Literacy
      Strategies for working around low literacy
      Access to sources of health information
      Internet
      Access to information
      Communication
      Having an advocate
      Continuity of care
      Prior satisfaction with a healthcare provider
       
      Disabling Factors
      Power imbalance
      Lack of an advocate
      Limited or no access to health information
      Administrative/logistic hassles
      † Work gets in the way (unemployment)
      17
    • 21. Thank You
      18
    • 22. Special Thanks To
      Phyllis Solomon, PhD
      Steven Marcus, PhD
      Ian Bennett, MD, PhD
      Leny Mathew, MS
      Jennifer Culhane, PhD, MPH
      All the members of
      Dr. Culhane’s Paper Group
      Sara Cullen, MSW
      And of course my terrific kids for all their love, patience and support
      19
    • 23. Some References (others available upon request)
      Agency for Healthcare Research and Quality. (2011, March 28). Low Health Literacy Linked to Higher Risk of Death and More Emergency Room Visits and Hospitalizations. Retrieved from http://www.ahrq.gov/news/press/pr2011/lowhlitpr.htm
      Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav, 36(1), 1-10.
      Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual
      Berkman, N. D., Dewalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L., Bonito, A. J. (2004). Literacy and health outcomes. Evid Rep Technol Assess (Summ), (87), 1-8.
      American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2000). Recommedations for preventive pediatric health care.
      Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics, 108(1), 90-97.
      Shulman, S. (2006). Poor preventive care achievement and program retention among low birth weight infant Medicaid enrollees. Pediatrics, 118(5), e1509-1515. doi: peds.2004-0489 [pii] 10.1542/peds.2004-0489
      20
    • 24. 21
    • 25. 22
    • 26. Measuring Health Literacy
      Rapid Assessment of Adult Literacy in Medicine
      REALM
      66 items
      Word familiarity
      Approximately three minutes
      Short Test of Functional Health Literacy in Adults
      STOFHLA
      36 items
      Functional health literacy
      Approximately 7 minutes
      23
      (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Davis, Bocchini, et al., 1996; Davis, et al., 1993; Davis, et al., 1994; Moon, et al., 1998)
    • 27. A Critical Case Emerges
      24
    • 28. Missed Opportunities
      “Yes, but I, but I’m like, OK, it prevents cancer, is there any side effects from it, he’s like no, no, it’s in the pamphlet and I’m like, I see that, I understand that, I understand it was on paper, but it’s different when you hear it from someone. And I just wish he would’ve had more of a conversation about it, ‘cause it was like, no, I, everybody’s getting it, and I’m like OK?”
      Note:
      This participant declined the HPV vaccine for her daughter, who she generally relies on to translate written materials.
      25
    • 29. Benefit of Mix Methods
      New Concepts
      Lay informants
      Pseudo experts
      Experts
      Confirmation
      Parity
      Employment
      Unexpected findings (dyslexia example)
      “I don’t take advice from family or friends as much as I would a doctor”
      “I would call the hospital…... I got reprimanded for calling”
      “My cousin is in nursing school”
      “Friends, but their kids are younger so they don’t know”
      26
    • 30. 27
    • 31. 28
    • 32. 29
    • 33. REALM Grade Equivalent Scores
      30
    • 34. Dependent Variables Operationalized
      We also documented the percent of dyads that were compliant with a minimum number of WCV per year
      There is a precedent in the literature for setting this bench-mark at 4 for year 1 and 2 for year 2 of life, slightly lower than the AAP recommendations
      CPT and ICD-9 Codes were used to identify these visits in the Medicaid claims files
      Compliant
      Year 1
      (WCV)
      Compliant
      Year 2
      (WCV)
      Shulmen, 2006
      31
    • 35. Hypotheses
      Mothers with low health literacy (< 6th grade) will be less likely than mothers with marginal to higher health literacy (> 7th grade) to meet pediatric preventive care recommendations.
      32
    • 36. Hypotheses
      Children of mothers with low health literacy (< 6th grade) will be more likely than children of mothers with marginal to high health literacy (> 7th grade) to
      visit an emergency room.
      be seen by a provider for a sick-child visit.
      33
    • 37. Hypotheses
      Low maternal health literacy will mediate the relationship between negative predisposing and enabling factors and
      timely receipt of pediatric preventive care.
      pediatric emergency room visits.
      the number of sick-child visits.
      34
    • 38. Hypotheses
      Low maternal health literacy will moderate the relationship between negative predisposing and enabling factors and
      timely receipt of pediatric preventive care.
      pediatric emergency room visits.
      the number of sick-child visits.
      35
    • 39. Quantitative Analysis
      Categorical Variable
      Chi-squared test of independence
      Continuous Variables
      Wilcoxon rank-sum test (Mann-Whitney-Wilcoxon) or Kruskal-Wallis non-parametric test
      Linear Regression
      Moderation Analysis
      Mediation Analysis
      Likelihood ratio test
      STATA Data Analysis Statistical Software
      36
    • 40. Qualitative Methods
      In depth semi structured interviews
      Issues of interest
      Need factors / perceived need
      Health beliefs
      Social support/relationships
      Ability to navigate the healthcare system
      Transcribed verbatim
      Coded using NVIVO8 (QSR) software guided by Andersen’s model
      37
    • 41. Guiding Qualitative Hypotheses
      Qualitative interviews will show that mothers with low health literacy will report different issues related to access to preventive pediatric care than mothers with marginal to high health literacy.
      Additionally, they will perceive different barriers to care and will suggest different interventions
      to reduce these barriers.
      38
    • 42. The Analytic Sample
      Quantitative
      visit (14.8 ± 0.2 weeks)
      • PH Centers in Philadelphia
      • 50. February 2000 -October 2002
      • 51. Income (75% <$11,610/yr)
      • 52. Children had >10 months of …Medicaid eligibility/yr
      • 53. 14% low HL
      39
      Non English Speakers (ESL OK)
      N=27
    • 54. Results
      40
    • 55. Andersen’s Model Modified
      3
      1
      2
      4
      41
    • 56. Pathway 1
      Percent of Participants in Education Group
      by Health Literacy Level
      REALM
      Percent of Participants in Each Age Group
      by Health Literacy Level
      Maternal Education
      REALM
      Maternal Age
      42
    • 57. Pathway 2
      43
    • 73. Statistically Significant Associations
      44
    • 97. Statistically Significant Associations
      Parity
      median (range) / p –value < 0.05*
      -WCV YR 1 / 0.02*
      1 child 4 (0-7)
      2+ children 3 (0-10)
      -SCV YR 2 / 0.01*
      1 child 1 (0-9)
      2+ children 0 (0-6)
      -ED Visits 1 / 0.01*
      1 child 1 (0-13)
      2+ children 0 (0-8)
      -ED Visits 1 / 0.01*
      1 child 1 (0-13)
      2+ children 0 (0-8)
      45
    • 98. Statistically Significant Associations
      Race
      median (range) / p –value < 0.05*
      • ED visits YR 1/ 0.001*
      Non Hispanic Whites 0.5 (0 – 5)
      Latina 3 (0-8)
      Non Hispanic Black 1 (1 -13)
      Other 0 (0 -0)
      46
    • 99. Statistically Significant Associations
      Age
      median (range) / p –value < 0.05*
      • ED visits YR 1/ 0.03*
      < 20 2 (0 -13)
      20-<25 1 (0 -10)
      25-<30 0.5 (0 -6)
      > 30 1 (0 – 8)
      47
    • 100. Statistically Significant Associations
      Language
      median (range) / p –value < 0.05*
      • ED visits YR 1/ 0.05*
      Eng (yes) 1 (0-13)
      Eng (no) 3 (0-8)
      Married
      median (range) / p –value < 0.05*
      • ED visits YR 1/ 0.03*
      M (yes) 1 (0-7)
      M (no) 3 (0-13)
      48
    • 101. Statistically Significant Associations
      Unemployment/Workman’s Comp
      median (range) / p –value < 0.05*
      • WCV YR 2 / 0.04*
      Received(yes) 2.5 (1-4)
      Received(no) 1 (0-9)
      • SCV YR 1 / 0.02*
      M (yes) 1.5 (1-4)
      M (no) 0 (0-9)
      49
    • 102. Statistically Significant Associations
      Mothers Insurance
      Status @ Enrollment
      median (range) / p –value < 0.05*
      • WCV YR 2 / 0.01*
      Private 1 (0-3)
      Medicaid 1 (0-5)
      Uninsured 2 (0-9)
      50
    • 103. Statistically Significant Associations
      Language
      median (range) / p –value < 0.05*
      • Compliant YR 2/ 0.05*
      Eng (yes) 1 (0-13)
      Eng (no) 3 (0-8)
      Married
      median (range) / p –value < 0.05*
      • ED visits YR 1/ 0.03*
      M (yes) 1 (0-7)
      M (no) 3 (0-13)
      51
    • 104. Statistically Significant Associations
      % Compliant Year 2
      Education (P-value 0.02*)
      Post HS 70% > 2 visits year 2
      HS or GED 50% > 2 visits year 2
      < HS 37% > 2 visits year 2
      Maternal Insurance Status (P-value 0.02*)
      Private 41% > 2 visits year 2
      Medicaid 29% > 2 visits year 2
      Uninsured 63% > 2 visits year 2
      52
    • 105. Pathway 3 and Mediation
      Maternal Health Literacy
      Mediator
    • 106. Controlling for the REALM ~ Likelihood Ratio Tests
      54
      1.49 (0.48)
      0.51 (0.76)
      1.77 (0.41)
      0.29 (0.87)
      1.09 (0.58)
      1.02 (0.60)
      1.89 (0.39)
      1.65 (0.44)
      0.39 (0.82)
      0.33 (0.85)
      0.56 (0.76)
    • 107. Pathway 4Moderation
      55
      Parity
      Well-Child Care Sick-Child CareED Visits % Compliance (Minimum # of visits/year)
      REALM
      (categorical)
      Parity
      X
      REALM
      Planned Analysis
      Barron & Kenny, 1986
    • 108. Quantitative Analysis Revealed
      HL was not associated with the number of well-child visits, sick-child visits, ED visits or % compliance with a minimum number of visits in year 1 and year 2 of life
      When we controlled for health literacy we saw no impact on establish associations between a set of independent variables and our outcome variables
      56
    • 109. Associations of Interest
      66% of the women in our sample had completed high school or GED however only 50% had a REALM score > 9th grade
      100% of the women in the highest HL group were born in the US while that was the case for only 80% of the women in the low HL group
      57
    • 110. Qualitative Analysis Revealed
      Women with low HL and women higher HL encountered an overlapping set of challenges when navigating the healthcare system 
      Confirmed the quantitative findings (for the most part kids are getting the minimum number of visits)
      Several themes emerged and were used to elaborate on Andersen’s Model and shed light on the quantitative findings
      Critical case emerged
      58
    • 111. Need Factors
      Views & evaluation of the child’s functional capacity, symptoms, & general state of health
       
      Informed by health beliefs, values about health and illness & attitudes towards about health services and knowledge about health
      Personal /Family Resources
      Income
      People @ home
      Financial Support
      Employment
      Insurance
      Community Resources
      Demographics
      Race/Ethnicity
      Nativity
      Age
      Education
      Literacy
      Language
      Housing
      Social Structure 
      Marital Status
      Parity
      59
      Discussion
    • 112. Need Factors
      Views & evaluation of the child’s functional capacity, symptoms, & general state of health
       
      Informed by health beliefs, values about health and illness & attitudes towards about health services (trust, respect†) and knowledge about health (literacy, access to information in order to appreciate need††).
       
      † Feeling respected by the provider and healthcare staff
      † Your opinion about your child’s health matters
      †† e.g. knowing when and what vaccinations a child needs
      Sources of information
      (lay, pseudo experts, experts)
       
      Compromises Ability to Assess Need
      Low Literacy
      Low Health Literacy
      Competing demands
      Lack of trust for the health care system or individual providers
      Demographics
      Race/Ethnicity
      Nativity *
      Age
      Education *
      Literacy
      • Health literacy
      • 113. Ability to function w/o reading
      Language
      Housing
      Social Structure 
      Marital Status
      Parity*
      Few competing demands
      Compromising Factors
       Low literacy
       Low health literacy
       Learning disabilities
      Dyslexia
        No coping strategy for dealing with .. literacy barriers
      Parity high
      too many competing demands
      Mental Illness
      * IV in the quantitative analysis and a theme in the qualitative analysis
      Personal /Family Resources
      Income
      People @ home
      Financial Support
      Employment *†
      Insurance
      Community Resources
      • Physical access to care
      • 114. Availability/Convenience
      • 115. Time in community /strength of ties
       .Social support
       
      Literacy
      Strategies for working around low literacy
      Access to sources of health information
      Internet
      Access to information
      Communication
      Having an advocate
      Continuity of care
      Prior satisfaction with a healthcare provider
       
      Disabling Factors
      Power imbalance
      Lack of an advocate
      Limited or no access to health information
      Administrative/logistic hassles
      † Work gets in the way (unemployment)
      60
    • 116. Benefit of Mix Methods
      New Concepts
      Lay informants
      Pseudo experts
      Experts
      Confirmation
      Parity
      Employment
      Unexpected findings (dyslexia example)
      “I don’t take advice from family or friends as much as I would a doctor”
      “I would call the hospital…... I got reprimanded for calling”
      “My cousin is in nursing school”
      “Friends, but their kids are younger so they don’t know”
      61
    • 117. Need Factors
      Views & evaluation of the child’s functional capacity, symptoms, & general state of health
       
      Informed by health beliefs, values about health and illness & attitudes towards about health services (trust, respect†) and knowledge about health (literacy, access to information in order to appreciate need††).
       
      † Feeling respected by the provider and healthcare staff
      † Your opinion about your child’s health matters
      †† e.g. knowing when and what vaccinations a child needs
      Sources of information
      (lay, pseudo experts, experts)
       
      Compromises Ability to Assess Need
      Low Literacy
      Low Health Literacy
      Competing demands
      Lack of trust for the health care system or individual providers
      Demographics
      Race/Ethnicity
      Nativity *
      Age
      Education *
      Literacy
      • Health literacy
      • 118. Ability to function w/o reading
      Language
      Housing
      Social Structure 
      Marital Status
      Parity*
      Few competing demands
      Compromising Factors
       Low literacy
       Low health literacy
       Learning disabilities
      Dyslexia
        No coping strategy for dealing with .. literacy barriers
      Parity high
      too many competing demands
      Mental Illness
      Personal /Family Resources
      Income
      People @ home
      Financial Support
      Employment *†
      Insurance
      Community Resources
      • Physical access to care
      • 119. Availability/Convenience
      • 120. Time in community /strength of ties
       .Social support
       
      Literacy
      Strategies for working around low literacy
      Access to sources of health information
      Internet
      Access to information
      Communication
      Having an advocate
      Continuity of care
      Prior satisfaction with a healthcare provider
       
      Disabling Factors
      Power imbalance
      Lack of an advocate
      Limited or no access to health information
      Administrative/logistic hassles
      † Work gets in the way (unemployment)
      62
    • 121. A Critical Case Emerges
      63
    • 122. Need Factors
      Views & evaluation of the child’s functional capacity, symptoms, & general state of health
       
      Informed by health beliefs, values about health and illness & attitudes towards about health services (trust, respect†) and knowledge about health (literacy, access to information in order to appreciate need††).
       
      † Feeling respected by the provider and healthcare staff
      † Your opinion about your child’s health matters
      †† e.g. knowing when and what vaccinations a child needs
      Sources of information
      (lay, pseudo experts, experts)
       
      Compromises Ability to Assess Need
      Low Literacy
      Low Health Literacy
      Competing demands
      Lack of trust for the health care system or individual providers
      Demographics
      Race/Ethnicity
      Nativity *
      Age
      Education *
      Literacy
      • Health literacy
      • 123. Ability to function w/o reading
      Language
      Housing
      Social Structure 
      Marital Status
      Parity*
      Few competing demands
      Compromising Factors
       Low literacy
       Low health literacy
       Learning disabilities
      • Dyslexia
       No coping strategy for dealing with literacy barriers
      Parity high – too many competing demands
       Mental Illness
      Personal /Family Resources
      Income
      People @ home
      Financial Support
      Employment *†
      Insurance
      Community Resources
      • Physical access to care
      • 124. Availability/Convenience
      • 125. Time in community /strength of ties
       Social support
       
      Literacy
      Strategies for working around low literacy
      Access to sources of health information
      Internet
      Access to information
      Communication
      Having an advocate
      Continuity of care
      Prior satisfaction with a healthcare provider
       
      Disabling Factors
      Power imbalance
      Lack of an advocate
      Limited or no access to health information
      Administrative/logistic hassles
      † Work gets in the way (unemployment)
      64
    • 126. Missed Opportunities
      “Yes, but I, but I’m like, OK, it prevents cancer, is there any side effects from it, he’s like no, no, it’s in the pamphlet and I’m like, I see that, I understand that, I understand it was on paper, but it’s different when you hear it from someone. And I just wish he would’ve had more of a conversation about it, ‘cause it was like, no, I, everybody’s getting it, and I’m like OK?”
      Note:
      This participant declined the HPV vaccine for her daughter, who she generally relies on to translate written materials.
      65
    • 127. Health Literacy
      50% of the group was compliant in year 1 and this did not vary by health literacy
      44% of the group was compliant in year 2 and again no variation by health literacy
      Does health literacy matter in this population?
      66
    • 128. Limitations & Lessons Learned
      Sample size / power
      Inclusion criteria
      10 month of eligibility
      Locating the poorest readers
      REALM
      Was it reliable in the population?
      Does it need to be validated in the context of LD?
      Did not take full advantage of the available data*
      Limited generalizability and transferability
      67
    • 129. Next Steps
      Augment the current analysis and submit a paper for publication
      Abstract has been sent to APHA
      Critical Case was presented at Health Literacy Annual Research Conference
      Need to further explore how a learning disability impacts health literacy
      68
    • 130. Next Steps Continued
      Now that the dyads have been established we plan to revisit the survey data in order to explore additional research questions (many of which were brought to light in the qualitative arm of the study)
      For example:
      Feeling respected by a provider (qualitative)
      Mastery Scale and Coping Questions (parent study)
      “Sometimes I feel that I am being pushed around in life”
      “There is little I can do to change many of the important things in life”
      For example:
      Depression/mental illness (qualitative)
      Depression (parent study)
      69
    • 131. Some References (others available upon request)
      Agency for Healthcare Research and Quality. (2011, March 28). Low Health Literacy Linked to Higher Risk of Death and More Emergency Room Visits and Hospitalizations. Retrieved from http://www.ahrq.gov/news/press/pr2011/lowhlitpr.htm
      Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav, 36(1), 1-10.
      Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual
      Berkman, N. D., Dewalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L., Bonito, A. J. (2004). Literacy and health outcomes. Evid Rep Technol Assess (Summ), (87), 1-8.
      American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2000). Recommedations for preventive pediatric health care.
      Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics, 108(1), 90-97.
      Shulman, S. (2006). Poor preventive care achievement and program retention among low birth weight infant Medicaid enrollees. Pediatrics, 118(5), e1509-1515. doi: peds.2004-0489 [pii] 10.1542/peds.2004-0489
      70
    • 132. 71
    • 133. 72
    • 134. 73

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