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 Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization:Is Low Health Literacy a ...
Agenda <br />Background and Significance <br />Methods <br />Results <br />Discussion<br />Limitations and Lessons Learned...
Background<br />Health Literacy (HL)<br />“the degree to which individuals have <br />the capacity to obtain, process, <br...
Background<br /> We know <br />   Women with low health literacy have poor health outcomes and underutilize preventive car...
Background<br /> We know <br />	Appropriate use of pediatric preventive care is associated with significant reductions in ...
Significance<br />We don’t know<br />Are children of mothers with low health literacy at a disadvantage similar to that of...
Methods<br />Mix methods <br />Quantitative  (secondary data analysis) <br />Qualitative<br />14 semi-structured interview...
Parent Study <br />Community based prospective cohort study of mothers and infants in Philadelphia<br />Investigating the ...
Operationalized Independent Variables<br />Predisposing<br />Enabling<br />Need<br />9<br />Demographic characteristics, s...
Dependent Variables Operationalized<br />10<br />The primary outcome measure of preventive care utilization is the overall...
Andersen’s Model Modified<br />3<br />1<br />2<br />4<br />11<br />
Maternal Health Literacy and  Outcomes of Interest Year 1 of Life<br />12<br />
Quantitative Analysis Revealed<br />HL was not associated with the number of well-child visits, sick-child visits, ED visi...
Frequency Distribution Well-Child Visits Year 1 <br />14<br />AAP Recommends 7 <br />82% of US children in this age group ...
Frequency Distribution Well-Child Visits Year 2 <br />15<br />AAP Recommends <br />3 WCV <br />
Qualitative Analysis Revealed<br />Women with low HL and women higher HL encountered an overlapping set of challenges when...
Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />...
 Ability to function w/o reading   </li></ul>Language <br />Housing <br />Social Structure <br />Marital Status  <br />Par...
 Availability/Convenience
 Time in community /strength of ties</li></ul> Social support<br /> <br />Literacy<br />Strategies for working around low ...
Thank You <br />18<br />
Special Thanks To <br />Phyllis Solomon, PhD<br />Steven Marcus, PhD<br />Ian Bennett, MD, PhD<br />Leny Mathew, MS<br />J...
Some References (others available upon request)<br />Agency for Healthcare Research and Quality. (2011, March 28). Low Hea...
21<br />
22<br />
Measuring Health Literacy <br />Rapid Assessment of Adult Literacy in Medicine<br />REALM <br />66 items <br />Word famili...
A Critical Case Emerges <br />24<br />
Missed Opportunities <br />“Yes, but I, but I’m like, OK, it prevents cancer, is there any side effects from it, he’s like...
Benefit of Mix Methods<br />New Concepts <br />Lay informants <br />Pseudo experts<br />Experts  <br />Confirmation <br />...
27<br />
28<br />
29<br />
REALM Grade Equivalent Scores<br />30<br />
Dependent Variables Operationalized<br />We also documented the percent of dyads that were compliant with a minimum number...
Hypotheses<br />Mothers with low health literacy (< 6th grade) will be less likely than mothers with marginal to higher he...
Hypotheses<br />Children of mothers with low health literacy (< 6th grade) will be more likely than children of mothers wi...
Hypotheses<br />Low maternal health literacy will mediate the relationship between negative predisposing and enabling fact...
Hypotheses<br />Low maternal health literacy will moderate the relationship between negative predisposing and enabling fac...
Quantitative Analysis<br />Categorical Variable <br />Chi-squared test of independence<br />Continuous Variables<br />Wilc...
Qualitative Methods<br />In depth semi structured interviews<br />Issues of interest <br />Need factors / perceived need<b...
Guiding Qualitative Hypotheses<br />Qualitative interviews will show that mothers with low health literacy will report dif...
The Analytic Sample<br />Quantitative<br /><ul><li>  84% African American
  5% White
  8% Latina
  89% Born in the US
All inner-city
> 19 years of age
  84% completed HS
  Enrollment 1st prenatal </li></ul>visit (14.8 ± 0.2 weeks)<br /><ul><li>  PH Centers in Philadelphia
  February 2000 -October 2002
  Income (75% <$11,610/yr)
Children had >10 months of …Medicaid eligibility/yr
 14% low HL</li></ul>39<br />Non English Speakers  (ESL OK) <br />N=27<br />
Results<br />40<br />
Andersen’s Model Modified<br />3<br />1<br />2<br />4<br />41<br />
Pathway 1<br />Percent of Participants in Education Group <br />by Health Literacy Level <br />REALM<br />Percent of Parti...
Pathway 2<br /><ul><li>Predisposing
Race
Nativity
Age
Education
First Language
Marital Status
Parity
      Enabling
Income
Number of people supported by income
Any other financial support
SSI and Unemployment /WMC
Money left over at the end of the month
Worried about Money
Insurance </li></ul>43<br />
Statistically Significant Associations<br /><ul><li>Predisposing
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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

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.

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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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  • Transcript of "Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization"

    1. 1.  Exploring the Association between Maternal Health Literacy and Pediatric Healthcare Utilization:Is Low Health Literacy a Barrier of Concern?<br />Rosemary Frasso<br />Dissertation Committee<br />Chair ~ Phyllis Solomon, PhD <br />Steve Marcus PhD<br />Ian Bennett, MD, PhD<br />Agency for Healthcare Research and Quality <br />Dissertation Grant<br />1 R36 HS017471-01<br />
    2. 2. Agenda <br />Background and Significance <br />Methods <br />Results <br />Discussion<br />Limitations and Lessons Learned<br />Next Steps <br />2<br />
    3. 3. Background<br />Health Literacy (HL)<br />“the degree to which individuals have <br />the capacity to obtain, process, <br />and understand basic health<br /> information and services needed to make appropriate health decisions”<br />DHHS, 2000<br />3<br />
    4. 4. Background<br /> We know <br /> Women with low health literacy have poor health outcomes and underutilize preventive care<br />4<br />
    5. 5. Background<br /> We know <br /> 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<br />5<br />
    6. 6. Significance<br />We don’t know<br />Are children of mothers with low health literacy at a disadvantage similar to that of their mothers? <br />Conflicting evidence about the impact of maternal HL on pediatric social and health outcomes <br />Pati et al (2011) -TANF/Vaccination compliance <br />6<br />
    7. 7. Methods<br />Mix methods <br />Quantitative (secondary data analysis) <br />Qualitative<br />14 semi-structured interviews<br />11 different mothers with varied HL<br />1 critical case exploration <br />MOTHERS FROM <br />THE PARENT <br />STUDY<br />(REALM)<br />CHILDREN FROM <br />THE MEDICAID <br />CLAIM DATA<br />185 DYADS<br />7<br />
    8. 8. Parent Study <br />Community based prospective cohort study of mothers and infants in Philadelphia<br />Investigating the contextual, social, behavioral, and family context of maternal child health (extensive surveys)<br />Followed from prenatal period to 24 months post partum <br />>5000 participants <br /> 1034 had health literacy assessments <br />REALM / STOFHLA<br />Funded by the CDC and National Institute of Child Health and Development <br />8<br />CDC (TS 312 15/15; Culhane) and NICHD (1R01 D36462 01A; Elo and Culhane)<br />
    9. 9. Operationalized Independent Variables<br />Predisposing<br />Enabling<br />Need<br />9<br />Demographic characteristics, such as race, age, and maternal education have been shown to impact parent driven pediatric health service use<br />Here Andersen grouped personal and family factors including social supports, income, insurance & physical access to providers<br />Need, the strongest predictor of health service use based on how people view their own functional capacity, symptoms, & general state of health <br />(and that of the children they care for)<br />
    10. 10. Dependent Variables Operationalized<br />10<br />The primary outcome measure of preventive care utilization is the overall number of documented well-child visits in the first two years of life<br />The AAP recommends 7 WCV in year 1 of life and 3 in year 2 of life <br />ED. SCV, % Compliance<br />CPT and ICD-9 Codes were used to identify these visits in the Medicaid claims files <br />Well- Child Visits Year 1 /Year 2<br />(WCV)<br />Sick - Child Visits Year 1 /Year 2<br />(SCV)<br />ED Visits <br />Year 1 /Year 2<br />(EDV)<br />% Compliant <br />Year 1 /Year 2 (WCV)<br />AAP, 2011<br />
    11. 11. Andersen’s Model Modified<br />3<br />1<br />2<br />4<br />11<br />
    12. 12. Maternal Health Literacy and Outcomes of Interest Year 1 of Life<br />12<br />
    13. 13. Quantitative Analysis Revealed<br />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 <br />HL did not prove to mediate or moderate the relationships between any of predisposing and enabling factors under study and our outcomes of interest <br />Higher health literacy was not protective in this population <br />13<br />
    14. 14. Frequency Distribution Well-Child Visits Year 1 <br />14<br />AAP Recommends 7 <br />82% of US children in this age group are meeting this guideline<br />
    15. 15. Frequency Distribution Well-Child Visits Year 2 <br />15<br />AAP Recommends <br />3 WCV <br />
    16. 16. Qualitative Analysis Revealed<br />Women with low HL and women higher HL encountered an overlapping set of challenges when navigating the healthcare system <br />Several themes emerged and were used to elaborate on Andersen’s Model and shed light on the quantitative findings and a critical case emerged <br />16<br />
    17. 17. Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />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††).<br /> <br />† Feeling respected by the provider and healthcare staff <br />† Your opinion about your child’s health matters <br />†† e.g. knowing when and what vaccinations a child needs <br />Sources of information <br />(lay, pseudo experts, experts)<br /> <br />Compromises Ability to Assess Need <br />Low Literacy <br />Low Health Literacy<br />Competing demands <br />Lack of trust for the health care system or individual providers <br />Demographics<br />Race/Ethnicity <br />Nativity *<br />Age <br />Education *<br />Literacy<br /><ul><li> Health literacy
    18. 18. Ability to function w/o reading </li></ul>Language <br />Housing <br />Social Structure <br />Marital Status <br />Parity*<br /> Few competing demands <br />Compromising Factors <br /> Low literacy<br /> Low health literacy <br /> Learning disabilities <br /><ul><li> Dyslexia</li></ul> No coping strategy for dealing with literacy barriers <br />Parity high – too many competing demands<br /> Mental Illness<br />Personal /Family Resources<br />Income <br /> People @ home <br /> Financial Support <br />Employment *†<br />Insurance <br />Community Resources<br /><ul><li> Physical access to care
    19. 19. Availability/Convenience
    20. 20. Time in community /strength of ties</li></ul> Social support<br /> <br />Literacy<br />Strategies for working around low literacy <br />Access to sources of health information <br />Internet<br />Access to information <br />Communication <br />Having an advocate <br />Continuity of care<br />Prior satisfaction with a healthcare provider <br /> <br />Disabling Factors<br />Power imbalance<br />Lack of an advocate <br />Limited or no access to health information <br />Administrative/logistic hassles<br />† Work gets in the way (unemployment) <br />17<br />
    21. 21. Thank You <br />18<br />
    22. 22. Special Thanks To <br />Phyllis Solomon, PhD<br />Steven Marcus, PhD<br />Ian Bennett, MD, PhD<br />Leny Mathew, MS<br />Jennifer Culhane, PhD, MPH<br />All the members of <br />Dr. Culhane’s Paper Group<br />Sara Cullen, MSW<br />And of course my terrific kids for all their love, patience and support<br />19<br />
    23. 23. Some References (others available upon request)<br />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<br />Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav, 36(1), 1-10. <br />Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual<br />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. <br />American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2000). Recommedations for preventive pediatric health care.<br />Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics, 108(1), 90-97. <br />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<br />20<br />
    24. 24. 21<br />
    25. 25. 22<br />
    26. 26. Measuring Health Literacy <br />Rapid Assessment of Adult Literacy in Medicine<br />REALM <br />66 items <br />Word familiarity <br />Approximately three minutes<br />Short Test of Functional Health Literacy in Adults<br />STOFHLA<br />36 items <br />Functional health literacy<br />Approximately 7 minutes <br />23<br />(Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Davis, Bocchini, et al., 1996; Davis, et al., 1993; Davis, et al., 1994; Moon, et al., 1998)<br />
    27. 27. A Critical Case Emerges <br />24<br />
    28. 28. Missed Opportunities <br />“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?”<br />Note: <br />This participant declined the HPV vaccine for her daughter, who she generally relies on to translate written materials. <br />25<br />
    29. 29. Benefit of Mix Methods<br />New Concepts <br />Lay informants <br />Pseudo experts<br />Experts <br />Confirmation <br />Parity <br />Employment <br />Unexpected findings (dyslexia example)<br />“I don’t take advice from family or friends as much as I would a doctor” <br />“I would call the hospital…... I got reprimanded for calling”<br />“My cousin is in nursing school” <br />“Friends, but their kids are younger so they don’t know”<br />26<br />
    30. 30. 27<br />
    31. 31. 28<br />
    32. 32. 29<br />
    33. 33. REALM Grade Equivalent Scores<br />30<br />
    34. 34. Dependent Variables Operationalized<br />We also documented the percent of dyads that were compliant with a minimum number of WCV per year<br />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 <br />CPT and ICD-9 Codes were used to identify these visits in the Medicaid claims files <br />Compliant <br /> Year 1<br />(WCV)<br />Compliant<br /> Year 2<br />(WCV)<br />Shulmen, 2006<br />31<br />
    35. 35. Hypotheses<br />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.<br />32<br />
    36. 36. Hypotheses<br />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<br />visit an emergency room.<br />be seen by a provider for a sick-child visit.<br />33<br />
    37. 37. Hypotheses<br />Low maternal health literacy will mediate the relationship between negative predisposing and enabling factors and<br />timely receipt of pediatric preventive care.<br />pediatric emergency room visits.<br />the number of sick-child visits.<br />34<br />
    38. 38. Hypotheses<br />Low maternal health literacy will moderate the relationship between negative predisposing and enabling factors and<br />timely receipt of pediatric preventive care.<br />pediatric emergency room visits.<br />the number of sick-child visits.<br />35<br />
    39. 39. Quantitative Analysis<br />Categorical Variable <br />Chi-squared test of independence<br />Continuous Variables<br />Wilcoxon rank-sum test (Mann-Whitney-Wilcoxon) or Kruskal-Wallis non-parametric test<br />Linear Regression<br />Moderation Analysis<br />Mediation Analysis <br />Likelihood ratio test <br />STATA Data Analysis Statistical Software<br />36<br />
    40. 40. Qualitative Methods<br />In depth semi structured interviews<br />Issues of interest <br />Need factors / perceived need<br />Health beliefs<br />Social support/relationships<br />Ability to navigate the healthcare system <br />Transcribed verbatim <br />Coded using NVIVO8 (QSR) software guided by Andersen’s model <br />37<br />
    41. 41. Guiding Qualitative Hypotheses<br />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. <br />Additionally, they will perceive different barriers to care and will suggest different interventions <br />to reduce these barriers.<br />38<br />
    42. 42. The Analytic Sample<br />Quantitative<br /><ul><li> 84% African American
    43. 43. 5% White
    44. 44. 8% Latina
    45. 45. 89% Born in the US
    46. 46. All inner-city
    47. 47. > 19 years of age
    48. 48. 84% completed HS
    49. 49. Enrollment 1st prenatal </li></ul>visit (14.8 ± 0.2 weeks)<br /><ul><li> PH Centers in Philadelphia
    50. 50. February 2000 -October 2002
    51. 51. Income (75% <$11,610/yr)
    52. 52. Children had >10 months of …Medicaid eligibility/yr
    53. 53. 14% low HL</li></ul>39<br />Non English Speakers (ESL OK) <br />N=27<br />
    54. 54. Results<br />40<br />
    55. 55. Andersen’s Model Modified<br />3<br />1<br />2<br />4<br />41<br />
    56. 56. Pathway 1<br />Percent of Participants in Education Group <br />by Health Literacy Level <br />REALM<br />Percent of Participants in Each Age Group <br />by Health Literacy Level <br />Maternal Education<br />REALM<br />Maternal Age<br />42<br />
    57. 57. Pathway 2<br /><ul><li>Predisposing
    58. 58. Race
    59. 59. Nativity
    60. 60. Age
    61. 61. Education
    62. 62. First Language
    63. 63. Marital Status
    64. 64. Parity
    65. 65. Enabling
    66. 66. Income
    67. 67. Number of people supported by income
    68. 68. Any other financial support
    69. 69. SSI and Unemployment /WMC
    70. 70. Money left over at the end of the month
    71. 71. Worried about Money
    72. 72. Insurance </li></ul>43<br />
    73. 73. Statistically Significant Associations<br /><ul><li>Predisposing
    74. 74. Race
    75. 75. Age
    76. 76. Marital Status
    77. 77. Parity
    78. 78. Enabling
    79. 79. SSI and Unemployment /WMC
    80. 80. Insurance
    81. 81. Predisposing
    82. 82. Race
    83. 83. Nativity
    84. 84. Age
    85. 85. Education
    86. 86. First Language
    87. 87. Marital Status
    88. 88. Parity
    89. 89. Enabling
    90. 90. Income
    91. 91. Number of people supported by income
    92. 92. Any other financial support
    93. 93. SSI and Unemployment /WMC
    94. 94. Money left over at the end of the month
    95. 95. Worried about Money
    96. 96. Insurance </li></ul>44<br />
    97. 97. Statistically Significant Associations<br />Parity<br />median (range) / p –value < 0.05*<br />-WCV YR 1 / 0.02*<br />1 child 4 (0-7)<br />2+ children 3 (0-10)<br />-SCV YR 2 / 0.01*<br />1 child 1 (0-9)<br />2+ children 0 (0-6)<br />-ED Visits 1 / 0.01*<br />1 child 1 (0-13)<br />2+ children 0 (0-8)<br />-ED Visits 1 / 0.01*<br />1 child 1 (0-13)<br />2+ children 0 (0-8)<br />45<br />
    98. 98. Statistically Significant Associations<br />Race<br />median (range) / p –value < 0.05*<br /><ul><li>ED visits YR 1/ 0.001* </li></ul>Non Hispanic Whites 0.5 (0 – 5)<br />Latina 3 (0-8)<br />Non Hispanic Black 1 (1 -13)<br />Other 0 (0 -0)<br />46<br />
    99. 99. Statistically Significant Associations<br />Age<br />median (range) / p –value < 0.05*<br /><ul><li>ED visits YR 1/ 0.03* </li></ul>< 20 2 (0 -13)<br />20-<25 1 (0 -10)<br />25-<30 0.5 (0 -6)<br />> 30 1 (0 – 8)<br />47<br />
    100. 100. Statistically Significant Associations<br />Language<br />median (range) / p –value < 0.05*<br /><ul><li>ED visits YR 1/ 0.05* </li></ul>Eng (yes) 1 (0-13) <br />Eng (no) 3 (0-8)<br />Married<br />median (range) / p –value < 0.05*<br /><ul><li>ED visits YR 1/ 0.03* </li></ul>M (yes) 1 (0-7) <br />M (no) 3 (0-13)<br />48<br />
    101. 101. Statistically Significant Associations<br />Unemployment/Workman’s Comp<br />median (range) / p –value < 0.05*<br /><ul><li>WCV YR 2 / 0.04* </li></ul>Received(yes) 2.5 (1-4) <br />Received(no) 1 (0-9)<br /><ul><li>SCV YR 1 / 0.02* </li></ul>M (yes) 1.5 (1-4) <br />M (no) 0 (0-9)<br />49<br />
    102. 102. Statistically Significant Associations<br />Mothers Insurance <br />Status @ Enrollment<br />median (range) / p –value < 0.05*<br /><ul><li>WCV YR 2 / 0.01* </li></ul>Private 1 (0-3) <br />Medicaid 1 (0-5)<br />Uninsured 2 (0-9)<br />50<br />
    103. 103. Statistically Significant Associations<br />Language<br />median (range) / p –value < 0.05*<br /><ul><li> Compliant YR 2/ 0.05* </li></ul>Eng (yes) 1 (0-13) <br />Eng (no) 3 (0-8)<br />Married<br />median (range) / p –value < 0.05*<br /><ul><li>ED visits YR 1/ 0.03* </li></ul>M (yes) 1 (0-7) <br />M (no) 3 (0-13)<br />51<br />
    104. 104. Statistically Significant Associations<br />% Compliant Year 2<br />Education (P-value 0.02*)<br />Post HS 70% > 2 visits year 2<br /> HS or GED 50% > 2 visits year 2<br /> < HS 37% > 2 visits year 2<br />Maternal Insurance Status (P-value 0.02*)<br />Private 41% > 2 visits year 2<br /> Medicaid 29% > 2 visits year 2<br /> Uninsured 63% > 2 visits year 2<br />52<br />
    105. 105. Pathway 3 and Mediation<br />Maternal Health Literacy<br />Mediator<br />
    106. 106. Controlling for the REALM ~ Likelihood Ratio Tests<br />54<br />1.49 (0.48)<br />0.51 (0.76)<br />1.77 (0.41) <br />0.29 (0.87)<br />1.09 (0.58)<br />1.02 (0.60)<br />1.89 (0.39)<br />1.65 (0.44)<br />0.39 (0.82)<br />0.33 (0.85)<br />0.56 (0.76)<br />
    107. 107. Pathway 4Moderation<br />55<br />Parity<br />Well-Child Care Sick-Child CareED Visits % Compliance (Minimum # of visits/year)<br />REALM<br />(categorical)<br />Parity <br />X <br />REALM<br />Planned Analysis <br />Barron & Kenny, 1986<br />
    108. 108. Quantitative Analysis Revealed<br />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 <br />When we controlled for health literacy we saw no impact on establish associations between a set of independent variables and our outcome variables <br />56<br />
    109. 109. Associations of Interest <br />66% of the women in our sample had completed high school or GED however only 50% had a REALM score > 9th grade <br />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<br />57<br />
    110. 110. Qualitative Analysis Revealed<br />Women with low HL and women higher HL encountered an overlapping set of challenges when navigating the healthcare system <br />Confirmed the quantitative findings (for the most part kids are getting the minimum number of visits) <br />Several themes emerged and were used to elaborate on Andersen’s Model and shed light on the quantitative findings <br />Critical case emerged <br />58<br />
    111. 111. Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />Informed by health beliefs, values about health and illness & attitudes towards about health services and knowledge about health<br />Personal /Family Resources<br />Income <br /> People @ home <br /> Financial Support <br />Employment<br />Insurance <br />Community Resources<br />Demographics<br />Race/Ethnicity <br />Nativity <br />Age <br />Education <br />Literacy<br />Language <br />Housing <br />Social Structure <br />Marital Status <br />Parity<br />59<br />Discussion<br />
    112. 112. Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />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††).<br /> <br />† Feeling respected by the provider and healthcare staff <br />† Your opinion about your child’s health matters <br />†† e.g. knowing when and what vaccinations a child needs <br />Sources of information <br />(lay, pseudo experts, experts)<br /> <br />Compromises Ability to Assess Need <br />Low Literacy <br />Low Health Literacy<br />Competing demands <br />Lack of trust for the health care system or individual providers <br />Demographics<br />Race/Ethnicity <br />Nativity *<br />Age <br />Education *<br />Literacy<br /><ul><li> Health literacy
    113. 113. Ability to function w/o reading </li></ul>Language <br />Housing <br />Social Structure <br />Marital Status <br />Parity*<br /> Few competing demands <br />Compromising Factors <br /> Low literacy<br /> Low health literacy <br /> Learning disabilities<br /> Dyslexia<br />  No coping strategy for dealing with .. literacy barriers <br />Parity high <br />too many competing demands<br />Mental Illness<br />* IV in the quantitative analysis and a theme in the qualitative analysis <br />Personal /Family Resources<br />Income <br /> People @ home <br /> Financial Support <br />Employment *†<br />Insurance <br />Community Resources<br /><ul><li> Physical access to care
    114. 114. Availability/Convenience
    115. 115. Time in community /strength of ties</li></ul> .Social support<br /> <br />Literacy<br />Strategies for working around low literacy <br />Access to sources of health information <br />Internet<br />Access to information <br />Communication <br />Having an advocate <br />Continuity of care<br />Prior satisfaction with a healthcare provider <br /> <br />Disabling Factors<br />Power imbalance<br />Lack of an advocate <br />Limited or no access to health information <br />Administrative/logistic hassles<br />† Work gets in the way (unemployment) <br />60<br />
    116. 116. Benefit of Mix Methods<br />New Concepts <br />Lay informants <br />Pseudo experts<br />Experts <br />Confirmation <br />Parity <br />Employment <br />Unexpected findings (dyslexia example)<br />“I don’t take advice from family or friends as much as I would a doctor” <br />“I would call the hospital…... I got reprimanded for calling”<br />“My cousin is in nursing school” <br />“Friends, but their kids are younger so they don’t know”<br />61<br />
    117. 117. Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />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††).<br /> <br />† Feeling respected by the provider and healthcare staff <br />† Your opinion about your child’s health matters <br />†† e.g. knowing when and what vaccinations a child needs <br />Sources of information <br />(lay, pseudo experts, experts)<br /> <br />Compromises Ability to Assess Need <br />Low Literacy <br />Low Health Literacy<br />Competing demands <br />Lack of trust for the health care system or individual providers <br />Demographics<br />Race/Ethnicity <br />Nativity *<br />Age <br />Education *<br />Literacy<br /><ul><li> Health literacy
    118. 118. Ability to function w/o reading </li></ul>Language <br />Housing <br />Social Structure <br />Marital Status <br />Parity*<br /> Few competing demands <br />Compromising Factors <br /> Low literacy<br /> Low health literacy <br /> Learning disabilities<br /> Dyslexia<br />  No coping strategy for dealing with .. literacy barriers <br />Parity high <br />too many competing demands<br />Mental Illness<br />Personal /Family Resources<br />Income <br /> People @ home <br /> Financial Support <br /> Employment *†<br />Insurance <br />Community Resources<br /><ul><li> Physical access to care
    119. 119. Availability/Convenience
    120. 120. Time in community /strength of ties</li></ul> .Social support<br /> <br />Literacy<br />Strategies for working around low literacy <br />Access to sources of health information <br />Internet<br />Access to information <br />Communication <br />Having an advocate <br />Continuity of care<br />Prior satisfaction with a healthcare provider <br /> <br />Disabling Factors<br />Power imbalance<br />Lack of an advocate <br />Limited or no access to health information <br />Administrative/logistic hassles<br />† Work gets in the way (unemployment) <br />62<br />
    121. 121. A Critical Case Emerges <br />63<br />
    122. 122. Need Factors<br />Views & evaluation of the child’s functional capacity, symptoms, & general state of health <br /> <br />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††).<br /> <br />† Feeling respected by the provider and healthcare staff <br />† Your opinion about your child’s health matters <br />†† e.g. knowing when and what vaccinations a child needs <br />Sources of information <br />(lay, pseudo experts, experts)<br /> <br />Compromises Ability to Assess Need <br />Low Literacy <br />Low Health Literacy<br />Competing demands <br />Lack of trust for the health care system or individual providers <br />Demographics<br />Race/Ethnicity <br />Nativity *<br />Age <br />Education *<br />Literacy<br /><ul><li> Health literacy
    123. 123. Ability to function w/o reading </li></ul>Language <br />Housing <br />Social Structure <br />Marital Status <br />Parity*<br /> Few competing demands <br />Compromising Factors <br /> Low literacy<br /> Low health literacy <br /> Learning disabilities <br /><ul><li> Dyslexia</li></ul> No coping strategy for dealing with literacy barriers <br />Parity high – too many competing demands<br /> Mental Illness<br />Personal /Family Resources<br />Income <br /> People @ home <br /> Financial Support <br />Employment *†<br />Insurance <br />Community Resources<br /><ul><li> Physical access to care
    124. 124. Availability/Convenience
    125. 125. Time in community /strength of ties</li></ul> Social support<br /> <br />Literacy<br />Strategies for working around low literacy <br />Access to sources of health information <br />Internet<br />Access to information <br />Communication <br />Having an advocate <br />Continuity of care<br />Prior satisfaction with a healthcare provider <br /> <br />Disabling Factors<br />Power imbalance<br />Lack of an advocate <br />Limited or no access to health information <br />Administrative/logistic hassles<br />† Work gets in the way (unemployment) <br />64<br />
    126. 126. Missed Opportunities <br />“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?”<br />Note: <br />This participant declined the HPV vaccine for her daughter, who she generally relies on to translate written materials. <br />65<br />
    127. 127. Health Literacy <br />50% of the group was compliant in year 1 and this did not vary by health literacy<br />44% of the group was compliant in year 2 and again no variation by health literacy<br />Does health literacy matter in this population? <br />66<br />
    128. 128. Limitations & Lessons Learned <br />Sample size / power<br />Inclusion criteria <br />10 month of eligibility <br />Locating the poorest readers <br />REALM <br />Was it reliable in the population? <br />Does it need to be validated in the context of LD? <br />Did not take full advantage of the available data* <br />Limited generalizability and transferability <br />67<br />
    129. 129. Next Steps<br />Augment the current analysis and submit a paper for publication <br />Abstract has been sent to APHA <br />Critical Case was presented at Health Literacy Annual Research Conference <br />Need to further explore how a learning disability impacts health literacy <br />68<br />
    130. 130. Next Steps Continued <br />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) <br />For example:<br />Feeling respected by a provider (qualitative)<br />Mastery Scale and Coping Questions (parent study) <br />“Sometimes I feel that I am being pushed around in life” <br />“There is little I can do to change many of the important things in life”<br />For example:<br />Depression/mental illness (qualitative)<br />Depression (parent study)<br />69<br />
    131. 131. Some References (others available upon request)<br />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<br />Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav, 36(1), 1-10. <br />Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual<br />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. <br />American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2000). Recommedations for preventive pediatric health care.<br />Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics, 108(1), 90-97. <br />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<br />70<br />
    132. 132. 71<br />
    133. 133. 72<br />
    134. 134. 73<br />
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