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Exploring the association between maternal health literacy and pediatric healthcare utilization: Is low health literacy a barrier of concern?

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Rosemary Frasso
Abstract:
Background. Women with low-health literacy (HL) underutilize preventive healthcare. However, there is little research on healthcare utilization for their children. In this mixed method study we examined the relationship between maternal HL and healthcare use in young children (0-24mo) in an inner city population. Methods. We assessed HL of mothers using the Rapid Assessment of Adult Literacy in Medicine, in a nested random sample from a cohort study (n=1,034) of low-income, urban women (n=235). We were able to link the Medicaid Claims data of 185 children (0-24 months) to unique women in our sample. Additionally we conducted 14 semi-structured interviews with mothers with varied HL, exploring many pediatric health related challenges faced by mothers living in an urban environment with their small children. Guided by Andersen's Behavioral Health Model we analyzed and coded verbatim transcripts. Results. In our sample 14.1% of the women had low HL (≤6th grade). While most children received some care, only 3.4% of the children in our sample received the recommended seven or more well-child visits between 0-12 months of age (national average 82%). Our study failed to document an association between compliance and health literacy but it documented a very low rate of service use. HL was not associated with the number of well-child visits, sick-child visits, and emergency department visits. Qualitative analyses of interview transcripts revealed that poor readers and strong readers encountered an overlapping set of challenges when navigating the healthcare system in an urban setting. Communication, power respect, and physical access (e.g. transportation) were among the themes that emerged as obstacles to care. Participants reported finding a way to access care despite such obstacles. Conclusions. In this study of low-income mothers we found no association between HL and utilization of pediatric health services. We determined that HL did not mediate or moderate the relationships between a set of predisposing and enabling factors and our primary outcome variables. Low-HL was not an additional risk factor and higher health literacy was not protective against risk.

Table of Contents Dedication n Acknowledgment in Abstract IV List of Diagrams, Graphs and Tables vi Chapter 1 Introduction and Specific Aims 1 Chapter 2 Background & Significance 6 Chapter 3 Research Design 29 Chapter 4 Results 58 Chapter 5 Conclusion and Discussion 99 Appendices 118 Bibliography 136

VI List of Diagrams Diagram 2 1 Maternal Characteristics 20 Diagram 2 2 Health Literacy A Potential Mediator and Moderator of Anderson's Perdisposing and Enabling Need Factors 27 Diagram 3 1 Sample Composition 36 Diagram 3 2 Theoretical Model with Numbered Pathways 42 Diagram 4 1 Pathway 1 59 Diagram 4 2 Pathway 2 68 Diagram 4 3 Pathway 3 83 Diagram 4 4 Pathway 4 90 Diagram 4 5 Qualitative Findings Incorporated into Anderson's Model 94 List of Graphs Graph 4 1 Percent of Participants in Each Education Group 61 Graph 4 2 Percent of Participants in Each Age Group by Health Literacy Level 63 Graph 4 3 Sample Frequency Distribution of Well-Child Visits in Year 1 88 Graph 4 4 Sample Frequency Distribution of Well-Child Visits in Year 2 88 List of Tables Table 2 1 NAAL Results and Category Definitions and Examples 9 Table 2 2 Study Hyoptheses 28 Table 3 1 Descriptions of REALM Grade Equivalent Scores 40 Table 3 2 Anderson's Factors Operationahzed 41 Table 4 1 Maternal Predisposing Factors and Health Literacy 62 Table 4 2 Maternal Enabling Factors and Health Literacy (Part 1) 66 Table 4 3 Maternal Enabling Factors and Health Literacy (Part 2) 67 Table 4 4 Maternal Predisposing Characteristics and Well-Child Visits 70 Table 4 5 Maternal Enabling Characteristics and Well-Child Visits 71 Table 4 6 Maternal Predisposing Characteristics and Sick-Child Visits 75 Table 4 7 Maternal Enabling Characteristics and Sick-Child Visits 76 Table 4 8 Maternal Predisposing Characteristics and ED-Child Visits 77 Table 4 9 Maternal Enabling Characteristics and ED-Child Visits 78 Table 4 11 Maternal Predisposing Charactenstics and % Compliant w/ Minimum Number of Well-Child Visits/Year 81 Table 4 12 Maternal Enabling and % Compliant w/ Minimum Number of Well-Child Visits/Year 82 Table 4 13 Maternal Health Literacy and Outcomes of Interest Year 1 of Life 85 Table 4 14 Maternal Health Literacy and Outcomes of Interest Year 2 of Life 86 Table 4 15 Dyslexia and Law Health Literacy The Experiences of a Mother with a Reading Disability in the Healthcare Setting 95

Maternal Health Literacy and Pediatric Health Care 1 Chapter 1

Maternal Health Literacy and Pediatric Health Care 2 Introduction and Specific Aims Introduction Women with low health literacy have poor health outcomes and underutihze preventive care in many settings and for a variety of diseases (Dewalt, Berkman, Sheridan, Lohr, & Pignone, 2004) However, there is little research on health outcomes and service utilization for the children of women with low health literacy We hypothesized that low maternal health literacy directly affects the utilization of pediatric health care services including pediatric preventive care (PPC) Well-child care is the mainstay of pediatric preventive care which is designed to prevent disease, injury and disability while promoting health and well being through continuant health monitoring, screening and regular immunizations (Zuckerman, Stevens, Inkelas, & Halfon, 2004) Appropriate use of pediatric preventive care is associated with significant reductions in morbidity and mortality among children (Dinkevich & Ozuah, 2002, The American Academy of Pediatrics [AAP], 2011) and has been shown to reduce health care costs (Byrd, Hoekelman, & Auinger, 1999, Freed, Clark, Pathman, & Schectman, 1999, Simon et al, 2006), decrease hospital admissions by assuring timely follow-up and treatment compliance (Flores, Abreu, Chaisson, & Sun, 2003, Hakim & Bye, 2001, Simon, et al, 2006), and promote appropriate family psychosocial development (Dinkevich & Ozuah, 2002, Freed, et al, 1999, Halfon et al, 2004) Specific Aims We employed both qualitative and quantitative techniques to understand the

Maternal Health Literacy and Pediatric Health Care 3 relationship between low maternal health literacy and adherence to guidelines for the number of well-child visits established by the National Committee for Quality Assurance (NCQA) and the American Academy of Pediatrics Additionally we explored the relationship between maternal health literacy and the number of acute or sick-child visits, defined as non routine visits to a pediatnc healthcare provider, (for example when a child presents with fever, vomiting or diarrhea), pediatric emergency department (ED) visits, defined as times when children report to the ED due to illness or injury or if they are referred there after a routine (well-child visit) or sick-child visit, and finally, compliance with a minimum number of well-child visits in the first two years of life, defined here as four or more visits in year one and two or more routine visits in year two of life (Shulman, 2006) Using Andersen's Model of Healthcare Use for Vulnerable Populations, we examined whether, and to what extent, maternal health literacy mediates (1 e explains) or moderates (1 e affects the strength and/or the direction of) the relationship between a broad set of maternal predisposing and enabling factors and our four outcomes of interest (Baron & Kenny, 1986, Byrd, et al, 1999) Additionally we explored these relationships as well as maternal perceptions of pediatric healthcare need, referred to as needs factors in Andersen's model, qualitatively The exploration of these relationships will establish valuable information to guide development of targeted interventions We conducted statistical analyses on a available sample of 185 low-income, inner city women from a longitudinal study (Culhane, Centers for Disease Control and Prevention [CDC], Elo National Institute of Health [NIH]) of maternal health factors and

Maternal Health Literacy and Pediatric Health Care 4 maternal/child health outcomes These mothers were followed from the prenatal period through two years postpartum and completed an extensive battery of assessments to gather information on a robust set of demographic and socioeconomic factors corresponding to the predisposing and enabling factors described by Andersen Mothers in the sample also completed sophisticated health literacy assessments We linked these survey responses to Medicaid claims data for the children of the women in our sample in order to assess adherence to the recommendations for optimal use of pediatric preventive care (AAP, 2000, CDC, 2006) as well as sick-child care, ED use and compliance with a minimum number of well-child visits in the first two years of life as established in the literature We conducted a series of in-depth interviews of mothers to help interpret and contextuahze the quantitative findings and to gain a broader understanding if, how and why maternal health literacy influences the receipt of preventive pediatric care When this research began we set out to 1 Determine the extent to which the children of mothers with low health literacy differ from the children of mothers with higher health literacy in meeting established pediatric preventive care guidelines (seven visits in year one of life and three visits in year two of life) 2 Determine the extent to which the children of mothers with low health literacy differ from the children of mothers with higher health literacy in being compliant with a minimum number of pediatric preventive care visits (at least four visits in year one of life and at least two visits in year two of life) 3 Determine the extent to which the children of mothers with low health literacy

Maternal Health Literacy and Pediatric Health Care 5 differ from the children of mothers with higher health literacy in their use of emergent care (ED care) and non routine (sick-child) care 4 Determine whether, or to what extent, maternal health literacy mediates and/or moderates the relationship between the identified predisposing and enabling factors and the outcomes of appropriate use of pediatric preventive care 5 Conduct interviews with mothers to understand and interpret the findings from Aims 1-3 as a first step toward informing the development of effective interventions to improve the access to and enhance the receipt of pediatric preventive care and to assess need

Maternal Health Literacy and Pediatric Health Care 6 Chapter 2

Maternal Health Literacy and Pediatric Health Care 7 Background and Significance Health Literacy Low literacy is common in the United States Approximately 90 million Americans have trouble finding information or numbers in a lengthy text, integrating multiple pieces of information in a document, finding two or more numbers in a chart and performing simple calculations (Kirsch, Jungeblut, & Jenkins, 2002) The mean reading level for US adults is 8th grade and the mean reading level for low income Medicaid enrollees is 5th grade (Weiss et al, 1994) These limitations not only impact a person's ability to function effectively in the work place and in society, they are often a barrier to managing one's health (Berkman et al, 2004, Dewalt, et al, 2004, Institute of Medicine [IOM], 2004) According to a 2004 IOM report, nearly half of all American adults have difficulty understanding and acting upon health information (2004) The role of literacy has proven to be pivotal in healthcare provider-consumer interactions As a result, the term health literacy has evolved out of efforts to conceptualize the unique literacy demands in the healthcare setting "Health literacy," is broadly defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Health and Human Services [HHS], 2000) While basic literacy skills (reading and writing) provide the foundation for achieving adequate health literacy, the terms "literacy" and "health literacy" are not completely interchangeable Additionally

Maternal Health Literacy and Pediatric Health Care 8 health literacy has been found to vary directly with level of education, which is the percentage of adults with low health literacy decreases dramatically as education level increases However, education is not a proxy for health literacy, in fact some 44 % of high school graduates and 12 % of college graduates have limited health literacy (HHS, 2008) So it is important and justified to assess health literacy independently of education Health literacy affects the ability to understand both written and oral communications which are key to successful patient-provider interactions (Doak, Doak, Fnedell, & Meade, 1998) Health literacy was specifically and widely examined for the first time during the 2003 National Assessment of Adult Literacy (NAAL), which included a measure of health literacy The NAAL study included a nationally representative sample of 19,000 participants (aged 16 and above) Health literacy was broken down into four categories below basic, basic, intermediate and proficient and the results are described below (Table 2 1) (White, 2008) According to the NAAL, only 12% of adults living in the United States have proficient health literacy and 77 million people, some one third of adults, would have difficulty with common health tasks, such as following directions on a medication label or using a simple chart to determine when a child is due for her vaccinations (White, 2008) Patients with low health literacy report significant difficulties navigating the healthcare system with its increasing complexities and literacy demands Signage, medication instructions, and examination preparation documents, as well as written consent forms often contain medical jargon and abbreviations, which can pose even

Maternal Health Literacy and Pediatric Health Care 9 Table 2.1; NAAL Results and Category Definitions and Examples Health Literacy Level Proficient Intermediate Basic Below Basic or Low Health Literacy Tasks Examples Using a table, calculate an employee's share of health insurance costs for a year Read instructions on a prescription label, and determine what time a person can take the medication Read a pamphlet, and give two reasons a person with no symptoms should be tested for a disease Read a set of short instructions, and identify what is permissible to drink before a medical test Percentage of Respondents 12% 53% 21% 14% greater challenges to those who have difficulty reading (Schwartzberg, VanGest, & Wang, 2005) Also, patients with low health literacy have less understanding of their medical conditions and their prescribed treatments (American Medical Association [AMA], 1999, Bains & Egede, 2011, Wolf et al, 2011) Low health literacy has been deemed a risk factor for decreased utilization of preventive healthcare, increased use of emergency care, increased hospital admissions, increased healthcare costs and poor health outcomes in adults (Weiss & Plamer, 2004 (Baker et al, 2002, IOM, 2004, Osborn, Paasche-Orlow, Bailey, & Wolf, 2011, Roter, Rudd, & Comings, 1998, Schilhnger, Barton, Karter, Wang, & Adler, 2006) Additionally, health literacy has been shown to be independently associated with disease knowledge, and self-report of morbidity (Gazmaranan, Williams, Peel, & Baker, 2003, Williams, Baker, Parker, & Nurss, 1998) In 2006 Sentell and Halpin employed National Assessment of Adult Literacy (NAAL) data to explore the relationship between health literacy and health disparities and concluded that literacy was a more powerful predictor

Maternal Health Literacy and Pediatric Health Care 10 of adult health status than education or race (Sentell & Halpin, 2006) According to the AMA, people with the greatest healthcare needs may have the least ability to read and comprehend information needed to function successfully as patients (1999) Low health literacy is prevalent among adults and is independently associated with poor health status (Baker, et al, 2002, IOM, 2004, Schilhnger, et al, 2006, B D Weiss, Hart, McGee, & D'Estelle, 1992) Patients with low health literacy face a host of communication challenges that include, but are not limited to, the comprehension of written materials which may interact to influence health outcomes (AMA, 1999, IOM, 2004 Low health literacy can lead to substandard care by impeding effective interaction between patients and their healthcare providers (Berkman, et al, 2004, Dewalt, et al, 2004, Pignone, DeWalt, Sheridan, Berkman, & Lohr, 2005) Preliminary studies have pointed to an increase in medical expenditures for people with low health literacy (AMA, 1999, Gazmararian et al, 1999) potentially as a result of delayed preventive care Research has also found low health literacy among women to be associated with decreased use of preventive services, increased use of acute care, including emergency room visits, and less medical screening including mammography and Pap smears (Davis, Arnold, et al, 1996, Lindau et al, 2002, Lindau, Tomori, McCarville, & Bennett, 2001) Recent studies have found that health literacy contributes to disparities attributed to race/ethnicity and educational attainment in self-rated health and utilization of some preventive healthcare services by older adults (Bennett, Chen, Soroui, & White, 2009, Rudd, Comings, & Hyde, 2003) However Bennett and colleagues noted that among a cohort of Medicaid recipients, low health literacy was not an additional risk factor for underutihzation of

Maternal Health Literacy and Pediatric Health Care 11 services and, importantly, higher health literacy was not protective (Bennett, 2006) In that study the rate of prenatal care observed was far below the recommended number and national average for pregnant women for all participants independent of their literacy level raising the possibility that within a relatively homogeneously deprived and under resourced group low literacy may not add a measurable additional disadvantage in care utilization - the baseline rate of care utilization for all women may be too low to detect an effect of low literacy The subjects of this study were inner city women in prenatal care and so very similar to women with infants that are the subject of this dissertation research These findings highlight the need to further investigate the impact of health literacy when it is likely not an isolated risk factor, but one on a long list of barriers to care Maternal Health Literacy and Pediatric Care In pediatrics, where preventive care is a crucial step in assuring the healthy development of a child, healthcare is routinely coordinated by adults, most frequently mothers Recommended appointments are frequent in the first two years of life as they are often the only opportunity for providers to assure that vaccination regimes are complied with and growth and development are monitored in order to assure a healthy passage from infancy to childhood Thus, low maternal health literacy, was a potential barrier to appropriate pediatric healthcare and worthy of exploration To date, most of the health literacy research has focused on the adult patient and little attention has been paid to the unique impact health literacy might have on the maternal child dyad Clearly, adequate maternal health literacy is necessary for effective navigation in the children's

Maternal Health Literacy and Pediatric Health Care 12 healthcare arena when the child is well and certainly, even more important during acute minor illnesses or long term treatment for complex and chronic health conditions impacting childhood (Betz, Ruccione, Meeske, Smith, & Chang, 2008) While not completely transferable it is important to note that studies of parental health literacy in the developing world (e g India) have documented an association between parental health literacy and infant mortality (Gokhale, Rao, & Garole, 2002) While the impact of parental health literacy on pediatric outcomes in the Umted States may seem diminished by our advanced healthcare system the story is not entirely different Here studies have documented an association between parental literacy and both access and utilization of pediatric services However, the nuances of these relationships have not been completely explored (Yin, Forbis, & Dreyer, 2007) Additionally, some studies have shown that low health literacy can result in improper medication administration, missed appointments, poor or suboptimal performance of home care (for example, contamination of "sterile" supplies), ultimately adversely affecting pediatric health outcomes (Leyva, Sharif, & Ozuah, 2005, Moon, Cheng, Patel, Baumhaft, & Scheldt, 1998, Yin, Dreyer, Foltin, van Schaick, & Mendelsohn, 2007, Yin et al ,2010) Also of note, maternal health literacy has been linked to lifestyle choices as well as disease management that can impact the health of both the mother and the child For example, in a study conducted by Kaufman, et al researchers found that only 23% of the women with lower literacy reported exclusively breast-feeding during the first two months compared with 54% of women in the higher literacy group (Kaufman, Skipper, Small, Terry, & McGrew, 2001) Other studies have documented an association between parental health literacy and management

Maternal Health Literacy and Pediatric Health Care 13 of common chronic pediatric diseases including asthma and diabetes (DeWalt, Dilhng, Rosenthal, & Pignone, 2007, Ross, Frier, Kelnar, & Deary, 2001) Yin and colleagues highlighted the extent of this problem in their study of parental health literacy in the United States They performed a cross sectional study of a nationally representative sample (N= >6,100) of parents who participated in the 2003 NAAL survey Yin et al reported that Some 28 7% of the parents in the sample had below-basic/basic health literacy, 68 4% were unable to enter names and birth dates correctly on a health insurance form and 46 4% were unable to perform at least one of two medication (prescription or over the counter) related tasks and they reported that 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 Parents with below-basic health literacy were less able to calculate insurance cost based on family size and were far 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 (Yin et al, 2009) Yet, little academic attention has been paid to the extent to which this might occur or the mechanisms that might surround it Mothers with low health literacy face significant obstacles that may impact their ability to seek and obtain timely and appropriate healthcare for their children One such obstacle is the mismatch between the literacy demands of the healthcare environment and the reading level of patients (Davis et al, 1994, IOM, 2004) This mismatch has been documented in the pediatric setting, where the median reading level for caregivers is grade 8 and the material provided is often written for readers well above that level

Maternal Health Literacy and Pediatric Health Care 14 (Sanders, Thompson, & Wilkinson, 2007) As a result, a significant portion of the patient population is unable to comprehend written materials related to pediatric care For example, mothers with low health literacy have notably worse outcomes for their children with chronic health conditions (DeWalt, et al, 2007) Educational attainment, while not a direct proxy for health literacy, has been shown to be a risk factor for limited reading skills a component of health literacy (IOM, 2004) According to a report issued by the CDC, children of mothers having less than a high school education tended to have inadequate prenatal care and patterns of delaying prenatal care (CDC, 2003, DHHS, 2003, Sword, 2003) Additionally at least one study has found that low functional health literacy among women with pre-gestational diabetes is associated with several factors that may adversely impact birth outcomes (Endres, Sharp, Haney, & Dooley, 2004) In light of the established associations discussed here we expected to find that mothers with low health literacy (who tend to use less healthcare services for themselves) would coordinate and secure less preventive healthcare services (and use healthcare services less effectively) for their children than their more literate counterparts (Baker, et al, 2002, Baker et al, 2004, IOM, 2004, Lindau, et al, 2002, Parker, Williams, Baker, & Nurss, 1996) Exploration of this association is an important first step toward reducing pediatric health disparities and enhancing the preventive pediatric healthcare receipt for all children Preventive Pediatric Care The American Academy of Pediatrics (AAP) recommends that well-children receive frequent, periodic preventive care in the first 3 years of life (2010) With the

Maternal Health Literacy and Pediatric Health Care 15 ultimate goal of preventing childhood morbidity and mortality, preventive pediatric care, known widely as well-child care plays a critical role in promoting the health and development of children (Guyer et al, 2009) Well-child visits provide an opportunity for clinicians to assess the child's biomedical health, indentify social and developmental delays and disorders, and evaluate family functioning (AAP, 2010) It also provides clinicians an important opportunity to screen for disease, abuse, bullying, neglect and physical anomalies as well as risky environmental exposures including lead poisomng (Dinkevich & Ozuah, 2002, AAP, 2010) Additionally, the visits secure an opportunity to identify potential health, development and emotional problems, and provide injury prevention advice, nutritional guidance and vaccinations (Freed, et al, 1999, AAP, 2010) Early detection of potential health and developmental problems allows pediatric healthcare providers to intervene at a point where treatment is often less invasive, less expensive, and most effective (Halfon & Olson, 2004, McMenamy, Sheldnck, & Perrin, 2011, Shannon & Anderson, 2008) For example, pediatric healthcare providers who identify children at risk for obesity can attempt to intervene early on, before the onset of any long-term adverse health effects, such as the development of Type II diabetes (CDC,2011, Kwapiszewski & Wallace, 2011, Mayo Clinic Staff, 2010) Early interventions may reduce mortality, morbidity and disability, thereby allowing children to live longer, healthier and more productive lives and are associated with a reduction in healthcare costs (Byrd, et al, 1999, HHS, 2000) Children with an inadequate number of well-child visits are more likely to have avoidable hospitalizations (Hakim & Bye, 2001) and less likely to be up to

Maternal Health Literacy and Pediatric Health Care 16 date on their immunizations (Freed, et al, 1999), which are responsible for controlling infectious diseases that have serious morbidity and mortality consequences for individual children and, by virtue of compromised herd immunity, the community (Selden, 2006) Well-child visits are also key opportunities for provider parent communication and education For mothers with low health literacy, who have limited ability to take advantage of written educational material, well-child visits are not only a chance to directly impact the health outcomes of their children, but they are also an opportunity (possibly the only opportunity) to learn about healthy and safe parenting, which can further contribute to normal child development Due to the importance of well-child care during infancy, the AAP has laid out a clear evidence-based preventive care plan The AAP recommends at least six (ideally 7) well-child visits in the first year of life, three in the second year, and one in each of the subsequent years (AAP, 2000, AAP, 2010) to ensure the appropriate physical and developmental growth of children during this critical period In addition, CDC recommends that children receive nineteen doses of vaccinations within their first two to four years of life (CDC, 2006, Selden, 2006) which are often delivered during routine well-child visits (Fiks, Hunter, Locaho, Grundmeier, & Alessandrim, 2008, Lozano, Connell, & Koepsell, 1995) Underutihzation of preventive pediatric care is a significant problem (Chung, Lee, Morrison, & Schuster, 2006, Mangione-Smith et al, 2007) In an analysis of the 2000- 2002 Medical Expenditure Panel Survey of United States households, it was shown that on average 56% of all children 0 to age 18 had no well-child visits in the preceding year,

Maternal Health Literacy and Pediatric Health Care 17 39% had no well-child visits over the preceding two years and the average rate of compliance with the AAP well-child visit recommendation was 61% with large differences in compliance rates among children in different age groups and populations (Chung, et al, 2006, Selden, 2006) The rate of compliance also varies dramatically by age of the child and perceived medical need with those under the age of two years showing the highest rate of care utilization For example Selden documented that 83% of infants were observed to be compliant with AAP guidelines for year one of life (7 well- child visits) and the rate climbed to 87% for children with special healthcare needs Some 74% of children with college-educated parents were reportedly compliant as were 72% of children with family incomes greater than four times the poverty level Dramatic regional differences also came to light in the 2002 survey, for example nearly 96% of children living in New England were reported to be getting the appropriate number of visits per year while that number drops to 83% for children living in the Middle Atlantic region Low levels of compliance with AAP guidelines were observed among uninsured children (35 3%) and especially uninsured children who were likely, according to standard criteria, eligible for public coverage (28 4%) Other subgroups with low compliance included teenagers (49 2%), noncitizen children (43 9%), and children in the West South Central (44 9%), East South Central (48 8%), and Mountain (49 7%) census divisions Lower rates (28 4 %) were found among uninsured children (Chung, et al, 2006, Selden, 2006) Continuity of care a positive byproduct of regular well-child visits has been associated with a decrease in emergency department utilization in children 0-2 years of age (Brousseau, Meurer, Isenberg, Kuhn, & Gorelick, 2004) and has been associated with

Full document contains 160 pages
Abstract: Background. Women with low-health literacy (HL) underutilize preventive healthcare. However, there is little research on healthcare utilization for their children. In this mixed method study we examined the relationship between maternal HL and healthcare use in young children (0-24mo) in an inner city population. Methods. We assessed HL of mothers using the Rapid Assessment of Adult Literacy in Medicine, in a nested random sample from a cohort study (n=1,034) of low-income, urban women (n=235). We were able to link the Medicaid Claims data of 185 children (0-24 months) to unique women in our sample. Additionally we conducted 14 semi-structured interviews with mothers with varied HL, exploring many pediatric health related challenges faced by mothers living in an urban environment with their small children. Guided by Andersen's Behavioral Health Model we analyzed and coded verbatim transcripts. Results. In our sample 14.1% of the women had low HL (≤6th grade). While most children received some care, only 3.4% of the children in our sample received the recommended seven or more well-child visits between 0-12 months of age (national average 82%). Our study failed to document an association between compliance and health literacy but it documented a very low rate of service use. HL was not associated with the number of well-child visits, sick-child visits, and emergency department visits. Qualitative analyses of interview transcripts revealed that poor readers and strong readers encountered an overlapping set of challenges when navigating the healthcare system in an urban setting. Communication, power respect, and physical access (e.g. transportation) were among the themes that emerged as obstacles to care. Participants reported finding a way to access care despite such obstacles. Conclusions. In this study of low-income mothers we found no association between HL and utilization of pediatric health services. We determined that HL did not mediate or moderate the relationships between a set of predisposing and enabling factors and our primary outcome variables. Low-HL was not an additional risk factor and higher health literacy was not protective against risk.