Faculty Bibliography

Health literacy is a foundational component of providing accessible pediatric care, influencing whether families can understand, access, and use health information. As families increasingly rely on online health resources, health literacy skills applied to digital information, or e-health literacy, has become an evolving dimension of pediatric health literacy. The concept of health literacy extends beyond an individual's abilities, intersecting with the demands placed on individuals by healthcare systems. There is a growing focus on organizational health literacy (OHL), which reflects how effectively systems support equitable communication, but this remains infrequently assessed or implemented. Limited parent, child, and adolescent health literacy is common and disproportionately affects families with lower income, minoritized racial/ethnic backgrounds, lower educational attainment, and who use languages other than English for care. Limited health literacy has been associated with decreased disease-specific knowledge, suboptimal health behaviors, and worse clinical outcomes. Although health literacy-informed strategies can improve comprehension and outcomes, best practices, such as teach-back, remain underutilized across pediatric care settings. The rapid expansion of digital tools offers new opportunities to enhance health literacy-informed communication but also introduces challenges related to equity, accuracy, and safety. Advancing pediatric health literacy requires coordinated efforts: embedding health literacy principles into institutional and national policies, integrating universal health literacy precautions into clinical workflows, expanding clinician and patient health literacy education, and advancing health literacy-focused research, including on digital interventions and artificial intelligence (AI)-supported communication. Prioritizing these efforts is essential to creating health literate-systems that enable all families to access, understand and use health information.

OBJECTIVE:To examine the relationship between dosage of the clinic component and child weight status in the Greenlight Plus Trial, a clinic plus digital intervention aimed to reduce early childhood obesity. STUDY DESIGN/METHODS:Longitudinal data were used from parent-child dyads (N=900) in the Greenlight Plus Trial. Clinic intervention dosage was assessed after each well child visit (WCV), as the sum of parent-reported receipt of: (1) a Greenlight booklet; (2) discussion of booklet content; and/or (3) goal setting. Multivariable models assessed the relationship between dosage and child weight-for-length (WFL). RESULTS:Across all WCVs (n=7200), parents reported not receiving any clinic intervention component at 20% of visits, receiving booklet only (dosage score=1) at 39.2% of visits, booklet receipt and discussion (dosage score=2) at 11.7% of visits, and booklet receipt, page discussion, and goal setting (dosage score=3) at 26.9% of visits. No association was detected between cumulative dosage and child WFL trajectory (p=0.31). However, we observed a statistically significant difference in the relationship of dosage to WFL in the 2 treatment arms (p=0.021). Within the clinic-only arm, there was a significant association between dosage and child WFL (p=0.005) in the first 6 months. CONCLUSIONS:Exposure to the full conceptual model of behavioral change was limited. Among those who received only the clinic intervention, dosage modestly and transiently improved infant weight. Enhancing primary care behavioral interventions with digital components, such as text messages, between visits may optimize their impact on child health outcomes including healthy growth.

OBJECTIVES/OBJECTIVE:Generative artificial intelligence (AI) holds promise for creating patient education materials (PEM). However, AI-produced content is often difficult to read. Prompts for AI to write at a lower reading level either fail to meet recommended targets (≤6th grade) or demonstrate inconsistent results. We aimed to determine whether a new AI prompt for plain language would create PEMs that are easier to read, understand, and act upon. METHODS:We analyzed PEMs from two websites (HealthyChildren.org, UpToDate) and two generative AI programs (ChatGPT, Gemini). For each AI program, we used a basic prompt and an advanced prompt to generate separate documents. From these sources, we collected six sets of PEMs about five acute pediatric conditions, evaluated them using a panel of readability indices, and used ANOVA to compare average readability scores between sources. Two pediatricians assessed understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). We calculated mean PEMAT scores, with values > 70% considered understandable/actionable. RESULTS:ChatGPT (advanced prompt) created PEM with the lowest mean grade reading level (5.8; SD 0.84) and highest PEMAT scores (91% understandable, 84% actionable). Documents from generative AI using the advanced prompt and UpToDate had mean readability scores ≤ 6th grade, with significantly better readability than AI-generated documents using the basic prompt or HealthyChildren.org. All sources except HealthyChildren.org had mean understandability > 70%; AIs using the advanced prompt and UpToDate exceeded the actionability threshold. CONCLUSIONS:A plain-language prompt for generative AI created PEMs that were readable, understandable, and actionable, with comparable results across two AI programs. PRACTICE IMPLICATIONS/CONCLUSIONS:Healthcare providers can use this new plain-language prompt for generative AI programs to quickly create free, patient-friendly PEM about acute healthcare topics. As these AI programs were not trained to provide medical guidance, medical professionals should continue to review PEM prior to sharing with patients.

OBJECTIVE:The quality of discharge processes impacts adverse outcomes post hospitalization for children with medical complexity (CMC). Perspectives of caregivers at risk for communication challenges (eg, non-English speakers, those with limited health literacy, immigrants) on understandability and feasibility of discharge instructions for CMC are understudied. Our objective was to explore their perspectives on barriers and facilitators to comprehension and implementation of discharge instructions for CMC. PATIENTS AND METHODS/METHODS:In this qualitative, descriptive study, we used maximum variation sampling to enroll caregivers of CMC (N = 40) discharged from acute or intensive care units of 2 urban hospitals. English- and Spanish-speaking caregivers of CMC (Pediatric Medical Complexity Algorithm) aged 18 years or older and discharged on 1 or more daily medications were eligible. We conducted semistructured interviews, audio-recorded and transcribed interviews, and performed content analysis. Two team members applied codes from a codebook (developed based on prior literature and preliminary analyses) and identified emerging themes. RESULTS:Equal numbers of participants spoke English and Spanish (n = 20 per language) and were recruited from each hospital (n = 20 per hospital). Half (47.5%) had low health literacy; 85% were of non-US birth. Themes emerged across 4 categories: (1) clinician and medication access; (2) patient- and family-centered approaches to discharge planning and education; (3) caregiver prior experience; and (4) resources and support systems. CONCLUSIONS:Caregivers identified barriers and facilitators affecting discharge plan comprehension and implementation. Optimizing postdischarge care for CMC is complex and requires family-centered, language-concordant, and health literacy-informed processes. Future interventions should focus on systems-level changes that enhance access and account for caregiver perspectives.

PurposeTo estimate the effect of the culturally-adapted Greenlight intervention on parent activation and locus of control (LOC) among Chinese-American immigrant parents.DesignProspective, quasi-experimental study.SettingA New York City-based federally-qualified health center with a large patient population of low-income, ethnically Chinese immigrant individuals and families.Sample444 Immigrant Chinese-American parents of infants (267 cross-sectionally enrolled historical controls and 177 Greenlight recipients followed prospectively).InterventionA culturally-adapted version of Greenlight, a health literacy- and communication-informed early childhood obesity prevention intervention in primary care which promotes certain healthy infant feeding practices at 12 months in the present sample.MeasuresParent activation and LOC were measured at 6, 12, 24, and 36 month well child visits.AnalysisGeneralized estimating equations were used to examine the effects of the Greenlight intervention on the outcome measures.ResultsCompared to historical controls, parents receiving Greenlight were more likely to strongly agree with the activation statements: "I know how to prevent my child from becoming overweight" (adjusted odds ratio (aOR): 9.62 [4.70, 19.73]); "I have been able to help my child maintain recommended changes like eating right or exercising" (aOR: 6.42 [4.14, 9.97]); and "I am confident I can keep my child eating and exercising right, even when I am busy or stressed" (aOR: 8.44 [5.35, 13.31]). Greenlight recipients also demonstrated increased internal LOC (aOR: 2.02 [1.35, 3.03]) and decreased powerful others external LOC (aOR: 1.76 [1.23, 2.51]).ConclusionTo reduce disparities in child obesity, especially among immigrant families, interventions must also prioritize parent factors like parent activation and LOC to build upon their inherent assets and promote long-term change.

OBJECTIVE:Studies have demonstrated that using milliliters (mL)-only in dosing instructions and on dosing devices for oral liquid medications (OLMs) can prevent patient/caregiver dosing errors. While previous studies have assessed the perceptions/practices of primary care providers (PCPs) regarding dosing units for OLMs, perceptions/practices of community-based pharmacists are not well described. METHODS:Data were collected in June 2024, through an online survey of retail pharmacists. Pharmacist perceptions/practices regarding OLMs were calculated overall and stratified by the number of years practicing pharmacy. Logistic regression was used to assess associations between certain characteristics and perceptions on pharmacist dispensing behaviors. RESULTS:A total of 201 pharmacists completed the survey. Pharmacists who had been practicing for <10 years were more likely to think that mL-only was safest to use in dosing instructions for OLMs (88.9%) and that patients/caregivers prefer dosing instructions in mL-only (73.3%) compared to those who had been practicing for ≥10 years (70.5% and 37.2%, respectively). Only one-third (33.8%) of all pharmacists reported that they would convert the dosing units dispensed on a prescription for oral liquid amoxicillin to mL-only if the prescriber wrote the dosing instructions in teaspoons; with pharmacist perception that mL-only was the safest to use in dosing instructions having the most significant impact on this dispensing behavior (adjusted odds ratio 11.37, 95% confidence interval 3.20-40.44). CONCLUSIONS:Educational efforts promoting the importance of using mL-only units on dosing instructions/devices for OLMs for pharmacists and PCPs may be necessary to promote safe dosing practices and reduce pediatric medication errors.

OBJECTIVE:To examine whether disparities in preventable adverse events (AEs) and family experience for hospitalized children of parents with and without limited comfort with English (LCE) changed following implementation of a health literacy-informed, structured family-centered rounds intervention, Patient and Family Centered I-PASS. METHODS:Seven-center prospective before and after intervention study conducted from December 2014 to January 2017. Inclusion criteria includes parents and caregivers of hospitalized children less than 18 years old. LCE defined as parent and caregiver reporting any language other than English as the language in which they were most comfortable speaking to physicians and nurses. Preventable AE rates determined via (1) daily medical record surveillance, solicited clinician reports, hospital incident reports, and family safety interviews, followed by (2) dual-physician masked review and consensus rating. Changes assessed through multivariable mixed-effects logistic regression, controlling for complex chronic conditions, length of stay, parent race and ethnicity, education, and clustering by site. Family experience assessed via predischarge survey (6 domains, 5-point scale). Mixed-effects linear regression estimated changes in mean domain scores by language comfort. RESULTS:Of 1666 patients, 8.8% (n = 147) had parents with LCE. Preimplementation, over twice as many children of parents expressing LCE experienced preventable AEs, compared with children of parents expressing comfort with English (18.8% vs 7.6%; P = .001; adjusted odds ratio, 3.29; 95% CI, 1.48-7.31). Postimplementation, there were no significant differences between groups (6.4 vs 5.3%; P = .68; adjusted odds ratio, 1.26; 95% CI, 0.42-3.75). Some domains of family experience improved for both groups, although disparities in experience persisted in nurse communication. CONCLUSIONS:Patient safety disparities related to parental comfort with English narrowed after implementing a family-centered rounds communication intervention.

OBJECTIVE:Cross-sectional analyses have demonstrated an association between lower social capital and higher food insecurity in families with children. This study examined the association between social capital in the newborn period and household food insecurity at child age two years in a diverse US sample. METHODS:This secondary analysis used survey data from 596 child-caregiver dyads enrolled at six US academic sites in Greenlight Plus, a childhood obesity prevention trial. Proportional odds regression models analyzed associations between two newborn-period social capital measures, caregiver social support and neighborhood social cohesion, and household food insecurity at child age two years, adjusted for newborn-period food insecurity and sociodemographic covariates. Additional models evaluated the interaction between the two social capital exposures. RESULTS:In adjusted analyses, a low caregiver social support score of 18 was associated with over three times the odds of higher food insecurity at child age two years, compared to a high score of 30 (aOR=3.23 with 95%CI=1.84-5.68). Low neighborhood social cohesion in the newborn period was not significantly associated with higher household food insecurity at child age two years, with similar odds for a low neighborhood social cohesion score of 10 compared to a high score of 20 (aOR= 1.24 with 95%CI=0.56-2.78). Results remained similar when both social capital exposures were included in the same model, and no significant interaction was detected. CONCLUSIONS:Caregiver social support in the newborn period may represent a modifiable protective factor against developing or worsening household food insecurity in families with young children.

BACKGROUND:Best practices for engaging patients and the community in biomedical research evolved significantly in recent years. However, few focus on patient engagement in the design and implementation of a national study. OBJECTIVES/OBJECTIVE:To describe the initial engagement development and implementation; present findings from data collected during the first year; and discuss lessons learned. METHODS:Data were collected as part of continuous quality improvement efforts to assess and refine the engagement strategy. Fifty-two patient, caregiver, and community representatives were invited to complete a brief online survey about their experience participating in a national initiative. RESULTS:A framework for engagement was created and 35 representatives completed the survey (67% response rate). Representatives demonstrated awareness related to their roles and responsibilities. Seventy-six percent indicated that they felt comfortable expressing opinions and the decision-making process. CONCLUSIONS:The RECOVER initiative's approach promoted greater transparency and trust between researchers and the community, leading to more impactful engagement.

OBJECTIVE:To identify optimal strategies to integrate early relational health (ERH) programs in pediatric primary care (PPC) and to describe the development of a best practices toolkit to provide guidance and useful tools that clinicians can use to navigate this process. METHODS:A two-phased approach to develop, assess, and refine a best practices toolkit for the integration of multiple ERH programs in PPC through a modified Delphi process. Phase One included identification and assessment around barriers to ERH program integration and strategies to address them through surveys and focus groups of PPC clinics nationwide. Phase Two then utilized the identified barriers and strategies from Phase One to create a toolkit of best practices on integrating ERH programs in PPC that included two rounds of revision for a final version. RESULTS:126 PPC personnel from 44 clinics nationwide completed the Phase One survey, with respondents reporting many notable strengths and challenges to ERH program integration. 18 survey participants also participated in follow-up focus groups, which reiterated the strengths and challenges found in the surveys. An initial toolkit was then drafted, and experts provided qualitative, free-response feedback around clarity and presentation. Further improvement was made to create the final toolkit, which was rated highly useful and important, though slightly less feasible, by practitioners using formal feedback questions. CONCLUSION/CONCLUSIONS:This study employed a modified Delphi process to create a consensus-based best practices toolkit for integrating multiple ERH programs in PPC to help meet the heterogeneous needs of families to promote optimal child development.