Faculty Bibliography

Children who become overweight by age 2 years have significantly greater risks of long-term health problems, and children in low-income communities, where rates of low adult literacy are highest, are at increased risk of developing obesity. The objective of the Greenlight Intervention Study is to assess the effectiveness of a low-literacy, primary-care intervention on the reduction of early childhood obesity. At 4 primary-care pediatric residency training sites across the US, 865 infant-parent dyads were enrolled at the 2-month well-child checkup and are being followed through the 24-month well-child checkup. Two sites were randomly assigned to the intervention, and the other sites were assigned to an attention-control arm, implementing the American Academy of Pediatrics' The Injury Prevention Program. The intervention consists of an interactive educational toolkit, including low-literacy materials designed for use during well-child visits, and a clinician-centered curriculum for providing low-literacy guidance on obesity prevention. The study is powered to detect a 10% difference in the number of children overweight (BMI > 85%) at 24 months. Other outcome measures include observed physician-parent communication, as well as parent-reported information on child dietary intake, physical activity, and injury-prevention behaviors. The study is designed to inform evidence-based standards for early childhood obesity prevention, and more generally to inform optimal approaches for low-literacy messages and health literacy training in primary preventive care. This article describes the conceptual model, study design, intervention content, and baseline characteristics of the study population.

BACKGROUND: Unintentional injury is a leading cause of infant mortality. PURPOSE: To examine the role of caregiver health literacy in infant injury prevention behaviors. METHODS: A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety. RESULTS: Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120 degrees F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9). CONCLUSIONS: Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

OBJECTIVE: To examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors. METHODS: Cross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in 2 urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child's medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. The primary dependent variable was observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses were performed, controlling for parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; and site. RESULTS: Of 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs 46.4%, P = .01; 21.8 vs 45.7%, P = .001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (adjusted odds ratio 0.3; 95% confidence interval 0.1-0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error. CONCLUSIONS: Provider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together.

OBJECTIVE: To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity. METHODS: Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson chi(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions. RESULTS: Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037). CONCLUSIONS: Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

Publisher: Abstract available from the publisher. OABL- FRE

OBJECTIVE: To examine the relationship between parent health literacy and "obesogenic" infant care behaviors. STUDY DESIGN: Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate >/=23; low <23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site. RESULTS: Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (<30 min/d), (aOR = 3.0 [1.5-5.8]). CONCLUSIONS: Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (rho = 0.21), WRAT-3 (rho = 0.25), and PHLAT Spanish scores (rho = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted beta: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted beta: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted beta: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

OBJECTIVE: Parent administration of multiple medications with overlapping active ingredients places children at risk for overdose. We sought to examine how parents use active ingredient information as part of the process of selecting a cough/cold medication for their child and how health literacy plays a role. METHODS: Experimental study of parents of children presenting for care in an urban public hospital pediatric clinic. Parents were asked to determine which of 3 cough/cold medications could be given to relieve a child's cold symptoms, as part of a scenario in which they had already given a dose of acetaminophen; only 1 did not contain acetaminophen. Primary dependent variable: correct selection of cough/cold medication by using active ingredient as the rationale for choice. Primary independent variable: parent health literacy (Newest Vital Sign test). RESULTS: Of 297 parents, 79.2% had low health literacy (Newest Vital Sign score 0-3); 35.4% correctly chose the cough/cold medication that did not contain acetaminophen. The proportion of those who made the correct choice was no different than expected from chance alone (Goodness of fit test; chi(2) = 2.1, P = .3). Only 7.7% chose the correct medication and used active ingredient as the rationale. Those with adequate literacy skills were more likely to have selected the correct medication and rationale (25.8% vs 3.0% (P = .001); adjusted odds ratio 11.1 (95% confidence interval 3.6-33.7), after we adjusted for sociodemographics, including English proficiency and education. CONCLUSIONS: Many parents, especially those with low health literacy, do not use active ingredient information as part of decision-making related to administering multiple medications.