M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, Deborah Winders Davis, PhD, Reetta Stikes, MSN, RN, Rachel Ratterman, RN, APRN, Lesa Ryan, BA, and John Myers, PhD
Acceptability and Initial Efficacy of
Science Photo Library / Alamy
EDUCATION for Teen Mothers
Abstract Purpose: Educational materials used by healthcare agencies frequently do not follow national health guidelines for plain talk. Adolescent mothers are a vulnerable population in need of accurate and accessible health information to promote their own health and that of their baby. The aims of our study were to: Determine acceptability of simple, written educational pamphlets to adolescent mothers; Determine efficacy of simple, written educational pamphlets in improving an adolescent mother’s knowledge related to breastfeeding, infant care, postpartum depression, and mother–infant relationship; Determine if higher knowledge scores are maintained after a 2-week period; and Determine general parenting health literacy of adolescent mothers. Study Design and Methods: Using a prospective, experimental design, students enrolled in a teen parent program (n = 123) completed a pretest and The Parent Health Literacy Activities Test (PHLAT), read the health educational materials, and completed an immediate posttest of knowledge and acceptability. Two weeks later, the same participants completed a second posttest of knowledge. Results: Adolescent mothers found the intervention (simple, written educational materials) to be acceptable. The intervention was initially effective in improving knowledge scores in all four content areas. However, knowledge was not retained and scores were not significantly different from baseline at the 2-week assessment. The mean health literacy of the adolescent mothers was poor. Clinical Implications: A booster session may be necessary for knowledge retention. Other methods of education should be studied to evaluate efficacy for adolescent mothers’ knowledge retention of important health information. Key words: Adolescents; Breastfeeding; Health literacy; Postpartum depression. 186
volume 40 |
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
BSIP SA / Alamy
L
ow health literacy continues to be a problem in the United States (Institute of Medicine, 2011) and has been linked to poor health outcomes (Berkman et al., 2011). Improving health literacy is a national health priority (Koh et al., 2012) as evidenced by passing the Plain Writing Act of 2010 (Sunstein, 2011), emphasis on health literacy in the Affordable Care Act of 2010 and in Healthy People 2020 (Office of Disease Prevention and Health Promotion, 2014), and publication of the National Action Plan to improve health literacy (U.S. Department of Health and Human Services, 2010). Education of healthcare consumers is a priority of healthcare professionals and healthcare organizations (Joint Commission, 2007). In addition to concern about health literacy for adults and their own health, evidence suggests low parental health literacy is associated with adverse outcomes (Yin et al., 2009), increased emergency department use (Herman & Jackson, 2010; Morrison et al., 2014; Morrison, Myrvik, Brousseau, Hoffmann, & Stanley, 2013), and inappropriate medication administration for their children (Yin et al., 2010). The majority of education for parents occurs in written form. Organizations such as the American Medical Association (Schwartzberg, Van Geest, & Wang, 2005) and the Agency for Healthcare Research and Quality (De Walt et al., 2010) have published guidelines or toolkits to assist healthcare providers and organizations in developing and adapting written consumer education materials to meet national plain talk guidelines. Essentially, the recommendations include using active voice, short sentences, and common everyday words (Plain Language Action and Information Network, 2011). Content of the material should be organized into the following categories: What is it, what action should I take, why should I take this action, and what resources are available? However noble the goals of these major federal policy initiatives, written educational materials used in clinical agencies continue to be problematic (Davis et al., 1994; Ryan et al., 2014). There is no difference between material developed locally compared to those developed by national organizations (Yin et al., 2013). Previous studies have reported that as many as 53% to 90% of educational materials are written at a ninth grade reading level or higher (Shieh & Hosei, 2008). Other factors, in addition to reading level, contribute to suitability of materials for those with limited education or literacy skills, including health literacy (Doak, Doak, & Root, 1996). Doak et al. (1996) describe six primary areas for evaluating written materials that include content, literacy demand, graphics, layout and topography, learning, stimulation and motivation, and cultural appropriateness. (Detailed descriptions of each topic and subtopic as well as the scoring methodology are published elsewhere and available at no charge [www.hsph. harvard.edu/healthliteracy/resources/teaching-patientswith-low-literacy-skills/].) In a previous study, we evaluated commonly used printed health education materials for readability and suitability (Ryan et al., 2014). Materials (n = 97) from three clinical areas that represented excellence in nursing care in
Low health literacy continues to be a problem in the United States and has been linked to poor health outcomes. our healthcare organization (stroke, cancer, and maternal– child) were reviewed for a composite reading grade level and a Suitability Assessment of Materials (SAM) score (Doak et al., 1996). Although the materials were from one agency, many of the materials were developed by national organizations such as the American Cancer Society and the American Heart Association. Two reviewers independently evaluated the materials. The SAM tool was easy to use and interrater reliability was acceptable. Results indicated that 28% of the materials were at a ninth grade or higher reading level and only 23% were fifth grade or below. The SAM ratings for Not Suitable, Adequate, and Superior were 11%, 58%, and 31%, respectively. Few materials were Superior for both the readability and suitability scales (Ryan et al., 2014). Of specific interest to this study, results from the suitability assessment of the maternal–child educational materials were as follows: 2.4% were rated as Not Suitable, 76.2% were rated as Adequate, and 21.4% were rated as Superior. Results from the readability assessment of the MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
187
maternal–child educational materials were as follows: 26.2% were rated as Not Suitable, 64.3% were rated as Adequate, and 9.5% were rated as Superior (Ryan et al., 2014). Thus, revision and further testing of the written educational materials was necessary in order to follow national recommendations. Parents, especially those with lower levels of education, have been shown to lack specific health literacy skills including numeracy skills and understanding directions written on commonly used over-the-counter medication (Davis, Jones, Logsdon, Ryan, & WilkersonMcMahon, 2013; Yin, Parker, et al., 2012). Additionally, parents reported that their pediatrician did not talk to them about important health promotion topics or they did not understand the information that was presented to them (Davis et al., 2013). Adolescent mothers are in need of accurate and accessible health information to promote their own health and that of their baby. In 2010, there were 367,678 births to adolescents aged 15 to 19 years of age in the United States (Hamilton & Ventura, 2012). Kentucky ranks among the top 10 states with the highest rates of adolescent pregnancies, all of which are in the southern United States (Mathews, Sutton, Hamilton, & Ventura, 2010). The aims of our study were as follows: Determine acceptability of simple, written educational pamphlets to adolescent mothers; Determine efficacy of simple, written educational pamphlets in improving an adolescent mother’s knowledge related to breastfeeding, infant care, postpartum depression, and mother–infant relationship; Determine if higher knowledge scores are maintained after a 2-week period; and Determine general parenting health literacy of adolescent mothers.
Methods This was a prospective, quasi-experimental study aimed to improve knowledge scores in the areas of breastfeeding, infant care, postpartum depression, and mother– infant relationships over time by using simple, written educational tools. We evaluated acceptability and feasibility of using simple, written educational tools in adolescent mothers by performing a straightforward descriptive analysis. We also explored the relationship between health literacy and knowledge. The study was approved by the Institutional Review Board of the University and the data collection site. Sample
The convenience sample of adolescent mothers (n = 129) attended a teen parent program, part of the public school system. The students receive some parenting education in addition to the standard academic curriculum appropriate to their grade level. Procedure
All students that attended the teen parent program were invited to participate in the study by the director of medical services at the facility. Data were collected in the school cafeteria. At the first time point, students read a research preamble, completed a pretest and The Parental 188
volume 40 |
A booster session may be necessary in this population in order for the information learned in the intervention to be retained.
Health Literacy Activities Test (PHLAT), read the health educational materials, and completed an immediate posttest of knowledge and acceptability. Two weeks later, also in the school cafeteria, the same participants completed a second posttest of knowledge. The tests were completed by paper and pencil, and monitors were present. Student interactions were discouraged. Intervention
An advisory group of five masters’ prepared nurses employed as nurse leaders in the maternity area of the healthcare organization served as advisors in choosing the topics and the content of educational pamphlets. New, simple, health education materials (following national health literacy guidelines for plain talk) were developed for the study on four topics: maternal infant relationship, postpartum depression, breastfeeding, and infant care (see Figure 1, for example). The four topics are core to the education of new mothers and are consistently taught to them before hospital discharge to prepare them for immediate self and infant care. A separate pamphlet was developed for each of the four topics. All pamphlets used the same template design and organization of content. These educational materials served as the study intervention. Instruments
Knowledge A 10-item multiple-choice test of factual knowledge was developed by the research team. One example is as follows: If a new mother feels sad for no reason when her baby is a month old, she may be experiencing which of the following? a. Baby blues b. Postpartum depression c. Teen mood swings d. Bipolar disorder An advisory group of nurse leaders from healthcare organizations that serve adolescent mothers informed development of test items. Because the item content was specific to the intervention materials, no standardized and validated instruments were available. The test was administered at baseline, immediately following the
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Figure 1. Sample Patient Education Pamphlet: Postpartum Depression What is Postpartum Depression? Postpartum Depression is when you feel: • Sad for no reason. • Tired. • Everything feels hard to do. These feelings: • Do not go away. • May start a month after birth.
What should I do? Ask for help. Tell your doctor, nurse, or teacher.
Why is this important? These feelings may make: • School and work harder. • It hard to be a mother. • Enjoying friends hard.
Where can I get help? Remember: • You are not alone. • You will get better. • Treatment helps. • Seven Counties Services, 502-589-8085.
intervention, and, again, 2 weeks following the intervention to assess retention of knowledge over time. Health Literacy The Parental Health Literacy Activities Test (PHLAT-10) is a 10-item test of health literacy that has been validated for use with diverse populations of parents (Kumar et al., 2010; Yin, Sanders, et al., 2012). The original instrument contained 20 items. The PHLAT-10 has been shown to have adequate psychometric properties (Kumar et al., 2010) and was chosen over the 20-item version to reduce burden to the participants. The PHLAT has not been validated for use with adolescence, but the PHLAT is the only measure of health literacy developed and validated for assessing parent health literacy. Items include assessment of skills commonly needed by parents such as following directions for mixing formula, reading nutrition labels, and interpreting an infant growth chart. Acceptability A 9-item test of acceptability was developed by the research team. The items are specific to the intervention of this study so no validated instruments are available. The test has a 5-point response set on a Likert-type scale from “Disagree” to “Agree.” Sample questions include, “The pamphlets are easy to read.” and “I would recommend these pamphlets to another teen mom.” Demographics The survey included four questions regarding demographic characteristics of the participants including age, race, ethnicity, and years of schooling. Data Analysis
A descriptive analysis of demographics, acceptability, feasibility, and health literacy was performed. A post
Nurses should take the lead in advocating for changes in patient and family education that are acceptable to, and effective with, specific populations.
hoc analysis of individual items on the PHLAT was performed. The Cochran-Armitage test for trend tested if knowledge scores improved over time, whereas repeated measures ANOVA techniques (RM-ANOVA) determined potential demographic confounders (e.g., age, race, education, etc.).
Results Of the convenience sample (n = 129) of adolescent mothers recruited from the public school system, the analytic sample (n = 123) were those who completed the surveys at all time points (95.3% response rate). Attrition rate was 4.7%. A majority were Black (n = 60, 53.6%), non-Hispanic (n = 103, 82.9%), a junior in high school (n = 63, 51.2%), and had a mean age of 16.98 years. Results of the study will be described in terms of each study aim. Determine acceptability of simple, written educational pamphlets to adolescent mothers. A majority of mothers agreed or partially agreed the pamphlet was easy to MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
189
Table 1. Acceptability of Intervention Agree
Partly Agree
Neutral
Partly Disagree
Disagree
Easy to read
96 (82.1%)
14 (12.0%)
7 (6.0%)
-
-
Good place to learn about depression
53 (44.9%)
43 (36.4%)
20 (16.9%)
-
2 (1.7%)
Good place to learn about infant care
72 (61.0%)
33 (28.0%)
9 (7.6%)
4 (3.4%)
-
Good place to learn to bond with baby
61 (51.7%)
40 (33.9%)
11 (9.3%)
4 (3.4%)
2 (1.7%)
Good place to learn about breastfeeding
48 (40.7%)
42 (35.6%)
20 (16.9%)
5 (4.2%)
3 (2.5%)
Know where to call for help for infant
98 (83.8%)
17 (14.5%)
1 (0.9%)
1 (0.9%)
-
Know what to do if help needed
92 (78.6%)
18 (15.4%)
5 (4.3%)
1 (0.8%)
1 (0.8%)
Would recommend these pamphlets
83 (70.3%)
25 (21.2%)
7 (5.9%)
3 (2.5%)
-
Likely to get treatment for depression due to pamphlet
69 (58.5%)
35 (29.7%)
9 (7.6%)
4 (3.4%)
1 (0.8%)
Question Concerning the Pamphlet
Key: n (%)
Table 2. Initial Efficacy of Intervention Question
Pretest
Immediate Posttest
Two-Week Posttest
p-Value
1. Crying
79.7%
90.2%
79.7%
0.007***
2. Why babies cry
92.7%
92.7%
93.5%
0.898
3. Not stop crying
69.1%
82.1%
68.3%
0.001***
4. Mother sad
74.8%
83.7%
75.6%
0.012***
5. Depression symptoms
92.7%
88.6%
93.5%
0.115
6. Car seat use
98.4%
97.6%
99.2%
0.566
7. Bathing baby
95.1%
96.8%
95.1%
0.319
8. Sleep on back
91.1%
95.9%
91.1%
0.033***
9. Engorgement
36.6%
57.7%
37.4%
0.05).
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Determine the general parenting health literacy of adolescent mothers. Overall health literacy was poor with a mean PHLAT score of 61.79% ± 16.7%; although, as seen in Table 3, health literacy in adolescent mothers is dependent on topic area. Adolescent mothers scored well on nutritional questions, but may have poor numeracy skills.
Discussion In this prospective, quasi-experimental study aimed to improve knowledge scores in the areas of breastfeeding, infant care, postpartum depression, and mother–infant relationships over time by implementing simple, written educational tools; adolescent mothers found the intervention (educational pamphlets) to be acceptable. Although development of the educational pamphlets followed national recommendations for plain talk, it was important to make sure that the adolescent mothers agreed before further use in the same population. The intervention was initially effective in improving knowledge scores in all four content areas. However, knowledge was not retained and scores were not significantly different from baseline at the 2-week follow-up assessment. With the brief dose of the intervention, this finding is not unexpected. Thus, a booster session may be necessary in this population in order for the information learned in the intervention to be retained, as recommended with other research interventions (Skinner et al., 2007). More data are needed to determine the exact dosage needed for retention. Other methods of teaching that
Table 3. Parental Health Literacy Activities Test (PHLAT) Mean % Correct
PHLAT Question
Suggested Clinical Implications • National plain talk guidelines for written consumer education include using active voice, short sentences, and common everyday words. • Simple educational pamphlets are acceptable to adolescent mothers and increase immediate health knowledge. • Health literacy of adolescent mothers should be a goal of parenting and health education programs. • Nurse researchers and direct care nurses should continue to partner to test the most effective and acceptable ways to prepare new mothers for hospital discharge, creating evidence for best nursing practice.
may enhance retention of important knowledge for this population warrant research. On average, the health literacy of the adolescent mothers was poor. We did not expect this finding because the teen parent program includes extensive health information in the curriculum. However, numeracy skills may not be emphasized. Anecdotally, some participants expressed difficulty with several items on the instrument. For example, they did not understand the difference between 100% juice and all natural juice. Further psychometric testing of the PHLAT in similar populations is recommended. The study advances the science of health literacy by demonstrating acceptability and initial efficacy of an intervention developed with plain talk guidelines and used adolescent mothers, an underserved population. Limitations include investigator-developed tools and intervention, and the use of one site for data collection. Researchers and clinicians should be cautious in applying results to dissimilar populations. Although the PHLAT has not been validated for use with adolescent mothers, it is the only tool available to measure parental health literacy. There was no way to control learning on the four topics between the initial data collection and data collection 2 weeks later. More input from adolescence may help to inform modifications of the materials for future use. Future studies are needed with randomization and with larger sample sizes in order to examine causal effects and comparative effectiveness across adolescents of diverse ages, races/ethnicities, and socioeconomic levels. ✜
1. Mix water and powder formula
96.8%
1a. Amount of formula
97.6%
2. Amount of water
41.7%
2a. Amount of concentrated formula
67.5%
3. Mix Pedialyte and formula
30.9%
4. Read growth chart
39.0%
5. Teaspoon to milliliter
46.3%
6. Read food label
46.3%
7. Read prescriptions
86.2%
Acknowledgment
8. Calculated amount of juice
54.4%
9. Read food label
76.4%
The study was funded by the a faculty research grant from the Office of Community Engagement, University of Louisville, Louisville, Kentucky.
10. Engorgement
27.6%
M. Cynthia Logsdon is a Professor, School of Nursing, University of Louisville, Associate Chief of Nursing MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
191
for Research, University of Louisville Hospital/Brown Cancer Center, 555 South Floyd Street, Health Sciences Center, Louisville, KY. She can be reached via e-mail at [email protected] Deborah Winders Davis is a Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. Reetta Stikes is a Perinatal Educator, University of Louisville Hospital, Louisville, KY. Rachel Ratterman is a Medical Coordinator, Teenage Parent Program, Louisville, KY. Lesa Ryan is a Research Assistant, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. John Myers is an Associate Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. All authors report that there are no conflicts of interest related to this study. DOI:10.1097/NMC.0000000000000126 References Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A. J., Crotty, K., . . ., Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. (AHRQ Publication No. 11-E006.) Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Davis, D. W., Jones, V. F., Logsdon, M. C., Ryan, L., & WilkersonMcMahon, M. (2013). Health promotion in pediatric primary care: Importance of health literacy and communication practices. Clinical Pediatrics, 52(12), 1127-1134. doi:10.1177/0009922813506607 Davis, T. C., Mayeaux, E. J., Fredrickson, D., Bocchini, J. A., Jr., Jackson, R. H., & Murphy, P. W. (1994). Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics, 93(3), 460-468. De Walt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R., & Brach, C. (2010). Health literacy universal precautions toolkit. (Prepared by North Carolina Network Consortium, the Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel HIll; under Contract No. HHSA290200710014; AHRQ Publication No. 10-0046-EF.) Rockville, MD: Agency for Health Care Research and Quality. Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia, PA: Lippincott. Hamilton, B. E., & Ventura, S. J. (2012). Birth rates for U.S. teenagers reach historic lows for all age and ethnic groups. NCHS data brief (Vol. 89). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health StatisticsNational Center for Health Statistics. Herman, A., & Jackson, P. (2010). Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention. Journal of Health Communication, 15(8), 895-910. doi:10.1080/10810730.2 010.522228 Institute of Medicine. (2011). Innovations in Health Literacy. http://www. iom.edu/Reports/2011/Innovations-in-Health-Literacy.aspx Joint Commission. (2007). What did the doctor say? Improving health literacy to protect patient safety. Oakbrook Terrace, IL: Joint Commission. Koh, H. K., Berwick, D. M., Clancy, C. M., Baur, C., Brach, C., Harris, L. M., & Zerhusen, E. G. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly ‘crisis care’. Health Affairs, 31(2), 434-443. doi:10.1377/ hlthaff.2011.1169
192
volume 40 |
Kumar, D., Sanders, L., Perrin, E. M., Lokker, N., Patterson, B., Gunn, V., . . ., Rothman, R. L. (2010). Parental understanding of infant health information: Health literacy, numeracy, and the Parental Health Literacy Activities Test (PHLAT). Academic Pediatrics, 10(5), 309-316. doi:10.1016/j.acap.2010.06.007 Mathews, T. J., Sutton, P. D., Hamilton, B. E., & Ventura, S. J. (2010). State disparities in teenage birth rates in the United States. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from www.cdc.gov/nchs/data/databriefs/db46.pdf Morrison, A. K., Chanmugathas, R., Schapira, M. M., Gorelick, M. H., Hoffmann, R. G., & Brousseau, D. C. (2014). Caregiver low health literacy and nonurgent use of the Pediatric Emergency Department for febrile illness. Academic Pediatrics, 14(5), 505-509. doi:10.1016/j. acap.2014.05.001 Morrison, A. K., Myrvik, M. P., Brousseau, D. C., Hoffmann, R. G., & Stanley, R. M. (2013). The relationship between parent health literacy and pediatric emergency department utilization: A systematic review. Academic Pediatrics, 13(5), 421-429. doi:10.1016/j.acap.2013.03.001 Office of Disease Prevention and Health Promotion. (2014). Healthy people health communication and health IT topic area. Retrieved May 14, 2014, from http://health.gov/communication/healthypeople/ Plain Language Action and Information Network. (2011). Federal plain language guidelines. Retrieved from www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/index.cfm Ryan, L., Logsdon, M. C., McGill, S., Stikes, R., Senior, B., Helinger, B., . . ., Davis, D. W. (2014). Evaluation of printed health education materials for use by low-education families. Journal of Nursing Scholarship, 46(4), 218-228. doi:10.1111/jnu.12076 Schwartzberg, J. G., Van Geest, J. B., & Wang, C. G. (2005). Understanding health literacy: Implications for medicine and public health. Washington, DC: American Medical Association. Shieh, C., & Hosei, B. (2008). Printed health information materials: Evaluation of readability and suitability. Journal of Community Health Nursing, 25(2), 73-90. doi:10.1080/ 07370010802017083 Skinner, C. S., Kobrin, S. C., Monahan, P. O., Daggy, J., Menon, U., Todora, H. S., & Champion, V. L. (2007). Tailored interventions for screening mammography among a sample of initially non-adherent women: When is a booster dose important? Patient Education and Counseling, 65(1), 87-94. doi:10.1016/j. pec.2006.06.013 Sunstein, C. R. (2011). Guidance for the Plain Writing Act of 2010. Washington, DC: Executive Office of the President, Office of Management and Budget. U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy. Washington, DC: Office of Disease Prevention and Health Promotion. Yin, H. S., Gupta, R. S., Tomopoulos, S., Wolf, M. S., Mendelsohn, A. L., Antler, L., . . ., Dreyer, B. P. (2013). Readability, suitability, and characteristics of asthma action plans: Examination of factors that may impair understanding. Pediatrics, 131(1), e116-e126. doi:10.1542/peds.2012-0612 Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., & Dreyer, B. P. (2009). The health literacy of parents in the United States: A nationally representative study. Pediatrics, 124(Suppl. 3), S289-S298. doi:10.1542/peds.2009-1162E Yin, H. S., Mendelsohn, A. L., Wolf, M. S., Parker, R. M., Fierman, A., van Schaick, L., . . ., Dreyer, B. P. (2010). Parents’ medication administration errors: Role of dosing instruments and health literacy. Archives of Pediatrics and Adolescent Medicine, 164(2), 181-186. doi:10.1001/ archpediatrics.2009.269 Yin, H. S., Parker, R. M., Wolf, M. S., Mendelsohn, A. L., Sanders, L. M., Vivar, K. L., . . ., Dreyer, B. P. (2012). Health literacy assessment of labeling of pediatric nonprescription medications: Examination of characteristics that may impair parent understanding. Academic Pediatrics, 12(4), 288-296. doi:10.1016/j.acap.2012.02.010 Yin, H. S., Sanders, L. M., Rothman, R. L., Mendelsohn, A. L., Dreyer, B. P., White, R. O., . . ., Perrin, E. M. (2012). Assessment of health literacy and numeracy among Spanish-Speaking parents of young children: Validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). Academic Pediatrics, 12(1), 68-74. doi:10.1016/j. acap.2011.08.008
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Acceptability and Initial Efficacy of
Science Photo Library / Alamy
EDUCATION for Teen Mothers
Abstract Purpose: Educational materials used by healthcare agencies frequently do not follow national health guidelines for plain talk. Adolescent mothers are a vulnerable population in need of accurate and accessible health information to promote their own health and that of their baby. The aims of our study were to: Determine acceptability of simple, written educational pamphlets to adolescent mothers; Determine efficacy of simple, written educational pamphlets in improving an adolescent mother’s knowledge related to breastfeeding, infant care, postpartum depression, and mother–infant relationship; Determine if higher knowledge scores are maintained after a 2-week period; and Determine general parenting health literacy of adolescent mothers. Study Design and Methods: Using a prospective, experimental design, students enrolled in a teen parent program (n = 123) completed a pretest and The Parent Health Literacy Activities Test (PHLAT), read the health educational materials, and completed an immediate posttest of knowledge and acceptability. Two weeks later, the same participants completed a second posttest of knowledge. Results: Adolescent mothers found the intervention (simple, written educational materials) to be acceptable. The intervention was initially effective in improving knowledge scores in all four content areas. However, knowledge was not retained and scores were not significantly different from baseline at the 2-week assessment. The mean health literacy of the adolescent mothers was poor. Clinical Implications: A booster session may be necessary for knowledge retention. Other methods of education should be studied to evaluate efficacy for adolescent mothers’ knowledge retention of important health information. Key words: Adolescents; Breastfeeding; Health literacy; Postpartum depression. 186
volume 40 |
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
BSIP SA / Alamy
L
ow health literacy continues to be a problem in the United States (Institute of Medicine, 2011) and has been linked to poor health outcomes (Berkman et al., 2011). Improving health literacy is a national health priority (Koh et al., 2012) as evidenced by passing the Plain Writing Act of 2010 (Sunstein, 2011), emphasis on health literacy in the Affordable Care Act of 2010 and in Healthy People 2020 (Office of Disease Prevention and Health Promotion, 2014), and publication of the National Action Plan to improve health literacy (U.S. Department of Health and Human Services, 2010). Education of healthcare consumers is a priority of healthcare professionals and healthcare organizations (Joint Commission, 2007). In addition to concern about health literacy for adults and their own health, evidence suggests low parental health literacy is associated with adverse outcomes (Yin et al., 2009), increased emergency department use (Herman & Jackson, 2010; Morrison et al., 2014; Morrison, Myrvik, Brousseau, Hoffmann, & Stanley, 2013), and inappropriate medication administration for their children (Yin et al., 2010). The majority of education for parents occurs in written form. Organizations such as the American Medical Association (Schwartzberg, Van Geest, & Wang, 2005) and the Agency for Healthcare Research and Quality (De Walt et al., 2010) have published guidelines or toolkits to assist healthcare providers and organizations in developing and adapting written consumer education materials to meet national plain talk guidelines. Essentially, the recommendations include using active voice, short sentences, and common everyday words (Plain Language Action and Information Network, 2011). Content of the material should be organized into the following categories: What is it, what action should I take, why should I take this action, and what resources are available? However noble the goals of these major federal policy initiatives, written educational materials used in clinical agencies continue to be problematic (Davis et al., 1994; Ryan et al., 2014). There is no difference between material developed locally compared to those developed by national organizations (Yin et al., 2013). Previous studies have reported that as many as 53% to 90% of educational materials are written at a ninth grade reading level or higher (Shieh & Hosei, 2008). Other factors, in addition to reading level, contribute to suitability of materials for those with limited education or literacy skills, including health literacy (Doak, Doak, & Root, 1996). Doak et al. (1996) describe six primary areas for evaluating written materials that include content, literacy demand, graphics, layout and topography, learning, stimulation and motivation, and cultural appropriateness. (Detailed descriptions of each topic and subtopic as well as the scoring methodology are published elsewhere and available at no charge [www.hsph. harvard.edu/healthliteracy/resources/teaching-patientswith-low-literacy-skills/].) In a previous study, we evaluated commonly used printed health education materials for readability and suitability (Ryan et al., 2014). Materials (n = 97) from three clinical areas that represented excellence in nursing care in
Low health literacy continues to be a problem in the United States and has been linked to poor health outcomes. our healthcare organization (stroke, cancer, and maternal– child) were reviewed for a composite reading grade level and a Suitability Assessment of Materials (SAM) score (Doak et al., 1996). Although the materials were from one agency, many of the materials were developed by national organizations such as the American Cancer Society and the American Heart Association. Two reviewers independently evaluated the materials. The SAM tool was easy to use and interrater reliability was acceptable. Results indicated that 28% of the materials were at a ninth grade or higher reading level and only 23% were fifth grade or below. The SAM ratings for Not Suitable, Adequate, and Superior were 11%, 58%, and 31%, respectively. Few materials were Superior for both the readability and suitability scales (Ryan et al., 2014). Of specific interest to this study, results from the suitability assessment of the maternal–child educational materials were as follows: 2.4% were rated as Not Suitable, 76.2% were rated as Adequate, and 21.4% were rated as Superior. Results from the readability assessment of the MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
187
maternal–child educational materials were as follows: 26.2% were rated as Not Suitable, 64.3% were rated as Adequate, and 9.5% were rated as Superior (Ryan et al., 2014). Thus, revision and further testing of the written educational materials was necessary in order to follow national recommendations. Parents, especially those with lower levels of education, have been shown to lack specific health literacy skills including numeracy skills and understanding directions written on commonly used over-the-counter medication (Davis, Jones, Logsdon, Ryan, & WilkersonMcMahon, 2013; Yin, Parker, et al., 2012). Additionally, parents reported that their pediatrician did not talk to them about important health promotion topics or they did not understand the information that was presented to them (Davis et al., 2013). Adolescent mothers are in need of accurate and accessible health information to promote their own health and that of their baby. In 2010, there were 367,678 births to adolescents aged 15 to 19 years of age in the United States (Hamilton & Ventura, 2012). Kentucky ranks among the top 10 states with the highest rates of adolescent pregnancies, all of which are in the southern United States (Mathews, Sutton, Hamilton, & Ventura, 2010). The aims of our study were as follows: Determine acceptability of simple, written educational pamphlets to adolescent mothers; Determine efficacy of simple, written educational pamphlets in improving an adolescent mother’s knowledge related to breastfeeding, infant care, postpartum depression, and mother–infant relationship; Determine if higher knowledge scores are maintained after a 2-week period; and Determine general parenting health literacy of adolescent mothers.
Methods This was a prospective, quasi-experimental study aimed to improve knowledge scores in the areas of breastfeeding, infant care, postpartum depression, and mother– infant relationships over time by using simple, written educational tools. We evaluated acceptability and feasibility of using simple, written educational tools in adolescent mothers by performing a straightforward descriptive analysis. We also explored the relationship between health literacy and knowledge. The study was approved by the Institutional Review Board of the University and the data collection site. Sample
The convenience sample of adolescent mothers (n = 129) attended a teen parent program, part of the public school system. The students receive some parenting education in addition to the standard academic curriculum appropriate to their grade level. Procedure
All students that attended the teen parent program were invited to participate in the study by the director of medical services at the facility. Data were collected in the school cafeteria. At the first time point, students read a research preamble, completed a pretest and The Parental 188
volume 40 |
A booster session may be necessary in this population in order for the information learned in the intervention to be retained.
Health Literacy Activities Test (PHLAT), read the health educational materials, and completed an immediate posttest of knowledge and acceptability. Two weeks later, also in the school cafeteria, the same participants completed a second posttest of knowledge. The tests were completed by paper and pencil, and monitors were present. Student interactions were discouraged. Intervention
An advisory group of five masters’ prepared nurses employed as nurse leaders in the maternity area of the healthcare organization served as advisors in choosing the topics and the content of educational pamphlets. New, simple, health education materials (following national health literacy guidelines for plain talk) were developed for the study on four topics: maternal infant relationship, postpartum depression, breastfeeding, and infant care (see Figure 1, for example). The four topics are core to the education of new mothers and are consistently taught to them before hospital discharge to prepare them for immediate self and infant care. A separate pamphlet was developed for each of the four topics. All pamphlets used the same template design and organization of content. These educational materials served as the study intervention. Instruments
Knowledge A 10-item multiple-choice test of factual knowledge was developed by the research team. One example is as follows: If a new mother feels sad for no reason when her baby is a month old, she may be experiencing which of the following? a. Baby blues b. Postpartum depression c. Teen mood swings d. Bipolar disorder An advisory group of nurse leaders from healthcare organizations that serve adolescent mothers informed development of test items. Because the item content was specific to the intervention materials, no standardized and validated instruments were available. The test was administered at baseline, immediately following the
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Figure 1. Sample Patient Education Pamphlet: Postpartum Depression What is Postpartum Depression? Postpartum Depression is when you feel: • Sad for no reason. • Tired. • Everything feels hard to do. These feelings: • Do not go away. • May start a month after birth.
What should I do? Ask for help. Tell your doctor, nurse, or teacher.
Why is this important? These feelings may make: • School and work harder. • It hard to be a mother. • Enjoying friends hard.
Where can I get help? Remember: • You are not alone. • You will get better. • Treatment helps. • Seven Counties Services, 502-589-8085.
intervention, and, again, 2 weeks following the intervention to assess retention of knowledge over time. Health Literacy The Parental Health Literacy Activities Test (PHLAT-10) is a 10-item test of health literacy that has been validated for use with diverse populations of parents (Kumar et al., 2010; Yin, Sanders, et al., 2012). The original instrument contained 20 items. The PHLAT-10 has been shown to have adequate psychometric properties (Kumar et al., 2010) and was chosen over the 20-item version to reduce burden to the participants. The PHLAT has not been validated for use with adolescence, but the PHLAT is the only measure of health literacy developed and validated for assessing parent health literacy. Items include assessment of skills commonly needed by parents such as following directions for mixing formula, reading nutrition labels, and interpreting an infant growth chart. Acceptability A 9-item test of acceptability was developed by the research team. The items are specific to the intervention of this study so no validated instruments are available. The test has a 5-point response set on a Likert-type scale from “Disagree” to “Agree.” Sample questions include, “The pamphlets are easy to read.” and “I would recommend these pamphlets to another teen mom.” Demographics The survey included four questions regarding demographic characteristics of the participants including age, race, ethnicity, and years of schooling. Data Analysis
A descriptive analysis of demographics, acceptability, feasibility, and health literacy was performed. A post
Nurses should take the lead in advocating for changes in patient and family education that are acceptable to, and effective with, specific populations.
hoc analysis of individual items on the PHLAT was performed. The Cochran-Armitage test for trend tested if knowledge scores improved over time, whereas repeated measures ANOVA techniques (RM-ANOVA) determined potential demographic confounders (e.g., age, race, education, etc.).
Results Of the convenience sample (n = 129) of adolescent mothers recruited from the public school system, the analytic sample (n = 123) were those who completed the surveys at all time points (95.3% response rate). Attrition rate was 4.7%. A majority were Black (n = 60, 53.6%), non-Hispanic (n = 103, 82.9%), a junior in high school (n = 63, 51.2%), and had a mean age of 16.98 years. Results of the study will be described in terms of each study aim. Determine acceptability of simple, written educational pamphlets to adolescent mothers. A majority of mothers agreed or partially agreed the pamphlet was easy to MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
189
Table 1. Acceptability of Intervention Agree
Partly Agree
Neutral
Partly Disagree
Disagree
Easy to read
96 (82.1%)
14 (12.0%)
7 (6.0%)
-
-
Good place to learn about depression
53 (44.9%)
43 (36.4%)
20 (16.9%)
-
2 (1.7%)
Good place to learn about infant care
72 (61.0%)
33 (28.0%)
9 (7.6%)
4 (3.4%)
-
Good place to learn to bond with baby
61 (51.7%)
40 (33.9%)
11 (9.3%)
4 (3.4%)
2 (1.7%)
Good place to learn about breastfeeding
48 (40.7%)
42 (35.6%)
20 (16.9%)
5 (4.2%)
3 (2.5%)
Know where to call for help for infant
98 (83.8%)
17 (14.5%)
1 (0.9%)
1 (0.9%)
-
Know what to do if help needed
92 (78.6%)
18 (15.4%)
5 (4.3%)
1 (0.8%)
1 (0.8%)
Would recommend these pamphlets
83 (70.3%)
25 (21.2%)
7 (5.9%)
3 (2.5%)
-
Likely to get treatment for depression due to pamphlet
69 (58.5%)
35 (29.7%)
9 (7.6%)
4 (3.4%)
1 (0.8%)
Question Concerning the Pamphlet
Key: n (%)
Table 2. Initial Efficacy of Intervention Question
Pretest
Immediate Posttest
Two-Week Posttest
p-Value
1. Crying
79.7%
90.2%
79.7%
0.007***
2. Why babies cry
92.7%
92.7%
93.5%
0.898
3. Not stop crying
69.1%
82.1%
68.3%
0.001***
4. Mother sad
74.8%
83.7%
75.6%
0.012***
5. Depression symptoms
92.7%
88.6%
93.5%
0.115
6. Car seat use
98.4%
97.6%
99.2%
0.566
7. Bathing baby
95.1%
96.8%
95.1%
0.319
8. Sleep on back
91.1%
95.9%
91.1%
0.033***
9. Engorgement
36.6%
57.7%
37.4%
0.05).
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Determine the general parenting health literacy of adolescent mothers. Overall health literacy was poor with a mean PHLAT score of 61.79% ± 16.7%; although, as seen in Table 3, health literacy in adolescent mothers is dependent on topic area. Adolescent mothers scored well on nutritional questions, but may have poor numeracy skills.
Discussion In this prospective, quasi-experimental study aimed to improve knowledge scores in the areas of breastfeeding, infant care, postpartum depression, and mother–infant relationships over time by implementing simple, written educational tools; adolescent mothers found the intervention (educational pamphlets) to be acceptable. Although development of the educational pamphlets followed national recommendations for plain talk, it was important to make sure that the adolescent mothers agreed before further use in the same population. The intervention was initially effective in improving knowledge scores in all four content areas. However, knowledge was not retained and scores were not significantly different from baseline at the 2-week follow-up assessment. With the brief dose of the intervention, this finding is not unexpected. Thus, a booster session may be necessary in this population in order for the information learned in the intervention to be retained, as recommended with other research interventions (Skinner et al., 2007). More data are needed to determine the exact dosage needed for retention. Other methods of teaching that
Table 3. Parental Health Literacy Activities Test (PHLAT) Mean % Correct
PHLAT Question
Suggested Clinical Implications • National plain talk guidelines for written consumer education include using active voice, short sentences, and common everyday words. • Simple educational pamphlets are acceptable to adolescent mothers and increase immediate health knowledge. • Health literacy of adolescent mothers should be a goal of parenting and health education programs. • Nurse researchers and direct care nurses should continue to partner to test the most effective and acceptable ways to prepare new mothers for hospital discharge, creating evidence for best nursing practice.
may enhance retention of important knowledge for this population warrant research. On average, the health literacy of the adolescent mothers was poor. We did not expect this finding because the teen parent program includes extensive health information in the curriculum. However, numeracy skills may not be emphasized. Anecdotally, some participants expressed difficulty with several items on the instrument. For example, they did not understand the difference between 100% juice and all natural juice. Further psychometric testing of the PHLAT in similar populations is recommended. The study advances the science of health literacy by demonstrating acceptability and initial efficacy of an intervention developed with plain talk guidelines and used adolescent mothers, an underserved population. Limitations include investigator-developed tools and intervention, and the use of one site for data collection. Researchers and clinicians should be cautious in applying results to dissimilar populations. Although the PHLAT has not been validated for use with adolescent mothers, it is the only tool available to measure parental health literacy. There was no way to control learning on the four topics between the initial data collection and data collection 2 weeks later. More input from adolescence may help to inform modifications of the materials for future use. Future studies are needed with randomization and with larger sample sizes in order to examine causal effects and comparative effectiveness across adolescents of diverse ages, races/ethnicities, and socioeconomic levels. ✜
1. Mix water and powder formula
96.8%
1a. Amount of formula
97.6%
2. Amount of water
41.7%
2a. Amount of concentrated formula
67.5%
3. Mix Pedialyte and formula
30.9%
4. Read growth chart
39.0%
5. Teaspoon to milliliter
46.3%
6. Read food label
46.3%
7. Read prescriptions
86.2%
Acknowledgment
8. Calculated amount of juice
54.4%
9. Read food label
76.4%
The study was funded by the a faculty research grant from the Office of Community Engagement, University of Louisville, Louisville, Kentucky.
10. Engorgement
27.6%
M. Cynthia Logsdon is a Professor, School of Nursing, University of Louisville, Associate Chief of Nursing MCN
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
191
for Research, University of Louisville Hospital/Brown Cancer Center, 555 South Floyd Street, Health Sciences Center, Louisville, KY. She can be reached via e-mail at [email protected] Deborah Winders Davis is a Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. Reetta Stikes is a Perinatal Educator, University of Louisville Hospital, Louisville, KY. Rachel Ratterman is a Medical Coordinator, Teenage Parent Program, Louisville, KY. Lesa Ryan is a Research Assistant, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. John Myers is an Associate Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY. All authors report that there are no conflicts of interest related to this study. DOI:10.1097/NMC.0000000000000126 References Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A. J., Crotty, K., . . ., Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. (AHRQ Publication No. 11-E006.) Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Davis, D. W., Jones, V. F., Logsdon, M. C., Ryan, L., & WilkersonMcMahon, M. (2013). Health promotion in pediatric primary care: Importance of health literacy and communication practices. Clinical Pediatrics, 52(12), 1127-1134. doi:10.1177/0009922813506607 Davis, T. C., Mayeaux, E. J., Fredrickson, D., Bocchini, J. A., Jr., Jackson, R. H., & Murphy, P. W. (1994). Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics, 93(3), 460-468. De Walt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R., & Brach, C. (2010). Health literacy universal precautions toolkit. (Prepared by North Carolina Network Consortium, the Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel HIll; under Contract No. HHSA290200710014; AHRQ Publication No. 10-0046-EF.) Rockville, MD: Agency for Health Care Research and Quality. Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia, PA: Lippincott. Hamilton, B. E., & Ventura, S. J. (2012). Birth rates for U.S. teenagers reach historic lows for all age and ethnic groups. NCHS data brief (Vol. 89). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health StatisticsNational Center for Health Statistics. Herman, A., & Jackson, P. (2010). Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention. Journal of Health Communication, 15(8), 895-910. doi:10.1080/10810730.2 010.522228 Institute of Medicine. (2011). Innovations in Health Literacy. http://www. iom.edu/Reports/2011/Innovations-in-Health-Literacy.aspx Joint Commission. (2007). What did the doctor say? Improving health literacy to protect patient safety. Oakbrook Terrace, IL: Joint Commission. Koh, H. K., Berwick, D. M., Clancy, C. M., Baur, C., Brach, C., Harris, L. M., & Zerhusen, E. G. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly ‘crisis care’. Health Affairs, 31(2), 434-443. doi:10.1377/ hlthaff.2011.1169
192
volume 40 |
Kumar, D., Sanders, L., Perrin, E. M., Lokker, N., Patterson, B., Gunn, V., . . ., Rothman, R. L. (2010). Parental understanding of infant health information: Health literacy, numeracy, and the Parental Health Literacy Activities Test (PHLAT). Academic Pediatrics, 10(5), 309-316. doi:10.1016/j.acap.2010.06.007 Mathews, T. J., Sutton, P. D., Hamilton, B. E., & Ventura, S. J. (2010). State disparities in teenage birth rates in the United States. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from www.cdc.gov/nchs/data/databriefs/db46.pdf Morrison, A. K., Chanmugathas, R., Schapira, M. M., Gorelick, M. H., Hoffmann, R. G., & Brousseau, D. C. (2014). Caregiver low health literacy and nonurgent use of the Pediatric Emergency Department for febrile illness. Academic Pediatrics, 14(5), 505-509. doi:10.1016/j. acap.2014.05.001 Morrison, A. K., Myrvik, M. P., Brousseau, D. C., Hoffmann, R. G., & Stanley, R. M. (2013). The relationship between parent health literacy and pediatric emergency department utilization: A systematic review. Academic Pediatrics, 13(5), 421-429. doi:10.1016/j.acap.2013.03.001 Office of Disease Prevention and Health Promotion. (2014). Healthy people health communication and health IT topic area. Retrieved May 14, 2014, from http://health.gov/communication/healthypeople/ Plain Language Action and Information Network. (2011). Federal plain language guidelines. Retrieved from www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/index.cfm Ryan, L., Logsdon, M. C., McGill, S., Stikes, R., Senior, B., Helinger, B., . . ., Davis, D. W. (2014). Evaluation of printed health education materials for use by low-education families. Journal of Nursing Scholarship, 46(4), 218-228. doi:10.1111/jnu.12076 Schwartzberg, J. G., Van Geest, J. B., & Wang, C. G. (2005). Understanding health literacy: Implications for medicine and public health. Washington, DC: American Medical Association. Shieh, C., & Hosei, B. (2008). Printed health information materials: Evaluation of readability and suitability. Journal of Community Health Nursing, 25(2), 73-90. doi:10.1080/ 07370010802017083 Skinner, C. S., Kobrin, S. C., Monahan, P. O., Daggy, J., Menon, U., Todora, H. S., & Champion, V. L. (2007). Tailored interventions for screening mammography among a sample of initially non-adherent women: When is a booster dose important? Patient Education and Counseling, 65(1), 87-94. doi:10.1016/j. pec.2006.06.013 Sunstein, C. R. (2011). Guidance for the Plain Writing Act of 2010. Washington, DC: Executive Office of the President, Office of Management and Budget. U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy. Washington, DC: Office of Disease Prevention and Health Promotion. Yin, H. S., Gupta, R. S., Tomopoulos, S., Wolf, M. S., Mendelsohn, A. L., Antler, L., . . ., Dreyer, B. P. (2013). Readability, suitability, and characteristics of asthma action plans: Examination of factors that may impair understanding. Pediatrics, 131(1), e116-e126. doi:10.1542/peds.2012-0612 Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., & Dreyer, B. P. (2009). The health literacy of parents in the United States: A nationally representative study. Pediatrics, 124(Suppl. 3), S289-S298. doi:10.1542/peds.2009-1162E Yin, H. S., Mendelsohn, A. L., Wolf, M. S., Parker, R. M., Fierman, A., van Schaick, L., . . ., Dreyer, B. P. (2010). Parents’ medication administration errors: Role of dosing instruments and health literacy. Archives of Pediatrics and Adolescent Medicine, 164(2), 181-186. doi:10.1001/ archpediatrics.2009.269 Yin, H. S., Parker, R. M., Wolf, M. S., Mendelsohn, A. L., Sanders, L. M., Vivar, K. L., . . ., Dreyer, B. P. (2012). Health literacy assessment of labeling of pediatric nonprescription medications: Examination of characteristics that may impair parent understanding. Academic Pediatrics, 12(4), 288-296. doi:10.1016/j.acap.2012.02.010 Yin, H. S., Sanders, L. M., Rothman, R. L., Mendelsohn, A. L., Dreyer, B. P., White, R. O., . . ., Perrin, E. M. (2012). Assessment of health literacy and numeracy among Spanish-Speaking parents of young children: Validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). Academic Pediatrics, 12(1), 68-74. doi:10.1016/j. acap.2011.08.008
number 3
May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
