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Column Editor: Terri H. Lipman, PhD, CRNP, FAAN

⁎ Corresponding aE-mail address: ch

0882-5963/$ – see frohttp://dx.doi.org/10.10

Parent Health Literacy: Risks and Outcomes

Carol J. Howe MSN, RN, CDEa,*, Erin Winterhalter MPH, RD, LDN, CDEb

aNursing Doctoral Candidate, University of Texas at Arlington, College of Nursing, Arlington, TXbThe Children’s Hospital of Philadelphia, Diabetes Center for Children, Philadelphia, PA

Health literacy involves a skill set needed to negotiatehealth within the health care environment including printliteracy (the ability to read and understand information),numeracy (the ability to use and understand numbers) andoral literacy (the ability to speak and listen) (Berkman,Sheridan, Donahue, Halpern, & Crotty, 2011; Nielsen-Bohlman, 2004). Over 21 million U.S. parents or 1 in 4parents have limited health literacy skills (Yin et al.,2009), defined as “the degree to which individuals havethe capacity to obtain, process, and understand basichealth information and services needed to make appro-priate health decisions” (Parker & Ratzan, 2010). Healthliteracy is a more powerful predictor than race oreducation of disparities in health outcomes (Sentell &Halpin, 2006).

The cost of low health literacy ranges from $106 to 238billion annually with future estimates rising to $1.6 to 3.6trillion if health care delivery fails to meet the health literacyneeds of patients (Vernon, 2007). The increased costs forpatients with low health literacy can be explained by healthcare utilization data. Medicare patients with low healthliteracy had higher medical costs using more emergencyroom and inpatient services than preventative primary care(Howard, Gazmararian, & Parker, 2005). Chronically illchildren of caregivers with low health literacy were twice aslikely to use more health services than those with caregiverswith adequate health literacy (Sanders, Thompson, &Wilkinson, 2007).

uthor: Carol J. Howe MSN, RN, CDE.owe@uta.edu.

nt matter © 2013 Elsevier Inc. All rights reserved.16/j.pedn.2013.06.001

Association of Social Determinants and LowHealth Literacy

Black and Hispanic parents were more likely to have lowhealth literacy compared to White parents (Janisse, Naar-King, & Ellis, 2010). Low parental literacy skills have beenassociated with less than 12th grade education; parents withless than high school education were eight times more likelyto have low health literacy skills than parents with highereducation experience (Bennett, Robbins, & Haecker, 2003).Low parental health literacy has been associated with lack ofhealth insurance for the child (Yin et al., 2009) and living in asingle parent household (Bennett et al., 2003), both proxiesfor lower socioeconomic status.

Association of Health Literacy andHealth Outcomes

Low health literacy is an independent predictor of poorglycemic control (Schillinger et al., 2002) and has beenassociated with less self-care behaviors in patients withdiabetes (Cavanaugh et al., 2008). Interpreting blood glucosevalues, reading food labels, counting carbohydrates, andcalculating insulin doses are frequent tasks for diabetesmanagement. In a sample of adult diabetic patients with lowhealth literacy, 26% could not interpret glucose values asbeing in target range, 56% could not accurately count thecarbohydrates in a snack size bag of chips, and 59% couldnot correctly calculate an insulin dose based on bloodglucose and carbohydrate intake (Cavanaugh et al., 2008).Studies have found that parents with limited health literacyhave difficulty understanding medication labels (Yin et al.,

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2009), make more dosing errors, and struggle with weightbased dosing (Yin et al., 2010).

Patients with low health literacy experience significantdisparities in diabetes outcomes. Low health literacy inadults has been associated with poor diabetes control(Powell, Hill, & Clancy, 2007) and a 2-fold increase inretinopathy complication (Schillinger et al., 2002). Hassanand Heptulla (2010) found that children of parents withinadequate health literacy had significantly poorer diabetescontrol compared to those with parents with adequate healthliteracy (A1C 10.4 % vs. 8.6% respectfully).

Implications for Nursing Research and Practice

Current existing data explains the risk and negative healthoutcomes related to low health literacy. Few studies havebeen conducted on how the health care system can reduce thehealth literacy demand placed on patients and families.Interventions to decrease demand include: improvement inthe navigation of the health care environment and innovativeeducational strategies that enhance clear communication. Inaddition, most health literacy research has focused on adultpatients with less pediatric data available (Betz, Ruccione,Meeske, Smith, & Chang, 2008).

It is vital for pediatric nurses to understand the healthliteracy level of their patients and the patients’ familymembers or caretakers. Medical providers, including nurses,often overestimate their knowledge of health literacy butindicate strong intentions to use techniques that foster clearcommunication (Mackert, Ball, & Lopez, 2011). Thesefindings indicate that there is a need and an interest in healthliteracy training programs.

The Health Literacy Universal Precautions Toolkit,commissioned by the Agency of Healthcare Research andQuality, provides extensive resources for clinical practices toimplement a health literacy quality improvement project. Thetoolkit can be accessed at http://www.ahrq.gov/legacy/qual/literacy/healthliteracytoolkit.pdf (DeWalt, 2010).

References

Bennett, Robbins, S., & Haecker, T. (2003). Screening for low literacyamong adult caregivers of pediatric patients. Family Medicine-KansasCity, 35, 585–590.

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty,K. (2011). Low health literacy and health outcomes: An updated

systematic review. Annals of Internal Medicine, 155, 97–107, http://dx.doi.org/10.7326/0003-4819-155-2-201107190-00005.

Betz, C. L., Ruccione, K., Meeske, K., Smith, K., & Chang, N. (2008). Healthliteracy: a pediatric nursing concern. Pediatric Nursing, 34, 231–239.

Cavanaugh, K., Huizinga, M. M., Wallston, K. A., Gebretsadik, T.,Shintani, A., Davis, D., et al. (2008). Association of numeracy anddiabetes control. Annals of Internal Medicine, 148, 737–746, http://dx.doi.org/10.7326/0003-4819-148-10-200805200-00006.

DeWalt, D. A. (2010). Health literacy universal precautions toolkit.Agency for Healthcare Research and Quality.

Hassan, K., & Heptulla, R. A. (2010). Glycemic control in pediatric type 1diabetes: Role of caregiver literacy. Pediatrics, 125, e1104–e1108,http://dx.doi.org/10.1542/peds.2009-1486.

Howard, D. H., Gazmararian, J., & Parker, R. M. (2005). The impact of lowhealth literacy on the medical costs of Medicare managed care enrollees.The American Journal of Medicine, 118, 371–377.

Janisse, H. C., Naar-King, S., & Ellis, D. (2010). Brief report: Parent'shealth literacy among high-risk adolescents with insulin dependentdiabetes. Journal of Pediatric Psychology, 35, 436–440, http://dx.doi.org/10.1093/jpepsy/jsp077.

Mackert, M., Ball, J., & Lopez, N. (2011). Health literacy awareness trainingfor healthcare workers: Improving knowledge and intentions to use clearcommunication techniques. Patient Education and Counseling, 85,e225–e228, http://dx.doi.org/10.1016/j.pec.2011.02.022.

Nielsen-Bohlman, L. (2004).Health literacy: A prescription to end confusion.National Academy Press. Retrieved from http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx.

Parker, R., & Ratzan, S. C. (2010). Health literacy: A second decade ofdistinction for Americans. Journal of Health Communication, 15,20–33, http://dx.doi.org/10.1080/10810730.2010.501094.

Powell, C. K., Hill, E. G., & Clancy, D. E. (2007). The relationshipbetween health literacy and diabetes knowledge and readiness to takehealth actions. The Diabetes Educator, 33, 144–151, http://dx.doi.org/10.11770145721706297452.

Sanders, L. M., Thompson, V. T., & Wilkinson, J. D. (2007).Caregiver health literacy and the use of child health services.Pediatrics, 119, e86.

Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C.,et al. (2002). Association of health literacy with diabetes outcomes.JAMA: The Journal of the American Medical Association, 288,475–482, http://dx.doi.org/10.1001/jama.288.4.475.

Sentell, T. L., & Halpin, H. A. (2006). Importance of adult literacy inunderstanding health disparities. Journal of General Internal Medicine,21, 862–866, http://dx.doi.org/10.1111/j.1525-1497.2006.00538.x.

Vernon, J. A. (2007). Low health literacy: Implications for national healthpolicy. Retrieved from http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/LowhealthLiteracyReport10_4_07.pdf.

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 unitedstates: A nationally representative study. Pediatrics, 124(Supplement),S289–S298, http://dx.doi.org/10.1542/peds.2009-1162E.

Yin, H. S., Mendelsohn, A. L., Wolf, M. S., Parker, R. M., Fierman, A.,van Schaick, L., et al. (2010). Parents' medication administrationerrors: Role of dosing instruments and health literacy. Archives ofPediatrics & Adolescent Medicine, 164, 181–186, http://dx.doi.org/10.1001/archpediatrics.2009.269.