Of concern, this study found that many caregivers had difficulty understanding basic health information for the care of infant children. For example, 1 in 4 could not properly dose prescription medication or read a digital thermometer, one half could not properly dose over-the-counter medication or understand a growth chart, and more than 3 in 4 could not understand a commonly used breastfeeding brochure. The Parental Health Literacy Activities Test (PHLAT) demonstrated excellent reliability and construct validity, suggesting that it may be a useful measure for assessing parental health literacy in the context of caring for young children. To our knowledge, this is the first study to comprehensively evaluate how literacy and numeracy correlate with basic understanding of health-based instructions related to infant care. It is also the first study to validate a specific parental health literacy and numeracy measure.
Psychometric analysis of the 20-item version of the PHLAT shows it has good reliability and validity in testing literacy and numeracy related skills of caregivers with young children. Higher PHLAT scores were significantly correlated with higher education level, literacy skill, and numeracy level. Compared with the Shortened Test of Functional Health Literacy in Adult (S-TOFHLA), the PHLAT seems to provide greater sensitivity as a measure of health literacy in the pediatric setting. While most caregivers had adequate literacy on the commonly used S-TOFHLA, they had a more diverse range in performance when tested with the PHLAT. This may be related to the ceiling effect on the S-TOFHLA, particularly among younger adults22–26
, and/or because the PHLAT tests a more robust array of applied skills (both literacy and numeracy) more pertinent to the caregiver with infant children.34
The shortened 10-item version of the PHLAT, the PHLAT-10, also showed good reliability and construct validity. The PHLAT could be a useful tool for research purposes, while the PHLAT-10 may be a more useful tool in the clinical setting. We are currently testing the validity and reliability of both English- and Spanish-language versions of the PHLAT-10 in a larger study. In this new study we have adapted the PHLAT-10 to use pictures of labels rather than actual products to make the test more feasible to administer in a busy clinic setting. Future work should focus on validating a variation of the PHLAT for parents with older children, and on identifying meaningful approaches for interpretation and application of the PHLAT results in a clinical setting.
Results from the PHLAT highlight the many challenges that caregivers face in trying to provide daily appropriate health-related care for their infants. Caregivers were often unable to understand nutrition and medication labels, simple child-health handouts, and basic child-safety recommendations. Many were also unable to mix infant formulas or to dose liquid medication appropriately. The framing of health-related instructions, such as two different versions of how to mix infant formula, was associated with significantly different rates of parent understanding; suggesting both the effect of individual experience and the importance of clearly presenting health information.
Recent studies have shown associations between low maternal literacy and a decreased likelihood of breastfeeding, greater likelihood of smoking, and greater likelihood to have depressive symptoms.6,35–38
Also, children of caregivers with lower literacy skills have more unmet healthcare needs,39,40
more preventable use of the emergency room,5
and worse control of asthma and type 1 diabetes.5,41
Infants with parents of lower education or literacy also have worse health outcomes.20,21
In our current study, caregivers, particularly those with lower literacy and numeracy skills, consistently had problems making formula and understanding breastfeeding instructions, and interpreting nutrition labels. Lower PHLAT score was associated with a higher likelihood of caregivers inappropriately interpreting age indications of OTC cough and cold medications. OTC medication labels contain dense information that can be more challenging, and potentially misleading, for patients with lower health literacy and numeracy skills to understand.12
The correlation between the PHLAT and these common nutrition and medication activities may relate to clinically relevant outcomes, such as medication administration, although this requires further study.
This study has several limitations. This cross-sectional study only demonstrates associations and not causation. The utility of the PHLAT for longitudinal study needs to be demonstrated. We recruited a convenience sample of English-speaking caregivers from a population whose children were being seen at academic medical centers. Therefore, our results may not be generalizable to all populations. Our literacy measure, the S-TOFHLA, had little variability among subjects and a ceiling effect, limiting the validation of our new measure against an assessment of caregiver health literacy. Additionally, we examined caregiver skills in a clinical setting, but these paper and pencil tests may not reflect actual behaviors at home. While we demonstrated the PHLAT was correlated with understanding of OTC labels, we did not specifically correlate performance on the PHLAT with any clinical outcomes, such as health status or receipt of preventative services. While we established the PHLAT had good construct validity, future prospective studies will need to demonstrate its predictive utility.
Our results have important implications for caregivers of young children, health care providers, industry, and federal agencies. All caregivers of young children –particularly the many caregivers with limited literacy and numeracy skills – face significant barriers to comprehending and implementing basic child-health tasks, such as providing appropriate nutrition, safety, and medication. Improving the clarity of child health information may be a critical factor for efforts that aim to improve the pediatric medical home – including preventive care, acute care, and care coordination for children. The Parental Health Literacy Activities Test may be useful to identify families who may benefit from verbal or pictorial instruction in the clinical setting. Our results suggest that pediatricians and health care providers may need to improve how they communicate with and educate caregivers of young children to perform many basic health-related skills. Health departments, pharmaceutical corporations, hospitals and academic medical centers can also use these results to inform future design improvements for the health system, including interactive health-education materials, user-friendly medication labels, and personal health records.