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1.  Glycemic Control in Young Children with Diabetes: The Role of Parental Health Literacy 
Patient education and counseling  2013;94(1):10.1016/j.pec.2013.09.002.
This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.
Seventy primary caregivers of children (age 3–9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients’ medical histories were obtained by medical chart review.
Parental diabetes related numeracy (r = −.52, p <.01), but not reading skills (r = −.25, p = NS) were inversely correlated with the child’s glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child’s HbA1c (r = −.47, p <.01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F = 12.93, p<.01) with both numeracy (β = − .46, p<.01) and parental perceived diabetes self-efficacy (β = − .36, p=.01) as significant predictors of HbA1c.
Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM. Practice Implications: Practitioners should assess parental health literacy and consider intervention when needed.
PMCID: PMC3865071  PMID: 24091252
Type 1 diabetes; health literacy; glycemic control; children; parents; numeracy
2.  Family, Community and Clinic Collaboration to Treat Overweight and Obese Children: Stanford GOALS -- a Randomized Controlled Trial of a Three-Year, Multi-Component, Multi-Level, Multi-Setting Intervention 
Contemporary clinical trials  2013;36(2):10.1016/j.cct.2013.09.001.
To test the effects of a three-year, community-based, multi-component, multi-level, multi-setting (MMM) approach for treating overweight and obese children.
Two-arm, parallel group, randomized controlled trial with measures at baseline, 12, 24, and 36 months after randomization.
Seven through eleven year old, overweight and obese children (BMI ≥ 85th percentile) and their parents/caregivers recruited from community locations in low-income, primarily Latino neighborhoods in Northern California.
Families are randomized to the MMM intervention versus a community health education active-placebo comparison intervention. Interventions last for three years for each participant. The MMM intervention includes a community-based after school team sports program designed specifically for overweight and obese children, a home-based family intervention to reduce screen time, alter the home food/eating environment, and promote self-regulatory skills for eating and activity behavior change, and a primary care behavioral counseling intervention linked to the community and home interventions. The active-placebo comparison intervention includes semi-annual health education home visits, monthly health education newsletters for children and for parents/guardians, and a series of community-based health education events for families.
Main Outcome Measure
Body mass index trajectory over the three-year study. Secondary outcome measures include waist circumference, triceps skinfold thickness, accelerometer-measured physical activity, 24-hour dietary recalls, screen time and other sedentary behaviors, blood pressure, fasting lipids, glucose, insulin, hemoglobin A1c, C-reactive protein, alanine aminotransferase, and psychosocial measures.
The Stanford GOALS trial is testing the efficacy of a novel community-based multi-component, multi-level, multi-setting treatment for childhood overweight and obesity in low-income, Latino families.
PMCID: PMC3844020  PMID: 24028942
children; overweight; obesity; treatment; community; family
3.  Association between medical home characteristics and staff professional experiences in pediatric practices 
Archives of Public Health  2014;72(1):36.
The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.
Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware’s seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice’s medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.
Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.
Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.
PMCID: PMC4216343  PMID: 25364502
Medical home; Pediatrics; CHIPRA; Staff; Survey
4.  The Role of Parent Health Literacy Among Urban Children with Persistent Asthma 
Patient education and counseling  2009;75(3):368-375.
Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.
To examine associations between parent HL and measures related to child asthma.
Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. Measures: The Rapid Estimate of Adult Literacy in Medicine for parent HL; NHLBI criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. Analyses: Bivariate and multivariate analyses of associations between parent HL measures related to child asthma.
Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry parent perception of greater asthma burden, and lower parent-reported quality of life. Measures of health care use (e.g., emergency care, preventive medicines) were not associated with parent HL.
Parents with limited HL worried more and perceived greater overall burden from the child’s asthma, even though reported health care use did not vary.
Practice Implications
Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.
PMCID: PMC3712512  PMID: 19233588
Health Literacy; asthma; asthma care; child health; child asthma; health behavior; health beliefs; provider-patient communication; pediatric care; medical care; REALM; poverty; low-income; PACQOL; asthma burden; urban children
5.  The Association of Acculturation and Health Literacy, Numeracy and Health-Related Skills in Spanish-speaking Caregivers of Young Children 
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 (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 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 β: 0.84, 95 % CI 0.26–1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95 % CI 0.11–1.21, P = 0.02) or numeracy (adjusted β: 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.
PMCID: PMC3435454  PMID: 22481307
Acculturation; Literacy; Numeracy; Infants
6.  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  2011;12(1):68-74.
To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT-10 Spanish).
Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8).
Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), while only 0.6% had 9th grade or higher numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than a third (31.8%) were able to interpret a food label to determine whether it met WIC guidelines. Higher PHLAT-10 score was associated with higher years of education (r=0.49), S-TOFHLA (r=0.53) and WRAT-3 (r=0.55) scores (p<0.001). Internal reliability was good (KR-20=0.61). An 8-item scale was highly correlated with the full 10-item scale (r=0.97, p<0.001), with comparable internal reliability (KR-20= 0.64).
Many Spanish-speaking parents have difficulty carrying out health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.
PMCID: PMC3259164  PMID: 22056223
anticipatory guidance; parenting skills; infants; health literacy
7.  Use of Farmers Markets by Mothers of WIC Recipients, Miami-Dade County, Florida, 2011 
Farmers market-based interventions, including the Farmers’ Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), represent a promising strategy for improving dietary behaviors in low-income communities. Little is known, however, about the health-related characteristics of low-income parents who frequent farmers markets in urban settings. The objective of this study was to examine the relationship between family-health factors and the use of farmers markets by mothers of WIC recipients.
We recruited a convenience sample of mothers of children seeking care at a primary care clinic in a large urban public hospital in Miami, Florida, in 2011 (n = 181 total). The clinic was adjacent to a newly established farmers market at the hospital. Each mother completed an interviewer-administered survey that included self-reported measures of maternal and child health, acculturation, dietary behaviors, food insecurity, and use of farmers markets.
Reported use of farmers markets was independently associated with maternal history of diabetes (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.3–38.3) and increased maternal vegetable (but not fruit) consumption (OR, 3.5; 95% CI, 1.5–8.1). Intended future use of farmers markets was independently associated with being unemployed (OR, 2.4; 95% CI, 1.0–5.7), increased maternal vegetable consumption (OR, 2.5; 95% CI, 1.1–5.7), and food insecurity (OR, 3.6; 95% CI, 1.3–10.3).
This study provides a snapshot of factors associated with farmers market use in a diverse population of urban low-income families. Understanding these factors may inform public health approaches to increase fresh fruit and vegetable consumption in communities at high risk for preventable chronic conditions.
PMCID: PMC3684356  PMID: 23764344
8.  The Charcot Foot in Diabetes 
Diabetes Care  2011;34(9):2123-2129.
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
PMCID: PMC3161273  PMID: 21868781
9.  Interventions Aimed at Decreasing Obesity in Children Younger Than 2 Years 
To assess the evidence for interventions designed to prevent or reduce overweight and obesity in children younger than 2 years.
Data Sources
MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and references from relevant articles.
Study Selection
Included were published studies that evaluated an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years.
Data Extraction
Extracted from eligible studies were measured outcomes, including changes in child weight status, dietary intake, and physical activity and parental attitudes and knowledge about nutrition. Studies were assessed for scientific quality using standard criteria, with an assigned quality score ranging from 0.00 to 2.00 (0.00–0.99 is poor, 1.00–1.49 is fair, and 1.50–2.00 is good).
Data Synthesis
We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n=2), clinic (n=3), classroom (n=4), or a combination (n=1). Intervention durations were generally less than 6months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28–1.43).
Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.
PMCID: PMC3369272  PMID: 21135337
10.  Parental Understanding of Infant Health Information: Health Literacy, Numeracy and the Parental Health Literacy Activities Test (PHLAT) 
Academic pediatrics  2010;10(5):309-316.
To assess parental health literacy and numeracy skills in understanding instructions for caring for young children, and to develop and validate a new parental health literacy scale, the Parental Health Literacy Activities Test (PHLAT).
Caregivers of infants (age <13 months) were recruited in a cross-sectional study at pediatric clinics at three academic medical centers. Literacy and numeracy skills were assessed with previously validated instruments. Parental health literacy was assessed with the new 20-item PHLAT. Psychometric analyses were performed to assess item characteristics and to generate a shortened, 10-item version (PHLAT-10).
182 caregivers were recruited. While 99% had adequate literacy skills, only 17% had >9th-grade numeracy skills. Mean score on the PHLAT was 68% (SD 18); for example, only 47% of caregivers could correctly describe how to mix infant formula from concentrate, and only 69% could interpret a digital thermometer to determine if an infant had a fever. Higher performance on the PHLAT was significantly correlated (p<0.001) with education, literacy skill, and numeracy level (r=0.29, 0.38, and 0.55 respectively). Caregivers with higher PHLAT scores were also more likely to interpret age recommendations for cold medications correctly (OR 1.6, 95% CI 1.02, 2.6). Internal reliability on the PHLAT was good (KR-20=0.76). The PHLAT-10 also demonstrated good validity and reliability.
Many parents do not understand common health information required to care for their infants. The PHLAT, and PHLAT-10 have good reliability and validity and may be useful tools for identifying parents who need better communication of health-related instructions.
PMCID: PMC2933956  PMID: 20674532
Literacy; Parenting Skills; Infants; Safety
11.  Parental Misinterpretations of Over-the-Counter Pediatric Cough and Cold Medication Labels 
Pediatrics  2009;123(6):1464-1471.
Concerns about the safety and efficacy of over-the-counter cold medications have led to a recent US Food and Drug Administration public health advisory against their use in children <2 years of age. Our goal was to examine caregiver understanding of the age indication of over-the-counter cold medication labels and identify factors, associated with caregiver understanding.
Caregivers of infant children (≤1 year old) were recruited from clinics at 3 institutions. Questions were administered regarding the use of 4 previously common “infant” over-the-counter cold and cough medicines labeled to consult a physician if used in children <2 years of age. Literacy and numeracy skills were assessed with validated instruments.
A total of 182 caregivers were recruited; 87% were the infants’ mothers. Mean education level was 12.5 years, and 99% had adequate literacy skills, but only 17% had >9th-grade numeracy skills. When examining the front of the product label, 86% of the time parents thought these products were appropriate for use in children <2 years of age. More than 50% of the time, parents stated they would give these over-the-counter products to a 13-month-old child with cold symptoms. Common factors that influenced parental decisions included label saying “infant,” graphics (eg, infants, teddy bears, droppers), and dosing directions. Caregivers were influenced by the dosing directions only 47% of the time. Caregivers with lower numeracy skills were more likely to provide inappropriate reasons for giving an over-the-counter medication.
Misunderstanding of over-the-counter cold products is common and could result in harm if medications are given inappropriately. Label language and graphics seem to influence inappropriate interpretation of over-the-counter product age indications. Poorer parental numeracy skills may increase the misinterpretation of these products. Opportunities exist for the Food and Drug Administration and manufacturers to revise existing labels to improve parental comprehension and enhance child safety.
PMCID: PMC2911576  PMID: 19482755
nonprescription drugs; literacy; safety
12.  A Prospective Study of Weight and Metabolic Syndrome in Young Hispanic Children 
Examine weight in young Hispanic children over a two-year period; investigate the relationships among overweight, physical activity, caloric intake, and family history in the development of the metabolic syndrome (MS).
Forty-seven children (ages 5–8) from diverse Hispanic backgrounds recruited from elementary schools were evaluated. Laboratory analyses, anthropometric data, and measures of physical activity and caloric intake were included.
The majority of the children were overweight at baseline (66%) and at follow-up (72%). Children who were overweight at baseline were more likely to exhibit MS at follow-up than were those who were not overweight at baseline.
Overweight appears to be an independent predictor of MS among Hispanic children.
PMCID: PMC2884161  PMID: 20548797
overweight; physical activity; caloric intake; children; metabolic syndrome

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