Health LiteracyRelationship between child health literacy and body mass index in overweight children☆
Introduction
Better health literacy, an individual's ability to read and interpret health information needed to make health decisions [1], has been correlated with better health outcomes in adults [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]. While some investigators have begun to explore the relationship between parental health literacy and child health outcomes [37], [38], no recent studies have evaluated the contribution of children's own health literacy to health outcomes.
While it is intuitive that children are under the influence and supervision of adults with regard to their own health care, there are a variety of instances where children's own health literacy – their ability to understand how to take medications, for example – may directly affect their health. Children even as young as 4 years old are involved in their own self-care [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50] and in one study, 9–12-year-old children with diabetes read carbohydrate details on food labels, estimated the amount of energy they would need for the next few hours, and calculated how much insulin they should inject [44]. Among children with asthma, a recent randomized trial indicated that group education of children ages 9–13 resulted in reduction of asthma morbidity in children, but education of their parents did not provide additional benefit [51].
The current epidemic of child obesity provides another important context for understanding the potential of health literacy as a contributor to health outcomes in children. For example, a study of a nationally representative sample of 2314 U.S. schoolchildren children reported that an average of 43% of children's meals were consumed in school [52]. Such information has been the impetus for school-based interventions to reduce the prevalence of overweight and obesity, through measures such as modifying the meals provided by school lunch, but also changing the options available in school vending machines. Such measures affirm the belief that children do in fact make unsupervised decisions that can affect their health. In support of this belief, studies looking at the effects of television exposure on children have shown that children exposed to television advertising for unhealthy foods are more likely to request unhealthy foods from their parents [53], eat fewer less fruits and vegetables [54], and eat more energy-dense foods [55], [56]. In fact, one study reported an increase of 167 kcal/d for each hour of television viewing, mediated by an increase in consumption of foods commonly advertised on television [56]. In the context of childhood obesity, we propose that children's own ability to obtain, use, and understand health information (food advertising, labeling) impacts their ability to understand the choices they face with regard to self-care (specifically, dietary intake), that in turn, impacts body mass index (BMI).
In response to the concerns about the relationship between literacy and childhood obesity, our research team was awarded a “Clear Health Communication” research grant from Pfizer to test whether an intervention to increase child and parental health literacy improved BMI among overweight children. The current report uses baseline data (before any intervention) from the study to examine the relationship between initial health literacy and a child's BMI Z-score. The a priori hypothesis was that higher health literacy scores (both parental and child) would be associated with better BMI scores.
Section snippets
Design/setting/participants
The parent study from which these baseline (pre-intervention) data were drawn enrolled children ages 6–19 with the following inclusion criteria: BMI at least 85th percentile for age and sex, and receiving primary care at the study site, an inner-city academic health center in the Bronx, New York. Children were enrolled with the one legal guardian who usually brought them to clinic visits. Children with diagnosed developmental impairment, hemo-dynamically significant heart disease, or
Results
Overall, 171 children were referred for participation in the obesity management program and study. Of these, 107 (62%) children agreed to participate. Seventy-eight (73%) children from 69 families had parental body mass index measured at baseline, and could therefore be included in this analysis. Children excluded for missing parental data had higher STOFHLA scores (Table 1). Overall, the study sample was representative of the health center population (largely Latino and African-American,
Discussion
A thorough review of the literature reveals one previous study of children with Type 1 diabetes, which found no relationship between children's literacy skill and their own health, as measured by hemoglobin A1C [67]. In contrast, we found, in this cross-sectional sample of overweight children, that higher literacy was significantly correlated with a lower body mass index, adjusted for age and gender.
We believe these results raise important questions for future research. First, the uncertainty
References (76)
- et al.
Nurse-delivered antiretroviral treatment adherence intervention for people with low literacy skills and living with HIV/AIDS
J Assoc Nurses AIDS Care
(2005) - et al.
Health literacy and health-related knowledge among persons living with HIV/AIDS
Am J Prev Med
(2000) - et al.
Health literacy and knowledge of chronic disease
Patient Educ Couns
(2003) - et al.
Health literacy and health risk behaviors among older adults
Am J Prev Med
(2007) - et al.
Reading skills and family planning knowledge and practices in a low-income managed-care population
Obstet Gynecol
(1999) - et al.
The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women
Am J Obstet Gynecol
(2002) - et al.
Low parental literacy is associated with worse asthma care measures in children
Ambul Pediatr
(2007) - et al.
Chronically ill children in self-care: issues for pediatric nurses 9
J Pediatr Health Care
(1993) - et al.
Kid cards: teaching children about their medicines
J Pediatr Health Care
(2006) Self-management and adherence of children and youth with special health care needs: implications for pediatric nursing practice
J Pediatr Nurs
(2006)
Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants
J Am Diet Assoc
Development of a brief test to measure functional health literacy
Patient Educ Couns
Psychosocial correlates of fruit, vegetable, and dietary fat intake among adolescent boys and girls
J Am Diet Assoc
Body mass index over the adult life course and cognition in late midlife: the Whitehall II Cohort Study
Am J Clin Nutr
Neuropsychological performance of a clinical sample of extremely obese individuals
Arch Clin Neuropsychol
Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association
J Am Med Assoc
The relationship of patient reading ability to self-reported health and use of health services
Am J Public Health
Health literacy and the risk of hospital admission
J Gen Intern Med
Health literacy and preventive health care use among Medicare enrollees in a managed care organization
Med Care
Barriers to HIV/AIDS treatment and treatment adherence among African-American adults with disadvantaged education
J Natl Med Assoc
Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective
J Gen Intern Med
Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study
J Gen Intern Med
Health literacy and adherence to glaucoma therapy
Am J Ophthalmol
Effect of literacy on breast-feeding outcomes
South Med J
Association of health literacy with diabetes outcomes
J Am Med Assoc
The relationship between health literacy and diabetes knowledge and readiness to take health actions
Diabetes Educ
Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes
BMC Fam Pract
Impact of health literacy on socioeconomic and racial differences in health in an elderly population
J Gen Intern Med
A multivariate analysis of factors associated with depression: evaluating the role of health literacy as a potential contributor
Arch Intern Med
Health literacy and functional health status among older adults
Arch Intern Med
Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes
Arch Intern Med
Health literacy is a predictor of HIV/AIDS knowledge
Fam Med
Relation of health literacy to gonorrhoea related care
Sex Transm Infect
Improving rates of cervical cancer screening and Pap smear follow-up for low-income women with limited health literacy
Cancer Invest
Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City
Prev Chronic Dis
Health literacy and pregnancy preparedness in pregestational diabetes
Diabetes Care
Literacy and knowledge, attitudes and behavior about mammography in Latinas
J Health Care Poor Underserved
The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study
BMC Fam Pract
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Presented in part at the annual meetings of the Pediatric Academic Societies in San Francisco, May 2006. Work supported in part by a “Clear Health Communication” research grant from Pfizer Pharmaceuticals, Inc. and by the Bronx Center for Reducing and Eliminating Health Disparities, Albert Einstein College of Medicine.