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The Relationship Between Parent Health Literacy and Pediatric Emergency Department Utilization: A Systematic Review

      Abstract

      Background

      Low health literacy in parents can potentially impact understanding of a child’s diagnosis and treatment course. No reviews have addressed parent health literacy in the emergency department (ED), the relationship between parent health literacy and child ED utilization, or the impact of low literacy interventions on child ED utilization.

      Objective

      To systematically evaluate the peer-reviewed literature pertaining to parental health literacy and ED utilization. The following key questions were addressed: question (Q) 1) What is the prevalence of low health literacy, as estimated by validated health literacy measures, of parents in the ED? Q2) Is parent low health literacy related to ED use for children? Q3) Do low literacy interventions targeting parents likely to have low health literacy affect ED use for children?

      Data Sources

      The authors reviewed 483 unduplicated titles and abstracts published between 1980 and May 2012 using PubMed and CINAHL, with 117 retained for full review and 17 included in the final analytic review.

      Study Eligibility Criteria, Participants, and Interventions

      All included articles had a valid measure of parent health literacy and a Q1) descriptive measurement of the population, Q2) ED utilization, or Q3) utilized a low literacy educational intervention.

      Study Appraisal and Synthesis Methods

      One author extracted data verified by a second author. Studies were rated for quality by both authors.

      Results

      Q1) A median of 30% (interquartile range 22–36%) of parents in the ED possesses low health literacy. Q2) Studies investigating the relationship between health literacy and ED yielded mixed results. Q3) Seven of 8 low literacy interventions were associated with a reduction in ED use. Random effects pooled odds ratios from 6 studies showed intervention effectiveness (odds ratio 0.35; 95% CI 0.15–0.81).

      Limitations

      No intervention studies measured health literacy, limiting the ability to determine whether the low literacy intervention targeted health literacy.

      Conclusions and Implications of Key Findings

      Roughly 1 in 3 parents of children presenting to the ED have low health literacy. Importantly, interventions targeting parents likely to have low health literacy have an impact in reducing ED utilization.

      Keywords

      What This Systematic Review Adds
      • Roughly 1 in 3 parents in the emergency department with their children have low health literacy.
      • Low health literacy may have a relationship with increased emergency department use in children.
      • Targeted low literacy interventions can reduce emergency department utilization.
      How to Use This Systematic Review
      • Update your knowledge about parents’ ability to understand, process, and use health information.
      • Use as a catalyst to use health literacy universal precautions in your clinical work.
      • Consider the implications of using materials addressing low health literacy in clinical and research interventions for parents.
      An estimated 90 million Americans have low health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
      Low health literacy serves as a potential mediator of health disparities, with low socioeconomic status, less than high school education, poor English proficiency, black race, Hispanic ethnicity, older age, and birth outside of the United States found to be risk factors.
      • Paasche-Orlow M.K.
      • Parker R.M.
      • Gazmararian J.A.
      • et al.
      The prevalence of limited health literacy.
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      National organizations, including the Institute of Medicine and the United States Department of Health and Human Services, recognize the detrimental impact of low health literacy, and the Joint Commission has characterized health literacy as an important consideration for patient safety.

      US Department of Health and Human Services. Proposed Healthy People 2020 objectives. Available at: http://www.healthypeople.gov/hp2020. Accessed May 15, 2012.

      • Joint Commission
      What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety.
      Although the relationship between health literacy and emergency department (ED) utilization is well established within the adult literature, relatively few studies have evaluated this relationship within the pediatric population. As many as 48% of adult ED patients demonstrate low health literacy,
      • Herndon J.B.
      • Chaney M.
      • Carden D.
      Health literacy and emergency department outcomes: a systematic review.
      • Baker D.M.
      • Parker R.M.
      • Williams M.V.
      • Clark W.S.
      Health literacy and the risk of hospital admission.
      • Baker D.W.
      • Gazmararian J.A.
      • Williams M.V.
      • et al.
      Functional health literacy and the risk of hospital admission among Medicare managed care enrollees.
      which is associated with worse global measures of health, more adverse health outcomes, and increased ED use and hospitalizations.
      • Baker D.M.
      • Parker R.M.
      • Williams M.V.
      • Clark W.S.
      Health literacy and the risk of hospital admission.
      • Baker D.W.
      • Gazmararian J.A.
      • Williams M.V.
      • et al.
      Functional health literacy and the risk of hospital admission among Medicare managed care enrollees.
      • Berkman N.D.
      • Dewalt D.A.
      • Pignone M.P.
      • et al.
      Literacy and health outcomes.
      • Mancuso C.
      • Rincon M.
      Impact of health literacy on longitudinal asthma outcomes.
      Considering that low health literacy can affect a patient’s understanding of diagnoses, treatment course, written materials, and follow-up appointments,
      • Davis T.C.
      • Mayeaux E.J.
      • Fredrickson D.
      • et al.
      Reading ability of parents compared with reading level of pediatric patient education materials.
      • DeWalt D.A.
      • Hink A.
      Health literacy and child health outcomes: a systematic review of the literature.
      • Moon R.Y.
      • Cheng T.L.
      • Patel K.M.
      • et al.
      Parental literacy level and understanding of medical information.
      • Sanders L.M.
      • Federico S.
      • Klass P.
      • et al.
      Literacy and child health: a systematic review.
      it is concerning that over 21 million parents in the United States have low health literacy.
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      When a child visits the ED, parents’ health literacy skills are crucial in providing the necessary information to guide medical decision making, make informed decisions about treatment, and establish follow-up for the child. Despite its importance, little is known about health literacy of parents who bring children to the ED.
      The purpose of this systematic review was to evaluate the peer-reviewed literature pertaining to the health literacy of parents in the pediatric ED and the relationship between parent health literacy and ED utilization for children. In addition, this review assessed the effectiveness of low literacy interventions for parents on childhood ED utilization.

      Methods

      Search Questions

      A comprehensive literature search was conducted on the basis of the following questions: Q1) What is the prevalence of low health literacy, as estimated by validated health literacy measures, of parents in the ED? Q2) Is parent low health literacy related to ED use for children? Q3) Do low literacy interventions targeting parents likely to have low health literacy affect ED use for children?

      Inclusion and Exclusion Criteria

      The literature search was restricted to studies completed between 1980 and May 2012 involving children aged 0 to 18 years and their parents. As ED use may be disparate between countries given health care systems, only studies completed within the United States were targeted. Review articles were excluded from analysis. For Q1, the search parameters included validated measures of health literacy and/or numeracy that measured characteristics in the ED. For Q2, the search included health literacy measures and ED utilization. For Q3, the search targeted low literacy interventions designed to address ED utilization. Studies were included if they reported numeric data on ED visits for at least 6 months after intervention, or a control group. We defined health literacy interventions as “interventions to improve patients’ and parents’ abilities to use printed materials to improve child health outcomes by targeting low parent health literacy” based on previous authors’ constructs.
      • DeWalt D.A.
      • Hink A.
      Health literacy and child health outcomes: a systematic review of the literature.
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      We chose to focus on interventions that incorporated low literacy printed materials; a definition can be readily established for low literacy materials, whereas other intervention types are difficult to categorize as low literacy. The search revealed insufficient articles for analysis when including only interventions labeled as health literacy interventions. Therefore, this study included interventions that addressed low health literacy in parents by targeting populations at risk for low health literacy (defined as at least 25% living under the poverty level, over 50% Medicaid insurance, or an inner-city population) with a health educational intervention designed for low literacy populations (defined as <9th grade reading level).

      Literature Search

      PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for articles pertaining to the key questions noted above as other systematic reviews of this topic have found all articles through these databases.
      • DeWalt D.A.
      • Hink A.
      Health literacy and child health outcomes: a systematic review of the literature.
      • Sanders L.M.
      • Federico S.
      • Klass P.
      • et al.
      Literacy and child health: a systematic review.
      The health literacy measure keywords searched for Q1 and Q2 included: “health literacy,” “literacy,” “educational status,” “reading skill,” “reading ability,” “Rapid Estimate of Adult Literacy,” “REALM,” “Test of Functional Health Literacy in Adults,” “TOHFLA,” “Wide-Range Achievement Test,” “WRAT,” “Newest Vital Sign,” “NVS,” “PHAT,” and “Parent Health Activities Test” as well as MeSH terms “health literacy” and “educational status.” For limiting results to enrollment in the ED, the keyword search for Q1 included: “emergency department,” “emergency ward,” and the MeSH term “emergency service, hospital.” The search for emergency department utilization for Q2 and Q3 included: “utilization,” “use,” “emergency department,” “emergency ward,” and “emergency service, hospital” as well as subheading search for “utilization.” The educational intervention search for Q3 included keywords “health education,” and “patient education” as well as MeSH terms “health education,” “patient education as topic,” and “patient education handout as publication type.” These search terms intentionally allowed for a broad search of both the measurement of health literacy and intervention types. All articles retrieved from the CINAHL search were also present in the PubMed search, and the resulting numbers of articles from the PubMed search are presented. Reference sections from all selected articles and available review articles were reviewed, and no additional articles were identified. The primary search was developed with the assistance of a medical reference librarian and completed by the first author (AM).

      Data Extraction and Assessment of Study Validity

      Studies were initially retrieved and evaluated for inclusion by applying the inclusion and exclusion criteria to the title and abstract by the first author (AM). Articles that clearly did not meet the criteria by review of the title and abstract were immediately excluded using explicit inclusion/exclusion criteria. The remaining articles were reviewed for full inclusion by authors AM and MM. If both reviewers agreed that the article did not meet the inclusion criteria, the article was excluded. Disagreements of inclusion/exclusion were handled through consensus. Data found in the tables accompanying this article were abstracted by one author (AM) into a database and verified by a second author (MM). Authors were contacted for missing outcome data.
      The quality of the articles was assessed for all 3 questions based on criteria adapted from West and colleagues.
      • West S.
      • King V.
      • Carey T.S.
      • et al.
      Systems to rate the strength of scientific evidence.
      This approach has been used in previous systematic reviews of health literacy.
      • Herndon J.B.
      • Chaney M.
      • Carden D.
      Health literacy and emergency department outcomes: a systematic review.
      • Berkman N.D.
      • Dewalt D.A.
      • Pignone M.P.
      • et al.
      Literacy and health outcomes.
      • DeWalt D.A.
      • Hink A.
      Health literacy and child health outcomes: a systematic review of the literature.
      • Sanders L.M.
      • Federico S.
      • Klass P.
      • et al.
      Literacy and child health: a systematic review.
      Both reviewers (AM and MM) graded the quality of articles based on 7 criteria (adequacy of study population, comparability of subjects, validity of literacy measurement or educational instrument, maintenance of comparable groups, outcome measurement, statistical analysis, and appropriate control of confounding) scoring 0, 1, or 2 points each. Total scores were categorized as good quality (10–14 points), fair quality (6–9 points), and poor quality (0–5 points).
      • West S.
      • King V.
      • Carey T.S.
      • et al.
      Systems to rate the strength of scientific evidence.
      Because not all criteria applied to all studies, a proportional cutoff (0.7, 0.4), equal to the cutoffs above, was applied for studies in which not all criteria were applicable.

      Data Analysis

      The prevalence of low health literacy was defined as the number of parents scoring in the inadequate or marginal level of the Test of Functional Health Literacy in Adults (TOFHLA) or the short TOFHLA (S-TOFHLA) or less than 9th grade on the REALM; 95% confidence intervals were calculated using sample size. A chi-square analysis was utilized to assess the heterogeneity, and thus the ability to utilize a pooled estimate of the sample, for the prevalence of low health literacy in parents within the ED. For Q2, the outcome data did not support combined analysis. For Q3, odds ratios (OR) were calculated on the basis of the available results from all included studies. In addition, a DerSimonian and Laird test for heterogeneity, a chi-square test with (K tables −1) degrees of freedom that assessed the need for a random-effects or fixed effects approach to pooling the OR, was utilized to determine the heterogeneity of the studies. When the heterogeneity was significant, the DerSimonian and Laird random effects method was used to obtain a pooled OR and the appropriate (larger) CI using the appropriate variability (taking into account the heterogeneity) for ED use of interventions targeting populations likely to have low health literacy. Peter’s test was performed to test for biased study inclusion. Statistical analyses were performed by Stata software, version 12 (StataCorp, College Station, Tex).

      Results

      Overall, 483 unduplicated articles were identified through the keyword searches, with 117 full-text articles evaluated for initial eligibility (Fig. 1). A total of 17 articles met the full criteria and were included for review; none were duplicate reports of the same study data. Studies were primarily excluded from full review for Q1 and Q2 as a result of lack of any health literacy measurement and study completion outside of the ED. Articles for Q3 were primarily excluded for lack of a low literacy intervention, for not including ED use as an outcome variable, or for utilizing a patient population not at risk for low health literacy.
      Figure thumbnail gr1
      Figure 1Literature search results flow diagram.

      Parent Health Literacy in the Pediatric ED (Q1)

      Seven studies, totaling 1043 patients, measured the health literacy of parents in the pediatric ED with a validated health literacy measure (Table 1).
      • Farber H.J.
      • Johnson C.
      • Beckerman R.C.
      Young inner-city children visiting the emergency room (ER) for asthma: risk factors and chronic care behaviors.
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      • Rosman S.L.
      • Dorfman D.
      • Suglia S.F.
      • et al.
      Predictors of prescription filling after visits to the pediatric emergency department.
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      • Tran T.P.
      • Robinson L.
      • Keebler J.
      • et al.
      Health literacy among parents of pediatric patients.
      • Trifiletti L.B.
      • Shields W.C.
      • McDonald E.M.
      • et al.
      Development of injury prevention materials for people with low literacy skills.
      • Yin H.S.
      • Dreyer B.P.
      • Foltin G.
      • et al.
      Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing.
      Five of the 7 studies were rated as good-quality studies.
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      • Rosman S.L.
      • Dorfman D.
      • Suglia S.F.
      • et al.
      Predictors of prescription filling after visits to the pediatric emergency department.
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      The REALM (or short version REALM-SF) and TOFHLA (or short version S-TOFHLA) were the most frequently used measures of health literacy. These measures are available in English and Spanish, and they are thought to measure the construct of print literacy in a health care setting.
      • Davis T.C.
      • Long S.W.
      • Jackson R.H.
      • et al.
      Rapid estimate of adult literacy in medicine: a shortened screening instrument.
      • Parker R.M.
      • Baker D.W.
      • Williams M.V.
      • Nurss J.R.
      The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills.
      The studies varied widely in location, subject selection procedure, and study purpose (Table 1). The range of parents with low health literacy was 10% to 48% across all 7 studies (Fig. 2), with a median estimated prevalence of 30% (interquartile range [IQR] 22–36%). Given that study groups were significantly different (P < .001), a pooled estimate was not calculated.
      Table 1Study Summary: Estimated Prevalence of LHL (Question 1)
      StudyYearInstrument/Cut PointSampling StrategyOutcomeParents in ED With Low Health LiteracyStudy Quality
      Farber
      • Farber H.J.
      • Johnson C.
      • Beckerman R.C.
      Young inner-city children visiting the emergency room (ER) for asthma: risk factors and chronic care behaviors.
      1998REALM/9th gradeSequential enrollmentCharacteristics of young patients with asthma in the ED, including parent LHL48.8%Fair
      Macy
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      2011REALM/9th gradeConvenience sampleRelationship between LHL and asthma knowledge, ED use after intervention31.4%Good
      Rosman
      • Rosman S.L.
      • Dorfman D.
      • Suglia S.F.
      • et al.
      Predictors of prescription filling after visits to the pediatric emergency department.
      2012REALM-SF/9th gradeConvenience sampleRelationship between parent characteristics (including LHL) and prescription filling30.8%Good
      Sanders
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      2007S-TOFHLA/IMACross-sectional sampleRelationship between LHL and cost of care and use of health care services22.8%Good
      Tran
      • Tran T.P.
      • Robinson L.
      • Keebler J.
      • et al.
      Health literacy among parents of pediatric patients.
      2008S-TOFHLA/IMAConvenience samplePrevalence of LHL10.5%Poor
      Trifiletti
      • Trifiletti L.B.
      • Shields W.C.
      • McDonald E.M.
      • et al.
      Development of injury prevention materials for people with low literacy skills.
      2006REALM/9th gradeConvenience sampleDevelopment of injury prevention materials for LHL population36.6%Good
      Yin
      • Yin H.S.
      • Dreyer B.P.
      • Foltin G.
      • et al.
      Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing.
      2007TOFHLA/IMACross-sectional sampleRelationship between LHL and ability to dose medication25.6%Good
      Median (IQR) estimate of parent low health literacy of all studies30 (22–36%)
      LHL = low health literacy (inadequate, marginal, or <9th grade); ED = emergency department; REALM = Rapid Estimate of Adult Literacy in Medicine; (S-)TOFHLA = (Short) Test of Functional Health Literacy in Adults; REALM-SF = REALM—Short Form; IMA = inadequate, marginal, adequate health literacy; IQR = interquartile range.
      Figure thumbnail gr2
      Figure 2Forest plot of prevalence estimate of parent low health literacy and 95% CI (Q1). For each study, the estimated prevalence of low health literacy is shown as a diamond. The lateral bars indicate 95% CI. The vertical line indicates the median across all studies (30%), with the IQR in gray (22–36%).

      Parent Health Literacy and ED Utilization (Q2)

      Four studies, all good quality, evaluated the association between parent health literacy and ED utilization (Table 2).
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      • DeWalt D.A.
      • Dilling M.H.
      • Rosenthal M.S.
      • Pignone M.P.
      Low parental literacy is associated with worse asthma care measures in children.
      • Shone L.P.
      • Conn K.M.
      • Sanders L.
      • Halterman J.S.
      The role of parent health literacy among urban children with persistent asthma.
      Two studies in parents of patients with asthma found that low health literacy was associated with a higher number of ED visits in children.
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      • DeWalt D.A.
      • Dilling M.H.
      • Rosenthal M.S.
      • Pignone M.P.
      Low parental literacy is associated with worse asthma care measures in children.
      Conversely, 2 studies, one involving children with asthma and the other study involving a general population, found no association between low health literacy and ED use; however, the general population study found a trend toward increased ED use in parents with low health literacy.
      • Sanders L.M.
      • Federico S.
      • Klass P.
      • et al.
      Literacy and child health: a systematic review.
      • Shone L.P.
      • Conn K.M.
      • Sanders L.
      • Halterman J.S.
      The role of parent health literacy among urban children with persistent asthma.
      Table 2Study Summary: LHL and Association With ED Use (Question 2)
      StudyYearInstrument/Cut PointOutcomeRelationship With LHLStudy Quality
      DeWalt
      • DeWalt D.A.
      • Dilling M.H.
      • Rosenthal M.S.
      • Pignone M.P.
      Low parental literacy is associated with worse asthma care measures in children.
      2007REALM/9th gradeRelationship between LHL and asthma medication use, ED utilization, and hospitalizationLHL associated with more ED visits (P < .05)Good
      Macy
      • Macy M.L.
      • Davis M.M.
      • Clark S.J.
      • Stanley R.M.
      Parental health literacy and asthma education delivery during a visit to a community-based pediatric emergency department: a pilot study.
      2011REALM/9th gradeRelationship between LHL and asthma knowledge, ED use after interventionLHL associated with more ED visits (P < .04)Good
      Sanders
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      2007S-TOFHLA/IMARelationship between LHL and cost of care and use of health care servicesNo association between LHL and ED useGood
      Shone
      • Shone L.P.
      • Conn K.M.
      • Sanders L.
      • Halterman J.S.
      The role of parent health literacy among urban children with persistent asthma.
      2009REALM/9th gradeLHL and parental perceptions of asthma and use of health care servicesLHL not associated with urgent care/ED use for asthmaGood
      LHL = low health literacy (inadequate, marginal, or <9th grade); ED = emergency department; REALM = Rapid Estimate of Adult Literacy in Medicine; (S-)TOFHLA = (Short) Test of Functional Health Literacy in Adults; REALM-SF = REALM—Short Form; IMA = inadequate, marginal, adequate health literacy.

      Interventions to Target Low Health Literacy and ED Use (Q3)

      Eight studies investigated low literacy interventions and the effect on ED use.
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      • Bryant-Stephens T.
      • Kurian C.
      • Guo R.
      • Zhao H.
      Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma.
      • Butz A.M.
      • Tsoukleris M.G.
      • Donithan M.
      • et al.
      Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.
      • Fisher E.B.
      • Strunk R.C.
      • Sussman L.K.
      • et al.
      Community organization to reduce the need for acute care for asthma among African American children in low-income neighborhoods: the neighborhood asthma coalition.
      • Herman A.
      • Jackson P.
      Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention.
      • Rector T.S.
      • Venus P.J.
      • Laine A.J.
      Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care.
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      • Yoffe S.J.
      • Moore R.W.
      • Gibson J.O.
      • et al.
      A reduction in emergency department use by children from a parent educational intervention.
      Six of those studies were scored as good-quality studies (Table 3). Overall, 4 studies utilized asthma-specific educational interventions,
      • Bryant-Stephens T.
      • Kurian C.
      • Guo R.
      • Zhao H.
      Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma.
      • Butz A.M.
      • Tsoukleris M.G.
      • Donithan M.
      • et al.
      Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.
      • Fisher E.B.
      • Strunk R.C.
      • Sussman L.K.
      • et al.
      Community organization to reduce the need for acute care for asthma among African American children in low-income neighborhoods: the neighborhood asthma coalition.
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      and the remaining 4 studies utilized general pediatric health educational interventions.
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      • Herman A.
      • Jackson P.
      Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention.
      • Rector T.S.
      • Venus P.J.
      • Laine A.J.
      Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care.
      • Yoffe S.J.
      • Moore R.W.
      • Gibson J.O.
      • et al.
      A reduction in emergency department use by children from a parent educational intervention.
      Table 3LL Interventions to Change ED Use in Populations Likely to Have LHL
      StudyYearStudy DesignControl GroupPopulationType of InterventionInterventionMeasure of ED useED Use OutcomeStudy Quality
      General Health Interventions
       Herman
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      2009NRCTPre- vs postinterventionPrimarily low income, minority population; ED nonurgent (triage levels 4–5) patients.Health aid book“What To Do When Your Child Gets Sick” (3rd–5th grade reading level) and instruction on use of the book.Parent report30% reduction in number of participants using ED in last 6 mo (P < .0001)Good
       Herman
      • Herman A.
      • Jackson P.
      Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention.
      2010NRCTPre- vs postinterventionHead Start population, majority Medicaid or uninsured.Health aid book“What To Do When Your Child Gets Sick” (3rd–5th grade reading level) and instruction on use of the book.Parent report58% reduction in ED visits per year per child (P < .001)Good
       Rector
      • Rector T.S.
      • Venus P.J.
      • Laine A.J.
      Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care.
      1999RCTNo educationUrban Medicaid beneficiaries; ED visit in previous 6 mo.Health aid bookMailed “First Look” (4th grade reading level) to participants.Medicaid recordsNo difference in ED visits for children whose parent received the intervention.Good
       Yoffe
      • Yoffe S.J.
      • Moore R.W.
      • Gibson J.O.
      • et al.
      A reduction in emergency department use by children from a parent educational intervention.
      2011NRCTPre- vs postintervention and comparable clinic sitePrimarily low income patients.Health aid bookEducation booklet, “The pediatric after-hours non-life-and-death almost-an-emergency booklet,” addressing most common pediatric ailments with (6th grade reading level) given in primary care clinicMedical record reviewClinic patients where the booklets were distributed used the ED less (P < .001) compared to control clinic patients.Fair
      Asthma Interventions
       Bryant-Stephens
      • Bryant-Stephens T.
      • Kurian C.
      • Guo R.
      • Zhao H.
      Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma.
      2009RCTRandomized crossover design with immediate and delayed interventionPrimarily minority and low income families; child with asthma and controller medicationHome visits with LL course, environmental interventionLay health educator home visits using “You Can Control Asthma” curriculum (5th grade reading level) and environmental intervention to avoid triggers.Hospital database30% reduction in mean ED visits per year per participant ED visits (P < .001).Good
       Butz
      • Butz A.M.
      • Tsoukleris M.G.
      • Donithan M.
      • et al.
      Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.
      2006RCTStandard asthma educationPrimarily minority, low income, and Medicaid patients; child with persistent asthma.Home visits with LL courseAsthma nurse specialist home visits for a 6-mo asthma education intervention based on Wee Wheezers and A+ Asthma Club programs (3rd–5th grade reading level).Parent report18% reduction in ED use (P < .05) for 1 or more visits. No difference in mean number of visits.Good
       Fisher
      • Fisher E.B.
      • Strunk R.C.
      • Sussman L.K.
      • et al.
      Community organization to reduce the need for acute care for asthma among African American children in low-income neighborhoods: the neighborhood asthma coalition.
      2004NRCTNo educationPrimarily low-income, African American families; child treated in ED or hospitalized for asthma.LL course, neighborhood education programAsthma education intervention using “Open Airways” (3rd–5th grade reading level), neighborhood involvement in programs.Hospital recordsSignificantly decreased number of ED visits for children with high caregiver participation (P = .014), but not in overall group (P = .35).Good
       Stout
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      1998NRCTPre- vs postinterventionPrimarily urban, African American, Medicaid patients; high health care utilizers; child with asthma.LL asthma education, coordinated care modelMonthly visits from asthma outreach worker, educational component with “Open Airways” (3rd–5th grade), frequently scheduled appointments.Chart review65% reduction in number of ED visits (P = .038).Fair
      LHL = low health literacy; ED = emergency department; LL = low literacy; RCT = randomized controlled trial; NRCT = non–randomized, controlled trial; UCT = uncontrolled trial.

      General Health Education Interventions and ED Use

      The 4 studies using low literacy pediatric general health educational interventions found reduced ED utilization in the majority of the studies. Three studies found reduced ED use after distributing a low literacy general pediatric health education book to nonurgent patients in the pediatric ED,
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      Head Start parents,
      • Herman A.
      • Jackson P.
      Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention.
      and patients in a family medicine residency primary care clinic.
      • Yoffe S.J.
      • Moore R.W.
      • Gibson J.O.
      • et al.
      A reduction in emergency department use by children from a parent educational intervention.
      In contrast, Rector and colleagues mailed a low literacy general health book about nonurgent pediatric and adult conditions to urban Medicaid beneficiaries that visited the ED in the 6 months before the distribution and found no difference in ED use for children after the intervention.
      • Rector T.S.
      • Venus P.J.
      • Laine A.J.
      Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care.

      Asthma-Specific Education Intervention and ED Use

      All of the studies involving children with asthma were performed on outpatients, and all demonstrated decreases in ED utilization after intervention. Three of the studies utilized home visits to educate parents using a low literacy curriculum,
      • Bryant-Stephens T.
      • Kurian C.
      • Guo R.
      • Zhao H.
      Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma.
      • Butz A.M.
      • Tsoukleris M.G.
      • Donithan M.
      • et al.
      Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      one of which included a coordinated care approach including education with monthly visits from asthma outreach worker and frequent clinic appointments.
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      The fourth study used a low literacy curriculum and neighbors as support workers and demonstrated decreased ED visits in parents that had high group participation (P = .014), but not in the intervention group overall (P = .35).
      • Fisher E.B.
      • Strunk R.C.
      • Sussman L.K.
      • et al.
      Community organization to reduce the need for acute care for asthma among African American children in low-income neighborhoods: the neighborhood asthma coalition.

      Evaluation of Intervention Effectiveness

      To further assess the effects from interventions, ORs were calculated from the 6 studies that utilized the proportion of children with an ED visit as the outcome measure. Two studies used individual ED use data and could not be incorporated into this analysis because of the different type of data. Peter’s test showed no evidence of bias in subject selection (P = .940). Overall, 5 of the 6 studies favored the treatment (Fig. 3). The DerSimonian and Laird test revealed significant heterogeneity (chi-square = 427.76, df = 5, P < .001). A pooled OR was calculated using a random effects model, given the heterogeneity (OR 0.35; 95% CI 0.15–0.81). An additional analysis of the 4 general health education interventions studies was completed. Three of the 4 studies favored the treatment (Fig. 3), and a pooled OR was calculated (OR 0.36; 95% CI 0.13–1.01) again using a random effects model given significant heterogeneity (chi-square = 426.45, df = 3, P = .000).
      Figure thumbnail gr3
      Figure 3Forest plot of ORs for educational interventions (all interventions and general health interventions) and ED use. For each study, the OR is shown as a diamond with area proportional to the sample size. The lateral bars indicate 95% CI. Treatment is favored by studies with OR and 95% CI left of the vertical line. *Mailed intervention, with no evidence that the intervention was received or read.

      Discussion

      To our knowledge, this is the first systematic review to address and provide a prevalence estimate for the health literacy of parents in the ED as well as explore the utility of low literacy interventions targeted at populations likely to have low health literacy on ED use. One previous systematic review concentrated on the relationship of health literacy and ED utilization; however, this review described mainly adult outcomes and did not provide an overall prevalence for parents in the ED with their child; nor did it explore the impact of interventions on ED use.
      • Herndon J.B.
      • Chaney M.
      • Carden D.
      Health literacy and emergency department outcomes: a systematic review.
      This study found that an estimated 1 in 3 parents seeking care for their children at the ED demonstrated low health literacy. Though similar to national estimates of low health literacy in parents,
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      this estimated prevalence of low health literacy for parents in the ED is lower than the estimated prevalence of low health literacy in the general adult population (46%)
      • Paasche-Orlow M.K.
      • Parker R.M.
      • Gazmararian J.A.
      • et al.
      The prevalence of limited health literacy.
      and adult patients seeking care in the ED (40%).
      • Herndon J.B.
      • Chaney M.
      • Carden D.
      Health literacy and emergency department outcomes: a systematic review.
      This difference may be partially explained by the age of the study subjects, as older age is associated with increasing low health literacy and parents are younger than the general adult population, thus decreasing low health literacy prevalence.
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      Additionally, in a national sample Yin et al found that nonparents had a significantly higher rate of low health literacy as compared to parents (38% and 28% respectively).
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.

      Variable Association Between Low Health Literacy and ED Use

      Consistent with previous studies in adults which showed increased ED use,
      • Berkman N.D.
      • Dewalt D.A.
      • Pignone M.P.
      • et al.
      Literacy and health outcomes.
      • Mancuso C.
      • Rincon M.
      Impact of health literacy on longitudinal asthma outcomes.
      and given poor parental understanding of diagnosis, treatment course, and discharge instructions,
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      • Trifiletti L.B.
      • Shields W.C.
      • McDonald E.M.
      • et al.
      Development of injury prevention materials for people with low literacy skills.
      • Yin H.S.
      • Dreyer B.P.
      • Foltin G.
      • et al.
      Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing.
      • Williams D.M.
      • Counselman F.L.
      • Caggiano C.D.
      Emergency department discharge instructions and patient literacy: a problem of disparity.
      • Rudd R.E.
      Health literacy skills of US adults.
      this systematic review found evidence to support the relationship between low health literacy and increased ED use in parents of children with asthma. Our study did not find an association between low health literacy and ED use in general pediatric populations. Chronic diseases, such as asthma, may intensify the impact of low health literacy due to the increased care demand associated with managing these medical conditions. Parents with low health literacy have difficulty with medication label interpretation, dosing instrument selection, and medication dosing accuracy which all impact chronic disease management.
      • Moon R.Y.
      • Cheng T.L.
      • Patel K.M.
      • et al.
      Parental literacy level and understanding of medical information.
      • Yin H.S.
      • Dreyer B.P.
      • Foltin G.
      • et al.
      Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing.
      • DeWalt D.A.
      • Dilling M.H.
      • Rosenthal M.S.
      • Pignone M.P.
      Low parental literacy is associated with worse asthma care measures in children.
      • Davis T.C.
      • Wolf M.S.
      • Bass P.F.
      • et al.
      Literacy and misunderstanding of prescription drug labels.
      • Lokker N.
      • Sanders L.
      • Perrin E.M.
      • et al.
      Parental misinterpretations of over-the-counter pediatric cough and cold medication labels.
      • Ross L.A.
      • Frier B.M.
      • Kelnar C.J.
      • Deary I.J.
      Child and parental mental ability and glycaemic control in children with type 1 diabetes.
      • Yin H.S.
      • Dreyer B.P.
      • van Schaick L.
      • et al.
      Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
      • Yin H.S.
      • Forbis S.G.
      • Dreyer B.P.
      Health literacy and pediatric health.
      Additionally, children of parents with low health literacy are less likely to have insurance and a primary care provider, both of which are significant risk factors for increased ED use and may be amplified in children with chronic disease.
      • Yin H.S.
      • Johnson M.
      • Mendelsohn A.L.
      • et al.
      The health literacy of parents in the United States: a nationally representative study.
      • Sanders L.M.
      • Thompson V.T.
      • Wilkinson J.D.
      Caregiver health literacy and the use of child health services.
      • Brousseau D.C.
      • Hoffmann R.G.
      • Nattinger A.B.
      • et al.
      Quality of primary care and subsequent pediatric emergency department utilization.
      • Brousseau D.C.
      • Dansereau L.M.
      • Linakis J.G.
      • et al.
      Pediatric emergency department utilization within a statewide Medicaid managed care system.
      • Jones D.S.
      • McNagny S.E.
      • Williams M.V.
      • et al.
      Lack of a regular source of care among children using a public hospital emergency department.
      • Stanley R.
      • Zimmerman J.
      • Hashikawa C.
      • Clark S.J.
      Appropriateness of children’s nonurgent visits to selected Michigan emergency departments.
      • Suruda A.
      • Burns T.J.
      • Knight S.
      • Dean J.M.
      Health insurance, neighborhood income, and emergency department usage by Utah children, 1996–1998.
      • Sanders L.M.
      • Lewis J.
      • Brosco J.P.
      Low Caregiver Health Literacy: Risk Factor for Child Access to a Medical Home.

      Low Literacy Interventions Potentially Effective in Reducing ED Use

      No previous review has examined the impact of low literacy educational interventions in populations likely to have low health literacy on ED use. The data from this review support the hypothesis that low literacy interventions result in reduced ED utilization. In patients with asthma, investigators used low literacy educational interventions along with comprehensive approaches such as home visits or increased office visits, which may independently lead to the success of the intervention.
      • Bryant-Stephens T.
      • Kurian C.
      • Guo R.
      • Zhao H.
      Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma.
      • Butz A.M.
      • Tsoukleris M.G.
      • Donithan M.
      • et al.
      Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.
      • Fisher E.B.
      • Strunk R.C.
      • Sussman L.K.
      • et al.
      Community organization to reduce the need for acute care for asthma among African American children in low-income neighborhoods: the neighborhood asthma coalition.
      • Stout J.W.
      • White L.C.
      • Rogers L.T.
      • et al.
      The asthma outreach project: a promising approach to comprehensive asthma management.
      However, the effect was also found with the use of only minimal teaching, such as providing a booklet in clinic
      • Yoffe S.J.
      • Moore R.W.
      • Gibson J.O.
      • et al.
      A reduction in emergency department use by children from a parent educational intervention.
      or supplying books to Head Start or nonurgent ED patients with negligible training.
      • Herman A.
      • Young K.D.
      • Espitia D.
      • et al.
      Impact of a health literacy intervention on pediatric emergency department use.
      • Herman A.
      • Jackson P.
      Empowering low-income parents with skills to reduce excess pediatric emergency room and clinic visits through a tailored low literacy training intervention.
      The only intervention not leading to significant reductions in ED use relied on a mailed brochure, with no evidence that the brochure was received or read, as opposed to more direct interventions.
      • Rector T.S.
      • Venus P.J.
      • Laine A.J.
      Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care.
      Notably, only 1 of these studies was performed in the ED, with the remainder conducted on outpatients.

      Limitations

      Similar to all reviews, this study is limited to the quality and quantity of peer-reviewed literature available. The studies that met our inclusion criteria varied in sample size, population, and subject recruitment strategies, and there was significant heterogeneity among studies. Overall, there was an effect of low literacy educational interventions on ED use; however, these results were obtained in populations at high risk for low health literacy and not documented low health literacy, of which none have been performed. Additionally, the intervention sustainability remains unknown, as none evaluated a time longer than 1 year after the intervention. This review is potentially limited by publication bias given that ineffective interventions may not be published; however, the outcome of interest (ED use) included in this review was not the main outcome of the studies, therefore limiting this bias. Additionally, we limited the review to studies in the United States, so health system differences may have impacted ED utilization rather than the construct of health literacy, and this may have resulted in the exclusion of studies that would have provided additional results.

      Future Directions

      Physicians need to be cognizant of the finding that a significant number of parents bringing their children to the ED have low health literacy. These physicians may need to adapt communication strategies and include low literacy strategies, such as the teach-back method and incorporation of health literacy–related education materials into ED discharge materials. Situations with high clinical demand likely exacerbate low parent health literacy (eg, providing incorrect doses of asthma medications), whereas parents of otherwise healthy children may not have a challenge to their ability to obtain, process, and use health information. Potential situations of high clinical demand are as diverse as chronic illness, infant care, acute gastroenteritis, and febrile illness, all of which may benefit from interventions.
      Interventions impacting ED use have great potential given the success of interventions targeting parents likely to have low health literacy. The dearth of literature on health literacy–related interventions and ED use reveals a clear gap in the literature and future study of health literacy–related interventions is crucial. Specific to the ED, health literacy–related interventions targeting populations with high clinical demands from parents (ie, chronic illness, infant care, acute illness) would be valuable.

      Conclusions

      Approximately 1 in 3 parents seeking care with their children at the ED have low health literacy, limiting their ability to process, understand, and make medical decisions for their children. A potential relationship exists between low health literacy and increased ED utilization. Low literacy interventions targeted at parents likely to have low health literacy seem to result in decreased ED utilization. However, a clear gap in the literature exists: there are no published interventions targeted specifically at parents with known low health literacy. Applying targeted or population-based health literacy related educational interventions has the potential to reduce repeat ED visits, reduce health care expenditures, and narrow the health disparities gap by empowering parents with low health literacy to obtain appropriate care for their child.

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