TABLE 2

Studies on the Relationship Between Literacy and Child Health Outcomes

AuthorInstrument/Cut PointsLevel of MeasurementOutcome AssessedLiteracy RelationshipQuality
Knowledge
    Campbell et al17 (2004)REALM; Woodcock Johnson Psycho-Educational Battery-Revised, part 2/8th gradePKnowledge about consent information for pediatric research studiesLL was best predictor of poor understanding of consent materials (P < .0001)G
    Cho et al21 (2007)REALM-7/continuousPKnowledge and understanding about prenatal screening for fetal aneuploidy and neural tube defectsLL less knowledge and understanding (P < .01)F
    Davis et al18 (1996)REALM/9th, 6th, and 3rd gradePComprehension of polio vaccine brochures written at 10th- and 6th-grade reading levelsLL less comprehension of both brochures; brochure written at 6th-grade reading level better understood by those at ≥6th-grade reading level (both P < .0001)G
    Davis et al22 (1998)REALM/9th, 6th, and 3rd gradePComprehension of 2 polio vaccine brochures (modified CDC and novel brochure) written at 6th-grade reading levelLL less global comprehension of either brochure; overall, novel brochure had better comprehension (both P < .01); no statistically significant difference among those at <9th-grade levelG
    Davis et al19 (2006)REALM/9th gradeCKnowledge about oral contraceptive pillsLL less knowledge (P < .01)F
    DeWalt et al23 (2007)REALM/9th gradePKnowledge about asthmaLL less knowledge (P < .001)G
    Moon et al20 (1998)REALM/continuousPKnowledge about child health careNo relationshipG
    Wilson et al16 (2008)REALM/continuousPRecall knowledge about childhood immunizations with brochure and teach-back methodLL less knowledge (P = .02)F
    Yin et al15 (2007)TOFHLAPKnowledge that liquid medication dosing is weight basedLL less knowledge about weight-based dosing compared with caregivers with adequate health literacy (61.2% vs 85.3%; P < .001)G
Health services
    DeWalt et al23 (2007)REALM/9th gradePAsthma ED visits and hospitalizationLL more likely to visit ED (IRR: 1.4 [95% CI: 0.97–2.0])G
LL more likely to be hospitalized (IRR 3.2 [95% CI: 1.8–12])
    Moon et al20 (1998)REALM/continuousPParental report of No. of hospitalizations in the pastNo relationshipG
    Rosenthal et al24 (2007)REALM/9th gradePSubjective quality of anticipatory well-child careLL higher-quality family-centered care (P = .01) and helpfulness/confidence building (P < .006); no difference in other domainsG
    Sanders et al25 (2007)S-TOFHLA/IMAPChild health care useNo difference according to literacyG
Child access to care
Cost of child health care
Health behaviors
    Conwell et al32 (2003)WRAT/Score of 85CAdolescent tobacco smokingLL more likely to smoke (P < .001, relationship was significant for boys only)G
    Davis et al19 (2006)REALM/9th gradeCAdherence to oral contraceptive pillsNo relationshipF
    Davis et al27 (1999)Slosson Oral Reading Test/2 grades behindCAdolescent gun-carryingLL more likely to carry gun (OR: 2.6 [95% CI: 1.1–6.2])G
Adolescent fightingLL more likely to fight (OR: 3.1 [95% CI: 1.6–6.1])
    Fredrickson et al31 (1995)WRAT/continuousPRate of parental smokingLL more likely to smoke (P < .05)P
Rate of breastfeedingLL less likely to breastfeed (P < .05)
Lack of private health insuranceLL less likely to have private health insurance (P < .05)
ObesityNo relationship to obesity
    Hawthorne29 (1997)Not specifiedCPreteenaged tobacco useLL more likely to use tobacco in past month (boys, OR: 4.2 [95% CI: 2.0–8.9]; girls, OR: 4.4 [95% CI: 1.8–10.7])F
Preteenaged alcohol useNo relationship to alcohol use
    Kaufman et al28 (2001)REALM/9th gradePPercent breastfeeding for ≥2 moLL less likely to breastfeed at least 2 mo (P = .018) (calculated RR: 0.4)F
    Sleath et al26 (2006)REALM/9th gradePReported barriers to giving medication to childrenLL more likely to report barriers (P = .014)F
    Stanton et al30 (1990)Burt Word Reading Test/continuousCProblem behavior in childrenLL more likely to have problem behavior (P < .01)F
    Yin et al15 (2007)TOFHLA/IMAPUse of nonstandardized medication-dosing instrumentsLL more likely to report use of a nonstandardized dosing instrument (34.7% vs 19.2%; P = .01)G
Health outcomes
    Andrasik et al33 (1988)WRAT/continuousCMigraine headaches in childrenNo relationshipF
    DeWalt et al23 (2007)REALM/9th gradePChild asthma severityLL asthma more severe (P = .03)G
Child asthma medication useLL more frequent medication use (P = .03)
Child missed school days because of asthmaLL more likely to miss school (IRR: 2.8 [95% CI: 2.3–3.4])
    Gong et al34 (2007)TOFHLiDPParent-reported child dental healthNo relationshipG
    Ross et al12 (2001)National Adult Reading Test/continuousP, CChild diabetes controlCorrelated with literacy (r = 0.28; P = .01)G
    Zaslow et al35 (2001)TALS/level 1 or 2PChild depressive symptoms and withdrawn behavior problemsLL more likely to have children with depressive symptoms and withdrawn behavior (P < .001)G
  • S-TOFHLA indicates Short-TOFHLA; WRAT, Wide Range Achievement Test; IMA, inadequate, marginal, adequate; TOFHLiD, Test of Functional Health Literacy in Dentistry; TALS, Test of Applied Literacy Skills; P, Parent; C, Child; CDC, Centers for Disease Control and Prevention; ED, emergency department; LL, lower literacy; HL, higher literacy; RR, relative risk; IRR, Incidence rate ratio; OR, odds ratio; G, good; F, fair; P, poor.