Running head: HEALTH LITERACY FOR PARENTS

Health Literacy Education:
For Parents of Children Preschool Aged and Younger
Damara Vasquez, RN, MSN
Mentor: Diana Jacobson PhD, RN, PPCNP-BC, PMHS, FAANP
Arizona State University

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HEALTH LITERACY FOR PARENTS

Abstract
Purpose: The purpose of health literacy education is to increase an individual’s
understanding of health and use of the healthcare system. Low health literacy is associated with
misuse of healthcare resources and misunderstanding of healthcare teaching. Education has
demonstrated efficacy in improving health literacy. A personalized educational program was
provided to parents of Head Start children, offered in Spanish and English, and at a 3rd to 5th
education level.
Design: Using an established program for health literacy education, a Doctor of Nursing
Practice project was implemented. The effect the program had on increasing the health literacy
of participants over a period of 4 weeks was examined. The predominately, Latina participants
received three hours of instruction based upon the health literacy book “What to do When Your
Child Gets Sick”.
Setting and Subjects: The educational program took place in a large, urban county in the
Southwestern United States with 24 parents of preschool age children in Head Start.
Intervention: The educational program contained three hours of classroom instruction
utilizing PowerPoint® presentation, demonstration, and teach-back techniques on how to care for
a child’s healthcare needs.
Measures and Analysis: Pre-, post- and telephone surveys were used to assess the
impact of the health literacy educational program. Wilcoxon and Freidman tests were used to
interpret the results.
Results: Despite no significant increases in health literacy post implementation,
participants’ remarked that they felt the class was helpful and wanted to share the information

HEALTH LITERACY FOR PARENTS
with friends and family. They appreciated the program and wanted more educational
opportunities.
Conclusion: Advanced practice nurses must acquire understanding, cultural sensitivity,
and assess the needs of the community when implementing health literacy educational projects.
Keywords: health literacy, health knowledge, parents, and education

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HEALTH LITERACY FOR PARENTS

Health Literacy Education: For Parents of Children Preschool Aged and Younger
Health literacy is defined as one’s ability to “communicate, process, and understand basic
health information and services to make appropriate health decisions” (Brega, et al., 2015, pp.
16-17). Low health literacy is associated with misuse of health resources and care (Morrison, et
al., 2014 ; Rasu, Bawa, Suminski, Snella & Warady, 2015). Low health literacy is linked to
mishandling medications and mismanagement of illness (Cheng, Dreyer, & Jenkins, 2009; Rasu,
Bawa, et al., 2015). It also can lead to frequent use of the ED leading to reduction of primary
care usage (Fieldston et al.,2013; Morrison et al., 2014). Increasing health literacy among parents
and caregivers requires educational methods that are in the first language of the learner and
without medical terms (Brega, et al., 2015; Herman & Jackson, 2010). An education program to
increase health literacy requires informed instructors, who are educated in the subject and
knowledgeable about their audience (Brega, et al., 2015). Improved health literacy improves
health understanding and healthcare decisions and lowers health care costs (Fieldston, et al.,
2013; Morrison, et al., 2014).
Purpose
This DNP project focused on providing parents with health information on how to care
for their children’s health and improve their health literacy. During the first five years of a
child’s life, establishing healthy habits is helpful for family health and lifestyle (Council on Early
Childhood and Council on School Health, 2016; Teutsch, Herman, Teutsch, 2016). According to
the American Academy of Pediatrics, preparing a child for school during the first five years of
life requires effort from both family and community (Council on Early Childhood and Council
on School Health, 2016). The child is developing physically, linguistically, cognitively, socially

HEALTH LITERACY FOR PARENTS
and creatively. A child, at this age, is exposed to many illnesses and accidents. Parents are

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expected to learn how to properly care for common health issues (Council on Early Childhood
and Council on School Health, 2016, Morrison et al., 2014).
Ensuring that the parents comprehend the information taught in a health literacy program
is a major part of the process. The educational material should be in the first language of the
learner and without medical terms. It should contain relevant pictures to the subject and utilize
the teach-back method for improved comprehension (Brega, et al., 2015). The teach-back
method is a technique that asks for information to be repeated (in their own words) and for return
demonstration of the information/concepts that were just taught (Brega, et al., 2015 pp.18-20).
The purpose of this Doctor of Nursing Practice (DNP) project was to effectively provide parents
with information on evidenced based health practice in order to improve behavioral practices and
increase health literacy.
PICOT Question
To inform the development and delivery of a health literacy educational program for
parents of preschoolers in a community setting, the following PICOT question (Riva, Malik,
Burnie, Endicott, & Busse, 2012) was used to search the scientific literature: In low health
literate caregivers of children preschool and younger, how does appropriate health literacy
materials and education on how to use health materials, compared with no material educational
support influencing the caregiver’s knowledge of health and use of the healthcare system within
a month period of time?
Evidence search process
PubMed, EBSCOhost, and ProQuest databases were searched for relevant articles. The
terms and keywords used in the database search included health literacy, health knowledge,

HEALTH LITERACY FOR PARENTS

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parent or caregiver, health utilization, and education. The limits set on the literature search were
human studies published in the last 10 years. The inclusion criteria were studies of health

knowledge improvement and healthcare literacy education that focused on acute pediatric illness.
Exclusion criteria were studies that provided information on health literacy for chronic
conditions, studies published greater than 10 years ago, and studies on the development of health
literacy surveys. Additional literature searches took place using the Centers for Disease Control
and Prevention and the Agency for Healthcare Research and Quality’s website (Brega, et al.,
2015) for current guidelines on health literacy teaching.
Synthesis and Critical Appraisal
A total of 10 articles were chosen for further appraisal from the1,892 articles obtained
from the initial search. The articles were published in the United States and all were published
between the years of 2010 to 2015. The 10 articles included in the evaluation and synthesis,
were Level II (Fieldston, et al., 2013;Herman & Jackson, 2010;Kunieck, 2014;Stockwell, et al.,
2014;Yin, et al., 2008) and Level III studies (Davis, Jones, Logsdon, Ryan, & WilkersonMcMahon, 2013;Herman, Nelson, Teutsch, & Chung, 2013;Morrison& Channugaha et al. ,
2014; Morrison and Schapira et al., 2014; Rasu,2015). One study was quasi-experimental
(Fieldston, et al., 2013), one was a case study (Herman, Nelson et al., 2013), two were cohort
studies (Kunieck, 2014; Herman & Jackson, 2010), two were randomized controlled partial blind
trials (Stockwell, et al., 2014; Yin, et al., 2008), and four were cross sectional studies (Davis et
al.,2013;Morrison and Schapira et al., 2014; Rasu,2015; Morrison& Channugaha et al. , 2014).
After further appraisal, five of the ten studies (Fieldston, et al., 2013; Herman & Jackson, 2010;
Herman, Nelson et al. 2013; Stockwell, et al 2014; Yin, et al., 2008) were found to focus on

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health literacy interventions and were used to design and implement this educational program for
parents.
A study by Fieldston et al. (2013) concluded that a health education program does
increase the caregiver’s knowledge directly after an educational intervention. When assessed six
months later, an increased health understanding and use of health resources was still present .
This study shows that healthcare education is effective in a sample of 32 caregivers of urban
children seven months to five years. In a study by Herman and Jackson (2010) a program by
Head Start provided education and continued support for three to six months. The education and
the support led to a 40%-50% decrease in emergency department visits, a 29% decrease in
missed school days, a 42% decrease in days of work missed by caregivers, and showed an
increase in health literacy among parents. In another article by Herman and other associates
(Herman, et al., 2013) the structured approach of improving health literacy in low-income
families of a federal program (Head Start) was described and the limitations of the program
discussed. The first step in the structured approach is training of trainers for 2 days. Meetings to
develop the class for parents and reduce barriers of attendance, such as transportation,
community advertisement, timing and translation of materials was recommended. Classes for
parents to teach health literacy were completed based on the development meeting. Following
the parental training the parents were visited in the home 3 times over a period of 3 to 4 months.

The home visits reinforced the concepts learned in the class. At the end of the 4 months, the class
participants met for a “graduation” and shared success stories or discussed needs for
improvement to sustain the program. The limitations of the study are no control groups and the
time-intensive demands of the program. The program is an appropriate health promotion method.
The program was “valuable and potentially cost-effective way to promote prevention and reduce

HEALTH LITERACY FOR PARENTS
health disparities in a vulnerable population” (Herman, et al., 2013 p.155). Another study

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(Stockwell, et al., 2014), focusing on education concerning upper respiratory symptoms and
urinary tract infections, also showed an increase in health literacy after 3.5-hour sessions on
urinary tract infections and medications management. A five-month follow-up allowed the 154
family participants to ask questions on their child’s health care and needs. The results of the
study showed that participants were less likely to utilize an pediatric emergency room when their
child was ill and less likely to mismanage over-the-counter medication for young children less
than 4 years of age (Stockwell, et al., 2014).
Yin, et al. (2008) evaluated a health literacy intervention to reduce medication errors in a
randomized controlled trial. The intervention took place in an urban emergency room, using “a
plain language, pictogram based medication instruction sheet”. (Stockwell, et al., 2014. p. 814)
Two hundred and twenty-seven caregiver participants were included in the results; 113 in the
intervention group and 114 in the control group. Greater than 20% of the caregivers had
increased dosing accuracy when telephoned 3-5 days later to assess their knowledge of the
prescribed medication dosing for their child.
These five studies provided the evidence base for the author’s DNP project intervention.
The findings from the studies include: teaching should be targeted to the community being
reached (language, timing, transportation, child care); and that programs utilizing an established
program, such as Head Start, are effective (Fieldston et al. 2013; Herman, et al., 2013; Herman &
Jackson, 2010;). Additionally, the planned health literacy program should contain health literate
materials to be most effective (Stockwell, et al., 2014; Yin, et al., 2008).
Method

HEALTH LITERACY FOR PARENTS
Design. The intervention was developed utilizing the Johns Hopkins Nursing Evidence-

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Based Practice Model (2016) and Social Cognitive Theory (Bandura, 1987). The intervention
was done in corroboration with a federal program, Head Start. Head Start is a federal school
readiness and developmental program for children 0 to 5 years of age whose families are below
the federal poverty level (Head Start, 2016). The educational program on health literacy was
delivered in Head Start classrooms, in a large urban county in the Southwestern, United States.
An average of 5 adult participants attended each educational session that were held at various
times of the day. The classroom was arranged for an adult audience for PowerPoint® slide
projection and presentation/discussion. The parents of Head Start students were given a book
entitled: What to do when your Child gets Sick by Gloria Mayer and Ann Kuklierus (2008). In a
study at another Head Start faculty, the book showed positive effects on health practices of
parents (Herman & Jackson, 2010). The book is easy to understand and contains pictures
relevant to the topics discussed. The book focuses on 50 common childhood acute illnesses and
management. The Arizona State University (ASU) Institutional Review Board (IRB) approved
the project. The project was approved with materials translated into Spanish by individuals
proficient in Spanish.
Theory and Evidence-Based Practice Model. Social Cognitive Theory focuses on
populations acquiring and maintaining certain behavior patterns (Bandura, 1987). People learn
skills, beliefs, rules and appropriate actions through influences from social environments and
interactions (Bandura, 1987). As the parents learn health knowledge and skills to increase their
health literacy level, Social Cognitive Theory was used in the classroom setting to guide a
change in health practices. The educational program and communication provided in a classroom
setting, and discussion with peers allowed parents to see the importance of the education about

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their child’s health. During the class, unhealthy habits and positive health habits were identified
in a positive social environment in order to impact behavior patterns.
The Johns Hopkins Nursing Evidence-Based Practice Model (2016) incorporates four
steps: identification of the problem, research, implementation and evaluation. This model is
appropriate to guide a health literacy educational project because it involves evidenced-based
problem solving and continual evaluation of the process. The identified problem, low health
literacy, has been found in many individuals and communities. To provide an educational
program on health literacy, the advanced practice nurse, must determine the best processes in
order to implement the educational program into the community. Through the critical appraisal

of the evidence on health literacy, it is clear that individualized education and close follow-up is
the best practice (Brega, et al., 2015; Cheng, et al., 2009; Head Start, 2016). The evidence
demonstrates that practice change or health education improvement is not always effective when
implementing a health literacy educational program into each new environment. Therefore, this
model includes evaluation as an important component. The Johns Hopkins Nursing EvidenceBased Practice Model is helpful when applying health literacy improvement into the community
and assisting in its effectiveness (John Hopkins Medicine, 2016).
Sample. There were twenty-four participants who agreed to take part in the project. The
participants were mostly of Hispanic origin, both Spanish and English speaking, and parents of at
least one child, ages 0 to 5 years, in the Head Start program. Three participants only completed
one survey (pre-survey) and were excluded from the data analysis. Nine participants (37%)
completed all three surveys (i.e., pre- survey , post- survey and post telephone survey). Eleven
participants (45.8%) completed two surveys (i.e., pre- survey and post- survey). One participant
(4.2%) completed a post- survey and a telephone survey only. Twenty-one participants (87%),

HEALTH LITERACY FOR PARENTS
of the twenty-four parents who agreed to take part in the project, were included in the project

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analysis based on their completion of two or more surveys.
Recruitment. Family support specialists invited the parents of the preschoolers in the
Head Start early education program to the health literacy educational program. A family support
specialist is a social worker employed by Head Start to work with families and help them find
community resources for assessed needs. The family support specialists were provided with a
flyer, times, and locations of the classes. This method of recruitment was chosen because of the
strong preexisting relationship established between the families and the family support
specialists. At the beginning of each class, the parents were introduced to the project and asked
to voluntarily participate. ASU IRB approved the consent process.
Measures. The surveys were developed with the input of four certified pediatric nurse
practitioners. The surveys were developed based on content covered in the book and the class.
A previous tool used in other health literacy classes at Head Start was used as a guide to develop
the surveys. The parents completed a pre- survey to understand their level of health
understanding before the educational program. The survey asked questions about ethnicity, the
use and perceived comfort in use of a healthcare clinic, and the actions they would take if their
child had a minor acute illness or an accident. Immediately after the educational program, the
parents completed a post- survey to assess their understanding of the concepts discussed. The
post-survey contained similar questions to the pre- survey with additional evaluation questions
about the class. Four weeks after the classroom instruction, the parents were telephoned in order
to obtain data on the telephone survey. The telephone survey contained similar questions asked
on the pre- and post-surveys with additional questions about doctor visits or emergency room
use. The post-survey contained multiple-choice questions and open-ended evaluation questions.

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HEALTH LITERACY FOR PARENTS

Educational Program. The health literacy content was delivered in a classroom based

upon the book What to do when your Child gets Sick by Gloria Mayer and Ann Kuklierus (2008)
by providing a PowerPoint® presentation and the teach-back method for discussing the content.
The educational program was three hours in length and was instructed in English or Spanish by
the Head Start nurse and family support specialist. The class instructors were trained in the
program for 2 days by the Johnson & Johnson Head Start Management Fellows Program
(Herman, et al., 2013). The educational program also included demonstration of a few basic
health care topics such as medication administration and taking a child’s temperature.
Analysis. The Wilcoxon test and the Friedman test were used to analyze the survey
results and examine the parent’s level of confidence and understanding when taking care of a
sick child after receiving a health literacy educational program. The Wilcoxon test is a nonparametric test used for two related samples. The Friedman test is a non-parametric test used for
three or more related samples. The multiple-choice responses on the surveys were placed on an
ordinal scale rating each question from “1” to “6” with “1” signifying the parent’s understanding
of best practice. One survey question about caring for a child with a fever was scored differently
with “0” representing the best answer and “1” representing the incorrect response.
Results
Quantitative. The Wilcoxon test was used to analyze multiple-choice questions asked on
the pre surveys and with those repeated on the telephone survey. To analyze the multiple-choice
questions asked on all three survey points (i.e. the pre-, post- and telephone surveys), the
Friedman test was utilized. Statistical significance was set at a p value of 0.05.
No significant differences were found in primary care provider utilization, comfort level
of parents in using a primary care clinic, the best source of obtaining healthcare information nor

HEALTH LITERACY FOR PARENTS
in the parent’s level of confidence and understanding of healthcare when taking care of a sick

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child after the health literacy education program was delivered (See Tables 1 and 2).
Qualitative. The parents remarked frequently to the author during the class and during
the telephone surveys that they enjoyed the class and felt that the length was appropriate. The
parents stated that they wanted their friends and family to have an opportunity to attend the class.
Many parents also noted that they wished they could attend more classes on health topics. The
parents stated appreciation that the materials were easy to use, relevant to them, and offered in
their primary language.
Discussion
The results of the DNP health literacy educational program for parents of Head Start
children indicated that this method of delivering health literacy information for this community
needs further refinement. Further examination of the use of the printed health material (What to
do When your Child gets Sick by Gloria Mayer and Ann Kuklierus, 2008), intensity of the class,
number of sessions, length of class, method of content delivery and the need for follow-up is
needed to evaluate whether this method of delivering a health literacy educational program can
improve parent health literacy. Although the project findings show that the class was not
statistically significant in influencing behavior change, the qualitative findings show that the
class was meaningful to the parents. The comments from the parents about the class and the
resources provided show that the class was a welcome resource for the parents. The parents
enjoyed the 3 hour time frame of the class. Some of the parents commented that the class was
“too short” or that they “wanted more classes”. When asked how they felt about the class, the
parents responded with “very good” or “good information”. The comments show that the parents
appreciated the information received. The quantitative data shows that the delivery method of

HEALTH LITERACY FOR PARENTS
the class needs to be defined further while the qualitative data shows that the class content,

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materials and timing was appreciated by the participants. Research evidence demonstrates that
every patient is an individual and that health literacy education should be provided in a way that
is culturally relevant to the patient (Brega, et al., 2015; Herman & Jackson, 2010).
Limitations. It was noted during the educational program, that the parents often had
difficulty getting to the class due to transportation issues and the timing of the classes. The
classes were offered at different times during the day (e.g., 8:30 a.m., 11:00 a.m., 12:00 p.m., and
4:00 p.m.). The classes that started at 8:30 a.m., 12:00 p.m. and 4:00 p.m. had lower attendance
than expected. The original plan was to hold 6 classes. However, due to rescheduling and class
cancelations, only five classes were held. Parents also showed up to the class late or had to leave
early due to personal needs or prior commitments. It was observed by the author, that parents
had difficulty focusing on the teach-back and discussions when other children and siblings were
present in the room.
The health literacy educational program was advertised through the Head Start family
support specialists who had a long-standing relationship with the parents and families. There was
also a flyer that was circulated through the Head Start classrooms informing parents of the class.
Many of the classrooms had 10-15 parents that initially reported that they were interested in
attending, but did not attend the class as scheduled. The majority of the classes contained 5
participants. The class that had the most participants (i.e., 15 participants) was offered in
Spanish, at 4:00 pm, had a long-term and active family support specialist, and childcare was
provided. The Head Start organization, in this large urban setting, had recently had financial cut
backs adding to the work of the family support specialists which caused many to terminate their
employment prior to the initiation of this project. Recently hired personnel had not yet received

HEALTH LITERACY FOR PARENTS
training in the health literacy program. These limitations require further investigation and

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problem solving in order to increase participation and recruitment methods in the future.
Implications for Future Practice. Participating parents appreciated the health literacy
educational program and found the book, What to do When your Child gets Sick by Gloria
Mayer and Ann Kuklierus (2008) a welcome resource. The project, as designed and delivered
was not sufficient to improve parent health literacy. In the future, health educational programs
will continue to need to be tailored to the population,times, and locations that are relevant to the
community. Childcare will need to be provided to encourage classroom participation.
Strengthening and establishing relationships with families will help increase attendance. Further
study should be considered to develop the class appropriately for the community it is serving.
Implications
Parents appreciated the class and felt that it was personally effective and wanted more
classes and the opportunity to share the educational session with friends. The quantitative results
showed no significant change. Further refinement of the health literacy educational program, for
this community setting, is needed.

HEALTH LITERACY FOR PARENTS
References

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Bandura, A. (1987). Social Foundation of Thought and Action: A social cognitive theory.
Englewood Cliffs, NJ: Presctice Hall.
Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., & West, D. R.
(2015). AHRQ health literacy universal precautions toolkit. Agency for Healthcare Research
and Quality, Rockville, MD. Retrieved from
https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy-toolkit/index.html

Cheng, T. L., Dreyer, B. P., & Jenkins, R. R. (2009). Introduction: Child health disparities and
health literacy. Pediatrics, 124, S161-S162. doi: 10.1542/peds.2009-1100C
Council on Early Childhood and Council on School Health (2016). The pediatrician's role in
optimizing school readiness. Pediatrics, 138(3), 1. doi: 10.1542/peds.2016-2293
Davis, D. W., Jones, V. F., Logsdon, M. C., Ryan, L., & Wilkerson-McMahon, M. (2013). Health
promotion in pediatric primary care: importance of health literacy and communication
practices. Clinical Pediatrics, 52(12), 1127-1134. doi:10.1177/0009922813506607
Fieldston, E. S., Nadel, F. M., Alpern, E. R., Fiks, A. G., Shea, J. A., & Alessandrini, E. A. (2013).
Effects of an education and training intervention on caregiver knowledge of non-urgent
pediatric complaints and on child health services utilization. Pediatric Emergency Care,
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Herman, A., & Jackson, P. (2010). Empowering low-income parents with skills to reduce excess

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pediatric emergency room and clinic visits through a tailored low literacy training
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Brousseau, D. C. (2014). Caregiver low health literacy and nonurgent use of the pediatric
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and nonurgent visits. Academic Pediatrics, 14(3), 309.
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HEALTH LITERACY FOR PARENTS
Table 1
Wilcoxon Analysis of Survey
Wilcoxon

Pre-Survey

Tele-Survey

M

SD

M

SD

p

Primary Care Provider

1.10

0.10

1.00

0.00

0.317

Comfort In the Clinic

1.36

0.20

1.18

0.12

0.414

Source of Healthcare

1.73

0.33

1.82

0.12

0.666

information
Note. M= Mean; SD=Standard deviation; p = Probability (p value)

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HEALTH LITERACY FOR PARENTS

Table 2
Friedman Analysis of Survey
Friedman Test

Pre-Survey

Post-Survey

Tele-Survey

M

SD

M

SD

M

SD

p

1.33

0.71

1.11

0.33

1.78

0.97

0.05

Fever

0.90

0.32

1.00

0.00

0.70

0.48

0.174

Caring for a Earache

3.50

1.35

2.60

1.07

3.20

1.03

0.179

Caring for a Cough

2.30

1.70

2.10

1.10

1.60

0.52

0.707

Medication Administration

1.00

0.00

1.10

0.32

1.00

0.00

0.368

Ingestion

2.50

0.85

2.00

1.33

2.10

1.29

0.381

Caring for Diarrhea

1.60

1.07

1.60

0.97

1.40

0.97

0.819

How do you feel when your
child is sick?

Note. M= Mean; SD=Standard deviation; p = Probability (p value)