Reading Ability of Parents Compared With Reading Level of Pediatric Patient Education Materials

(1)

Reading

Ability

of Parents

Compared

With

Reading

Level

of Pediatric

Patient

Education

Materials

Terry

C. Davis,

PhD*j;

E.

J.

Mayeaux,

MD;

Doren

Fredrickson,

MDI; Joseph A.

Bocchini,

Jr.,

MD*;

Robert

H. Jackson,

MDX;

and

Peggy

W. Murphy,

MEd

ABSTRACT. Objectives. To test the reading ability of

parents of pediatric outpatients and to compare their

read-ing

ability

with

the ability necessary to read commonly

used educational materials; to compare individual

read-big gradelevels

with

thelevels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings.

Design. Prospective survey.

Setting. Pediatrics

outpatient

clinic

in a large,

public

university, teaching

hospital.

Participants.

Three

hundred

ninety-six

parents

or

other caretakers

accompanying

pediatric

outpatients.

Measurements.

Demographics

and educational

status

were assessed using astructured

interview.

Reading

abil-ity was tested using the Rapid Estimate of Adult Literacy

in Medicine (REALM) and the Wide Range Achievement

Test-Revised2.

Written

educational

materials

were

as-sessed for readability levels

with

a

computer

program

(Grammatik

IV).

Results. The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range,

despite the mean self-reported last grade completed in

school being 11th grade 5th month. Wide Range

Achieve-ment Test-Revised2 scores correlated well

with

REALM

scores (0.82).

Eighty

percent of 129 written

materials

from

the American Academy of Pediatrics, the Centers for

Dis-ease Control, the March of

Dimes,

pharmaceutical

corn-panies, and commercially available baby books required

at least a

10th grade

reading

leveL

Only

25% of 60 Amen-can Academy of Pediatrics items and 19% of all materials tested were

written

at less than a

ninth

grade level, and only 2% of all materials were written

atless

than a seventh grade level.

Conclusion.

This

study demonstrates that parents’

self-reported

education

level

will not accurately indicate

their reading ability. Testing is needed to screen at-risk

parents for low reading levels. In a public health

setting,

a significant amount of available parent education

mate-nials and instructions require a higher reading level than

most parents have achieved. In such settings, all materials

probably should be written at less than a high school

level if most parents are to be expected to read them.

The REALM can easily be used in busy public health

clinics to screen parents for reading ability. Pediatrics

199493:460-468; parents, reading levels, patient

educa-tion.

From the Departments of *Pediatrics, Interna1 Medicine, and §Family

Medicine, Louisiana State University MediCal Center School of Medicine,

Shreveport, LA, and #{182}Departments of Preventive Medicine and Pediatrics,

Kansas University School of Medicine, Wichita, KA.

Received for publication Mar 22, 1993; accepted Sep 1, 1993.

Reprint requests to (T.C.D.) Depts of Pediatrics and Internal Medicine

Loin-siana State University MediCal Center School of Medicine-Shreveport

(LSUMC-S), P0 Box 33932, Shreveport, LA 71130-3932.

PEDIATRICh (ISSN 0031 4005). Copyright C 1994 by the American

Acad-emy of Pediatrics.

ABBREVIATIONS. LSUMC-S, Louisiana State University Medical Center in Shreveport; WRAT-R2, Wide Range Achievement

Test-Revised; REALM, Rapid Estimate of Adult Uteracy in Medicine;

CDC, Centers for Disease Controland Prevention; AAP, American

Academy of Pediatrics.

Parents of pediatric patients frequently are given

written

information

by

physicians

and

nurses.

Par-ents

must

be able

to read

and

understand

these

writ-ten instructions,

immunization

information,

and

pre-scniption

labels

if they

are to adequately

care

for their

children

or give

informed

consent.

Yet little

attention

has

been

paid

to parent

literacy.

Pediatricians

rarely

screen

the parents

of their

patients

for reading

abifity.

have

found

low

reading

levels

in adult

patients,

particularly

those

cared

for in public

clinics.

These

studies

also

indicate

that

a patient’s

highest

grade

completed

is not a reliable

indicator

of

their

reading

abifity.

In addition,

the reading

abifity

of patients

in family

practice,’2

internal

medicine,2

and

obstetric-gynecology

clinics4;

in public

hospitals3;

and

in emergency

departments5

has been

shown to be

much

lower

than

the

required

reading level of the

written

materials

used

in these

settings.

Similar

stud-ies

of pediatric

caretakers

and

of written

materials

used

in public

pediatric

health

care

settings

are not

available.

Objective

studies

are

needed

to

assess

reading levels of parents of pediatric

patients

so

that

appropriate

patient

education

materials

can

be

developed.

The

purpose

of this

study

was

to test

the

reading

ability of parents or other caretakers of pediatric out-patients in a public

clinic

and to compare that

reading

abifity

with

the reading

level

required

to read

patient

education

material

and

consent

forms

developed

by

the American

Academy

of Pediatrics

and by the

Loui-siana

State

University

Medical

Center

in Shreveport

(LSUMC-S)

Pediatric

Clinic, as well as a sample of

baby

books

available

through

bookstores

and

public

libraries.

The

study

also

compared

individual

reading

grade

levels

with

the

levels

of the

last

grade

com-pleted

in school

and

further

validated

a new

literacy

screening

test

designed

specifically

for

medical

set-tings

and

developed

by one

of the

authors

(T.C.D.).

METHODS

The study site was LSUMC-S, a large public university facility

that serves predominantly indigent and Medicaid populations of

northwest LOuiSiana. The pediatric clinic has 46 000 visits

annu-ally. The study population consisted of a convenience sample of

(2)

ARTICLES

461 LSUMC-S Pediatric Clinic duringJune and July, 1992. A caretaker

of each child waiting

to be

seen in the dinic was interviewed by a

research assistant in a private testing room in the Pediatric Clinic and invited to participate in the study. Confidentiality was

em-phasized, and all subjects signed a consent form. Testing was

conducted by four research assistants, each of whom had training in test administration and interviewing. Pilot test administration was supervised directly by two of the authors.

Of 414 potential subjects, 18 (4%) refused to participate. The

primary reasons given for refusal were forgetting their glasses or

being tired of waiting. Subjects who chose to participate were

enthusiastic about the study and responsive to the testing

proce-dure.

After written consent was obtained, caretakers were inter-viewed orally using astructured questionnaire that elicited

demo-graphic information and grade level completion. Subjects then

were given the reading recognition subtest of the Wide Range

Achievement Test-Revised (WRAT-R)6 and the Rapid Estimate of

Adult Literacy in Medicine (REALM).7

Study Population

The 396 caretakers tested ranged in age from 15 to 73 years, with a mean age of 30. Thirteen percent of the parents were teen-agers. The race of the subjects, last grade completed in school,

insurance status, relationship to the child, and other population

characteristics are noted in Table 1. Although 10% of caretakers

were family members other than parents, for simplicity we will

henceforth refer to all caretakers as “parents.”

Written Materials Analyzed for Readability

Ninety-four currently available baby and child care health

edu-cation materials were collected for reading analysis. These

in-duded 60 items distributed by the American Academy of

Pediat-rica (AAP): 23 brochures from The Injury Prevention Program; 5

vaccination brochures; 2 parenting reference books; I poster; I

vaccination card; 2 baby books; Healthy Kids magazines 0 through

3and 4 through 10 (intended for public distribution in pediatric

clinic waiting rooms); and 20 miscellaneous brochures. Specific

AAP titles are listed in Appendix I.Representative patient

educa-tion materials routinely distributed to parents in the Pediatrics

Clinic at LSUMC-S also were induded for analysis. These included 5 pamphlets from the Centers for Disease Control and Prevention (CDC), of which 3 were immunization pamphlets mandated by

the National Childhood Vaccine Injury Act of i986, pamphlets

from the March of Dimes; 14 pamphlets from formula and

phar-maceutical companies; 12 pamphlets developed by the LSUMC-S

TABLE 1. Demographic Chara

(N = 396)

cteristics of Stud y Population

n %

Relationship to child

Mother 329 83

Father 24 6

Other family member 40 10

Foster parent 4 1

Gender

Male 24 6

Female 372 94

Race

Black 325 82

White 63 16

Other 8 2

Payment for care

Medicaid 249 63

Freecare 103 26

Private insurance 20 5

Self-pay 24 6

Last grade completed

:3rd 4 1

4thto6th 4 1

7thto8th 12 3

9th 376 95

Pediatric Clinic and a local public health dinic; and I pamphlet

from a health coalition. Sources, titles, and reading level indices are listed in Appendix II.Sixteen commercial

baby books

available

in bookstore chains also were analyzed. Specific titles, prices,

pub-ushers, and reading level indices are listed in Appendix ifi.

Readability

Analyses

Grammatik IV,’#{176}a commercial computer program, was used to

analyze the reading levels of 129 materials. The entire text of

pamphlets and brochures, the first two paragraphs of every 50th

page of books, and the first two paragraphs of all feature artides in magazines were entered as a computer file and analyzed for

reading leveL Grammatik IV calculates the Fog Index” and the

Flesch-Kincaid’2; ,th

indices

give estimates of the reading level

needed to read a document. The Fog Index was preferred by the

authors because it is more stringent.

Testing Instruments

The structured questionnaire induded 11 demographic items

written in standard national survey format. Research assistants

asked parents to indicate orally their race, age, means of payment for medical care, and highest grade completed in schooL

The WRAT-R2 is a nationally standardized achievement test.6 Currently it is the reading test most commonly used in medical settings. The reading recognition subtest assesses a person’s

abil-ity to pronounce individual words in ascending order of difficulty.

Raw scores, which range from I to 89, can be converted to grade

equivalents ranging from less than 3rd grade to more than 12th

grade. The WRAT-R2 takes 3 to 5 minutes to administer and score. The REALM is an individually administered screening

instru-ment designed specifically for use in busy public health settings.

This reading recognition test measures patients’ ability to

pro-nounce common medical words and lay terms for body parts

and

illnesses. The 66-word test, developed at LSUMC-S, correlates highly with other standard reading tests, induding the WRAT-R and can be administered and scored in I to 2 minutes by personnel

with minimal training. The REALM identifies people with low

reading ability and provides a reading grade range estimate for

those who read on a ninth grade level or less.

Neither the WRAT-R2 nor the REALM measures comprehen-sion. Both are reading recognition tests in which subjects read

aloud words in isolation. Reading recognition tests are quick, easy to score, accepted as useful predictors of general reading ability, and considered an especially appropriate measure of reading for low-level readers.’3 If patients have trouble reading and pronounc-ing words, medical professionals should be aware that

compre-hension also will be a problem.

Statistical Analysis

Microsoft Excel’4 was used for basic descriptive statistics.

PC-SAS 6.04’s was used to calculate correlation coefficients, and

Stu-dent’s t-test for significance of the difference between mean of

reading raw scores and educational levels.

RESULTS

Both

the

mean

and

the

median WRAT-R2 raw

scores

of the 396 parents

tested

indicated

a sixth

grade

reading

equivalent.

According

to the WRAT-R2,

73%

of parents were reading at less than a

ninth

grade

level,

55%

were

reading

at

less

than a seventh grade

level, and 31 % were reading at

less

than a fourth

grade

level.

Subjects

tended

to score

lower

on

the

WRAT-R2

than

on the REALM;

however,

the Pearson

correlation

coefficient

between

the locally developed

REALM

and

the

nationally

standardized

WRAT-R2

was excellent (.82, P <

.0001).

Both

the mean and the

median

REALM raw scores placed parents in the

5ev-enth

to eighth

grade

reading

range.

Despite

the

fact

that

95%

of

the

subjects

reported

that they had

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(3)

Actual Reading Grade Level by WRAT-R2

15

Highest Academic Grade Completed

I 95% Conf Interval Mean Reading Grade

Fig 2. ACtual reading grade level as measured by Wide Range Achievement Test-Revised2 (WRAT-R2). N = 396 parents at

Loui-siana State University Medical Center Pediatrics Clinic,

Shreve-port, LA.

I

100%

90%

80%

70%

80%

50%

40%

30%

20%

10%

0%

L

I

UR Gr.ds Lsv&

LL.Gr.d.Com

I

1%

- L.vs

11%

1%

‘3

--H

reached

high

school,

65%

were

reading

at less

than

a

ninth grade level,

28%

were

reading

at less

than

a

seventh

grade

level,

and

I I % were

reading

on a third

grade

level

or less on the REALM.

Figure

1 shows

the

distribution

of the REALM-determined

reading

levels

of the

study

population

and

the

distribution

of the

self-reported

grade

levels.

Figure

2 shows

the reading

grade

level

measured

by

the

WRAT-R2

and

corre-sponding

95%

confidence

intervals

plotted

against

highest

academic

grade

completed.

Mean

WRAT-R2

reading

levels

are

not

reported

in the figures

for

sub-jects

who

completed

fewer

than

8 or more

than

14

years

of school,

because

the

WRAT-R2

is not

valid

at

the

high

end,

and

small

sample

numbers

produced

unstable

estimates

at the

low

end.

We

indicate

the

trend

produced

by

outlying

data

in these

extreme

ranges

using

arrows

in the

figures.

These

trends

are

consistent

with

the trajectories

of the midrange

scores.

Self-reported

educational

status

of parents

ranged

from

no schooling

to college

graduate.

The

mean

edu-cational

level

was

11th

grade

5th

month,

and

the

me-dian

was

12th

grade.

Thirty-seven

percent

of the

par-ents

had

dropped

out

of school.

The

parents

tested

were

reading

on an average

of four

grade

levels

less

than

the grade

they

last attended;

however,

there

was

marked

individual

variability

in

results.

Thus,

the

reading

ability

of any

individual

subject,

as measured

by the REALM or the WRAT-R2, could not be

pre-dicted

based

on

parents’

self-reported

grade

level.

The discrepancy

between

educational

level

and

read-ing

ability

was

most

pronounced

with

the

parents

who

read

in the

lowest

reading

ranges.

For

example,

the

mean

educational

status

of the

44 parents

who

scored

at

less

than

a

third

grade

reading

level

(REALM)

was

tenth

grade.

Figure

3 shows

the

mean

gap

between

self-reported

educational

level

and

ac-tual

reading

level

as measured

by the

WRAT-R2.

Of

the

129

written

materials

analyzed,

81 %

re-quired

a 9th

to 19th

grade

reading

level

(Appendices

I through

III). None

of the materials

were

written

at

less

than

a fifth

grade

level.

The

reading

level

of 60

AAP

leaflets

analyzed

ranged

from

6th to 16th

grade,

with an average readability of 10th

grade

(Appendix

I). Only

15 (25%)

were

written

at

less

than

a high

school

level,

and

only

2 (3%)

were

written

at less

than

a seventh

grade

level.

The

AAP Healthy Kids

maga-zine,

0 through

3 and

4 through

10, are written

on a

12th

and

a 10th

grade

level,

respectively.

The

parent-ing

reference

books,

Caring for Your Baby and Young Child: Birth to Age 5

and

Caring for Your Adolescent:

Ages 12 to 21,

are written

on a 12th

and

a 15th

grade

level,

respectively.

The

three

CDC

vaccine

informa-tional

pamphlets

(D.P.T., M.M.R.,

and

Polio)

are

writ-ten

on a 10th

to 12th

grade

level.

These

pamphlets,

which

are

the

only

patient

education

materials

man-dated

by law,

are well

above

the reading

ability

of the

average

public

clinic

parent.

The

readability

of the

materials

developed

by the LSUMC-S

Pediatric

Clinic

staff

(Appendix

II) range

from

8th to 14th

grade,

with

an average

of I I .5th

grade.

Pharmaceutical

compa-nies’

patient

education

material

ranged

from

5th

to

12th

grade,

with

an average

of 10.5th

grade.

The

av-erage

reading

grade

level

of the

16 commercial

baby

books

evaluated

was

13.lth

grade

level,

and

half

were

written

at or above

a college

level

(Table

2).

Fig 1. Reported grade level versus

(4)

Highest Academic Grade Completed

__________________________________

In recent

years,

concern

about

patient

literacy

and

the readability of patient educational material and

forms

has increased.4’16

Physicians,

nurses,

and

public

health

officials

are more aware of the problem, and an

increasing

number

of low

literacy

materials

are

be-ginning

to appear.

A larger

proportion

of materials

published

by the AAP

is written

on seventh

to eighth

grade levels than are materials dealing with adult

health.”

However,

in public

health

settings

all

ma-terials

should

probably

be rewritten

at a less than

high

school

grade level before

most

parents can be

ex-pected

to read

them.

In addition,

consideration

must

be given

to rewriting

patient

education

and

informed

consent

materials

at a grade

level

suitable

for parents

- ___________________________________ who are marginally literate.

Readability

formulas

have

been

used

by educators

7 8 9 10 11 12 13 14 15

and

educational

publishers

since

the

1940s.719

They

are an adequate means of

judging

patient education

materials;

however,

there

are limitations

to their

ac-curacy.’72#{176}All

provide a reading level estimate of

written

material and are appealing to physicians

be-cause

they

give

an exact

grade

level.

Although

the

results

of

these

readabffity

formulas

are

strongly

correlated

(.74

to .99),

their

estimates

of grade

levels

of the

same

text

can

vary

between

I and

5 grade

levels.’7

Despite

these

limitations,

readabffity

for-mulas

provide

an

important

guide for health care

professionals.

The

federal

act9 that

mandates

that

CDC

vaccine

informational

pamphlets

be

given

to

parents

also

mandates

that the materials

be understandable,

yet all

three

CDC

vaccine

pamphlets

are written at a level

well

above

the

reading

ability

of

two thirds

of the

parents

tested

in this

study.

Public

health

care

work-ers and private physicians submitted written

com-ments

to the

CDC during

the 180-day

public

comment

period

regarding

the high

reading

levels

of the

pam-phlets.9

The

CDC

assessment

of the vaccine

informa-tion

pamphlets

indicated

they

were

written

on

an

eighth

grade

reading

level9;

however,

the

CDC

used

the

Flesch-Kincaid1’

to assess

readability.

The

Flesch-Kincaid’2

classifies

documents as meeting a specific

grade

level

if only

50% of persons

reading

at a given

I

95% Conf Interval Mean Gap

Fig 3. Difference between reading grade as measured by Wide

Range Achievement Test-Revised2 and highest grade completed.

N = 396 parents at Louisiana State University Medical Center

Pediatrics Clinic, Shreveport, LA.

DISCUSSION

An important

part

of medical

care of children

is the

provision

of written

educational

materials

to parents.

Pediatric

physicians

and

nurses

frequently

provide

take-home

instructions

concerning

management

of

acute ifiness,

newborn

care,

feeding,

and

correct

use

of prescribed medications. Also, as required by law,

written

information

concerning

immunizations

and

informed

consent

is given

to the parents.

Children’s

health

care

will

be compromised

if physicians

incor-redly

assume

that

all parents

can

read

and

under-stand health-related materials. In this

study,

almost

two-thirds

of parents

tested

could

not

read

at more

than

a ninth

grade

level,

whereas

81 % of the written

materials

they

were

expected

to read

required

at least

a high

school

reading

ability.

More

than

one

fourth

of

parents

read

at less

than

a seventh

grade

level

and

could be considered marginally literate.

Difference in Grades

ARTICLES 463

0

-1

-2

-3

-4

-5

-6

1

TABLE 2. Mean and Median R eading Lev els of Materials by Source and Perc entage Written at Lower Levels

Source of Materials All Written Materials Materials Written

<9th Grade <7th Grade

n Mean Median n (%) n (%)

American Academy of 60 10.2 10.0 15 (25) 2 (3)

Pediatrics

Centers for Disease 5 10.6 10.0 0 (0) 0 (0)

Control and Prevention

LSUMC-S Pediatric 12 11.5 11.0 1 (8) 0 (0)

C1iniC

March of Dimes 7 9.9 9.0 3 (43) 0 (0)

Formula and 14 10.5 10.3 2 (14) 1 (7)

pharmaceutical companies

Commercial baby 16 13.1 13.0 0 (0) 0 (0)

books

Other 15 10.1 9.5 4 (27) 0 (0)

Totals 129 25 (19) 3 (2)

*J5jJf..5, Louisiana State University Medical Center in Shreveport.

at Viet Nam:AAP Sponsored on September 1, 2020

(5)

grade level can comprehend the document. It is

usu-ally

two

to three

grades

lower

than

the

Fog

Index,’1

which

requires

that 75% of persons

reading

at a given

grade level be able to comprehend the text. The FOG

Index’0 indicates that the D.P.T.

pamphlet

is at the

10th grade

level,

the

M.M.R.

at the 12th grade,

and

the

Polio

at the 10th grade.

National

data

suggest

that one

third

of American

adults

are

reading

at less

than

a

ninth

grade level.21

Readability

is an essential

element

to consider

in

developing

written

materials.’7

However,

a patient’s

abifity

to read

and

comprehend

material

is

deter-mined

not

only

by his or her ability,

but by elements

in the

text

such

as format,

learnability,

motivational

messages,

accuracy,

and

legibility.12

Recommenda-tions

for

preparing

low-reading

level

materials

are

available.4

These

include

using

simple

words

and

short

sentences

that

give

few

directives,

large

print

and

additional

space

between

words

and paragraphs,

and

culturally

sensitive

graphics

and

pictures

of

tar-get

individuals

modeling

the

recommended

behav-ior. For

functionally

illiterate

patients,

written

patient

education materials and

informed

consent

forms

need

to be brief,

contain

few

words,

and

use

pictures.

Re-peated oral

instructions

may

be

the

most

effective

way

to impart

important

information

to the

function-ally

illiterate

patient.4

Video

and

audio

tapes

also

may

be helpful.

Further

studies

are needed

to determine

the influence

of parents’

reading

ability

on the health

status

and outcomes of their children. Research is also

needed

on parent

comprehension

of patient

educa-tion

and

immunization

materials

they

are expected

to

read.

This

study

confirms

that

public

patients’

self-reported

highest

grade

completed

will

not provide

an accurate

measure

of reading

ability.’5

Physical

appearance

also

has

been

shown

to be an

unreliable

predictor

of reading

ability.”

Many

well-groomed,

articulate,

and

apparently

bright

parents

were

reading

at very

low

levels.

Reading

ability

can-not be accurately

assessed

without

direct

testing.

The REALM proved to be a practical tool for

screen-ing parents

in busy

public

health

clinics.

Participants

were receptive rather than apprehensive about the

in-strument

because

it was

presented

in a collaborative,

nonthreaterung

manner

and

could

easily

be

com-pleted in 1 to 2 minutes. In this and previous studies,8

the

authors

found

that

adults

in most

public

clinics

give up on the WRAT-R2 rather quickly. This may be

one reason that individual scores on the WRAT-R2

are

commonly

lower

than

on

other

standardized

reading tests. The words on the WRAT-R2 rapidly

be-come

difficult,

and almost

one third

(29%)

of

its

words

are at more

than

a ninth

grade

reading

level.

In

ad-dition,

it does

not score

atless

than

a third

grade

level.

These

parameters

suggest

the WRAT-R2,

although

an

excellent reading assessment, would not be the

in-strument

of choice for screening patient literacy levels

in public

health

dinic

populations.

The REALM had a

high

criterion

validity,

based

on

its correlations

with

the

WRAT-R2,

and

a high

face

validity,

based

on parents’

acceptance

of the

test

and

their perception that its words are relevant to a

pe-diatric

clinic

setting.

This

study

also

demonstrated

that

the

REALM

can be used

easily

in busy

clinics

to

screen

patients and, when necessary, can help tailor

oral

and

written

instructions

to their

level.

As of this

writing,

the REALM is beginning to be used in several

medical

centers

and

other

settings

around

the United

States,

but

data

are

not

yet

available

on

results

of

patient

testing.

These

findings

should

be generalized

with

caution,

because

all subjects

were tested in a pediatric dinic at

a public

hospital

in a single

southern

state.

Further

research

is needed

to define reading levels of specific

populations

in other

areas

of the country

and in other clinic settings. However, the findings are in

agree-ment with published national surveys of literacy of

the

general

adult

population,21

which

estimate

the

prevalence

of national

illiteracy

to range

from

13% of

American

adults

who

are

severely

illiterate

(reading

at less than a fourth grade level) to 55% who have

marginal

reading

skills

insufficient

for meeting

spe-cific

requirements

of adult

living.224

People

with

lit-eracy

problems

may

be

found

among

all

ethnic

groups,

races,

and

classes;

however,

a

disproportion-ate number have low education and low income

levels.24

The

high

prevalence

of adults

with

mar-ginal

reading

skills

indicates

the need

for low-literacy

written

materials.

Pediatricians

have an opportunity to offer guidance

to parents concerning the importance of reading.

Children

become

literate

more

easily

if their

parents

read to them. Pediatricians and public health

nurses

can encourage parents to read to their children

by offering

free

books,26

and

physicians

can refer

par-ents

to adult

literacy

classes

when

appropriate.

These

interventions may enhance

the

literacy,

health,

and

quality of life

of

both child

and

parent.

ACKNOWLEDGMENTS

The authors would like to acknowledge the critical review of

(6)

APPENDIX I

American Academy of Pediatrics Fog Index

Grade Level

The Injury Prevention Program (TIPP) Pamphlets

Safe Driving ...A Parental Responsibility HE0038 12

The Child as Passenger on an Adult’s Bicycle: HE0037 10

Safe Bicycling Starts Early: HE0036 11

Choosing the Right Size Bicyde for Your Child: HE0035 10

Safe Swimming for Your Young Child: HE0034 11

Protect Your Home Against Fire ...Planning Saves Lives: HE0039 10

Protect Your Child ... Prevent Poisoning: HE0033 12

Baby Sitting Reminders: HEOO3I 10

Infant Furniture: Cribs: HEOO3O 7

Framingham Safety Survey From Ten to Twelve Years: HE0067-B 6

Framingham Safety Survey From Six to Nine Years: HE0067-A 7

Framingham Safety Survey From One to Five Years (Part 2): HE0022-C 7

Framingham Safety Survey From One to Five Years (Part 1): HE0022-B 9

Framingham Safety Survey the First Year of Life: HE0022-A 7

Safety for Your Child 10 Years: HE0064-D 8

Safety for Your Child 8 Years: HE0062-C 7

Safety for Your Child 6 Years: 1-1110064-B 6

Early ChildhOod Years Birth to Six Months: HEOO21-A 8

Early Childhood Years Seven to Twelve Months: HEOO2I-B 8

Early Childhood Years One to 1\vo Years: HEOO21-C 9

Early Childhood Years Thro to Four Years: HEOO2I-D 10

Safety for Your Child 5 Years: HE0064-A 7

Safety lips for Home Playground Equipment ...: HE0032 9

Guidelines for Parents

Child Sexual Abuse: What It Is and How to Prevent It HE0029 10

Hepatitis B: HEOI2O 13

Other Pamphlets

Newborns: Care of the Uncircumcised Penis: HEOO23R (Rev 2/92) 12

Child Care: What’s Best for Your Family: HE0028 (Rev 2/92) 10

Television and the Family: HEOOI5A 13

Guidelines For Your Family’s Health Insurance: HE0077 12

Sex Education: A Bibliography of Educational Materials for Children, 17

Adolescents, and Their Families: HEOO24A (Rev 11/90)

A Guide to Children’s Dental Health: HE0085 10

Sports and Your Child: HE0058 (Rev 2/92) 11

Deciding to Wait: Guidelines for Teens: HE0125 8

Guidelines for Teens: Acne Treatment and Control: HE0087 9

Marijuana: Your Child and Drugs: HE0052 13

Better Health Through Fitness: HEOO9O 12

Smoking: Straight Talk for Teens: HE0088 10

Tobacco Use: A Message to Parents and Teens: HE0065 9

Choking Prevention and First Aid for Infants and Children: HE0066 8

Important Information for Teens Who Get Headaches: HEOIO7 14

Surviving: Coping with Adolescent Depression and Suicide: HE0046 11

Teens Who Drink and Drive: Reducing the Death Toll: HE0026 16

Cocaine: Your Child and Drugs: HE0056 11

Alcohol: Your Child and Drugs: HE0059 10

Making the Right Choice: Facts Young People Need to Know About 11

Avoiding Pregnancy: HE0055

Hepatitis B: HEOI18 12

Healthy Start Food to Grow On Program

Produced as a cooperative effort by:

The American Academy of Pediatrics (AAP)

The American Dietetic Association (ADA) The Food Marketing Institute (FMI)

Feeding Kids Right Isn’t Always Easy 9

Tips for Preventing Food Hassles: HE0097

Growing Up Healthy: Fat, Cholesterol and More: HE0096 9

Right from the Start: 8

ABC’s of Good Nutrition for Young Children: HE0095

What’s to Eat? Healthy Foods for Hungry Children: HE0094 10

Patient Medication Instructions

Codeine: PM1005 12

Diphenhydramine: PMIOO4 10

Acetaminophen: PMIOO6 10

Pseudoephedrine: PM1OI8 11

Posters

Choking/CPR HE0008 (Rev 1/89) 8

Cards

Child Vaccination Record Card 12

ARTICLES 465

at Viet Nam:AAP Sponsored on September 1, 2020

(7)

APPENDIX I Continued

American Academy of Pediatrics Fog Index

Grade Level

Parenting Books

Caring for Your Baby and Young Child: Birth to Age 5. New Yorlc 12

Bantam Books; 1991

Caring for Your Adolescent: Ages 12 to 21. New Yorlc Bantam Books; 15

October 1991

Magazines

Healthy Kids Birth-3. Spring/Summer 1992 12

Healthy Kids 4-10. Spring/Summer 1993 10

Centers for Disease Control and Prevention Fog Index Grade Level

Immunization Pamphlets

Before It’s Too Late Vaccinate: Diphtheria, Tetanus, and Pertussis: HE0054 11

Before It’s Too Late Vaccinate: Ten Questions and Answers About How to 10

Help Protect Your Child From Getting Deadly Diseases: HEOIO9

Diphtheria, Tetanus, and Pertussis: What You Need to Know: 10 HEOII3 (Rev 2/92)

Measles, Mumps, and Rubella What You Need to Know: HEOII4 12

Polio: What You Need to Know: HEOII5 10

APPENDIX!!

Fog Index Grade Level

Caddo-Shreveport Health Unit

Pamphlet

Important Information About Polio and Oral Polio Vaccine (Poll Rev 3/83) 14

American Dietetic Association

Pediatric diets

Guidelines for Daily Food Intake 13

Citizens for Public Action on Blood Pressure and Osolesterol, Inc.

Pamphlet

Cholesterol and Kids: A Parent’s Guide-1991. Bethesda, MD 13

Fisher-Price Family Alert Program

Pamphlet

Information for Parents About Choking Risks Involving Little People 15

and Other Small Objects

Louisiana Drug and Poison Information Center

US Consumer Product Safety Commission Poison Lookout 11

Checklist (Rheumatology)

Louisiana State University Medical Center Pediatric Clinic

Pediatric endocrinology and diabetes education

Information about Diabetes for School Personnel 13

Forms

Vaccine Administration Record (DTP 10/15/91) 17

Influenza Vaccine Consent Form 13

After-care Instructions 10

L,aflets

Feeding Guide 8

When Your Child Has Asthma 12

House Dust 10

Home Instructions Chicken Pox 10

SickDay 14

Instructions for Home Under 10 9

Pediatrics Endocrinology and Diabetes Education 13

Instructions for Home Age 10+ 9

Louisiana Office of Public Health

Nutrition section

Feeding Children One to Two Years 8

Feeding Children Three to Five Years 8

Participating in the WIC Program, Special Food for Special People 9

Scriptographic booklets

About Hepatitis B (No. 37762F-7-92) 7

Your Child’s Heating, A Guide for Parents (No. 11809) 10

Shots for Tots (No. 1I55IAF-6-92) 10

When Your Child is ifi (No. 11502) 9

About ChildhOOd Communicable Diseases (No. 37200) 10

About Pregnancy and Drugs (No. 37309C-6-92) 9

(8)

APPENDIX II Continued

ARTICLES

467

Fog Index Grade Level

March of Dimes

Pamphlets

3 Words About Drinking While Pregnant: Don’t Do It! 8

Double Trouble Drugs, Alcohol, Tobacco Abuse during Pregnancy 11

Be Good to Your Baby Before It is Born (Booklet pp 2, 7, 9) 9

Drinking During Pregnancy: Fetal Alcohol Syndrome and Fetal 13

Alcohol Effects

Give Your Baby a Healthy Start: Stop Smoking 7

Will My Baby Be All Right? (MSAFP) 09438-00 13

Eating for Two, Nutrition During Pregnancy: 09-219-00 8

Meadjohnson Nutritionals

Pamphlets

Jaundice and Your Baby: L-F30-ll-90 10

Weaning and Supplementing A Guidebook for Breastfeeding Mothers: 11 L-F58-11-90

Ohio Neonatal Nutritionists

L,aflets

Questions You May Have About Your Child’s Special Formula 10

Questions You May Have About Your Child’s Tube Feeding 8

Ross Laboratories

Pamphlets

WHAT IS WIC?: G374(0.15)/March 1988 5

Your Baby and Crying (indudes Coping With Infant Colic): 11

51226 09899WB(0.25)/Dec 1991

Becoming a Parent Preparing For and Welcoming Your New Baby: 10

G34(1.00) Jan 1991

Cooking With Isomil: G714/May 1989 10

Leaflets (adaptation of CDC pamphlet)

Polio: (10-15-91) 11

Diphtheria, Tetanus, and Pertussis: (DiP l0-15-91)(DTaP 3-25-92) 11

Nutrition Prescriptives, 1988

Toddler Diet (1-3 years)/Child Diet (3-6 years) 10

Fleischmann’s

Leaflet

Nutrition Update: The Adolescent Years 12

Nabisco

Diabetes, Exercise, and You 13

Herbert Laboratories

Pamphlets

Understanding and Treating Scabies Patient Instruction Sheet 12

DTP, diphtheria-tetanus-pertussis; WIC, The Special Supplemental Food Program for W and Children.

APPENDIX III

omen, Infants,

Commercial Baby Books Fog Index

Grade Level

Brazelton TB. Infants and Mothers: Differences in Development. New York: Ban-tam Doubleday Dell Publishing Group; 1983. $14.95

11

Carter JM, ed. The Good Housekeeping Illustrated Book of Pregnancy and Baby Care.

New Yorlc William Morrow; 1990. $25

II

Quistophersen ER. The Baby Owner’s Manual: What to Expect and How to

Sur-vive the First Year. Shawnee Mission, KS: Westport; 1988. $7.95

12

Eisenberg A, Murkoff HE, Hathaway SE. What to Expect the First Year. New

York: Workman; 1989. $12.95

14

Eisenberg A, Murkoff HE, Hathaway SE. What to Expect When You’re

Expect-ing. New York: Workman; 1991. $10.95

15

Ferber R. Solve Your Child’s Sleep Problems. New York: Simon and Schuster;

1985. $8.95

14

Greenspan SI. The Essential Partnership: How Parents and Children Can Meet the

Emotional Challenges of Infancy and Childhood. New York: Penguin; 1989. $8.95

15

Hull KH. The Mommy Book. New York: Harper Collins; 1986. $5.99 10

Leach P. Babyhood: Stage by Stage, From Birth to Age Ttvo. New York: Random

House; 1983. $12.95

14

Leach P. Your Baby and Child from Birth to Age Five. 2nd rev ed. New York: Ran-dom House; 1989. $29.95

11

at Viet Nam:AAP Sponsored on September 1, 2020

(9)

APPENDIX III Continued

Commercial Baby Books Fog Index

Grade Level

Olds SW. The Complete Book of Breastfeeding. New York: Workman; 1987. $7.95 16 Popper A. Parents’ Book for the TOddler years. New York: Ballantine; 1986. $4.95 11

Princeton Center for Infancy & Early Childhood. The First Twelve Months of

Life. New York: Putnam Publishing Group; 1982. $10.95

11

Samuels M, Samuels N. The Well Pregnancy Book. New Yorlc Simon and

Sch-uster; 1986. $16.95

16

Shapiro HI. The Pregnancy Book for Today’s Woman. New York: Harper and

Row; 1983. $12.95

19

Speck B, Rothenberg M. Dr. Speck’s Baby and Child Care. 6th ed. New York:

Pocket Books; 1992. $6.99

10

REFERENCES

1. Davis TC, Crouch MA, Wills C, et al. The gap between patient reading comprehension and the readability ofpatient education materials. JFam Pract. 199031:533-538

2. Jackson RH, Davis TC, Bairnsfather LE,George RB, Crouch MA, Gault

H. Patient reading ability: an overlooked problem in health care. South

Med J.199184:llfl-1175

3. Zion AB, Aiman J. Level ofreading difficUlty in the American College

of Obstetricians and Gynecologists patient education pamphlets. Obstet Gynecol. 1989;74:955-960

4. Doak CC, Doak LG, Root JH. Teaching Patients With Low Literacy Skills.

Philadelphia: JB Uppincott; 1985

5. Powers RD. Emergency department patient literacy and thereadability

of patient-directed materials. Ann Emerg Med. 1988;17:124-126

6. Jastak

Pc

Wilkinson B. Wide Range Achievement Test-Revised.

Wilming-ton DE: Jastak; 1987

7. Davis TC, Crouch MA, Long SW, Jackson RH, Bates P. George RB.

Rapid assessment of literacy levels of adult primary care patients. Fam

Med. 199123:433-435

8. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy

in medicine: a shortened screening instrument. Fam Med. 199325:

391-395

9. Department of Health and Human Services. Vaccine information

ma-terials (45 CFR Part 110). Centers for Disease ControL Federal Register. 199156:51798-51818

10.Wampler BE,Williams MP. Grammatik for Windows. San Francisco CA:

Reference Software international; 1991

ii. Gunning R. The Technique of Clear Writing. New York: McGraw-Hill;

1974

12. Flesch R The Art of Readable Writing. New York Harper & Row; 1974

13. Markwardt PS. Peabody Individual Achierement Test Revised. Cirde Pines,

MN: American Guidance Service; 1989

14. Microsoft Excel. Version 4.0. Redmond, WA: Microsoft Corporation;

1992

15. SAS. Release 6.03. Cary, NC: SAS Institute mc; 1991

16. Weiss BD, Hart C, Pust RE. The relationship between literacy and

health.

1

Health Care Poor Underserued. 1991;1:351-363

17. Meade CD, Smith CF. Readability formulas: cautions and criteria.

Patient Educ Couns. 1991;17:153-158

18. Dale E,OallJS. Aformula forpredicting readability instructions. Educ Res Bull. 194827:37-M

19. Reach R. A new readability yardstick. JAppl Psychol. 194832:221-233

20. PiCheTtJW, Elam P. Readabifity formulas may mislead you. Patient E4uc Couns. 1985;7:181-191

21. Office of Continuing Education. Adult Functional Competency: A Sum-mary. Austin, TX: The Adult Performance Level Project, The University

ofTexas atAustin; 1975

22. BriziusJ, Foster S. Enhancing Adult Literacy: A Policy Guide. Washington,

DC: Council of State Policy and Planning Agencies; 1987

23. Hunter5, Harnan 0. Adult illiteracy in the United States: A Report to the Ford Foundation. New York: McGraw-Hill; 1985

24. English Language Proficiency Study. Washington, DC: US Government

Printing Office; 1982 Bureau ofthe Census(Suitland, MD), Form ELPS-4

25. Kirsch IS, Jungeblut A. Literacy: Profiles of America’s Young Adults.

Na-tional Assessment of Educational Progress Report No. 16-PF-02. Prince-ton NJ: Educational Testing Service; 1986

26. Needlman R, Fried LE, Morley DS, TaylorS, Zuckerman B. Jinic-based

intervention to promote literacy. AJDC. 1991;145:881-884

27. Scarborough H, Dobrich W, Hager M. Preschoolliteracy experience and

later reading achievement. I Learn Disabil. 199124:508-511

28. Whitehurst GJ,Falco FL, thnigan CJ, et aL Accelerating language

de-velopment through picture book reading. Dev Psychol. 198824:552-559

READY! FIRE! . . .

AIM!

Technologies

have gained a foothold because insurance paid for them. For

ex-ample,

balloon

angioplasty

. . . spread

rapidly

and

is now

used

more

widely

than

by-pass

surgery.

Yet only

now

are clinical

trials

under way to see which provides

better

long-term

results.

Kolata G. When doctors say yes and insurers say no. The New York Times. August 16,1992.

(10)

1994;93;460

Pediatrics

Jackson and Peggy W. Murphy

Terry C. Davis, E. J. Mayeaux, Doren Fredrickson, Joseph A. Bocchini, Jr., Robert H.

Education Materials

Reading Ability of Parents Compared With Reading Level of Pediatric Patient

Services

Updated Information &

http://pediatrics.aappublications.org/content/93/3/460

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

at Viet Nam:AAP Sponsored on September 1, 2020

(11)

1994;93;460

Pediatrics

Jackson and Peggy W. Murphy

Terry C. Davis, E. J. Mayeaux, Doren Fredrickson, Joseph A. Bocchini, Jr., Robert H.

Education Materials

Reading Ability of Parents Compared With Reading Level of Pediatric Patient

http://pediatrics.aappublications.org/content/93/3/460

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml