Maternal Health Literacy in Australia

Alita Gonsalves Summer Research Proposal Background: Maternal Health Literacy in Australia The term health literacy has been in the literature for over thirty years. The term is used in the United States to describe the relationship between patient literacy levels and their ability to comply with prescribed therapeutic regimens. However, this definition is narrow and fails to consider the deeper meaning of literacy and what health-related decisions it may affect (Nutbeam, personal communication). Health literacy is more broadly defined by the World Health Organization: Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health. Health literacy means more than being able to read pamphlets and successfully make appointments. By improving people s access to health information and their capacity to use it effectively, health literacy is critical to empowerment. (Nutbeam 1998). Health education programs are directed towards improving health literacy. Such programs have evolved in the past few decades. In developed countries, health education programs of the 1960s and 70s focused on the transmission of information and failed to consider social and economic factors. These programs failed to achieve substantial results in terms of behavior change. The current approach to health education encompasses the social determinants of health. Recent epidemiological evidence suggests that, in addition to individual characteristics and behavior patterns, social, economic, and environmental factors are all important in determining the response to health risks and adverse outcomes (Nutbeam, unpublished). When social and economic factors are taken into account, health education programs have been able to reach a wider audience. Prenatal health education affects maternal health literacy. It is becoming more complex as more screening tests are offered. Prenatal education classes are available, but there are no standards for class content or certification in either the U.S. or Australia. Australian prenatal educators who have participated in focus groups have said that their students come from a wide variety of social and economic backgrounds (Renkert, personal communication). Research in the UK has suggested that there may be better ways to present prenatal educational materials to pregnant women. Traditional methods of 1

conveying information include the use of pamphlets and verbal information provided by health care professionals. The type of healthcare setting may also affect the quality of education provided to the women, with different types of information being provided by public versus private clinics. Researchers in England are attempting to provide consistent information to pregnant women by making available touch screen information systems. These systems also may reduce patient overload of information since they are patient driven (Graham et al 2000). Specific Aims: This project aims to develop and apply a questionnaire to measure health literacy levels among pregnant mothers participating in some form of prenatal care. There is a fundamental relationship between maternal and child health and parental education and literacy levels. This project will examine the concept of health literacy (WHO 1998) as it relates to maternal health. This project aims to develop a more sensitive and comprehensive instrument for health professionals to use in order to determine the health literacy levels of pregnant women and to use the results in order to tailor health education to meet their needs. This project offers an opportunity to apply contemporary approaches to health education to maternal and child health programs. Most health education strategies tend to be generic in content and form. Such an approach often fails to meet the specific needs of the individual pregnant woman, her partner and children. In summary, the families most at risk are often those least able to benefit from prenatal and postnatal education because it is presented in an inappropriate form and they do not possess the skills to implement the best health choices for their families. Often, what is needed is targeted information in an interpretable format. Currently, it is difficult for health professionals to identify the specific educational needs of individual patients. This project will develop an instrument that will assist health professionals in identifying mothers with low health literacy levels early in pregnancy. Information obtained through this screening process will provide the health professionals with a more informed basis on which to target prenatal and postnatal education with these families. Information derived from the questionnaire will assist health professionals in better meeting individual needs. 2

Conceptual model: Maternal motivation to learn Maternal characteristics Access to prenatal education Maternal health literacy Method and content of prenatal education Hypotheses: 1) Women without insurance and access to prenatal health education have a lower maternal health literacy. 2) Women with a greater motivation to learn have a higher level of health literacy. 3) Women who participate in prenatal educational programs that are more generic in content and form have a lower level of health literacy as opposed to women who receive more individualized education. 4) Contrary to general logic, initial focus groups with health educators have suggested that the generic content of health education programs in Australia leads to lower maternal health literacy for women with higher education levels but are able to better educate women with low education levels. Methodology: I will work with Don Nutbeam, PhD, who is a Professor or Public Health and Community Medicine at the Universiy of Sydney, and Susan Renkert, MPH, a research assistant in the same department. Ms. Renkert will conduct focus groups with pregnant women at the King George V Memorial Hospital for Children and Babies in Sydney before my arrival there in June. When I arrive in 3

Sydney, I will conduct sturctured interviews with approximately10-15 midwives and health educators to learn more about the content of prenatal education in the Sydney area and to identify areas of concern about the health literacy of the women. The results of the focus groups and interviews will identify key terms and elements of prenatal health literacy. Based on the results of the focus groups and interviews, I will develop a questionnaire that will measure health literacy in pregnant women. I will give the questionnaire to approximately 50 pregnant women. The women will be recruited by healthcare providers at the King George V Memorial Hospital for Children and Babies. The questionnaire will determine the level of health literacy of the women by asking them specific questions related to prenatal and postnatal care. A scoring system will be developed to identify women with low health literacy. Ms. Renkert will continue the project over the long term to develop ways to intervene in the health education of women who scored low on the questionnaire. If the instrument is successful at targeting women with low health literacy, healthcare staff may eventually use the questionnaire to identify high risk women and to tailor their educational strategies to these women. The project may continue to follow the women postnatally to examine the degree of health literacy on health outcomes such as immunizations, well-child visits, postnatal depression, and failure to thrive. Significance: This study will help elucidate disparities in prenatal education and maternal health literacy in Australia and provide recommendations to healthcare providers about how to improve their prenatal health education. The providers may then target their educational efforts to address identified gaps in knowledge and to equip mothers with the specific skills they may lack for implementing this knowledge (e.g. signs of onset of labor, breast feeding technique, settling techniques, etc.) It is anticipated that this will lead to short and longer term improvements in health outcomes in these families. In the short term it should be possible to observe improved knowledge, self-confidence, independence, and better skills for accessing family health care needs. In the longer term, outcomes may include improved rates of immunisation and breast feeding, lower rates of postnatal depression and of infant failure to thrive and increased number of wellchild visits. References: Graham, W, Smith, P., Kamal, A., Fitzmaurice, A., Smith, N., and Hamilton, N. Randomised controlled trial comparing effectiviness of touch screen system with leaflet for providing women with information on prenatal tests. British Medical Journal 2000; 320: 155-60. 4

Guyer, B., Hoyert, D., Martin, J., Ventura, S., MacDorman, M., and Strobino, D. Annual Summary of Vital Statistics-1998. Pediatrics 1999;104: 1229-1446. Kogan, M., Alexander, G., Jack, B., and Allen, M. The association between adequacy of prenatal care utilization and subsequent pediatric care utilization in the United States. Pediatrics 1998;102:25-30. Nutbeam, Don. Personal communication. World Health Organization; 1986. Ottawa Charter for Health Promotion. World Health Organization: Geneva. 5

International Experience: Australia Summer 2000 Alita Gonsalves I went to Sydney, Australia through the international health elective. When I started the elective last year, I knew that I was interested in going to Asia or the south Pacific. I looked at the webpages of universities and public health departments in Australasia, and I found my advisors at the University of Sydney simply by emailing Don Nutbeam, the head of the department of public health. He told me that he would be happy to have me come and work in the department with him and his research assistant, Susan Renkert. Don has been one of the pioneers in the area of health literacy. In the U.S., health literacy is considered to be the relationship between patients literacy levels and their adherence to therapeutic regimens. However, Don has expanded this area to also include the impact of other factors such as cognitive and social skills, self-efficacy, and self-confidence on health. He and Susan are working on a project concerning maternal health literacy, which is the health literacy of women while they are pregnant and then while they are mothers. In both the U.S. and Australia, prenatal health education classes are offered to pregnant women, but there are no standards for class content or certification. Don and Susan research how prenatal health education and other factors affect maternal health literacy. We decided that my role in the project would be to help make a comprehensive diagnostic questionnaire for health professionals to use in order to determine the health literacy levels of pregnant women. This instrument would score women s health literacy so that their health

providers and prenatal educators would be able to tailor their health education accordingly. The questionnaire that I developed included demographic questions, and scales for locus of control and for self-efficacy. There was also a scale for maternal health literacy, which was rated by the women s knowledge, skills, and confidence in various issues related to pregnancy and motherhood. I gave the questionnaire to fifty-five women at the King George V Memorial Hospital for Mothers and Babies. Most of these women were highly educated and attended prenatal health education classes. It would have been better to use a sample of women with more educational and socioeconomic variation, but I surveyed who I could in the short amount of time that I had. Basically, my work was a pilot study for Don and Susan s work. They will expand the questionnaire and the scales that I used, and try to standardize it so that healthcare providers in the Sydney area can use it to score their female patients health literacy levels. I lived in a dorm on campus. The dorm, St. John s, has a visitors section which they rent out. I found out about this on the internet through the University of Sydney housing webpage. The room had its own bathroom and TV, and breakfast was included. The rent was about $700 per month. It is definitely possible to find something much cheaper than this, probably about half that price. The best way to do so is to book a room in St. John s or a youth hostel (the YHA near Central Station is brand new and very nice) for a week, and then look at postings in the hostel for available housing, ask other travelers, and look at ads in magazines for travelers. There are a lot of English and Irish people who go to

Sydney on three month working visas, so there is cheap short term housing available. Sydney is a beautiful, cosmopolitan city. The harbor with the Opera House is the most beautiful harbor that I have ever seen. There are many things to in Sydney, and most are within walking distance of each other. There are beaches nearby, which are accessible by bus or by ferry from the harbor. There are many cultural events going on at the Opera House. The Rocks is the historic section next to the harbor, and there are historic pubs and shops there. The Botanical Gardens are next to the harbor as well, and they are great for walking, jogging, and picnicking. There is also another smaller harbor, Darling Harbor, with the Omni theater and Chinese Gardens and many events each weekend. The downtown area, George Street, has skyscrapers and plenty of shopping. Oxford Street is a street filled with clubs and cafes, and many young people. It is very gay-friendly, and this is where they have gay Mardi Gras, a huge parade, every year. King s Cross, near Oxford Street, is the red-light district. It has some good clubs and restaurants, but is kind of seedy. Newtown is right next to the university, full of students, and has several blocks of restaurants. You can get any kind of food imaginable in Newtown, and it is not too expensive. The Blue Mountains are an hour away from Sydney, and great for hiking, although they are more like big hills and rock cliffs than mountains. Since Sydney is below the equator, the seasons are reversed. It was winter when I went there during our summer. The winter was very mild. I brought a fleece jacket, light sweaters, long-sleeved shirts, jeans and pants, and

a leather jacket, and that was fine. It was pretty warm in the daytime, in the sixties to seventies, and got colder at night. I traveled to the northeast coast, to Cairns in Queensland, to see the Great Barrier Reef. This was beautiful and the weather is much warmer there. The reef was gorgeous and I went snorkeling and diving. The weather was rainy though when I saw the reef, so it was not as vibrant as I had heard. Then I saw the famous Ayers Rock, which is in the middle of nowhere in the outback. It is worth seeing for the historic and cultural value. The best part of my travels was in the Northern Territory, where I camped in Kakadu National Park. The north is extremely hot year round. Kakadu is amazing and a must-see. It is a vast park full of national wonders and wildlife. There are waterfalls and beaches, crocodiles, and Aboriginal Rock Art. If you only have the chance to see one thing in Australia, it would have to be Kakadu. Sydney is a beautiful, cosmopolitan city, but Kakadu is the most unique place I saw.