Abstract
Objective:
To examine sources and perceived credibility of child nutrition information by maternal health literacy.
Methods:
US mothers of children (0–12 years) who used social media regularly (N=340) completed an online survey. Health literacy was assessed using the Newest Vital Sign. Child nutrition information sources and perceived credibility of sources were compared by health literacy using logistic and quantile regression models.
Results:
Seventeen percent of mothers had limited health literacy. Compared to mothers with adequate health literacy, those with limited health literacy were more likely to get child nutrition information from siblings, extended family, dietitians, doctors, nurse practitioners, or physician assistants, and government agencies, and less likely to get information from Facebook. Mothers with limited health literacy rated information from parents, friends, Facebook, and Instagram as more credible than mothers with adequate health literacy. While perceived credibility of information from doctors, nurse practitioners, or physician assistants was high overall, mothers with limited health literacy perceived information from these health care providers as less credible.
Conclusions:
Sources of child nutrition information and perceived credibility differ by maternal health literacy.
Practice Implications:
Pediatric providers are encouraged to refer parents to engaging resources that provide evidence-based child nutrition information.
Keywords: Childhood Nutrition, Mothers, Health Literacy, Information Seeking, Health Misinformation, Social Media
1. Introduction
Mothers influence the development of children’s eating habits.[1–3] Nutrition information or feeding advice that is inconsistent with dietary and feeding guidelines may contribute to what and how parents feed their children.[4] Mothers receive parenting information from many sources, but many have concerns about the trustworthiness of advice and information received.[5–9] Health literacy may play a role in where mothers get information about child nutrition and how trustworthy or credible they find these sources.[10,11] A greater understanding of mothers’ sources of child nutrition information and how credible they find these sources can inform public health messaging and behavioral interventions improve parents’ information ecosystems and ultimately children’s dietary intake. In this study, we examined where mothers get child nutrition information and how credible they perceive information from these sources in relation to maternal health literacy.
2. Methods
In mid-to-late March 2020, mothers of children 0–12 years old from the US completed an online survey. Recruitment messages seeking moms to complete an online survey about child nutrition were posted on Facebook, Twitter, and Craigslist (Appendix A). Administrators of Facebook groups for moms/parents were asked permission to join their group and post about the survey. Interested individuals completed questions to determine eligibility: aged ≥18 years, identified as a mother of child(ren) aged 0–12 years, posted or commented on Facebook, Instagram, and/or Twitter in the past 7 days, live in the US, able to complete the survey in English, and willing to provide informed consent. Eligible individuals were invited to complete an online survey designed to take 15–30 minutes. Participants electronically provided informed consent. Participants who completed the survey were emailed a $20 gift card. This study was approved by the University of Connecticut Institutional Review Board.
Health literacy was evaluated using the Newest Vital Sign (NVS), a 6-item measure that assesses individuals’ ability to read a nutrition label.[12] Participants were shown a nutrition label for a pint of ice cream and answered six open-ended questions (e.g., “if you eat the entire container, how many calories will you eat?”). Research staff scored each response as correct or incorrect. Zero to 3 correct answers indicated limited health literacy.[12] The NVS has high sensitivity to detect limited health literacy,[13] and is a commonly used measure of parents’ health literacy,[14] including via participant survey.[15,16]
We introduce the series of questions about child nutrition information with the following statement: “by ‘child nutrition’, we mean what to feed your children, when or how often to feed your children, where to feed your children, how to feed your children, or information about what foods children should or shouldn’t eat”. We then asked mothers “in the past 4 weeks, did you get any information about child nutrition from your spouse (e.g., husband, partner, wife)?” Participants responding affirmatively were asked “How credible do you find information about child nutrition you get from your spouse (for example, husband, partner, wife)?” using a visual analog scale from 0 (not credible at all) to 100 (very credible). We then asked about information from a series of other sources using the same two questions. Only participants who reported using Facebook or Instagram, respectively, were asked about child nutrition information from that platform.
Participants self-reported demographics and social media use. Participants selected which race(s) best describes them from a checklist and reported whether they considered themselves Hispanic or Latina. Few women (n=11) had at most a high school diploma or GED; we collapsed education groups to represent less than Bachelor’s degree. Participants with Facebook and Instagram accounts, respectively, were asked posting or replying frequency in the past 4 weeks. We collapsed responses into not at all, once/about once a week, or more than once a week but not every day/every day.
We used Research Electronic Data Capture (REDCap)[17] for survey administration and participant tracking and SAS 9.4 (SAS Institute, Inc, Cary, NC) for data management and analyses. We reviewed survey responses to identify potentially fraudulent and/or low-quality responses (n=17 excluded; Appendix A). We used logistic regression models to compare information sources by health literacy. We used quantile regression models to compare median perceived credibility of information sources by health literacy.[18] We included age, education, and race/ethnicity in adjusted regression models based on associations with health information sources or trust in previous literature.[10,19–22]
3. Results
We excluded survey respondents who terminated the survey before the questions about information sources (n=26) or did not complete the health literacy measure (n=47), resulting in an analytic sample of 340 mothers (Appendix A). The sample was predominantly non-Hispanic white and college-educated (Table 1). Seventeen percent (n=57) had limited health literacy.
Table 1.
Characteristics of mothers of children 0–12 years by health literacy
| Limited Health Literacy (n=57) | Adequate Health Literacy (n=283) | |
|---|---|---|
|
| ||
| Age (years), M ± SD | 32.6 ± 6.0 | 36.1 ± 5.2 |
|
| ||
| Race/Ethnicity, n (%) | ||
| Non-Hispanic White | 27 (47) | 237 (84) |
| Non-Hispanic Black | 2 (4) | 7 (3) |
| Hispanic/Latina (any race[s]) | 5 (9) | 20 (7) |
| Non-Hispanic Asian | -- | 14 (5) |
| Native American/Alaska Native | 16 (28) | -- |
| Non-Hispanic, other race/multiracial | 7 (12) | 5 (2) |
|
| ||
| Educational attainment | ||
| HS/GED/trade/technical/1–3 years of college/Associates | 29 (51) | 34 (12) |
| Bachelor’s degree | 18 (32) | 98 (35) |
| Graduate degree | 10 (18) | 151 (53) |
|
| ||
| Receives WIC benefits, n (%) | 1 (2) | 3 (1) |
|
| ||
| Receives SNAP benefits, n (%) | 2 (4) | 6 (2) |
|
| ||
| Children aged 0–12 years in household, n (%) | ||
| One child | 45 (79) | 102 (36) |
| Two children | 9 (16) | 134 (47) |
| Three or more children | 3 (5) | 47 (17) |
|
| ||
| 1+ teenagers 13–17 years in household, n (%) | 1 (2) | 22 (8) |
|
| ||
| Facebook use, n (%) | ||
| Does not have an account | 1 (2) | 1 (<1) |
| Has account but did not post/comment in past 7 days | 3 (5) | 11 (4) |
| Posted or commented in past 7 days | 53 (93) | 271 (96) |
|
| ||
| Instagram use, n (%) | ||
| Does not have an account | 23 (40) | 47 (17) |
| Has account but did not post/comment in past 7 days | 7 (12) | 53 (19) |
| Posted or commented in past 7 days | 27 (47) | 183 (65) |
|
| ||
| Sources of child nutrition information (of 10 queried), median (IQR; range) | 3 (1–5; 0–9) | 3 (1–4; 0–8) |
Mothers with limited health literacy were more likely than mothers with adequate health literacy to get child nutrition information from their siblings, extended family, dietitians, doctors, nurse practitioners, or physician assistants, and government health agencies or programs (Table 2). In contrast, mothers with limited health literacy were less likely to report getting child nutrition information from Facebook (Table 2).
Table 2.
Sources of information about child nutrition reported by mothers of children 0–12 years with limited health literacy compared to mothers with adequate health literacy, n (%)
| Limited Health Literacy (n=57), n (%) | Adequate Health Literacy (n=283), n (%) | Crude OR (95% CI) | Adjustedc OR (95% CI) | |
|---|---|---|---|---|
| Spouse/partner | 16 (29) | 76 (27) | 1.1 (0.6–2.1) | 1.0 (0.5–2.2) |
| Parents | 23 (41) | 89 (31) | 1.5 (0.8–2.7) | 1.7 (0.9–3.4) |
| Siblings | 19 (33) | 41 (14) | 3.0 (1.6-5.6) | 3.8 (1.8-8.1) |
| Members of extended family | 22 (39) | 22 (8) | 7.4 (3.7-14.8) | 7.9 (3.5-18.2) |
| Friends | 23 (40) | 125 (44) | 0.8 (0.5–1.5) | 1.1 (0.6–2.2) |
| Registered dietitian (RD) | 17 (30) | 24 (8) | 4.6 (2.3-9.3) | 4.9 (2.1-11.2) |
| Doctor, nurse practitioner, or physician assistant | 30 (53) | 107 (38) | 1.8 (1.0-3.2) | 2.4 (1.2-4.7) |
| Government health agencies or programsa | 18 (32) | 29 (10) | 4.0 (2.0-7.9) | 3.6 (1.6-8.0) |
| Facebookb | 25 (45) | 187 (66) | 0.4 (0.2-0.8) | 0.5 (0.2-0.9) |
| Instagramb | 10 (29) | 72 (31) | 0.9 (0.4–2.1) | 1.0 (0.4–2.4) |
For example, USDA, CDC, city/state public health department, WIC, SNAP
Among participants who reported using the platform
Adjusted for age, race/ethnicity (non-Hispanic white vs other race/ethnicity), and education
Mothers with limited health literacy rated child nutrition information from their spouse/partner, friends, Facebook, and Instagram as more credible than did mothers with adequate health literacy, but rated child nutrition information from doctors, nurse practitioners, or physician assistants less credible (Table 3).
Table 3.
Perceived credibility of sources of information about child nutrition reported by mothers of children 0–12 years, by health literacy
| Limited Health Literacy (n=57), median (IQR) | Adequate Health Literacy (n=283), median (IQR) | Crude beta (95% CI) | Adjustedb beta (95% CI) | |
|---|---|---|---|---|
| Spouse/partner | 82.5 (78–94.5) | 77 (65–91) | 5 (−4, 14) | 9 (1, 18) |
| Parents | 81(75–85) | 71 (53–82) | 10 (3, 17) | 4 (−4, 13) |
| Siblings | 82.5 (78–89) | 78 (65.5–93) | 1 (−9, 11) | 4 (−9, 16) |
| Members of extended family | 79 (78–86) | 70 (57–82) | 9 (−5, 23) | 6 (−12, 24) |
| Friends | 83 (73–87) | 72 (62–80) | 11 (5, 17) | 8 (2, 14) |
| Registered dietitian (RD) | 82 (77–92.5) | 90 (86.5–96) | −6 (−17, 5) | 3 (−15, 8) |
| Doctor, nurse practitioner, or physician assistant | 82.5 (76–95) | 93 (84–98) | −10 (−18, −2) | −9 (−17,−1) |
| Government health agencies or programsa | 85 (73–92) | 90 (67–100) | −4 (−18, 10) | −4 (−17, 9) |
| 79 (69–87) | 50 (34–65) | 29 (21, 37) | 33 (23, 44) | |
| 87 (78–92) | 66 (56–82) | 21 (10, 32) | 18 (9, 28) |
For example, USDA, CDC, city/state public health department, WIC, SNAP
Adjusted for age, race/ethnicity (non-Hispanic white vs other race/ethnicity), and education
4. Discussion and Conclusion
4.1. Discussion
In this study, perceived credibility of information from doctors, nurse practitioners, or physician assistants was high overall, consistent with research among US adults generally,[10,20] and mothers with limited health literacy perceived information from these health care providers as less credible, also consistent with previous research.[10] US adults’ trust in their usual doctor is strongly related to how patients’ perceive how well the provider communicates, and the extent to which they are perceived to be caring and competent,[23] and patients with higher health literacy rate their relationships with health care providers more positively.[24] It may be that mothers with limited health literacy come away from visits with their children’s pediatric primary care team with unanswered questions about what or how to feed their children, or feel that nutrition advice provided is not relevant to their life circumstances or family eating patterns.[25]
We also found that mothers with limited health literacy were more likely to report getting child nutrition information from dietitians and government agencies and programs such as the USDA, the CDC, city/state public health departments, WIC, and SNAP. Mothers who received information from these sources rated them as highly credible, regardless of health literacy level. Pediatric care teams are encouraged to screen for family food insecurity and refer families with food insecurity or limited financial resources to WIC, SNAP, and other assistance programs, especially those that provide nutrition counseling or education along with financial assistance.
Mothers with limited health literacy rated information from Facebook and Instagram as more credible than mothers with adequate health literacy, consistent with previous research in adults generally.[10] Typically Facebook users “friend” their family, friends, and other personal contacts,[26] and the higher median credibility rating of Facebook among mothers with limited health literacy may be related to their perceived higher credibility of friends compared to mothers with adequate health literacy. Alternatively, mothers with limited health literacy may be less able to evaluate health information encountered online,[27] and thus may be more susceptible to trusting misinformation. Future research could explore how credible mothers find child nutrition information they see on social media posted by different people or organizations (e.g., family, friends, health care professionals, public health organizations, influencers, magazines, news outlets). Future studies could also examine whether child nutrition content mothers see on social media is consistent with national dietary and child feeding guidelines,[28,29] and explore how mothers respond to child nutrition information they think is misleading or false.
This study has additional limitations. Our sample was more highly educated, less likely to receive SNAP or WIC benefits, and less racially/ethnically diverse compared to mothers nationally.[30–32] Our sample only included English-speaking mothers, and findings may not be generalizable to mothers with limited English proficiency, who may be more likely to have low health literacy.[33] Few participants received information from siblings, extended family, registered dietitians, and public health programs or government agencies, limiting our power to detect differences in information credibility from these sources.
4.2. Conclusion
Sources of child nutrition information and perceived credibility of information sources may differ by maternal health literacy. Further research is needed to examine how mothers evaluate the credibility of child nutrition information and advice from their offline and online networks, and whether evaluation strategies differ by maternal health literacy.
4.3. Practice Implications
While overall mothers perceived doctors, nurse practitioners, or physician assistants to be highly credible sources of child nutrition information, mothers with limited health literacy perceived information from these healthcare providers as less credible compared to mothers with adequate health literacy. Pediatric providers are encouraged to leverage parents’ trust in them as an information source to recommend engaging resources that provide evidence-based child nutrition information such as offered by the USDA and SNAP-Ed, and refer appropriate children and families for nutrition counseling with a registered dietitian.
Supplementary Material
Highlights.
17% of mothers in this sample had limited health literacy
Where mothers get child nutrition information differs by maternal health literacy
Mothers perceive nutrition information from health care providers as highly credible
Credibility of information sources differs by maternal health literacy
Mothers with limited health literacy rate information from providers as less credible
Mothers with limited health literacy rate information on social media as more credible
Acknowledgements
This work was supported by the USDA National Institute of Food and Agriculture, Hatch project 1020701 (PI: Waring). Additional support for SLP provided by NIH grant K24HL124366 (PI: Pagoto).
Footnotes
Declaration of Interest
None.
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