Abstract
We examined the influence of maternal health literacy on child participation in social welfare programs. In this cohort, 20% of the mothers had inadequate or marginal health literacy. Initially, more than 50% of the families participated in Temporary Assistance for Needy Families (TANF), the Food Stamp Program, and Special Supplemental Nutrition Program for Women, Infants, and Children, whereas fewer than 15% received child care subsidies or public housing. In multivariate regression, TANF participation was more than twice as common among children whose mothers had adequate health literacy compared with children whose mothers had inadequate health literacy.
Reports have documented underenrollment in public programs known to improve child health (e.g., food or cash assistance, housing).1–8 Although the mechanisms underlying this phenomenon are complex, one possible explanation is that participation is hampered by the literacy demands of the application process. Low health literacy (“an individual's ability to read, understand and use healthcare information to make decisions and follow instructions for treatment”9) affects more than 90 million American adults (approximately 20% of the adult population).10 In a prospective, longitudinal cohort study of Medicaid-eligible mothers and infants, we hypothesized that mothers with adequate health literacy would be more likely than those with inadequate health literacy to participate in public programs.
METHODS
We analyzed data from the Health Insurance Improvement Project,11,12 a prospective cohort study of Medicaid-eligible mothers and their infants. Between June 2005 and August 2006, mother-infant dyads were recruited from a large Philadelphia, Pennsylvania, hospital's postpartum wards. Inclusion criteria were maternal Medicaid eligibility and maternal English proficiency. Exclusion criteria were gestational age younger than 36 weeks, birth weight less than 2500 g, and infants entering foster care or adoption.
Primary outcomes were self-reported participation in 5 social welfare programs: (1) Temporary Assistance for Needy Families (TANF); (2) Food Stamp Program; (3) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); (4) child care subsidies, and (5) public housing, measured with survey items adapted from the National Health Interview Survey. Covariates included child's sex and birth order; maternal age, education, marital status, and employment status; and household income. Maternal health literacy was measured with the short-form Test of Functional Health Literacy in Adults. Scores range from 0 to 36 and are categorized as follows: 16 or lower (limited); 17 to 22 (marginal); and 23 or higher (adequate).13,14
We used the χ2 test to compare the rate of participation in each social welfare program among the literacy levels. We used best subsets multivariate logistic regression to estimate the relation between maternal health literacy and program participation. We assessed associations between explanatory variables to exclude multicollinearity.
RESULTS
Our study enrolled 744 participants (53.3% of eligible mother–infant dyads). No significant or clinically relevant differences were seen between participants and nonparticipants. Analytic sample sizes were 626 (of 744) at birth and 499 (of 580) at 6 months.
At baseline, 8% had inadequate (n = 50) and 12% had marginal (n = 75) health literacy. Most mothers were African American (80%), were single (87%), had more than 1 child (63%), and had annual household incomes lower than $12 000 (77%). No significant differences in health literacy were related to race/ethnicity (P = .16), marital status (P = .2), income (P = .44), or employment status (P = .26). Health literacy was related to education (P = .004; 38% with inadequate health literacy had an education beyond high school) and number of children (P = .019).
At birth, more than half of the families participated in TANF, the Food Stamp Program, or WIC, and fewer than 15% received child care benefits or public housing (Table 1). At birth and 6 months, children whose mothers had adequate or marginal health literacy were more likely (P < .05) to receive TANF. At birth, children of mothers with adequate or marginal health literacy were more likely to receive food stamps. No significant differences in participation in WIC, child care, or housing were related to health literacy levels.
TABLE 1.
Maternal Health Literacy and Participation in Social Welfare Programs: The Health Insurance Improvement Project, June 2005–August 2006
| Birth (n = 626) |
6 Months (n = 499) |
|||||||||
| Health Literacy, No. (%) |
Health Literacy, No. (%) |
|||||||||
| Overall Participation, % | Inadequate | Marginal | Adequate | P a | Overall Participation, % | Inadequate | Marginal | Adequate | P a | |
| TANF | 52 | 17 (34) | 44 (59) | 266 (53) | .018 | 55 | 15 (36) | 38 (62) | 206 (55) | .03 |
| Food Stamps | 65 | 23 (46) | 50 (67) | 333 (67) | .01 | 71 | 26 (59) | 43 (71) | 272 (72) | .19 |
| WIC | 66 | 35 (70) | 48 (64) | 330 (66) | .78 | 93 | 43 (98) | 57 (93) | 345 (92) | .35 |
| Child care | 12 | 6 (12) | 6 (8) | 65 (13) | .47 | 29 | 8 (18) | 24 (39) | 108 (29) | .06 |
| Housing | 11 | 6 (12) | 8 (11) | 55 (11) | .97 | 14 | 6 (14) | 9 (15) | 53 (14) | .99 |
Note. TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Analytic samples were 626 (of 744) at birth and 499 (of 744) at 6 months. No significant differences were found in the distribution of demographic variables (infant birth weight, maternal age, maternal birth country, maternal education, maternal employment) between the analytic sample and the full cohort (data not shown).
P value for the χ2 test of association between maternal health literacy and participation in social welfare programs. All analyses were conducted with SAS (Version 9.1.3; SAS Institute Inc, Cary, NC).
In multivariate analysis (Table 2), children whose mothers had adequate or marginal health literacy were more than twice as likely to participate in TANF as were children whose mothers had inadequate health literacy at baseline and 6 months. Other significant predictors were number of children, income, and age. For food stamps participation, the association with maternal health literacy at birth was not statistically significant.
TABLE 2.
Multivariate Logistic Regression Results Showing Influence of Maternal Health Literacy on TANF and Food Stamp Program Participation at Birth and 6 Months: The Health Insurance Improvement Project, June 2005–August 2006
| TANF |
Food Stamps |
|||||||
| Baseline (n = 626) |
6 Months (n = 499) |
Baseline (n = 590) |
6 Months (n = 472) |
|||||
| OR (95% CI) | P | OR (95% CI) | P | OR (95% CI) | P | OR (95% CI) | P | |
| Maternal health literacy | ||||||||
| Inadequate | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| Marginal | 2.41 (1.04, 5.61) | .04 | 2.61 (0.96, 7.11) | .06 | 2.13 (0.89, 5.08) | .09 | 1.59 (0.60, 4.23) | .35 |
| Adequate | 2.18 (1.09, 4.35) | .03 | 3.04 (1.35, 6.84) | .008 | 1.95 (0.97, 3.92) | .06 | 1.72 (0.78, 3.77) | .18 |
| Maternal age, y | ||||||||
| ≤ 20 | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| 21–24 | 1.36 (0.80, 2.33) | .26 | 4.22 (2.11, 8.44) | < .001 | 1.63 (0.94, 2.83) | .08 | 1.37 (0.74, 2.54) | .31 |
| 25–29 | 1.10 (0.55, 2.21) | .80 | 3.13 (1.29, 7.62) | .01 | 2.13 (1.00, 4.55) | .05 | 0.92 (0.38, 2.23) | .86 |
| 30–34 | 0.59 (0.25, 1.40) | .23 | 2.49 (0.79, 7.85) | .12 | 0.86 (0.35, 2.11) | .74 | 0.50 (0.17, 1.48) | .21 |
| ≥ 35 | 0.08 (0.02, 0.41) | .003 | 1.57 (0.36, 6.79) | .55 | 0.37 (0.12, 1.15) | .09 | 0.24 (0.06, 0.93) | .04 |
| Income, $ | ||||||||
| < 250/mo | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| 251–500/mo | 1.43 (0.86, 2.37) | .16 | 1.04 (0.55, 2.00) | .9 | 1.18 (0.68, 2.03) | .56 | 2.76 (1.35, 5.65) | .005 |
| 501–999/mo | 0.62 (0.36, 1.07) | .09 | 0.29 (0.14, 0.59) | .001 | 0.79 (0.43, 1.42) | .42 | 1.32 (0.66, 2.66) | .44 |
| 1000–1499/mo | 0.17 (0.08, 0.36) | < .001 | 0.11 (0.04, 0.27) | < .001 | 0.31 (0.15, 0.64) | .001 | 0.68 (0.28, 1.62) | .38 |
| > 1500/mo | 0.20 (0.10, 0.41) | < .001 | 0.07 (0.03, 0.17) | < .001 | 0.28 (0.14, 0.57) | .001 | 0.49 (0.22, 1.11) | .09 |
| No. of children | ||||||||
| 1 | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| 2 | 1.65 (1.02, 2.67) | .04 | 1.33 (0.74, 2.38) | .34 | 2.10 (1.29, 3.41) | .003 | 2.90 (1.61, 5.19) | < .001 |
| ≥ 3 | 3.05 (1.78, 5.22) | < .001 | 2.62 (1.36, 5.04) | .004 | 5.53 (3.07, 9.96) | < .001 | 9.37 (4.44, 19.77) | < .001 |
| Education | ||||||||
| Less than high school | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| High school | 0.81 (0.49, 1.34) | .41 | 0.67 (0.35, 1.29) | .23 | 0.72 (0.43, 1.23) | .23 | 1.00 (0.52, 1.92) | .99 |
| High school or greater | 0.80 (0.49, 1.29) | .36 | 0.42 (0.22, 0.77) | .006 | 0.89 (0.53, 1.50) | .66 | 0.74 (0.39, 1.39) | .35 |
| Race | ||||||||
| Black | … | … | 1.00 | … | … | 1.00 | … | |
| Other | … | … | 0.44 (0.23, 0.84) | .01 | 0.62 (0.38, 1.02) | .06 | 0.53 (0.29, 0.99) | .05 |
| Employment | ||||||||
| Student | … | … | 1.00 | … | … | … | … | |
| Full time | … | … | 1.49 (0.78, 2.84) | .23 | … | … | … | … |
| Unemployed, looking for work | … | … | 0.66 (0.27, 1.59) | .35 | … | … | … | … |
| Unemployed, not looking for work | … | … | 2.39 (0.96, 5.92) | .06 | … | … | … | … |
| Missing | … | … | 0.60 (0.30, 1.21) | .15 | … | … | … | … |
| Baseline housing situation | ||||||||
| Living alone | … | … | … | … | 1.00 | 1.00 | ||
| Living with friends or relatives | … | … | … | … | 0.71 (0.46, 1.10) | .12 | 0.68 (0.39, 1.17) | .16 |
Note. OR = odds ratio; CI = confidence interval; TANF = Temporary Assistance for Needy Families. Multivariate logistic regression was performed to obtain the best estimate of the relation between maternal health literacy and participation with a best subsets approach to arrive at final models separately for birth and 6 months of age. Analytic samples for TANF participation were 626 (of 744) at birth and 499 (of 744) at 6 months; for Food Stamp Program participation, samples were 590 (of 744) at birth and 472 (of 744) at 6 months. No significant differences were found in the distribution of demographic variables (infant birth weight, maternal age, maternal birth country, maternal education, maternal employment) between the analytic samples and the full cohort (data not shown). ORs present estimates for all predictors included in each of the 4 best models. Associations between explanatory variables were assessed to exclude multicollinearity. Although health literacy was related to maternal education, 38% of the mothers with inadequate health literacy had an education greater than high school. Although income and employment were significantly related (P < .001), they were not collinear, and both contributed to the model. All analyses were conducted with SAS (Version 9.1.3; SAS Institute Inc, Cary, NC).
DISCUSSION
To our knowledge, our study is the first to examine the relation of maternal health literacy to public program participation. We found that mothers with poor health literacy were much less likely to receive TANF than were mothers with adequate health literacy. We also found that although maternal education and health literacy were highly correlated, maternal education was not distinctly associated with participation in any of the social welfare programs examined. Programs with streamlined institutionalized enrollment protocols, such as WIC, also appear to have much higher enrollment rates than do those with more complex and fragmented procedures.
These results had some caveats. First, generalizability is limited by the study population composition and single location. Second, self-reported data about public program participation are subject to recall bias. Third, only 53% of the eligible mothers participated; this could result in selection bias. Fourth, we did not analyze the literacy demands of the application process. Fifth, we chose a health literacy measure, which is correlated with but not the same as a more general literacy assessment.10 Finally, we examined participation at birth and at 6 months of age; multisite observation over a longer period is likely to contribute additional information to assist policymakers in program development.
Our findings indicated that systematic changes in enrollment procedures can be made to promote participation in public programs that benefit children. Initiatives to increase enrollment in public programs might focus on simplifying procedures, whereas welfare-to-work evaluations may focus on promoting educational attainment. Further research into solution-oriented approaches to these problems is warranted.
Acknowledgments
Funding for this study was provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grants K23HD047655 and R03HD0536363).
We gratefully acknowledge the investigators, staff, and participants of the Health Insurance Improvement Project for their commitment to the success of this project.
Human Participant Protection
All study activities were approved by the institutional review boards at the Children's Hospital of Philadelphia and the University of Pennsylvania. Participants provided written consent and were remunerated according to the study protocol.
References
- 1.The National WIC Evaluation: An Evaluation of the Special Supplemental Food Program for Women, Infants, and Children. Vol 1: Summary Alexandria, Va: US Department of Agriculture Food and Nutrition Service; 1987 [Google Scholar]
- 2.Kenney G, Haley J, Dubay L. Why aren't eligible uninsured children enrolling in Medicaid and SCHIP? Abstr Acad Health Serv Res Health Policy Meet. 2001;18:6 [Google Scholar]
- 3.Halfon N, Inkelas M, Newacheck PW. Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement. Milbank Q. 1999;77:181–204 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ellwood MR, Lewis K. On and Off Medicaid: Enrollment Patterns for California and Florida in 1995. Washington, DC: The Urban Institute; July 1999. Occasional Paper 27 [Google Scholar]
- 5.Davidoff AJ, Garrett AB, Makuc DM, Schirmer M. Medicaid-eligible children who don't enroll: health status, access to care, and implications for Medicaid enrollment. Inquiry. 2000;37:203–218 [PubMed] [Google Scholar]
- 6.Bartlett S, Bobronnikov E, Pacheco N, et al. WIC Participant and Program Characteristics 2004, WIC-04-PC. Alexandria, Va: US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation; March 2006 [Google Scholar]
- 7.Barrett A, Poikolainen A. Food Stamp Program Participation Rates: 2004. Washington, DC: US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation; June 2006 [Google Scholar]
- 8.Medicaid Enrollment: Amid Declines, State Efforts to Ensure Coverage After Welfare Reform Vary. Washington, DC: US General Accounting Office; 1999 [Google Scholar]
- 9.Health literacy. Available at: http://en.wikipedia.org/wiki/Health_literacy. Accessed April 21, 2010.
- 10.Nielsen-Bohlman L, Panzer AM, Kindig DA, Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004 [PubMed] [Google Scholar]
- 11.Pati S. K23HD047655: Health Care Access: Maternal, Child, and Policy Factors. Philadelphia, Pa: The Children's Hospital of Philadelphia and the University of Pennsylvania; 2005–2010 [Google Scholar]
- 12.Pati S, Shea JA. R03HD0536363: Maternal Health Literacy and Child Health Program Participation. Philadelphia, Pa: The Children's Hospital of Philadelphia and the University of Pennsylvania; 2008. –present. [Google Scholar]
- 13.Nurss JR, Parker RM, Williams MV, Baker DW. TOFHLA: Test of Functional Health Literacy in Adults. 2nd ed Snow Camp, NC: Peppercorn Books & Press; 2001 [Google Scholar]
- 14.Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med. 1995;10:537–541 [DOI] [PubMed] [Google Scholar]