Child health

Cross-sectional study

Low parent health literacy is

associated with obesogenic infant
care behaviours
10.1136/eb-2014-101881

EunSeok Cha, Jennifer Lee Besse

Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta,
Georgia, USA
Correspondence to: Dr EunSeok Cha, Nell Hodgson Woodruff School of
Nursing, Emory University, 1520 Clifton Road NE Atlanta, GA 303224201, USA; echa5@emory.edu

Commentary on: Yin HS, Sanders LM, Rothman RL, et al. Parent
health literacy and obesogenic feeding and physical activityrelated infant care behaviours. J Pediatr 2014;164:57783.e1.

Implications for practice and research

Obesogenic infant care behaviours may increase childhood obesity,
and predict obesity and related health risks in adulthood.
Poor parent health literacy predicts poor child health outcomes including childhood obesity.
Nurses should assess parent health literacy and provide appropriate
support to prevent obesogenic infant care behaviours.
Future research could focus on evaluating parent educational programmes tailored to health literacy level and effectiveness on reducing
obesogenic care behaviours.

Context
Family-centred childhood obesity prevention programmes are recommended
from the prenatal period onwards.1 2 Such programmes address obesogenic
infant care behaviours including: infant feeding including formula feeding,
provision of sweet drinks and early introduction of solid foods; parent behaviours such as feeding immediately in response to crying and bottle-propping
and physical activity-related care behaviours such as excessive television (TV)
exposure and limited prone tummy time position.3 Health literacy is an
important consideration for obesity risk. A parentchild dyad study found
that parent health literacy was related to childhood obesity, while adolescent
health literacy is linked to obesity in adolescence.4 Few studies, however, have
examined parent health literacy and obesogenic infant care behaviours specically. Yin and colleagues examined this relationship and the potential to
inform childhood obesity prevention initiatives.

Methods
A cross-sectional analysis of baseline data, obtained as part of the Greenlight
cluster randomised trial, from 844 caregiverchild dyads, was undertaken.
Participants were enrolled during the infants 2-month well-child visits at
four university afliated paediatric continuity clinics. Parental interviews,
guided by an adapted Infant Feeding Style Questionnaire, assessed obesogenic
infant care behaviours (formula feeding, provision of sweet drinks, early
introduction of solid foods, controlling, laissez-faire and unresponsive parent
behaviours, TV exposure, and inadequate tummy time). Parental health literacy was measured using the Short Test of Functional Health Literacy in
Adults (S-TOFHLA). Data were analysed using the R data analysis software

46

(V.2.15). Comparisons were made between the analysis of unadjusted and

adjusted data for child, parent and household characteristics to examine relationships between health literacy and obesogenic infant care behaviours.

Findings
Of the 844 participating dyads, 95% (n=808) of caregivers were mothers
with about 11% (n=93) identied as having low health literacy
(S-TOFHLA22: 7.8% inadequate, 3.2% marginal). Parents with low
health literacy were more likely to primarily feed their infants formula
milk, coerce their child to feed, feed immediately when their baby cried
and report bottle-propping and inadequate tummy time. About 3% and
11% of parents reported giving their infant sweet drinks and introducing
solid foods early, respectively; there was no signicant difference by
level of parent health literacy. Likewise, TV watching while feeding did
not signicantly differ by level of parent health literacy.

Commentary
Despite the signicance of the study undertaken by Yin and colleagues,
the ndings must be carefully interpreted, as the relationships between
specic care behaviours and obesity are not yet fully supported by evidence. Recommendations prohibiting TV viewing before the age of 2 and
encouraging tummy time from birth, for example, are primarily concerned with child development not obesity.5 The reported proportion of
low health literacy in this study was also signicantly lower than other
studies (11% compared with 46%).6 It is unclear if study participants had
higher levels of health literacy or if ndings were inuenced by variations in the way S-TOFHLA was administrated. Finally, the studys specic aims and data analysis strategies were not clearly articulated. Yin
and colleagues compared study variables after dichotomising health literacy (low vs adequate), instead of examining associations among variables, and reported using the Mann-Whitney U test for categorical
outcomes despite it being a non-parametric test intended for continuous
variables.
This study has important implications for nursing practice and research.
Obesogenic infant care behaviours are common among parents. Nurses are
well positioned to support parents in reducing these behaviours through
health literacy-sensitive support. Nurses should be empowered to assess
parent health literacy and provide appropriate support to parents to reduce
obesogenic infant care behaviours. Family-centred childhood obesity prevention programmes tailored to parent health literacy level should be developed.
Competing interests None.

References
1. Davison KK, Jurkowski JM, Li K, et al. A childhood obesity intervention developed
by families for families: results from a pilot study. Int J Behav Nutr Phys Act
2013;10:3.
2. Tyler JM, Fruh SM, Mulekar MS. Pediatric obesity screening and prevention
strategies. J Contin Educ Nurs 2014;45:199200.
3. Perrin EM, Rothman RL, Sanders LM, et al. Racial and ethnic differences associated
with feeding- and activity-related behaviours in infants. Pediatrics 2014;133:
e85767.
4. Chari R, Warsh J, Ketterer T, et al. Association between health literacy and child and
adolescent obesity. Patient Educ Couns 2014;94:616.
5. Koren A, Reece SM, Kahn-Dangelo L, et al. Parental information and behaviours
and provider practices related to tummy time and back to sleep. J Pediatr Health
Care 2010;24:22230.
6. Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure
functional health literacy. Patient Educ Couns 1999;38:3342.

Evid Based Nurs April 2015 | volume 18 | number 2 |