'Breaking It Down': Patient-Clinician Communication and Prenatal Care Among African American Women of Low and Higher Literacy

Abstract

PURPOSE Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored. METHODSWe undertook a concurrent mixed methods study among 202 African American women of low (≤6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defi ned by (1) starting care after the fi rst trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identifi ed and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confi rmatory focus groups stratifi ed by literacy.RESULTS Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the fi rst trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identifi ed a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confi rmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplifi ed by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care.CONCLUSION Women who had both low-and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians infl uenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians. INTRODUCTIOND espite efforts to improve utilization of maternal health services, vulnerable populations are more likely to enter prenatal care late or receive no care.1 In 2002 African American women were 3 times as likely as white women to have no prenatal care.2 Although increasing the utilization of prenatal care alone will not eliminate the wide disparities in maternal-child health outcomes experienced by African American women, reducing obstacles to prenatal care that may contribute to improved utilization of postpartum and pediatric care is an important goal of the US health system. [3][4][5][6][7][8] Low literacy has been proposed as a possible mediator of health dis- parities, in part through its effects on health care utilization, yet we are not aware of any research that has explored the role of low literacy as an obstacle to utilization of prenatal care.9 What is known is that women with less than a high school education, a risk factor for low literacy, are less likely to initiate early prenatal care. 1,10,11 Literacy is also a critical skill needed for health literacy, which involves both health care navigation and health decision-making skills.9 Studies that identify obstacles to care faced by women of low literacy are needed to guide interventions to improve ...

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