Health Literacy in Pediatric Consultations on Allergy Prevention
Abstract
Background:
The first 3 years of life offer an opportunity to prevent allergic diseases. Pediatricians are an important source of health information for parents. However, a certain degree of health literacy is necessary to understand, appraise, and apply preventive behavior, which can be supported by health literacy (HL) sensitive consultations and a HL friendly environment.
Objective:
In this study, we want to shed light on how pediatricians in outpatient care in Germany advise on early childhood allergy prevention (ECAP) and how they consider parental HL.
Methods:
We conducted 19 semi-standardized telephone interviews with pediatricians from North-Rhine-Westphalia and Bavaria. The interviews were audio-recorded, transcribed, pseudonymized, and subjected to content analysis.
Key Results:
Current ECAP recommendations were well known among our sample. Despite the shift of evidence from avoidance of allergens toward early exposure, providing advice on ECAP was considered non-controversial and it was widely assumed that recommendations were easy to understand and apply for parents. However, ECAP was treated as an implicit topic resonating among others like infant nutrition and hygiene. Regarding HL, our interview partners were not aware of HL as a concept. However, they deemed it necessary to somehow assess parental information level and ability to understand provided information. Formal HL screening was not applied, but implicit strategies based on intuition and experience. Concerning effective HL-sensitive communication techniques, interviewees named the adaptation of language and visual support of explanations. More advanced techniques like Teach Back were considered too time-consuming. Medical assistants were considered important in providing an HL-sensitive environment. Time constraints and the high amount of information were considered major barriers regarding HL-sensitive ECAP counseling.
Conclusion:
It seems warranted to enhance professional education and training for pediatricians in HL and HL-sensitive communication, to reach all parents with HL-sensitive ECAP counseling. [HLRP: Health Literacy Research and Practice. 2024;8(2):e47–e61.]
Plain Language Summary:
We asked pediatricians how they advise parents on prevention of allergy in children. We found that pediatricians were well aware of the recommendations on allergy prevention, but they did not pass on all the information to parents. The HL of parents (that is the ability to find, understand, appraise, and apply health information) was not an important issue for the doctors.
Introduction
Allergic diseases, including allergic rhinitis, food allergy, asthma, and atopic dermatitis are a major public health concern (Asher et al., 2006; Bergmann et al., 2016; Peters et al., 2017). Preventive measures are crucial for optimizing health outcomes across the lifespan and may reduce the risk of allergies, particularly when addressed in young children (Caffarelli et al., 2018; Morniroli et al., 2021). However, guidelines and recommendations regarding early childhood allergy prevention (ECAP) are complex and keep changing. In 2010, the official German recommendation regarding the introduction of solid food changed from avoidance of allergens to early exposure (Muche-Borowski et al., 2009). This change has been confirmed in 2014 and 2022 (Kopp et al., 2022; Schäfer et al., 2014). However, knowledge around ECAP is still incomplete and new studies and recommendations are published continuously. Thus, the transfer of the latest knowledge can be challenging, such as when pediatricians are supposed to communicate evidence from research or recommendations from guidelines to parents (Gupta et al., 2020).
Pediatricians are an important and oftentimes highly trusted source of information for parents including ECAP. In Germany, six preventive check-ups are scheduled during the children's first year of life (Schmidtke et al., 2018). In accordance with widely accepted conceptualizations of health literacy (HL), which emphasize health systems' and health care institutions' role in enabling individuals to access, understand, appraise, and apply health information (Sørensen et al., 2012); it is necessary for physicians to consider parental HL during their consultations. Studies indicate that low parental HL is associated with worse health outcomes in children (DeWalt et al., 2007), and parents with low HL also tend to prevent diseases in their children less effectively (de Buhr & Tannen, 2020; Miller et al., 2010; Morrison et al., 2019). However, several studies have shown that health care professionals often overestimate their patients' HL (Dickens et al., 2013; Griffeth et al., 2022). This overestimation may cause misunderstandings, especially as those with low HL tend to ask fewer questions (Katz et al., 2007; Menendez et al., 2017). Davis et al. (2013) highlight the importance of HL regarding health promotion in pediatric primary care, concluding that targeted health information is needed to ensure understanding and application, and they are suggesting that HL screening in pediatric primary care settings is essential.
This study aims to shed light on how HL is considered in pediatric consultations with ECAP as a use case. Our objectives were to explore how pediatricians advise on ECAP, to what extent and how they assess whether parents are health literate, how they account for HL, and which barriers they encounter regarding HL-sensitive communication and creating a HL-sensitive environment in pediatric outpatient care when providing advice on ECAP.
Methods
Study Design
The ethic committee of the University of Regensburg approved this study (18-1205-101). Written consent was obtained from all study participants in accordance with the ethics approval. Participation was voluntary and financial incentives for participation were offered.
We chose an exploratory qualitative study design allowing us to explore meanings of social phenomena as experienced by pediatricians in their natural context in depth (Malterud, 2001) and without envisaging broader representativeness (Mays & Pope, 1995). The approach is flexible and open-minded. Personal experiences and subjective views provide different perspectives that might be missed out on when working with predefined categories and assumptions (Ritchie, 2011). Our study was registered in OSF ( https://osf.io/) and published as a protocol beforehand (Curbach et al., 2021).
Theoretical Underpinning
According to the comprehensive HL model of Sørensen et al. (2012), the ability of an individual to find, understand, appraise, and apply health information is put into the context of personal, situational, social, and environmental determinants. This model defines our understanding of HL in this study. Pediatricians are an important source of health information for parents and by providing a HL-sensitive environment may co-determine parental HL. The model, with its core elements of supporting parents in accessing, understanding, appraising, and applying health-related information, served as a basis to develop the interview guide. Subsequently, the categories for analyzing data were derived deductively from the interview guide and inductively from the generated interview data.
Data Collection
From July 2020 to February 2021, two early-career research fellows with previous qualitative research experience and backgrounds in Comparative European Ethnology (J.v.S., E.-M.S.) conducted semi-structured interviews. The interviews were conducted via telephone, audio-recorded, transcribed verbatim, and pseudonymized. The interview guide consisted of questions regarding (1) ECAP in pediatric consultations, (2) ECAP information acquisition and transfer to parents, and (3) consideration and support of parental HL when providing advice on ECAP (Table A). Information on characteristics of the participants was collected after the interview.
| The interviews started with questions on COVID-19, as the pandemic was very much in focus at the time of the interviews. These were analyzed separately (von Sommoggy et al.: Pediatricians' Experiences of Managing Outpatient Care and Patient Counselling during the COVID-19 Pandemic: A Qualitative Study in Germany. Submitted.) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Introduction – Early Childhood Allergy Prevention (ECAP) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Information acquisition and transfer to parents | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| HL-sensitive consultations | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Recruitment
A purposive sampling strategy was applied to obtain rich information, with a maximum variation of perspectives to ensure rigor (Mays & Pope, 1995; Palinkas et al., 2015). We recruited pediatricians working in outpatient care in Germany, with a focus on reaching a variety regarding the catchment area of the practice (rural/urban), gender, form of practice (shared/single), working experience (less than or more than 15 years) and specialization regarding allergies (Table 1). Pediatricians working solely in a hospital setting were excluded. Initial contact to interview partners was established through “PaedNetz Bayern,” a Bavarian association of pediatricians, and the Professional Organization of Pediatricians Nordrhein.
| Sample Category | Pediatricians |
|---|---|
| Catchment area | |
| Rural: Village/small town: <20,000 inhabitants | 6 |
| Urban: Medium-sized/large town: >20,000 | 13 |
| Gender | |
| Male | 9 |
| Female | 10 |
| Practice | |
| Single | 8 |
| Shared | 11 |
| Experience | |
| ≥15 years | 9 |
| <15 years | 10 |
| Specialization in pediatric allergy | |
| Yes | 6 |
| No | 13 |
Written information material was forwarded to potential participants by the chairperson of the respective association. After sending emails with detailed information on the study, further information was provided via telephone and dates for interviews were scheduled. Subsequent snowballing and personal contacts completed our sample. Recruitment was stopped once theoretical saturation was reached. During the collection of the interview data, the research team continuously discussed topics and themes in the data.
After 15 interviews, three researchers (J.v.S., E.-M.S., J.C.) jointly agreed that no more topics had emerged. Four additional interviews were conducted to ensure that data saturation was reached (Saunders et al., 2018).
Sample
Of the 10 female and 9 male study participants, 9 worked in North-Rhine-Westphalia and 10 in Bavaria. The ages ranged between 39 and 67 years. Eight pediatricians worked in a single practice and 11 in a shared practice. Further characteristics are provided in Table 1.
Analysis
Data were subjected to content analysis (Kuckartz, 2018). Initially, the interviews (range: 26–103 minutes; mean: 48 minutes) were deductively divided into three main topics following the topic guide to become familiar with the data (Malterud, 1993). For each main topic, four interviews were coded jointly by two researchers (J.v.S., E.-M.S.) using Atlas.ti (Version 8) identifying emerging topics and organizing them into a code scheme. Thereafter, all interviews were coded following this code scheme by two researchers independently (J.v.S., E.-M.S.). After completion, divergent coded passages were discussed until consensus was reached (Fereday & Muir-Cochrane, 2006). By grouping codes into higher levels, overarching themes were identified. These were summarized and enriched with the most significant quotes (Patton, 2009). The study adheres to the COREQ (COnsolidated criteria for REporting Qualitative Research) guideline for reporting qualitative research results (Tong et al., 2007).
Informed Consent and Confidentiality
Participation in the study was only possible after providing informed consent to the audio recording and scientific use of the interview data. Data storage and handling of personal information followed the data protection policy of the Medical Sociology of the University of Regensburg (Medizinische Soziologie, 2021).
Results
First, we will present our results focusing on ECAP in pediatric consultations in general. Then, we will take a closer look at ECAP related HL-sensitive advice in pediatric practices to lastly identify barriers in providing HL-sensitive advice on ECAP.
ECAP in Pediatric Consultations
Considering allergy risk. Most pediatricians considered allergy risk anamnesis during the first consultation essential for all children. They described different strategies to assess the allergy risk (e.g., asking verbally during the examination or handing out a questionnaire beforehand) (Table 2). However, they emphasized that allergy anamnesis poses a challenge during consultations, as parents oftentimes lack understanding of how the term “allergy” is defined. Sometimes it is necessary to explicitly inquire if, for example, hay fever has occurred in the family to correctly determine the child's allergy risk (Table 2).
| Allergy Risk | Quotes | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Considering allergy risk | |||||||||||||||||||
| Assessing allergy risk |
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| Advising families with children with an allergy risk |
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| ECAP evidence transfer to parents | |||||||||||||||||||
| Dealing with the evidence shift |
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| Allergy Risk | Quotes | ||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Integrating ECAP in pediatric consultations |
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| Topics considered important for ECAP |
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| Allergy Risk | Quotes | ||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Adapting ECAP recommendations |
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| Reassuring parents regarding allergies |
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Even though the allergy risk was assessed by pediatricians most of the time, the pediatricians also stated that they do not adapt the content of advice regarding ECAP, as recommendations are similar for families with or without a risk of allergy (e.g., early introduction of solid food while breast-feeding, no omission of allergens) (Table 2). Families with children who have risk factors for allergies are advised to adhere to general prevention recommendations and only sometimes advised more specifically (e.g., regarding skin care) (Table 2).
ECAP evidence transfer to parents. All interviewees were well aware of current ECAP recommendations and the shift of evidence from avoidance of allergens to early exposure. It was mostly reported there weren't difficulties explaining this change in recommendations. They appeared highly confident that parents were able to understand and accept their explanations and assumed that parents trusted their advice (Table 2).
Our interview partners described ECAP as usually not being a stand-alone topic, but as included in recommendations on health behavior in general (Table 2). They did not perceive ECAP and passing on respective information to parents as difficult or controversial.
As ECAP is resonating within basic topics, they described it as rather easy to explain and most interviewees were generally convinced that it was also easy to understand for parents and most recommendations would be easy to apply (Table 2).
The topics considered most important in which ECAP resonates during consultations are nutrition (breast-feeding, choice of formula, introduction of solid food), hygiene, skin care, and the living environment (smoke-free, recommendations regarding pets) (Table 2).
Scientific evidence regarding ECAP was only sometimes described to be directly passed on to parents. A process of filtering and translating information according to parents' abilities was outlined (Table 2). Some pediatricians recounted to adapt their recommendation according to their own interpretation of current scientific evidence (Table 2).
Referring to the early introduction of peanuts in child nutrition—an example for a very specific and rather radical recommendation—pediatricians were largely aware of current evidence, but reluctant to communicate it explicitly. Only when asked by parents, they would elaborate on this in more detail. Fear of unwanted side effects (e.g., aspiration of a peanut) and cultural inhibitions, as peanuts not being an integral part of most Germans' nutrition, were reasons to omit these recommendations (Table 2).
Reassuring parents regarding allergies. Several interviewees stated that part of providing advice on ECAP is also to reassure insecure or overcautious parents (e.g., who are feeding hypoallergenic infant formula or omitting food without any indication). These pediatricians emphasized the need to calm parents down and put recommendations into perspective (Table 2).
Pediatricians' Consideration and Support of Parental HL
Knowledge of HL concept. We asked the interviewees if they knew the term “health literacy.” Most pediatricians of our sample stated that they had heard of the term (Table 3). However, in their accounts it became clear that most were not aware of HL as the competence to find, understand, appraise, and apply health information. HL was rather perceived as another term for knowledge about health and health behavior, which, according to the interviewees, should be provided in school (Table 3). Only pediatricians with a strong background in research had heard about HL as in our understanding (Table 3).
| Parental Health Literacy | Quotes | ||||||||||||||||||||||||||||||
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| Pediatricians' consideration and support of parental health literacy | |||||||||||||||||||||||||||||||
| Knowledge of health literacy concept |
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| Assessment of parental health literacy | |||||||||||||||||||||||||||||||
| Intuition and experience of pediatricians |
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| Question-asking behavior of parents |
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| Education and profession of parents |
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| Parental Health Literacy | Quotes | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health literacy sensitive consultations | |||||||||||||
| Adapting the language |
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| Demonstrating explanations |
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| Fostering question-asking behavior |
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| Using Teach Back |
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| Summarizing the most important messages in the end |
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| Health literacy sensitive environment | |||||||||||||
| Providing written information |
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| Other providers of information within the practice |
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| Offering additional advice |
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Assessment of parental HL. All interviewees considered assessing parents' information needs during initial appointments important, as well as parents' current state (e.g., suffering sleepless nights or post-natal depression). None of the pediatricians used a formal strategy (e.g., questionnaires) to assess parental HL, but all applied implicit strategies. They described their intuition and experience as most important to judge parental HL and frequently recounted that, especially during initial medical check-ups, they usually take their time to get to know parents during a longer conversation (Table 3). The questions parents asked during the first conversations were described as a strong indicator on how well parents are informed, what knowledge they are lacking and, thus, where the consultation needs to start and how it needs to be adapted, respectively (Table 3). Besides verbal interaction with parents, pediatricians frequently referred to their visual impression (e.g., clothing and parent-child interaction, and parents' education and profession as further indicators of parental HL) (Table 3).
Overall, pediatricians appeared rather confident in correctly assessing information needs and judging parents' ability to understand health information. Some considered this as one of their core skills as a pediatrician (Table 3).
HL-sensitive consultations. When asked about ECAP communication strategies, which consider parents' ability to understand and apply health information, our interview partners deemed the use of easy language and the omission of science language most important. Some stated to adapt their language based on their previous assessment of parents (Table 3), whereas others thought it to be important to use easy language with all parents, regardless of education, profession, or personal impression (Table 3). Most pediatricians were convinced that they were well understood by all parents.
As another strategy to facilitate understanding, pediatricians referred to the use of pictures, pictograms, videos and mimicking to explain conditions more in depth (Table 3). However, this was rarely described for advising on ECAP, but rather when explaining physical conditions, like the occurrence of an asthma attack, or interventions like the use of asthma spray.
To ensure that the information provided was understood, most interviewees asked the parents at the end of the consultation if they still had any questions; this was a common strategy (Table 3). The interviewees were convinced that parents do feel free to ask questions and have no inhibitions. It was sometimes recounted that it is possible to observe if information was understood or not, due to the frequent contact with the families during the first year of life (e.g., if parents adhered to recommendations or not) (Table 3). Only one pediatrician reported to apply Teach Back and have parents sum up what was explained in their own words to ensure understanding (Table 3). Others summarized the most important messages of their consultation in the end themselves (Table 3).
HL-sensitive environment. Handing out written information was regarded as mostly helpful. This would allow parents to go more into depth on certain topics at home when they had more time and were less distracted. However, written information specifically on ECAP was only rarely passed on, as the pediatricians had the impression parents were overwhelmed by written information (Table 3). Writing down individual take-home messages was considered helpful (e.g., how to take the medication) (Table 3).
Furthermore, some pediatricians mentioned the importance of other personnel within the practice setting (e.g., physician assistants or pediatric nurses). Not only were they described as contributing to reduce the time needed for consultations and to answer parents' questions beforehand, but they were also sometimes considered an information resource that parents could contact more easily (Table 3).
Additionally, some interview partners stated to offer the possibility to ask further questions via telephone or email after the consultation within the practice, which was described as being readily accepted by parents (Table 3).
Barriers in Providing HL-Sensitive Advice on ECAP
Timing of Providing Advice on ECAP
First contact with the family pediatrician usually takes place when the child is between the ages 3 and 8 weeks old. Pediatricians in our sample consented that this was too late for providing advice on ECAP adequately, since parents decide for or against breastfeeding right after birth. Hence, they favored a preventive medical check-up before delivery to advise on ECAP in a more timely and suitable moment (Table 4). Some pediatricians suggested the provision of ECAP information by obstetricians and midwives, as they are providing health information during pregnancy and can therefore lay the foundation for comprehensive ECAP (Table 4).
| Health Literacy Advice | Quotes | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Barriers in providing health literacy advise on ECAP | |||||||||||||||||||
| Timing of providing advice on ECAP |
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| Cooperation with midwives |
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| Time and amount of topics |
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Cooperation with Midwives
The crucial role of midwives for providing adequate advice on ECAP was mentioned in some interviews, as those are closely connected to the families and oftentimes attend them before, during, and after birth. Thus, a strong relationship of trust can be developed and recommendations by midwives might be adhered to more strongly.
Therefore, the need to align consultations by midwives more strongly with pediatric consultations was emphasized as there are sometimes discrepancies regarding recommendations on feeding (e.g., some midwives would still recommend 6 or 7 months of exclusive breastfeeding, whereas an earlier introduction of solid food is recommended in current guidelines) (Table 4).
Time and Amount of Topics
Time constraints constitute a major barrier regarding HL-sensitive provision of advice on ECAP according to the interviewees. Health topics to be covered during the first appointments are numerous and parents are oftentimes distracted by the (crying) baby and thus not able to take up all the information provided within the time foreseen. Applying HL-sensitive communication strategies like Teach Back to ensure understanding was perceived as too time-consuming. Additionally, interview partners emphasized a lack of financial compensation regarding intensive consultations and some stated that integrating HL-sensitive communication techniques and providing more comprehensive ECAP information would overburden them (Table 3).
Discussion
In our study, all pediatricians deemed ECAP a relevant topic for families of infants. While allergic risks are normally assessed during initial encounters, ECAP is addressed only implicitly as part of general advice on nutrition, hygiene, and smoking. Morniroli et al. (2021) concluded that mothers need a thorough knowledge on prevention topics, as otherwise benefits of breastfeeding and vaccines may be underestimated. This may be the case for ECAP as well, because parents may underestimate the potential of prevention of advice on ECAP when it only resonates in other areas such as nutrition, hygiene, and living environment.
Even though there was a shift of ECAP evidence, pediatricians of our sample described it as an easy to explain topic. In their everyday practice they sometimes refer to scientific evidence to underline changes in recommendations, but mostly they filter and adapt information to the parents' needs. The provision of scientific information to parents can enhance adherence (Buffarini et al., 2020; Griffeth et al., 2022); thus, it is necessary to consider to what extent information is filtered and adapted to ensure parents are provided with adequate information.
In line with Chang et al. (2021), who conducted a qualitative study on early peanut introduction and testing in the United States, we also observed that specific recommendations were rather reluctantly passed on by pediatricians. However, in our study, lack of pediatricians' awareness was not a barrier, as the recommendation of introducing peanut early was well known, but rather fear of “side effects” was mentioned as inhibiting factor (e.g., the aspiration of peanuts) (Alvarez et al., 2020; Chang et al., 2021).
Pediatricians are an important source of health-related information for families. They have the possibility to provide access to information and help parents understand, appraise, and apply health information. However, like in other studies, our interview partners were mostly unaware of HL as a concept and the responses regarding the meaning of HL differed (Gillis et al., 2013; Lambert et al., 2014). Nevertheless, our interviewees did consider it important to somehow assess how parents handle health information. HL assessment tools were not applied, which is in line with the findings of a study on HL perceptions and knowledge in pediatric continuity practices (Griffeth et al., 2022) as well as a study on nursing and allied health professionals (Brooks et al., 2020). However, parental HL was assessed based on intuition and experience by considering parental education and profession, questions asked by parents, language used and parent-child interaction. It is common to assess people based on their appearance, as was frequently mentioned in the interviews, and was described similarly in another qualitative study with nursing and allied health professionals (Brooks et al., 2020). However, for health professionals and regarding HL, everyday life preconceptions should not be the guiding principle to estimate patients' information needs, as patients' HL can easily be overestimated or underestimated. Even though some researchers recommend formal HL screening (Davis et al., 2013; Hadden & Kripalani, 2019), there are also some studies that indicate that formal HL screening is not always considered advisable; the potential harm from shame and alienation may outweigh benefits (Bitzer, 2017; Kronzer, 2016; Paasche-Orlow & Wolf, 2008). In turn, however, patients can be overestimated in how well they understand health information (Dickens et al., 2013; Griffeth et al., 2022; Storms et al., 2019; Voigt-Barbarowicz & Brütt, 2020). This may be particularly disadvantageous regarding preventive topics like ECAP, as they are considered easy to understand and to apply and parents' comprehension of information might thus be overestimated.
Therefore, the universal precaution approach could substitute explicit HL screening, meaning that all patients are treated as if of low HL (DeWalt et al., 2011; Griffeth et al., 2022).
In our study, pediatricians regarded the use of simple language as the most important in HL-sensitive communication. However, in practice some speak plainly with all patients, whereas others adapted their language according to how they perceived a parent's HL. This is the perspective of the interviewees on their professional practice, and it remains unclear what is actually perceived by the patients. The use of simple language and avoidance of medical jargon may be overestimated, as was shown in a study on physicians' use of clear verbal communication (Howard et al., 2013). Our findings are similar to the findings of Griffeth et al. (2022) on HL perceptions and knowledge in pediatric continuity practices. In a mixed-methods survey, they could show that participants were convinced they could identify patients with low HL; only some (19% of the residents and 26% of faculty) were familiar with universal HL precautions and many received no HL training. Different to our results their participants could correctly identify the definition of HL.
Similarly, pediatricians of our sample perceived time constraints as a major barrier in providing advice HL-sensitively, which is also in line with a review by Rajah et al. (2018) on provider and patients' HL perspectives (Griffeth et al., 2022). Teach Back, although found an effective method (Talevski et al., 2020), was only applied by one of our interviewees due to time-constraints and lack of knowledge on how to apply Teach Back sensitively. This is in line with the findings of a mixed-methods study on limited health literacy. This study showed that physiotherapists agreed on the importance of communication techniques like Teach Back; however, this technique was only infrequently applied (Teach Back in 2% of consultations) (van der Scheer-Horst et al., 2023). However, Teach Back may actually save time in the long-term, as patients have fewer follow-up questions and are better prepared for appointments (Anderson et al., 2020). Family and internal medicine residents in the United States highly overestimated their application of Teach Back as they lacked knowledge on how to actually put this into practice. A 1-hour skills training increased their use of Teach Back significantly (Feinberg et al., 2019). It may be worth considering such training for pediatricians as well.
Practical Implications
The importance of considering HL in consultations on prevention should be more strongly emphasized in medical education and training. This might reduce health care professionals' reluctance to implement helpful techniques. The advantages of HL-sensitive communication (e.g., saving time in the long-term) should be emphasized to encourage its application with all patients. A closer alignment with midwives' consultations and maybe even earlier contact between pediatricians and parents (e.g., before the child is born) seems relevant, not only to cover topics like ECAP early, but also to foster parents' HL by providing evidence-based recommendations on certain topics such as high-quality websites on infant nutrition.
Strengths and Limitations
To our knowledge, this is the first study with ECAP as a use case for HL-sensitive consultations by pediatricians. The sample entailed a great variety of pediatricians, in terms of practices (rural vs. urban; individual vs. shared), age, and experience, and could capture distinct perspectives. This allowed for detailed insights into pediatricians' perceptions of their daily working life and their approach to providing advice on ECAP. However, a limitation of this study is that it is based solely on interview data from pediatricians and their own experiences and practices. We did not observe pediatricians' practice nor did we triangulate the data (e.g., with their patients' perception) and can thus make no assumption about the actual effects and effectiveness of the pediatricians communication behavior.
Originally, we had planned to collect the data via face-to-face interviews to perceive the context more closely (e.g., practice environment, interview situation, facial expressions and gestures) (Curbach et al., 2021). However, switching to telephone interviews, given the COVID-19 pandemic-related restrictions, offered more flexibility, as the interviews were conducted whenever convenient for the pediatricians. Subsequently, the interview situation was often relaxed and friendly, which was explicitly expressed by the interviewees oftentimes directly after the interviews.
Lastly, pediatricians with a special interest in ECAP or HL might have been more interested in study participation; therefore, the interviewees were possibly better informed on ECAP or had greater awareness of HL.
Conclusion
ECAP recommendations are well-known by pediatricians and considered easy to counsel on. However, ECAP is only seldomly addressed specifically, but rather in connection with recommendations on nutrition, hygiene, living environment and skin care. Even though all pediatricians of our sample considered it important to account for parents' information needs and abilities to understand, appraise, and apply health information, there is no systematic assessment of parental HL and the universal approach of treating all patients as if low HL is not always applied. It seems warranted to enhance professional education and training for pediatricians in HL and HL-sensitive communication to reach all parents with HL-sensitive advice on ECAP.
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