BACKGROUND: Increased participation of adolescents in sports has led to a significant rise in pediatric sports injury rates in recent years and limited health literacy puts patients at risk for worse outcomes through decreased patient satisfaction and compliance. Surprisingly little is known about the state of health literacy among pediatric sports injury patients and their guardians.
OBJECTIVE: We aimed to evaluate the extent of health care literacy disparities in patients populations at two clinics -- at the UCLA Medical Center in Santa Monica and the Orthopaedic Institute for Children, for both English and Spanish speaking patient populations. We evaluated health literacy through both self-reported health literacy measures and direct assessment of musculoskeletal care concepts and characterized disparities between groups based on socioeconomic status, demographics, and primary language at these two sites.
METHODS: We distributed questionnaires to patients and their guardians at both the UCLA Medical Center in Santa Monica (SMH) and the Orthopaedic Institute for Children (OIC) in downtown Los Angeles. Consenting guardians of patients and patients ages 10-17 visiting the clinic for treatment of a sports-related musculoskeletal injury were included in the study and questionnaires were available in both English and Spanish. Patients and guardians completed the questionnaires while waiting to be seen at the clinic. The survey was designed to include both self-reported health literacy measures and contain direct assessment of the patient’s knowledge and literacy regarding care for musculoskeletal injuries. Scores of self-reported general health literacy, self-reported musculoskeletal health literacy, and directly assessed musculoskeletal literacy were compared across groups of differing primary language spoken at home, type of health insurance, and by geographic location of care. Statistical analysis was performed using t-tests and significance was determined as p < 0.05.
RESULTS: Overall, 172 patient surveys were collected, with n = 91 girls and n = 81 boys participating at an average age of 14.5 years (SD 2.1). 157 guardian surveys were collected with n = 125 female and n = 28 male guardians at an average age of 42.1 years (SD 10.7). Self-reported general health literacy measured confidence filling out medical forms alone with 1 = Not at All Confident and 5 = Extremely Confident. There were significant disparities in self-reported general health literacy among guardian groups based on primary language spoken in the home [English mean 4.5 (SD 0.8) vs Non-English mean 3.9 (SD 0.9); p < 0.001] as well as by geographic location of care [OIC mean 4.2 (SD 1) v. SMH mean 4.6 (SD 0.7); p = 0.049], but no such disparities among the patient groups when compared by geography, health insurance type, or language. Self-reported musculoskeletal health literacy questions measured agreement with statements of understanding for musculoskeletal concepts. There were no significant disparities in self-reported musculoskeletal health literacy in patient or guardian groups based on primary language spoken in the home, type of health insurance, or geographic location of care. Directly-measured musculoskeletal literacy was evaluated using 5 multiple-choice, single best answer questions. Scores were calculated as the number correct out of 5. There were significant disparities in directly assessed musculoskeletal health literacy in guardian and patient groups based on geographic location [guardian OIC mean 3.3 (SD 1.2) v. SMH mean 4 (SD 1.1); p < 0.001] [patient OIC mean 3.1 (SD 1.2) v. SMH mean 3.8 (SD 1); p < 0.001] and health insurance type [guardian public/no insurance mean 3.9 (SD 1.2) vs private insurance mean 3.3 (SD 1.2); p = 0.006] [patient public/no insurance mean 3.6 (SD 1.1) vs private insurance mean 3.2 (SD 1.2); p = 0.035] as well as significant differences in only the guardian group by primary language spoken in the home [English mean 3.8 (SD 1.1) vs Non-English mean 3.0 (SD 1.4); p = 0.002]. In general, guardians scored better than the patients for health literacy in all categories: self-reported general health literacy, self-reported musculoskeletal health literacy, and directly-assessed musculoskeletal health literacy. Work to improve patient and guardian education can best be targeted towards guardians, who prefer medical education through verbal instruction (39%) and paper/pamphlet (41%) over online education.
CONCLUSIONS: Significant disparities in self-reported general health literacy and directly-assessed musculoskeletal health literacy exist, most notably between guardian groups based on primary language in the home and by geography. Improving disparities in health care literacy for this patient population may best be aimed at the guardians, using medical education through verbal and written instruction.