A mixed-methods assessment of the role of health literacy and numeracy in contraceptive decision-making among postpartum patients in an urban Chicago population

Abstract

OBJECTIVE: Low health literacy and numeracy are increasingly recognized as predictors of poor health outcomes, yet little is known about the role of literacy and numeracy in family planning. This study assessed the role of health literacy and numeracy in contraceptive decision-making.DESIGN: Brief surveys, including literacy and numeracy assessment tools, and semi-structured interviews were conducted with 30 postpartum patients.MATERIALS AND METHODS: This study combined ethnographic interviews on contraceptive decision-making with quantitative assessments of health literacy and numeracy. Participants were postpartum, English-speaking women. Health literacy was assessed using the REALM-7 scale. Health numeracy was assessed using a 3-item scale developed by Schwartz et al (Schwartz 1997). Descriptive statistics were completed with SPSS. Literacy and numeracy data informed the traditional qualitative analysis, which was conducted using a grounded theory approach with NVivo software.RESULTS: In this cohort of African American (63%) and Hispanic (37%) women (median age 26), mean REALM-7 score was 6.03. 50% scored a 6 or less, indicating low health literacy. REALM-7 scores did not differ by age, parity, education, ethnicity, pregnancy intention, or use of contraception at time of conception. Mean Schwartz scale score was 1.03; only 10% were able to answer all questions accurately. A high school education or less was associated with lower Schwartz scores (0.50 vs 1.30, p=0.029); numeracy scores did not differ by any other variable. On mixed methods analysis, women with low literacy or numeracy scores were more likely to endorse feelings of invulnerability or ambivalence about pregnancy. These same women had poorer contraceptive knowledge, held more misconceptions about contraception, and felt contraception was difficult to use. Oral contraception was particularly challenging for this population, due to the difficulties of daily medication use and understanding the missed-pill protocol.CONCLUSIONS: Low health literacy and numeracy is a common problem in this population, and may be an obstacle to effective family planning via its relationship to poor contraceptive knowledge and subsequent utilization challenges. Contraceptive counseling should be at a literacy and numeracy level appropriate to the individual. Additional research should expand this investigation of the impact of low literacy and numeracy on contraceptive use. OBJECTIVE: Low health literacy and numeracy are increasingly recognized as predictors of poor health outcomes, yet little is known about the role of literacy and numeracy in family planning. This study assessed the role of health literacy and numeracy in contraceptive decision-making. DESIGN: Brief surveys, including literacy and numeracy assessment tools, and semi-structured interviews were conducted with 30 postpartum patients. MATERIALS AND METHODS: This study combined ethnographic interviews on contraceptive decision-making with quantitative assessments of health literacy and numeracy. Participants were postpartum, English-speaking women. Health literacy was assessed using the REALM-7 scale. Health numeracy was assessed using a 3-item scale developed by Schwartz et al (Schwartz 1997). Descriptive statistics were completed with SPSS. Literacy and numeracy data informed the traditional qualitative analysis, which was conducted using a grounded theory approach with NVivo software. RESULTS: In this cohort of African American (63%) and Hispanic (37%) women (median age 26), mean REALM-7 score was 6.03. 50% scored a 6 or less, indicating low health literacy. REALM-7 scores did not differ by age, parity, education, ethnicity, pregnancy intention, or use of contraception at time of conception. Mean Schwartz scale score was 1.03; only 10% were able to answer all questions accurately. A high school education or less was associated with lower Schwartz scores (0.50 vs 1.30, p=0.029); numeracy scores did not differ by any other variable. On mixed methods analysis, women with low literacy or numeracy scores were more likely to endorse feelings of invulnerability or ambivalence about pregnancy. These same women had poorer contraceptive knowledge, held more misconceptions about contraception, and felt contraception was difficult to use. Oral contraception was particularly challenging for this population, due to the difficulties of daily medication use and understanding the missed-pill protocol. CONCLUSIONS: Low health literacy and numeracy is a common problem in this population, and may be an obstacle to effective family planning via its relationship to poor contraceptive knowledge and subsequent utilization challenges. Contraceptive counseling should be at a literacy and numeracy level appropriate to the individual. Additional research should expand this investigation of the impact of low literacy and numeracy on contraceptive use.