title: 'Breaking it down': patient-clinician communication and prenatal care among African American women of low and higher literacy.
abstract: OBJECTIVE
  Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored.
  
  
  METHODS
  We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first 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 identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy.
  
  
  RESULTS
  Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified 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 confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care.
  
  
  CONCLUSIONS
  Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.
authors.affiliation: Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA. ian.bennett@uphs.upenn.edu
authors.forename: Ian
authors.initials: I
authors.lastname: Bennett
authors.forename: Julia
authors.initials: J
authors.lastname: Switzer
authors.forename: Abigail
authors.initials: A
authors.lastname: Aguirre
authors.forename: Kelley
authors.initials: K
authors.lastname: Evans
authors.forename: Frances
authors.initials: F
authors.lastname: Barg
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American; D003142:Communication; D003144:Communication Barriers; D004522:Educational Status; D005260:Female; D006801:Humans; D008484:Medicaid; D010817:Physician-Patient Relations; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D014505:Urban Population