July 2020, Volume 8, Issue 3, Number 19 Systematic Review: Health Literacy Measurement in Childhood: A Systematic Review Kobra Abedian Kasgari1 , Nooshin Peyman1,2 , Safa Momeni Badeleh3 , Mehdi Gholian Avval1,2 , Kosar Momeni Badeleh4 , Moham- mad Vahedian Shahroodi1,2 , Seyedeh Belin Tavakoly Sany1,2* 1. Department of Health Education and Health Promotion, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran. 2. Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. 3. Department of Food and Drug Control, School of Pharmacy, Zanjan University of Medical Science, Zanjan, Iran. 4. Department of Science, Islamic Azad University, Sari Branch, Sari, Iran. Use your device to scan and read the article online Citation Abedian Kasgari K, Peyman N, Momeni Badeleh S, Gholian Avval M, Momeni Badeleh K, Vahedian Shahroodi M, Tavakoly Sany SB. Health Literacy Measurement in Childhood: A Systematic Review. Journal of Pediatrics Review. 2020; 8(3):163-174. http:// dx.doi.org/10.32598/jpr.8.3.850.1 http://dx.doi.org/10.32598/jpr.8.3.850.1 : A B S T R A C T Background: Children constitute the main target population for Health Literacy (HL) research. There is limited academic agreement and measurement regarding the knowledge and skills of Article info: children concerning making health decisions. Received: 17 Sep 2019 Objectives: This review aimed to address this gap of data by providing an outline of current First Revision: 27 Sep 2019 studies of HL in childhood. Moreover, we attempted to comprehend available theories and Accepted: 10 Nov 2019 models concerning the needs and characteristics of children. Published: 01 July 2020 Methods: Six databases, including Scopus, PubMed, Cumulative Index to Nursing, Educational Resources Information Centre (ERIC), Web of Science, and Allied Health Literatures (CINAHL) were systematically searched using relevant keywords regarding HL and childhood. We included the relevant publications of up to July 2019. Interventional and cross-sectional studies with main focuses on generic HL and relevant content for conceptualizing and defining HL in children were included in this research. The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guideline was used to design this review study. Results: Overall, 25 studies conceptualized and defined HL; 8 definitions and 9 models have specifically focused on children aged 3-18 years. HL in children is defined as several main dimensions, each emerging as a collection of related ability, knowledge, and skills that allow an individual to derive at health-promoting actions and decisions, and approach health data, effectively. Conclusions: Identified models and definitions are highly diverse, signifying HL concepts are complex, multidimensional, and constructive. HL has been conceptualized as an action qualification, with the main attention on individual attributes, and understanding its Key Words: interrelationship with sociocontextual factors. Life phase specialty is mostly conceptualized Health literacy, from disregarding children’s specific needs, developmental viewpoint, susceptibilities, and Childhood, Child health social structures poorly synthesized within most definitions and models. * Corresponding Author: Seyedeh Belin Tavakoly Sany, PhD. Address: Department of Health Education and Health Promotion, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: +98 (915) 0060122 E-mail: tavakkolisanib@mums.ac.ir 163July 2020, Volume 8, Issue 3, Number 19 1. Introduction of children. To our knowledge, this systematic review is the first study to investigate the theoretical definitions rom a public health viewpoint, children and understanding of HL in children. This finding could are among the main target populations be practical for future HL interventions to promote chil- for Health Literacy (HL) studies and health dren’s health. F educational interventions. This is because, during childhood, fundamental cogni- 2. Methods tive skills, as well as emotional and physi- cal development processes occur, and Six databases, including Scopus, PubMed, Cumulative health-related behaviors and abilities are Index to Nursing, Educational Resources Information developed. Consequently, this stage of life is essential Centre (ERIC), Web of Science, and Allied Health Litera- for personal health and welfare during adulthood (1-4). tures (CINAHL) were searched. We conducted search Furthermore, HL is understood as a key construct to at- strategy based on the Medical Subject Heading (MESH) tain a life learning action, i.e., begins in early childhood keywords related to term “health competence”, “health (5-7). Then, target groups of HL interventions could be literacy”, and combined the following terms: “concept”, enabled to reducing health risks and promoting healthy “skills”, “model”, “theory”, “framework”, and “child- behaviors. In clinical settings, more studies have focused hood”. There were no limitations on the publication on the impact of maternal and parental HL on children’s time frame, peer-review criteria, or study design. health status. Several studies clarified how children are influenced by their parents’ lack of adequate skills and Interventional and cross-sectional studies with main knowledge. Such deficits complicate making health focuses on generic HL and relevant content for con- decisions and taking actions regarding their children’s ceptualizing and defining HL in children were included health (1, 2, 8). in this study. The papers were included if they met the following criteria: a. full-texts available in English; b. be- Therefore, some studies investigated children’s HL for ing focused on the HL concept and its core dimensions health promotion in schools (2, 9, 10). Furthermore, in childhood, and c. providing the relevant concept for there is limited academic agreement and measurement conceptualizing and defining HL in children. The exclu- of children concerning the knowledge and skills required sion criteria consisted of letters, reviews, poor quality to make health decisions. For the European population, articles, conference abstracts, and editorials. Initially, the HL consortium included differing dimensions and two independent authors screened the titles and ab- drivers to recommend HL. HL is “linked to literacy and stracts of the collected articles. Then, they evaluated improves individuals’ knowledge, incentive, and abili- the selected full-texts to examine whether the included ties to access, understand, appraise, and use health in- articles meet the inclusion criteria. The two authors formation”. “Such a process helps to make judgments were in 100% agreement over the articles included, and and take decisions in daily living regarding healthcare, a third reviewer resolved any doubts and discrepancies. disease prevention, and health promotion to maintain or improve the quality of life” (11, 12). It was evidenced This systematic review was conducted based on the that a specific outline for child HL is missing. Therefore, Preferred Reporting Items for Systematic Reviews and it is unclear how theoretical actions for demonstrating Meta-Analyses (PRISMA) guidelines for ensuring the HL in children identify related trials and do consider high quality and clarity of the collected information the sole features of the target population. Rothman et (12). In this study, HL was considered as a multidimen- al. identified 4 classifications of unique requirements sional construct or dimension for which the available and features to balance the child population from the studies were assessed and synthesized. We attempted adults. These classes include dependency on skills and to extract HL dimensions from available theoretical resources, developmental changes, vulnerability to so- definitions and models. Overall, 356 articles were iden- cial-demographic predictors and health determinants, tified (Figure 1), and 100 abstracts were selected after and epidemiological differences (13). Therefore, we at- removing duplicates. Figure 1 shows that 25 articles met tempted to address these gaps in the present research. the inclusion criteria and were selected for the full-text analysis. All these selected studies were qualitatively This study aimed to scope the recent definition and un- evaluated. First, selected articles were checked for theo- derstandings of HL in children. Moreover, we attempted retical models and definitions, i.e., adapted for the chil- to comprehend what available theories and models dren, and included pertinent concept on HL of children. provide the distinct requirements and characteristics Then, we coded these models and definitions following 164 Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 an inductive attitude. The relevant characteristics were Of the 8 definitions (Table 1), one study was related extracted, such as the author’s name, the time of re- to children aged 3 to 18 years (14); another two articles search conduction, the age of the target group, models targeted children <12 years (15, 16), and 4 definitions and theories explained, the primary target of study, tar- targeted 13- to 18-year-olds (9, 17-19). Five definitions get participation in development, empirical test, as well focused on a school health education program (9, 11, as the definitions and identified dimensions of HL. The 17, 18, 20). However, Massey et al. specifically targeted quality of all studies was assessed by a 12-item check- HL in the healthcare system (19). list; accordingly, those studies that obtained the mini- mum acceptable score were included in this review. The only research groups that linked empirical and exploratory dimensions to development in defining HL 3. Results were Fok and Wong (15), as well as Massey and associ- ates (19). Gordon et al. introduced this concept as stake- In this review of the literature, 8 definitions (Table 1) holder participation with school health community and 9 models (Table 2) on children’s HL were presented. partners (18). Therefore, HL was introduced not limited to reading, writing, or understanding the numbers (14). Records identified through database searching (n = 302) 165 noitacifitnedI gnineercS ytilibigilE dedulcnI gnineercS Additional records identified through other sources (n = 54) Records after duplicates were removed (n = 250) Records excluded (n = 125) : Records screened based on abstract/ title and abstract (n = 125) no full text available/ HL not estimated or not estimated with valid instruments Full-text articles assessed Full-text articles excluded (n = 105): for inclusion criteria Oral and mental se tting No validated, objective measure of (n = 20) HL/replication Studies included from in reference review (n=5) Full-text included in qualitative synthesis (n = 25) Figure 1. Flowchart of summarized search results Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 Table 1. HL definitions in children and youth populations No Authors Definitions Children aged <12 y “The ability to understand health information and actions taken by child and youth to affect health later 1 Brown 2009, (16) in life, combined with the ability to access valid health information”. “To understand and act upon biopsychosocial activities, being able to cope with necessary changes and 2 Fok & Wong 2002, (15) interact with others; demanding reasonable autonomy to achieve complete biopsychosocial health”. “HL is a degree to evaluate, seek, comprehend, and use health information, especially if materials are 3- to 18-year-olds presented in culturally-relevant, age-appropriate, and socially-supported manners”. The development of 3 G Borzekowski 2009, (14) HL among children could empower this “marginalized” and vulnerable population to be more productive and engaged, and healthier”. “HL is the degree to which individuals can obtain, process, and understand basic health services and data 10- to 18-year-olds 4 required to take suitable health decisions and involves an ongoing process of community capacity and Gordon, 2011 (18) enabling individuals to understand the components of health”. “Health literate individuals can apply and understand health information to better control their health, 5 Wu 2010 (17, 18) e.g., appraising the accuracy, credibility, and acting on that information to modify their living conditions and health behaviors”. “HL comprises a broad range of competencies and knowledge that individuals seek to evaluate, en- compasses, employ, and construct. Through HL competencies, individuals become able to understand 6 Paakkari & Paakkari, 2012 (9) others, themselves, and the world in a way that allows them to work on, and to make appropriate health decisions and change the condition that constitutes others’ health promotion chances and their own”. “HL is a set of skills used to apply and organize relevant health information, practices, and attitudes 7 Massey 2012, (19) when managing one’s health environment”. “HL entails individuals’ knowledge and literacy, competences, and motivation to understand, access, implement and appraise health information to make decisions and make judgments in everyday life; 8 Sørensen, 2012 (11) such measures are important concerning disease prevention, healthcare, and health promotion to im- prove life quality during the life course”. Table 2. Health literacy models in children Models The target popula- Authors Target group Context The primary target of the study ex- tion in develop- Empirical test plained ment 9- to 13-year- Health educa- A conceptual basis for measuring Brown, 2007 (20) old students Yes No Yes tion tool (operationalization) in grade s 5-8 12- to 13-year-old Health social- Testing and Paek, 2011 (21) Yes Yes Yes students in ization explorative(conceptualization) grade 7 9- to 13-year- Schmidt, 2010 Health educa- A specific model for the interven- old students Yes No Yes (22) tion tion program(operationalization) in grade 5 Students, Paakkari & Paak- Health educa- Theoretical exploration (concep- aged 9-13 Yes No No kari, 2012 (9) tion tualization) years Children of School health A conceptual basis for scale Wu, 2010 (17) Yes No Yes grade 10 education development(operationalization) Different Sanders, 2009 Children of dif- health-related Conceptualization, explorative Yes No No (23) ferent ages domains Population Health care, Sørensen, 2012 Conceptualization, explorative & across the life health promo- No No Yes (11) testing course tion Deductive for evalua- Subramaniam, Students aged School health tion and intervention Yes No Yes 2015 (24) 10-15 years program testing(operationalization) DE students, School health Zeyer & Oder- aged 12-15 education/ Conceptualization, explorative No No No matt, 2009 (25) years biology 166 Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 Table 3. HL dimensions in children Authors Dimensions of HL Self-directedness, productivity, responsibility, problem-solving, critical thinking, and effective com- munication concerning HL were used in the assessment to comprehend issues related to disease Bown, 2007 (20) prevention and health promotion; these data are useful to advocate for health by describing health and sharing information. Understanding health topics, interests in health subjects, motivation to learn about a healthy life- Paek, 2011 (21) style. Schmidt, 2010 (22) Communication, behavior, health knowledge, self-efficacy, and attitude. Practical knowledge (capability to perform tasks, skills or procedural-based knowledge); theoreti- cal knowledge (factual, explicit, declarative, & knowledge about health issues); self-awareness (own decisions, ability to oneself as learner or self-reflect); Paakkari & Paakkari, 2012 (9) citizenship (an individual’s ability to take social responsibility, and act in an ethically-responsible manner), and basic skills and abilities (speech, reading, writing, communication, & information- gathering). Interactive/communicative literacy (potential to perform in daily communication and activities); basic/functional literacy (basic ability & skills); critical literacy (ability to assess information); and Rask & Uusiautti, 2013 (28) developed 4 dimensions: holistic HL: understanding culture as a multidimensional and main phe- nomenon, environmental consciousness, tolerance, the analysis of the information from various viewpoints. General characteristics/abilities (e.g., ability to listen, health-related knowledge, intention, com- munication, motivation, & self-efficacy); information needed to question, formulation, & iden- Subramaniam, 2015 (24) tification; information assessment and management; access to health-related information, and information comprehension. HL types (document, numeracy, & prose) and health information, i.e., a conclusion and judgment Wu, 2010 (17) were evaluated according to the following criteria: impartiality, internal consistency, accuracy, comprehensiveness, & relevance. Oral HL skills (communication or negotiation); document-based HL skills (completing form, writ- ing, & text comprehension); systems-navigation skills (explaining media effect on health behavior Sanders, 2009 (26) to conduct enrolment process); numeracy skills (understanding screening results or food portion size), and foundational skills, i.e., collective HL skills of family. Foundational HL skills (numeracy/literacy) and knowledge components; operational ability, includ- Soellner, 2010 (29) ing communication and cooperation, self-regulation and self-awareness, and healthy information processing. Conceptual knowledge (understanding health-relevant terms, facts, & principles); Situation-specific knowledge (understanding situations related to health); the assessment of Zeyer & Odermatt, 2009 (25) health promotion behaviors (performing such behaviors/action feasible in daily life or improving health); operational knowledge (appropriately acting in a situation), and the evaluation of self- reflection and its consequences. Psychosocial abilities setting (communication, self-efficacy, & prior experience), Wolf, 2009 (16) cognitive skills setting (reasoning, attention, memory, verbal & reading ability, processing speed, literacy, & numeracy). Comprehensive (potential to realize health information); access (ability to find, obtain, & seek health information); use (use and communicate with the health information to decide based on Sørensen, 2012 (11) the following criteria: disease prevention, healthcare, & health promotion behaviors (ability to judge, filter, interpret, & assess health information). HL was expressed as a combination of abilities, compe- processing and seeking health information (knowledge, tencies, health awareness, and an individual’s motiva- health services, practices, & attitudes). tional factors (11). In all definitions, the focus was on collaborative actions that often led to access, process, They use the obtained data in the health-related de- and the use of health information (11). This required cisions-making. This approach could be a strategy for cognitive or behavioral functioning that enables per- the diagnosis and measurement of HL in children and sonal empowerment in their life course in certain situ- adolescents (9). Fok and Wong (15) focused not only ations on demand of health-related decision-making or on health information and practices but also on mea- implementing healthcare data and by benefiting the sures related to biopsychosocial activities in which HL, is prepared for actions. Therefore, children were children participated. They describe the process of ac- considered as rule-makers who are actively evaluating, complishing the specific characteristics that children need to achieve for health and well-being. Moreover, Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174. 167July 2020, Volume 8, Issue 3, Number 19 Table 4. Consequences and antecedents of HL in children Authors Consequences Antecedents Demographics, access to health information, environmental risk fac- tors, Paek, 2011 (21) Behavioral outcomes socialization actions (media & socialization agents), health informa- tion behaviors, and health information sources. Schmidt et al., 2010 (22) Health behavior and health outcome Individual characteristics (e.g., gender, age, cultural background, ethnicity, social skills, biosocial skills, & cognitive abilities); media use; Health behavior; health service use, and Manganello, 2008 (31) parental and peer influences, including literacy, home setting, and health costs parental literacy, and system conditions (e.g., education, healthcare, & media). Health environment requires indi- viduals to be skilled and informed about healthcare consumers and overcome Massey et al., 2012 (19) environmental, interpersonal, and envi- ronmental barriers Empowerment (make sound health deci- Paakkari & Paakkari, sions, ability to understand oneself and Precepting the environment, conditions, and processes. 2012 (9) others, ability to change the factors that influence one’s own and other’s health) Skills and knowledge in improving own Rask, Uusiautti, & Gender, educational level, poverty, socioeconomic status, and cultural health and discuss health-related social Määttä, 2013 (28) differences. content Micro-issues, including internal influences (e.g., gender, age, values, experiences, & beliefs), literacy (ability to listen, speak, read, write, and represent; technological abilities; meso-issues (family, peer, Wharf Higgins, 2009 (16) and school), health curricula (assignments, testing, & teaching), and macro-issues: external influences: (community, neighborhood, & societal). Parental HL, health behavior, and health affect children’s health, Children HL level impacts the HL of Martin & Chen, 2014 academic outcomes, and informal home setting, and system effect parents, and health behaviors (30) (education & health setting, potential intervention point, society & culture). Family characteristics (language, education, income, social support, Sanders, 2009 (23) &culture); social characteristics, and differences in educational/com- munity and health systems. Empowerment, health costs, health out- Distal factors (e.g., environmental & social determinants), and proxi- Sørensen, 2012 (11) comes, equity, health service use, health mal factors (e.g., personal characteristics & situational determinants). behavior, sustainability Health behavior and outcomes, health Wolf et al., 2009 (16) knowledge Ability to participate in private and public Zarcadoolas, 2005/2003 conversations about scientific knowl- Health status (e.g., psychosocial, socio-political, cultural, and demo- (5) edge, health graphic factors). Information, and medicine these characteristics include personal health, enjoying The intermediate- or long-term HL outcomes are gen- school time, emotional stability, and the ability to cope erally related to personal health promotion (17); health with multiple situations (15). Definitions of HL express outcomes address health risks reduction and quality of one dimension, as well as the medium- and long-term life improvement (17) or one’s living conditions (18). objectives of HL outcomes; they include specific per- Borzkfasky (14) believes that children are especially formance concerning health-related decision-making vulnerable, and to some extent, “marginalized” social that express the other dimensions, e.g., personal envi- groups that must be engaged with their health and re- ronmental health management (19) or the correct and sist to remain healthier. Paakkari et al. (9) emphasized informed selection (17). the social dimension of HL and suggested that HL allows students to identify and change factors that threaten 168 Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 their health and that of the others (15). The first prereq- Parents and peers could be a role model for achieving uisite for HL is an ability, i.e., the level of reasoning and and interpreting HL by teaching their children to assess independence on sociocultural-related health issues the credibility of the sources from which they obtain and should be presented at an appropriate age (14). information. In this context, the type and quality of communication significantly affect children. This is be- In total, 9 studies defined HL models (Table 2). Five cause children mainly consult with their trusted peers dimensions reconstructed the HL models, either op- and family. Access to online media and resources also erationally to develop measurement tools (17, 20), or influences their health status. The social level also refers as an impact or assessment model for an intervention to health, education, social systems, as well as cultural program (22, 24). In these studies, HL was examined in and political forces. This includes the general conditions terms of several systems (health, community, & edu- and learning environment of the individual. Such factors cational systems). Besides, numerous fields, such as may include the safety of students at school, and the healthcare, health promotion, and disease prevention teacher’s skills that could promote reflexing and critical are related to health. In the field of school health educa- thinking in students (9, 32). tion, 6 models with 4 articles (20, 22, 24-26) related to children aged <12 years, and 5 articles related to those Ten articles suggested that HL in children leads to indi- aged ≥12 years (9, 11, 17, 21, 25) were assessed. vidual and social benefits (Table 4). At the individual lev- el, HL enables the young population to be skilled users Child HL is defined as a set of capabilities, skills, com- of the healthcare system and to overcome the related mitments, and information that allows individuals to ac- interpersonal and environmental problems (14, 17, 27). cess the health information competently and efficiently Moreover, HL allows children to better perceive them- to benefit from the health-related decision-making and selves, others, and the world, discuss health-related actions. Likewise, our findings suggested the main as- social issues and make proper health decisions (9, 21, pects of children’s HL (Table 3). Due to focus on indi- 28). It is also believed that young people with adequate vidual characteristics, the dimensions with three main HL could start and accomplish their health objectives, categories were selected; cognitive (9, 20-22, 27), be- including participating in physical activity or avoid alco- havioral or functional (17, 23, 24, 26, 28), and emotional hol consumption (25). Furthermore, HL benefits cover (3, 11, 16, 25, 29). a wide range of living performances, at home, work, community, and even economic levels (5, 11). In terms The factors affecting the HL of children and youth or of communicational and societal benefits, HL could pro- the outcomes, i.e., influenced by HL are listed in Table mote participation in community health programs to 4. In the 9 identified models, differentiation has been increase the general capacity and community empow- made between individual characteristics, demographic erment; it could eventually impact one’s health, the factors, situation or context, and the broader system health of others, and the social norms (9, 16, 34). (the social factors) (5, 21, 22). These studies highlighted the effect of parental influences and family’s demo- 4. Discussion graphic factors. Younger children are more prone to trust- ing their parents concerning socioeconomic support. In In this review article, we identified 8 definitions and 9 these conditions, the individual’s socioeconomic status models regarding the HL status for children and young or occupation plays no role in these variables (18, 26, individuals. As a high heterogeneous definition and 30). Family demographic factors include socioeconomic complex model, HL is a complex concept with multi- status, health status, and parental HL. dimensional constructs or dimensions. Furthermore, by explaining these constructs along with multiple in- Martin and Chen (30) reported that these family char- tegrated classifications, presenting a combination of acteristics significantly impact health status, HL, and the HL constructs recovered from the literature seems educational variables in children. These characteristics reasonable (35, 36). However, these definitions may include their willingness on going to school and the overlap due to different reasons, resulting in differen- educational outcomes. In addition, families, schools, tial focuses. These findings are consistent with those and peers are the main socialization factors in chil- of Paakkari and colleagues (4); they highlighted that dren’s lives; they affect their potential for being health “there are differences in the components of HL and its literate. Peers and family can encourage or discourage associated characteristics” (9, 37). Concerning the first HL practices and health-promotion behaviors through research question, in most definitions and models, the their social supports, norms, and practices (11, 32, 33). focus of HL is beyond the set of healthcare settings. It Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174. 169July 2020, Volume 8, Issue 3, Number 19 seems that HL in children is related to multiple contexts socio-economic and cultural factors are discussed to and occasions of daily life that influence the promotion act as mediators or antecedents for HL and tend to be of one’s health and well-being. ignored at the core of HL. Focusing on HL, as specific abilities and skills, leads to disregarding the condition in HL in children, like adults (11), involves agency and which HL occurs, as well as the relevant social action to actions which alter according to the HL viewpoint; e.g., that (11). Likewise, the main gap is observed between from healthcare or clinical setting models to a more the recognition of the effect of cultural and contextual general public health or health system and health pro- characteristics for HL and their usage within skill-based motion model (24, 28, 35). As a result, HL is content- conceptualizations, individualism, and operationaliza- and context-specific and concordant with the present tion that emphasize specific HL dimensions (22, 29). contextual factors and the complexity of the task (20). Thus, more effort is required to shift from a skill- and The contextual factors’ influence was supported in the functional-based HL perspective to an alternative view- literature; however, they often remained underscored. point of understanding HL. It was evidenced that the individual characteristics in- clude the skills and knowledge that an individual re- The second research objective identified the extent to quires to encounter certain situational requirements. which the current HL models cover the characteristics These necessities include the general health center-re- and needs of children and youth. In included studies in lated situational requirements that communities pose this review, specific attention was contributed to charac- upon an individual (35). Furthermore, the behavioral teristics in the analysis of the children and youth groups’ components of HL are usually not distinguished from recognition. Accordingly, the findings highlighted the main the HL outcome (Table 4). Some strong skills and indi- points, as follow: while several models and definitions of vidual-based HL concepts are required for individuals HL were presented for young people (>10 years or second- to be actively involved in understanding, seeking, mak- ary school level), same results are lacking for children aged ing health-related decisions. Moreover, such skills also <10 years (primary school) (20, 22, 40). Moreover, the facilitate accessing information that reflects children’s same is true for transitional stages, including from youth everyday lives. to adulthood, or primary school to secondary school. HL models especially focus on the healthcare system; Our findings indicated that the emphasis is strongly on they seem to significantly and primarily view individuals. caregiver or material’s HL abilities; empowering them to They adhere to a perspective complying with the pro- secure their children’s healthcare requirements (14, 20, fessional health instructions and receive the provided 41). Children under the age of 10 years have not been health information. Models that target the healthcare at the focus of HL intervention and conceptual study system appear to be fully supportive of the behavioral plans. Studies investigated the relationship between the approach. In this attitude, health promotion consider- health outcome, HL, and healthcare costs for adults. Fur- ations must be fully identified, because it holds individu- thermore, studies explored the literature to assess such als accountable for their health. Concerning the social de- relationships for children and youth (14). Therefore, the terminants of health, socioeconomic conditions strongly social condition has a significant contribution to HL in influence the ability of individuals and communities (30, children by their communities, society, and caregivers. 36). By ignoring the nature and complexity of decision- Overall, younger children are more dependent on their making, changing human behavior is challenged and the parents in terms of social support, economic resources, goals of health promotion, at the individual level may and parents’ HL (14, 20, 42). However, data about how not have much justification (16, 38). Thus, employing children and parents’ HL interact and interwoven in the HL is only possible by participation in HL planning efforts development process are scarce. and participation in day-to-day decision making. In the future, families and communities must enable youth to Besides, most HL dimensions in children and youth dynamically participate in their health-related issues and were similar to those considered for adults (14, 43). This engage in the literacy process (35, 39). poor linkage of life stage factors may result from the fact that their perspectives mainly remain unaddressed. In terms of the interrelatedness of sociocultural and Overlaps to HL dimensions in adults were mainly report- environmental characteristics, the following is empha- ed in models that emphasized on a life course viewpoint sized; the children and youth are especially dependent of HL. Therefore, their applicability and validity for the upon their caregivers or parents for accessing social, children and youth populations were questionable. This financial, and material resources (29). Initially, these is the main challenge and gap of data since they have 170 Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 considered it as conceptual foundations for HL educa- reflections influence the current understanding of HL; tional health interventions for children and youth (14, these data could be useful when considered in future 35). health promotion explorations and interventions. Thus, further efforts are required to address these gaps and Implementing general HL models to the children and challenges based on a multidisciplinary viewpoint. youth, i.e., not particularly developed to cover the de- mands and needs of this target group may hinder the Ethical Considerations effectiveness of HL development in these groups. Thus, children’s and youth’s HL, due to their life situations and Compliance with ethical guidelines needs, must be conceptualized as a concept in its char- acter and not as the extraction of adult HL”. Therefore, All ethical principles are considered in this article. The the further empirical and conceptual study is required participants were informed about the purpose of the to detect children’s and youth’s specific characteristics; research and its implementation stages; they were also such measures encourages them to further engage with assured about the confidentiality of their information; HL concepts and eventually promote healthy behaviors. moreover, they were free to leave the study whenever they wished, and if desired, the research results would This systematic review concentrated on searching the be available to them. models and definitions of general HL in children; thus, it excluded domain, disease-specific health literacies, or Funding target groups. Though, focusing on general HL facilitates This research did not receive any specific grant from an extensive recognition of the whole field of HL (17). funding agencies in the public, commercial, or non-prof- Extending the review links a life period viewpoint on HL; it sectors. thus, it could have biased the analysis towards non-target group models and definitions. However, we included all Authors' contributions articles based on the agreement that if they claim to pro- vide a life period viewpoint on HL, they comprise young All authors contributed to designing, running, and writ- persons and children, as well. Accordingly, they are of ing all parts of the research. relevance for the complete framework of the present HL concept for the children. Likewise, this review imple- Conflicts of interest mented the PRISMA method to ensure its validity and correctness, and other limitations must be considered. The authors declared no conflicts of interest. 5. Conclusion Addressing the HL concept and its key dimensions in children must be designed based on experimental stud- References ies. Moreover, thorough and measurable descriptions 1. Clarke AM, Kuosmanen T, Barry MM. A systematic review and applicable theoretical scopes that meet the char- of online youth mental health promotion and prevention acteristics of children must be considered. This review interventions. Journal of Youth and Adolescence. 2015; recognized a wide theoretical base for HL in children 44(1):90-113. [DOI:10.1007/s10964-014-0165-0] [PMID] while pointing to key concepts and dimensions, espe- 2. Robinson C, Seaman EL, Montgomery L, Winfrey A. A review cially correlated to the data and abilities accepted for of hip hop-based interventions for health literacy, health the children. Moreover, implementing these HL dimen- behaviors, and mental health. Journal of Racial and Eth- sions is required to examine whether these models and nic Health Disparities. 2018; 5(3):468-84. [DOI:10.1007/ definitions are measurable to explain the specific HL s40615-017-0389-2] [PMID] [PMCID] constructs or dimensions for children and youth. Simi- 3. Peyman N, Oakley D. Married Iranian women’s knowledge, larly, HL could endow children susceptible to become attitude, and sense of self-efficacy about oral contracep- more involved with their health and receive more up-to- tives: Focus group discussion. Journal of Reproduction & date data for future health-related decision making. The Infertility. 2011; 12(4):281. relevance of social support and structures based on HL 4. Peyman N, Alipour Anbarani M. The effect of training diabe- skills are used in very life positions. Besides, children’s tes prevention behaviors on promotion of knowledge, at- distinctiveness from adults is a critical consideration in titude and practice of students for prevention of diabetes understanding HL. We believed that numerous critical Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174. 171July 2020, Volume 8, Issue 3, Number 19 in Mashhad city. International Journal of Pediatrics. 2015; 2009; 124(Suppl 3):S275-S81. [DOI:10.1542/peds.2009- 3(2.2):501-7. 1162C] [PMID] [PMCID] 5. Zarcadoolas C, Pleasant A, Greer DS. Understanding health 17. Wu AD, Begoray DL, MacDonald M, Wharf Higgins J, Frank- literacy: An expanded model. Health Promotion Inter- ish J, Kwan B, et al. Developing and evaluating a relevant and national. 2005; 20(2):195-203. [DOI:10.1093/heapro/ feasible instrument for measuring health literacy of Cana- dah609] [PMID] dian high school students. Health Promotion International. 2010; 25(4):444-52. [DOI:10.1093/heapro/daq032] [PMID] 6. Tavakoly Sany SB, Peyman N, Behzhad F, Esmaeily H, Taghipoor A, Ferns G. Health providers’ communica- 18. Gordon SC, Barry CD, Dunn DJ, King B. Clarifying a vision tion skills training affects hypertension outcomes. Medi- for health literacy: A holistic school-based community cal Teacher. 2018; 40(2):154-63. [DOI:10.1080/014215 approach. Holistic Nursing Practice. 2011; 25(3):120-6. 9X.2017.1395002] [PMID] [DOI:10.1097/HNP.0b013e3182157c34] [PMID] 7. Avan A, Tavakoly Sany SB, Ghayour-Mobarhan M, Rahimi 19. Massey PM, Prelip M, Calimlim BM, Quiter ES, Glik DC. HR, Tajfard M, Ferns G. Serum C-reactive protein in the Contextualizing an expanded definition of health literacy prediction of cardiovascular diseases: Overview of the lat- among adolescents in the health care setting. Health Edu- est clinical studies and public health practice. Journal of cation Research. 2012; 27(6):961-74. [DOI:10.1093/her/ Cellular Physiology. 2018; 233(11):8508-25. [DOI:10.1002/ cys054] [PMID] [PMCID] jcp.26791] [PMID] 20. Brown SL, Teufel JA, Birch DA. Early adolescents per- 8. Kharazi SS, Peyman N, Esmaily H. Association between ma- ceptions of health and health literacy. Journal of ternal health literacy level with pregnancy care and its School Health. 2007; 77(1):7-15. [DOI:10.1111/j.1746- outcomes. Iranian Journal of Obstetrics, Gynecology and 1561.2007.00156.x] [PMID] Infertility. 2016; 19(37):40-50. 21. Paek H-J, Reber BH, Lariscy RW. Roles of interpersonal and 9. Paakkari L, Paakkari O. Health literacy as a learning out- media socialization agents in adolescent self-reported come in schools. Health Education. 2012; 112(2):133-52. health literacy: A health socialization perspective. Health [DOI:10.1108/09654281211203411] Education Research. 2011; 26(1):131-49. [DOI:10.1093/ her/cyq082] [PMID] 10. Siuki HA, Peyman N, Vahedian-Shahroodi M, Gholian-Aval M, Tehrani H. Health education intervention on HIV/AIDS 22. Schmidt CO, Fahland RA, Franze M, Splieth C, Thyrian JR, prevention behaviors among health volunteers in health- Plachta-Danielzik S, et al. Health-related behaviour, knowl- care centers: An applying the theory of planned behavior. edge, attitudes, communication and social status in school Journal of Social Service Research. 2019; 45(4):582-8. [DOI children in Eastern Germany. Health Education Research. :10.1080/01488376.2018.1481177] 2010; 25(4):542-51. [DOI:10.1093/her/cyq011] [PMID] 11. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, 23. Sanders LM, Federico S, Klass P, Abrams MA, Dreyer B. Lit- Slonska Z, et al. Health literacy and public health: A system- eracy and child health: A systematic review. Archives of atic review and integration of definitions and models. BMC Pediatrics & Adolescent Medicine. 2009; 163(2):131-40. Public Health. 2012; 12(1):80. [DOI:10.1186/1471-2458- [DOI:10.1001/archpediatrics.2008.539] [PMID] 12-80] [PMID] [PMCID] 24. Subramaniam M, Jean BS, Taylor NG, Kodama C, Follman 12. Dehghankar L, Panahi R, Kekefallah L, Hosseini N, Hasannia R, Casciotti D. Bit by bit: Using design-based research to E. The study of health literacy and its related factors among improve the health literacy of adolescents. JMIR Research female students at high schools in Qazvin. Journal of Health Protocols. 2015; 4(2):e62. Literacy. 2019; 4(2):18-26. 25. Zeyer A, Odermatt F. [Gesundheitskompetenz (Health 13. Rothman RL, Yin HS, Mulvaney S, Homer C, Lannon C. Literacy)-Bindeglied zwischen Gesundheitsbildung und Health literacy and quality: Focus on chronic illness care naturwissenschaftlichem Unterricht (German)] (Health Lit- and patient safety. Pediatrics. 2009; 124(Suppl 3):S315- eracy – a Link between Health Education and Science Edu- S26. [DOI:10.1542/peds.2009-1163H] [PMID] cation). Zeitschrift für Didaktik der Naturwissenschaften. 2009; 15:265-85. [DOI:10.5167/uzh-31004] 14. Borzekowski D. Considering children and health literacy: A theoretical approach. Pediatrics. 2009; 124:S282-8. 26. Sanders LM, Shaw JS, Guez G, Baur C, Rudd R. Health liter- [DOI:10.1542/peds.2009-1162D] [PMID] acy and child health promotion: Implications for research, clinical care, and public policy. Pediatrics. 2009; 124(Suppl 15. Fok MS, Wong TK. What does health literacy mean to 3):S306-S14. [DOI:10.1542/peds.2009-1162G] [PMID] children? Contemporary Nurse. 2002; 13(2-3):249-58. [DOI:10.5172/conu.13.2-3.249] [PMID] 27. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, et al. National standards for diabetes self-man- 16. Wolf MS, Wilson EA, Rapp DN, Waite KR, Bocchini MV, Da- agement education. Diabetes Care. 2008; 31(Suppl 1):S97- vis TC, et al. Literacy and learning in health care. Pediatrics. S104. [DOI:10.2337/dc08-S097] [PMID] 172 Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174.July 2020, Volume 8, Issue 3, Number 19 28. Rask M, Uusiautti S, Määttä K. The fourth level of health lit- issue-2/ijamh-2017-0103/ijamh-2017-0103.xml. eracy. International Quarterly of Ccommunity Health Edu- [DOI:10.1515/ijamh-2017-0103] [PMID] cation. 2014; 34(1):51-71. [DOI:10.2190/IQ.34.1.e] [PMID] 39. Nejatian M, Alami A, Tehrani H, Lael-Monfared E, Jafari A. 29. von Eckhard Klieme H, Leutner D, Kenk M. [Kompetenz- Perceptions and personal use of Complementary and Al- modellierung Zwischenbilanz des DFG-Schwerpunktpro- ternative Medicine (CAM) by Iranian health care provid- gramms und Perspektiven des Forschungsansatzes. In: Soe- ers. Complementary Therapies in Clinical Practice. 2018; llner R, Huber S, Lenartz N, Rudinger G, editors. Facetten 32:145-50. [DOI:10.1016/j.ctcp.2018.06.002] [PMID] der Gesundheitskompetenz-eine Expertenbefragung (Ger- man)]. Projekt Gesundheitskompetenz. Frankfurt: Pedocs; 40. Lael-Monfared E, Tehrani H, Moghaddam ZE, Ferns GA, Tatari M, Jafari A. Health literacy, knowledge and self- 2010. https://www.pedocs.de/volltexte/2010/3384/ care behaviors to take care of diabetic foot in low-in- pdf/Soellner_Huber_Lenartz_Rudinger_Projekt_ come individuals: Application of extended parallel pro- Gesundheitskompetenz_D_A.pdf cess model. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019; 13(2):1535-41. [DOI:10.1016/j. 30. Martin LT, Chen P. Child health and school readiness: The sig- dsx.2019.03.008] [PMID] nificance of health literacy. In: Health and Education in Early Childhood: Predictors, Interventions, and Policies. Reynolds 41. Hejazi S, Peyman N, Esmaily H. Effect of educational inter- JA, Rolnick JA, Temple JA (Eds). Cambridge: Cambridge Univer- vention based on self-efficacy on preventive behaviors of sity Press; 2014. [DOI:10.1017/CBO9781139814805.018] overweight and obesity among secondary-school female [PMCID] students in Mashhad. Iranian Journal of Endocrinology and Metabolism. 2017; 19(4):261-9. 31. Manganello JA. Health literacy and adolescents: A framework and agenda for future research. Health Education Research. 42. Charoghchian Khorasani E, Peyman N, Esmaily H. Relations 2007; 23(5):840-7. [DOI:10.1093/her/cym069] [PMID] between breastfeeding self-efficacy and maternal health literacy among pregnant women. Evidence Based Care. 32. Higgins JW, Begoray D, MacDonald M. A social ecologi- 2017; 6(4):18-25. cal conceptual framework for understanding adolescent health literacy in the health education classroom. Ameri- 43. Mazloomy Mahmoodabad SS, Tehrani H, Gholian-aval M, can Journal of Community Psychology. 2009; 44(3-4):350. Gholami H, Nematy M. The effect of social class on the [DOI:10.1007/s10464-009-9270-8] [PMID] amount of salt intake in patients with hypertension. Blood Pressure. 2016; 25(6):360-3. [DOI:10.1080/08037051.201 33. Jafari Y, Vahedian-Shahroodi M, Tehrani H, Haresabadi M, 6.1179508] [PMID] Shariati M. The relationship between caregivers’ health lit- eracy and the behavior of women with multiple sclerosis. Iranian Journal of Obstetrics, Gynecology and Infertility. 2018; 21(7):71-64. 34. Pirzadeh A, Nodooshan T, Nasirian M. Association between maternal health literacy level and prenatal care in Iran. Journal of Health Literacy. 2019; 4(1):60-7. 35. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, et al. Health literacy in childhood and youth: A system- atic review of definitions and models. BMC Public Health. 2017; 17(1):361. [DOI:10.1186/s12889-017-4365-x] [PMID] [PMCID] 36. Mackert M, Champlin S, Su Z, Guadagno M. The many health literacies: Advancing research or fragmentation? Health Communication. 2015; 30(12):1161-5. [DOI:10.108 0/10410236.2015.1037422] [PMID] 37. Mahdizadeh F, Tatari M, Sheykhotayefeh M. Study of health literacy and its related factors in Torbat Heydarieh students of medical sciences in 2019. Journal of Health Literacy. 2019; 4(2):44-8. 38. Olyani S, Tehrani H, Esmaily H, Rezaii MM, Vahedian-shah- roodi M. Assessment of health literacy with the newest vital sign and its correlation with Body Mass Index in fe- male adolescent students. International Journal of Adoles- cent Medicine and Health. 2017; 32(2):/j/ijamh.2020.32. Abedian Kasgari K. et al. Health Literacy in Childhood. J Pediatr Rev. 2020; 8(3):163-174. 173