Journal of Adolescence 62 (2018) 116–127 ContentslistsavailableatScienceDirect Journal of Adolescence journal homepage: www.elsevier.com/locate/adolescence Review article Adolescent health literacy and health behaviors: A systematic review T Sasha A. Flearya,∗ , Patrece Josephb, Jessica E. Pappagianopoulosb aEliot-PearsonDepartmentofChildStudyandHumanDevelopment,TuftsUniversity,574BostonAve,Medford,MA02155,USA bEliot-PearsonDepartmentofChildStudyandHumanDevelopment,TuftsUniversity,USA A R T I C L E I N F O A B S T R A C T Keywords: Objectives: Tosystematicallyreviewandsynthesizeliteratureontherelationshipbetweenhealth Healthliteracy literacyandhealthbehaviorsinadolescents. Adolescents Methods: Searches in PsychInfo, PUBMED/MEDLINE, and Educational Resources Information Preventivehealth Center(ERIC)wereconducted.Studieswereincludediftheyreportedoriginaldataonthere- Healthriskbehaviors lationshipbetweenhealthliteracyandahealthbehaviorinadolescents,werewritteninEnglish, Healthcommunication andthepopulationdidnothaveachronicillnessordisability. Healthinformation-seeking Results: Seventeenstudiesmetinclusionarycriteria.Definitionandmeasurementofhealthlit- eracy, and theoretical frameworks varied across studies. Studies investigated the relationship betweenfunctionalandmediahealthliteracyandadolescenthealthbehaviors,thirteenreported significant,linearrelationships. Conclusions: Theresultssuggestthatthereisameaningfulrelationshipbetweenhealthliteracy andadolescents'healthbehaviors.Tofullyunderstandtheroleofhealthliteracyinadolescents' healthdecision-making,futureresearchshouldusecomprehensivedefinitionsandmeasuresof health literacy, and integrate health behavior and adolescent development theoretical frame- worksinstudydesign. Accordingtothe2015YouthRiskBehaviorSurveillanceSystem,∼18%ofU.S.adolescentsengagedinbinge-drinking,∼11% smokedcigarettes,80%and85%atelessthantherecommendedservingsoffruitsandvegetablesrespectively,and51%engagedin insufficient physical activity (Kann, 2016). In addition, 41% were sexually active with ∼14% to ∼21% engaging inrisky sexual behavior(Kann,2016).Thesebehaviorsinadolescencearerelatedtoadulthealthbehaviorsandincreaseddiseaserisk.Forexample, adolescentswhoengageinobesogenicbehaviorsareatgreaterriskforobesityandobesity-relatedhealthcomplicationsinadulthood (Fuemmeler,Pendzich,&Tercyak,2009;Juonalaetal.,2011;Tiroshetal.,2011).Adolescents'alcoholuseisassociatedwithalcohol- relateddisorders,mentalhealthproblems,andchronicdiseasesinadulthood(Baranowskietal.,1997;Berkeyetal.,2010;Charakida et al., 2014; DeWit, Adlaf, Offord, & Ogborne, 2000; Duncan, Alpert, Duncan, & Hops, 1997). Similarly, individuals who begin smokinginadolescencearemorelikelytobenicotine-dependent(Lanza&Vasilenko,2015),andareatincreasedriskforcancerand cardiovascular diseases (Charakida etal.,2014; Marcus etal., 2000;Strand et al.,2004)inadulthood. Moreover, studies suggest clusteringofpreventiveandriskbehaviorsamongadolescentsimplicatingamoreglobalapproachtohealthbehaviorchangemaybe necessary.Forexample,Fleary(2017)foundadolescentsengagedincombinationsofriskandpreventivehealthbehaviorsandthese patternsdifferedbysex(e.g.,28%boysengagedinrecommendedphysicalactivityandcigarette,alcohol,andmarijuanause;21% girls engaged in alcohol and marijuana use but no physical activity or healthy eating). Several researchers have also found that ∗Correspondingauthor. E-mailaddresses:sasha.fleary@tufts.edu(S.A.Fleary),Patrece.joseph@tufts.edu(P.Joseph),Jessica.pappagioanopoulos@tufts.edu(J.E.Pappagianopoulos). https://doi.org/10.1016/j.adolescence.2017.11.010 Received28March2017;Receivedinrevisedform12October2017;Accepted17November2017 Available online 25 November 2017 0140-1971/ © 2017 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.S.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 adolescentswhoparticipateinsportsarelikelytoengageinacombinationofpreventiveandriskyhealthbehaviors(Kwan,Bobko, Faulkner,Donnelly,&Cairney,2014;Pate,Trost,Levin,&Dowda,2000;Veliz,Boyd,&McCabe,2015). Both animal and human studies suggest that engagement in health risk behaviors or failure to engage in preventive health behaviorsalsoaffectthedevelopingadolescent'sbrain.Forexample,Allen,Rivier,andLee(2011)foundthatalcoholexposurein adolescentratswasrelatedtoalterationsinthehypothalamic-pituitary-adrenal axiswhichregulatesthestressresponse.DeBellis et al. (2000) also found that early age of onset of alcohol use and duration of alcohol use disorder were associated with lower hippocampal volumes in[human] adolescents. Adolescents' brainsare sensitive to nicotine, especially inthestill developing pre- frontalcortex.Theprefrontalcortexisimportantforexecutivefunctionsandattention,andnicotineuseaffectscognitionbymod- ifyinginformationprocessing,thusadolescentsmokersareatincreasedriskforcognitiveimpairmentinadulthood(Goriounova& Mansvelder,2012).Verbalintelligenceinadolescentsisalsoreducedwithpoornutritionandinsufficientphysicalactivity(Jackson& Beaver,2015). Importantaspectsofadolescentdevelopmentrelatedtohealthbehaviorsincludeautonomy,cognitiveprocesses,andsocialin- fluences (Chassin, Presson, Sherman, & McConnell, 1995). Autonomy provides adolescents with the opportunity to engage in in- dependent health decision-making with lifelong consequences. However, the cognitive processes influencing adolescent decision- making are equally important. Decision-making and judgment skills in adolescents are not fully developed. Albert and Steinberg (2011)arguedthatadolescents'decision-makingisinfluencedbysocio-emotionalandself-regulatoryfactors.Similarly,Blakemore andRobbins(2012)proposedthatslowdevelopmentofimpulsecontrolandresponseinhibitionincreasesadolescents'relianceon socialfactorsandemotionstomakedecisions;thus,adolescentsaremorelikelytomakenon-deliberatedecisions.Giventhisandthe long-term consequences ofadolescents' health behaviors, itis imperative that health behavior interventions focus on adolescents' decision-making. Severalhealthbehaviorinterventionshaveaddressedadolescentdecision-makingviaknowledge-basedcurriculumswithmixed success(e.g.,Coyleetal.,2001;Horn,Dino,Gao,&Momani,1999;Malmbergetal.,2015;Neumark-Sztainer,Story,Hannan,&Rex, 2003;Peralta,Jones,&Okely,2009;Slobodaetal.,2009).Weproposethatsuccesshasvariedbecausethesestudiesexcludeakey elementofhealthbehaviordecision-making,healthliteracy.Healthliteracyistheextenttowhichindividualsattain,manage,and understand health information and apply that information in health decision-making (Parker, Ratzan, & Lurie, 2003). Nutbeam (2000,2008)proposedthreetypesofhealthliteracy:functional,communicative/interactive,andcriticalhealthliteracy. Functionalhealthliteracyistheapplicationofliteracyandnumeracyskillstohealth-relatedmaterialssuchasmedicinelabelsand prescriptions(Nutbeam,2000;Parker,Baker,Williams,&Nurss,1995).Functionalhealthliteracyisthemostcommontypeofhealth literacyassessedandcommonobjectivemeasuresincludetheRapidEstimateofAdultLiteracyinMedicine(REALM;Murphy,Davis, Long,Jackson, &Decker,1993),REALM-Teen(Davisetal.,2006),TestofFunctionalHealthLiteracyinAdults(TOFHLA;Parker etal.,1995),Short-TestofFunctionalHealthLiteracyinAdults(s-TOFHLA;Baker,Williams,Parker,Gazmararian,&Nurss,1999) andNewestVitalSign(NVS;Weissetal.,2005).Communicative/interactivehealthliteracyistheapplicationofcognitionandsocial skills to actively participate in understanding varying forms of communications and applying the new information to evolving situations(Nutbeam,2000).Criticalhealthliteracyinvolvescriticallyanalyzingandactingonhealthinformationforpersonaland social benefit (Nutbeam, 2000). Critical health literacy empowers individuals to act on the social, economic, and environmental determinantsofhealththroughindividualandcollectiveefforts,yet,itistheleastdevelopedandunderstoodaspectofhealthliteracy (Chinn,2011;Sykes,Wills,Rowlands,&Popple,2013). Manganello(2008)includedmedialiteracyasafourthlevelofhealthliteracyforadolescents.Levin-Zamir,Lemish,andGofin (2011) further distinguished media health literacy from media literacy by incorporating Nutbeam (2000)’s three types of health literacyintheirdefinitionandmediahealthliteracymeasuredevelopment.Specifically,mediahealthliteracyincludesidentification ofhealth-relatedmedia,recognitionofitseffectsonhealthbehavior,criticalanalysisofthecontent,andactionorintentiontoacton mediamessageforone'sselforsociety.Conversely,Primack,Gold,Switzer,etal.(2006)developedabehavior-specificmediahealth literacymeasure,theSmokingMediaLiteracyScale.NormanandSkinner(2006b)introducedanothertypeofhealthliteracyrelated tomedia:electronichealthliteracy.Electronichealthliteracyinvolvestheapplicationofhealthinformationacquiredfromelectronic sources to address health problems. Theydeveloped theElectronic Health Literacy Scale (eHEALS; Norman&Skinner, 2006a)to measuretheconstruct. Medialiteracy,ingeneral,hasbeenwidelystudiedinadolescenceoverthelastdecade (e.g., Chen,2013; Kaestle,Chen,Estabrooks,Zoellner,&Bigby,2013;Primack,Douglas,Land,Miller,&Fine,2014)butfewstudieshavefocusedon health-relatedliteracyininteractionswiththemediaasdefinedbyLevin-Zamiretal.(2011). Health literacy is worthy of further analysis regarding its value to improving adolescent health and ultimately adult health. ApproximatelyonethirdofAmericanadultshavebasicorbelowbasichealthliteracy(Kutner,Greenburg,Jin,&Paulsen,2006),and lowhealthliteracyisassociatedwithlesssatisfactionwithdiseasestatus,increaseduseoftreatmentandemergencyservicesrather thanpreventiveservices,embarrassmentduetolowhealthliteracy,andreducedinterestindecision-makingregardinghealth(Baker etal.,1996,2004;Mancuso&Rincon,2006;Scott,Gazmararian,Williams,&Baker,2002).Barriersinlanguageandcommunication arealsoassociatedwithlowhealthliteracyandresultinimpairedcommunicationwithmedicalproviders,understandingofinformed consent,andadherencetotreatment(Davis,Williams,Marin,Parker,&Glass,2002;Williamsetal.,1995).Lowhealthliteracyalso increases the risk for health disparities and researchers argue that low health literacy is sometimes misinterpreted as health dis- parities(Osborn,Paasche-Orlow,Davis,&Wolf,2007).Nonetheless,thecommonalitiesbetweenindividualswithlowhealthliteracy andhealthdisparitiesincludeloweducation,racial/ethnicminoritystatus,lowincome,andnon-nativeEnglishspeaking(Braveman, 2006; Gazmararian et al., 1999). While researchers have begun exploring health literacy levels in adolescents (see Ormshaw, Paakkari,&Kannas,2013;Perry,2014forreviews),andsomeresearchsuggestthatadolescentswhoparticipateinsportsteamshave higher health literacy (Paakkari, Kokko, Villberg, Paakkari, & Tynjälä, 2017), connecting health literacy with adolescents' health 117 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 behaviorsisrelativelynew.Thegoalofthecurrentreviewistosynthesizetheexistingresearchontherelationshipbetweenhealth literacy and health behaviors in adolescents to (1) determine the extent to which adolescent developmental characteristics are consideredand(2)informfutureresearchontheroleofhealthliteracyinadolescenthealthdecision-making. Tomeetourgoals,wewilladdressthefollowingresearchquestions: (a) Howishealthliteracydefined?Whatarethetheoretical/conceptualframeworksused? (b) Whattypeofhealthliteracywasassessed? (c) Whatistherelationshipbetweenhealthliteracyandhealthbehaviors? 1. Method 1.1. Literaturesearch Researchersorganizedandpresentedthesystematicreviewaccordingtothepreferredreportingitemsforsystematicreviewsand meta-analyses(PRISMA; Moher,Liberati, Tetzlaff,Altman, &Group, 2009). Eligible studies wereidentified usingelectronic data- bases.LiteraturesearcheswereconductedinPsychInfo,PUBMED/MEDLINE,andEducationalResourcesInformationCenter(ERIC). Primarysearchitemsincluded1)healthliteracy*,2)healthknowledge*,3)health*ANDliteracy*,and4)health*ANDknowledge*. The asterisks were used to ensure all variations of the terms were included in the search. The four primary search items were combined with secondary search terms, adolescent* and teen* for a total of eight search combinations, and 24 searches across databases. Note thathealth knowledge* wasincluded asa searchterm inanticipation ofincorrect cataloguing of health literacy. Search limiters were applied to exclude books and encyclopedias. Dissertations were included in the searches. Reference lists of reviewed studies and other systematic reviews on adolescent health literacy were also manually searched. The cut-off date for publishedarticlesandthosepublishedonlineaheadofprintwasAugust31,2016. 1.2. Inclusion/exclusioncriteria The current review sought to examine only studies that measured adolescents' health literacy and reported health behaviors. Studieswereincludedinthecurrentreviewifthey:(1)objectively(ratherthanperceptionmeasure)measuredhealthliteracy,(2) examinedahealthbehavior–noaprioriinclusionarycriteriaforbehaviors,(3)analyzedtherelationshipbetweenhealthliteracyand healthbehavior,and(4)reportedonthehealthbehaviorofadolescents(i.e.,10to23years)whowerenotchronicallyillordisabled exclusively.Studiesthatotherwisemettheinclusionarycriteriawereexcludedfromthecurrentreviewiftheywereprimarilyabout mentalhealth,ornotwritteninEnglish. 1.3. Dataextractionandmanagement ThePRISMAdecisiontree(Fig.1)outlinestheresultsofthesearchprocessandstudyselection.Initially,45,359papersexcluding duplicateswereimportedintoEndnote(Reuters,2011).Theword“literacy”wassearchedwithintheEndnotefileandproduced2497 articlesthatwerefurtherscrutinizedbasedontheexclusionarycriteria.Exclusionarycriteriawereappliedinafixedordertoallow forsinglecountsofeachstudy.Specifically,astudymightbeineligibleforseveralreasons,itwouldonlybeexcludedforthefirst exclusionarycriterionmet.Studieswereexcludedfromfurtheranalysisinthefollowingorder:notwritteninEnglish(n=59),not exclusively adolescent (n = 1778), population had a chronic illness or disability (n = 114), health literacy was not measured (n=457),andhealthbehaviorswerenotmeasured(n=19). Seventystudiesremainedafterexclusionarycriteriawereappliedtotitlesandabstracts.Analysesofthefulltextoftheremaining studieswereindependentlyconductedbytwoauthors.Discrepancieswerediscussedbetweenallauthorsandresultedin53studies beingexcludedduetonon-scientific(n=4),notexclusivelyadolescent(n=4),nomeasureofhealthliteracy(n=4),measured medialiteracyratherthanmediahealthliteracyorhealthbehavior-specificmedialiteracy(n=17),measuredhealthliteracyonly (n=8),measuredhealthliteracyandhealthbehaviorsbutnotrelationshipbetweenvariables(n=4),measuredhealthknowledge orhealtheducationratherthanhealthliteracy(n=10),andnotmeetingothercriteriaforinclusion(n=2). 1.4. Analysis Theseventeenremainingstudiesweresystematicallyreviewedtodetermine(1)howtheydefinedhealthliteracyandifathe- oretical or conceptual framework was used; (2) the type of health literacy assessed and measures used; and (3) the relationship betweenhealthliteracyandhealthbehaviorsinadolescents.Asinglestudycouldcontributemultiplefindingstothereview. 2. Results 2.1. Studiescharacteristics Oftheseventeenstudiesreviewed,ninewereconductedintheUnitedStates,threeinTaiwan,andtheotherfiveinArgentina, Guatemala,Hungary,Israel,andVietnam.Samplesizesacrossstudiesrangedfrom112(Dharmapurietal.,2015)to3470(Salgado 118 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 Records identified through database searching after duplicates removed (n =45,359) Records screened for key word of “literacy” in Records excluded Endnote (n =42, 862) (n = 45,359) Titles and abstracts assessed for eligibility using Records excluded exclusionary criteria (1) Not written in English(n=59) (n = 2,497) (2) Not exclusively adolescent (n =1,778) (3) Chronic illness or disability (n =114) (4) Health literacywas not measured (n = 457) (5) Did not measureahealth behavior(n =19) Total: (n = 2,427) Full-text articles further assessed for eligibility (n= 70) Full-text articles excluded (1) Non-scientific (n = 4) (2) Not exclusively adolescent (n = 4) (3) No measure of health literacy (n = 4) (4) Measured media literacy rather than media health literacy or health-specific media literacy (n = 17) (6) Measured health literacyonly (n = 8) (7) Measured health literacy and health behavior but not the relationship between both (n =4) (8) Measured health knowledge or health education Studies included in review rather than health literacy(n = 10) (9) Other (n = 2) (n= 17) Total: (n=53) Fig.1.PRISMAdecisiontreeforstudyselection. etal.,2012),withameanandmedianof1158.2and878.5,respectively.Twosetsofstudiesusedthesamesampleandweretherefore only counted once when calculating the mean and media sample size: (1) Hove, Paek, and Isaacson (2011) and Paek and Hove (2012);(2)Primack,Gold,Land,andFine(2006)andPrimackandHobbs(2009).Participants'agerangedfrom10to23yearsold. 2.1.1. Demographics Threestudiesdidnotexamineassociationsbetweendemographicvariablesandhealthliteracy(Hoffman,Marsiglia,Nevarez,& Porta,2017;Primack&Hobbs,2009;Salgadoetal.,2012).Eightstudiesincludedageorgradelevel(proxyforage):fourreporteda positiverelationshipbetweenhealthliteracyandage(Changetal.,2015;Chisolm,Manganello,Kelleher,&Marshal,2014;Ghaddar, Valerio,Garcia,&Hansen,2012;Primack,Gold,Land,etal.,2006)andfourfoundnorelationship(Hoveetal.,2011;Paek&Hove, 2012;Page,Piko,Balazs,&Struk,2010;Shone,King,Doane,Wilson,&Wolf,2011). Ofthethirteenstudiesexaminingsex,ninefoundnorelationshipbetweensexandhealthliteracy(Changetal.,2015;Chisolm etal.,2014;Dharmapurietal.,2015;Ghaddaretal.,2012;Hoveetal.,2011;Paek&Hove,2012;Pageetal.,2010;Primack,Gold, Land, et al., 2006; Shone et al., 2011), one found a positive relationship for boys (Chang, 2011), and three found a positive re- lationshipforgirls(Changetal.,2016;Levin-Zamiretal.,2011;Page,Huong,Chi,&Tien,2011).OfthefiveU.S.studiesincluding race/ethnicity, identifying as Black or Hispanic was associated with lower health literacy in three studies (Chisolm et al., 2014; Ghaddaretal.,2012;Shoneetal.,2011)whiletwostudiesfoundnorelationship(Paek&Hove,2012;Primack,Gold,Land,etal., 2006). 119 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 Table1 Definitionsofhealthliteracyandtheoreticalframeworks. Study TypeofHealth DefinitionofHealthLiteracy TheoreticalFramework Literacy Chang(2011) Functional Anindividual'scapacitytoacquireandunderstandbasichealth N/A informationandtheservicesneededtomakeadequatehealth decisions(fromParkeretal.,2003) Changetal.(2015) Media Anindividual'sabilitytofind,evaluate,andapplyhealth N/A informationfromelectronicsourcesinordertoaddressorsolve ahealthissue. Changetal.(2016) Media Theabilitytounderstand,analyze,evaluate,andcreatemedia CombinationofMessageInterpretationModel messagesinawidevarietyofforms andsocialcognitivetheory Chisolmetal.(2014) Functional SeeChang(2011) Expectancytheory Dharmapurietal. Functional Theabilitytoread,understand,andnavigateinformation N/A (2015) withinahealthcaresystem(fromU.S.DepartmentofHealth andHumanServices,2000) Ghaddaretal.(2012) Media& SeeChang(2011) N/A Functional Hoffmanetal.(2017) Functional SeeChang(2011) Manganello's(2008)framework Hoveetal.(2011) Media SeeChangetal.(2015) Persuasionknowledgemodel Levin-Zamiretal. Media Thecognitiveandsocialskills,whichdetermineanindividual's Developedownmediahealthliteracy (2011) motivationandabilitytogainaccessto,understand,anduse theoreticalframeworkusingNutbeam's(2008) informationtopromoteandmaintaingoodhealth(fromSmith, modelofhealthliteracy Tang,&Nutbeam,2006). Needhametal.(2010) Functional SeeChang(2011) None PaekandHove(2012) Media Theuseofinformationalandcommunicativetechnologyto Outcomeexpectationfromsocialcognitive improve,orenablehealthandhealthcare theory; Pageetal.(2010) Media Theskillstounderstand,analyze,evaluate,andcritically Medialiteracyconceptualframework appraiseadvertisingandothermediamessages(fromPrimack, Gold,Land,&Fine,2006) Pageetal.(2011) Media SeePageetal.(2010) Medialiteracyconceptualframework Primack,Gold,Land, Media SeePageetal.(2010) Theoryofreasonedaction etal.(2006) PrimackandHobbs Media SeePageetal.(2010) Medialiteracyconceptualframework (2009) (combinationoftwomedialiteracytheoretical frameworks) Salgadoetal.(2012) Media Theabilitytoanalyzeandevaluatemediamessages None Shoneetal.(2011) Functional None None Fivestudiesexaminedtherelationshipbetweenhealthliteracyandincome.Chisolmetal.(2014)andGhaddaretal.(2012)found freelunchstatus(proxyforincome)wasnegativelyrelatedtohealthliteracy.Similarly,Changetal.(2015)foundhouseholdpoverty was related to lower health literacy. Chang (2011) found that adolescents' knowledge of their monthly household income was positivelyrelatedtohealthliteracy;however,healthliteracywasunrelatedtohouseholdincome.Levin-Zamiretal.(2011)foundno relationshipbetweenhealthliteracyandincome.Educationwasincludedinsixstudiesandfivefoundapositiverelationshipbetween parents'educationandadolescents'healthliteracy(Changetal.,2015;Chang,2011;Chisolmetal.,2014;Levin-Zamiretal.,2011; Primack,Gold,Land,etal.,2006).Shoneetal.(2011)foundapositiverelationshipbetweenadolescents'educationlevelandhealth literacy.Primack,Gold,Land,etal.(2006)andChangetal.(2015)foundthatacademicperformancewaspositivelyrelatedtomedia healthliteracy. 2.2. Howishealthliteracydefined? Definitions of health literacy were inconsistent across studies (see Table 1). Five studies (Chang, 2011; Chisolm et al., 2014; Ghaddaretal.,2012;Hoffmanetal.,2017;Needham,Wiemann,Tortolero,&Chacko,2010)definedhealthliteracyasanindividual's capacitytoacquireandunderstandbasichealthinformationandtheservicesneededtomakeadequatehealthdecisions.Dharmapuri etal.(2015)describedhealthliteracyastheabilitytoread,understand,andnavigateinformationwithinahealthcaresystem.Levin- Zamiretal.(2011)definedhealthliteracyasthecognitiveandsocialskillswhichdetermineanindividual'smotivationandabilityto gainaccessto,understand,anduseinformationtopromoteandmaintaingoodhealth. Hoveetal.(2011)andChangetal.(2015)definedelectronichealthliteracyasanindividual'sabilitytofind,evaluate,andapply health information from electronic sources in order to address or solve a health issue. However, Paek and Hove (2012) defined electronichealthliteracyastheuseofinformationalandcommunicativetechnologytoimprove,orenablehealthandhealthcare. Otherresearchersusedageneraldefinitionofmedialiteracyandappliedthedefinitiontohealthcontent.Specifically,Salgadoetal. (2012) defined media literacy as the ability to analyze and evaluate media messages. Primack, Gold, Land, et al. (2006) further delineatedmedialiteracyastheskillstounderstand,analyze,evaluate,andcriticallyappraiseadvertisingandothermediamessages; Pageetal.(2011,2010),andPrimackandHobbs(2009)alsousedthisdefinition.Changetal.(2016)expandedPrimack,Gold,Land, etal.(2006)'sdefinitiontoincludeskillsrelatedtothecreationofmediamessagesinavarietyofforms. 120 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 2.3. Whatarethetheoretical/conceptualframeworksused? Tenstudiesincludedtheoreticalframeworksintheirresearchdesign(seeTable1).Chisolmetal.(2014)usedexpectancytheory, whichsuggeststhatindividualsengageincertainbehaviorsbasedontheirdeterminationthattheirbehaviorwillresultinaspecific outcome(Jones,Corbin,&Fromme,2001).PaekandHove(2012)utilizedoutcomeexpectationfromsocialcognitivetheory,which posits that behavior is shaped by an individual's anticipation of the consequences and rewards associated with the behavior (Rosenstock,Strecher,&Becker,1988).Hoveetal.(2011)usedthepersuasionknowledgemodel,whichisaguideforperception aboutamessage'spersuasiveintentandthecognitiveprocessesindividualsusetocontestthesemessages(Friestad&Wright,1994). Primack,Gold,Land,etal.(2006)usedthetheoryofreasonedaction,whichidentifiesattitudesandnormsasinfluencingbehavioral intention, the single determinant of behavior (Fishbein, 1979). Chang et al. (2016) combined the Message Interpretation Model (Austin&Johnson,1997)andsocialcognitivetheory,whichpositsthatbehaviorisaproductofinteractionsbetweencognitiveand socioenvironmental influences (Bandura, 2001). Primack and Hobbs (2009) combined two media literacy theoretical frameworks (Bazalgette, 1992, pp. 198–219; Primack, Switzer, & Dalton, 2007) into a media literacy conceptual framework that focuses on understandingthatauthorscreatemessagesforandtargetspecificaudiences,messagescontainvalues,interpretationofmessages differbyperson,messagesaffectattitudesandbehaviors,multipleproductiontechniquesareusedtocreatemessages,andmessages filterrealityandomitinformation.Pageetal.(2010,2011)alsousedthisconceptualframeworkintheirstudies.Levin-Zamiretal. (2011) developed a media health literacy theoretical framework using Nutbeam (2000, 2008)’s health literacy definitions. This framework included concepts related to health literacy and media literacy such as identification, influence, critical analysis, and action.Hoffmanetal.(2017)usedManganello(2008)'sframework,whichidentifiesindividualcharacteristics,thesocialenviron- ment(e.g.,parentsandpeers),andbroadersystems(e.g.,education)asinfluencingadolescenthealthliteracy.Salgadoetal.(2012) highlighted attitudes and norms as important to adolescent cigarette smoking, but did not use a specific theoretical framework. Similarly,Changetal.(2015)acknowledgedtheinfluenceofparentsonadolescentreceiptofhealthinformationbutdidnotincludea theoreticalorconceptualmodel. 2.4. Whattypeofhealthliteracywasassessed? Sevenstudiesassessedfunctionalhealthliteracyandelevenstudiesassessedmediahealthliteracy(seeTable2).Sevenmeasures wereusedacrossstudies:theREALM,REALM-Teen,eHEALS,NVS,Chineseadaptedversionofthes-TOFHLA,MediaHealthLiteracy, andSmokingMediaLiteracy.TheREALMandREALM-Teenassessfunctionalhealthliteracyandareadministeredbyaninterviewer (Davisetal.,2006).Theinterviewerprovidestheintervieweewithawordlisttoreadandrecordstheinterviewee'scorrectresponses. TheeHEALSisaself-completedmeasureofperceivedelectronichealthliteracyskills(Norman&Skinner,2006a);participantsrate howmuchtheyagreewitheightstatementsregardingtheirelectronichealthliteracyskillsona5-pointscale.Administeredbyan interviewer,theNVSassessesfunctionalhealthliteracybytheinterviewerpresentinganutritionlabeltotheintervieweeandasking themsixquestionsrelatedtothelabel(Weissetal.,2005).Thes-TOFHLA,alsoadministeredbyaninterviewer,isatimedreading comprehension test for health-related materials (functional health literacy) using passages and multiple-choice fill-in-the-blanks questions about the passages (Baker et al., 1999). Media Health Literacy is a self-completed measure that includes six questions relating to the categories of identification, critical evaluation, influence, and action (Levin-Zamir et al., 2011), and the Smoking MediaLiteracyscaleisan18-item,behavior-specific,self-completemeasureofsmokingspecificmediahealthliteracy(Primack,Gold, Switzer,etal.,2006).TwostudiesusedanadaptedversionoftheSmokingMediaLiteracyscale(Changetal.,2016;Salgadoetal., 2012). Two studies used multiple measures: Ghaddar et al. (2012) used the eHEALS and NVS, and Shone et al. (2011) used the REALMandREALM-Teen.TheREALM-Teen,NVS,eHEALS,MediaHealthLiteracy,andSmokingMediaLiteracyhavebeenvalidated foruseonadolescentpopulations. 2.5. Whatistherelationshipbetweenhealthliteracyandhealthbehaviors? Health behaviors investigated in the reviewed studies include health promoting behaviors, alcohol use, tobacco use, medical adherence,health-relatedinformation-seeking,andriskysexualbehaviors.Oftheseventeenstudiesreviewed,thirteenfoundare- lationship between health literacy and health behaviors and the findings were maintained after controlling for demographics in elevenofthestudies(seeTable2). Twostudiesexaminedtherelationshipbetweenhealthliteracyandhealthpromotingbehaviors.Levin-Zamiretal.(2011)found thatmediahealthliteracywaspositivelyrelatedtoatotalhealthpromotingbehaviorscore(scoreincludedpreventionbehaviorsfor cigaretteandwaterpipesmoking,nutritionalanddietinghabits,physicalandsedentaryactivity,safetyandinjurybehaviors,and sexualbehavior).Similarly,Chang(2011)foundfunctionalhealthliteracywasanindependentpredictorofatotalhealthpromoting behaviorscore(combinationofnutrition,socialsupport,lifeappreciation,healthresponsibility,stressmanagement,andexercise). However,thisfindingwasnotconsistentforexercise,stressmanagement,andhealthresponsibilitywhenexploredindividually. One study assessed the association between functional health literacy and risky sexual behaviors (Needham et al., 2010) and foundnorelationshipaftercontrollingforsocio-demographiccharacteristics. Severalstudiesexploredtherelationshipbetweenhealthliteracyandsubstanceuse.Chisolmetal.(2014)foundlowfunctional health literacy increased adolescents' odds of engaging in problem-drinking and binge-drinking. Four studies (Page et al., 2010; Primack, Gold, Land, et al., 2006; Primack & Hobbs, 2009; Salgado et al., 2012) found current smokers had low smoking media literacy.Additionally,Pageetal.(2011)foundhighsmokingmedialiteracywasrelatedtoreducedsmokingduringthepast30days. 121 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseTable2 Samplecharacteristics,measures,andresultsofreviewedstudies. Authors Sample Measure(type) Demographics HealthBehavior&HealthLiteracy Significantaftercontrolling fordemographics Chang(2011) Meanage=17years(agerangenot s-TOFHLA(Functional) Boys+ Behavior:Healthpromotingbehaviorcomposite; Yes;controlledforin provided)Highschoolstudents, Taiwanese+ R/ship:LowHL/lowhealthbehaviors originalanalyses Taiwan Knowledgeofmonthly income+ Parentincomens Parenteducation+ Changetal.(2015) 7th-9thgradestudents,Taiwan eHEALS Gradelevel+ Behavior:Onlinehealthinformationseeking Yes;controlled (Media) Sexns R/ship:LowHL/lesslikelytoseekonlinehealthinformation forinoriginalanalyses Householdpoverty −Parentaleducation+ ParenteHealthliteracy+ Urbanarea+ Academicperformance:+ Changetal.(2016) 10thgradestudents(15–17years RevisedAlcoholandTobacco Girls+ Behavior:Alcoholandtobaccouse Yes;butonlycontrolledfor old),Taiwan MediaHealthLiteracyScale R/ship:HigheralcoholandtobaccomediaHL/lesslikelytouse sex (Media) alcohol; Fornon-users,Highalcohol/tobaccomediaHL/lesslikelyto haveintentionstodrinkandsmoke Chisolmetal.(2014) 14-19yearsoldadolescentmedicine REALM-Teen Age+ Behavior:Alcoholusebehaviors(problemandbingedrinking) Yes;controlledforin clinicsinurbanareas,USA (Functional) Sexns R/ship:LowHL/highhealthbehaviors originalanalyses Black− Freelunchstatus− Parenteducation+ Dharmapurietal. 12-21yearsold,urbanadolescent REALM-Teen Sexns Behavior:Medicationadherence(AdherencetoRefillsand No (2015) healthcenter,USA (Functional) Chronicillnessns MedicationsScale) R/ship:ns Ghaddaretal.(2012) 14-20yearolds eHEALSandNVS Grade+ Behavior:Healthrelatedinformationseeking(checkinghealth Notreported IndependentSchooldistrict,USA (Media&Functional) Sexns informationonline) Hispanic− R/ship:ns Freelunchstatus− Hoffmanetal.(2017) 10-16yearoldsStudents, NVS Didnotreport Behavior:Alcoholandcigaretteuse Yes;controlledforin Guatemala (Functional) demographicsbyHL R/ship:HighHL/loweralcoholuse; originalanalyses Cigaretteusens Hoveetal.(2011) 6th,7thand8thgradersruralpublic eHEALS Agens Behavior:Healthrelatedinformationseeking(selectionofleast No schooldistrict,USA (Media) Sexns reliablewebsite) R/ship:HighHL/highhealthbehaviors Levin-Zamiretal. 13-17yearolds MediaHealthLiteracy Girls+ Behavior:Healthpromotingbehaviorcomposite(cigaretteand Yes;controlledforin (2011) twourbanschools,Israel (Media) Ethnicityns waterpipesmoking,nutritionalanddiethabits,PAandSA, originalanalyses Incomens safetyandinjurybehaviorsandsexualbehavior)R/ship:High Maternaleducation+ HL/highhealthbehaviors Needhametal.(2010) 16-21yearolds REALM Girlsonly Behavior:Highrisksexualbehavior(ageoffirstcoitus,>3 No;controlledforin reproductivehealthclinic,USA (Functional) lifetimesexualpartners,previousSTIcontraction,nocondom originalanalyses useatlastcoitus) R/ship:ns PaekandHove(2012) 6th,7thand8thgradersruralpublic eHEALS Agens Behavior:Healthinformationseeking(motivationtoacquire No schooldistrict,USA (Media) Sexns healthrelatedinformation) Race/ethnicityns R/ship:ns (continuedonnextpage) 122 Journal of Adolescence 62 (2018) 116–127 S.A.Flearyetal. 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseTable2(continued) Authors Sample Measure(type) Demographics HealthBehavior&HealthLiteracy Significantaftercontrolling fordemographics Pageetal.(2010) 8thand12thgradestudents, SMLScale Gradens Behavior:Smoking Yes;controlledforin Hungary (Media) Sexns R/ship:LowHL/currentsmokerstatus; originalanalyses Smokingstatus:non- Susceptibilitytosmoking:nsamongnon-smokers smoker+ Pageetal.(2011) 10th-12thgradestudents,Vietnam SMLScale Girls+ Behavior:Smokeinpast30daysR/ship:HighSML/reduced Yes;controlledforin (Media) Smokingstatusns smoking(Hanoischoolandgrade10students); originalanalyses Susceptibilitytosmoking:nsamongnon-smokers Primack,Gold,Land, 14-18yearolds,USA SMLScale Age+ Behavior:Smoking Yes;controlledforin etal.(2006) (Media) Sexns R/ship:SMLindependentlyassociatedwithcurrentsmoking originalanalyses Racens status; Parentaleducation+ HighSML/lowsusceptibilitytosmokingamongnon-smokers Academicperformance+ PrimackandHobbs 14-18yearolds,USA SMLscale Didnotreport Behavior:Smoking Yes;controlledforin (2009) (Media) demographicsbySML R/ship:HighSML/Lowcurrentsmokingstatus;HighSML/Low originalanalyses susceptibilitytosmokingamongnon-smokers Salgadoetal.(2012) 8th-12thgradestudents(12–17 AdaptedSMLscale(9-items Didnotreport Behavior:Smoking Yes;controlledforin yearsold),Argentina used;Media) demographicsbySML R/ship:HighSML/lowcurrentsmokingstatus; originalanalyses HighSML/lowersusceptibilitytosmokingamongnon-smokers Shoneetal.(2011) 16-23yearsold,foureducational REALM(>18)andREALM- Agens Behavior:Familiarityanduseofacetaminopheninthepast Notreported andtwohealthcaresites,USA Teen(<18) Sexns month (Functional) Black+ R/ship:HighHL/highhealthbehavior Participanteducation+ Note:eHEALS=eHealthLiteracyScale;HL=healthliteracy;NVS=NewestVitalSign;REALM=RapidEstimateofAdultLiteracyinMedicine;R/ship=significantrelationshipbetweenbehaviorandHL;SML=Smoking MediaLiteracyScale;s-TOFHLA=Short-TestofFunctionalHealthLiteracyinAdults;TOFHLA=TestofFunctionalHealthLiteracyinAdults;ns=nosignificantrelationshipwithhealthliteracy;+=positiverelationshipwith healthliteracy;−=negativerelationshipwithhealthliteracy. 123 Journal of Adolescence 62 (2018) 116–127 S.A.Flearyetal. 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 Twostudiesfoundnorelationshipbetweensusceptibilitytosmoking(i.e.,howlikelyparticipantswouldbetosmoke)andsmoking medialiteracy(Pageetal.,2010,2011).However,Primack,Gold,Land,etal.(2006),PrimackandHobbs(2009),andSalgadoetal. (2012) reported that non-smokers had high smoking media literacy and low susceptibility to smoking. For the two studies that measuredbothalcoholandtobaccouse,highmedia(Changetal.,2016)andfunctionalhealthliteracy(Hoffmanetal.,2017)were associatedwithloweralcoholuse,butunrelatedtotobaccouse.Changetal.(2016)alsofoundthathighermediahealthliteracywas relatedtolowerintentionstousealcoholortobacco. Regardingmedicationuse,Dharmapurietal.(2015)foundnorelationshipbetweenadolescents'functionalhealthliteracyand medicationadherence.Conversely,Shoneetal.(2011)foundthatincreasedfunctionalhealthliteracywasassociatedwithadoles- cents'familiarityanduseofover-the-counteracetaminophen.Shoneetal.(2011)didnotstatewhethertheycontrolledfordemo- graphicvariables,therefore,itisunclearwhethertherelationshipissignificantafteraccountingfordemographics(e.g.,age,race, SES)knowntoberelatedtoadolescents'medicationuse(Vlasnik,Aliotta,&DeLor,2005). Fourstudiesassessedtherelationshipbetweenadolescents'healthliteracyandtheirhealthinformation-seekingbehaviors.Chang etal.(2015)foundapositiverelationshipbetweenmediahealthliteracyandhealthinformation-seekingamongadolescents.Findings fromGhaddaretal.(2012)werevariedbasedonthehealthliteracyinstrumentused.Specifically,fortheeHEALS,electronichealth literacywaspositivelyrelatedtoonlinehealthinformation-seeking;however,fortheNVS,therelationshipwasinsignificant.After controllingforadolescents'frequencyofinternetuse,experiencevisitinghealth-relatedwebsites,baselineelectronichealthliteracy, andbaselinetrustincommercialwebsites,Hoveetal.(2011)concludedhigherelectronichealthliteracywasrelatedtoparticipants' increasedselection ofbrandwebsites astheleast reliable health-information source.However,when Hove etal.(2011) included demographicvariablesintheirmodel,themodelwasnolongersignificant.PaekandHove(2012)concludedthatadolescents'health information-seeking,measuredashealthmotivation,wasnegativelyrelatedtoachangeintheirelectronichealthliteracy.Yet,when researchers controlled for demographics and other relevant variables, the relationship between health motivation and adolescent changeinelectronichealthliteracywasnolongersignificant. 3. Discussion This review synthesizes literature on the relationship between adolescents' health literacy and health behaviors. Across the studies,thereweresevenmeasuresandeightuniquedefinitionsofhealthliteracy.Ofthe10studiesguidedbytheoreticalframe- works, three used similar frameworks, and two included adolescents' environmental influences. No study deliberately included adolescentdevelopmentalcharacteristicsortheory.Functionalandmediahealthliteracywererelatedtohigherhealthpromoting behaviors(whenexploredinaggregate),loweralcohol/tobaccouse,andimprovedhealth-relatedinformation-seeking.Additionally, high smoking media literacy was associated with lower tobacco use and lower susceptibility to smoking. No study examined the moderatingroleofsocio-demographicfactorsintherelationshipbetweenhealthliteracyandhealthbehaviors. Therelationshipbetweenage,sex,andhealthliteracywereinconsistentacrossstudiesandfewstudiesexploredtherace/ethnicity and health literacy relationship. Given the sex and age differences in the timing of developmental characteristics related to ado- lescents' health behaviors (e.g., impulsivity, sensation-seeking), health literacy may be more affected by these differences than is reflected in the studies reviewed. The inclusion of developmental characteristics and tests of mediation and moderation of these characteristics,sex,andage,intherelationshipbetweenadolescents'healthliteracyandhealthbehaviorswillimproveourunder- standingofhowhealthliteracyservesasahealthdecision-makingtoolforadolescentsspecifically. Therelationshipsbetweenparenteducation,income,andadolescenthealthliteracywereconsistentacrossstudiesandreflective oftheadult literature such thatadults' education andincomewere positively related totheir health literacy (Gazmararian et al., 1999). Adolescents in households with high parent education and income are more likely to have parents who have high health literacy.Theseparentsarethusbetterequippedtoteachadolescentshealthliteracyskillsandmorelikelytohavetheresourcesto createopportunitiesforadolescentstofurtherlearnandpracticetheseskills.Researchshowsthatparentswithhigheducationand incomearemore likely to engagein preventive health behaviors fortheir children (Stella, Bellamy, Schwalberg, &Drum, 2001). Theseearlypreventivehealthexperiencesserveasateachingtoolsinthedevelopmentofhealthliteracythattranslatesintobehavior inadulthood(Missinne,Neels,&Bracke,2014).Thus,adolescentswithlowincome/loweducationparentsareatincreasedriskfor lowerpreventivehealthbehaviors inadulthoodandincreasing theirhealthliteracythrough interventionsiscriticaltoimproving theirpreventivehealthandreducingdisparities. Asdiscussed,Nutbeam(2000,2008)proposedthreetypesofhealthliteracy:functional,communicative/interactive,andcritical. Other definitions ofhealth literacy alsoinclude translating knowledge intobehavior, thus further emphasizingthe importance of communicative/interactiveandcriticalhealthliteracy.Themajorityofthemeasuresonlyassessedfunctionalhealthliteracy,thus ignoring the role of health literacy in translating knowledge into behavior through communication/interactions with health pro- fessionalsandhealthcontent,andsociopoliticalaction.Thoughnostudyexploredcriticalhealthliteracy,Levin-Zamiretal.(2011)’s emphasisofcriticalanalysisandactioninmediahealthliteracyismostconsistentwithcriticalhealthliteracy.Measuressuchasthe AllAspectsHealthLiteracyScale(Chinn&McCarthy,2013)attempttoassessalltypesofhealthliteracyoutlinedby(Nutbeam,2000, 2008);however,thisadultmeasureassessesperceptionsratherthanobjectiveskills.Measurementdevelopmenttoobjectivelyassess alltypesofhealthliteracyandbaselineresearchonalltypesofhealthliteracyinadolescentsarecriticallyneededtofullyunderstand andinterveneonhealthliteracyasahealthbehaviordecision-makingtool. Unlikefunctionalhealthliteracy,themediahealthliteracymeasuresanddefinitionsvarysignificantlyincontent.Specifically, Levin-Zamiretal.(2011)'sdefinitionMediaHealthLiteracyscaleappliedNutbeam(2000,2008)'shealthliteracydefinitiontomedia, whereastheeHEALSandelectronichealthliteracydefinitionfocusedsolelyonaccessingandunderstandinginternet-basedhealth 124 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 information(Norman&Skinner,2006a,b),andPrimack,Gold,Switzer,etal.(2006)'sdefinitionandSmokingMediaLiteracyscale focused on critically evaluating media advertisements related to smoking. Comparing media health literacy studies using these definitionsisnotpossibleinthecurrentform.Whetherthethreeapproachesandcontentareasrepresentdifferentfacetsofmedia healthliteracyorareuniqueformsofhealthliteracyisyettobedetermined.However,itislikelythateachcontentareawillrequire different intervention strategies and have different effects on behavior. Future studies should explore the content areas simulta- neouslytodeterminewhethertheyrepresentasingleconceptandtheirdifferentialimpactonhealthbehaviorinadolescents. Noneofthetheoreticalframeworksinthereviewedstudiesweregroundedindevelopmentaltheory.Allofthestudies,therefore, failedtoconsiderdevelopmentalcharacteristics thatinfluenceadolescents'behavior(e.g.,impulsecontrol,sensation-seeking,and judgmentskills).Hoffmanetal.(2017)wastheonlystudythatconsideredenvironmentalinfluencesbyacknowledgingthechallenges accompanying Guatemala health and education systems. To fully appreciate the relationship between health literacy and health behaviors in adolescents, future research should incorporate explanatory theoretical frameworks for adolescent development and developmental characteristics known to influence health behavior decision-making. These frameworks and developmental char- acteristicsshouldbeusedincombinationwithhealthbehaviortheoryandresultantmodelsshouldbesensitivetosocialdeterminants ofhealthgiventhehighcorrelationwithhealthliteracyandhealthdisparities. The relationships between health literacy and health behaviors were mixed. Functional and media health literacy was sig- nificantlyrelatedtohealthpromotingbehaviors.Functionalhealthliteracywasalsorelatedtoreducedalcoholuseandincreased over-the-counter acetaminophen use and familiarity with acetaminophen. Conversely, functional health literacy was unrelated to riskysexualbehavior,medicaladherence,andhealthinformation-seeking.Theseresultsportrayasmallpartoftheadolescenthealth literacy/health behavior picture as the studies reviewed did not measure all aspects of health literacy and did not account for environmentalanddevelopmentalcharacteristicscriticaltoadolescents'healthbehaviordecision-making.Despitethis,theresults providesufficientevidencetosuggestthattherelationshipbetweenhealthliteracyandhealthbehaviorsinadolescentsismeaningful and should be investigated further. In addition to the measurement and theoretical considerations outlined above, future studies shouldalsoexplorethemoderatingroleofdemographiccharacteristics. The majority of studies utilizing the Smoking Media Literacy scale found a positive relationship between health literacy and substanceusebehaviors.Thissuggeststhatmediahealthliteracyinterventionsmaybeanimportantstrategytoreduceadolescents' substance use behaviors. In addition to individual-level interventions, social policies addressing the marketing of substances to adolescentsandpopulationlevelinterventionseducatingadolescentsabouthowtheyaretargetedviamediaarenecessary.Though theSmokingMediaLiteracyscaledidnotmeasurecriticalhealthliteracy,webelievethatinterventionsthatprovideadolescentswith opportunities to learn how to critically analyze health messages and media sources will serve to strengthen the impact of health literacy in decision-making regarding substance use behaviors. Given the increase in online health information-seeking (Lenhart, Purcell,Smith,&Zickuhr,2010)andtheuseofmediaasatooltopromotehealthbehaviorsamongadolescents(seeShaw,Mitchell, Welch,&Williamson,2015forreview),interventionstobolsteradolescents'mediahealthliteracyandcriticalhealthliteracymay servetomaximizetheimpactofmediacampaignstopromotepublichealth.Further,criticalmediahealthliteracyskillsshouldbe integrated into school curriculums and clinical settings as the ability to access, understand, critically evaluate, and apply health informationtohealthdecisionsisalifeskillwithimportantconsequences. 4. Limitations Most of the limitations of this review are related to the paucity of research on the relationship between health literacy and adolescenthealthbehaviors.Giventhatresearchersdidnotsolicitunpublishedstudies,thepresentreviewisnotwithoutrisksofbias andmayunderestimatethequantityofresearchonthetopic.However,webelievethatthelackofstudiesismostlyduetohealth literacy beingunderstudied inadolescents. Thestudies reviewed variedintheassessmentofhealth literacy andhealth behaviors measured.Thismakesitimpossibletocalculateeffectsizesandlimitsusfromdrawingconclusions.Thewideagerangeofparti- cipantsacrossstudiesisanotherlimitation:10-year-oldsto23-year-oldsvaryinthebrainmaturation,judgmentskills,expectedlevel ofautonomy,andlifeexperiences,allofwhichpotentiallyinteractwithhealthliteracyandopportunitiesforengagementsinhealth behaviors.Inaddition,ourreviewattemptedtofocusonobjective(ratherthanperception)measuresofhealthliteracyasresearchon adolescents' judgment skills suggest that adolescents overestimate their ability to manage situations (Albert & Steinberg, 2011); however,wewerecompelledtoincludestudieswithaperceptionmeasureofelectronichealthliteracy(i.e.,eHEALS)asitistheonly measureofelectronichealthliteracyinadolescents. 5. Conclusions Thegoalofthispaperwastosummarizetheexistingstudiesontherelationshipbetweenhealthliteracyandadolescents'health behaviors. Although only 17 studies were identified, the results suggest that there is a meaningful relationship between health literacy and adolescents' health behaviors. We believe that developing and/or identifying validated objective measures of health literacythatassessallaspectsofhealthliteracy(i.e.,functional,communicative/interactive,critical,andmediahealthliteracy),and integratingdevelopmentaltheoryinresearchdesigniscriticalindeterminingtherelationshipbetweenadolescents'healthliteracy andhealthbehaviorsandidentifyingareasforintervention.Interveningonhealthliteracymaylikelyimprovehealthbehaviorsin adolescentsasitprovidesthetoolsfortranslatingknowledgeintobehaviorandempowersadolescentsinhealthdecision-makingin theircurrentlivesandacrosstheirlifespan.Policiesshouldbegeneratedtosupportadolescents'developmentofhealthliteracyskills astheskillsrequiredtomakeinformedhealthdecisionsareessentialandamatterofpublichealth. 125 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 Conflictofinterest Nodisclosures. References Albert,D.,&Steinberg,L.(2011).Judgmentanddecisionmakinginadolescence.JournalofResearchonAdolescence,21(1),211–224. Allen,C.D.,Rivier,C.L.,&Lee,S.Y.(2011).Adolescentalcoholexposurealtersthecentralbraincircuitsknowntoregulatethestressresponse.Neuroscience,182, 162–168. Austin,E.W.,&Johnson,K.K.(1997).Immediateanddelayedeffectsofmedialiteracytrainingonthirdgrader'sdecisionmakingforalcohol.HealthCommunication, 9(4),323–349. Baker,D.W.,Gazmararian,J.A.,Williams,M.V.,Scott,T.,Parker,R.M.,Green,D.,etal.(2004).HealthliteracyanduseofoutpatientphysicianservicesbyMedicare managedcareenrollees.JournalofGeneralInternalMedicine,19(3),215–220. Baker,D.W.,Parker,R.M.,Williams,M.V.,Pitkin,K.,Parikh,N.S.,Coates,W.,etal.(1996).Thehealthcareexperienceofpatientswithlowliteracy.Archivesof FamilyMedicine,5(6),329–334. Baker,D.W.,Williams,M.V.,Parker,R.M.,Gazmararian,J.A.,&Nurss,J.(1999).Developmentofabrieftesttomeasurefunctionalhealthliteracy.PatientEducation andCounseling,38(1),33–42. Bandura,A.(2001).Socialcognitivetheory:Anagenticperspective.AnnualReviewofPsychology,52(1),1–26. Baranowski,T.,Cullen,K.W.,Basen-Engquist,K.,Wetter,D.W.,Cummings,S.,Martineau,D.S.,etal.(1997).Transitionsoutofhighschool:Timeofincreasedcancer risk?PreventiveMedicine,26(5),694–703. Bazalgette,C.(1992).Keyaspectsofmediaeducation.MediaEducation:AnIntroduction.London,England:BritishFilmInstitute. Berkey,C.S.,Willett,W.C.,Frazier,A.L.,Rosner,B.,Tamimi,R.M.,Rockett,H.R.,etal.(2010).Prospectivestudyofadolescentalcoholconsumptionandriskof benignbreastdiseaseinyoungwomen.Pediatrics,Peds,2009–2347. Blakemore,S.-J.,&Robbins,T.W.(2012).Decision-makingintheadolescentbrain.NatureNeuroscience,15(9),1184–1191. Braveman,P.(2006).Healthdisparitiesandhealthequity:Conceptsandmeasurement.AnnualReviewofPublicHealth,27,167–194. Chang,L.C.(2011).Healthliteracy,self-reportedstatusandhealthpromotingbehavioursforadolescentsinTaiwan.JournalofClinicalNursing,20(1–2),190–196. Chang,F.-C.,Chiu,C.-H.,Chen,P.-H.,Miao,N.-F.,Lee,C.-M.,Chiang,J.-T.,etal.(2015).Relationshipbetweenparentalandadolescentehealthliteracyandonline healthinformationseekinginTaiwan.Cyberpsychology,Behavior,andSocialNetworking,18(10),618–624. Chang,F.-c.,Miao,N.-f.,Lee,C.-m.,Chen,P.-h.,Chiu,C.-h.,&Lee,S.-c.(2016).Theassociationofmediaexposureandmedialiteracywithadolescentalcoholand tobaccouse.JournalofHealthPsychology,21(4),513–525. Charakida,M.,Khan,T.,Johnson,W.,Finer,N.,Woodside,J.,Whincup,P.H.,etal.(2014).LifelongpatternsofBMIandcardiovascularphenotypeinindividualsaged 60–64yearsinthe1946Britishbirthcohortstudy:Anepidemiologicalstudy.TheLancetDiabetes&Endocrinology,2(8),648–654. Chassin,L.,Presson,C.C.,Sherman,S.J.,&McConnell,A.R.(1995).Adolescenthealthissues. Chen,Y.-C.(2013).Theeffectivenessofdifferentapproachestomedialiteracyinmodifyingadolescents'responsestoalcohol.JournalofHealthCommunication,18(6), 723–739. Chinn,D.(2011).Criticalhealthliteracy:Areviewandcriticalanalysis.SocialScience&Medicine,73(1),60–67. Chinn,D.,&McCarthy,C.(2013).Allaspectsofhealthliteracyscale(AAHLS):Developingatooltomeasurefunctional,communicativeandcriticalhealthliteracyin primaryhealthcaresettings.PatientEducationandCounseling,90(2),247–253. Chisolm,D.J.,Manganello,J.A.,Kelleher,K.J.,&Marshal,M.P.(2014).Healthliteracy,alcoholexpectancies,andalcoholusebehaviorsinteens.PatientEducation andCounseling,97(2),291–296. Coyle,K.,Basen-Engquist,K.,Kirby,D.,Parcel,G.,Banspach,S.,Collins,J.,etal.(2001).Saferchoices:Reducingteenpregnancy,HIV,andSTDs.PublicHealthReports, 116(1suppl),82–93. Davis,T.C.,Williams,M.V.,Marin,E.,Parker,R.M.,&Glass,J.(2002).Healthliteracyandcancercommunication.CA:ACancerJournalforClinicians,52(3), 134–149. Davis,T.C.,Wolf,M.S.,Arnold,C.L.,Byrd,R.S.,Long,S.W.,Springer,T.,etal.(2006).DevelopmentandvalidationoftheRapidestimateofadolescentliteracyin medicine(REALM-Teen):Atooltoscreenadolescentsforbelow-gradereadinginhealthcaresettings.Pediatrics,118(6),e1707–e1714. DeBellis,M.D.,Clark,D.B.,Beers,S.R.,Soloff,P.H.,Boring,A.M.,Hall,J.,etal.(2000).Hippocampalvolumeinadolescent-onsetalcoholusedisorders.American JournalofPsychiatry,157(5),737–744. DeWit,D.J.,Adlaf,E.M.,Offord,D.R.,&Ogborne,A.C.(2000).Ageatfirstalcoholuse:Ariskfactorforthedevelopmentofalcoholdisorders.AmericanJournalof Psychiatry,157(5),745–750. Dharmapuri,S.,Best,D.,Kind,T.,Silber,T.J.,Simpson,P.,&D'angelo,L.(2015).Healthliteracyandmedicationadherenceinadolescents.TheJournalofPediatrics, 166(2),378–382. Duncan,S.C.,Alpert,A.,Duncan,T.E.,&Hops,H.(1997).Adolescentalcoholusedevelopmentandyoungadultoutcomes.DrugandAlcoholDependence,49(1),39–48. Fishbein,M.(1979).Atheoryofreasonedaction:Someapplicationsandimplications. Fleary,S.A.(2017).Combinedpatternsofriskforproblemandobesogenicbehaviorsinadolescents:Alatentclassanalysisapproach.JournalofSchoolHealth,87(3), 182–193. Friestad,M.,&Wright,P.(1994).Thepersuasionknowledgemodel:Howpeoplecopewithpersuasionattempts.JournalofConsumerResearch,21(1),1–31. Fuemmeler,B.F.,Pendzich,M.K.,&Tercyak,K.P.(2009).Weight,dietarybehavior,andphysicalactivityinchildhoodandadolescence:Implicationsforadultcancer risk.ObesityFacts,2(3),179–186. Gazmararian,J.A.,Baker,D.W.,Williams,M.V.,Parker,R.M.,Scott,T.L.,Green,D.C.,etal.(1999).HealthliteracyamongMedicareenrolleesinamanagedcare organization.Jama,281(6),545–551. Ghaddar,S.F.,Valerio,M.A.,Garcia,C.M.,&Hansen,L.(2012).Adolescenthealthliteracy:Theimportanceofcrediblesourcesforonlinehealthinformation.Journal ofSchoolHealth,82(1),28–36. Goriounova,N.A.,&Mansvelder,H.D.(2012).Short-andlong-termconsequencesofnicotineexposureduringadolescenceforprefrontalcortexneuronalnetwork function.ColdSpringHarborPerspectivesinMedicine,2(12),a012120. Hoffman,S.,Marsiglia,F.F.,Nevarez,L.,&Porta,M.(2017).HealthliteracyamongyouthinGuatemalacity.SocialWorkinPublicHealth,32(1),30–37. Horn,K.,Dino,G.,Gao,X.,&Momani,A.(1999).FeasibilityevaluationofNotonTobacco:TheAmericanLungAssociation'snewstopsmokingprogrammefor adolescents.HealthEducation,99(5),192–207. Hove,T.,Paek,H.-J.,&Isaacson,T.(2011).UsingadolescenteHealthliteracytoweightrustincommercialwebsites.JournalofAdvertisingResearch,51(3),524–537. Jackson,D.B.,&Beaver,K.M.(2015).Theroleofadolescentnutritionandphysicalactivityinthepredictionofverbalintelligenceduringearlyadulthood:A geneticallyinformedanalysisoftwinpairs.InternationalJournalofEnvironmentalResearchandPublicHealth,12(1),385–401. Jones,B.T.,Corbin,W.,&Fromme,K.(2001).Areviewofexpectancytheoryandalcoholconsumption.Addiction,96(1),57–72. Juonala,M.,Magnussen,C.G.,Berenson,G.S.,Venn,A.,Burns,T.L.,Sabin,M.A.,etal.(2011).Childhoodadiposity,adultadiposity,andcardiovascularriskfactors. NewEnglandJournalofMedicine,365(20),1876–1885. Kaestle,C.E.,Chen,Y.,Estabrooks,P.A.,Zoellner,J.,&Bigby,B.(2013).Pilotevaluationofamedialiteracyprogramfortobaccopreventiontargetingearly adolescentsshowsmixedresults.AmericanJournalofHealthPromotion,27(6),366–369. Kann,L.(2016).Youthriskbehaviorsurveillance—UnitedStates,2015.MMWR.SurveillanceSummaries,65. Kutner,M.,Greenburg,E.,Jin,Y.,&Paulsen,C.(2006).ThehealthliteracyofAmerica'sAdults:Resultsfromthe2003Nationalassessmentofadultliteracy.NCES2006-483. NationalCenterforEducationStatistics. Kwan,M.,Bobko,S.,Faulkner,G.,Donnelly,P.,&Cairney,J.(2014).Sportparticipationandalcoholandillicitdruguseinadolescentsandyoungadults:Asystematic reviewoflongitudinalstudies.AddictiveBehaviors,39(3),497–506. 126 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseS.A.Flearyetal. Journal of Adolescence 62 (2018) 116–127 Lanza,S.T.,&Vasilenko,S.A.(2015).Newmethodsshedlightonageofonsetasariskfactorfornicotinedependence.AddictiveBehaviors,50,161–164. Lenhart,A.,Purcell,K.,Smith,A.,&Zickuhr,K.(2010).Socialmedia&mobileinternetuseamongteensandyoungadults.Millennials.Pewinternet&Americanlifeproject. Levin-Zamir,D.,Lemish,D.,&Gofin,R.(2011).Mediahealthliteracy(MHL):Developmentandmeasurementoftheconceptamongadolescents.HealthEducation Research,26(2),323–335. Malmberg,M.,Kleinjan,M.,Overbeek,G.,Vermulst,A.,Lammers,J.,Monshouwer,K.,etal.(2015).SubstanceuseoutcomesintheHealthySchoolandDrugs program:Resultsfromalatentgrowthcurveapproach.AddictiveBehaviors,42,194–202. Mancuso,C.A.,&Rincon,M.(2006).Asthmapatients'assessmentsofhealthcareandmedicaldecisionmaking:Theroleofhealthliteracy.JournalofAsthma,43(1), 41–44. Manganello,J.A.(2008).Healthliteracyandadolescents:Aframeworkandagendaforfutureresearch.HealthEducationResearch,23(5),840–847.http://dx.doi.org/ 10.1093/her/cym069. Marcus,P.M.,Newman,B.,Millikan,R.C.,Moorman,P.G.,Baird,D.D.,&Qaqish,B.(2000).Theassociationsofadolescentcigarettesmoking,alcoholicbeverage consumption,environmentaltobaccosmoke,andionizingradiationwithsubsequentbreastcancerrisk(UnitedStates).CancerCausesandControl,11(3),271–278. Missinne,S.,Neels,K.,&Bracke,P.(2014).Reconsideringinequalitiesinpreventivehealthcare:Anapplicationofculturalhealthcapitaltheoryandthelife-course perspectivetothetake-upofmammographyscreening.SociologyofHealth&Illness,36(8),1259–1275. Moher,D.,Liberati,A.,Tetzlaff,J.,Altman,D.G.,&Group,P.(2009).Preferredreportingitemsforsystematicreviewsandmeta-analyses:ThePRISMAstatement. PLoSMedicine,6(7),e1000097. Murphy,P.W.,Davis,T.C.,Long,S.W.,Jackson,R.H.,&Decker,B.C.(1993).Rapidestimateofadultliteracyinmedicine(REALM):Aquickreadingtestforpatients. JournalofReading,37(2),124–130. Needham,H.E.,Wiemann,C.M.,Tortolero,S.R.,&Chacko,M.R.(2010).Relationshipbetweenhealthliteracy,readingcomprehension,andriskforsexually transmittedinfectionsinyoungwomen.JournalofAdolescentHealth,46(5),506–508. Neumark-Sztainer,D.,Story,M.,Hannan,P.J.,&Rex,J.(2003).Newmoves:Aschool-basedobesitypreventionprogramforadolescentgirls.PreventiveMedicine, 37(1),41–51. Norman,C.D.,&Skinner,H.A.(2006a).eHEALS:TheeHealthLiteracyScale.JournalofMedicalInternetResearch,8(4),e27.http://dx.doi.org/10.2196/jmir.8.4.e27. Norman,C.D.,&Skinner,H.A.(2006b).eHealthliteracy:essentialskillsforconsumerhealthinanetworkedworld.JournalofMedicalInternetResearch,8(2),e9. Nutbeam,D.(2000).Healthliteracyasapublichealthgoal:Achallengeforcontemporaryhealtheducationandcommunicationstrategiesintothe21stcentury.Health PromotionInternational,15(3),259–267. Nutbeam,D.(2008).Theevolvingconceptofhealthliteracy.SocialScience&Medicine,67(12),2072–2078. Ormshaw,M.J.,Paakkari,L.T.,&Kannas,L.K.(2013).Measuringchildandadolescenthealthliteracy:Asystematicreviewofliterature.HealthEducation,113(5), 433–455. Osborn,C.Y.,Paasche-Orlow,M.K.,Davis,T.C.,&Wolf,M.S.(2007).Healthliteracy:AnoverlookedfactorinunderstandingHIVhealthdisparities.AmericanJournal ofPreventiveMedicine,33(5),374–378. Paakkari,L.,Kokko,S.,Villberg,J.,Paakkari,O.,&Tynjälä,J.(2017).Healthliteracyandparticipationinsportsclubactivitiesamongadolescents.Scandinavian JournalofPublicHealth.http://dx.doi.org/10.1177/1403494817714189Jul1:1403494817714189,1–7.[online,aheadofprint]. Paek,H.-J.,&Hove,T.(2012).SocialcognitivefactorsandperceivedsocialinfluencesthatimproveadolescenteHealthliteracy.HealthCommunication,27(8), 727–737. Page,R.M.,Huong,N.T.,Chi,H.K.,&Tien,T.Q.(2011).SmokingmedialiteracyinVietnameseadolescents.JournalofSchoolHealth,81(1),34–41. Page,R.M.,Piko,B.F.,Balazs,M.A.,&Struk,T.(2010).MedialiteracyandcigarettesmokinginHungarianadolescents.HealthEducationJournal,70(4),446–457. Parker,R.M.,Baker,D.W.,Williams,M.V.,&Nurss,J.R.(1995).Thetestoffunctionalhealthliteracyinadults.JournalofGeneralInternalMedicine,10(10),537–541. Parker,R.M.,Ratzan,S.C.,&Lurie,N.(2003).Healthliteracy:Apolicychallengeforadvancinghigh-qualityhealthcare.HealthAffairs,22(4),147–153. Pate,R.R.,Trost,S.G.,Levin,S.,&Dowda,M.(2000).Sportsparticipationandhealth-relatedbehaviorsamongUSyouth.ArchivesofPediatrics&AdolescentMedicine, 154(9),904–911. Peralta,L.R.,Jones,R.A.,&Okely,A.D.(2009).Promotinghealthylifestylesamongadolescentboys:ThefitnessimprovementandlifestyleawarenessprogramRCT. PreventiveMedicine,48(6),537–542. Perry,E.L.(2014).Healthliteracyinadolescents:Anintegrativereview.JournalforSpecialistsinPediatricNursing,19(3),210–218. Primack,B.A.,Douglas,E.L.,Land,S.R.,Miller,E.,&Fine,M.J.(2014).Comparisonofmedialiteracyandusualeducationtopreventtobaccouse:Acluster- randomizedtrial.JournalofSchoolHealth,84(2),106–115. Primack,B.A.,Gold,M.A.,Land,S.R.,&Fine,M.J.(2006a).Associationofcigarettesmokingandmedialiteracyaboutsmokingamongadolescents.Journalof AdolescentHealth,39(4),465–472. Primack,B.A.,Gold,M.A.,Switzer,G.E.,Hobbs,R.,Land,S.R.,&Fine,M.J.(2006b).Developmentandvalidationofasmokingmedialiteracyscaleforadolescents. ArchivesofPediatrics&AdolescentMedicine,160(4),369–374. Primack,B.A.,&Hobbs,R.(2009).Associationofvariouscomponentsofmedialiteracyandadolescentsmoking.AmericanJournalofHealthBehavior,33(2),192–201. Primack,B.A.,Switzer,G.E.,&Dalton,M.A.(2007).Improvingmeasurementofnormativebeliefsinvolvingsmokingamongadolescents.ArchivesofPediatrics& AdolescentMedicine,161(5),434–439. Reuters,T.(2011).EndNote.NewYork:ThomsonReuters. Rosenstock,I.M.,Strecher,V.J.,&Becker,M.H.(1988).Sociallearningtheoryandthehealthbeliefmodel.HealthEducation&Behavior,15(2),175–183. Salgado,M.V.,Pérez-Stable,E.J.,Primack,B.A.,Kaplan,C.P.,Mejia,R.M.,Gregorich,S.E.,etal.(2012).Associationofmedialiteracywithcigarettesmoking amongyouthinJujuy,Argentina.Nicotine&TobaccoResearch,14(5),516–521. Scott,T.L.,Gazmararian,J.A.,Williams,M.V.,&Baker,D.W.(2002).HealthliteracyandpreventivehealthcareuseamongMedicareenrolleesinamanagedcare organization.MedicalCare,40(5),395–404. Shaw,J.M.,Mitchell,C.A.,Welch,A.J.,&Williamson,M.J.(2015).Socialmediausedasahealthinterventioninadolescenthealth:Asystematicreviewofthe literature.DigitalHealth,12055207615588395. Shone,L.P.,King,J.P.,Doane,C.,Wilson,K.M.,&Wolf,M.S.(2011).Misunderstandingandpotentialunintendedmisuseofacetaminophenamongadolescentsand youngadults.JournalofHealthCommunication,16(sup3),256–267. Sloboda,Z.,Stephens,R.C.,Stephens,P.C.,Grey,S.F.,Teasdale,B.,Hawthorne,R.D.,etal.(2009).Theadolescentsubstanceabusepreventionstudy:Arandomized fieldtrialofauniversalsubstanceabusepreventionprogram.DrugandAlcoholDependence,102(1),1–10. Smith,B.J.,Tang,K.C.,&Nutbeam,D.(2006).WHOhealthpromotionglossary:Newterms.HealthPromotionInternational,21(4),340–345. Stella,M.Y.,Bellamy,H.A.,Schwalberg,R.H.,&Drum,M.A.(2001).FactorsassociatedwithuseofpreventivedentalandhealthservicesamongUSadolescents. JournalofAdolescentHealth,29(6),395–405. Strand,T.-E.,Malayeri,C.,Eskonsipo,P.K.,Grimsrud,T.K.,Norstein,J.,&Grotmol,T.(2004).Adolescentsmokingandtrendsinlungcancerincidenceamongyoung adultsinNorway1954–1998.CancerCausesandControl,15(1),27–33. Sykes,S.,Wills,J.,Rowlands,G.,&Popple,K.(2013).Understandingcriticalhealthliteracy:Aconceptanalysis.BMCPublicHealth,13(1),150. Tirosh,A.,Shai,I.,Afek,A.,Dubnov-Raz,G.,Ayalon,N.,Gordon,B.,etal.(2011).AdolescentBMItrajectoryandriskofdiabetesversuscoronarydisease.NewEngland JournalofMedicine,364(14),1315–1325. USDepartmentofHealthandHumanServices(2000).Healthypeople2010,Vol.1.USDept.ofHealthandHumanServices. Veliz,P.T.,Boyd,C.J.,&McCabe,S.E.(2015).Competitivesportinvolvementandsubstanceuseamongadolescents:Anationwidestudy.SubstanceUse&Misuse, 50(2),156–165. Vlasnik,J.J.,Aliotta,S.L.,&DeLor,B.(2005).Medicationadherence:Factorsinfluencingcompliancewithprescribedmedicationplans.TheCaseManager,16(2), 47–51. Weiss,B.D.,Mays,M.Z.,Martz,W.,Castro,K.M.,DeWalt,D.A.,Pignone,M.P.,etal.(2005).Quickassessmentofliteracyinprimarycare:Thenewestvitalsign.The AnnalsofFamilyMedicine,3(6),514–522. Williams,M.V.,Parker,R.M.,Baker,D.W.,Parikh,N.S.,Pitkin,K.,Coates,W.C.,etal.(1995).Inadequatefunctionalhealthliteracyamongpatientsattwopublic hospitals.JAMA,274(21),1677–1682. 127 10959254, 2018, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1016/j.adolescence.2017.11.010 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License