Bröderetal.BMCPublicHealth (2017) 17:361 DOI10.1186/s12889-017-4267-y RESEARCH ARTICLE Open Access Health literacy in childhood and youth: a systematic review of definitions and models Janine Bröder1* , Orkan Okan1, Ullrich Bauer1, Dirk Bruland1, Sandra Schlupp1, Torsten M. Bollweg1, Luis Saboga-Nunes2, Emma Bond3, Kristine Sørensen4, Eva-Maria Bitzer5, Susanne Jordan6, Olga Domanska6, Christiane Firnges6, Graça S. Carvalho7, Uwe H. Bittlingmayer5, Diane Levin-Zamir8, Jürgen Pelikan9, Diana Sahrai10, Albert Lenz11, Patricia Wahl11, Malcolm Thomas12, Fabian Kessl13 and Paulo Pinheiro1 Abstract Background: Children and young people constitute a core target group for health literacy research and practice: during childhood and youth, fundamentalcognitive, physical and emotionaldevelopment processes take place and health-relatedbehavioursandskillsdevelop.However,thereislimitedknowledgeandacademicconsensusregarding theabilitiesandknowledgeachildoryoungpersonshouldpossessformakingsoundhealthdecisions.Theresearch presentedinthisreviewaddressesthisgapbyprovidinganoverviewandsynthesisofcurrentunderstandingsof healthliteracyinchildhoodandyouth.Furthermore,theauthorsaimtounderstandtowhatextentavailablemodels capturetheuniqueneedsandcharacteristicsofchildrenandyoungpeople. Method:SixdatabasesweresystematicallysearchedwithrelevantsearchtermsinEnglishandGerman.Ofthen=1492 publicationsidentified,N=1021enteredtheabstractscreeningandN=340full-textswerescreenedforeligibility.Atotal of30articles,whichdefinedorconceptualizedgenerichealthliteracyforatargetpopulationof18yearsoryounger,were selectedforafour-stepinductivecontentanalysis. Results:Thesystematicreviewoftheliteratureidentified12definitionsand21modelsthathavebeenspecifically developedforchildrenandyoungpeople.Intheliterature,healthliteracyinchildrenandyoungpeopleisdescribedas comprisingvariablesetsofkeydimensions,eachappearingasaclusterofrelatedabilities,skills,commitments,and knowledgethatenableapersontoapproachhealthinformationcompetentlyandeffectivelyandtoderiveathealth- promotingdecisionsandactions. Discussion:Identifieddefinitionsandmodelsareveryheterogeneous,depictinghealthliteracyasmultidimensional, complexconstruct.Moreover,healthliteracyisconceptualizedasanactioncompetence,withastrongfocusonpersonal attributes,whilealsorecognisingitsinterrelatednesswithsocialandcontextualdeterminants.Lifephasespecificitiesare mainlyconsideredfromacognitiveanddevelopmentalperspective,leavingchildren’sandyoungpeople’sspecificneeds, vulnerabilities,andsocialstructurespoorlyincorporatedwithinmostmodels.Whileacriticalnumberofdefinitionsand modelswereidentifiedforyouthorsecondaryschoolstudents,similarfindingsarelackingforchildrenundertheageof tenorwithinaprimaryschoolcontext. Keywords:HealthLiteracy,HealthCompetencies,Children,YoungPeople,Adolescents,Pupils,Definitions,Conceptual Models,Dimensions,LiteratureReview *Correspondence:Janine.broeder@uni-bielefeld.de 1CentreforPreventionandInterventioninChildhoodandAdolescenceCPI, BielefeldUniversity,Bielefeld,Germany Fulllistofauthorinformationisavailableattheendofthearticle ©TheAuthor(s).2017OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0 InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto theCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.Bröderetal.BMCPublicHealth (2017) 17:361 Page2of25 Background characteristics to contrast the target group from the From a public health perspective, children and young general adult population, namely (1) developmental people constitute a core target group for health literacy changes, (2) dependency on resources and skills, (3) research and intervention as during childhood and epidemiological differences, and (4) vulnerability to youth, fundamental cognitive, physical and emotional social-demographicdeterminantsof health. development processes take place [1] and health-related To address these described research gaps, this art- behaviours and skills develop. As a result, these stages of icle aims: life are regarded as crucial for healthy development, as well as for personal health and well-being throughout (a) toscopecurrent understandings ofhealth literacy adulthood [2, 3]. Moreover, health literacy is understood inchildhoodandyouth and as a variable construct that is acquired in a life-long (b)tounderstandtowhat extent availablemodels learning process, starting in early childhood [4]. Hence, capture theuniqueneeds andcharacteristicsof targeting children and young people with health literacy childrenandyoung people. interventions can help promoting healthy behaviors and ameliorate futurehealth risks. For this purpose, a systematic review and inductive Whilst we acknowledge the recent increase in publica- content analysis of health literacy definitions and models tions which focus on children and young people, the for persons aged 18 or younger was conducted in attention contributed to children’s and young people’s English andGermanacademicliterature. To the authors’ health literacy is still small compared to the momentum knowledge, this work is the first to scope the conceptual health literacy is currently experiencing in research, understanding of health literacy in children and young practice and policy-making. Within health care settings, people in a systematic manner. The research is con- research has mainly focused on the impact of parental ducted in the context of the German Health Literacy in or maternal health literacy on children’s health. Accord- Childhood and Adolescence (HLCA) Consortium [13] ingly, most research primarily addresses questions of and seeks to provide a first step towards future effective how children are affected when their parents lack the health literacy interventions to promote children’s and knowledge and skills required for making sound health young people’shealth. decisions concerning their children’s health [5]. Within health promotion, some attention has been drawn to Method addressing children’s and young people’s health literacy A systematic review of available generic health literacy inschool health education andhealthpromotion [6–9]. definitions and models for children and young people Moreover, there is limited knowledge and academic aged 18 or younger was conducted in accordance with consensus regarding the abilities and knowledge a child the Preferred Reporting Items for Systematic Reviews oryoung person shouldpossessformakingsoundhealth and Meta-Analyses (PRISMA) guidelines for ensuring decisions. For the general population, the European high quality and transparent reporting of reviews [14]. Health Literacy Consortium integrated both drivers and Within this research, health literacy is regarded as a differing dimensions to suggest: health literacy is “linked multidimensional construct for which the available latest to literacy and entails people’s knowledge, motivation research is being synthesized and evaluated. Hence, it and competences to access, understand, appraise, and consists of multiple underlying dimensions that entail apply health information in order to make judgments thegeneralizable characteristicsof healthliteracy.Health and take decisions in everyday life concerning health- literacy dimensions were extracted from available care, disease prevention and health promotion to main- conceptual models. These were clustered according to tain or improve quality of life during the life course.” their stated purpose as conceptualisation – the process [10]. Moreover, an individual’s health literacy depends by which imprecise constructs and their constituent upon their personal situation including their health sta- dimensions are defined in concrete terms – or operatio- tus, risks or problems, their affiliation with social nalisations, which provide the base for measuring the group(s) (e.g. health practitioners, patients, and different constructortesting itwithdefined variables[15]. age-groups) and other socio-economic determinants [11]. A more specific overview for child and youth Searchstrategyandscreeningprocess health literacy is lacking. Hence, it is unclear, to what Between May - Nov. 2015, six bibliographic databases extent conceptual and theoretical efforts for shaping and were searched, including PubMed, the Educational describing health literacy in children and young people Resources Information Centre (ERIC), the Cumulative currently do consider the unique characteristics of the Index to Nursing and Allied Health Literature target group and recognise related challenges. Rothman (CINAHL), PsycINFO, Web of Science, in English and et al. [12] proposed four categories of unique needs and the FIS Bildung Literaturdatenbank in German. SearchBröderetal.BMCPublicHealth (2017) 17:361 Page3of25 terms in English and German were defined for three and progress from birth to death. Thus, even without distinctive search clusters - main topic, subtopic, and specifically stating the target group, the life course target population (seeTable 1) - and were selected upon concept specifically encompasses children and young a narrative search. Search terms were combined through people as well. Therefore, the articles were included Boolean operators (AND/OR) and truncations and as they added to the comprehensiveness and the en- wildcard characters were used to increase the sensitivity tirety of the analysis. of the searches. The searches were not limited to any Whether articles were included for full-text analysis publication time frame, research design or peer-review was determined by JB and SS based on the articles’ criteria (dissertations and essays were included). Theory- assessed fit with the eligibility criteria. Publications, for building or conceptual, explorative publication are often which the researchers reached a differential decision, part of an inductive research process, providing the were discussed within the core research team and if theoretical base for hypothesis-testing research. There- necessary assessed againuntilconsensuswasreached. fore, not allquality standards as outlined inthe PRISMA guidelinesappliedtoourresearchquestion. The search identified n = 1492 publications (see Dataextractionandanalysis PRISMA Chart in Fig. 1). After removing duplicates The30 articles were selected for the full-text analysis for (n = 471), 1020 abstracts were screened by JB and OO. the following reasons: four contained only a definition Database searches were complemented by hand [1, 17–19], thirteen only a model [5, 20–31] and eight searches,e.g.inGoogleScholar,andacross-checkofthe described a definition and a model [4, 8, 10, 32–36]. For reference lists of studies included for analysis, retrieving three models two original references [37–39] were in- 13additionalarticlesthatenteredtheselectionprocess. cludedasbothprovidedadditionalinsightstothemodel. Articles were eligible if they: a) were fully available All these articles were qualitatively assessed and synthe- in English or German; b) focused on generic health sized applying a four-step inductive content analysis. literacy – while excluding any domain or topic- Firstly, eligible publications were scanned for definitions specific health literacy models, to ensure a focus on and conceptual models that were either developed for the core dimensions of health literacy [16]; c) offered the target group or adapted to it, or included relevant relevant content for defining and conceptualizing perspectives on health literacy for children and young health literacy in children and young people and d) people. Secondly, these definitions and models were addressed a target population that were 18 years or coded and extracted by the research team following an younger. Articles incorporating a life course perspec- inductive approach. Overlapping definitions and models tive on health literacy were included as well. The life from the same research group, were only included once. course concept refers to the sequence of age categor- For non-related publications that described the same ies that people normally pass through as they develop health literacy definitions or models, only the original reference was included and marked accordingly in Table 3. Thirdly, relevant background variables were defined Table1Searchtermsforsystematicliteraturesearch and extracted into a matrix. These background variables Topic Sub-topic included the age of the target group, the reasons for fo- English: lH ite ea ralt ch y”li ,t her ea ac lty h,“ ch oe malt ph etence S thk eill o* r, *c ,o mm op de et le *n ,f* r, ac mo en wce op rkt* *, , cussing on the target group, whether the target groups’ Defin* perspectives were considered (a) in the development of the definition or model, or (b) in the applicability and Fähigkeit*,Kompetenz*, Konzept*,Theorie*,Model*, relevanceofthese,andthe setting(s) forwhichtheywere And Rahmen*,Definition* developed. The articles’ research design and methodo- OR logical quality was not assessed as many studies were German: Gesundheitskompetenz, Targetpopulation theoreticalexplorations forwhichtheassessmentcriteria −mündigkeit,−bildung of PRISMA did not apply. Finally, the definitions and Child*,adolescen*,youth, teen*pupil*,student* identified dimensions were discussed with a whole re- Kind*,Jugend*,Teen*, search team in autumn 2015 and the feedback was inte- Schüler* grated intothe finalanalysis. Notes:Examplesforacombinationofsearchterms,inEnglish:(healthliteracy (healthANDliteracy)ORhealthcompetence)OR(skill*ORcompetenc*)AND (child*ORadolescen*ORyouth*ORteen*)AND(concept*ORtheor*OR Results model*ORframeworkORdefin*) InGerman:(Gesundheitskompetenz(GesundheitANDKompetenz)OR Thesystematic review of the literatureidentified 12 defi- GesundheitsmündigkeitORGesundheitsbildungORFähigkeit)AND(Kind*OR nitions (Table 2) and 21 models (Table 4) of health liter- Jugend*ORHeranwachsend*ORTeen*)AND(Konzept*ORTheor*ORModel* ORRahmen*ORDefin*) acy forchildrenandyoungpeople.Bröderetal.BMCPublicHealth (2017) 17:361 Page4of25 Fig.1PRISMAchartofsystematicsearchprocess Definitionsofhealthliteracyinchildhoodandyouth communitypartnersandSørensenetal.[10]evolvedfrom Of the 12 definitions (Table 2), two specifically targeted theresultsoftheirsystematicliteraturereview. children younger than 12 [17, 32], another one included The inductive narrative synthesis [40] of the defini- children from 3 to 18 years [1]. Four definitions focused tions revealed seven content categories: (1) components, on young people at different ages between 13 and namely skills, abilities, competences, etc., (2) actions or 18 years [8, 18, 19, 33], while five articles considered agency, (3) subjects, (4) sources of information, (5) pur- health literacy over the life course without specifying a pose,(6)conditions,(7)time perspective (seeTable3). target group [10, 20, 34–36]. Four definitions were Although diversely defined, health literacy was developed from a school health education perspective commonly portrayed as an individual-based construct, [8, 18, 19, 32]. While Massey [33] specifically targeted with a multidimensional nature [20]. As such, it exceeds health literacy in the health care setting, Mancuso [34] basic reading, writing or numerical abilities [1]. In and Sørensen et al. [10] stressed the relevance of health addition, health literacy entails a combination of differ- literacyinmultiplehealth-relatedsettingsincludinghealth ent health-related skills, competences, and knowledge, care, disease prevention, health promotion, and public as well as a motivational component that an individual health.ThedefinitionsbyFokandWong[17]andMassey possesses[10]. et al. [33] were the only ones where the target group par- All definitions share a dominant demand or action- ticipated in the development of empirical and explorative related focus mostly directed towards the access, process dimensions.Gordonetal.[19]developedthedefinitionas andapplicationof health information[10].Theseactions a result of a stakeholder consultation with school health entail immediate cognitive or behavioural tasks thatBröderetal.BMCPublicHealth (2017) 17:361 Page5of25 Table2Definitionsofchildren’sandyoungpeople’shealthliteracy Children&PrimarySchoolStudents A Fok&Wong[17] Themeaningofhealthliteracytochildrenisdefinedas“tounderstandandactuponphysicalandpsycho-social activitieswithappropriatestandards,beingabletointeractwithpeopleandcopewithnecessarychangesand; demandsreasonableautonomysoastoachievecompletephysical,mentalandsocialwell-being. B Brownetal.[32] “Forthisstudy,healthliteracywasdefinedsimplyastheabilitytounderstandhealthinformationandtounderstand thatactionstakeninyouthaffecthealthlaterinlife,combinedwiththeabilitytoaccessvalidhealthinformation.” Youngpeople&SecondarySchoolStudents C Masseyetal.[33] “Wetakeanexpandedperspectiveofhealthliteracyanddefineitasasetofskillsusedtoorganizeandapplyhealth knowledge,attitudesandpracticesrelevantwhenmanagingone’shealthenvironment.” D Paakkari&Paakkari[8] “HealthLiteracyisdefinedinthefollowingterms:Healthliteracycomprisesabroadrangeofknowledgeand competenciesthatpeopleseektoencompass,evaluate,constructanduse.Throughhealthliteracycompetenciespeople becomeabletounderstandthemselves,othersandtheworldinawaythatwillenablethemtomakesoundhealth decisions,andtoworkonandchangethefactorsthatconstitutetheirownandothers’healthchances.” E Wuetal.[18] “Healthliterateindividualsareabletounderstandandapplyhealthinformationinwaysthatallowthemtotakemore controlovertheirhealththrough,forexample,appraisingthecredibility,accuracyandrelevanceofinformationand actingonthatinformationtochangetheirhealthbehavioursorlivingconditions.” F Gordonetal.[19] “HealthLiteracyisthedegreetowhichindividualshavethecapacitytoobtain,access,process,andunderstandbasic healthinformationandservicesneededtotakeappropriatehealthdecisionsandinvolvesanongoingprocessof buildingindividualandcommunitycapacitytounderstandthecomponentsofhealth.” Differentagegroupsorconsideringalifecourseperspective G Borzekowski[1] “Healthliteracyisnotjusttheabilitytoread,rather,itisasetofskillsthatinvolverecognizing,processing,integrating, andactingoninformationfromavarietyofplatforms.Thosebetweentheagesof3and18canseek,comprehend, evaluate,andusehealthinformation,especiallyifmaterialsarepresentedinwaysthatareageappropriate,culturallyrelevant, andsociallysupported.Thedevelopmentofhealthliteracyamongchildrenandyoungpeoplecanempowerthisvulnerable and“marginalized”grouptobemoreengaged,moreproductive,andhealthier.” H Soellneretal.[36] [Translated]Theworkingdefinitiondefineshealthcompetences(Gesundheitskompetenz)asanaccumulationofskills andcapabilitiesthatsomeonehasatone’scommandtobeabletoactindailylifeandindealingwiththehealth system,insuchawaysthatpositivelyaffectone’shealthandwell-being. I Mancuso[34] “Aprocessthatevolvesoverone’slifetimeandencompassestheattributesofcapacity,comprehension,and communication.Theattributesofhealthliteracyareintegratedwithinandprecededbytheskills,strategies,andabilities embeddedwithinthecompetenciesneededtoattainhealthliteracy.Theoutcomesofhealthliteracyaredependentupon whetheronehasachievedadequateorinadequatehealthliteracyandhavethepotentialtoinfluenceindividualsandsociety.” J Nutbeam[35] “Thepersonal,cognitiveandsocialskillswhichdeterminetheabilityofindividualstogainaccessto,understand,and useinformationtopromoteandmaintaingoodhealth” K Sørensenetal.[10] “Healthliteracyislinkedtoliteracyandentailspeople’sknowledge,motivationandcompetencestoaccess,understand, appraise,andapplyhealthinformationinordertomakejudgmentsandtakedecisionsineverydaylifeconcerning healthcare,diseasepreventionandhealthpromotiontomaintainorimprovequalityoflifeduringthelifecourse.” L Zarcadoolas,Pleasant& “Healthliteracyevolvesoverone’slifecourse,startingatanearlyage,and,likemostcomplexhumancompetencies,is Greer[20] impactedbyhealthstatusaswellasdemographic,socio-political,psychosocialandculturalfactors.”“Wedefinehealth literacyasthewiderangeofskills,andcompetenciesthatpeopledeveloptoseekout,comprehend,evaluateanduse healthinformationandconceptstomakeinformedchoices,reducehealthrisksandincreasequalityoflife.” health literate persons should be able to perform when achieve health and well-being by obtaining certain attri- encountering situations that demand health-related butes as personal hygiene, emotional stability, enjoyment decision-making in daily life or within the health care in school life, and the ability to cope with various context. As such, children and young people are viewed circumstances [17]. as actors that actively and deliberately participate in All definitions state an outcome dimension of health seeking, processing, and evaluating health information literacy - an intermediate or distant goal or purpose of (as well as health services, knowledge, attitudes and health literacy. Outcomes of health literacy include practices). The acquired information can be adequately rather specific tasks linked to health-related decision- used in health-informed decision-making, which form a making, e.g. to manage one’s health environment [33] or direct output dimension for observing or measuring to make informed or appropriate health choices [18]. children’s or young people’s health literacy [8]. Fok and The intermediate or long term outcomes of health Wong [17] focus not only on health information-related literacy refer, rather generally, to the promotion of tasks but on actions related to physical and psycho- personalhealth[35]andhealthoutcomes,e.g.thereduc- social activities children engage in. They point out that tion of health risks and the improvement of ones quality children are health literate once they understand how to of life [20] or living conditions [18]. Borzekowski [1]Bröderetal.BMCPublicHealth (2017) 17:361 Page6of25 Table3Resultsfromtheinductivecontentanalysisofdefinitions Components: (cid:129)motivation(n=1) (cid:129)collection/setofskills(n=6) (cid:129)strategies(n=1) (cid:129)competencies(n=5) (cid:129)comprehension(n=1) (cid:129)knowledge(n=3) (cid:129)communication(n=1) (cid:129)capacity(n=2) Action/Agency: (cid:129)toappraising(n=2)thecredibility,accuracyandrelevanceof (cid:129)tounderstand(n=5) (cid:129)toprocess(n=2), (cid:129)toaccess(n=4) (cid:129)toobtain(n=1) (cid:129)touse(n=4) (cid:129)toencompass(n=1) (cid:129)toapply(n=3) (cid:129)tointegrate(n=1) (cid:129)tocomprehend(n=3) (cid:129)toconstruct(n=1) (cid:129)toevaluate(n=3) (cid:129)tointeractwithpeople(n=1) (cid:129)toact(upon)(n=3) (cid:129)tocopewithnecessarychanges(n=1) (cid:129)toseek(out)(n=2) (cid:129)toorganize(n=1) Subjects: (cid:129)healthknowledge,attitudesandpractice(n=1) (cid:129)(basic)healthinformation(n=7) (cid:129)physicalandpsycho-socialactivitieswithappropriatestandards(n=1) (cid:129)health-relatedconcepts(n=1) (cid:129)healthservices(n=1) Sources:fromavarietyofplatforms(n=1) Purposes: (cid:129)totakemorecontrolovertheirhealth(n=1) (cid:129)totake/makeappropriate/soundhealthdecisions(n=3) (cid:129)tounderstandthemselves,othersandtheworld(n=1) (concerninghealthcare,diseasepreventionandhealthpromotion) (cid:129)toreducehealthrisks(n=1) (cid:129)tomakeinformedchoice(n=1) (cid:129)tochangetheirhealthbehavioursorlivingconditions(n=1) (cid:129)tomanageone’shealthenvironment(n=2) (cid:129)toempowerthisgrouptobemoreengaged,moreproductive,and (cid:129)tomaintainorimprovequalityoflife(n=2) healthier(n=1) (cid:129)toimproveorachievecompletewell-being(n=2) (cid:129)tobuildindividualandcommunitycapacitytounderstandthecomponents topromoteandmaintaingoodhealth(n=1) ofhealth(n=1) (cid:129)tomakejudgments(n=1) (cid:129)thepotentialtoinfluenceindividualsandsociety(n=1) (cid:129)tounderstandthatactionstakeninyouthaffecthealthlaterinlife(n=1) Age-anddevelopment-specificconditions: (cid:129)ifmaterialsarepresentedinwaysthatareageappropriate,culturallyrelevant,andsociallysupported(n=1) (cid:129)demandsreasonableautonomy(n=1) Time: (cid:129)duringthelifecourse(n=1) (cid:129)ongoingprocess(n=2) (cid:129)startingatanearlyage(n=1) (cid:129)evolvesoverone’slifetime(n=2) perceives children and young people as vulnerable and Modelsofhealthliteracyinchildrenandyoungpeople “marginalized” groups that can be empowered to be A total of 21 articles included models of health literacy more engaged, more productive, and healthier. Paakkari (Table 4). These 16 articles conceptualized health and Paakkari [8] emphasise the societal dimension of literacy at a theoretical/abstract level. The other five health literacy, indicating that health literacy enables operationalized health literacy dimensions for the devel- students “to work on and change the factors that consti- opment of measurement tools [18, 32] or as an effect tute their own and others’ health chances”. Gordon et al. or evaluation model for an intervention programme [19] take an even more general view, stating that health [22, 25, 26, 41]. Three models represented a clinical- literacy is building individual and community capacity to medical perspective [21, 23, 33], but the majority of understand the components of health. The categories them (n = 18) took on a public health perspective. “requirement” and “time perspective” are the ones that These studies developed health literacy from a multi- specifically relate to the target group of children and system perspective (i.e. the health system, education young people: The first includes preconditions for being system, community system), covering several health- (able to be) health literate, namely, a reasonable degree related domains, as health care, disease prevention of autonomy [17] or supporting external conditions, as and health promotion. Nine models were developed the ways health-related materials are presented in an age from a school health education perspective [8, 18, 22, appropriate manner, are culturally relevant and socially 25–27, 29, 30, 32]. Three articles [25, 26, 32] included supported [1]. Lastly, health literacy is viewed as being children younger than 12 years, while nine addressed an evolving construct or ongoing process [19], which young people or secondary school children aged needs to be acquired and developed during the life 12 years or older. One article, Sanders et al. [5] course [10,20,34]. covered four distinctive developmental phases. Eight)redrolacitebahpladnapuorgtegratotgnidroccadepuorg(ycaretilhtlaehs’elpoepgnuoydnas’nerdlihcfosledoM4elbaT yllaciripmE GT sledoM hcihwnitxetnoC esoprupyramirP :ecruoS(noitinifedLH )GT(puorgtegraT rohtuA oN ?detset ninoitapicitrap debircsed hcihwrofro ydutsfo emasyb=yramirp srepapybdesserpxesa tnempoleved seiticificeps detset/depoleved ;)ledomsarohtua GTfo tnereffid=yradnoces )ecruos stnedutSloohcSyradnoceSrewoLdnayramirP&nerdlihC seY oN seY noitacudehtlaeh)loohcS( :noitazilanoitarepO )2elbaTees(yramirP 31-9egA,8-5edarg,stnedutS ]23[.latenworB 1 rofesablautpecnoC ehtrofyralpmexE loottnemerusaem ]73[SEHNSU seY seY seY htlaeH ;noitazilautpecnoC )8991,OHW(yradnoceS 31-21egA,7edarg,stnedutS ]82[.latekeaP 2 noitazilaicoS gnitset&evitarolpxe seY oN seY noitacudehtlaeh)loohcS( :noitazilanoitarepO ,maebtuN(yradnoceS sraey31–9,5edarg,nerdlihC ]52[.latetdimhcS 3 rofledomtceffE )8002 ydutsnoitnevretni stnedutSloohcSyradnoceS&elpoepgnuoY oN oN seY esaesiD;erachtlaeH ;noitazilautpecnoC )4002,MOI(yradnoceS .s.n,elpoepgnuoY ]12[ollenagnaM 4 noitneverp evitarolpxE oN seY seY metsyserachtlaeH noitazilautpecnoC )2elbaTees(yramirP 71-31dega,elpoepgnuoY ]33[.lateyessaM 5 evitarolpxednaevitcudni oN oN seY noitacudehtlaeh)loohcS( ;noitazilautpecnoC )2elbaTees(yramirP .s.n,stnedutS &irakkaaP 6 noitarolpxelaciteroeht ]8[irakkaaP oN seY oN noitacudehtlaeh)loohcS( ;noitazilautpecnoC ,)8991(OHW,yradnoceS ,stnedutsloohcsyradnoceS ]92[,ättääM,ittuaisuU,ksaR 7 evitcudni osucnaMybdeticsa 02-81.ppadega )9002( seY oN seY emmargorpalucirrucloohcS :noitazilanoitarepO )4002,MOI(yradnoceS 81-61egA,11edarg,stnedutS greblekcetS 8 rofledomtceffE ]22[.late ydutsnoitnevretni seY oN seY emmargorphtlaehloohcS :noitazilanoitarepO ,LAAN(yradnoceS 51-01dega,elpoepgnuoY mainamarbuS 9 noitnevretnirofevitcudeD )3102 ]62[.late noitaulave&gnitset seY oN seY noitacudehtlaehloohcS ;noitazilautpecnoC .g.e(yradnoceS naidanaC(01edarg,stnedutS ,sniggiHfrahW 01 gnitsetdnaevitcudni )7002,hcsubkciK )metsys &,yarogeB ]72[dlanoDcaM seY oN seY noitacudehtlaehloohcS :noitazilanoitarepO )2elbaTees(yramirP naidanaC(01edarg,stnedutS ]81[.lateuW 11 elacsrofesablautpecnoC )metsys tnempoleved evitcepsrepesruocefilagniredisnocrospuorgegatnereffiD seY oN oN detalerhtlaehtnereffiD ;noitazilautpecnoC renlleoS(yradnoceS yllaciripme,noitalupoplareneG .lateztraneL 21 sniamod gnitsetdnaevitcudni )9002,.late .12-71elpoepgnuoyrofdetset ED]96,83[ oN oN oN detalerhtlaehtnereffiD ;noitazilautpecnoC )2elbaTees(yramirP efilehtssorcanoitalupoP ]43[osucnaM 31 sniamod evitarolpxe .s.n,esruoc oN oN oN dlihcnosrotcaftcapmI ;noitazilautpecnoC detatsenoN efilehtssorcanoitalupoP &nitraM 41 htlaeh evitarolpxe esruoc ]42[nehC Bröderetal.BMCPublicHealth (2017) 17:361 Page7of25)deunitnoC()redrolacitebahpladnapuorgtegratotgnidroccadepuorg(ycaretilhtlaehs’elpoepgnuoydnas’nerdlihcfosledoM4elbaT seY oN oN htlaehtnereffid;htlaehcilbuP ;noitazilautpecnoC )2elbaTees(yramirP sucof,noitalupoplareneG ]53[maebtuN 51 sniamoddetaler evitarolpxe noitacudehtlaehnopu oN oN seY detalerhtlaehtnereffiD ;noitazilautpecnoC )4002,MOI(yradnoceS segatnereffidtanerdlihC srednaS 61 sniamod evitarolpxe ]13,5[.late seY oN oN detalerhtlaehtnereffiD ;noitazilautpecnoC )2elbaTees(yramirP gnidulcni,noitalupoplareneG .laterenlleoS 71 sniamod gnitsetdnaevitcudni elpoepgnuoy ED]63[ seY oN oN esaesiD;erachtlaeH ;noitazilautpecnoC )2elbaTees(yramirP efilehtssorcanoitalupoP nesnerøS 81 htlaeH;noitneverp gnitset&evitarolpxe .s.n,esruoc ]01[.late noitomorP oN oN oN erachtlaeH ;noitazilautpecnoC )4002,MOI(yradnoceS efilehtssorcanoitalupoP .latefloW 91 evitarolpxE .s.n,esruoc ]32[ oN oN oN htlaeHcilbuP ;noitazilautpecnoC )2elbaTees(yramirP efilehtssorcanoitalupoP ,saloodacraZ 02 dnaevitcudni .s.n,esruoc ]4[.late evitarolpxe oN oN oN htlaeh)loohcS( ;noitazilautpecnoC ,baL-CCH(yradnoceS s.n,stnedutS &reyeZ 12 ygoloib/noitacude evitarolpxe )5002 ttamredO ED]03[ Bröderetal.BMCPublicHealth (2017) 17:361 Page8of25Bröderetal.BMCPublicHealth (2017) 17:361 Page9of25 studies did not exclusively focus on children and especially pointed out in models that were developed young people but considered health literacy over the within the context of school health education [18, 22, life course. 25–29, 32]. Paakkari and Paakkari [8] stated that while health literacy learning conditions in school may include Howaretargetgroupspecificitiesconsidered? aspects of each of their five core health literacy compo- Twelve of the identified articles elaborated on children nents, students’ age-specific needs and characteristics and young people’s distinctiveness towards adults and need to be taken into account. The identified health how these specificities are relevant for understanding education models conceptualized health literacy for a health literacy in these age groups. However, most of small and distinctive age group or specific school these considerations remained on a very broad level, grade(s). Commonly, the complexity and comprehen- strongly incorporating an “external”, adult view on the siveness of their health literacy components increased by target group’s situation and the relevance of health school grades. From a health promotion perspective, literacyforthem.Insummary,childrenandyoungpeople: Sanders et al. [5, 31], similar to Borzekowsik [1], explored the development of health literacy compe- – areexpectedtounderstandincreasinglycomplex tencies from a cognitive development perspective for healthinformation[5]andlargeamountofeducational different age groups. They distinguish between four materialsdistributedtothembyhealthproviders, successive developmental stages, providing examples schoolsandinterventionprogrammes[21]; ofhealthliteracyskillsinfourcategories(prose/document – become increasingly responsiblefortheir ownhealth and oral literacy, numeracy and system-navigation skills) andfordealing with different kindsofhealth-related thatwereadoptedfromtheUSNationalHealthEducation issues[22]; Standards(NHES)[37]. – areincreasingly engagedintheir health, theirhealth serviceutilization[23]andusage ofinsurance Dimensionsofhealthliteracyforchildrenandyoungpeople benefits [33]; inthe21models – developskillstoday thatinfluence theirhealth Healthliteracyinchildrenandyoung people isdescribed (outcomes) andwell-beingovertheir lifecourse[24] in the literature as comprising variable sets of key andreducehealthexpenditures [33]; dimensions – clusters of related abilities, skills, commit- – arecitizens intheir ownright,within their current ments, and knowledge that enable a person to approach surroundings[8]; health information competently and effectively and to – areabletoconstructtheirownviewsonhealth derive at health-promoting decisions and actions. This matters[8,35]; section provides an overview of the inductive content – areatacrucialstageofdevelopmentcharacterizedby analysis which reveals the important aspects of health manyphysical,emotionalandcognitivechanges[21]. literacy in children and young people (Table 5). It also offers a meta-perspective of health literacy in children Most prominently, articles considered children and and young people that enables comparison between young people’s situations and needs by exploring their differentaspects.Astheretrieveddimensionsarediverse social embeddedness, namely the interrelated pathways and overlapping, classification was challenging. Due to between the individual and their close and distal social the strong focus on individual attributes, the dimensions contexts. Wharf Higgins et al. [27] stated that in order were selected to be clustered according to three core to be effective approaches to teaching health literacy categories: (1) cognitive, (2) behavioural or operational “also need to reflect a thorough understanding of the and(3)affective andconative. structure of adolescents’ social worlds, and their developmental appropriateness”. While, Wharf Higgins Cognitive attributes The mental abilities and actions et al. [27] reflected on health literacy from a socio- thatenableapersontothink,learnandprocessinforma- ecological understanding, Paek et al. [28] complemented tion areattributed tothis category. the social ecological approach with health socialization perspectives, adopted from political and consumer Knowledge socialization. As pathways of contextual influences are considered to be strong influencing factors of health Knowledge is regarded as an essential component of literacy in the literature, an extensive description of the health literacy in children and young people. Mancuso inductive content analysis is provided in the “anteced- [34] states that a certain level of knowledge is required ents and consequences” section. Moreover, the import- for comprehending content as well as for managing and ance of an age- and development-specific understanding analysing information and becoming empowered regard- of health literacy for children and young people was ing one’s health and the related decisions. It is eitherelpoepgnuoydnanerdlihcrofsnoisnemidycaretilhtlaehfonoitpircseddnaepyT5elbaT elcitranidebircsedsa,LHfognidnatsrednu/erutaN )…,egdelwonk,llikS(LHfosnoisnemiD rohtuA oN stnedutSloohcSyradnoceSrewoLdnayramirP&nerdlihC )SEHN(sdradnatSnoitacudEhtlaeHlanoitaNseilppA dnaytilibisnopser)2(,gnivlosmelborpdnagniknihtlacitirC)1( ]23[,7002.latenworB 1 tnemurtsnitnemerusaemni noitacinummocevitceffe)4(dna,ssendetcerid-fles)3(,ytivitcudorp ]73[SEHNSUehtrofyralpmexE ytilibaehtsatnemerusaemnidezilanoitareposawycaretilhtlaeH esaesiddnanoitomorphtlaehotdetalerstpecnocdneherpmocot- noitneverp noitamrofnihtlaehdilavsseccaot- gnirahsybhtlaehrofetacovdaotytilibaehtetartsnomedot- noitamrofni laicosmorfsevitcepsrepsetargetniledomehT ,scipothtlaehnistseretnI ]82[1102,.latekeaP 2 ,sledomnoitazilaicoshtlaehdnasledomlacigoloce ,stcejbushtlaehfognidnatsrednU noitazilaicosremusnocdnalacitilopmorfdetpoda yhtlaehgniyatstuobadenraeldahyehttahwnotcaotnoitavitoM gnitsisnoctcurtsnocadessessasawycaretilhtlaeH ::tnemerusaemnidezilanoitarepoerewhcihw,sniamodycaretilhtlaeH ]52[0102.latetdimhcS 3 erewsnoisnemid;denoitnemsnoisnemidevifehtfo ycaciffe-fleS,ruoivaheB,edutittA,noitacinummoC,egdelwonkhtlaeH ;)0002(maebtuNfognidnatsrednus’rohtuanodesab stnedutSloohcSyradnoceS&elpoepgnuoY )0002(maebtuNfognidnatsrednus’rohtuanodesaB )etirwdnadaerotytilibacisab(ycaretillanoitcnuF ]12[8002ollenagnaM 4 )6002(noitadnuoFylimaFresiaK& yliadnietapicitrapotytiliba(ycaretilevitcaretni/evitacinummoC noitacinummocdnaseitivitca )noitamrofnietaulaveotlaitnetops’nosrep(ycaretillacitirC )segassemaidemetaulaveyllacitircotytilibaeht(ycaretilaideM fonoitacifitnedI:gnitteserachtlaehnosucoF )-non(dnatsrednu,ecivressseccaot.g.e(metsysehtgnitagivaN ]33[2102.lateyessaM 5 spuorgsucofmorfstlusernodesabsawsnoisnemid )noitpircserpallif&tnemtnioppaekamot,eracycnegreme eracyramirphtiwsweivretni&elpoepgnuoyhtiw ,snoitseuqgniksa,snoitpecreperac-fles(seitilibisnopserdnasthgiR snaicisyhp )scipotevitisnesgnidragersthgirgniwonk detaler,sruoivahebgnineercs,tisiverac-llew(eracevitneverP )rotcodtisivotsnoitpecrep/sedutitta dnaevissap,noitamrofnietaulaveotytilibA(gnikeesnoitamrofnI ybdedivorpnoitamrofnifoecnaveler,gnikeesnoitamrofnievitca )naicisyhp ,leveltrofmoc,tsurtdeviecrep(pihsnoitalerredivorp–tneitaP )eracredivorpfoytiunitnoc,seussinoitacinummoc htlaehehtnihtiwsecitcarp,sedutitta,egdelwonk:lanoitces-ssorC gnitteserac fosemoctuogninraelasadenifedsiycaretilhtlaeH :seicnetepmocdnaegdelwonkfoegnardaorbsaycaretilhtlaeH ]8[2102,irakkaaP&irakkaaP 6 tI.dnalniFnitcejbusnoitacudehtlaehloohcseht evitaralceddnalamrof,lautcaf,ticilpxe(egdelwonklaciteroehT tnemrewopmednagnitomorphtlaehanosessucof )srettamhtlaehtuobaegdelwonk lateicosdnalanosrepehtrofstceffehtiwevitcepsrep ;egdelwonkdesab-slliksrolarudecorp(egdelwonklacitcarP .htlaeh )gnihtemosodotytilibapac dnatsrednu.g.e;yllanoitardnaylraelcknihtotytiliba(gniknihtlacitirC saetapicitrap,seciohcdnuosekam,yawrepeedniseussihtlaeh )yteicosforebmemevitca dna,snoisicednwo,flesenonotcelfer-flesotytiliba(ssenerawa-fleS ;renraelsafleseno ekatdnayawelbisnopser-yllacihtenanitcaotytiliba(pihsnezitiC nwos’enodnoyebsrettamhtlaehredisnoc;ytilibisnopserlaicos )evitcellocehtfodnasrehtofosenoeht(evitcepsrep Bröderetal.BMCPublicHealth (2017) 17:361 Page10of25)deunitnoC(elpoepgnuoydnanerdlihcrofsnoisnemidycaretilhtlaehfonoitpircseddnaepyT5elbaT laicossllikshceepsdnagnitirw,gnidaercisaB:sllikslanoitces-ssorC slliksgnirehtag-noitamrofnidna,slliksnoitacinummoc,slliks s’maebtuNfognidnatsrednus’rohtuanodesaB )etirwdnadaerotytilibacisab(ycaretillanoitcnuF/cisaB ]92[3102,ättääM,ittuaisuU,ksaR 7 citsilohnwohtiwdetnemelpmoc,)0002(ygolopyt yliadnietapicitrapotytiliba(ycaretilevitcaretni/evitacinummoC .latetrawetSmorfdetpada(sledomycaretilhtlaeh noitacinummocdnaseitivitca ’stnedutsmorfdetarobaleerasnoisnemid,)8002 )noitamrofnietaulaveotlaitnetops’nosrep(ycaretillacitirC srewsnariehtnodesab,sweivfotniop&sevitcepsrep :noisnemidhtruofhtiwdednetxE noitanimaxEnoitalucirtaMhsinniFehtmorf :snoisnemidbusruofhtiw,ycaretilhtlaehcitsiloH ,ecnarelot- ,anemonehplanoisnemiditlumdnaediwsaerutlucgnidnatsrednu- ,ssensuoicsnoclatnemnorivne- weivfostniopsuoiravmorfdlrowehtfoetatsehtfosisylana lacitircs’maebtuNfognidnatsrednusrohtuadesaB -ecnediveotdetalerycaretilhtlaehlacitircfoselpicnirP ]14,22[b&a9002,.lategreblekcetS 8 noisnemidycaretil :)MBE(enicidemdesab demrofni.g.e(stpecnoclacidemgnidnatsrednU )noitamrofnitneitapgnisiarppa;stsetcitsongaidnieciohc dnatenretniehtgnihcraes.g.e(erutaretilgnihcraesfosllikS )sesabatad )s’TCRfolasiarppalacitirc.g.e(scitsitatscisaB dnaseicallaF.g.e(gnilpmasdnastnemirepxehtlaehfongiseD susrevselcitralanoitavresbo:noitatneserperatadfosnoitaterpretnisim ;?secnereffidehteratahW–)TCR(slairtdellortnocdezimodnar )sweivercitametsysgnidnatsrednU erutaretilevitarrannwonamorfstluserfonoitargetnI :seirogetacniamhtiwyrotnevnislliksycaretilhtlaeH ]62[5102.latemainamarbuS 9 sledomdnasnoitinifednoweiver -htlaeh.g.e(scitsiretcarahc/seitilibalareneg:stnemelelanoitadnuoF ,noitavitom,etacinummoc,netsilotytiliba,egdelwonkdetaler noitamrofniotssecca,)ycaciffe-fles&noitnetni,sedutitta dnanoitacifitnedideennoitamrofni:noitamrofnidetaler-htlaeH ,noisneherpmocnoitamrofni,hcraesnoitamrofni,noitalumrofnoitseuq esunoitamrofni,tnemeganamnoitamrofni,tnemssessanoitamrofni )gnikeesnoitamrofnihtlaehfolaog/txetnocnotnedneped( noweivererutaretilamorfstluserfonoitargetnI ,noitamrofnihtlaehetacinummocdna,dnatsrednu,sseccaotsllikS ]72[9002,.latesniggiHfrahW 01 oicosatcelfer,snoisnemidycaretilhtlaehlareneg secivresdnasecruoser noitomorphtlaehdnagnidnatsrednulacigoloce edutitta,egdelwonk:sllikslanoitces-ssorC evitcepsrep :noitamrofnihtlaehdnatsrednU ]81[0102.lateuW 11 .ytluciffidfoslevel&)tnemucoddnaycaremun,esorp(sepytycaretil- :noitamrofnihtlaehgnitaulavE sitahtnoitamrofniehttuobanoisulcnocrotnemgdujasitluser- dna;detneserp eromroenogniylppanodesabsinoisulcnocrotnemgdujsiht ,ssenevisneherpmoc)4(,ecnaveler)3(,ytilaitrapmi)2(,ycarucca)1(:airetirc ycnetsisnoclanretni)5( evitcepsrepesruocefilagniredisnocrospuorgegatnereffiD ;)9002(.laterenlleoSybledomehtfonoitargetnI :sllikscisaB ]96,83[2102;4102.lateztraneL 21 ruofybdetaulavednanidetseterewsledom smretcisabfonoisneherpmoC(egdelwonkcisabdetaler-htlaeh- )namreGmorfdetalsnarT( selpmasnoitalupoptnereffid dnasecnerehocdetaler-htlaehelpmisroydobehtgnibircsed )snoitcnuf Bröderetal.BMCPublicHealth (2017) 17:361 Page11of25)deunitnoC(elpoepgnuoydnanerdlihcrofsnoisnemidycaretilhtlaehfonoitpircseddnaepyT5elbaT dnagnitirw,gnidaerdetaler-htlaeh(sllikscisabdetaler-htlaeh- )slliksycaremun :slliksdecnavdA ,noitpecrep-flesdetaler-htlaeh:levellanoitavitom-lautpecrep- )emhanrebüsgnutrowtnareV(ytilibisnopserfoecnatpecca -fles)b(,noitamrofnihtlaehhtiwgnilaed)a(:leveldetneiro-noitca- .noitarepoocdnanoitacinummoc)d(,noitaluger-fles)c(,lortnoc ]detalsnart[ ytilibapacehtevahot:ecnetepmocsaycaretilhtlaeH :ycaretilhtlaehfosetubirttA ]43[8002,osucnaM 31 ;snoitautiserac-htlaehniylevitceffenoitcnufot ,gnirehtaggnidulcni,laudividnifolaitnetopetannidnaslliks(yticapaC htlaeh,ecneicsyrarbil,noitacudenamorfderolpxe dnaytilibidercrofnoitamrofnihtlaehgnitaulavednagnisylana .txetnochtlaehlatnemdnahtlaehcilbup,erac ecnadiuggnikees,secruosergniganam,rehtegotgnikrow,ytilauq gnitaerc,flesfoesnesagnisserpxednagnipoleved,troppusdna ;egnahchtiwecapgnipeekdna,slaogdnanoisivagniusrupdna -noisiced,lacitylana,gninetsil,gnidaer,sllikslaicos,slliksegaugnallaro ).ctenoitamrofnihtlaehnotcaotytiliba,seitilibalaciremundnagnikam fonoitcaretnievitceffenodesabssecorpxelpmoc(noisneherpmoC ;sdnatsrednulaudividniehttahw;ecneirepxedna,egaugnal,cigol )seussihtlaehsserddaylevitaercdnayfitnedi gnidulcni,ssecorpegnahcxenoitamrofniroegassem(noitacinummoC ,gnidoced,tupnisevlovnidnaruoivahebrognitirw,slangis,hceeps htiwgnidaererasllikslaitnessE.kcabdeefdnatuptuo,gnidocne nacsrehtoosgnikaeps,gnitirwnisaedigniyevnoc,gnidnatsrednu )yllacitircgnivresbodna,ylevitcagninetsil,dnatsrednu ytilibaborpcisabdnatsrednuotytiliba(ycaremun,gnitirw,gnidaer ]42[4102,nehC&nitraM 41 gnikaepsdna,)egaugnallarua(gninetsil,)stpecnoclaciremundna txetnochtlaehanihtiwslliks)egaugnallaro( tnemrewopmednagnitomorphtlaehanosucoF otgnitirwdnagnidaernisllikscisab(ycaretilhtlaehlanoitcnuF/cisaB ]53[0002,maebtuN 51 .evitcepsrep )snoitautisyadyreveniylevitceffenoitcnuf evitingocdecnavdaerom(ycaretilhtlaehevitcaretnI/evitacinummoC ,hcihwslliksycaretildna nietapicitrapylevitcaotdesuebnac,sllikslaicoshtiwrehtegot morfgninaemevireddnanoitamrofnitcartxe,snoitautisyadyreve gnignahcotsihtylppadna,noitacinummocfosmroftnereffid )ecnatsmucric rehtegot,hcihwslliksevitingocdecnavdaerom(ycaretilhtlaehlacitirC noitamrofniesylanayllacitircotdeilppaebnac,sllikslaicoshtiw )snoitautisdnastneveefilrevolortnocretaergtrexeotsihtesudna tnereffidoterusopxe,tnempolevedevitingoC:lanoitadnuoF ,)egassemdnatnetnocnoitacinummoc(segassem/noitamrofni ycaciffe-fles,sllikslaicosdnalanosrep erutaretilcitametsysnwoamorfstluserfonoitargetnI gnillif,noisneherpmoctxet,gnitirW(slliksycaretil-tnemucod/esorP ]13,5[b&a,9002srednaS 61 morfdetpadA;ycaretildnahtlaehdlihcnoweiver )mroftuo yllaudividnieraslliks;senilediuGerutuFthgirB&SEHN )noitaitogenotnoitacinummoccisabmorf(slliksycaretillarO ;desopmoc gnidnatsrednuotroezisnoitropdoof.g.e(slliksycaremuN dedivorperaselpmaxe(egahtiwsesaercniytixelpmoc )stlusergnineercs )81dna41,01,4egarof otruoivahebnoecneulfniaidemebircsed(slliksnoitagivan-smetsyS )ssecorptnemlorneetelpmoc Bröderetal.BMCPublicHealth (2017) 17:361 Page12of25)deunitnoC(elpoepgnuoydnanerdlihcrofsnoisnemidycaretilhtlaehfonoitpircseddnaepyT5elbaT tnatropmisislliksycaretilhtlaehylimaffoevitcelloc:lanoitadnuoF )srevigeracrehto,)s(tnerap,dlihc( erutaretilevitarrannwonamorfstluserfonoitargetnI ,)ycaremun/ycaretil(sllikslanoitadnuoF ]63[0102,.laterenlleoS 71 gnippamtpecnocredlohekatsadnasledomnoweiver :ecnetepmoclanoitarepO )namreGmorfdetalsnarT( dnanoitacinummoc)2(,metsyshtlaehehtnitcadnaetagivanot)1( ,noitarepooc -flesdnassenerawa-fles)4(,gnissecorpdnalaveirternoitamrofni)3( .noitaluger :tnenopmocegdelwonK ,egdelwonkdetaler-htlaeh)2(dnucificeps-metsys)1( :noitavitoM ]detalsnart[.htlaehnworofytilibisnopserekatotssengnilliw)1( erutaretilcitametsysnwonamorfstluserfonoitargetnI ;)noitamrofnihtlaehniatbodnadnif,keesotytiliba(sseccA ]01[2102,.latenesnerøS 81 sledomdnasnoitinifednoweiver sitahtnoitamrofnihtlaehehtdneherpmocotytiliba(dnatsrednU ;)dessecca htlaehehtetaulavednaegduj,retlif,terpretniotytiliba(esiarppA ;)noitamrofni aekamotnoitamrofniehtesudnaetacinummocotytiliba(ylppA htlaehevorpmidnaniatniamotnoisiced htlaeh,noitneverpesaesid,erachtlaeh:sniamodhtlaeheerhtnI noitomorp noitavitomdnaecnetepmoc,egdelwonk:lanoitces-ssorC ehtniyticapacgninraelsaycaretilhtlaeHnosesucoF dnagninosaer,yromem,deepsgnissecorp(steslliksevitingoC ]32[9002.latefloW 91 .gnittes)erac(htlaeh )gnidaerdnaytilibalabrev,ycaremun&ycaretil;noitnetta roirpdnanoitacinummoc,ycaciffe-fles(tesllikslaicosohcysP )ecneirepxe ,egaugnalnekopsdnadetnirp(ycaremun/ycaretillatnemadnuF ]4[5002,.latesaloodacraZ 02 )smretdnaslobmyslacitamehtamcisabdna,slaremun latnemadnuffoegdelwonk.g.e(ycaretilygolonhcetdnaecneicS )ytixelpmoclacinhcetdneherpmoc,stpecnoccifitneicsdnahtlaeh noitamrofnifosecruostuobaegdelwonk(ycaretilcivic/ytinummoC -noisiceddnaeugolaidniegagneotsneziticselbane,sadnegadna dnacivicfoegdelwonkdnaslliksycaretilaidemsedulcni,gnikam )sessecorplatnemnrevog ,smotsuc,sfeilebevitcellocgnisudnagnizingocer(ycaretillarutluC )ytitnedilaicosdna,sweiv-dlrow .secnetepmocfotesasadedragersiycaretilhtlaeH ,snoitautistnaveler-htlaehezilaerot(egdelwonkcificeps-noitautiS ]03[9002,ttamredO&reyeZ 12 )noitamrofnihctamot )namreGmorfdetalsnarT( ,stcaf,selpicnirptnaveler-htlaehezilaerot(egdelwonklautpecnoC )smret nitcayletauqedaotwohnoegdelwonk(egdelwonklanoitarepO )noitautisna htlaehetomorpnoitcasihtseoD(noitomorphtlaehfonoitaulavE )?efilyliadnielbisaefsidna secneuqesnoclanosrepfonoitaulavE dnaredisnocotdnasenituoryadyrevepukaerbot(noitcelfer-fleS )nalpnoitcanwos’enoesylana Bröderetal.BMCPublicHealth (2017) 17:361 Page13of25Bröderetal.BMCPublicHealth (2017) 17:361 Page14of25 described as (a) a separate core dimension [8, 30], as (b) based on effective interaction of logic, language, and an element of several dimensions [4], or (c) a founda- experience, allowing an individual to become a critical tional or cross-sectional component [10, 26, 27, 33]. thinker and problem-solver who can identify and Lenartz et al. [38] and Soellner et al. [36] describe creatively address health issues. Subramaniam et al. [26] health-related basic knowledge as the comprehension of identified the following elements of comprehension: (a) basic terms describing the body or basic health-related an ability to read, comprehend and recall situated infor- coherences and functions. Others distinguish between mation; (b) an ability to perform basic mathematical (a) theoretical or conceptual knowledge (i.e. facts, terms, functions (e.g. numeracy); (c) an ability to comprehend principles in health-related matters), (b) situation- simple charts (e.g. visual literacy), and (d) an ability to specific knowledge (i.e. knowledge of specific health filter information found and extract only relevant situationsin health-related domains), and (c) practical or information. operational knowledge (e.g. the knowledge of what actionsare adequatein agivensituation) [8,30].Paakkari Appraisaland evaluation and Paakkari [8] describe conceptual knowledge as proceduralknowledgeortheskillsneeded“tobehaveina The ability to interpret, filter, judge, and evaluate health-promoting way” which is often experimental, healthinformationwasanothercoredimensionof health situation-specific, and linked to daily practices. Massey literacy [8, 10, 18, 21, 26, 29, 30, 32, 34, 35]. Moreover, [33] recognises that individuals must be knowledgeable appraising information refers to making sense of infor- and confident health care consumers. This includes the mation gathered from diverse sources by identifying knowledge of one’s rights regarding sensitive topics, or misconceptions, main and supporting ideas, conflicting knowledge of one’s responsibilities related to health care, information, point of view, and bias [26]. In the litera- e.g. health insurance benefits, how and where to find tureseveralrelevant criteria but,asWuet al.[18]stated, information. not necessarily mutually exclusive criteria for evaluating information, were identified: (a) accuracy, validity, and Basic orfunctional health-related skills appropriateness (correct information or the message’s credibility); (b) impartiality (unbiased communication); Most articles recognise that health literacy requires (c) relevance (applicability to the problem); (d) compre- being able to read, write, fill out a form or comprehend hensiveness (broad coverage of the information); and (e) a text [4, 21, 38]. Nutbeam [35] labels these skills as internal consistency (logical relationships exist between functional literacy which is needed in order to under- information and/or concepts). The credibility of the stand health-related materials (e.g. medicine labels, sources of a message or information, as well as the prescriptions, or directions for home health care) and to medium through which it is transported is also import- function effectively in everyday situations. Some authors ant [18, 21, 26]. Manganello [21] stresses that “media point out the relevance of numeracy skills (e.g. the have been shown to influence physical and social devel- ability to understand basic mathematical symbols and opment of youth, have been associated with health terms, basic probability and numerical concepts) and behaviourandareoften cited asa source of health infor- active listening skills (aural language) [5, 24]. Wolf et al. mation for adolescents”. Zeyer and Odermatt [30] con- [23] take on a cognitive development perspective, defin- sider the evaluation of possible alternatives for action ing the mentioned health literacy skills as “higher order with regards to whether an action is health promoting mental tasks”. The latter are determined by one’s (a) and feasible in daily life. Hence health literacy entails processing speed, (b) attention, (c) working memory, (d) evaluating the personal consequences of acting in a long-term memory, and (e) reasoning (ibid. p.4). certain ways and the consideration concerning whether Consensus is lacking whether the described basic skills andhow anintended action isfeasible. are considered as core dimensions of health literacy, or being integral in other dimensions, or rather precondi- Critical thinking tionsfor healthliteracy. Critical literacy skills or critical thinking are argued to Comprehension andunderstanding be core dimension of health literacy [8, 29, 35]. They refer to the ability to think clearly and rationally and Theability to comprehend, tograsps ameaning ofand approach knowledge from various angles, formulate to understand health information or concepts related to arguments, and make sound decisions [8]. As children health care, promotion and disease prevention was con- and young people receive health messages from numer- sidered to be a core dimension of health literacy [10, 18, ous sources, “they may gain a fragmented picture of 28, 32]. Mancuso [34] refers to it as a complex process health issues unless they are able to criticallycreatelinksBröderetal.BMCPublicHealth (2017) 17:361 Page15of25 between diverse pieces of information” [8]. As a result, aspect of health literacy [23, 25, 27, 32, 36, 38]. Accord- “critical thinking enables students to deal with large ing to Nutbeam [35], more advanced cognitive, literacy amounts of knowledge and to have power over that and social skills are needed in order to “communicate in knowledge”[8]. ways that invite interaction, participation and critical analysis”, to extract information and derive meaning Behavioural or operational attributes All dimensions from different forms of communication, and to apply referring to actions that take place outside of the indi- this to changing circumstances [35]. Basic communica- vidual’smindwere assignedtobebehaviouralattributes. tion about health (issues) in health care settings requires providing an overview of personal medical history or Seeking and accessinginformation participating in informed consent discussions about medical treatment options [33]. Essential communica- Information seeking is described as another core di- tion skills involve reading with understanding, conveying mension of health literacy. Subramaniam et al. [26] view ideas in writing and speaking so others can understand, it as a fluid and iterative process, including two main listeningactively,andobservingcritically[34].Moreover, elements, namely information access and search. Acces- young people and children need listening (aural sing information is the ability to seek, find and obtain language) and oral literacy or verbal/expressive skills in healthinformation [10]. According to Subramaniam et al. order to effectively communicate [5, 26]. While Paakkari [26] it includes being able to adapt to new technologies, and Paakkari [8] recognise that health literacy involves being aware of primary health resources to begin search, being able to “clearly communicate one’s ideas and havingtoaccessvalidinformation,products,andservices, thoughts to others”, they regard general communication being exposed to computers in everyday life and being and social skills as foundational for health literacy and awareofsearchenginesandtheircapabilities.Massey[33] not asadistinctivedimension of healthliteracy. distinguishes between materials received from healthpro- viders (“passive information”) and information accessed Applicationofinformation overtheInternetorbyothermeansoutsideoftheclinical setting (“active information”). Searching information This core aspect of health literacy refers to the ability entails developing appropriate search strategies, using to communicate and use health information for health- relevant and correctly spelled search terms, applying an related decision-making with the rational that one wants adequate search strategy drawing on reputed credibility to maintain and improve one’s health and that of the and an understanding of how search engines work (e.g. people in one’s surrounding. The use of health informa- hits,orderofsearchresults,snippets,inclusion/placement tion strongly depends upon the context and the goal of of ads, etc.). Moreover, Subramaniam et al. [26] included the health information seeking process [26]. It entails other elements such as being able to limit reliance on being able to synthesize information from multiple surface characteristics,amongothersthedesignofaweb- sources, draw conclusions, answer questions originally site, the language used, etc. (e.g. surface credibility), to formulated topresentinformationneed, oreven sharing, reduce search result selection based solely on word collaborating, communicating, creating information and familiarity and to use translation features on the adapting them as needed for intended audience (e.g. self, search engine or Web page if needed. As such critical peers, family). On an outcome or impact level, applying media literacy and critical digital literacy have become health information refers to addressing or solving health important dimensions of health literacy in the infor- problems, and make health-related decisions. This in- mation society. Moreover, Paek et al. [28] distinguish cludes using health information for practicing health- traditional media, such as TV, radio and newspapers, enhancing behaviours or mitigating or avoiding health from digital media, e.g. the internet. risks. Massey et al. [33] focus on young people’s health prevention behaviours, such as participating in annual Communicationand interaction check-ups or screening interventions as well as their at- titudes and perceptions about visiting a doctor. On a Communication, according to Mancuso [34], refers to population level, applying health information entails how thoughts, messages or information are exchanged advocating for personal, family, and/or community and includesspeech, signals, writing or behaviour. Itfur- health [8, 26]. From a critical scientific perspective, it ther involves input, decoding, encoding, output and includes being able to interpret data of scientific articles feedback. Being able to effectively communicate about to articulate potential limitations of published research one’s own health or health information and, if necessary, findings and the cumulative impact of scientific know- to cooperate with other people, including friends and ledge (i.e. incremental process of discovery), as well as health care providers was considered an important being able to recognise inaccurate information and toBröderetal.BMCPublicHealth (2017) 17:361 Page16of25 practice appropriate ethical standards for information Self-awareness involves the ability toreflect ononeself. (e.g.copyright,security,privacy)[22,26]. It refers to being conscious about one’s thoughts, feel- ings, attitudes, values, motives and experiences as well Other context-specific skills for the application of as one’s health-related decisions [8]. “Self-awareness information and accessing services requires being able to link together and describe health topics from one’s own personal perspective, and to The ability to navigate through the health care system examine reasons for one’s ways of behaving and thinking was defined as a core dimension of health literacy [36]. in a particular way”. An adequate perception of one’s It entails knowing how to access health services and needs, wants and sensations is seen as key factor for being able to make an appointment or filling out a pre- regulating one’s own behaviour [36, 38] and for breaking scription [33]. Sanders et al. [5] provide age-adjusted through daily-routines and considering and analysing a examplesfornavigationskillswhichrangefromknowing strategy for action [30]. Paakkari and Paakkari [8] also properusage ofemergency numbers (e.g.911)for school stress the ability to reflect oneself as a learner, namely aged children to accessing confidential health and coun- the ability to evaluate their learning strategies, define selling services (young people) or completing enrolment learning goals,andmonitor theirprogress. processes for a health insurance and obtaining appropri- atehealthservices(youngadults,18-20years). Self-control andself-regulation Citizenship Accordingto Lenartz et al. [38],self-regulation enables individuals to formulate health-related goals in line with Citizenship, the ability to act in an ethically- as many personal needs, feelings, values, and interests as responsible way and take social responsibility, defines a possible. Self-control refers to an inner focus to reach a coredimension of health literacy inthework ofPaakkari certain goal, while possibly struggling with competing and Paakkari [8]. It involves considering health matters personal needs, feelings, wishes and interests. A certain beyond one’s own perspective, namely through the lens level of self-control and self-regulation is therefore of others and of the collective, as well as moving from needed to resist the internal and external (social) individual behaviour changes towards wider changes (i.e. pressure (e.g. to continue or start smoking again) and organisational changes). Similarly, Zarcadoolas et al. [4] to deal with e.g. unpleasant feelings and emerging consider civic literacy a core dimension of health liter- doubts [36, 38]. acy. It describes the “knowledge about sources of infor- mation, and about agendas and how to interpret them, Self-efficacy that enables citizens to engage in dialogue and decision- making”. Rask et al. [29]take on a societal perspective in Self-efficacy – a person’s own belief in their own their holistic health literacy dimension by identifying ability to complete certain health-related tasks and particular skills: People who possess holistic health liter- reach defined goals was considered a foundational acy are (a) tolerant to various groups of people, (b) anti- dimensions of health literacy in children and young racist, (c) widely aware of the influence of cultural people [23, 25, 26, 35]. differences on health, (d) aware of the importance of art and civilization for health, (e) concerned about the en- Interest andmotivation vironmental threat. Moreover, they (f) understand the significance of social capital for physical, mental, and Young people’s interest in health topics and their mo- social health, (g) appreciate and protect environment, tivation to act upon what they have learned in staying (h) criticize the negative aspects of western life because healthyweredescribedbyPaeket al.[28]ascoredimen- they pose a threat to health, and (i) want to promote sions of health literacy. Similarly, Sørensen et al. [10] health globally. regard motivation as an essential cross-sectional compo- nent, and Soellner et al. [36] emphasize the willingness Affective and conative attributes This category in- totakeresponsibilityfor one’sownhealth. cludes dimensions of health literacy that evolve around the experience offeeling or emotions (affective attribute) Antecedentsandconsequencesofhealthliteracyinchildren or describe personality traits and mental stages that in- andyoungpeople fluence how individuals strive towards action and direct Table 6 displays the factors that the literature review theirefforts(conativeattributes). identified as influencing children’s or young people’s health literacy (antecedents) or as being influenced by Self-awareness and self-reflection health literacy (consequences).)nwohstoneraynaetatstondidtahtsledom(elpoepgnuoydnanerdlihcniycaretilhtlaehfosecneuqesnocdnastnedecetnA6elbaT ehtnotcapmiroycaretiLhtlaeHybdecneulfnieratahtsrotcaF LHfoecnanetniamdnatnempolevedehtecneulfnitahtsrotcaF rohtuA oN semoctuohtlaeh&LHneewtebpihsnoitaler stnedutSloohcSyradnoceSrewoLdnayramirP&nerdlihC semoctuolaruoivaheb)htlaeH( stnemnorivnE&scihpargomeD ]82[1102.latekeaP 2 latnemnorivne,sutatshtlaeh,)nabru/larur(ecnediseR,yticinhtE,redneG( .noitamrofnihtlaehotssecca,srotcafksir :ssecorPnoitazilaicoS )loohcs,reep,stnerap(lennahclanosrepretni)astneganoitazilaicos- ,)tenretnI:aidemllup;repapsweN,oidaR,VT:aidemhsup(aideM)b.sv htlaehfonoitpmusnoctneuqerf,ruoivahebnoitamrofnihtlaeh- noitamrofnihtlaehfoecruos,noitamrofni )emoctuohtlaehetaidemretnisa(ruoivahebhtlaeh .m.n ]52[0102.latetdimhcS 3 stnedutSloohcSyradnoceS&elpoepgnuoY erachtlaehdelliksdnademrofniebot.g.e:ruoivahebhtlaeH larutluc,redneg,yticinhte,egasahcus:scitsiretcarahc/stiartlaudividni- ]12[8002,ollenagnaM 4 ,sremusnoc ;sllikslaicosdnaseitilibalacisyhpdnaevitingoc,dnuorgkcab erachtlaehehtetagivanylevitceffeot.g.e:esuecivreshtlaeH esuaidem- stifenebecnarusnihtlaehesu&metsys ;ycaretil)htlaeh(latnerap,gnittesemoh:secneulfnilatnerapdnareep- stsochtlaeH erachtlaehdnanoitacude,aidem:smetsys- demrofniebotslaudividniseriuqertnemnorivnehtlaeh- .m.n ]33[2102.lateyessaM 5 ,sremusnocCHdelliksdna nehwsreirrablanosrepretni&latnemnorivneemocrevo- metsysCHehthtiwgnitcaretni ehtdnasrehto,flesenodnatsrednuotelbaeb,tnemrewopmE :snoitidnoc/tnemnorivnegninraeldnassecorpgninraeL ]8[2102,irakkaaP&irakkaaP 6 gnignahcotetubirtnoc,snoisicedhtlaehdnuosekam,dlrow -lipup,detsujda-egaebotdeenycaretilhtlaehrofsdohtemgnihcaet htlaehehtdnahtlaehnwos’enotcapmitahtsrotcafeht noitaitogendnanoissucsidhguorht,evitcelfer,desucof rehtofo ytiliba,htlaehnworiehtgniniatniamnislliks&egdelwonk laicos,noitacudefolevel,secnereffidlarutluc,redneg,ytrevop ]92[3102,ättääM,ittuaisuU,ksaR 7 seussilaicosdetaler-htlaehssucsidot sutatscimonoce slaogdetaler-htlaehs’laudividninaniatniamdnahsilbatseoT ,seulav,sfeileb,redneg,ega:secneulfnilanretnI-:txetnocociM ]72[9002,.latesniggiHfrahW 01 )esicrexeot,gnivirderofebknirdtonod.g.e( ,kaeps/netsil,etirw/daerotytiliba(ycaretillareneG-,SES,secneirepxe ;tneserper/weiv oseMaidemnoitamrofnihtiwseitilibalacigolonhcet.g.e,seitilibarehto- ylimaf.g.e(htlaehgnitceffasrotcafreepdna,ylimaf,loohcS-:txetnoC htlaeH-).ctesloohcsyhtlaeh/efas,ruoivahebdnasmronreep,SES orcaM.cte,secruoser,gnitset,seitivitca,stnemngissa,gnihcaet:alucirruc doohruobhgiendnaytinummoc,lateicos:secneulfnilanretxE-:txetnoc ,aidem,erutluc,SESlevel-ytinummoc.g.e(htlaehgnitceffasrotcaf .).cte,seiciloptnemnrevog evitcepsrepesruocefilagniredisnocrospuorgegatnereffiD htlaehdnaruoivahebhtlaeH .m.n ]96,83[2102;4102.lateztraneL 21 ,stnemtaertdnasesaesidfoegdelwonk,stsocerachtlaeH dna,serudecorp,slootezilituotytiliba(lanoitarepO:secnetepmoC ]43[8002,osucnaM 31 ,snoitidnoccinorhcroferacotytiliba,sllikstnemeganam-fles ,)yltneiciforpegaugnalgnildnahrofseuqinhcet srorretnemtaertnoitacidemrolacidem,ecnailpmoc &tnemevorpmilaudividnirofsrehtohtiwnoitaroballoc(evitcaretnI- secivreserachtlaehfoesudnaotsseccA- ,).tnemeganam-fleshguorhttnemecnahne ,)ssenerawa-fles&tnemrewopmelanosrep(suomonotuA- Bröderetal.BMCPublicHealth (2017) 17:361 Page17of25)deunitnoC()nwohstoneraynaetatstondidtahtsledom(elpoepgnuoydnanerdlihcniycaretilhtlaehfosecneuqesnocdnastnedecetnA6elbaT dnaeracycnegremesahcussecivresevisnepxefoesU- foycnerrucehtdnaytirohtuaenimretedotytiliba(lanoitamrofnI- snoissimdatneitapni ,)noitamrofnihtlaeh sruoivahebgnitomorp-htlaehdna,gnineercs,noitneverP- ,)tnemnorivne)erachtlaeh(ehtfoyretsam(lautxetnoC- fosnoitpecreprossenllilacisyhpsadenifed,sutatshtlaeH- )secitcarplaicosfometsysgninaemehtterpretniotytiliba(larutluC- tnemriapmiroesaesid,ssenlli dna,htlaeh,SESlatnerap,stnerapsaLHsecneulfniLHdlihc ruoivahebhtlaehdnahtlaeh,SESlatnerap&ycaretilhtlaehlatnerap- ]42[4102,nehC&nitraM 41 sruoivahebhtlaeh ;semoctuocimedacadna,ssenidaerloohcs,htlaehnerdlihcecneulfni cimedacalamrofnistceffemaertsnwodhtiw,gnittesemohlamrofni ;gnittes :tniopnoitnevretnilaitnetopdnasecneulfnimetsyS ,yteicosdnaerutluc,metsys/gnittesnoitacudednahtlaeh- stifeneblaudividnI :snoitcanoitomorphtlaeH ]53[0002,maebtuN 51 tnemrewopmelanosrepdnaymonotuaretaerG- dnaaidemtsacdaorb,noitacudeloohcs&tneitap.g.e(noitacudE- secivreshtlaehdnasksirfoegdelwonkdevorpmI- ,)noitacinummocaidemtnirp .snoitcadebircserphtiwecnailpmoC- ,noitatilicafpuorg,tnempolevedytinummoc.g.e(noitazilibomlaicoS- egdelwonknoyltnednepednitcaotyticapacdevorpmI- ,)noitacinummocssamdetegrat ecnedifnoc-flesdnanoitavitomdevorpmI- ,msivitcadnanoitazinagrolacitilop,gniybbol.g.e(ycacovdA- ytisrevdaotecneiliserlaudividnidevorpmI- )aitrenicitarcuaerubgnimocrevo stifeneblaicos/ytinummoC semmargorphtlaehnoitalupopninoitapicitrapdesaercnI- htiwtcaretnidnasmronlaicosecneulfniotyticapacdevorpmI- .spuorglaicos stnanimretedcimonocednalaicosnotcaotyticapacdevorpmI- htlaehfo tnemrewopmeytinummocdevorpmI- semoctuohtlaehdlihC,sruoivahebhtlaehylimaF ;troppuslaicos,erutluc,egaugnal,noitacude,emocni:srotcafylimaF ]13[a9002.latesrednaS 61 ,troppushtlaehcilbup,secruoserlanoitacude,yhpargoeg:srotcaflaicoS htlaehlatnemnorivne :smetsystnereffiD boj/noitacudetluda,alucirruc21-K,loohcserP(metsyslanoitacudE- ,)gniniart ,egaugnal/erutluc,semmargorploohcs-retfa(smetsysytinummoC- ,)semmargorphtlaehcilbup ,)slootnoitamrofni,slliksredivorP(tnemnorivneeractneitaP- )metsysnoitamrofni,metsysyreviled(smetsyshtlaeH- htlaeh,semoctuohtlaeh,stsochtlaeh,esuecivreshtlaeh :srotcaflatsiD ]01[2102,.latenesnerøS 81 ytilibaniatsus,ytiuqe,tnemrewopme,noitapicitrap,ruoivaheb ,noitautiscihpargomed.g.e(stnanimretedlatnemnorivnednalaicoS- ;)smetsyslateicos,secroflacitilop,egaugnal,erutluc :srotcaflamixorP ,sutatscimonoceoicos,yticinhte,redneg,ega(stnanimretedlanosrep- ,)ycaretil,emocni,tnemyolpme,noitapucco,noitacude reepdnaylimaf,troppuslaicos.g.e(stnanimretedlanoitautis- .)tnemnorivnelacisyhpdnaesuaidem,secneulfni semoctuohtlaeh,ruoivahebhtlaeh,egdelwonkhtlaeH .m.n ]32[9002.latefloW 91 etavirpdnacilbupnietapicitrapot,noitamrofniylppaotytilibA laicosohcysp,lacitilop-oicos,cihpargomeD;sutatshtlaeH ]4[3002/5002,.latesaloodacraZ 02 dnaegdelwonkcifitneics,enicidem,htlaehtuobaseugolaid srotcaflarutlucdna sfeileblarutluc Bröderetal.BMCPublicHealth (2017) 17:361 Page18of25Bröderetal.BMCPublicHealth (2017) 17:361 Page19of25 Antecedents Twelve of the identified models included socioeconomic level on the health literacy in that antecedents and distinguished between individual char- community. Political and cultural factors refer to differ- acteristics,demographic,situational orcontextualfactors ences in cultural practices, political decision-making, e.g. aswellasbroader systemorsocial factors. governmental policies that decide whether to include Internal characteristics refer to an individual’s beliefs, health literacy in the school health curriculum. Synthe- values, experiences, cognitive and physical abilities, sizing it, health literacy is argued to be promoted general literacy skills or other abilities, e.g. technological through health promotion actions in the general popula- abilities. Paakkari and Paakkari [8] argue, in line with tion which include an education for health, efforts to Manganello [21], that general skills such as social or mobilize people’s collective energy, resources, skills, to- communication skills, as well as self-efficacy are ante- wards the improvement of health and advocacy for cedents for health literacy and not per se separate core health, e.g. in form of lobbying activities and political dimension of health literacy. Rather, they are important activism[35]. for different core dimensions and are not attributable to one. However, other authors [35] regard these as being Consequences Fifteen articles mention that health liter- coredimensionof health literacy(seeTable5). acy in children and young people leads to benefits on Models that focus specifically on children and young the individual, community or societal-level (applied from people emphasize the family’s demographic factors and Nutbeam [35]). On individual level, health literacy en- parental influences. The younger the child is the more ables young people to be skilled health care consumers likely he/she isto rely ontheirparents for economic and and to overcome environmental and interpersonal bar- social support and, therefore, their own socioeconomic riers when interacting with the health care system [21, status (SES) oroccupation are notapplicableto variables 33, 35]. Moreover, it is argued that health literacy can [24, 31]. Family demographic factors include parental empoweryoung people tounderstand themselves,others health literacy levels, socio-economic status, as well as and the world, to make sound health decisions, and to their own health status and health behaviour. Martin discuss health-related social issues [8,29].Healthliterate and Chen [24] argue that these family factors strongly young people are also believed to possess an enhanced influence children’s health literacy, health status, and ability to establish and maintain their self-defined other educational variables such as school readiness and health-related goals such as to engage in physical activ- achild’sacademicoutcomes. ities or not to drive after drinking [27]. In addition, the Furthermore, families, peers, and schools are all benefitsof healthliteracyarearguedtoextendtothefull regarded as major socialization agents in children’s and range of life’s activities – at home, at work, in society young people’s lives that influencetheopportunitiesthey and culture and at wider health economic levels [4, 10]. have for being or becoming health literate. Family and Martin and Chen [24] and Sanders et al. [31] take on a peerscan encourage ordiscouragehealth literacy actions life course perspective, viewing health literacy as set of as well as health promoting lifestyles through their competencies that are passed from a parent to the child norms, actions, and social support [27]. Parents can be and do not only affect the child’s health behaviour and role models of how to access and interpret health infor- outcomesbut alsotheonesofthefamily. mation and teach children to critically evaluate the cred- In terms of societal and communicational benefits, ibility and validity of information sources and media health literacy is argued to increase the participation in channels. In this context, the quality and the type of the population health programmes, to improve community relationship play a major role, as children or young empowerment and the general capacity to influence people are likely to consult peers and adults they trust, one’s own health and the health of others, as well as which is crucial as trust also plays a role in accessing broader social norms [8,35]. mediaandonlinehealth resources. The social and system levels refer to education, health, Discussion and community systems as well as political and cultural The objectives of this study was (a) to scope current forces. These include the general learning conditions understandings of health literacy in childhood and youth and environment, e.g. students’ safety on school and (b) to understand to what extent available models grounds,teachersthatare equippedwith the appropriate capture the unique needs and characteristics of children skills and teaching practices that could promote critical and young people. The 12 definitions and 21 models thinking and reflexion through negotiation and discus- identified enabled a sound depiction of health literacy sion [8, 27]. Next, the community where a child or for children and young people. As a strong commonality youngpersonlivesmayhaveanimpactonhis/herhealth of the complex and heterogeneous definitions and literacy: Martin and Chen [24] and Wharf Higgins et al. models,healthliteracyisdepictedasamultidimensional, [27] draw attention to the influence of the community- complex construct. Moreover, by describing theBröderetal.BMCPublicHealth (2017) 17:361 Page20of25 construct along multiple integrated categories, a synthe- understanding, appraisal and use of health information sis of the health literacy dimensions retrieved from the or services, or as Fok and Wong [17] point out, general literature was possible. However, it may be the case that physical and psycho-social activities. However, this these categories overlap as the same phenomena can be individual-based, action-focused perspective “appears to described in various ways and many models regarded limit the problem of health literacy to the capacity and health literacy through different lenses, resulting in competenceoftheindividual”[44].Moreover,thebehav- differential focuses. These observations are in line with ioural components of health literacy (e.g. to apply health Paakkari and Paakkari [8] who pointed out that “there information) are often not distinguishable from the out- are differences regarding what is regarded as a compo- come categories of health literacy, namely the health nent of health literacy and what may follow on from or choices and behaviours that are health literacy is beassociatedwith healthliteracy”. expected to influence (listed in Table 6). Given the Regarding the first part of the research question, the strong individual and skill-based focus of health literacy focus of health literacy exceeds the health care setting in definitions and models that require individuals to take most definitions and models. It was recognised that charge of and become actively involved in seeking, health literacy in children and young people is relevant understanding, accessing information and make health- in many occasions and contexts of daily life that have a related decisions, really reflects children’s and young potential impact on the well-being and the promotion of people’s everyday realities. In other words, do they over- one’s health. Similar to health literacy in adults [10], estimate the opportunities (Möglichkeitsraum) and health literacy involves actions or agency which vary scope for action (Handlungsspielraum) of children and according to the health literacy perspective that is young people within health literacy and decision-making applied – e.g. from a clinical or health care setting para- processes? According to Schulz and Nakamoto [45], digm, to a more comprehensive health system or public health literacy and personal empowerment do not auto- health or health promotion paradigm [42, 43]. While the matically derive from one another, as one can have the first perspective aims to impact on the health outcomes capacities and skills necessary to promote one’s health of the individual through healthier decision-making, the but may lack the empowerment to do so. Moreover, the latter includes actions for advocating for one’s own preferred“societal”outcomeofmostmodelsis“healthier healthandthatofsociety throughcitizenship[8]andad- behaviour” – namely such behaviour that is considered dressing broader social determinants of health [29]. “healthy” by health professionals, experts or society. These definitions and models are referred by De Leeuw Especially models targeting the health care system still [42] as “third generation” health literacy research appear to strongly favour an adherence perspective, which recognise that health literacy enables personal viewing individuals primarily as receiving health infor- empowerment and is interrelated with broader deter- mation and complying with the professional (health or minants of health. As a result, health literacy is con- care) instructions provided. Such strongly “subject-fo- text and content-specific and as such varies according to cused” health literacy perspectives entail – as known the complexity of the task at hand and the context- from health promotion discussions – the risk of primar- ual factors present [35, 43]. Hence, an individual is ily holding the individual responsible and accountable always interwoven with and subjected to the social fortheirownhealth.Thisreflectsacultureofindividual- and cultural context it is embedded. While these isation in late modernity and “the risk society” [46, 47]. “two sides of a coin” – the individual’s attributes and This victim blaming approach [48] ignores the universal the many contextual factors – were considered in recognition that social determinants of health – the eco- most definitions and models identified, the review re- nomic and social conditions that affect individuals and vealed a strong emphasis on the individual attributes communities –strongly influence a person’s individual which were elaborated in detail. The contextual fac- ability to be health literate [11]. By ignoring the multifa- tors were acknowledged but often remained under- ceted and complex nature of human decision-making scored in the literature. In the following paragraphs, and behavioural change [49, 50] and by clashing with we offer our reflection and perspective on the ob- health promotion goals and practice, individual-level served discrepancy. health literacy perspectives “may do little to achieve the The individual attributes include the knowledge and ultimate goal of promoting equitable health status” [51]. skills that a person should have in order to meet certain As a result, exercising health literacy is only possible if situation-demands, e.g. in the health (care) system, or opportunities for engaging in health literacy actions as general health-related demands that society poses upon well as for participating in everyday decision-making are the individual. These demands mostly are diverse and present. Hence, the extent to which families, communi- overlapping within the definitions and models. Mostly, ties and societies allow children and young people to they refer to performing actions related to the gathering, take an active role and participate in health literacyBröderetal.BMCPublicHealth (2017) 17:361 Page21of25 practices remains a question for future research. A pos- Therefore, further research is needed that shifts from a sibility for exploring this could be by drawing upon a functional,skill-basedhealthliteracyperspectivetoalter- resource-focused health perspective, for instance the native approaches of understanding health literacy, e.g. salutogenic paradigm by Antonovsky [52]. Saboga- by observing health literacy within the context that it Nunes [53] stressed the connectedness between health takes place in and through the social practices in which literacy and salutogenesis by arguing that childhood and it is performed. Such a comprehensive health literacy youth could be considered most permeable life stages construct will be challenging to implement and where salutogenicresourcesarebuilt upbytransforming operationalize. One option for addressing this challenge health information into action and the other way could be amodular design, which isthenadjusted as ne- around.InlinewithAntonovsky[52],healthinformation cessary tospecifictargetgroups,contentsandcontexts. could be understood as stimuli from one’s internal and Thesecondpart oftheresearchquestion wastoclarify external environment that are met with a dynamic feel- to what extent available models capture the unique ing of confidence. This feeling would be retrieved from needs and characteristics of children and young people. theability tocomprehendsuchstimuli, toconsiderthem Here, special attention was contributed to the target to be relevant for one’s health, and to access the re- groups' recognition and characteristics in the analysis, sources needed for successfully addressing the stimuli which revealed thefollowingdiscussionpoints: andthedemandsposedbyit. While many definitions and models were identified for In terms of the interrelatedness of social, cultural, and youngpeople,includingsecondaryschoolstudents,simi- environmental contextual factors, especially the role of lar findings are lacking for children under the age of ten the intermediate environment of children and young orwithinaprimaryschoolcontext.Inaddition,thesame people is emphasized: The target group is especially is true for transitional stages, e.g. from primary to dependent upon their parents or caregivers for the ac- secondary school level or from youth to adulthood. cess to material, financial, and social resources (e.g. These findings are in line with conclusions drawn by health care). However, this dependence decreases asthey Hagell, Rigby and Perrow [57]. Especially with regards to develop and become more mature. While most articles young children, the focus is strongly on maternal or also identify a strong impact of adults’ health literacy on caregivers’ health literacy competencies, enabling them their children,little is known about thenatureof this in- to secure the child’s care needs. Children, including fluence and the impact of social agents in the target primary school level or younger have not yet been at the group’s environment. Sanders et al. [31] refer to it as focus of health literacy conceptual and intervention re- “collective health literacy”, which can be regarded as a search efforts. Given that research has linked health form of social and cultural capital according to Bourdieu literacy to health outcomes, and to health (care) costs [54]. Moreover, several articles highlight the role of for the adult population, research should follow up on available and accessible social support structures and past efforts [58] in order to explore the relevance for peer assistance for the health literacy of children and young people aswell aschildren. young people: they benefit from the health literacy re- Life phase specificities are only considered in 12 lated knowledge and skills which they can access models, which incorporate a strong focus on children’s through their social informal or formal support struc- age-specific cognitive development. These dominantly tures. This kind of assistance can help children to consider health literacy to take place in several consecu- accomplish health-literate-related tasks or actions that tive age or developmental stages, as Piaget suggested in they otherwise would not be able to succeed in on their his theory of cognitive development [59]. Although life own [1, 55]. Vygotsky [56] termed this external assist- phase specificities are argued to manifest in the target ance “scaffolding”. Overall, these social-cultural and group’s social embeddedness, the articles attribute little economic contextual factors are primarily argued to act attention to sociological approaches to childhood as antecedents or mediators for health literacy and tend [54, 60] as well as to children and young people’s social to be neglected at the core of health literacy itself. We role and position, as argued by the New Sociology of argue thatthestrongemphasis onhealth literacyasa set Childhood [61]. The latter perspective of childhood of skills tends to neglect and disregard the situation in stresses that children should not be regarded as ‘becom- which health literacy takes place, as well as the social ings’(incomplete)butasindividual“beings”andmembers practices relating to health literacy. In conclusion, there oftheirownsocialgroups.Thisdrawsattentiontotheso- is a gap between the recognition of the role of context- cial role that is contributed to children and young people ual and cultural factors for health literacy and their im- by their caregivers, communities and society. Generally, plementation within strongly individualistic, skill-based the younger children are the moredependent they are on conceptualisations, as well as operationalisations that their parents in respect to economic resources and social focus on few distinctive health literacy dimensions [25]. support as well as their parents’ health literacy. However,Bröderetal.BMCPublicHealth (2017) 17:361 Page22of25 little is known about how parental and child health liter- group was found to be questionable. This is especially acyareinterwovenandinteractinthechild’sdevelopmen- problematic as they have served [67, 68] or may in the talprocesses.Brady,Lowe,andLauritzen[62]forinstance future serveasconceptual foundationsfor health literacy argue that even from a very young age onward, children programs or interventions for children and young are already active agents of their own social worlds that people. Applying general health literacy models to the take on an active role in their health. Viewing children target group that were not especially developed to meet and young people as active social agents draws attention the needs and demands of children and young people to considering children’s perspective of health and how may actually hinder effective health literacy promotion they deal with it while being subjected to different social and development in that target group. Such practices contexts and cultures. Children continuously develop and have been observed in some summarizing articles on change through socialization processes and interaction children’s and young people’s health literacy as well [39, with their environment, including their parents, other 57].Thedescribed scarcity of healthliteracyunderstand- adults or their peers [61]. How we view children and ings that incorporate specific target group characteristics youngpeople,therefore, largelydependsonour–adult– andperspectives revealsacurrent researchgap. perception of childhood and youth and the social role we Therefore, it is argued in line with Rubene et al. [55] attribute to children and young people in everyday inter- that children’s and young people’s health literacy, due to actions, e.g. between teachers and students or between their distinctive needs and life situations, should be doctorsandchildpatients. “conceptualized as an issue in its own right and not as a The essential role of media and digital communication derivation of adult health literacy”. Hence, future channels for the target group [63] was a theme that was conceptual and empirical research efforts need to recog- found to remain underscored in available health literacy nise children’s and young people’s special character and dimensions for children and young people, apart from encourage the target group to actively participate, few exceptions [21, 27, 28]. Media plays an increasing providing them with the opportunity to contribute with role in children’s personality, cognitive and emotional their own understandings and perspectives of health development. Ittransportsmoral andculturalvaluesand literacyandtothepromotionof healthy behaviour. facilitatestheirsocialandpoliticalsocializationprocesses [64].Inanattempttobridgethe conceptualgapbetween Limitations approaches to health and media literacy, a media health For pragmatic reasons, this review focused on exploring literacy model for adolescents was developed and definitions and models of general health literacy of successfully tested for the target group by Levin-Zamir young people, excluding domain- (e.g. media), target- et al. [65]. Moreover, critical media health literacy for group or disease-specific health literacies (e.g. mental or young people was defined by Wharf Higgins and diabeteshealth literacy). However, concentrating on gen- Begoray [66] as consisting of a skill set of reflection, eric health literacy enables a broader recognition of the discrimination and interpretation abilities, as well as overall field of health literacy, hopefully preventing us empowerment and engaged citizenship. Given the im- from ‘not seeing the wood for the trees’ due to specific portant role of media in the target group, we propose to interest areas [16]. Macket et al. [16] point out that a recognise the interrelatedness of (critical) media, digital model valid for one context is less helpful for enabling and health literacies more profoundly in future models, knowledge construction and learning in other contexts interventions,andeducationalcurricula. through cross-contextual comparison and transfer. Most of the identified dimensions of health literacy in While this is an acknowledged problematic, we strongly childhoodandyouthwerefairlysimilartotheonesiden- stress the need to view health literacy as being socially tified for adults (cf. the review results by Sørensen, et al. constructed, varying according to the context one is in [10]). This poor incorporation of life phase specificities and the tasks at hand and hence recognising the unique might result from the fact that their voices and perspec- characteristics ofthetarget group. tives largely remain unheard: Their active participation Extending the review to articles that incorporate a life in the conceptual development process was only realized courseperspectiveonhealthliteracymayhavelettobias in three articles. Overlaps to adult health literacy dimen- the analysis towards non-target group-specific defini- sions were observed most strongly in models that tions and models. However, these were included based focused on a life course perspective of health literacy on the argumentation that if they claim to provide a life (and hence implicitly target children and young people course perspectives on health literacy, they implicitly as well). Those six models were analysed to be adult- includes children and young people as well. Therefore, focused as they incorporate neither target group spe- they are of relevance for the comprehensive scoping of cifics nor age- or development-flexible components. current health literacy understandings for the target Therefore, their applicability and validity for the target group. While the review was conducted using sound andBröderetal.BMCPublicHealth (2017) 17:361 Page23of25 systematic methods, following the PRISMA guidelines to future health choices. For this, it is crucial to not focus the extent possible for qualitative reviews [14], in order on an individualistic perspective only. Rather, it is of to ensure its validity and accurateness, several limita- importance to recognize the interrelatedness and tionscertainlyarepresentandneedtobeconsidered.Ef- contextualisation of health literacy where people are forts were made to enhance the sensitivity of the search empowered to interact with health, social and educa- strategy, using a comprehensive list of search terms and tional systems to the benefit for themselves as well as applying relevant operators. The databases that were for the society as a whole. In turn organisations and used covered multiple disciplines indexing bibliographic systems are providing health literacy friendly services records of a variety of journals and publication types. that can facilitate health for all. In such a two-sided Nevertheless, we might have missed relevant literature, approach, we must pursue to (i) strengthen children’s among others, due to limitations in availability and of and young people’s and their care takers’ personal individual databases’ search algorithms. Focussing only knowledge, motivation and competences to take well-- on English and German language articles led to distor- informed health decisions; and (ii) decrease the com- tioninfavourofnativeEnglishandGermanspeakingre- plexity of society as a whole, and of the health care search contexts.Toensurethatthefocusremainsonthe system in particular to better guide, facilitate and em- key research question, the assessment and evaluation of power citizens, including children and young people the selected articles was performed according to a to sustainably manage their health. Future efforts systematic data extraction method, applying a coding must target the redesigning of systems to be inclusive protocol. While the core research team was independ- and friendly towards children and young people, the ently involved in the selection and the assessment of the adjustment of curricula and training of health profes- articles to minimize subjectivity and interpretation, the sionals, teachers and other relevant stakeholders in risk of selection, coding or opinion bias still remains. order to better meet the challenge of the health liter- Due to the differing focus of analysed definitions and acy deficit, and the recognition of children and young models, an explicit evaluation of the content was often people as active partners in their health decision- difficult. Hence, the final assessment depended on the re- making. searchers’ interpretation of the written content. Moreover, given the relevance of social structures and Furthermore, no assessment of the articles’ methodo- support on the way health literacy skills are acquired, logical quality took place, as many were theory-building applied and hence practiced in very varying life situa- or conceptual, explorative publications that often did not tions, children’s and young people’s distinctiveness from follow an outlined methodological approach. Therefore, adults, however, should become a crucial consideration notallqualitystandardsasoutlinedinthePRISMAguide- when understanding health literacy. Moreover, we stress lineswereapplicableandviableforourresearchdesign. thathealth literacyshouldnotbecomealiability forchil- dren and young people with responsibilities exceeding Conclusion their influence. Hence, several critical reflections and Addressing health literacy in children and young people considerations that challenge current understandings of should be based upon an empirical sound and measur- health literacy were pointed out that could be beneficial able definitions as well as on conceptual frameworks when taken into account in future research and inter- that are valid, hands-on, and meet the specificities of the ventions. Therefore, future efforts should encompass target group. This systematic review of the literature these gaps and challenges identified, addressing them identified a broad theoretical base for health literacy in from a multidisciplinary perspective, viewing the target children and young people, while also pointing to group as active social agents, who are deeply embedded conceptual shortfalls, especially related to a coinciding in their close and distant surrounding (e.g. family, set of knowledge and skills adopted for the target group friends, and social institutions). As such, the greatest and how these are developed during the life course. challenges for conceptualizing health literacy might Moreover, further operationalisation and implementa- ensure its generalizability and validity across tion of these dimensions are necessary to test whether context, while recognising its context- and content- the described commonalities of the definitions and dependency. models are sound and measurable to describe the construct of health literacy of children and young Acknowledgements TheauthorsthankallpartnersintheHLCAconsortiumforcontributingto people. 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