Child and Youth Health Literacy: A Conceptual Analysis and Proposed Target-Group-Centred Definition. — TEI-tagged view

Janine BröderpersName, Orkan OkanpersName, Torsten M. BollwegpersName, Dirk BrulandpersName, Paulo PinheiropersName, Ullrich BauerpersName (2019date). “Child and Youth Health Literacy: A Conceptual Analysis and Proposed Target-Group-Centred Definition..” International Journal of Environmental Research and Public Healthtitle·j.

Object of study — understandings of health literacyterm·dom in childhood and youth

Research question — what target-group-specific characteristics a differentiated understanding of child and youth health literacyterm·dom must consider

Contribution — a target-group-centredterm·key definition of health literacyterm·dom for childrenterm·key and young peopleterm·key

Full text — tagged

Child and Youth Health Literacyterm·dom: A Conceptual Analysisterm·key and Proposed Target-Group-Centredterm·key Definition.

Abstract (1) Background: This article adopts an interdisciplinary perspective to analyse, examine, and reflect upon prominent health literacyterm·dom (HLterm·dom) understandings in childhood and youth. (2) Method: The conceptual analysisterm·key combined Rodgers’ and Jabareen’s approaches to conceptual analysisterm·key in eight phases. (3) Results: First, we present exploratory entry points for developing a child-specific HLterm·dom understanding based on the six dimensions of a ‘health-literacy 6D modelterm·key’. Second, we describe and reflect upon five meta-level dimensions covering the HLterm·dom definitions and models for childrenterm·key and youth found in the conceptual analysisterm·key. Third, we integrate our findings into a target-group-centredterm·key HLterm·dom definition for childrenterm·key and youth. (4) Discussion/Conclusion: This article raises awareness for the heterogeneity of the current conceptual HLterm·dom debate. It offers a multidisciplinary approach for advancing the existing understanding of HLterm·dom. Four recommendations for future actions are deduced from the following four principles, which are inherent to the proposed target-group-centredterm·key HLterm·dom definition: (a) to characterize HLterm·dom from an asset-based perspective, (b) to consider HLterm·dom as socially embedded and distributed, (c) to recognize that HLterm·dom develops both in phases and in flexible ways, and (d) to consider the multimodal nature of health-related information. Further research is necessary to test the feasibility and applicability of the proposed definition and conceptual understanding in both research and practice.

Keywords: health literacyterm·dom, childrenterm·key, young peopleterm·key, adolescents, pupils, conceptterm, definition, conceptual analysisterm·key 1. Introduction From an early age onwards, childrenterm·key and young peopleterm·key are exposed to and have to deal with different, often complex health-related information and messages coming from various sources [ 1 ]. Health literacyterm·dom, commonly defined as comprising a broad range of knowledge and competencies, can empower childrenterm·key and young peopleterm·key to seek, engage with, and use health informationterm·key to enable and access health-promoting activities [ 2 , 3 ].

Through health literacyterm·dom competencies, people become able to understand themselves, others and the world in a way that will enable them to make sound health decisions, and to work on and change the factors that constitute their own and others’ health chances [ 2 ].

Moreover, Fairbrother, Curtis, and Goyder [ 1 ] have drawn attention to childrenterm·key’s health literacyterm·dom practices in accessing and understanding health informationterm·key and their reliance on their embodied experiences. From a health promotion perspective, it is, therefore, essential to recognize childrenterm·key and young peopleterm·key as a target group of health literacyterm·dom research and interventions: childhood and youth are regarded as foundational life phases for healthy human development and for personal health and well-being throughout adulthood e.g., [ 4 ]. Because crucial pathways for future health throughout the life course are already evolving and manifesting during childhood and youth [ 5 ], childrenterm·key should be supported by meeting their information needs and fostering their active involvement in their own health [ 6 , 7 ]. Accordingly, it is prominently voiced that failing to provide young populations with health literacyterm·dom and health-promoting capacities would constitute an increased risk for the individual and society in terms of poorer health outcomes and higher costs [ 8 , 9 , 10 ].

Although child and youth health literacyterm·dom has received increasing attention, the conceptual debate is characterized by a high degree of fragmentation and differentiation as well as the lack of a conclusive theoretical framework [ 11 , 12 ]. The conceptual work within this article was preceded by a systematic literature review of the available definitions and methods of health literacyterm·dom for childrenterm·key and people younger than 18. This identified 12 definitions and 21 models that have been reported in detail elsewhere [ 11 ]. One main conclusion of this review was that there is limited consensus regarding any conceptual foundation and meaning of health literacyterm·dom for childrenterm·key and young peopleterm·key, as well as a lack of clarity regarding target-group-specific health literacyterm·dom characteristics.

Hence, in order to assess and adequately bolster health literacyterm·dom during childhood and youth, it is important to be explicit and specific about what health literacyterm·dom entails and means in these life phases. Conceptual understandings of health literacyterm·dom should be evaluated critically and assessed in terms of their relevance, feasibility, and applicability for the target group [ 10 , 11 ]. In other words, transferring health literacyterm·dom conceptsterm developed for adults to childrenterm·key and young peopleterm·key requires proper consideration and evaluation of their applicability and how well they fit these life phases, as well as the target populations’ realities and needs [ 13 , 14 ].

Drawing on the results of the systematic literature review [ 11 ], the aim of the present research here was to examine and narrow down health literacyterm·dom for school-aged childrenterm·key and young peopleterm·key in light of their age and developmental differences. First, this article applies a conceptual analysisterm·key designed to examine and reflect upon prominent understandings of health literacyterm·dom in childhood and youth. Second, it explores dimensions for a target-group-centredterm·key conceptual understanding of health literacyterm·dom in childhood and youth by drawing on relevant, interdisciplinary perspectives and then condensing these into a ‘differentiated’ multifaceted definition. Specifically, the article addresses the following research questions: What target-group-specific characteristics have to be considered in a differentiated, tailored understanding of health literacyterm·dom in childhood and youth?

What are the current challenges in the existing health literacyterm·dom conceptsterm for childrenterm·key and young peopleterm·key and what implications arise from these challenges?

How can these considerations be transferred into a differentiated conceptual understanding?

2. Methods This is an analytical and explorative article that uses a conceptual analysisterm·key to examine health literacyterm·dom in childhood and youth. This analysis was conducted by combining Rodgers’ [ 15 , 16 ] evolutionary conceptterm analysis with a more recent systematic ‘conceptual framework analysis’ approach from Jabareen [ 17 ]. According to Rodgers [ 15 ], ‘a conceptterm is considered to be an abstraction that is expressed in some form, either discursive or non-discursive’. Conceptsterm are subjected to continuous change and ‘through socialization and repeated public interaction, a conceptterm becomes associated with a particular set of attributes that constitute the definition of the conceptterm’ [ 15 ]. This is complemented by Jabareen’s [ 17 ] philosophical approach, which understands a conceptterm as being defined by and consisting of its individual components that are not only distinct and heterogeneous but also related to one another and inseparable. Both approaches acknowledge that conceptsterm overlap with other conceptsterm. Jabareen’s [ 17 ] conceptual framework analysis is an iterative process, characterized by a continuous interplay between data collection, analysis, and reasoning. It requires a continuous comparison between different types of evidence, conceptual exploration, and discussion to constantly control the conceptual scope and level. Our conceptual/dimensional analysis was conducted along the phases reported in Table 1 .

Steps in the conceptual analysisterm·key (revised approach drawing on Rodgers [ 11 ] and Jabareen [ 13 ]).

Phase 1 consisted of mapping the data sources identified and selected in two earlier research steps: First, in order to identify, explore, and analyse unique particularities and characteristics of childrenterm·key and young peopleterm·key that are of relevance for health literacyterm·dom research and practice, we applied an iterative process to search for and analyse relevant, multidisciplinary literature from childhood studies, educational science, and sociology. We then structured the findings along six dimensions (the 6-D modelterm·key) [ 13 , 18 ]. Second, we drew on the results of a systematic review of available conceptual understandings of health literacyterm·dom for childrenterm·key and young peopleterm·key [ 11 ]. In Phase 2, the selected data were read and categorized, ensuring adequate representation of relevant multidisciplinary evidence from health science, sociology, childhood (development) studies, and literacy research. Next, in Phase 3, we analysed the identified body of literature to identify attributes and components of health literacyterm·dom. The identified attributes and components were deconstructed and categorized in Phase 4. This entailed clarifying their characteristics, their assumptions, and their relation towards each other. In Phases 5 and 6, we integrated the results of the earlier phases by grouping relevant ones together and synthesizing them through an iterative process facilitated by reflective and analytical discussions within the research team. As an output, we identified a draft definition as well as the following five meta-level dimensions of current child and youth health literacyterm·dom definitions and conceptsterm: (a) content and attributes, (b) antecedents and contextual interrelatedness, (c) subject matter or topic purpose, (d) expected outcomes, and (e) life course relevance and target group sensitivity. The drafted target-group-centredterm·key health literacyterm·dom definition and key conceptual dimensions were then discussed critically and validated communicatively at two expert workshops held in October 2016 and February 2018 (Phase 7). As part of this step, results were also presented and discussed within the academic setting though presentations at several national and international scientific conferences. The final Phase 8 entails continuing the critical review and reflection process and adopting or revising the conceptterm according to need in light of new insights and evidence. Hence, this phase is still ongoing.

3. Results 3.1. What Special Characteristics of Childrenterm·key and Young Peopleterm·key are Relevant for Health Literacyterm·dom?

Childhood and youth are life phases in which needs, assets, and perspectives have unique characteristics [ 19 ]. Therefore, this section argues for the need to recognize childrenterm·key and youth as a distinctive target group for health literacyterm·dom and to integrate their characteristics, needs, assets, and perspectives into target-group-specific health literacyterm·dom definitions and conceptsterm. Therefore, we reviewed relevant literature from multiple disciplines and structured the findings into a framework of six ‘Ds’—the so called ‘health-literacy 6-D modelterm·key’. An earlier version of this model has been published elsewhere [ 13 , 18 ]. Drawing on and extending past ‘D’ models proposed by, among others, Rothman et al. [ 20 ], all dimensions start with the letter ‘D’ and represent exploratory entry points for developing a child-specific health literacyterm·dom understanding ( Figure 1 ). The entry points emphasize how and in what ways childrenterm·key and young peopleterm·key are a unique target group compared to the general adult population. Table 1 gives an overview of the core attributes of each dimension or ‘entry point’.

Health literacyterm·dom 6-D modelterm·key, highlighting six target-group-oriented health literacyterm·dom dimensions.

Each of the six dimensions of the 6-D modelterm·key, described in Table 2 , highlights relevant aspects that are important in order to elaborate on and explore health literacyterm·dom holistically in terms of its relevance and meaning for childrenterm·key and young peopleterm·key. Essentially, we argue that, from a very young age onwards, childrenterm·key acquire experiences, form opinions, and develop their own unique understanding and meaning of not only the world around them, but also their health and well-being [ 1 , 21 ]. Nonetheless, intergenerational power relationsterm·dom are evident in every social interaction, and they influence childrenterm·key’s and young peopleterm·key’s roles regarding their health along with their active contribution to health-related decision-making processes. Hence, it is important to understand the nature and dynamics of these power structures for health literacyterm·dom in a given social environment or situation and to create opportunities for childrenterm·key and young peopleterm·key to take ownership of and actively participate in their health literacyterm·dom processes and actions.

Description of dimensions of the health literacyterm·dom 6-D modelterm·key (for an earlier version, see [ 13 , 18 ]).

3.2. Health Literacyterm·dom of Childrenterm·key and Young Peopleterm·key: Conceptual Analysisterm·key and Reflection The following section summarizes key results from the conceptual analysisterm·key and the challenges it raises when trying to understand health literacyterm·dom in the target populations. The following five meta-level dimensions were identified by drawing on available child and youth health literacyterm·dom definitions and conceptsterm [ 11 ]: (a) content and attributes of health literacyterm·dom, (b) antecedents and contextual interrelatedness, (c) subject matter or topic purpose, (d) expected outcomes, and (e) life course relevance and target group sensitivity.

3.2.1. Content and Attributes Prevailingly, health literacyterm·dom has been defined as a multi-dimensional, complex construct, entailing, among others, relevant skills and knowledge to seek and deal with health informationterm·key and health-related decision-making in the health care, work, and other life settings [ 11 ]. Available definitions and models can be characterized along a continuum of two approaches that can be phrased as two questions, namely: (a) ‘what should a health literate person be able to do?’, hence the direct purpose or aim of health literacyterm·dom; and (b) ‘what are the abilities, competencies and other attributes that characterize a health literate person or a health literate entity/community?’

Within the first approach, typical actions or tasks related to childrenterm·key’s and young peopleterm·key’s health literacyterm·dom are: Receiving or actively seeking access to relevant information for one’s health through various personal or medial channels (e.g., after encountering a situation, problem, or demand that requires more information); Cognitively processing, concentrating (attention) on, and comprehending the information in order to understand its content; Critically appraising the credibility, accuracy, and relevance of information as well as interacting with that information by constructing meaning from the information and relating it to one’s situation or reality; and Following up on this information through health-related actions and decision-making [ 11 ].

The given action areas are broad and have varying degrees of complexity depending on the specific context or situation. Moreover, definitions and models representing this approach draw on the underlying assumption that health literacyterm·dom skills, health informationterm·key, and other components are per se relevant and meaningful for the target group, and that these can be used to achieve the defined health literacyterm·dom actions and decisions [ 12 ].

Within the second approach, health literacyterm·dom is described predominantly in terms of different combinations of individual cognitive abilities such as reading, writing, critical thinking, or information-processing skills. Whereas the focus on cognitive abilities prevails, health literacyterm·dom has also been viewed as an umbrella conceptterm encompassing, in addition to cognitive attributes, affective attributes (e.g., self-reflection, self-efficacy, motivation), operational or behavioural attributes (e.g., communicative and social skills), or specific technical skills (e.g., navigating the health care setting or system, technological information-searching skills) [ 11 ]. Moreover, different researchers have stressed that health literacyterm·dom and its respective components represent ‘broader competence fields’ and not single skills e.g., [ 2 , 37 ] However, a variety of terms have been used to describe similar components without authors reporting their definition of such terms or the reasoning behind their choices. This is challenging, because labelling or defining health literacyterm·dom as a set of skills creates a normative standard regarding what skills (levels) childrenterm·key and young peopleterm·key should possess or be compared to at a certain development stage in order to be considered health literate.

The heterogeneity within health literacyterm·dom definitions and conceptsterm regarding what health literacyterm·dom is and which components it is composed of remains a crucial challenge for health literacyterm·dom research, practice, and policymaking. Notably, health literacyterm·dom has been criticized as being a ‘top-down’ or expert-driven conceptterm [ 38 ]. Expert-driven approaches leave little room for individualized health literacyterm·dom profiles, for recognizing childrenterm·key’s own assets, or for viewing them as active health agents and experts on their own lives from a young age onwards [ 13 ]. In a similar vein, Fairbrother et al. [ 1 ] stressed the need to move ‘beyond what childrenterm·key know’ towards research on ‘how childrenterm·key actively construct meaning from health informationterm·key’ (p. 476). Table 3 provides a summary of the main findings and aspects raised.

Summary of conceptual reflections regarding health literacyterm·dom content and attributes.

3.2.2. Antecedents and Contextual Interrelatedness There is a widespread emphasis on the importance of viewing health literacyterm·dom in relation to not only a given environment but also the social context and situational demands [ 3 ]: health literacyterm·dom is regarded as a productterm·dom of situational requirements and individual attributes that are influenced by various social, demographic, and economic factors. Nonetheless, this widespread emphasis on the interrelatedness of context factors and health literacyterm·dom is still considered and reflected only very implicitly in the most commonly used definitions for childrenterm·key and young peopleterm·key. In the systematic literature review [ 11 ], we summarized that contextual factors are still addressed most frequently as antecedent variables for health literacyterm·dom. Hence, currently, little is known about how the contextual factors interact with one another, and how this interaction affects how childrenterm·key and young peopleterm·key can build up and use their personal health literacyterm·dom skills. One approach to such interaction processes comes from Paek, Reber, and Larsccy [ 39 ] and Chuen, Miachel, and Teck [ 36 ], who have discussed the role of interpersonal and media socialization agents for adolescents’ health literacyterm·dom from a sociological perspective. Contextual factors relevant for health literacyterm·dom can be distinguished in: The interpersonal context such as the parental socio-economic status, parental education level, and the home setting; Situational determinants such as the degree of social support as well as influences from family and peers, the school and community setting, and the media; and The distal social and cultural environment such as characteristics of the health and education system as well as political and social variables.

This is in line with results published by Malloy-Weir et al. [ 12 ] who pointed out that ‘there was variability, in terms of the context and/or time frames in which the various abilities and/or actions are believed to be important’ (p. 338). One example for the general population is the definition of health literacyterm·dom by Kickbusch, Wait, and Maag [ 40 ] as the ability to ‘make sound health decisions in the context of everyday life at home, in the community, at the workplace, in the health care system, the marketplace and the political arena’. Moreover, Sørensen et al. [ 41 ] point towards being able to ‘make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion’ (p. 13). Although both definitions state clearly the relevance of health literacyterm·dom in multiple contexts, including a broad range extending from rather technical/medical settings to ‘everyday life’, both fail to integrate the complex interrelatedness between the individual and the structures in which that individual is embedded. Similarly, Malloy-Weir et al. [ 12 ] critically assessed that Kickbusch et al.’s [ 40 ] definition ‘does not take into account contextual factors that may limit/prevent “sound health decisions”.’ Table 4 provides a summary of the main findings and aspects raised.

Summary of conceptual reflections regarding health literacyterm·dom antecedents and their contextual interrelatedness.

3.2.3. Subject of Interaction: Health Informationterm·key/Message Health informationterm·key, health messages, or health knowledge are placed at the core of most health literacyterm·dom definitions and models for childrenterm·key and young peopleterm·key. However, very few of them specify what type, form, or mode of information and messages they are referring to [ 11 ]. Two dimensions surface with regards to health informationterm·key: (a) how is ‘health informationterm·key’ defined, and (b) what are its characteristics or nature with regards to how individuals interact with different modes and formats of information.

Regarding the terminology, Borzekowski [ 8 ], while not defining the term ‘health informationterm·key’, provides case examples on topic-specific health informationterm·key and highlights the multimodal nature of health informationterm·key by stating that it can come from ‘a variety of sources’. Nutbeam [ 42 ] focuses on ‘information’ or ‘messages’ related to ‘different forms of communication’ including the communication content and method. Paakkari and Paakkari [ 2 ] refer to knowledge and competencies as a resource and ‘input’ as a central subject within health literacyterm·dom.

Next, ‘health informationterm·key’ as it is commonly used within health literacyterm·dom conceptsterm and definitions, incorporates the notion of being evidence-based, scientifically proven, or expert advice; hence, strongly implying some kind of ‘objectivity’. In other words, this evidence-based, fact-oriented perspective suggests that there is a ‘right’ way to interpret a piece of information and that this information is useful for further decision-making and actions. Not only is this perspective with its underlying assumption highly problematic, it also does not fit childrenterm·key’s and young persons’ everyday life realities: most childrenterm·key and young peopleterm·key report accessing health informationterm·key through (a) their parents or other close adults who are typically lay persons, (b) the Internet, or (c) their peers [ 43 , 44 ]. Young peopleterm·key report using websites and video platforms such as YouTube as information sources for lifestyle and health-related topics such as food, sports, personal hygiene, and beauty [ 32 ]. Because much digital information is provided by private persons or companies with a direct or indirect commercial interest, it is crucial that the childrenterm·key and young peopleterm·key who access them are able to understand and critically analyse the information’s content, its potential purpose, and its intention. With regards to food-related health informationterm·key, Fairbrother et al. [ 1 ] discovered that 9- to 10-year-old school childrenterm·key often access or receive diverse, sometimes contrasting, or even conflicting information through their parents, teachers and, less frequently, health professionals. Next, this underlying assumption on expert knowledge as being evidence-based ignores the complexity of many health topics and the tremendous importance of the source, format, and communication channel.

When zooming in on the characteristics of health informationterm·key, a piece of information content may be packaged in different ‘modes’: textual, oral, aural, numeric, pictorial, or symbolic. Literacy and communication researchers have argued that information and messages are packaged in or composed of multiple, different modes. They call this multimodalityterm·dom and describe it as ‘the normal state of human communication’ [ 45 ]. In other words, health informationterm·key is not neutral content; it is loaded with power, because there is always a communication or interaction taking place when encountering or dealing with a piece of health informationterm·key.

When it comes to elementary school childrenterm·key, oral and visual modes of conveying information seem to resonate more than written text [ 1 ]. For complex digital environments, Grossen and Nürnberger found that childrenterm·key’s success in seeking information online depends strongly on whether it is presented in ways tailored to their target group, such as using many pictures [ 46 ]. Because prominent social media channels, including YouTube, Facebook, and Twitter all have multimodal designs, such as combinations of text-based, visual, and audio modes, young persons need to familiarize themselves with multimodal (health) information instead of learning how to use single modes such as information from print-based media [ 33 ].

These examples highlight the ambiguity in the terminology of ‘health informationterm·key’, even though most health literacyterm·dom definitions and models for childrenterm·key and young peopleterm·key place such terminology at the core of health literacyterm·dom. Hence, what is meant or referred to by these terms within health literacyterm·dom definitions and models remains largely unclear and unspecified. Table 5 provides a summary of the main findings and aspects raised.

Summary of conceptual reflections regarding ‘health informationterm·key’ within health literacyterm·dom.

3.2.4. Purpose and Expected Outcome Many models and definitions of childrenterm·key’s and young peopleterm·key’s health literacyterm·dom follow a sequential design by illustrating an effect relationship between personal skills, health informationterm·key, and the ability to use both for health decision-making and health itself [ 11 , 41 ]. Due to the strong emphasis on cognitive abilities—often highlighted as ‘functional’ health literacyterm·dom skills e.g., [ 42 ] or information-processing skills—it is suggested that childrenterm·key and young peopleterm·key participate both rationally and actively in their health and health-related decision-making. Moreover, some regard health literacyterm·dom as a social determinant of health itself, and have postulated that promoting health literacyterm·dom could help to reduce health inequalities [ 3 ]. Up to now, however, there is still no consistent evidence base to support these assumed effect relationships. Moreover, these assumptions fail to give adequate consideration to the complexity and broader sets of factors affecting behaviour and behavioural change: the interdependencies between the subject and her or his social and life contexts and cultural factors, as well as affective and emotional aspects such as self-efficacy, self-determination, habits, and belief systems [ 11 , 12 ].

In addition, it is assumed in the literature that health informationterm·key and health literacyterm·dom abilities are per se relevant and useful for promoting one’s own health. This would imply that having access to information and abilities will lead to better decision-making. However, what is understood as ‘better decision-making’ and ‘actions for promoting one’s health’ is determined decisively by health experts and in terms of societal norms regarding ‘what is healthy’. Hence, such a line of argumentation falls in line with historical perspectives on functional literacyterm·dom [ 47 ] in which the purpose of literacy is to be able to fulfil and succeed in the function or role an individual holds in society, such as accomplishing one’s work-related tasks and responsibilities as a citizen (e.g., voting, organizing one’s financial affairs). Within this historical perspective, functional literacyterm·dom has been defined mainly by economic and employment contexts and the requirements these impose on the individual [ 47 ]. Such a perspective that emphasizes the role of the individual as a rational actor and aims for compliance with and fulfilment of prescribed societal demands conflicts strongly with other outcomes of health literacyterm·dom for childrenterm·key and young peopleterm·key such as personal and social empowerment, participation, and equity. Moreover, this implication ignores the vast evidence surrounding the complexity of individual decision-making and behavioural change. Table 6 provides a summary of the main findings and aspects raised.

Summary of conceptual reflections regarding the purpose and expected outcomes of health literacyterm·dom.

3.2.5. Target-Group Characteristics Childrenterm·key’s and young peopleterm·key’s characteristics and life stage considerations were lacking in half of the models and definitions assessed by BröderpersName et al. [ 11 ]. Moreover, when they were considered, these explorations and recognition of the characteristics remained on a very broad level, decisively incorporating an ‘external’, adult view on the target group’s situation and the relevance of health literacyterm·dom for them.

Recent approaches that consider developmental factors in childrenterm·key’s and young peoplesterm·key’ health literacyterm·dom can generally be characterized as being based on successive stages that build upon each other e.g., [ 8 , 9 ]. The focus is especially on cognitive development aspects, namely ones focusing mainly on Piaget’s model of cognitive development [ 48 ] that distinguish between specific age-related stages of development in the skills and competencies childrenterm·key should be able to master and employ at a certain age. Borzekowski [ 8 ] and Sanders et al. [ 9 ] conceptualize health literacyterm·dom within four skill areas (prose/document literacy, oral literacy, numeracy, and system-navigation skills), providing examples of activities for each development stage. Similarly, the US National Health Education Standards (NHESterm) [ 49 ] provide an extensive classification of the health literacyterm·dom skills that students attending a certain school grade should achieve and that can be used to test them. Some researchers address target-group perspectives from a sociological perspective, proposing a health literacyterm·dom socialization model [ 39 ] or highlighting contextual influences within a socio-ecological model of health literacyterm·dom for adolescents [ 50 ].

Besides focusing on childrenterm·key’s or young peopleterm·key’s health literacyterm·dom as an individual attribute, many studies have also addressed the health literacyterm·dom of persons close to the child such as caregivers, mothers, parents, and teachers (see [ 51 ]). Because these persons are certainly important contributors to childrenterm·key’s or young peopleterm·key’s health and health literacyterm·dom, researchers have proposed that child and adolescent health literacyterm·dom should be regarded as the productterm·dom of both individual health literacyterm·dom skills and the skills or resources available in the proximal social context—namely, the adults, peers, or institutions that young peopleterm·key trust. Among others, this is referred to as ‘collective’ [ 9 ] or ‘distributed’ [ 52 ] health literacyterm·dom. This would entail not looking at an individual’s competencies and skills but at (a) the sum of health literacyterm·dom resources available within this proximal social context, and (b) how these resources are then applied and used by whom within such a social entity in a specific situation—given the present power dynamics, layers of autonomy, and decision-making habits and cultures (for further information, see [ 21 , 53 ]). Mostly, and above all, this includes encouraging childrenterm·key and young peopleterm·key to express their views and ideas and to participate actively. Moreover, childrenterm·key from a young age onwards are to some extent already involved in their own self-care. In practice, however, manifest power relationships, time constraints, or other barriers lead to childrenterm·key being excluded from active participation; for instance, Coyne et al. [ 54 ] observed that while many childrenterm·key in Irish clinical care settings expressed a strong motivation to participate in health decision-making, a large proportion of them felt that they actually were not included. Hence, from a childrenterm·key’s rights perspective, we find it crucial to promote rights to participate while taking into account their right for protection and care [ 18 ]. Table 7 provides a summary of the main findings and aspects raised.

Summary of conceptual reflections on health literacyterm·dom and target-group characteristics.

3.3. Proposing and Discussing a Differentiated Understanding of Health Literacyterm·dom The results of the conceptual analysisterm·key and the exploration of target-group characteristics in the 6-D modelterm·key can be used to conclude that there is a need for a differentiated conceptterm of childrenterm·key’s and young peopleterm·key’s health literacyterm·dom that is better tailored to their specific characteristics. Moreover, the challenges identified above also need to be addressed—or at least reflected—in the differentiated conceptterm. This section describes an approach designed to advance the available health literacyterm·dom understanding by proposing a target-group-centredterm·key health literacyterm·dom definition for childrenterm·key and young peopleterm·key: Health literacyterm·dom of childrenterm·key and young peopleterm·key starts early in life and can be defined as a social and relational construct. It encompasses how health-related, multimodal information from various sources is accessed, understood, appraised, and communicated and used to inform decision-making in different situations in health (care) settings and contexts of everyday life, while taking into account social, cognitive, and legal dependence.

As such, health literacyterm·dom is observable in childrenterm·key’s and young peopleterm·key’s interaction and practices with health-related information, knowledge, messages in a given environment (so called ‘health literacyterm·dom events or interactions’), while encountering and being promoted or hindered by social structures (in micro, meso, and macro contexts), power relationships, and societal demands.

This definition recognizes health literacyterm·dom as a combination of complex processes related to how childrenterm·key and young peopleterm·key seek and interact with health-related information in different contexts in their daily lives. These processes are becoming increasingly important in a society that depends on digital communication. Moreover, it encompasses a public health and health promotion perspective on health literacyterm·dom by explicitly stating the conceptterm’s relevance in different situations in everyday life and health (care) settings. It integrates characteristics of the respective target groups, recognizing not only childrenterm·key and young peopleterm·key as social beings in their own right but also the need to achieve a balance between their participation needs and their protection needs.

The relatedness and contextual embeddedness of health literacyterm·dom is placed at the core of this definition by recognizing individual and distributed resources within given structures. In addition, socio-ecological factorsterm, especially those underlying social practicesterm·dom and the persistence of habitual mechanisms, as well as the entanglement with the milieu-specific conditions of social background are considered to be factors exerting a strong influence on health literacyterm·dom in childhood and youth.

On the outcome and impact level, it is assumed that health literacyterm·dom leads to being engaged with personal and social health (decision-making) and that it has a high capacity to determine the development of skills relating to the management of one’s own health. Therefore, health literacyterm·dom may also be considered as a variable for influencing health over the life course.

The proposed target-group-centredterm·key health literacyterm·dom definition integrates three conceptual dimensions that are interrelated but need to be operationalized independently: 1. Individual Health Literacy Assetsterm·dom: namely, the personal cognitive and habitual characteristics/attributes including the child’s independent knowledge along with abilities such as the ability to change, belief systems, cultural norms, and motivations.

2. Social Health Literacy Assetsterm·dom: namely, the social and cultural resources one can access via present social support structures in the close social environment (family/peer/community context). This also points to the importance of the health literacyterm·dom available to individuals and groups within their social environment and that, as such, is also part of the childrenterm·key’s health literacyterm·dom.

3. Situational Attributesterm of an Occasion in which Health Literacyterm·dom is Relevant: namely, characteristics and demands of a given environment in which health literacyterm·dom interactions—specifically the interaction with information or the health care setting—take place and that promote or hinder childrenterm·key in making use of individual and social health literacy assetsterm·dom. This, in turn, influences their agency and their real opportunitiesterm to practise and engage in health literacyterm·dom interactions in their everyday lives.

4. Discussion This article aimed to examine, reflect on, and clarify a conceptual understanding of health literacyterm·dom in childrenterm·key and young peopleterm·key from various interdisciplinary perspectives by asking what are the distinctive components of a child-centred health literacyterm·dom understanding. Based on the available literature, we have argued that within health literacyterm·dom research, perspectives on childhood and youth are influenced decisively by adult or expert perspectives, while, at the same time, largely ignoring target-group-specific characteristics (as pointed out in the 6-D modelterm·key). Hence, developing a differentiated understanding of childrenterm·key’s and young peopleterm·key’s health literacyterm·dom requires us to move beyond perceiving them from an adult perspective that claims to act in their best interest. The results of the conceptual analysisterm·key were then used to develop a differentiated, target-group-centredterm·key definition. The proposed definition will now need to be discussed further, and its validation and applicability will need to be tested in different cultural contexts—within and across countries—as well as in distinct health-related settings. Nonetheless, four implications can be deduced from the present definition and conceptual analysisterm·key. These can serve as guiding principles for future health literacyterm·dom research and practice: 4.1. Characterizing Health Literacyterm·dom from an Asset-Based Perspective Nutbeam [ 42 ] has pointed out that health literacyterm·dom can be an asset for one’s personal health. However, an asset-based approachterm·dom e.g., [ 55 ] to health literacyterm·dom goes beyond this perspective. It entails recognizing any factor (or resource) that enables or enhances the health literacyterm·dom of individuals or groups. Hence, the asset-based perspective shifts from a deficit focus looking at problems and needs towards a resource-oriented perspective on health and well-being. It does this by emphasizing the strengths and capabilities of an individual or a community [ 56 ]. Therefore, an asset-based perspective includes exploring and identifying a person’s or community’s practices for accessing, understanding, appraising and applying information relevant for their health instead of predefining the necessary skills. What personal strategies and resources do childrenterm·key and young peopleterm·key possess for dealing with health informationterm·key and messages? What contextual conditions are necessary to promote their abilities to do so, and what strategies are known to promote these assets? What assets related to health literacyterm·dom are located within the individual, the immediate, direct surroundings/community, the broader community, or the distant context? These are crucial questions when applying an asset-based health literacyterm·dom approach.

4.2. Considering Health Literacyterm·dom as Being Socially Embedded and Distributed on Individual, Family, and Social Levels Although health literacyterm·dom has been regarded as a productterm·dom of inherent personal skills and contextual demands [ 3 ], we have illustrated the need for a nuanced recognition of its complex contextual interdependencies. This entails considering a three-fold relational conceptterm: (a) individual attributes, (b) social or contextual attributes, and (c) the situational attributesterm and characteristics when health literacyterm·dom practices occur. Therefore, we regard health literacyterm·dom not as a productterm·dom (what?) but as a process and social practiceterm·dom (how?) of engaging with one’s health by seeking, dealing with, and using information for health-related decision-making. Moreover, we consider health literacyterm·dom as being socially embedded, because the situational attributesterm and the demands imposed upon the individual by given cultural and social structures strongly influence that individual’s real opportunitiesterm to practise health literacyterm·dom in a specific situation. These opportunities depend decisively on whether health literacyterm·dom assets are available, accessible, and relevant to the individual when needed. Childrenterm·key’s and young peopleterm·key’s opportunities for being health literate are strongly influenced by the characteristics of intergenerational relationships, as well as the social roles attributed to them by adults, peers, and society within everyday interactions such as those between teachers and students or between doctors and child patients. Within such intergenerational negotiations, childrenterm·key and young peopleterm·key’s social status is consolidated or challenged. Being aware of these, sometimes implicit, intergenerational processes is key to understanding how childrenterm·key and young peopleterm·key are perceived, and which difficulties and opportunities they face when practising health literacyterm·dom and actively promoting their health and well-being [ 14 ]. A nuanced milieu perspective on the childrenterm·key’s family milieu and their social and cultural capital can help to understand how personal health literacyterm·dom is acquired and practised within the given social structures and mechanisms [ 13 ]. With regard to immigrant adolescents’ health literacyterm·dom, Santos et al. [ 57 ] have proposed a similar focus, namely to view health literacyterm·dom as a socially situated practice, using a bike-riding metaphor: Bike-riding requires the coordination of many working parts (gears, brakes, handle bars, and pedals). Each part has a unique purpose, but their contributions have little meaning apart from the whole. Similarly, we view an immigrant adolescent’s process of becoming ‘health literate’ as an evolving coordination of many working parts (e.g., reading skills, math skills, form-filling skills, linguistic choices, digital tools, or interactions that involve any of these skills and tools). The significance of these parts cannot be accurately understood when apart from the social, cultural, and historical context in which immigrant childrenterm·key are growing up.

([ 57 ] page 4) 4.3. Recognizing that Health Literacyterm·dom Starts Early in Life and Develops in Flexible Ways Many researchers have stressed the conceptterm’s relevance for all ages and life phases, and they link health literacyterm·dom to lifelong learning e.g., [ 41 ]. This is especially valid, because the amount of available information increases significantly with age and the complex (digital) information landscape is changing rapidly. It requires a certain agility in individuals and communities to adapt to changing demands. Whereas some personal abilities, experiences, and community capacities may be transferable and adaptive to new situations and circumstances, some are highly contextual and culture-dependent, making them difficult to transfer. Some may even be lost over time. This requires a person to adopt and learn new knowledge, resources, and skills throughout the life course. Therefore, we propose considering health literacyterm·dom as a multifaceted socio-cultural learning process (and not a purely cognitive one), because it is built up through personal experiences and interactions within a given environment. Whereas developmental stages may offer a reference point, they should not be seen as nominal categories for classification and evaluation. In other words, predefining skill categories for different age stages may offer a guiding orientation for what health literacyterm·dom skills a child may possess at a certain age, but this approach needs to be complemented with a differentiated, child-centred picture [ 14 ]. Childrenterm·key and young peopleterm·key are beings in their own right with individualized developmental histories and portfolios. Next, when deriving health literacyterm·dom profiles and levels, these should be adaptable to constantly changing personalities and reflect increasing maturity and autonomy processes as well as changing cognitive and social skill levels and social-ecological conditions [ 14 ].

4.4. Considering that Health-Related Information is Multimodal, Complex, and Power-Loaded By using the term ‘health-related’ information, we aim to stress that alongside evidence-based sources, information is received and retrieved from various, often informal, sources, including lay persons whom one trusts or even one’s own embodied experiences [ 43 ]. On the most basic level, the latter include a person’s own embodied messages about themselves, their bodies, and their minds as well as their place and role in a health context or situation. Hence, information may be highly subjective, controversial, and complex. When encountering a piece of information, meaning-making processes confirm, integrate, or reject it depending on whether it conflicts with or confirms a person’s values, attitudes, and belief systems [ 1 ]. In addition, it is crucial to recognize the multimodalityterm·dom of health-related information or messages, that information is power-leaded, and that there is always some sort of communication or interaction with this information [ 45 ]. Moreover, there are textual, oral, aural, numeric, pictorial, or symbolic modes of packaging a piece of content. Digital or media information, in particular, is composed of several modes (multimodal) such as visual, aural, or linguistic elements [ 45 ]. Because literacy practices are multimodal by their very nature, this requires the individual or group to be able to compensate for a lack of certain skills by drawing on other personal or social assets in innovative and creative ways and thus even to overcome limiting structural conditions [ 47 ]. At the same time, these are examples of culture- and context-dependent skills: a person who is able to read and write in one language is frequently not able to read and write in another language. Therefore, there is a need to distinguish between culturally independent and culturally dependent modes of interacting and communicating health-related information.

5. Conclusions The primary aim of this article has been to raise awareness for not only the heterogeneity of the current conceptual debate on health literacyterm·dom, but also the gaps and shortfalls in adequately representing target-group characteristics. The proposed child-centred health literacyterm·dom understanding takes a sociological view on childhood and youth. This approach emphasizes how childrenterm·key and young peopleterm·key access health-related information, derive meaning from this information, and engage in health-related decision-making processes while being embedded within complex social contexts. Whether the proposed definition and conceptual understanding prove feasible to guide future health literacyterm·dom research as well as actions to promote health literacyterm·dom in childhood and youth remains an open question and calls for further research. This will include the analytical testing, operationalization, and practical evaluation of the definition and the guiding principles described here.

Acknowledgments The authors thank Patricia Wahl and Alexandra Fretian for their comments on the manuscript and Kristine Sørensen and Diane Levin-Zamir for their critical reflections.

Author Contributions U.B. and P.P. supervised the research; J.B. led the research process, conducted the conceptual analysisterm·key, and carried out the critical reflections on the conceptterm. O.O., T.M.B., P.P., D.B., and U.B. supported and discussed the conceptual analysisterm·key and J.B., O.O., U.B., and P.P. developed the 6-D modelterm·key. All authors contributed to the development of the definition and conceptual dimensions. J.B. and U.B. prepared the manuscript that was then critically reviewed and revised by T.M.B., O.O., D.B., and P.P. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding This work has been prepared within the framework of the Health Literacyterm·dom in Childhood and Adolescence (HLCA) Consortium ( www.hlca-consortium.com ) funded by the German Federal Ministry of Education and Research (BMBF; Grant No: 01EL1424A). We further acknowledge support with the publication fee/open access charge from the Deutsche Forschungsgemeinschaft (DFG) and the Open Access Publication Funds of Bielefeld University. None of the funding entities were involved in any way in the design of the study or in the collection, analysis, and interpretation of data and in writing the manuscript.

Conflicts of Interest The authors are members and scientific advisors of the German Health Literacyterm·dom in Childhood and Adolescence (HLCA) consortium and declare no conflict of interest.

References