Health literacy in the context of child health promotion: a scoping review of conceptualizations and descriptions | BMC Public Health

Figure 1 presents the flow chart of the search and selection process. The literature search generated a total of 9,302 references out of which 26 publications were eligible for inclusion. In spite of the search including specific contexts, we had to exclude some publications based on domains and settings which did not match the health promotion context. The focus of this scoping review is on how dimensions of general HL within health promotion in children are described. A review of the related HL constructs focused on specific areas will be described elsewhere.

Flowchart of the search and selection procedure of publications

Study characteristics

Table 2 presents the characteristics of the included publications. Publication dates ranged from 2000 to 2022, with the majority (n = 17) published after 2012. Five publications were grey literature such as government reports (n = 2) and educational program designs (n = 3). Other scientific publications reported on randomized controlled trials (n = 2), literature reviews (n = 2), development (n = 3) and validations studies (n = 2) for measurement instruments, cross sectional studies (n = 6), educational program (n = 3) evaluation studies (n = 3) and qualitative studies (n = 3). The age range of participants in the sampled studies was 5–15 years old.

To analyze the HL descriptions, publications were grouped based on setting: School, After school and Public setting.

In nine publications, a measurement instrument was developed and/or evaluated. Most instruments were adapted from existing instruments for adults. However, one instrument was newly developed for children by Franze et al. [37].

The use of definitions and skills

Deductive analysis showed that the descriptions of HL were conceptualized as competencies, learning outcomes and skills. Figure 2 presents the distribution of all code groups, as well as how often codes from that group were grounded within the included literature. The competencies definition, based on Sørensen et al. [1] was dominant, occurring in a total of 222 quotations across all publications. Additionally, many descriptions were related to the learning outcomes definition from Paakkari et al. [16]. All included publications indicated HL skills, as described by Nutbeam et al. [15]. With ‘knowledge’ and ‘comprehension’ for cognitive skills and ‘critically analyzing information’ and ‘use/apply information’ for critical skills being dominant. In some educational oriented publications, descriptions from both HL definitions [1, 16] were found [24, 31,32,33,34, 44,45,46, 49, 50]. The cognitive skill ‘knowledge’ was frequently described, closely followed by the competency ‘understanding’. This was reflected by the occurrence of descriptions on the skills ‘comprehension’ and ‘derive meaning’, as well as ‘critical thinking’ for learning outcomes.

Sankey diagram presenting the distribution of code groups with imbedded codes (in legenda) based on competencies definition (orange), learning outcome definition (green), HL skills (blue) for all publications towards the left, and per setting towards the right. The numbers in the figure indicate the total number of quotations coded in the code group

Nine codes emerged through open coding. Kostenius and colleagues [44] described ‘caring and confirming’ and ‘engaging and empowering’ as important. Three new codes were found in the South Dakota Education Standards [49]: ‘problem solving’, ‘goal setting’, and ‘stress management’. ‘Motivation’ [28, 38], ‘recognition’, ‘help-seeking behavior’, and ‘satisfaction’ [28] could also not be related to the predefined definitions or skills.

HL definitions and skills in measurement instruments

We found nine studies which developed or validated an HL measurement instrument for children. Five instruments were developed or validated after the latest reviews on instruments from 2018 [17, 51] namely: Taiwanese Children’s Health Literacy (TCHL) [46], Newest Vital Sign (NVS) adaptation [26], Health literacy Survey-Child Questionnaire 15 in German and Dutch (HLS-Child_Q15-DE and HLS-Child-Q15-NL) [29, 30, 38, 40], and Health Literacy for School-Aged Children (HLSAC) in German [34]. We also found the GeKoKidS (GesundheitsKomptenzKids) instrument [37] which was included in the review by Okan et al. [51] in the study by Schmidt [48], however we found GeKoKids through the study by Franze et al. [37]. Most instruments found their origin in validated instruments for older populations, contexts, and settings outside health promotion context. The competencies definition was used most often, indicating an emphasis on understanding [26, 29, 30, 35, 37, 38, 40, 46]. Two instruments, namely TCHL and HLSAC, could be linked to HL as learning outcomes [34, 46]. In the study by Diamond et al., [35] the preferences of teens could be linked to the learning outcome definition but did not match align with the original instrument for that definition. In all instruments we found descriptions of ‘cognitive’ and ‘critical skills’ most frequently.

Settings in which HL is described

The school setting was the most prevalent setting with an almost equal distribution of descriptions related to the learning outcome definition as to the competency definition (Fig. 2). Within the school setting, HL skills were mostly focused on learning ‘cognitive’ and ‘“critical skills’ while ‘functional skills’ were rarely mentioned in all settings. The descriptions of learning outcomes varied from activities for learning or play to actual learning outcomes for educational programs. Far less descriptions were described in the afterschool, daily life, and public health settings.

Terms to describe HL

The top five terms found in all publications were Health, Information, Can, Understand and Ability. The diversity of terms used to describe HL dimensions confirmed the need for a concept analysis on the descriptions of HL in the included literature to gain insight into how topics were described in more detail.

Frequently used topics

Health was the most frequently occurring topic in all descriptions, as “health information”, “health issues”, “your health” and “personal health”. Information was second, however, in the codes ‘self-awareness’, ‘citizenship’, ‘functional skills’ and ‘interactive skills’ information was not in the top five topics. Information was described as “health information” and “good/valid information”.

For the competencies definition, most frequently found topics were Service (26), Products (22), Development (17), Food (17) and Skill (15). The learning outcomes had more diverse topics: Community (30), Services (18), Family (17), Products (17), Disease (13) and Development (13). Functional skills, such as ‘reading’ and ‘numeracy’, were only assessed using the NVS tool, in which children read an ice-cream label [36, 42]. ‘Cognitive’” and ‘critical skills’” had the most diverse topics which were well-grounded in the literature. The top 5 topics for ‘cognitive’, ‘interactive’, and ‘critical skills’ were Development (20), Life (20), Service (20), Product (18) and Community (18). All topics per code with corresponding noun phrases are presented in Appendix G.

Co-occurence of HL dimensions within the descriptions of HL

The complexity of the construct was reflected in the co-occurrence of codes within the descriptions of HL with links to multiple HL dimensions. Figure 3 represents the co-occurance of codes, and the thicker arrow lines in this figure represent more co-occurences. A description with quotations is provided for the most common co-occurences.

Network of co-occurrences between HL dimensions found in the descriptions of HL. The arrows vary in thickness to indicate whether the co-occurrence was found often (over 20 times) or very often (over 35 times)

Understanding, theoretical knowledge, knowledge, comprehension and derive meaning

The co-occurrences between ‘understanding’ and ‘knowledge’ described what children need to understand or referred to the specific knowledge children need to elaborate on in order to evaluate their understanding of the specific knowledge. For example, in Liao et al. [45] describe the need for “[b]asic health knowledge and skills that can be used to take health-related actions.” (p. 74) in 11 reference abilities (p.77).

‘Understanding’ and ‘derive meaning’ referred to the processing of information. In Bhagat et al. [26], they ask about the difficulty of a HL related task: “Is it easy or hard to understand the health information you get from (fill in each source)? What makes is hard or easy to understand?” (p.3).

‘Understanding’ and ‘theoretical knowledge’ was found as a description of an objective instruction with assessment criteria by Paakkari & Paakkari [47]. “Pupils should be able to describe life course stages and to explain key characteristics of growth and development in puberty, plus individual variations” (p. 528).

‘Knowledge’ and ‘comprehension’ often co-occurred where ‘knowledge’ indicated what children know about health topics whereas ‘comprehension’ indicated an understanding of what children can do in certain situations. An example was found in scenario eight by Liu et al. [46] “Can wearing a mask prevent you from getting sick? What is your understanding of sanitary masks? Learning outcome: Can understand the influence of lifestyle on disease” (p.39).

The co-occurrence of ‘comprehension’ and ‘derive meaning’ was found in Boberova [27] describing the following criteria students should consider: “How is your notion of health different from your schoolmates’ view? What is and makes it different (similar) [and why?]” (p.475).

Appraising, critical thinking, derive meaning and analyzing information critically

Examples of ‘appraising’ and ‘critical thinking’ were found in De Buhr et al., [34]. For instance, the following items from the instrument De Buhr et al. used for children illustrate how critical thinking is necessary to judge and/or compare health information: “Ability to compare health-related Information from different sources; Ability to decide if health-related information is right or wrong.” (p.6).

‘Appraising’ and ‘derive meaning’ were found in quotations from Bollweg [29]. They asked children to indicate how difficult it is for them to: “Judge what helps a lot for you to stay healthy and what does not help much?” (p. e127).

An example of ‘critical thinking’ and ‘analyzing information critically’ were found in Brey [31], in the following learning outcome: “Identify at least 3 reasons a health agency, organization, or institution would be considered a credible source of health information, services, or products.” (p.641).

‘Derive meaning’ and ‘analyzing information critically’ was found as a well-grounded co-occurrence with an example in Franze [37], describing what we could ask children about prevention on starting smoking. Two examples from the measure are: “How do children learn about the health-related consequences of tobacco-smoking?” and “How do they evaluate these consequences?” (p.341).

Applying, practical knowledge, communication, analyzing information critically, Use/apply information and decision making

The co-occurrence of ‘applying information’ and ‘practical knowledge’, when children have been ‘analyzing information critically’ and ‘deciding’ it is appropriate to use was found in learning outcomes in the Health Framework for California Public Schools [33]; “Students will understand and demonstrate behaviors that prevent disease and speed recovery from illness.” (p.68) and the South Dakota Health Education Standard [49]; “Explain ways to achieve and maintain good health; determine personal health progress and make adjustments for improvement.” (p.36).

The relationship between ‘communication’ and ‘use/apply information’ was found in assessment criteria by Paakkari & Paakkari [47] for grade 4–6: “Pupils should be able to describe practices related to…practices for expressing and regulating emotions, and for applying them in different roles” (p.528). In Liu et al. [46] the authors described short scenarios with a follow-up question in which students can demonstrate their skills: “[students] can understand and respond to other people in interpersonal interactions and can express proper rejection skills in health-related life situations” (p.38).