PEDIATRICS Vol. 124 Supplement November 2009, pp. S282-S288 (doi:10.1542/peds.2009-1162D)
SUPPLEMENT ARTICLE |
Considering Children and Health Literacy: A Theoretical Approach
Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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ABSTRACT |
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 TOP ABSTRACT THE DEFINITION AND MEANING...CHILDREN'S HEALTH AND...CHILD DEVELOPMENTCHILDREN AND HEALTH LITERACYCONCLUSIONSREFERENCES |
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The theoretical approaches of Paulo Freire, Jean Piaget, and Lev Vygotsky frame the consideration of children and health literacy. This article includes a general discussion of literacy from the Freirian perspective. A definition of health literacy is then presented; first, the established meaning is introduced, but then a Freirian extension is proposed. Next, the theories of cognitive development by Piaget and Vygotsky are discussed, and examples related to children's health literacy are given. Finally, there is a discussion of why it is important to encourage and enable health literacy among children and adolescents.
Key Words: Freire • Piaget • Vygotsky • health literacy • children
Abbreviations: ZPD—zone of proximal development
An influential educational theorist and Brazilian educator, Paulo Freire discussed and wrote about literacy. He felt that the attainment of literacy was inextricably linked to personal, social, and political liberation. Becoming literate occurred within the specific lives and culture of the people attaining literacy. The true purpose of education and literacy, according to Freire, was to liberate people so that they could achieve their full potential.1
As background, Freire believed that many of the world's inequities were perpetuated by existing educational systems. Such systems withheld the tools that would allow certain groups to attain power. For example, the ways that some societies conceived of and taught literacy kept people, especially those from more marginalized groups, politically powerless. Offering only rote learning and discouraging critical thinking skills helped to immobilize large population groups. Sociopolitical power would remain in the hands of the few when vulnerable peoples could not obtain the tools to challenge inadequate literacy education.
In a Freirian literacy program, the teacher and student develop through the act of dialogue and reflection. The teacher does not hold a superior position, nor does the student accept a passive role. A successful interaction involves the teacher developing an awareness of the learner's world. The student increases the inherent control over his or her life by taking control in the educational environment. Teachers and students engage in a mutually beneficial relationship—a partnership.
Literacy, according to Freire, is more than the learning of text. One is literate when he or she can "read the word as well as the world."2 People achieve higher literacy levels when they can critically decipher obstacles (which Freire terms "limit situations") in their personal and social lives. Consciousness of these situations, regardless of whether reading or writing is involved, can be a tool toward gaining personal freedom.1 Individuals who may be unfamiliar with text or writing can be extremely literate in the environments they inhabit but also cultivate.2 For example, in an agrarian community, a woman who cannot read or write text may be an expert with various plant species and social types. She might be able to "read" the resource to increase production in a range of situations.
A Freirian educational process results in personal and social transformation. Education and literacy allow students to clarify goals and desires and recognize how they can bring about these changes. This occurs when students not only read the world and word but also write the word and the world.2 A personal level of ownership and empowerment can stimulate changes on a public level.
Freirian thought provides an interesting lens through which to think about health literacy in general and its development among children and adolescents more specifically. Similar to educational systems that perpetuate unequal power relationships, one could assert that certain medical environments are responsible for keeping groups powerless. The absence of problem-solving skills related to health literacy renders people, especially vulnerable groups such as children, unable to improve their health on their own. Furthermore, the relationship that Freire describes between the teacher and the student might be comparable to the relationship between the health provider and the patient. A partnership would facilitate a young child to have more control over his or her own health and behaviors. Lastly, a broader definition of health literacy may be necessary. Although a child or adolescent may be unable to read and define medical texts, that same person might understand healthy behaviors or medical management in his or her home environment and actively participate in decision-making regarding his or her own health care. In fact, the child or adolescent may be more skilled at "reading the world" to determine the best path toward healthy behaviors than the medical provider. Freirian philosophy suggests that we address a broader meaning of health literacy and attempt to understand how children and adolescents may achieve it.
The rest of this article is organized in the following way. First, we present a traditional definition of health literacy, and then we describe how Freirian philosophy can extend our thinking about health literacy. Next, we offer a brief description of Jean Piaget's and Lev Vygotsky's theories on child development. Finally, we discuss how Piagetian, Vygotskian, and Freirian thought contribute to emerging health literacy.
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THE DEFINITION AND MEANING OF HEALTH LITERACY |
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TOPABSTRACTTHE DEFINITION AND MEANING...CHILDREN'S HEALTH AND...CHILD DEVELOPMENTCHILDREN AND HEALTH LITERACYCONCLUSIONSREFERENCES |
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Various media and interpersonal channels convey important health messages. An individual's ability to receive, comprehend, integrate, and act on those messages makes up their level of health literacy. True health literacy requires understanding different message types and using the conveyed messages in appropriate ways. Such literacy can be extremely complex and varied. Consider the following 3 situations, all which involve individuals having higher functioning levels of health literacy.
A teenaged girl or young woman flips through a magazine and comes across an article that describes different birth-control options. She reads and flags them, with the intention of e-mailing her health provider and asking whether she can adopt any of these options. In this example, the young woman is exposed to messages and decides to follow-up with an electronic conversation with her physician.
A mother hears on the radio a recruitment advertisement for a research study on children's sleep habits. She goes to the study site and receives a packet of information. After reading the parental consent form, the mother realizes that her child might be at higher risk if he participates, because his current medication might interfere with the protocol. The mother refuses consent and does not allow her child to join the study.
A child wakes up in the middle of the night with a fever. Her father remembers that the family recently purchased some over-the-counter fever medication that is in the medicine cabinet. He reads the dosage-by-weight and age information on the label and determines that his 35-lb 3-year-old daughter needs just 1 teaspoon of the medicine. He administers it, and they both go back to sleep.
The Healthy People 2010 report defined health literacy as the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."3 Health literacy is not just the ability to read health text; rather, it is a set of skills that involves recognizing, processing, integrating, and acting on information from a variety of platforms. To be health literate, an individual must be able to develop functional, interactive, and interpretive skills. In addition, media-literacy skills seem essential, especially when we consider health literacy in today's media-rich environment.
Besides acquiring knowledge, health literacy includes interactive and critical health literacy.4 Interactive health literacy requires social skills that help individuals interact in health-promoting ways, whereas critical health literacy involves the ability to analyze and apply knowledge to function and be in more control.4
Community and societal factors affect health literacy. As an example, when it becomes necessary to include more information on over-the-counter medication instructions, from either governmental or population-wide demands, text becomes smaller, more dense, and harder to read. This, of course, affects health literacy. As another example, disease management now involves connecting with more subspecialists across facilities and institutions. Decision-making about care now requires an awareness and understanding of complex systems, including not only scheduling but also receiving and paying for services. From decreasing font size to increasing complexity of health systems, environmental factors can help or hinder access and use of health information.
Besides systemic issues, individual factors relate to and influence health literacy. Poor health literacy is strongly and significantly correlated to limited general literacy skills. Such deficits result from weak or lacking educational opportunities, suboptimal support for literacy within the family, and/or learning and cognitive disabilities. The elderly (aged 
65 years), minority populations, immigrant populations, low-income groups, and people with chronic mental and/or physical health conditions are considered to be at much higher risk for poor literacy.5
It is intriguing to think that children and adolescents were not mentioned when describing vulnerable groups. Although recommended initiatives to improve health literacy often include primary and secondary school teachers, nurses, and librarians, the populations with whom these professionals work are hardly ever mentioned.
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CHILDREN'S HEALTH AND DEVELOPMENT |
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Why do we care about children's health literacy? In the United States, there are
74 million children under the age of 18 (almost 25% of the national population).6 Reportedly, most US children are in very good or excellent health; however, 10% lack any health insurance coverage. Injury is the main cause of death for those aged 1 to 14 years, and chronic illnesses remain a problem for many.7 In a 2006 survey, 5% of children had reportedly missed 11 or more days of school in the previous year; this rate was twice as high for children in the lowest income bracket or from single-mother households.8 Currently, 16% of children and adolescents are overweight, and 34% are at risk of being overweight.9 Approximately 14% of US children have been diagnosed with asthma, and 9% to 12% suffer from different types of respiratory allergies.8 It is estimated that among children aged 3 to 17 years, 8% have a learning disability and 7% suffer from attention-deficit/hyperactivity disorder.8 |
CHILD DEVELOPMENT |
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Besides physical growth, childhood is a time of tremendous cognitive, social, and emotional development. Two 20th-century theorists—Piaget and Vygotsky—offered important observations and concepts to consider in our thinking of healthy child development.
Although other researchers and theorists have contributed to current thinking, it is Piaget's theories that form the foundation and much of our understanding of child development. Drawing on early interests in biology and philosophy, Piaget tried to answer a fundamental question: "How does knowledge evolve?"
Piagetian theory suggests that children move along a linear course of development; Table 1 summarizes the different stages.10 First is the sensorimotor period, which characterizes the time from birth through approximately the second birthday. Infants in this stage move from reflexive behaviors to habits. A 4-month-old may pick up a rattle and learn that shaking the object causes a sound. The child will recognize that a personal action results in a manipulative outcome. From the ages of 2 through 6 years, most children are in the preoperational period. During this stage, children's recognition of symbolic thinking emerges, mental reasoning grows, and the use of concepts increases. A 4-year-old child in this stage will recognize a "stop" sign and know that it means that mommy must stop the car when she sees it.
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The concrete-operation period follows, typically from the age of 7 through 11 years. This stage is characterized by the active and appropriate use of logic. Despite changes in situations, children learn to apply general and known rules in a consistent way. Children can take multiple aspects of a new environment into account, an ability known as "decentering." The child is no longer the center of the world and can consider that others have preferences and perspectives. In the next stage, the formal operational period, those aged 11 years and older develop the ability to think abstractly. Hypothetico-deductive resounding is used, in which individuals start with a general theory about what produces a particular outcome and then they deduce explanations for what has brought about that outcome.10
Central to Piagetian thought are 3 major developmental processes: assimilation, accommodation, and equilibration.10 Assimilation is the means by which children interpret incoming information to make it understandable within their existing stage of cognitive development and way of thinking. Accommodation refers to the ways in which children change their thinking in response to new experiences, stimuli, or events. Equilibration is a 3-stage process that integrates accommodation and assimilation. First, children are in a state of equilibrium. Then, failure to assimilate new information leads to their becoming aware of short-comings in their current thinking. Finally, their mental structure accommodates to incorporate the new information in a way that creates a more advanced equilibrium. These processes allow cognitive development and movement from 1 stage to the next to occur.
To further illustrate the Piagetian stages, it is interesting to consider how children of different ages might understand illness.11–13 A child younger than 2 years might know illness as something associated with feeling poorly. He or she may not be able to use the appropriate language to explain; however, his or her understanding and thoughts about being sick may be enough to evoke tears. Like the younger child, the preschool-aged child will associate illness with a vague emotion (eg, it makes you feel sad), but also this child may explain illness with physical appearance or observable action. For example, a 5-year-old girl might explain being sick as when you have "bumps" on your body or when you "throw up." A child in the next stage associates illness with particular behaviors and consequences. A 9-year-old may not be capable of describing why a child has a fever, but he or she would certainly be able to tell you that such a child has to stay in bed and cannot go to school for several days. Those who are slightly older and in the formal operational stage could hypothesize, on the basis of subtle clues, that certain environments might put someone at risk for illness. It is interesting to note that some recent research on children's understanding of health and illness provided evidence that comprehension may not be as limited as the Piagetian theory would suggest.12,13 For example, children younger than those in the formal operational stage can provide sophisticated and accurate descriptions of abstract processes (eg, what might occur if one did not brush his or her teeth).13
Although Piaget and other theorists formed a foundation for thinking about children's development, it was the Russian psychologist Vygotsky who broadened our thinking to include ideas about how social interactions and cultural factors could greatly affect a child's cognitive development.14 Children, in partnership with peers and adults, learn within established cultural and social institutions. Two concepts advanced by Vygotsky that pertain to the discussion of children and health literacy are the "zone of proximal development" (ZPD) and "scaffolding."
A child's abilities are more likely to increase if they are presented within the child's ZPD. The ZPD is defined as the difference between what a child can do with assistance and what a child can do on his or her own. Independently, a child may not comprehend something or be unable to perform a task, but with assistance or "scaffolding," he or she can master a new topic or skill. Across different cultures, scaffolding occurs in practically every successful learning situation.15 An optimal learning environment is one that challenges the child just at the edge of his or her current understanding. Peers and adults aide the child in gaining new knowledge, and in fact, these relationships promote faster and better comprehension. Vygotsky saw development as learning-specific and general tasks; such learning would always be more successful in social and cooperative settings.
"Dynamic assessment," proposed Vygotsky, should be used to measure one's intelligence and abilities. Instead of looking at cognitive processes that are fully developed, those that are being developed need to be considered. In practical terms, this means that one should not test children in isolation to measure what they know and can do; rather, a better assessment would take into consideration how they perform when helped by peers and adults. This has clear implications for children's health literacy and what and how we should communicate to them, as well as what role they should have in managing their own health and illness. In contrast to developmental surveillance, in which a child's actions are considered in isolation, the pediatrician should do a dynamic assessment—noting how a child adheres to his or her medical treatment with a parents' assistance—because this is how medical self-management would occur in the child's natural environment.
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CHILDREN AND HEALTH LITERACY |
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TOPABSTRACTTHE DEFINITION AND MEANING...CHILDREN'S HEALTH AND...CHILD DEVELOPMENTCHILDREN AND HEALTH LITERACYCONCLUSIONSREFERENCES |
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Given these notions of child development, at what age should an individual become responsible for his or her own health? When should an individual try to gain health-literacy skills? And how might one assess a child's level of health literacy?
Answers to these questions must start with how one perceives the relationship between the individual and medical system. Traditionally, it has been the physician who has defined the needs of the patient. It has been argued that that an "unbridgeable competence gap exists between physicians and lay people," and because this wealth of knowledge is impossible to share, patients must accept the word of the physician on faith.16,17 Others believe that established relationships and interactions persist to keep patients from challenging physicians' high status and societal standing, contesting medical conduct, second-guessing decisions, and even detecting medical errors.16 Parents and children would adhere to rather than challenge their pediatrician's advice and instructions.
We know that such medical paternalism is obsolete. Especially in today's world of patient- and family-centered care, physicians need and want individuals to be health literate. With new technology, more accessible health information, and the sometimes-transitory relationship between physicians and patients, the patient's understanding is fundamental for health. There is a growing movement among pediatricians and adolescent health specialists for improving the health literacy of their patients, encouraging even young children to become knowledgeable consumers of health information and environments.
Piaget and Vygotsky
If we expect the relationship between patients and health providers to be more balanced and we want children and adolescents to be more involved in their own health, then it is essential to develop health literacy skills at an early age. Piagetian and Vygotskian theories can inform when and how children can achieve certain levels of health literacy. Considering age-related developmental stages, even young children can recognize icons and images that convey health information. Those who are slightly older might be able to read and understand health recommendations printed on a Web site and incorporate these "rules" into their daily activities. Quite likely, a preadolescent could read a label on an over-the-counter medication, consider his or her age and weight, and measure the correct dosage. An adolescent might see a theatrical production about drug abuse, recognize the relevant themes, and realize that the lessons learned by the on-stage characters might inform his or her own engagement in risky behaviors. Vygotskian theory could suggest that social support, from family, friends, or health providers, might facilitate the learning of more difficult health concepts at a younger age. Early elementary school-aged children with diabetes might learn to monitor their own blood sugar levels if given assistance, even if they are at a cognitive stage that would suggest that they cannot "handle" the measurement activities. A diabetic preadolescent, if in a social cohort with other diabetics, might better understand the more abstract implications of his or her behaviors if slightly older peers helped to clarify the pertinent issues. When health concepts and behaviors are culturally relevant and part of the child's environment, a child may understand their importance at an earlier-than-expected age. To date, studies examining these approaches do not appear in the published literature; empirical evidence is needed to show that such approaches can lead to improved health behaviors in children.
It is important to be familiar with developmental stages when creating health materials and programs; however, boundaries should not be seen as barriers. Imagine designing a television program with the purpose of conveying useful injury-prevention information to a preschool-aged child. Through recognizable storylines, characters could encounter familiar and less familiar safety symbols (eg, cross-walk signs, poison symbols) in their neighborhoods. More advanced thought and understanding might be achieved if the producers recommend that children watch the program with their older siblings or parents or as part of a preschool experience. Learning at levels even higher than expected would also be achieved if, after watching the program, the program instructed older viewers to walk around and point out these symbols within the child's own neighborhood.
Freire
Children and adolescents who may be marginalized by current health practices could be taught to take on a more active role in health care practice. Parents may discuss the content of a medical examination or test results with the health provider without including the child or adolescent, perhaps wanting to "protect" the child or adolescent from the negative aspects of the conversation. Even the selection of medications and medical or surgical procedures may occur without the child or adolescent being present and part of the conversation. Fostering more participatory strategies, however, can encourage greater responsibility for learning and well-being; this, in turn, alters patterns of dependence.16 When children are provided with and reinforced to have empowering experiences, youth become agents of change, for personal as well as community health. When children are more aware of the health issues facing them and their peers, they may take action to improve their health.
Health literacy skills should be encouraged at a very young age. First, children and adolescents are increasingly involved in their own health care management; young people see and regularly interact with health messages, interventions, and health practitioners. Healthy literacy skills can alter existing and future behaviors; with greater health literacy, children and adolescents can take more control and ownership of their own habits and decisions. When children take more control of their own health, it is possible that they might adopt and build on health-promoting lifestyles. Second, children already make decisions that affect their current health. A 7-year-old may or may not put on a helmet when riding his or her scooter to school. An 11-year-old has a choice when offered to try a cigarette. A pregnant 17-year-old resolves to terminate or continue a pregnancy. Finally, health attitudes and behaviors formed during childhood greatly predict adult health patterns. For example, children's food preferences and media behaviors are significantly related to being overweight or at risk for obesity in adulthood.18
As promoted in the Freirian literacy program, emerging health literacy should involve dialogue. When the health provider or health system is more aware of the learner's world, then the experience is better for all participants. Children should not be placed in a passive role when learning about health; interaction should be encouraged so that a partnership occurs to promote better understanding and more healthy behaviors. An optimal learning experience requires growth not only by the student but also by the teacher. Likewise, an optimal medical experience should involve patients as well as health educators learning from the particular circumstance or encounter. Imagine a pediatric nurse explaining to a 7-year-old child who suffers from asthma how to use an inhaler. Improved compliance is achieved when the child actively listens to the nurse but also when the nurse knows the environmental barriers that keep the child from using the inhaler. As another example, consider a Web-based intervention that encourages physical activity among middle school students. The site might be more effective if designers evaluate and modify the online experience so that greater interactivity occurs.
To date, most tools that assess health literacy focus on the "reading" of health text.19 No instruments have focused on measuring health literacy–related behaviors that involve deciphering obstacles and symptoms in one's own personal environment. A child may be unfamiliar with letters, numbers, or graphic representations; however, he or she might be able to identify or react to specific hazards that compromise the health of community members. For example, even a very young child can recognize a noxious odor coming from a container. Despite the fact that the child cannot read the label "hazardous waste," he or she might still avoid the container and get an adult to help alleviate the immediate predicament. The child can also be taught to understand the pictogram or "symbol" for poison on containers.
With literacy, Freire believed that personal and social transformation was possible. Similarly, the development of health literacy will enhance both individual and public health. Teaching youth to recognize, use, and interact with different resources for personal health will empower them to engage in health-promoting activities, leading to personal and societal changes.
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CONCLUSIONS |
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TOPABSTRACTTHE DEFINITION AND MEANING...CHILDREN'S HEALTH AND...CHILD DEVELOPMENTCHILDREN AND HEALTH LITERACYCONCLUSIONSREFERENCES |
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This consideration of Freire, Piaget, and Vygotsky suggests that even the youngest child is able to gain the necessary skills on a path toward health literacy. Those between the ages of 3 and 18 can seek, comprehend, evaluate, and use health information, especially if materials are presented in ways that are age appropriate, culturally relevant, and socially supported. The development of health literacy among children and adolescents can empower this vulnerable and "marginalized" group to be more engaged, more productive, and healthier.
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FOOTNOTES |
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Accepted Jul 20, 2009.
Address correspondence to Dina L.G. Borzekowski, EdD, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 N Broadway, 745, Baltimore, MD 21205. E-mail: dborzeko{at}jhsph.edu
The views presented in this article are those of the author, not the organizations with which she is affiliated.
Financial Disclosure: The author has indicated she has no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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