From Health Education to Health Literacy: A Research Review

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From Health Education to Health Literacy: A Research Review Powered By Docstoc
 From a traditional health education program to a health literacy
approach in schools: A systematic review of the literature
Iraj M. Poureslami 1, Irving Rootman 2, James Frankish 3, and Xiaomei Li 4

Ensuring children‘s health and learning capability is essential for the Canadian Education
System (20). Young people‘s health can be greatly improved by reducing their health risk
behaviours (2,3,6,36,76,81). This is one of the major targets incorporated into the current
"health of young people" program in Canada (9,53,54). Many studies report the importance
of school health education programs in promoting health for students and in preventing
the adoption of many high-risk behaviours (36,39,44,77). However, its effectiveness depends
upon factors such as time available for instruction, family and community involvement,
comprehensiveness of the health program, and students‘ participation (8,9,22,38,43). Because
of the lack of specific evaluation of school health education programs in Canada, mixed
results have been reported in terms of the effectiveness of these programs in enhancing
students‘ overall knowledge on health practices and, thereby, on further improvement of
student‘s health status (84). This critical analysis explored the severe lack of information
among young people related to health knowledge, particularly in the areas of regular
exercise, proper nutrition, substance abuse, and behaviours to maintain and enhance
health (9,77). Recent studies in the US, Europe, and across the world have revealed the
importance of skills-based health education approaches (19,27,35, 36,42,74) (like the health
promoting education program) (6,79) that have been shown in many countries to make
significant contributions to the health development among children and adolescents, and
that have been shown to have a positive impact on reducing health risk behaviours (35,39).
These studies revealed the crucial role health literacy, as a major outcome of health
promoting programs, has on young people‘s health. (45,46,65) The Canadian Association for
School Health (7,8) reported that urgent health and social problems have underscored the
need for collaboration among young people, families, schools, agencies, communities and
governments in taking a comprehensive approach to school-based health promotion (52).
Recent studies indicated that in order for school health promotion programs to influence
students‘ health behaviours and empower them to take control over their health (28),
enhancing school-age children‘s health literacy, as the major outcome of health
promoting program, should be one important component included in the school health
education curricula (58). This issue has not been studied or planned in Canada yet.

The major challenges facing health researchers, policy-makers, and school officials in
Canada are how to develop valid and reliable instrument tools to measure health literacy

  Research Associate, Adjunct Professor, Institute of Health Promotion Research (IHPR), UBC, Canada
  Professor, Centre for Community Health Promotion Research, U-VIC, Canada
  Associate Professor, Associate Dean, IHPR, UBC, Canada
  Post-doc, IHPR, UBC, Canada
   Address correspondence to Iraj Poureslami; 2206 East Mall room 419 Library Processing Center, IHPR,
   UBC, Vancouver, V6T 1z3

and its health outcomes among school-age children and how to assess its impact on
overall health of school staff and community at large. Another challenge would be how to
incorporate a health literacy component in school health curricula in Canadian schools.

According to Health Canada (9,20), the major causes of morbidity and mortality among
young people are motor vehicle crashes and other unintentional injuries, violence and
homicide, suicide, sexually transmitted diseases (including AIDS), and unintended
pregnancies (4,20). Among adults, these are heart disease, stroke, cancer, lung diseases, and
diabetes (29,76). According to the literature, all these causes are generated from a few
patterns of health risk behaviors that are established during school-age years (4,6,12,76).
These behaviors are classified as (1) behaviors that lead to intentional and unintentional
injuries; (2) tobacco use; (3) alcohol and other drug use; (4) sexual behaviors leading to
STDs, HIV, and unintended pregnancy; (5) poor nutrition; and (6) lack of physical
activity (2,3,10,11,82,85). The literature also reveals that youth from marginalized groups and
those from low-income families, Aboriginal youth, and new immigrant youth are
especially vulnerable for the aforementioned behaviours and the consequences (9,64,66).
Furthermore, international studies (17,76,78) show that the increased availability of tobacco,
alcohol, and other psychoactive drugs for children; the increased misleading messages in
mass media; and the ongoing problems of poverty and family conflicts are major barriers
to adolescent development (51,66). Yet, many studies in Canada and across the world
suggest that engaging young people in health risk behaviours can be controlled or
manipulated through proper health education programs provided by schools. (9,17,48,70)

In this review paper, we attempted to focus on health literacy issues among school-age
children and summarize relevant studies, articles, and documents that address this issue,
and relevant concepts from educational and promotional perspectives. Our goal is to
identify any works in Canada and across the world that aimed to assess or find links
between health education provided in school and students‘ behavioral modification or
adaptation pattern, as well as their health literacy. In addition to a literature review, we
summarize key-informants‘ and experts‘ views about health literacy in school-age
children that we obtained during personal interviews and focus group sessions. Our major
aims were to determine the gaps in the literature in the relevant concept, and also to
identify items and components that would enable us to develop a measurement tool to
assess school-age children‘s health literacy in Canadian schools.

At the end of this paper, we provide some recommendations for policy consideration and
also for further research in the area of health literacy in schools. Finally, we suggest a
framework to adopt in Canadian schools to promote health and health literacy for
secondary school-age children.

Materials selection
The attempt made here to determine the link between health education and health literacy
among school-age children involved both reviewing relevant literature and reaching key-
informants and experts. Electronic and hand searches were conducted for reports in
English on the subject. In addition, sources identified by the Health Literacy key-

informants through a web-based survey were examined. The World Wide Web and many
national and international databases – ERIC, Medline, PubMed, MEBASE, Social
Science Citation Index (BIDS), and the Health Education Authority's Unicorn database
were searched for materials. Hand searches were carried out of the journals Health
Education Research, Health Education Journal, Health Education Quarterly, Journal of
School Health, and Health Communication from 1980 to 2005.
Despite all these efforts, this review paper does not include all available materials about
health education and health literacy. We also tried to include a combination of key titles
and obscure, gray and little-known publications. While health information provided both
in school (through health education curricula) and non-school settings (i.e. through
media, family, etc.) have significant influence on children and young people‘s health
knowledge, beliefs, and practices, this review paper emphasised only health education
provided in schools.

School Health Education Programs
Schools have long been recognized as ideal settings to educate children about healthy
choices and behaviors (8,12,17,36,65). Proper school health education can potentially play an
important role in promoting health, protecting children‘s health and assisting them in
achieving their individual potential and contributing to a healthy society (43,54,58,66). It is
vital for schools to equip young people with knowledge, attitudes and skills at the highest
level to enable them to develop life-long healthy behaviors and to make sound decisions
that impact on their own health, and the health of their community and country (16,17,31,32,

Health education is considered to be an important and essential component of an effective
school health programme, and it is believed it could be most effective when
complemented by skill development and empowerment of young people to make
responsible decisions to maintain and enhance their health (9,25,26,33,37). Researchers have
determined through different studies that providing information packages to students
about health risk behaviours produced little-to-no change in health behaviour, making it
clear that more innovative methods need to be examined (13,36,43,44,58). Many studies have
identified the effectiveness of health education approaches that have turned more to skill
development and to addressing all aspects of health, including physical, social,
emotional, and mental well-being, than the traditional ―information-based‖ or ―problem-
focused‖ approach (8,9,37,39,43,44,67,76). There have been different approaches to achieve
health education goals throughout the decades of providing health information to students
in schools, ranging from single focus, categorical programs to multiple topic,
comprehensive and health-promoting programs (1,14,18,39,59). The studies have
demonstrated that the prevention of problems in young people has focused mainly on the
immediate and distal effects of health educational programs – in other words, on the
reduction of negative outcomes and difficulties such as mental health problems, early
sexual activity, academic failure, drug and other substances use, and the like (16,32,33,39,
      . The literature reveals that most of these interventions are able to increase children‘s
knowledge but that changing other factors that influence health, such as attitudes and
behaviours, is much harder to achieve, even in the long-term (36). Demonstrating that such
outcomes are achieved is essential for developing credible empirical support for

prevention, and there is now a great deal of outcome data offering such support (37,47,58,59,
70, 74,77,81)
             . However, a focus on the negative side of adjustment has often obscured the fact
that many educational interventions attempt prevention by promoting skills and
developmental competencies, through the process of health promotion (31-33).

Over the last three decades, some initiatives have been proposed by various national and
international organizations and researchers with a view to achieving greater integration of
youth-oriented health education activities, while at the same time influencing individual
and social determinants of health (14,76). The literature shows that this approach has been
taken in different forms (39,59). For instance, in the late 1980s the Comprehensive (more
recently called Coordinated) School Health Program (CSHP) (1,37) from Kindergarten to
grade 12 students with eight components (i.e. health education, physical education, health
services, nutrition services, counselling and psychological and social services, healthy
school environment, health promotion, and parent/community involvement) was
developed in the USA (30,72,80). The aims of CSHP were to motivate students to maintain
and improve their health, to prevent disease and to avoid or reduce health-related risk
behaviours (12,16,24,43). In Canada, CSHP concept is used as an integrated set of planned,
sequential, school-affiliated strategies, activities, and services designed to promote
optimal, physical, emotional, social, and educational development of students (10,14,21,52).
In 1994 the CSHP model along with ―Social Supports‖ was endorsed by 24 organizations
in Canada. Some linkages between schools and communities have also recently been
created in Canada in this model to improve school health programs (8). The assumption
behind this approach is that since comprehensive school health education occurs within
the context of education and learning (1), it contributes to the broader mission of school
activities (63,69). However, many studies in the US, Australia and elsewhere have pointed
out that there is something fundamentally limiting in this approach about viewing youth
in terms of preventing their future problems as opposed to developing their strengths and
potential (14,39,40).

After working with a health education curriculum focus for many decades, educational
leaders, researchers and curriculum developers have expressed the need for a more
organizational and structural approach to school health, including attention to
development of useful participatory strategies and collaborations with external agencies
       . It might be due to lack of engagement of local community and low participation of
families and students in health education and intervention program development in
schools (2,3,6,43,72,76). Evidenced by the literature, the comprehensive school health
program relies mainly on a ―school-based‖ approach, meaning that it is in the school
environment that a whole range of selected activities come together to form an integrated
whole (2,14,31). However, recent research has emphasized the idea that school health
education programs should be ―community-wide/community-based‖, ―proactive‖,
―multidimensional‖, and ―ongoing‖ process (13,14,33). It should also employ strategies to
promote age-appropriate cognitive-behavioural skills, and consider the role of social-
environment and family (6,9,12,47) setting that facilitate adaptation, autonomy, support,
participation, and empowerment of school-age children (25,26). The idea was matched with
health promotion approach (47) that emphasises the integration of individuals, families,
settings, community contexts, and macro-level social structures and policies in an aim to

empower individuals to take control over their health and its determinants (26,47). The
related concepts of participation, empowerment and supportive environments of the new
approach fit perfectly within a health promotion framework (6,9), specifically the
empowerment concept, as it is considered to be the key mechanism of health promotion
       . The comprehensive school health approach was followed by the introduction of the
health promoting schools concepts in the early 1990s in Europe (19,27,33,35,43).

Developmental perspectives on Health Promoting Schools: Since the mid 1980s,
WHO has focused on the need for ―supportive social and natural environments‖ for
promoting health, often summarized as the ―healthy settings‖ approach (14,17,47). The
settings included the factors that are different from health attitudes, beliefs and practices
of individuals, which are normally believed to influence the health of individuals the
most (6,12,30,47). To suit for the healthy settings of WHO, a ―health promoting school‖
approach, also called ―coordinated school health‖ approach, has been developed in the
last decade (37,39,43,72,78). The health promoting school concept is based on a social model
of health (30, 39). It focuses on the individual while simultaneously emphasising the entire
organization of the school, as well as the social environment external to school (8). The
approach recognizes that students‘, teachers‘, and school staffs‘ health is the product of a
myriad of interconnected and interacting physical, social and psychological factors
              . It has three strategic aims: to contribute to reducing health inequalities, to
promote social inclusion and to raise students‘ achievement (6,8,78). It therefore attempts to
shape a total context that is conducive to health, and where not only the physical
environment, but also the cultures and relationships provide a supportive pattern to
positive health and well-being (12,25,39). The very explicit goals of health promoting school
are, therefore, ―to build capacity for collaboration between schools and external
environments‖ (29) and also ―to increase students‘ understanding of their health and its
determinations‖, thereby, enabling them to ―increase control‖ over and to ―improve their
own health‖ and ―the health of community‖ (17,26,61). Increasing control is essentially
important in adolescence, as it leads to participation and empowerment -increasing
autonomy, independence, and self determination through which young people see a
closer correspondence between their goals and a sense of how to achieve them, and a
relationship between their efforts and life outcomes (25-27,47).

Health promoting schools attempted to break down the traditional separation of the
school from community by finding ways to routinely bring about a collaborative
interaction between schools, parents, and the wider community (6,44). This popular
approach was initiated first by European Region of WHO (14,17). In 1992, the European
Network of Health Promoting School was started and was integrated across the health
curriculum (14,17,78). The 1997 European Network of Health Promotion Schools (ENHPS)
conference published 10 principles for the health promoting school (27,75): democracy,
equity, empowerment and action competence, school environment, curriculum, teacher
training, measuring success, collaboration, communities and sustainability (14,26,30). After
WHO‘s ―health settings‖ initiative and also the ENHPS conference, many countries
across the world have quickly adopted this model on most continents (14,17,43,75). As
reported, the regional networks for Health Promoting Schools fostered in the Western

Pacific started in 1995, in Latin America in 1996, in Southern Africa in 1996, and in
South East Asia in 1997 (30,78).

St Leger and Nutbeam (69) summarized some essential priorities in school health
promotion and education to be considered for the next decade. The first of which is
―finding effective ways to link the health curriculum with other school-based
interventions‖ (6). They indicated that the success, effectiveness and sustainability of
school health interventions depend on this link (69). Kickbusch and Maag (25) highlighted
the importance of health promoting schools for two main reasons: one because it offers
the potential for individual‘s empowerment, and second it increases student‘s skills, both
of which are necessary for the development and maintenance of his/her health and also
the health of community (12). These researchers recommended the development of new
outcome measures (i.e., health literacy) (5) for school health promotion interventions
       . They further stated that an effective health education in the context of a health
promotion approach provides health knowledge, facilitates the development of life skills
and provides opportunities for learning that are intended to improve health literacy (28,69).

St. Leger (66) also notes that the concept of health literacy is very compatible with the
health promoting school concept and could form an acceptable outcome by which the
success of a health promoting school could be achieved and assessed. St. Leger further
identifies three challenges (55) that must be addressed to enable schools to achieve this
level: First, the traditional structure and function of schools; second, teachers‘ practices
and skills; and third, time and resources (66).

From an international perspective, a growing – but still limited- number of studies have
shown promising results in terms of better meeting the educational and health needs of
school-age children by conducting school health promotion programs (14,33,44). However,
the results of recent evaluation studies show that the application of whole-school
approaches to health promotion and also the school/community links are still limited in
this approach (14,39,65). This is due to the fact that encouraging schools to adopt
comprehensive health promotion programs is often difficult in the current education
climate of developed decision-making, crowded curricula, an increasing number of
curriculum areas vying for status and time on school agendas and industrial disturbances
           . There is a big gap between common practices and ―what ought to be‖ in the
health education area (13,32,60). Furthermore, the results of studies conducted in the US,
Europe and Australia indicate a considerable gap between what is recognized as
providing the greatest potential for health gains in school-age children, and the situation
that currently prevails in most schools in these countries (6,14,19,40,75). This is because most
of the studies published on the effect of school health promotion programs deal with only
one behaviour (i.e., smoking or drug use, sex education, nutrition and obesity, etc) (2,77,84,
    or with only a few aspects of a school health promotion policy (i.e., disciplinary
aspects, health education) (11,39,40). Mukoma and Flisher (44) in their attempt to evaluate
health promoting school programs around the world revealed that although overall
positive development of health promoting schools was reported by some countries, they
were unable to conclude that there was strong evidence for the efficacy of the health
promoting interventions on the health of students, staff and the community, and on the

school ethos and environment (43,44). Therefore, regardless of comprehensive approaches
in theoretical discussion, the practice of school health promotion programs is often
reduced to rather traditional health interventions (30).

A workshop on practice of evaluation of the health promoting school that took place in
Switzerland in 1998 (17) revealed that the traditional, knowledge-based approach (66) is
insufficient to enable students to make healthy choices and change unhealthy behaviors
       . The participants from across the world strongly supported the idea that the major
goal of health-promoting school should be the empowerment of school-age children with
skills to enhance health (26,27). The challenge was identified, however, in the definition of
the criteria and objectives, which are not always so clearly perceived nor defined with
sufficient precision to allow their measurement (30,55). The European forum, therefore,
emphasized the need for development of indicators by which to judge and communicate
the success of the health promoting school (17,26,27,75).

Some recent studies in the USA, Australia and Europe showed the effectiveness of
comprehensive school health programs and health promoting schools to improve
students‘ health knowledge and practices (17,27,35,40,76). Likewise, the evaluation of health-
promoting education and life skills curricula in developing countries have appeared to be
effective in preventing risk behaviours, and creating healthy lifestyles among school-age
children (17,30). These studies confirmed that health education programs were somewhat
effective in enhancing students‘ health knowledge, could hardly resulted in informed
citizens who would be able to seek services and advocate for policies and environments
that affect their health (42,67). The same studies indicated that without the involvement of
parents and community, as external factors to the school environment, the educational
interventions barely led to positive behavioural results, such as engaging in delinquent
behaviour and delaying the onset of using alcohol, tobacco, and other drugs (35,40,76).

On the other hand, current literature on the subject shows that evaluation results are still
few in number and inconclusive as whether these approaches have the potential to enable
our educational systems to meet children‘s needs in terms of their access to proper health
information in school, their ability to assess, understand and communicate the obtained
health information, and to end up with healthy choices and sound decisions (14,39). Studies
that show the impacts of health education on health outcome tend to include more
comprehensive interventions that include but go beyond skills-based health education in
schools. (8,17,35,40). This includes the assessment of determinants, such as school-based and
external factors, affecting students‘ access, finding, understanding, evaluating and
communicating health information. These studies have also recommended a new concept
that should be entered in the health education and promotion debate in schools: Health
literacy (62): That is to empower young people to have the capacity to exercise control
over their health, to access necessary and needed health information, and to gain
knowledge and understanding about health and its determinants (25,28,41,66). The most
recent United States health objectives for the nation, published in ―Healthy People 2010‖,
contain an objective to improve health literacy (42,46, 49,64). The report indicates that a
young person with an adequate level of health literacy has basic and elaborated
knowledge, competencies and learned abilities to take responsibility for his or her health

    . More recently, the British Government public health policy ―Saving Lives: Our
Healthier Nation‖ identified the range of social determinants of health and inequalities in
health (43,62). The report clearly identifies the connection between educational status,
literacy and health (15). Each reflects the fundamental and long-established relationship
between access to information, population literacy levels and health outcome (25,62).

These efforts to advance health literacy have common roots; health literacy is a
distinguishable concept from health knowledge, health education and health promotion
             . Nutbeam (45) has argued, that we need to focus on ―health literacy‖ as one of the
―health promoting schools‖ major outcomes (67). This means that the personal, cultural,
social and environmental factors need to be changed or modified in order to enhance the
health of young people (9,28,45). Therefore, one of the ways to improve the health
promoting school approach, suggested by recent research, is to promote health literacy of
young people; that is to improve their ability to access, understand, assess and
communicate health information (26,41,66).

Health Literacy and School Health Education
Studies in the last decade have indicated the potential for an innovative approach to
school health, as portrayed through the health promoting school to provide a promising
strategic framework that will enable the outcomes of health literacy to be achieved (5,66).
Kolbe (29) states that the innovative health-promoting schools could be designed to
achieve one or a combination of four different types of goals. First, they can be designed
to improve health literacy. The Institute of Medicine (IOM) recently called for a
delineation of actions relevant agencies could take to help the nation‘s schools improve
health literacy (23,63). Second, school health programs can be designed to improve health
behaviors and health outcomes. Third, they can be designed to improve educational
achievement. Fourth, they can be designed to improve social outcomes (29).

The IOM (23) has identified three major sectors responsible for the improvement of health
literacy among adults (15). They include the educational system, the health system, and the
cultural system. These sectors provide intervention points that are both challenges and
opportunities for improving health literacy of young people (55). Integrated strategies
between these three systems may ultimately contribute to better health outcomes among
general population and less cost (2,25). In the US, healthy people– a set of public health
objectives for the United States – put health literacy on their action list (3,6,15,42,49). The
Joint Committee on National Health Education Standards in the US (5,73,80) urge students
to become health literate. The Committee defines health literacy as ―the capacity of
individuals to obtain, interpret and understand basic health information and services and
the competence to use such information and services in way that enhance health‖ (41,42,76).
The American Medical Association has made health literacy one of the core components
of its professional-patient communication training, and in 1999 convened an ad hoc
committee to look at the problem of health literacy in the US health care systems (6,15,41).
The committee recommended four areas for future research (34): (1) health literacy
screening, (2) improving communication with low-literacy people, (3) costs and
outcomes of poor health literacy, and (4) causal pathways of how poor health literacy
influences health (41). While empirical data on the effects of low health literacy in Canada

are limited, research from the US and Europe have assessed and reported the effect of
low health literacy on rates of hospitalization and emergency use, lack of or low level of
preventive and health promoting behaviours, and health status among adults and senior
citizens (15,27,35,42,49,62,75). In Canada, only within the last few years have researchers
identified the problems associated with low health literacy (71). However, fewer attempts
have been made to assess health literacy and its impact on younger individuals‘ (i.e.
school-age students) health outcomes.

School Health Education in Canada
School based health education has been in effect for many years in Canada (4,7-10).
Educating young people about health has been an important strategy for preventing
illness and injury (20,52). This approach has drawn heavily from the fields of public health,
social science, communications, and education (53,54). In Canada, instruction about health
and healthy behaviours in schools has been described as ―health education.‖ (4,10) Early
experiments with health education in Canadian schools relied heavily on the delivery of
information and facts to students (4,7,9).

On the other hand, health education in school has been poorly described and inadequately
evaluated in Canada (84). Of those evaluated, most describe the process of implementing
interventions rather than the impact of these on health related outcomes (84). A few studies
that attempted to evaluate the impacts of health education on health outcomes of students
showed that although school health education programs form a very solid foundation in
facilitating the development, they are not effective in reducing risk behaviors or sufficient
to enable students leaving school to be empowered in engaging in healthy behaviors to
enhance health (84).

Integrate Health Literacy into the Canadian School Health Education
Health literacy is a relatively new concept in health promotion research (64,71). The first
research and practice in Canada date back to the late 1980s, with the Ontario Public
Health Association (OPHA) collaboration with Frontier College on a Literacy and Health
project (71). In 1994, the Canadian Public Health Association (CPHA) established the
National Literacy and Health Program (NLHP) to improve health services of health
service users with literacy difficulties (56). In 2002, a team of researchers from across
Canada, in partnership with the Canadian Public Health Association developed a nation
wide literacy research project to run an environmental scan of Canadian research and
practice in literacy and health (57). This work ended up to a National workshop regarding
the gaps and needs in this area and a national agenda for further research. The NLHP and
CPHA works helped Canada to take an international leadership in the field of literacy and
health (56). In spite of these efforts, little attention has been given to date to the more
persistent problem of inadequate health literacy as a barrier to obtain and use of health
information, in particular among young people in Canada.

According to a Canadian Health Literacy Research Team (71), health literacy among
young people is the extent to which school-age children have the ability to obtain,
understand and communicate heath information and to assess it (41,56). It is a critical

empowerment skill to increase young people‘s control over their health behaviours (28),
their ability to seek out health information, and their ability to make sound decision and
take responsibility for their own health and their community health (25).

As indicated in recent studies in Canada and elsewhere, many socio-cultural and
environmental factors have direct or indirect influence on young people‘s attempt to seek
health care for their needs, on their beliefs about health and illness, and on their ability to
develop values and attitudes that would help them make healthy choices, all of which
significantly influence their health outcomes (47,84). A review by Rootman and Ronson in
Canada found that health literacy has both direct and indirect effects on people‘s health
    . While, direct effects may include medication use and safety practices, indirect effects
include use of services, lifestyles, income, work condition and environment and stress
levels. Health literacy is undoubtedly reliant on basic literacy skills and cognitive
development (15,25). Poor literacy not only hinders health literacy but can also limit an
individual‘s personal, social, and cultural development (15,49,83). The improvement of
health literacy among school-age students, which would eventually contribute to their
health status and development, is dependent on students‘ empowerment (22). The
empowerment is also an important goal of school education (66). This dimension of health
literacy includes variables such as motivation and interest, self-esteem, self-efficacy,
critical abilities, perceived control and intentions to act (22,25), all of which are amongst
the goals of Canadian education systems (8,10).

Regarding the school health literacy concept, although, the term ‗health literacy‘ was first
used in 1974 in a paper calling for minimum health education standards for all grade
school levels in the USA (3,30), the idea of health literacy among school-aged children
originated only in the last few years in Canada. Consequently, although our youth may
not be considered ―health-illiterate‘, they are likely to have serious deficiencies in their
ability to obtain, understand and use health information in everyday activities. These
deficiencies are determined as major challenges encountered by policy and decision-
makers aiming to improve the health of young people in Canada. The ‗critical skills‘ that
enable students to avoid risky behaviours or making sound responsible decisions to
enhance health are not well developed in many schools in Canada (84).

Some of the reasons given for the correlation between limited health literacy and low
health status among young people include limited access to health information and lack
of skills to evaluate and share received health information (85). Recognizing literacy‘s
impact on health outcome (8,15,26), most of these health issues can be prevented (48) by
exposing young individuals to proper health education and empowering them with
necessary knowledge and skills, in particular during childhood and adolescence (40).

The concept health literacy among young people is itself evolving and the core
characteristics that distinguish it need to be understood at the school level (6,12). There is a
need to develop clearly defined, valid, feasible and useable measurement tools to assess
health literacy and its outcome among school-age children (67). The measurement
instruments should be carefully developed to recognize the age development and gender
issues of students, and also being culturally competent (19). The task at hand would be,

therefore, to identify and measure (67) those factors that increase young people‘s ability to
access health information, assess and understand received health information, both within
the context of their everyday lives and also within the environments inside and outside of
school, and the way they communicate health matters with others.

Future Challenges
In enabling schools to become healthier places, Canadian school health education
programs need to integrate health promotion into every aspect of the curriculum, foster
better relations between schools and their local communities, and more importantly,
introduce health literacy as an important component and evaluate it as an outcome of
health promotion in school. More research projects need to be created to study the
country‘s current health education system and the ways to integrate health promotion
concepts into the curriculum in an aim to achieve healthy lifestyles for the whole school
population by developing a supportive environment conducive to the promotion of health.

Evidence indicates that traditional approaches to school health education under current
school education structures have not only failed to produce the outcomes expected
beyond the limitations of highly artificial experimental studies, but may have
unintentionally offered a justification for not taking more effective actions. However,
producing changes in school structures and practices to achieve better education and
health outcomes to reflect ―best practice‖ in school health is a major challenge facing
policy-makers in both education and health contexts in Canada and most developed
countries (48). To overcome this challenge (55), the multi-level partnership needs to
generate suitable school education models with the consideration of the relationship
between school education objectives, the school environment, socio-cultural factors, and
their influence on health outcomes of young people.

Lister-Sharp and Chapman (36) in their study concluded that most of the successful school
health education projects are characterized by a combination of actions including: 1.
Effective communication of research information about adolescent health issues and
potential actions to support adolescent health. 2. A systematic approach to building a
climate of public interest and support for action to promote adolescent health. 3. Direct
communication with decision-makers and politicians to build a constituency of support
for action. Assisting young people to act as advocates for themselves is a particularly
powerful way to work. 4. Realistic assessment of the policy options—respecting the
difficulties of introducing new policy and legislation (36).

The role of the school health program must move in a health promotion approach, beyond
its responsibility for providing educational services (65). Health literacy, as a major
outcome of health-promoting schools, will need to become a key component of Canadian
health curriculum in schools. This will require changes in the professional education and
training of teachers and the school health team (44,67), as well expanding the health
professions involved. Furthermore, there must be a change of attitude and organization of
the school health service, which refocuses on the total needs of the student as a whole

Researchers and planners need also to pay more attention to several issues in their
attempts to integrate health literacy in school health curricula. First, Canada is a
multicultural society with rapid growth of immigrant populations from all over the
World. Large varieties of cultural and ethnic backgrounds have formed the complex
reality of vast differences among people‘s understanding and attitudes toward health
issues. This has both direct and indirect impacts on school-age children‘s health beliefs,
perceptions and practices. However, little has been done to date to address the effect of
culture on young people‘s health and their help-seeking behaviour in Canada. Second,
beside age differences, physiological and psychological differences between male and
female make gender an important variable for school health research (9,19). O‘Hara et al
     in the West Virginia Health Education Assessment Project showed that female
students scored significantly higher than male students on total score and subtest scores
for most of the health education contents (74). Gabhainn‘s (19) study showed that studies
attempting to evaluate health education programs has given minimal attention to gender
analysis as an important concept (19) . These findings suggested that health education
should be presented in a way to meet the needs of students in their gender groups (9).
Third, studies have suggested that the health literacy levels among teachers have a
significant influence on health literacy levels among their students (67,72). Health literacy
among teachers is defined by Peterson and his colleagues (50) as ― the capacity of teachers
to obtain, interpret, and understand basic health information and services, with the
competence to use such information and services in ways that enhance the learning of
health concepts and skills by school students‖. Their study and other research indicated
that teachers‘ health literacy is the counterpart to student health literacy (50,72), thereby,
improving both teacher and student health literacy is very important to maximize the
effect of school health promotion (50,72). Finally, to ensure the success of school health
education, a close partnership among multiple levels of Canadian society is very
necessary. A school health education program can only be effective if it combines health
education with other health-promoting initiatives in the school, and involves parents and
families (38,60) and also motivates the community engagement (9,39,43). It is essential that
the education the students receive in the school be reinforced by their experiences in their
school life, in their homes, and in the wider community. Creating such supportive
environments for health often requires the development of supportive policies by
government, referred to as ―healthy public policy‖ in health promotion framework, and
appropriate legislation and regulation (48).

Depending on the individual and community, there is a wide range of youth risk factors.
All youth need opportunities to foster confidence, character, and connection to safe
places and people. They also need opportunities to develop different competencies and
skills at different ages. The environment should assist youth by responding to their needs
and promoting their strengths and potential. A participatory health promotion orientation
can be used effectively to help schools and local neighbourhoods/communities across
Canada develop interventions that are ecologically sound and coordinated. Finding ways
to offer an integrated approach to serving the needs of youth in different contexts can be
challenging (55), but as the results of many studies in Europe suggest (27), it can be also
done in Canada.

The improvement of health literacy can contribute to lowering and overcoming
inequalities that might be observed in different communities in Canada. It could also
enable young people to navigate health and health information systems in the face of high
prevalence of obesity, improper physical activity, drug and other substances abuse, and
engaging in risky behaviours by this group. Both educational and health systems in
Canada should clearly expand their commitment to health literacy in schools. Useful first
steps would be to develop and validate a measurement tool to assess health literacy
among school-age children. Next would be to create a Canadian network or centre on
health literacy among young people to help develop health curricula in schools with the
approach to health literacy and act as a resource for researchers, academia, community
organizations, and health and education systems for networking, information transfer and
capacity building. Most critical of all is to realize that this is no longer just an issue of
importance to the education sector and its outcomes but critical to the future development
of Canadian communities and social systems.

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