Article Test

Introduction

Health literacy (HL) has been defined as the ability of people to access quality health information and to apply it in self-care activities, making appropriate decisions and correct use of health services1,2. As a research area, HL emerged in the 1990s at the international level, with studies based on population surveys in different countries. The first studies focused on the use of printed materials and, in general, a difficulty was shown in most of the adult population, when performing daily tasks3,4. Based on these results, additional studies focused on the effect or impact that this situation could have on the individual’s health, verifying the existence of a strong association between the level of HL and the observed health status5. For instance, people with low health skills participate less in health promotion and disease prevention activities, manage their disease worse and present a higher number of hospitalizations and readmissions, among other similar health results6-8.

Traditionally, researchers in this field placed special emphasis on the responsibilities of the patient or the person when acquiring a good level of HL and healthy behaviors. This way of understanding HL puts the burden of responsibility on the patient, without taking into account what, more recently, has also been valued as responsible for the level of HL: the health determinants that influence the personal ability to acquire a good level of HL9-10.

Subsequently, different studies also focused on assessing the professionals skills in their communication with patients11,12, as well as the characteristics of health centers and the physical spaces and signals in order to favor navigation and patient participation, overall13-15. Different studies related to this topic can be found on the website of the Harvard T. H. Chan School of Public Health16. At this point, researchers classified HL at the individual and the contextual level. The individual HL level focuses on the persons knowledge, skills and attitudes when making decisions regarding health. In contrast, contextual HL focuses on the social, cultural or structural aspects and resources that allow the person to be more or less competent. In this scenario, the concepts of distributed health literacy, social health literacy and organizational health literacy also emerged17-19. Despite the large body of literature produced since these first studies on the adult population, there is less scientific documentation regarding the child and youth population, especially the youngest children9. The aim of this study was to review the state of the art regarding HL of children and adolescents.

Methods

The research team (RT) carried out a bibliographic search in the Medline database. It consisted on a generic search on HL, in order to obtain an overall idea of the state of the art in this area of knowledge. For this reason, studies focused on a specific disease or health condition were excluded from the search.
The RT looked for English and Spanish papers published in the last five years (from 2017 to 2022). Key words were health literacy in children, health literacy in adolescence, digital health literacy in children, and digital health literacy in adolescents. After this first search, the RT selected the systematic reviews published in the previous year (2021-2022).
Of the 48 systematic reviews found, the RT discarded some of them because of repetition of articles in the different searches or being disease- specific papers and not general. From the 23 systematic reviews about health literacy in children, the RT discarded 21 because the articles focused in specific health conditions. From the 14 systematic reviews about health literacy in adolescents, the RT discarded 10 because the articles focused in specific health conditions and three because of repetition.
From the six systematic reviews about digital health literacy in children, and the five systematic reviews about digital health literacy in adolescents, the RT discarded four articles in both cases because the articles focused in specific health conditions. Table 1 presents the summary of this search.

Table 1. Results from the literature search

I   Number of articles in the last 5 years
II  Number of articles in the las year
III Number of systematic reviews in the last year
IV Number of selected systematic reviews

The RT selected the resulting five systematic reviews from the articles published during the previous year (2021-22). Tables 2 and 3 summarize the characteristics of the selected systematic reviews about HL in children and adolescents and about digital HL in children and adolescents, respectively.

Table 2. Characteristics of the selected systematic reviews about HL in children and adolescents

Table 3. Characteristics of the selected systematic reviews about digital HL in children and adolescents

Findings

Health literacy during childhood and adolescence

The results from the reviewed scientific literature showed that HL is not a static concept; on the contrary, it develops during the individuals life through personal, educational and social factors. However, researchers do not usually consider these structural and contextual factors, much less when talking about childhood and adolescence. The characteristics and peculiarities of children and adolescents are not taken into consideration when defining the HL level of the population9,18.
HL during childhood is crucial to obtain a good physical, emotional and cognitive development. Moreover, HL relates with the acquisition of healthy behaviors and lifestyles, obtained through a learning process that extends over time9,21. During this same period in the development of the human being is when the implementation of actions to promote health and prevent disease becomes more important, not only in the child, but together with the family20. In fact, a low level of HL in parents is associated with worse health outcomes in children21. Researchers have also observed that the level of HL of the parents influences three aspects of healthy behaviors: access and use of health services, communication between patients and professionals and self-management of the disease24.

Children and adolescents are usually exposed to different environments and contexts. In addition, they frequently depend on parents or caregivers in terms of health decisions. Although HL interventions must be designed taking into account the needs of the target population, it is difficult to assess these needs in children and adolescents, assuming that the needs of this group of the population are similar to those of adults18.

The age of the child determines the agents to whom the interventions must be addressed. With the youngest, one must work directly with their parents or caregivers and incorporate the child, depending of his/her age, in concrete actions. The opposite would happen in adolescence, where actions are taken directly with the young person and the family would participate in specific actions if necessary. Thus, most of the research in the health environment has been developed around the impact that the level of parents’ HL would have on the children and young peoples health9.

The HL level of a person depends on many factors such as the personal situation, the health status, the existing diseases, the socio-economic and, cultural level, as well as demographic determinants, among others. These aspects at the level of parents, friends, and school, moreover, influence children. Therefore, these groups are considered agents of the childs socialization. There are many models where HL exceeds the healthcare environment. Thus, HL in children and adolescents is important in many aspects and contexts of daily life and has a potential impact on the well-being and promotion of ones own health9.

Table 4 presents the socio-ecological model of HL in children and adolescents. This model considers three levels (intrapersonal, interpersonal and community level) when characterizing HL in this population group.

Table 4. Socio-ecological model of HL during childhood and adolescence

Adapted from: Schulenkorf et al., 202219; Higgins et al., 200925.

Despite the diversity of instruments and approaches to measure the level of HL in children and adolescents, some studies have provided categories when analyzing this area. These categories would be cognitive, behavioral or operational and affective attributes9. Table 5 presents the relationship between these categories and the different dimensions of HL.

Table 5. Categories and dimensions of health literacy

Adapted from: Bröder et al., 20179

Digital health literacy

One of the aspects discussed within this topic in the literature was the different types of existing HL gaps. Thus, not only are differences in access and understanding of digital information, for example, but there are also other ways to distance the person and not access the information. These other gaps are social and economic, attitudes and intolerances, previous knowledge, cultural diversity, vulnerability, according to age or emotional gap, among others10,19,23.
Nowadays, digital technologies are a frequent way of sharing information overall and about health. This information can be accessible to users at any time and place, which makes it highly used22. The level of digital literacy of the population, or the ability of the person to use digital platforms and resources when obtaining and evaluating information, is increasingly influencing society. For example, in the educational or in the social areas individuals connect, learn and relate to others through the digital world23.
This also happens in the child and youth population, where the level of digital literacy of children and adolescents will largely determine their inclusion in online education, their learning, their access to information about health and well-being or about leisure activities, among many other topics of their daily activities23,26.
From this point of view, nowadays, the fact of searching, creating and sharing information and knowledge can be very easy and fast in addition to favoring a certain comfort and privacy when connecting online. However, it is necessary to assess the quality of the information available on the internet27,28. Children and adolescents face great challenges when accessing information via the internet, such as discerning whether information and sources are reliable, understanding technical terms, or managing ones own beliefs26. Nevertheless, despite having good information, there are still people and groups in the population who may have difficulties accessing and understanding the information given in digital format28.
There are other kinds of gaps in accessing good quality information to make informed decisions about health. For instance, healthcare and the existing barriers with regard to the agility in responding to what patients need or the gap in access to care and treatments; as well as the gap in training and communication between the different health agents. These are among the observed gaps in todays society29,30.
However, among all the different divides one can find, the social gradient is one of the most frequent causes of the gap in the general population and also in children and adolescents31. In addition, being part of this group of the population and having a complex chronic disease, make the child or adolescent even more vulnerable to health21,32.
Some of the characteristics of this body of the literature are the variability of the study designs and their heterogeneity in terms of the studies subjects (children, adolescents or parents), age groups included, small sample sizes, focus in different aspects (disease-specific versus general topics), among other (tables 2 and 3).
The results of the review showed that, although HL plays an important role in disease management behavior, health service utilization and health outcomes in pediatric patients; especially in cases of children and adolescents with complex chronic diseases, the scientific evidence to date is still limited. It would be necessary to conduct more studies in order to find out the existing relationship between the level of HL and health outcomes in the child and youth population in general, and with complex chronic diseases in particular21. Equally, it is necessary to continue studying the role of HL, moving from its more functional aspects based on competences and skills to those models that focus HL in the context in which people live and develop their social practices9,33.
Overall, there is a lack of studies and models that value HL in younger children (under 10 years old), as well as at transition ages, for example, from primary to secondary, or from high school to university. In the first case, the HL is studied through the characteristics usually of the mother, who most frequently provides a response to the childs needs. Therefore, the child must be seen as an active social agent who continuously develops and changes with the process of socialization and interaction with the environment, including his/her parents and other relatives, teachers or friends9.
There is a tendency to focus on the cognitive development of the child, thinking that HL will be achieved at different consecutive ages or stages of development. This approach tends to give little importance to sociological approximations that take place during this period of the individuals development5. In fact, different studies about the Life Course Health Development suggest that health development can be affected by risk and protective factors occurring during childhood, adolescence and adult life in family, community, and society34.
Another aspect to highlight for future research is the extent to which families, communities and society will allow children and young people to take an active role and participate in the practice of HL. These ages in humans are considered the most permeable, where information about health can be transformed into concrete actions9.
Collective HL plays an important role in this age group as well. Moreover, although in the youngest the parents or caregivers are the ones who determine the childs access to health resources, as the child grows older, social support, friends or classmates are the ones who will help he/she to do or understand homework and activities related to lifestyles. Therefore, it is necessary to recognize the role of the childs environment (apart from the family), the school, and the cultural and social context when designing improvement actions, without focusing solely on actions at the individual level of the child or youth.
Another aspect is to keep in mind that the way we see the child/adolescent depends largely on our adult viewpoint, our perception and the social role we attribute, for example, between pediatrician and patient or between teacher and student. Therefore, it is necessary to incorporate the child and young person actively in the study of HL and health promotion from their point of view9.
Apart from the lack of definition, HL is difficult to measure in young children. There is a heterogeneity in measuring the level of HL in children and young people and there is no consensus regarding the appropriate age for children to participate actively in the management of their health20. Therefore, and in order to obtain valid results, it is necessary to develop measuring instruments adapted to this population and to the differences that may be related to age21. An adequate conceptualization of HL during childhood and adolescence is also necessary when designing appropriate interventions and policies for this population group. To do that, it is necessary to define what is meant by HL and how it will be measured19.
It is also necessary to develop guidelines that help in the research of HL, in its application in different groups of the population, including children and adolescents, its adaptation to specific cases, and in the measurement of results35. In addition, researchers should also notice the importance of health professionals’ communication and the characteristics of health institutions in order to find different ways to improve HL of patients36.
The literature highlighted the role played by the gaps in vulnerability and precariousness of the population, and those of the health systems. The digital divide can still leave people behind if we do not try to include them in all actions so they can access the information they need about their health. As some studies concluded, it is important to know the role that HL plays in the reduction of disparities in the health of children and adolescents37.
There are many models where HL exceeds the healthcare environment. Thus, HL in children and adolescents is important in many aspects and contexts of daily life and has a potential impact on the well-being and promotion of ones own health9. However, it is necessary to go deeper into how these other factors influence the health of children and adolescents; as well as in terms of HL measurement instruments for children and adolescents38.

Conclusions
As conclusions of this review, it is important not to focus only on an individual perspective; on the contrary, it is necessary to understand HL in the context where the child and youth lives and develops and with his/her interactions with the health, educational and social system.
In children and adolescents, the health status and healthy lifestyles are not only influenced by the level of individual (or parental) HL, but also by the social context in which the child is immersed.
It is necessary to strengthen personal motivation, knowledge and skills to be able to make appropriate health decisions; but it is necessary to help to reduce the complexity of the childs environment (family, school, social aspects), to facilitate his/her empowerment.
It is necessary to promote research on the role of HL in children and adolescents, as well as on the measurement of health outcomes.
Health professionals play an important role in preparing children with chronic diseases and their families to understand what is happening to them and what they need to do to improve their health and well-being.
Health is a key element in peoples lives and in their ability to develop their potential and contribution to society. Thus, the quality and social justice of the society of the future depends, in part, on the health of todays children and young people. The HL of pediatric age populations is an issue that should deserve the highest consideration.

Conflict of interest statement
The authors have no conflicts of interest to declare

Acknowledgments
The authors would like to acknowledge Rosana Basurto, Ana Bosque, Paula Cañal, Alicia Cañellas- Mayor, and Arian Tarbal, members of the School of Health of the Sant Joan de Déu Children’s Hospital.

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