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Table 5 Type and description of health literacy dimensions for children and young people

From: Health literacy in childhood and youth: a systematic review of definitions and models

No Author Dimensions of HL (Skill, knowledge, …) Nature/understanding of HL, as described in article
Children & Primary and Lower Secondary School Students
1 Brown et al. 2007, [32]
Exemplary for the US NHES [37]
(1) Critical thinking and problem solving, (2) responsibility and productivity, (3) self-directedness, and (4) effective communication
Health literacy was operationalized in measurement as the ability
- to comprehend concepts related to health promotion and disease prevention
- to access valid health information
- to demonstrate the ability to advocate for health by sharing information
Applies National Health Education Standards (NHES) in measurement instrument
2 Paek et al., 2011 [28] Interests in health topics,
Understanding of health subjects,
Motivation to act on what they had learned about staying healthy
The model integrates perspectives from social ecological models and health socialization models, adopted from political and consumer socialization
3 Schmidt et al. 2010 [25] Health literacy domains, which were operationalized in measurement::
Health knowledge, Communication, Attitude, Behaviour, Self-efficacy
Health literacy was assessed a construct consisting of the five dimensions mentioned; dimensions were based on author’s understanding of Nutbeam (2000);
Young people & Secondary School Students
4 Manganello 2008 [21] Functional literacy (basic ability to read and write)
Communicative/interactive literacy (ability to participate in daily activities and communication
Critical literacy (person’s potential to evaluate information)
Media literacy (the ability to critically evaluate media messages)
Based on author’s understanding of Nutbeam (2000) & Kaiser Family Foundation (2006)
5 Massey et al. 2012 [33] Navigating the system (e.g. to access service, understand (non-)emergency care, to make appointment & fill a prescription)
Rights and responsibilities (self-care perceptions, asking questions, knowing rights regarding sensitive topics)
Preventive care (well-care visit, screening behaviours, related attitudes/perceptions to visit doctor)
Information seeking (Ability to evaluate information, passive and active information seeking, relevance of information provided by physician)
Patient–provider relationship (perceived trust, comfort level, communication issues, continuity of provider care)
Cross-sectional: knowledge, attitudes, practices within the health care setting
Focus on health care setting: Identification of dimensions was based on results from focus groups with young people & interviews with primary care physicians
6 Paakkari & Paakkari,2012 [8] Health literacy as broad range of knowledge and competencies:
Theoretical knowledge (explicit, factual, formal and declarative knowledge about health matters)
Practical knowledge (procedural or skills-based knowledge; capability to do something)
Critical thinking (ability to think clearly and rationally; e.g. understand health issues in deeper way, make sound choices, participate as active member of society)
Self-awareness (ability to self-reflect on oneself, own decisions, and oneself as learner;
Citizenship (ability to act in an ethically-responsible way and take social responsibility; consider health matters beyond one’s own perspective (the ones of others and of the collective)
Cross-sectional skills: Basic reading, writing and speech skills social skills, communication skills, and information-gathering skills
Health literacy is defined as a learning outcomes of the school health education subject in Finland. It focusses on a health promoting and empowerment perspective with effects for the personal and societal health.
7 Rask, Uusiautti, Määttä, 2013 [29] Basic/Functional literacy (basic ability to read and write)
Communicative/interactive literacy (ability to participate in daily activities and communication
Critical literacy (person’s potential to evaluate information)
Extended with fourth dimension:
Holistic health literacy, with four sub dimensions:
- tolerance,
- understanding culture as wide and multidimensional phenomena,
- environmental consciousness,
analysis of the state of the world from various points of view
Based on author’s understanding of Nutbeam’s typology (2000), complemented with own holistic health literacy models (adapted from Stewart et al. 2008), dimensions are elaborated from students’ perspectives & point of views, based on their answers from the Finnish Matriculation Examination
8 Steckelberg et al., 2009 a&b [22, 41] Principles of critical health literacy related to evidence-based medicine (EBM):
Understanding medical concepts (e.g. informed choice in diagnostic tests; appraising patient information)
Skills of searching literature (e.g. searching the internet and databases)
Basic statistics (e.g. critical appraisal of RCT’s)
Design of health experiments and sampling (e.g. Fallacies and misinterpretations of data representation: observational articles versus randomized controlled trials (RCT) – What are the differences?; Understanding systematic reviews)
Based authors understanding of Nutbeam’s critical literacy dimension
9 Subramaniam et al. 2015 [26] Health literacy skills inventory with main categories:
Foundational elements: general abilities/characteristics (e.g. health-related knowledge, ability to listen, communicate, motivation, attitudes, intention & self-efficacy), access to information
Health-related information: information need identification and question formulation, information search, information comprehension, information assessment, information management, information use (dependent on context/goal of health information seeking)
Integration of results from an own narrative literature review on definitions and models
10 Wharf Higgins et al., 2009 [27] Skills to access, understand, and communicate health information, resources and services
Cross-sectional skills: knowledge, attitude
Integration of results from a literature review on general health literacy dimensions, reflect a socio ecological understanding and health promotion perspective
11 Wu et al. 2010 [18] Understand health information:
- literacy types (prose, numeracy and document) & levels of difficulty.
Evaluating health information:
- result is a judgment or conclusion about the information that is presented; and
this judgment or conclusion is based on applying one or more criteria:(1) accuracy, (2) impartiality, (3) relevance, (4) comprehensiveness, (5) internal consistency
Different age groups or considering a life course perspective
12 Lenartz et al. 2014; 2012 [38, 69]
(Translated from German)
Basic skills:
- health-related basic knowledge (Comprehension of basic terms describing the body or simple health-related coherences and functions)
- health-related basic skills (health-related reading, writing and numeracy skills)
Advanced skills:
- perceptual-motivational level: health-related self-perception, acceptance of responsibility (Verantwortungsübernahme)
- action-oriented level: (a) dealing with health information, (b) self-control, (c) self-regulation, (d) communication and cooperation. [translated]
Integration of the model by Soellner et al. (2009); models were tested in and evaluated by four different population samples
13 Mancuso, 2008 [34] Attributes of health literacy:
Capacity (skills and innate potential of individual, including gathering, analysing and evaluating health information for credibility and quality, working together, managing resources, seeking guidance and support, developing and expressing a sense of self, creating and pursuing a vision and goals, and keeping pace with change; oral language skills, social skills, reading, listening, analytical, decision-making and numerical abilities, ability to act on health information etc.)
Comprehension (complex process based on effective interaction of logic, language, and experience; what the individual understands; identify and creatively address health issues)
Communication (message or information exchange process, including speech, signals, writing or behaviour and involves input, decoding, encoding, output and feedback. Essential skills are reading with understanding, conveying ideas in writing, speaking so others can understand, listening actively, and observing critically)
Health literacy as competence: to have the capability to function effectively in health-care situations; explored from an education, library science, health care, public health and mental health context.
14 Martin & Chen, 2014 [24] reading, writing, numeracy (ability to understand basic probability and numerical concepts), listening (aural language), and speaking (oral language) skills within a health context  
15 Nutbeam, 2000 [35] Basic/Functional health literacy (basic skills in reading and writing to function effectively in everyday situations)
Communicative/Interactive health literacy (more advanced cognitive and literacy skills which,
together with social skills, can be used to actively participate in everyday situations, extract information and derive meaning from different forms of communication, and apply this to changing circumstance)
Critical health literacy (more advanced cognitive skills which, together with social skills, can be applied to critically analyse information and use this to exert greater control over life events and situations)
Foundational: Cognitive development, exposure to different information/messages (communication content and message), personal and social skills, self-efficacy
Focus on a health promoting and empowerment perspective.
16 Sanders 2009, a&b [5, 31] Prose/document-literacy skills (Writing, text comprehension, filling out form)
Oral literacy skills (from basic communication to negotiation)
Numeracy skills (e.g. food portion size or to understanding screening results)
Systems-navigation skills (describe media influence on behaviour to complete enrolment process)
Foundational: collective of family health literacy skills is important (child, parent(s), other caregivers)
Integration of results from a own systematic literature review on child health and literacy; Adapted from NHES & Bright Future Guidelines; skills are individually composed;
complexity increases with age (examples are provided for age 4, 10, 14 and 18)
17 Soellner et al., 2010 [36]
(Translated from German)
Foundational skills (literacy/numeracy),
Operational competence:
(1) to navigate and act in the health system, (2) communication and cooperation,
(3) information retrieval and processing, (4) self-awareness and self-regulation.
Knowledge component:
(1) system-specific und (2) health-related knowledge,
(1) willingness to take responsibility for own health. [translated]
Integration of results from an own narrative literature review on models and a stakeholder concept mapping
18 Sørensen et al.,2012 [10] Access (ability to seek, find and obtain health information);
Understand (ability to comprehend the health information that is accessed);
Appraise (ability to interpret, filter, judge and evaluate the health information);
Apply (ability to communicate and use the information to make a decision to maintain and improve health
In three health domains: health care, disease prevention, health promotion
Cross-sectional: knowledge, competence and motivation
Integration of results from an own systematic literature review on definitions and models
19 Wolf et al. 2009 [23] Cognitive skill sets (processing speed, memory, reasoning and attention; literacy & numeracy, verbal ability and reading)
Psychosocial skill set (self-efficacy, communication and prior experience)
Focuses on Health literacy as learning capacity in the health (care) setting.
20 Zarcadoolas et al., 2005 [4] Fundamental literacy/numeracy (printed and spoken language, numerals, and basic mathematical symbols and terms)
Science and technology literacy (e.g. knowledge of fundamental health and scientific concepts, comprehend technical complexity)
Community/civic literacy (knowledge about sources of information and agendas, enables citizens to engage in dialogue and decision-making, includes media literacy skills and knowledge of civic and governmental processes)
Cultural literacy (recognizing and using collective beliefs, customs, world-views, and social identity)
21 Zeyer & Odermatt, 2009 [30]
(Translated from German)
Situation-specific knowledge (to realize health-relevant situations, to match information)
Conceptual knowledge (to realize health-relevant principles, facts, terms)
Operational knowledge (knowledge on how to adequately act in an situation)
Evaluation of health promotion (Does this action promote health and is feasible in daily life?)
Evaluation of personal consequences
Self-reflection (to break up every day routines and to consider and analyse one’s own action plan)
Health literacy is regarded as a set of competences.