Understanding and assessing health literacy development in primary school children

<b>Background:</b> The development of health literacy is a key means of reducing health inequities and improving health outcomes globally. Health education during childhood has been identified as crucial for the development of health literacy. Developing health literacy in childhood may benefit the child both at the time and into adulthood. Although adult health literacy has been previously examined, little is understood about how best to support health literacy development in educational settings throughout the critical childhood period. <br><b>Aims:</b> The overall aim of this thesis was to investigate mechanisms that support children’s health literacy development in educational settings. This thesis first sought to develop an approach to analyse international curricula for their ability to support and implement health literacy development, and then demonstrate this method through the analysis of the Australian, British Columbian (Canada), and New Zealand curricula. Second, the thesis aimed to gain a greater understanding of the characteristics of health education that best promote health literacy development, through the systematic review and synthesis of existing international literature. Third, it sought to assess the ethical acceptability of a health literacy professional development program, via case-study of the Australian <i>HealthLit4Kids</i> program. Fourth, this thesis aimed to develop a valid and reliable approach to teacher-led assessment of children’s health literacy that may be transferable to international contexts. Finally, Australian primary school teachers’ opinions of this health literacy assessment approach were obtained to determine the suitability, acceptability, and feasibility of the approach in their teaching practice. <br><b>Methods/Results:</b> Through five interrelated studies, the best ways to support children’s health literacy development were explored, using Thijs and van den Akker’s (2009) Levels of Curriculum framework (i.e., intended, implemented, and attained curriculum). <br><i>Intended Curriculum – Study One</i> <br>The first aim of this thesis was addressed through the creation of a framework within which health curricula could be analysed. A framework comprised of Nutbeam’s (2000) Levels of Health Literacy and Hjelm’s (2010) Dimensions of Health was created and then used to perform content analysis on the Australian, British Columbian, and New Zealand health and physical education curricula to determine their capacity to support childhood health literacy development. The curriculum analysis showed that learning descriptors that were related to social and physical health occurred the most commonly across the three curricula studied, with less emphasis on emotional and spiritual health. Additionally, across all three curricula, interactive health literacy skills were most frequently included in learning descriptors, whereas critical health literacy skills were less common. <br><i>Implemented Curriculum – Studies Two and Three </i><br>Study Two involved a systematised review of the available literature to qualitatively examine the characteristics of health education that best promote health literacy development internationally. The review revealed six core characteristics of education that have been reported to promote health literacy development in primary school classrooms: collaboration, contextualisation, accessibility, autonomy, reflectiveness, and continuity. In the included studies, a range of methods were used to report, measure, or assess children’s health literacy development. There was found to be a lack of valid and reliable health literacy measures for children aged twelve years and under. <br>In Study Three, the ethical imperative to develop health literacy and the implementation of professional development programs for teachers were assessed, by applying Spike’s four principles for public health ethics. The assessment used the World Health Organization recognised <i>HealthLit4Kids</i> program as a case study. This study concluded that an ethical imperative exists for primary school teachers to invest in their students’ health literacy development.<i> HealthLit4Kids</i> was demonstrated to be an ethically acceptable health literacy professional development program. <br><i>Attained Curriculum – Studies Four and Five</i> <br>A valid and reliable approach to health literacy measurement is necessary to extend the current understanding of the pedagogical strategies that best facilitate children’s health literacy development. Study Four presents a health literacy assessment framework, using contemporary health literacy and educational research, as well as the key components of assessment (outcome of interest, and collection, analysis, and interpretation of data) to guide the discussion. The Australian Curriculum was used as a case study to demonstrate the approach in practice. <br>Using semi-structured interviews and thematic analysis, Study Five assessed primary school teachers’ opinions of the suitability, acceptability, and feasibility of the framework. It was found that teachers were familiar with creating rubrics. However, the approach described in Study Four may only be suitable in schools where generalist teachers are responsible for the teaching of health education and assessment of health literacy. Teachers interviewed had positive views regarding the framework (acceptability) but believed that barriers such as a lack of allocated time and confidence could hinder feasibility. Additional resources, further professional development, and the clear allocation of teaching time and responsibility were suggested to support the adoption of the approach among generalist teachers in the Australian primary school setting.<br><b>Conclusion:</b> A curricular approach to health literacy assessment provides a potential solution to the measurement of children's health literacy, addressing the limitations associated with current measurement instruments. However, the approach relies on the delivery of a comprehensive health curriculum and on teachers who have the capacity, capability, and confidence to implement the framework in practice. This thesis demonstrates how curricula can be analysed and improved for their ability to support health literacy development. It also shows how health literacy professional development programs for teachers can be examined for their ethical acceptability. Further, the current work provides insight into the barriers and facilitators that teachers may experience when implementing the health literacy assessment framework. The thesis thus provides the critical groundwork for future research focused on childhood health literacy development, teacher professional development, and teacher assessment of children’s health literacy development.

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