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DOI: 10.1542/peds.2009-1162D 2009;124;S282Pediatrics

Dina L.G. BorzekowskiConsidering Children and Health Literacy: A Theoretical Approach

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Considering Children and Health Literacy: ATheoretical Approach

abstractThe theoretical approaches of Paulo Freire, Jean Piaget, and LevVygotsky frame the consideration of children and health literacy. Thisarticle includes a general discussion of literacy from the Freirian per-spective. A denition of health literacy is then presented; rst, theestablished meaning is introduced, but then a Freirian extension isproposed. Next, the theories of cognitive development by Piaget andVygotsky are discussed, and examples related to childrens health lit-eracy are given. Finally, there is a discussion of why it is important toencourageand enablehealth literacy among children and adolescents.Pediatrics 2009;124:S282S288

AUTHOR: Dina L. G. Borzekowski, EdD

Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

KEY WORDSFreire, Piaget, Vygotsky, health literacy, children

ABBREVIATIONZPDzone of proximal development

The views presented in this article are those of the author, not the organizations with which she is afliated.

www.pediatrics.org/cgi/doi/10.1542/peds.2009-1162D

doi:10.1542/peds.2009-1162D

Accepted for publication Jul 20, 2009

Address correspondence to Dina L. G. Borzekowski, EdD, JohnsHopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 N Broadway, 745, Baltimore,MD 21205. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2009 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The author has indicated she has no nancial relationships relevant to this article to disclose.

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An inuential educational theorist andBrazilian educator, Paulo Freire dis-cussed and wrote about literacy. Hefelt that the attainment of literacy wasinextricably linked to personal, social,and political liberation. Becoming liter-

ate occurred within the specic livesand culture of the people attaining lit-eracy. The true purpose of educationand literacy, according to Freire, was to liberate people so that they couldachieve their full potential. 1

As background, Freire believed thatmany of the worlds inequities wereperpetuated by existing educationalsystems. Such systems withheld the tools that would allow certain groups

to attain power. For example, theways that some societies conceivedof and taught literacy kept people, es-pecially those from more marginalizedgroups, politically powerless. Offeringonly rote learning and discouragingcritical thinking skills helped to immo-bilize large population groups. Socio-political power would remain in thehands of the few when vulnerable peo-ples could not obtain the tools to chal-

lenge inadequate literacy education.In a Freirian literacy program, the teacher and student develop through the act of dialogue and reection. The teacher does not hold a superior posi- tion, nor does the student accept apassive role. A successful interactioninvolves the teacher developing anawareness of the learners world. Thestudent increases the inherent controlover his or her life by taking control in

the educational environment. Teachersandstudentsengage in a mutually bene-cial relationshipa partnership.

Literacy, according to Freire, is more than the learning of text. One is literatewhen he or she can read the word aswell as the world. 2 People achievehigher literacy levels when they cancritically decipher obstacles (whichFreire terms limit situations) in theirpersonal and social lives. Conscious-

ness of these situations, regardless of whether reading or writing is involved,can be a tool toward gaining personalfreedom. 1 Individuals who may be un-familiar with text or writing can be extremely literate in the environments

they inhabit but also cultivate. 2 For ex-ample, in an agrarian community, awoman who cannot read or write textmay be an expert with various plantspecies and social types. She might beable to read theresource to increaseproduction in a range of situations.

A Freirian educational process resultsin personal and social transformation.Education and literacy allow students to clarify goals and desires and recog-

nize how they can bring about thesechanges. This occurs when studentsnot only read the world and word butalso write the word and the world. 2 Apersonal level of ownership and em-powerment can stimulate changes ona public level.

Freirian thought provides an interest-ing lens through which to think abouthealth literacy in general and its devel-opment among children and adoles-cents more specically. Similar to ed-ucational systems that perpetuateunequal power relationships, onecould assert that certain medicalenvironments are responsible forkeeping groups powerless. The ab-sence of problem-solving skills related to health literacy renders people, es-pecially vulnerable groups such aschildren, unable to improve theirhealth on their own. Furthermore, the

relationship that Freire describes between the teacher and the studentmight be comparable to the relation-ship between the health provider and the patient. A partnership would facilitate a young child to have more controlover his or her own health and behav-iors. Lastly, a broader denition of health literacy may be necessary. Al- though a child or adolescent may beunable to read and dene medical

texts, that same person might under-stand healthy behaviors or medicalmanagement in his or her home envi-ronment and actively participate indecision-making regarding his or herown health care. In fact, the child or

adolescent may be more skilled atreading the world to determine thebest path toward healthy behaviors than the medical provider. Freirianphilosophy suggests that we address abroader meaning of health literacyand attempt to understand how chil-dren and adolescents may achieve it.

The rest of this article is organized in the following way. First, we present a traditional denition of health literacy,

and then we describe how Freirian phi-losophy can extend our thinking abouthealth literacy. Next, we offer a brief description of Jean Piagets and LevVygotskys theories on child develop-ment. Finally, we discuss how Piaget-ian, Vygotskian, and Freirian thoughtcontribute to emerging health literacy.

THE DEFINITION AND MEANING OFHEALTH LITERACY

Various media and interpersonal chan-nels convey important health messages.An individuals ability to receive, com-prehend, integrate, and act on thosemessages makes up their level of health literacy. True health literacy re-quires understanding different mes-sage types and using the conveyedmessages in appropriate ways. Suchliteracy can be extremely complex andvaried. Consider the following 3 situa-

tions, all which involve individuals hav-ing higher functioning levels of healthliteracy.

A teenaged girl or young woman ips through a magazine and comes acrossan article that describes differentbirth-control options. She reads andags them, with the intention of e-mailing her health provider and ask-ing whether she can adopt any of theseoptions. In this example, the young

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woman is exposed to messages anddecides to follow-up with an electronicconversation with her physician.

A mother hears on the radio a recruit-ment advertisement for a researchstudy on childrens sleep habits. She

goes to the study site and receives apacket of information. After reading the parental consent form, the motherrealizes that her child might be athigher risk if he participates, becausehis current medication might interferewith the protocol. The mother refusesconsent and does not allow herchild to join the study.

A child wakes up in the middle of thenight with a fever. Her father remem-bers that the family recently pur-chased some over-the-counter fevermedication that is in the medicine cab-inet. He reads the dosage-by-weightand age information on the label anddetermines that his 35-lb 3-year-olddaughter needs just 1 teaspoon of themedicine. He administers it, and theyboth go back to sleep.

The Healthy People2010reportdenedhealth literacy as the degree to whichindividuals have the capacity to obtain,process, and understand basic healthinformation and services needed tomake appropriate health decisions. 3

Health literacy is not just the ability toread health text; rather, it is a set of skills that involves recognizing, pro-cessing, integrating, and acting on in-formation from a variety of platforms.To be health literate, an individualmust be able to develop functional, in-

teractive, and interpretive skills. In ad-dition, media-literacy skills seem es-sential, especially when we considerhealth literacy in todays media-richenvironment.

Besides acquiring knowledge, healthliteracy includes interactive and crit-ical health literacy. 4 Interactivehealth literacy requires social skills that help individuals interact inhealth-promoting ways, whereas criti-

cal health literacy involves the ability to analyze and apply knowledge tofunction and be in more control. 4

Community and societal factors affecthealth literacy. As an example, when itbecomes necessary to include more in-formation on over-the-counter medication instructions, from either govern-mental or population-wide demands, text becomes smaller, more dense,and harder to read. This, of course, af-fects health literacy. As another exam-ple, disease managementnow involvesconnecting with more subspecialistsacross facilities and institutions.Decision-making about care now re-quires an awareness and under-standing of complex systems, includ-ing not only scheduling but alsoreceiving and paying for services.From decreasing font size to increas-ing complexity of health systems,environmental factors can help orhinder access and use of healthinformation.

Besides systemic issues, individual factors relate to and inuence health liter-

acy. Poor health literacy is strongly andsignicantly correlated to limited gen-eral literacy skills. Such decits resultfrom weak or lacking educational op-portunities, suboptimal support for lit-eracy within the family, and/or learn-ing and cognitive disabilities. Theelderly (aged 65 years), minoritypopulations, immigrant populations,low-income groups, and people withchronic mental and/or physical health

conditions are considered to be atmuch higher risk for poor literacy. 5

It is intriguing to think that childrenand adolescents were not mentionedwhen describing vulnerable groups.Although recommended initiatives toimprove health literacy often includeprimary and secondary school teach-ers, nurses, and librarians, thepopula- tions with whom these professionalswork are hardly ever mentioned.

CHILDRENS HEALTH ANDDEVELOPMENT

Whydo we care about childrens healthliteracy? In the United States, there are

74 million children under the age of 18 (almost 25% of the national population). 6 Reportedly, most US childrenare in very good or excellent health;however, 10% lack any health insur-ance coverage. Injury is the maincause of death for those aged 1 to 14years, and chronic illnesses remain aproblem for many. 7 In a 2006 survey,5% of children had reportedly missed11 or more days of school in the previ-ous year; this rate was twice as highfor children in the lowest income

bracket or from single-mother house-holds. 8 Currently, 16% of children andadolescents are overweight, and 34%are at risk of being overweight. 9 Ap-proximately 14% of US children havebeen diagnosed with asthma, and 9% to 12% suffer from different types of respiratory allergies. 8 It is estimated that among children aged 3 to 17years, 8% have a learning disabilityand 7% suffer from attention-decit/

hyperactivity disorder.8

CHILD DEVELOPMENT

Besides physical growth, childhood isa time of tremendous cognitive, social,and emotional development. Two20th-century theoristsPiaget andVygotsky offered important obser-vations and concepts to consider in our thinking of healthy child development.

Although other researchers and theo-

rists have contributed to current thinking, it is Piagets theories thatform the foundation and much of ourunderstanding of child development.Drawing on early interests in biologyand philosophy, Piaget tried to answera fundamental question: How doesknowledge evolve?

Piagetian theory suggests that chil-dren move along a linear courseof development; Table 1 summarizes



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the different stages. 10 First is the sen-sorimotor period, which characterizes the time from birth through approxi-mately the second birthday. Infants in this stage move from reexive behav-iors to habits. A 4-month-old may pickup a rattle and learn that shaking theobject causes a sound. The child willrecognize that a personal action re-sults in a manipulative outcome. From the ages of 2 through 6 years, mostchildren are in the preoperational pe-riod. During this stage, childrens rec-ognition of symbolic thinking emerges,mental reasoning grows, and the useof concepts increases. A 4-year-oldchild in this stage will recognize astop sign and know that it means that mommy must stop the car whenshe sees it.

The concrete-operation period follows, typically from the age of 7 through 11years. This stage is characterized by the active and appropriate use of logic.Despite changes in situations, childrenlearn to apply general andknown rulesin a consistent way. Children can takemultiple aspects of a new environmentinto account, an ability known as de-centering. The child is no longer thecenter of the world and can consider that others have preferences and per-spectives. In the next stage, the formaloperational period, those aged 11 yearsand older develop the ability to think ab-

stractly. Hypothetico-deductive resound-ing is used, in which individuals startwith a general theory about what pro-duces a particular outcome and then they deduce explanations for what hasbrought about that outcome. 10

Central to Piagetian thought are 3 ma- jor developmental processes: assimi-lation, accommodation, and equilibration.10 Assimilation is the means bywhich children interpret incoming in-formation to make it understandable

within their existing stage of cognitivedevelopment and way of thinking. Ac-commodation refers to the ways inwhich children change their thinkingin response to new experiences, stim-uli, or events. Equilibration is a 3-stageprocess that integrates accommodation and assimilation. First, childrenare in a state of equilibrium. Then, fail-ure to assimilate new informationleads to their becoming aware of

short-comings in their current think-ing. Finally, their mental structure ac-commodates to incorporate the newinformation in a way that creates amore advanced equilibrium. Theseprocesses allow cognitive develop-ment and movement from 1 stage to the next to occur.

To further illustrate the Piagetianstages, it is interesting to considerhow children of different ages might

understand illness. 1113 A child younger than 2 years might know illness assomething associated with feelingpoorly. He or she may not be able touse the appropriate language to ex-plain; however, his or her understand-ing and thoughts about being sick maybe enough to evoke tears. Like theyounger child, the preschool-agedchild will associate illness with a vagueemotion (eg, it makes you feel sad), butalso this child may explain illness withphysical appearance or observable action. For example, a 5-year-old girlmight explain being sick as when youhave bumps on your body or whenyou throw up. A child in the nextstage associates illness with particu-lar behaviors and consequences. A9-year-old may not be capable of de-scribing why a child has a fever, but heor she would certainly be able to tellyou that such a child has to stay in bedand cannot go to school for several

days. Those who are slightly older andin the formal operational stage couldhypothesize, on the basis of subtleclues, that certain environments mightput someone at risk for illness. It isinteresting to note that some recentresearch on childrens understandingof health and illness provided evidence that comprehension may not be as lim-ited as the Piagetian theory would sug-gest. 12,13 For example, children younger

TABLE 1 Piagetian Stages of Cognitive Development

Stage ApproximateAge, y

Children in This Stage . . . Example

Sensory motor Birth to 2 Acquire knowledge through physical manipulation andones senses.

A child will learn about a rattle by sucking on it orshaking it.

Preoperational 27 Develop symbolic thought and consider the worldfrom an egocentric perspective; everyone and

everything share the childs point of view.

A child says that his teddy bear only likes to eat thefoods that the boy likes to eat.

Concrete operational 711 Develop understanding if they are able to manipulatea physical object. In the latter part of this stage,abstract symbols can represent objects and bemanipulated instead of the objects themselves. Thechild considers the perspectives of others.

A child can create a map of her neighborhood withblocks and show the path she likes to use to walk to afriends house.

Formal operational 1116 Can think abstractly, logically, and in terms of organized systems.

When facing a choice of 2 activities (eg, doing homeworkversus watching a movie), a child or adolescent can think of the possible outcomes and hypothesize whatwould be the optimal solution.

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cial support, from family, friends, orhealth providers, might facilitate thelearning of more difcult health con-cepts at a younger age. Early elemen- tary school-aged children with diabe- tes 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 cannothandle the measurement activities. Adiabetic preadolescent, if in a socialcohort with other diabetics, might better understand the more abstract im-plications of his or her behaviors if slightly older peers helpedto clarify thepertinent issues. When health conceptsand behaviors are culturally relevantand part of the childs environment, achild may understand their importanceat an earlier-than-expected age. To date,studies examining these approaches donot appear in the published literature;empirical evidence is needed to show that such approaches can lead to im-proved health behaviors in children.

It is important to be familiar with de-velopmental stages when creating

health materials and programs; how-ever, boundaries should notbe seen asbarriers. Imagine designing a televi-sion program with the purpose of conveying useful injury-prevention in-formation to a preschool-aged child.Through recognizable storylines, char-acterscould encounter familiar and lessfamiliar safety symbols (eg, cross-walksigns,poison symbols) in their neighbor-hoods. More advanced thought and un-

derstanding might be achieved if theproducers recommend that childrenwatch the program with their oldersiblings or parents or as part of a pre-school experience. Learning at levelseven higher than expected would alsobe achieved if, after watching the pro-gram, the program instructed olderviewers to walk around and point out these symbols within the childs ownneighborhood.

Freire

Children and adolescents who may bemarginalized by current health prac- tices could be taught to take on a moreactive role in health care practice. Par-ents may discuss the content of a med-ical examination or test results with the health provider without including the child or adolescent, perhaps want-ing to protect the child or adolescentfrom the negative aspects of the con-versation. Even the selection of medi-cations and medical or surgical proce-dures may occur without the child oradolescent being present and part of the conversation. Fostering more par- ticipatory strategies, however, can

encourage greater responsibility forlearning and well-being; this, in turn,alters patterns of dependence. 16 Whenchildren are provided with and rein-forced to have empowering experi-ences,youth becomeagentsof change,for personal as well as communityhealth. When children are more awareof the health issues facing them and their peers, they may take action to im-prove their health.

Health literacy skills should be encour-aged at a very young age. First, chil-dren and adolescents are increasinglyinvolved in their own health care man-agement; young people see and regu-larly interact with health messages, in- terventions, and health practitioners.Healthy literacy skills can alter exist-ing and future behaviors; with greaterhealth literacy, children and adoles-cents can take more control and own-

ership of their own habits and deci-sions. When children take morecontrol of their own health, it is possi-ble that they might adopt and build onhealth-promoting lifestyles. Second,children already make decisions thataffect their current health. A 7-year-oldmay or may not put on a helmet whenriding his or her scooter to school. An11-year-old has a choice when offered to try a cigarette. A pregnant 17-year-

old resolves to terminate or continue apregnancy. Finally, health attitudes andbehaviors formed during childhoodgreatly predictadult health patterns.Forexample, childrens food preferencesandmediabehaviorsaresignicantly re-

lated to being overweight or at risk forobesity in adulthood. 18

As promoted in the Freirian literacyprogram, emerging health literacyshould involve dialogue. When thehealth provider or health system ismore aware of the learners world, then the experience is better for allparticipants. Children should not beplaced in a passive role when learningabout health; interaction should be en-

couraged so that a partnership occurs to promote better understanding andmore healthy behaviors. An optimallearning experience requires growthnot only by the student but also by the teacher. Likewise, an optimal medicalexperience should involve patients aswell as health educators learning from the particular circumstance or en-counter. Imagine a pediatric nurseexplaining to a 7-year-old child who

suffers from asthma how to usean inhaler. Improved compliance isachieved when the child actively lis- tens to the nurse but also when thenurse knows the environmental barri-ers that keep the child from using theinhaler. As another example, considera Web-based intervention that encour-ages physical activity among middleschool students. The site might bemore effective if designers evaluate

and modify the online experience so that greater interactivity occurs.

To date, most tools that assess healthliteracy focus on the reading of health text. 19 No instruments have fo-cused on measuring health literacyrelated behaviors that involve deci-phering obstacles and symptoms inones own personal environment. Achild may be unfamiliar with letters,numbers, or graphic representations;

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however, he or she might be able toidentify or react to specic hazards that compromise the health of commu-nity members. For example, even avery young child can recognize a nox-ious odor coming from a container.

Despite the fact that the child cannotread the label hazardous waste, heor she might still avoid the containerand get an adult to help alleviate theimmediate predicament. The childcan also be taught to understand thepictogram or symbol for poison oncontainers.

With literacy, Freire believed that per-sonal and social transformation waspossible. Similarly, the development of health literacy will enhance both indi-vidual and public health. Teachingyouth to recognize, use, and interact

with different resources for personalhealth will empower them to engage inhealth-promoting activities, leading topersonal and societal changes.

CONCLUSIONS

This consideration of Freire, Piaget,and Vygotsky suggests that even the

youngest child is able to gain the nec-essary skills on a path toward healthliteracy. Those between the ages of 3 and 18 can seek, comprehend, eval-uate, and usehealth information,espe-cially if materials are presented in

ways that are age appropriate, culturally relevant, and socially sup-ported. The development of healthliteracy among children and adoles-cents can empower this vulnerableand marginalized group to be moreengaged, more productive, andhealthier.

REFERENCES

1. Freire P. Pedagogy of the Oppressed . NewYork, NY: Seabury Press; 1970

2. Freire P, Macedo D. Literacy: Reading the Word and the World . Westport, CT: Begin &Garvey; 1987

3. US Department of Health and Human Ser-vices. Healthy People 2010 . Washington, DC:US Government Printing Ofce; 2000

4. Nutbeam D. Health literacy as a publichealth goal: a challenge for contemporaryhealth education and communication strat-egies into the 21st century. Health Promot Int. 2000;15(3):259267

5. Nielson-Bohlman L, Panzer A, Kindig D, eds.Health Literacy: A Prescription to End Con-

fusion . Washington, DC: Institute of Medi-cine, National Academies Press; 2004

6. Child TrendsData Bank. Number of childrenunder age 18 in the U.S. (in millions), se-lected years 19502030. Available at:www.childtrendsdatabank.org/gures/53-Figure-1.gif. Accessed October 20, 2008

7. Child Trends Data Bank. Infant, child, andyouth death rates. Available at: www.childtrendsdatabank.org/indicators/

63ChildMortality.cfm. Accessed October 20,2008

8. Bloom B, Cohen RA. Summary health statis- tics for U.S. children: National Health Inter-viewSurvey,2006. Vital HealthStat 10. 2007;(234):179

9. Wang Y, Beydoun MA. The obesity epidemicin the United States: gender, age, socioeco-nomic, racial/ethnic, and geographic char-acteristicsasystematicreviewand meta-regression analysis. Epidemiol Rev. 2007;29:628

10. Siegler RS. Childrens Thinking . EnglewoodCliffs, NJ: Prentice-Hall; 1986

11. Daigle K, Hebert E, Humphries C. Childrens

understanding of health and health-relatedbehavior: the inuence of age and infor-mation source. Education. 2007;128(2):237247

12. Goldman SL, Whitney-Saltiel D, Granger J,Rodin J. Childrens representations of ev-eryday aspects of health and illness. J Pe- diatr Psychol. 1991;16(6):747766

13. Myant KA, Williams JM. Childrens conceptsof health and illness: understanding of con-

tagious illnesses, non-contagious illnessesand injuries. J Health Psychol. 2005;10(6):805819

14. VygotskyLS.Mindin Society: TheDevelopment of High Mental Processes . Cambridge, MA:Harvard University Press; 1979 [Originalworks published in 1930, 1933, and 1935]

15. Gutierrez KD, Rogoff B. Cultural ways of learning: individual traits or repertoires of practice. Educ Res. 2003;32(5):1925

16. Roter D. The medical visit context of treat-ment decision-making and the therapeuticrelationship. HealthExpect. 2000;3(1):1725

17. Parsons T. The Social System . Glencoe,

Scotland: Free Press; 195118. Hancox R, Milne B, Poulton R. Association

between child and adolescent televisionviewing and adult health: a longitudinalbirth cohort study. Lancet. 2004;364(9430):257262

19. DeWalt DA, Hink A. Health literacy and childhealth outcomes: a systematic review of the literature. Pediatrics. 2009;124(5 suppl3):S265S274



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DOI: 10.1542/peds.2009-1162D 2009;124;S282Pediatrics

Dina L.G. BorzekowskiConsidering Children and Health Literacy: A Theoretical Approach

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rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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