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TRANSCRIPT
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Ryan, Mary, Rossi, Tony, Hunter, Lisa, Macdonald, Doune, & McCuaig,Louise(2012)Theorising a framework for contemporary health literacies in schools.Curriculum Perspectives, 32(3), pp. 1-10.
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1
Theorising a framework for contemporary health literacies
in schools
Mary Ryan1, Anthony Rossi2, Doune Macdonald2, Louise McCuaig2, lisahunter3
1Queensland University of Technology, Australia; 2The University of Queensland, Australia; 3University of Waikato, New Zealand.
Introduction
This paper first reviews the current state of health and health education in Australia,
and outlines popular uses and applications of the term ‘health literacy’. Then, drawing
on Antonovsky’s (1996) salutogenic model of health and mainstream literacy theory,
a new definition of health literacies is proposed. We continue by presenting a robust
framework for guiding the development of a health curriculum based on wellness and
critical health literacies that accounts for the complexity of health and well being in
contemporary society. Furthermore, the framework incorporates capacities for making
meaning of integrated multimodal texts, which is a crucial skill for being (health)
literate in the 21st century and which goes beyond the limited conventions of how
health literacy is both accepted and generally understood (Fetro, 2010; Ozdemir,
Alper, Uncu, & Bigel, 2010).
Given the centrality of literacy education in contemporary schooling, ‘health literacy’
offers the potential to close the perceived gap between community expectations of
health education and schools’ capacities to develop curriculum that focuses on healthy
living. To date, there has been no research as to what a literacies based health
curriculum could look like. By placing education at the centre of the emerging health
literacy discourse, we argue that the research that informs literacy more generally can
be recruited to broaden the current narrow discourse of health literacy that seldom
2
ventures beyond the language of medicine. We suggest that this approach provides an
innovative yet familiar framework for much-needed curriculum reform in school-
based health education (SBHE).
Background
There is a compelling case for health reform in Australia (National Health and
Hospitals Reform Commission, 2009; National Preventative Health Taskforce, 2009)
because the health of a nation is so inextricably tied to its economy, national security
even national identity. The NHHRC under the third goal of its report (Creating an
agile and self-improving health system) recommended that one way to strengthen
consumer engagement within a health system is to ensure health literacy comprise a
core element of the National Curriculum for primary and secondary schooling.
Nutbeam and Kickbush (2000) also recognise the essential role that health literacy in
schooling could play in enabling people to make healthy choices leading to
productive and fulfilling lives. However, there is no universal agreement over the role
of schools in educating for health. Health promotion advocates believe schools fall
short of their alleged responsibilities, citing ongoing issues of: competing agendas;
low priority and low status; few trained health education teachers; lack of resources;
ad hoc support from health services and significant gaps between the policy and
practice of health promotion within Australian schools (Marks, 2010; Ridge, et al.,
2002). Consequently whilst schools are mandated to teach health education, there is
considerable disjuncture between broad expectations and schools’ capacities to
deliver programs that promote healthy living.
Almost one fifth of Australia’s population comprises children aged 0-14 years. Their
health and wellbeing are critical as they are considered to be the key to Australia’s
3
future (Australian Institute of Health and Welfare, 2009). The latest national report on
their health indicates that significant concerns still exist regarding disability, diabetes
and dental decay, as well as there being too many children who are sedentary,
overweight, eating unhealthily, homeless or at risk of homelessness, and who are
victims of assault (Australian Institute of Health and Welfare, 2009). Further, in 2009,
the top ten issues of concern to young Australians (n=48,000), aged predominantly 11
– 19 years, were in ranked order: drugs, suicide, body image, family conflict,
bullying/emotional abuse, alcohol, physical/sexual abuse, personal safety, coping with
stress, and depression (Mission Australia, 2010).
Schools, health and education
International health and education sector organisations readily support the notion that
“healthier students are better learners” (Basch, 2010, p. 4). Health and Physical
Education (HPE) commentators have captured the health related significance of
school settings noting, the “school is one of the key institutional influences on
children and youth...and a key site for education about healthy lifestyles” (Tinning,
1996, p. 8). Advocates within the health sector argue that the “interaction between
schools and young people, and the overall experience of attending school, provides
unique opportunities for health promotion which can be sustained and reinforced over
time” (National Health and Medical Research Council (NHMRC), 1996, p.1). Health
and education advocates suggest that schools exhibit a number of characteristics
which are critical to the successful implementation of health promotion initiatives
including: the close and regular student–teacher contact; coverage of formative years,
unique opportunities to provide a sustained and reinforced program; and, the capacity
to capture all children irrespective of socioeconomic status, ethnicity, or location
(Basch, 2010; Marks, 2010).
4
Health education in schools, however, has been fraught with political agendas and
territorial debates. From the early nineties, efforts by educators to name and define a
HPE related Key Learning Area (KLA) have stimulated considerable debate and
contestation, with some commentators even claiming a crisis of identity for PE (Kirk,
1996; Thorpe, 2003). PE and sport advocates have depicted a desperate state of
affairs, variously arguing that Australian children: had poor fitness and motor skill
levels; experienced poorly designed school PE and sport; lacked role models or
trained teachers; and, faced inequitable opportunities (SSCERA, 1992). Meanwhile,
health and education experts treated sport advocacy with suspicion, drawing attention
to reductions in youth participation, highly competitive adult attitudes, inequitable
opportunities and rising participation costs (QG, 1992). Despite this, the KLA was
eventually entitled Health and Physical Education, flagging the formal union of
health education, physical education and personal development outcomes to be
pursued under the auspices of this KLA (Macdonald & Kirk, 1999). Nationally, the
HPE KLA reflected Australia’s commitment to WHO initiatives and health promotion
theories. Consequently, the rationale of the Queensland HPE KLA establishes a
sociocultural approach to health as one of four key messages of the syllabus, with
physical activity engagement, social justice principles and learner-centred approaches
constituting the other three (QSCC, 1999). According to syllabus support materials a
sociocultural approach to HPE emphasises a multi-dimensional nature of health, the
promotion of health through individual and collective action and the influence of
social, cultural and physical environments on health, physical activity and personal
development (QSCC, 1999).
5
Within the rubric of health promoting schools, the curriculum continues to be
regarded as the essential site to achieve maximal influence on the health behaviours of
young people (Fetro, 2010; Rowling, et al., 1998). Interest in a health agenda for
Australian school curricula has ensured the inclusion of health as a component of
Australia’s goals of schooling (MCEETYA 1989, 1999). In the latest iteration of
these goals, confident and creative individuals are those who “have the knowledge,
skills, understanding and values to establish and maintain healthy, satisfying lives”
(MCEETYA 2005, p.9) and “a sense of self-worth, self-awareness and personal
identity that enables them to manage their emotional, mental, spiritual and physical
wellbeing” (MCEETYA 2005, p. 9). Such potential is reflected in the World Health
Organisation’s Health Promoting Schools (HPS) approach, an internationally
recognized strategy for the design and delivery of positive and comprehensive school
health promotion programs. These have included a range of macro and micro health
intervention strategies focusing on community partnerships and school policy such as
physical activity and dietary strategies promoted in Queensland, Australia through the
Eat Well Be Active: Healthy Kids for Life action plan (Queensland Health, 2005).
In spite of significant investments of time and effort into school based health
programs (McCuaig, 2011; Wright & Harwood, 2009) many believe that such
programs “have never been fully embraced” (Basch, 2010, p.7). Although education
authorities recognise the opportunities of intersecting health and education agendas,
“this rhetoric is not matched by a carefully articulated policy and plan which is
adequately funded, on a sustainable basis, in human and financial terms” (Stewart,
Parker, & Gillespie, 2000, p. 253). Nationally and internationally, research would
suggest that “high quality, strategically planned, and effectively coordinated school
6
health programs and policies have not been widely implemented” (Basch, 2010, p. 7).
Central to the tensions between education and health agendas is the perception by
schools and teachers that health promoters and their organisations attempt to dictate
school policy and practice, with schools viewing health and education sector goals as
having competing agendas and languages (Macdonald, Abbott, Hay, McCuaig, &
Monsen, 2010; Macdonald, et al., 2009). As Ridge et al (2002) argue, the “language
that emanates from the health sector is not central to the running of schools, or a part
of teachers’ thinking” (p. 28). Paradoxically then, SBHE curricula, considered to be
the essential site of impact, have failed to achieve the accountability that would
ensure its sustained presence within the core business of Australian classrooms.
Consequently, Australian SBHE is littered with well intentioned and thoroughly
researched programs that have failed to gain sustained purchase within the everyday
curriculum of Australian classrooms (McCuaig, 2008). Literature pertaining to SBHE
programs has consistently identified the classroom teacher as the most significant
component of effective school health education (Ridge, et al., 2002). Consequently,
the limited support and training to ensure the uptake of SBHE principles and
pedagogical approaches by teachers has been of considerable concern (Ridge, et al.,
2002; Rowling, et al., 1998). In the absence of teacher confidence and competence,
schools have tended to rely on health promotion professionals, external agencies
and/or one-off issue related presentations. It is against this background, that we argue
the strength of a health literacy approach to SBHE.
Health literacy in practice
Health literacy is complicated by multiple definitions contingent upon the context in
which health literacy demands are made (e.g., health care, media, fitness facilities)
and the skills that people bring to that situation (Bush, et al., 2010; Rudd, Moeykens,
7
& Colton, 1999). Many studies purporting to discuss ‘health literacy’ focus on
information, knowledge and action within health care settings; what might be better
termed ‘medical literacy’ (Peerson & Saunders, 2009). Health literacy then, as it is
generally reported in the literature, relates to an individual's ability to read, understand
and use healthcare information to make decisions and follow instructions for
treatment. The 2006 Adult Literacy and Life Skills survey revealed that nine million
Australians or 60 percent of the population between the ages of 15 and 74 years do
not have the basic knowledge and skills to understand and use information about their
own health (Australian Bureau of Statistics, 2006). Further afield, it has been
suggested that some 90 million Americans have difficulty reading texts with moderate
levels of complexity and yet most health related texts use highly sophisticated and
complex forms of language.
Although the term ‘health literacy’ has been in use for at least 30 years, Nutbeam
(2008) has more recently drawn attention to the continuing lack of systematic
attention to a broader approach to health literacy. Indeed, contemporary international
literature on health literacy provides a limited evidence base for current models of
health literacy (Rootman & Gordon-El-Bihbety, 2008) and highlights the need for
further research (Keleher & Hagger, 2007). Researchers indicate a need to increase
our understanding of the role of various factors and relationships relevant to the
‘decisional balance’ about health issues for individuals and population groups, and the
impacts on everyday life (Peerson & Saunders, 2009). Others claim that there is a
paucity of research concerning the ‘complex interaction between general literacy,
health literacy, information technologies and the existing health care infrastructure’
(McCray, 2005, p. 158). Consequently, more comprehensive analytic frameworks are
8
needed to better capture the meaning of ‘health literacy’ as opposed to ‘medical
literacy’ (Peerson & Saunders, 2009), in order to make it user-friendly for
professionals in, and consumers of, medical and allied health services, including
school based health educators. Finally, such work needs to address individuals and
population groups of different ages and life stages (Fetro, 2010; Nutbeam, 2008).
In arguing for a more holistic and critical view of health literacy we suggest that
health literacy should address the capacity of individuals to understand and act on
multiple health messages not only in health-related settings, but also in the social
communities and environments in which they live. This approach highlights the social
conditions within which individuals live their lives, thus it shifts the locus of control
from individuals alone, to more complex conditions of influence from groups,
governments, institutions and global media, and the resources they provide and/or
withhold. Thus we prefer the term ‘health literacies’ in a move away from an
individual capacity to control one’s health, to a focus on the way in which an
individual comprehends and manages their health across multiple contexts, with
multiple messages relayed in multiple forms from multiple stakeholders. Further,
critical literacies focus upon the broader socio-historical influences on the production
of texts, whereby text interpretation and production invite multiple meanings,
perspectives and points of view at different times in different places by different
groups and individuals. This perspective, underpinned as it is by critical theory (see
Landow, 2006), also advocates active (virtual and real) civic participation for social
change.
9
Contemporary social messages are relayed in both local and global contexts via
different and often interconnected text forms including linguistic or written, visual,
audio, gestural, and spatial modes. These modes are often combined within texts, so
the ability to make meaning from integrated modalities within texts is a crucial feature
of being literate in contemporary society (Cope & Kalantzis, 2000). Being health
literate is no exception as health information, knowledge and understandings are
drawn from a wide range of modalities (Rossi & Ryan, 2006; Ryan & Rossi, 2008).
For example, the use of written information and slogans, visual images and tabulated
nutrition data on packaged food needs to be understood in terms of the new meanings
that are created by the relationships between, and possible contradictory messages
across, these modes. Unsworth and Chan (2009) suggest that integrative interpretation
of multimodal texts is one of the most challenging tasks of understanding texts in
today’s world. In other words, it is not only important to understand the visual
components or written components or audio components of a text; one must
understand how the integration of these modes affects the meaning and impact of the
text and the ways in which it can be used, for example, to enhance or harm one’s own
health or the health of others.
This holistic and critical approach to health literacies is guided by complementary
theories of salutogenic health and wellbeing advocated by Anton Antonovsky (1996),
and socio-cognitive and transformative literacy theories and pedagogies (for example
Freebody & Luke, 1990; Luke, Comber & Grant, 2003; Kalantzis & Cope, 2005). A
salutogenic approach to health eschews a deficit model of health and non-illness, and
recognizes both individual and social influences on being healthy. This approach
complements socio-cognitive literacy theory and pedagogy that sees students’
10
backgrounds, prior knowledges and literacy abilities in productive rather than deficit
terms, and utilizes both cognitive (individual) strategies and social influences to
enhance literacy development (Kalantzis & Cope, 2005). The complementarity of
these approaches enables a powerful conceptualisation of health literacies as an
active, participatory curriculum agenda that meets the needs of young Australians in
diverse contexts, operating within different social, political and cultural conditions.
A Health Curriculum Framed by Wellness and Literacies
In the dominant pathogenic model of health literacy as outlined previously, a person’s
health is generally considered in deficit terms and is referenced against states of
illness with the objective of medical and health services to return the person to a state
of non-illness. Such a ‘downstream’ focus on health lies outside the optimal
conception of health advocated by the World Health Organisation (Antonovsky,
1996). Antonovsky conceptualised health as a multidimensional continuum with what
he called ‘health-ease’ at one end and ‘dis-ease’ at the other. This means that health is
defined by wellness and people fit on to the continuum in various places. A
salutogenic model of health mobilised through more comprehensive health literacies
curricula aims to move young people closer to the ‘health-ease’ end of the continuum.
Hence Antonovsky’s approach to health is not simply a conception of what health is,
rather it focuses attention on an individual’s access to, and use of, resources in the
creation, preservation and development of healthy living within their social
environments.
Antonovsky (1996) took this philosophy of health further by arguing that the degree
to which an individual coped with the “inherent stressors of human existence” (p.15)
was an indicator as to where someone might be on the health-ease/dis-ease
11
continuum. He indicated that these general resources of resistance give an individual
their ‘sense of coherence’. The strength of a person’s ‘sense of coherence’ (SOC),
shaped by consistency of experiences, underload-overload balance, and participation
in socially accepted decision-making, is what places them in the health-ease/dis-ease
continuum. The SOC is a generalised orientation towards the world, on a continuum,
which perceives one’s place in the world as meaningful, comprehensible and
manageable. Meaningfulness is denoted by a motivation and a wish to cope with the
inevitable stressors of life; comprehensibility is realised by a belief that one
understands the challenge of life; and manageability is evident in a belief that
resources are available to help cope with the challenge. The particular combination of
cognitive, behavioural, social and motivational factors, which can vary for
individuals, contexts and cultures, is what makes it a powerful, comprehensive and
systematic theoretical guide for practice (Antonovsky, 1996).
Following Antonovsky, we contend that health literacies must incorporate people’s
own literate practices, prior knowledge and circumstances, so that health decisions are
manageable and meaningful for them in their specific social environment. This view
sees health literacies as the knowledge and wide range of skills that people start to
develop in their early years and continue over their lifetimes to seek out, comprehend,
evaluate, and use health information and concepts to make informed choices, reduce
health risks, and increase quality of life (Zarcadoolas, Pleasant, & Greer, 2005). This
focus on active participation in one’s health (see also Kickbusch, Wait, & Maag,
2005) is closely aligned with Kalantzis and Cope’s (2005) pedagogy of multiliteracies
with its commitment to active forms of learning by individuals within particular social
and cultural contexts. Multiliteracies pedagogy sees learning across various modes as
12
a combination of: experiencing both known and new ideas, practices and
understandings; conceptualising new concepts and theorising about outcomes, risks
and effects; analysing knowledge in different forms and relating it critically to
broader issues and contexts; and applying new understandings in both conventional
and innovative ways. Nutbeam (1999) also suggests a concept of health literacy needs
to include critical elements. He sees critical health literacy as the ability to critically
analyse information, increase awareness and participate in action to address barriers
to good health. This concept has strong parallels with multiliteracies and Freebody
and Luke’s (1990) Four Resources Model of literacy, central to educational reforms in
Australia. Freebody and Luke note that effective literacy draws on a repertoire of
practices that allow learners, as they engage in reading and writing activities, to break
the code of texts, participate in the meanings of text, use texts functionally, and
critically analyse and transform texts (Ryan & Rossi, 2008). These approaches to
literacy teaching and learning are underpinned by the central idea that literacy is a
cultural practice with significant implications for how schools contribute to social
access and equity, cultural assimilation and discrimination and economic power
(Luke, Comber, & Grant, 2003). Texts in all their forms are key moments where
social identity and power relations are negotiated and established, and they do so
through a variety of textual and semiotic features (Fairclough, 1989). Thus it is
important to understand the lexical, grammatical and semiotic features of texts that
are both consumed and produced to identify the meanings and subject positions that
bestow or reduce power in everyday life.
A framework for guiding health (literacies) curriculum development
The framework we propose (see Figure 1) uses Antonovsky’s continuum of health
for quality of life, and recognises that individuals and groups need to be active
13
participants in their own health (under their particular social/cultural/economic
conditions) by making decisions that are best for their lifestyle and situation at
different times (Fetro, 2010). The value of this framework is that it offers a systematic
blueprint for collaborative curriculum development across national, state and school-
based stakeholders.
In providing a framework for collaborative curriculum development, rather than a
prescribed curriculum package, we take the position that knowledge is emergent
rather than static and transmitted (Davis & Sumara, 2000), and that it is generated
through an array of experiential possibilities. Thus, in practice it recognises that
teachers and students and the idiosyncracies of their context, relationships,
background knowledge, interests etc are pivotal to student learning outcomes (Hayes,
Mills, Christie, & Lingard, 2006). Accordingly, curriculum innovation research (often
seen in health-related content areas), that takes a quasi-experimental approach relying
on teaching fidelity to a curriculum package may produce disappointing outcomes in
terms of student learning and behaviour changes (see for example, beyondblue
initiatives, Sawyer et al., 2006). Therefore the curriculum making process we
advocate helps to overcome criticisms of curriculum innovation, for example in
Australia over the past two decades, whereby design has resided with bureaucrats
(Marsh, 1987) and ‘done’ as little more than “batch processing and transmission”
(Green, 2003, p. 129).
Within the framework (Figure 1), the multiliteracies knowledge processes (Kalantzis
& Cope, 2005) indicate ways in which we actively come to know our health through
experiencing, conceptualising, analysing and applying our knowledge. School
14
curriculum can utilise scenarios and real-life examples that enable students to engage
with, and create health knowledge in active ways. From our salutogenic and critical
perspective, being health literate requires the provision of inter-connected resources at
local and global sites of health pedagogy, to enable individuals and groups to engage
meaningfully in health contexts and with multimodal health-related texts. The New
London Group (2000) posits multiple modes from which we make meaning and
understand our world. The framework foregrounds the importance of literacy
resources to make meaning of combinations of visual, written, audio, gestural and
spatial texts, given that the ability to process information from integrated modes of
delivery is a key element of being (health) literate in contemporary society (Unsworth
& Chan, 2009). Luke and Freebody’s (1999) Four Resources Model of literacy has
been utilised in the framework to indicate key foci for health literate behaviours.
Explicit attention to codes and conventions of health-related texts and contexts (code
breaking) is essential, yet on its own is not sufficient. Understanding such texts and
contexts in relation to one’s own background, experiences and current situation
(meaning making), and having the skills and knowledge to use these understandings
in practical ways (pragmatic use) is crucial for health literate citizens. Of course, the
three resources of code breaking, making meaning, and pragmatic use, do not occur in
a vacuum. Health literate citizens must also be aware of the impact of their choices
and understandings on others, whether they have the best information for their
situation and what other alternatives they may have (critical analysis). Indeed,
sometimes health choices are group decisions or require a sustained collective effort
to enact change (Antonovsky, 1992). These resources need to be developed
interdependently so that individuals and groups have repertoires of skills and
knowledge to draw upon as active participants in their own health.
15
Insert about here: Figure 1 Framework for Health Literacies Curriculum
Development
The framework outlined here recognizes core principles of literacy development used
in school literacy programs, namely the complex repertoires of practice required to
engage with different texts and contexts. Thus, it can provide a smooth extension into
the health education curriculum for classroom teachers who are already familiar with
key mainstream literacy approaches. Intellectual rigour in the curriculum necessitates
deep and substantive knowledge of discipline areas. Freebody, Maton and Martin
(2008) argue that the ways of working within disciplines will vary according to key
topics, social and cultural functions, and the ways in which knowledge is generated.
These values and philosophies about how knowledge is generated, its purposes and
cultural functions, also determine the kinds of texts that are consumed and produced.
Moje (2008) sees these disciplinary knowledges and skills as integral to becoming
active and informed participants in society. Moje (2008) argues that students should
learn how to enact particular identities in different disciplines. She suggests that
teachers need to provide opportunities for students to develop metadiscursive skills,
whereby they not only engage in the different discourse communities of the different
disciplines, but they also know how and why they are engaging and what those
engagements mean for them and others in terms of social positioning and power
relations. In attending to the disciplinary literacies of health as degrees of wellness,
using familiar literacy frameworks, the model accounts for active, salutogenic ways of
knowing and understanding that can be implemented by classroom teachers in an
ongoing, context specific manner.
16
Conclusion
Utilising Antonovsky’s (1996) philosophy of healthy living to underpin the
framework outlined in this paper enables a comprehensive and more sophisticated
view of health literacies in contemporary society. Schools and teachers in particular,
can use the framework we have developed to plan robust SBHE, which attends to
rigorous content knowledge, socially just views of health development, and also to
salutogenic decision-making skills that enhance young people’s ‘sense of coherence’.
Our approach is consistent with national curriculum design initiatives (Australian
Curriculum Assessment and Reporting Authority, 2010) in that it prioritises the
importance of context in curriculum-making. We envisage the next step in our
research program is to work with schools to trial the model, ascertain its impact on
students’ health literacies, and consequently refine the framework. Further,
foregrounding educational discourse, and particularly current theorising from the field
of literacy, provides a framework and resources for health educators beyond the
school context to understand and promote positive, ongoing, healthy decision-making.
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Figure 1 Framework for Health Literacies Curriculum Development