Critical health literacy: reflection and action for health

Conceptualisation of critical health literacy-insights from Western and East Asian perspectives: a scoping review

This article describes a scoping review of components of critical health literacy (CHL) and examines how these components have been conceptualised, highlighting fundamental differences from the Western and East Asian perspectives. The review includes 23 studies, with the majority (n=19) from Western countries and only two from East Asia. Three primary components of CHL were identified: 'information appraisal', 'understanding of social determinants of health (SDH)' and 'actions to address SDH'. The findings indicate that these prevailing components of CHL are largely grounded in Western social structures, while East Asian studies primarily focused on the first component. Given the distinct social and cultural norms in these regions, this study explored the potential differences in how social factors influencing health are understood and prioritised in Western versus East Asian contexts. From a Western universalistic perspective, actions to address SDH often involve political and social movements aimed at improving individual and community health. However, such actions may not be feasible or relevant for many East Asian population groups, who may have more limited opportunities to engage in Western-style social movements, and culturally, have a stronger focus on family and local community. Furthermore, building on the theory of 'distributed health literacy', we argued that interpersonal-level actions to address SDH are also crucial and can serve as a stepping stone to social-level actions, which have been more extensively discussed in Western literature. We conclude that CHL is a context-specific concept, and its definition and practical application need further examination across different contexts.

Sociodemographic and health-related factors associated with low health literacy among Indigenous populations: a systematic review

Indigenous people represent 6% of the world's population and, over time, this population has faced different negative consequences, including those related to health. Health literacy is a variable that can help reduce the health-related harm faced by Indigenous people, since low health literacy has been considered a public health problem. The aim was to review the literature on sociodemographic and health-related factors associated with low health literacy among Indigenous people. To do this, we conducted a systematic review following the recommendations of the PRISMA Statement and approved by PROSPERO (CRD42024591888). A total of seven articles make up the results of this review. The findings show that the low health literacy of Indigenous people is associated with sociodemographic characteristics (e.g. older age, male gender, lower income and educational level) and health-related aspects such as having more than one chronic condition, low perception of COVID-19 risk, low chance of cancer screening, poorer glycemic control, eating behavior, self-monitoring of blood glucose and knowledge about diabetes and difficulty in understanding health information (e.g. medication labels). Although the number of articles selected for this review was small, it should be noted that they all presented a low risk of bias. Sociodemographic and health factors are associated with low health literacy among the Indigenous population. The findings demonstrate the importance of planning public policies to promote health and especially health literacy among this neglected population.

Association of Health Information Literacy and Health Outcomes Among Individuals with Type 2 Diabetes and Metabolic Syndrome

Objectives: Based on social cognitive theory, this study aims to explore the associated factors of and whether and how health information literacy was correlated to health behavior and glycemic control among individuals with type 2 diabetes and metabolic syndrome. Methods: Following convenient sampling, this cross-sectional, correlational study was conducted among 225 patients with type 2 diabetes and metabolic syndrome from an outpatient clinic in a suburban area of Beijing, China. Hierarchical multiple regression and mediation analysis were performed to explore the effect of health information literacy on self-management practice and hemoglobin A1c in this sample. The STROBE guidelines for cross-sectional studies were followed. Results: The findings showed incompetent health information literacy, inadequate self-management behavior, and suboptimal glycemic control in a sample of patients with type 2 diabetes and metabolic syndrome. Based on social cognitive theory, the results of regression analysis indicated that self-management attitude, health problem-solving, and chronic illness resources were correlated with self-management practice, and health problem-solving and health information evaluation were correlated with hemoglobin A1c. Mediation analysis revealed that self-management attitude, health problem-solving, and chronic disease resources fully mediated the effect of health information literacy on self-management practice. There was an indirect effect of health information literacy on hemoglobin A1c through health problem-solving. Conclusions: The findings demonstrated that health information literacy has significant indirect and direct effects on self-management behavior and glycemic control through self-management attitude, health problem-solving, and chronic disease resources in a sample of patients with type 2 diabetes and metabolic syndrome.

eHealth Literacy and Cyberchondria Severity Among Undergraduate Students: Mixed Methods Study

Background

With the development of the internet, health care websites have become increasingly important by enabling easy access to health information, thereby influencing the attitudes and behaviors of individuals toward health issues. However, few studies have addressed public access to health information and self-diagnosis.

Objective

This study investigated the background factors and status of cyberchondria severity among college students by conducting a nationwide sample survey using the Cyberchondria Severity Scale. Further, we explored the perspective of eHealth literacy of those with scores higher than 1 SD from the mean by analyzing their recent experiences using web-based health information.

Methods

A nationally representative sample of college students was surveyed, and 802 valid responses were obtained (male: 435/802, 54.2%; female: 367/802, 45.8%; mean age 20.3, SD 1.4 years). The Cyberchondria Severity Scale was used, which consisted of 4 dimensions (increased anxiety, obsessive-compulsive hypochondria, perceived controllability, and web-based physician-patient interaction). Additionally, we recruited 9 volunteers who scored more than 1 SD above the mean for in-depth interviews on their web-based health information-seeking behaviors.

Results

Significant differences were found across the 4 dimensions of cyberchondria severity (F3,2403=256.26; P<.001), with perceived controllability scoring the highest (mean 2.75, SD 0.87) and obsessive-compulsive hypochondria scoring the lowest (mean 2.19, SD 0.77). Positive correlations were observed between perceived controllability, web-based physician-patient interactions, increased anxiety, and obsessive-compulsive hypochondria (r=0.46-0.75, P<.001). Regression analysis indicated that health concern significantly predicted perceived controllability (β coefficient=0.12; P<.05) and web-based physician-patient interaction (β coefficient=0.16; P<.001). Interview data revealed that students often experienced heightened anxiety (8/9, 89%) and stress (7/9, 78%) after exposure to web-based health information, highlighting the need for improved health literacy and reliable information sources.

Conclusions

The study identified both benefits and risks in college students' use of web-based health information, emphasizing the importance of critical consciousness and eHealth literacy. Future research should examine how college students move from self-awareness to actionable change and the development of critical health literacy, which are essential for effective digital health engagement.

[The emancipatory perspective of health literacy in Brazil: contributions from the Freirean thought to knowledge translation regarding a global concept]

This article seeks to reveal the potential for applying key principles of Freirean pedagogy for the effective translation of knowledge and practices associated with the concept of health literacy followed worldwide, based on a critical and emancipatory perspective. It starts from the observation that the process of adopting the concept in Brazil has been more utilitarian than critical, with initiatives predominantly focused on the translation and use of instruments to assess health literacy among population groups. In doing so, this approach has overlooked the academic contributions, practical actors, and social movements in various regions of the country, regarding the application of principles and values of Paulo Freire's thought for the emancipatory promotion of health for individuals and population groups. Based on the identification of Freirean thought's core principles, as reflected in the vast international literature on health literacy, the article highlights possible contributions of Paulo Freire's thought and pedagogy to the consolidation of knowledge and practices for promoting health literacy in Brazil, in its critical and emancipatory perspective. Finally, it argues that health literacy must be considered a key element for promoting autonomy and empowerment among individuals and population groups, enabling them to recognize their fundamental right to health and their role as citizens. This empowers them to interact with other community members, engage in initiatives for individual and collective health promotion, and engage in dialogue with representations of social structures within their territory or community.

Research on the status and influencing factors of maternal health literacy among postpartum women in urban villages

AIM

To comprehensively identify the status and influencing factors on maternal health literacy among postpartum women in Guangzhou urban villages.

DESIGN

An explanatory sequential mixed-method research was conducted from November 2021 to July 2022.

METHODS

The quantitative survey was conducted among postpartum women in Guangzhou urban villages using the convenience sampling principle, and a questionnaire survey was used to reflect the status and influencing factors on maternal health literacy. The qualitative interview conducted purposive sampling based on the survey and semi-structured interviews with women to supplement the non-quantifiable influencing factors.

RESULTS

The quantitative survey showed that the maternal health literacy score of 501 women was 193.84 ± 22.23. The quantitative results suggested that ethnicity, education, income, household registration, delivery mode and social support were important influencing factors (p < .15). The qualitative interviews were conducted with 16 women and revealed three themes and eight sub-themes, including demographic factors (ethnicity, education, income, occupation and family history), pregnancy factors (delivery mode and pregnancy complications) and social factors (social support), which influenced maternal health literacy through three routes: women's motivation, access and ability in screening health information.

CONCLUSION

Maternal health literacy among postpartum women in urban villages needs to be improved, especially critical health literacy. Maternal and infant workers need to guide women to develop appropriate health information concepts and consider the realistic knowledge needs of women in different socio-cultural and economic backgrounds. They should also construct a comprehensive social support system for women to better improve maternal health literacy.

IMPACT

Highlights the positive benefits of maternal health literacy among postpartum women, as preparation for providing accurate and effective maternal and child health education services.

PATIENT OR PUBLIC CONTRIBUTION

The information on maternal health literacy in this study was based on an interview with postpartum women in Guangzhou urban villages during the study period.

Overcoming doubt: developing CDoH Essentials, a practical tool to introduce the commercial determinants of health

Despite growing awareness of the importance of commercial determinants of health (CDoH), there has been limited development or evaluation of educational and practice-focused support for public health professionals. This article reports findings from an action-research approach bringing together people with academic and practice expertise (n = 16) to co-create workshop materials (called 'CDoH Essentials'), test and improve them through five trial workshops and explore their effects. Five English local public health teams co-facilitated the workshops in their organizations, with participants from public health teams and their internal partners (n = 94). Quantitative and qualitative data were collected throughout and analysed to understand: (1) whether the workshops met the expectations of participants, public health and academic observers, and (2) the effects of workshop participation on (a) participants' knowledge, understanding and critical CDoH literacy, and (b) subsequent working practices and attitudes. The co-created CDoH Essentials appeared effective in meeting expectations, improving knowledge and critical CDoH literacy and promoting action on CDoH. The proportion of participants reporting 'little' or 'no' CDoH knowledge fell significantly following the workshop (55.4% vs 2.7%). Participants' increased understanding supported reflection on the implications of the CDoH for their roles and for wider strategy and action. After 3 months, all five settings reported greater consideration of CDoH and had initiated or planned action. CDoH Essentials could be used to galvanize more effective public health action to tackle the CDoH in England and trialled in other public health contexts.

Evaluation of a multi-component prevention concept for hazardous substance use among refugees in shared accommodations: study protocol for a cluster randomized controlled trial

BACKGROUND

Refugees are exposed to various risk factors in shared accommodations in Germany where they are housed after their arrival. Due to their often traumatic experiences before, during, and after their flight and socio-structural post-migration stressors, refugees are potentially vulnerable to hazardous substance use. They form a structurally disadvantaged group for substance use prevention and intervention. Various barriers make it difficult for them to access the healthcare system and to get health information. Therefore, a participatory multi-component prevention concept for refugees in shared accommodations was developed. The aim of the trial is to evaluate the efficacy of this concept regarding the increase in knowledge about substance use among refugees living in shared accommodations.

METHODS

Based on a randomized controlled stepped-wedge design, the study will be conducted in a multicenter setting in nine shared accommodations and will aim to include refugees living in shared accommodations as well as social workers and psychologists working there.

DISCUSSION

This trial will be one of the first to generate evidence about effective participatory prevention concepts for refugees in shared accommodations. Evidence-based concepts for refugees can improve access to health care and might be helpful for the multidisciplinary workforce in shared accommodations.

TRIAL REGISTRATION

OSF Registry: osf.io/ebnj3. Registered on May 24, 2024. Registration DOI: https://doi.org/10.17605/OSF.IO/EBNJ3.

'You are making it sound like you are talking to a child': exploring community sentiment on developing and disseminating tailored sexual health education resources for migrants

Health communication is a critical component of public health, which includes health education resources. Resource effectiveness is improved where health literacy demands, including the cultural appropriateness of resources, match the intended audience. International guidelines support the tailoring of resources for migrants from culturally and linguistically diverse backgrounds (CaLD). Five focus groups (n = 18) and interviews (n = 9) with people from CaLD migrant backgrounds explored community perspectives on sexual health resources developed by a state department of health, specifically clarity, comprehensiveness, cultural appropriateness and strategies for dissemination. We identified three major thematic areas relating to simplicity, cultural norms and beliefs and dissemination. Participants recommended resource delivery in different formats as part of a broader intervention. Generally, sexual health information was deemed appropriate and easily understood. However, the resources used simplified language that participants reported was vague and inaccurate at times, potentially contributing to misinformation and reinforcing stigma relating both to the status of being a migrant and sexual health. Findings suggest the need for more nuanced health resource development beyond translation and language simplification. Resources developed in different formats, including different health literacy demands, using approaches that engage the target group in design and dissemination and contextualized within a comprehensive health promotion project, are likely to be more effective.

Practices and Barriers in Developing and Disseminating Plain-Language Resources Reporting Medical Research Information: A Scoping Review

BACKGROUND

The intent of plain-language resources (PLRs) reporting medical research information is to advance health literacy among the general public and enable them to participate in shared decision-making (SDM). Regulatory mandates coupled with academic and industry initiatives have given rise to an increasing volume of PLRs summarizing medical research information. However, there is significant variability in the quality, format, readability, and dissemination channels for PLRs. In this scoping review, we identify current practices, guidance, and barriers in developing and disseminating PLRs reporting medical research information to the general public including patients and caregivers. We also report on the PLR preferences of these intended audiences.

METHODS

A literature search of three bibliographic databases (PubMed, EMBASE, Web of Science) and three clinical trial registries (NIH, EMA, ISRCTN registry) was performed. Snowball searches within reference lists of primary articles were added. Articles with PLRs or reporting topics related to PLRs use and development available between January 2017 and June 2023 were identified. Evidence mapping and synthesis were used to make qualitative observations. Identified PLRs were quantitatively assessed, including temporal annual trends, availability by field of medicine, language, and publisher types.

RESULTS

A total of 9116 PLRs were identified, 9041 from the databases and 75 from clinical trial registries. The final analysis included 6590 PLRs from databases and 72 from registries. Reported barriers to PLR development included ambiguity in guidance, lack of incentives, and concerns of researchers writing for the general public. Available guidance recommendations called for greater dissemination, increased readability, and varied content formats. Patients preferred visual PLRs formats (e.g., videos, comics), which were easy to access on the internet and used short jargon-free text. In some instances, older audiences and more educated readers preferred text-only PLRs. Preferences among the general public were mostly similar to those of patients. Psychology, followed by oncology, showed the highest number of PLRs, predominantly from academia-sponsored research. Text-only PLRs were most commonly available, while graphical, digital, or online formats were less available. Preferred dissemination channels included paywall-free journal websites, indexing on PubMed, third-party websites, via email to research participants, and social media.

CONCLUSIONS

This scoping review maps current practices, recommendations, and patients' and the general public's preferences for PLR development and dissemination. The results suggest that making PLRs available to a wider audience by improving nomenclature, accessibility, and providing translations may contribute to empowerment and SDM. Minimizing variability among available guidance for PLR development may play an important role in amplifying the value and impact of these resources.

A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study

INTRODUCTION

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them.

METHODS

Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis.

RESULTS

Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication.

CONCLUSION

SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Digitalized Social and Emotional Learning and Better Wellbeing among Displaced Syrian Adolescents in Lebanon

Syrian adolescent refugees are one of the largest forced displaced populations in the world. Displaced adolescents experience significant stressors on their mental health, including high poverty and severely limited access to mental health services. Studies show that game-based learning interventions offer the potential for increasing access to mental health supports. We employed a mixed-method pilot and feasibility study to explore how the Happy Helping Hand (HH) game app contributed to improved well-being and emotional problem-solving skills in displaced Syrian adolescents in Lebanon. A 5-week, 10-session digital learning HH psychosocial program was administered by teachers. Adolescent and teacher focus groups were used to assess how emotional problem-solving skills were applied in-depth. A single group pre-post design measured well-being using the World Health Organization's Well-Being Index (WHO-5). Thematic analysis was used for qualitative analysis. Descriptive and bivariate t-tests were used for quantitative analyses. Qualitatively, adolescent's demonstrated increased emotional problem-solving skills and well-being, and attributed the changes to the usefulness of the app. Quantitative findings show well-being significantly increased at post-test compared to pretest. The study supports the use of e-health and role-playing games for Syrian adolescents. Future research should examine an up-scaled implementation of the app with displaced adolescents.

Developing critical HIV health literacy: insights from interviews with priority migrant communities in Queensland, Australia

In Australia, surveillance data establish that there are higher rates of late HIV diagnoses among heterosexual migrants from Sub-Saharan Africa and new HIV diagnoses among gay and bisexual men (GBM) from Southeast and Northeast Asia and Latin America. Together, these groups are identified as priority migrant communities in current efforts to eliminate HIV transmissions. HIV health literacy is recognised as a key means of improving access to services and health outcomes. This qualitative paper explores critical HIV health literacy among priority migrant communities in Queensland, Australia. To foreground community voices, peer researchers from priority migrant communities participated in the project design, data collection and analysis, with 20 interviews completed. The findings demonstrate how participants' engagement with HIV health information and services is highly relational and situated within the framework of sexual health and wellbeing. Participants strategically selected where to seek information and who they trusted to help them appraise this information. They further demonstrated reflective capacities in identifying the contextual barriers that inhibit the development of their HIV health literacy. The findings highlight the need for HIV health promotion strategies that embrace a sex positive approach, promote cultural change, and involve collaboration with general practitioners (GPs).

Decolonizing nursing education: Reflecting on Paulo Freire's pedagogy of the oppressed

Historically, nursing education's foundation has been framed by colonial practices of whiteness, which serves as a fulcrum for oppression, Western epistemic ideology, racial injustice, and health inequity. As a microcosm of the broader academy, nursing education must pivot to dismantle practices impeding the advancement of the profession and move to decolonize processes of professional edification. Decolonization is not a metaphor; it requires unlearning the deep socialization of Eurocentric perspectives embedded in nursing education and relearning in a new, inclusive manner that embraces historically marginalized knowledge systems and experiences. This paper aims to operationalize what this decolonization process would look like for nursing education while reflecting on Paula Freire's Pedagogy of the Oppressed. The authors will highlight the interrelationship of the main concepts of Paulo Freire's critical pedagogy, including liberation, critical consciousness, dialog, humanization, dehumanization, problem posing, and banking education.

Serial mediation roles of empowerment and self-care activities connecting health literacy, quality of life, and glycemic control in people with type 2 diabetes

BACKGROUND

Health literacy, empowerment, and self-care activities are likely the crucial concepts affecting the quality of life and glycemic control in people with type 2 diabetes (T2D). However, evidence demonstrating the mechanisms underlying these concepts is scarce.

AIMS

The aim of this study was to test the serial mediation roles of empowerment and self-care activities on the relationships between health literacy and quality of life and between health literacy and hemoglobin A1c (HbA1c) in people with T2D.

METHODS

A cross-sectional study was conducted among 319 people with T2D in Guangzhou, China, from July 2019 to January 2020. Data were collected using the Health Literacy Scale, the Diabetes Empowerment Scale-Short Form, the Summary of Diabetes Self-Care Activities Measure, and the Adjusted Diabetes-Specific Quality of Life Scale. RStudio 4.2.1 was used for serial mediation analysis.

RESULTS

The dimension of communicative health literacy accounted for the most total variance (β = 0.810, p < .001) in the construct of health literacy. The serial multiple mediation of empowerment and self-care activities in the associations between health literacy and quality of life (β = -.046, p = .019) and between health literacy and HbA1c (β = -.045, p = .005) were statistically significant.

LINKING EVIDENCE TO ACTION

This study emphasized the vital role of communicative health literacy when improving health literacy in people with T2D. Diabetes care and education specialists could implement empowerment approaches and flexible self-care strategies to improve the quality of life and glycemic control in people with T2D. Enhancing health literacy was suggested as a favorable strategy for promoting empowerment and self-care activities in people with T2D.

Specific Medication Literacy in Older Adults with Asthma

Purpose

To explore specific medication literacy (SML) of older adults and associations of SML strength.

Methods

This was an observational study. Participants were at least 60 years old, with an asthma diagnosis and in good health. Data were collected by a registered nurse researcher. The SML data collection instrument gathered information about each medication a participant used: name, purpose, how taken, special instructions, adverse effects, and drug-drug or drug-disease interactions. An SML scoring rubric was developed.

Results

All could provide name, and most provided purpose, how taken. The lowest SML domains were side effects and interactions. Age at time of asthma diagnosis correlated with stronger SML scores and living in a disadvantaged neighborhood correlated with lower SML scores.

Discussion

Gaps in medication literacy may create less ability to self-monitor. Patients want medication literacy but struggle with appropriate, individualized, information.

Conclusion

The study provides insights on gaps and opportunities for SML.

Publishing clinical trial results in plain language: a clash of ethical principles?

Plain language resources (PLR) are lay summaries of clinical trial results or plain language summaries of publications, in digital/visual/language formats. They aim to provide accurate information in jargon-free, and easy-to-understand language that can meet the health information needs of the general public, especially patients and caregivers. These are typically developed by the study sponsors or investigators, or by national public health bodies, research hospitals, patient organizations, and non-profit organizations. While the usefulness of PLR seems unequivocal, they have never been analyzed from the perspective of ethics. In this commentary, we do so and reflect on whether PLR are categorically advantageous or if they solve certain issues but raise new problems at the same time. Ethical concerns that PLR can potentially address include but are not limited to individual and community level health literacy, patient empowerment and autonomy. We also highlight the ethical issues that PLR may potentially exacerbate, such as fair balanced presentation and interpretation of medical knowledge, positive publication bias, and equitable access to information. PLR are important resources for patients, with promising implications for individual as well as community health. However, they require appropriate oversight and standards to optimize their potential value. Hence, we also highlight recommendations and best practices from our reading of the literature, that aim to minimize these biases.

Health literacy and cultural responsiveness of primary health care systems and services in Australia: reflections from service providers, stakeholders, and people from refugee backgrounds

BACKGROUND

Primary health care [PHC] services with general practitioners (GPs) as the first point of access to health care services for people from refugee backgrounds in Australia can play a crucial role in building health literacy and promoting access to culturally appropriate services. To achieve equitable access and engagement, services and systems must be responsive to diverse health literacy and cultural needs. This study aims to explore how primary health services respond as a system and organisation to the health literacy and cultural needs of people from refugee backgrounds in Australia.

METHODS

This exploratory qualitative study involved 52 semi-structured interviews among 19 Africans from refugee backgrounds, 14 service providers, including GPs and nurses, and 19 other stakeholders, such as service managers/directors. Participants resided in New South Wales, Victoria, and Queensland. Interviews were audio-recorded, transcribed, and coded into QSR NVivo 12. Data analysis was guided by reflexive thematic analysis.

FINDINGS

Three interrelated themes were identified from the data relating to the health literacy and cultural responsiveness of PHC systems and services. The first theme, 'variable and ad hoc organisational response to health literacy and culturally responsive care,' demonstrated that some organisations did not systematically address the inherent complexity of navigating the health system nor the capacity of services and providers to respond to the cultural needs of people from refugee backgrounds. The second theme, 'individual provider responsibility,' captured the individual providers' interpersonal and relational efforts in supporting the health literacy and cultural needs of people from refugee backgrounds based on their motivation and adaptation. The third theme, 'refugee patient responsibility,' encapsulated people from refugee backgrounds' adaptations to and learning of the health system to navigate and access services.

CONCLUSION

Health literacy and culturally responsive practices need to be systematised by PHC organisations to be implemented and sustained over time. There is a need for diversity in the organisational leadership and health care workforce, organisational commitment, health literacy and culturally responsive care policies, provider training, and auditing practice as essential components of the change process. Engaging with refugee communities would allow services to focus on people from refugee backgrounds' needs by design.

Understanding Critical Health Literacy Among Adolescents: Psychometric Properties of the CHLA Questionnaire in Lower Secondary Schools in Norway

BACKGROUND

Schools are important arenas for the promotion of critical health literacy (CHL) among adolescents. Key domains of CHL are information appraisal, understanding social determinants of health, and abilities to act on determinants of health. In this paper, we examine the psychometric properties of the Critical Health Literacy for Adolescents Questionnaire (CHLA-Q).

METHODS

A cross-sectional survey study was performed at 5 schools in Norway. Respondents included 522 pupils aged 13-15 years old. Confirmatory factor analysis (CFA) was conducted to examine the structural validity. Internal reliability was assessed using ordinal Cronbach's alpha.

RESULTS

The estimated model had acceptable closeness of fit. Five of 6 scales displayed adequate internal reliability.

CONCLUSION

The results indicate acceptable fit of the CHLA-Q framework and that 5 of the 6 scales are applicable to inform future research and interventions. More research is needed on measurement of the second domain of CHL.

What should we talk about? Contributions from Freirean Thematic Investigation in health education with adolescents

Adolescence is an essential stage of life for developing actions related to health promotion, especially in health education (HE). Public policies advocate for the expansion of participative technologies in this field, as well as different theoretical and methodological perspectives subsidize these. Among these, Paulo Freire's reference guide is practiced in Brazil and around the world. From the Freirean perspective, Thematic Investigation (TI) defines the content of the educational practice. This paper describes a methodological proposal of the Freirean Thematic Investigation for developing health educational practices and promoting health among adolescents. Initially, we describe the conception of the Freirean rationale that sets the grounds for the proposed method: human being, dialogical education and reality and their connections with HE with adolescents in a critical perspective. The methodological proposal is systematized into five stages: (i) Approaching adolescents and the field of educational practices; (ii) Reading reality; (iii) Seminars for analyzing reality reading and preparing the codifications; (iv) Critical analysis of reality; and (v) Planning educational practices. The TI confronts the adult-centric perspectives that characterize adolescent health care. Moreover, as a praxis, TI is a process of reflection and action with adolescents, allowing for not only the discovery of the themes that build educational practices but also for solutions (untested feasibility) for the individual and collective problems experienced by adolescents concerning their health.

The conceptualization and development of critical health literacy in children: a scoping review

The cognitive and social practices associated with critical health literacy, such as critical appraisal of health messages and participation in political processes to address wider determinants of health, are of lifelong benefit. Understanding how and where critical health literacy development can be supported early in the life course may improve health outcomes now and in the future. This scoping review focuses on how critical health literacy in children is conceptualized and the supportive environments available for its development. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines are used in reporting. Evidence retrieved was eligible for inclusion if it contained a substantive conceptual or empirical study of critical health literacy in populations aged 7-11 (middle childhood). From the included 18 peer-reviewed and grey literature sources, schools are identified as the setting most associated with the development of critical health literacy in the target age group. However, the action-oriented dimension of critical health literacy is rarely supported in the school setting. The review concludes that further research is needed to clarify how and where to support children to develop critical health literacy in and outside of school settings.

Extending the sociology of candidacy: Bourdieu's relational social class and mid-life women's perceptions of alcohol-related breast cancer risk

Alcohol is a modifiable breast cancer risk, increasing risk in a dose-dependent manner. Mid-life women (aged 45-64 years) consume alcohol at higher rates than younger women and this, combined with age, make them a high-risk group for breast cancer. This critical public health problem has a seemingly obvious solution (reduce drinking); however, women do not necessarily know alcohol causes breast cancer, and if they do, reducing consumption is not always possible, or desirable. To innovate public health responses, we employ an interpretative sociological framework 'candidacy' to understand women's perspectives on breast cancer risk relative to alcohol consumption and their social class. Drawing on 50 interviews with Australian mid-life women, our findings reveal the socio-structural determinants of 'candidacy', that mean modifying alcohol consumption for breast cancer prevention is impacted by social class. Utilising Bourdieu's relational capitals, our interpretations show how social class shapes women's ascriptions and enactments of breast cancer candidacy. We offer an important theoretical extension to 'candidacy' by demonstrating more or less fluidity in women's assessment of breast cancer risk according to their agency to adopt breast cancer prevention messages. Understanding the social class possibilities and limitations in women's perceptions of breast cancer risk provides a new opportunity to reduce inequities in breast cancer incidence.

Fostering pupils' critical health literacy: examining the potential of physical education in lower secondary school

Background

In Norway, the introduction of an interdisciplinary subject named Public Health and Life skills has brought about renewed attention to how health is conceptualized and taught within and across school subjects. Physical education (PE) is one subject that has traditionally been linked to health outcomes. However, a narrow focus on increased physical activity as the main outcome of PE could be counterproductive in the pursuit of health. Critical health literacy (CHL) is put forward as a resource for health that can be nurtured in the PE context; this study hypothesizes that academic achievement in PE is positively associated with some aspects of CHL.

Methods

This cross-sectional study included 521 pupils aged 13-15 years old from five lower secondary schools in Norway. Structural equation models were used as the primary statistical analysis to test the hypothesis. The study controlled for parents' education, leisure physical activity, and participation in sports club activities.

Results

The results confirm the hypothesis, showing a positive and significant association between PE and CHL. The association remains when controlling for parents' education, leisure physical activity, and participation in sports club activities (β^_PE→_CHL-C1= 0.264, p = 0.001; β^_PE→_CHL-C2= 0.351, p < 0.000).

Conclusion

In our sample, academic achievement in PE was associated with higher levels of CHL. This study contributes to the ongoing discussion on the health benefits of PE. We argue that a resource-based health perspective can produce the appropriate aims for health in PE contexts and that the CHL concept contributes to illuminating key areas, promoting suitable teaching strategies, and bringing balance between an individual and collective focus for future health education, both within PE and across different subjects in school contexts.

Involving Children in Health Literacy Research

Despite the volume and breadth of health literacy research related to children, children's involvement in that research is rare. Research with children is challenging, but the principles of involvement and engagement underpin all health promotion work, including health literacy. This commentary reflects on the process of setting up a Children's Advisory Group to consult on an institutional ethnography study of health literacy work from children's standpoint. The Children's Advisory Group contributed feedback on the study ethics and design and piloted methods for rapport-building and data collection, including livestreamed draw-and-describe and modified Interview to the Double. Consulting with the Children's Advisory Group highlighted the importance of listening to children and recognizing and valuing children's imaginative contributions to methods for involving children in health literacy research. Insights from this commentary can be used to foreground equity-focused approaches to future research and practice with children in the field of health literacy.