Social determinants of health literacy in children and adolescents: a scoping review

Gomes, Adenilson da Silva; Santos, Gabrielle Morgana Rodrigues dos; Bastos, Ilka Jenifer Menezes Taurino; Sales, Jackeline Kérollen Duarte de; Perrelli, Jaqueline Galdino Albuquerque; Frazão, Cecília Maria Farias de Queiroz

doi:10.1590/1983-1447.2024.20240002.en

ABSTRACT

Objective: To map scientific evidence on social determinants related to health literacy in children and adolescents.

Method: Scoping review conducted from April to June 2023, following the Joanna Briggs Institute guidelines and the PRISMA-ScR protocol, and registered on the Open Science Framework. The keywords "health literacy," "adolescent," and "social determinants of health," including their orthographic derivatives, were combined in a search strategy used in 12 databases. The identified articles were independently screened, selected, and extracted by two researchers. Data was analyzed and discussed based on Dahlgren and Whitehead’s model of social determinants of health.

Results: Twenty-one studies found one or more social determinants related to health literacy, namely: sex, cognitive characteristics, eating habits, family structure and models, school characteristics, school environment, and parents’ conditions. Social determinants of health were classified from individual layers to macrodeterminants, according to the model adopted.

Conclusion: Multiple social determinants are related to health literacy among children and adolescents, ranging from immediate to broader contexts in their lives, requiring intersectoral educational and health approaches aligned with the Sustainable Development Goals.

Descriptors:
Health literacy; Social determinants of health; Health promotion; Adolescent; Child

RESUMO

Objetivo: mapear as evidências científicas sobre determinantes sociais relacionados com o letramento em saúde de crianças e adolescentes.

Método: revisão de escopo, realizada entre abril a junho de 2023, seguindo as diretrizes da Joanna Briggs Institute e pelo protocolo PRISMA-ScR e registrada na Open Science Framework. As palavras-chave health literacy, adolescent, e social determinants of health, incluindo as derivações ortográficas, foram combinadas numa estratégia de busca utilizada em 12 bases de dados. Os artigos identificados foram examinados, selecionados e extraídos de forma independente por dois pesquisadores. Os dados foram analisados e discutidos com base no modelo de determinantes sociais da saúde de Dahlgren e Whitehead.

Resultados: 21 estudos evidenciaram a presença de um ou mais determinantes sociais relacionados ao letramento em saúde de acord, a saber: sexo, características cognitivas, hábitos alimentares, estrutura e modelos familiares, características escolares, ambiente escolar e condições parentais. Foram identificados determinantes sociais da saúde desde camadas individuais até macrodeterminantes com base no modelo adotado.

Conclusão: múltiplos determinantes sociais relacionam-se com o letramento em saúde de crianças e adolescentes, que permeiam desde contextos imediatos até os mais amplos de suas vidas, requerendo abordagens intersetoriais educativas e de saúde alinhadas com os Objetivos de Desenvolvimento Sustentável.

Descritores:
Letramento em saúde; Determinantes sociais da saúde; Promoção da saúde; Adolescente; Criança

RESUMEN

Objetivo: Mapear la evidencia científica sobre los determinantes sociales relacionados con la alfabetización en salud de niños y adolescentes.

Método: Revisión de escopo realizada entre abril y junio de 2023, siguiendo las directrices del Joanna Briggs Institute y el protocolo PRISMA-ScR, y registrada en Open Science Framework. Las palabras clave "alfabetización en salud", "adolescente", y "determinantes sociales de la salud", incluyendo sus derivados ortográficos, se combinaron en una estrategia de búsqueda utilizada en 12 bases de datos. Los artículos identificados fueron examinados, seleccionados y extraídos de forma independiente por dos investigadores. Los datos fueron analizados y discutidos según el modelo de determinantes sociales de la salud de Dahlgren y Whitehead.

Resultados: Veintiún estudios evidenciaron la presencia de uno o más determinantes sociales relacionados con la alfabetización en salud, a saber: sexo, características cognitivas, hábitos alimenticios, estructura y modelos familiares, características escolares, ambiente escolar y condiciones parentales. Se identificaron determinantes sociales de la salud desde camadas individuales hasta la camada de los macrodeterminantes, según el modelo adoptado.

Conclusión: Múltiples determinantes sociales se relacionan con la alfabetización en salud de niños y adolescentes, que abarcan desde contextos inmediatos hasta los más amplios de sus vidas, requiriendo enfoques intersectoriales educativos y de salud en acuerdo con los Objetivos de Desarrollo Sostenible.

Descriptores:
Alfabetización en Salud; Determinantes Sociales de la Salud; Promoción de la Salud; Adolescente; Niño

INTRODUCTION

Child development includes several capacities and abilities that intersect with characteristics such as language (expressive and receptive), motor skills (gross and fine), cognitive capacity, and socioemotional aspects¹. Attitudes, beliefs, and health-related behaviors are created and modulated in this period and can help or harm life conditions²^-³.

In childhood and adolescence, behavioral standards help determine one’s current state of health and future health results⁴. In this stage, there are also more risks, negative behaviors, and health issues that can remain until adulthood⁵.

By socializing in different settings, environments, and contexts, children and adolescents expose themselves to different influences. These can be visible or invisible, and often prevent them from making their own health-related decisions⁶. This public must develop adequate health literacy to promote good health⁷.

Healthy literacy (HL) has become a complex and heterogeneous term⁸ with multiple facets, which is understood in many different ways, conceptually and semantically³^,⁹. It is a social practice that allows individuals to get, understand, and use health information to maintain and promote good health¹⁰^-¹¹. During childhood, HL gains space, and its presuppositions can be understood¹².

Acquiring HL abilities is a continuous process, starting with the first relationships between parents and children, in which the same family learns new forms of care, given the same situations they face during their contact with personal health demands¹³. HL for children and adolescents is not quite the same as HL for adults, since, even when they are unable to read and define health texts, they can learn or understand healthy behaviors in their domestic environment, actively intervening in their own care¹³.

HL also encompasses intergenerational relations of power, which are evident in all social interactions. This influences the role of children and youths regarding their health, and the formation of active behaviors in the decision making processes related to them³^,¹⁴.

HL is considered to be a social determinant of health (SDH), since it is the result of learning from one's environment. It is also a mediating factor that influences the relationship between other SDH and health outcomes⁴^,⁶^-⁷^,¹²^,¹⁵. SDH are all conditions with which people are born, live, grown, work, and age. They correspond to social, economic, political, cultural, ethnic, psychological, and behavioral factors that influence, affect, and condition the health of the population¹⁴.

Among the SDH models, Dahlgren and Whitehead's model stands out by dividing the SDH in three layers¹⁶. In the first, we find individual determinants related to the intrinsic characteristics of a subject, such as sex, age, genetic factors, and others. Then, there is a layer corresponding to behavior and lifestyle. The third layer includes community and social networks in which the individual lives. In the fourth, factors related to life and work conditions. The fifth and last layer includes the macrodeterminants, such as the structural conditions of the environment in which the individual is inserted, as well as their socioeconomic, cultural, and developmental characteristics. Considering these layers, the authors refer to the knowledge of adequate interventions and health policy formulations¹⁶.

Some studies have shown significant relationships between isolated determinants in the health literacy of children and adolescents, such as socioeconomic levels, parents educational level, and school performance¹⁶^-¹⁸. However, few works have investigated the contextual dynamics of health literacy and specified its variation throughout the early stages of life, considering the influence of the available resources²^,¹⁵.

A search for reviews with this topic at PubMed and CINAHL was carried out, but did not locate scoping reviews that listed the social determinants associated with the HL of children and adolescents, nor their equivalence with the layers in Dahlgren and Whitehead's model.

This scoping review can identify gaps in the knowledge and areas of agreement and disagreement, in addition to highlighting emerging trends and needs for future research about health literacy, in order to develop efficient policies and interventions to promote youth health and achieve the Sustainable Development Goals (SDGs). Understanding these determinants allows nursing practitioners to adapt education and communication approaches according to the specific needs of children and adolescents, promoting a better understanding and adherence to preventive and self-care health practices. This is essential to train youths to make decisions about their mental health and adopt healthy behaviors throughout their lives.

Considering the above, this review aimed to map scientific evidence surrounding the social determinants related with the health literacy of children and adolescents.

METHOD

This scoping review was conducted according to the methodology of the Joanna Briggs Institute (JBI) for scoping reviews¹⁹. To start the research, the study protocol was developed and registered in the Open Science Framework²⁰. This manuscript followed the checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR)²¹. All stages were conducted from February to May 2023.

Eligibility criteria were defined according with the PCC strategy (Population, Concept, and Context), according to the JBI recommendations described below:

Population: Original studies carried out with children and/or adolescents from 6 to 18 years of age whose topic was HL and SDH. There were no restrictions regarding geographic location, language, or time of publication.
Concept: This review considered studies and articles that evaluated the relationship between the SDH and SL of children and adolescents. For these purposes, HL is understood as abilities that enable individuals to obtain, understand and use the available health information to make decisions and perform actions that may affect the state of their health¹¹. SDH, in turn, was understood as the set of interconnected factors and social structures in the lives individuals that influence the state of their health¹⁴. Therefore, this study included all studies found that could demonstrate a relationship between SDH and HL via association tests, correlation tests, mean or median difference tests, or regression analyses. The p-value was p<0.05, and papers were excluded from this study when they did not inform or analyzed the relationship significantly.
Context: studies with adolescents and/or children in several contexts were included.

This was done considering the following questions: Which social determinants are related to the HL of children and adolescents? In which layers of the Dahlgren and Whitehead model are the SDH related with the HL of children and adolescents?

This scoping review considered randomized clinical trials, non-randomized controlled trials, case-control, cross-sectional studies, and observational analytical studies, including prospective and retrospective cohort studies. We also included descriptive cross-sectional studies that described the tests used to verify the existence of relationships between SDH and HL. Regarding gray literature, theses and dissertations that pointed out some kind of relationship between DHS and HL were consulted.

The next step was the development of a three-step research strategy. At first we carried out an initial research, limited to MEDLINE (PubMed) and CINAHL, to identify studies relevant to the topic. These were analyzed in the search for words in their titles, abstracts, and the descriptors used to describe them. These keywords and descriptors were used by a librarian, who developed a complete search strategy in MEDLINE via PubMed.

The terms Health literacy, adolescent, and social determinants of health were used as MeSH (Medical Subject Headings) descriptors in all fields. The search for the descriptors included all its orthographic variations, (e.g.: “Health Literacy"[MeSH Terms] OR “Health Literacy”[All Fields]). Finally, all searches carried out with each separate descriptor were crossed, leading to the following search strategy: ("Health Literacy"[MeSH Terms] OR "Health Literacy"[All Fields] OR ("Health Behavior"[MeSH Terms] OR "Health Behavior"[All Fields] OR "Health Behaviors"[All Fields] OR "health related behavior"[All Fields] OR "health related behavior"[All Fields] OR "health behaviour"[All Fields] OR "health promoting behavior"[All Fields] OR "health promoting behaviour"[All Fields] OR "health related behaviour"[All Fields])) AND ("Child"[MeSH Terms] OR "Child"[Title/Abstract] OR "Children"[Title/Abstract] OR "Adolescent"[MeSH Terms] OR "Adolescent"[Title/Abstract] OR "Adolescents"[Title/Abstract] OR "Adolescence"[Title/Abstract] OR "Teens"[All Fields] OR "Teen"[Title/Abstract] OR "Teenagers"[All Fields] OR "Teenager"[All Fields] OR "Youth"[Title/Abstract] OR "Youths"[All Fields] OR "young"[All Fields] OR "youngs"[All Fields] OR "adolescences"[All Fields] OR "adolescency"[All Fields]) AND ("Social Determinants of Health"[MeSH Terms] OR "Social Determinants of Health"[All Fields] OR "Health Social Determinant"[All Fields] OR "Health Social Determinants"[All Fields] OR "Structural Determinants of Health"[All Fields] OR "Health Structural Determinants"[All Fields]).

From April to May 2023, a search was carried out in all databases below, incorporating all keywords and descriptors relevant. To do so, the search strategy was adapted by the librarian for each database and/or information source, considering the technical specificities of each of them.

The following databases were selected: National Center for Biotechnology Information/Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed; Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOHost; PsycINFO, the search platform of the American Psychological Association (APA); Scopus, via Elsevier; Cochrane Library; Educational Resources Information Centre (ERIC); Web of Science; LILACS; and EMBASE. The ProQuest Theses and Dissertations (Ovid), the CAPES/Brazil Catalog of Theses and dissertations, and Google Scholar were searched to identify unpublished gray literature studies. Finally, the third stage consisted in consulting the bibliography of all evidence sources already included to identify additional studies.

After finishing the research, all citations found were grouped, classified, and loaded into the Rayyan® software. Duplicates were only counted once. Two independent reviewers conducted a pilot test to verify the selection of the sources regarding inclusion criteria. Since there were no disagreements, we proceeded to a reading of titles and abstracts.

The final sample of articles was imported into Covidence (Veritas Health Innovation, Melbourne, Australia) for data extraction. This stage was also carried out by two independent reviewers, using a data extraction form based on the model suggested by the JBI, in line with the objectives and questions of the review and inserted in the software in order to standardize extraction procedures.

Two reviewers carried out a pilot test including 10 articles to ensure that data was captured with precision. There were no disagreements regarding any item/variable in the form. The main information included authors, year of publication, country of origin, participants, design/methodology/statistical features of the relationship and discoveries related to SDH distributed in each layer of Dahlgren and Whitehead's model. Each article was read, this information was extracted and stored in a form. Then, a spreadsheet was made including all relevant data. The reviewers found a found a consensus about the information from each article, so there were no disagreements.

Considering the criteria established for this review, 2426 articles were found in the databases and libraries. 220 were found in Cinahl, 664 in Embase, 09 in Lilacs, 39 in PsycINFO, 540 in Pubmed, 620 in Scopus, 119 in Web of Science, 38 in ERIC, 29 in Cochrane, 34 in Proquest, 100 in Google Scholar, and 14 in the CAPES catalog of theses and dissertations.

Two independent reviewers (AG, GM) read the titles and abstracts of all articles, evaluating duplicates only once. From the results found (n=1,358), 91 were kept for eligibility analysis; 39 were eligible for full text analysis. As a result, 19 studies were included.

From the bibliography of these 19 studies, 77 papers were found. Only 2 of them were in accordance with our eligibility criteria. 21 studies were included in this review. The results of the search strategy and of the inclusion process are described below (Figure 1). They have been reported in full and presented in a PRISMA flowchart for scoping reviews - PRISMA-ScR²¹.

These results are presented using tables and schemes, with a narrative description that is in accordance with the guiding questions of this review. The methodological quality of the articles was not evaluated, as this is not mandatory in a scoping review¹⁹.

Figure 1 -
Search results; process of selection and inclusion of studies. Recife, Pernambuco, Brazil, 2023.

RESULTS

Chart 1 shows the authors, year of publication, country of origin, statistical measures of relationships, participants, context of the study, and SDH related to HL.

Thumbnail

Chart 1
Characteristics of the publications included, addressing Social Determinants of Health related to Health Literacy. Recife, Pernambuco, Brazil, 2023.

The countries with the highest number of publications were Iran (21%), Brazil and China (both with 13%), followed by Germany and the USA (both with 8%). There was also one publication from each of the following countries: Ghana, Poland, Korea, Finland, Denmark, the West Bank, Lebanon, and Italy.

Multivariate analyses, such as linear regressions and univariate and multivariate logistic regressions, were the most common methods of analysis in the studies included, being used in approximately 70% of them and showing a consistent and fixed dynamic in the express relationship between SDH and HL. Most studies were carried out in an educational context, involving nearly 71,692 students, all of whom were children and adolescent from the 4th grade to the first years of higher education.

According with Chart 1, SDHs related to the HL of children and adolescents can be described as: sex; age group; cognitive characteristics; access to health information; alcohol intake; religion; parents' conditions; access to health services; social-community support; school characteristics; school environment; family structure and models; ethnicity; smoking; eating habits; physical activity; general socioeconomic situation; housing; access to books and cell phones; personal income; and quality of life.

The SDH listed above were organized according with Dahlgren and Whitehead's model, which is shown in Figure 2. Each SDH in the layers was in accordance with the definitions proposed by these authors.

In the macrodeterminant layers, we find the general socioeconomic situation experienced by children and adolescents²⁶^,²⁸^,³¹^,³⁶. In the life conditions layer, we find personal income³¹, access to books and cell phones²⁸, housing²⁸^,³⁰^,³⁵, school environment ¹⁷, access to health services(23,28) and parent's financial conditions ¹⁷^,²³^,²⁷^-²⁸^,³⁰^,³³^-³⁵^,³⁹^-⁴¹. In the social and community network layer, are included family structure and models ²²^,²⁹^,³⁰^,³⁴^,³⁶^-³⁷, religion²⁴^,³², school characteristics ²⁶^,²⁸^,³⁰^-³¹^,³⁷^,³⁹^-⁴⁰, and social-community support²⁸^,³¹.

In the layer of behavior and lifestyle, we find quality of life³², physical activity²⁶, eating habits²⁶, smoking²⁶, access to health information²³^,⁴⁰, and alcohol intake²⁴. In the proximal layer, related to an individual level, we found sex¹⁷^,²²^-²⁴^,²⁶^-²⁸^,³³^-³⁴^,³⁷^,³⁹, age group²²^,²⁴^,³⁰^-³¹^,³⁴^-³⁵^,³⁸, cognitive characteristics¹⁷^,²³^,²⁷^,³³^-³⁵^,³⁹^-⁴⁰, and ethnicity²⁴.

Figure 2 -
Social Determinants of Health that are associated with the Health Literacy of children and adolescents, organized and disposed according to the layers of Dahlgren and Whitehead's model. Recife, Pernambuco, Brazil, 2023.

DISCUSSION

The identification of the SDH related with the HL of children and adolescents allows discovering multiple factors that influence health results. On a bigger scale, the changes required can support strategies to support government actions such as the United Nations (UN) Sustainable Development Goals (SDGs).

Regarding the SDH in the individual layer, we find sex, age group, cognitive characteristics, and ethnicity. The main element, in this case, is not the ability of individuals to show their literacy and numeracy, as much as the actions literacy enables them to do¹⁵.

It is essential to go "beyond what teenagers know", towards an investigation about "how they actively build meaning from health information"³, so they develop their knowledge and adopt healthy choices, going against the effects of poverty on their family and community. Thus, the SDG 1 (elimination of poverty) can benefit from these healthy choices.

In the behavior and lifestyle layer, the SDH that stand out are quality of life, physical activity, smoking, access to health information, alcohol intake, and eating habits. The ability of children and adolescents to learn is varied, and responds to different types of communication and media²². Thus, the government must act towards simplifying the communication and the transmission of health information to improve collective well-being. This can help change the behaviors of children and adolescents and reduce the inequalities in health systems, increasing compliance with the SDG 1.

Furthermore, new behavior must be linked to the good habits parents transmit to their children, as they are models that generate information to improve the HL of these children, leading to better choices in several capacities, such as dietary habits. These influences could work together with global initiatives as part of government policies and interventions aimed at preventing malnutrition and hunger in all relevant sectors, thus helping achieve SDG 2 (zero hunger) and SDG 3 (health and well-being).

Regarding the layer of social and community networks, the SDH found were family structure and models, religion, school characteristics, and social-community support. By approaching family structures and models, we found that the insufficient HL of children and adolescents is associated with low family support, living with a parent³⁰^,²², parents with low levels of HL and self-perceived poor health³⁴, parents with little knowledge about health³⁶, and poor relationships with parents³⁷. Similar results can be found in other studies⁴²^-⁴³, according to which parents are essential in the construction of their children's HL.

In order to intervene in these cases, health workers, such as nurses, can use educational strategies to minimize the influence of these SDH, such as fostering a bond between the family and the health unit in the territory, family counseling, referral to community resources, and others.

Vulnerable parents may need additional support to improve their knowledge about health, accessing available health information, navigate the health care system, and make health-related decisions⁴⁴. Therefore, increasing health-related knowledge and skills of parents can improve the results of their children and adolescents, especially in the fields of nutrition, exercise, and self-care, reflecting on SDG 3 (health and well-being).

These influences also take place in the school environment. One's educational level⁴¹, school performance ³¹, and school evasion²² are also related to HL. Although HL is mediated by the community and the organizational structures, resources, and commitments, this relationship is bidirectional⁴⁵. Community organizations that promote HL in their community, such as schools, can benefit from this. They can reach their goals better and fulfill their responsibility with their members, leading to the achievement of SDG 4 (quality education) and SDG 16 (peace, justice, and effective institutions).

Regarding the layer “life and work conditions”, the following SDH were found: personal income, access to books and cell phones, housing, access to health services, school environment, and parental conditions, the latter two being widely discussed in the studies. Children and adolescents that developed their studies in urban public schools ²⁶^,³⁵^,⁴², as well as those who are satisfied with their school educational system²⁹ have higher HL levels.

Similar results can be seen in studies⁴⁶^-⁴⁷ which showed the influence of school on young people's health behaviors. This shows an association with the role of teachers who are not held back by the gaps and obstacles in the public educational system or difficulties of the student, implementing broader teaching practices that foster the life skills necessary to avoid risks to one's health. This can result in environments that are favorable to the construction of individuals more coherent in their life and career choices, contributing for SDG 8 (decent work and economic growth), and SDG 9 (industry, innovation and infrastructure).

In the layer of macrodeterminants, it became clear that the general socioeconomic situation influences the HL of children and adolescents³³. Families that perceive their economic situation as unfavorable tend to influence their children to engage in risky behaviors²⁶. We believe this is due to the fact that the social status of the family affects the attitude of parents regarding their children, as they pass on limited knowledge and risky practices that have been established by the family, in addition to the lack of resources which prejudice the acquisition of abilities to promote health.

The development of public policies regarding income, education, and health can ensure better conditions for the development of the HL of children and youths, which will guarantee better future results in the health of many population groups. This will create a population that will take advantage of their right to health, and ensure this right is guaranteed for all. This could help reach the SDG 10 (reduction of inequalities).

Dahlgren and Whitehead's model, used here, highlights the interconnectedness and complexity of SDH, emphasizing the importance of multifaceted and interdisciplinary approaches involving health workers and the health system. The authors provided a useful structure to understand how social, economic, and environmental factors relate to the HL of children and adolescents and can guide public health interventions and policies aimed at promoting health and addressing health inequalities. These strategies can lead to the formation of a more equal, fair, solidary, and healthy society, ensuring that SDG goals are achieved.

Limitations of this study include difficulties comparing these findings between countries, since different HL measures were used in the different socioeconomic and cultural settings where these children and adolescents are located. Another limitation is the fact that the SDH may influence only some areas of the HL, not necessarily all of them, since it is a multifaceted concept with multiple areas of evaluation (acquisition, use, understanding, decision-making). Therefore, we must consider what is the actual influence of an SDH on each of them. The third limitation is the interpretative power of the statistical methods employed. Even though inferential statistics (several tests) were used, they cannot identify the subjective effects of the concepts studied, as these are hidden at the time these children and adolescents are interviewed and answer their questionnaires.

CONCLUSION

Some SDH widely described in literature showed significant influence on the HL of children and adolescents, namely: sex, cognitive characteristics, eating habits, family structure and models, school characteristics, school environment, and parents' conditions. The presence of SDH in all layers of Dahlgren and Whitehead's model gives even more credence to the thought that proximal factors are as important to identify HL as distal factors. This implies that there are many potential targets for action, depending on the life context to which these children and adolescents are exposed.

In practice, the health and educational systems must create connections that allow formulating health education interventions in schools, composing educational materials pertinent to reflections on the development of health skills, creating campaigns to provide health orientation, involving parents in the health-related actions in which their children participate, providing extracurricular health programs in schools, and strengthening educational and health programs and policies in schools.

With these interventions, the impact of SDH can be minimized. Once the HL of children and adolescents are improved, government policies to promote health and social development can be successful, including the Sustainable Development Goals, which would have a prospective impact on the social inequality in these populations.

It is essential to carry out future studies that can mitigate the limitations imposed by the methodological processes in this review. Alternatives include the elaboration of systematic reviews to evaluate the methodological rigor of the relationships indicated by the several studies, in an attempt to mitigate the exploration of the concept of HL, in addition to population-based analytical studies that can clarify the actual influence SDH have over the multiple HL areas. The identification of the SDH related with the HL of children and adolescents allows discovering multiple factors that influence health results. On a bigger scale, the changes required can support strategies to support government actions such as the United Nations (UN) Sustainable Development Goals (SDGs).