01. Introduction to youth health literacy
“Youth health literacy” brings together many different concepts related to what youth and communities need to make effective health decisions for themselves, their families, and their communities as a means to develop healthier lifestyles necessary to achieve a greater state of health and well-being. what is health literacy? In a general sense, health literacy refers to personal skills and social resources needed by an individual to access, understand, apply, and use information and services to make health decisions, and the ability, the capacity to communicate, affirm, and implement those decisions. Therefore, health literacy of individuals and communities influences health behaviour, characteristics of society, and the health system; so, the reason why it is essential to invest in health literacy.
The concept of health literacy was first proposed in health education as social policy, emphasising the importance of health literacy on national health and the provision of the most basic health literacy education for the students in schools. Its goal was later to highlight that: Health literacy is an important predictor of health status and outcomes; Health literacy is a key factor for determining the effective use of health information and making choices for promoting health; Individuals with low health literacy have a limited understanding of health information or low health self-management ability that increases hospitalisation, and the medical expenses as well as causes high mortality. Both good health-promoting behaviours and healthy lifestyle habits are developed in youthhood, the vital developmental stage, which involves physical, psychological, and social changes that affect both youth health outcomes and the quality of life in adulthood. Early youth health literacy can aid in the youth gaining an understanding of health information and promoting interaction with healthcare system, thereby providing positive health outcomes and well-being in the future.
Hence, understanding the health literacy of the youth is crucial for youth health and well-being towards youth’s physical, psychological, and social development. Herein defined as the degree to which young people have the capacity to obtain, process, understand, and apply most basic health information needed to make appropriate health decisions, youth health literacy is an important public health issue and a fundamental component of the pursuit of the youth health and well-being. Early family, school, community, and media-based interventions for promotion of youth health literacy are therefore crucial from both a public and youth health perspective. This requires a dynamic that involves both youth health skills and supportive, inclusive, diverse environments that make available easily accessible health information and youth health literacy education and facilitate interaction between youth and those environments since youth health literacy is developed in different contexts.
02. Essentials of youth health literacy
To explore the essentials of youth health literacy, herein we begin by looking at and understanding what health literacy means in the European context in order to form the knowledge base of what the youth health literacy entails. Health literacy has gained considerable importance, visibility in European health policies. Closely linked to empowerment and capacity strengthening, health literacy entails the ability of citizens to make sound, informed decisions concerning their health in their daily life, such as at home, at work, in the healthcare system, at the marketplace, and in the civil and the political arena. So, the concept of health literacy is not only in healthcare, but also within the public health contexts and discourse. At the European levels, the importance and the visibility of health literacy is amplified by its inclusion in the European policy documents such as the European Commission White Paper “Together for Health”; and the Vilnius Declaration on Sustainable Health Systems for Inclusive Growth in Europe, agreed to by health ministers during Lithuanian Presidency of the European Union.
However, in spite of growing attention being paid to the concept of health literacy among the European health policymakers, information about and on the status of health literacy in Europe remains scarce. And while several studies have demonstrated the prevalence of limited health literacy across the world, the population data on health literacy levels within the European Union remains unavailable. A systematic literature review of existing health literacy literature, namely from the WHO and HLS-EU, resulted in an integrated definition of the concept health literacy as the knowledge, skills, attitudes, competences to access, understand, appraise, and apply health information to make judgments or take decisions in everyday life concerning healthcare, disease prevention, and health promotion to maintain and/or improve quality of life throughout the course of life.
Hence, this integrated definition serves as the basis for developing a multidimensional and comprehensive definition of what youth health literacy entails in the context of youth work.
A youth health literacy implies the degree to which youth have the capacity and the skills to obtain, process, understand, and apply the most basic health information needed to make appropriate health decisions. Thus, achieving optimal levels of youth health literacy among the youth requires empowerment and capacity strengthening through what we will later on come to understand as youth health literacy education. the ultimate goal of youth health literacy education is facilitating youth to work towards optimal health outcomes and well-being. Youth well-being is about how the youth are doing and how they feel about their life.
03. Digital and youth health literacy
Frequent searching for the youth health information online, use of sophisticated search strategies or thorough verification of identified youth health information sources are indicators of high levels of digital health literacy. In general, young people have a higher degree of digital health literacy than other age groups, as they make frequent use of social media and digital devices. Therefore, the digital environment can be a fertile ground for interventions in the field of youth health literacy, but rapidly changing and relatively unregulated nature of the Internet makes it a more difficult context in which to work.
That is, as modern societies grow more complex in terms of communication and technologies, the youth are increasingly, continuously bombarded with various health information, but more worryingly, with youth health misinformation and disinformation. The Internet is inherently interactive and collaborative but with the explosion of social media and user-generated content, it is also an increasingly central part of the youth’s life. In addition to knowledge exchange, the Internet is increasingly becoming a service delivery site as the youth health services move towards digital systems. Though access to the Internet and the ability, capacity to use it are prerequisites for effectively finding the health information online, this requires skills that may not be shared equally among the youth. Therefore, digital youth health literacy should be made accessible to all young people so that they can search for quality health information online and develop the ability to understand, analyse, and evaluate this information and use it to make sound decisions about their health.
The health information that young people find through surfing the Internet can influence their eating habits, physical activity levels, the knowledge of healthcare and services, etc. which play a major in youth health outcomes and well-being. Youthhood is considered the earliest period in which the individual is considered to be more independent in terms of media use and health behaviours. There is an association between media exposure and health behaviour in youthhood and the transition to adulthood. In particular, eating habits, substance use and abuse, sexual and gender violent behaviour are correlated with exposure to misleading media content on the Internet. Thus, digital youth health literacy correlates with youth health behaviours, to a point that, proficiency in online health information acquisition yields positive results for youth health behaviours: nutrition, physical activity, sexual activity, safety behaviours, no substance use behaviours, etc. That is, the youth are more likely to engage in positive health behaviours when they feel more competent in obtaining health information.
04. A rights-based youth health literacy
A rights-based youth health literacy implies a generally recognised agreement that the human rights-based approach acknowledges that young people are key actors in all aspects of their own health, well-being, and development, and that both the duty-bearers (state and its institutions), and the responsibility holders (youth workers and the youth organisations) have the responsibility to enable the rights-holders (young people) to recognise, claim, exercise, and enjoy their right-to-health. So, a human rights-based approach to youth health literacy entails the youth’s rights-centred empowerment process to engaging with the youth in determining, planning, designing, delivering, monitoring, and evaluating the youth health literacy education interventions that are relevant for young people through a participatory youth work.
So, youth empowerment fosters youth’s meaningful, inclusive, and diverse participation in youth health literacy education to take control of health issues and policies that affect youth health and well-being. Whereas youth work entails a grassroots, community-based process that strives to create non-formal youth health literacy education practices necessary to facilitate the transfer of youth health knowledge and the development of youth health skills and attitudes that encourage youth health behavioural change that contribute to an optimal youth health outcome and well-being. In our context, the rights-based approach is guided by four working principles: meaningful and inclusive participation in youth health literacy education; non-discrimination and equality in youth healthcare and services; accountability and rule of law in the context of youth health literacy; transparency and access to youth-friendly health information.
Community-based participatory health literacy education entails a community-based participatory action research where the youth are consulted on how the youth workers and youth-based organisations can: Tackle inequality, promote fairness, create opportunities for young people in all their diversity to claim, exercise, and enjoy their right to health; Strengthen the young people health literacy capacity to make informed health decisions, prevent disease, and promote health; Empower youth with health literacy skills necessary to respond to youth exclusion and discrimination in making decisions about the issues and policies that affect their health and well-being. A rights-based youth health literacy not only recognise unique characteristics of young people as a target group and their human rights, but it also recognises the young people as social beings in their own right and their need to achieve a balance between their participation and protection. Young people are embodied beings and social actors within their own right who encounter and engage in health discourse and health-relevant situations on a daily basis.
05. A participatory youth health literacy
A rights-based approach to youth health literacy places importance on the process of how youth health literacy education interventions are planned, designed, and implemented. It implies that the setting-up of youth health literacy education intervention must be youth-rights-based; meaning that the youth's health needs, and their human rights must be at the centre of the intervention’s activities. A rights-based approach to youth health literacy leads to effective youth health literacy education interventions which deliver sustained results based on youth’s health needs, while ensuring both youth ownership and engagement around the planning, designing, delivery, monitoring, evaluation of the intervention.
In the set-up of youth interventions, the rights-based approach ensures, through both a gender-sensitive and a participatory approach, that in a particular context of concern, youth’s health needs and their lived experiences, as well as health-related contextual, social, cultural, racial, gender, educational, and economic obstacles the youth face are assessed, analysed, and included in health literacy education interventions to address inequalities and multiple often intersecting discriminations that young people confront. Then, two approaches: (1). A gender-sensitive approach, and (2). A participatory approach: are at the core of a rights-based approach to youth health literacy if it is to function.
Gender-sensitive approach means integrating youth health literacy education in youth work from both a gender and a racial perspective; acknowledging that in the public health system and discourse, young people are not only discriminated against on the basis the binary notion of gender, but also and most often so, on the basis of their race and/or their non-binary gender identity and/or expression, such as youth who belong to racial minority groups and lesbian, gay, bisexual, trans, intersex, and queer youth in the LGBTIQ. So, youth health literacy becomes gender-sensitive, when there is informed participation and inclusion of the most marginalised and most vulnerable youth regardless of sex, race, ethnicity, ethnic origin, colour, religion, language, sexual orientation, gender identity/expression, age, or disability. Whereas a participatory approach means active, meaningful, inclusive, and diverse participation of young people in health literacy education, which is the most important factor that enables both learning and performance; considering young people’s characteristics, their own lived experience, and their local realities, and facilitating critical reflection and analysis of their health needs, so that they can develop health literacy attitudes, skills, and knowledge through experiential learning.
06. Youth development and health literacy
Youthhood is a life phase in which essential biological, cognitive, psychological, emotional, and social development processes take place. It is a developmental phase accompanied by the specific developmental features, typical challenges, and social expectations. Apart from the cognitive development aspects, namely the skills and the competencies the youth should be capable of mastering and employing in the context of health literacy, it is crucial to recognise sociological and psychosocial development processes that are also taking place during this phase. Moreover, it is equally crucial to look at and/or understand how positive youth development contributes to optimal youth health outcomes and wellbeing. Positive youth development entails combination of positive experiences, positive relationships, and positive environments. It is an intentional, pro-social approach that engages the youth in their communities, schools, organisations, peer groups, and families in a manner that is more productive and constructive; providing the opportunities, fostering healthy relationships, and furnishing the support needed to build strengths.
So, given the conceptual heterogeneity and gaps in understanding youth health literacy, positive youth development explores the youth’s particularities for health literacy through a development perspective structured into psychological and sociological perspectives. These developmental aspects are thus important for better understanding of (1) how youth health literacy develops in youthhood; (2) how general developmental processes and changes interact and affect youth health literacy. A common approach to a psychological perspective on youth health literacy and development is to focus on cognitive abilities, for example, health literacy levels at the successive developmental stages. One development perspective is when health literacy is conceptualised within four skill areas (prose literacy, oral literacy, numeracy, and the systems-navigation skills) and the activities are provided for each youthhood developmental stage.
Even though such a stage model may provide an overview, or a guideline of what health literacy skills can be expected of youth at the specific stage, this development perspective is strongly “top-down” as it limits the youth health literacy to the predefined set of abilities: if the youth develop such abilities, then they are considered health literate; if not, the youth is left to a low score. Moreover, stage models offer an idealistic, one-size-fits-all approach, implying that all youth develop at the same speed and reach certain levels at a particular age, not taking into account individual-experience-relationships-environmental interaction. Thus, they are based on questionable assumptions that it is possible to determine how the youth understanding of health and/or illness and their health literacy skills typically evolve, regardless of the setting or culture in which a youth lives.
07. A sociological approach to youth development
From a sociological perspective, it is critical to review and discuss considerations of sociological perspectives of youth development for youth health literacy by focusing on four prominent sociological approaches: (1). sociocultural aspects of youth development: To highlight the fundamental role of social interactions with regards to youth health literacy and development. How cognitive processes are influence by specific sociocultural factors in youth's surrounding results in the concept: inter-subjectivity of social meanings. (2). socio-ecological approaches: To highlight the relationships between youth and their social world within health literacy research. To promote youth health literacy effectively needs to consider the structure of youth's social worlds, and the reciprocal interaction between youth and their social environment.
(3). youthhood socialisation: a modern perspective: Focuses on direct, and mediating role of interpersonal (parents, peers, schools) and medial socialisation agents for youth health literacy. The emphasis on youth as the central agent of socialisation can help to understand the active role that is attributed to youth health literacy. And (4). sociology of youthhood: concept of intergenerational order: Viewing youth as being positioned in intergenerational relations sheds light on unequal power structures and the ways youth, as their own social groups, are viewed, listened to, and involved in health literacy in different health-related settings (home, school, healthcare setting).
Currently though little is known about how the contextual factors interact with one another, and how this interaction affects how the youth can build up and use their personal health literacy skills. One approach could be looking at the role of interpersonal and media socialisation for youth health literacy from a sociological perspective. Contextual factors relevant for youth health literacy can be distinguished in: The interpersonal context such as the parental socio-economic status, parental education level, and the home setting; Situational determinants such as the degree of social support as well as influences from family and peers, the school and community setting, and the media; and The distal social and cultural environment such as characteristics of the health and education system as well as political and social variables.
08. Youth health literacy education
Youth health literacy education is both a teaching and a learning process that involves a wide spectrum of youth health literacy education interventions (family, school, community, media-based interventions) aimed at empowering youth by strengthening their knowledge, skills, attitudes, and competences as a means to access, obtain, process, analyse, understand, appraise, and apply health information to make judgments and take decisions in their everyday life concerning healthcare, disease/illness prevention, and health promotion, as well as strengthening their ability to communicate, affirm, and implement those decisions in order to maintain or improve quality of life throughout the course of life. Therefore, empowering youth through health literacy education interventions as teaching and learning processes, is what leads to optimal youth health outcomes and well-being. Thus, a youth health literacy education intervention herein refers to organised efforts to transfer youth health knowledge and develop youth health skills, attitudes, and/or competences, which encourage positive youth health behaviours that contribute to high level of health literacy among the youth.
A youth health literacy education intervention is a teaching and a learning process through which youth strengthen their health knowledge and develop their health skills, attitudes, and competences that encourage positive youth health behaviours. (1). Organised efforts: a youth health literacy education intervention should not be improvised. The implantation phase of a youth health literacy education intervention is one of the final stages of its life cycle, which starts with planning and design. (2). Transfer health knowledge: knowledge does not refer to just accessing and understanding of health information about healthcare, disease prevention, and health promotion, but also to both consider and act on this information to make informed health decisions.
(3). Develop health skills: in a youth health literacy education intervention, skills to obtain, process, appraise, and apply health information are strengthened by practice and application, a process which needs to continue throughout and beyond the intervention. (4). Develop health attitudes: to change negative health attitudes and reinforce positive ones, so that the youth can assume responsibility for their own health and well-being, and thus, take the necessary actions to tackle and prevent youth health misinformation and disinformation about healthcare, disease prevention, and health promotion. And (5). Encourage health behaviours: the effectiveness of a youth health literacy education intervention lies in the actions that the intervention fosters among the youth, and its effects on health behavioural change at the individual levels that reasonably contribute to the ability to communicate, affirm, and implement informed health decisions to maintain or improve quality of life throughout the course of life.
09. Non-formal youth health literacy education
Although schools are the spaces that allow most children and young people to access health educational topics, materials, and/or resources, it is important to consider that not all the young people are in or use these spaces, rather there are those young people who for various reasons are not formally studying or have finished their studies and/or are working in different sectors. Though this does not mean that they should not have equal rights and opportunities to learn and/or acquire the skills related to health literacy that are very favourable for their future. Health literacy aligns the individual skills and abilities of those requiring health information and services with the demands and complexities of health information and health services. A youth health literacy-friendly environment makes it easier for youth to navigate, understand, and use health information and services to take care of their own health. One setting relevant to youth health literacy education is extracurricular youth work settings within the of context of non-formal education.
So, to make these settings more youth-centred, nonformal education reduces the organisational demands and provide a system that is easy to navigate, understand, and use by young people. In fact, this manual stems from the need to convey the importance of promoting youth health literacy at the level of the youth organisations working with the young people in youth work settings within non-formal education contexts. It does so by considering youth health literacy as a set of competences and skills classified into three main types: (1). Functional health literacy, which refers to the literacy skills needed to function effectively in everyday situations, like basic reading and speaking skills; (2). Interactive health literacy, which refers to the more advanced cognitive and literacy skills that enable a person to actively participate in their own healthcare; and (3). Critical health literacy, which refers to the more advanced cognitive skills, including the ability to critically analyse health information, apply the knowledge, make decisions, and evaluate health information.
It is important that youth become aware of these skills and are able to develop them in appropriate environments. This manual sought to move its focus beyond individual cognitive skills, such as reading, writing, critical thinking, and/or information processing, to include affective attributes (e.g., self-reflection, self-efficacy, and motivation), operational or behavioural attributes (e.g., communication and social skills); and specific technical skills (e.g., navigating the context or the health system, or technological information search skills). And since youth health literacy is also a competence-related concept and a learning outcome of a non-formal youth health literacy education, in youth work settings the young people learn, perform, and retain health-related skills effectively.
10. Youth health literacy education in youth work
Youth Work entails a grassroots and a community-based process that strives to create non-formal youth health literacy education interventions that are necessary to, essential in facilitating the transfer of youth health knowledge and the development of youth health skills, attitudes, or competences that can encourage youth health behavioural change that can contribute to an optimal youth health outcome and well-being. Youth workers, youth educators who are health literacy practitioners offering the youth health education and training interventions within the confines of youth work within non-formal education settings, are the most therefore well positioned to encourage and/or motivate, to educate, to training, and empower the youth they interact with to develop health behaviours which contribute to the optimal youth health outcomes and well-being.
That is, youth workers, youth educators with youth health literacy training skills can facilitate, accompany, support, and help the youth to connect their health knowledge, skills, attitudes, competences, and behaviours to their health needs, aspirations, and challenges by evoking their abilities of making and implementing informed health decisions in their daily life and throughout the course of life. Therefore, youth work should pay attention to key attitudes, beliefs, social barriers, context, and lived experience that can enable the youth to engage in skills and behaviour that could facilitate them to (1). become responsible for their own health and for dealing with different kinds of health-related issues; and (2). become engaged in their health, healthcare services utilisation, disease/illness prevention, and reduce health expenditure. Indeed, this the goal of empowerment. Youth empowerment in the context of youth health literacy, has been defined as process that fosters youth’s meaningful, inclusive, and diverse participation in youth health literacy education so the youth can take control of health issues and policies that affect their own health and well-being.
Youth workers, youth educators should be able to identify and measure positive changes or results, to which the training has contributed to at various levels of change: (1). Individual level: this is the change that the youth workers, youth educators want to see in the individual youth attending the training. (2). Organisation or group level: this is the change that the youth workers, youth educators expect when the training participants transfer their learning experiences to their peers, organisations, or groups they work with. And (3). Community or society level: this is the change that the youth workers, youth educators anticipate when the participants’ organisation transfers its incorporated, integrated participatory youth health literacy education training approach to the broader community or society.
11. Community-based youth health literacy interventions
Community-based youth health literacy education interventions in youth work imply a community-based participatory action research process where young people are consulted on how youth workers and youth organisations can tackle inequality, promote fairness, and create opportunity for young people in all their diversity to claim, exercise, and enjoy their right to health. This manual places importance on the process of how effective community-based youth health literacy education interventions are determined, planned, designed, implemented, and evaluated: setting-up of a community-based youth health literacy education intervention must be collaborative, rights-based: youth and their rights must be at the centre of the intervention. Such an approach aligns with youth work principles to youth empowerment.
Youth exclusion and discrimination undermine youth participation, especially youth in vulnerable situations such as youth who belong to racial, sexual, and gender minority groups. So, community-based youth health literacy education interventions foster an evidence-based youth health literacy education grounded in the rights-based, gender-sensitive, participatory approach. In this context, rights-based, gender-sensitive, participatory approach and intersectionality share principles and reinforce each other. They all focus on dismantling inequalities in access to resources and opportunities among young people (e.g., health services, health information, education, or decision-making, etc.). Inequality undermines youth empowerment, decision-making power, and equal, non-discriminatory health services, especially for the most marginalised youth. By participating in the community-based youth health literacy education interventions, young people learn that there are others who share their values, common struggles, and working for a collective acknowledgment of shared goals: claiming rights and advocating for better life conditions within their community.
For instance, youth counselling or training services offered by different actors at community level. So, when designed and targeted to young people needs, these can effectively improve youth health knowledge, self-care practices, and positive lifestyle behaviours. And due to their participatory action research nature, community-based youth health literacy education interventions promote the access to health education and initiatives to improve youth health literacy skills through a wide range of activities and policies. The majority of interventions implemented aim to: (1). disseminate health information via websites and/or large media campaigns; (2). promote access to health education and/or incentivise health literacy skills of the youth; and (3). develop counselling and training sessions at the community level. Thus, these interventions contribute to reducing health problems; health misinformation or disinformation; harshness of disease; and reduce the number of hospital visits among youth.
12. Media-based youth health literacy interventions
Media and information literacy refers to the skills, knowledge, attitude, and competences that allow one to use media and information critically, effectively, and safely. Given the ubiquity of media messages and platforms for media exposure in adolescence, media literacy skill to critically analyse media messages is effective at preventing health risk behaviours such as substance use, smoking, risky sexual activity. But media literacy skills alone are unlikely to produce meaningful changes in attitudes and behaviours without the associated knowledge to resist the medium's message. Youth naturally learn and become socialised with digital media formats because digital media are an integral component of their daily lives. And because youth encounter and access health information in various or multiple digital forms and formats, considering the opportunities and the challenges present in digital and media settings with their various multi-model formats is crucial for improving the young people’s health literacy levels and their digital health information seeking.
The purpose of media-based youth health literacy education interventions is to facilitate youth to separately examine the main elements of an information disorder: the agent, message, and interpreter. By dissecting, analysing, and interpreting information disorder from this perspective, youth can understand these nuances: The agent who creates a fabricated message might be different to the agent who produces that message, who might also be different from the agent who distributes that message. Moreover, there is a need for a thorough understanding of who these agents are and what motivates each, since once a misleading health information has already been created and distributed, it can be reproduced and redistributed endlessly via the mainstream media operating without any scrutiny, by various actors, with different motivations. So, there is a need to consider the 4 possible different phases of information disorder: creation, production, distribution, and re-production.
Another important aspect of media-based interventions in context of digital youth health literacy education in youth work is facilitating the youth to develop digital health information fact-checking skills, attitudes, and behaviours. Fact-checking is an analysis driven by one basic question: How do we know that? So, fact-checking is not spell-checking. There is not a dictionary style guidebook with all the facts about online health information, nor a simple software that will examine information and flag something misstated as fact. Generally speaking, fact-checking is composed of three phases: (1). Finding fact-checkable health information by scouring through trusted records such as the WHO or the UNFPA websites. (2). Finding the facts by looking for the best available evidence regarding the digital health information at hand. And (3). Correcting the record by evaluating digital health information in light of the evidence.